FOR OFFICIAL USE ONLY RESTRUCTURING PAPER ON A

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF STRENGTHENING REPRODUCTIVE HEALTH PROJECT IDA GRANT- H7530 BOARD APPROVAL DATE: DECEMBER 20, 2011 TO THE REPUBLIC OF MALI OCTOBER 2, 2014 Report No: RES16425 HEALTH, NUTRITION AND POPULATION GLOBAL PRACTICE (GHNDR) AFRICA REGION This document has a restricted distribution and may be used by recipients only in the performance of their official duties Its contents may not otherwise be disclosed without World Bank authorization

2 Acting/Regional Vice President: Country Director: Practice Manager/Manager: Task Team Leader: Sri Mulyani Indrawati Paul Noumba Um Trina S Manager Aissatou Diack

3 DATA SHEET Mali ML-Strengthening Reproductive Health (P124054) AFRICA Report No: RES16425 Basic Information Project ID: P Lending Instrument: Specific Investment Loan Regional Vice President: Sri Mulyani Indrawati Original EA Category: Partial Assessment (B) Country Director: Paul Noumba Um Current EA Category: Partial Assessment (B) Senior Global Practice Director: Practice Manager/Manager: Team Leader: Timothy Grant Evans Original Approval Date: 20-Dec-2011 Trina S Haque Current Closing Date: 28-Feb-2017 Aissatou Diack Borrower: Responsible Agency: Republic of Mali Ministry of Health Restructuring Type Form Type: Short Form Decision Authority: Country Director Approval Restructuring Level: Level 2 Financing ( as of 05-Sep-2014 ) Key Dates Project Ln/Cr/TF Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P IDA-H7530 Effective 20-Dec Feb Mar Feb Feb-2017 Disbursements (in Millions) Project Ln/Cr/TF Status Currency Original Revised Cancelle d Disburse d Undisbur sed % Disburse d P IDA-H7530 Effective XDR Policy Waivers Does the project depart from the CAS in content or in other significant respects? Yes [ ] No [ X ]

4 Does the project require any policy waiver(s)? Yes [ ] No [ X ] A Summary of Proposed Changes The proposed changes include the scaling back of activities, the cancellation of approximately SDR 25 million (US$5 million equivalent taking into account the exchange rate fluctuation), and the reallocation of the remaining funds Approximately US$284 million in activities are identified for scaling back and reallocation as follows: (a) Reduction in the funding for the proposed health voucher scheme (category 3 by SDR 420,000) to reflect the length of time remaining for project implementation; (b) Reduction in project management cost/scope; (c) Reduction in the scope of technical assistance to strengthen solidarity funds; (d) Reduction in funding for annual Population Coalition Conferences, again to reflect the limited timeframe; (e) Reduction in funding for the proposed health facility surveys; and (f) Reduction in the financing for RBF impact evaluation B Project Status The PDO is rated Moderately Unsatisfactory The project has not yet implemented the activities needed to report progress on the program level data used to assess achievement of the PDO, because of delays in contracting out the implementing agencies and financing the health districts action plans Therefore the project has been restructured to streamline its designed and clear communication has been shared with the government on the need for accelerated action to address this situation The IP is also rated Moderately Unsatisfactory Although the procurement plan and terms of reference to recruit the NGOs have been approved, the delay in signing the contract with UNFPA and implementing NGOs has delayed project activities Implementation of the procurement plan is being closely monitored by the PIU and the task team A restructuring has been agreed with Government to streamline the project and should improve overall implementation C Proposed Changes

5 1 The Grant Agreement (IDA-H7530) for the above-mentioned project was approved by the Board on December 20, 2011 and signed on February 24, 2012 The project became effective on March 15, 2013, after more than one year of delay due to the political crisis that triggered numerous institutional changes within the Ministry of Health (MOH) 2 Project development objective (PDO): The Mali Strengthening Reproductive Health Project aims at improving women s access to and use of quality reproductive health services, and accelerating progress towards the Millennium Development Goals that fall due in 2015 The direct beneficiaries of the project include over 22 million women between 15 and 49 years of age Adolescents, men, and older women will also benefit from social marketing campaigns that would inform people on ways to achieve their desired family size The interventions will target selected regions of Mali that have the worst reproductive health indicators, including Sikasso (South), Koulikoro (near Bamako) and Ségou (Center) and peri-urban Bamako where there are dense pockets of poverty, and quick gains can be made Besides focusing on antenatal care, assisted deliveries, and family planning, the project will help build a base for policy discussions on girls education, age at first marriage, and the role of women This is very important because reproductive health is not just about health; it is also closely linked to education and women s empowerment The project supports high-impact reproductive health interventions, such as deliveries by skilled health workers, an effective referral system that gets mothers with complications to hospital quickly, availability of equipment, drugs and other supplies at health facilities, and community schemes that eliminate financial barriers to obstetric care 3 Following a very long delay in appointing the project coordinator and component facilitators, as well as setting up the multisectoral project steering committee, the project is suffering multiple implementation challenges Despite persistent and careful monitoring by the World Bank task team and strong management support, the project is still characterized by long delays in approving action plans and financing communitybased activities; which results in slow disbursement of grant proceeds The recruited private fiduciary firm in charge of financial management and procurement is operational and has set up project management systems, but its performance has been hampered by slow responsiveness of the MOH to management challenges 4 Recognizing that reproductive health remains a key priority in the development agenda, the MOH has recently set up a functional project implementation unit and steering committee and agreed with the World Bank on the need to restructure the project to streamline its design and revise its results framework This resulted in an initial level II restructuring request from the Government of Mali (dated May 9, 2014), in which the Borrower also reaffirmed its interest in proceeding with the Project There were a number of issues with this request, and further discussions were held with the Government during a follow-up mission from June 20-27, 2014 A new element in this discussion was the participation of Mali in the regional Sahel Women s Empowerment and Demographic Dividend project (SWEDD), and the cancellation and reallocation of US$5 million of the original Grant proceeds to support the country contribution to this

6 project The June mission resulted in a further restructuring request dated July 15, 2014, which reflects the decisions reached Both requests are attached 5 Project design and reallocation of grant proceeds: the PDO for the project remains the same, but given the time available until the project closing date of February 28, 2017, activities were carefully reviewed, and a number of them were suggested for a reduced level of funding, based on overall priority compared to the PDO, the complexity of its implementation, and the ability to complete the activity within the available timeframe Approximately US$284 million in activities are identified for scaling back and reallocation as follows: (a) Reduction in the funding for the proposed health voucher scheme (category 3 by SDR 420,000) to reflect the length of time remaining for project implementation; (b) Reduction in project management cost/scope; (c) Reduction in the scope of technical assistance to strengthen solidarity funds; (d) Reduction in funding for annual Population Coalition Conferences, again to reflect the limited timeframe; (e) Reduction in funding for the proposed health facility surveys; and (f) Reduction in the financing for RBF impact evaluation 6, In addition, the total grant amount will be reduced from SDR 19 million to SDR 165 million, reflecting the agreed cancellation and reallocation to the Sahel Women Empowerment and Demographic Dividend (SWEDD) Project At the same time, it was agreed to increase the level of financing for family planning commodities and resultsbased financing (category 2) by SDR 860,000, building on the existing scheme in the Koulikoro region Annex 1 presents a detailed table of the proposed reallocation A revised results framework (RF) is attached in Annex 2 to reflect the new activities and review the targets for selected indicators 7 Implementation arrangements: in order to ensure the timely and cost-effective procurement of family planning commodities, medical supplies and equipment, it was agreed that the government contract the UNFPA to supply these items 8 Risks and mitigation measures: the underlying assumptions under which the grant was approved have not changed While the higher riskiness of the country context following the military coup and subsequent events is triggering a higher implementation risk for the operation, the technical and financial risks remain unchanged No changes are deemed necessary to ensure the project's viability at this stage, but the team will closely monitor and be proactive, if the country context were to affect the project's implementation and viability The team is of the view that, with these changes in place, it should be possible to complete the remaining tasks as planned by the closing date and achieve the development objectives 8 We are seeking your approval on the proposed level II restructuring of the grant to: a) revise the Project Description Annex, b) include UN Agencies in the procurement section of the FA, c) cancellation and reallocation of the Grant proceeds among disbursement categories If you agree to the proposed restructuring, please countersign

7 this memo and sign the attached notification letter of restructuring for the Project addressed to the Government of Mali

8 Annex 1 Restructuring of Project Categories Categories Amount of the Grant Allocated (expressed in SDR) Amount of Changes (in SDR) Revised Costs (in SDR) Percentage of Expenditures to be Financed (inclusive of Taxes) (I) Goods, works, non consulting services, consultant s services, Training and Operating Costs for Parts A2, A3, B1, B2 (a), B2 (c) and C of the Project (2) Goods, nonconsultant services, consultant services, Training and Operating Costs required for each Reproductive Health Service provided under a Representative Health Service Sub-Project and to be financed from the proceeds of Reproductive Health Services Grants under Part A1 of the Project and to be paid at the Unit Cost for said services 17,000,000-2,940,000 (Cancellation of 5,000,000 USD from NGO contract costs) 14,060, % 100% (a) First scheduled disbursement 400, , ,000 (b) Second scheduled disbursement 400, , ,000 (c) Third scheduled disbursement (3) Cash Transfers under Part B2 (b) of the Project 380, , , , , , % TOTAL AMOUNT 19,000,000-2,500,000 16,500, %

9 Core Annex 2: REVISED Results Framework and Monitoring (September 30, 2014) Project Development Objective (PDO): The PDO is to improve access to and use of quality reproductive health services by women of reproductive age, in selected regions of Mali 1 PDO Level Results Indicators* POI# 1: Modern contraceptive use among women 15 to 49 years old POI# 2: Pregnant women who have at least 4 antenatal care visits Unit of Measur e Percent Percent Baselin e (2012) 100 (MICS 2010) (MICS 2010) Cumulative Target Values** Frequency Every 2-3 years Every 2-3 years Data Source/ Methodolo gy MICS2010 MICS 2014 MICS 2018 MICS 2010 MICS 2014 MICS 2018 Responsibil ity for Data Collection CPS/ INSTAT CPS/ / INSTAT Description (indicator definition etc) Num: #women in union using modern contraception methods Den: #women years old MICS definition Num: #women age who had 4+ ANC visits Den: #women who had a live birth in the survey sample (per 100) MICS 1 Geographical areas were selected based on population growth, health status and poverty levels Thus, interventions will target the urban poor, peri-urban areas and rural regions with the worst reproductive health indicators For most indicators, the age group is defined as women 15 to 40 years old, as described in the MICS methodology 2 Data for POI # 1, POI # 2 and POI # 3 as well as AI#1 was calculated using a weighted average taking into account the percentage and population of the regions of Bamako, Koulikoro, Sikasso and Segou

10 definition POI# 3: Births (deliveries) attended by skilled health personnel Percent 35 (MICS 2010) POI# 4: Post partum women using modern methods of contraception 3 Number POI#5: Couple- Year Protection s reached through project interventions Number , , , , , ,00 0 Every 2-3 years Semi-Annual Semi-Annual MICS 2010 MICS 2014 MICS 2018 HMIS, NGO and private sector reports HMIS, NGO and private sector reports CPS/ / INSTAT MOH NGOs Private Health Facility Staff MOH NGOs Private Health Facility Staff Num: #births attended by skilled personnel (doctors, midwives, nurses) Den: #women who had a live birth in the survey sample (per 100) MICS definition #postpartum women who use modern contraceptive method 0-1 year after delivery 3 Post partum period in this context refers to the period from delivery to one year after childbirth Women who have sterilization immediately will be included in the tally Baseline is 0 because this intervention is directly linked to project interventions by NGOs and health facility personnel in health centers and outreach clinics

11 Core INTERMEDIATE RESULTS Intermediate Result (Component One): Strengthening Supply and Quality of Reproductive Health Services (US$ 75 million) Sub-component 1(a): Scale-up RBF mechanism in pilot districts (Koulikoro Region) Indicators Unit of Measur e IOI#1: Women provided with access to a package X Number ,000 of RH services 4 IOI#2: Health facilities that experience 2 or more weeks stock- % N/A ( to be determi ned in Data Source/ Methodolo gy Baselin Cumulative Target Values** e Frequency (2012) To be def ine To be d if defined RB if RBF F Annually pilot is pil scaled ot up is sca led up Sub-component 1(b): Intensify family planning by decentralizing interventions Less Less Less Less Less than than than than than Annually 10% 10% 5% 5% 5% RBF reports HMIS, Health Facility Survey Responsibil ity for Data Collection MOH RBF Implementin g Agency Description (indicator definition etc) # women provided with access to a package of RH services through RBF (2-year pilot that should be evaluated before scaling up) Num: #Health facilities that experience stock-outs of 4 According with what will be purchased, the package would include: ANC3 (with VAT2, Vitamin A, SP, ITN, and PMTCT), delivery with skilled health worker, postnatal visit, FP Baseline is 0 because this intervention is directly linked to project RBF interventions by health facility personnel in health centers in the Region of Koulikoro

12 outs of contraceptives 5 during the last 2 weeks preceding the survey 6 IOI#3: Health personnel trained to provide family planning services (number) 7 [Core indicator] 2012) CPS, Directorate of Pharmacy X Number Sub-component 1(c): Strengthen the capacity of health facilities to deliver quality SRH/FP services IOI#4: Pregnant women receiving antenatal care during a visit to a health care provider X Number , , ,0 00 Semi- Annually Project documents Annually HMIS MOH MOH, Regional Health Directorates Pills, intrauterine device and implants for 2 weeks plus over a 6 month period Den: #health facilities that were surveyed # health personnel who receive training in family planning # pregnant women receiving antenatal care during a visit to a health care provider 5 List of contraceptives according to TAC (Tableau d Acquisition des Contraceptifs) - Pills, intrauterine device and implants 6 According to a recent survey (of 153 facilities) on the availability of contraceptives at health facilities, 54% reported stock-outs in the last 6 months 7 This indicator will measure increased capacity at four decentralized levels of facilities: community health centers, referral health centers, private providers, and home and communitybased services It will measure the number of providers who are provided with support in the following areas: a) capacity building in training and supervision; b) strengthen the supply chain for contraceptives and related products; c) improved capacity in drug management; and d) extend the outreach family planning services provided by NGOs

13 IOI# 5: Deliveries by Caesarean section Number 16,151 (2010) ,000 20,000 30,00 0 Annually HMIS MOH # women who had a delivery by caesarean section IOI #6: Women provided with postpartum care within the first 7 days of delivering in a health facility IOI #7: Health personnel trained to provide obstetric service (number) 8 % 554 (2010) 0% 0% 60% 65% 70% Annually Number Semi- Annually HMIS, Health Facility Survey Project documents Intermediate Result (Component Two): Strengthening Demand for Reproductive Health Services (US$ 156 million) Sub-component 2(a): Strengthening outreach RH services and IEC/BCC interventions IOI#8: People (Women and Men) attending social marketing interventions that promote family planning Number , , ,0 00 Semi- Annually Project documents MOH MOH, Regional Health Directorate s Num: #women provided with PPC within first 7 days Den: #deliveries in health facilities # health personnel who receive training in obstetric care (antenatal, delivery or postnatal care) Number of people attending social marketing interventions which promote FP 8 Obstetric services include antenatal, delivery and postpartum services

14 Sub-component 2(b): Increasing financial access to health services at local level IOI#9: Pregnant women provided with vouchers to access selected services and who use them Number ,000 8,000 10,000 Semi- Annually Sub-component 2(c): Strengthening the capacity to develop effective advocacy on population interventions Project documents Number of pregnant women provided with vouchers to access selected services and who use them IOI # 10: Advocacy sessions held with civil society, political, religious and traditional leaders on demographic issues and family planning Number Semi- Annually Project documents Number of FP advocacy sessions (meetings, peer education talks and conferences, radio and TV shows) held with Religious groups, Local Authorities Community health Associations and Traditional Leaders *Please indicate whether the indicator is a Core Sector Indicator (see further **Target values should be entered for the years data will be available, not necessarily annual