Document of The World Bank FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: PAD3547
INTERNATIONAL DEVELOPMENT ASSOCIATION
PROJECT PAPER
ON A
PROPOSED ADDITIONAL GRANT
IN THE AMOUNT OF SDR 16.8 MILLION (US$23 MILLION EQUIVALENT) OF WHICH SDR 11 MILLION (US$15 MILLION EQUIVALENT) IS Public Disclosure Authorized FROM THE IDA18 REGIONAL SUB-WINDOW FOR REFUGEES AND HOST COMMUNITIES
TO THE
ISLAMIC REPUBLIC OF MAURITANIA
FOR THE
HEALTH SYSTEM SUPPORT PROJECT
Public Disclosure Authorized March 9, 2020
Health, Nutrition and Population Global Practice Africa Region
Public Disclosure Authorized
This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.
CURRENCY EQUIVALENTS
(Exchange Rate Effective December 31, 2019)
Currency Unit = Mauritania Ouguiya (MRU) MRU 36.61 = US$1 US$1 = SDR 0.723
FISCAL YEAR January 1 – December 31
ABBREVIATIONS AND ACRONYMS
AF Additional Financing CBO Community-based Organization CCT Conditional Cash Transfer CERC Contingent Emergency Response Component CF Counterpart Funding CNCR National Consultative Commission on Refugees (Commission Nationale Consultative sur les Réfugiés) DAF Directorate of Financial Affairs (Direction des Affaires Financières) PSHC/EPCV Permanent Surveys on Household Living Conditions (Enquête Permanente sur les Conditions de Vie des ménages) ESMF Environmental and Social Management Framework FM Financial Management GAVI Global Alliance for Vaccines and Immunization GBV Gender Based Violence GDP Gross Domestic Product GEMS Geo-Enabling initiative for Monitoring and Supervision GFF Global Financing Facility HCI Human Capital Index HMIS Health Management Information System IBM Iterative Beneficiary Monitoring ICER Incremental Cost-Effectiveness Ratio IMF International Monetary Fund INAYA1 Health System Support Project IRI Intermediate Results Indicator M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MoH Ministry of Health NCHS National Community Health Strategy
1 INAYA: means taking care in Arabic
NGO Nongovernmental Organization OAU Organization for African Unity PBF Performance-based Financing PCU Project Coordination Unit PDO Project Development Objective PHCPI Primary Health Care Performance Initiative PNDS National Plan of Health Development (Plan National de Développement Sanitaire) RBF Results-based Financing RVC Regional Verification Committee RMNCH Reproductive, Maternal, Neonatal and Child Health RSW Regional Sub-window for Refugees and Host Communities SARA Service Availability and Readiness Assessment Index of Availability and Operational Capacity of Services SBCC Social and Behavioral Change Communication SG Secretary General UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund WDI World Development Indicators WFP World Food Programme
Regional Vice President: Hafez M. H. Ghanem Country Director: Nathan M. Belete Country Manager: Laurent Msellati Regional Director: Amit Dar Practice Manager: Gaston Sorgho Task Team Leader(s): Moussa Dieng/Christophe Rockmore
MAURITANIA
HEALTH SYSTEM SUPPORT PROJECT- ADDITIONAL FINANCING
TABLE OF CONTENTS
I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ...... 7 II. DESCRIPTION OF ADDITIONAL FINANCING ...... 14 III. CLIMATE SCREENING AND CLIMATE CO-BENEFITS ...... 25 IV. KEY RISKS ...... 25 V. APPRAISAL SUMMARY ...... 27 VI. WORLD BANK GRIEVANCE REDRESS ...... 31 VII. SUMMARY TABLE OF CHANGES ...... 32 VIII. DETAILED CHANGE(S) ...... 32 IX. RESULTS FRAMEWORK AND MONITORING ...... 36 ANNEX 1: OUTCOMES ON SELECTED RMNCH AND NUTRITION INDICATORS ...... 47 ANNEX 2: REFUGEES AND HOST COMMUNITIES—WORLD BANK PROGRAM IN MAURITANIA 48 ANNEX 3: THEORY OF CHANGE ...... 52 ANNEX 4. FINANCIAL MANAGEMENT AND DISBURSEMENTS ARRANGEMENTS ...... 54 ANNEX 5. CLIMATE CHANGE SCREENING AND CLIMATE CO-BENEFITS...... 55 ANNEX 6. MAURITANIAN MAP OF REFUGEES AND HOST COMMUNITIES ...... 57
The World Bank Health System Support Additional Financing (P170585)
BASIC INFORMATION – PARENT (Health System Support - P156165)
Country Product Line Team Leader(s) Mauritania IBRD/IDA Moussa Dieng
Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P156165 Investment Project HAFH3 (9542) AFCF1 (6550) Health, Nutrition & Financing Population
Implementing Agency: Ministry of Health ADD_FIN_TBL1 Is this a regionally tagged
project?
No
Bank/IFC Collaboration
No Expected Original Environmental Approval Date Closing Date Guarantee Current EA Category Assessment Category Expiration Date 19-May-2017 30-Jun-2021 Partial Assessment (B) Partial Assessment (B)
Financing & Implementation Modalities Parent
[ ] 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)
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The World Bank Health System Support Additional Financing (P170585)
Development Objective(s)
The Project Development Objective is to improve utilization and quality of Reproductive Maternal Neonatal and Child Health (RMNCH) services in selected regions, and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency.
Ratings (from Parent ISR) RATING_DRAFT_NO
Implementation Latest ISR
24-Jul-2017 16-Jan-2018 24-Aug-2018 13-Mar-2019 04-Nov-2019
Progress towards achievement of S S S S S
PDO Overall Implementation S S MS MS S
Progress (IP) Overall Safeguards S S MS MS MS Rating
Overall Risk M M M M S
BASIC INFORMATION – ADDITIONAL FINANCING (Health System Support Additional Financing - P170585)
ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P170585 Health System Support Restructuring, Scale Up No Additional Financing Financing instrument Product line Approval Date Investment Project IBRD/IDA 30-Mar-2020 Financing Projected Date of Full Bank/IFC Collaboration Disbursement 30-Apr-2023 No Is this a regionally tagged project?
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No
Financing & Implementation Modalities Child
[ ] 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)
[✓] Contingent Emergency Response Component (CERC)
Disbursement Summary (from Parent ISR)
Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments
IBRD %
IDA 17.00 4.95 12.32 29 %
Grants %
PROJECT FINANCING DATA – ADDITIONAL FINANCING (Health System Support Additional Financing - P170585)
PROJECT FINANCING DATA (US$, Millions)
SUMMARY-NewFin1
SUMMARY (Total Financing)
Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 19.00 24.50 43.50
Total Financing 19.00 24.50 43.50
of which IBRD/IDA 17.00 23.00 40.00
Financing Gap 0.00 0.00 0.00
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The World Bank Health System Support Additional Financing (P170585)
DETAILSNewFinEnh1- Additional Financing
World Bank Group Financing
International Development Association (IDA) 23.00
IDA Grant 23.00
Non-World Bank Group Financing
Counterpart Funding 1.50
Borrower/Recipient 1.50
IDA Resources (in US$, Millions)
Credit Amount Grant Amount Guarantee Amount Total Amount Mauritania 0.00 23.00 0.00 23.00
National PBA 0.00 8.00 0.00 8.00
Refugee 0.00 15.00 0.00 15.00
Total 0.00 23.00 0.00 23.00
COMPLIANCE
Policy
Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No
Does the project require any other Policy waiver(s)? [ ] Yes [ ✔ ] No
INSTITUTIONAL DATA
Practice Area (Lead) Health, Nutrition & Population
Contributing Practice Areas Social Protection & Jobs
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Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks
PROJECT TEAM
Bank Staff Name Role Specialization Unit Team Leader (ADM Moussa Dieng Economist HAFH3 Responsible) Christophe Rockmore Team Leader HAFH2 Procurement Specialist (ADM Brahim Hamed Procurement EA2RU Responsible) Mohamed El Hafedh Procurement Specialist EA2RU Hendah Financial Management Fatou Fall Samba Financial Management EA2G1 Specialist (ADM Responsible) Mame Safietou Djamil Social Specialist (ADM Social Safeguards SAFS4 Gueye Responsible) Environmental Specialist (ADM Tracy Hart Safeguards SENDR Responsible) Aissatou Chipkaou Team Member Operations, Quality Control HAFH3 Faly Diallo Team Member Disbursement WFACS Ghislaine Kouedi Nombi Team Member WFACS Matthieu Boris Lefebvre Team Member Social Protection HAFS2 Mohamed Vadel Taleb El Team Member Health HAFH3 Hassen Nejma Cheikh Team Member Health Specialist HHNGE Nicolas Kotschoubey Environmental Specialist SAFE1 Operations, Quality control Sariette Jene M. C. Jippe Team Member HAFH3 and Tasks Management Sophie Martine Olivia Counsel LEGAM Wernert Sophie Naudeau Team Member HD program leadership HAFD2 Operations, Quality control Yahya Ould Aly Jean Team Member AFMMR and Tasks Management
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Extended Team Name Title Organization Location
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The World Bank Health System Support Additional Financing (P170585)
I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING
A. Background
1. This Project Paper seeks the approval of the Executive Directors to proceed with the additional financing (AF) of the Health System Support Project “INAYA” (P156165) in the amount of US$23 million equivalent of which US$15 million equivalent is financed by the IDA18 Regional Sub-window for Refugees and Host Communities (RSW). The AF will scale up INAYA to improve the utilization and quality of reproductive, maternal, neonatal, and child health (RMNCH) and nutrition services in the Hodh Chargui region (wilaya) of Mauritania, benefiting refugees and the Mauritanian host population. This will be achieved by adapting INAYA’s results-based approach to strengthen health services throughout the wilaya, with specific support to address health needs of refugees and reinforce the health facilities of the M’bera camp where most of the refugee population is living.
2. The Government of the Islamic Republic of Mauritania meets the criteria to access financing through the RSW. The World Bank, in consultation with the United Nations High Commissioner for Refugees (UNHCR), has determined that Mauritania adheres to the framework for the protection of refugees and approved Mauritania’s eligibility for the IDA18 RSW in November 2018 (see annexes 2 and 5 for more details). Mauritania continues to receive refugees, mainly due to the unstable situation in Mali. As of October 2019, Mauritania has received about 56,000 refugees2 and close to 3,000 urban refugees and asylum seekers. Most refugees (95 percent)3 are settled in the M’bera refugee camp and in the moughata’a of Bassikounou in the Hodh Chargui wilaya, just 50 km from the border with Mali. The M’bera camp has received 2,161 new arrivals since January 2019. There are also an unknown number of refugees living throughout the wilaya. With the M’bera camp, the Bassikounou moughata’a has seen its population double.
3. Conscious of the likely prolonged nature of forced displacement in the country, the Government has developed a Refugee and Host Community Policy Development Letter which lays out strategic directions to ensure the protection of refugees while promoting their increased self-reliance and the resilience of host communities. The Hodh Chargui wilaya previously received minimum development support. Four sectors have been prioritized initially for multisectoral regional support by the World Bank (annex 2): (a) health, (b) social protection, (c) water and sanitation, and (d) urban infrastructure and services of intermediate cities. Also, economic opportunities are scarce in this region and competition has increased for sources of energy and for water and pastures for livestock, the main economic sector for both refugees and host communities. Since approximately 2012, UNHCR and other humanitarian partners such as World Food Programme (WFP), including nongovernmental organizations (NGOs), have been providing health, education, shelter, and food support to the refugees in the M’bera camp and Bassikounou4 and, to some extent, host communities in Mauritania. To date, this has mitigated the impact of the demographic shock on service delivery. However, as humanitarian support declines, access to services will become a challenge. UNHCR support for health services has been reduced progressively since
2 Source: https://data2.unhcr.org/fr/country/mrt, accessed November 25, 2019. 3 There are also some refugees from countries such as the Central African Republic, the Syrian Arab Republic, and Côte d’Ivoire. 4 A mapping of partner projects in the wilaya was conducted, and INAYA will coordinate with relevant partners, which include United Nations Children’s Fund (UNICEF), UNHCR, the Islamic Development Bank, and the WFP.
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January 2020 and the Government of Mauritania is expected to take over the delivery of the health services in the M’bera camp and Bassikounou gradually.
4. The parent project, INAYA, is a US$19 million operation of which US$17 million is from IDA grant funds and US$2 million is in counterpart funding (CF) from the Government of Mauritania. INAYA is in its second year of implementation. The project was approved on May 19, 2017 and became effective on November 5, 2017. The closing date is June 30, 2021. The focus is on two wilayas with high poverty and large rural populations (Guidimagha and Hodh Gharbi, see Table 1). INAYA includes interventions to strengthen the quality and availability of services in health facilities, local governance of services, community outreach and demand for services in rural areas, and barriers to accessing services by poor households.
5. In Hodh Chargui, INAYA will continue to reinforce the National Health Sector Development Plan (Plan National de Développent Sanitaire 2012–2020 [PNDS]) of the Ministry of Health (MoH) and the MoH’s implementation of the Government’s refugee strategy, specifically the objective of providing health and nutrition services in the Bassikounou moughata’a. INAYA was designed by the Government to support implementation of its Results-based Financing (RBF) Strategy (Stratégie Nationale du Financement basé sur les Résultats dans le Secteur de la Santé 2015) and the National Community Health Strategy (Document Nationale de Stratégie Communautaire en Santé 2012 [NCHS]). INAYA also coordinates with Tekavoul, the National Social Transfers Program of the General Delegation of Taazour which replaces the Tadamoun agency responsible for the implementation of the Tekavoul Program. This program is based on the Social Registry launched in 2016—a database to help address inequities by targeting services to poor families. The wilayas of INAYA serve as a learning ground to develop lessons to scale up RBF in the next PNDS and to learn how to implement the refugee strategy of the Government in the health sector.
B. Country Context
6. Mauritania is a sparsely populated, arid, and resource-rich country, with high poverty levels in the south and rural areas. The country’s population of over 4 million people is spread across 12 wilayas and the capital area of Nouakchott. Mauritania is classified as a lower-middle-income country with a gross national income per capita of US$1,160 in 2018 (Atlas method, World Development Indicators [WDI]). Since 2007, the gross domestic product (GDP) has grown by over 60 percent due to discoveries of mineral resources. However, growth is highly volatile, with drops in the GDP in recent years (WDI). Nationally, extreme poverty has declined from 45 percent to 31 percent, from 2007 to 2014. However, 44 percent of the population continue to live in moderate to extreme poverty in some region, with poverty concentrated in rural areas and in the South (Survey on Household Living Conditions, 2014 [EPCV]). The regions supported by INAYA and the proposed AF are among these poorest regions (see table 1).
7. Mauritania ranks near the bottom in terms of human development, particularly human capital, and climate change may hamper any progress. Although it is a lower-middle-income country, Mauritania is ranked 159 out of 189 countries on the Human Development Index and ranks among the 10 lowest on the Human Capital Index (HCI) in the world. The Mauritanian HCI is 0.35, meaning children born in Mauritania today will be only 35 percent as productive when they grow up as they could be if they enjoyed complete education and full health. Stunting, child survival, and adult survival are key contributors in addition to education factors. The current and proposed INAYA regions are among those with the worst
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The World Bank Health System Support Additional Financing (P170585)
health outcomes. Climate change may further exacerbate poor health outcomes in these regions due to the projected rise in mean annual temperature and intense rainfall that could lead to extreme climate events such as heat waves and flooding. This would affect nutrition due to food insecurity, damage to general infrastructure (that is, water and sanitation, roads, and homes), and threaten households and their capacity to boost their productive capital.
8. The arrival of refugees is exacerbating the existing poverty in the border area in the southeast and changing the needs for regional development of health and social services. Hodh Chargui is a vast, rural (81 percent), and desert region with a population of over 500,000. The poverty rate in Hodh Chargui (28 percent living in moderate to extreme poverty or about 140,000 people; 14 percent or about 70,000 people living in extreme poverty) is lower than the national average. The arrival of the refugees has increased the total population and the number of vulnerable households in the wilaya. The population of the moughata’a of Bassikounou has nearly doubled. Almost all the refugees arriving are classified as vulnerable and poor—UNHCR has classified about 34 percent of refugees to be in the most vulnerable group that risk living in severe poverty once humanitarian assistance is reduced in 2020.5 The refugee and host population are living side by side in peace and have similar cultural practices. However, there are language barriers, and a need to provide health services for women and children, given the large number of women-led household among refugees, as well as mental health support (about 400 cases are followed annually in the M’bera camp). The concentration of refugees in Bassikounou and the M’bera camp is changing rural-urban settlement patterns and putting pressure on water and vegetation for grazing animals and constructing homes—with implications on the Government’s planning for regional development and decentralization of health and social services. Moreover, the border situation remains fragile, with the ongoing conflict in Mali and continued arrival of refugees. It is expected that the refugee population will likely continue to increase in the coming years.
C. Sectoral and institutional Context
9. In Hodh Chargui, progress on RMNCH and nutrition outcomes in the Mauritania host population remains inadequate despite increasing Government health expenditures (annex 1). While under-5 mortality and stunting of children have decreased, 28 percent of children are chronically malnourished. Few children receive the complete series of vaccinations in their first year (24 percent), with 49 percent vaccinated by their second birthday. In terms of reproductive health, contraceptive utilization remains low (18 percent). In terms of maternal health, maternal mortality is high and assisted delivery remains low (69 percent), with many births taking place at home. Moreover, only 63 percent of women receive four or more antenatal visits (SMART Nutrition Survey 2017, Multiple Indicator Cluster Survey [MICS] 2015). This is despite health expenditures increasing since 2007 from US$32 to US$47 per capita in 2017 (WDI), which have focused on hospital investments, rather than primary or periphery service improvements.
10. Generally, health services offered are of poor quality. Health facilities nationally often lack equipment, have inadequate space for consultation, and lack human resource competencies to deliver health services: 67 percent of facilities provide family planning, 58 percent provide the basic package of prevention services for children, and 69 percent provide assisted delivery services (Service Availability and
5 UNHCR and WFP. 2019. Rapport de profilage socio-économique des ménages réfugiés du camp de M’bera, Mauritanie. The grouping used the Consolidated Approach to Reporting Indicators of Food Security methodology.
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Readiness Assessment Index of Availability and Operational Capacity of Services 2016 [SARA]). Among Hodh Chargui facilities, 33 percent had no water, 28 percent were closed when visited due to absent personnel, and 55 percent had not received a supervision visit in the past six months (UNICEF Real Time Monitoring 2018). However, the results of the first semester 2019 of performance-based financing (PBF) in the INAYA region (Guidimagha and Hodh Gharbi) show that the quality of services has increased from 14 percent to 37 percent in six months through the small-scale investments that the facilities have made using the RBF resources. These results are obtained despite the delay in the execution of the investment units. In line with improving services is the need to improve the decentralized coordination of services. Decentralization is still in the early phases in Mauritania.
11. Utilization of health services is lowest among the poor and underserved households, which are often in rural areas. Extremely poor communities often have low utilization of health services: 70 percent of women give birth at home, only about 23 percent have a postnatal examination, and about 27 percent of children 12–23 months have a vaccination card. There is also an inequitable allocation of resources across wilayas as well as challenges reaching rural populations. The NCHS aims to reinforce community health committees, community agents, and community-based organizations (CBOs) organized around basic health units to provide home visits, social and behavioral change communication (SBCC), and other outreach activities. However, these units often remain nonfunctional. Guidimagha and Hodh Gharbi have a total of 161 such basic health units that require reinforcement and Hodh Chargui has 158 (Health Management Information System 2017 [HMIS]).
12. Over half of total health expenditure is out of pocket, implying financial barriers. The 2016 national health accounts place the private financing level at 55 percent, presenting a barrier for the poor. INAYA will address this through supply (fee waivers) and demand (conditional cash transfers [CCTs]) incentives for extremely poor households. The identification is done by the Social Registry, which is supported by the Social Safety Net Project (P150430) to facilitate social protection and access to services. As Table 1 shows, the actual and proposed INAYA regions have low levels of health spending per capita compared to the national average.
13. In Mauritania, women experience several forms of gender based violence (GBV), such as female genital mutilation child marriage and teenage pregnancy as well as overall low access to quality health services. The short and long-term consequences of such violence on the health and well-being of women are many and significant. In addition to the immediate trauma and injuries, women have to face other health issues including unintended pregnancy, mental health problems, sexually transmitted infections, and, in some regions, HIV. The capacity of health services to respond to survivors of violence is limited and many survivors do not seek care. The refugee women in refugee camp are at an even increased risk of violence in an already vulnerable region. At least 666 983 girls and women have undergone female genital mutilation (FGM), including about three in five girls (66.6%) aged 15–19 years. Every year, 35.2% of girls get married before the age of 18 years. 21.5 % births occur among adolescent girls aged under 18 years each year, contributing to maternal mortality and lasting health problems. Approximately 1050 women died from preventable causes related to pregnancy and childbirth in 2019. One woman out of three still has no access during childbirth to a skilled health professional, who could prevent or manage most complications. Nutritional status is also a major issue with iron deficiency anemia affecting a substantial number of adolescent girls. The project will support Mauritania through a series of mitigation activities.
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14. The M’bera camp has its own local leaders and health facilities that have been reinforced by humanitarian partners; these services need to be sustainably and equitably integrated within the Government system. The quality of health services received by the refugee community to date through humanitarian efforts is superior to those provided by the Government of Mauritania elsewhere in the wilaya–they provide over 5,000 medical consultations to refugees per month (UNHCR, 2019). The refugee population has received a package of high-quality RMNCH and nutrition services, including support for surgeries and mental health (300–400 cases per year are supported in the camp), which has limited availability in the Mauritanian system outside of selected hospitals. The support for these services is being phased out starting in January 2020 and the health services in the camp are being integrated in the Government system. This needs to be done in a way that ensures a reasonable continuation of services as per the Government’s strategy and addresses constraints to equitably improve the utilization of services throughout the wilaya for refugees and the Mauritanian host community.
Table 1. RMNCH and Nutrition Indicators for the INAYA Wilayas Indicators (in percentages of the population unless Hodh Guidimagha Hodh Gharbi National otherwise stated) Chargui Total population (number) 308,457 324,165 515139 4,077,347 Rural population 71 85 81 47 Population living in extreme poverty 34 19 14 17 Population classified as poor 49 39 28 31 RMNCH and nutrition Women utilizing modern contraceptives 10 16 14 18 Prenatal care utilization 68 73 80 86 Women having four or more prenatal visits 39 50 53 63 Births assisted by qualified personnel 33 49 51 69 Home births 66 50 49 30 Postnatal examination of newborn baby 28 14 42 57 Children 12–23 months vaccinated for measles 52 70 69 78 Children 12–23 months completely vaccinated 30 51 11 49 Children 0–5 months exclusively breastfed 52 38 51 41 Children 6–23 months having minimum meals 30 32 40 37 Children 0–5 years with chronic malnutrition 25 28 27 20 Literacy of women 15–24 years of age 21 36 40 52 Health services Population greater than 5 km from a health facility 30 25 26 17 Population not utilizing health service package 57 65 46 40 Birth registration seen and confirmed 31 32 34 40 Nurses and midwives (number per 5,000 population) 0.9 0.5 0.6 1.5 Health centers (number) 8 9 11 117 Health posts (number) 52 93 147 733 Basic health units for community interventions 59 102 158 850 (number) Public health spending per capita (US$) 6.8 8.2 9.1 22.3 Sources: MICS 2015; HMIS 2015, 2017; SMART Nutrition Survey 2017; EPCV 2014; WDI 2017.
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D. Current Project Status and Results
15. The implementation of INAYA in Guidimagha and Hodh Gharbi is satisfactory, with steadily increasing disbursement (25 percent in January 2020). It is important to note the slow start of the project, which is explained by the heavy up-front need at the beginning to build capacity of the MoH and wilayas to manage the RBF strategy, including the rollout of PBF in health facilities, as well as the use of PBF for wider systems improvements. This early capacity building was important given the innovation of the operation and new knowledge required for the MoH to implement PBF as part of a system to facilitate improvements in health planning, efficiency of health expenditure, supervision, technical platforms in facilities, monitoring and evaluation (M&E), and demand for services and equity of resource allocations. The project has established a network of more than 150 people in the MoH centrally and in Guidimagha and Hodh Gharbi trained on PBF processes, which will facilitate an expediated process to build capacity in Hodh Chargui. In addition, the existing technical assistance organizations for PBF implementation and counter-verification can help prepare the Hodh Chargui extension.
16. INAYA is on track to achieve its Project Development Objective (PDO), improving the utilization and quality of assisted births, immunization and prenatal care, and other RMNCH and nutrition services. Table 2 shows progress on PDO and selected intermediate indicators.6 The results from the first semester of the rollout of the PBF in 2019 suggest an increasing utilization of services: women receiving four prenatal care visits and children receiving consultations in health facilities are on average 1.92 times the 2018 end-of-year results. Progress on assisted births remains steady, with promising results seen through the monitoring of women to receive prenatal care. In total, 114,514 children used primary health services in health centers and health posts in Guidimagha and Hodh Gharbi in the first semester of 2019 compared to 62,086 in 2018. The number of children fully vaccinated increased in 2019, with more children being followed for consultations. The score of the quality of services in health facilities has increased by more than 20 percentage points between December 2018 and June 2019. This should further increase as health facilities benefit from quality bonuses and execute their investment by the end of 2019, with the allocation of quality bonuses to facilities and investment grants to improve the delivery of services.
Table 2. Progress on Key Project Indicators in Guidimagha and Hodh Gharbi Cumulative Baseline First Semester 2019 Indicator 20187 Target End (2017) (cumulative) of Project Births attended by skilled health staff (number, 13,020 12,225 16,475 78,812 cumulative) Pregnant women completing four antenatal 1,740 2,064 4,518 41,211 care visits (number, cumulative) Children 12–23 months fully immunized 19,390 15,974 21,826 63,289 (number, cumulative) Average score of the quality of care checklist — 14 36.63 60 (percentage)
6 Table 2 uses the reference of 2017, since the project started implementation in 2018, and PBF in facilities started in 2019. 7 The indicators for 2018 are being verified to improve the quality of data reporting, and in some cases, this may result in a reduction of the indicator in year 1. For example, immunization previously estimated full coverage using a proxy and now will assess the full coverage of children.
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Women accepting modern family planning 8,970 11,957 24,465 94,622 methods (number, cumulative) Basic equipment availability (percentage) — 45 45 94 Visits by children under-5 children to health 43,620 62,086 114,514 450,169 facilities (number, cumulative) Post-natal consultation visits (number, 3,560 3,147 6,325 26,764 cumulative) Sources: HMIS 2017, 2018; PBF portal 2019.
E. Rationale for Additional Financing and Proposed Changes
17. The INAYA AF will be implemented as part of a US$60 million multisectoral World Bank program (annex 2). The sectoral projects will use a coordinated approach to synergize underlying determinants to build human capital in the wilaya, deepen results, and make the project more cost-effective overall. This approach will include a framework for joint coordination of interventions and a shared M&E mechanism. An important synergy will be the common use of the Social Registry8 to identify poor refugee and Mauritanian households to benefit from targeted interventions (including CCTs) to address inequalities in access to social services. This will involve classification of the vulnerability of refugees by Tekavoul and UNCHR. This effort will be supported by the Social Safety Net Project (P150430).
18. The proposed investments are aligned with the Country Partnership Framework for the Period FY18–FY239 (CPF) and the Government’s strategic objective to improve social protection and access to basic services. The AF will support the Government’s strategy to improve the decentralized delivery of services for refugees and the Mauritanian host community. Specifically, it supports the Government’s objective to improve social protection and access to basic services with a view to gain a better balance between service delivery to refugee and host communities. This priority includes providing health and nutrition services in Bassikounou moughata’a. INAYA also supports the CPF objectives of building human capital for inclusive growth, specifically to increase access to RMNCH and nutrition services, including the number of beneficiaries of prenatal care, immunization services and child growth promotion, and equitable (geographical, social, and financial) access to these services by vulnerable groups. The AF will also boost climate change resilience in the original and proposed INAYA wilaya, including the refugee communities. INAYA also supports the Sustainable Development Goals 1 (no poverty), 2 (zero hunger), 3 (good health and well-being), 5 (gender equity), 6 (clear water and sanitation), and 10 (reduced inequalities).
19. The project is aligned with the objectives of IDA18 RSW, including (a) mitigating the shocks caused by an inflow of refugees and creating social and economic development opportunities for refugees and host communities, (b) facilitating sustainable solutions to protracted refugee situations including through the sustainable socioeconomic inclusion of refugees in the host country, and (c) strengthening preparedness for increased or potential new refugee flows.
8 The methodology to identify poor refugee households for inclusion in the social registry will be based on the profiling work carried out in 2018 by the UNHCR and WFP. It identified six different household categories: (a) deprived, (b) precarious, (c) unstable, (d) fragile, (e) emerging, and (f) catalyst. Each category gradually receives (or will receive) differentiated assistance based on its needs. This profiling work was carried out with the participation of camp and Government authorities. 9 Country Partnership Framework for the Islamic Republic of Mauritania for the Period FY18-FY23, dated June 13, 2018. Report No. 125012-MR.
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20. The AF will adapt the activities of INAYA to improve health services for refugees and the Mauritanian population in Hodh Chargui.
(a) Capacity building will support regional coordination with humanitarian efforts, including a road map to roll out INAYA, and technical support, studies, and planning to improve the delivery of health services, with an emphasis on M&E and learning how best to respond to the needs of refugees. INAYA will not address all the unique needs of refugees in Bassikounou but will coordinate with specialized humanitarian actors and deliver a basic package of nutrition and health services, planned jointly with other partners and led by the MoH.
(b) The quantity—that is, the number of beneficiaries receiving services—and quality reinforcement of the package of services in health facilities throughout the wilaya will be the same as the parent INAYA project. However, the AF will allow for a tailored package of services in Bassikounou and the M’bera refugee camp (which includes two health posts, one health center, and one maternity center) to address specific needs of refugees. Moreover, the PBF contracting will include nongovernment leaders in the M’bera camp and refugee employees in health facilities. The INAYA PBF Manual will be adapted through a collaborative process with partners to describe the specific indicators as well as the road map for the rollout of PBF support in Hodh Chargui. This will build on the lessons learned from the recent national review of INAYA’s implementation performance and benefit from the presence of the technical assistance providers.
(c) The implementation of the NCHS to mobilize community actors will include CBOs and leaders in the M’bera refugee camp. These groups will receive PBF contracts to deliver home visits, conduct SBCC, and refer missed cases to health facilities for vaccination, prenatal care, and other services.
(d) The expansion of the partnership with Tekavoul to provide CCTs to poor households among refugees and host populations; this is to promote utilization of key childhood services by extremely poor families. The identification of refugees eligible for CCTs will be done by Tekavoul in collaboration with UNHCR and the process is ongoing.
(e) The use of a PBF equity bonus to waive or reduce the cost of accessing health services for refugees. The AF will extend the current practice applied to the Tekavoul-identified poor to the eligible refugees. The equity bonus is intended to provide sufficient resources to health providers to allow them to minimize or to waive the fees for targeted groups. The services covered by the equity bonuses will be in the PBF Manual. The amount paid for PBF indicators will be reviewed iteratively during the M&E of the project implementation, that is, reviewing the actual quarterly utilization of services by the poor as well as beneficiary feedback to determine if the PBF design is adequate to promote their use of services or course corrections may be required.
II. DESCRIPTION OF ADDITIONAL FINANCING
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A. Project Development Objective
21. PDO and results. The PDO is “to improve utilization and quality of Reproductive, Maternal, Neonatal and Child Health (RMNCH) services in selected regions, and in the event of an eligible crisis or emergency, to provide immediate and effective response to said eligible crisis or emergency” and will be reformulated as “to improve utilization and quality of Reproductive, Maternal, Neonatal, and Child Health (RMNCH) services in selected regions.” The baseline of indicators was changed in 2017 to reflect that INAYA began implementation in 2018.
22. An additional PDO indicator (PDO 5) has been added (Table 3), the “Refugee populations benefiting from preventive and curative interventions provided by the health facilities (PMA + PCA) (Number).” This will enable INAYA to monitor the utilization of the package of preventive and curative services by refugee groups.
23. PDO indicators are disaggregated to reflect utilization of services by refugee groups (table 3). PDO 1a. “Births attended by skilled health staff among the refugee population (Number)”; PDO 2a. “Pregnant women completing four antenatal care visits to a health facility among the refugee population (Number)”; PDO 3a. “Children 12–23 months fully immunized among the refugee population (Number)”
Table 3. Proposed PDO Indicators including Revisions Indicator Rationale PDO 1. Births attended by skilled health staff Assesses utilization of maternal and neonatal services (number) and the quality concern around unassisted home births PDO 1a. Births attended by skilled health staff among Assesses utilization by refugee populations of maternal the refugee population (Number) and neonatal services and the quality concern around unassisted home births PDO 2. Pregnant women completing four antenatal Assesses utilization of reproductive health and care visits to a health facility during pregnancy nutrition services and the continuity of care for quality (Number) services • PDO 2a. Pregnant women completing four • Assesses utilization by refugee populations of antenatal care visits to a health facility among the reproductive health and nutrition services and the refugee population (Number) continuity of care for quality services PDO 3. Children 12–23 months fully immunized Assesses the utilization of child health services and the (number) quality concern of reaching full immunization • PDO 3a. Children 12–23 months fully immunized • Assesses the utilization by refugee populations of among the refugee population (Number) child health services and the quality concern of reaching full immunization PDO 4. Average score of the quality of care checklist Assesses the quality of the package of services (Percentage) delivered in health posts, health centers, and hospitals PDO 5. Refugee populations benefiting from Assesses the utilization of the package of preventive preventive and curative interventions provided by the and curative services by refugee groups (new FOSA (PMA + PCA) (Number) indicator)
24. Revision of intermediate results indicators (IRIs). Several intermediate indicators have been revised in the Results Framework to monitor refugee beneficiaries, as well as to better track the community activities implemented by INAYA:
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(a) One IRI is marked for deletion. IRI3, “Children under 5 years treated for severe and acute malnutrition,” has been deleted given the indicator is highly prone to seasonal changes and does not give a good assessment of the utilization of preventive nutritional services.
(b) Two IRIs have been added to replace the indicator. IRI3, “Number of home visits received by children 0–5 years old (Number),” has been added to monitor the success of the community- based PBF activities to benefit young children; IRI14 “Grievances registered related to delivery of project benefits satisfactorily addressed (Percentage)” has been added to monitor the effectiveness of the grievance redress mechanism.
(c) Three IRIs have been disaggregated to reflect the specific impact on the refugee population. (i) IRI1, Women refugees accepting modern family planning methods (Number); (ii) IRI6, Post- natal consultation visits among the refugee population (Number); and (iii) IRI7, User satisfaction with health care services among the refugee population (Percentage).
B. Project Beneficiaries
25. Project beneficiaries include refugees and the host population in Hodh Chargui. Table 4 presents the main beneficiaries in the Hodh Chargui region. The primary beneficiaries are women of reproductive age and children 0–5 years. The addition of further breakdowns focusing on the poor and the refugees is relevant for the RSW-specific aspects of the AF and for the overall project design with the social registry link. Among the refugees, family separation linked to displacement has resulted in 58 percent of households in the M’bera camp without a male head present. Most of these households are headed by women of reproductive age.
Table 4. Beneficiaries of the AF Population Group Total Population Beneficiaries Mauritanian - general 456,791 • 111,276 women of reproductive age • 91,313 children 0–5 • 221,141 children 0–14 • 20,770 pregnancies expected annually Mauritanian - poor 140,000 • 33,600 women of reproductive age • 25,200 children 0–5 • 61,600 children 0–14 • 6,384 pregnancies annually Refugees 58,348 • About 41,450 women and children Sources: HMIS 2017; EPCV 2014; UNHCR Update, April 2019.
26. The IDA18 RSW resources will foster a key synergy across World Bank programs: the inclusion of the poorest/most vulnerable refugee and host communities’ households in targeted interventions to address extreme poverty and promote access to services. The RSW allocation will support the government to improve the access of health services for refugees and host communities. In Mauritania, three other projects will be seeking financing from the IDA18 RSW: the Water and Sanitation Project (P167328), the Decentralization and Productive Intermediate Cities Support Project (P169332), and the Social Safety Net System Project II (P171125). The overall objective is to improve the delivery of basic social services and infrastructure for refugees and host communities in targeted areas (see annex 2).
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C. Theory of Change
27. The INAYA theory of change is adjusted to address the challenge of serving the needs of the refugee population in Hodh Chargui (figure 1, annex 3). The PDO will be achieved through a multifaceted strategy of:
(a) Improving coordination among government and humanitarian actors, including joint learning, studies, and M&E around how to provide health services to protect refugees and implement the Government’s strategy;
(b) Using PBF to finance and incentivize the delivery of key RMNCH services in facilities, including in the M’bera camp;
(c) Providing grants and quality bonuses to health facilities to support efforts to progressively improve their equipment and technical platforms and quality delivery of services;
(d) Utilizing equity bonuses to enable facilities to recover the cost of delivering services to extremely poor women and children among refugees and host populations;
(e) Increasing demand for health services through the provision of CCT to extremely poor families’ households among refugee and host populations, which provide cash transfers to families of children who utilize key services—this will be done with the Social Safety Net Project (P150430);
(f) Mobilizing community groups in the M’bera refugee camp and rural areas to provide home visits and SBCC to promote the utilization of services in facilities and track missed cases, that is, of child vaccination; and
(g) Strengthening the regional health system to coordinate, plan, and finance the health services, inclusive of the refugee population.
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Figure 1. Theory of Change of INAYA adapted for the AF
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D. Additional Financing Components
28. The proposed components are described in the following paragraphs.
29. Component 1: Improving utilization of quality RMNCH services through performance-based financing (PBF). Total cost under parent project: US$10.5 million equivalent. Total costs with AF: US$28.5 million equivalent (table 5), with US$16 million equivalent from national IDA and US$12.5 million equivalent from the IDA18 RSW. The parent project supports the PBF implementation and verification in Guidimagha and Hodh Gharbi. The AF will extend the PBF to Hodh Chargui to address challenges related to the delivery of quality services to refugees and the Mauritanian host population.
30. Subcomponent 1A: Provision of PBF payments to health service providers. The AF will support the following:
(a) The expansion of PBF payments to all public health facilities in Hodh Chargui and facilities in Bassikounou and the M’bera refugee camp. The health facilities in the M’bera camp will be integrated into the health pyramid of the MoH. Some of the facilities are currently managed by NGOs, which will phase out their support in the first semester of 2020. A transition road map is being developed by the MoH and UNHCR to include these health facilities and refugee workers in the PBF. Nongovernment facilities that meet eligibility requirements will also be eligible for PBF support, as is the case in the INAYA parent project. Health facilities will receive PBF payments for the number of beneficiaries (per women or child) utilizing services, as well as a bonus for quality delivery of the package of services. The indicators and mechanisms will be clearly defined in the revised version of the PBF Manual.
(b) The development of business plans by health facilities in Hodh Chargui, including in Bassikounou and the M’bera refugee camp, using a problem-based planning approach to review progress quarterly and identify actions to improve services. Business plans may include activities such as training, community outreach, technical improvements, improving the stock of commodities, waste management, minor repairs, and minor renovation works focused on small-scape upgrading. Eligible health facilities will receive a one-time small grant to support initial investments to improve the baseline quality score of services as with the parent project. The business plans will integrate gender-based activities such as: (i) strengthening health systems response to violence against women and girls and against children; (ii) equipping health care providers with the skills and knowledge to better support the management of gender-based violence.
(c) A PBF equity bonus for health facilities in Hodh Chargui to waive/reduce service fees for refugees and poor Mauritanians. INAYA will work with Tekavoul and UNHCR to develop the eligibility requirements for the equity bonus. These bonuses will be PBF incentives paid to facilities for serving poor patients among refugees and host populations. The terms for the equity bonuses will be outlined in the revised version of the PBF Manual adapted. The bonus will focus on key indicators for the minimum package of RMNCH and nutrition services.
(d) PBF to reinforce interventions of community actors (community health workers, community sanitation workers, refugee leaders, women leaders, CBOs, and so on). This will
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consist of performance-based contracts with identified community actors and groups in moughata’a. These actors will receive PBF payments to refer pregnant women to health centers, register home deliveries, conduct monthly home visits for child growth monitoring, and conduct SBCC sessions on targeted themes. This includes involving traditional birth practitioners in bringing women to the health facility to change the incentives around their support to home births.
31. Subcomponent 1B: Verification and counter-verification. The AF will support the following:
(a) Routine verification to reinforce M&E of health services (quantity, quality, and beneficiary feedback). A Regional Verification Committee (RVC) will be created for Hodh Chargui, including the M’bera refugee camp, for the regular verification of the quantity of services delivered by health facilities. In terms of quality, the regional and district medical teams will conduct quarterly assessment of the quality of the package of services. In addition, community health committees, refugee groups, and CBOs will be identified for the community-level verification of the quality of services.
(b) External verification activities to ensure reliability. An agency has been recruited to support external counter-verification of the PBF data and is building the capacity of the Inspector General’s Office to take over the function. Counter-verification will involve validation of the M&E information on health services to ensure accurate reporting on indicators and payment for services delivered by health facilities.
(c) PBF contracts with regulatory actors to strengthen the coordination of health services. Regulatory actors will receive PBF contracts including possibly (i) central directorates of the MoH (such as units responsible for fiduciary aspects, public hygiene, refugees, and pharmaceuticals); (ii) decentralized health pyramid structures, such as the RVCs and Regional Health Direction; and (iii) decentralized structures such as Regional Councils, moughata’a, and the local government of the M’bera camp. These actors will receive PBF contracts with defined roles to coordinate health services. This will help respond to systemic constraints, which impede service improvements, such as weak supervision and communication, weak management of drugs, and inadequate attention to vulnerable populations. This will extend what is already being done under the parent project.
32. Component 2: Support to increasing demand for health services. Total cost under parent project: US$3.5 million equivalent, with US$2.5 million equivalent IDA and US$1 million equivalent from CF. Total costs with AF: US$8 million equivalent, with US$4 million equivalent from national IDA, US$2 million equivalent from the IDA18 RSW, and US$2 million equivalent from CF. The parent project supports CCTs and the community health strategy in Guidimagha and Hodh Gharbi. The AF will support CCTs for poor Mauritanians and refugees and the community health strategy in Hodh Chargui, with the view of increasing the demand for services, among the most vulnerable (poor, refugees, and rural populations).
33. Subcomponent 2A: Conditional Cash Transfers to stimulate demand for health care. The AF will support extension of the CCTs to benefit households living in extreme poverty in Hodh Chargui (refugees and poor Mauritanians). Mauritanian poor and eligible refugee households will be identified in partnership with Tekavoul and UNHCR. The focus will be on supporting the most vulnerable refugee households. The list of recipients will be monitored annually with Tekavoul and UNHCR to ensure that the
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management of the CCTs is reflective of changes in the refugee population. Families will receive SBCC and CCT payment for utilization of child immunization, nutrition, and birth registration services. The SBCC sessions will also be used to provide more information on management of gender-based violence impact on health. This will include activities such as: (i) raising awareness against female genital mutilation and obstetric fistula; (ii) prevention activities against child marriage and teenage pregnancy, and (iii) counseling and health education. This will help alleviate inequalities faced by poor and refugee children, in terms of access and continuity of follow-up of these services to maximize outcomes for young children.
34. Subcomponent 2B: Strengthening of community health. The AF will support extension of activities to implement the NHCS in Hodh Chargui and the M’bera refugee camp. The selection will include villages with significant refugee, poor, and vulnerable rural populations. The ministry will contract local NGOs to implement social mobilization and capacity building of community actors to operationalize the NCHS, including health committees, CBOs, refugee groups, and community health workers. These actors will be mobilized and will receive training and coaching support to conduct home visits, SBCC activities, and referral of cases to the health center. This will promote knowledge around the utilization of services and reinforce the community-level PBF support in Component 1.
35. Component 3: Capacity building and project management. Total cost under parent project: US$5 million equivalent with US$4 million equivalent IDA and US$1 million equivalent CF. Total costs with AF: US$7 million equivalent with US$5 million equivalent from national IDA, US$0.5 million equivalent from the IDA18 RSW, and US$1.5 million equivalent from CF. The parent project supports the strengthening of the MoH’s capacity and other entities involved in RBF, project management, and technical assistance for Guidimagha and Hodh Gharbi. The AF will include technical support, learning, and coordination and research activities to strengthen the health system in Hodh Chargui, including coordination with humanitarian actors, M&E to review the regional situation, fiduciary support, strengthening of the technical platform in health facilities, and learning to deliver new services to support refugees. Technical assistance will also be provided on (i) building a climate-resilient health system, and (ii) supporting the operationalization of the National Gender Institutionalization Strategy and implementing the Gender Based Violence (GBV) response. This includes strengthening M&E such as the health management information system (HMIS) and database management by including gender-based violence data.
36. Component 4: Contingent Emergency Response (CERC). Total cost under parent project: US$0 million. The CERC manual will be updated to support eligible emergencies. The activities financed under the CERC will comply with the RSW eligibility criteria and focus on refugees and hosts where relevant.
E. Project Costs and Financing
37. AF resources will primarily improve the supply side. Table 5 shows the breakdown of costs. Building on the lessons learned from the parent financing and the recent restructuring, the counterpart resources will be allocated to specific lines that are entirely financed by the counterpart budget.
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Table 5. Project Costs and Financing Current AF (IDA18) Revised Budget Budget Project Component From From From From IDA CF National CF National CF RSW RSW PBA PBA Component 1: Improving 10.5 — 5.5 12.5 — 16.0 12.5 — utilization of quality RMNCH services through performance-based financing (PBF) 1A. Provision of PBF 8.5 — 4.5 9.0 — 13.0 9.0 — payments to health service providers 1B. Verification and counter- 2.0 1.0 3.5 — 3.0 3.5 verification Component 2: Support to 2.5 1.0 1.5 2.0 1.0 4.0 2.0 2.0 increasing demand for health services 2A. Conditional Cash 1.5 — 1.0 1.5 — 2.5 1.5 — Transfers to stimulate demand for health care 2B. Strengthening of 1.0 1.0 0.5 0.5 1.0 1.5 0.5 2.0 community health Component 3: Capacity 4.0 1.0 1.0 0.5 0.5 5.0 0.5 1.5 building and project management Total project costs 17.0 2.0 8.0 15.0 1.5 25.0 15.0 3.5
38. Closing date. The closing date of INAYA will be extended from June 30, 2021, to April 30, 2023. This will allow for three years of implementation after Board Approval of the AF. This will also enable INAYA to make up for the delayed implementation in its first year. It will also enable the MoH to align the time line of the PBF activities in Guidimagha and Hodh Gharbi with those in Hodh Chargui through the AF.
F. Implementation Arrangements
39. The implementation arrangements will include minor adjustments to support Hodh Chargui and strengthen technical coordination. The Administrative and Financial Manual of Procedures and the PBF Manual will be updated to describe the roles and responsibilities of implementers and procedures required by IDA. Table 6 presents the detailed list of changes.
(a) Existing strategic and technical coordination mechanisms will continue and will be strengthened, considering the lessons learned from implementation and to reflect the new institutional organization of the ministry. The Secretary General (SG) will oversee the overall coordination of the project and the Directorate General of Regulation, Organization, and Quality of Services and Care will ensure the technical coordination of the project. The RBF Technical Unit will continue to coordinate the implementation of the project and will be responsible for monitoring day-to-day implementation. Project oversight is provided by the
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MoH Steering Committee supervising the PNDS. A technical committee chaired by the General Directorate of Regulation, Organization, and Quality of Services and Care will be established to facilitate the technical coordination of the implementation of the project. The AF for Hodh Chargui will also coordinate with a multisectoral working group on the refugee strategy.
(b) Technical assistance will be strengthened. A PBF Specialist will be based in Hodh Chargui financed by the project to support the implementation of the AF and coordination with humanitarian efforts. Moreover, an independent agency will support the Inspector General’s Office to conduct counter-verification activities for the PBF. An RVC will be created to conduct internal PBF verification activities, including refugee representation. The Regional Council, Regional Health Direction, and District Health Team will coordinate the PBF activities in the wilaya. However, communes and the local government in the M’bera refugee camp can also coordinate activities with performance contracts. NGOs and CBOs (including refugee groups) in communities will implement community verification and the NCHS.
(c) The RBF Technical Unit will be reinforced to support the AF. The RBF Technical Unit currently includes the following personnel: Technical Coordinator, Deputy Technical Coordinator, M&E Specialist, Information Systems Specialist, Tekavoul Program Coordinator, and Environmental Specialist. The AF will add a senior PBF Specialist to support the RBF Technical Unit and a Coordination and Communication Specialist to work with the MoH units to ensure the coordination of actions to support the wilaya, refugees, and communication of PBF activities and a Community Health Specialist, given the need for strong social mobilization support to roll out the NCHS in M’bera camp and rural areas.
(d) Refugee and host community focal points. Two refugee and host community focal points based in Hodh Chargui will be recruited to ensure the permanent presence of the projects with RSW-funded components in this area and dialogue with other actors working with refugees and host populations. The focal points will be responsible for updating the coordination teams for the four projects on the refugee and host community situation and to identify any critical points related to the implementation of the projects in the related areas. The focal point based in Nema will be financed under the Decentralization and Productive Intermediate Cities Support Project (P169332). The focal point based in Bassikounou will be financed under this proposed Safety Net System Project II (P171125).
Table 6. Summary of Institutional Arrangements Level Element Responsibility National MoH Steering Committee Oversight of project and lessons for the PNDS Working Group on the Coordination on refugee strategy of the Government, Refugee Strategy including coordination with UNHCR Office of the SG of the MoH Project coordination RBF Technical Unit Overall management of project implementation DAF (Direction of Fiduciary management of project and PBF payments Administration and Finance, Direction des Affaires Financières)
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Level Element Responsibility Sectoral Unit in charge of Support procurement of project the procurement process Public Hygiene Department Safeguards of project Units of the MoH Technical support to PBF implementation and directorates10 capacity building, according to their respective mission Tekavoul program of the CCTs and unified Social Registry to identify poor General Delegation of Taazour UNHCR Coordination to identify refugees and support to assess needs of refugees Office of the Inspector Support to counter-verification activities General Technical Working Group Orientation of regional PBF implementation Regional RVCs, Regional Health Regulatory agencies involved in verification activities Direction, Regional Council, and decentralized coordination of PBF moughata’a, including M’bera camp administration NGOs, CBOs, refugee Community verification activities and support to the groups, and other service NCHS providers Technical assistance Support to PBF, capacity building, and operations providers research activities Health facilities (health Provision of health services (promotional, preventive, posts, health centers, and and curative) hospitals), including NGO and non-government facilities in the M’bera camp Community agents, Implementation of community-level PBF activities for including refugee groups the NCHS
40. M&E arrangements. The existing process of data collection will be extended to cover the new region and used for quarterly planning and decisions to improve services and reinforce the quality of the HMIS. The important difference in Hodh Chargui will be the coordination with UNHCR and other partners in the review and sharing M&E information and decisions on actions to improve implementation. Moreover, the PBF portal will be expanded to Hodh Chargui. It is already online and available to all interested parties at http://portailpbf.gov.mr/. Key aspects of the INAYA M&E system are summarized in Table 7.
41. Digital innovations will be leveraged to support the M&E of the project during implementation. In particular, the Geo-Enabling initiative for Monitoring and Supervision (GEMS) under the Kobo Toolbox Platform project will continue to be leveraged for this project. The GEMS will enable the Project Coordination Unit (PCU) to collect and structure digital data that automatically feed into a centralized
10 The project will coordinate with units in central directorates of the MoH responsible for finance, refugees, nutrition and basic services, hospitals, planning and international cooperation, information systems, public hygiene, reproductive, maternal and child health, infrastructure, public health research, pharmaceuticals, and human resources in the implementation of the PBF and capacity building of health systems.
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M&E system. The platform will be customized to capture relevant indicators, photos, audio, videos; time and date stamps; and GPS coordinates that allow for automated geo-mapping of the project during implementation. This platform is already used in other Sahel countries and is being deployed to the other developing partners members of the Sahel Alliance. Using these tools systematically allows the Government and the World Bank frequent monitoring and coordination across projects and with partners working in the same area.
Table 7. INAYA M&E Arrangements Element Change Made PBF portal Ability to access data by region to monitor service utilization and quality indicators. Routine review Regional actors and facilities meet to review PBF results and inform planned actions, meetings monthly to quarterly. Humanitarian representatives will be invited to support review of progress on refugee services. User satisfaction Data on the quality of services in health facilities as perceived by beneficiaries Surveys and studies Various studies to support implementation learning on the Government’s strategy to scale up RBF and services for refugees Iterative beneficiary IBM will be used to ensure the needs of refugee and poor communities are being monitoring (IBM) met. This will be done in collaboration with other partners supporting refugees in the wilaya. IBM uses small samples to ask questions about outcomes at the beneficiary level. IBM will collect quantitative and qualitative data, including testimonies of experiences. By assessing outcomes iteratively during the AF, it will provide information to reinforce the impact of the PBF design. Triangulation of The RBF Technical Unit will coordinate with other partners (such as UNICEF and refugee disaggregated UNHCR) to triangulate the PBF data with other data on services and refugees for data with Hodh Chargui. This will include routine disaggregation of all PBF indicators to monitor humanitarian the refugee situation and review and decide jointly with partners on course community corrections for areas of concern.
III. CLIMATE SCREENING AND CLIMATE CO-BENEFITS
42. This project has been screened for climate change and the following vulnerabilities were identified through the process (see annex 5). The potential risks are assessed as High in the Summary Climate and Disaster Risk Screening Report. Mauritania is categorized as High due to extreme temperature, precipitation and flooding, drought, sea level rise, storm surge, and coastal erosion. This exposure risk is assessed at this level for both the current and future timescales. However, the risk on project activities and outcomes is categorized as Moderate due to a number of adaptation measures that will enable health care workers, communities, and vulnerable groups such as refugees to cope in the next few years and in the future. Some mitigation measures will also be put in place to reduce the impact of the project’s activities on the environment and reduce greenhouse gases.
IV. KEY RISKS
43. The overall risk rating of the AF is Substantial. This is driven by the political economy of hosting refugees, the protection of refugees, and the fragility of the security and refugee situation in the region. Other risks remain moderate and the same as the parent project. This includes institutional capacity and fiduciary risks identified for INAYA, which remain relevant.
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Table 8. Systematic Operations Risk Rating Tool (SORT)
Risk Category Rating 1. Political and Governance Substantial 2. Macroeconomic Moderate 3. Sector Strategies and Policies Moderate 4. Technical Design of Project or Program Moderate 5. Institutional Capacity for Implementation and Sustainability Moderate
6. Fiduciary Moderate 7. Environment and Social Moderate 8. Stakeholders Low 9. Other: Refugee Protection Substantial Overall Substantial
44. Political and governance risks. The risk related to the political economy of refugee hosting is Substantial. The Government of Mauritania is committed to its strategy to protect refugees and integrate them in the national systems of services. Moreover, the MoH is committed to integrate the refugee services in the health pyramid. However, the integration of refugees in the national services structure has the potential to be politicized or ill-perceived by the host community. The change in the level of services received also has the potential to create problems in the short run, although the phased exit process and the gradual change in the level of services will help mitigate against this. Moreover, the increased arrival of refugees or changes in the security situation in the country could affect how the refugee situation is perceived by Mauritanians. This risk will be mitigated through close coordination of the implementation of the AF with UNHCR, the MoH, and other actors in the region, as well as the development of a transition road map to plan the integration of the health services and rollout of INAYA.
45. Other, security and refugee risks. The other risk related to security and the refugee situation is substantial. Arrival of more refugees or heightened conflict in the border areas could further exacerbate the vulnerability of the population in Hodh Chargui. The main mitigation approach will be quarterly coordination with partners in Hodh Chargui including UNHCR and other sectors in the World Bank program to monitor the regional situation and emerging challenges and needs. This is critical to review changes in the refugee population, respond to the unique needs of the refugee community, and work with partners to develop the initial transition road map to roll out INAYA in Hodh Chargui and the annual planning of activities, conduct triangulate M&E data, and restructure INAYA as relevant. The project can also use the CERC if an eligible crisis arises.
46. Other, refugee protection risks. The World Bank, in consultation with UNHCR, confirms the continued adequacy of the protection framework. The World Bank Group will continue to monitor the developments and remain in close contact with both the Government and UNHCR to assess the level of this risk and to discuss appropriate mitigation measures, such as the asylum law adoption that would formalize refugee protection in Mauritania. The Mauritanian framework for the protection of refugees includes access to health care. This is the main protection risk addressed by the AF. Humanitarian efforts
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have been providing free health services in the M’bera camp which will reduce progressively from January 2020. The main risk is a delay in project implementation to roll out PBF to support the delivery of services for refugees. This risk is being addressed by developing a transition road map for the INAYA support. The MoH has developed the road map with humanitarian partners. The technical committee comprising the MoH, the World Bank, and UNHCR has been created to work on this road map and monitor its implementation.
47. Sustainability. The risk of sustainability remains moderate for the following reasons:
(a) RBF strategy and vision. The strategy was adopted by the Government and its partners and the ongoing implementation and adjustments will refine it further. The ministry intends to use the PBF approach more broadly in the next PNDS and has already worked with UNICEF on the community health aspects. This stabilizes the primary implementation approach.
(b) RBF technical capacity. The initial consultant support has been expanded with the arrival of technical assistance firms and training for various implementers. Additional support will be provided to prepare and coordinate in Hodh Chargui. The gradual transfer of capacity from the technical assistance firms and individual consultants to ministry staff is already under way and will continue. The transfer will also include additional responsibilities for the ministry in the coordination of the health aspects of the refugee response and in the development of an appropriate package of services to potentially include mental health and gender-based violence.
(c) Efficiency gains through cross-sector approaches. The link with the Tekavoul Program strengthens government’s systems and ensures better resource targeting. The initial phase of vouchers will be evaluated and adapted to further strengthen the links and to support care for the most vulnerable thus improving equity. This will be complemented by the identification and provision of support for vulnerable groups in the Hodh Chargui phase.
(d) Health financing and strategy. In conjunction with the Global Alliance for Vaccines and Immunization (Gavi), the Global Financing Facility (GFF), and the Primary Health Care Performance Initiative (PHCPI), the World Bank is providing multiple levels of analytical and technical support. With Gavi TF resources, the team is finalizing a fiscal space analysis to support the health financing strategy. With the GFF, the ministry is working with key United Nations and other donors to identify high-impact interventions that can be used in the planned RMNCAH+N investment case and potentially the next PNDS. Finally, the PHCPI vital signs analysis will support the increased focus on primary health care by identifying key weaknesses and feeding the responses into the development of the investment case.
V. APPRAISAL SUMMARY
A. Economic and Financial Analysis
Economic Analysis
48. The project will target increased provision and utilization of higher-quality services through a mix of supply- and demand-side incentives. Direct project benefits will include the survival of childbirth by
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more mothers and their infants, the ability for women to more closely achieve their desired fertility rates, improved management of childhood illnesses, and reduction in malnutrition.11 Indirectly, the project will increase the potential economic attainment of individuals through its interventions related to the first 1,000 days after conception. Over time, this will compound into macroeconomic effects.
49. The sector diagnostic highlights the resource imbalance in which high-impact, low-cost preventive programs (immunization, reproductive health, and malaria) receive 4 percent of resources, primary care receives 21 percent, and hospitals receive 60 percent. The overwhelming majority of facilities benefiting from INAYA will be health centers and health posts. This will support the most cost-effective approach to provide high-impact health services. The focus on results, including data quality, will also help the sector to more strategically align its resources to where it can most productively contribute. The results-oriented approach will also support the move toward program budgets in 2020 and beyond.
50. World Bank engagement in this project builds on the Public Expenditure Review (Report No. 110766-MU, October 2016) and the work on the RBF strategy for the sector. The value added of the institution going forward is both its technical ability to support the process with experiences gained elsewhere and the ability to help the Government mobilize additional resources to support the development of the sector. An example of this is the support for the Health Financing Strategy.
51. A cost-effectiveness evaluation was performed based upon the approach presented in Shepard, Zeng, and Nguyen (2016). The model developed using the Lives Saved Tool generated projections of the impact of the interventions over the project period and allowed for comparisons to a ‘no change’ case. The incremental lives saved were 1,140 children below the age of 1 month, 3,723 children between the ages of 1 and 59 months, and 128 mothers. Where possible, Mauritania-specific parameters were used, and the others were drawn from the best available evidence. The maternal lives saved is driven by the expected impact of project interventions, in particular on improved antenatal care and skilled birth attendance.
52. An incremental cost-effectiveness ratio (ICER) was estimated for the overall program cost. Trimming the global burden of disease estimates to reflect current life expectancy in Mauritania, the cost per year of life lost is estimated to be US$911. This is roughly three-quarter of the GDP per capita (US$1,390 in 2018). Assuming that children saved will have average productivity between the ages of 15 and 49 months and zero economic growth, the ICER is 7.23, primarily because of the overhead of setting up the program (capacity building and technical assistance in the first 18 months). Sensitivity tests using per capita growth of 3.6 percent per year (ICER =19.82) or 6.5 percent (48.34) or extending the productive life to 55 years (7.30), all show higher returns.
Financial Analysis
53. Mauritania is a resource-rich country and politically stable. It is a new lower-middle-income country, with gross national income per capita (current US$, Atlas method) estimated at US$1,160 in 2018. According to the WDI, Mauritania’s average per capita GDP growth is 0.414 percent (2008–2018) compared to the average of 0.966 for Sub-Saharan Africa.
11 According to MICS 2015, as many women (33.6 percent) express unmet contraceptive needs as those who report being satisfied (34.7 percent).
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54. The latest International Monetary Fund (IMF) Country Report No. 19/145 (May 2019) indicates that real economic growth in Mauritania has remained positive since 2015 and the forecast is for high positive growth until 2020. The recovery that started in 2016 and confirmed in 2017 and 2018 is expected to accelerate in 2019. Economic growth is expected to increase from 3.6 percent in 2018 to 6.7 percent in 2019, driven by domestic demand and diversification of economy. The improvement of the terms of trade following the increase in commodity prices and the exploitation in 2021 of the large Hmeyim gas field create favorable prospects for the development of the country’s economic activity and the significant improvement of the well-being of the population.
55. Health in Mauritania is primarily domestically financed, with 37 percent from the government, 51 percent from households, and only 8 percent from abroad in 2016.12 The IMF has warned that social programs will need to be sustained and strengthened through targeted transfers to offset the effects of fiscal consolidation. Government allocations for health have averaged 4.9 percent of the budget over 2002–2014.
56. This project, at US$24.5 million over three years, will be the largest flow of funds directly to health providers. The latest budget data for the MoH (2019) show that the capital budget was MRU 2.45 billion (US$69.1 million), of which 94 percent was executed. Comparatively, approximately US$8 million will be disbursed annually by the project between June 2020 and April 2023. Project inflows will be important but not overwhelming compared to government expenditure. Although a general consolidation of the fiscal position is anticipated, the Government has indicated that it will provide the US$3 million in CF over the project’s duration.
B. Technical
57. The technical design of the project remains broadly the same as under the parent project. Through demand- and supply-side interventions with the focus on the results, the project has mechanisms to ensure equity of access of quality health care for the poor and vulnerable population. The combination of schemes will also help reduce or remove the cost of care supported by poor and vulnerable population.
C. Financial Management
58. As for the parent project, the SG of the MoH will continue to be responsible for coordination, supported by the DAF for financial activities. The financial management (FM) arrangements for the AF will be based on the existing arrangements in place under the ongoing project. The interim unaudited financial reports for the ongoing project have been submitted on time with acceptable quality; the FM system operates satisfactorily; and an internal audit function in place performs well. The overall FM performance of the original project was rated Moderately Satisfactory further to the FM review undertaken on September 2019. However, the FM risk is Substantial: the assessment has revealed FM issues related to (a) lack of accountant in charge of project activities, (b) lack of implementation of external auditor and internal auditor recommendations, (c) lack of an updated FM manual that takes into account the new activities, and (d) irregular expenditures.
12 WHO Global Health Expenditure Database, Mauritania Health System Financing Profile, http://apps.who.int/nha/database/Country_Profile/Index/en, accessed November 11, 2019.
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59. In addition, the project accountant has resigned and there is a need to hire an accounting officer for the project.
60. As a result of the above-mentioned FM issues, the following mitigation measures should be taken:
(a) Implement external and internal audit recommendations
(b) Update the FM manual and clearly define role and responsibilities
(c) Document and regularize irregular expenditures
(d) Before the first disbursement of AF activities, recruit an Accounting and Financial Specialist with experience and qualification satisfactory to the World Bank.
61. The conclusion of the assessment is that the FM arrangements meet the World Bank’s minimum requirements under OP/BP 10.00. However, mitigation measures listed earlier should be implemented. The residual FM risk rating for the SG of MoH will be Moderate after implementation of these measures.
62. The FM arrangements for the project are presented in annex 4.
D. Procurement
63. The same procurement arrangements of the parent project will continue for the AF. Procurement under the parent project is the responsibility of the Financial Direction within the Health Ministry. In the last evaluation, procurement was rated Moderately Satisfactory. The overall procurement risk for the project is rated Moderately Satisfactory. The project's administrative, financial, and procurement procedures manual will be updated to integrate this AF.
E. Social (including Safeguards)
64. The overall Environmental and Social rating is Moderate. It is not anticipated that the project activities will have a large-scale negative impact on the environment and population. The parent project is currently rated low but had a moderate rating (Category B) at preparation, which was later downgraded.
65. Citizen engagement. The preparation of the AF is based on a participatory and consultative process. The preparation includes groups from the Government, development and humanitarian partners, members from key sectors (health, social protection, water and sanitation, governance, urban infrastructure, and services). All these actors contributed to defining the scope of the AF. During implementation, the citizen engagement processes of the parent project will continue. Specifically, PBF includes a beneficiary survey to assess user satisfaction with health services. This mechanism will be implemented with local NGOs and CBOs. The survey results will be monitored in PBF portal and in the project’s Results Framework.
F. Environment (including Safeguards)
66. This AF will make use of the Environmental and Social Framework safeguards policies to scale up the INAYA activities to Hodh Chargui, as the proposed scale-up activities will not trigger any additional
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safeguards policies. OP 4.01, Environmental Assessment, remains relevant to (a) guide the design, construction, and use of minor quality upgrades to health facilities in Hodh Chargui, and (b) provide quality guidelines to worker and patient health and safety with respect to infection control, sanitation, and medical waste management. The scope of the proposed scale-up can be accommodated by existing capacity in the Directorate of Public Hygiene and the Environmental Specialist in INAYA. The client has updated the Environmental and Social Management Framework (ESMF) of INAYA to include the AF activities for Hodh Chargui and it has been disclosed on the MoH’s website and the Worldbank’s website on January 15, 2020. The ESMF makes use of a National Biomedical Waste Management Plan in place, supported by the MoH as well as the Ministry of Environment, World Health Organization, Gavi, and UNICEF.
G. Other Safeguard Policies (if applicable)
67. No other safeguards policies are triggered.
VI. WORLD BANK GRIEVANCE REDRESS
68. Communities 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 or the WB’s Grievance Redress Service (GRS). The 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 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.
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VI SUMMARY TABLE OF CHANGES
Changed Not Changed
Project's Development Objectives ✔ Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Implementing Agency ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔
VII DETAILED CHANGE(S)
PROJECT DEVELOPMENT OBJECTIVE
Current PDO The Project Development Objective is to improve utilization and quality of Reproductive Maternal Neonatal and Child Health (RMNCH) services in selected regions, and, in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency.
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Proposed New PDO The Project Development Objective is to improve utilization and quality of Reproductive, Maternal, Neonatal, and Child Health (RMNCH) services in selected regions.
COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Improving Utilization of 10.50 Revised Improving utilization of 28.50 Quality RMNCH Health quality RMNCH Services Services through PBF through performance- based financing (PBF) Increasing Demand for 2.50 Revised Support to increasing 8.00 Health Services demand for health services Capacity Building and 4.00 Revised Capacity building and 7.00 Project Management Project Management Contingency Emergency 0.00 Contingency Emergency 0.00 Response Component Response Component TOTAL 17.00 43.50
LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IDA-D1890 Effective 30-Jun-2021 30-Jun-2021 30-Apr-2023 30-Aug-2023
Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative
2017 0.00 0.00
2018 1,654,367.00 1,654,367.00
2019 3,182,694.00 4,837,061.00
2020 4,634,523.00 9,471,584.00
2021 4,741,979.00 14,213,563.00
2022 4,853,897.00 19,067,460.00 2023 3,932,540.00 23,000,000.00
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SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating
⚫ Substantial ⚫ Substantial Political and Governance ⚫ Moderate ⚫ Moderate Macroeconomic ⚫ Moderate ⚫ Moderate Sector Strategies and Policies ⚫ Moderate ⚫ Moderate Technical Design of Project or Program Institutional Capacity for Implementation and ⚫ Moderate ⚫ Moderate Sustainability ⚫ Moderate ⚫ Moderate Fiduciary ⚫ Moderate ⚫ Moderate Environment and Social ⚫ Low ⚫ Low Stakeholders ⚫ Substantial ⚫ Substantial Other Overall ⚫ Substantial ⚫ Substantial
LEGAL COVENANTS2
LEGAL COVENANTS – Health System Support Additional Financing (P170585) Sections and Description SCHEDULE 2.Section I.A.1. The recipient shall, b) maintain a technical working group at all times during Project implementation, to provide orientation for regional PBF implementation; and c) establish and maintain a multisectoral working group on the refugee strategy no later than three (3) months after the Effective Date, or a later date agreed upon in writing with the Association; all with the terms of reference and composition satisfactory to the Association; SCHEDULE 2.Section I.A.1. B. The recipient shall recruit or designate for the Project no later than three (3) months after the Effective Date, or a later date agreed upon in writing with the Association: a) two PBF specialists, b) a coordination and communications specialist, and c) a monitoring and evaluation specialist; all with terms of reference and qualifications satisfactory to the Association. SCHEDULE 2.Section I.A.2. The Recipient shall cause the Ministry of Health to maintain until the completion of the Project, a Ministry of Health Steering Committee, with terms of reference, resources and key staff satisfactory to the Association, including responsibility for providing Project oversight. To that end, the Recipient shall no later than three (3) months after the Effective Date, or a later date agreed upon in writing with the Association, provide evidence satisfactory to the Association that said terms of reference encompass the additional Project activities.
Conditions
Type Description Effectiveness The Association is satisfied that the Recipient has an adequate refugee protection framework;
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Type Description Effectiveness the Recipient has updated the Administrative and Financial Manual of Procedures, the PBF Manual, and the Tekavoul Manual, to reflect the additional Project activities, all in form and substance acceptable to the Association; Type Description Effectiveness the Subsidiary Agreement has been duly authorized and executed, in form and substance acceptable to the Association; and, Type Description Effectiveness the Recipient shall have recruited for the Project an accounting specialist with terms of reference, qualifications and experience satisfactory to the Association. Type Description Disbursement (b) for payments under Category (2), until and unless the financing under Category (7) under the Original Financing Agreement, has been fully disbursed or committed; or,
Type Description Disbursement (c) for payments under Category (4), until and unless the financing under Category (4) under the Original Financing Agreement, has been fully disbursed or committed; or,
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VII. RESULTS FRAMEWORK AND MONITORING
Results Framework COUNTRY: Mauritania RESULT_NO_PDO Health System Support Additional Financing Project Development Objective(s)
The Project Development Objective is to improve utilization and quality of Reproductive, Maternal, Neonatal, and Child Health (RMNCH) services in selected regions.
Project Development Objective Indicators by Objectives/ Outcomes
RESULT_FRAME_T BL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3
Improve utilization and quality of Reproductive, Maternal, Neonatal, and Child Health services
Births attended by skilled health 13,020.00 26,150.00 60,140.00 96,600.00 135,360.00 staff (Number) Rationale: Action: This indicator has been Cumulative number, includes implementation in a third region (Hodh El Charbi) starting in 2020. Revised
Births attended by skilled health staff among the refugee 0.00 6,960.00 population (Number)
Action: This indicator is New
Pregnant women completing four antenatal care visits to a health 1,740.00 92,340.00 facility during pregnancy (Number) Action: This indicator has been Rationale: Revised
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RESULT_FRAME_T BL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018-2019; 3 regions from 2020 to 2022.
Pregnant women completing four antenatal care visits to a 0.00 5,890.00 health facility among the refugee population (Number)
Action: This indicator is New
Children 12-23 months fully 19,390.00 28,600.00 55,080.00 84,540.00 117,470.00 immunized (Number) Rationale: Action: This indicator has been Addition of a third region Hodh el Charbi. Cumulative number. Includes 2 regions in 2018 and 2019; 3 regions from 2020 to 2022. Revised
Children 12-23 months fully immunized among the refugee 0.00 5,820.00 population (Number)
Action: This indicator is New
Average score of the quality of care 14.00 28.00 45.00 60.00 checklist (Percentage) Rationale: Action: This indicator has been Addition of a third region - Hodh el Charbi - for 2020 to 2022. Revised
Refugee populations benefiting from preventive and curative interventions provided by the FOSA 0.00 59,090.00 66,020.00 151,250.00 (PMA + PCA) (Number) Action: This indicator has been
Revised
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PDO Table SPACE
Intermediate Results Indicators by Components
RESULT_FRAME_T BL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3
Improving Utilization of Quality RMNCH Health Services through PBF
Women accepting modern family planning methods (Number) 6,690.00 13,010.00 52,260.00 99,300.00 164,560.00 Rationale: Action: This indicator has been Revised Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018; 3 regions from 2020 to 2022.
Women refugees accepting modern family planning 0.00 20,110.00 methods (Number)
Action: This indicator is New
People who have received essential health, nutrition, and population 0.00 345,750.00 (HNP) services (CRI, Number) Rationale: Action: This indicator has been Addition of a third region Hodh el Charbi. Cumulative number. Includes 2 regions in 2018 and 2019; 3 regions from 2020 to 2022. Revised
Number of children immunized 0.00 117,470.00 (CRI, Number) Rationale: Action: This indicator has been Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018; 3 regions from 2020 to 2022. Revised
Number of women and children who have received basic 0.00 12,840.00 31,810.00 52,880.00 78,270.00 nutrition services (CRI, Number)
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RESULT_FRAME_T BL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Rationale: Action: This indicator has been Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018-2019; 3 regions from 2020 to 2022. Revised
Number of deliveries attended by skilled health personnel (CRI, 0.00 135,360.00 Number) Rationale: Action: This indicator has been Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018-2019; 3 regions from 2020 to 2022. Revised
Health facilities without essential medicines stockouts over the last 28.00 94.00 three months (Percentage) Rationale: Action: This indicator has been Revised Addition of a third region - Hodh el Charbi - for 2020 to 2022.
Basic equipment availability 19.90 94.00 (Percentage) Rationale: Action: This indicator has been Addition of a third region - Hodh el Charbi - for 2020 to 2022. Revised
Visits by under-5 children to health 43,620.00 153,450.00 355,640.00 577,110.00 822,020.00 facilities (Number) Rationale: Action: This indicator has been Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018-2019; 3 regions from 2020 to 2022. Revised
Post-natal consultation visits 3,560.00 6,960.00 20,080.00 35,740.00 53,550.00 (Number) Action: This indicator has been Rationale: Revised
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RESULT_FRAME_T BL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Addition of a third region, Hodh El Charbi. Cumulative number. Includes 2 regions in 2018-2019; 3 regions from 2020 to 2022.
Post-natal consultation visits among the refugee population 0.00 6,140.00 (Number)
Action: This indicator is New
User satisfaction with health care 0.00 60.00 65.00 70.00 services (Percentage) Action: This indicator has been Revised User satisfaction with health care services among the refugee 0.00 75.00 population (Percentage)
Action: This indicator is New
Number of poor people and / or eligible refugees who have 0.00 7,460.00 15,860.00 25,595.00 benefited from free curative consultations (Number)
Action: This indicator is New
Support to increasing Demand for Health Services (Action: This Component has been Revised)
Pregnant women referred for ANC1 by community health workers 0.00 3,010.00 9,890.00 17,300.00 252,820.00 (cumulative) (Number) Rationale: Action: This indicator has been Addition of a third region Hodh el Charbi. Cumulative number. Includes 2 regions in 2018 and 2019; 3 regions from 2020 to 2022. Revised
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RESULT_FRAME_T BL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Districts that implement the community health strategy 0.00 12.00 (Number) Rationale: Action: This indicator has been Addition of the 6 districts from the Hodh el Charbi region Revised
Conditional cash transfer beneficiaries (% eligible households 0.00 50.00 60.00 70.00 receiving full transfers) (Percentage) Rationale: Action: This indicator has been Revised Addition of a third region - Hodh el Charbi - for 2020 to 2022.
Number of home visits received by children 0-5 years old (cumulative) 0.00 15,580.00 34,220.00 54,990.00 (Number) Rationale: Action: This indicator has been Addition of a third region - Hodh el Charbi - for 2020 to 2022. Revised
Capacity Building and Project Management
Health facilities transmitting complete HMIS reports on time 0.00 95.00 (Percentage) Rationale: Action: This indicator has been Addition of a third region - Hodh el Charbi - for 2020 to 2022. Revised
Health facilities with a functional CoSa health committee (%) 0.00 80.00 90.00 90.00 (Percentage) (Percentage)
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RESULT_FRAME_T BL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 Rationale: Action: This indicator has been Addition of a third region - Hodh el Charbi - for 2020 to 2022. Revised
Grievances registered related to delivery of project benefits 0.00 65.00 70.00 75.00 satisfactorily addressed (Percentage)
Action: This indicator is New
IO Table SPACE
Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Births attended by skilled health staff. Cumulative The data will be Annual HMIS HMIS Births attended by skilled health staff number. Includes 2 regions extracted from the HMIS
in 2018-2019; 3 regions from 2020 to 2022. The data will be Births attended by skilled health staff Annual HMIS HMIS extracted from the HMIS among the refugee population
HMIS - Cumulative number. Monthly HMIS The data will be Pregnant women completing four Includes 2 regions in 2018 Annual indicator extracted from the FBR Unit/HMIS antenatal care visits to a health facility and 2019; 3 regions from (ANC4 + urine HMIS during pregnancy 2020 to 2022. test)
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Pregnant women completing four antenatal Pregnant women completing four The data will be care visits to a health Annual HMIS FBR unit/HMIS antenatal care visits to a health extracted from the HMIS facility during her facility among the refugee population pregnancy among the refugee population Cumulative number. The data will be Includes 2 regions in 2018 Annual HMIS FBR Unit/HMIS Children 12-23 months fully immunized extracted from the HMIS and 2019; 3 regions from
2020 to 2022. Children 12-23 months fully The data will be Annual HMIS FBR Unit/HMIS immunized among the refugee extracted from the HMIS
population The data will be Semi- Average score of the quality of care RBF reports extrcated from the RBF RBF Technical Unit Annually checklist reports
Cumulative number of refugee receiving Refugee populations benefiting from PBF portal/ PBF verification of preventive and curative Quarterly Technical unit FBR preventive and curative interventions verification services PBF supported services in provided by the FOSA (PMA + PCA) health facilitates in the project regions ME PDO Table SPACE
Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Cumulative number. HMIS, FBR The data will be Women accepting modern family Annual FBR Technical Unit Includes 2 regions in 2018 portal collected from the HMIS planning methods and 2019; 3 regions from
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2020 to 2022.
The data will be Women refugees accepting modern Annual FBR Portal collected from the FBR FBR technical unit
family planning methods portal
People who have received essential The data will be Annual HMIS HMIS health, nutrition, and population (HNP) extracted from the HMIS services The data will be Annual HMIS FBR Technical Unit/HMIS Number of children immunized extracted from the HMIS
The data will be Number of women and children who Annual HMIS FBR Technical Unit/HMIS extracted from the HMIS have received basic nutrition services
The data will be Number of deliveries attended by Annual HMIS FBR Technical Unit/HMIS extracted from the HMIS skilled health personnel
RBF information system as part Health facilities without essential Semiannua Data extracted from RBF of verification. RBF technical unit medicines stockouts over the last three lly. portal Baseline months derived from HMIS data.
RBF information Semiannua The data will be system as part RBF Technical unit Basic equipment availability lly extracted from the HMIS of verification.
Baseline derived from
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HMIS data.
Cumulative number of visits to health facilities Semiannua The data will be Visits by under-5 children to health from children 0-5 years old. HMIS FBR technical Unit/HMIS lly extracted from the HMIS facilities Includes 2 regions in 2018-
2019 and 3 regions from 2020 onwards Semiannua The data will be HMIS FBR Technical unit/HMIS Post-natal consultation visits lly extracted from the HMIS
The data will be Post-natal consultation visits among Annual HMIS FBR technical unit/HMIS extracted from the HMIS the refugee population
The data will be Annual RBF reports extracted from RBF RBF technical unit User satisfaction with health care services reports
The data will be User satisfaction with health care Annual RBF reports extracted from RBF RBF technical unit services among the refugee reports population
The data will be Number of poor people and / or eligible Annual RBF portal extracted from the RBF RBF Technical Unit refugees who have benefited from free portal curative consultations
The data will be Semiannua Pregnant women referred for ANC1 by RBF reports extracted from the RBF RBF technical unit lly community health workers (cumulative) reports
Districts that implement the community Annually RBF Report Data will be extracted RBF Technical Unit health strategy from the RBF reports
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Tekavoul The data will be Conditional cash transfer beneficiaries (% Tekavoul and RBF Annual information extracted from the RBF eligible households receiving full technical unit system reports transfers)
Cumulative number of The Data will be households visits from Number of home visits received by FBR Portal extracted from the RBF FBR Technical Unit community health workers children 0-5 years old (cumulative) portal received by children 0-5
years old Semiannua The data will be Health facilities transmitting complete HMIS HMIS lly extracted from the HMIS HMIS reports on time
The data will be Health facilities with a functional CoSa Annual FBR portal extracted from the FBR FBR Technical Unit health committee (%) (Percentage) portal
Grievances registered Grievances registered related to delivery Data extracted from the related to delivery of Annual RBF reports RBF technical unit of project benefits satisfactorily RBF reports project benefits that are addressed actually addressed (%) ME IO Table SPACE
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ANNEX 1: OUTCOMES ON SELECTED RMNCH AND NUTRITION INDICATORS
Indicators 2007 2011–2013 2015–2017 Change Population health Infant mortality per 1,000 live births 77 75 43 ++ Under-5 mortality per 1,000 live births 122 115 54 ++ Total fertility rate 5.1 4.7 4.6 ++ Low birth weight (percent) 30 35 37 -- Stunting of children under 5 years (percent) 27 28 20 + Maternal mortality ratio 744 704 582 ++ Utilization of RMNCH and nutrition services Women utilizing modern contraceptives (percent) 9 11 18 + Unmet demand for family planning (percent) 32 31 34 NC Prenatal care (percent) 75 84 86 ++ Women having four or more prenatal visits (percent) 48 63 ++ Births assisted by qualified personnel (percent) 57 65 69 ++ Children 12–23 months vaccinated for measles (percent) 67 67 78 ++ Children 12–23 months completely vaccinated (percent) 36 38 49 ++ Reproductive health and nutrition behaviors Girls 15–19 years married (percent) 25 26 28 NC Female genital mutilation (percent) 72 69 67 NC Children 0–5 months exclusively breastfed (percent) 12 27 41 ++ Children 6–23 months having minimum meals (percent) 19 37 ++ Water Households with access to an improved water source 6 53 62 ++ (percent) Quality, availability, and coverage of services Facilities with essential medicines (percent) 28 26 NC Facilities providing preventive package for children 54 58 NC (percent) Facilities offering family planning services (percent) 59 67 + Facilities with personnel trained to provide prenatal care 32 58 ++ (percent) Facilities providing assisted delivery services (percent) 55 69 + Facilities providing vaccination services (percent) 52 65 ++ Utilization of health service package (percent) 44 41 60 ++ Birth registration (percent) 62 59 66 NC Health financing Government health expenditure per capital (US$) 32 32 60 ++ Out-of-pocket health care expenditure (percent) 67 65 51 ++ Total expenditure on health as a percentage of gross 3.6 3.1 4.2 ++ domestic product Sources: MICS 2007, 2011, 2015; WDI; SARA 2013, 2016; HMIS 2017. Note: NC = no change; + = improvement of at least 5 percent; ++ = improvement of at least 10 percent; --= deterioration of at least 5 percent.
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ANNEX 2: REFUGEES AND HOST COMMUNITIES—WORLD BANK PROGRAM IN MAURITANIA
Country Context
1. One of the more stable countries across the Sahel region, Mauritania hosts a large population of refugees from neighboring conflicts. As of October 2019, Mauritania hosts 59,000 refugees, 95 percent of whom are Malians who have been arriving in the country since 2012. In addition to the large Malian population, there are around 3,000 urban refugees and asylum seekers, mostly from the Central African Republic, Syria, and Côte d’Ivoire. Most of the refugees in Mauritania live in the arid moughata’a (district) of Bassikounou, located approximately 50 km from the Malian border. The Malian refugee population is predominantly concentrated in the M’bera refugee camp, with some small enclaves scattered in host communities near the camp.
2. Mauritania is a party to several international conventions related to refugees. These include the 1951 United Nations Convention Relating to the Status of Refugees, the 1967 United Nations Protocol Relating to the Status of Refugees, and the 1969 Organization for African Unity (OAU) Convention Governing the Specific Aspects of Refugee Problems in Africa. A draft law providing the basis for a national asylum system was developed in 2014 and reviewed by the relevant Government ministries in 2016. The bill is still pending submission to the Parliament. The new law would formalize refugee protection, including the commitment to not force refugees to return to insecurity and/or persecution in their country of origin (the principle of ‘non-refoulement’), grant civil rights, and provide access to social services. In the interim, a decree (number 022 of 2005) regulates the application of the norms contained in the 1951 United Nations Convention and the 1969 OAU Convention. The World Bank and UNHCR will continue the dialogue with the interministerial National Consultative Commission on Refugees (Commission Nationale Consultative sur les Réfugiés [CNCR]) on the progress of the bill.
3. Assistance for refugees in Mauritania is coordinated by the Ministry of the Interior and Decentralization, through the CNCR. The CNCR has the authority to recommend decisions on the recognition of refugee status for urban refugees, based on positive individual assessments carried out by UNHCR. Refugees from Northern Mali receive their status on a prima facie basis. The National Agency for Identification and Population Registration (Agence Nationale du Registre des Populations et des Titres Sécurisés) is responsible for the issuance of identity cards and has set up a field office in the M’bera camp.
4. Humanitarian actors, led by UNHCR and WFP, have traditionally provided the bulk of assistance to refugees and, to some extent, host communities in Mauritania. Status–as refugee—rather than poverty/vulnerability is the key targeting factor for assistance. Direct support to refugees has been accompanied by the provision of basic social services and activities to promote self-reliance and income generation. However, many of these services are of short duration. Humanitarian actors have opened their services to and made some smaller investments for host populations. However, their support has focused predominantly on refugees and their immediate needs, rather than on social, economic, and human capital development to ensure long-term development of both refugee and host communities.
5. Until recently, the southern border regions (Hodh Chargui and Hodh El Gharbi) were not benefiting much from development assistance from the international community but this is changing fast. The Sahel Alliance, a multidonor initiative that aims to increase financial and technical support to the G5-Sahel countries over 2018–2023, decided to concentrate its efforts there. Similarly, the European
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Union is supporting an agriculture and pastoralist project in the area. From 2020 onwards, the African Development Bank also plans to support priority infrastructure investments in sectors of wider relevance (Declic II project). The African Development Bank will intervene in these two regions through a project to support the promotion of micro and small enterprises and youth employment more broadly (PAMPEJ).
6. The local government has limited capacity to support the increasing population and changing service and infrastructure needs in the region. The refugees increase the size of the poor and vulnerable population in the region. Overall, there is weak capacity both in the Bassikounou moughata’a as well as throughout the region to coordinate an integrated and cost-effective response for regional development. The M’bera refugee camp is an emerging economic center of activities in the subregion, with impacts on key resources such as water, pasture, and firewood. At present, the provision of services and resource management run in parallel between the camp and host region, with little coordination between UNHCR and the relevant line ministries, which limits synergies and cost-effectiveness.
7. Conscious of the likely prolonged nature of forced displacement in the country, the Government of Mauritania is strongly committed to ensuring the protection of refugees while promoting their increased self-reliance and the resilience of the host communities. In its Refugee and Host Community Policy Development Letter, the Government stressed this commitment, including the adoption of a national asylum law. The Government has laid out the following three strategic directions for the national short- and medium-term response to the situation: (a) transforming local economic opportunities in a timely, sustainable, and inclusive manner; (b) improving social protection and access to basic services; and (c) strengthening the governance and management of the refugee response.
8. In December 2019, during the first World Refugee Forum, Mauritania, represented by the Minister of Foreign Affairs, made (or reiterated) strong commitments in favor of local solutions for all refugees in Mauritania: (a) to adopt the national asylum law by 2020; (b) to register all refugees with the civil registry services to allow them to obtain a national identification number, issue them a secure national identification card, and allow their inclusion in national systems, including statistical systems; (c) to ensure the inclusion of refugees in health services on the same basis as nationals; and (d) to ensure that refugees have the same conditions of access to the labor market as nationals.
World Bank Program for Refugees and Host Communities in Mauritania
9. The World Bank Board approved Mauritania’s eligibility for the IDA18 RSW in November 2018. Mauritania currently meets the three eligibility criteria: (a) the number of UNHCR-registered refugees, including persons in refugee-like situations, and it hosts at least 25,000 or 0.1 percent of the country population; (b) the country adheres to an adequate framework for the protection of refugees; and (c) the country has an action plan, strategy, or similar document in place. The RSW allocation will enable the World Bank to support the implementation of a program to support refugees and host populations in Mauritania.
10. The World Bank Group has adopted a programmatic multisectoral approach to support the implementation of the Government’s strategy, through policy dialogue, operations, and analytical work. The program will consider the fact that this is a new area for the World Bank Group and will complement UNHCR’s interventions and policy work. It will also factor in the challenge stemming from a
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lack of existing World Bank Group engagement in the refugee-affected areas and in the broader region, which borders Mali.
11. The proposed overall development objective of the program is to improve the delivery of basic social services and infrastructure for refugees and host communities in targeted areas. Specifically, this will be achieved through strengthening the institutional capacity of the Mauritanian Government’s social services and selected infrastructure within the two Hodhs. A key synergy across the World Bank programs will be to support the inclusion of the poorest/most vulnerable refugee and host communities’ households in targeted interventions to address inequities and promote access to services. Initially the multisectoral program will include sectors prioritized by the Government: (a) health, (b) social protection, (c) water and sanitation, and (d) urban infrastructure—including electricity—and services in intermediate cities. This overall development objective is aligned with the Government strategy, the World Bank Group CPF, and the focus areas of the Sahel Alliance.
12. The RSW resources will provide support to existing projects, building on existing partnerships and delivery mechanisms, or to projects under preparation to extend their activities in the targeted areas. The tentative breakdown of the financing between projects is presented in table 2.1.
Table 2.1. RSW Program in Mauritania From National From the RSW Project PDO PBA (IDA18) (US$, millions) (US$, millions) Social Safety Net To increase the effectiveness and efficiency of 27 System Project II the nationwide adaptive social safety net system (P171125) and its coverage of poor and vulnerable households, with targeted social transfers, including in refugee and host communities. Health System Support To improve utilization and quality of 8 Additional Financing Reproductive Maternal Neonatal and Child (P170585) Health services in selected regions Water and Sanitation To Increase access to improved water and 30 67 Project (P167328) sanitation services in selected rural areas and small towns, and to strengthen the operational and monitoring performance of sector institutions. Decentralization and To improve (i) access to services for the 46 Productive population and economic actors in selected Intermediate Cities localities; and (ii) Local Governments’ capacities Support Project in public FM (P169332) Total 111 67
13. The refugees and host communities’ program will strengthen the ’spatial approach’ developed by the World Bank in Mauritania (see annex 6) and enhance cross-sectoral collaboration between several global practices including Social Protection, Health, Urban Development, Water, and Energy. The spatial approach will also help generate links between the host regions and the camp as an economic center. The program will seek to maximize synergies with other existing and pipeline projects (such as the Sahelian
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Regional Support Project, Projet Régional d'Appui au Pastoralisme au Sahel or the Mauritania Youth Employability project). Given the overall development challenges facing the region, many of which are closely linked to efforts at the national level, the World Bank Group could take advantage of many of its core areas of engagement to mitigate some of the existing pressures and to benefit host communities and/or refugees. The World Bank program for refugees and host communities will seek to complement other partners’ interventions, considering the value added and current expertise of the World Bank Group in Mauritania as well as donors’ ongoing and upcoming operations.
14. A coordination framework will be developed for monitoring and planning synergistic actions across World Bank projects, as well as with other development and humanitarian partners to effectively support the Government’s strategy. This framework will be developed in the first year of program implementation. The idea is to use a coordinated approach to synergize underlying constraints to build human capital and sustainable development processes in the border regions.
15. Refugee and host community focal points. Two refugee and host community focal points based in Hodh Chargui will be recruited to ensure the permanent presence of the projects with RSW-funded components in this area and dialogue with other actors working with refugees and host populations. The focal points will have the responsibility to update the four projects’ coordination teams on the refugees and host communities’ situation and to identify any critical point related to the implementation of the projects in the related areas. The focal point based in Nema will be financed under the Decentralization and Productive Intermediate Cities Support Project’ (P169332). The focal point based in Bassikounou will be financed under this proposed Safety Net System Project II (P171125).
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ANNEX 3: THEORY OF CHANGE
1. Coordination with the humanitarian partners, including joint planning, studies, and M&E will support the transition of refugee services to the Government system, reinforcing the refugee strategy and joint learning to address needs of refugees as well as issues of equity in service delivery in the host population. M&E will involve triangulation of data from multiple partners, including information on the quality and impact of services on beneficiaries (both refugees and host communities) and changes in the refugee situation. Joint studies will provide learning on how to deliver services to refugees, such as mental health, and address issues of equity in service delivery. Joint planning of PBF will faciliate learning around results-based methods and how to use them to deliver the package of services. A road map is also being developed to support the transition of services from UNHCR to the Government system, which will be tracked quaterly.
2. PBF incentives will support health personnel including workers in the M’bera camp to deliver a complete package of RMNCH and nutrition services in their facilities (health posts, health centers, and hospitals). PBF payments will be provided to public facilities as well as nongovernment facilities, such as in the M’bera camp on a per capita basis, that is, per women or child benefiting from each service in the PBF Manual. This will incentivize facilities to increase the number of women and children utilizing RMNCH and nutrition services.
3. PBF equity bonuses will enable health facilities to waive/reduce fees to promote the utilization of RMNCH and nutrition services by refugees and the poor. Facilities will receive a higher PBF payment for providing services to these groups to recover costs, motivating them to reach more refugee and poor beneficiaries.
4. PBF grants and quality bonuses will support facilities to improve the quality of services. Small grants will enable all health facilities, particularly in low-equipped settings, to plan investments to improve services or newly offer missing services. Quality bonuses will further motivate health personnel and refugee workers to progressively improve the quality score of the package of services in their health posts, health centers, and hospitals. The quality bonuses will provide a higher payment to facilities that can deliver services that meet quality standards as per a quarterly assessed quality assessment score.
5. Implementation of CCTs and the NCHS will increase demand for child health services, reach rural areas, and mobilize behavioral change to utilize services. PBF will contract a network of community actors (health agents, refugee leaders, CBOs, and so on) to conduct monthly visits to reach households with young children, SBCC activities to promote knowledge and behavioral changes to utilize services, and referral of women to health facilities to utilize prenatal care, assisted delivery, and other services. These activities will be reinforced by local NGOs recruited in selected moughata’a and the M’bera camp. In addition, the extreme poor and the most vulnerable refugee households will receive cash transfers to promote their utilization and completion of vaccination, birth registration, and nutrition services. Eligible beneficiaries for CCTs as well as equity bonuses will be identified jointly by UNHCR and Tekavoul.
6. Institutional capacity of the health system will be built nationally and in Hodh Chargui to manage refugee-sensitive services and provide lessons to improve delivery of services in the next PNDS. This will be through coordination around operational guidelines, planning, and reforms to the health pyramid to learn how to intergate refugee populations and facilities in the M’bera camp in the
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Government health system. Moreover, central units in the MoH, decentralized government in the wilaya, and local government leaders (including in the M’bera camp) will receive PBF contracts, with a clear acocuntability framework for coordinating and planning services, conducting supervision of all facilities and providing techncial support to services. Techncial assistance will ensure support to implement PBF, improve the HMIS system, implement community mobilization, and learn how to addess refugee needs, filling gaps in techncial knowledge and experience.
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ANNEX 4. FINANCIAL MANAGEMENT AND DISBURSEMENTS ARRANGEMENTS
1. External audit. The terms of reference of the original project will be expanded to include the AF activities. Consolidated audited financial statements (original project and AF) will be submitted to IDA within six months after year end. The auditor will issue an opinion on the audited project’s consolidated financial statements and in compliance with the International Federation of Accountants and a specific opinion on additional activities will be required. The external auditors will prepare a Management Letter giving observations and comments and providing recommendations for improvements in accounting records, systems, controls, and compliance with financial covenants in the Financial Agreement.
2. Internal control arrangements. The existing manual of administrative financial and accounting procedures will be updated to include AF activities and clearly define role and responsibilities. The internal auditor already in place will include this AF in his scope of activities.
3. Accounting arrangements. The current accounting standards in use in Mauritania are acceptable to the World Bank. They are used for ongoing World Bank-financed project and will be applicable for this AF. The existing multiprojects’ computerized accounting system in place will be customized to integrate this AF’s accounts.
4. Reporting and monitoring. The unaudited interim financial report format of the ongoing project will be updated to include the AF. It will comprise sources and uses of funds according to project expenditures classification and a comparison of budgeted and actual project expenditures (commitments and disbursements) to date and for the quarter. The Project Implementing Unit will submit the financial reports to the World Bank within 45 days following the end of each calendar quarter. The SG of the MoH will produce the project’s annual financial statements, which will include the AF and will comply with Mauritania’s standards and World Bank requirements.
5. Budgeting arrangements. Periodic reports of budget monitoring variance analysis and recommendations should be prepared by the SG of the MoH’s FM team on a quarterly basis. The budgeting process and monitoring will be defined in the updated Administrative and Accounting Manual of Procedures.
6. Disbursement arrangements and flow of funds. Disbursement for the project will follow the existing disbursement arrangements for the original project. Disbursements would be transaction-based whereby withdrawal applications will be supported with Statement of Expenditures. Documentation will be retained at the SG of the MoH for review by World Bank staff and auditors. The Disbursement and Financial Information Letter (DFIL) provides details of the disbursement methods, required documentation, Designated Account’s ceiling, and minimum application size. The Financial Agreement was also discussed and agreed during negotiations.
7. A Designated Account for the AF will be opened in the Central Bank of Mauritania and a Project Account in local currency will be opened in a commercial bank in Nouakchott on terms and conditions acceptable to the World Bank.
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ANNEX 5. CLIMATE CHANGE SCREENING AND CLIMATE CO-BENEFITS
1. Mauritania is vulnerable to climate change with more intense rainfall in shorter periods in the southern regions leading to frequent flooding and deteriorating water quality. Higher mean annual temperatures and long-lasting heat waves are also projected, which could lead to food insecurity due to (a) lengthy periods of drought reducing the amount of available grazing land and (b) reduced fishery productivity from altered water quality and lack of oxygen content in the lakes. These climate events have adverse health consequences such as malnutrition and increases in vector-borne and waterborne diseases. In particular, an increased incidence or changed distribution is projected for mosquito-borne diseases such as malaria, waterborne diseases such as cholera due to the lack of quality/viability of water resources, vector-borne and parasitic diseases such as schistosomiasis and soil-transmitted helminths, and mental health issues due to the potential financial stress from lowered pastoral production of livestock and agricultural output.
2. It is important to note that there will be regional differences; Guidimagha, Hodh Gharbi, and Hodh Chargui, where the project will take place, are at increased risk of waterborne diseases such as cholera and diarrheal diseases due to flooding, overcrowding, and poor sanitation. In August 2019, Guidimagha experienced an intense flooding event that led to damage of general infrastructure, houses (homelessness), and roads and washed away household food stocks. There was a risk of outbreak of waterborne diseases in the flooded areas. Refugees that have resettled in Hodh Chargui are at even greater risk due to refugee camp conditions and the increased pressure on freshwater resources and food production in an already vulnerable region. Therefore, climate change can be an additional stressor by degrading water resources and contributing to land degradation, which can increase the risk of intercommunity conflicts.
3. The AF will support Mauritania through the following adaptation activities:
(a) Component 1 (US$28.5 million equivalent). The PBF business plans for health facilities will integrate climate-resilient activities such as (i) training health workers (that is, community health workers) on coping mechanisms for working in higher temperatures due to heat stress/exhaustion concerns and improving awareness of climate-related health issues; (ii) including climate-resilient strategies in SBCC sessions, which will enable community outreach to raise awareness of preparedness and response to climate shocks, particularly as it relates to nutrition; and (iii) ensuring adequate stocks of medicine and other commodities in case of a climate-related disaster. Similar to the original project, a small grant will be provided to health facilities that meet certain quality-related criteria. This will include minor repairs and water and sanitation and waste management measures that will reduce the risk of damage to the facilities and prevent exposure to hazardous material in case of a flood event or another climate-related disaster that could increase morbidity and mortality rates.
(b) Component 2 (US$8 million equivalent). The CCTs that will be provided to the poor and refugee populations to promote and facilitate access to health services will enable beneficiaries to have additional funds to deal with adverse shocks related to climate change, among other needs. Beneficiaries that receive CCTs also attend quarterly sessions organized by Tekavoul and UNHCR that are mandatory to ensure beneficiaries are adhering to various conditionalities. These sessions will also include SBCC, which will be used to provide more
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information on the impacts of climate change on children and women’s health. This would include themes such as (i) adapting to climate-induced food shortages to reduce the chances of an increase in malnutrition rates, (ii) how to manage post-traumatic stress from climate- related disaster, and (iii) prevention and response to sexual and gender-based violence after a climate-related disaster (that is, where to seek assistance).
(c) Component 3 (US$7 million equivalent). The MoH’s capacity will be strengthened in various areas, one of which will be to provide technical assistance on building a climate-resilient health system. This will include an assessment to identify the gaps for a climate-resilient health system in Mauritania, strengthening M&E such as the HMIS and database management by including climate data, which will strengthen the early warning system and enable improved monitoring of disease outbreaks (that is, vector borne and waterborne) and disaster risk management. The biomedical waste management plan will also include climate-resilient measures for the selected wilayas.
4. The project will support Mauritania through the following mitigation activities under Component 1 (US$28.5 million equivalent) and Component 2 (US$8 million equivalent). Health facilities will be provided energy-efficient light bulbs and some health posts will be provided with solar panels. Furthermore, women will be provided with more information on how to prevent certain health hazards through the SBCC sessions such as using cleaner technologies rather than biomass fuels for cooking. This will reduce the environmental impact as these technologies are more energy efficient, reduce local deforestation impacts, and improve indoor air quality. Measures will be put in place to reduce emissions from waste and increase energy efficiency of health facilities thereby reducing greenhouse gas emissions as stipulated in their Nationally Determined Contributions.
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ANNEX 6. MAURITANIAN MAP OF REFUGEES AND HOST COMMUNITIES
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