Report No: ICR00179 IMPLEMENTATION COMPLETION AND RESULTS REPORT (Grant IDA D1890/Grant IDA D5760) ON A GRANT IN THE AMOUNT OF (SDR12.6 MILLION (US$16.59 MILLION EQUIVALENT) AND AN ADDITIONAL GRANT IN THE AMOUNT OF SDR16.8 MILLION (US$22.124 MILLION EQUIVALENT) TO THE Islamic Republic of Mauritania FOR A Health System Support October 1, 2024 Health, Nutrition and Population Global Practice Western And Central Africa The World Bank Health System Support (P156165) ICR DOCUMENT CURRENCY EQUIVALENTS (Exchange Rate Effective {August 30, 2024}) Currency Unit = MRU MRU 39.54= US$1 US$ 1.34 = SDR 1 FISCAL YEAR January 1 – December 31 Regional Vice President: Ousmane Diagana Country Director: Keiko Miwa Regional Director: Trina S. Haque Practice Manager: Moulay Driss Zine Eddine El Idrissi Mariam Noelie Hema, Samuel Nii Lantei Mills, Mohamed Vadel Task Team Leader (s): Taleb El Hassen ICR Main Contributor: Mariam Noelie Hema The World Bank Health System Support (P156165) ICR DOCUMENT ABBREVIATIONS AND ACRONYMS AF Additional Financing AFD Agence française de Développement ANC Antenatal care CAMEC Centrale d'Achat des Médicaments Essentiels Génériques (Central Purchasing of Medicines, Equipment and Medical Consumables) CCT Conditional Cash Transfer CERC Contingency Emergency Response CHW Community Health Worker CoSA Comité de santé (Health Committee) CPF Country Partnership Framework CPN Certified Pediatric Nurse CRI Cumulative Result Indicator DAFA Direction des Affaires Administratives et Financières (Director of Administrative and Financial Affairs) DALYs Disability-adjusted Life Years DMTs District Management Teams DoF Director of Finance DPs Development Partners DHS Demographic and Health Survey EmONC Emergency Obstetric and Newborn Care FA Financing Agreement FM Financial Management FOSA Health Facility Formation Sanitaire (Health Center) GDP Gross Domestic Product (Grosse Per Capital) RM Grievance Redress Mechanism HDI Human Development Indicator HMIS Health Management Information System HNP Health Nutrition and Population HP Health Post HRH Humane Resources for Health ICER Incremental Cost Effectiveness Ratio ICR Implementation Completion Report IDA International Development Association IES Intervention in Emergency Situations IFR Interim Financial Report IRI Intermediate Result Indicator INAYA Health in local language ISR Implementation Status and Results Report MDGs Millennium Development Goals MICS Multiple Indicator Cluster Surveys MMR Maternal Mortality rate MoH Ministry of Health The World Bank Health System Support (P156165) ICR DOCUMENT M&E Monitoring and Evaluation MPA Multi-Phase Approach MTR Mid-term Review NCHP National Community Health Policy NCHS National Community Health Strategy NHDP National Health Development Plan OP Operational Policy PAD Project Appraisal Document PBF Performance Based Financing PCA Paquet Complet d'Activités (Complete package of activities) PCER Project Cost-effectiveness Ratios PER Public Expenditure Review PDO Project Development Objective PHC Peripheral Health Center PIM Project Implementation Manual PIU Project Implementation Unit PMA Paquet Minimum d'Activités (Minimum package of activities) PTU Project Technical Unit QUALYs Quality-adjusted Life Years RMNCH Reproductive, Maternal, Newborn, and Child Health SCAPP Growth and Shared Prosperity Strategy SDG Sustainable Development Goal SMART Standardized Monitoring and Assessment of Relief and Transitions STEP Systematic Tracking of Exchanges in Procurement TTL Task Team Leader UHC Universal Health Coverage UNDP United Nation Development Program UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children and Education Fund UNOCHA United Nations Office for the Coordination of Humanitarian Affairs WB World Bank WHO World Health Organization The World Bank Health System Support (P156165) ICR DOCUMENT TABLE OF CONTENTS DATA SHEET ................................................................................................................................................. i I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................................................1 A. CONTEXT AT APPRAISAL ........................................................................................................................................ 1 B. SIGNIFICANT CHANGES DURING IMPLEMENTATION ............................................................................................ 6 II. OUTCOME ...................................................................................................................................................9 A. RELEVANCE OF PDO ............................................................................................................................................... 9 B. ACHIEVEMENT OF PDOs (EFFICACY) .................................................................................................................... 11 C. EFFICIENCY ........................................................................................................................................................... 15 D. JUSTIFICATION OF OVERALL OUTCOME RATING................................................................................................. 16 E. OTHER OUTCOMES AND IMPACTS ...................................................................................................................... 16 III. KEY FACTORS AFFECTED IMPLEMENTATION AND OUTCOME ...................................................................... 20 A. KEY FACTORS DURING PREPARATION ................................................................................................................. 20 B. KEY FACTORS DURING IMPLEMENTATION .......................................................................................................... 21 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME ................................ 25 A. QUALITY OF MONITORING AND EVALUATION (M&E)......................................................................................... 25 B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE ................................................................................ 26 C. BANK PERFORMANCE .......................................................................................................................................... 28 D RISK TO DEVELOPMENT OUTCOME........................................................................................................................... 29 V. LESSONS AND RECOMMENDATIONS .......................................................................................................... 30 Recommendations ................................................................................................................................................... 31 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ................................................................................................ 32 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION .............................................................. 48 ANNEX 3. PROJECT COST BY COMPONENT ................................................................................................................ 50 ANNEX 4. EFFICIENCY ANALYSIS ............................................................................................................................... 52 ANNEX 5. BORROWER, CO-FINANCIER, AND OTHER PARTNER/STAKEHOLDER COMMENTS ........................................ 64 The World Bank Health System Support (P156165) ICR DOCUMENT DATA SHEET @#&OPS~Doctype~OPS^dynamics@icrbasicdata#doctemplate BASIC DATA Product Information Operation ID Operation Name P156165 Health System Support Product Operation Short Name Investment Project Financing (IPF) INAYA Operation Status Approval Fiscal Year Closed 2017 Original EA Category Current EA Category Partial Assessment (B) (Restructuring Data Sheet - 10 Aug Partial Assessment (B) (Approval package - 19 May 2017) 2023) CLIENTS Borrower/Recipient Implementing Agency Islamic Republic of Mauritania Ministry of Health DEVELOPMENT OBJECTIVE Original Development Objective (Approved as part of Approval Package on 18-May-2017) The Project Development Objective is to improve utilization and quality of Reproductive, Maternal, Neonatal, and Child Health (RMNCH) services in selected regions. PDO as stated in the legal agreement There is no difference between the PDO in Legal Agreement and the PAD s s s s s s s s s s s s s s @#&OPS~Doctype~OPS^dynamics@icrfinancing#doctemplate FINANCING i The World Bank Health System Support (P156165) ICR DOCUMENT Financing Source Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing 40,000,000.00 40,000,000.00 40,029,747.66 IDA-D1890 17,000,000.00 17,000,000.00 17,472,471.39 IDA-D5760 23,000,000.00 23,000,000.00 22,557,276.27 Total 40,000,000.00 40,000,000.00 40,029,747.66 RESTRUCTURING AND/OR ADDITIONAL FINANCING Amount Disbursed Date(s) Type Key Revisions (US$M) 26-Aug-2019 Portal 3.07 • Reallocations • Results • Disbursement Estimates 22-Sep-2022 Portal 27.52 • Loan Closing Date Extension • Reallocations • Implementation Schedule 10-Aug-2023 Portal 36.89 @#&OPS~Doctype~OPS^dynamics@icrkeydates#doctemplate KEY DATES Key Events Planned Date Actual Date Concept Review 30-Aug-2016 06-Sep-2016 Authorize Negotiations 29-Mar-2017 31-Mar-2017 Approval 19-May-2017 19-May-2017 Signing 15-Jun-2017 16-Jun-2017 Effectiveness 15-Nov-2017 ICR/NCO 30-Sep-2024 01-Oct-2024 Restructuring Sequence.01 Not Applicable 26-Aug-2019 Restructuring Sequence.02 Not Applicable 22-Sep-2022 Restructuring Sequence.03 Not Applicable 10-Aug-2023 ICR Sequence.01 (Final) -- 30-Sep-2024 Mid-Term Review No. 01 04-Apr-2022 04-Apr-2022 ii The World Bank Health System Support (P156165) ICR DOCUMENT Operation Closing/Cancellation 31-Dec-2023 31-Dec-2023 @#&OPS~Doctype~OPS^dynamics@icrratings#doctemplate RATINGS SUMMARY Outcome Bank Performance M&E Quality ISR RATINGS Actual Disbursements No. Date ISR Archived DO Rating IP Rating (US$M) 01 24-Jul-2017 Satisfactory Satisfactory 0.00 02 16-Jan-2018 Satisfactory Satisfactory 1.00 03 24-Aug-2018 Satisfactory Moderately Satisfactory 1.10 04 13-Mar-2019 Satisfactory Moderately Satisfactory 1.54 05 04-Nov-2019 Satisfactory Satisfactory 3.49 06 18-Jun-2020 Moderately Satisfactory Moderately Satisfactory 6.22 07 17-Mar-2021 Moderately Satisfactory Moderately Satisfactory 11.19 08 03-Nov-2021 Moderately Satisfactory Moderately Satisfactory 16.76 09 25-May-2022 Satisfactory Satisfactory 22.83 10 21-Dec-2022 Satisfactory Satisfactory 31.40 11 26-Jun-2023 Satisfactory Satisfactory 35.98 12 22-Dec-2023 Satisfactory Satisfactory 40.11 @#&OPS~Doctype~OPS^dynamics@icrsectortheme#doctemplate SECTORS AND THEMES Sectors Adaptation Mitigation Major Sector Sector % Co-benefits (%) Co-benefits (%) Themes iii The World Bank Health System Support (P156165) ICR DOCUMENT Major Theme Theme (Level 2) Theme (Level 3) % iv The World Bank Health System Support (P156165) ICR DOCUMENT ADM STAFF Role At Approval At ICR Practice Manager Voahirana Hanitriniala Rajoela Regional Director Trina S. Haque Global Director Juan Pablo Eusebio Uribe Restrepo Practice Group Vice President Mamta Murthi Country Director Keiko Miwa Regional Vice President Ousmane Diagana ADM Responsible Team Leader Mariam Noelie Hema Mariam Noelie Hema Mohamed Vadel Taleb El Hassen, Samuel Nii Lantei Mills, Mohamed Vadel Co-Team Leader(s) Samuel Nii Lantei Mills Taleb El Hassen ICR Main Contributor Mariam Noelie HEMA v The World Bank Health System Support (P156165) ICR DOCUMENT I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES A. CONTEXT AT APPRAISAL Country Context 1. At appraisal, Mauritania was an arid, resource-rich country with a population of 3.5 million people, dispersed throughout the country. It had an average of 3.9 people per square kilometer, making it the fourth least-densely populated country in Africa. Sixty percent of the population is concentrated in urban areas. At that time, Mauritania experienced economic growth translated into a faster poverty reduction from 44.5 percent to 33 percent, while inequality (Gini Index) decreased from 35.3 percent in 2008 to 31.9 percent in 20141. However, poverty levels were still high and social indicators remained low. Poverty was more concentrated in rural areas (43 percent compared with 28 percent in urban areas) and more pronounced in the south (ranging from 28 percent to 49 percent) compared with 15 percent to 37 percent in the north and 14 percent in the capital, Nouakchott. Mauritania’s Human Development Indicators (HDIs) were among the lowest in the world, ranking 156th out of the 188 countries tracked in United Nations Development Program (UNDP). 2. Despite these challenges, Mauritania achieved the status of lower-middle-income country, with a gross national income per capita (current US dollar, Atlas method) estimated at US$1,270 in 2014 against US$700 in 2007. Gross Domestic Product (GDP) grew by 22.5 percent in real terms, mainly due to the discovery of mineral resources, such as iron, copper, gold, phosphate, quartz, diamonds, chromium, manganese, lead, zinc, platinum group elements, rare earth minerals, black sands, salts, and peat. Sectoral and Institutional Context 3. Mauritania made significant progress in improving health outcomes. The under-five mortality rate decreased significantly from 118 deaths for 1,000 live births in 2011 (MICS 2011) to 54 deaths for 1,000 live births in 2015 (MICS 2015). However, maternal mortality ratio (MMR) was estimated at 602 per 100,000 live births in 2015, leaving Mauritania among the countries with the highest level of maternal mortality in the region. The immunization coverage increased slowly from 38.4 percent in 2011 to 48.7 percent in 2015. Mauritania did not meet the health-related Millennium Development Goal (MDG) targets, including child nutrition, child mortality, and maternal mortality. High- impact health intervention coverage was low, especially for the poorest and in rural areas. Indeed, the high-quality emergency obstetric and newborn care (EmONC) and diagnostic services were not widely available in Primary Healthcare (PHC) facilities. There were large urban–rural disparities in health outcomes because of inequitable access to essential health and nutrition services. 4. The Government made significant efforts in expanding access to health and nutrition services across the country. Indeed, the National Health Development Plan (NHDP 2012–2020) was developed with the objectives of: (i) improving physical and financial access to healthcare; (ii) revitalizing the National Community Health Policy (NCHP); (iii) reforming the pharmaceutical sector; reforming the hospital sector; (iv) developing a strategic plan for human resources for health (HRH); (v) improving social health protection; and (vi) reinforcing institutional capacity and improving efficiency. 1 Poverty Dynamics and Social Mobility, World Bank, 2016 1 The World Bank Health System Support (P156165) ICR DOCUMENT 5. The amount of Central Government spending between 2012 and 2015 remained below the funding needed to finance the interventions identified in the NHDP (2012–2020). Health as a proportion of Government expenditure rose to 30 percent between 2012 and 2015, but represented 6 percent of total Government expenditure, which is far below the Abuja Declaration (2001) target of allocating at least 15 percent of the budget to the health sector. Over the same period, external financing rose from 6.7 percent to 11.9 percent of total health expenditure. The annual gap between projections and disbursements for donor funding was chronic and relatively high. 6. The results of the mid-term review of NHDP 2012–2020 were mixed. Even though geographical access to health centers had increased, the objectives of the NHDP were not achieved. Therefore, the Government decided to adopt and implement the Performance-based Financing (PBF) strategy to improve efficiency and access to quality health services. This strategy aimed at improving efficiency of the health system and better access to health services, with a focus on Reproductive, Maternal, Newborn, and Child Health (RMNCH). Mauritania’s PBF strategy comprised two components: (i) the supply-side PBF (performance-based financing, PBF); and (ii) the demand-side PBF (conditional cash transfers, CCTs). Rationale for Bank’s Involvement 7. The development of the PBF policy was part of the Country Partnership Strategy 2014–2017. The Health System Support Project called the INAYA2 Project supported Pillar 2 (Economic Governance and Service Delivery), which aims to improve public sector performance and promote increased access to basic social services. The Project targeted the poor and used PBF mechanisms to strengthen service delivery at community, primary healthcare, and regional levels. It also supported access to basic health services for the most vulnerable households. 8. The Project targeted 620,000 people as direct beneficiaries, among whom 78.8 percent were women and girls, in the two selected regions (Guidimagha and Hodh El Gharbi). These two regions were selected because of the poor access to healthcare. Nationally, 69 percent of births were assisted by trained staff, but only 52 percent of rural births were assisted by skilled staff, compared with 91 percent in urban areas. Looking at the regional variation, Nouakchott had 96 percent assisted deliveries, compared with Guidimagha (32 percent) and Hod El Barbi (47 percent) were the worst regions. In addition, the doctor-to-population ratio in Guidimagha was 0.02 percent and in Hod El Barbi 0.05 per thousand people; the nurse and midwife ratios were 0.18 and 0.58 per thousand people respectively3. 9. The Project sought to address the World Bank Group’s twin objectives of reducing poverty and promoting shared prosperity; the Africa Regional Strategy, which focuses on strengthening governance and public sector capacity; and the HNP Universal Health Coverage (UHC) strategy. The Mauritanian NHDP identified PBF as a central strategy to address health system challenges and contribute toward achieving UHC. 10. The Project was also aligned with the Sustainable Development Goals, in particular Goal 3 (Ensure healthy lives and promote well-being for all at all ages). Goal 3 has several targets, among which the Project directly supports: the reduction of MMR (Target 3.1); the reduction of under-five and neonatal mortality (Target 3.2); achieving universal access to sexual and reproductive healthcare services (Target 3.7); achieving UHC (Target 3.8); and increasing health financing and the recruitment, development, training, and retention of the health workforce (Target 3.9(c)). The Project also supported the achievement of Goal 1 (End poverty in all its forms, everywhere), through its links with social safety 2 INAYA means “take care of” in local language. 3 INAYA PAD page 13-14 2 The World Bank Health System Support (P156165) ICR DOCUMENT net programs and improved financial protection (against catastrophic health expenditures) among the poor and vulnerable. Theory of Change (Results Chain) 11. The Project aimed at improving utilization and quality of services through strengthening service delivery. The ultimate long-term objective was to contribute to reducing maternal and child mortality. No Theory of Change (TOC) was developed, as this was not yet a requirement in the PAD at appraisal. Therefore, for this Implementation Completion Report (ICR), a TOC (Figure 1) was developed, taking into consideration the Project Development Objective (PDO), component description, and the Results Framework (RF). 3 The World Bank Health System Support (P156165) ICR DOCUMENT Figure 1: Theory of Change Problem Statement: Inadequate access, coverage and quality of RMNCH-Services impacting maternal, child health and nutrition outcomes. 4 The World Bank Health System Support (P156165) ICR DOCUMENT Administrative and implementation milestones and processes AAd 12. Over five years of Project implementation were marked by key milestones and processes (Table 1). Table 1: Administrative and Implementation Milestones and Processes Event/Processes Dates Administrative Milestones Approval May 19, 2017 Effectiveness November 15, 2017 Original Closing Date June 30, 2021 Actual Closing Date December 31, 2023 First Restructuring August 26, 2019 Second Restructuring with Additional Financing March 30, 2020 Third Restructuring September 22, 2022 Fourth restructuring August 10,2023 Implementation Milestones First Disbursement February 12, 2018 Beginning of PBF January 1, 2019 First Extension June 30, 2021– April 30, 2023 Second Extension April 30, 2023 – December 31, 2023 Project Completion December 31, 2023 Project Development Objectives (PDOs) 13. The Project Development Objective (PDO) was to improve the utilization and quality of Reproductive, Maternal, Newborn, and Child Health (RMNCH) services in selected regions and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. Key Expected Outcomes and Outcome Indicators 14. The key expected Project outcomes and their associated outcome indicators were as follows: Increased Health Services Utilization: • PDOI 1: Pregnant women completing four antenatal care visits to a health facility during pregnancy (number) • PDOI 2: Births attended by skilled health staff (number) • PDOI 3: Children 12–23 months fully immunized (number). Improved Quality of Health Services: • PDOI 4: Average score of the quality-of-care checklist (percentage) These indicators were supported by 18 intermediary indicators. Components The Project consisted of four mutually reinforcing components: 5 The World Bank Health System Support (P156165) ICR DOCUMENT 15. Component 1: Support to Improving Utilization of Quality RMNCH Services through PBF (Appraisal Estimate US$9.85 million, Actual US$29.63 million). This component was to support the PBF subsidies payment for Health services in public facilities (health posts, health centers, and hospitals). The selected services supported by the Project include nutrition services, prevention services, and maternal, neonatal, adolescent, infant, and child health services, along with treatment for malaria, HIV/AIDS, and tuberculosis, and family planning. The PBF payments were linked to predefined qualitative and quantitative indicators. The quality assessment would be undertaken: (i) at the community level to evaluate the quality perceived by the population; and (ii) at the facilities level verification of results. PBF payments were used to: (i) motivate health workers in the form of performance-based bonuses; and (ii) improve the utilization and quality of care through conducting outreach activities, purchasing light equipment, commodities, medication, etc. Small investment grants were provided to public health facilities that met certain criteria before starting the PBF process. A quarterly performance review would be conducted directly at facility level and Community Health Workers (CHWs) would be paid through PBF payment at the health facility to which they were linked. To minimize the risk of fraud and errors in reporting, the counter-verification process was to be carried out by an independent international agency. 16. Component 2: Support to Increasing Demand for Health Services (Appraisal Estimate US$2.50 million, Actual US$0.91 million). This component would support demand-side activities to promote and facilitate access to health services, especially for the poorest communities. Demand-side PBF interventions were to be built on the existing national social registry system, through a cash transfer program implemented by Taazour with support from the World Bank-financed program (Social Safety Net Project – P150430, the Tekavoul Program). Through this program, the Project would provide additional cash transfer to the poorest families with conditions linked to the use of healthcare, with a focus on families with children under the age of four who are fully vaccinated. 17. Component 3: Capacity Building and Project Management (Appraisal Estimate US$4.65million, Actual US$9.20 million). The objective of this component was to finance project management and comprehensive capacity- building activities, such as monitoring and evaluation, public financial management and procurement, a health management information system (HMIS), PBF methods, database management, as well as substantial technical assistance. The Project would also finance operating costs, some equipment for the PBF Technical Unit, and the salaries of international and national consultants hired by the unit. Finally, the component was to finance implementation of the environmental safeguard activities. 18. Component 4: Contingency Emergency Response (CERC) (Appraisal Estimate US$0.0 million, Actual US$0.0 million). A CERC was included under the Project in accordance with Operational Policy (OP) 10.00 paragraphs 12 and 13, for projects in Situations of Urgent Need of Assistance or Capacity Constraints, to allow for rapid reallocation of Project funds in case of disaster or crisis that caused a major adverse economic and/or social impact. B. SIGNIFICANT CHANGES DURING IMPLEMENTATION 19. The Project underwent four restructurings (three Level 2 restructurings 4 and one Level 1 restructuring). The first restructuring (Level 2) focused on reallocation of expenditure categories. The second restructuring (Level 1) reallocated the expenditure categories, revised the Results Framework, an Additional Financing (AF) of US$23 million was provided, and the closing date of the Project was extended by 22 months from June 30, 2021, to April 30, 2023. The PDO was also slightly modified during the second restructuring to remove the CERC. A third restructuring (Level 2) focused on revising the expenditure categories, revising the 4 A Level 2 restructuring does not require Board approval. 6 The World Bank Health System Support (P156165) ICR DOCUMENT Results Framework, and extending the closing date from April 30, 2023, to December 31, 2023. The fourth restructuring (Level 2) focused on to transfer the safeguard oversight and clearance function of the Project from the Regional Safeguards Adviser (RSA) to the Practice Manager, as recommended by the RSA. The following sections provide details of the changes made at the Project restructuring. Revised PDOs and Outcome Targets 20. The PDO was revised at the second restructuring to remove the CERC aspect because it was considered as an instrument but not a result. The revised PDO was: “to improve utilization and quality of Reproductive, Maternal, Newborn, and Child Health (RMNCH) services in selected regions”. Revised PDO Indicators 21. At the AF in April 2020 the Project coverage was increased to include the Malian refugees in the eastern part of the country. New PDO indicators were introduced to monitor the utilization of health services by refugee groups. Table 2 below shows the revised PDO indicators. Table 2: revised PDO indicators at the second restructuring N0 Indicator Remarks 1. PDOI 1: Births attended by skilled health staff (number) No change 2. PDOI 1a: Births attended by skilled health staff among the refugee population (number) New 3. PDOI 2: Pregnant women completing four antenatal care visits to a health facility No change (number) 4. PDOI 2a: Pregnant women completing four antenatal care visits to a health facility among New the refugee population (number 5. PDOI 3: Children 12–23 months fully immunized (number) No Change 6. PDOI 3a: Children 12–23 months fully immunized among the refugee population New (number)= 7. PDOI 4: Average score of the quality-of-care checklist (percentage) No Change 8. PDOI 5: Refugee populations benefiting from preventive and curative interventions New provided by the health centers (FOSA) (number). Revised Components 22. The components were not revised. Although the CERC was dropped from the PDO, its CERC component was kept. The scope of the Project remained the same. Other Changes 23. During the Project’s life, four restructurings were carried out (i) first Level 2 restructuring in 2019; (ii) then a Level 1 restructuring with AF in 2020 and (iii) second Level 2 restructuring to enable the Project to respond to the emerging needs of the populations with flexibility and (iv) the third Level 2 restructuring in August 2023 focused on the safeguard clearance aspects. These restructurings did not affect the Project implementation. 7 The World Bank Health System Support (P156165) ICR DOCUMENT 24. First restructuring: On September 6, 2019, a Level 2 restructuring was carried out. The rationale was to create a new category to simplify disbursement arrangements and reallocation of funds from categories where savings were identified to categories where more funding was needed. A new disbursement category, Category 8, was created to support the PBF payments to health facilities and community actors (Annex 2, table1-B2). The PDO and institutional arrangements remained the same. 25. Second restructuring: a Level 1 restructuring with US$23 million AF was approved in April 2020. It aimed to scale up the PBF in the Hodh Chargui region (close to the Mali boarder) to support the Government’s strategy of improving health service delivery for the refugees from Mali and the host communities. The targeted population increased by 105 percent (from 620,000 to 1,275,139 people) with 198,348 new poor people and refugees. Services at public health facilities increased by an additional 202 health posts, 12 health centers, and 2 hospitals through the inclusion of Hod El Chargui region. This brought the total number of health facilities covered to 354 (323 health posts, 27 health centers, and 4 hospitals). In addition, two focal points were recruited to represent the Project Implementation Unit (PIU) in the UNHCR-established refugee camp to ensure that PBF guidelines were adhered to. This action was taken because this region is far away from Nouakchott (1,600 km). The results framework was adjusted to reflect the new activities proposed under this AF. As stated above, the PDO was revised to remove the CERC aspects as the guidelines did not require a compulsory inclusion of those aspects. This did not have any impact whatsoever on the Project design as the original PDO simply included reference to the crisis response in case it would be necessary which was not required for operations with a CERC component. In addition, several intermediate indicators were revised in the Results Framework to monitor activities for the refugee beneficiaries, as well as to better track the community activities implemented by INAYA Project. (i) One Intermediate Results Indicator (IRI) was deleted, namely IRI3 (Children under five years treated for severe and acute malnutrition). The indicator was highly prone to seasonal changes and did not give a good assessment of the utilization of preventive nutritional services. (ii) Two IRIs were added to replace IRI3. IRI13 (Number of home visits received by children 0–5 years old (number)) was added to monitor the success of the community-based PBF activities to benefit young children and IRI14 (Grievances registered related to delivery of project benefits satisfactorily addressed (percentage)) was added to monitor the effectiveness of the grievance redress mechanism. (iii) Three IRIs were disaggregated to reflect the specific impact on the refugee population: • IRI1: Women refugees accepting modern family planning methods (number); • IRI6: Post-natal consultation visits among the refugee population (number); and • RI7: User satisfaction with healthcare services among the refugee population (percentage). 26. The task team revised the baseline values at AF to account for the delay of 15 months between approval and the start of the Project, and consider the additional beneficiaries covered in the third region. The closing date was extended from June 30, 2021, to April 30, 2023, to enable INAYA to make up for the delayed implementation period in its first year and for the Ministry of Health (MoH) to align the timeline of the PBF activities in Guidimagha and Hodh Gharbi with those in Hodh Chargui (Annex 1, table1-B2). 27. Third restructuring: The third restructuring was a Level 2 restructuring approved on September 2, 2022. This restructuring again extended the closing date from April 30, 2023, to December 31, 2023, to allow three years of PBF implementation in selected regions, particularly in Hodh Chargui, and to ensure knowledge transfer and capacity building of stakeholders who will be involved in the implementation of PBF activities under the second phase of the Project. During this restructuring exercise, the targets of one Parent Project PDO indicator and three PDO indicators related to refugees were revised downwards to align the new targets with the number and the profile of the refugees, 8 The World Bank Health System Support (P156165) ICR DOCUMENT including the results of the 2020 Demographic and Health Surveys (DHS). The PDO and institutional arrangements remained the same as they were at the AF (Annexe1, table1-B3). 28. In addition to the revision to the indicators’ targets, funds were reallocated between disbursement categories to address the financing gaps in some expenditure categories. Funds were reallocated from Category 5 (CCT) to Category 8 (PBF payments and small investment grants under Part A.1.a, and Part A.1.b of the Project). Funds were also reallocated from Category 1 (CCT), Category 2 (Goods, works, non-consulting, and consulting services), and Category 3 (PBF payments and small investment grants under Part A.1 of the Project) to Category 4 (Performance bonus to PBF- implementing bodies) under the AF (see Annexe2, tableB3). 29. Fourth restructuring: the only purpose of the fourth restructuring was to transfer the safeguard oversight and clearance function of the Project from the Regional Safeguards Adviser (RSA) to the Practice Manager. No other change was done. II. OUTCOME A. RELEVANCE OF PDO Assessment of Relevance of PDOs and Rating Relevance of the PDO is rated High. 30. The PDO was and remains highly relevant to the priorities of the World Bank’s Country Partnership Framework (CPF)5. The Project was aligned with Focus Area 2 (Build Human Capital) and contributed to the achievement of its Objective 2.4 (Improve access to maternal and child healthcare), which focuses on promoting greater access to basic social services. Indeed, the barriers to access, both in terms of supply and demand, remain relevant. Many health facilities lacked basic services, and there was a low coverage of essential services. These factors, along with significant geographic, financial, and cultural barriers, led to a very low utilization of healthcare services with severe consequences on health indicators (e.g. the MMR was 424 per 100,000 live births in 2020 and is among the worst in West Africa), and 25 percent of children under five experience stunted growth. 31. The Project was also aligned with the World Bank Group’s twin goals of eliminate poverty and promoting shared prosperity, and with the WBG 2024 plan to expand the delivery of quality health services to 1.5 billion people by 2030. The Project is fully aligned with the World Bank’s Africa Regional Strategy, which emphasizes strengthening governance and public sector capacity, and the HNP strategy on UHC. It is also consistent with the Sustainable Development Goals, particularly focusing on Goal 3 (Ensure healthy lives and promote well-being for all at all ages) with the following targets: reduction of maternal mortality (target 3.1; (ii) reduction of under-five and neonatal mortality (target 3.2); (iii) achieving universal access to sexual reproductive healthcare services (target 3.7); (iv) achieving UHC (target 3.8) and (v) increasing health financing, and development, training and retention of health workforce(target 3.c). 5 Country Partnership Framework Y 2018–Y2023 which is still operational. 9 The World Bank Health System Support (P156165) ICR DOCUMENT 32. The Project is also consistent with the Mauritania Government’s vision, highlighted in Mauritanian Growth and Shared Prosperity Strategy (SCAPP 2016–2030)6, which was developed through consultations and dialogue between the administration, elected officials, academia, civil society (including, for the first time, members of the diaspora), the private sector, and Development Partners (DPs). SCAPP 2016–2030 was adopted by the Council of Ministers on October 19, 2017, and formed the basis of economic and social policies. This vision is built around: (i) promoting strong, inclusive, and sustainable growth; (ii) developing human capital and access to basic social services; and (iii) strengthening governance in all its dimensions. In addition, the Government’s commitment to strengthen the health system and reduce the rate of maternal and child mortality is highlighted in the National Health Development Plan (NHDP 2012–2030) 7 , which stems from SCAPP 2016–2030, particularly in Priority Program 1 (Accelerating the reduction in maternal, newborn, and infant/juvenile mortality) and Priority Program 4 (Strengthening the health system to achieve Universal Health Coverage). 33. In the three regions covered, the Project contributed to reducing the financial barrier for poor purchasing equipment for health facilities, and therefore the equipment and use of healthcare services. The Project contributed to achieve the WB’ CPF objective and the NHDP in term of maternal and child health as well as the nutrition. 6 Stratégie de Croissance Accélérée et de Prospérité Partagée 2016–2030 7 National Health Development Plan (NHDP) 2012–2030 10 The World Bank Health System Support (P156165) ICR DOCUMENT B. ACHIEVEMENT OF PDOs (EFFICACY) Efficacy is rated Substantial. Assessment of Achievement of Each Objective/Outcome 34. The INAYA has substantially achieved its PDO “to improve utilization and quality of Reproductive, Maternal, Newborn, and Child Health (RMNCH) services in selected regions”. The Project provided quality essential health services to 1,208,369 people, including 627,317 women. It increased demand for healthcare through conditional cash transfers to the poorest population, particularly among the refugees, which enabled this group to access quality healthcare. The capacity-building and coaching interventions implemented by the Project strengthened health facilities and frontline health workers’ capacity to implement the PBF initiatives. Besides, community involvement was an important element of health facility level management. The achievement of the PDO is assessed against the following two objectives: (i) to increase the utilization of health services with a focus on maternal and communicable diseases; and (ii) to improve the quality of health services. It is important to note that a split rating was not done because most of the targets were increased, and the scope also increased. Objective 1: Increase utilization of health services with a focus on Reproductive, Maternal, Newborn, and Child Health (RMNCH): Rating – Substantial 35. This objective was achieved. PDO indicator 1 (Number of births attended by skilled health staff) exceeded its target by 20 percent (160,021 births against the end target of 135,360). Similarly, the target of the same indicator measured among refugees, notably PDO indicator 1.a (Number of births attended by skilled health staff among refugees) was achieved and surpassed by 23 percent (4,291 achieved against the target of 3,480). The PDO indicator 2 (Number of pregnant women completing four antenatal care visits to a health facility during pregnancy) also exceeded its target by 56 percent (81,307 achieved against the target of 53,557) and the PDOI 2.a (Number pregnant women completing four antenatal care visits to a health facility among the refugee population) achieved 81 percent of its target. The achievement of the PDOIs was supported by IRI3 (Number of districts that implement community health). At completion, 17 out of 17 districts (100 percent) implemented community health interventions. IRI9 target (Pregnant women referred for ANC1 by community health workers) was surpassed by more than double the planned target (16,580 achieved against the target of 7,720). 36. The PDOI 3 (Number of children 12–23 months fully immunized) was achieved and significantly exceeded its target by 179 percent (203,860 children aged 12–23 months were fully immunized, against the target of 117,470). PDO indicator 3.a (Number of children 12–23 months fully immunized among the refugee population) was also exceeded by 176 percent (5,110 children immunized against the target of 2,910). The achievement of these indicators was supported by four IRIs, all of which surpassed their targets. For example, IRI4 (Number of visits by under–5 children to health facilities), was exceed by 36 percent (1,117,527 achieved against the target of 822,020); IRI6 (Percentage of eligible households receiving full conditional cash transfers) was exceeded by 59 percent (85,190 actual against a target of 53,550); IRI14 (Number of home visits received by children 0–5 years old) was surpassed by 11 percent, (81 percent achieved against the target of 70 percent); and IRI15 (Number of post-natal consultation visits) was surpassed by76.4 percent (84,117 against the target of 9,257). PDO Indicator 5 (Refugee populations benefiting from preventive and curative interventions provided by the health centers (FOSA)) was achieved and exceeded its target by 1,186 percent (562,874 achieved against the target of 151,250). The IRI supporting this PDO indicator, IRI11 (Number of poor people and/or eligible refugees who have benefited from free curative consultations), was also achieved and its target 11 The World Bank Health System Support (P156165) ICR DOCUMENT surpassed by 382 percent (879,373 against the target of 25,595). Table 3 provides the level of achievement of the PDO indicators. Table 3: Achievement of project objective 1 indicators N0 Indicators Baseline End Actual % target achieved 1. ODP-1: Births attended by skilled health staff (number) 12,278 135,360 160,021 120 2. ODP-1. a. r: Births attended by skilled health staff among the 0 3,480 4,291 123 refugee population (number) 3. ODP-2: Pregnant women completing four antenatal care 4,444 53,557 81,307 156 visits to a health facility during pregnancy(number) ODP-2. a. r: Pregnant women completing four antenatal care 0 2,954 2,391 81 4. visits to a health facility among the refugee population (number) 5. ODP-3: Children 12-23 months fully immunized (number) 9,046 117,470 203,860 179 6. ODP-3. a. r: Children 12-23 months fully immunized among 0 2,910 5,110 176 the refugee population (number) 7. ODP-5: Refugee populations benefiting from preventive and 113,357 151,250 56,2874 1,186 curative interventions provided by the FOSA (PMA + PCA) (number) 37. Major activities that led to the achievement of Objective 1 included: (i) the direct payment of subsidies to health facilities to provide them with the needed resources to improve the quality and the availability of healthcare through the purchase of basic equipment and the hiring of additional health workers to provide facility-based level services; (ii) demand-side interventions, such as free healthcare to poor families, reduced the financial barrier and increased access to healthcare in the three regions. The conditional cash transfers intervention helped increase the poor families’ access to nutrition and immunization services for children under five; and (iii) the use of community health workers to increase the communities’ access to a range of services such as immunization, nutrition, ANC, and family planning. 38. The implementation of PBF clearly led to better results than the national average of services such as ANC, immunization, and births assisted by skill health personnel. The three regions supported by the Project (Hodh Chargui, Hodh El Gharbi, and Guidimagha) showed significant improvements in the key maternal and child health indicators compared with national averages. As shown in Figure 2 below, ANC4 services were 53 percent in Guidimagha, 47 percent in Hodh Chargui and 48 percent Hodh El Gharbi, compared with the national average of 29 percent. The number of births assisted by skilled health workers was 84 percent in Hodh El Gharbi, 75 percent in Guidimagha and Hodh Chargui, well above the national average of 70 percent. The children fully vaccinated reached 115 percent in Hodh Chargui, 106 percent in Hodh El Gharbi, and 99 percent in Guidimagha, compared with the national average of 90 percent. 12 The World Bank Health System Support (P156165) ICR DOCUMENT Figure 2: Comparison of service delivery indicators by region and national average (2019–2023) Source: DHIS2, MoH Objective 2: Improve quality of health services: Rating – Substantial The objective of improving the quality of health services was achieved. The target (60 percent) of its main PDOI4 (Average score of the quality-of-care checklist (percentage)8) was achieved (see Table 4 below). Table 4: Achievement of project objective 2 indicator N0 Indicators Baseline End target Actual % achieved 8. ODP-4: Average score of the quality of care checklist 0% 60% 60% 100 % (percentage) 39. A health facilities satisfaction survey conducted at the end of the Project showed significant improvement in structural changes, as well as users’ satisfaction with the quality of care provided by the health facilities across the three regions supported by the Project. The survey showed that 60 percent of the health facilities have the required equipment, medication, qualified health workers, etc., and 98 percent of users of the health facilities were satisfied with the quality of care they received. The targets of four out of six IRIs that contributed to the achievement of PDO 4 have all been achieved or surpassed. Fifty-eight percent and 72 percent of the remaining two IRIs have been achieved. 40. Available project-level data showed a good trend in the quality indicator from the beginning to the end of the Project. As shown in Figure 3 below, the minimum quality scores for health services in Hodh Charghi, Hodh El Gharbi, and Guidimagha improved significantly from 2019 to 2023. Hodh Charghi scores rose from 15 percent in 2019 8This is a composite indicator which is measured by check list of indicators which include: (i) the availability of basic equipment, (ii) the availability of quality personnel (iii), the Monitoring & Evaluation management, (iv) the management of medicines, (v) the waste management, and (vi) the promptness and completeness of data transmitted to the national health information system. 13 The World Bank Health System Support (P156165) ICR DOCUMENT to 52 percent in 2023. Hodh El Gharbi saw a steady increase from 45 percent in 2019 to 57 percent in 2023, showing a gradual improvement of the quality of health services provided. Guidimagha achieved the highest increase in scores from 56 percent in 2019 to 76 percent in 2023, highlighting a highly successful PBF implementation. Despite the overall positive impact, more efforts will be needed to sustain the improvements in health service delivery. The dearth of data on the quality of care in regions not covered by the Project did not allow a comparison of INAYA quality indicators with those in other regions. Figure 3: Evolution of the PDO objective 2 indicators by region 41. The results were underscored by changes in the way business was conducted at all levels of the health system. The PBF approach brought improved work ethics at all levels of the health system. Civil servants at national, regional, district, and health facility levels were motivated with PBF bonuses on top of their regular salaries. This led to reduced absenteeism and lateness, and an increased commitment to achieve results. At the health facility level, health workers worked around the clock to provide uninterrupted services. Moreover, the PBF brought a sense of ownership and empowerment to health workers, making them more committed to their work. The Project strengthened decentralization through the involvement of decision makers and local leaders in the organization and management of health facilities. Health facility management also improves the work environment, as well as users’ satisfaction. A high standard of hygiene practices was part of the routine service delivery in all health facilities. Good management also led to improved user satisfaction in terms of users being able to make their grievances known. In all health facilities, standardized grievance redress mechanisms (GRMs) boxes were installed at vantage points to allow users to easily submit their complaints to the health facility’s committee. Justification of Overall Efficacy Rating 42. The overall efficacy of the PDO is rated Substantial, considering that six out of the seven PDO indicators and 15 out of 18 IRIs were achieved. Except for one target, all the targets of Objective 1 indicators were achieved and surpassed. The Objective 2 PDO indicator was also fully achieved, while four of the six IRIs surpassed their targets. Overall, the Project overwhelmingly contributed to improving the quality of health service delivery and hence utilization of health services in the coverage area as evidenced by high user satisfaction. 14 The World Bank Health System Support (P156165) ICR DOCUMENT C. EFFICIENCY Assessment of Efficiency and Rating Efficiency is rated Substantial. 43. Cost effectiveness: A cost effectiveness analysis conducted from the available service delivery costs and output data at the end of the Project resulted in an incremental cost effectiveness ratio (ICER)of US$726.53, which was found to be well below the country’s GDP per capita (US$1,616.8). The results were compared with the ICER estimated at appraisal (0.01). 44. Implementation of strategic interventions. INYANA’s strategic focus on activities that benefit the vulnerable population to achieve its objective of improving utilization and quality of RMNCH services, was an efficient strategy aimed at increasing maternal and child health services in the Project’s target areas. The Project’s investments in demand-side and supply-side activities enhanced efficiency in that they: (i) provided performance-based subsidies for health facilities to enable them to use the subsidies to strengthen primary healthcare systems that served as the catalyst to delivery of quality essential health services; (ii) provided CCTs to the vulnerable population to allow them to access healthcare right in their communities; and (iii) strengthened the capacity of health institutions (MoH, RHD and other relevant health institutions) for effective oversight of service delivery at all levels of the healthcare delivery systems. 45. Operational efficiency was assessed by comparing actual Project costs with appraisal estimates. Project cost at appraisal was estimated at US$17.00 million, which comprised Component 1 (US$9.85 million), Component 2 (US$2.50 million), and Component 3 (US$4.65 million). The total Project cost at ICR was US$39.74 million (233.80 percent cost variance), consisting of Component 1 (US$29.63 million), Component 2 (US$0.91 million), and Component 3 (US$9.20 million) was increased through restructurings and AFs. The high variance of US$22.74 million was mainly due to the AFs provided by the World Bank during Project implementation. As noted earlier, the AF extended the Project to cover refugee communities in Hod El Chargui region. This increased access to essential health services (inpatient and outpatient consultations, minor surgery, normal and complicated delivery, Cesarean sections, laboratory examinations, etc.) to over 1.1 million refugees and the host population. Efficiency was also enhanced because of better management of health centers’ and health posts’ revenues and medicines, coupled with systems strengthening. The Project financed medical equipment, strengthened the cold chain system for routine vaccination, and significantly improved medical waste management with the installation of incinerators in all the beneficiary facilities. Drugs and medicines were readily available because of a significant reduction in the stock-out rate. Project administrative cost was 20.3 percent higher than the acceptable Bank-wide practice, which is between 5 percent and 10 percent of total Project cost. This was deemed reasonable because of the apparently high operational cost of PBF projects. 46. Implementation efficiency was assessed by comparing specific time periods at each stage of the project cycle from concept to effectiveness with accepted country and regional averages. Overall, INAYA performed remarkably well from concept to the first disbursement (15.5 months), compared with Mauritania’s average (19 months), Africa’s average (22 months), and the Bank’s average (24 months). When disaggregated to different time periods, the Project again performed well from concept to approval and effectiveness to first disbursement. Although slightly lower than the averages for Africa (6.3 months) and Bank (6.2 months), approval to effectiveness activities took six months to complete, compared with Mauritania (3.7 months). As noted earlier, the main causes of the delays were recruitment of staff of the Project Implementation Unit (PIU), development and validation of the PBF implementation manual, and 15 The World Bank Health System Support (P156165) ICR DOCUMENT establishment of PBF schemes. These difficulties were addressed together with the government (See Annex 4 for the detailed efficiency analysis). D. JUSTIFICATION OF OVERALL OUTCOME RATING 47. The relevance of the PDO is rated High, the efficacy of the Project is rated Substantial, and the efficiency is assessed as Substantial. Thus, the overall outcome rating is Satisfactory. Table 5: Summary of Outcome Rating Dimension Rating Relevance High Efficacy Substantial Efficiency Substantial Outcome rating Satisfactory E. OTHER OUTCOMES AND IMPACTS Gender 48. The Project was designed to explicitly focus on women of reproductive age, especially pregnant women, and children under the age of two years as the primary beneficiaries. From 2017 to 2023, most of the Project beneficiaries in the target regions were women (52 percent or 627,317). Over 164,312 births assisted by qualified personnel were recorded and 248,491 women benefited from family planning services. In addition, women were represented on each health committee; overall, about 30 percent (189 out of 633) of the health committees’ members were women. The training financed by the Project at all levels of the healthcare delivery system significantly benefited women. The quarterly survey set up by INAYA Project assessed the healthcare users’ satisfaction. This survey was the opportunity for women’s voices to be heard on health facility management and healthcare quality. Furthermore, the grievance redress mechanism set up in each health facility covered by the Project gave another opportunity to women to complain about or make suggestions to improve the quality of healthcare. Institutional Strengthening 49. Central level. The Project strengthened the capacity of some key MoH directorates. These include: (i) the Directorate of Hospitals (DoH), which benefitted from PBF training in the development of evaluation tools, standards, and procedures; and (ii) the Directorate of Administration and Financial Management (DAFM) with storage facilities, IT equipment, and additional staff to improve its staffing capacity. The Project also supported DAFM with an accounting software to improve processing of financial transactions. It provided PBF training for staff of the Directorate of Hospitals (DoH) and supported revision of hospitals’ norms guidelines for hospital care. The Central Medical Stores (CMS) was also provided with means of transport (fives trucks) to facilitate distribution of drugs and supplies to the regions. 16 The World Bank Health System Support (P156165) ICR DOCUMENT 50. The capacity of the National Health Information System (HMIS), under the Directorate of Public Health (DPH), was strengthened in terms of promptness, completeness, and data quality thanks to the introduction of a decentralized health data management mechanism, enabling health facilities to have permanent data collection tools and the capacity to collect quality data in real time. 51. Regional level. The Project upgraded the regional medical store in Hodh Chargui and the departmental branch in Tintane, procured five refrigerated lorries and three buses for medicine distribution, set up the regional health management team, and created the regional verification team. Indeed, at the beginning of the Project implementation, the counter-verification was done by an international independent agency. To minimize implementation costs and ensure sustainability, a local verification team composed of health workers was established. The team was trained and understudied the international agency from 2019 to 2022. Thereafter, the team took over and carried out this task until Project closing. The Ministry of Health effectively took over the three functions of PBF: provider, purchaser, and regulator/verifier. To mitigate the risk of conflict-of-interest, the health workers assigned to counter-verification were separated from their regular functions and exclusively dedicated to the verification process. 52. The INAYA supported the decentralization process by involving locally elected representatives, especially the Regional Councils (RCs), in PBF implementation. The responsibility of signing contracts, which is traditionally an MoH function, was transferred to the RCs. The President of the RC signed the performance contracts with the peripheral facilities, as health indicators purchaser and monitored and validated the performance of the health facilities. While this approach was good and to some extent worked well, it defeated the principle of cascading accountability from the central MoH, to the regional health administrations, down to the peripheral health facilities. It is also not sustainable, as the RCs are elected officials whose end-of-office term affects the smooth execution of contracts. 53. District level. The INAYA Project set up district management teams (DMT) in the three Project regions to improve the governance of health centers and hospitals. All the members of these teams benefited from training on health center management. The introduction of DMTs has improved the governance of the centers by involving key people from the district in decision making. In fact, decisions are no longer taken solely by the chief medical officer but by the whole DMT team, resulting in greater transparency in the management of the districts, especially in terms of financial management, and the management of property and human resources. This good practice is currently being rolled out by the MoH to all regions of the country. The Project financed the training of ten health workers from the three regions in the management of medicine stock. Moreover, 426 accounting officers were trained in financial management to improve the governance of health centers. All the health workers were trained in PBF strategy. Thanks to the INAYA Project, the health districts and training centers in the three regions have benefited from an exemption from the Ministry of Health, allowing them to open bank accounts. 54. Health facility level. In Bassikounou district (the Hod El Chargui region), the INAYA Project renovated and equipped the M’bera refugee camp’s health facilities, established by United Nations High Commissioner for Refugees (UNHCR) in 2018. Thanks to the impact of PBF, these health facilities are now integrated into the public health system. This has enabled locally elected representatives to be involved in certain aspects of the facility’s decision making and management. It has also allowed the health center to benefit from government funding for its development and management. Expansion and improvement of health facilities were the hallmarks of the INAYA Project. PBF payments were primarily allocated to building additional rooms and incinerators. The PBF payments significantly address human resources shortages, providing incentives to frontline health workers, procure medicines, purchase small equipment and maintain cleanliness within the health facilities. Major infrastructure improvements include: (i) the 17 The World Bank Health System Support (P156165) ICR DOCUMENT rehabilitation of 200 basic healthcare facilities; (ii) the supply of water for 100 health centers in rural areas by connecting them to village water networks; (iii) setting up solar lighting and sterilization equipment for 150 rural health centers; (iv) the procurement of complete or partial basic equipment for 300 health centers (maternity units, vaccinations, etc.); and (v) the construction of 95 Monfort-type incinerators to support biomedical waste management. These investments resulted in an improvement in the quality of healthcare provided to the population, which consequently led to an increased utilization of health services. To improve waste management, the Project procured six generators to ensure the continuity of electricity supply in beneficiary health centers, supplied equipment to ten health centers’ laboratories, and funded the renovation and extension of 14 health facilities in the three regions (Bassiknou, Vassala, Tembedra Wompo, Tintane and Douerara, etc.). 55. Community level. The Project strengthened the community engagement through revitalizing the health committees and training all local community representatives on PBF and grievance management. These committees oversaw a grievance redress mechanism and the quarterly satisfaction survey for health users. The RC, in collaboration with the Regional Director of Health (RDH) and community representatives, established monthly follow-up meetings to monitor activities and make important decisions as and when needed. Mobilizing Private Sector Financing Not applicable Poverty Reduction and Shared Prosperity 56. The poverty impact of the Project was substantial. Indeed, the INAYA Project targeted the three most disadvantaged regions in Mauritania (Guidimaka, El Chargui, and Hod El Garbi). These regions are among the regions with poor health indicators, particularly maternal and child health indicators, and low rates of health services utilization. In the Hod El Chargui region, in addition to poverty, the region has been experiencing an influx of refugees from Mali for more than 10 years. The INAYA Project provided 1,027,893 free healthcare services to the poor host population and refugees in these regions. This included assisted deliveries by qualified personnel, Cesarean sections, minor surgeries, consultations, etc. Table 6 summarizes the health services provided to the poor and refugees. Table 6: Service Utilization by the Indigent and Vulnerable Population in the Three Selected Regions HEC Gui HEG Total Indicator 31 Dec 2024 31 Dec 2024 31 Dec 2024 31 Dec 2024 Hospitalization (one day) 61,024 16545 15877 93446 Minor surgery 19,550 9143 9202 37895 Normal delivery 9,706 6998 3754 20458 Outpatient consultation 578,853 157158 130749 866760 Major surgery 1,207 223 130 1560 Cesarean section 451 512 30 993 Reference 3,858 223 2700 6781 Total 674,649 190,802 162,442 1,027,893 Source: PIU Database 57. The Project also demonstrated strong collaboration among World Bank Global Practice teams to reach the poor. In fact, thanks to the collaboration between HNP and Social Protection and Jobs (SPJ) teams through INAYA 18 The World Bank Health System Support (P156165) ICR DOCUMENT Project and the Taazour program,9 29,421 extremely poor women (including refugees) benefited from conditional cash transfers for a total amount of US$706,371, which improved the use of healthcare services by the poor people. Other Unintended Outcomes and Impacts 58. Although unplanned, the INAYA Project contributed to the measles outbreak response in 2020 by purchasing 1 million doses of measles and rubella vaccine and funding the vaccination campaign. This support enabled 557,135 children to be immunized at a success rate of 108 percent, thereby helping to control the epidemic. Similarly, the INAYA Project contributed to the response to the COVID-19 pandemic through the development and production of vaccination tools, the acquisition of 300 tablets to manage COVID-19 vaccination data, and the training of all COVID- 19 vaccination campaign supervisors. Thanks to the combined efforts of INAYA and other projects and partners, Mauritania is one of the West African countries with the highest vaccination coverage rate, with 1,541,225 people vaccinated, or 52 percent of the targeted population. The INAYA Project also financed the Standardized Monitoring and Assessment of Relief and Transitions (SMART) 2022 nutrition survey, which will provide countries and partners with up-to-date nutrition indicators for evidence-based decision making. 9 Taazour is the General Delegation for National Solidarity and the Fight against Exclusion created in November 2019, is an agency with ministerial status. Its main mission is to promote integrated development in the sphere of poor and vulnerable populations, enabling their socio-economic inclusion and improving their living conditions. 19 The World Bank Health System Support (P156165) ICR DOCUMENT III. KEY FACTORS AFFECTED IMPLEMENTATION AND OUTCOME A. KEY FACTORS DURING PREPARATION 59. The INAYA Project, the first of its kind in Mauritania, was conceived at a time when there was no World Bank- financed Project in the health sector. Project preparation was very participatory, encompassing key stakeholders including development partners, such as WHO, United Nations Population Fund (UNFPA), UNICEF, and the French Development Agency (AFD). Key factors that enhanced Project design are: 60. Soundness of the background analysis. In consultation with the Government and to contribute to the implementation of the NHDP 2012–2020, a feasibility study for appropriateness of implementing the PBF project was carried out. The study, which was co-financed by UNICEF, was carried out by the World Bank (WB). The WB financed the supply aspects of the feasibility study, while UNICEF financed the demand ones. The study was led by the WB in close collaboration with the Ministry of Health, the Ministry of Finance, and other key partners, such as WHO, UNFPA, ADF, and UNICEF. In addition, the WB developed the PBF strategy, which was presented and adopted by the Council of Ministers. Thereafter, a decision was taken to initiate the INAYA Project with US$15 million from IDA and US$2 million from the national budget. The WB also carried out the Public Expenditure Review (PER) that served as basis for the PBF costing, and organized PBF training in Nouakchott for all the key stakeholders, including MoH Directorates, WHO, UNICEF, etc. These studies provided significant input into the Project design and were used as the basis for the preparation of the Project. Full participation of all the relevant ministries and development partners enabled the rapid development of the Project. 61. Novelty of the design. One of the key features of the Project was the novelty of the design. Unlike many other situations, where a PBF project starts with consultants, the Project document emphasized and clearly laid out the use of civil servants, who were given the mantle of Project implementation. By design, the MoH was the implementation agency, particularly in financial management, while the Directorate of Finance (DoF) was given the mandate of managing Project funds. The central level of the MoH was mandated to provide oversight and stewardship to the Project, reflecting their roles for the entire health sector. This level was meant to focus on policy development, financial reporting, auditing, and monitoring and evaluation. The peripheral health facilities were responsible for the implementation of the Project and reporting the data to the MoH. The community health workers were directly linked to the peripheral health facilities and the communities. 62. Project design and PDO. During preparation, the project preparation team kept the project design simple, with only three components. The Project beneficiaries were well defined and targeted. The PDO was well formulated, realistic, and easy to measure using routine data from the Health Management Information System (HMIS) and data from the Project’s own data management system. This clear and simplified design made it easier for the various stakeholders to understand and contribute to the development of the Project, reducing the Project preparation time to 8.3 months from the concept note to the Project approval. 63. Results framework. The results framework was logically formulated, with both intermediate and outcome indicators linked to the PDO. The PDO was realistic, with two clearly defined outcome objectives (increased utilization of health services and improved quality of health services). The PDO level indicators included both quantity and quality indicators. To make it easier to report on the indicators, the routine indicators collected by the HIMS were preferred. 20 The World Bank Health System Support (P156165) ICR DOCUMENT Also, for indicators whose denominators are difficult to control, the absolute values were considered. The monitoring and evaluation plan was clearly defined. 64. Project risks. Project risks at appraisal were rated Moderate overall. The Project team appropriately identified key risks that could potentially affect implementation and outcome and outlined mitigation measures to address them. The two main risks highlighted were: 65. Institutional capacity, including environmental safeguards: The Project was embedded within the MoH, which does not have experience with PBF and Conditional Cash Transfer approaches. The risk was mitigated through the support provided to the ministry by a PBF advisory firm for a limited period, and by internationally recruited consultants for a longer duration, both to mitigate the risks and to build capacity through knowledge transfer. In addition, the Ministry’s staff participated in workshops and study tours related to PBF. Moreover, the MoH collaborated with the Tekavoul Program for the implementation of cash transfers. (i) Fiduciary risk. The MoH had little experience with World Bank-financed operations, so the Project recruited consultants to carry out procurement and financial management and developed the Administrative and Financial Manual of Procedures to integrate IDA’s guidelines and the purchase of the accounting software. (ii) Lessons learned from other operations. The INAYA Project preparation gathered technical, institutional, and operational lessons from other PBF projects in low- and middle-income countries in Africa. These included: allocating resources proportionately to priority indicators; improving the quality of care through PBF; community involvement; the importance of giving incentives to health workers; and verifying the results of health service delivery, as well as publishing the results on a public website. These lessons were incorporated into the Project design with a clear and strong focus on community- based interventions and the autonomy of health facilities. 66. Government commitment. During the preparation of the Project, there was strong Government commitment. Indeed, the PBF was part of the electoral program of the President of the Republic at that time. In view of the impact of the PBF strategy in other African countries, such as Cameroon, Burundi, Rwanda, etc., this strategy was seen by the Government as an asset for reducing maternal and infant mortality in Mauritania, which remained among the highest in the West African region. Throughout the preparation of the Project, the World Bank task teams regularly worked with the MoH team. Key Project preparation staff were provided with training in PBF to increase their contribution to Project formulation. B. KEY FACTORS DURING IMPLEMENTATION 67. The Project was approved on May 19, 2017, and declared effective on November 15, 2017, almost seven months after approval. The delay in effectiveness was due to delays in the preparation of the Project Implementation Manual and opening of the designated account in a commercial bank. However, this was not unusual for a first-time project in the country. Project implementation kicked off smoothly after the early delays and was boosted by the following factors. 21 The World Bank Health System Support (P156165) ICR DOCUMENT a) Factors subject to Government and/or implementing entities’ control 68. Commitment and leadership. The Government committed to implementing the PBF strategy through the INAYA Project. The Government implemented two key measures to ensure implementation was not delayed. These measures were: (i) the provision of exemptions in the finance law to allow heath facilities to open accounts to receive PBF subsidies; and (ii) the provision of upfront counterpart funds to finance the setting up of a financial audit system, including the labor inspectorate and auditors, to help improve transparency during implementation. 69. Integration of the PBF in the Government system. A key feature of the INAYA Project is that it was integrated directly into the public service system. Unlike in other countries where the start-up project staff are usually consultants, the INAYA Project staff, including the verification teams at all levels, were all civil servants. The financial management aspects were also integrated into the Ministry of Health, with the Director of Administration and Financial Affairs (DAFA) carrying out the day-to-day financial management. 70. Project coordination. The Project benefited from effective coordination. The Government quickly set up a steering committee headed by the Minister's Secretary General, and a technical committee headed by the Director General of Regulation, Organization and Quality of Healthcare Services. The former was responsible for strategic guidance and decision making for the Project, while the latter was responsible for organizing and monitoring the day- to-day implementation of the Project. 71. Health facilities’ organizational capacity. As part of the PBF strategy and the institutional capacity building efforts, all the health workers, including the district managers in the selected three regions and the central level staff, received PBF training. In addition, the newly established district management committees received leadership training. PBF has also improved the organization of health centers through a better specification of the tasks and responsibilities of each worker. 72. Human resources. Before INAYA, there was a general shortage of qualified health workers who were expected to be the main frontline workers at the peripheral level. Capacity gaps were experienced at all levels. Only about 10 percent of peripheral health facility compounds met the standard of three staff at the beginning of the Project. To address this issue, the INAYA Project signed a performance contract with the Secretary General of the MoH to appoint and deploy health workers to peripheral health facilities. At the end of the Project, all the health centers complied with these standards. The quarterly client satisfaction surveys showed significant improvement of health workers’ availability and the quality of care at the peripheral health facility level (around 98 percent overall satisfaction). 73. Infrastructure and equipment. At the beginning of INAYA project, health centers were often poorly equipped, and the buildings do not always meet national standards. These health centers do not have the minimum facilities needed to provide good quality healthcare. They are generally limited to one or two small rooms built from local materials or tents. In the Hod El Chargui region, for example, 52 percent of health centers are dilapidated. The disadvantaged health centers received start-up funds to enable them to acquire basic equipment and medicines, among other things. In some health centers, the PBF funds enabled them to undertake construction and extensions to improve the functionality of buildings and facilitated the acquisition of small items of equipment. 74. Despite these enabling factors the project experienced challenges due to the following factors: • Delay in the beginning of implementation. It took 15.5 months after effectiveness before the project activities started due to (i) delay in the recruitment of the staff of the Project Technical Unit 22 The World Bank Health System Support (P156165) ICR DOCUMENT (PTU); (ii) development and validation of the PBF implementation manual; and (iii) establishment of PBF schemes at all levels of the health system. It took the intervention of the World Bank's team, including the Country Manager, and the decision taken by the Ministry of Health to address these challenges. • Turnover of the decision makers at MoH level. Frequent changes of the most senior level MoH staff occurred throughout the Project implementation. During the Project cycle, there were five (5) Ministers, four (4) Secretaries General, and two (2) Directors General of the Regulation, Organization, and Quality of Healthcare Services. This slowed down implementation of the Project from time to time, especially with regard to awarding contracts and the time taken to sign contracts. However, the commitment and the leadership were sustained overall, founded on the consistency in policies and priorities, and the professional relationships with the World Bank. • Drug supplies. More than half of individuals’ healthcare spending is on pharmaceuticals, yet generic drugs are not easily available in Mauritania. CAMEC has a monopoly on ordering and distributing medicines to health facilities throughout the country. However, this purchasing center has structural, organizational, staff availability, and storage capacity constraints that prevent it from fulfilling its role. As a result, there were frequent shortages of medicines, and the rigid regulations prevent health facilities from obtaining supplies from other private wholesalers. This bottleneck had a negative impact on the quality of healthcare services throughout Project implementation, with periods of essential medicine shortages of varying lengths. To address this difficulty, some health centers under the PBF had to violate the measures and obtain their supplies from private wholesalers to ensure the availability of medicines in the health centers, which exposed the centers to the risk of sanctions. In addition, there is no regulation of the medicines sector in terms of quality control, authorizations to market, or pharmacovigilance, exposing consumers to the risk of drug toxicity. • Limited involvement of MoH key directorates. A significant number of the central directorates of the MoH were not at all involved in Project implementation. Almost all decisions, including infrastructural improvements at the health facility level, were essentially taken by the PIU. Apart from the theoretical courses on the PBF that some members of the Ministry attended, they were excluded from monitoring and learning about the implementation of the PBF in the field. In short, there was no real integration of PBF into the health system. The Project therefore remained on the fringes of the Ministry of Health throughout its implementation, with the technical unit operating as an independent entity. As a result, very few people at the central level have a good working knowledge of PBF. This situation has not had a direct impact on the implementation of the Project, but it has tended to create a parallel MoH that deals with the PBF, thereby weakening the MoH ownership of the Project. • Procurement management. At the beginning of Project implementation, there was a limited procurement capacity at the PIU level. Also, the Ministry of Health's technical teams had weak capacity, resulting in slow submission of requests to the PIU and poor quality of technical specifications of equipment. In addition, procurement implementation was affected by the multiple steps for approval processes. After the PIU has completed the approval process, the PIU must submit the documents to the national procurement committee for their review and the selectin of the suppliers, before the contract is signed by the Minister. The process can take a long time to complete, as it is difficult for the committee members to meet regularly. Therefore, it can take several months 23 The World Bank Health System Support (P156165) ICR DOCUMENT for the national procurement committee and the Ministry of Health to complete their work. Moreover, this is compounded by the fact that the PIU does not monitor the files closely enough, and once the contract has been signed, the suppliers do not always meet the delivery deadlines. This caused significant delays in delivering essential logistics in the first half of the Project. Thanks to the practical training programs organized by the Bank’s procurement team, the quality of documentation, delivery, and response to the Bank have been significantly improved. At the end of the Project, procurement management was rated as Satisfactory. b) Factors subject to World Bank control 75. World Bank support and collaboration. In addition to day-to-day support, the World Bank team undertook all the planned six-monthly supervisions before and after the COVID-19 pandemic. To ensure smooth and interrupted supervision missions, the team organized virtual missions at the peak of the COVID-19 pandemic. This approach allowed the team to provide the needed support to the client, addressing key implementation bottlenecks together with the Government team. 76. Adequacy of reporting. All supervision missions were adequately reported, with ten aides-memoire and five ISRs produced and documented. Despite the high turnover of the World Bank Task Team Leaders (TTLs) (six in total), the reports were prepared after each supervision mission. The Mid-term Review (MTR), carried out in March 2022, brought together the PIU and the main development partners to discuss the overall implementation progress and address bottlenecks to implementation. During this mission, a decision was made to restructure the Project to focus on the revision of the results framework and the reallocation of expenditure categories. 77. Additional Financing. Mauritania has been hosting refugees for several years, mainly in the Hodh Chargui region, primarily because of the unstable situation in Mali, located just 50 km from the border. Because of the high influx of refugees, the Bank approved US$23 million additional financing to extend the Project to cover the affected region. The AF allowed the Project to increase the refugees’ and the host communities’ access to quality essential health services. 78. High turnover of the World Bank Task Team Leaders (TTLs). Over the five years of implementation, the Project has been under the oversight of six TTLs. The frequent changes led to delays in giving No Objections, which to some extent affected the Project’s implementation. c) Factors outside the control of Government and/or implementing agency 79. Security issue and influx of refugees. The Hod El Chargui region is subject to potential insecurity because of its proximity to Mali, where there are terrorist attacks. The Government issued a statement drawing the attention of the partners and the population to the precarious security situation in the area and its limited capacity to ensure the safety of the partners when they move into the area. Therefore, the eastern part of Hod El Chargui region, from Nema town to the Mali border, became a red zone for World Bank staff. The implementation of INAYA's activities continued in Bassikounou and in the M'Bera refugee camp, right up until the end of the Project. However, the Bank's team was unable to carry out supervision and field visits. The latest supervisions were therefore based on the information transmitted by the PIU. 80. Reluctance of health workers. The PBF strategy was well received by health workers in the peripheral health centers because of the incentives and autonomy of decision that the PBF gave them. However, the improvement in 24 The World Bank Health System Support (P156165) ICR DOCUMENT the quality of healthcare and the promotion of healthcare demand led to an increase in the frequency of visits to the health centers, which in turn led to a heavy workload that varied from one health center to another, even though the number of health workers remained the same. The subsidies were deemed insufficient for this additional workload, leading some health workers to reject the PBF strategy. The dialogue was maintained with these health workers to motivate them to continue with the Project implementation and the recruitment of additional health workers, paid for from their own funds, was proposed to reduce the workload on the team. IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME A. QUALITY OF MONITORING AND EVALUATION (M&E) M&E Design M&E design is rated Substantial. 81. The M&E design was well organized, as outlined in the M&E section of the Project Implementation Manual (PIM). The PIM provided comprehensive guidance on implementing M&E activities, detailing the frequency of monitoring, methods for data collection, stakeholder roles and responsibilities, and reporting protocols. The design also included multiple types of evaluations, baseline and endline studies, and regular reporting mechanisms. A key factor in the design of the M&E was a robust approach to assessing Project progress and outcomes. This ensured accountability and informed evidence-based decision making. The PDO was clearly stated and focused on two main outcomes: (i) quantity of healthcare use; and (ii) quality of health services. To measure these outcomes, PDO level indicators were supported by the intermediate level result indicators. The M&E plan was effectively executed, and efforts were made to strengthen the monitoring and evaluation capacity of stakeholders. M&E Implementation M&E implementation is rated Substantial. 82. Project level M&E was implemented with the use of the PBF portal to monitor Project outputs and results at all levels of the health system. Results provided by the M&E system were used during the entire implementation period. The Project’s M&E mechanisms relied on several factors, such as: (i) routine data collection from the health information system; (ii) activity reports on PBF and institutional capacity building; and (iii) quarterly client satisfaction surveys. 83. These were validated biannually by the Technical Committee after thorough review. All reports were prepared and submitted on time. Three rounds of evaluations – baseline, midline, and endline – were conducted. The results framework was adjusted twice, in 2020 and 2022 during the second and the third restructuring, to add an indicator related to refugees and to revise the end targets after the 2021 population census. It was regularly completed and sent to the World Bank every six months for the Implementation Status and Results Report (ISR) to be drawn up. M&E Utilization The M&E utilization is rated Substantial. 84. The reporting and dissemination of M&E outcomes were crucial components of the INAYA/PBF Project's M&E 25 The World Bank Health System Support (P156165) ICR DOCUMENT system in the Islamic Republic of Mauritania, as outlined in the September 2018 Guide and Scheme for Monitoring and Evaluation. Beyond the meticulous tracking of Project indicators and assessment of outcomes, effective communication and sharing of findings were essential for informing stakeholders; this fostered transparency and facilitated evidence-based decision making. Through the PBF portal, the M&E system ensured regular reporting intervals, including monthly, quarterly, and annual updates on Project progress and performance against established indicators. These reports served as vital tools for stakeholders to gauge the Project's trajectory, identify areas of success, and pinpoint challenges requiring attention. Moreover, they enabled timely adjustments to Project strategies and interventions, maximizing the likelihood of achieving desired outcomes. 85. In addition to routine reporting, the M&E system emphasized the dissemination of evaluation findings through various channels. Supervision and midterm review were conducted to assess the Project's effectiveness and generate insights into its outcomes. The results of these evaluations were disseminated widely among stakeholders, including the National Unit for Results-Based Financing, the Financial Affairs Director, Regional Medical Directors, and the World Bank. Furthermore, baseline studies provided essential benchmarks for assessing the Project's progress over time, while regular reporting ensured ongoing transparency and accountability. The utilization of data for decision- making purposes was encouraged, with stakeholders encouraged to draw upon M&E findings to inform policy adjustments, resource allocation, and programmatic interventions. Additionally, M&E findings informed adaptive management practices to address emerging challenges and optimize Project outcomes. Ongoing review and adjustment were necessary to ensure the M&E system remains responsive and effective throughout the Project duration. Justification of Overall Rating of Quality of M&E 86. The overall level and quality of M&E is rated Substantial, based on the ratings for M&E design, M&E implementation and M&E Utilization described above. Table 7: Summary of M&E Rating Overall rating M&E Design M&E Implementation M&E Utilization Substantial Substantial Substantial Substantial B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE Environmental Compliance 87. The Project complied with the World Bank’s Safeguards Policies and Procedures at appraisal. According to the OP 4.01 on Environmental Assessment, the Project was classified as Environmental Category B due to the medical waste management and triggered only OP/BP 4.01 on Environmental and Social Assessments. To address the issues and mitigate any potential risk associated with disposal of medical wastes, an Environmental and Social Management Framework was prepared, implemented, and documented. In addition, at appraisal, the MoH developed its first Biomedical Waste Management Plan, which was validated by a technical inter-ministerial committee comprising representatives of the key Government ministries (MoH and Ministry of Environment), including WHO and UNICEF. The Project financed the operationalization of this plan in the areas of intervention and worked closely with the ministry, which led to improved medical waste management in the target regions with the construction of 95 incinerators. Health workers were trained in infection, prevention, and waste management practices. 26 The World Bank Health System Support (P156165) ICR DOCUMENT 88. Despite this effort, only 52 percent of the health centers had a functioning health incinerator at the end of the Project. In addition, there was very weak collaboration between the World Bank and PIU safeguards teams. Quarterly reports on the implementation of safeguard activities were sent to the World Bank in a very inconsistent manner, making it difficult for the Bank's safeguard specialists to monitor these activities and provide technical support to the PIU. Only one supervisory and monitoring visit to the health facilities involved the World Bank safeguards specialists. Social Compliance 89. The Project did not trigger the involuntary resettlement policy (OP4.12) since Project activities did not include land acquisition, resettlement, or restriction of access. The Project target populations were women and children as well as the poorest and vulnerable groups living in the Project coverage areas. The Project improved the social inclusion of poor communities through a cash transfer to the poorest to facilitate their access to health services, until the last eight months, when the activity was stopped. Additionally, the Project engaged communities in healthier behaviors and the use of health services promotion. The Project further enhanced citizen engagement with increased autonomy in planning and funds allocation by health facilities at the peripheral health centers level. In fact, activity reports indicated that trust had been built PHC staff and community members, resulting in increased service utilization. Furthermore, the Project established the GRM and extended its efforts to the quarterly surveys to measure client satisfaction in all the health facilities in the three target regions. But as stated above, the weak involvement of World Bank safeguard specialists prevented them from monitoring and giving technical assistance to the PIU and the reports of social safeguard were rarely sent to the World Bank. Fiduciary Compliance 90. Financial management. Overall, the Project operated a good financial management (FM) system. INAYA complied with the Bank’s FM operational policies and procedures (OP/BP 10.00). Through the PIU, the Director of Administrative and Financial Affairs of the Ministry of Health in charge of the financial management of the Project consistently submitted Interim Financial Reports (IFR), but not always on time. The annual external audit reports were submitted and qualified favorable, and the recommendations were implemented. The external auditor for fiscal year 2023 was completed on June 30, 2024, and the report accepted by the World bank team. The Project recorded a good disbursement rate (100.26 percent) at Project closure. Apart from the slow disbarment at the beginning, no issues were signaled throughout implementation. The FM performance was rated Moderately Satisfactory. 91. Procurement. The Project complied with the Bank’s procurement policies and procedures, especially the World Bank Procurement Regulations for Borrowers: “Investment Project Financing” dated July 1, 2016, and the World Bank’s Anti-Corruption Guidelines: “Guidelines on Preventing and Combatting Fraud and Corruption”, revised in January 2011 and as of July 1, 2016. As part of Project preparation requirements, the Project team prepared an 18- month procurement plan, which was constantly updated to include new activities that emerged during Project implementation. Procurement activities at the beginning of the Project implementation were delayed by the weak procurement capacity, the inadequate technical specification at the beneficiary’s level, and the long duration for document reviews and contract approval. The situation improved progressively as the Bank closely monitored procurement activities and organized procurement clinics and training to improve the capacity of the procurement staff of the PIU including on the use of the Systematic Tracking of Exchanges in Procurement (STEP) system. At the end of the Project, procurement was rated Moderately Satisfactory. 27 The World Bank Health System Support (P156165) ICR DOCUMENT C. BANK PERFORMANCE Quality at Entry The World Bank’s performance during the project preparation is rated as Satisfactory. 92. In 2014, Mauritania did not have any project or technical assistance financed by the World Bank in health sector therefore, the INAYA Project was the first health project financed by the World bank in Mauritania that time. During the Project preparation the Bank financed two study tours for the technical staff of the beneficiary ministries. The first one with three participants occurred in Burundi. The objective was to allow them to familiarize themselves with the PBF strategy and concepts. The second study tour, which also benefited three participants from Ministry of Health occurred in Senegal and it focused on cash transfers. The objective was to learn from Senegal’s experience in implementing cash transfers. This enhanced the Project team’s understanding of PBF and cash transfer mechanisms. Moreover, the World Bank financed four different groups, 35 people in total from MoH to attend international training on PBF in Cotonou (Benin). The Bank also co-financed the initial studies and assessment whose recommendations served as inputs into the Project design. The Project preparation team considered lessons learned from previous PBF projects implemented in other African countries, such as Senegal and Burundi in the Project design. The Project design was simple, and the components were reasonably developed and linked to the achievement of the PDO. The team assessed and included in the design social determinants of health with a special attention to gender and equity. The fiduciary assessments, implementation arrangements and M&E system were carried out and together with the Project team, the Bank appropriately identified Project risks and developed measures to mitigate them. Quality of Supervision Quality of supervision is rated satisfactory. 93. The World Bank team regularly supervised the Project. The twelve Implementation Status Results Reports (ISRs) were reported on time. All the aides-memoire objectively documented implementation issues that needed the Government and Bank team’s attention. In addition, lead specialists and the senior management of the Bank and other development partners were regularly informed about implementation progress. The World Bank team successfully conducted the three restructurings of the Project out of which, 23 million AF. The team has been being always flexible to accommodate the Project objectives with the needs and priorities of the country through the Project life. The Task Team was also successful in engaging senior officials, including the Minister of Health and the Secretary General of MoH, in technical discussions during and after the missions. The last two TTLs were based in the country, which facilitated the day-to-day policy dialogue. Both the PIU and the task team regularly engaged closely on implementation progress to identify bottlenecks and took necessary actions to fix the problems in a timely manner. However, the Project registered frequent leadership changes. In fact, Task Team leadership changed six times, a new TTL almost every year. These changes impacted on Project implementation, especially at the start of implementation. The Bank’s No Objection to the development of Project implementation manuals and other implementation instruments was significantly delayed. The high turnover of TTLs was highlighted by the Government several times as a matter of concern. Nonetheless, the team continuously remained flexible and responsive to the requests of Government (in the case of support during the 2022 measles outbreak). The Bank team held regular supervision missions, both physically and virtually during the COVID-19 pandemic. The Bank’s fiduciary specialists were always part of the supervision missions and provided adequate support and follow ups. 28 The World Bank Health System Support (P156165) ICR DOCUMENT Justification of Overall Rating of Bank Performance 94. Overall rating of Bank Performance is rated as Satisfactory, based on the above ratings of quality at entry and quality of supervision D RISK TO DEVELOPMENT OUTCOME 95. The key identifiable risks to development outcomes are: (i) Non-payment of PBF subsidies to health facilities. The INAYA Project follows on the Mauritania Health System Support Project (INAYA Elargi) as Phase 1 of the Multiphase Programmatic Approach (MPA) on Advancing Universal Health Coverage Program for Human Capital in Mauritania (P179558) that has just been declared effective on June 28, 2024, creating a six-month gap between the closure of INAYA and the start of the new INAYA Elargi Project. However, the Government has not stepped in to pay the subsidies. This situation has led to non-payment of subsidies to the health facilities to enable them to pay bonuses of the frontline health workers. (ii) Parallel system created by the PIU. The sustainability of the Project is also threatened because of a seemingly parallel system created by the PIU. The PIU essentially makes all the infrastructure and budgetary allocation decisions without the involvement of the relevant central MoH directors and the regional health directors. (iii) Removal of the financial management function from the DAFA: One of the key initiatives that is behind the success of the INAYA Project is the integration of financial management in the central MoH with the director of finance and administration acting as the FM specialist of the Project. This arrangement helped build the capacity of the directorate and FM implementation was largely Satisfactory. However, for some reason this function has been taken away from the DAFA and given to the Project coordination unit. While this might be a good idea, it defeats the PBF principle of separation of functions as one institution should not handle the technical operations and at the same time act as the payer. 96. Despite the above, the Government has incorporated PBF in the NHDP (2022–2030) with the aim of allowing 85 percent of health centers to implement this strategy by 2025. It has asked the World Bank for assistance in its efforts to achieve this objective. Also, the Government will provide US$20 million co-financing of the new 10-years Multi-phase Programmatic Approach (MPA), which will scale up the PBF strategy to nine (9) out of 14 regions, covering 80 percent of health centers and 60 percent of the country's population. This contribution should increase progressively to ensure financial sustainability of the PBF after the end of the World Bank's financing period. However, at the negotiation of the first stage of the MPA, the Government stated that its contribution cannot be more than 10 percent of the total Project envelope and there is no promise of any increase in this contribution. 29 The World Bank Health System Support (P156165) ICR DOCUMENT V. LESSONS AND RECOMMENDATIONS Lessons learned. 97. The following are key lessons learned: (i) A client-focused design is critical to the success of the PBF strategy . The feasibility studies conducted prior to the project preparation, enabled the team to gain a thorough understanding of the challenges in the health sector and to make evidence-based decisions for the design of the PBF in the three pilot regions of the Project. It also provided them with the right information on the appropriate institutional arrangements to put in place by integrating the Project within the Ministry of Health structures, including the Directorate of Administrative and Financial Affairs, which carried out the fiduciary aspects of the Project. Contrary to the general practice of using consultants for Project implementation, INAYA exclusively used civil servants, including national PBF technical unit throughout the Project implementation. (ii) Using PBF as a strategic purchasing tool for health services increases utilization of health services and improves quality of care for the beneficiaries. The PBF contracting arrangements and pricing allowed health facilities to have the autonomy to manage their own resources which led to improve provider performance, equity, and facility level systems governance. The PBF transformed work ethics and commitment of frontline health workers in the delivery of health services. By purchasing services for the venerable population, including refugees, the project substantially addressed equity issues, allowing the poor communities’ access quality healthcare. Thanks to the PBF contracting and purchasing mechanism, INAYA project targeted the disadvantaged regions with low rates of health services utilization and poor maternal and child health indicators. INAYA also improved health systems governance at all levels, particularly at the health facility level. Through contacting arrangements, the project set up by the DMTs which managed routine service delivery in all the health facilities supported by the project. (iii) Involvement of the sector ministry in the verification process is good, but it led to higher administrative costs. The Project utilized a private firm to undertake verification activities with the aim of transferring knowledge to the nationals and reducing operational costs of the verification. But it turned out that the costs of verification were still high because there were too many institutions involved in the process at all levels of the health systems. Future projects should focus on streamlining and simplifying the government-based verification arrangements. (iv) A combination of demand and supply side interventions are crucial to increasing access to health services. The Conditional Cash Transfers (CCT) was intended to help increase service utilization the three regions, including the refugee communities, but it had limited impact on service utilization because of delays in its implementation. The activity was implemented by Taazour, which is another agency outside MoH, which was not very committed to Project implementation . Collaboration issues between INAYA’s PIU and Taazour led to the cessation of this activity after only two years of implementation as a result beneficiaries were deprived of cash transfers. (v) Implementing standardization of certain key initiatives is a good practice in addressing key service delivery issues in the sector. The Project has standardized the waste management systems in health 30 The World Bank Health System Support (P156165) ICR DOCUMENT facilities by establishing incinerators with unique designs in health facilities across the Project coverage area. One of the significant achievements of INAYA is the improvement of waste management through the construction of standardized and functional incinerators in the majority of the health facilities. All the incinerators built with subsidies to health facilities are of the same type and color and are managed by trained personnel. Recommendations Based on the above lessons, the following recommendations are proposed: (i) Maintain effective institutional arrangements with the involvement of civil servants as the core of the design of similar project in future. (ii) Institutionalize the strategic purchasing approach for health services delivery to improve efficient and equitable access to quality health services. (iii) Streamline and simplify the government-based verification arrangements to reduce the operational cost and ensure the sustainability of the PBF in Mauritania. (iv) Involve early and well defined the role of each sectoral ministries in charge of common Project implementation in important to strengthen the accountability of each side. (v) Grant more autonomy to health facilities to allow them to make decisions and improve the work environment as well as the quality of healthcare provided to the population and scale up the good practices. 31 The World Bank Health System Support (P156165) ICR DOCUMENT ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS @#&OPS~Doctype~OPS^dynamics@icrresultframework#doctemplate A. RESULTS FRAMEWORK PDO Indicators by Outcomes Not Categorized Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year 12,278.00 Dec/2017 135,360.00 Dec/2023 160,021 Dec/2023 Births attended by skilled health staff Comments on achieving targets This indicator is achieved and exceeded (Number) Births attended by skilled 0.00 3,480.00 4,291 health staff among the Comments on achieving targets This indicator is achieved and exceeded refugee population (Number) Pregnant women completing four 4,444.00 Dec/2017 53,557.00 Dec/2023 81,307 Dec/2023 antenatal care visits to a health Comments on achieving targets This indicator is achieved and exceeded facility during pregnancy (Number) Pregnant women completing 0.00 2,954.00 2,391 four antenatal care visits to a Comments on achieving targets This indicator achieved 81 percent of the planned traget. health facility among the refugee population (Number) 9,046.00 Dec/2017 117,470.00 Dec/2023 203,860.00 Dec/2023 Children 12-23 months fully Comments on achieving targets This indicator is achieved and exceeded immunized (Number) 0.00 2,910.00 5,110.00 Page 32 The World Bank Health System Support (P156165) ICR DOCUMENT Children 12-23 months fully Comments on achieving targets This indicator is achieved and exceeded immunized among the refugee population (Number) 14.00 Dec/2017 60.00 Dec/2023 60.00 Dec/2023 Average score of the quality of care Comments on achieving targets This indicator is achieved and exceeded. checklist (Percentage) Refugee populations benefiting from 0.00 Apr/2019 151,250.00 Dec/2023 562,874.00 Dec/2023 preventive and curative interventions Comments on achieving targets This indicator is achieved and exceeded provided by the FOSA (PMA + PCA) (Number) Intermediate Indicators by Components Not Categorized Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Pregnant women referred for ANC1 0 Dec/2017 16,580.00 Dec/2023 16,580.00 Dec/2023 by community health workers Comments on achieving targets This indicator is achieved and exceeded (cumulative) (Number) Health facilities transmitting 0 Dec/2017 99 Dec/2024 99 Dec/2023 complete HMIS reports on time Comments on achieving targets This indicator is achieved and exceeded (Percentage) Districts that implement the 0 Apr/2019 17 Dec/2023 17 Dec/2023 community health strategy Comments on achieving targets This indicator is achieved and exceeded (Number) Health facilities with a functional 39.70 Dec/2017 100 Dec/2024 100 Dec/2023 CoSa health committee Comments on achieving targets This indicator is achieved and exceeded (Percentage) 8,960 Dec/2017 164,560.00 Dec/2023 242,254.00 Dec/2023 Women accepting modern family planning methods () Comments on achieving targets This indicator is achieved and exceeded 0.00 10,055.00 6,237.00 Page 33 The World Bank Health System Support (P156165) ICR DOCUMENT Women refugees accepting Comments on achieving targets This indicator achieved 62 percent of the planned end target. modern family planning methods (Number) 9,046. Dec/2017 203,860 Dec/2023 203,860 Dec/2023 Number of children immunized (Number of people) CRI Comments on achieving targets This indicator is achieved and exceeded Number of women and children who 4,885. Dec/2017 746,328 Dec/2023 746,328 Dec/2023 have received basic nutrition services () CRI Number of women receiving 12,278. Dec/2017 160,021 Dec/2023 160,021 Dec/2023 deliveries attended by skilled health Comments on achieving targets This indicator is achieved and exceeded personnel (Number of people) CRI Grievances registered related to 0 Apr/2019 100 Dec/2024 100 Dec/2023 delivery of project benefits Comments on achieving targets This indicator is achieved and exceeded satisfactorily addressed (Percentage) The proportion of households eligible 0 Dec/2017 81 Dec/2023 81 Dec/2023 for conditional cash transfers that have fulfilled the conditions during the year and received the tranches for which they are eligible () 0 Apr/2019 84,553 Dec/2023 84,553 Dec/2023 Home visits received by children 0-5 years old (cumulative) (Number) Comments on achieving targets This indicator is achieved and exceeded People who have received essential 94,427.00 Dec/2017 345,750.00 Dec/2023 746,328.00 Dec/2023 health, nutrition, and population Comments on achieving targets This indicator is achieved and exceeded. (HNP) services () 9,046.00 Dec/2017 117,470.00 Dec/2023 203,860 Dec/2023 Number of children immunized (Number) Comments on achieving targets This indicator is achieved and exceeded. Number of women and 4,885.00 Dec/2017 78,270.00 Dec/2023 746,328.00 Dec/2023 children who have received Comments on achieving targets This indicator is achieved and exceeded. basic nutrition services (Number) Page 34 The World Bank Health System Support (P156165) ICR DOCUMENT Number of deliveries attended 12,278.00 Dec/2017 135,360.00 Dec/2023 160,021.00 Nov/2023 by skilled health personnel Comments on achieving targets This indicator is achieved and exceeded. (Number) Health facilities without essential 0 Dec/2017 94.00 Dec/2023 58 Dec/2023 medicines stockouts over the last Comments on achieving targets This indicator achieved 61 percent of the planned end target. three months () 19.90 Dec/2017 94.00 Dec/2023 72.00 Dec/2023 Basic equipment availability () Comments on achieving targets This indicator achieved 76 percent of the planned end target. 68,185 Dec/2017 822,020.00 Dec/2023 1,175,317 Dec/2023 Visits by under-5 children to health facilities () Comments on achieving targets This indicator is achieved and exceeded. 2,568 Dec/2017 53,550.00 Dec/2023 94,531.00 Dec/2023 Post-natal consultation visits () Comments on achieving targets This indicator is achieved and exceeded. Post-natal consultation visits 0.00 3,070.00 2,715.00 among the refugee population Comments on achieving targets This indicator is achieved and exceeded. (Number) 0.00 Dec/2017 70.00 Dec/2023 98.00 Dec/2023 User satisfaction with health care services () Comments on achieving targets This indicator is achieved and exceeded. User satisfaction with health 0.00 75.00 90.00 care services among the Comments on achieving targets This indicator is achieved and exceeded. refugee population (Percentage) Number of poor people and / or 0 Apr/2019 230,000.00 Dec/2023 879,373.00 Dec/2023 eligible refugees who have benefited Comments on achieving targets This indicator is achieved and exceeded. from free curative consultations () Pregnant women referred for ANC1 0.00 Dec/2017 7,720.00 Dec/2023 16,580.00 Dec/2023 by community health workers Comments on achieving targets This indicator is achieved and exceeded. (cumulative) () 0.00 Apr/2019 12.00 Dec/2023 17.00 Dec/2023 Page 35 The World Bank Health System Support (P156165) ICR DOCUMENT Districts that implement the Comments on achieving targets This indicator is achieved and exceeded. community health strategy () The proportion of households eligible 0.00 Dec/2017 90.00 Dec/2023 81.00 Dec/2023 for conditional cash transfers that Comments on achieving targets This indicator is achieved and exceeded. have fulfilled the conditions during the year and received the tranches for which they are eligible () Number of home visits received by 0.00 Mar/2019 9,257.00 Dec/2023 84,553 Dec/2023 children 0-5 years old (cumulative) (Number) Health facilities transmitting 0.00 Dec/2017 95.00 Dec/2023 99 Dec/2023 complete HMIS reports on time (Percentage) Health facilities with a functional 39.70 Dec/2017 90.00 Dec/2023 100.00 Dec/2023 CoSa health committee (%) Comments on achieving targets This indicator is achieved and exceeded (Percentage) () Grievances registered related to 0.00 Apr/2019 100 Dec/2023 100.00 Dec/2023 delivery of project benefits satisfactorily addressed (Percentage) Page 36 The World Bank Health System Support (P156165) ICR DOCUMENT B. KEY OUTPUTS BY COMPONENT Objective/Outcome 1: Increase utilization of health services with a focus on health and communicable disease 1. Births attended by skilled health staff (number). 1a. Births attended by skilled health staff among the refugee population (number) 2.Pregnant women completing four antenatal care visits to a health facility during pregnancy (number). 2.a Pregnant women completing four antenatal care visits to a health facility Outcome Indicators among the refugee population (number). 3. Children 12–23 months fully immunized (number). 3a. Children 12–23 months fully immunized among the refugee population (number). 4. Refugee populations benefiting from preventive and curative interventions provided by the health centers (number). 1. Women accepting modern family planning methods (number) 2. Women refugees accepting modern family planning methods (number) 3. People who have received essential health, nutrition, and population (HNP) services (Cumulative Results Indicator (CRI), number) 4. Children immunized (number) 5. Number of women and children who have received basic nutrition services (number) 6. Deliveries attended by skilled health personnel (number) 7. Visits by under-5 children to health facilities (number) Intermediate Results Indicators 8. Post-natal consultation visits (number) 9. Post-natal consultation visits among the refugee population (number) 10. Poor people and/or eligible refugees who have benefited from free curative consultations (number) 11. Pregnant women referred for ANC1 by community health workers (cumulative) (number) 12. Districts that implement the community health strategy (number) 13. Conditional cash transfer beneficiaries (% eligible households receiving full transfers) (percentage) 14. Home visits received by children 0–5 years old (cumulative) (number) Page 37 The World Bank Health System Support (P156165) ICR DOCUMENT Healthcare services delivery - Hospital admissions (one day) - Minor surgery: 694,422 - Normal Delivery: 333,438 - Complicated delivery: 20,063 - Cesarean Section: 25,036 - Major surgery: 54,401 - Outpatient consultations: 8,134,334 Capacity building/Institutional support - Capacity building for 10 health workers in the management of medicines - Building the capacity of 426 accounting officers in financial management - Setting up district management teams in the three regions covered by the Project. Key Outputs by Component Infrastructure and equipment (linked to the achievement of the Objective/Outcome 1) - Setting up a CAMEC regional branch in Hodh Chargui - Setting up a CAMEC departmental branch in Tintane - Construction of 7 storage sites to improve biomedical waste management (2 hospitals and 5 health centers) - Rehabilitation and extension of 6 health centers in the 3 regions (Bassiknou, Vassala, Tembedra Wompo, Tintane and Douerara) - Extension of 8 maternity units in the health posts and health centers Infrastructure and equipment - Setting up a CAMEC regional branch in Hodh Chargui - Setting up a CAMEC departmental branch in Tintane - Construction of seven storage sites to improve biomedical waste management (2 hospitals and 5 health centers) - Rehabilitation and extension of six health centers in the three regions (Bassiknou, Vassala, Tembedra Wompo, Tintane and Douerara) - Extension of 8 maternity units in the health posts and health centers Page 38 The World Bank Health System Support (P156165) ICR DOCUMENT - Rehabilitation, renovation, and equipping of the regional direction of health of Hod El Chargui, and health of Hod El Garbi - Procurement of 10 generators to ensure continuity of electricity supply in beneficiary health centers. - Procurement of 5 refrigerated lorries for CAMEC - Procurement of 3 buses for the regions to support the transport of medicines in each region. - Equipment for 10 health centers laboratories - Procurement of 8 vehicles for supervision - Procurement of 4 cold stores: 2 for Hod El Chargui, 1 for Guidimaka region and 1 for Hod El Chargui region Realizations through PBF payment - Building of more than 200 basic healthcare facilities - Supplying water to more than 100 health centers in rural areas by connecting them to village water networks - Solar lighting and sterilization equipment for 150 rural health centers - Procurement of complete or partial basic equipment for more than 300 health centers (maternity units, vaccinations, etc.) - Construction of 95 Monfort-type incinerators to support biomedical waste management. - These investments resulted in the improvement of the quality of healthcare provided to the population, which consequently led to an increased utilization of health services. - Pandemic preparedness and response - The Project has also contributed to financing the response to the measles epidemic in 2022 through the acquisition of one million doses of vaccines against measles and rubella and the financing of the measles–rubella vaccination campaign, which reached 557,135 children. - Procurement of 300 tablets of COVID-19 vaccines management as well as the procurement of all the tools used for COVID-19. Page 39 The World Bank Health System Support (P156165) ICR DOCUMENT Objective/Outcome 2: Improve quality of health services Outcome Indicators 1. Average score of the quality-of-care checklist (percentage). 1. Health facilities without essential medicines stockouts over the last three months (percentage) 2. Basic equipment availability (percentage) 3. User satisfaction with healthcare services (percentage) Intermediate Results Indicators 4. User satisfaction with healthcare services among the refugee population (percentage) 5. Health facilities with a functional health committee (percentage) 6. Grievances registered related to delivery of Project benefits satisfactorily addressed (percentage) 1. 100 percent of healthcare users were satisfied with healthcare services Key Outputs by Component received, including among the refugee population (linked to the achievement of the Objective/Outcome 2) 2. 100 percent of health facilities had a functioning health committee 3. 100 percent of grievances registered were satisfactorily addressed Page 40 The World Bank Health System Support (P156165) ICR DOCUMENT Improve utilization and quality of Reproductive, Maternal, Neonatal, and Child Health services 2. Births attended by skilled health staff 4. Pregnant women completing four antenatal care visits to a health facility during pregnancy PDO Indicators 6. Children 12-23 months fully immunized 8. Average score of the quality of care checklist 9. Refugee populations benefiting from preventive and curative interventions provided by the FOSA (PMA + PCA) 1. Key Outputs 2. (linked to the achievement of the PDO Outcome) 3. 4. Page 41 The World Bank Health System Support (P156165) ICR DOCUMENT Contingency Emergency Response Component Intermediate Results Indicators 1. Key Outputs 2. (linked to the achievement of the Component) 3. 4. Capacity building and Project Management 1. Health facilities transmitting complete HMIS reports on time 2. Health facilities with a functional CoSa health committee Intermediate Results Indicators 3. Grievances registered related to delivery of project benefits satisfactorily addressed 1. Key Outputs 2. (linked to the achievement of the Component) 3. 4. Support to increasing demand for health services 1. Pregnant women referred for ANC1 by community health workers (cumulative) 2. Districts that implement the community health strategy Intermediate Results Indicators 3. The proportion of households eligible for conditional cash transfers that have fulfilled the conditions during the year and received the tranches for which they are eligible 4. Home visits received by children 0-5 years old (cumulative) 1. Key Outputs 2. (linked to the achievement of the Component) 3. 4. Page 42 The World Bank Health System Support (P156165) ICR DOCUMENT Improving utilization of quality RMNCH Services through performance-based financing (PBF) 1. Women accepting modern family planning methods 2. Women refugees accepting modern family planning methods 3. Number of children immunized 3. Number of women and children who have received basic nutrition services 3. Number of women receiving deliveries attended by skilled health personnel 6. Health facilities without essential medicines stockouts over the last three months Intermediate Results Indicators 7. Basic equipment availability 8. Visits by under-5 children to health facilities 9. Post-natal consultation visits 10. Post-natal consultation visits among the refugee population 11. User satisfaction with healthcare services 12. User satisfaction with healthcare services among the refugee population 13. Number of poor people and/or eligible refugees who have benefited from free curative consultations 1. Key Outputs 2. (linked to the achievement of the Component) 3. 4. 2. Women accepting modern family planning methods 4. People who have received essential health, nutrition, and population (HNP) services Intermediate Results Indicators 8. Health facilities without essential medicines stockouts over the last three months 9. Basic equipment availability 10. Visits by under-5 children to health facilities Page 43 The World Bank Health System Support (P156165) ICR DOCUMENT 16. Pregnant women referred for ANC1 by community health workers (cumulative) 17. Districts that implement the community health strategy 18. The proportion of households eligible for conditional cash transfers that have fulfilled the conditions during the year and received the tranches for which they are eligible 19. Number of home visits received by children 0-5 years old (cumulative) 20. Health facilities transmitting complete HMIS reports on time 21. Health facilities with a functional CoSa health committee (%) (percentage) 22. Grievances registered related to delivery of project benefits satisfactorily addressed 11. Post-natal consultation visits 13. User satisfaction with healthcare services 15. Number of poor people and / or eligible refugees who have benefited from free curative consultations 1. Key Outputs 2. (linked to the achievement of the Component) 3. 4. Page 44 The World Bank Health System Support (P156165) ICR DOCUMENT Table 2- B1: Summary of Service delivery indicators by region (2019–2023) Total 2021 2023 Indicator 2019 2020 2022 HEC HDG Gui HEC HDG Gui HEC HDG Gui HEC HDG Gui HDG Gui HEC Consultation of children 375,434 262,008 683,991 376,415 271,023 187,913 474,358 286,102 243,336 under 5 - 273,606 202,639 190,727 334,194 630,976 4,792,722 Minor surgery - 10,545 9,489 4,680 13,049 7,444 14,906 9,438 7,475 15,617 12,842 6,585 19,615 17,360 8,740 157,785 Normal delivery assisted by 8,655 8,334 15,639 9,992 9,515 6,669 12,756 8,351 8,563 qualified health workers - 8,776 8,494 4,449 9,104 13,608 132,905 Hospitalization (one day) - 33,252 13,334 23,162 48,958 14,800 58,792 22,196 17,467 85,182 26,418 19,841 75,744 24,325 19,708 483,179 Major surgery - 301 130 183 310 96 67,030 254 134 1,299 459 146 1,148 184 170 71,844 Cesarean section - 405 129 134 400 163 487 325 175 535 372 178 657 474 247 4,681 Family planning - 11,095 18,554 3,928 16,443 18,354 12,214 11,047 25,686 20,695 13,394 26,428 31,413 21,835 33,795 264,881 Total 337,980 252,769 227,263 422,458 235,439 640,543 337,713 302,836 767,912 437,574 323,520 828,207 450,585 343,198 5,907,997 Table2- B2; Revised results framework at the second restructuring Original Revised Original AF Target No. Indicator Baseline Baseline Target Comments PDO Level Indicators 1. Births attended by skilled health staff (number) 12,278 13,020 78,812 135,360 Baseline and Target revised 1.a. Births attended by skilled health staff among the – 00 – 6,960 New refugee population (number) 2. Pregnant women completing four antenatal care 4,444 1,740 41,211 92,340 Baseline and Target visits to a health facility during pregnancy revised (number) 2.a Pregnant women completing four antenatal care – 00 – 5890 New visits to a health facility among the refugee population (number) 3. Children 12–23 months fully immunized 9,046 19,390 63,289 117,470 Baseline and Target (number) revised Page 45 The World Bank Health System Support (P156165) ICR DOCUMENT 3.a Children 12–23 months fully immunized among – 00 19,390 5,820 New the refugee population (number) 4. Average score of the quality-of-care checklist 00 14 60 60 Baseline and Target (percentage) revised 5. Refugee populations benefiting from preventive – 00 – 151,250 New and curative interventions provided by health centers (number) Intermediate Outcome Indicators 1. Women accepting modern family planning 8,969 6,690 94,622 164,560 Baseline and Target methods (number) revised 2. Women refugees accepting modern family – 00 – 20,110. New planning methods (number) 3. People who have received essential health, 94,427 00 1,761,769 345,750 Baseline and Target nutrition, and population (HNP) services revised (number)) 4. Number of children immunized (number)) – 00 – 117,470 new 5. Number of women and children who have 4,885 00 43,089 78,270 Baseline and Target received basic nutrition services (number) revised 6. Number of deliveries attended by skilled health – 00 78,812 135,360 Baseline and Target personnel (number) revised 7. Health facilities without essential medicines 00 28 94 94 Baseline revised stockouts over the last three months (percentage) 8. Basic equipment availability (percentage) 19,5 – 94 94 No change 9. Visits by under-5 children to health facilities 68,185 43,620 450,169 822,020 Baseline and Target (number) revised 10. Post-natal consultation visits (number) 2,568 3,560 26,764 53,550 11 Post-natal consultation visits among the refugee – 00 – 6,140 new population (number) 12. User satisfaction with healthcare services 00 – 80 70 Target revised (percentage) 13. User satisfaction with healthcare services among – 00 – 75 New the refugee population (percentage) 14. Number of poor people and/or eligible refugees – 00 – 25,595 New who have benefited from free curative consultations (number) 15. Pregnant women referred for ANC1 by 00 – 23,084 252,820 Target revised community health workers (cumulative) (number) Page 46 The World Bank Health System Support (P156165) ICR DOCUMENT 16. Districts that implement the community health 00 – 6 12 Target revised strategy (number) 17. Conditional cash transfer beneficiaries (% eligible 00 – 60 70 Target revised households receiving full transfers) (percentage) 18. Number of home visits received by children 0–5 – 00 – 54,990 New years old (cumulative) (number) 19. Health facilities transmitting complete HMIS 00 – 95 – No change reports on time (percentage) 20. Health facilities with a functional health 39,7 00 100 90 Baseline and Target committee (%) (percentage) revised 21. Grievances registered related to delivery of – 00 – 75 New project benefits satisfactorily addressed (percentage) Page 47 The World Bank Health System Support (P156165) ICR DOCUMENT ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION A. TASK TEAM MEMBERS Name Role Mariam Noelie Hema Team Leader Samuel Nii Lantei Mills Team Leader Mohamed Vadel Taleb El Hassen Team Leader Ahohouindo Mongnihoude Jean L Gbaguidi Financial Management Specialist Fatou Fall Samba Financial Management Specialist Angelo Donou Financial Management Specialist Brahim Hamed Procurement Specialist Sarra Saleck Procurement Specialist Joelle Nkombela Mukungu Environmental Specialist Mamadou Samba Sow Environmental Specialist Cheikh Hamallah Diagana Social Specialist Mame Safietou Djamil Gueye Social Specialist Helene Bertaud Counsel Sachiko Morita Counsel Anta Tall Diallo Procurement Team Maimouna Toure Procurement Team Yahya Ould Aly Jean Team Member Alice Museri Team Member Matthieu Louis Bonvoisin Team Member Aissatou Diallo Team Member Sariette Jene M. C. Jippe Team Member Rebekka E. Grun Team Member Silvanie Ekeme Epse Lifongo Team Member Nejma Cheikh Team Member Thierno Mamadou Bocar Ba Team Member Moussa Dieng Team Member Page 48 The World Bank Health System Support (P156165) ICR DOCUMENT Faly Diallo Team Member Matthieu Boris Lefebvre Team Member Charlotte Pram Nielsen Team Member @#&OPS~Doctype~OPS^dynamics@icrannexstafftime#doctemplate B. STAFF TIME & COST Staff Time & Cost Stage of Project Cycle No. of Staff Weeks US$ (including travel and consultant costs) Preparation FY16 12.147 76,861.94 FY17 25.501 173,500.51 FY18 0.754 4,259.94 FY19 0.000 1,978.43 FY22 0.000 15,105.08 FY23 0.000 7,240.03 Total 38.40 278,945.93 Supervision/ICR FY18 11.487 84,372.33 FY19 35.200 207,867.98 FY20 44.961 190,062.13 FY21 39.999 195,384.14 FY22 24.347 128,305.93 FY23 16.860 134,540.06 FY24 17.100 108,571.70 Total 189.95 1,049,104.27 Page 49 The World Bank Health System Support (P156165) ICR DOCUMENT ANNEX 3. PROJECT COST BY COMPONENT Component Amount at Approval (US$M) Actual at Project Closing (US$M) Improving utilization of quality RMNCH Services through 28.5 28.50 performance-based financing (PBF) Support to increasing demand for 8.0 8.0 health services Capacity building and Project 7.0 7.0 Management Contingency Emergency Response 0.0 0.0 Component Table 2-B1: Original disbursement Category No. Category Original amount (SDR) 1. Category 1: Conditional cash transfers under Part B.1.a(ii) of the Project 1,800,000 2. Category 2: Goods, works, non-consulting services, training, operating costs, and 3,300,000 consulting services for Parts A, B and C of the Project 3. Category 3: PBF payments and small investment grants under Part A.1.a of the 9,800,000 Project 4. Category 4: Performance bonuses to PBF-implementing bodies under Part A.2(b) 1,900,000 of the Project TOTAL 12,600,000 Table 2-B2: Revised Disbursement Category under First Restructuring No. Category Revised amount (SDR) 1. Category 1: Goods, works, non-consulting services, training, operating costs, and 733,416.00 consulting services for Part A (except Part A.1.a, A.1.b, and Part A.2.b), Part B (except Part B.1.a(ii)), and Part C of the Project 2. Category 2: PBF payments and small investment grants under Part A.1.a of the Project 473,321.00 3. Category 3: PBF payments Part A.1.b of the Project 0 4. Category 4: Performance bonuses to PBF-implementing bodies under Part A.2.b of the 1,384,560.00 Project 5 Category 5: Conditional cash transfers under Part B.1.a(ii) of the Project 1,100,000.00 6 Category 6: Emergency expenditures under Part D of the Project 0 7 Category 7: Goods, works, non-consulting services, training, operating costs, and consulting services for Parts A (except Part A.1.a, A.1.b, and Part A.2.b), B (except Part 2,014,353.00 B.1.a(ii)), and C of the Project 8 Category 8: PBF payments and small investment grants under Part A.1.and Part A.1.b 6,894,350.00 of the Project TOTAL 12,600,000 Page 50 The World Bank Health System Support (P156165) ICR DOCUMENT Table 2-B3: Revised Disbursement Categories Increase (+)/ Original Reallocated Decrease (–) No. Expenditure Category Amount (US$) Amount (US$) (%) Parent Project 1. Category 1: Goods, works, non-consulting services, training, 733,416 733,416 0 operating costs, and consulting services for Parts A (except Part A.1.a, A.1.b, and Part A.2.b), B (except Part B.1.a(ii)), and C of the Project 2. Category 2: PBF payments and small investment grants under 473,321 473,321 0 Part A.1.a of the Project 3. Category 3: PBF payments Part A.1.b of the Project – – Closed 4. Category 4: Performance bonuses to PBF-implementing bodies 1,384,560 1,384,560 0 under Part A.2.b of the Project 5 Category 5: CCTs under Part B.1.a(ii) of the Project 1,100,000 495,000 – 45 6. Category 6: Emergency expenditures under Part D of the Project 0 0 0 7. Category 7: Goods, works, non-consulting services, training, 2,014,353 2,014,353 0 operating costs, and consulting services for Parts A (except Part A.1.a, A.1.b, and Part A.2.b), B (except Part B.1.a(ii)), and C of the Project 8. Category 8: PBF payments and small investment grants under 6,894,350 7,499,350 +8.8 Part A.1. and Part A.1.b of the Project Total 12,600,000 12,600,000 – Additional financing Category 1: Conditional cash transfers under Part B.1.(a)(ii) of the 1,800,000 843,950 –53 project Category 2: Goods, works, non-consulting services, consulting 3,300,000 4,256,050 +29 services, operating costs, training under Part A, B and C of the project Category 3: PBF payments and small investment grants under 9,800,000 9,369,403 –4.4 Part A.1 of the project Category 4: Performance bonuses to PBF-implementing bodies 2,330,597 2,330,597 0 under Part A.2(b) of the project Category 5: Emergency expenditures under Part D of the project – – – Total 16,800,000 16,800,000 Page 51 The World Bank Health System Support (P156165) ICR DOCUMENT ANNEX 4. EFFICIENCY ANALYSIS Economic and financial analysis upon completion 1. Introduction 1. The Project Development Objective (PDO) is to improve the use and quality of reproductive, maternal, newborn and child health services (RMNCHS) in selected regions. The priority target regions are those of Guidimagha and Hodh El Gharbi, with a population of 620,000. The expected impacts or benefits of the Project include: (i) improving the use of quality reproductive, maternal, newborn and child health) services (RMNCHS) through the PBF; (ii) increasing the demand for health services; (iii) strengthening the capabilities of the Ministry of Health and entities involved in PBF and Project management; and (iv) strengthening emergency response capabilities. Cost effectiveness analysis 2. The methodology used for this economic and financial analysis note of the Project upon its completion first consisted of the economic and financial analysis carried out during appraisal to verify whether the expected benefits of the Project are confirmed by the results obtained at completion. Because the economic and financial advantages (benefits) expected from the implementation of the Project were not systematically programmed during Project appraisal, it was necessary to use some of the effects and impact indicators of the Project that were supplemented by certain standard indicators of economic benefits of public health projects. This choice stems from the fact that the INAYA Project operationalizes not only the objectives of the World Bank Group, which aims to reduce poverty and promote shared prosperity within the framework of its Regional Strategy for Africa, but also the fact that it is in line with the United Nations Sustainable Development Goals (SDGs) 1 and 3. 3. As a reminder, SDG 1: End poverty in all its forms everywhere, notably through social safety net interventions and better financial protection (against catastrophic health expenditure) among the poor and vulnerable. SDG 3: Ensure a healthy life and promote the well-being of all ages targets several economic and social benefits among the ones which the Project directly supported: the reduction of maternal mortality (Target 3.1), the reduction of under-five mortality and neonatal mortality (Target 3.2), facilitating universal access to sexual and reproductive health services (Target 3.7), achieving Universal Health Coverage (Target 3.8), and increasing health financing and recruiting, developing, training and retaining health workers (Target 3.c). The economic and financial analysis of the Project's benefits upon completion is structured according to the main expected benefits of the Project and identified throughout the Project components. An impact analysis completes the note. A. Cost Effectiveness Benefits of improving the use of quality Reproductive, Maternal, Neonatal and Child Health services (RMNCHS) through PBF 4. Through its first component, the Project was supposed to improve the use of quality Reproductive, Maternal, Newborn and Child Health Services (RMNCHS) through Performance-based Financing (PBF). The hypothesis is that by granting RMNCH health services of public health facilities (posts, centers, and hospitals) Page 52 The World Bank Health System Support (P156165) ICR DOCUMENT as well as Community Health Worker (CHW) subsidies from the PBF mechanism, this would generate the following economic and social benefits: (i) improvement in the motivation of health workers measured by the increase in performance bonuses received; (ii) improvement in the use of RMNCH services; and (iii) improvement in the quality of care. 5. Based on the assumptions retained, the projected targets for the main effect indicators of Component 1 of the Project are as follows: (i) to increase the number of pregnant women having attended four prenatal consultations in a health facility during the pregnancies from 4,444 in 2015 to 53,557 in 2023; (ii) to increase the number of births attended by qualified health personnel from 12,278 in 2015 to 135,360 in 2023; and (iii) to increase the number of fully vaccinated children from 9,046 in 2015 to 117,470 in 2023. 6. Thus, as part of the implementation of the Project, the activities carried out – in particular, the provision of nutrition services, prevention services, maternal, newborn, adolescent and child health services, as well as treatments for malaria, HIV/AIDS, tuberculosis, and family planning – have induced the below levels of achievement of the expected benefits of the improved use of RMNCH care. Page 53 The World Bank Health System Support (P156165) ICR DOCUMENT Table 4.1: Evolution of improvement indicators in the use of RMNCH services N° Indicator Title 2015 Target Target Realization Realization Final Target 2021 finale 2021 2023 Achievement (%) ODP-1 Number of births attended by skilled 12,278 78,812 135,360 93,188 160,021 120 health personnel ODP-1. Number of births attended by skilled 3,480 1,350 4,291 123 a. r health personnel ODP-2 Number of pregnant women who attended four antenatal 4,444 41,211 53,557 32,589 81,307 156 consultations at a health facility during pregnancy ODP-2. Number of pregnant women who a. r attended four antenatal 2,954 796 2,391 81 consultations at a health facility during pregnancy ODP-3 Number of children fully vaccinated 9,046 63,289 117,470 129,730 203,860 179 ODP-3. Number of children fully vaccinated 2,910 1,311 5,110 176 a. r Source: Data from project document and project completion report. 7. As the data in Table 4.1 indicates, the US$10.85 million allocated to Component 1 of the INAYA Project made it possible to improve the service offerings of the RMNCH health service package defined in the PBF manual, to increase in the territories of the two regions targeted by the Project, both within the general population and among refugees, births attended by qualified health personnel and the number of fully vaccinated children. At this level, the Project made it possible to achieve results that are equivalent to 120% of the target number of births attended by qualified health personnel and 123% of the same number among the refugee population. 8. Likewise, the quantitative objectives for the number of fully vaccinated children in the general population of the target regions and among refugees were achieved by 179% and 176% respectively, following Project interventions. Finally, the targets of Indicator 2, the number of pregnant women having attended four prenatal consultations in a health facility during pregnancy (within the population and among refugees) reached 156% and 81% respectively. In view of these results, we can conclude that, through the PBF, the INAYA Project has truly induced a significant improvement in the use of quality RMNCH services in the area of intervention. Benefits of increasing demand for health services 9. Through its second component, the Project aims to support the demand for health services through activities that promote and facilitate access to health services, particularly for the poorest. This involves relying on the national social registry system and the cash transfer program, transferring additional financial resources to the poorest families on condition of the use of health services. 10. The hypothesis is that granting additional financial aid on condition of the use of RMNCH health services would generate the following economic and social benefits: (i) an increase in the number of home visits received by children from 0 to 5 years, and (ii) an increase in the number of pregnant women referred for ANC1 by community health workers. The effectiveness of this strategy to promote the demand for health services is presented in Table 4.2. Page 54 The World Bank Health System Support (P156165) ICR DOCUMENT TABLE 4.2: TRENDS IN INDICATORS OF INCREASED DEMAND FOR HEALTH SERVICES N° Indicator Title Final Target Actual 2021 Actual 2023 Final Target Achievement (%) IRI-9 Number of pregnant 7,720 2,893 16,580 152% women referred for ANC1 by community workers IRI-12 Number of home visits 9,257 3,812 84,553 913% received by children aged 0 to 5 years cumulative Source: Data from the project document and project completion report 11. The data in Table 4.2 show that the demand for services for pregnant women was exceeded by 152% and that the number of home visits for children aged 0–5 was exceeded by 913%. Thus, even if we think that the projection of the evolution of this last indicator was too pessimistic at the time of the revision of the Project results framework in 2021, the results achieved led to the conclusion that the demand for health services from the target population has increased. Benefits of building the capacity of community health actors 12. The Project also supported the operationalization of the community health approach as well as local organizations involved in community health. The Project thus helped the Government in the development of a national community health strategy, accompanied by its budgeted action plan and implementation tools, such as training manuals, profiles, and terms of reference. The Project provides PBF mechanism resources to community health workers and community health volunteers. Likewise, it strengthened the capabilities of local organizations to increase the demand for services by conducting health awareness activities and the empowerment of women and mothers. 13. The underlying hypothesis is that these specific interventions could strengthen the use of preventive and high-impact services. The economic and social benefits are as follows: (i) an increase in the number of users of modern family planning methods within the population and among refugees, and (ii) an increase in the number of districts implementing the community health strategy. At the end of the Project, the situation of the two indicators measuring the economic benefits of strengthening the capabilities of community health actors is as shown in Table 4.3 below. TABLE 4.3: EVOLUTION OF INDICATORS RELATING TO THE IMPACT OF CAPACITY BUILDING OF COMMUNITY HEALTH ACTORS N° Indicator Title Final Actual Actual Final target target 2021 2023 achievement (%) IRI-1 Number of users of modern 164,560 94,700 242,254 147% family planning methods IRI-1.a-r Number of users of modern 5,328 1,968 6,237 117% family planning methods Page 55 The World Bank Health System Support (P156165) ICR DOCUMENT IRI-10 Number of districts 17 12 17 100% (Moughataa) implementing the community health strategy Source: Data from the project document and the project completion report 14. The data in Table 4.3 show that, at the end of the Project, the capacity-building actions of community health actors carried out had the effect of inducing an increase in the use of modern family planning methods by women and refugee women. The same efforts made it possible to cover 100% of the quantitative objective of the application of the community health strategy by the health districts of the Moughataa region. Benefits of strengthening emergency response capacities 15. During the global refugee forum in December 2019, the Mauritanian Government made the commitment to integrate refugees into its national health system. Thus, the INAYA Project provides, in its Component 4, intervention in emergency situations (IES). Through this component, the Project mainly helped refugees and host communities. 16. The expected benefits of emergency interventions, particularly for refugees, are summarized as follows: (i) increase in the number of births attended by qualified health personnel; (ii) number of pregnant women who attended four prenatal consultations in a health facility during pregnancy; (iii) number of children fully vaccinated; and (iv) number of refugees benefiting from preventive and curative interventions provided by the health centers. At the end of the Project implementation, the situation of the economic impact indicators of emergency interventions is as shown in Table 4.4. Table 4.4: Evolution of Impact Indicators of Emergency Response N° Indicator Title Final Actual Actual Final target target 2021 2023 achievement (%) OPD- Number of births attended by skilled 3,480 1,350 1,364 123% 1.a.r health personnel (number) OPD- Number of pregnant women who 2.a.r attended four antenatal consultations at a 2,954 796 2,391 81% health facility during pregnancy OPD- Number of children fully vaccinated 2,910 1,311 5,110 176% 3.a.r (number) OPD-5 Number of refugee women benefiting from preventive and curative 151,250 113,357 562,874 372% interventions provided by health centers Source: Data from the project document and project completion report Page 56 The World Bank Health System Support (P156165) ICR DOCUMENT 17. The data in Table 4.4 indicates that, except for the indicator relating to the number of pregnant women having attended four prenatal consultations in a health facility during pregnancy (which did not reach its target), the other three indicators fully achieved their targets. These are the number of births attended by qualified health personnel, for which the target is achieved and exceeded (123%); the number of fully vaccinated children, for which the target has been achieved and exceeded (176%); and the number of beneficiaries of preventive and curative interventions provided by the health centers, for which the target has been achieved and exceeded (372%). 18. The Project increased the economic potential of individuals in emergency situations. Over time, this has resulted in notable economic benefits which are: • resource savings linked to the avoidance of catastrophic health expenses due to serious complications or emergency medical interventions avoided or reduced; • the reduction of premature deaths in refugee families and host communities, which is synonymous with the absence or reduction of the emotional and financial costs associated with the loss of a mother or child; • increased work and productivity because, by guaranteeing safe deliveries attended by qualified personnel, mothers are allowed to recover and return to work more quickly; • the reduction in morbidity resulting from access to preventive and curative measures increases the productivity of refugees and their hosts, increases their income, and reduces poverty within this population; and • the improvement in children's health, the strengthening in their schooling, their cognitive capability and the freeing up of time for their parents' productivity. B. Cost-Efficiency Ratios of the Main Project Interventions 19. Cost-efficiency analysis in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs) from the Project is most often used to evaluate the impact of health projects. The cost-efficiency analysis is often supplemented by a cost-benefit analysis. This analysis does not simply count QALYs or DALYs averted but goes beyond to determine the likely monetary value of these DALYs and/or QALYs relative to the actual cost of the intervention. These two analyses first require, on the one hand, the quantification of the total number of DALYs avoided thanks to each of the Project services and, on the other hand, the estimation of the economic values or nominal DALYs or QALYs for each of the services delivered during the Project period and for the age distributions of the different beneficiaries. In the absence of a Project impact study dedicated to this purpose, it is difficult to conduct cost-efficiency and cost-benefit analyses based on the use of QALYs and DALYs. 20. In view of this difficulty and the fact that the literature has not made it possible to have data on similar interventions that could feed into the estimation of cost-efficiency and cost-benefit ratios using QALYs and DALYs, the evaluation of the cost-efficiency ratio was made according to the incremental cost-efficiency ratio (ICER) method. The latter is obtained by relating the incremental cost (cost of the intervention) to the difference between the final value of the indicator considered and its initial value. The value of the ICER obtained is compared with that of GDP per capita at constant price. The intervention is said to be “very cost -effective” if the value obtained is lower than the GDP per capita at constant price. It is simply called “cost-efficient” if the value is less than three times the GDP. Page 57 The World Bank Health System Support (P156165) ICR DOCUMENT 21. The ICERs were assessed for the main Project interventions, alternatively considering 2015 and then 2021 as base years (reference years), with 2021 being the base year of the adjusted/revised performance measurement framework of the Project. 22. Thus, considering the ICER (ICER1 in Table 4.5 below) estimated taking 2015 as the base year, the values of all Project interventions – whether they relate to improving RMNCH services, supporting growing demand in health services or the development objective of the Project – turned out to be lower than the amount of the GDP per capita at constant price. We conclude that the Project was “very cost-efficient”. 23. On the other hand, considering 2021 as the reference year for the main Project result indicators, the ICER values (ICER 2) establish two levels of efficiency. Indeed, given that the ICER 2 values are lower than the GDP per capita at constant prices for all interventions relating to the improvement of RMNCH services and support for the growing demand for health services, the Project was assessed as "very cost-efficient” at the level of these two components. 24. The Project was assessed as simply "cost-efficient" regarding the complete monitoring of the pregnancy by women and the provision of preventive and curative care provided by the health centers to refugees, which fell under the development objective of the Project. The ICER 2 of these services were US$3,234.5 and US$1,974 respectively, against a GDP per capita of US$1,616.8 in 2022. 25. A second alternative for assessing the cost-effectiveness of the Project was used. It consists of calculating and comparing the projected Project cost-effectiveness ratios (PCER) (Project cost divided by the initial targeted outcomes) and the actual cost-effectiveness ratios achieved (CE-Project) (Project cost divided by the results achieved). In this case, the Project is said to be cost-effective if the difference between the actual cost- effectiveness ratio of the Project and the projected cost-effectiveness ratio is negative. This means that, at the end of its implementation, the Project was more cost-effective, i.e. it achieved more results within the planned budget. The results of this second evaluation are shown in Table 4.6. Whether it is the development results or the basic outcomes of the components, improvement of the use of health services and support of the growing demand for services, this second alternative of evaluating the budgetary efficiency of the Project confirms the fact that the Project was highly cost-effective. Page 58 The World Bank Health System Support (P156165) ICR DOCUMENT Table 4.5: Cost-analysis of benefits ratios of different Project interventions Indicator Title Ref. 2015 Ref. 2021 Real. 2023 Total cost 2023–2015 2023–2021 ICER1 ICER2 Improved Health Services Utilization (RMNCH): Amount US$48.15 million Users of modern family planning methods (new and continuing, 8,969 96,668 248,491 48.15 239,522 151,823 201.025 317.1456 number) 4 People who received essential health, nutrition, and population 94,427 424,818 746,328 48.15 651,901 321,510 73.8609 149.7621 (HNP) services (number) 1 Children under 5 years of age who have been consulted in health 68,185 589,154 1,175,317 48.15 1,107,132 586,163 43.5 82.1 facilities (number) Postnatal consultations (number) 2,568 40,516 97,246 48.15 94,678 56,730 508.6 848.8 Support for the growing demand for health services: US$9 million Pregnant women referred for ANC1 by community workers 0 2,893 16,580 9 16,580 13,687 542.8 657.6 (number) Number of home visits received by children aged 0 to 5 years 0 3,812 9,257 9 9,257 5,445 972.,2 1652.9 (cumulative) Project development target: US$74.8 million Births attended by skilled health personnel (number) 12,278 94,538 138,840 74.8 126,562 44,302 591,0 1,688.4 Pregnant women who attended four antenatal consultations at a 4,444 33,385 56,511 74.8 52,067 23,126 1,436.6 3,234.5 health facility during pregnancy (number) Number of children fully vaccinated 9,046 129,730 203,860 74.8 194,814 74,130 384,0 1,009.0 Refugee populations benefiting from preventive and curative 113,357 151,250 74.8 151,250 37,893 494,5 1,974.0 interventions provided by health centers (number), Ref.2021 GDP per capita (US$ 2015) 1,560 1,616.8 [2022] Page 59 The World Bank Health System Support (P156165) ICR DOCUMENT Table 4.6: Assessment of Incremental Cost-Effectiveness Ratios Intervention Indicator Ref. Target CER CER 2015 Real.2023 2023 CT PCER Project Difference Improved Health Services Utilization (RMNCH): Amount US$48.15 million Users of modern family planning methods (new and 8,969 248,491 169,888 48.15 283.4 193.8 –89.7 continuing, number) People who received essential health, nutrition, and population services (number) 94,427 746,328 345,750 48.15 139.3 64.5 –74.7 Children under 5 years of age who have been consulted in health facilities (number) 68,185 1,175,317 822,020 48.15 58.6 41.0 –17,6 Postnatal consultations (number) 2,568 97,246 56,620 48.15 850.4 495.1 –355.3 Support for the growing demand for health services: US$9 million Pregnant women referred for ANC1 by community workers (number) 0 16,580 3,070 9 2,931.6 542.8 –2,388.8 Number of home visits received by children aged 0 to 5 years (cumulative) 0 84,553 9,257 9 972.2 106.4 –865.8 Project development objectives: US$74.8 million Births attended by skilled health personnel (number) 12,278 164,312 138,840 74.8 538.7 455.2 –83.5 Pregnant women who attended four antenatal consultations at a health facility during pregnancy (number) 4,444 56,511 7,720 74.8 9,689.1 1,323.6 –8,365.5 Number of children fully vaccinated 9,046 203,860 120,380 74.8 621.4 366.9 –254.4 Refugee populations benefiting from preventive and curative interventions provided by the FOSA (PMA + PCA) (number), Ref.2021 113,357 562,874 151,250 74.8 494.55 132.89 –361.66 GDP per capita (US$ 2015) 1,616.8 [2022] Economic and financial impacts of the Project (Number of lives saved, increase in income, and increase in public health financing and improvement in absorption rates) 26. One of the major impacts of the Project is its contribution to the preservation of lives of all ages and the reduction of mortality monitored through the targets of SDG 3. Thus, through the data in Table 4.7, we see the fact that the implementation of the Project made it possible to improve the indicator profiles of targets 3.1 and 3.2 of SDG 3, which relate to maternal mortality and child mortality. 27. On these bases and considering the number of women aged 15–49 and children under 5 years old, it was possible to estimate the contribution of the Project to the preservation of mothers’ and children’s lives affected by RMNCH. Table 4.7 indicates that the total number of deaths avoided increased from 2,415 in 2017 to 5,835 in 2021. TABLE 4.7: EVOLUTION OF MORTALITY INDICATORS AND ESTIMATES OF THE NUMBER OF LIVES SAVED AS A RESULT OF THE PROJECT 'S CONTRIBUTION. Indicators 2015 2017 2018 2019 2020 2021 Target OMD Maternal mortality ratio per 100,000 510 458 461 431 464 target 3.1 Births Page 60 The World Bank Health System Support (P156165) ICR DOCUMENT Infant mortality ratio per 1,000 37.2 35.5 34.7 33.8 33 32.2 target 3.2 Under-5 mortality ratio for 1,000 live births 48.9 46 44.6 43.2 41.8 40.5 target 3.2 Estimated Number of Lives Saved Number of maternal deaths averted 524 197 289 –33 Number of deaths under 5 years of age averted 1,892 2,831 3,821 4,845 5,835 Total number of deaths averted 2,415 3,028 4,111 4,812 5,835 Sources : Calculate based on data World Development Indicators, Updated March 2024 28. The wealth effect that these saved lives would generate was estimated (Table 4.8), based on the number of lives saved, the per capita income of Mauritania and a budgetary multiplier equal to 2, giving the direct and indirect effects of the injection into the economy. Thus, the data in the mentioned table indicate that, by injecting the income from lives saved into the economy, this would have result, depending on the level of the budgetary multiplier retained for Mauritania, in a total effect (direct and indirect) of the enrichment of the economy ranging from US$7,7 million in 2017 to US$18,2 million in 2021. TABLE 4.8: WEALTH EFFECTS OF SAVING LIVES IN THE ECONOMY Year 2017 2018 2019 2020 2021 GDP per capita (US$ 2015) 1,595 1,628 1,636 1,588 1,560 Total number of lives saved 2,415 3, 028 4,111 4,812 5,835 Effect of the fiscal multiplier 7,705,922 9,860,426 13,448,732 15,284,848 18,203,958 Source : GDP and number of lives saved estimated based on database data World Development Indicators, Updated March 2024 29. Operational efficiency was assessed by comparing actual Project costs with appraisal estimates. Project cost at appraisal was estimated at US$17.00 million, which comprised Component 1 (US$9.85 million), Component 2 (US$2.50 million), and Component 3 (US$4.65 million). The total Project cost at ICR was US$39.74 million (233.80 percent cost variance), consisting of Component 1 (US$29.63 million), Component 2 (US$0.91 million), and Component 3 (US$9.20 million) was increased through restructurings and AFs. The high variance of US$22.74 million was mainly due to the AFs provided by the World Bank during Project implementation (Table 4.9). As noted earlier, the AF extended the Project to cover refugee communities in Hod El Chargui region. This increased access to essential health services (inpatient and outpatient consultations, minor surgery, normal and complicated delivery, Cesarean sections, laboratory examinations, etc.) to over 1.1 million refugees and the host population. Efficiency was also enhanced because of better management of health centers’ and health posts’ revenues and medicines, coupled with systems strengthening. The Project financed medical equipment, strengthened the cold chain system for routine vaccination, and significantly improved medical waste management with the installation of incinerators in all the beneficiary facilities. Drugs and medicines were readily available because of a significant reduction in the stock-out rate. Project administrative cost was 20.3 percent higher than the acceptable Bank-wide practice, which is between 5 percent and 10 percent of total Project cost (Table 4.10). This was deemed reasonable because of the apparently high operational cost of PBF projects. Page 61 The World Bank Health System Support (P156165) ICR DOCUMENT Table 4.9: Cost overrun/underrun analysis Appraisal % Component Estimate Actual Variance of appraisal Support to improving utilization and quality RMNCH services through PBF 9.85 29.63 19.78 300.8 Support to increasing demand for health services 2.50 0.91 1.59 36.4 Capacity building and project management 4.65 9.20 4.55 197.8 Total 17.00 39.74 22.74 233.8 Source: PIU Table 4.10: Project’s operating and administrative costs Amount Amount % of Item of Expenditure (in MRU) (in US$) Total PIU operational cost Personnel salaries 33,27,087 919,368 2.30 Communication 1,707,473 47,103 0.12 MoH supervision 11,967,944 330,150 0.83 PIU Supervision 4,925,175 135,867 0.34 Seminars and workshops 18,813,336 518,989 1.30 Training of PTU staff and others 23,560,930 649,957 1.62 Rental 1,389,600 38,334 0.10 Study tours (domestic and international) 319,373 8,810 0.02 Fuel and Maintenance 8,989,658 247,991 0.62 Car rental 3,366,000 92,855 0.23 Logistics 12,753,978 351,834 0.88 Office supplies and IT/print 15,029,568 414,609 1.04 Consultations and studies 38,684,045 1,067,146 2.67 Regional level monitoring 119,741,264 3,303,207 8.26 Subtotal 261,248,344 8,126,226 20.30 Bank staff Preparation 138,151.97 Supervision 523,181.62 Subtotal 661,333.59 Total 8,787,559.9 30. Implementation efficiency was assessed by comparing specific time periods at each stage of the project cycle from concept to effectiveness with accepted country and regional averages. Overall, INAYA performed remarkably well from concept to the first disbursement (15.5 months), compared with Mauritania’s average (19 months), Africa’s average (22 months), and the Bank’s average (24 months). When disaggregated to different time periods, the Project again performed well from concept to approval and effectiveness to first disbursement. Although slightly lower than the Page 62 The World Bank Health System Support (P156165) ICR DOCUMENT averages for Africa (6.3 months) and Bank (6.2 months), approval to effectiveness activities took six months to complete, compared with Mauritania (3.7 months) (Table 4.11 below). As noted earlier, the main causes of the delays were recruitment of staff of the Project Implementation Unit (PIU), development and validation of the PBF implementation manual, and establishment of PBF schemes. These difficulties were addressed together with the government. Table 4.11. Project processing and implementation times Concept to Approval to Effectiveness to First Concept to First Approval Effectiveness Disbursement Disbursement INAYA Project 8.13 6.00 1.00 15.50 Mauritania 16 3.7 2 19 Africa 13 6.3 2,7 22 Bank 14 6.2 3.8 24 Page 63 The World Bank Health System Support (P156165) ICR DOCUMENT ANNEX 5. BORROWER, CO-FINANCIER, AND OTHER PARTNER/STAKEHOLDER COMMENTS INTRODUCTION 1. This report is a final evaluation of the INAYA Project. The project's development objective (PDO) was to improve the utilization and quality of Reproductive, Maternal, Newborn, and Child Health (RMNCH) services in selected regions and, in the event of an Eligible Crisis or Emergency, to provide an immediate and effective response to the said Eligible Crisis or Emergency. This assignment aims to determine: (a) the extent to which the project has achieved its development objectives and targeted results; (b) the likelihood of sustainability of the project's results; and (c) the performance of the World Bank and the Mauritanian Government, including compliance with relevant cross-cutting and safeguarding policies. It provides data to identify the main lessons learned from its implementation. 2. The report essentially includes three parts, followed by a general conclusion. The first, introductory section outlines the essential elements of the project: its objectives, components, and financing. The second part reviews the project's implementation and performance in terms of activity execution, financial execution, and the achievement of objectives, measured by indicators tracked throughout the implementation period. This work has been based on the project's basic documentation (PAD, audit reports, etc.), as well as on the compilation of quarterly financial monitoring reports and on the quarterly and annual monitoring reports produced regularly by the National Unit for Results-Based Financing since 2019. Unless otherwise stated, the data presented in this report are as at 12/31/2023. The third part of the report presents a summary of the results obtained after a series of interviews with the parties involved in its implementation (beneficiaries, project management unit, donors). Finally, a conclusion presents all the results obtained following the implementation of the project. A. BASIC PROJECT DATA • The project was financed in two stages: (i) initial financing and (ii) additional financing. • This was a new approach to health system reform, tested in three regions of the country: Hodh El Gharbi, Guidimagha and Hodh El Chargui (selected based on vulnerability criteria: poverty and low coverage of high- impact health interventions). The last region was added at the end of 2020. • Beneficiary population: 28% of the country's population (1,160,388 inhabitants in 2020) with over 70,000 refugees. • Beneficiary health facilities: All public health facilities in the three regions are now under PBF contract (393 health facilities: over 40% of the country's health facilities). All decentralized regulators (Region, District, Regional verification team) were under PBF contract. • Promoting decentralization: The region pilots and supervises the regional health system • Focus on quality of care: Quarterly monitoring of technical and perceived quality, with a quality bonus only awarded when the overall score exceeds 30%. Page 64 The World Bank Health System Support (P156165) ICR DOCUMENT • Establishment of mechanisms to protect vulnerable people (over 16% of the population (extreme poverty) benefits from this mechanism, which can go as far as total exemption from payment for care. • INAYA is jointly funded by the government (US$3.5 million) and the WB (US$40 million). • Approval: May 19, 2017. • Implementation: November 15, 2017 to December 2023. A.1 Cost and Financing Table 5.1 shows the breakdown of project costs by component IDA Project components Government Financing Total Financing Component 1: Improved use and quality of 28.5 0 28.5 healthcare services through PBF 1a. Payment to healthcare service providers 22 0 22 1b. Verification and cross-checking 6.5 0 6.5 Component 2: Support for greater demand for 6 2 8 health services 2a. CCT to boost demand for care 4 0 4 2b. Strengthening community health 2 2 4 Component 3: Capacity building and project 5.5 1,5 7 management TOTAL PROJECT COST 40 3,5 43.5 Page 65 The World Bank Health System Support (P156165) ICR DOCUMENT B. IMPLEMENTATION REPORT B.1 Activities Implemented Table 5.2: Summary of Main Achievements by Component Component I: Improving the use and the quality Component II: Increasing demand Component III: Strengthening the of healthcare services through PBF for health services social and environment safeguards aspects and project management • Regularity of the verification, counter- • Establishment of an active • Support for the SMART 2022 survey verification, evaluation, and payment process community system in the pilot • Management of a measles and in accordance with the PBF manual. (No zone (operational health rubella vaccination campaign in the delays recorded from 2019–2023) committees, contractualized pilot zone (with 557,135 children • Regular publication of statistical and financial CHWs and popularized tools) immunized, corresponding to a data on the PBF portal • Payment of CCT covering all success rate of 108%) (http://portailpbf.gov.mr/) Moughataa including refugees • Support for the malaria response at • Regular production of quarterly monitoring • Active involvement of local community level through the reports on the implementation of the PBF, elected representatives organization of a campaign in 7 with complete dashboards of results endemic districts (Moughataa) in framework indicators. the pilot zone • Strengthening community PBF • Progressive upgrading of health • Regular adjustment of the validity criteria for facilities: refurbishment of premises quantitative indicators, gradually introducing and acquisition of basic equipment more qualitative criteria • Acquisition of lab equipment for 10 • Performance of cross-checks in fiscal years health centers 2019, 2020, 2021, 2022 and 2023 with data • Construction of Montfort certification incinerators • Provision of 5 refrigerated vehicles for CAMEC and 3 buses for Regional Directorate of health, all intended for transporting medicines • Construction of 7 storage facilities • Training on PBF for region, district, health centers, and verification teams • Financial management training • Training of administrative authorities and local elected representatives on the PBF approach in Hod El Chargui and Hod El Garbi • Regular preparation of quarterly healthcare users’ satisfaction survey reports. Page 66 The World Bank Health System Support (P156165) ICR DOCUMENT B.2 Status of Monitoring Indicators a) Project Development Objectives 3. Of the eight project development objectives, only one (related to the number of pregnant refugee women who attended four prenatal consultations in a health facility during pregnancy) was not achieved. Table 5.3: Achievement of Project Development Indicators Ref Indicator name Achievements Final target Comments (percentage) ODP-1 Births assisted by qualified health personnel 160,021 135,360 118 (number) ODP-1.a.r Births assisted by qualified health personnel 4,291 3,480 123 (number) ODP-2 Pregnant women who attended four prenatal 81,307 53,557 152 consultations at a health facility during pregnancy (number) Pregnant women who attended four prenatal 2,391 2,954 81 ODP-2.a.r consultations at a health facility during pregnancy (number) ODP-3 Number of children fully vaccinated (number) 203,860 117,470 174 ODP-3.a.r Number of children fully vaccinated (number) 5,110 2,910 176 ODP-4 Average care quality checklist score 61 60 100 (percentage) ODP-5 Refugee populations benefiting from 562,874 151,250 372 preventive and curative interventions provided by the health centers (number) 4. The indicator relating to the average score on the quality-of-care checklist (percentage of annual increase) had reached, by 12/31/2023, exactly the project target value (61%). The other six indicators far exceeded the values targeted by the project. Page 67 The World Bank Health System Support (P156165) ICR DOCUMENT b) Intermediate Objectives Table 5.4: Objectives related to Component 1: Improving the use of health services. Number Indicator Realization Final target Comments (percentage) IRI-1 Users of modern family 24,2254 164,560 47 planning methods (new and continuing, number) IRI-1.a-r Users of modern family 6,237 5,328 117 planning methods (new and continuing, number) IRI-2 People who received 746,328 345,750 216 essential health, nutrition, and population (HNP) services (IRC, number) IRI-3 Health facilities with no 58 94 61.50 stock-outs of essential medicines in the last three months (percentage) IRI-4 Availability of basic 72 94 76.59 equipment (percentage) IRI-5 Children under 5 1,175,317 822, 020 143 consulted in health facilities (number) IRI-6 Postnatal consultations 94,531 53,550 177 (number) IRI-6.a–r Postnatal consultations 2,715 3,070 88 (number) IRI-7 Health service user 98 70 140 satisfaction (percentage ) IRI-7-a.r Health service user 90 75 120 satisfaction (percentage) IRI-8 Eligible poor people 879,373 230,000 382 and/or refugees who benefited from free curative consultations (number) 5. Eight indicators exceeded the project's target values. Three indicators made good progress but did not achieve their targets. 6. Objectives related to the "Support for growing demand for healthcare services" component. Four intermediate results indicators were used to monitor this component. Of these, three exceeded the target values, in some cases by a considerable margin (such as the number of home visits received by children aged 0–5, with an implementation rate of 913%). The fourth indicator had reached, by 12/31/2023, exactly the value targeted by the project. Page 68 The World Bank Health System Support (P156165) ICR DOCUMENT Table 5.5: Objectives related to "Support for growing demand for healthcare services" Indicator name Achievements Final target Comments (Percentage) Pregnant women referred 16,580 7,720 215 IRI-9 for CPN1 by community workers (number) Districts (Moughataa) 17 17 100 implementing the IRI-10 community health strategy Recipients of conditional 81 70 115.71 cash transfers (percenatge of eligible IRI-11 households receiving full transfers according to protocol) Number of home visits 84,553 9,257 913 IRI-12 received by children aged 0 to 5 (cumulative) Objectives related to the "Capacity building and project management" component: By December 2023, the three intermediate results indicators used to monitor this component had exceeded the project's target values. Table 5.6: Objectives related to "Capacity building and project management" Achievements Comments Indicator name Final target Health facilities submitting complete SNIS reports on 99 Satisfactory IRI-13 95 time (percenatge) progress Proportion of health facilities with an operational 100 Satisfactory IRI-14 90 health committee, total (percenatge) progress Complaints related to project delivery dealt with 100 Satisfactory IRI-15 75 satisfactorily (percenatge of complaints recorded) progress 2.3 Financial performance Mobilizing resources 7. On 31/12/2023, a total of US$43,378,472 had been disbursed, out of a planned total of US$43,500,000, representing an overall disbursement rate of 99.7%. Page 69 The World Bank Health System Support (P156165) ICR DOCUMENT Table 5.7: Disbursement status of project Sources Total programmed Total disbursed Disbursement rate IDA $ 40,000,000 40,000,000 100% BE/counterpart $ 3,500,000 3,378,472 96,5% Total 43,500,000 43,378,472 99,7% Use of resources 8. As at 31/12/2023, total project expenditure amounted to MRU1.5 billion, equivalent to around US$43.3 million, representing a 99.7% implementation rate of the initial project cost. Page 70 The World Bank Health System Support (P156165) ICR DOCUMENT Table 5.8: Use of project resources (in MRU) Components and sub-components Anticipated costs Expenses incurred Achieved (Percentage) Component 1: Improving the use of 1,008,615,000 1,029,006,984 102 SRMNE services 1a. Payment to healthcare service 778,580,000 782,060,801 100.4 providers 1b. Verification and cross-checking 230,035,000 246,946,182 107.4 Component 2: Support for greater 283,120,000 112,025,098 39.6 demand for health services. 2a. TMC to boost healthcare demand 141,560,000 34,428,371 24.3 2b. Strengthening community health 141,560,000 77,596,727 54.8 Component 3: Capacity building 247,730,000 393,243,857 158.7 TOTAL PROJECT COST 1,539,465,000 1,534,275,939 99.7 9. Another nomenclature was used in the financial monitoring reports to present a breakdown of project expenditure by category. For the period 2019–2023, technical costs represent 77% of total expenditure. Administrative and operational costs each account for 12% of total expenditure. Figure 5.1: Expenditure by Category 100% 50% 0% 2017 2018 2019 2020 2021 2022 2023 Technical expenses (quantity + quality) Administrative expenses Operating costs 10. Spending during the 2019–2023 period placed particular emphasis on the preventive, promotional and curative package. Indeed, 87% of spending was directed towards basic structures. Spending has been evenly distributed across the three regions. On average, spending in healthcare services by individuals has evolved from US$2 in 2019 to US$5 in 2023. Table 5.9: Evolution of healthcare costs per person per year in the three regions covered by the Project Region 2019 2020 2021 2022 2023 HEC - 1 3 6 5 HEG 3 3 3 4 4 GUI 3 4 4 5 5 Average 2 2 3 5 5 Page 71 The World Bank Health System Support (P156165) ICR DOCUMENT ACHIEVEMENTS AND IMPACTS 11. The INAYA project has achieved a number of results with a positive impact on the target population and the health system as a whole. These include: (i) investments, (ii) epidemiological surveillance and public health, (iii) health system decentralization, (iv) social safeguards, and (v) environmental safeguards. Epidemiological surveillance and public health: • Acquisition of all tools used for vaccinating against COVID19 • Acquisition of 300 tablets to manage COVID19 vaccinations • Training of COVID19 vaccination campaign supervisors. Strengthening decentralization and the healthcare system: • Institutional support through the creation of district management teams (a practice introduced by the Project and currently being rolled out by the MoH in all regions) • Health committees are operational in all health areas • Integration of refugee camp health facilities into the public health system • Substantial strengthening of the health system information (promptness, completeness, and data quality) with the implementation of a decentralized mechanism for health data management, enabling health facilities to ensure permanent availability of tools, reports, and the ability to produce quality data in a timely manner. Status of social safeguards: 12. The Project set up and monitored complaint management mechanisms and social safeguards on the ground in the three regions. The social safeguards flagship measures include: • Regular quarterly user satisfaction surveys (to be carried out before the end of the month following each quarter, based on samples drawn randomly each month from all health facilities) • Strengthening complaints management through training and ongoing monitoring of health committee in the management GRM • Installation of complaint boxes with registers to document the treatment process • Set up hospital-specific complaints management committees. Implementation status of environmental safeguards: 13. The Project has set up a system for the regular (quarterly) assessment of the biomedical waste situation in health facilities based on a grid designed for this purpose. Between the actual start of project activities in January 2019 to December 2023, 21 assessments were carried out. Positive results were documented in the reports from these assessments. The average score for health facilities stakeholder opinions: 14. As part of the mission to draw up the completion report for the Inaya Project (Ministry of Health), the PTU team included in the mission's terms of reference discussions between the consultant in charge of this mission and the project's main stakeholders at central and decentralized levels. The aim of these interviews was to gather the views of the various Page 72 The World Bank Health System Support (P156165) ICR DOCUMENT parties involved in the PBF scheme on the project as a whole and its implementation. Stakeholders include government departments, doctors, healthcare facilities receiving funding, beneficiaries of healthcare services, local elected representatives, etc. Due to a lack of time and resources to conduct interviews with officials at the deconcentrated level in the project's three pilot regions, the Hodh Gharbi region was chosen for the collection of information in the field. 15. Regarding the project's relevance, all the players we met were unanimous on the interest shown by the activities carried out within the framework of the project for all stakeholders: target populations, beneficiary health structures, local authorities and administrative structures involved in the project's implementation. They all felt that the PBF approach had clearly improved the health system in the project's intervention zones. 16. Stakeholder feedback covered the following themes: (i) project strengths, (ii) project weaknesses and (iii) recommendations for future phases of the project. Project strengths/highlights: • Fairly smooth operation of the project steering structures: Steering Committee and PTU. The latter was a major driving force behind the success of the project • PBF concept appreciated by all stakeholders: MoH’s human resources, elected representatives, and the general public • Motivation of health workers, especially those involved in operations • Remarkable improvement in equipment at health facilities benefiting from the project • Stimulate HR initiatives at all levels of the healthcare system • Operationalization of a system for monitoring and evaluating activities and performance indicators in healthcare facilities • Transparency in the management of performance bonuses for teams involved in Project implementation • Remarkable improvement in health indicators in project areas. Project weaknesses: • Structural shortage of human resources, particularly at decentralized level. This can, in some cases, affect the results evaluation process (basis for payment of actors) • Cumbersome procurement procedures • Lack of visibility regarding the sustainability of the results obtained thanks to the project, and the risk of the momentum already in place collapsing if the question of funding for future phases of the project is not resolved in a sustainable way. • Weak communication, both locally and nationally, on the project, its results and the transition period between phases • PBF approach covering only maternal and child health and nutrition services Page 73 The World Bank Health System Support (P156165) ICR DOCUMENT • Presence of unbuilt health posts and difficulties in evaluating them • Budgets for setting up health committees are not always in place (training, travel) • The list of reference drugs drawn up by the central level is not always convenient for doctors in the local field (this list is used to calculate certain indicators). Recommendations for future phases of the project: • New project phases to cover all services: health centers and hospital care • Extend the approach nationwide • Set up a financing mechanism to ensure the long-term viability of achievements • Adapt the size of steering structures to that of the project and its activities, with a view to generalizing the approach • Prioritize human resources training in new project components • Capitalize on human resources already familiar with the FBR approach to transform some of them into trainers in the project's new zones • Maintain the rigor required for the success of the project in the selection of personnel, particularly in the audit component • Improve coordination between the INAYA project and other Ministry of Health projects, particularly the pooling of resources • Make communities aware of the role of their participation in the financial equilibrium of the system as a whole • Renew health committee members for a better representation of populations • Revise and improve health committee payment procedures, with the aim of meeting deadlines, raising the level of premiums and payment frequency, and adding a remoteness premium (considering the geographical nature of the moughtaas) • Introduce the principle of performance contracts between the project, health committees, and health facilities • Comply with project payment deadlines. CONCLUSION 17. The aim of the INAYA Project is to improve the use and quality of reproductive, maternal, neonatal and child health services in certain regions and, in the event of an eligible crisis or emergency, to provide an immediate and effective response to said eligible crisis or emergency. 18. The start of its implementation coincided with a worldwide crisis, the COVID-19 crisis, which caused major delays in the execution of activities during 2020. Since the mid-term review, these delays have been caught up and a sustained rate of disbursements has been recorded. On 09/30/2023, the rate of disbursement of project resources had reached around 96%. In terms of activity execution, a good proportion of the programmed activities were carried out, despite a few delays caused, often, by a combination of factors: slow procurement procedures, weak human resources, and Tekavoul's lack of Page 74 The World Bank Health System Support (P156165) ICR DOCUMENT responsiveness. In terms of objectives, the project has performed remarkably well, with almost all the project monitoring indicators in the PAD meeting or exceeding their targets. 19. In terms of sustainable impact, the activities carried out under the project and the achievement of the targets set for the project's monitoring indicators reflect that the project's structuring action has been beneficial to community health in the project's pilot zones. Training activities, the acquisition of equipment aimed at modernizing beneficiary structures, and the introduction of a culture of monitoring and rewarding efforts are all actions whose scope is structuring in the medium and long term. 20. The opinions of the project's beneficiary structures on its implementation show that it was very satisfactorily piloted and implemented. This is confirmed by the significant improvement in health indicators in the pilot regions. The main wish of the beneficiaries is to see a new phase of the project pursuing the same logic of action and coordination followed in the phase that is ending. They also expressed their wish to see the new phase take charge of services other than the maternal and child health, and throughout the national territory. Page 75