The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) MA-Health Sector Support (P148017) MIDDLE EAST AND NORTH AFRICA | Morocco | Health, Nutrition & Population Global Practice | Requesting Unit: MNC01 | Responsible Unit: GHN05 IBRD/IDA | Program-for-Results Financing | FY 2015 | Team Leader(s): Aissatou Diack, Fatima El Kadiri El Yamani Seq No: 8 | ARCHIVED on 19-Dec-2018 | ISR35254 | Created by: Cassandra De Souza on 04-Dec-2018 | Modified by: Aissatou Diack on 18-Dec-2018 Program Development Objectives Program Development Objective (from Program Appraisal Document) The objective of the Program is to expand access to primary healthcare in targeted rural areas in the Program Area. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Implementation Status and Key Decisions The project was approved on April 24, 2015, became effective on September 21, 2015, and had an original closing date of December 31, 2019. A Level 2 restructuring was approved in August 2017 to: (i) revise the project’s target regions following a recent government administrative reform; (ii) update baseline data for 6 of the 7 disbursement-linked indicators (DLIs) to reflect the new target areas; and (iii) address problems related to the definition of several indicators. The Project is performing well and disbursement is improving. The project improved on its disbursement with a substantial increase in disbursement since the last ISR (from 51% to 63%). Indicators of DLIs 1, 2, 3, 4 and 5 of 2016 were sent to Inspection Generale du Ministere (IGM) for verification as requested by the Bank team in September 2018 mission. The IGM conducted the verification exercice and is finalizing the report. A 4th disbursement is expected in early 2019. There is notable progress towards achieving the PDO, with its focus on improving access to health services in rural areas: 3 PDO indicators exceeded their targets in 2015, 1 partially achieved its target and 1 exceeded its target significantly: - DLI 1 (i.e. increase in utilization of antenatal care by rural pregnant women) had a 1.2% increase from the baseline vs. the 2015 target of 0.97%. - DLI 2 (i.e. increase in deliveries attended by skilled health personnel by rural women in the target regions) had a partial achievement of progress with a 0.4% increase vs. the 2015 target of 1.71%. - DLI 3 (i.e. increase in number of new visits of children under 5 to a rural primary health care center facility (ESSP) in the Program Area for curative care) exceeded its target with a 2.23% increase vs. the 2015 target of 1.5%. - DLI 4 (i.e. increase in number of diabetic patients diagnosed and treated by rural primary health care – PHC - services) greatly exceeded the target with a 22% increase vs. the 2015 target of 4%. - DLI 5 (i.e. increase in number of visits (new cases) to rural ESSPs in the Program Area) showed a minor increase with a 1.31% increase vs. the 2015 target of 1.30%. There has been considerable progress to extend access to PHC in rural areas of the 7 targeted regions: Tanger-Tetouan-Al Hoceima, Oriental, Fès- Meknes, Beni Mellal-Khénifra, Marrakech-Safi, Drâa-Tafilalet And Souss-Massa. The MOH continues to take the necessary actions and implement strategies for greater availability and better quality of PHC in rural areas such as: (i) implementation of interventions accelerate the reduction of maternal mortality, neonatal mortality and deaths for children under five years; (ii) strengthening the detection and support for non-communicable diseases, including diabetes and high blood pressure (HTA); and (iii) improving the coverage of mobile health services to nomadic populations or those living far from health centres. A substantial improvement of health system governance at the primary level has been achieved through: (i) implementation of measures to increase incentives to improve the presence and performance of health human resources as noted through system diagnostics and to be validated within the framework of the health human resources development strategy; (ii) strengthened accountability through the development of the main quality control tool (competition quality) which includes more than 23% of PHC institutions (ESSP); (iii) setting up a comprehensive mechanism for the treatment of grievances – the "Centre d’écoute et de gestion des reclamations" (CEGR), which is now fully operational, was institutionalized and decentralized in the 12 regions of Morocco; and; 12/19/2018 Page 1 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) (iv) development of an integrated, computerized and accessible health information system. Progress on the DLIs is being reported and will improve further when the agreed upon restructuring is completed. Requests for a second restructuring has been received from the government asking for cancellation and reallocation of undisbursed funds allocated to DLI 7 related to the strengthening of the Health Management Information System (HMIS). The government proposed cancellation of the 2 final results under DLI 7 and to reallocate the undisbursed amount (US$ 14 million) among the other DLIs (with US$5 million, US$2 million, US$2 million and US$5 million reallocated to DLIs 1, 3, 4 and 5, respectively). The task team will expedite the restructuring process, now that the formal request from the MOF has been received. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P148017 IBRD-85070 Effective USD 100.00 100.00 0.00 62.76 37.24 63% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P148017 IBRD-85070 Effective 24-Apr-2015 02-Jul-2015 21-Sep-2015 31-Dec-2019 31-Dec-2019 Program Action Plan Finalize the POM by incorporating the new procedures of the National Plan for Medical and Pharmaceutical Waste Action Description Management. Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-May-2016 Completed Comments The responsible persons in the seven targeted regions will ensure follow up of environmental aspects according to Action Description regulation (decret 2009). Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-Dec-2018 Not Yet Due Comments Creation of a budgetary line in the annual Budgetary of MoH regional directorate and of MoH delegations to Action Description externalize the medical and pharmaceutical waste management at the ESSP levels Responsibility Recurrent Frequency Due Date DLI# Status Client No 30-Mar-2018 Completed 12/19/2018 Page 2 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) Comments Action Description The seven target regions implement the externalization of the medical and pharmaceutical waste management. Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-May-2019 Not Yet Due Comments Action Description The diagnosis of the current GRMs, the strategy and the draft GRM implementation manual are completed. Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-Dec-2015 Completed Comments Action Description The pilot GRM was completed and the GRM is scaled up is at national level. Responsibility Recurrent Frequency Due Date DLI# Status Client No 30-Dec-2016 Completed Comments Action Description The pilot GRM is evaluated and the implementation manual is reviewed. Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-Dec-2017 Completed Comments Action Description The GRM is rolled out at the regional level. Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-Dec-2021 Not Yet Due Comments Audit: Action Description 1) Setting up of internal audit and management control functions at the central and regional levels of the MoH. At the regional levels, these functions will be located within the Regional directorate of Health. 12/19/2018 Page 3 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-Dec-2019 In Progress Comments Audit: Action Description 2) Agree on improved terms of reference for audit, including procurement and governance. Responsibility Recurrent Frequency Due Date DLI# Status Client No 09-Jun-2017 Completed Comments Support to the implementation of the new PFM framework and organic finance law. This involves support in the Action Description preparation of a multi-year budget and a draft performance plan, contracting and monitoring and evaluation system. Responsibility Recurrent Frequency Due Date DLI# Status Client No 31-Dec-2019 In Progress Comments Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Moderate Moderate Macroeconomic -- Low Low Sector Strategies and Policies -- Low Low Technical Design of Project or Program -- Substantial Substantial Institutional Capacity for Implementation and Sustainability -- Moderate Moderate Fiduciary -- Moderate Moderate Environment and Social -- Substantial Substantial Stakeholders -- Moderate Moderate Other -- -- -- Overall -- Substantial Substantial RiskComments 12/19/2018 Page 4 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) Comments No change in ratings Results PDO Indicators by Objectives / Outcomes The objective of the program is to expand access to primary health care in targeted rural areas IN00652902 ►Increase in number of pregnant women receiving antenatal care during a visit to a rural ESSP in the Program Area (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 5.83% increase from Value 161 829 163 820 163 820 baseline Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2019 Comments IN00652903 ►Increase in number of deliveries of rural women attended by skilled health personnel in public health facilities in the Program Area (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 7.26% increase from Value 180 812 181 540 181 540 baseline Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2019 Comments IN00652904 ►Increase in number of new visits of children under 5 to a rural ESSP in the Program Area for curative care (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 5.00% increase from Value 1 013 436 1 036 084 1 036 084 baseline Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2019 Comments IN00652905 ►Increase in number of patients with diabetes diagnosed and treated at a rural ESSP in the Program Area (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 17.63% increase from Value 136 238 167 086 167 086 baseline Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2019 Comments Intermediate Results Indicators by Results Areas 12/19/2018 Page 5 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) Expanding equitable access to primary care in rural areas IN00652966 ►Increase in number of visits to rural ESSPs in the Program Area (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 4.3% increase from Value 3 753 120 3 844 947 3 844 947 baseline Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2019 Comments IN00652968 ►Number of patients with hypertension diagnosed and treated in rural ESSPs (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 180,000.00 199,838.00 199,838.00 287,000.00 Date 31-Dec-2013 31-Dec-2015 31-Dec-2015 31-Dec-2019 Comments IN00652969 ►Establishment of a comprehensive GRM (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Diagnosis, strategy and Diagnosis, strategy and draft GRM draft GRM Roll out of the Value GRM not established Implementation Manual Implementation Manual comprehensive GRM completed completed Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2018 Comments IN00652970 ►Definition of an HR incentive mechanism in rural ESSPs (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Implementation mechanism defined, including target diagnostic study not yet diagnostic study not yet indicators, Value Diagnostic not completed completed completed performance criteria, and beneficiaries. Legal documents drafted. Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 30-Dec-2016 Comments IN00652971 ►Establishment of the HMIS in one region within the Program Area (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Legal documents drafted, HMIS Value HMIS not established urbanization completed urbanization completed operational in >80% of facilities in one region. 12/19/2018 Page 6 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 31-Dec-2018 Comments IN00654720 ►People who have received essential health, nutrition, and population (HNP) services (Number, Corporate) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 728.00 13,126.00 Date 31-Dec-2014 -- 31-Dec-2015 31-Dec-2019 Comments IN00654727 Number of deliveries attended by skilled health personnel (Number, Corporate Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 728.00 13,126.00 Date 31-Dec-2014 -- 31-Dec-2015 31-Dec-2019 Improving health system governance at the primary level IN00652967 ►% of rural health centers with delivery services (CSCAs) in the Program Area that participate in the main annual quality assessment (concours qualité) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 11.49 23.00 23.00 60.00 Date 31-Dec-2013 31-Dec-2015 31-Dec-2015 31-Dec-2018 Comments Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 Increase in number of pregnant women receiving antenatal care during a visit to a rural ESSP in the Program Area (Output, 14,000,000.00, 21%) Baseline Actual (Previous) Actual (Current) CY2019 Value 161,829.00 163 820 163,820.00 -- Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 -- Comments ►DLI 2 Increase in number of deliveries of rural women attended by skilled health personnel in public health facilities in the Program Area (Output, 14,000,000.00, 6%) Baseline Actual (Previous) Actual (Current) CY2019 12/19/2018 Page 7 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) Value 180,812.00 181 540 181,540.00 -- Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 -- Comments ►DLI 3 Increase in number of new visits of children under 5 to a rural ESSP in the Program Area for curative care (Output, 10,000,000.00, 45%) Baseline Actual (Previous) Actual (Current) CY2019 Value 1,013,436.00 1 036 084 1,036,084.00 -- Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 -- Comments ►DLI 4 Increase in number of patients with diabetes diagnosed and treated at a rural ESSP in the Program Area (Output, 20,000,000.00, 100%) Baseline Actual (Previous) Actual (Current) CY2019 Value 136,238.00 167 086 167,086.00 -- Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 -- Comments ►DLI 5 Increase in number of visits to rural ESSPs in the Program Area (Output, 10,000,000.00, 31%) Baseline Actual (Previous) Actual (Current) CY2019 Value 3,794,877.00 3 844 947 3,844,947.00 -- Date -- 31-Dec-2015 31-Dec-2015 -- Comments ►DLI 6 % of rural health centers with delivery services (CSCAs) in the Program Area that participate in the main annual quality assessment (concours qualité) (Output, 8,000,000.00, 16%) Baseline Actual (Previous) Actual (Current) CY2019 Value 11.49 23.00 23.00 -- Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 -- Comments 12/19/2018 Page 8 of 9 The World Bank Implementation Status & Results Report MA-Health Sector Support (P148017) ►DLI 7 Establishment of the HMIS in one region within the Program Area (Output, 24,000,000.00, 21%) Baseline Actual (Previous) Actual (Current) CY2019 Urbanization process Urbanization process Value Not established -- completed completed Date 31-Dec-2014 31-Dec-2015 31-Dec-2015 -- Comments 12/19/2018 Page 9 of 9