Liberia-Institutional-Foundations-To

Public Disclosure Authorized FOR OFFICIAL USE ONLY Report No: PAD3449

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT

IN THE AMOUNT OF US$ 54 MILLION

Public Disclosure Authorized FROM THE IDA SCALE-UP FACILITY

TO THE

REPUBLIC OF LIBERIA

FOR THE

INSTITUTIONAL FOUNDATIONS TO IMPROVE SERVICES FOR HEALTH PROJECT

April 30, 2020 Public Disclosure Authorized

Health, Nutrition & Population Global Practice Africa Region

This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s policy on Access to Information.

Public Disclosure Authorized

CURRENCY EQUIVALENTS

(Exchange Rate March 31, 2020)

Currency Unit = Liberian Dollar 199.58 = US$1

FISCAL YEAR

July 1 – June 30

Regional Vice President: Hafez M. H. Ghanem Country Director: Pierre Frank Laporte Regional Director: Amit Dar Practice Manager: Gaston Sorgho Task Team Leaders: Opope Oyaka Tshivuila Matala, Preeti Kudesia

ABBREVIATIONS AND ACRONYMS

AF Additional Financing ANC Antenatal Care ASRH Adolescent Sexual and Reproductive Health ASRHR Adolescent Sexual and Reproductive Health and Rights AWP&B Annual Work Plan and Budget BEmONC Basic Emergency Obstetric and Neonatal Care BMZ German Federal Ministry for Economic Development and Cooperation C-EHSMP Contractor’s Environmental, Health, and Safety Management Plan CBL Central Bank of Liberia CEmONC Comprehensive Emergency Obstetric and Neonatal Care CHA Community Health Assistant CHT Community Health Team CMS Central Medical Store CMU Country Management Unit CPF Country Partnership Framework CPIA Country Policy and Institutional Assessment CPS Country Partnership Strategy CRVS Civil Registration Vital Statistics CSO Civil Society Organization DA Designated Account DHIS2 District Health Information Software-2 DLI Disbursement-Linked Indicator DLR Disbursement-Linked Result DMA Deputy Minister Administration DPs Development Partners EEP Eligible Expenditure Program EmONC Emergency Obstetric and Neonatal Care ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESMF Environment and Social Management Framework ESRS Environmental and Social Review Summary EVD Ebola Virus Disease FCV Fragile Conflict Violence FHD Family Health Division GA Grant Agent GAC General Audit Commission GAVI Global Alliance for Vaccines and Immunization GBV Gender-Based Violence GDP Gross Domestic Product GFF Global Financing Facility GGHE General Government Health Expenditure GNI Gross National Income GOL Government of Liberia HCI Human Capital Index

HIES Household Income and Expenditure Survey HWF Health Workforce HSCC Health Sector Coordinating Committee HRH Human Resources for Health HNP Health, Nutrition and Population HMER Health Information Systems, Monitoring and Evaluation and Research IBRD International Bank for Reconstruction and Development IC Investment Case ICT Information Communications Technology IDA International Development Association IDA-SUF International Development Association – Scale-Up Facility IFISH Institutional Foundation to Improve Services for Health IFR Interim Financial Report IMF International Monetary Fund INTOSSAI International Organization of Supreme Audit Institutions IPF Investment Project Financing IR Implementation Research IVA Independent Verification Agent LCPS Liberia College of Physicians and Surgeons LMIS Logistic Management Information System LMP Labor Management Procedure MFDP Ministry of Finance and Development Planning MNDSR Maternal and Neonatal Death Surveillance and Response MOE Ministry of Education MOH Ministry of Health NDS National Drugs Store NVA National Verification Agency OOP Out of Pocket Spending PBF Performance-Based Financing PFM Public Financial Management PFMRS Public Financial Management Reforms for Institutional Strengthening PFMU Public Financial Management Unit PHC Primary Health Care PHCFs Public primary healthcare facilities PIM Project Implementation Manual PIU Project Implementation Unit PNC Postnatal Care PPP Purchasing-Power-Parity PPSD Project Procurement Strategy for Development RMNCAH Reproductive, Maternal, Neonatal Child, and Adolescent Health SCMU Supply Chain Management Unit SEP Stakeholder Engagement Plan STEP Systematic Tracking of Exchanges in Procurement SUF Scale Up Facility SWEDD Sahel Women’s Empowerment and Demographic Dividend Project UHC Universal Health Coverage

UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development WBG World Bank Group WDI World Development Indicator WHO World Health Organization WISN Workload Indicators of Staffing Need

The World Bank Institutional Foundations to Improve Services For Health (P169641)

TABLE OF CONTENTS

DATASHEET...... 1 I. STRATEGIC CONTEXT ...... 7 A. Country Context ...... 7 B. Sectoral and Institutional Context ...... 9 C. Building on PFM inputs...... 14 D. Relevance to Higher Level Objectives ...... 15 II. PROJECT DESCRIPTION ...... 16 A. Project Development Objective ...... 16 B. Project Components ...... 18 C. Project Beneficiaries ...... 24 D. Results Chain ...... 24 E. Rationale for Bank Involvement and Role of Partners...... 25 F. Lessons Learned and Reflected in the Project Design ...... 27 III. IMPLEMENTATION ARRANGEMENTS ...... 28 A. Institutional and Implementation Arrangements ...... 28 Figure 2: Overall Project implementation arrangement ...... 29 B. Results Monitoring and Evaluation Arrangements...... 32 C. Sustainability ...... 32 IV. PROJECT APPRAISAL SUMMARY ...... 33 A. Technical, Economic and Financial Analysis ...... 33 B. Fiduciary ...... 39 C. Legal Operational Policies ...... 40 D. Environmental and Social...... 40 V. GRIEVANCE REDRESS SERVICES ...... 44 VI. KEY RISKS ...... 44 VII. RESULTS FRAMEWORK AND MONITORING ...... 47 ANNEX 1: Implementation Arrangements and Support Plan...... 73 ANNEX 2: Disbursement- Linked Indicators ...... 81

The World Bank Institutional Foundations to Improve Services For Health (P169641)

DATASHEET

BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name

Liberia Institutional Foundations to Improve Services For Health

Project ID Financing Instrument Environmental and Social Risk Classification

Investment Project P169641 Moderate Financing

Financing & Implementation Modalities

[ ] Multiphase Programmatic Approach (MPA) [ ] Contingent Emergency Response Component (CERC)

[ ] Series of Projects (SOP) [✓] Fragile State(s)

[✓] Disbursement-linked Indicators (DLIs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a non-fragile Country

[ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made Disaster

[ ] Alternate Procurement Arrangements (APA)

Expected Approval Date Expected Closing Date

21-May-2020 31-Aug-2026

Bank/IFC Collaboration

Proposed Development Objective(s)

To improve health service delivery to women, children and adolescents in Liberia.

Components

Component Name Cost (US$, millions)

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Component 1: Improved service delivery 68,000,000.00

Component 2: Institutional strengthening to address key binding constraints 11,000,000.00

Component 3: Project Management 5,000,000.00

Component 4: Contigency Emergency Response Component 0.00

Organizations

Borrower: Republic of Liberia Implementing Agency: Ministry of Health

PROJECT FINANCING DATA (US$, Millions)

SUMMARY-NewFin1

Total Project Cost 84.00

Total Financing 54.00

of which IBRD/IDA 54.00

Financing Gap 30.00

DETAILS-NewFinEnh1

World Bank Group Financing

International Development Association (IDA) 54.00

IDA Credit 54.00

IDA Resources (in US$, Millions)

Credit Amount Grant Amount Guarantee Amount Total Amount Liberia 54.00 0.00 0.00 54.00

Scale-up Facility (SUF) 54.00 0.00 0.00 54.00

Total 54.00 0.00 0.00 54.00

Expected Disbursements (in US$, Millions)

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WB Fiscal Year 2020 2021 2022 2023 2024 2025 2026 2027

Annual 0.00 2.85 5.02 7.63 9.29 10.96 12.86 5.39

Cumulative 0.00 2.85 7.87 15.50 24.78 35.75 48.61 54.00

INSTITUTIONAL DATA

Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Education, Fragile, Conflict & Violence, Governance

Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks

SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT)

Risk Category Rating

1. Political and Governance ⚫ Substantial

2. Macroeconomic ⚫ Substantial

3. Sector Strategies and Policies ⚫ Moderate

4. Technical Design of Project or Program ⚫ Substantial

5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial

6. Fiduciary ⚫ Substantial

7. Environment and Social ⚫ Moderate

8. Stakeholders ⚫ Low

9. Other

10. Overall ⚫ Substantial

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COMPLIANCE

Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No

Does the project require any waivers of Bank policies? [ ] Yes [✓] No

Environmental and Social Standards Relevance Given its Context at the Time of Appraisal

E & S Standards Relevance

Assessment and Management of Environmental and Social Risks and Impacts Relevant

Stakeholder Engagement and Information Disclosure Relevant

Labor and Working Conditions Relevant

Resource Efficiency and Pollution Prevention and Management Relevant

Community Health and Safety Relevant

Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Relevant

Biodiversity Conservation and Sustainable Management of Living Natural Relevant Resources

Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Not Currently Relevant Local Communities

Cultural Heritage Relevant

Financial Intermediaries Not Currently Relevant

NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS).

Legal Covenants

Sections and Description

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Section 1.3.a(ii): The Recipient shall no later than six (6) months after the Effectiveness Date: (A) update the current accounting manual; (B) customize the existing accounting software to include an account for the Project; and (C) recruit external auditors for the Project, all in a manner satisfactory to the Association.

Conditions

Type Description Effectiveness Article IV, 4.01: The Recipient has prepared and adopted a Project Implementation Manual, in form and substance satisfactory to the Association.

Type Description Disbursement Section III, B1: No withdrawal shall be made: (a) for payments made prior to the Signature Date; and (b) under Category (2) unless and until Recipient has furnished evidence satisfactory to the Association that: (i) a PBF Verification Agent with qualifications and experience and under terms of reference satisfactory to the Association has been recruited; and (ii) the appropriate mechanisms for verification of PBF related results have been established in accordance with the PIM.

Type Description Disbursement Section III, B2. No withdrawal shall be made under Category (3) for EEP unless and until the Recipient has furnished evidence satisfactory to the Association that: (a) an IVA with qualifications and experience and under terms of reference satisfactory to the Association has been recruited; (b) payments for certified EEPs have been made in compliance with the procedures set forth in the Verification Protocol; and (c) the DLIs for which payment is requested have been met and verified in accordance with the Verification Protocol;

Type Description Disbursement Section III, B5. No withdrawal shall be made under Category (5), for Emergency Expenditures, unless and until the Association is satisfied, and notified the Recipient of its satisfaction, that all of the following conditions have been met in respect of said activities: (a) the Recipient has determined that an Eligible Crisis or Emergency has occurred, has furnished to the Association a request to include said activities in the CERC Part in order to respond to said Eligible Crisis or Emergency, and the Association has agreed with such determination, accepted said request and notified the Recipient thereof; (b) the Recipient has prepared and disclosed all safeguards instruments required for said activities, and the Recipient has implemented any actions which are required to be taken under said instruments, all in accordance with the provisions of Section I.F of Schedule 2 to this Agreement; (c) the Recipient’s Coordinating Authority has adequate staff and resources, in accordance with the provisions of Section I.F of this Schedule 2 to this Agreement, for the purposes of said activities; and (d) the Recipient has adopted a CERC Operations Manual

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in form, substance and manner acceptable to the Association and the provisions of the CERC Operations Manual remain or have been updated in accordance with the provisions of Section I.F of this Schedule 2 so as to be appropriate for the inclusion and implementation of said activities under the CERC Part.

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I. STRATEGIC CONTEXT

A. Country Context

1. Liberia is a fragile state striving to overcome the legacy of two devastating civil wars, and the twin shocks of the Ebola Virus Disease (EVD) crisis (2014-2016) and the protracted slump in global commodity prices. The two civil wars between 1989-2003 caused widespread loss of life, suppressed economic activity, and destroyed vital infrastructure. Thereafter, Liberia experienced sustained economic growth, and its per capita Gross Domestic Product (GDP) grew by 6.2 percent on average per year between 2003 and 20131. However, the twin shocks brought Liberia's renewed expansion to a halt. Between 2014-2016, the economy contracted at an average rate of 0.8 percent per year or 3.2 percent in per capita terms. The recovery from the twin shocks was brief and fragile, and the macroeconomic situation deteriorated markedly in 2018-2019. Following modest growth of 1.2 percent in 2018, the economy contracted by an estimated 2.3 percent in 2019, on the back of falling demand and output2. Headline inflation reached 27 percent in 2019 from 23.4 percent in 2018, largely due to the currency depreciation (by 29.4 percent y/y) combined with supply-side constraints, the monetization of the fiscal deficit, and financing of the Central Bank of Liberia’s (CBL) large deficit. Domestic food prices increased by 35.9 percent as a result of a poor harvest.

2. Liberia’s fledgling economy, which has never fully recovered from the multiple shocks during 2014-2016, is now facing the COVID-19 outbreak. Under the baseline scenario, real GDP is projected to contract by 2.2 percent in 2020 due to the adverse effects of COVID-19 on output in various sectors amid falling global demand and travel disruptions. A sharp rebound is expected over the medium-term, supported by an improved performance of the non-mining sectors, underpinned by post-COVID-19 recovery and structural reforms designed to alleviate constraints on productivity growth and enhance economic diversification. Growth is projected to recover to 4.0 percent on average during 2021-22. Risks are tilted to the downside: as COVID-19 spreads locally, further disruptions in economic activity would lead to a further contraction in 2020, followed by a modest recovery in 2021.

3. With Gross National Income (GNI) per capita at US$600 in 2018, Liberia remains a low-income country and among the ten poorest countries in the world. More than half of Liberia ’s 4.9 million people live in urban areas, and one quarter resides in the capital city, Monrovia. Adolescents and youth3 (10-24 years old) represent approximately one-third of the total population. According to the 2016 Household Income and Expenditure Survey (HIES), 40.9 percent of the population lives below the international poverty line of US$1.9/day in 2011 purchasing-power-parity (PPP) terms. Negative per capita GDP growth rates during 2017-2019 further increased the poverty incidence to an estimated 44.5 percent in 2019. The proportion of poor households living below the international poverty line of US$1.9/day (2011 PPP) is projected to increase further to 45.4 percent in 2020 in line with continued negative per capita income growth before marginally decreasing to 44.4 percent in 2022. While it is difficult to gauge the welfare impact of the COVID-19 pandemic precisely, households are expected to be affected negatively due to potential impact on employment, particularly the non-farm self-employed in

1 World Bank (2018) Republic of Liberia Systematic Country Diagnostic. From growth to development: Priorities for sustainably reducing poverty and achieving middle-income status by 2030. 2 Liberia: Macro-Poverty Outlook, Spring Meetings 2020. 3 World Health Organization (WHO) defines young people as individuals between ages 10 and 24. Adolescents represent the 10-19 years old age group and youth represent the 15-24 years old age group.

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urban areas, high prices of imported goods, restrictions on trade, and losses either in terms of the sale of productive assets or consumption of working capital as they try to cope.

4. Non-monetary poverty indicators in Liberia, including access to healthcare, education, and basic utility services are also low by regional and international standards, with especially acute rural-urban and gender disparities. For example, among wealthier households and households in urban areas, 48 percent of children between the ages of 6 and 11 years attend primary school, compared to just 26 percent of children from poorer households and households in rural areas. Significant urban-rural and gender disparities in poverty rates are largely driven by unequal access to land and other productive assets, infrastructure and public services, and markets for both goods and labor.

5. Women face severely limited economic opportunities and endure poor human development outcomes. Liberian women experience high rates of early pregnancy, school dropout, and child and maternal mortality, all of which are especially common among poor households. Female retention in school is low, with only 15 out of every 100 girls who begin primary school advancing to grade 10. Dropout rates during grades 10, 11, and 12 is a critical issue. In addition to poverty, other factors driving high dropout and low retention rates among females include a lack of support at school/home to continue with education, lack of school safety and limited, if any, gender-appropriate facilities (water and sanitation), food insecurity, and pregnancy and early marriage. Early marriage and childbearing, especially in rural areas, widen gender gaps in education, and poor households often focus their limited resources on educating boys. Early childbearing is associated with young women dropping out of school, with lasting negative impacts on their skills and economic empowerment.

6. Fragility is both a cause and consequence of poor human capital outcomes; the Human Capital Index (HCI) for Liberia is 0.32, ranking 153 of 157 countries. The HCI4 – a composite index based on measures of health, education, and nutrition – shows that the average Liberian child born today will only be 32 percent as productive when they grow up as they could be if they enjoyed complete education and full health.5 Adequate nutrition, particularly in the first five years of a child’s life, is vital to physical, social, and cognitive development; and to a child’s readiness to learn and is linked to better educational and economic outcomes. According to the most recent Demographic and Health Survey (2013), a third of Liberian children under-five years are stunted (32 percent), and while stunting declined between 2007 (39 percent) and 2013 (32 percent)6, Liberia still reports the sixth-highest stunting rate in West Africa7, which poses cognitive and physical limitations that can last a lifetime. This is further compounded by poor learning outcomes in schools. For example, a child in Liberia can expect to complete 4.4 years of pre-primary, primary and secondary school by age 18. However, when years of schooling are adjusted for quality learning, this is only equivalent to 2.3 years8.

4 HCI is made up of five indicators and data for Liberia shows: the probability of survival to age five (93 out of 100 children born in Liberia survive to age five); a child’s expected years of schooling (a child who starts school at age four can expect to complete 14.4 years of school by her 18th birthday (and 2.3 is the learning-adjusted years of school); harmonized test scores as a measure of quality of learning (332 on a scale where 625 represents advanced attainment and 300 represents minimum attainment), adult survival rate (fraction of 15-year old that will survive to age 60 -77 percent); and the proportion of children who are not stunted (68 out of 100 children, and therefore 32 out of 100 children are at risk of cognitive and physical limitations that can last a lifetime). 5 The HCI for Africa Region is 0.40 (lowest amongst all Regions), and the target for 2023 (aligned with the Sustainable Development Goals and World Bank Group’s Africa Strategy) is to increase to 0.45. 6 Liberia DHS report 2013. 7 Akombi, BJ et al. (2017). Child malnutrition in sub-Saharan Africa: A meta-analysis of demographic and health surveys (2006-2016). PloS ONE 12(5): e0177338. 8 World Bank (2018) Liberia Human Capital Index.

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B. Sectoral and Institutional Context

7. Liberia has some of the worst maternal and child health outcomes in the region and globally (Table 1). Liberia’s maternal mortality rate at 1,072 deaths for every 100,000 live births (i.e., one death for every 93 women) is among the highest in the world. The neonatal mortality rate (deaths within the first 28 days of life) is also high, at 37 per 1,000 live births, and accounts for a third (35 percent) of all under-five deaths9. Of Liberia’s 15 counties, Montserrado county, which is home to a large proportion of the population of the country and the capital city Monrovia, reports the highest number of maternal and neonatal deaths (details described in Technical Analysis Section IV A). Deaths in mothers and neonates are largely driven by preventable and treatable complications. These include hemorrhage (25 percent), hypertension (16 percent), unsafe abortion (10 percent), and sepsis (10 percent) in mothers, and birth asphyxia and sepsis in neonates, all of which point to the critical gap in quality care during the antenatal, perinatal and postpartum period. Outside the neonatal period, children in Liberia mainly die from infectious diseases, including pneumonia (14 percent), malaria (13 percent), and diarrhea (9 percent).10

Table 1: Select reproductive, maternal, neonatal, child, and adolescent health indicators in Liberia and comparable neighboring countries. Selected indicators Liberia Guinea Sierra Leone Ghana SSA Total fertility rate (births per women (yr.: 2017) 4.4 4.7 4.3 3.9 4.8 Child mortality rate (1,000 live births) 70.9 100.8 105.1 47.9 77.5 Infant mortality rate (per 1,000 live births) 54 61 87 43 52.7 Maternal mortality ratio (per 100,000 live births) 1,072 650 1,100 380 534 Births attended by skilled health personnel (percentage) 61 45 60 68 57.8 Adolescent fertility rate (2017) births per 1000 women age 136.6 135.3 112.8 66.6 102.8 15-19) Source: Republic of Liberia: Investment case for reproductive, maternal, new-born, child and adolescent health, 2016-2020; WDI 2020

8. Adolescent health and fertility remain an area of serious concern. A third (31 percent) of teenagers in Liberia begin childbearing by age 19, and maternal deaths disproportionately affect adolescent girls11. Liberian adolescents rank as having the fourth highest fertility rate (136.6 births per 1,000 women age 15-19 years) in West African countries, after Niger, Mali, and Guinea (194 births, 171 births, and 137 births per 1,000 women age 15-19 years respectively)12. Moreover, compared to its neighboring countries – Sierra Leone and Guinea – Liberia experienced the lowest rate of decline in the adolescent fertility rate between 2000 and 2016. Adolescent fertility contributes to total fertility and limits the ability of young women to accumulate human capital. Fertility is both a driver of Human Capital outcomes and requires added efforts to improve Human Capital at risk. Regional experience shows that rapid progress is possible – Senegal, Malawi, Uganda, and Rwanda reduced adolescent fertility rate by more than 6 percent a year13. Multisectoral interventions, including

9 Source: Republic of Liberia: Investment case for reproductive, maternal, new-born, child and adolescent health, 2016-2020 10 Idem. 11 Idem. 12 WDI 2018 13 The Africa Human Capital Plan, draft March 2018, The World Bank

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focused behavior change, will be key drivers. Improving adolescent sexual and reproductive health outcomes is a priority area of investment for the Government of Liberia (GOL) to create the conditions for demographic transition and human capital accumulation for women and girls.

9. Female retention in schools is very low, particularly at the high school level, and schools are generally not a safe environment for girls. A recent study14 found that 32 percent of girls who had dropped out of school reported feeling unsafe in school, and 30 percent of female students were forced to have sex against their will. Girls and young women are victims of sexual exploitation and abuse, often being forced to engage in transactional sex to have their basic needs met, including the cost of transportation to school and money to cover school fees15. Moreover, schools do not sufficiently address sexual and reproductive health for adolescents. Collaboration between the Health and Education sector is critical to keeping girls, and particularly adolescents, in school in a safe and informed environment.

10. Health outcomes and access to health services suffer wide socio-economic and geographic disparities. The poorest are twice as likely to encounter problems in accessing reproductive health care compared to the richest16. The gap in antenatal coverage is seven percentage points higher for the richest than the poorest; this gap widens to 46 percentage points for coverage of skilled birth deliveries. Similarly, children aged 12-23 months from the richest population are 1.6 times more likely to receive full vaccination compared to those from the poorest. Furthermore, children under five from the richest population are 1.2 times as likely to have febrile treatment sought for them from a healthcare provider compared to those from the poorest population. Consequently, outcomes are worse for the poorest. For example, children under five from the poorest population are 1.7 times more likely to be stunted, and twice as likely to be underweight compared to those from the richest17. In 2016, the share of women accessing postnatal care ranged from 50 percent in Bong County to 17 percent in Margibi County. Similar variations were observed across indicators of child healthcare coverage, and full-immunization rates for children below the age of one ranged from 94.5 percent in Bong County to just 34 percent in River Gee.

HEALTH SYSTEM CHALLENGES

11. The protracted civil wars and the EVD outbreak severely eroded Liberia’s institutions and organizational capacity. The health sector was particularly affected as it lost an invaluable mass of its skilled human resource and institutional asset base. At the same time, the capacity and organizational abilities of institutions essential for enabling an effective and efficient health system to function were severely depleted. This weak institutional base is reflected in an inadequate health workforce (in terms of inadequate numbers, limited skill-mix and distribution, and necessary technical skills to provide quality health care), with no clearly defined career path or incentives to work in the system, and with little accountability and transparency. Moreover, the dysfunctional management and organizational system hinder the availability of timely and affordable drugs and services for the sick and needy.

14 World Bank 15 IDA Project Appraisal Document for Improving Results in Secondary Education Project, June 2019: Primary and junior secondary school are tuition-free; however, enrollment fees are required at the senior secondary level. 16 Based on analysis of data from 2017 World Development Indicators (WDI) dataset 17 All other data referenced in this paragraph were based on analysis of the 2013 LDHS

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12. Liberia made significant progress in health service delivery after the civil wars, and until 2013; however, the EVD outbreak (2014-16) reversed some of the previous gains and constrained the health system’s functionality. Between 1986 and 2013, the country’s under-five and infant mortality rates declined from 220 to 94 deaths per 1,000 live births and 144 to 54 deaths per 1,000 live births, respectively. Moreover, health and service-delivery indicators improved between 2000 and 2013. Measles immunization coverage increased from 52 to 74.2 percent; the prevalence of stunting among children under five years old declined from 39 percent in 2007 to 32 percent in 2013, and life expectancy at birth increased from 52 to 61 years. The EVD crisis reversed some of these achievements: deliveries by skilled birth attendants fell by 7 percent; fourth antenatal care (ANC) visits dropped by 8 percent, measles coverage rate declined by 21 percent, and health-facility utilization rates plummeted by 40 percent18. Liberia also lost a staggering 10 percent of its doctors and 8 percent of its nurses and midwives to the EVD—over 8 percent of the nation’s health workforce. A 2015 study estimated that the deaths of these workers potentially increased the maternal mortality rate by 111 percent relative to the pre- EVD baseline19.

13. Significant gaps in the quality of care contribute to the persistently high levels of maternal and neonatal mortality. A review of maternal and neonatal death audit reports indicate significant gaps in the available quality of Emergency Obstetric and Neonatal Care (EmONC) – both at hospitals (meant to provide cesarean sections and neonatal intensive care) and primary level facilities (meant to manage uncomplicated labor and routine care of the newborn). The quality gaps in service provision cover the full range, including (i) a lack of reliable and consistent availability of power supply and water; (ii) skilled and committed human resources to provide quality antenatal, intrapartum and postnatal care; (iii) access to 24*7 care; (iv) essential life-saving commodities – oxygen, blood, oxytocin, magnesium sulfate, and intravenous antibiotics; (v) poor use of data for decision making; and (vi) lack of accountability amongst service providers.

14. While funding to the health sector has increased in recent years, it remains insufficient to provide basic health services to the population and make sustained progress on health outcomes; and this is exacerbated by inefficiencies resulting from poor accountability and transparency. The GOL has prioritized the health sector over time: General Government Health Expenditure (GGHE) as a percentage of general Government expenditure increased from 7 percent in 2000 to 12 percent in 2014,20 before reaching 13.6 percent for the 2017/18 fiscal year21. The health sector’s appropriation in the FY 2019/2020 budget is 14.16 percent of the total national budget. Given the relatively small size of the total Government budget, the increase of the GGHE is not enough to respond to the significant needs in the health sector. Almost three-fourths of the total budget expenditure in the health sector is accounted for within the wage bill. Over 40 percent of compensation payments are paid in the form of discretionary allowances, creating both inequity and inefficiency. Financing and the proportion of the total quantum of annual financing (allocated and released by the GOL) is insufficient22 to meet the basic health needs of the population. Consequently, the country’s per capita health expenditure remains low at US$72

18 Source: Republic of Liberia: Investment case for reproductive, maternal, new-born, child and adolescent health, 2016-2020 19 Source: Evans, DK; Goldstein, M.; Popva, (2015) A. Health-care worker mortality and the legacy of the Ebola epidemic. Lancet vol 3 pg. e440. 20 Global Health Expenditures Database from WHO 21 MOH 2017 22 Estimated annual cost of essential package of drugs and supplies is US$ 22 million – of this US$ 11 million is provided (mainly in kind) by donors. The remaining US$ 11 million budgetary request made by MOH to MFPD, since the last 2 years only about US$ 4 million has been allocated, of which only US$ 640,000 was released to MOH in FY19.

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(current US dollars), below the US$86 threshold necessary to provide a basic package of health services.23 The health sector systematically begins with an annual shortfall of required essential drugs and medical supplies, and even the scarce resources allocated are not efficiently used, with a significant lack of accountability in the system. The most impoverished bear the brunt: 15 percent of poor households encounter catastrophic health expenditures compared to only 8 percent among the rich24. Outpatient services25 and over-the-counter payment for drugs are the main drivers of out of pocket (OOP) spending.

15. The ongoing COVID-19 pandemic could have a detrimental impact on the already fragile health sector. As of April 21, 2020, Liberia has 99 confirmed cases of COVID-19 and 8 deaths. Considering the contextual and health system challenges in Liberia, in the absence of a rapid, effective, and sustained response, a COVID-19 outbreak could once again have a devastating impact on the fragile health system, health outcomes, and the broader Liberian economy. In response to this, the World Bank has already mobilized support from the ongoing Regional Disease Surveillance Systems Enhancement Program (REDISSE) II project (P159040); and is also in the final stages of providing additional financing through a new project to complement this financing (Liberia COVID-19 Emergency Response Project; P173812). The new Liberia COVID-19 Emergency Response Project will focus on supporting the GOL’s National response to the current COVID-19 pandemic, while REDISSE II continues to address issues related to sustainability, and One health.

NATIONAL POLICY RESPONSE

16. The Government of Liberia, in partnership with Development Partners, (DPs), launched a coordinated response to challenges affecting Reproductive, Maternal, Child, and Adolescent Health (RMNCAH). To address some of the key lagging health outcomes in the country, the GOL prepared and endorsed the RMNCAH Investment case (IC) (2016-2020). Implementation of the IC is funded by the GOL and DPs, including the World Bank Group (WBG)/Global Financing Facility (GFF) Trust Fund26, USAID, Global Fund, UNICEF, WHO, UNFPA, Government of Japan, GAVI, BMZ, and Last Mile Health. The IC accelerates strategies to improve essential health services nationally, prioritizing six27 out of fifteen counties, which, in 2015-16, had comparatively worse RMNCAH indicators and fewer resources. The six priority areas are: (i) quality emergency obstetric and neonatal care including ANC and postnatal care (PNC) and child health; (ii) strengthening the civil registration and vital statistics (CRVS) system; (iii) adolescent health interventions to prevent pregnancies at school level, mortality and morbidity during antenatal, childbirth, and postpartum periods, unsafe abortion, early and unintended pregnancy and sexually transmitted infections, and gender-based violence; (iv) emergency preparedness,

23 High Level Task Force on Innovative International Financing for Health 2009 estimates. 24 2014 household survey. Catastrophic health expenditures are defined as 10% of total household consumptions. 25 Payment of outpatient services mostly apply to public facilities per the 2014 household survey. 72% of households went to a public health provider while 18% visited a private for-profit provider. 26 The GFF is a broad partnership that supports countries to get on a trajectory to achieve the Sustainable Development Goals (SDGs) by strengthening dialogue among key stakeholders under the leadership of governments. It facilitates the identification of a clear set of priority results that all partners commit their resources to achieving; getting more results from existing resources and increasing the total volume of financing from domestic government resources, financing from IDA and IBRD, aligned external financing and private sector resources; and strengthens systems to track progress, learn, and course-correct. This approach is guided by two key principles: country ownership and equity. The GFF is driven at the country level by a ‘country platform’: a forum or committee that brings together, under government leadership, the broad set of partners involved in improving the health outcomes of women, children, and adolescents, including different parts of the government, civil society, the private sector, and DPs. A multi-donor trust fund—the GFF trust fund—has been established at the World Bank Group to be a catalyst for this process. 27 Six priority counties include: Gbarpolu, Grand Bassa, Grand Kru, Rivercess, Rivergee and Sinoe county

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surveillance and response, especially maternal and neonatal death surveillance and response (MNDSR); (v) sustainable community engagement; and (vi) leadership, governance and management at all levels. While progress has been made in some areas, more is needed to address the high levels of maternal and newborn deaths, as well as health needs for adolescents. The joint development of the next IC, with the Government in the lead, is an opportunity to broaden the scope (geographic, health system, and health financing issues) within the available resources. The timing of the next IC aligns well with the next funding cycle of main financiers showing interest to further align, including the Global Fund, USAID, and the WBG IDA (with a possible GFF TF second-round of financing).

17. Additional financing by the GFF Trust Fund to the ongoing IDA Health Systems Strengthening Project (P128909) is fully aligned with Liberia’s RMNCAH IC. Performance-Based Financing (PBF), supported by the GFF, has now been rolled out to eight hospitals and three counties28. Counties and hospitals are paid on results linked to improving coverage and quality of RMNCAH services. This results-based approach helps the country move towards strategic purchasing as part of the Government’s plan for Universal Health Coverage (UHC). A Technical Assistance agency has also been put in place to build the capacity of County Health Teams (CHTs) to deliver on these results. The payment of the agency is linked to increased competencies and skills of the CHTs. Improving community-level services with support to the Community Health Assistance (CHA) program has also been critical to improved access and utilization of services. The GFF also adds value by strengthening existing mechanisms for coordination between Government, financiers, and other non-governmental stakeholders, including through improving financial resource mapping and tracking, and improving data analysis and use for decision making to prioritize and course-correct during implementation. The GFF provides implementation support for the IC through technical assistance on health financing, monitoring and evaluation, and technical implementation. Moreover, a Liberia-based Liaison Officer supports the Government’s Investment Case Implementation. With a portion of the available financing undisbursed, the GoL plans to continue these activities through an extension for one year after May 31, 2020.

18. There have been several critical achievements during the implementation of Liberia’s RMNCAH IC, which represent important steps towards improved RMNCAH services in Liberia. First, the Ministry of Health (MOH) has started to annually map the IC resources contributed by partners and the Government. PBF is now implemented in nine counties (six supported by USAID and three by the GFF/WBG)29 as well as eight hospitals supported by the GFF/WBG. PBF covers four of the country’s six RMNCAH priority counties. The country now implements MNDSR, a major step in reporting and understanding maternal and newborn mortality. Trainings and mentorships on EmONC have taken place to improve maternal and newborn care, with more than 900 health workers trained. Revisions to the Country’s Public Health Law are underway to improve access to adolescent sexual and reproductive health services (ASRH). Community health workers are an important avenue to reach people in remote rural areas and engage with hard to access communities. Liberia’s CHA program supports community health workers in rural areas more than five kilometers from facilities. Support for CHAs is coordinated between partners with common guidelines, indicators, and a training curriculum.

28 Counties include: Gbarpolu, Rivercess and Sinoe. Hospitals include: (i) CB Dunbar hospital, (ii) Phebe hospital, (iii) Redemption hospital; (iv) Tellewoyan hospital, (v) Jackson F Doe hospital, (vi) FJ Grant hospital, (vii) St. Francis, (viii) Chief Jallalhone. 29 World Bank supported counties include: Gbarpolu, Rivercess, Sinoe. USAID supported counties include Bong, Lofa, Nimba, Grand Gedeh, River Gee and Grand Cape Mount.

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19. There have been challenges in the implementation of the IC. They include: (i) severe shortages of essential medicines at facilities due to inadequate budget allocation and supply chain challenges; (ii) gaps in primary and secondary care due to reductions in government allocations to facilities and counties, and (iii) inconsistencies in the regularity of county platform meetings as well as the use of data to track the IC progress. In addition, there are substantial disparities in the coverage of critical maternal and newborn health services across the country. For example, the rate of skilled delivery varies from 31 percent in Montserrado County to 99 percent in Nimba County) and PNC for women range from 14 to 95 percent between the same two counties, at the extreme ends of the spectrum. These challenges contribute to the country’s high maternal and neonatal mortality rates and underscores the need to build on the IC achievements by focusing on RMNCAH results to improve outcomes.

20. Plans and programs are in place, but low financial investment and binding constraints often hinder the attainment of desired results. In addition to the RMNCAH IC, during the last few years, many elaborate plans have been prepared and agreed to improve Liberia’s health system and its corresponding health indicators. These plans, however, have usually not been implemented as planned; and where implemented, the focus has not been sufficiently technical to address the challenge. Moreover, there is limited orientation towards governance, institutional, and organizational reforms for sustainable impact. There are a range of underlying critical challenges that Liberia faces, and these translate into some of the key binding constraints to implementation. Key areas include: (i) human resource management; (ii) availability of inputs, and drug procurement and supply chain management systems; (iii) public financial management (PFM) and efficiency; (iv) bringing citizen’s voices into health governance; and (v) improving transparency and accountability at all levels of the system. Moreover, digitization and technology provide opportunities that have not been exploited to the fullest in the country30. To contribute towards improving health outcomes for women, children, and adolescents in Liberia, this project will address these key binding constraints31. International experience in similar country contexts show that governance and institutional issues are often most effectively addressed by financing results instead of inputs. Creating a framework of incentives to support the long-term implementation of strategic institutional reforms will be critical to creating sustainable change in Liberia.

C. Building on PFM inputs.

21. The Public Financial Management Reforms for Institutional Strengthening (IPFMRS) project (P165000), approved in July 2019, has a component with Disbursement-Linked Indicators (DLI) that focuses on PFM reforms in the health and education sectors. The Auditor General’s Office has conducted a series of audits to determine the main PFM bottlenecks that impede service delivery in Liberia. The two sectors are among the top five in terms of proposed budget appropriations over the past three years32. Issues requiring attention within the

30 Technology and innovation offer countless opportunities to address supply and demand side constraints to Human Capital acceleration. 31 Key binding constraints to implementing health sector programs and plans are fourfold. Stakeholder consultation, analysis, and discussions have identified an exhaustive list of constraints, which can be categorized into four broad areas: (i) resource availability and management: drugs, people, finance, assets, and information; (ii) organizational structure and systems: organizational, managerial, individual accountability, lack of enforcement and lack of compliance with regulation, decentralization, and devolution (the structure of power); (iii) managerial: information for evidence-based decision-making managerial issues at all levels including managerial incentives for performance; and (iv) institutional: civil service structure, and political economy incentives. Further inquiry and deliberations point to the urgent need to address the underlying constraints in at least the areas of human resources, supply chain management, and information for evidence-based decision-making. Implementation of all existing plans and programs would significantly improve if practical reforms and solutions are supported in these key areas. 32 Based on the proposed budget appropriations, sectors are health, education, finance and development, justice, and public works.

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health sector include: (i) poor financial reporting; (ii) the need for payroll cleaning; (iii) the lack of inventory records; (iv) poor record management; and (v) the improper use of ministry bank accounts.

D. Relevance to Higher Level Objectives

22. The Liberia Country Partnership Framework (CPF) for FY2019-24 (Report No. 130753-LR, October 26, 2018) describes the main elements of the WBGs support to Liberia as it strives to achieve sustainable, resilient, pro- poor economic growth. The CPF lending program embodies key strategic shifts from the heavily skewed infrastructure portfolio of the previous Country Partnership Strategy (CPS) towards a strong focus on education, agriculture, economic empowerment of women and youth, and maternal and child health. Therefore, the CPF investment portfolio will increasingly concentrate on human development and intangible capital. Its overarching goal is to support Liberia as it strives to achieve pro-poor, private sector-led growth underpinned by human- capital development, institutional capacity-building, infrastructure development, and economic diversification. This project will support (i) Pillar 1 (strengthening institutions and creating enabling environment for inclusive and sustainable growth through objective 1 - greater transparency, accountability, and efficiency of public institutions); and (ii) Pillar 2 (building human capital to seize economic opportunities through objective 6 - improved early childhood and maternal health).

23. The project will support IDA 18 policy priorities, particularly Gender and Governance in an FCV context. After the civil war period, when Liberia was beginning to slowly improve health outcomes, the EVD crisis had a devastating impact on the health system. The country now records one of the highest maternal mortality rates in the world, a large proportion of which is teenage girls below 20 years of age. Along with the health impacts of early childbearing, young parenthood also affects youths’ education and livelihood generation potential. The project will work with the WBG Governance Global Practice to address critical institutional binding constraints, including the underpinning lack of accountability and transparency in the health sector, particularly for: (i) human resources for health, (ii) last mile availability of essential drugs and medical supplies, and (iii) the use of data for evidence-based decision making, including citizen engagement.

24. The project design is also aligned with the Scale Up Facility (SUF) objectives. SUF financing has been mobilized for the proposed project given its potential transformative impact on the entire health sector in Liberia. Specifically, the SUF funds will support: (i) implementation of the Government’s Pro-Poor Strategy and MOH’s health sector plans; and (ii) construction and operationalization of the largest secondary care public sector hospital in the country. Even today, the health system and hospitals in Liberia cannot meet not only daily health demands but particularly the enhanced patient load during health emergencies like the Ebola outbreak, and now potentially the ongoing COVID-19 pandemic. This activity is also likely to contribute to the climate co- benefits; (iii) continue inputs to increase the current inadequate health workforce in the country through financing selected undergraduate and post-graduate teaching faculty; (iv) address key institutional binding constraints that have the potential to enhance and improve transparency in the use of not only government financing, but that provided by all health sector donors; and (v) all activities and objectives of the project, directly and indirectly, are designed to reduce the number of women dying in pregnancy, improve health and wellbeing and survival of the adolescent girl, and thereby, significantly contribute to improving the country’s HCI. Both the infrastructure component and the adolescent healthcare support will also address and mitigate GBV risks. The SUF financing (US$54 million) will be blended with proposed IDA 19 financing (US$30 million) to achieve concessionality. In addition, it is likely that Liberia would be a beneficiary of additional GFF grant financing in the next few months, and this would further increase the concessionality.

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25. The project will align and expand the support of interventions financed by the GFF Trust Fund to support the implementation of the RMNCAH IC and provide the necessary support to ensure the inputs provided thus far (through WBG support to the health sector) are fully completed and utilized.

26. The WBG HNP Global Practice is in the process of refreshing its Strategy and has articulated high-quality health systems with reimagined primary health care (PHC) as its foundation. This foundation would be laid with a governance and financing lens to influence the redesign of PHC service delivery in an integrated manner, including human resources, data science, technology and innovation, strengthened people-centered approaches and strengthened leadership and management. The project focuses on these principles.

27. The proposed project is strongly aligned with the WBG’s twin goals of reducing poverty and sustainably boosting shared prosperity by improving the coverage and quality of primary and secondary health service delivery for women, adolescents and children, and supporting Liberia’s efforts to achieve Universal Health Coverage (UHC). In the long-run, investments made through this project will improve health outcomes, human capital, productivity, with lifetime and intergenerational effects on wealth and poverty.

II. PROJECT DESCRIPTION A. Project Development Objective

PDO STATEMENT

To improve health service delivery to women, children, and adolescents in Liberia.

PDO LEVEL INDICATORS

The following indicators will be used to monitor progress towards the achievement of the PDO: (i) Redemption Hospital Phase 1 and 2 fully completed and operational to provide comprehensive services to women, children and adolescents; (number); (ii) Pregnant women with four antenatal care visits (percentage); (iii) Proportion of new users of modern contraception who are adolescents (10-19 years) (percentage); (iv) Institutional deliveries attended by skilled birth attendants (medical doctors, physician assistants, registered nurses, registered/certified midwife) (percentage); (v) Adolescent girls (10-19 years) leaving selected health facilities with 2 counselling sessions on family planning (percentage).

PROJECT DESCRIPTION

28. The project will build on the ongoing quality improvement and resilience-building activities implemented by the WBG and GFF, particularly in the post-EVD period. This will include completing, operationalizing, and improving the efficiency of the new Redemption Hospital in Caldwell, Montserrado County. The Redemption Hospital is the largest public sector hospital in the country, and at present, functions under a constrained environment, which led to a rapid spread of EVD during the outbreak – with the hospital as the

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locus of infection. Construction of Phase 1 of this hospital is being supported under the current Ebola Emergency Response Project (P152359) and is likely to be completed by September 2021 at the latest. Due to a lack of available resources at the time, the WBG was unable to support the equipping of Phase 1 or the construction of Phase 2 of the hospital. Having explored all other possible sources of viable potential financing with no success, the GOL has requested financing from the WBG for this activity. Specifically, the GOL requests that the proposed project prioritize the construction of Phase 2 (in the same location as Phase 1) and equipping of both Phases to ensure an efficient hospital for the entire population, with a continued focus on women and children. The project will also provide continued (selected) and conditional support to undergraduate and post-graduate training to ensure that essential skilled human resources are available to improve health outcomes. The proposed project will continue to support and scale up PBF interventions at select primary and secondary health facilities, and the CHA program in select counties. Additionally, based on ongoing assessments, including contributions from other DPs, the project would consider supporting, as needed, selected critical inputs required to ensure a minimum quality of health care. This would primarily address the acute shortages of essential drugs and supplies for preventing maternal and neonatal deaths, e.g., oxytocin, oxygen, magnesium sulfate, intravenous antibiotics, blood, and intravenous fluids.

29. Disbursement Linked Indicators (DLIs) as a mechanism to focus on some of the desired results. For additional financing to the health sector to best complement and enhance the ongoing development support and programs, the proposed project will finance a set of DLIs. The DLIs aim to signal to key stakeholders the importance of focusing on critical results. These DLIs would correspond to key priorities identified by stakeholders in Liberia as binding constraints that impact the implementation of technical solutions, and major bottlenecks along the results chain. Supporting a program that links financing to results through mechanisms such as DLIs could promote transparency and accountability in the system. This mechanism is likely to incentivize actors in the health sector to take a more proactive stand in addressing stewardship functions in public sector management, which over time, would facilitate more equitable and affordable service delivery and improvements in human capital.

30. The DLIs will reflect key results of the program related to Governance. The structure and design of the DLIs ensure financing of results chains in a few select critical areas, thereby supporting the strengthening of the institutional and organizational base of the health sector in Liberia. Marker indicators and results for all DLIs are designed to directly or indirectly (in the short or medium-term) focus on improved health outcomes for women, children, and adolescents. The key results chains address institutional and governance issues and specific technical issues. These include: (i) enhanced and reliable data availability and evidence-based decision making; (ii) improved human resource management; (iii) enhanced supply chain management in collaboration with DPs financing this area; and (iv) support for the high school adolescent health program. The project will disburse resources against the following DLIs: • DLI1: Key RMNCAH data regularly available and used for evidence-based follow-up at the national county level; • DLI2: Contribute to a reduced stock-out of essential package of drugs evidenced by a functional supply chain; • DLI3: Functional HR system in place at MOH, counties, hospitals and facilities; • DLI4: Improved adolescent health (with focus on girls) as measured by specific marker indicators; • DLI5: Citizen engagement and grievance redress system functional in the health sector; • DLI6: 25 Selected hospitals/health centers increasing percentage of adolescent girls leaving the hospital with 2 counseling sessions on contraceptive methods after delivery over baseline.

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FINANCING MODALITIES

31. Financing Gap. The scope and design of a new health sector project to adequately support the underlying health service delivery and institutional challenges and concomitant persistent material needs in the health sector in Liberia is estimated to need financing of at least US$84 million. Given the severe fiscal constraint of Liberia’s IDA 18 budget, a successful case was made in August-September 2019 by the Country Management Unit (CMU) and the HNP GP to access financing from the FY20 envelope of the IDA Scale-Up Facility (IDA-SUF). The Liberia HNP sector was then allocated US$54 million from IDA-SUF, provided that the project is sufficiently developed for Board Approval in FY20. Given that this is a non-concessional IDA Credit, the Liberia Ministry of Finance and Development Planning (MFDP) requested that the project prioritize the financing of a long-pending need – completion, and operationalization of both Phase 1 and 2 of the new Redemption Hospital. Under its current HNP portfolio, the WBG is supporting the construction of Phase 1 of the hospital, which was conceptualized during the previous administration. Since then, the new administration in the country has exhausted all possible sources of economically viable financing, hence this request to the WBG. The HNP GP carefully considered this request and agreed that hospital infrastructure takes time and given that at present, only IDA-SUF is available, the project be prepared so that this activity can be started earliest. Meanwhile, the CMU has committed to allocating US$30 million from the first-year allocation of the IDA 19 cycle to the Liberia HNP sector – however, this would only be available after July 2020. Therefore, to utilize the available US$54 million IDA-SUF, this project is being prepared for an FY19 Board Approval, while describing a financing gap within the different components. Once the committed US$30 million from IDA 19 becomes available, an Additional Financing (AF) will be processed to fill the financing gap. Additional time will not be required to implement and utilize the AF, given the activities described to be supported. There is also a possibility (which should be confirmed before end-2020) that Liberia receives a second round of GFF grant financing. This AF would also be accommodated within this parent project, further complementing the non-concessional IDA-SUF, and enabling the project to improve health outcomes for women, children, and adolescents in Liberia.

32. GFF is exploring additional financing to Liberia’s RMNCAH IC (beyond 2020) through a second round and has agreed to the full utilization of remaining grant funds, to continue supporting PBF for improved health service delivery, and further supporting adolescent health. An estimated US$5.8 million will remain undisbursed from the GFF grant (total US$ 16 million) provided as an AF to the Health Systems Strengthening Project (P128909) closing on May 31, 2020. The GFF has agreed that it could extend this grant until May 31, 2021, thereby providing continued support to the PBF program and other ongoing activities. This would ensure full utilization of the grant and prevent disruptions in the implementation of current project activities, particularly for PBF, until funds are made available through this proposed project. Access to the second round of GFF financing is contingent on the matching of IDA financing, which will be committed by the CMU from IDA 19 resources. The IDA-SUF is not considered as matching since it is non-concessional.

B. Project Components

33. The total proposed financing envelope is US$84 million. The project components are described below based on the amount of IDA-SUF available at present (US$54 million), and the US$30 million additional IDA that will be made available from the IDA 19 resource envelope for Liberia. Any potential new GFF financing has not been represented in the project financing amounts; however, the current project design and scope

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would be able to include any such AF made available during project implementation. Table 2 illustrates a summary of the focus areas financed under the proposed project and stratified according to whether financing supports costs related to inputs/training or the achievement of performance indicators (DLIs and PBF indicators).

Table 2: Summary of focus areas of Institutional Foundations to Improve Services for Health (IFISH) project financing ($US$ Million) Areas strengthened through financing Component Financing Total % (US$m) (US$ m) Inputs/ Performance training indicators (DLI, and PBF) 1 Construction, equipping and 1.1 35 - 35 41.7 operationalization of Redemption hospital 2 Health human resources 12 3.0 15.0 17.9 - Medical education 1.2 8 - - CHA program 1.4 4 - - Human resource management 2.3 - 3.0 3 Strategic purchasing (PBF) 1.3 - 12 12 14.3 4 Adolescent health care 4 3 7 8.3 - Community-level 1.5 3 - - Schools 2.4 and 1.5 1 3 5 Essential medicine and 5 1.5 6.5 7.7 pharmaceutical products - Procurement of essential 1.6 5 - medicines and RMNCAH products - Strengthen supply chain 2.2 - 1.5 management 6 Evidence-based decision making 2.1 - 2 2 2.4 and HMIS 7 Citizen engagement 2.5 0 1.5 1.5 1.8 8 Project management 3 5 - 5 6.0 - Project coordination 3.1 4 - - Monitoring & evaluation 3.2 1 - 9 Emergency response 4 0 0 0 0 84 100.0

34. The proposed project has four components: Component 1: Improved service delivery (US$68 million equivalent), Component 2: Institutional strengthening to address key binding constraints (US$11 Million equivalent), Component 3: Project management (US$5 million equivalent)), and Component 4: Contingency

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Emergency Response Component (CERC) (US$0 million equivalent). The details of each component are as follows:

Component 1. Improved Service Delivery (Total US$68 million equivalent, including US$47 million equivalent from IDA-SUF and a financing gap of US$21 million equivalent from IDA 19): This component would be financed using the traditional IPF approach and include the following subcomponents:

• Subcomponent 1.1. Operationalizing new Redemption Hospital Phases 1 and 2 (Total US$35 million equivalent from IDA-SUF).

35. This subcomponent will finance the design, construction and supervision of Phase 2, and the procurement and installation of equipment for both Phases 1 and 2 of the new Redemption Hospital. The procurement of equipment will be conducted in stages, based on the respective construction completion timelines for Phases 1 and 2. Construction of Phase 1 is ongoing, financed by the ongoing Ebola Emergency Response Project (P152359). While construction is scheduled to be completed by March 2021, construction progress to date indicates that there may be a delay of a few months. The Government will inform the WBG by mid- 2020 at the latest if an extension is required. Preliminary design and cost estimates were done for Phase 2 at the conceptualization stage, and a design and supervision consultant firm will need to be contracted to detail and finalize these elements.

• Subcomponent 1.2. Enhancing human resource skills (Total US$8 million equivalent, including US$1 million from IDA-SUF, and a financing gap of US$7 million from IDA 19).

36. To ensure the delivery of quality health services at all levels, qualified and skilled personnel are required. Since 2013, the WBG – through several HNP operations – has directed an estimated US$13.5 million towards the training of Liberian health personnel. This included support to the undergraduate medical education at A.M.Dogliotti. Medical College and initiate post-graduate training at the Liberia College of Physicians and Surgeons (LCPS). Forty-five medical doctors have graduated, with specialties in internal medicine (11), general surgery (12), pediatrics (9), and Obstetrics & Gynecology (13). Under this sub-component, the project will cover costs related to the training of undergraduate and post-graduate health personnel at the A.M.D Medical College and LCPS, and will finance training of nurses and midwives33.

• Subcomponent 1.3. Scaling-up the successes of PBF (Total US$12 million equivalent, including US$3 million from IDA-SUF, and a financing gap of US$9 million from IDA 19).

37. Under this subcomponent, the proposed project will support costs related to the provision of maternal, adolescent, and child services through PBF to select primary health care centers and hospitals. While the WBG and USAID both currently support PBF in Liberia34, each institution implements its own model of PBF. The GOL has requested that USAID and the WBG design an integrated model, which will be scale-up to the

33 The GOL has requested financing for five years (2020-2025) to address a financing gap of US$11.5 million to support (i) the undergraduate program, (ii) 48 post-graduates in four specialities (internal medicine, surgery, pediatrics and obstetrics & gynecology), and (iii) 19 post-graduates in other specialities. 34 The ongoing Health System Strengthening Project (P128909) supports PBF in three counties and eight hospitals, and USAID supports PBF in six counties

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rest of the country. To inform the design of the new PBF model, the GFF is financing implementation research on Liberia’s experience with PBF and an impact evaluation of the current PBF models, financed by the Health Results Innovation Trust Fund, is being conducted (end line study to commence in June 2020). Once the new PBF model is developed, the proposed project will support costs related to the implementation of the model, including (i) PBF subsidies to primary health care facilities, hospitals and counties; (ii) verification of results by independent verification agencies/modalities; (iii) technical assistance to support the design and implementation of the new model, and (iv) training, monitoring and evaluation (M&E), and other operational costs.

• Subcomponent 1.4. Support to the national Community Health Assistant (CHA) Program (Total US$4 million equivalent, including US$2 million from IDA-SUF, and a financing gap of US$2 million from IDA 19).

38. This subcomponent will finance costs related to the CHA program, with the aim to improve the quality of preventative, promotional and curative RMNCAH services, including ANC, PNC, and follow-up in the community, and serve as a link between the community and health facilities. This subcomponent aligns with the country’s priority to invest in community health, particularly those related to RMNCAH priorities35. The CHA program uses an innovative service delivery model to expand the coverage of essential services to populations living in remote areas in Liberia where communities lack access to health facilities. In these settings, CHAs are the best, and sometimes, the only option for primary health care. A recent assessment of the CHA program in rural Konobo district showed that, between 2012-2015, the program was associated with a significant increase in the coverage of maternal and child health services, including facility-based deliveries (28.2 percent increase between 2012-2015) and treatment of diarrhea in children (60.1 percent increase between 2012-2015)36.

• Subcomponent 1.5. Support for community and school health interventions to improve access to adolescent health care (Total US$4 million equivalent, including US$2 million from IDA-SUF, and a financing gap of US$2 million from IDA 19).

39. This subcomponent will finance a basic package of evidence-based interventions at schools and in the community that supports the longer-term objective of contributing to the reduction of teenage pregnancies and maternal mortality. In addition, the project will support costs related to the contracting of an experienced non-governmental organization (NGO), to implement activities that enhance community engagement and behavior change37 towards teenage pregnancy and appropriate health care. At the school level, this subcomponent will finance inputs related to joint activities by the Ministry of Health (MOH) and the Ministry of Education (MOE) to improve sexual and reproductive health.

35 Republic of Liberia, Ministry of Health (2015) Investment plan for building a resilient health system, Liberia (2015-2021). 36 Luckow, PW.; Kenny, A.; White, E, et al. (2017) Implementation research on community health workers’ provision of maternal and child health services in rural Liberia. Bull World Health Organ. v95:113-120 37 Proposed community based adolescent activities in the project would include some activities that SWEDD has successfully implemented, e.g., promoting social and behavioral changes, empowering women and girls to increase demand for RMNCHN services; and better awareness of populations to foster political commitment and capacity for policy making and advocacy.

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• Subcomponent 1.6. Improve availability of essential medicines and RMNCAH products (Total US$5 million equivalent, including US$4 million IDA-SUF, and a financing gap of US$1 million from IDA 19).

40. Access to quality pharmaceuticals is a significant constraint to improving RMNCAH outcomes in Liberia. This subcomponent will cover costs related to the procurement of selected essential medicines and supplies, required to save lives of mothers and neonates (oxytocin, misoprostol, magnesium sulfate, intravenous antibiotics for mothers and newborn, intravenous fluids, oxygen, blood, anesthetic drugs for caesarean sections, etc.).

Component 2. Institutional Strengthening to Address Key Binding Constraints (Total US$11 million equivalent, including US$6 million equivalent IDA-SUF, and a financing gap of US$5 million equivalent from IDA 19): This component would be financed using IPF with DLIs. The DLI matrix and verification protocol is described in Annex 2. The annual Disbursement-Linked Results (DLRs), except for the “Year Zero” DLRs, are based on annual accomplishments, and hence will be time-bound to that year and not scalable. Only the DLRs for Year Zero can be carried over to Year 1. If they are not achieved by the end of Year 1, then a detailed discussion will be held to change/restructure the DLRs.

• Subcomponent 2.1. Enhanced and reliable data availability and evidence-based decision making (Total US$2 million equivalent, including US$1 million IDA-SUF, and a financing gap of US$1 million from IDA 19).

41. In Liberia, the availability of reliable and timely data, and its use for evidence-based decision making is unsystematic and weak, contributing to ineffective service delivery. Moreover, there is limited accountability in data reporting and where data exists, it is often partial or outdated. This DLI-financed subcomponent will support the development of standards and procedures that ensure the availability of reliable and timely data at all levels and across all functions of the health system. It aims to incentivize: (i) effective planning and management; (ii) the use of facility-level data for implementation, and decision- making at a more senior level, and (iii) mechanisms for data sharing with communities. Improved systems will allow for regular data capture and monitoring of disaggregated data, which can be consolidated and used for planning and decision making, including equitable resource allocations.

• Subcomponent 2.2. Effective supply chain management (Total US$1.5 million equivalent, including US$0.5 million IDA-SUF, and a financing gap of US$1.0 million from IDA 19).

42. The MOH does not have a robust logistics and supply chain management system, which makes it difficult to assess, manage, and monitor drug availability at counties and facilities. This subcomponent will support activities that enhance coordination between DPs to strengthen medical supply management, including family planning and reproductive health commodities. Specifically, this subcomponent will finance activities that strengthen procurement management and forecasting, improves inventory management and logistics, warehousing - accessibility, security, stock management, and information systems. Enabling proper planning, budgeting, execution of procurement and quality assurance, and improved efficiency in the distribution and reporting will lead to reductions in drug stock-outs and enable the timely availability of drugs at health facilities, and to all populations. The major bottleneck, however, of an overall limited annual drug budget made available to MOH, will be addressed through continuous policy discussions and maximizing efficiencies.

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• Subcomponent 2.3. Improved human resource management (Total US$3.0 million equivalent, including US$2.0 million IDA-SUF, and a financing gap of US$1 million from IDA 19):

43. Effective strategies are needed to encourage and incentivize the availability of appropriate staffing, especially in remote areas, to ensure quality of care at the point of service delivery. This subcomponent will support costs related to the MOH’s development and implementation of an effective human resource strategy and performance management system. This would include addressing critical inefficiencies in the current system that impacts on the effectiveness of service delivery and the motivation and accountability of staff – e.g. lack of clear job descriptions, non-existent career paths, no transparency in selection, postings and transfers, urban-rural disparities, untimely payment of salaries, disparities in salaries, and incentives and motivation. Enabling the creation and implementation of effective strategies for human resource management will encourage equitable distribution and retention of motivated personnel and health support staff at different levels of the organization – M0H, counties, hospitals, and primary level – support better service delivery across the health system in Liberia.

• Subcomponent 2.4. Support for school-based interventions to improve adolescent health (with a focus on girls) (Total US$3 million equivalent, including US$2 million IDA-SUF, and a financing gap of US$1 million from IDA 19).

44. This subcomponent will support activities that address institutional barriers to the joint implementation of the school-based adolescent program by the MOH and MOE. It will support costs related to the coordination between the MOH and MOE, to jointly develop, implement and monitor school-based activities under subcomponent 1.5, as well as an adolescent sexual and reproductive health and rights training (ASRHR) module by female health counselors in high schools, recruited through the WBG’s Education project (Improving Results for Secondary Education Project; IRISE; P164932). These female health counselors aim to enhance the sexual and reproductive health knowledge and behavior of adolescents in schools, and support girls who drop-out because of pregnancy. This subcomponent is complementary to sub-component 1.5.

• Subcomponent 2.5. Strengthened citizen engagement (Total US$1.5 million equivalent, including US$0.5 million IDA-SUF, and a financing gap of US$1 million from IDA 19).

45. This subcomponent will support activities to strengthen community and citizen engagement by improving their access to information, and capturing their voice and feedback, which will enhance the responsiveness of the Government in addressing constraints to access. Improved accountability will encourage service providers to “supply” the services for which they are responsible.

Component 3. Project Management (Total US$5 million equivalent including IDA-SUF US$1 million equivalent and a financing gap of US$4 million equivalent from IDA 19).

• Subcomponent 3.1: Project coordination (Total US$4 million equivalent, including US$0.5 million IDA-SUF, and a financing gap of US$3.5 million from IDA 19).

46. This subcomponent will provide administrative support to the Project Implementation Unit (PIU), including contractual specialists, administrative supplies, and capacity building.

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• Subcomponent 3.2: Monitoring & Evaluation (monitoring, supervision, and support) (Total US$1 million equivalent, including US$0.5 million IDA-SUF, and a financing gap of US$0.5 million from IDA 19).

47. The general underlying principle is to ensure alignment of the M&E process developed for the project with the national M&E system. This subcomponent will support costs related to the M&E of project activities, capacity building, technical assistance to formulate an M&E plan for the project and hiring of the independent verification agency/organization for DLI verification.

Component 4. Contingency Emergency Response Component (CERC) (US$0).

48. This component is included in accordance with paragraphs 12 and 13 of the World Bank IPF Policy, contingent emergency response through the provision of immediate response to an Eligible Crisis or Emergency, as needed. There is a moderate to high probability that during the life of the project, the country could experience another epidemic or outbreak of public health importance or another health emergency with the potential to cause significant adverse economic and/or social impact on the health sector. This would result in a request to the World Bank to support mitigation, response, and recovery activities in the county(s) affected by such an emergency. The CERC will allow the Government to request from the World Bank rapid reallocation of project funds to respond promptly and effectively to an emergency or crisis. An operation manual for this component will be developed if/when needed.

C. Project Beneficiaries

49. The beneficiaries of the project inputs and incentives, through the DLIs, will be the women, children, and adolescents in the country and the workforce of the MOH at all levels as a result of increased health service delivery and strengthened and more accountable institutional systems and processes.

D. Results Chain

50. Theory of Change. Figure 1 illustrates the causal link between the project activities, outputs, intermediate and final outcomes, including the longer-term results expected to occur beyond the project’s closing date, as a result of the support provided by the project and other partners in the health sector in Liberia. This project is designed to contribute towards improving the health outcomes of the mothers, children, and adolescents through a variety of interventions. These include: (i) health service delivery through the provision of comprehensive primary and secondary health services for women, children, and adolescents; (ii) systems strengthening by addressing the critical binding institutional constraints that are hampering the country's achievement of its desired health outcomes. This, in turn, has the potential to significantly contribute to the improvement of child health, which would lead to increased productivity as adults, a development impact across generations, and an improvement in Liberia’s HCI.

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E. Rationale for Bank Involvement and Role of Partners

51. The value add of the WBG’s support to Liberia lies in financing critical inputs and addressing critical institutional bottlenecks to the delivery of RMNCAH services, and thereby supporting the Government’s pro- poor agenda to boost human development outcomes. The comparative advantage of the World Bank includes its technical input based on international experience on health systems strengthening, including on human resources for health (HRH), supply chain, health financing systems, and the capacity to mobilize a wide range of technical expertise to support key strategies and reforms (e.g., health financing system assessment, health financing strategy, RMNCAH investment case). Additionally, in the health sector in Liberia, the WBG is one of the key partners that has been supporting the financing of hospital infrastructure and building-up the undergraduate and post-graduate medical cohort. The majority of financing from other partners has focused significantly on supporting improved access to primary health care, reduction of specific disease burdens, and supporting specific systems strengthening in areas of supply chain and HRH.

52. The World Bank has a comparative advantage and proven access to global knowledge, particularly the application of the DLI -approach worldwide. The stock of knowledge gained from the ongoing health projects in Liberia, including from similar operations in the Africa region and elsewhere in the world, are valuable advantages of this project. While other donors are operating in the sector, the World Bank is unique in its ability to mobilize both investment financing, technical assistance, and advisory services in support of the Government’s development agenda. Therefore, the World Bank will use its convening power to work with relevant stakeholders, including DPs, to support the conceptualization and implementation of the project.

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Figure 1: Theory of change

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53. During the early implementation phase, the project is likely to receive an AF from the GFF Trust Fund in support of Liberia’s next RMNCAH IC. Through the GFF process, the Government coordinates partners to align financing of the RMNCAH IC for improved health of women, children, and adolescents. This close collaboration with partners under the Government’s leadership will continue in the new project to allow the Government and partners to collectively review and use data to make decisions, identify resource gaps and overlaps to maximize limited resources, and engage in dialogue in support of the Government’s priorities, and help Liberia reach its goal of UHC.

F. Lessons Learned and Reflected in the Project Design

54. IDA (both country-specific and Regional) with GFF and other Trust Funds (Ebola Trust Fund) have been supporting the health sector in Liberia through several projects, focusing on health systems strengthening, the post-Ebola response, and building back resilience, and the RMNCAH IC. Several lessons have been learned which are summarized below:

(i) Realism of implementation timelines and need for sustained implementation periods: Implementation delays in HSSP AF underscored the need to build adequate time into implementation start-up, given institutional challenges and capacity constraints. This experience also demonstrated that enough time for implementation is needed, not only because implementation startup takes time, but also to allow enough time for results to be observed during implementation. PBF implementation experience demonstrates that it takes stakeholders some time to clearly understand and engage in project implementation. Enough implementation time offers opportunities to adjust and make course corrections to improve implementation. Additionally, given limited local capacity and availability of building materials, and the long annual monsoon season, any major construction needs to be given adequate time with contingencies built in.

(ii) Need to strengthen PFM and flow of committed project funds from the Ministry of Finance and Development Planning (MFDP) to MOH and further to implementing agencies: Annual budget commitments by MFPD do not often translate into actual release. This is compounded by weak reporting and delayed implementation of activities by line ministries. This affects implementation of projects in all sectors, often with a severe impact on service delivery sectors such as health and education. The World Bank’s PFMRS project is also designed to address some of these bottlenecks, and thereby support the health project implementation.

(iii) Plans need to be prepared taking the reality on the ground into consideration (e.g., HRH and skill availability in the country, availability of the budget, and allocation for pharmaceuticals) while supporting improvements towards remedying these basic constraints. Implementation experience demonstrates project components geared towards addressing contextual constraints, such as pharmaceutical availability, resource management, and staffing gaps may be critical to ensure project implementation. Project components should be designed and articulated clearly and practically. Finally, hands-on technical assistance and capacity development at all levels (Central MOH, County Health Teams, facilities) help improve the quality and speed of implementation; however, the sustainability of these efforts remains an issue.

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(iv) PBF implementation: The WBG/GFF have been supporting PBF in the health sector in many countries, including Liberia, over the last few years. The WBG/GFF is likely to learn several lessons from the experience in Liberia. For this reason, an Implementation Research (IR) is underway. This IR, supported through a World Bank Executed Trust Fund, is designed to draw lessons from all the different PBF initiatives being implemented in Liberia. Given the situation that additional matching IDA funds would become available after July 2020, and potentially a second round of GFF TF financing, the lessons learned from the ongoing PBF could then be incorporated into the design of the scaled-up PBF under this project. To date, the National Verification Agency (NVA) and Technical Assistance Agency (TA) contracted for the ongoing PBF activities are very expensive, compared to both its proportion versus the total PBF financing and, in comparison to the costs of similar activities contracted by other countries. This project will explore and put in place more reasonable and sustainable mechanisms to deliver the tasks of verification of results, and TA as required.

(v) Strengthening institutions to address key systemic binding constraints. The proposed project, in collaboration with the Governance GP, aims to strengthen the institutional foundations of health care provision in Liberia. In doing so, it both builds on and learns lessons from the existing health sector portfolio in Liberia being supported by the WBG/GFF. This portfolio currently supports: (i) post-Ebola systems strengthening, (ii) implementation of the RMHNCAH IC in six priority counties, including PBF at eight hospitals and disease surveillance in three counties; (iii) Phase 1 of a new hospital (infrastructure only); and (iv) support to undergraduate and post-graduate medical education. Most of this portfolio, except for the PBF, focuses on input-based financing. Implementation of several of the activities agreed under these projects has been challenging due to capacity and accountability constraints. Programs and projects financed by other DPs also face similar implementation challenges. Lessons learned from the WBG engagement over the last decade and incorporated into this project, indicate that improved public sector governance is critical to achieve further enhanced health outcomes and to overcome these implementation challenges. There is no doubt that continued and concerted engagement and financing is needed in the country. However, to be sustainable, this financing needs to also focus on addressing these implementation challenges. Unless practical and feasible institutional reforms and solutions are supported, implementation of health sector plans and existing programs will continue to be a challenge. Weak systems and low organizational abilities will continue to negatively impact health outcomes

III. IMPLEMENTATION ARRANGEMENTS

A. Institutional and Implementation Arrangements

55. Ministry of Health - The MOH will serve as the executing Ministry of the Government for the project (Figure 2). It will make full utilization of all its departments and units relevant to the Project. Personnel from relevant units will be involved with the planning and execution of activities and have access to the financial resources available under the project. Specific responsibilities of MOH will include:

• Establish project implementation arrangements; • Maintenance of the Project Implementing Unit (PIU) as part of the MOH with staff and resources satisfactory to the World Bank;

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• Ensure that all MOH departments and relevant units act in harmony and that necessary cooperative arrangements with other ministries and agencies are undertaken to complete project activities in a timely and efficient manner; • Approve the Project Implementation Manual (PIM); • Approve the Project Annual Work Plans including, Project Procurement Plans and Project Budgets; • Report the Project Implementation Status to the MFDP.

Figure 2: Overall Project implementation arrangement

Government of Liberia The World Bank (Lead: MFDP)

Departments and relevant Units Ministry of Health Other agencies/institutions MoE Department of Administration (Implementing Units) EPA DLIs Independent Verification HRH Division Agency Procurement unit MPW Infrastructure unit MGCSP Collaboration Department of Planning HMER

Department of Health Services PFMU Family H ealth division Coordination Project Implementation Unit Coordination PBF Unit (Financial Management & SCMU (Management & Coordination) disbursement) CHSD

56. Project Implementation Unit (PIU) - The PIU will be responsible for overall project planning, oversight, coordination, and management. In the conduct of its responsibilities, the PIU serves as the principal liaison with the WBG. Additionally, it will coordinate and support the different departments and their implementing units, agencies, technical working groups, and institutions to ensure effective and efficient execution of activities, as well as attainment of the PDO. Its Coordinator or designate provides status updates on implementation and serves as the hub for overall project result monitoring and evaluation. Core in the functions of the PIU shall be the development of work plans and budgets, and procurement planning, implementation, and monitoring. Currently, MOH has a PIU that manages and coordinates the full Liberia HNP portfolio, including three active projects and two projects which closed recently. While the PIU could potentially benefit from some more capacity in specific areas, it has been performing and delivering satisfactorily. It is proposed that the PIU, with some enhanced capacity, also be responsible for the management of the new project. Specific PIU responsibilities will include the following:

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• Procurement and Financial Management (i) Manage and supervise daily procurement and financial activities of the project; (ii) Prepare internal reports, review and ensure correct procurement and financial performance; (iii) Provide training and support to the beneficiaries in procurement and financial management; (iv) Prepare, update and submit the annual project procurement and financial plan; (v) Facilitate fund flow to the beneficiaries; (vi) Organize and manage the project auditing (both internal and external audit). • Monitoring and Evaluation (M&E) of Project Performance (i) Continuously monitor the effective implementation and reporting of the project; (ii) Collect data needed to keep track of the project activities and the overall status of implementation of the project; (iii) Meet the reporting requirements of the project; (iv) Provide progress reports to the WBG, on a semi-annual basis. • Communication (i) Prepare the Communication Strategy and be responsible for all communication activities of the Project; (ii) Responsible for liaising with the WBG on Project activities, including communication regarding administrative tasks between the WBG and MOH on project-related matters. • Safeguards (i) Overall responsibility for the implementation of the Environment and Social Management Framework (ESMF), and monitoring of its implementation to ensure compliance with the WBG’s Environmental and Social Framework (ESF).

• Contracting/selecting of the Independent Verification Agencies as described below: (i) DLI Independent Verification Agency - An independent agency will be selected, based on agreed criteria and Terms of Reference, for the verification of the DLIs as per the agreed DLI Verification Matrix. (ii) PBF Implementation and Verification of Results - The implementation arrangements for the PBF activities will be agreed upon with MOH and other partners supporting PBF in the country, preferably having a unified approach for implementation and verification of results.

57. Project Financial Management Unit - The Project Financial Management Unit (PFMU) of the MFDP shall be responsible for the financial management aspects of the project in accordance with the Financing Agreement, PFM law, accounting, and auditing requirements of the Financial Procedure Manual and the PIM. Specific responsibilities will include: • Carry out all aspects of financial management required under the project; • Ensure payments are processed expeditiously on behalf of the PIU-MOH; • Ensure that adequate internal controls are in place; • Prepare Quarterly Interim Financial Reports on a timely basis; • Ensure that financial information required by the PIU is prepared on a regular and timely basis; • Prepare the unaudited annual financial statements on a timely basis; • Ensure that the annual external audit is completed on time and audit findings and recommendations are implemented expeditiously and effectively;

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• Maintain project financial records and book of accounts, documentation of the project, and institute adequate internal controls; • Be responsible for preparing budgets based on work-plans submitted by the implementing agencies, monthly and quarterly reports, and provide regular financial reports; and • Ensure compliance with financial management requirements of the World Bank, and the Government of Liberia, where applicable.

58. Within the MOH, different units will be the focal points for the thematic areas of support agreed to: (i) HRH, (ii) data and decision making, (iii) supply chain management, (iv) adolescent health and PBF. A brief description of the relevant units is provided below:

• Human Resource for Health (HRH) Division – The unit manages the human resources for health in the MOH. It is divided into three main streams: HR Planning, Management, and Development. The Unit is responsible for the effective implementation of the critical health workforce interventions, as described in the National Health Investment Plan. HRH is responsible for ensuring that there is a workforce that is fit for purpose, productive and motivated, available, and equitably distributed to provide quality health services to the population. The unit is supervised by the Deputy Minister Administration (DMA) and deals with the recruitment and retention of a needs-based public sector health workforce for core health systems functions.

• Health Information Systems, Monitoring and Evaluation and Research (HMER) – This is comprised of sub- units, and leads and oversees the development and management of all information systems and subsystems, coordinates all research, monitoring and evaluation studies and functions of the MOH to ensure quality, efficiency, and value for money. It provides oversight for all data collection activities, including routine data, M&E, research, and surveillance in the health sector. The HMER guides the development, in collaboration with departments, divisions, programs, donors, and implementing partners, of data collection and reporting tools to ensure quality assurance and avoid duplication.

• Supply Chain Management Unit (SCMU) – The SCMU is responsible for overseeing all supply chain activities within the Liberian Public Health Supply Chain. It is the primary mechanism for institutionalizing good supply chain management practices and linking logistics activities throughout the supply chain. The role of the SCMU is to monitor and supervise the national supply chain, including the National Drugs Store (NDS); manage the Logistic Management Information System (LMIS); oversee national level forecasting and quantification, undertake health commodity procurement planning and monitoring; promote coordination and collaboration and supply chain workforce development. SCMU functions include increasing the visibility of data up and down the system, monitoring the performance of NDS and counties in the supply chain, facilitating greater coordination between stakeholders, and ensuring the alignment of demand with supply through data-based quantifications and development of unified procurement plans.

• Family Health Division (FHD) – The FHD leads the implementation and management of the RMNCAH IC. The unit leads the coordination of partners supporting the implementation of the IC, as well as work with other sectors, including managing various technical working groups and county health teams. It is responsible for (i) building capacity, including mechanisms for skills transfer and support to health managers; (ii) training of health workers in customer/patient prioritization in service delivery; and (iii) supporting health facility quality improvement and coaching. The unit collaborates with the community

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health division, M&E unit to monitor and track the progress of RMNCAH IC implementation and establish robust feedback systems and mechanisms from communities, through facility, district, and county levels by having quarterly stakeholders’ fora at these levels involving communities, which discuss health issues and services.

• Performance-Based Financing Unit (PBF Unit) – Serves as the technical focal point for the management, implementation, and monitoring of PBF activities (supported by the World Bank/GFF and USAID) in- country, develops PBF management tools along with Technical Assistance and relevant stakeholders’ consultations, organizes, leads, and facilitates PBF trainings, orientations and seminars/workshop nationally.

B. Results Monitoring and Evaluation Arrangements

59. A comprehensive description of the project’s result-framework for M&E is provided in Section VII.

Monitoring of the results will include:

(i) For the DLIs – the annual DLRs will be reported and verified by the selected independent agency based on the agreed DLI Verification Matrix (Annex 2). A list of agreed National and county-level indicators will be used by MOH to monitor and discuss progress against the agreed results; (ii) For the PBF results – routine monitoring and reports will be provided through the agreed indicators, and a mechanism for the independent verification of the results will also be agreed to; and (iii) Use of routine MOH data – DHIS2 and other data sources.

C. Sustainability

60. The objective is to improve women’s, children’s and adolescents’ health outcomes, by means of a mix of input-based and results-driven interventions and activities. Supporting the key institutional challenges by incentivizing incremental results, and thereby enhancing and supporting the effective use of all available resources is the basis for sustainability. The DLIs in the areas of human resources for health, data and evidence-based decision making, and supply chain management will complement the adolescent health interventions, and the incentivization for enhanced performance through PBF – all together enabling results that are likely to be long-lasting, and finally financed through public sector resources.

Financial Sustainability

61. Achieving fiscal sustainability may be challenging for Liberia, but the Government and donors are currently working to address the issues. Following the projected contraction in 2019, GDP growth is projected to recover to 1.4 percent in 2020 and further to 3.4 percent in 2021, driven by the recovery in the non-mining sector and a moderate expansion in the mining sector.38 There are three main downside risks to the medium-term outlook: first, delayed implementation of fiscal adjustment measures, which could lead to a rapid increase in public debt, compromise macro-economic stability, and limit medium-term growth prospects. Second, further deterioration in terms of trade and a decline in donor support, which could

38 MPO AM2019.

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increase the country’s vulnerability to external shocks, given its already low level of reserve buffer. Finally, over-reliance on high-cost external loans could lead to Liberia transitioning to a high risk of debt distress. The fiscal sustainability is likely to come through policy and technical support provided by IMF and the World Bank to address the macroeconomic stabilization and economic growth issues.

62. Government resources allocated for the health sector remain relatively low compared to needs (despite being about 14 percent of the national budget). The objective of the project is to improve health services for women, children, and adolescents in Liberia. The project will strengthen the institutional management to enhance health services to women, children, and adolescents, which will improve health sector governance and efficiency of public health spending in Liberia. More than 70 percent of the health budget goes to the payment of employees. Through the project, component 2 would utilize DLI financing to support human resource management and provide key information to inform the allocation and utilization of resources leading to high allocative efficiency. Moreover, component 2 will also support the Government to strengthen the health data information system, which secures the availability of reliable and timely data to improve the planning. This planning will be used to inform resource allocation and utilization for better efficiency. The project will support The Redemption Hospital, the key public sector hospital, thereby creating potential fiscal space in the national budget. This would contribute to improving the financial sustainability of the project and that of government resources.

63. Institutional Sustainability: Liberia’s institutional capacity declined during the long civil war crisis and donor disengagement. The World Bank’s Country Policy and Institutional Assessment (CPIA) for 2019 shows that Liberia has stagnated at a score of 3.1. Liberia underperformed on individual scores for financial sector policies and public-sector management and institutions. There is a significant backlog in maintaining health facilities due to poor governance record, low administrative capacity, and mismanagement of public resources. The project, which focuses on strengthening institutional management in the health sector will significantly contribute to the institutional sustainability in the health sector. More importantly, positive externalities are expected from the project to improve the institutional capacity of other stakeholders within the Government agencies.

IV. PROJECT APPRAISAL SUMMARY

A. Technical, Economic and Financial Analysis

Technical Analysis

64. Background: Liberia’s Investment Plan for Building a Resilient Health System (2015-21) complements the country’s National Health Policy and Plan (2011 -2021). The focus of the Investment Plan is to restore gains that were lost during the Ebola crisis and accelerate progress towards UHC. As such, the Investment Plan has three broad areas of focus: (i) quality service delivery systems; (ii) health workforce; and (iii) health infrastructure. To address some of the key lagging health outcomes in the country, the GOL prepared and endorsed the RMNCAH IC (2016-2020). In addition to GOL’s over-arching plan and the RMNCAH IC, several other elaborate plans have also been prepared and agreed to improve Liberia’s health system and its corresponding health indicators. Several DPs finance and provide technical assistance to address the very

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high maternal and neonatal mortality and teenage pregnancy rates in the country. For the last two years, GFF has also supported the resource mapping and envelope committed for the Investment Plan (Table 3).

65. Current status and RMNCAH Outcomes: Liberia has one of the world’s highest rates of maternal and neonatal death and teenage pregnancy, coupled with a healthcare system that has not yet fully recovered from the double impact of the civil war and the Ebola crisis of 2014-16. A recent analysis of DHIS 2 and MNDSR data (years 2018-2019; Table 4,5)39 show that maternal deaths in Liberia are mostly due to direct causes, including (i) hemorrhage (37 percent), (ii) pre-eclampsia/eclampsia (11 percent), (iii) sepsis (11 percent); and 85 percent of neonatal are as a result of sepsis (38 percent), asphyxia (38 percent) or prematurity (9 percent). In 2018, 47,000 adolescents (15-19 years) received ANC 1 services: 31 percent in Montserrado county, 16 percent in Nimba county, and 11 percent in Bong county. Moreover, 3600 young adolescents (10-14 years) received ANC1 services, the majority (60 percent) in Montserrado county, followed by Nimba (10 percent) and Bong (5 percent) county. Counties reporting the highest proportions of adolescent maternal deaths are Montserrado (32 percent) and Bong (16 percent) counties. Montserrado county carries the largest burden of maternal, neonatal and adolescent morbidity and mortality – in part because of the concentration of a large part of the country’s population here, and also because of the presence of a private sector that is poorly regulated and does not necessarily provide quality services.

66. Poor quality of Emergency Obstetric and Neonatal Care (EmONC) remains the greatest challenge observed in the implementation of RMNCAH IC. The key factors that would improve the quality of service delivery, and which need prioritization are: (i) Using a phased approach, operationalizing a limited number of comprehensive EmONC (CEmONC) facilities (at least one per county) and basic EmONC (BEmONC) facilities while simultaneously ensuring that these structures have (i) a full complement of appropriately skilled staff, (ii) essential drugs and supplies (oxytocin, misoprostol, magnesium sulfate, intravenous antibiotics for mother and newborn, intravenous fluids, oxygen, blood, anesthetic drugs) (iii) appropriate infrastructure, including water, power, labor room, operation theatre; and (iv) 24/7 availability of the service; (ii) Improved reporting and greater accountability for results (iii) Community engagement and feedback.

67. The MOH has identified 36 hospitals as CEmONC and 537 public primary healthcare facilities (PHCFs) as BEmONC, and in 2019 a total of 88,483 deliveries took place in these PHCFs. However, in reality, there are no fully functional CEmONC facilities in Liberia due to the lack of a full complement of skilled personnel; limited availability of blood (there are only two national blood banks in the country, both of which do not have a regular supply of stored blood); and the perpetual stock out of essential drugs and supplies, including oxytocin, magnesium sulfate, intravenous antibiotics, and oxygen. Based on these challenges, the proposed project will support the MoH to convert 25 hospitals in Liberia [at least one in each of the 15 counties where cesarean sections (CS) are conducted] into centers of excellence for maternal, adolescent, and child health (List of hospitals: Annex 2: Table 2.6). These hospitals will focus on getting the minimum staff complement, and drugs and supplies to provide quality, comprehensive obstetric and neonatal care services. Moreover,

39 Important sources of RMNCAH data include routine DHIS2 database (managed by the HMER Unit) and the MNDSR databased (managed by the National Public Health Institute of Liberia – NPHIL).39 In addition, the FHD also conducts audits of all maternal and neonatal deaths, to determine the chronology of events leading to each death, including the exact cause and location. To date, FHD has been unable to complete the audit exercise for all the reported deaths; however, as the exercise is institutionalized, it will become a source of valuable data to enable priority interventions that would save an increasing number of mothers and neonates

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of the 537 public PHCF that report institutional deliveries, 117 (that reported at least 20 deliveries per month in 2019), will be supported to increase the availability of the basic minimum staff (i.e., at least two trained personnel) (List of public PHCF: Annex 2: Table 2.7) and 36 will be supported to improve the availability of essential medicines and supplies (Annex 2: Table 2.8).

68. Redemption hospital in Montserrado county, currently reports the highest maternal mortality rate in the Liberia40. Redemption Hospital is the largest public sector hospital in Liberia; it provides secondary health care, and health services are free.41 The hospital is in a cramped and crowded market location, with severe space limitations, contributing to the poor quality of service delivery. During the 2014-2016 EVD outbreak, it was the hub of the spread of the virus. Based on this situation, under the Ebola Emergency Response Project (P152359), the WBG financed the building of the New Redemption Hospital, at a new and more spacious site. Due to the limited availability of funds, only Phase 1 (Women and Children) of the hospital was constructed, and it was agreed that the then administration would seek additional financing for the equipping of Phase 1 and building of Phase 2. The GOL has now requested that the WBG finance the construction of Phase 2 and equipping of both phases, to ensure the provision of quality health services for the population, particularly the poor.

69. This health sector project is therefore designed to provide necessary inputs to maximize the use and efficiency of existing plans and projects; address key institutional binding constraints including efficient use of resources available, in the areas of human resources for health, supply chain management for drugs and medical supplies, evidence-based decision making with the appropriate use of digital technology, and citizen voice and engagement; and continue to support successful PBF models at the primary and secondary levels of health care. This project has the potential to be transformative for improved maternal, neonatal, and adolescent health outcomes; and will also significantly leverage other donor partner resources

40 DHIS2 2017, 2018, Jan-Jun 2019): Hospitals reporting highest maternal mortality: Redemption (Montserrado county); JFK Medical Center (Montserrado county); CH Rennie (Margibi county); Phebe (Bong county) ; CB Dunbar (Bong county); and JJ Dossen (Maryland county). Hospitals reporting highest neonatal mortality JFK Medical Center (Montserrado county); James N. David Memorial (Montserrado county); CB Dundar (Bong county); CH Rennie (Margibi county); Martha Tubman Memorial (Grand Gedeh county); JJ Dossen (Maryland county); and Chief Jallahlon (Gbarpolu county). 41 The JFK Hospital, also in Montserrado county and larger than the Redemption Hospital, while receiving some subsidies from the government, does not provide free health services to the population.

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Table 3: Summary of RMNCAH Investment case RMNCAH outcomes contributing to Liberia’s poor HCI of 0.32: High maternal and neonatal mortality and high teenage pregnancy. • Key DPs /Implementing NGOs: Current scope/key areas (including geographical) of partner-support 1. IDA with GFF: training of HRH – medical undergraduates and postgraduate; essential infrastructure at primary and secondary levels; equipment; Ebola response and building back resilient systems; disease preparedness and response; hospital PBF at eight hospitals and county PBF in three counties; adolescent health in one country; civil registration and vital statistics (birth and death registration); CHA in seven counties; M&E. 2. USAID: primary health care PBF in six counties now to be scaled up to three more; CHA; supply chain management at Central Drug Warehouse and distribution to County Warehouses); disease surveillance and preparedness; adolescent health; MNDSR. 3. Global Fund: primary care: Malaria, TB, HIV/AIDS across the country; supply chain management at Central Drug Warehouse and distribution of malaria, TB, and HIV/AIDs drugs to last-mile. 4. GAVI: primary care: immunization across the country including the reach of vaccines to last-mile 5. UNICEF: primary health care for children, including supporting pre-service and in-service training to health workers/midwives, task shifting, and CHA program in five South East counties (financing of these counties is now done by the WBG), support for the supply chain of vaccines. 6. UNFPA: primary health care for reproductive and adolescent health, family planning. 7. WHO: technical support to MOH, implementing IDA financing (Ebola Emergency Response Project; P152359) of US$ 19.5 million for Ebola and post-Ebola activities. 8. GIZ: primary health care including disease surveillance and response preparedness in South East counties 9. Last Mile Health: primary care; implements the CHA program in counties 10. CHAI: primary and community level; implements adolescent health activities in counties 11. EU: adolescent health; supports a program (not through MOH) on Gender-based Violence (GBV). • MOH budget (FY20) and resource envelope for the implementation of the IC 1. Based on the resource mapping for the IC conducted for FY19-20, the total estimated committed budget is about US$181 million, of which 38 percent is financed by the GOL, and 62 percent is financed by partners. 2. Resource allocation for the three IC priorities: • Quality service delivery systems: US$75.5 million (of which US$30.4 million for Quality of EmONC services); • Health Workforce Program US$33.5 million; • Health infrastructure US$26 million. 3. MOH budget (FY 20) major line items include: • Compensation/salaries (both MOH and county) US$36.3 million; • Drugs and supplies US$5.7 million (both MOH and county); • Grants to hospitals US$4.4 million (all except JFK, Phebe and Jackson which get a separate line item

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budget from MFPD); • Grants to CHTs, health centers and clinics US$6.9 million Source: Republic of Liberia: IC for RMNCAH, 2016-2020

Table 4: Distribution of maternal and neonatal deaths in Liberia, 2018-2019 Geographical Location Number of DHIS2 MNDSR DHIS 2 MNDSR Deaths Jan-Dec 2018 Jan-Dec 2018 Jan-Dec 2019 Jan-Dec 2019 Country Maternal 372 285 298 278 Neonatal 981 752 1007 950 Montserrado Maternal 142 79 92 88 Neonatal 435 366 266 409 RMNCAH Priority Maternal 53 47 62 38 42 Counties (six) Neonatal 141 117 196 136 8 Remaining counties in Maternal 177 159 144 152 43 country (eight) Neonatal 405 269 545 405

Table 5: Distribution of maternal and neonatal deaths in the community (MNDSR 2017-19) Geographical Location Number of 2017 2018 2019 Total Proportion of Deaths (six months) Community Deaths Country Maternal 245 285 278 808 137 (17.0%) Neonatal 611 752 950 2313 190 (8.2%) Montserrado Maternal 59 79 88 226 30 (17.0%) Neonatal 225 366 409 1000 29 (2.9%) RMNCAH Priority Maternal 53 47 38 138 41 (29.7%) Counties (six)44 Neonatal 114 117 136 367 69 (18.8%)

8 Remaining counties Maternal 133 159 152 444 66 (14.9%) in country (eight)45 Neonatal 272 269 405 946 92 (9.7%)

42 Six RMNCAH IC Counties: Gbarpolu, Grand Bassa, Grand Kru, River Gee, Rivercess and Sinoe 43 Other Eight counties: Bomi, Bong, Grand Cape Mount, Grand Gedeh, Lofa, Margibi, Maryland, and Nimba 44 Six Counties: Gbarpolu, Grand Bassa, Grand Kru, River Gee, Rivercess and Sinoe 45 Other counties: Bomi, Bong, Grand Cape Mount, Grand Gedeh, Lofa, Margibi, Maryland, and Nimba

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Economic Analysis

70. The proposed health project is likely to contribute to increased economic productivity and GDP growth. Liberia’s human capital index (0.32) is currently lower than its three closest neighbors: Sierra Leone (0.35), Guinea (0.37), and the Gambia (0.40). The proposed project is expected to improve the coverage and quality of health services for women, adolescents, and children, and strengthen the performance of the Liberian health sector. Project investments will contribute to enhancing the quality of health service delivery, improving the responsiveness of health services by investing in infrastructure, increasing the effective coverage of RMNCAH, and addressing binding constraints while strengthening governance. Moreover, the investment in RMNCAH is a pillar for capturing the demographic dividend. The proposed project’s supply, and demand-side interventions contribute towards human capital development and are likely to have a long-term impact on economic productivity, with a positive macroeconomic impact.

71. The World Bank CPF identified fundamental development challenges as the country transitions to an economic model where GDP growth reliably generates broad-based improvements in poverty and social development indicators. The transition process requires the building of human capital, boosting productivity, acceleration of job creation, strengthening of socio-economic resilience, enhancing governance and fighting corruption, diversifying the economy, and expanding institutional capacity. To address the challenges mentioned above, the proposed project will play a critical role by improving the institutional framework, human resource management as well as increasing access to health care services for women, children, and adolescents.

72. There is a clear rationale for public intervention in the health sector. It is well established that health interventions are public goods that would not be provided in sufficient amounts if only provided for by an unregulated private sector. Liberia’s health sector is mainly public in terms of financing. The project's investment in health interventions for the Liberian population will create positive social and economic externalities: the societal benefit will exceed the costs. While negative externalities of not providing these interventions are a risk for all members of society.

73. The project will focus on addressing institutional bottlenecks that prevent access to cost-effective RMNCAH interventions. By reducing key constraints to effective health service delivery, through the financing of DLIs, the project will support effective coverage of the RMNCAH IC to address the high maternal and child mortality rates and alarmingly high rates of teenage pregnancy. Cost-effectiveness studies on contraceptives are well-established and confirm that the use of modern contraceptives is cost-effective in all countries as measured by the benefits to mothers’ and children’s health46 . Another key feature of the RMNCAH package is “deliveries provided by skilled birth attendants”. These critical elements of the RMNCAH package face implementation bottlenecks because of the institutional weaknesses, which the proposed project will address by financing and incentivizing the achievement of results. Moreover, with improved efficiency and access to quality and reliable health services, there would be an impact on lowering public and out of pocket health expenditure resulting from improved maternal and child morbidity.

46 Babigumira J B, Stergachis A, Veenstra D L, Gardner J S, Ngonzi J., and others. 2012. “Potential Cost-Effectiveness of Universal Access to Modern Contraceptives in Uganda.” PLoS One 7 (2): e30735; Seamans Y, Harner-Jay C M. 2007. “Modelling Cost-Effectiveness of Different Vasectomy Methods in India, Kenya, and Mexico.” Cost Effectiveness and Resource Allocation 5: 8.

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74. The investment returns on the construction of a hospital are enormous. The economic theory establishes a clear link between investment and economic growth. With a focus on infrastructure construction, the project will certainly contribute to economic growth. The project will increase the demand for construction materials such as iron, cement, and woods with a positive impact on the economy. The completed and operational hospital would result in a significant increase in the volume and quality of health services leading to improve reproductive and maternal health and economic benefits. Moreover, the construction of a hospital is labor-intensive and requires technology and skills. Therefore, Component 1 will enable the Government to generate jobs. Young people with limited qualifications will be employed through the construction of the hospital. Redemption hospital is expected to bring positive externalities on job creation.

B. Fiduciary

(i) Financial Management

75. The FM arrangements will be based on the existing arrangements under the Project Financial Management Unit (PFMU), which is implementing 90 percent of the WBG and other donor-financed projects in Liberia. The PFMU is comprised of 24 staff headed by the director, who is a Chartered Accountant, and all PFMU staff are familiar with World Bank procedures.

76. A FM assessment of the PFMU concluded that the control risk is assessed as ‘Moderate’, and the overall residual FM risk for the project is assessed as ‘High’ but reduced to ‘Substantial’ due to the articulated risk mitigating measures. A detailed overview of the assessment findings and proposed risk mitigation measures, including among others: an independent verification agent (IVA) for the DLIs, and external auditing by an independent qualified auditor, is included in Annex 1. The new project will need to be accommodated within the existing FM system. To do this, the PFMU will need to: (a) update the current accounting manual, (b) customize the existing accounting software to include the account of the new project in order to generate the IFRs and financial statement, (c) recruit external auditors, and (d) recruit an independent verification agent (IVA), to be managed by MOH. This should be completed within six months of the project becoming effective. These arrangements were deemed adequate to ensure: (a) timely reporting of project activities, (b) the safeguarding of project assets, and (c) the strength of internal controls despite considering them to be high with reasonable mitigation measures.

(ii) Procurement

77. Applicable procurement procedures for the IFISH: The Borrower will carry out procurement implementation under the project in accordance with the WBG’s Procurement Regulations for IPF Borrowers (Procurement Regulations) dated July 1, 2016 and revised in November 2017 and August 2018 under the “New Procurement Framework” and the “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants,” dated July 1, 2016, and other provisions stipulated in the Financing Agreement. The latest versions of the WBG Standard Procurement Documents will be used. Other stipulated provisions will be provided in the Financing Agreement.

78. Preparation of the Project Procurement Strategy for Development (PPSD): The MOH (with technical assistance from the WBG) has prepared a PPSD (dated April 15, 2020, which describes how procurement

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activities will support project operations for the achievement of project development objectives and deliver value for money. In addition, the WBG has approved an 18-month project procurement plan. . Procurement activities will principally be based on the approved market options, which are in line with the WBG Procurement Regulations. The project actors will leverage the use of ICT to improve participation, delivery, monitoring, and reporting while utilizing the World Bank procurement electronic system (STEP) as the primary platform to submit, review, and clear all procurement plans. The client has general experience in implementing WBG funded projects but given the broad scope of activities under the project, the MOH will hire an additional Procurement Officer, a Procurement Assistant, and an Administrative Assistant to complement the work of the two Procurement Officers.

79. Implementation Arrangements for Procurement: The proposed project will be implemented by MOH through the PIU. Currently, the MOH’s PIU is headed by a Project Coordinator who manages and coordinates the full Liberia HNP portfolio, which currently has three active projects. The PIU, while it could benefit from some more capacity in specific areas (as mentioned above), has been performing and delivering satisfactorily. It is proposed that the PIU, with some enhanced capacity, be responsible for managing the new project also. The client will also require further training on the features of the WBG’s New Procurement Framework and STEP.

80. The WBG conducted a Procurement Capacity and Risk Assessment of the MOH. The procurement risk is still rated as Substantial. There were a limited number of suppliers of heavy equipment and complex professional services in Liberia. However, the client has sound knowledge of the market and has approached the market adequately in the previous and ongoing projects. Procurement activities will be based principally on international competition. The PIU will enhance its contract management capacity through training. The risks that have been identified in the procurement capacity risk assessment and the recommended mitigations measures are provided in Annex 1.

. C. Legal Operational Policies . Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No .

D. Environmental and Social

81. Environmental and Social Risks and Impacts: The Environmental and Social Risk of the project is rated as Moderate. The Environmental and Social Review Summary (ESRS) at appraisal level has been prepared and cleared. Assessment of the project components identified potential risks and impacts related to (i) non- discrimination and inclusion of vulnerable and disadvantaged groups– this will be particularly relevant to the component that supports adolescent reproductive health and teenage pregnancy, given the extensive stakeholder engagement and communication/messaging on social norms and behavior change; (ii) labor and working conditions (ESS2) of project direct workers, including staff of the project implementing agency and contracted workers under the project component on the human resource management; (iii) community health and safety (ESS4) under supply chain management component – disposal and management of medical waste, lack of awareness among people, lack of medical waste disposal sites, proper waste management

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procedure for unused, expired and damaged drugs, may pose risks and threats for community health and safety. The existing National Medical Waste Management Plan developed under the Ebola Emergency Response Project is being updated to include additional risks and impacts that may arise from activities of this project. The updated plan will be disclosed on April 30, 2020; (iv) given the focus on adolescent reproductive health, teenage pregnancy and fertility, the contextual and project-level GBV risks would need to be assessed in line with the emerging World Bank GBV risk assessment procedure; (v) the proposed activities under the component that supports enhanced data collection and availability may pose risk of data privacy and protection. The security issues related to data protection will be assessed further during project preparation; and (vi) the aspects of behavioral change, introducing new practices and systems under the project may pose risks and threats for intangible cultural traits and traditions (ESS8).

82. Project Component 1 has been modified to include the design, construction and supervision for Phase 2, and equipment procurement and installation for both Phases 1 and 2 of Redemption Hospital after the Concept- Stage ESRS had been cleared. In addition to the risks and impacts identified in the cleared Concept-Stage ESRS, the introduction of civil works will generate additional environmental, social, occupational health and safety, and community health and safety risks and impacts. The proposed Redemption Hospital Phase 2 will be at the same site as Phase 1, a site that has already been cleared and fenced under Phase 1. Therefore, Phase 2 construction is not expected to have a significant impact on the natural environment. Possible environmental concerns associated with Phase 2 will include the management of construction wastes during construction, management of healthcare wastes during hospital operation, and possible impacts arising from sourcing of local construction materials. Phase 2 construction will exclusively be carried out on land that was acquired under Phase 1. The land is secure and has no encumbrances. There will be no involuntary resettlement, land acquisition, restriction to land use, or loss of livelihood.

83. The ESMP developed and disclosed for Phase 1 has been updated to incorporate the additional risks and impacts associated with Phase 2 construction and disclosed on the WBG’s website on April 8, 2020 and in- country on April 7, 2020. The Stakeholder Engagement Plan (SEP), Environmental and Social Commitment Plan (ESCP), and Labor Management Procedure (LMP) have also been developed and disclosed on the WBG’s website, and in-country as required. The National Healthcare Waste Management Plan developed for the World Bank-funded REDISSE II, and Ebola Emergency Response projects is being updated and will be disclosed on April 30, 2020. Actions to be completed after Board Approval, such as updating and implementation of the SEP, development, and implementation of the project GRM, and ensuring preparation of the Contractor’s Environmental, Health, and Safety Management Plan (C-EHSMP) are outlined in the ESCP.

84. Implementation Arrangements for Safeguards: The PIU of the MOH has experience in implementing safeguards for World Bank-financed projects. It is currently implementing several World Bank-financed projects, and safeguard implementation has so far been satisfactory. The PIU has a full-time environmental and social (E&S) safeguard specialist who oversees the implementation of project safeguard instruments. In addition, the MOH has an Environmental Health Division that is charged with executing its environmental health plans under the overall policy guidance of the National Environmental Protection Agency. The E&S specialist of the PIU and staff of the Environmental Health Division work together from time to time to ensure safeguard compliance at project level. This has worked very well in the past, and it is hoped that the same approach will be adopted for this project. The E&S specialist of the PIU was one of several safeguard specialists who benefited from the ESF Borrower Training delivered in FY18. Staff of the Environmental Health Division would benefit from similar training to ensure in-house capacity for safeguard implementation is developed

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and sustained. Given the expanded scope of the ESF and the number of ESF related documents that are required to be developed and implemented, the project will be required to engage a Social Development Specialist, in addition to the Environmental Specialist in the PIU, with experience in GBV and Labor Issues to assist implementation of ESMP, National Medical Wastes Management Plan, SEP, ESCP, GRM, LMP and GBV Action Plan.

Climate and Disaster Risk Screening and Climate Co-Benefits

85. This project has been screened for climate risk and assessed as being at ‘medium’ risk, based on the exposure and vulnerability risks assessed to be moderate.

Exposure:

86. This project has been assessed for climate and disaster risk and assessed as being ‘moderate’ risk due to exposure of the project location and target beneficiaries to the climate, and geophysical hazards of extreme precipitation and flooding. While being highest along the coast, the southern areas of Liberia receive rain year-round, whilst the rest of the country experiences two rainy seasons. The average annual rainfall exceeds 2,500 mm. Annually, the heavy rainfall significantly affects the poor infrastructure, including roads in the country. As a result of which, the access to health services to the population becomes limited, often severely, during the wet months. Liberia’s infrastructure is highly vulnerable to climate change, and annual damage to the road network from rainfall and flooding alone could equal as much as 40 percent of GDP by 2030.47 Liberia’s pervasive poverty and dependence on environmentally sensitive sectors exacerbate its vulnerability to climate change. An increase in the frequency and severity of extreme weather events would inflict a heavy toll in human lives and welfare while damaging the country’s scarce and valuable capital, and the poorest households and communities will be hit hardest, as income and health shocks will drive them deeper into poverty

Vulnerability:

87. The identified exposures to climate and disaster risks described above could affect the project’s target population, and the vulnerability of this impacting project activities has hence been assessed to be ‘moderate’. While the entire population of the country is climate-vulnerable, women and children, whom this project targets have been identified as a particularly climate-vulnerable group since they are both dependent on utilizing health services as well as vulnerable to many climate-related health outcomes in particular water- borne diseases such as diarrhea, nutritional vulnerabilities and also less able to travel quickly in times of extreme weather impacts such as flooding. During the heavy monsoon and flooding seasons, access to health services and facilities becomes difficult and restricted, disproportionately affecting some of the most climate- vulnerable groups such as women and children. The flooding and heavy rains also contribute to an increased incidence of water-borne and vector-borne diseases, including Lassa Fever. Any significant disruptions in transportation and agriculture due to flooding, and extreme heat, could potentially threaten food security and nutrition available to the remote communities, particularly the vulnerable under-five children and pregnant and lactating mothers. The whole population of Liberia is climate-vulnerable due to chronically poor access to healthcare services compounded by poverty and poor infrastructure.

47 Koi’s et al. (2019) “A Global Multi-Hazard Risk Analysis of Road and Railway Infrastructure Assets.” Nature Communications.

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Adaptation:

88. Specific project activities which will support climate change adaptation include under Component 1: Improved service delivery (total US$ 68 million), the sub-component Operationalizing Redemption Hospital Phases 1 and 2 (US$35 million). The hospital is being built in two phases. US$35 million will finance (i) construction of Phase 2 estimated to be US$20 million; and (ii) equipment for both Phases 1 and 2. The ‘new’ Redemption Hospital will provide access and resilience to the population of Montserrado county and surrounding, where more than a third of the country’s total population of 4.2 million resides; and serve as a referral facility for the remaining counties. Phase 1 will only fund equipment and not the construction itself through this project. Phase 2 will be staffed with appropriate skills and equipment to diagnose and manage the water and vector- borne diseases, including complications such as dehydration, that the entire population is vulnerable to and moderate to severe malnutrition in children. Nevertheless, Phase 1 will contribute to enhancing the climate adaptation of the population since climate-vulnerable groups (women and children) will have improved access to obstetric, gynecological and pediatric services as a result of the new facilities being properly equipped. In Phase 2, both the building work and equipment will be expanding coverage to all climate-vulnerable population groups. Additionally, Component 2: Institutional strengthening to address key binding constraints (US$ 11 million), will support financial incentives to support a more efficient supply chain management of drugs and supplies, enhancing availability of routine data for evidence-based decision making, and citizen engagement. The regular and efficient data reporting systems will enable the Ministry of Health to launch an improved response to water and vector borne diseases, and management of malnourished children; including the ability for a timely response to ‘red flags’ for impending disease outbreaks amongst the climate-vulnerable population of the country. This will enable the system to respond more quickly to emerging climate-related diseases thereby enhancing climate adaptation.

Mitigation:

89. Specific project activities which will support climate change mitigation include under Component 1: Improved service delivery (US$68 million), the Operationalizing Redemption Hospital Phases 1 and 2 (US$35 million). For the construction of Phase 2 (US$20 million), energy efficiency and mitigation measures will be built into both the design and actual construction stages. This is also likely to include an energy efficiency audit early on, the recommendations from which will be included in the design and construction of phase 2, including factors such as selection and procurement of energy-efficient construction materials. The equipment procurement for Phases 1 and 2 (US$ 15 million) will include the development of normative guidelines for procuring energy-efficient equipment to ensure that net greenhouse gas emissions from these are reduced compared to the current situation in the facilities being replaced. Component 2: Institutional strengthening to address key binding constraints (US$8 million) supporting improved data collection and reporting, supply chain citizen engagement will ensure disaggregated routine data for the climate-vulnerable groups, and including them in the citizen engagement and feedback mechanisms. The data systems, including incentivizing the use and reporting of electronic, human resource systems, logistics management systems, and health services utilization data, will contribute towards energy efficiency and mitigation by reducing the need for carbon-intensive travel between currently geographically dispersed facilities.

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V. GRIEVANCE REDRESS SERVICES

90. Communities, groups, and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms under SEP or the WB’s Grievance Redress Service (GRS). The GRC/GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel, which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and World Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org

VI. KEY RISKS

91. The overall risk rating for the proposed project is Substantial due to substantial risks in the areas of political and governance, macroeconomic, technical design of the project, institutional capacity for implementation and sustainability, and fiduciary.

92. Political and governance risks are substantial: The peaceful transition of power following the 2017 legislative and presidential elections was a landmark achievement in Liberia’s history. All indications point towards lasting peace and development, with the Government forging ahead with efforts to strengthen the rule of law and carrying out meaningful reforms to sustain social gains earned since 2003. The substantial political and governance risks are primarily associated with the increasing frustration in the general population with corruption, and deep-rooted mistrust of the Government, coupled with historical fragility to external and internal shocks that would threaten its system. The security situation has improved as the United Nations Security Council has wound down its UNMIL mission. However, Liberia remains a fragile country. While the recent transitions in power were uneventful, major events, such as the ongoing COVID-19 crisis or other exogenous factors, could lead to shifts in public opinion and public support for the Government and introduce complications in the public sector, including for the project. Moreover, key governance risks include (a) inadequate accountability measures to ensure that resources supporting the project reach the intended health care facilities and beneficiaries; and (b) low priority given to public accountability and transparency in program management. To help mitigate the political and governance risks, the World Bank continues its intensive engagement with Government, which includes support to the Government’s COVID-19 response through the REDISSE II project (P159040) and Liberia COVID-19 Emergency Response Project (P173812). The project would support the implementation of anti-corruption strategies and activities that have been adopted to guide the implementation of the World Bank Group-funded portfolio of projects in Liberia. The project will also monitor project implementation closely, with clear reporting and decision-making arrangements, and third-party verification arrangements to help safeguard the effects of these risks on the project during implementation.

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93. The macroeconomic risk is substantial. This assessment is driven by the economy’s vulnerability to external shocks and high inflationary pressures. Moreover, the ongoing COVID-19 crisis will contribute to a reduction in the fiscal capacity of the Government due to global economic disruption and slowdown, and potential unavailability of fiscal resources. Under the baseline scenario, real GDP is projected to contract by 2.2 percent in 2020 due to the adverse effects of COVID-19 on output in various sectors amid falling global demand and travel disruptions. Risks are tilted to the downside as COVID-19 spreads locally, further disruptions in economic activity would lead to a further contraction in 2020, followed by a modest recovery in 2021. This would have a negative impact on the delivery of essential health service, and limit the additional resources required to accommodate salaries for healthcare personnel. The project will attempt to mitigate these risks by (i) supporting the delivery of essential health services and critical public health programs; (ii) utilizing PBF to provide resources-based incentives for health care worker deployment; (iii) working closely with other development partners under the umbrella of GFF to support sustained reforms to improve the efficiency of health spending, enhance domestic resource mobilization, and increase the focus on outcomes and rationalizing capital investments in the sector; and (iv) ensure pro-poor targeting of project activities. In addition, the World Bank also plans to provide policy advice on both fiscal policy and management through its DPO operation (P168218) and will support macroeconomic stability and growth.

94. Technical design of project risk is substantial. The GOL and MOH are committed to improving health outcomes in Liberia; however, given the macro-fiscal situation, and competing political priorities, often, the commitments are not being translated into action. Input-based financing is particularly at risk of being influenced and affected. Therefore, to reduce this risk, this project is proposing to earmark a proportion of the financing against the achievement of agreed results through a set of DLIs. Moreover, DLIs are a new modality of financing for the health sector and may thus pose a risk during the early stages of project implementation; however, the stakeholders have understood the DLIs, and believe it will be a good mechanism to address some the persistent and difficult institutional weaknesses. To mitigate the risk of the technical complexity of the DLIs, significant implementation support will be provided throughout project implementation, and progress will be assessed on an annual basis to identify bottlenecks and challenges.

95. Institutional capacity for implementation and sustainability risk is substantial. The MOH and PIU are currently implementing four World Bank projects, and IFISH will be the fifth.48 While this has allowed for the MOH and PIU to gain significant experience in managing World Bank operations, the addition of IFISH may overstretch their limited capacity. In addition, this is the first time the MOH is exposed to DLIs and the new environmental and social framework. The MOH seems committed and senior officials have been fully engaged during the entire project preparation phase. During project preparation and implementation, the organizational, management and implementation capacity of the MOH, relevant technical units and the PIU will be strengthened. Significant technical and implementation support will also be provided, particularly in support of specific activities in the project which are technically complex. The sustainability risk will be addressed by continuing to support the GOL in its efforts to increase domestic resource mobilization and overall health sector efficiency.

96. The fiduciary risk is substantial. The overall residual FM risk for the project is assessed as ‘High’ but reduced to ‘Substantial’ due to the articulated risk-mitigating measures. Risk mitigation measures include the use of the PFMU, which has experience with World Bank FM procedures, and an independent verification agent (IVA)

48 These include (i) Liberia Health System Strengthening Project (P128909); (ii) the Ebola Emergency Response Project (P152359); (iii) REDISSE II (P159040)) and (iv) the Liberia COVID-19 Emergency Response Project (P173812).

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for the DLIs, and external auditing by an independent qualified auditor. The procurement risk is also rated as Substantial. These are related to (i) some gaps concerning knowledge and experience of carrying out procurement activities in accordance with the World Bank Procurement Regulations for IPF Borrowers, rules, and procedures (particularly regarding the new possibilities afforded by the Procurement Framework), despite having some experience with World Bank-funded projects; (ii) limited procurement capacity for the PIU with the addition of IFISH. This may cause implementation challenges because the two procurement officers may not be able to efficiently handle the workload for four projects: (iii) inadequate experience in procurement of works, contract management and consulting services and (iv) limited number of office equipment. The project will implement the following mitigation measures (a) enhance the capacity of the PIU through training and coaching, and implementation support under the project; (b) provide procurement training for PIU staff during project preparation and immediately after effectiveness, with constant support to the PIU to ensure the proper use of the World Bank Procurement Regulations for IPF Borrowers; (c) recruiting an International Procurement Consultant, additional qualified procurement officer, a procurement assistant, and administrative assistant to complement the two procurement officers’ work to ensure the procurement plans developed are implemented, monitored, and updated in a proper and timely manner; (d) updating the project implementation manual (PIM) to reflect the needs of the project and current operational/procurement environment in the relevant sections; (e) providing appropriate training in Contract Management and Selection of Consultants to PIU staff during the initial 18 months of project implementation and collaborate more with the Ministry of Public Works (MPW); (f) providing the PIU with transportation to support administrative function and a high-volume scanner with internet service to enable migration from manual to electronic documentation and record keeping; and (g) the World Bank will carry out regular implementation . support missions and conduct annual procurement post review.

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VII. RESULTS FRAMEWORK AND MONITORING

Results Framework COUNTRY: Liberia Institutional Foundations to Improve Services For Health

Project Development Objectives(s) To improve health service delivery to women, children and adolescents in Liberia.

Project Development Objective Indicators

RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 To improve health services to women, children and adolescents in Liberia

Redemption Hospital Phase 1 and 2 fully completed and operational to provide 0.00 0.00 0.00 0.00 0.00 1.00 comprehensive services to women, children and adolescents (Number)

Pregnant women with 4 antenatal care visits 38.97 42.51 46.97 50.01 53.97 58.24 (Percentage)

Proportion of new users of modern contraception who are 30.61 36.20 39.65 40.85 42.59 44.19 adolescents (10-19 years) (Percentage)

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RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Institutional deliveries attended by skilled birth attendant (MD, PA, RN, 62.76 65.66 68.27 70.99 73.81 76.75 registered/certified midwife) (disaggregated by age group) (Percentage)

Adolescent girls (10-19 years) leaving selected health facilities with 2 counselling DLI 6 0.00 5.00 10.00 20.00 30.00 40.00 sessions on family planning (Percentage)

PDO Table SPACE

Intermediate Results Indicators by Components

RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Component 1: Improved service delivery Redemption Hospital Phase 1 - 01-Jan-2021 21-Dec-2021 Fully Equipped (Date) Redemption Hospital Phase 1 - 23-Dec-2021 30-Apr-2022 Operational (Date) Redemption Hospital Phase 2 - Construction Completed (Date) 31-Dec-2021 30-Sep-2025 Redemption Hospital Phase 2 - 01-Oct-2025 30-Apr-2026 Fully Equipped (Date) Redemption Hospital Phase 2 - 01-May-2026 31-Aug-2026 Operational (Date) Number of identified 6.00 18.00 25.00 25.00 25.00 25.00

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RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 hospitals/HCs with a paediatrician and obstetrician (the first cohort of specialist will incrementy be provided through the Bank financing to the postgraduate education progra (Number) Availability of essential drugs/supplies in identified hospitals/health centers 0.00 21.00 30.00 33.00 36.00 36.00 providing caesarian section (Number) Health facilities certified (quality) to provide maternal, newborn, child and adolescent 0.00 20.00 40.00 60.00 80.00 100.00 health services (Percentage) Component 2: Institutional strengthening to address key binding constraints Number of quarterly Country Platform meetings held to discuss key indicator report DLI 1 0.00 4.00 4.00 4.00 4.00 4.00 and decisions with minutes available (Number) Number of complete and timely monthly narrative reports available (per hospital) from 25 identified 0.00 10.00 10.00 10.00 10.00 12.00 Hospitals/Health Centers providing cesarean section services (Number) Percentage of counties with <15% drug variance between DLI 2 0.00 7.00 50.00 100.00 100.00 100.00 allocated & distributed (Percentage)

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RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Annual report available from HR database reporting recruitment, transfers, and DLI 3 No Yes Yes Yes Yes Yes disciplinary action taken during previous year (Yes/No) Citizen feedback mechanism implemented and report discussed in the HSCC, and publicly available in all DLI 5 No Yes Yes Yes Yes Yes identified Hospitals/Health centers providing C-Section with minimum staff (Yes/No) People who have received essential health, nutrition, and population (HNP) services (CRI, 0.00 131,792.00 271,703.00 420,233.00 577,913.00 923,011.00 Number) Number of deliveries attended by skilled health 0.00 131,792.00 271,703.00 420,233.00 577,913.00 923,011.00 personnel (CRI, Number) Number of students counselled by female counselors in high DLI 4 0.00 1.00 schools (Number) Component 3: Project Management Regular reporting on GBV action plan implementation (any changes in the GBV action No Yes Yes Yes Yes Yes plan will be notified to the Bank and recorded) (Yes/No) PIU monitors the independent verification agency for DLI and No Yes Yes Yes Yes Yes PBF (Yes/No) PIU maintains essential staff in No Yes Yes Yes Yes Yes

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RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 these position throughout project implementation, and reports to the Bank (Yes/No)

IO Table SPACE

UL Table SPACE

Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection This indicator monitors the Visual inspection and Redemption Hospital Phase 1 and 2 fully MOH project construction, equipping and supervision by the completed and operational to provide Quarterly monitoring MOH and PIU operationalization of phase1 MOH infrastructure comprehensive services to women, report and 2 of Redemption unit and PIU children and adolescents hospital Numerator - Numerator - Number of 4th DHIS2; Generate data from Pregnant women with 4 antenatal care ANC visits reported; Annual Denominator routine health HMER/MOH visits Denominator - Estimated - Population information system pregnancies census

Numerator - Number of new acceptors of modern Generate data from Proportion of new users of modern contraceptive that are of Monthly DHIS2 routine health HMER/MOH contraception who are adolescents (10-19 ages between 10-19 years; information system years) Denominator - Total new

acceptors (all ages) of modern contraceptive

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Numerator - number of Generate data from deliveries conducted in routine health health facilities by a nurse, Numerator - information system. Institutional deliveries attended by skilled physician assistant, DHIS2 and Disaggregated data by birth attendant (MD, PA, RN, physician, certified or Annual Denominator age is beginning to be HMER/MOH registered/certified midwife) registered midwife during a - Population collected and will be (disaggregated by age group) specified reporting period; Census data made available at close Denominator - Estimated of year 1 of deliveries within a specified implementation. population Numerator: Number of adolescent girls (10-19 years) who after delivery leaves the selected 25 health facility having Adolescent girls (10-19 years) leaving Hospital Project monitoring received at least 2 Quarterly MOH/PIU selected health facilities with 2 reports reports counselling sessions on counselling sessions on family planning family planning/ Denominator: Total number of adolescent girls (10-19 years) who deliver in the 25 select health facilities ME PDO Table SPACE

Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection MOH project Visual inspection and This indicator monitors the Redemption Hospital Phase 1 - Fully Quarterly monitoring supervision by the MOH and PIU equipping of Phase 1 of Equipped report MOH infrastructure Redemption hospital unit and PIU

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Visual inspection and This indicator monitors MOH project supervision by the Redemption Hospital Phase 1 - when Phase 1 of Quarterly monitoring MOH and PIU MOH infrastructure Operational Redemption hospital will report unit and PIU become operational

Visual inspection and MOH project This indicator monitors the supervision by the Redemption Hospital Phase 2 - Quarterly monitoring MOH and PIU construction of Phase 2 of MOH infrastructure Construction Completed report Redemption hospital unit and PIU

Visual inspection and MOH project This indicator monitors the supervision by the Redemption Hospital Phase 2 - Fully Quarterly monitoring MOH and PIU equipping of Phase 2 of MOH infrastructure Equipped report Redemption hospital unit and PIU

Visual inspection and This indicator monitors MOH project supervision by the Redemption Hospital Phase 2 - when Phase 2 of Quarterly monitoring MOU and PIU MOH infrastructure Operational Redemption hospital will report unit and PIU become operational

Integrated Number of identified hospitals/HCs with a This indicator monitors how Human Generate data from paediatrician and obstetrician (the first many hospitals/health Resources Monthly routine health HMER/MOH cohort of specialist will incrementy be facilities have a Information information system provided through the Bank financing to paediatrician and System the postgraduate education progra obstetrician (IHRIS)

Availability of essential drugs/supplies in This indicator monitors the Site visits to verify Annual Site visits MOH and PIU identified hospitals/health centers availability of essential availability of essential providing caesarian section medicine/supplies in 36 medicines and supplies

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identified hospitals/health facilities providing C-section with minimum staff. They include: oxytocin, misoprostol, magnesium sulfate, IV antibiotics, IV fluids, blood and oxygen The proportion of the 25 target hospitals/HCs Health facilities certified (quality) to certified as having attained Quarterly MOH Site visits MOH/PIU provide maternal, newborn, child and a specific level of quality adolescent health services based on a pre-defined, standardized protocol. Number of country platform meetings conducted in each year where key indicators Filed signed (as agreed by the CP) are HSCC Review of signed Number of quarterly Country Platform discussed and minutes minutes and meeting minutes and meetings held to discuss key indicator Quarterly MOH/IVA available. One of the HSCC attendance attendance (self- report and decisions with minutes meetings in each quarter (in hard signed) available will be used as the Country copies) Platform Meeting for the comprehensive quarterly data review. Numerator - Number of months for which all Number of complete and timely monthly HIS required HIS reports from narrative reports available (per hospital) subsystems the specified Monthly Health facility reports MOH/IVA from 25 identified Hospitals/Health report rate Hospitals/Health centers Centers providing cesarean section summary were submitted ; services Denominator - Total number of months for which HIS

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reports from specified Hospitals/ Health centers were required Number of counties among all 15 counties with a <15% LMIS (paper- variance between allocated based for and distributed to their primary Generate data from Percentage of counties with <15% drug health facilities. Numerator Monthly proof of routine health MOH/IVA variance between allocated & distributed - Number of counties with Delivery and information system less than 15% drug variance eLMIS at between allocated & County seat) distributed; Denominator - Number of counties Annual report available from HR database Generate data from Number of verifiable criteria HRH annual reporting recruitment, transfers, and Annual routine health HMER/IVA satisfied by the HRH report disciplinary action taken during previous information system department annual report year This indicator assesses whether the citizen Filed signed Citizen feedback mechanism feedback mechanism is HSCC Review of signed implemented and report discussed in the implemented, and the minutes and meeting minutes and Quarterly MOH/IVA HSCC, and publicly available in all report is discussed in the attendance attendance (self- identified Hospitals/Health centers HSCC and publicly available (in hard signed). providing C-Section with minimum staff in all identified copies) Hospitals/HCs providing C- Section with minimum staff. Generate data from People who have received essential Monthly DHIS2 routine health HMER health, nutrition, and population (HNP) information system services

Number of deliveries attended by Monthly DHIS2 Generate data from HMER

skilled health personnel routine health

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information system

This indicator assesses the number of students Joint accessing ASRHR-related monitoring counseling from female Project monitoring Number of students counselled by female Annual report of the MOE/MOH/IVA counselors in high schools report counselors in high schools MOE and under the Ministry of MOH Education's. Targets will be

defined during the first year of implementation. Regular reporting on GBV action plan Project This indicator monitors that implementation (any changes in the GBV 6-Monthly monitoring Project report PIU the PIU will report regularly action plan will be notified to the Bank report on the GBV action plan and recorded) DLI verification matrix This indicator monitors that IVA reports and PBF indicator PIU monitors the independent verification the PIU regularly monitors 6-Monthly for DLI and matrix (PBF verification PIU agency for DLI and PBF activities of the verification PBF matrix still to be agency for DLI and PBF determined)

This indicator monitors that the PIU maintains the following essential staff at all times during project Project PIU maintains essential staff in these implementation: a Project 6-Monthly monitoring Project report PIU position throughout project coordinator, an report implementation, and reports to the Bank accountant/financial

management specialist, a procurement specialist, an environment and social specialist, and an evaluation

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and monitoring officer (This list of staff is as specified in the legal agreement) ME IO Table SPACE

Disbursement Linked Indicators Matrix

DLI_TBL_MATRIX DLI 1 Key RMNCAH Data regularly available and used for evidence-based follow-up at the national level and county level

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Process No Yes/No 1,000,000.00 1.85

Period Value Allocated Amount (USD) Formula Baseline No

Year 0 50,000.00

Year 1 100,000.00

Year 2 100,000.00

Year 3 200,000.00

Year 4 200,000.00

Year 5 Yes 350,000.00

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DLI_TBL_MATRIX DLI 2 Contribute to a reduced stock-outs of Essential Package of Drugs evidenced by a Functional Supply Chain

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Outcome Yes Percentage 500,000.00 0.92

Period Value Allocated Amount (USD) Formula Baseline 0.00

Year 0 29,000.00

Year 1 71,000.00

Year 2 77,000.00

Year 3 101,000.00

Year 4 111,000.00

Year 5 100.00 111,000.00

DLI_TBL_MATRIX DLI 3 Functional HR system in place at MOH, counties, hospitals and facilities

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Outcome Yes Yes/No 2,000,000.00 3.70

Period Value Allocated Amount (USD) Formula Baseline No

Year 0 142,500.00

Year 1 287,500.00

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Year 2 342,000.00

Year 3 342,000.00

Year 4 442,100.00

Year 5 Yes 443,900.00

DLI_TBL_MATRIX DLI 4 Improved adolescent health (with focus on girls) as measured by specific marker indicators

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Output Yes Yes/No 1,000,000.00 1.85

Period Value Allocated Amount (USD) Formula Baseline No

Year 0 50,000.00

Year 1 150,000.00

Year 2 200,000.00

Year 3 200,000.00

Year 4 200,000.00

Year 5 Yes 200,000.00

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DLI_TBL_MATRIX DLI 5 Citizen engagement and grievance redressal system functional in the health sector

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Output No Yes/No 500,000.00 0.92

Period Value Allocated Amount (USD) Formula Baseline No

Year 0 0.00

Year 1 100,000.00

Year 2 100,000.00

Year 3 100,000.00

Year 4 100,000.00

Year 5 Yes 100,000.00

DLI_TBL_MATRIX 25 selected hospitals/health centers increasing percentage of adolescent girls leaving the hospital with 2 counselling DLI 6 session on contraceptive methods after delivery over baseline

Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount

Outcome Yes Percentage 1,000,000.00 1.85

Period Value Allocated Amount (USD) Formula Baseline 0.00

Year 0 150,000.00

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Year 1 175,000.00

Year 2 200,000.00

Year 3 225,000.00

Year 4 225,000.00

Year 5 40.00 25,000.00

Verification Protocol Table: Disbursement Linked Indicators

DLI 1 Key RMNCAH Data regularly available and used for evidence-based follow-up at the national level and county level MoH and Counties use disaggregated data from various sources to monitor health sector outcomes and for annual and Description periodic planning. Ref. Year 0. (i) a & b: Signed memo, with attached indicators, filed (after circulation) in the office of the HMER Coordinator, with copies filed in the Offices of the Deputy Minister for Administration, Chief Medical Officer and Office of the General Counsel. Ref. Year 0. (ii): Signed memo filed (after circulation) in the office of the Minister of Health with copies filed in the Offices of the Deputy Minister for Administration, Chief Medical Officer, General Counsel County Health Services Unit, office of the HMER Coordinator and at the County Health Team offices. Ref. Year 1,2,3,4,5 (i): Filed Quarterly Analytical Reports (in hard copies or emailed scanned copy) in the Office of the HMER Coordinator Ref. Year 1,2,3,4,5 (ii): Filed Signed HSCC Data source/ Agency Minutes and Attendance (in Hard copies or emailed scanned copies) in the Office of External Aid Director. Ref. Year 1,2,3,4,5 (iii): Filed Signed CHT monthly minutes (in hard copies or emailed scanned copies) and participants (self-signed) in the offices of the County Health services and County Health Teams with the proof that CHS Unit has received the meeting minutes for all 15 counties no later than the 20th day of the following months. Ref. Year 1,2,3,4,5 (iv): Filed facility reports (in hard copies or emailed scanned copies) in the Office of Hospital Medical Director with the proof that the FHD has received the reports for all identified facilities providing CS no later than the 20th day of the following month.

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Verification Entity Independent Verification Agency Year 0 (i) Verify a signed Memo by the Minister of Health indicating that: a). Office of HMER Coordinator has been assigned to lead the technical group consisting of the following heads of units: Health Information System Unit, Monitoring & Evaluation Unit, Research Unit, Human Resource, Supply Chain Unit, Central Medicine Store, Family Health Division, Quality Management Unit, County Health Services Unit, Community Health Services Division, Assistant Minister for Vital Statistics, National Public Health Institute of Liberia and Office of Financial Management. b). Memo clearly outlines reporting indicators including programmatic indicators on maternal and neonatal mortality and other annual key agreed RMNCAH coverage indicators, supply chain indicators, indicators on human resources, vital statistics, financial data, and data quality indicators (can be attached to Memo). (ii) Verify MOH signed Memo by the Minister of Health establishing the county mechanism to analyze and review key data monthly. This mechanism must include: County M&E officer, Surveillance officer, County Pharmacist, County Health Services Administrator, Accountant, County Reproductive Health Supervisor, Clinical Supervisor and Community Health Services Director. Procedure Years 1, 2, 3, 4, and 5: (i) Verify at least four (4) Quarterly Analytical Reports are available in the Office of the HMER Coordinator at the MOH. The reports should summarize national and county performance, including analysis of indicators (list from the Memo signed in Year0) that have been achieved and not achieved, explanation of variances, descriptions of decisions made, implemented, and actions followed up. (ii) Verify through Signed HSCC meeting minutes and attendance (self-signed) that at least four Country Platform meetings have been held to discuss annual key indicators report (including analysis of indicators that have been achieved and not achieved, explanation of variances, descriptions of decisions made, implemented, and actions followed up). (iii) Verify through CHT meeting minutes and participants (self-signed) that at least 10 of the required 12 monthly CHT meetings were held and documented in a fiscal year. Minutes should be available for each meeting describing the following: data from approved list of indicators, explanation of variances, recommended actions & those taken, timeline for follow-up actions. In addition, verify signed copies of the monthly minutes of meetings at the County Health Services Unit was submitted no later than the 20th day of the following month. (iv) Verify through identified health facilities providing CS that at least 10 of the 12 monthly facility reports are complete

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and submitted not later than the 20th day of the following month to the office of the FHD. Completeness is defined as report which must include data from DHIS2, iHRIS, consumption report, and financing report, and key agreed indicators.

DLI 2 Contribute to a reduced stock-outs of Essential Package of Drugs evidenced by a Functional Supply Chain Increased availability of essential medicines/supplies: oxytocin, misoprostol, magnesium sulfate, IV anti-biotic for mother Description and newborn, IV fluids, blood, oxygen and at least one of the following anesthetic drugs (ketamine/ Propofol /bupivacaine (Marcaine)) Ref. Year 0. (i) Signed Memo by the Minister of Health approving annual distribution plan (attached to memo) for period January – December 2020 available in the Office of Minister of Health with attached Annual Distribution Plan in the Office of SCMU Manager Ref. Year 0. (ii): Drug invoice and waybill available in the office of the Managing Director of the CMS Ref. Year 1. (i): Quarterly County level allocation, distribution and consumption report is available for Montserrado County in the office of the Manager for Supply Chain. Ref. Year 1. (ii): LMIS (paper-based for primary Proof of Delivery and eLMIS at County seat) Ref. Year 1. (iii): Site visits to verify availability of Essential medicines and supplies in 21/36 identified hospitals/HCs. Ref. Year 2. (i): Quarterly County level allocation, distribution and consumption report is available for eight Counties (Gbarpolu, Grand Cape Mount, Bomi, Margibi, Grand Bassa, Bong, Nimba and Montserrado in the office of the Manager for Supply Chain. Ref. Year 2. (ii): LMIS (paper-based for primary Proof of Delivery and eLMIS at County seat) Ref. Year 2. (iii): Site visits to verify availability of Essential medicines and supplies in 30/36 identified hospitals Ref. Year 3. (i): Data source/ Agency Quarterly County level allocation, distribution and consumption report is available in 15 Counties in the office of the Manager for Supply Chain. Ref. Year 3. (ii): LMIS (paper-based for primary), Proof of Delivery and eLMIS at County seat Ref. Year 3. (iii): Site visits in sampled hospitals/hc to verify availability of Essential medicines and supplies in 33/36 identified hospitals/HCs Ref. Year 4. (i): Quarterly County level allocation, distribution and consumption report is available in all 15 Counties in the office of the Manager for Supply Chain. Ref. Year 4. (ii): LMIS (paper-based for primary), Proof of Delivery and eLMIS at County seat Ref. Year 4. (iii): Site visits to verify availability of Essential medicines and supplies in 36/36 identified hospitals/HCs Ref. Year 5. (i): Quarterly County level allocation, distribution and consumption report is available in 15 Counties in the office of the Manager for Supply Chain. Ref. Year 5. (ii): LMIS (paper-based for primary), Proof of Delivery and eLMIS at County seat Ref. Year 5. (iii): Site visits to verify availability of Essential medicines and supplies in 36/36 identified hospitals/HCs. Verification Entity Independent Verification Agency

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Year 0 (i) Verify a signed Memo by the Minister of Health approving annual distribution plan (attached to memo) for period January – December 2020 is based on consumption reports and disease burden and including clearly defined responsibilities and reporting lines is available in the Office of the Supply Chain Management Unit Manager (ii) Verify from the Central Medical Store using drug requisitioning and issuing documents made available by the SCMU to determine the quarterly variance between CMS to Montserrado and Margibi counties and 36 high volume hospitals for 2 quarters before effectiveness of the project Year 1 (i) Verify that quarterly county level allocation, distribution and consumption report is available for Montserrado County in the office of the Manager for Supply Chain (distribution plans to be based on consumption and disease burden) . (ii) Verify that variance between CMS allocated quantity and received quantity by the Montserrado county office is not more than 15%. B) Verify that the quarterly verification report was submitted not later than two months after the distribution through the LMIS and eLMIS. (iii) verify availability of Essential medicines and supplies in identified 21/36 hospital/HCs. Availability defined as no stockout of any of the items within the year of implementation. This will be confirmed through a record review of the product Procedure register at the facility, for 3 random months. Year 2 (i) Verify Quarterly County level allocation, distribution and consumption report is available for eight Counties (Gbarpolu, Grand Cape Mount, Bomi, Margibi, Grand Bassa, Bong, Nimba and Montserrado) in the office of the Manager for Supply Chain. (distribution plans to be based on consumption and disease burden). (ii) Verify that variance between CMS allocated quantity and quantity received by the Montserrado county depot is not more than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS. (iii) verify availability of Essential medicines and supplies in 30/36 hospitals/HCs. Availability defined as no stockout of any of the items within the year of implementation. This will be confirmed through a record review of the product register at the facility, for 3 random months. Year 3 (i)Verify Quarterly County level allocation, distribution and consumption report is available in 15 Counties (in the office of the Manager for Supply Chain. (distribution plans to be based on consumption and disease burden) (ii) Verify that variance between CMS allocated quantity and quantity received by the Montserrado county depot is not

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more than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS. (iii Verify availability of Essential medicines and supplies in 33/36 hospitals/HCs. Year 4 (i) Verify Quarterly County level allocation, distribution and consumption report is available in all 15 Counties (in the office of the Manager for Supply Chain. (distribution plans to be based on consumption and disease burden) (ii) Verify that variance between CMS allocated quantity and quantity received by the Montserrado county depot is not more than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS. (iii) Verify availability of Essential medicines and supplies in 36/36hospitals/HCs. Availability defined as no stockout of any of the items within the year of implementation. This will be confirmed through a record review of the product register at the facility, for 3 random months. Year 5 (i) Verify Quarterly County level allocation, distribution and consumption report is available in all 15 Counties (in the office of the Manager for Supply Chain. (distribution plans to be based on consumption and disease burden) (ii) Verify that variance between CMS allocated quantity and quantity received by the Montserrado county depot is not more than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS. (iii) Verify availability of Essential medicines and supplies in 36 hospitals/HCs.

DLI 3 Functional HR system in place at MOH, counties, hospitals and facilities

Description HR staff and policies available and implemented at central MoH, counties, hospitals and facilities Ref. Year 0. (i): Filed Senior Management Team Meeting Minutes (in hard copy) attached to Signed HR policy approval memo (in hard copy) by the Minister of Health in the office of the Minister of Health. Ref. Year 0. (ii): Filed Signed memo by Deputy Minister for Administration (in hard copy) communicating instructions of in clear job descriptions for all Cadres Data source/ Agency available in the offices of the Director of HR Unit and the County HR officers. Ref. Year 0. (iii): Filed Senior Management Team Meeting Minutes with attached approved document (Workload Indicators for Staffing Needs Report-WISN) in the offices of the Minister of Health and Deputy Minister of Administration. Ref. Year 0. (iv): filed Needs Assessment Report (in hard copy) with (Deployment procedure and package in the office of the director of human resources. Ref. Year 1. (i):

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Printouts generated from the iHRIS from access provided by the Director of Human Resource. Ref. Year 1. (ii): Filed semi- annual supportive Supervision Report (in hard copies), including Action Taken available in the office of the Director of Human Resources. Ref. Year 1. (iii) a & b: HR records retrieved from iHRIS and with checks at 18 identified hospitals capable of providing C-Section and public primary health facilities providing institutional deliveries respectively Ref. Year 2. (i): Filed HR Annual Report (in hard copies) available in the office of the Director of Human Resource Ref. Year 2. (ii): Filed semi- annual supportive Supervision Report (in hard copies), including Action Taken available in the office of the Director of Human Resources. Ref. Year 2. (iii) a & b: HR records retrieved from iHRIS and with checks at 25 identified hospitals capable of providing C-Section and 70% of public primary health facilities providing institutional deliveries respectively Ref. Year 3. (i): Filed HR Annual Report (in hard copies) available in the office of the Director of Human Resource Ref. Year 3. (ii): Filed semi-annual supportive Supervision Report (in hard copies), including Action Taken available in the office of the Director of Human Resources. Ref. Year 3. (iii) a & b: HR records retrieved from iHRIS with checks at 25 identified hospitals capable of providing C-Section and 60% of public primary health facilities providing institutional deliveries respectively Ref. Year 4. (i): Filed HR Annual Report (in hard copies) available in the office of the Director of Human Resource Ref. Year 4. (ii): Filed semi- annual supportive Supervision Report (in hard copies), including Action Taken available in the office of the Director of Human Resources. Ref. Year 4. (iii) a & b: HR records retrieved from iHRIS with checks at 25 identified hospitals/HCs providing C-Section with minimum staff and 70% of public primary health facilities providing institutional deliveries respectively Ref. Year 5. (i): Filed HR Annual Report (in hard copies) available in the office of the Director of Human Resource Ref. Year 5. (ii): Filed semi-annual supportive Supervision Report (in hard copies), including Action Taken available in the office of the Director of Human Resources. Ref. Year 5. (iii) a & b: HR records retrieved from iHRIS with checks at 25 identified hospitals/HCs providing C-Section and 80% of public primary HFs providing institutional deliveries. Verification Entity Independent Verification Agent Year 0 (i) Verify through a signed memo and Senior Management Team Meeting Minutes that the Human Resources Policy has been formally approved by the Senior Management Team of the MOH through a signed Memo by the Minister of Health for implementation. Signed memo should have attached the policy which includes: Clear guidelines for recruitment, Procedure deployment, retention, transfers, and disciplinary action Available in the office of the Minister of Health. (ii) Verify through a signed memo by the Deputy Minister for Administration that Clear job descriptions for all cadres both administrative and professional within the health sector are communicated at Central and County HR management levels. (iii) Verify through the Senior Management Team Meeting Minutes (In hard copy) that an approved document (attached to

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Minutes) is available in the MOH that describes Staffing norms[1] agreed and approved for different facility types, administrative levels (including CHTs) and catchment populations. (iv) Verify through a Need Assessment report available in the office of Human resources in the MOH, technically reviewed by the Bank, and verified based on copy of email response. Year 1 (i) Verify through physical assessment that the HR database is operational and able to provide current information on recruitment, and transfers. Provide printouts of this information from database. Access to the HR database will be allowed by the director of Human Resource. The annual HR report should be able to highlight disciplinary action taken each year. (ii) Verify through quarterly supportive Supervision reports (in hard copy) in the office of the Director of Human Resource that MOH has conducted semi-annual supportive supervision visits to 12 counties. Semi-annual supportive supervision reports should feature actions taken during visits . (iii) (a) Verify and check through HR records retrieved through iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visit 18 identified hospitals/HCs providing Cesarean Section that minimum staff complement in is present (minimum staffing level will be established in year 0 when WISN is completed). (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visit 40% and public primary health facilities (117) providing institutional deliveries[1]. Public primary Health facilities providing institutional deliveries as per agreed staffing norms. Year 2 (i) Verify that HR annual report is available in the office of the Director for Human Resource indicating completion by the 31st of August of the current year using data from HR database on recruitment, transfers, and disciplinary action taken during previous year. (ii) Verify through quarterly supportive Supervision reports (in hard copy) in the office of the Director of Human Resource that MOH has conducted semi-annual supportive supervision missions to 15 counties with report on actions taken available. (iii) (a) Verify and check through HR records retrieved through iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visit 25 identified hospitals/HCs providing Cesarean Section that minimum staff complement is present. (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visits 50% of identified public primary health facilities providing institutional delivery[1] with at least two professional staff. Year 3

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(i) Verify that HR annual report is available in the office of the Director for Human Resource indicating completion by the 31st of August of the current year using data from HR database on recruitment, transfers, and disciplinary action taken during previous year. (ii) Verify through semi-annual supportive Supervision reports (in hard copy) in the office of the Director of Human Resource that MOH has conducted quarterly supportive supervision missions to 15 counties with report on actions taken available. (iii) (a) Verify and check through HR records retrieved through iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visit 25 identified hospitals capable of preforming of Cesarean Section that minimum staff complement is present (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visits 60% and public primary health facilities providing institutional delivery Year 4 (i) Verify that HR annual report is available in the office of the Director for Human Resource indicating completion by the 31st of August of the current year using data from HR database on recruitment, transfers, and disciplinary action taken during previous year. (ii) Verify through quarterly supportive Supervision reports (in hard copy) in the office of the Director of Human Resource that MOH has conducted quarterly supportive supervision missions to 15 counties with report on actions taken available. (iii) (a) Verify and check through HR records retrieved through iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visit 25 identified hospitals/HCs providing Cesarean Section that minimum staff complement is present. (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visits 70% of public primary health facilities providing institutional delivery[1] with at least two health professionals. Year 5 (i) Verify that HR annual report is available in the office of the Director for Human Resource indicating completion by the 31st of August of the current year using data from HR database on recruitment, transfers, and disciplinary action taken during previous year. (ii) Verify through semi-annual supportive Supervision reports (in hard copy) in the office of the Director of Human Resource that MOH has conducted quarterly supportive supervision missions to 15 counties with report on actions taken available. (iii) (a) Verify and check through HR records retrieved through iHRIS (Access to the HR database will be allowed by the

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director of Human Resource) and site visit 25 identified hospitals capable of preforming of Cesarean Section that minimum staff complement is present. (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visits 80% and public primary health facilities providing institutional delivery[1] with at least two health professionals.

DLI 4 Improved adolescent health (with focus on girls) as measured by specific marker indicators

Description Increase number of adolescents accessing ASRH services through in-school and out-of-school programs. Ref. Year 0. (i): Filed Joint agreed workplan (in hard copies) between the MOE and MOH with the monitoring framework in the office of the Director for Family Health Ref. Year 0. (ii): Filed Agreed workplan with stakeholders and Civil Society Organization available in the office of Director of Family Health Ref. Year 1. (i): Filed Female counsellors training modules inclusive of ASRH training modules available in the office of the Director of Family health Ref. Year 2. (i): Filed Joint Data source/ Agency Monitoring report of MOE and MOH available in the Office of the Director of Family Health. Ref. Year 3. (i): Filed Joint Monitoring report of MOE and MOH available in the Office of the Director of Family Health. Ref. Year 4. (i): Filed Joint Monitoring report of MOE and MOH available in the Office of the Director of Family Health. Ref. Year 5. (i): Filed Joint Monitoring report of MOE and MOH available in the Office of the Director of Family Health. Verification Entity Independent Verification Agency Year 0 (i) Verify that a joint MOE & MOH workplan is available in the office of the Director for Family health and includes monitoring framework for the counselling of adolescent boys and girls in school. (ii) Verify that an Agreed workplan with stakeholders and CSO which has a description of range and scope of activities to Procedure reach adolescents in community (youth club, churches, etc.) is available in the office of the Director of Family Health. Year 1 (i) Verify through the developed Female counsellors training modules that ASRH training module is available in the office of the Director of Family Health.

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Year 2 (i) Verify based on the Joint monitoring report of MOE and MOH available in the Office of the Director of Family Health describing ASRH activities coordinated by the female counsellors, number of students counselled by female counselors, peer education activities conducted in schools (quiz, debate, drama, radio talk shows) teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy. Year 3 (i) Verify based on the Joint monitoring report of MOE and MOH available in the Office of the Director of Family Health describing ASRH activities coordinated by the female counsellors, number of students counselled by female counselors, peer education activities conducted in schools (quiz, debate, drama, radio talk shows) teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy. Year 4 (i) Verify based on the Joint monitoring report of MOE and MOH available in the Office of the Director of Family Health describing ASRH activities coordinated by the female counsellors, number of students counselled by female counselors, peer education activities conducted in schools (quiz, debate, debate, drama, radio talk shows), teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy. Year 5 (i) Verify based on the Joint monitoring report of MOE and MOH available in the Office of the Director of Family Health describing ASRH activities coordinated by the female counsellors, number of students counselled by female counselors, peer education activities conducted in schools (quiz, debate, debate, drama, radio talk shows) teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy.

DLI 5 Citizen engagement and grievance redressal system functional in the health sector

Description Increase citizens’ voices in decision making process for inclusiveness and responsiveness to citizens’ needs Ref. Year 1. (i): Signed memo by the Minister of Health accompanied by the roll out plans with strategy that identified mechanism(s) for implementation in the Office of HMER Coordinator Ref. Year 1. (ii): Filed Roll out Plan including approved list of mechanisms for addressing clients/patients’ grievances in the 25 hospitals/HCs providing C-Section in the Office of Data source/ Agency HMER Coordinator Ref. Year 1. (iii): Site visits findings from random checks at hospitals providing C-section. Ref. Year 2,3,4 &5 (i): Filed HSCC meetings minutes capturing key actions on citizens inclusiveness and grievances addressed available in the office of the Director for External Aid and is publicized. Ref. Year 2,3,4 &5 (ii): Filed 6-monthly reports summarizing

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patients /clients grievances redressal, including minutes of meeting deliberations and actions taken available, and relevant information made public from all identified 25 hospitals/HCs providing C-Section available in the office of the HMER Coordinator Verification Entity Independent verification agency Year 1 (i) Verify that a Signed memo by the Minister of Health approving the Roll out plan (attached to memo) or receiving feedbacks from citizens is available in the office of the HMER Coordinator. Verify that MoH through the strategy has identified and agreed on 1-2 mechanisms for implementation. Options include: Social audit; Community surveys; patient feedback; citizen report cards. (ii) Verify that the approved mechanisms for dealing with patient/client grievances and citizen feedbacks in the identified 25 hospitals/HCs providing C-Section. (iii) Verify through random checks at 40% of hospitals/HCs providing C-section that mechanisms for dealing with grievances Procedure and feedbacks are functioning. Years 2, 3, 4 and 5 (i) Verify through HSCC meeting Minutes in the Office of Director of External Aid that Feedback Mechanism is discussed as an agenda item; and the report is endorsed and made available to the public. (ii) Verify by reviewing the Semi-annual report that summarizes patients /clients’ grievances redressal, including minutes of meeting deliberations and actions taken available, and relevant information made public from all identified 25 hospitals/HCs providing C-Section available in the office of the HMER Coordinator

25 selected hospitals/health centers increasing percentage of adolescent girls leaving the hospital with 2 counselling DLI 6 session on contraceptive methods after delivery over baseline With the final objective of reducing second and further pregnancies in adolescent girls, the objective is to increase the Description number of adolescents leaving 25 selected hospitals having received 2 counselling sessions on contraceptive methods over baseline. (i)Baseline defined in each one of the 25 selected hospitals. Baseline review will be made using last two years and should define increased percentages (goals) per year and per hospital. (ii) One annual analytic report produced, which summarizes Data source/ Agency 25 hospitals reports; (iii) Points will be accredited to the to the hospitals . (iii) Non-monetary incentives made only to hospitals that achieved the goal over baseline.

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Verification Entity Independent Verification Agency Year 0 (i) Verify with the Director of M&E that the MOH has a system to collect this information ; (ii )Verify that management agreement has been signed between MOH and each hospital – Review of the management agreement at the Office of the Deputy Minister of Administration ; (iii)Verify with the Director of M&E that baselines are defined in e ach one of the 25 selected hospitals. (iv) Verify that baseline review was made using the last two years and (v) verify that baselines have been defined; and targets (goals) on the percentages of adolescent girls leaving per year and per hospital with2 counselling sessions on family planning have been set. (vi) Verify with the Director of Family health that supervision team w as defined by the MOH for the 25 hospitals/HC, and that national standards on the topic was set and approved by the MoH. Year 1,2,3 and 4 (i) Verify that management agreements were signed with each one of the 25 hospitals between the Medical Director of the hospital and the MoH. Review the annual definitions for each hospital included in the Project Operations Manual. (ii) One analytic report produced, which summarizes 25 hospitals reports and common trends. The report should include a full analysis on the topic, as well as defined targets for hospitals on the proportion of adolescents who received 2 Procedure counselling sessions on family planning, which will be annually included in Management Agreements. (iii) Verify the way transfers (in points) will be made to the 25 hospitals/HC. (iv) Verify whether menu on non-monetary incentives is developed by MOH in consultation with each hospital – Minutes of negotiations /consultation will be kept in Director of Family health Office. (v) Verify if hospital/HC has achieved the target using hospital/ HC by: (a) site visits to review the ledger at a random sample of the 25 hospitals/HCs (high and low performing facilities) and (b) review the server at the level of the MOH. (vi) Verify whether each of the 25 hospital/HC have achieved the annual target and whether they have received the non- monetary incentives: (a) site visits of a random sample of the hospitals/ and (b) review the server at the level of the MOH. Year 5 (i) Verify that end report is available at the office of the Director of Family health and that the report follows the same trends of previous years as well as the baseline.

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ANNEX 1: Implementation Arrangements and Support Plan

COUNTRY: Liberia Institutional Foundations to Improve Services For Health

Financial Management

1. The PFMU will continue to be responsible for the day-to-day management of funds and accounting for the World Bank and others in the donor portfolio in Liberia. The project shall use the project’s Financial Procedures Manual already developed for ongoing projects, and it will be brought into the IFMIS system. The PFMU shall be responsible for the project’s financial reporting, using already agreed unaudited IFR formats in use for other projects with DLIs. The PFMU is adequately staffed with competent finance professionals who have garnered the requisite experience and have qualifications acceptable to the World Bank. The agreed proposal is to have a PIU, which will be responsible for the day-to-day operations of the project. The PIU will have one FM specialist who will be responsible for financial management, as well as for working closely with the PFMU on the reporting requirements for the World Bank.

2. The Annual Work Plan and Budget (AWP&B) will be derived from the procurement plan and disbursement plans. It will be updated to reflect implementation progress. The PIU, in consultation with the PFMU, will prepare the AWP&B. The PIU will submit the approved AWP&B to the World Bank for no objection before the end of the financial year.

Accounting and Reporting

3. Project accounts will be maintained on a cash basis, supported with appropriate records and procedures to track commitments and to safeguard assets. The use of the project funds will be reported through the rendition of quarterly IFRs acceptable to the World Bank. The PFMU is responsible for preparing the quarterly IFRs using the existing agreed template. The IFRs are to be submitted to the World Bank 45 days after the end of each fiscal calendar quarter. The IFRs comprise, at a minimum: (a) sources and uses of funds, (b) uses of funds within components, (c) fund disbursement status, (c) a schedule of fixed assets, (d) a schedule of withdrawal applications, and (e) bank account reconciliation statements.

Internal Controls and Audit

4. The internal audit under PFMU is headed by a Chartered Accountant who has relevant experience in internal auditing. The PFMU has already established internal control procedures and processes that ensure appropriate personnel approve transactions. Adequate segregation of duties between approval, execution, accounting, and reporting functions should be in place. The Internal Audit Unit that is currently in use will continue to be used for the internal audit of the project. Internal auditors are supposed to submit internal audit reports to the World Bank 45 days after the end of every six months (that is, in September and March).

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External Audit Arrangements

5. An independent and qualified auditor, acceptable to the World Bank, will conduct annual audits at the end of each GOL fiscal year. The auditor should be selected within six months of project effectiveness on a competitive basis and in accordance with the World Bank's Procurement Guidelines. The General Audit Commission (GAC) will have preference to conduct the audit as per the Liberian laws and the audit should be based on terms of reference acceptable to the World Bank. The project financial statements, including movements in the Designated Accounts, will be audited in accordance with International Organization of Supreme Audit Institutions (INTOSSAI) guidelines, as issued by the INTOSSAI, and a single opinion will be issued to cover the project financial statements in accordance with the World Bank’s audit policy. The auditors’ report and opinion with respect to the financial statements and activities of the Designated Account (DA), including the Management Letter, will be furnished to the World Bank within six months after the end of each governmental fiscal year.

Funds Flow Arrangements

6. The project will use the report-based disbursement method which will also be used for accessing funds into the designated account for project implementation. Funds will flow from the IDA to a Designated US Dollar account to be opened at commercial bank acceptable by the World Bank in Liberia and managed by the PFMU. Payments will be made for eligible project expenses from the Designated US Dollar account. The report-based disbursement method (Interim Financial Reports) will be used as a basis for the withdrawal of all credit and grant proceeds. An initial advance will be provided for the implementing entity, based on a forecast of eligible expenditures against each component, linked to the appropriate disbursement category. These forecasts will be premised on the annual work-plans that will be provided to the IDA and cleared by the World Bank task team leader. Replenishments, through fresh withdrawal applications to the World Bank into the designated accounts, will be made subsequently, at quarterly intervals, but such withdrawals will equally be based on the net cash requirements that are linked to approved work-plans and percentage contribution to the pooled fund. Supporting documentation will be retained by the implementing agencies for review by the IDA missions and external auditors. For a period of four months after the closing date, disbursement for expenses incurred prior to the closing date will be allowed.

7. The disbursements for DLIs will be made against the achievement of DLI targets. A certain amount of credit proceeds has been allocated to each DLI, referred to as the DLI allocation, which is the amount that the MOH can claim as disbursements against eligible expenditure programs (EEPs) that DLI has been achieved and verified. These EEPs are a part of recurrent expenses of the eligible activities, clearly identifiable in the MOH’s financial statements. The limit for each DLI has been agreed.

8. This mode of disbursement will mainly involve reimbursement of certified EEPs supported with achieved DLIs and other relevant documentation. The disbursements will be made against identified EEPs, and the triggers will be the actual values of predefined DLIs. Decisions over compliance and disbursement against indicators will be made based on reports prepared by the MOH and submitted to the independent verification agent with necessary documentation assuring that they have been satisfied. Disbursements against EEPs and DLIs will flow to a special account to be opened. The World Bank will issue a Disbursement Letter which will set out and summarize all the disbursement arrangements and procedures under the project. The letter will include the World Bank Disbursement Guidelines.

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Figure: Flow of Funds Diagram

World Bank

DA (commercial DA (Commercial bank) EEP bank) non DLI as as Defined in PAD. (for MoH) defined in the PAD.

Finance Activities in AWP&B (Non DLIs) MoH upon meeting the DLI

FM Covenants

9. Quarterly progress reports on financial progress will be prepared and sent to the World Bank no later than 45 days from the end of the quarter. Internal auditors are required to submit internal audit reports to the World Bank 45 days after the end of every six months (that is, in September and March). Annual audit reports will be prepared and submitted to the World Bank within six months of the end of the year audited. AWP&B shall be prepared and submitted to the World Bank by the end of each FY year.

Supervision Plan

10. Consistent with the overall residual risk rating of substantial, two supervision and implementation missions shall be carried out each year complemented with a lot of handholding for the clients in the initial two years.

Disbursements

11. The arrangements will consider, among other things, an assessment of the Borrower’s FM and procurement arrangements, cash flow needs for the project, and IDA disbursement experience with the Borrower. Those arrangements will be outlined in the Financing Agreement and additional information will be provided in the Disbursement Letter, which will form part of the Financing Agreement. Table 1.1 details the disbursement categories.

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Table 1.1: Disbursement Categories

Category Amount of the Credit Percentage of Expenditures Allocated (expressed in to be Financed USD) (inclusive of Taxes) (1) Goods, works, non-consulting 44,865,000 100% services, consulting services, Operating Costs and Training under Parts A (except under Part A.3 (b) and C) of the Project (2) PBF Grants under Part A.3 (b) of 2,000,000 100% the Project (3) Eligible Expenditure Program 6,000,000 100% of each DLI Amount set (EEP) under Part B of the Project out in the Annex to Schedule 2 (or such lesser percentage as represents the total Eligible Expenditures paid by the Recipient under the Eligible Expenditure Program as of the date of withdrawal). (4) Goods, works, non-consulting 1,000,000 100% services, consulting services, Operating Costs and Training under Part C of the Project (5) Emergency Expenditures under 0 n/a Part D of the Project (6) Front-end Fee 135,000 Amount payable pursuant to Section 2.03 of this Agreement in accordance with Section 3.08 (b) of the General Conditions (7) Interest Rate Cap or Interest Rate 0 Amount due pursuant to Collar premium Section 4.06 (c) of the General Conditions TOTAL AMOUNT 54,000,000

12. Disbursements of funds to the project will follow any of the following methods: (a) reimbursement, where IDA may reimburse the Borrower for expenditures eligible for financing, pursuant to the Financing Agreement (eligible expenditures), that the Borrower has pre-financed from its own resources; (b) advances, where IDA will advance funds from the Financing Account into a Designated Account of the Borrower to finance eligible expenditures as they are incurred and for which supporting documents will be provided; (c) direct payment, where IDA will make payments, at the Borrower’s request, directly to a third party (for example, supplier, contractor, or consultant) for eligible expenditures; and (d) special commitment, where IDA will pay amounts to a third party for eligible expenditures under special commitments entered into, in writing, at the Borrower’s request and on terms and conditions agreed between the Borrower and the World Bank.

13. The following are requirements for funds to be withdrawn or committed. Before funds from the Financing Account are withdrawn or committed, the authorized representative of the Borrower (as designated in the

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Financing Agreement) will furnish to the World Bank, electronically through the Client Connection website (http://clientconnection.worldbank.org), or through an authorized signatory Designation Letter, the name(s) of the official(s) authorized to: (a) sign and submit applications for withdrawal and applications for a Special Commitment (collectively, applications); and (b) receive secure identification credentials from the World Bank. The GOL will notify the World Bank of any changes in signature authority, either electronically in Client Connection or through an updated authorized signatory Designation Letter. Applications will be provided to the World Bank in such form as is required to access funds from the Financing Account and will include such information as the World Bank may reasonably request. Applications and necessary supporting documents will be submitted to the World Bank electronically, in a manner and on terms and conditions specified by the World Bank, through the Client Connection website at http://clientconnection.worldbank.org. The World Bank will, at its discretion, temporarily or permanently, disallow the electronic submission of applications by the Borrower. The World Bank will permit the GOL to complete and submit applications manually in paper form. Paper application forms can be found on the Client Connection website at http://clientconnection.worldbank.org or may be obtained from the World Bank upon request. The World Bank establishes a minimum value for applications for Reimbursement, Direct Payment, and Special Commitment. The World Bank reserves the right to not accept applications that are below such a minimum value. DLI disbursement and verification protocol can be found in Annex 2.

Procurement Management

14. The Borrower will carry out procurement under the project in accordance with the World Bank’s Procurement Regulations for IPF Borrowers (Procurement Regulations) dated July 1, 2016, revised November 2017 and August 2018, under the New Procurement Framework and the Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants, dated October 15, 2006 and revised in January 2011 and July 1, 2016, and other provisions stipulated in the financing agreements.

Procurement Arrangements

15. Procurement implementation under this project will be carried out by the PIU of MOH. The institutional arrangements for procurement will be built on the existing procurement structure and arrangements used for the previous and current projects. The procurement capacity assessment of the MOH was conducted by the World Bank team during the project preparation process on September 4, 2019. MOH is already implementing World Bank–funded projects, including the ongoing HSSP, EERP and REDISSE, and nothing has changed to date. The projects are supervised by an individual PIU headed by a Program Coordinator who reports to the Deputy Minister Administration.

Procurement Assessment

16. The assessment findings revealed the following weaknesses that could adversely influence the project implementation if not mitigated: a. some gaps concerning knowledge and experience of carrying out procurement activities in accordance with the World Bank Procurement Regulations for IPF Borrowers, rules, and procedures (particularly regarding the new possibilities afforded by the Procurement Framework), despite having some experience with World Bank–funded projects; b. limited procurement capacity for the PIU with the addition of IFISH. This may cause implementation challenges because the two procurement officers may not be able to efficiently handle the workload

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for four projects; c. inadequate experience in procurement of works, contract management and consulting services. d. limited number of office equipment;

17. The proposed mitigation measures include the following: a. providing procurement training for PIU staff during project preparation and immediately after effectiveness, with constant support to the PIU to ensure the proper use of the World Bank Procurement Regulations for IPF Borrowers; b. recruiting an International Procurement Consultant, additional qualified procurement officer, a procurement assistant and administrative assistant to complement the two procurement officers’ work to ensure the procurement plans developed are implemented, monitored, and updated in a proper and timely manner; c. updating the project implementation manual (PIM) to reflect the needs of the project and current operational/procurement environment in the relevant sections; d. providing appropriate training in Contract Management and Selection of Consultants to PIU staff during the initial 18 months of project implementation and collaborate more with the Ministry of Public Works (MPW). e. providing the PIU with transportation to support administrative functions and a high-volume scanner with internet service to enable migration from manual to electronic documentation and record keeping; f. The World Bank to carry out regular implementation support missions and conduct an annual procurement post review.

18. The assessment rated the overall procurement risk as substantial, given the procurement scope and associated risks identified.

19. Filing and record keeping. The Procurement Procedures Manual will be finalized along with PIM to set out the detailed procedures for establishing and maintaining an electronic document management system. This will provide ready access to project procurement records for audit and post review purposes.

20. Project procurement strategy for development. As part of project preparation, the PIU (with support from the World Bank) prepared its Project Procurement Strategy for Development (PPSD) (dated April 15, 2020), using inputs taken from a market survey and analysis of potential contractors and suppliers available for the proposed procurement scope, the assessment of operational context, their institutional capacity, and procurement related risk analysis, as well as the mitigation measures against the identified procurement risks. Through these analytical assessments, the PPSD made recommendations on procurement arrangements under the proposed project and informed the preparation of the first eighteen (18) months procurement plan. The PPSD also addresses how procurement activities support the achievement of the PDO and deliver the best value for money under a risk-managed approach. Details of procurement scope for IDA financing, which will support the achievement of the PDO, are included in the PPSD.

21. Procurement thresholds. The World Bank’s Guidance on Thresholds for Procurement Approaches and Methods by Country, dated August 25, 2016, will be used. These thresholds apply to all procurement activities regardless of their procurement or selection methods. The procurement prior review thresholds are also project risk oriented. There is no automatic requirement to undertake prior review for direct selection for values less than these thresholds. These thresholds are for the purposes of the initial procurement plan for

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the first 18 months. The thresholds will be revised periodically

22. Procurement plan. The PIU has prepared a procurement plan for the project based on the findings and recommendations of the PPSD. The procurement plan will be subject to public disclosure and will be updated regularly or as needed by including contracts previously awarded and to be procured. The updates or modifications of the procurement plan will be subject to the World Bank’s prior review and “no objection.” For all open international competitive procurement packages, the World Bank will arrange for publication of the procurement plan and updates on the World Bank’s external website and UNDB online directly from STEP, and for all open national competitive procurement packages, the PIU will publish on the e-mansion and widely read local newspapers.

23. Monitoring by STEP. Through mandatory use of Systematic Tracking of Exchanges in Procurement (STEP) by the Borrowing agencies, the World Bank will be able to consolidate procurement and contract data for monitoring and tracking of all procurement transactions. Using STEP, comprehensive information of all prior and post review contracts for goods, works, technical services, and consultants’ services awarded under the whole project will be available automatically and systematically on a real-time basis whenever required, including, but not limited to, the following: (i) reference number as indicated in the procurement plan and a brief description of the contract, (ii) estimated cost; (iii) procurement method; (iv) timelines of the bidding process; (v) number of participated bidders; (vi) names of rejected bidders and reasons for rejection; (vii) date of contract award; (viii) the name of the awarded supplier, contractor, or consultant; (ix) final contract value; and (x) contractual implementation period.

24. Publication of procurement information. The project will follow the World Bank’s policies on publication of procurement information that are set forth in the World Bank’s Procurement Regulations.

25. Procurement Post Review. Contracts below the prior review thresholds previously stated will be subject to post review annually by the fiduciary team of the World Bank. The exercise will be carried out according to procedures set forth in the procurement regulations. PPR reports will review procurement process, award of contract and implementation. The rate of post review is initially set at 20 percent. This rate may be adjusted periodically based on the procurement performance of the PIU.

26. Training, workshops, study tours, and conferences. Training activities would comprise workshops and training based on individual needs, and group requirements, on-the-job training, and hiring of consultants for developing training materials and conducting trainings. Selection of consultants for training services follows the requirements for selection of consultants previously stated. All training and workshop activities (other than consulting services) would be carried out on the basis of approved annual work plans or training plans that would identify the general framework of training activities for the year, including: (i) type of training or workshop; (ii) personnel to be trained; (iii) institutions which would conduct the training and reason for selection of this particular institution; (iv) justification for the training, focusing on how it would lead to effective performance and implementation of the project; (v) duration of the proposed training; and (vi) cost estimate of the training. Reports by the trainees, including a completion certificate or diploma on completion of training, will be provided to the project coordinator to be kept as part of the records, and will be shared with the World Bank if required.

27. A detailed plan of the training or workshop describing the nature of the training or workshop, number of trainees or participants, duration, staff months, timing, and estimated cost will be submitted to IDA for review

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and approval before initiating the process. The selection methods will derive from the activity requirement, schedule, and circumstance. After the training, the beneficiaries will be asked to submit a brief report indicating the skills acquired and how these skills will contribute to enhancing their performance and attaining the project objective.

28. Operational costs. Operational costs financed by the project would be incremental expenses, including office supplies, operation and maintenance of vehicles, maintenance of equipment, communication, rental expenses, utilities, consumables, transport and accommodation, per diem, supervision, and salaries of locally contracted support staff. Such services needs will be procured using the procurement procedures specified in the PIM accepted and approved by the World Bank.

29. Procurement Manual. Procurement arrangements, roles and responsibilities, and methods and requirements for carrying out procurement will be elaborated in detail in the Procurement Manual, which will be a section of the PIM. The PIM will be prepared by the Borrower and agreed with the World Bank by the time of project effectiveness

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ANNEX 2: Disbursement- Linked Indicators

1. The selection and structuring of the DLIs were jointly carried out between the MOH and the WBG team during preparation. The selection was driven by desired outcomes and outputs to lessen foundational bottlenecks within the health sector. The selection of the DLIs would serve the role of signaling and monitoring critical milestones along the planned results chain. The selection also considered key practical aspects of measuring, monitoring, and verifying the results, given the capacity of the respective ministries and country context.

2. The DLIs are key actions that aim to address specific constraints that impede service delivery. The financing amounts allocated to each were based on the relative importance of the indicator to provide the requisite incentive needed for achieving overall project goals and outcomes. Most of the DLIs have achievement dates (usually end of each implementation year); however, some DLIs are designed to give the MOH flexibility such that the incentive amount can be paid on verification of achievement at any time.

3. The selection of the DLIs for the project has taken into consideration the practical aspects of measuring, monitoring, and verifying achievement of the results. The chosen DLIs are clearly defined and measurable, with clear protocols for monitoring (DLI Verification Matrix); greater detail will be specified in the PIM. The DLIs are structured, considering the country’s context and Borrower capacity — and whether it is feasible to achieve the results selected as DLIs during the implementation period. The DLIs are not premised on outcomes; neither are they intermediate outcomes or outputs. Rather they are process indicators that address specific risks or constraints to achieving the improved service delivery. Ultimately, these are driven by the desired outputs and outcomes of the key programs being run in the sector. The absolute number of DLI-anchored intermediate outcomes aims to ensure that they are the main milestones that are considered critical to: (a) keeping the key sectoral programs, including efficiency and effectiveness, on track; and (b) ensuring that agreed upon improvements and mitigation measures are carried out. They have been selected to ensure that they are practical and manageable.

4. As targets are achieved, the World Bank will disburse funds to the GOL against the Eligible Expenditure Program (EEP) budget lines listed in Table 2.1). Rollover of any of the DLIs Is described in the DLI Matrix (Tables 2.4, 2.5).

5. Compensation of Employees Basic Salary-Civil Service: this budget line will be used mainly to pay salaries for all staff who may not be fully covered by the normal civil service salaries budget and include all departments within the MOH.

• General Allowance: this budget line will be used mainly to provide allowances or incentives to healthcare workers assigned to the 25 Hospitals and/or 117 selected facilities after careful selection year by year, based on which facilities should receive incentives. In the parameters for the incentives, at least the following two parameters should be incorporated: (i) hard-to-reach areas at health facilities, and (ii) increase in productivity in the 25 selected hospitals. This will also serve as motivation for staff to take up an assignment in hard-to-reach and remote terrains, as well as to increase productivity and quality of care. The MOH will present the proposal to the World Bank for No objection each year.

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Table 2.1 Eligible Expenditure Program (EEP)

Departments/Divisions/Cost Entity Centers Code/Chat of Accounts Budget Lines Compensation of Employees MOH Curative: 0100-101409-022103-0760-0000-211101 Basic Salaries Curative: 0100-101409-022103-0760-0000-211110 General Allowance Preventive: 0200-101409-022103-0760-0000-211101 Basic Salaries Preventive: 0200-101409-022103-0760-0000-211110 General Allowance Planning, Research & Development: 0400-101409-022103-0760-0000-211101 Basic Salaries Planning, Research & Development: 0400-101409-022103-0760-0000-211110 General Allowance Health & Vital Statistics: 0500-101409-022103-0760-0000-211101 Basic Salaries Health & Vital Statistics: 0500-101409-022103-0760-0000-211110 General Allowance Administration & Management: 0600-101409-022103-0760-0000-211110 Basic Salaries Administration & Management: 0600-101409-022103-0760-0000-211110 General Allowance

6. The disbursement of DLI-related financing will be made at the request of the GOL upon the achievement of DLIs as specified in the agreed DLI Matrix. The World Bank’s task team will routinely monitor the GOL’s progress toward DLI achievement, including progress reports and the verification protocol. When a DLI is achieved, in full or partially, the PIU team will inform the task team and provide evidence according to the verification protocol. This will serve as justification that the DLI has been achieved. The task team will review the documentation submitted and may request any additional information considered necessary to verify the achievement of the DLI.

7. Disbursement requests will be submitted to the World Bank using the World Bank’s standard disbursement form, signed by an authorized signatory of the GOL. The requisite withdrawal applications will be submitted electronically using the e-disbursement functionality in Client Connection. The aggregate disbursements under the operation will not exceed the total expenditures over the implementation period. Table 2.2 details the periods per DLI, evaluation periods, and disbursements; Table 2.3 details the categories of eligible expenditures.

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Table 2.2: Project Evaluation and Disbursements

Project Evaluation and Year 0 (FY2021) Year 1 (FY2022) Year 2 (FY2023) Year 3 (FY2024) Year 4 (FY2025) Year 5 (FY2026) Disbursements Period being Evaluated Project July 2021- July 2022- July 2023 July 2024 July 2025 effectiveness - June 2022 June 2023 June 2024 June 2025 August 2026 June 2021 Evaluation Period July 2021- July 2022- July 2023- July 2024- July 2025 - July 2026 - September 2021 September 2022 September 2023 September 2024 September 2025 September 2026 Disbursement October 2021 October 2022 October 2023 October 2024 October 2025 October 2026 Disbursement amount US$ 410,000 US$ 855,000 US$ 940,000 US$ 1,175,000 US$ 1,325,000 US$ 1,295,000

Table 2.3: Categories of Eligible Expenditures

Amount of the Credit Allocated (expressed in Percentage of Expenditures to be Financed Category US$) (inclusive of Taxes) DLI 1 1m 100% up to the DLI amount DLI 2 0.5 m 100% up to the DLI amount DLI 3 2m 100% up to the DLI amount DLI 4 1m 100% up to the DLI amount DLI 5 0.5 m 100% up to the DLI amount DLI 6 1m 100% up to the DLI amount Total amount 6m

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Table 2.4: Disbursement-Linked Indicators Matrix

Disbursement Linked Results DLI Total DLI

Baseline Amount in USD Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 1.1 (a) Quarterly 1.2 (a) Quarterly 1.4 (a) Quarterly 1.5 (a) Quarterly 0 1.0 (a) MOH technical 1.3 (a) Quarterly analytic reports analytic reports analytic reports analytic reports group assigned to analytic reports summarizing summarizing summarizing summarizing collate, analyze and summarizing national & county national & county national & county national & county synthesize data; and national & county trends of key trends of key trends of key trends of key provide quarterly trends of key indicators. indicators. indicators. indicators. reports based on indicators.

approved list of key national and county level health system and DLI 1: RMNCAH indicators Key RMNCAH 25,000 25,000 25,000 50,000 50,000 75,000 250,000 Data regularly 1.0 (b) Established 1.1 (b) Quarterly 1.2 (b) Quarterly 1.4 (b) Quarterly 1.5 (b) Quarterly available and 1.3 (b) Quarterly Country Mechanism to Country Platform Country Platform County Platform County Platform used for Country Platform Analyze and Review Meetings held to meetings held to meetings held to meetings held to evidence-based meetings held to Key Data monthly, and discuss key discuss key discuss key indicator discuss key follow-up at the discuss key report actions taken. indicator report and indicator report and report and decisions indicator report national level indicator report and decisions made decisions made made with minutes and decisions and county level decisions made with minutes with minutes available. made with with minutes available. available. minutes available. available.

25,000 25,000 25,000 50,000 50,000 75,000 250,000 1.1 (c) At least ten 1.2 (c) At least ten 1.3 (c) At least ten 1.4 (c) At least ten 1.5 (c) At least ten

monthly county monthly county monthly county monthly county monthly county health team health team health team health team health team meetings (per year meetings (per year meetings (per year meetings (per year meetings (per year per county) held to per county) held to per county) held to per county) held to per county) held

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discuss key discuss key discuss key discuss key indicator to discuss key indicator report and indicator report and indicator report and report and minutes indicator report minutes available. minutes available. minutes available. available. and minutes available.

25,000 25,000 50,000 50,000 100,000 250,000 1.1 (d) Complete 1.2 (d) Complete 1.4 (d) Complete 1.5(d) Complete 1.3(d) Complete and timely monthly and timely monthly and timely monthly and timely and timely monthly reports available reports available reports available monthly reports reports available from 25 Identified from 25 Identified from 25 Identified available from 25 from 25 Identified Hospitals/Health Hospitals/Health Hospitals/Health Identified Hospitals/Health Centers providing Centers providing Centers providing Hospitals/Health Centers providing caesarian section caesarian section caesarian section Centers providing caesarian section services services services caesarian section services services Disbursement Disbursement Disbursement Disbursement rule: rule: rule: Disbursement rule: rule: Based on unit cost of Based on unit cost Based on unit cost Based on unit cost Based on unit cost US$2000 per of US$1000 per of US$1000 per of US$ 2000 per of US$4000 per hospital/health hospital/health hospital/health hospital/health hospital/health facility facility facility facility facility 25,000 25,000 50,000 50,000 100,000 250,000 Total Amount for DLI 1 50,000 100,000 100,000 200,000 200,000 350,000 1,000,000 DLI 2: 2.0 (a) Develop and 2.1 (a) County 2.2 (a) County 2.3 (a) County 2.4 (a) County level 2.5 (a) County 0 Contribute to a agree on annual level allocation, level allocation, level allocation, allocation, level allocation, reduced stock- distribution plans using distribution and distribution and distribution and distribution and distribution and outs of Essential consumption data consumption consumption consumption consumption reports consumption Package of reported from health quarterly reports reports available reports available available for all 15 reports available Drugs facilities through the available for for 7 additional for all 15 counties. counties. for all 15 counties. evidenced by a eLMIS Montserrado counties

Functional County Supply Chain (distribution plans to be based on consumption and disease burden)

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Disbursement Disbursement Disbursement rule: Disbursement rule: rule: Based on unit cost of rule: Based on unit cost Based on unit cost US$4000 per county Based on unit cost of US$3000 per of US$3000 per of US$4000 per county county county 9,000 15,000 21,000 45,000 45,000 45,000 180,000 2.0 (b) Implement Last 2.1 (b) Variance 2.2 (b) Variance 2.3 (b) Variance 2.4 (b) Variance 2.5 (b) Variance Mile Delivery to between CMS between CMS between CMS between CMS between CMS improve access and allocated quantity allocated quantity allocated quantity allocated quantity, allocated quantity, maximize quality of and quantity and quantity and quantity quantity received by quantity received care in Montserrado, received by county received by county received by county county depot and by county depot Margibi Counties and depot is not more depot is not more depot is not more quantity received by and quantity to 36 high volume than 15%. than 15%. than 15%. health facilities in received by health hospitals. Implement Two months after Two months after Two months after county is not more facilities in county distribution from distribution of distribution of distribution of than 15%. is not more than Central Medical Store medications submit medications submit medications submit Two months after 15%. (CMS) to the county quarterly report. quarterly report quarterly report distribution of Two months after depots in the remaining medications submit distribution of 13 counties quarterly report medications submit quarterly report 20,000 20,000 20,000 20,000 20,000 40,000 140,000 2.1 (c) Availability 2.2 (c) Availability 2.3 (c) 2.4(c) Availability 2.5(c) Availability

of essential of essential Availability of of essential of essential medicine/supplies medicine/supplies essential medicine/supplies in medicine/supplies in 36 Identified in 36 Identified medicine/supplies 36 Identified in 36 Identified Hospitals/Health Hospitals/Health in 36 Identified Hospitals/Health Hospitals/Health Centers providing Centers providing Hospitals/Health Centers providing Centers providing caesarian section. caesarian section. Centers providing caesarian section. caesarian section. caesarian section. Disbursement Disbursement Disbursement Disbursement rule: Disbursement

rule: Based on unit rule: Based on unit rule: Based on unit Based on unit cost of rule: Based on cost of US$1000 cost of US$1000 cost of US$1000 US$1000 per unit cost of per hospital/health per hospital/health per hospital/health hospital/health US$1000 per facility facility facility facility hospital/health facility

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36,000 36,000 36,000 36,000 36,000 180,000 Total Amount for DLI 2 29,000 71,000 77,000 101,000 111,000 111,000 500,000 DLI 3: 3.0 (a) HR Policy 3.1 (a) HR 3.2 (a) Annual 3.3 (a) Annual 3.4 (a) Annual 3.5 (a) Annual 0 Functional HR formally approved by database reports available reports available reports available reports available system in place MOH for operational from HR database from HR database from HR database from HR database at MOH, implementation, including on recruitment, reporting reporting reporting counties, communicated to all information on transfers, and recruitment, recruitment, recruitment, hospitals and MOH employees. recruitment, disciplinary action transfers, and transfers, and transfers, and facilities transfers, and taken in year 1 disciplinary action disciplinary action disciplinary action disciplinary action taken in year 2. taken in Year 3. taken in Year 4 taken. 50,000 50,000 50,000 50,000 100,000 100,000 400,000 3.0 (b) Standardized 3.1 (b) MOH 3.2 (b) MOH 3.3 (b) MOH 3.4 (b) MOH 3.5 (b) MOH HR management conducts quarterly conducts quarterly conducts quarterly conducts quarterly conducts quarterly systems in place integrated integrated integrated integrated integrated including (i) clear job supportive supportive supportive supportive supportive descriptions for all supervision supervision supervision supervision missions supervision cadres both missions to 15 missions to 15 missions to 15 to 15 counties with missions to 15 administrative and counties with counties with counties with report on actions counties with professional within the report on actions report on actions report on actions taken available. report on actions health sector approved taken available. taken available. taken available. taken available. by MoH; and (ii) staffing norms agreed and approved for different facility types, administrative levels (including CHTs) and catchment populations based on an Efficiency Analysis and key factors including population, disease profile, health outcomes. Disbursement Disbursement Disbursement Disbursement rule: Disbursement rule: Based on unit rule: Based on unit rule: Based on unit Based on unit cost of rule: Based on cost of US$5000 cost of US$5000 cost of US$5000 US$6000 per county unit cost of

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per county per county per county US$6000 per county 45,000 75,000 75,000 75,000 90,000 90,000 450,000 3.0 (c) MOH conducts 3.1 (c) Minimum 3.2 (c) Minimum 3.3 (c) Minimum 3.4 (c) Minimum staff 3.5 (c) Minimum needs analysis and staff complement staff complement staff complement complement staff complement finalizes, deployment (OBGYN, (OBGYN, (OBGYN, (OBGYN, Pediatrics, (OBGYN, packages and Pediatrics, Pediatrics, Pediatrics, Registered Nurse) Pediatrics, appropriate staffing Registered Nurse) Registered Nurse) Registered Nurse) available in 25 Registered Nurse) plans to provide basic available 25 available in 25 available in 25 identified available in 25 maternal and childcare identified identified identified hospitals/Health identified services for hard-to- hospitals/Health hospitals/Health hospitals/Health Centers providing hospitals/Health reach /rural areas Centers providing Centers providing Centers providing caesarian section Centers providing caesarian section caesarian section caesarian section caesarian section Disbursement rule: Disbursement rule: Disbursement rule: Disbursement rule: Disbursement rule: Disbursement This DLR can be carried Based on unit cost Based on unit cost of Based on unit cost of Based on unit cost of rule: over and disbursed of US$ 2500 per US$ 4000 per US$ 4000 per US$ 4000 per Based on unit cost whenever it is achieved hospital/health hospital/health hospital/health hospital/health center of US$ 4000 per during the life of the center center center hospital/health Project center 47,500 62,500 100,000 100,000 100,000 100,000 510,000 3.1 (c) identified 3.2 (c) identified 3.3(c) identified 3.4 (c) 70% of 3.5(c) 80% of Public Primary Public Primary Public Primary identified Public identified Public Health Facilities Health Health Facilities Primary Health Primary Health providing Facilities providing providing Facilities providing Facilities institutional institutional institutional institutional providing deliveries with deliveries with any deliveries with any deliveries with any institutional any two of the two of the skilled two of the skilled two of the skilled deliveries with skilled health health professionals health health professionals any two of the professionals (Medical doctor, professionals (Medical doctor, PA, skilled health (Medical doctor, PA, Registered (Medical doctor, Registered nurse and professionals PA, Registered nurse and Midwife) PA, Registered Midwife) (Medical doctor, nurse and Midwife) nurse and PA, Registered Midwife). nurse and Midwife) Disbursement Disbursement Disbursement Disbursement rule: Disbursement rule: Based on unit rule: Based on unit rule: Based on unit Based on unit cost of rule: Based on

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cost of US$1000 cost of US$1000 cost of US$1000 US$1300 per unit cost of per hospital/health per hospital/health per hospital/health hospital/health US$1315 per center with a center center center hospital health maximum of center US$100,000 100,000 117,000 117,000 152,100 153,900 640,000 Total Amount for DLI 3 142,500 287,500 342,000 342,000 442,100 443,900 2,000,000 4.0 MOH/FHD agree 4.1 ASRHR 4.2 Report based 4.3 Report based 4.4 Report based on 4.5 Report based 0 with MOE on a plan, training module on the Agreed on the Agreed the Agreed on the Agreed and baseline, including incorporated into Monitoring Matrix Monitoring Matrix Monitoring Matrix Monitoring Matrix timelines and curriculum for the DLI 4: monitoring results, to female health Improved reach adolescents (girls counsellors in adolescent and boys) in school schools being health (with through the female recruited by MOE focus on girls) health counselors as measured by specific marker Disbursement rule: indicators Year 0 allocation will be carried forward to year one if not met 50,000 150,000 200,000 200,000 200,000 200,000 1,000,000 Total Amount for DLI 4 50,000 150,000 200,000 200,000 200,000 200,000 1,000,000 DLI 5: Citizen 5.1 (a) Strategy for 5.2 (a) Citizen 5.3 (a) Citizen 5.4 (a) Citizen 5.5 Citizen engagement and receiving feedback Feedback Feedback Feedback Feedback grievance from citizens and Mechanism is Mechanism is Mechanism is Mechanism is redressal system final detailed conducted, is conducted, is conducted, is conducted, is functional in the implementation discussed in the discussed in the discussed in the discussed in the health sector plan approved by HSCC, and report HSCC, and report HSCC, and report is HSCC, and report the HSCC. is publicly is publicly publicly available. is publicly available. available. available 25,000 50,000 50,000 50,000 50,000 225,000 5.1 (b) Establish 5.2 (b) Semi-annual 5.3 (b) Semi- 5.4 (b) Semi-annual 5.5 (b) Semi- appropriate reports produced annual reports reports produced annual reports mechanisms for summarizing produced summarizing produced

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identifying and patient/client summarizing patient/client summarizing dealing with grievance redressal, patient/client grievance redressal, patient/client patient/client including minutes grievance redressal, including minutes of grievance grievances and of meeting including minutes meeting redressal, citizen feedback in deliberations and of meeting deliberations and including minutes all identified actions taken deliberations and actions taken of meeting Hospitals/HCs available, and actions taken available, and deliberations and providing Cesarean relevant available, and relevant information actions taken section with information made relevant made public from all available, and minimum staff. public from all information made identified relevant identified public from all Hospitals/HCs information made Hospitals/HCs identified providing Cesarean public from all providing Cesarean Hospitals/HCs section with identified section with providing Cesarean minimum staff. Hospitals/HCs minimum staff. section with providing minimum staff Cesarean section with minimum staff. (US$100,000) 75,000 50,000 50,000 50,000 50,000 275,000 Total Amount for DLI 5 100,000 100,000 100,000 100,000 100,000 500,000 6.0 (a) Baseline 6.1(a) Management 6.2 (a) management 6.3 (a) (i) management (i) End report DLI 6 defined in each one of agreements signed agreements signed management agreements signed produced, which 25 selected the 25 selected with hospitals that with hospitals as agreements signed with hospitals as summarizes all 25 hospitals/health hospitals. Baseline will be conducting well as defining the with hospitals as well as defining the hospitals centers review will be made the counselling and use of the budget well as defining the use of the budget achievements, increasing using last two years reporting to the based on a menu. use of the budget based on a menu. trends, and each percentage of and should define MOH; as well as Menu is attached as based on a menu. Menu is attached as one of the adolescent girls increased percentages defining the use of an annex to the Menu is attached as an annex to the hospitals and leaving the (goals) per year and the budget based management an annex to the management trends of the key hospital with 2 per hospital/HCs. on a menu agreement. management agreement. problems counseling developed in developed in agreement. developed in session on consultation with consultation with developed in consultation with the contraceptive the hospitals. Menu the hospitals. consultation with hospitals. methods after is attached as an the hospitals. delivery over annex to the baseline management

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agreement Disbursement rule Disbursement rule Disbursement rule Disbursement rule Disbursement rule Based on unit cost of Based on unit cost Based on unit cost Based on unit cost Based on unit cost of US$1000 per of US$1000 per of US$1000 per of US$1000 per US$1000 per hospital/health center hospital/health hospital/health hospital/health hospital/health center center center center 25,000 25,000 25,000 25,000 25,000 25,000 150,000 6.0 (b) Supervision 6.1 (b) One 6.2 (b) One 6.3(b) One analytic 6.4(b) One analytic team defined and MOH analytic report analytic report report produced, report produced, directive signed by produced, which produced, which which summarizes which summarizes Senior management summarizes 25 summarizes 25 25 hospitals reports 25 hospitals reports hospitals reports hospitals reports (includes the (includes the (includes the (includes the following following following following information: information: number information: information: number of of counselling number of number of counselling sessions/routine

counselling counselling sessions/routine information of sessions/routine sessions/routine information of adolescent information of information of adolescent pregnancies number adolescent adolescent pregnancies of acceptances of pregnancies pregnancies number of contraceptive number of number of acceptances of methods). acceptances of acceptances of contraceptive contraceptive contraceptive methods). methods). methods). 25,000 25,000 25,000 25,000 25,000 0 125,000 6.0(c) The MOH 6.1(c) Register has 6.2(c) Register has 6.3(c) Register has 6.4(c) Register has 6.5 (c) Top 5 develops a register to been implemented been implemented been implemented been implemented in hospitals will collect this information in 25 health in 25 health in 25 health 25 health receive the non- and monitor this facility/hospital facility/hospital facility/hospital facility/hospital monetary indicator incentives based on amount remaining from the previous 4 years Disbursement rule Disbursement rule Disbursement rule Disbursement rule

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Based on unit cost Based on unit cost Based on unit cost Based on unit cost of of US$1000 per of US$1000 per of US$1000 per US$1000 per hospital/health hospital/health hospital/health hospital/health center center center center 100,000 25,000 25,000 25,000 25,000 0 200,000 6.1(d) Non- 6.2(d) Non- 6.3(d) Non- 6.4(d) Non- monetary monetary monetary monetary Incentives Incentives to Incentives to Incentives to to hospitals/health hospitals/health hospitals/health hospitals/health centers that achieved centers that centers that centers that the goal achieved the goal achieved the goal achieved the goal Disbursement rule Disbursement rule Disbursement rule Disbursement rule Based on unit cost Based on unit cost Based on unit cost Based on unit cost of of equivalence of of equivalence of of equivalence of equivalence of

US$4000 per US$5000 per US$6000 per US$6000 per hospital/health hospital/health hospital/health hospital/health center center) center) center) 100,000 125,000 150,000 150,000 525,000 Total Amount for DLI 6 150,000 175,000 200,000 225,000 225,000 25,000 1, 000,000 TOTAL DLI 6,000,000 AMOUNT

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Table 2.5: DLI Verification Protocol Table Independent Verification Agency:

Protocol to Verify Achievement of DLIs DLI. Definitions/Description of Based on Submitted Documentation as Well as its Own DLIs Data Source & Means of no Achievement Independent Review, as Necessary, the Independent verification Verification Agency will: 1 Key RMNCAH data MoH and Counties use Year 0 regularly available and disaggregated data from various Ref. Year 0. (i) a & b: Signed memo, (i) Verify a signed Memo by the Minister of Health indicating that: used for evidence- sources to monitor health sector with attached indicators, filed (after a). Office of HMER Coordinator has been assigned to lead the based follow-up at the outcomes and for annual and circulation) in the office of the technical group consisting of the following heads of units: Health national level and periodic planning. HMER Coordinator, with copies filed Information System Unit, Monitoring & Evaluation Unit, Research county level in the Offices of the Deputy Minister Unit, Human Resource, Supply Chain Unit, Central Medicine Store, for Administration, Chief Medical Family Health Division, Quality Management Unit, County Health Officer and Office of the General Services Unit, Community Health Services Division, Assistant Counsel Minister for Vital Statistics, National Public Health Institute of Liberia and Office of Financial Management.

b). Memo clearly outlines reporting indicators including programmatic indicators on maternal and neonatal mortality and other annual key agreed RMNCAH coverage indicators, supply chain indicators, indicators on human resources, vital statistics, financial data, and data quality indicators (can be attached to Memo).

Ref. Year 0. (ii): Signed memo filed (ii) Verify MOH signed Memo by the Minister of Health establishing (after circulation) in the office of the the county mechanism to analyze and review key data monthly. Minister of Health with copies filed in This mechanism must include: County M&E officer, Surveillance the Offices of the Deputy Minister officer, County Pharmacist, County Health Services Administrator, for Administration, Chief Medical Accountant, County Reproductive Health Supervisor, Clinical Officer, General Counsel County Supervisor and Community Health Services Director. Health Services Unit, office of the HMER Coordinator and at the County Health Team offices

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Ref. Year 1,2,3,4,5 (i): Filed (i)Verify at least four (4) Quarterly Analytical Reports are available Quarterly Analytical Reports (in in the Office of the HMER Coordinator at the MOH. The reports hard copies or emailed scanned should summarize national and county performance, including copy) in the Office of the HMER analysis of indicators (list from the Memo signed in Year0) that Coordinator have been achieved and not achieved, explanation of variances, descriptions of decisions made, implemented, and actions followed up.

Ref. Year 1,2,3,4,5 (ii): Filed Signed (ii) Verify through Signed HSCC meeting minutes and attendance HSCC Minutes and Attendance (in (self-signed) that at least four Country Platform49 meetings have Hard copies or emailed scanned been held to discuss annual key indicators report (including copies) in the Office of External Aid analysis of indicators that have been achieved and not achieved, Director. explanation of variances, descriptions of decisions made, implemented, and actions followed up).

Ref. Year 1,2,3,4,5 (iii): Filed Signed (iii) Verify through CHT meeting minutes and participants (self- CHT monthly minutes (in hard signed) 50 that at least 10 of the required 12 monthly CHT meetings copies or emailed scanned copies) were held and documented in a fiscal year. Minutes should be and participants (self-signed) in the available for each meeting describing the following: data from offices of the County Health approved list of indicators, explanation of variances, services and County Health Teams recommended actions & those taken, timeline for follow-up with the proof that CHS Unit has actions. In addition, verify signed copies of the monthly minutes of received the meeting minutes for meetings at the County Health Services Unit was submitted no all 15 counties no later than the 20th later than the 20th day of the following month.

49 One of the HSCC meetings in each quarter would be used for as the Country Platform Meeting for the comprehensive quarterly data review 50 Meeting participants: CHO, M&E officer, surveillance officer, pharmacist, county health services administrator, accountant, county reproductive health supervisor, and community health department director, program officers, civil society representative/s

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Ref. Year 1,2,3,4,5 (iv): Filed facility (iv) Verify through identified health facilities providing CS that at reports (in hard copies or emailed least 10 of the 12 monthly facility reports are complete and scanned copies) in the Office of submitted not later than the 20th day of the following month to the Hospital Medical Director with the office of the FHD. Completeness is defined as report which must proof that the FHD has received the include data from DHIS2, iHRIS, consumption report, and financing reports for all identified facilities report, and key agreed indicators. providing CS no later than the 20th day of the following month. 2 Contribute to a Increased availability of Ref. Year 0. (i) Signed Memo by the Year 0 reduced stock-outs of essential medicines/supplies: Minister of Health approving (i) Verify a signed Memo by the Minister of Health approving essential package of oxytocin, misoprostol, annual distribution plan (attached annual distribution plan (attached to memo) for period January – drugs evidenced by a magnesium sulfate, IV anti- to memo) for period January – December 2020 is based on consumption reports and disease functional Supply biotic for mother and newborn, December 2020 available in the burden and including clearly defined responsibilities and reporting Chain IV fluids, blood, oxygen and at Office of Minister of Health with lines is available in the Office of the Supply Chain Management least one of the following attached Annual Distribution Plan Unit Manager anesthetic drugs in the Office of SCMU Manager (ketamine/propofol/bupivacaine (Marcaine)) Ref. Year 0. (ii): Drug invoice and (ii) Verify from the Central Medical Store using drug requisitioning waybill available in the office of the and issuing documents made available by the SCMU to determine Managing Director of the CMS the quarterly variance between CMS to Montserrado and Margibi counties and 36 high volume hospitals for 2 quarters before effectiveness of the project. Year 1 Ref. Year 1. (i): Quarterly County (i) Verify that quarterly county level allocation, distribution and level allocation, distribution and consumption report is available for Montserrado County in the consumption report is available for office of the Manager for Supply Chain (distribution plans to be Montserrado County in the office of based on consumption and disease burden). the Manager for Supply Chain

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Ref. Year 1. (iii): Site visits to verify (iii) verify availability of Essential medicines and supplies in availability of Essential medicines identified 21/36 hospital/HCs. Availability defined as no stock out and supplies in 21/36 identified of any of the items within the year of implementation. This will be hospitals/HCs. confirmed through a record review of the product register at the facility, for 3 random months.

Year 2 Ref. Year 2. (i): Quarterly County (i) Verify Quarterly County level allocation, distribution and level allocation, distribution and consumption report is available for eight Counties (Gbarpolu, consumption report is available for Grand Cape Mount, Bomi, Margibi, Grand Bassa, Bong, Nimba and eight Counties (Gbarpolu, Grand Montserrado) in the office of the Manager for Supply Chain. Cape Mount, Bomi, Margibi, Grand (distribution plans to be based on consumption and disease Bassa, Bong, Nimba and burden) Montserrado in the office of the Manager for Supply Chain.

Ref. Year 2. (ii): LMIS (paper-based (ii) Verify that variance between CMS allocated quantity and for primary Proof of Delivery and quantity received by the Montserrado county depot is not more eLMIS at County seat) than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS.

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Year 3 Ref. Year 3. (i): Quarterly County (i) Verify Quarterly County level allocation, distribution and level allocation, distribution and consumption report is available in 15 Counties (in the office of the consumption report is available in Manager for Supply Chain. (distribution plans to be based on 15 Counties in the office of the consumption and disease burden) Manager for Supply Chain.

Ref. Year 3. (ii): LMIS (paper-based (ii) Verify that variance between CMS allocated quantity, and for primary), Proof of Delivery and quantity received by the Montserrado county depot is not more eLMIS at County seat than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS.

Ref. Year 3. (iii): Site visits in (iii verify availability of Essential medicines and supplies in 33/36 sampled hospitals/HCs to verify hospitals/HCs. availability of Essential medicines and supplies in 33/36 identified hospitals/HCs Year 4 Ref. Year 4. (i): Quarterly County (i) Verify Quarterly County level allocation, distribution and level allocation, distribution and consumption report is available in all 15 Counties (in the office of consumption report is available in the Manager for Supply Chain. (distribution plans to be based on all 15 Counties in the office of the consumption and disease burden) Manager for Supply Chain.

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Ref. Year 4. (iii): Site visits to verify (iii verify availability of Essential medicines and supplies in availability of Essential medicines 36/36hospitals/HCs. Availability defined as no stock out of any of and supplies in 36/36 identified the items within the year of implementation. This will be hospitals/HCs confirmed through a record review of the product register at the facility, for 3 random months.

Year 5 Ref. Year 5. (i): Quarterly County (i) Verify Quarterly County level allocation, distribution and level allocation, distribution and consumption report is available in all 15 Counties (in the office of consumption report is available in the Manager for Supply Chain. (distribution plans to be based on 15 Counties in the office of the consumption and disease burden) Manager for Supply Chain. Ref. Year 5.

(ii): LMIS (paper-based for (ii) Verify that variance between CMS allocated quantity and primary), Proof of Delivery and quantity received by the Montserrado county depot is not more eLMIS at County seat than 15%. B) Verify that the quarterly end user verification report was submitted not later than two months after the distribution through the LMIS and eLMIS.

Ref. Year 5. (iii): Site visits to verify (iii verify availability of Essential medicines and supplies in 36 availability of Essential medicines hospitals/HC. and supplies in 36/36 identified hospitals/HCs. 3 Functional HR system HR staff and policies available Year 0

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Ref. Year 0. (ii): Filed Signed memo (ii) Verify through a signed memo by the Deputy Minister for by Deputy Minister for Administration that Clear job descriptions for all cadres both Administration (in hard copy) administrative and professional within the health sector are communicating instructions of in communicated at Central and County HR management levels. clear job descriptions for all Cadres available in the offices of the Director of HR Unit and the County HR officers.

Ref. Year 0. (iii): Filed Senior (iii) Verify through the Senior Management Team Meeting Minutes Management Team Meeting (In hard copy) that an approved document (attached to Minutes) Minutes with attached approved is available in the MOH that describes Staffing norms51 agreed and document (Workload Indicators for approved for different facility types, administrative levels Staffing Needs Report-WISN) in the (including CHTs) and catchment populations. offices of the Minister of Health and Deputy Minister of Administration.

51 Key staff and functionality to be defined and agreed, and reflected in signed document on staffing norms for CHT, Identified Hospitals/HCs providing C-Section, supply chain, M&E, surveillance officers, HR staff, etc.

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Year 1 Ref. Year 1. (i): Printouts generated (i) Verify through physical assessment that the HR database is from the iHRIS from access operational and able to provide current information on provided by the Director of Human recruitment, and transfers. Provide printouts of this information Resource. from database. Access to the HR database will be allowed by the director of Human Resource. The annual HR report should be able to highlight disciplinary action taken each year.

Ref. Year 1. (ii): Filed semi-annual (ii) Verify through quarterly supportive Supervision reports (in hard supportive Supervision Report (in copy) in the office of the Director of Human Resource that MOH hard copies), including Action Taken has conducted semi-annual supportive supervision visits to 12 available in the office of the counties. Semi-annual supportive supervision reports should Director of Human Resources. feature actions taken during visits.

Ref. Year 1. (iii) a & b: HR records (iii) (a) Verify and check through HR records retrieved through retrieved from iHRIS and with iHRIS (Access to the HR database will be allowed by the director of checks at 18 identified hospitals Human Resource) and site visit 18 identified hospitals/HCs capable of providing C-Section and providing Cesarean Section that minimum staff complement in is public primary health facilities present (minimum staffing level will be established in year 0 when providing institutional deliveries WISN is completed). respectively (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of

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Ref. Year 2. (i): Filed HR Annual (i) Verify that HR annual report is available in the office of the Report (in hard copies) available in Director for Human Resource indicating completion by the 31st of the office of the Director of Human August of the current year using data from HR database on Resource recruitment, transfers, and disciplinary action taken during previous year.

Ref. Year 2. (ii): Filed semi-annual (ii) Verify through quarterly supportive Supervision reports (in hard supportive Supervision Report (in copy) in the office of the Director of Human Resource that MOH hard copies), including Action has conducted semi-annual supportive supervision missions to 15 Taken available in the office of the counties with report on actions taken available. Director of Human Resources.

Ref. Year 2. (iii) a & b: HR records (iii) (a) Verify and check through HR records retrieved through retrieved from iHRIS and with iHRIS (Access to the HR database will be allowed by the director of checks at 25 identified hospitals Human Resource) and site visit 25 identified hospitals/HCs capable of providing C-Section and providing Cesarean Section that minimum staff complement is 70% of public primary health present facilities providing institutional (iii) (b) Verify and check through records retrieved from iHRIS deliveries respectively (Access to the HR database will be allowed by the director of Human Resource) and site visits 50% of identified public primary health facilities providing institutional delivery53 with at least two professional staff.

52 Subject to WISN report 53 Subject to WISN report

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Ref. Year 3. (ii): Filed semi-annual (ii) Verify through semi-annual supportive Supervision reports (in supportive Supervision Report (in hard copy) in the office of the Director of Human Resource that hard copies), including Action Taken MOH has conducted quarterly supportive supervision missions to available in the office of the 15 counties with report on actions taken available. Director of Human Resources.

Ref. Year 3. (iii) a & b: HR records (iii) (a) Verify and check through HR records retrieved through retrieved from iHRIS with checks at iHRIS (Access to the HR database will be allowed by the director 25 identified hospitals capable of of Human Resource) and site visit 25 identified hospitals capable providing C-Section and 60% of of preforming of Cesarean Section that minimum staff public primary health facilities complement is present providing institutional deliveries respectively (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visits 60% and public primary health facilities providing institutional delivery54 Public primary Health facilities providing institutional deliveries.

Year 4 Ref. Year 4. (i): Filed HR Annual (i) Verify that HR annual report is available in the office of the

54 Subject to WISN report

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Ref. Year 4. (ii): Filed semi-annual (ii) Verify through quarterly supportive Supervision reports (in supportive Supervision Report (in hard copy) in the office of the Director of Human Resource that hard copies), including Action Taken MOH has conducted quarterly supportive supervision missions to available in the office of the 15 counties with report on actions taken available. Director of Human Resources.

Ref. Year 4. (iii) a & b: HR records (iii) (a) Verify and check through HR records retrieved through retrieved from iHRIS with checks at iHRIS (Access to the HR database will be allowed by the director of 25 identified hospitals/HCs Human Resource) and site visit 25 identified hospitals/HCs providing C-Section with minimum providing Cesarean Section that minimum staff complement is staff and 70% of public primary present. health facilities providing (iii) (b) Verify and check through records retrieved from iHRIS institutional deliveries respectively (Access to the HR database will be allowed by the director of Human Resource) and site visits 70% of public primary health facilities providing institutional delivery55 with at least two health professionals. Year 5 Ref. Year 5. (i): Filed HR Annual (i) Verify that HR annual report is available in the office of the Report (in hard copies) available in Director for Human Resource indicating completion by the 31st of the office of the Director of Human August of the current year using data from HR database on Resource recruitment, transfers, and disciplinary action taken during previous year.

55 Subject to WISN report

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Ref. Year 5. (iii) a & b: HR records (iii) (a) Verify and check through HR records retrieved through retrieved from iHRIS with checks at iHRIS (Access to the HR database will be allowed by the director of 25 identified hospitals/HCs Human Resource) and site visit 25 identified hospitals capable of providing C-Section and 80% of preforming of Cesarean Section that minimum staff complement public primary HFs providing is present. institutional deliveries. (iii) (b) Verify and check through records retrieved from iHRIS (Access to the HR database will be allowed by the director of Human Resource) and site visits 80% and public primary health facilities providing institutional delivery56 with at least two health professionals. 4 Improved access to Increase number of adolescents Year 0 adolescent health accessing ASRH services through Ref. Year 0. (i): Filed Joint agreed (i) Verify that a joint MOE & MOH workplan is available in the office services (with focus on in-school and out-of-school workplan (in hard copies) between of the Director for Family health and includes monitoring girls) as measured by programs. the MOE and MOH with the framework for the counselling of adolescent boys and girls in specific marker monitoring framework in the office school. indicators of the Director for Family Health

Ref. Year 0. (ii): Filed Agreed (ii) Verify that an Agreed workplan with stakeholders and CSO workplan with stakeholders and which has a description of range and scope of activities to reach Civil Society Organization available adolescents in community (youth club, churches, etc.) is available in the office of Director of Family in the office of the Director of Family Health.

56 Subject to WISN report

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Year 1 Ref. Year 1. (i): Filed Female (i) Verify through the developed Female counsellors training counsellors training modules modules that ASRH training module is available in the office of the inclusive of ASRH training modules Director of Family Health. available in the office of the Director of Family health

Year 2 Ref. Year 2. (i): Filed Joint (i) Verify based on the Joint monitoring report of MOE and MOH Monitoring report of MOE and available in the Office of the Director of Family Health describing MOH available in the Office of the ASRH activities coordinated by the female counsellors, number of Director of Family Health. students counselled by female counselors, peer education activities conducted in schools (quiz, debate, drama, radio talk shows) teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy

Year 3 Ref. Year 3. (i): Filed Joint (i) Verify based on the Joint monitoring report of MOE and MOH Monitoring report of MOE and available in the Office of the Director of Family Health describing MOH available in the Office of the ASRH activities coordinated by the female counsellors, number of Director of Family Health. students counselled by female counselors, peer education activities conducted in schools (quiz, debate, drama, radio talk shows) teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy.

Year 4 Ref. Year 4. (i): Filed Joint (i) Verify based on the Joint monitoring report of MOE and MOH

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Year 5 Ref. Year 5. (i): Filed Joint (i) Verify based on the Joint monitoring report of MOE and MOH Monitoring report of MOE and available in the Office of the Director of Family Health describing MOH available in the Office of the ASRH activities coordinated by the female counsellors, number of Director of Family Health. students counselled by female counselors, peer education activities conducted in schools (quiz, debate, debate, drama, radio talk shows) teenage pregnancies recorded/reported by female counsellors and school records indicating dropouts of girls due to pregnancy.

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Ref. Year 1. (ii): Filed Roll out Plan (ii) Verify that the approved mechanisms for dealing with including approved list of patient/client grievances and citizen feedbacks in the identified 25 mechanisms for addressing hospitals/HCs providing C-Section. clients/patients’ grievances in the 25 hospitals/HCs providing C- Section in the Office of HMER Coordinator

Ref. Year 1. (iii): Site visits findings (iii) Verify through random checks at 40% of hospitals/HCs from random checks at hospitals providing C-section that mechanisms for dealing with grievances providing C-section. and feedbacks are functioning.

Years 2, 3, 4 and 5 Ref. Year 2,3,4 &5 (i): Filed HSCC (i) Verify through HSCC meeting Minutes in the Office of Director meetings minutes capturing key of External Aid that Feedback Mechanism is discussed as an agenda actions on citizen’s inclusiveness item; and the report is endorsed and made available to the public. and grievances addressed available in the office of the Director for External Aid and is publicized.

Ref. Year 2,3,4 &5 (ii): Filed 6- (ii) Verify by reviewing the Semi-annual report that summarizes monthly reports summarizing patients /clients’ grievances redressal, including minutes of

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Protocol to Verify Achievement of DLIs DLI. Definitions/Description of Based on Submitted Documentation as Well as its Own DLIs Data Source & Means of no Achievement Independent Review, as Necessary, the Independent verification Verification Agency will: patients /clients’ grievances meeting deliberations and actions taken available, and relevant redressal, including minutes of information made public from all identified 25 hospitals/HCs meeting deliberations and actions providing C-Section available in the office of the HMER taken available, and relevant Coordinator information made public from all identified 25 hospitals/HCs providing C-Section available in the office of the HMER Coordinator DLI Year 0 6 25 selected hospitals With the final objective of (i)Baseline defined in each one of (i) Verify with the Director of M&E that the MOH has a system to increasing percentage reducing second and further the 25 selected hospitals. Baseline collect this information; of adolescent girls pregnancies I n adolescent girls, review will be made using last two leaving the hospital the objective is to increase the years and should define increased after delivery, with 2 number of adolescents leaving percentages (goals) per year and counselling sessions on 25 selected hospitals having per hospital. contraceptive method received 2 counselling sessions over baseline on contraceptive methods over (ii) One annual analytic report (ii)Verify that management agreement has been signed between baseline. produced, which summarizes 25 MOH and each hospital – Review of the management agreement hospitals reports. at the Office of the Deputy Minister of Administration;

(iii) Points will be accredited to the (iii)Verify with the Director of M&E that baselines are defined in to the hospitals. each one of the 25 selected hospitals.

(iv) Non-monetary incentives (iv) Verify that baseline review was made using the last two years made only to hospitals that and achieved the goal over baseline. (v) verify that baselines have been defined; and targets (goals) on the percentages of adolescent girls leaving per year and per hospital with2 counselling sessions on family planning have been set.

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Year 1,2,3 and 4 (i) Verify that management agreements were signed with each one of the 25 hospitals between the Medical Director of the hospital and the MoH. Review the annual definitions for each hospital included in the Project Operations Manual. (ii) One analytic report produced, which summarizes 25 hospitals reports and common trends. The report should include a full analysis on the topic, as well as defined targets for hospitals on the proportion of adolescents who received 2 counselling sessions on family planning, which will be annually included in Management Agreements. (iii) Verify the way transfers (in points) will be made to the 25 hospitals/HC. (iv) Verify whether menu on non-monetary incentives is developed by MOH in consultation with each hospital – Minutes of negotiations /consultation will be kept in Director of Family health Office. (v) Verify if hospital/HC has achieved the target using hospital/ HC by: (a) site visits to review the ledger at a random sample of the 25 hospitals/HCs (high and low performing facilities) and (b) review the server at the level of the MOH. (vi) Verify whether each of the 25 hospital/HC have achieved the annual target and whether they have received the non-monetary incentives: (a) site visits of a random sample of the hospitals/ and (b) review the server at the level of the MOH.

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Table 2.6: List of Hospitals conducting cesarean sections regularly (Source: DHIS2) County District Name of Hospital 1. Bomi Senjeh Liberia Government Hospital (Bomi) 2. Bong Jorquelleh Charles B Dunbar Hospital 3. Bong Suakoko Phebe Hospital 4. Bong Fuamah Bong Medical Hospital 5. Gbarpolu Bopolu District Chief Jallahlon Medical Center 6. Grand Bassa Buchanan District Liberia Government Hospital (Buchanan) 7. Grand Gedeh Tchien District Martha Tubman Memorial Hospital 8. Grand Kru Jraoh District Sass Town Health Center 9. Grand Kru Barclayville District Rally Time Hospital 10. Grand Cape Mount Garwula District Sinje Health Center 11. Lofa Zorzor District Curran Lutheran Hospital 12. Lofa Voinjama District Tellewoyan Memorial Hospital 13. Lofa Foya District Foya Boma Hospital 14. Lofa Kolahun District Kolahun Hospital 15. Margibi Kakata District CH Rennie Hospital 16. Maryland Harper District JJ Dossen Hospital 17. Nimba Saclepea Mah District Sacleapea Comprehensive Health Center 18. Nimba Tappita District Jackson F. Doe Memorial Hospital Sanniquelleh Mahn 19. Nimba District GW Harley Hospital 20. River Gee Potupo District Fish Town Hospital 21. Rivercess Timbo District St Francis Hospital 22. Sinoe Greenville District F J Grante Hospital Central Monrovia 23. Montserrado district JF Kennedy Medical Center 24. Montserrado Bushrod District Redemption Hospital 25. Montserrado Somalia Drive District James N. David Memorial Hospital

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Table 2.7: List of Health Facilities conducting at least 20 deliveries monthly (Source: DHIS2)

Del./ Month/ # County Districts Health Facilities Year AVG 1 Nimba Zoe-Geh Bahn HC 1101 92 2 Bong Salala Totota Clinic 1054 88 3 Nimba Gbehlay-Geh Karnplay HC 917 76 4 Bong Salala Salala Clinic 884 74 5 Nimba Sanniquelleh Mahn Duo Tiayee Clinic 730 61 6 Montserrado Bushrod Clara Town HC 707 59 7 Maryland Pleebo Pleebo HC 703 59 8 Nimba Gbehlay-Geh Beo-Yoolar Clinic 691 58 9 Montserrado Commonwealth Duport HC 679 57 10 Nimba Zoe-Geh Payee Community Clinic 645 54 11 Nimba Yarwein Mehnsohnneh Zekepa HC 613 51 12 Bong Suakoko Gbartala Clinic 607 51 13 Montserrado Bushrod Star of the Sea HC 579 48 14 Margibi Mambah-Kaba Unification Town HC 577 48 15 Grand Bassa District # 3 Compound # 3 Clinic 563 47 16 Lofa Voinjama Barkedu Clinic 561 47 17 Grand Bassa Owensgrove Bokay Town Clinic 550 46 18 Montserrado Commonwealth Pipeline HC 541 45 19 Nimba Tappita Toweh Town Clinic 532 44 20 Bong Suakoko Zeanzue Clinic 523 44 21 Nimba Zoe-Geh Buutuo Clinic 508 42 22 Lofa Vahun Vahun HC 488 41

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Del./ Month/ # County Districts Health Facilities Year AVG 23 Lofa Zorzor Konia HC 481 40 24 Bong Sanoyea Sanoyea Clinic 481 40 25 Nimba Tappita Zuaplay Clinic 453 38 26 Nimba Zoe-Geh Wehpilay Clinic 449 37 27 Nimba Tappita New Yourpea Clinic 448 37 28 Nimba Zoe-Geh Gblalay Clinic 444 37 29 Nimba Sanniquelleh Mahn Lugbehyee Clinic 437 36 30 Nimba Sanniquelleh Mahn Equip Clinic 434 36 31 Bong Kpaai Palala Clinic 429 36 32 Nimba Tappita Glahn's Town 427 36 33 Bong Fuamah Haindi Clinic 417 35 34 Nimba Gbehlay-Geh Loguatuo Clinic 409 34 35 Grand Gedeh Gbao Gbarzon HC 408 34 36 Bong Suakoko Fenutoli Clinic 401 33 37 Lofa Voinjama Sarkonnedu Clinic 396 33 38 Bong Sanoyea Gbonota Clinic 395 33 39 Nimba Saclepea Mah Kpein Clinic 390 33 40 Grand Cape Mount Gola konneh Lofa Bridge Clinic 388 32 41 Bong Kpaai Zowienta Clinic 386 32 42 Montserrado Somalia Drive RH Ferguson HC 384 32 43 Bong Jorquelleh Samay Clinic 384 32 44 Nimba Zoe-Geh Beadatuo Clinic 382 32 45 Bong Kokoyah Gbecohn Clinic 377 31

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Del./ Month/ # County Districts Health Facilities Year AVG 46 Bong Suakoko Gbarnla Clinic 373 31 47 Nimba Saclepea Mah Bunadin Clinic 370 31 48 Lofa Zorzor Zolowo Clinic 368 31 49 Lofa Foya Sorlumba Clinic 367 31 50 Nimba Sanniquelleh Mahn Ganta Community Clinic 366 31 51 Nimba Yarwein Mehnsohnneh Menhla Clinic 365 30 52 Nimba Gbehlay-Geh Vayenglay Clinic 364 30 53 Margibi Firestone Cotton Tree HC 362 30 54 Lofa Zorzor Borkeza Clinic 362 30 55 Bong Panta Foequelleh Clinic 362 30 56 Nimba Gbehlay-Geh Zorgowee Clinic 360 30 57 Bong Zota Naama Clinic 359 30 58 Grand Bassa Owensgrove Owensgrove Clinic 351 29 59 Bong Panta Garmue Clinic 350 29 60 Grand Bassa District # 2 St John Clinic 348 29 61 Nimba Saclepea Mah Flumpa Clinic 346 29 62 Nimba Zoe-Geh Lepula Clinic 337 28 63 Nimba Tappita Mid Baptist Clinic 337 28 64 Montserrado Central Monrovia Soniwen Health Center 335 28 65 Montserrado Somalia Drive New Georgia Community HC 331 28 66 Lofa Foya Porluma Clinic 326 27 67 Grand Bassa Campwood Senyah Community Clinic 326 27 68 Bong Zota Belefanai HC 324 27

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Del./ Month/ # County Districts Health Facilities Year AVG 69 Grand Bassa District # 1 Compound No. 1 Clinic 314 26 70 Bong Jorquelleh Wainsue Clinic 314 26 71 Sinoe Tarjuwon Juahzon Clinic 313 26 72 Margibi Kakata Kakata HC 312 26 73 Nimba Gbehlay-Geh Goagortuo Clinic 307 26 74 Nimba Tappita Graie Clinic 306 26 75 Bong Kokoyah Bah-ta Clinic 306 26 76 Maryland Barrobo Whojah Glofarken Clinic 305 25 77 Lofa Voinjama Lawalzu Clinic 298 25 78 Grand Cape Mount Porkpa Bendaja Clinic 292 24 79 Grand Bassa District # 2 Compound # 2 Clinic 291 24 80 Margibi Mambah-Kaba Dolo's Town HC 289 24 81 Montserrado Somalia Drive Chocolate City HC 286 24 82 Lofa Kolahun Fangoda Clinic 286 24 83 Grand Bassa District # 1 Lloydsville Clinic 284 24 84 Grand Gedeh Putu Putu Pennokon Clinic 283 24 85 Nimba Saclepea Mah Karnwee Clinic 281 23 86 Margibi Gibi Worhn Clinic 278 23 87 Nimba Zoe-Geh Gbloulay Clinic 274 23 88 River Gee Gbeapo Gbeapo Health Center 268 22 89 Nimba Gbehlay-Geh Garplay Clinic 266 22 90 Montserrado Somalia Drive Barnersville HC 264 22 91 Nimba Gbehlay-Geh Duoplay Clinic 261 22

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Del./ Month/ # County Districts Health Facilities Year AVG 92 Bong Kokoyah Botota Clinic 261 22 93 Nimba Yarwein Mehnsohnneh Boyee Clinic 258 22 94 Lofa Kolahun Gondalahun Clinic 256 21 95 Grand Kru Buah Buah HC 255 21 96 Lofa Kolahun Korworhun Clinic 254 21 97 Lofa Kolahun Bolahun HC 253 21 98 Lofa Foya Shelloe Clinic 253 21 99 Grand Gedeh B'Hai Toe Town Clinic 251 21 100 Gbarpolu Kongba Kungbor Clinic 251 21 101 Grand Cape Mount Porkpa Kongo Mano River Clinic 247 21 102 Nimba Sanniquelleh Mahn Young Men's Christian Association Clinic 245 20 103 Nimba Tappita Diallah Clinic 244 20 104 Montserrado Central Monrovia Joanna Maternity Clinic 243 20 105 Gbarpolu Bokomu Gbangay Clinic 242 20 106 Nimba Sanniquelleh Mahn St Mary's Clinic 241 20 107 Nimba Tappita Zuolay Clinic 240 20 108 Lofa Salayea Ganglota Clinic 240 20 109 Nimba Saclepea Mah Duayee Clinic 239 20 110 Nimba Saclepea Mah Cocopa Clinic 238 20 111 Grand Cape Mount Tewor Diah Community Clinic 237 20 112 Montserrado Commonwealth German Liberia Clinic 236 20 113 Lofa Kolahun Kamatahun Clinic 236 20 114 Lofa Voinjama Voinjama Free Pentecostal Clinic 236 20

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Del./ Month/ # County Districts Health Facilities Year AVG 115 Bong Fuamah Degei Clinic 235 20 116 Lofa Salayea Salayea Clinic 234 20 117 Grand Gedeh Putu Karlorwleh Town Clinic 234 20

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Table 2.8: List of 36 Health Facilities for Supply chain intervention (Source: DHIS2)

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