SIERRA LEONE: Quality Essential Health Services and Systems Support Project (QEHSSSP) – P172102 Mid Term Review October 21-November 15, 2024 Aide Memoire I. INTRODUCTION 1. A Mid Term Review (MTR) Mission1 took place in Sierra Leone from October 21 – November 15, 2024 for the aforementioned World Bank-financed project. The objectives of the MTR mission were to: (i) Evaluate the project performance, achievements and implementation progress since effectiveness; (ii) Reassess the relevance, effectiveness, and efficacy of the design and implementation arrangements including financial management and procurement, environmental and social standards; (iii) Review the proposed changes to the Results Framework indicators and reach consensus on revised targets; and (iv) Identify and prioritize appropriate actions regarding the future of the project, including a possible restructuring to align remaining financing, and the results framework, with current reforms and priorities of the Government of Sierra Leone (GoSL). 2. The MTR mission greatly appreciates the continuous support and leadership of the GoSL, through the Ministry of Finance (MoF), the Ministry of Health (MoH), and the Integrated Health Projects Administration Unit (IHPAU). The mission would like to express gratitude to the Chief Medical Officer, Dr Sartie M. Kenneh for his leadership, guidance and participation in the mission as well as the various MoH directorates and Agencies, Partners in Health (PIH) and health development partners for their participation and meaningful contributions. The full list of stakeholders met during the mission is presented in Annex 1. This Aide Memoire summarizes the key issues and next steps discussed and agreed during the MTR at the wrap-up meeting with the GoSL on November 15, 2024, chaired by the Minister of Health. The final version of the Aide Memoire was endorsed by World Bank management. II. PROJECT DATA AND RATINGS Table 1. Key Project Data and Ratings Project Data USD (millions) Original Project Amount IDA Grant – US$40m GFF Grant – US$20m Total Disbursement US$ 16.71m (as of December 2, 2024) (29%) Disbursement in FY US2.52$ m Closing Date 12-21-2027 Project Ratings: Previous (May Current 2024) (December 2024) Project Development Objective (PDO) S S 1 The mission was led by: Yohana Dukhan (Senior Economist, Task Team Leader). Mission participants included: Olga Guerrero (Health Specialist), Angus Fayia Tengbeh (Health Specialist, Extended Term Consultant), Tomo Morimoto (GFF Focal Point), Daniel Kamara (GFF Liaison Officer), Kirsten Gagnaire (GFF, Consultant), Innocent Kamugisha (Senior Procurement Specialist), Pamela Chebiwott Tuiyott (Senior Social Development Specialist), Sydney Godwin (Financial Management Specialist), Rahat Jabeen (Senior Environmental Specialist), and Jeneba Kamara (Team Assistant). Seble Berhanu (Analyst) supported the mission remotely. 1 Implementation Progress MS MS Component 1: Improving Quality, Efficiency, and Effectiveness of MS MS Reproductive, Maternal, Newborn, Child Health, and Nutrition Services Component 2: Strengthening National Level Systems MS MS Component 3: Project Management and Monitoring and Evaluation S S Component 4: CERC S S Project Management S S Procurement S S Financial Management S S Monitoring & Evaluation S S Environment & Social Standards MS MU 3. Since its effectiveness, the project has made notable progress towards the achievement of the PDO. Progress towards achievement of the PDO is considered Satisfactory based on the performance against the Project’s results framework, both in terms of PDO indicators and intermediate results indicators (IRIs). 4. Performance as of Q2 2024 (latest data available at the time of the MTR) is as follows: • PDO indicators: Two of the four PDO indicators are likely to meet the end of project target (PDO2 on ANC-4 attendance and PDO4 on Quality of Care in health facilities) given that they have met the annual target for 2023 and are on track to meet the target for 2024. PDO1 (People who have received essential health, nutrition, and population (HNP) services) is likely to be met once the initial errors on target setting are corrected based on revised population statistics. PDO3 (Institutional deliveries) was met in 2023 and is likely to be met as a result of investments and improvements currently being made to target health facilities and commitment to boost community outreach and improve data collection. • IRIs: The performance of intermediate results indicators is mixed and illustrates the unbalanced performance between Component 1 and Component 2. Seven of the fourteen indicators (five related to Component 1 and two related to Component 2) are likely to meet the end of project targets (IRI4 Penta 3 vaccination, IRI5 CYPs, IRI6 Maternal death reviews, IRI7 Health facilities with personnel trained in GBV, IRI10 Monthly facility management committee meetings, IRI13 RMET completed and used, IRI 14 Quarterly reports produced by the UFMP), given that their respective targets for 2023 were met and they are on track to meet the targets for 2024.The remaining seven indicators (of which five are related to Component 2) that are not on track, can be grouped in three categories: (i) Indicators for which initial target settings or definitions were inaccurate, and hence the performance of activities is not truly reflected by the indicator and which are proposed to be adjusted following the MTR (IRI1 Treatment of SAM, IRI8 Timely and routinely HMIS reporting); (ii) Indicators which are not clearly linked to current project activities and where the scope of work and/or the indicator might need to be reconsidered (IRI2 CHW visits; IRI9 Centralized bio-medical waste treatment facility); and (iii) Indicators related to activities that have suffered from a slow implementation but possible to meet end of project targets with accelerated implementation plan and corrective measures (IRI3 Referrals to hubs, IRI11 EHS service delivery monitoring, IRI12 Grievances addressed). 5. Despite these achievements, overall implementation progress has been slower than expected with a disbursement rate at 29 percent (Table 1) as the Project is about to complete its third year of implementation. This performance translated in several downgrades across the Project since its effectiveness; Implementation Progress was downgraded to Moderately Satisfactory (MS) in June 2024 and both Component 1 on service delivery activities and Component 2 on 2 support to national level systems were downgraded to MS in June 2024 and June 2023, with a disbursement rate of 32 percent and 7 percent respectively. 6. Given the recent progress noted for high value activities/ procurement processes and the expected acceleration of implementation and disbursement in the coming months, current project ratings are proposed to be maintained at MTR, at the exception of environmental and social standards. Hence, PDO remains rated Satisfactory and IP Moderately Satisfactory. Components 1 and 2 remain as Moderately Satisfactory and Component 3 on M&E and Project Management remains as Satisfactory. CERC has never been activated under Component 4 and so is rated Satisfactory. Ratings for Project Management M&E, Financial Management and Procurement are kept as Satisfactory. E&S is downgraded to Moderately Unsatisfactory due to the persistent delays in the establishment of the project Grievance Redress Mechanism. III. MTR KEY ISSUES AND FINDINGS 7. The Project has made significant progress in terms of service delivery in the five districts. Some of the main project’s achievements under Component 1 to date include: (i) capacity building and technical assistance to five decentralized district health management teams (DHMTs) and clinical staff has been provided on clinical and project management competences and will continue throughout the project cycle; (ii) referral mechanisms have been established and supported through the National Emergency Medical Services (NEMS) to conduct referrals in all the 179 health facilities benefiting from the project, moving patients from lower levels of care (spokes) to a higher level (hubs) or district referral hospitals for specialized care and 14 new ambulances have been procured and delivered to expand the ambulance fleet in the districts; (iii) procurement and distribution of drugs and medical supplies and equipment for the hubs has been completed in all the five districts for the first round for the next round are ongoing; (iv) delivery of maternal and child health services is in progress across the 14 hubs health facilities; (v) recruitment and deployment of technical staff has been undertaken in all project districts with some additional personnel still being recruited; (vi) rehabilitation of the 14 hubs is in progress and actual works will be initiated in the second half of the year; and (vii) capacity building in clinical management of intimate partner violence and sexual violence has been complemented and a GBV training manual has been finalized. 8. In terms of support to national level systems under Components 2 and 3, the project has strengthened the following areas: (i) Capacity building for 523 senior management and MoH staff has been provided on various courses including Project Management in Global Health, Economic Evaluation in Global Health, Leadership and Management in Global Health, Policy Development and Advocacy in Global Health and Fundamentals of Implementation of Science online in collaboration with the University of Washington; (ii) Academic staffing and training programs have been strengthened through the development of a curriculum in health economics - additional curriculum are being developed in dentistry, public health and medico- surgical nursing and midwifery & obstetrics nursing – Tuition and other university charges have been supported for about 300 students enrolled in 2024 in the Bachelor of Science in Clinical Medicine, and Advanced diploma in Science in Clinical Medicine programs at the Makeni School of Clinical Sciences; (iii) The Unified financial management and reporting portal has been established and is fully operational, three resource mapping and expenditure tracking (RMET) exercises have been completed and the fourth one is ongoing; (iv) An assessment is ongoing to inform the digitalization of the Health Management Information Systems (HMIS); (v) Policy and regulatory instruments for Public-Private Partnerships in health are under-development; (vi) Design of ICT tools to harmonize insurance platforms with the HMIS, development of a matrix for billing and claims management under Sierra Leone Social Health Insurance (SLeSHI) are being 3 finalized; (vii) A five-year strategic and business plan has been developed for NMSA and TA is being provided on warehouse management and commodities distribution; (viii) The feasibility study for the establishment of the Centralized Biomedical Waste Management Treatment Facility is being finalized; and (ix) Curriculum to support Para-Veterinary training at Najala University has been finalized, and tuition and other university charges have been supported for 30 para-veterinary students enrolled in 2024 at the Njala university; (x) Data collection and reporting systems have been strengthened at three levels (health facility, district, central) resulting in improved monitoring and evaluation of key project and RMNCHN indicators; and (xi) Dedicated project management and supervision of project activities has been ensured through the project’s PIU (IHPAU). 9. The MoH2 and the MTR mission identified three main underlying challenges to account for implementation delays and slow disbursements, which were the focus of the discussions during the mission: (i) Insufficient technical details to operationalize the hub and spoke service delivery model: Whilst the project’s technical design seems adequate to improving health outcomes in the project districts, it presents a new approach to health service delivery, particularly in the four districts where the DHMTs are expected to lead the project implementation. For example, the project is designed following PIH’s experience in Kono district, which categorizes investments as around 5S: Staffing, Stuff, Systems, Space, and Social support in the hubs to improve maternal and child health outcomes. Yet, at the time of project start up, no comprehensive document to guide implementers on the actual requirements in terms of numbers and cadres of staff needed per hub, the standard technical designs of a hub as well as the level of services and medicines to be delivered in these hubs and their spokes, and how the various systems are supposed to support service delivery in the hubs was available. Similarly, the model alters the standard referral pathways these had not been defined during project preparation and the criteria for referral from spoke to hub was only agreed during the first year of implementation. These issues are compounded with the lack of standards for health facilities in the context in Sierra Leone and the huge disparity amongst hubs in terms of infrastructure, personnel, package of services provided, volume of demand for services and existing supplies/equipment. The lack of granularity in the model, practical technical details and guiding documents have hindered the translation of the idea into practice and resulted into decision-making in parallel to the roll out of the model, thereby delaying project implementation. In addition, the evolving donor landscape since Project preparation has increased expectations and demands on the scope of the Project and the hub and spoke model. (ii) Complex and ineffective decentralized institutional arrangements: The success of the hub and spoke model in the delivery of quality health RMNCAH-N as initially designed depended crucially on the institutional arrangements devised and key stakeholders involved, specifically it relied on: (a) the ability and accountability for service delivery of decentralized MOH structures (namely the DHMTs); (b) the assumption that the successful model developed by the international NGO (PIH) in Kono district could be replicated and scaled up through a public-private partnership with the Ministry of Health under a WB project; (c) the continued leadership and engagement of the MoH at various levels to support this innovative approach. Whilst there continues to be a strong buy-in for the project and high expectations for its results, constraints at different levels have hindered an implementation as swift as initially intended and resulted in slower disbursements: 2 The Ministry of Health prepared a MTR assessment report prior to the mission which was used as a reference for all discussions throughout the mission. 4 • Ability and accountability of DHMTs: The project has seen an increasing level of engagement of DHMTs, demonstrated by the participation to regular project discussions and meetings. However, the systems to ensure an adequate management of resources and processes did not exist at project effectiveness and has had to be built progressively. A mechanism for the direct disbursement of quarterly advances and eligibility of expenditures was developed jointly by IHPAU and guidelines for recruitment processes have benefited from considerable handholding from IHPAU and WB teams. Limited capacity of DHMT personnel and structures also limits the extent to which IHPAU wishes to confidently decentralize decisions, funds and responsibilities to DHMTs given risks of potential ineligible expenditures. • Partnership with PIH: PIH’s service delivery model in Kono is implemented under rules and regulations from different donors, where PIH has more autonomy over foundational activities such as recruitment, procurement and training activities. In addition, prior to QEHSSSP, PIH had no experience in executing project under WB rules and regulations for IPF projects nor undertaking public procurement processes. Some effective measures were put in place such as agreeing on a streamlined no- objection process for recruitments, providing capacity building on procurement through IHPAU’s TA and dedicated regular meetings and guidance from the World Bank teams. • Engagement of MoH: Despite high level support and commitment to the project and hub and spoke model, the project has continuously suffered from lack of technical coordination and oversight at MoH level. This has been documented in the two most recent missions, evidenced by the fact that the Steering Committee Meetings outlined in the project’s Financial Agreements have not taken place. (iii) Systemic issues hindering successful Project implementation: The health system in Sierra Leone is constrained by serious structural issues across all health system pillars, which in turn affect effective and efficient project implementation. Challenges are particularly salient on pharmaceuticals supply chain with weak distribution and monitoring systems, human resources for health with a low density of skilled workers, inequitable distribution and a large number of unsalaried workers, health financing with very limited government spending for the health sector (less than 5 percent of government spending) and a constrained fiscal space for resource mobilization, and governance. 10. The MTR addressed the inconsistencies in the Results Framework that had been identified during project implementation. Inconsistencies included: (i) Calculation errors in the number of target beneficiaries (for instance PDO1b Number of children who have received a third dose of Penta 3 had a target that was largely overestimated); (ii) Unclear linkages between project activities and indicators, for instance in the case of nutrition services offered at primary level being treatment of MAM but the indicator referring to SAM treatment (IRI1 Children 0-59 admitted for SAM that are cured for SAM in the target districts) or the case of FMC meetings across all target health facilities, when the focus of the project is on a selected few; (iii) Incoherent targets considering baselines or annual performance, for instance in the case of PDO4 Average Score of the Health Facility Quality of Care or IRI5 on Couple Year Protection reached through project interventions. The discussions during the MTR focused on a thorough revision of issues with problematic indicators, in terms of targets, denominators, definitions and data points used. The MTR also considered the possibility of additional indicators that could help to better monitor quality of health services and the progress/success of the hub and spoke model. 5 11. One key finding from the MTR is that the project will need adjustments and funds reallocations to address increased service delivery needs, particularly at spoke and district hospital levels, which were considered under-resourced by the MoH MTR assessment. More funds should be allocated for drugs, medical and laboratory supplies and equipment to hubs, spokes and hospitals as well as for rehabilitations of hubs, including access to water and energy. Original allocated amounts during project preparation were found in several instances insufficient, particularly for procurements of pharmaceutical supplies, medical equipment and rehabilitations. In terms of support to national level systems, investments should be prioritized on activities that will have a direct impact on service delivery and can produce results before the closure of the Project. A costing exercise is underway to identify the gaps for Component 1, and consequently reprioritize Component 2 activities to focus on strategic areas that will have the greatest impact. The agreed areas during MTR include: (i) pharmaceuticals supply chain; (ii) emergency referrals mechanism; and (iii) comprehensive rehabilitations of hubs. Procurement 12. The overall rating of the project’s procurement performance is Satisfactory, and the project risk remains Moderate. The mission noted that at mid-term the procurement had procured equivalent to US$4,846,328 out of the planned projected amount of US$7,553,155 for IHPAU representing 36 contracts both signed and under the procurement process at different stages in the procurement process roadmap. PIH has procured contracts equivalent to US$ 2,194,225 out of the planned projected amount of US$ 3,899,267 representing 23 contracts both signed and under the procurement process at different stages in the procurement process roadmap. 13. The mission was informed of challenges of significant delays in starting the planned procurement processes due to technical activities not completed in time and providing technical inputs to procurement processes. Though this is not purely a procurement challenge, but it affects project disbursement as well achievement of PDO, the mission advised that before planning, the project team should think of sequencing of activities to avoid lapses since the procurement system starts counting from the date of planning. The mission was also informed of delays in internal review and approval of project documents from service provider, the mission encouraged the project team to put in place strategies to ensure quality and timely review of project documents and reports to enhance delivery. The project has experienced recurrent significant discrepancies between the budgeted amount and the response from the market where market prices emerge to be abnormally higher. The team was advised to do market research, update PPSD and revise the budgets to match with the current market trend. The mission was informed about the poor performance of some service providers, the team was advised to strengthen contract management systems because a contract is sharing of risks and obligations to deliver a given output, and a strong relationship and monitoring must be put in place so that each party to the contract fulfils its obligations. Financial Management (FM) 14. The overall FM performance and FM risk rating for the Project remain Satisfactory and Substantial, respectively. The existing financial management procedures and systems continue to meet the minimum World Bank requirements for financial management. However, some FM arrangements described in the PIM pertaining to the payment of advances to IPs were deemed ineffective and will be revised to provide more autonomy and effective decentralization of funds to DHMTs activities. 15. As of December 2, 2024, project disbursements total US$16.71 million, representing 15 percent of the IDA grant and 45 percent and 64 percent of the GFF grants. Given the earlier closing dates 6 of the GFF grants, the project has prioritized expenditure relevant to those grants, particularly the WCA grant linked to ensuring continuity of essential health services following the COVID-19 pandemic. A reposting exercise of expenditure from the EWEC to the WCA grant is underway due errors in withdrawals amounts across the funding sources which will increase the disbursement of WCA grant and lower the EWEC grant disbursement. 16. Total expenditure by the Project from January 1 to November 30, 2024 was USD 6.1million which is approximately 41 percent of the 2024 total annual work plan (AWP) budget. The 2025 AWP is under preparation and must be submitted by Tuesday 30th November 2024. 17. The unrealized foreign exchange loss as on Monday 30th September 2024was approximately USD 1.98 million. This should be regularly monitored over the course of the project and budgets adjusted as needed. This volatility could also result in a greater “loss� if the USD continues to strengthen against the SDR. 18. The IFR for the quarter ended 30th September 2024 has been submitted and accepted by the Bank. The internal audit report relating to the project’s activities undertaken during the period 1st January – 30th June 2024 has been received by the Bank. The audit report, management letter and remedial action plan for the year ending December 31, 2024, should be submitted to the World Bank before the due date June 30, 2025. The project has a substantial amount of undocumented balances. The project should document the amounts spent but not yet documented as soon as possible. Environmental and Social Safeguards 19. The overall Environmental and Social risks classification is maintained as Substantial and the Environmental performance during this MTR mission is downgraded to Moderately Unsatisfactory. As set out in the ESCP, the E&S safeguard unit at IHPAU is fully functional with requisite staff including Environmental Specialist, Social Specialist, and Medical Waste management specialist. The unit is supporting on E&S aspects by ensuring compliance with E&S standards during the implementation of project activities. The mission noted a satisfactory progress in the implementation of actions agreed during the last mission. The project has completed the implementation of all the E&S actions agreed during last mission (May-2024), except the action on timely submitting the progress reports for second and third quarters of 2024. These reports were expected to be submitted by September 2024. The mission recommends IHPAU to share the reports by November 15, 2024. As of October-2024, the project has conducted E&S screening of 19 subprojects employing approved Screening checklist. The screened subprojects include three health facilities in Kailahun, Tonkolili, and Falaba, respectively, two health facilities each in Bonthe and Western Area Rural, one proposed Health Economic Building at Fourah Bay College, and four Points of Entry (POEs) in Kailahun. The mission however noted that the physical work at sites is yet to commence as hiring process of contractors for Bandajuma and Buedu is in progress. Currently submitted bids are being assessed and evaluated. Notwithstanding the delays, ESMP instruments for Bandajuma and Buedu have been finalized and will be disclosed immediately following the award of contracts to be followed by training of all staff and contractors on OHS, and E&S risk management to ensure compliance with E&S Standards. In addition, ESMPS for the priority health facilities in Bonthe, Falaba, Western Area, and Tonkolili are under development and would be disclosed after the hiring of contractors for the civil works, while work on four Point Of Entries ESMPs is yet to commence as this activity has been put on hold. 7 20. The mission noted that the project has conducted the Feasibility Study (FS) for the construction of a Centralized Bio-medical Waste treatment plant (CBMWMP), and the report has since been received by IHPAU. The report is however yet to be submitted to the World Bank. The mission advised the project to conduct a thorough review on the contents and assess the feasible non- burning waste management technological options. The project should share the report with comments/recommendation for World Bank’s review and feedback on priority. 21. The mission noted with concern the continued delays in actualizing the implementation of the approved GRM roadmap. These delays resulted in the downgrading of the E&S rating from Moderately Satisfactory to Moderately Unsatisfactory. Although the importance of establishing a functional web-based GRM platform was highlighted during the last mission, no significant progress was achieved since then for the transitioning of the GRM platform from the ACC GRM Platform to the National Public Health Agency’s 117 platform. As a result, the project is currently documenting, and tracking grievances manually but these are not being reported. The mission advised the MoH to accelerate the implementation of the GRM roadmap. Despite this delay, the project has established Grievance Redress Committees and trained committee members in all project districts and 14 hub communities to ensure that grievances are documented and resolved at the community level. In parallel, the mission recommended that the MoH accelerate efforts to establish a functional online GRM system. Upgrading to MS will be considered once the GRM mechanism is fully functional. Monitoring & Evaluation 22. The mission noted the sustained positive performance of the M&E unit at IHPAU. This is reflected in the proposed revisions to the RF put forward during the MTR, the regular timely submission of agreed actions and quarterly Results Framework updates, as well as the improvement in the qualitative explanations of performance and collaboration with DPPI and decentralized implementation partners. Nevertheless, the timely submission of bi-annual progress reports of quality remains an area for improvement. Further, the transition plan and the sustainability of the Technical Assistance being provided to the team remains an area of concern. Global Financing Facility 23. The mission provided an opportunity to formally announce the transition of the GFF Country Focal Point for Sierra Leone from Mr. Lawrence Mumbe (outgoing) to Ms. Tomo Morimoto (incoming). With His Excellency Minister Demby formally appointed as Chair of the GFF Ministerial Network, the mission reaffirmed the GFF's continued support in close partnership with the World Bank to improve the country’s reproductive, maternal, newborn, child, adolescent health, and nutrition (RMNCAH+N) outcomes. 24. Investment Case (IC): As the current RMNCAH+N strategy, which serves as the country's investment case for improving RMNCAH+N outcomes, expires in December 2025, the RMNCAH+N multistakeholder platform will lead the process of an endline evaluation of the current strategy which will guide the development of a new RMNCAH+N strategy for the period 2026-2030. The mission noted that a comprehensive TOR for the evaluation and development of the new strategy is being developed. In the meantime, the mission welcomed the planned annual review meeting of the RMNCAH+N Strategy to be held in mid-December, which will allow for all stakeholders to assess the progress and identify key challenges for further action. 25. Country platform: The mission was pleased to note that the RMNCAH+N multi-stakeholder platform is meeting regularly to review progress on the RMNCAH+N strategic objectives, with a particular view to identifying the actions needed to maintain or accelerate the pace of results 8 and to mobilize the resources needed to implement the RMNCAH+N strategy. The GFF will explore further ways to support this platform, including technical support for data analysis and use, coordination and alignment, and operational aspects. 26. CRVS: Following a request from the National Civil Registration Authority (NCRA), the GFF agreed to support the endline evaluation of the current CRVS Strategic Plan (2019-2024) and the development of a new Strategic Plan through an international consultant who will provide technical assistance for both the endline evaluation and the development of the new strategy. In close coordination with other supporting partners, including UNFPA and UNECA, a detailed implementation plan will be developed by the NCRA. The new strategic plan will be costed and include a detailed M&E framework. IV. AGREED CHANGES 27. Agreed adjustments to Component 1: • Develop Project implementation guidelines: Given the limited information on the operationalization of the hubs and spoke model and limited understanding amongst the various project implementers, the mission agreed to develop implementation guidelines moving forward. • Intensify and expand support to health facilities within the five target districts: a. At spoke and community levels: (i) include as spokes supported by the Project all Community Health Centers/Basic Emergency Obstetric Neonatal Care facilities existing in the five districts, increasing the total number of health facilities supported from 179 (165 spokes and 14 hubs) to 228 (214 spokes and 14 hubs); (ii) provide essential drugs, medical supplies, basic medical and lab diagnostic equipment to all 214 spokes (in addition to the 14 hubs); and (iii) provide essential medical supplies to Community Health Workers (CHWs); b. At hub level, the Project will expand the scope of rehabilitations to strengthen and expand maternity sections and will fully solarize the 14 hubs3. c. At the district hospital level, the Project will provide: (i) essential drugs and medical equipment with a focus on maternity and children under-five, lab equipment and supplies and blood supplies; (ii) minor rehabilitations to improve hospitals theaters. d. At the district level, support will be provided to (i) first and last mile distribution of Free Health Care commodities to all health facilities in the five project districts; and (ii) NEMS referral systems for all health facilities across the project districts. • Enhance autonomy to DHMTs: Improve decentralization of Project implementation by providing more autonomy to DHMTs and hubs along revised SOPs for the disbursement of funds to Implementing Partners (IPs). • Strengthen district capacities for last-mile delivery of drugs and medical supplies: Given the lack of a sustained mechanism at the district levels for the constant supply and replenishment of drugs and medical supplies in the health facilities, the establishment a district owned system to spearhead the last-mile delivery of drugs and medical supplies was discussed and agreed. 28. Agreed adjustments to Component 2: a. Re-prioritize investments on strategic areas that can demonstrate impact on service delivery and RMNCAH-N outcomes at district level: 3 Additional solarization will be provided to 14 spokes under the ESLEAP Project. 9 b. Strengthen pharmaceuticals supply chain to improve planning and management of overall supply chain as well as distribution and monitoring; and (ii) Support referrals system to improve NEMS management and operations. • Establish a supply chain monitoring system: rollout of Mobile M-Supply to monitor drugs utilization in the hubs and spokes was deemed necessary to aid the prompt replenishment of supplies to the health facilities as well as provision of consumption data to procurement processes. • Streamline Component 2 and reallocate funds balance to component 1: scope of activities will be reduced or dropped under a number of areas/ sub-components (e.g. SLeSHI, MSc in health economics, specialized trainings, centralized biomedical waste management treatment facility). 29. Agreed adjustments to Component 3: • Streamline M&E capacity building activities which appear to overlap between Component 2 and 3. 30. Agreed adjustments to Institutional and Implementation Arrangements: • Changes in Project oversight and coordination: the Chief Medical Officer will become the Project technical coordinator and will be supported by a Grant Management Specialist (new role to be recruited under IHPAU) who will support the technical coordination under the project. The composition of the Project Steering Committee will be revised and the meetings frequency will be changed to biannually instead of quarterly. • More autonomy to districts: implementation arrangements and the PIM will be revised to provide more autonomy to districts. 31. Agreed adjustments to Project’s Results Framework: • A new Results Framework will be considered following the MTR based on the thorough review undertaken that will include the following: (i) Updated population-based denominators ; (ii) Revised definitions and data points aligned with national tools and standard indicators; (iii) Disaggregate certain indicators (eg IRI3 referrals) to align with project implementation activities; (iv) Increased targets for indicators where the baseline had been higher than anticipated (eg PDO4 on Quality of Care and potentially IRI5 CYPs); and (v) Proposed additional indicators to better capture quality dimension and project activities and removed indicators for which related activities might be down scoped (IRI9 Healthcare waste treatment). A preliminary version of the updated RF and overview of changes by indicator is included in Annex 2. 32. The Government and the World Bank agreed to restructure the Project as described above and to fix the inconsistencies across the Project documents and the Results Framework. NEXT STEPS AND AGREED ACTIONS Table 2: Summary of Agreed Actions Actions Responsible Due Date 1 Component 1: - Develop Hub and Spoke model implementation PIH June 15, 2025 guidelines on selected topics (to be agreed with MoH) - Expand Project coverage at community, spoke, MoH, IHPAU, PIH February 1, 2025 hospital across the 5Ss NMSA 10 - Expand Project support to distribution of Free February 1, 2025 Health Care commodities and referrals to the entire five districts IHPAU - Recruit an engineering firm to supervise the February 20, 2025 rehabilitation of the hubs MoH, IHPAU, PIH - Undertake the rehabilitation of 13 hubs following June 15, 2025 the revised scope, including full solarization of 14 hubs MoH, NMSA, IHPAU, - Submit a budgeted plan to enhance DHMT’s PIH January 30, 2025 capacity to conduct last-mile delivery and replenishment of pharmaceutical supplies in the QEHSSSP health facilities 2 Component 2: - Reprioritize activities around key strategic areas: o Supply chain: provide comprehensive TA to MoH, NMSA, IHPAU February 1, 2025 NMSA, support first and last mile distribution of Free Health Care commodities to all health facilities in the five project districts, establish a commodities monitoring system at health facility level o Emergency referrals: provide comprehensive TA MoH, NEMS, IHPAU February 1, 2025 and strengthen NEMS referrals system and operations to the entire five districts 3 Component 3: - Submit 2025 IHPAU staff contracts IHPAU December 30, 2025 4 M&E: - Submit a revised RF with annual and end of project IHPAU December 20 targets after MTR - Submit Q3 report December 20 - Submit final annual 2024 RF February 28 - Submit a transition plan with roles and January 15 responsibilities of M&E team after the phasing out of TA 5 Institutional and implementation arrangements: - Restructure the membership of the project steering IHPAU January 15, 2025 committee and change the meeting frequency to MoH, IHPAU biannually - Recruit a Grant Management Specialist February 1, 2025 - Revise the SOPs for the disbursement of funds and IHPAU December 30, 2024 provide capacity building to IPs - Revise the PIM IHPAU January 30, 2025 - Revise the Project costing and finalize needed MoH, IHPAU, WB January 15, 2025 reallocations 6 Procurement: - Conduct market research, update PPSD and revise IHPAU, PIH December 15, 2024 the budgets to match with the current market trend - Use framework agreement with suppliers for district IHPAU December 15, 2024 level activities - Conduct capacity building of procurement teams at IHPAU May 15, 2025 district level 7 Financial Management: - Document expenditures incurred from the DAs IHPAU November 30, 2024 - Revise PIM FM arrangements for the disbursement of fund to IPs December 30, 2024 11 - Repost expenditure from EWEC to WFA grant IHPAU/ WB June 30, 2025 - Submit the audit report, management letter and IHPAU remedial action plan for the year ending 31st December 31, 2024 8 Environmental and Social Standards: - Submit a detailed plan for the operationalization of IHPAU December 30, 2024 the GRM - Establish a functioning GRM February 15, 2025 - Submit ESCP monitoring report for quarters 2 and 3 December 20. 2024 of 2024 91 GFF Investment Case: - Finalize the TOR for the endline evaluation of the January 30, 2025 current RMNCAH-N strategy and development of the new strategy - Conduct the annual review of the RMNCAH-N MoH December 30, 2024 strategy Annexes: Annex 1: List of officials met and composition of the World Bank team Annex 2: Summary of Planned Revisions to the RF during MTR mission Annex 3: Results Framework at MTR 12 Annex 1 – List of Participants No. Name Institution Designation Telephone Email Address Ministry of Health 1 Dr Jalikatu MoH Deputy Minister II +23276968557 jalikam@yahoo.com Mustapha 2 Dr Sartie Kenneh MoH CMO +23276644009 sartiekenneh@gmail.com 3 Dr Nkechi Olalere MoH Health Advisor +23230370090 nkechi.olalere@yahoo.com 4 Dr Alie H Wurie MoH Deputy Chief +23279771946 wuriealieh@yahoo.com Medical Officer Public Health 5 Dr Santigie Sesay MoH Director -NCD +23276604658 sanniesay@gmail.com 6 Dr. Francis Smart MoH Director - DPPI/ WB +23278300933 dir.dppi@mohs.gov.sl Projects Coordinator 7 Stephen Gaojia MoH Chief Ops. Advisor sgaojia@gmail.com 8 Dr. Augustine MoH DMO Tonkolili +23278963789 augsjim@gmail.com Jimissa 9 Dr. Brima Bobson MoH DMO Bonthe +23276757468 brimabobsonsesay@gmail.com Sesay 10 Benedict J John- NEMS Field Operations +2327664765 bjjohn-simbo@mohs.gov.sl Simbo Manager 11 Henny P. Nyukeh NEMS Regional Operations +23279517553 hpnyukeh@mohs.gov.sl Coordinator 12 Dr. Tom Sesay MoH RCH Director +232 76619900 tommahunsesay@gmail.com 13 Dr. Daniel Lavallie MoH DMO Falaba +23278687476 Danlavalirl023@yahoo.com 14 Ibrahim Pemagbi NEMS +23276699474 ipemagbi@moh.gov.sl 15 Edward Foday MoH Director of Research +23278366493 efoday@mohs.gov.sl and Publication 16 Cyril Caulker MoH District Pharmacist – +23278432309 Caulkercyril736@gmail.com Bonthe 17 Victor G Karim MoH Communications +23276775502 gbadiak@yahoo.com and Admin Officer SAHP 18 Patricia Abu MoH Program Manager +23276302977 Patmati69@yahoo.com SAHP 19 Gibrilla I Sesay NEMS +23278461355 gisesay@mohs.gov.sl 20 Emanuel Bangura MoH District Pharmacist – +23279119995 emmaneulfbangura@gmail.com Falaba 21 Hassan Sesay MoH DFR +23276606684 hbaisesay@yahoo.com 22 Dr Moses N P DPS Director +23278086098 batemamnp@gmail.com Batema 23 Jatu J Abdulia NMSA +23278626502 Jatu_313@yahoo.com 24 Robert Dixon NMSA +23276588882 romardinex@gmail.com 25 Maurice Juma MoH Health Supply Chain +23279444479 maurice.jumasd@gmail.com TA, QEHSSSP 26 Prof Mohamed MoH Director of Training dhmsamai@yahoo.com Samai 27 Dr Abdul Njai MoH Senior Fellow +23276850340 abdul.njai@mohs.gov.sl 28 Joseph David MoH HMIS Fellow +23278621647 Josephkoroma01@gmail.com Koroma 29 Teopolina MoH ODI Fellow - teonamanajie@gmail.com Namandje 30 Sorie S Kargbo MoH Senior Fellow M&E +23276905587 Sorieskargbo87@gmail.com 31 Dr Jowo MoH DMO Kailahun +23278202404 joworsaberdeen@gmail.com Aberdeen 32 Dr Christine MoH Senior Fellow -Policy +23276925242 christine.williams@mohs.gov.sl Williams Analyst Integrated Health Projects Administration Unit 13 1 Alpha U. Jalloh IHPAU Team Lead +23277002864 aujalloh@mohsihpau.gov.sl 2 David Muana IHPAU Deputy Team Lead +23272225493 dkmuana@mohsihpau.gov.sl 3 Joseph M. B IHPAU Senior Accountant +23279964611 jmbh@mohsihpau.gov.sl Heimoh 4 John Turay IHPAU Senior Internal +23278929888 jturay@mohsihpau.gov.sl Auditor 5 Kh Zahir Hussain IHPAU M&E TA +23272391880 kzahirhr@gmail.com 6 Alhassan Bampia IHPAU MEAL Specialist +23276430442 abampia@mohsihpau.gov.sl 7 Doris Mani IHPAU M&E Officer +23278220901 dmani@mohsihpau.go.sl 8 Musa Sesay IHPAU Procurement +23274836741 msesay@mohsihpau.gov.sl Specialist 9 Solomon Tucker IHPAU Executive Assistant +23278266074 stucker@mohsihpau.gov.sl 10 Juliana Kamanda IHPAU Senior Safeguards +23276267748 jkamanda@mohsihpau.gov.sl Specialist 11 Francis Koroma IHPAU Environmental and +23278938884 franciskoroma76@gmail.com Safeguards Specialist 12 Christiana M. IHPAU Environmental +23278403189 ramtulai@yahoo.com Fortune Safeguards Specialist 13 Ibrahim Sesay IHPAU Assistant ICT Officer +23277254754 isesat@mohsihpau.gov.sl World Bank 1 Yohana Dukhan World Task Team Leader +23278754591 ydukhan@worldbank.org Bank 2 Olga Guerrero World Co- Task Team oguerrerohoras@worldbank.org Horas Bank Leader 3 Angus Fayia World Health Specialist +23276139889 atengbeh@worldbank.org Tengbeh Bank Consultant 4 Tomo Morimoto GFF Senior Health tmorimoto@worldbank.org Specialist 5 Sydney A.O World Financial +2327607206 sgodwin@worldbank.org Godwin Bank Management Specialist 6 Lois Simche World Consultant +23278617705 llebbie@worldbank.org Lebbie Bank 7 Pamela World Senior Social ptuiyott@worldbank.org Chebiwott Bank Development Tuiyott Specialist 8 Rahat Jabeen World Senior rjabeen@worldbank.org Bank Environmental Specialist 9 Kirsten Gagnaire GFF Results Specialist kgagnaire@worldbank.org Consultant 10 Daniel Kamara GFF/WB Liaison Officer +23279169754 Danbanjamin78@gmail.com 11 Innocent World Senior Procurement +23278913232 ikamugisha@worldbank.org Kamugisha Bank Specialist Partners In Health 1 Evrard Nahimana PIH Chief of Party +23230389202 enahimana@pih.org 2 Viviana PIH Snr. Program +23279185152 vgranobles@pih.org Granobles Manager 3 Issa B. Samura PIH Snr. Grant Specialist +23278997443 ibsamura@pih.org 4 Paras Chipalu PIH District Adviser WAR pchipala@pih.org 5 Madalitso Mkata PIH District Adviser +23290762782 Mmkata@pih.org Bonthe 6 Usman John PIH Senior M&E +23276899541 ubakundu@pih.org Bakundu Manager 14 7 Michael Mhango PIH Analyst +23299144112 mmhango@pih.org 8 John Enoch PIH M&E Officer +23276944182 jefofanah@pih.org Fofanah 9 Abdul S. Kayrbo PIH M&E Officer +23277463376 askayrbo@pih.org 10 Ricard Pognon PIH Strategic HIS Lead +23280118514 rpognon@pih.org 11 Leah Blezard PIH Project Advisor +23233997960 lblezard@pih.org 12 Michael Mhango PIH Analyst +23299144112 mmhango@pih.org 13 Joseph J Toe PIH Procurement officer +23278650268 jjtoe@pih.org 14 Jamie Arena PIH Partnership +23230299638 jarena@pih.org 15 Lolly Durotoye PIH Dir Health Policy ldurotoye@pih.org Health Development Partners 1 Saskia Goldman FCDO Human +23299502002 Saskia.goldman@fcdo.gov.uk Development Counsellor 2 Amanda Parry FCDO Senior Programme amanda.parry@fcdo.gov.uk Manager 3 Paul McDermott USAID Health Officer pmcdermott@usaid.gov 15 Annex 2 – Summary of Planned Revisions to the Results Framework The table below provides a summary of the proposed modifications to each of the PDOs and IRIs discussed during the MTR: Indicator Issue Revision agreed during MTR PDO 1. People who have received essential health, Targets need to be reviewed based on revisions of Target to be revised downwards and presented as cumulative nutrition, and population (HNP) services other aspects of this indicator (PDO1b and 1c) based on revised population estimates and corrected target for [To be revised] PDO 1b PDO1a- People who have received essential health, Targets need to be reviewed based on revisions of Target to be reduced and presented as cumulative based on nutrition, and population (HNP) services - Female other aspects of this indicator (PDO1b and 1c) revised population estimates and revision of PDO1b (RMS requirement) [To be revised] PDO 1b. Children 0-11 months that received third Target was based on an incorrect calculation and Target to be reduced using updated population growth estimates dose of Penta vaccine in target districts was highly overestimated. Surviving infants for and Countdown. Penta 3 is measured as the proxy for full [To be revised] target districts and vaccination coverage expected vaccination. should be the basis for the calculation. PDO 1c. Number of women and children who have Changes in nutrition services provided to pregnant Target to be revised based on updated population. Two proxy received basic nutrition services women as per country policy (iron folate for MMS) nutrition services captured: Vitamin A for children and MMS for [To be revised] call for a revision of indicator definition. pregnant women PDO 2 Pregnant women attended ANC4+ times by Double-counting of beneficiaries who receive ANC The indicator has been revised to ‘Pregnant women attending skilled health personnel in target districts 8th visits and 4th visit is masking performance and ANC4 by skilled health personnel in target districts’. An additional (Percentage)Numerator Antenatal client 4th visit target is inaccurate. indicator related to ANC1 visit is also proposed. Antenatal client 8th visit [To be revised] PDO 3 Institutional delivery rate in the target No issues No major revisions needed, but IHPAU to confirm if the districts (Percentage) denominator needs to be updated given revised population statistics PDO 4 Average Score of Health Facility Quality of The target for this indicator has already been met Target to be increased. Scoring of the health facilities might be Care in the target facilities (Percentage) and the baseline was higher than expected. slightly revised. [To be revised] IRI 1. Children 0-59 months admitted for SAM, that This indicator should be shifted to IMAM from No suitable alternative was identified during the MTR and are cured of SAM in target facilities (Percentage) SAM given the services offered at primary level. discussions with relevant departments is needed. (See RF for data elements) Adequate target needs to be proposed. [To be revised] 16 IRI 2. Pregnant Women and Children under 5 years Revisions in data collection tools and reporting of No suitable alternative was identified during the MTR and old who receive a CHW visit in target district CHW do not allow for adequate monitoring of this discussions with relevant departments is needed. (Number) indicator. [To be revised] IRI 3. Deliveries referred from spokes to hubs in Indicator does not capture referrals to higher level Indicator to be an aggregate of referrals at different levels target districts (Number) facilities which is at times needed, including whilst supported by the project (spoke to hub, hub to hospital, spoke to hubs are not fully established. hospital). Target to be increased as a result of additional referrals being captured. IRI 4. Children 0-11 months that received third dose Coherence with PDO calculations and target is No major revisions but ensure same denominator as PDO is used. of Penta vaccine in target districts (Percentage) needed. [To be revised] IRI 5. Couple-Year Protections (CYP) reached Overachieved in 2023 and likely to have used WB and GFF to provide technical assistance for an in-depth analysis through project interventions in target districts incorrect conversion factors. Target might be too of CYP performance in the district level and target setting. (Number) low. [To be revised] IRI 6. Maternal deaths reviewed in target districts No issues with this indicator. Agreement over importance ofin investigating perinatal deaths (Percentage) too.. IHPAU submitted a proposal to have a sub-indicator but a [to be revised] separate indicator might be more appropriate/easier to account for. IRI 7. Health facilities in target district with staff Slow progress in roll out of training has resulted in No changes but programmatic efforts are required to improve trained to identify, refer, and provide clinical lower than expected performance. performance and/or psychosocial care for GBV (Number) IRI 8. Health facilities submitting timely Challenges with timeliness due to contextual Agreement over focusing the indicator on quality of data rather routine/HMIS reports according to national constraints/factors negatively impact indicator. than timeliness – data is entered but after agreed timelines during guidelines (Percent) contextual issues. IHPAU and DPPI have submitted a proposal for [to be revised] the WB to consider IRI 9. Healthcare Waste treated at the Centralized Activities behind this indicator are slow and No revisions during MTR as activity (and hence indicator) might get Medical Waste Treatment Facility (Metric relevance of this activity is questioned vs other dropped as re-prioritization of Component 2 activities is finalized. tons/year) potential investments for waste management. IRI 10. Monthly facility management committee Lack of clarity regarding the health facilities that Indicator revised to ‘ monthly FMC meetings held in project (FMC) meetings held in target districts are being accounted for, only the hubs are being supported health facilities’ . Consideration to whether indicator (Percentage) reported on as it is what is supported under the needs to be increased. [To be revised] project 17 IRI 11. Essential Health service delivery monitored Currently no country level forum performs these Agreement over the Country Platform being the forum for this on a regular basis, with quarterly review of data to reviews discussion and RCH Department taking responsibility. Discussions inform efforts to strengthen delivery (Number) with GFF to be finalized to ensure meetings are supported to the extend needed. IRI 12. Grievances addressed each year Grievance reporting is below expected target. Ensure definition is consistent with existing and planned systems. (Percentage) IRI-13: RMET completed and used annually, No issues with this indicator No agreed changes including data from the district level (Yes/No) IRI-14: Quarterly reports produced by unified No issues with indicator No agreed changes financial management reporting system and reviewed at national level (Number) Pregnant women who received first ANC 1 visit ANC1 is proposed as a proxy indicator to community health with skilled health personnel before 12 weeks of services to promote care-seeking behavior and also of ANC for gestation in target districts (percentage second time mothers. ANC1 is important to achieve ANC8. Target [Additional indicator] needs to be set but would be aligned with national policies/targets for quality RCH Perinatal deaths reviewed in target districts Complimentary to maternal death review indicator. Innovative (Number) indicator to track program support towards reducing child [Additional indicator] mortality in SL. 18 Annex 3 –Results Framework at MTR 2022Total 2024 Total End of (Apr to (Jan to project Indicator Baseline 2022 Target Dec) 2023 Target 2023 Total 2024 Target June) target People who have received essential PDO 1 health, nutrition, and population (HNP) services (ICR, Number) 1,676,654 1,758,234 643,024 1,839,814 1,024,673 1,921,395 347,627 2,084,555 a. People who have received essential health, nutrition, and population (HNP) services - Female (RMS requirement) 1,110,493 1,160,194 343,948 1,209,896 545,694 1,259,597 190,957 1,359,000 b. Children 0-11 months that received third dose of Penta vaccine in target districts 1,060,233 1,102,642 59,930 1,145,052 95,504 1,187,461 45,169 1,272,280 c. Number of women and children who have received basic nutrition services 563,384 596,922 538,222 630,460 862,455 663,998 268,172 731,074 d. Number of deliveries attended by skilled health personnel 53,037 58,670 44,872 64,303 66,714 69,935 34,286 81,201 Pregnant women attended ANC4+ PDO 2 times by skilled health personnel in target districts (Percentage) 64.0% 67.0% 78.6% 70.0% 89.1% 73.0% 75.5% 77 Institutional delivery rate in the target PDO 3 districts (Percentage) 57.0% 60.0% 59.8% 65.0% 70.0% 70.0% 61.2% 80 Average Score of Health Facility Quality PDO 4 of Care in the target facilities (Percentage) 50.0% 47.0% NA 50.0% 53.0% 54.0% 64.8% 64 Children 0-59 months admitted for IRI 1 SAM, that are cured of SAM in target facilities (Percentage) 32.0% 38.0% 35.0% 45.0% 29.7% 52.0% NA 70 19 Pregnant Women and Children under 5 IRI 2 years old who receive a CHW visit in target district (Number) 178,838 58,051 84,116 61,996 178,838 324,148 122,816 70,450 Deliveries referred from spokes to hubs IRI 3 in target districts (Number) - 2,000 - 2,500 547 3,500 665 5,000 Children 0-11 months that received IRI 4 third dose of Penta vaccine in target districts (Percentage) 84.0% 86.0% 87.3% 90.0% 111.1% 92.0% 94.9% 95 Couple-Year Protections (CYP) reached IRI 5 through project interventions in target districts (Number) 45,922 48,218 166,165 52,810 291,864 57,403 - 68,883 Maternal deaths reviewed in target IRI 6 districts (Percentage) 80.0% 85.0% 100.0% 90.0% 91.8% 95.0% 92.9% 100 Health facilities in target district with staff trained to identify, refer, and IRI 7 provide clinical and/or psychosocial care for GBV (Number) 0.00 50 0.00 100 0 150 0 250 Health facilities submitting timely IRI 8 routine/HMIS reports according to national guidelines (Percent) 82.0% 90.0% 38.1% 92.0% 50.0% 94.0% 66.0% 98 Healthcare Waste treated at the IRI 9 Centralized Medical Waste Treatment Facility (Metric tons/year) 0 0 NA 0 0 548 0 548 Monthly facility management IRI 10 committee (FMC) meetings held in target districts (Percentage) 24.0% 0.0% 0.0% 30.0% 24.0% 40.0% 38.0% 50 Essential Health service delivery monitored on a regular basis, with IRI 11 quarterly review of data to inform efforts to strengthen delivery(Number) 0 3 3 4 1 4 0 4 Grievances addressed each year IRI 12 (Percentage) 0.0% 55.0% 0.0% 64.0% 0.0% 75.0% 0.0% 95 20 RMET completed and used annually, IRI 13 including data from the district level (Yes/No) No Yes Yes Yes Yes N/A yes Quarterly reports produced by unified financial management reporting IRI 14 system and reviewed at national level (Number) 0.00 1 0 4 4 4 1 4 21