FOR OFFICIAL USE ONLY Report No: PAD3008 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF EUR 123 MILLION (US$140 MILLION EQUIVALENT) AND A PROPOSED GRANT IN THE AMOUNT OF US$10 MILLION FROM THE MULTI-DONOR TRUST FUND FOR THE GLOBAL FINANCING FACILITY TO THE REPUBLIC OF SENEGAL FOR THE INVESTING IN MATERNAL, CHILD AND ADOLESCENT HEALTH September 5, 2019 Health, Nutrition, and Population Global Practice Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective June 30, 2019) Currency Unit = CFA Franc (CFAF) CFAF 576 = US$1 US$1 = EUR 0.8785 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AEC Local NGO contracted by CLM (Agence d’Exécution Communautaire) ANACMU Agency for Universal Health Insurance (Agence Nationale pour la Couverture Maladie Universelle) ANSD National Statistics and Demography Agency (Agence Nationale de la Statistique et de la Démographie) ASA Advisory Services and Analytics BALIKA Bangladeshi Association for Life skills, Income, and Knowledge for Adolescents CBHI Community-based Health Insurance CEC Equality of Opportunities Card (Carte d’Égalité des Chances) CERC Contingency Emergency Response Component CLM Unit of Fight against Malnutrition (Cellule de Lutte contre la Malnutrition) CMU Universal Health Insurance (Couverture Maladie Universelle) CPF Country Partnership Framework DA Designated Account DAGE Fiduciary Unit at the MoHSA (Direction de l’Administration Générale et de l’Equipement) DALY Disability-adjusted Life Year DFIL Disbursement and Financial Information Letter DGPSN Direction for Social Protection in Senegal (Délégation Générale à la Protection Sociale au Sénégal) DHIS2 District Health Information Software 2 DHS Demography and Health Survey DLI Disbursement-linked Indicator GRM Grievance Redress Mechanism DSME Maternal and Child Health Unit at the MoHSA (Direction de la Santé de la Mère et de l'Enfant) EmONC Emergency Obstetric and Neonatal Care FM Financial Management FY Fiscal Year GDP Gross Domestic Product GFF Global Financing Facility GGE General Government Expenditure GGHE General Government Health Expenditure GHED Global Health Expenditures Database GPN General Procurement Notice HCI Human Capital Index HFS Health Financing Strategy HRH Human Resources for Health IC Investment Case ICER Incremental Cost-effectiveness Ratio IDA International Development Association IFR Interim Financial Report IMF International Monetary Fund IPF Investment Project Financing IPM Informed Push Model LiST Lives Saved Tool LMIC Low- and Middle-income country M&E Monitoring and Evaluation MMR Maternal Morality Ratio MoHSA Ministry of Health and Social Action MWMP Medical Waste Management Plan NGO Non-governmental Organization NHA National Health Accounts NPF New Procurement Framework OOP Out-of-Pocket PCU Project Coordination Unit PDO Project Development Objective PFM Public Financial Management PFSN Health and Nutrition Financing Project (Projet Financement de la Sante et de la Nutrition) PHC Primary Health Care PHCPI Primary Health Care Performance Initiative PNA National Pharmacy Agency PNBSF National Family Safety Net Program (Programme National de Bourses de Sécurité Familiale) PNDS National Sanitary Development Plan (Plan National de Development Sanitaire) PSE Emerging Senegal Plan (Plan Senegal Emergent) PPSD Project Procurement Strategy for Development RBF Results-based Financing REDISSE Regional Disease Surveillance Systems Enhancement RMNCAH-N Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition SAFI Mobile Midwives (Sages-Femmes Itinérantes) SCD Systematic Country Diagnostic SDG Sustainable Development Goal SG General Secretariat SIGICMU Integrated Information System for Management of the CMU (Système d’Information de Gestion Intégré de la CMU) SORT Systematic Operations Risk-Rating Tool SPA Service Provision Assessment SPN Specific Procurement Notice SWEDD Sahel Women Empowerment and Demographic Dividend TF Trust Fund ToR Terms of Reference UHC Universal Health Coverage UNDB United Nations Development Business UNFPA United Nations Population Fund USAID U.S. Agency for International Development VfM Value for Money WDI World Development Indicators WHO World Health Organization ZCTP Zomba Cash Transfer Program Regional Vice President: Hafez M.H. Ghanem Country Director: Nathan M. Belete Global Director: Muhammad Ali Pate Practice Manager: Gaston Sorgho Task Team Leader: Maud Juquois The World Bank Investing in Maternal, Child and Adolescent Health (P162042) TABLE OF CONTENTS DATASHEET ........................................................................................................................... 1 I. STRATEGIC CONTEXT ...................................................................................................... 7 A. Country Context................................................................................................................................ 7 B. Sectoral and Institutional Context .................................................................................................... 8 C. Relevance to Higher Level Objectives............................................................................................. 17 II. PROJECT DESCRIPTION.................................................................................................. 18 A. Project Development Objective ..................................................................................................... 18 B. Project Components ....................................................................................................................... 19 C. Project Beneficiaries ....................................................................................................................... 30 D. Results Chain .................................................................................................................................. 31 E. Rationale for World Bank Involvement and Role of Partners......................................................... 31 F. Lessons Learned and Reflected in the Project Design .................................................................... 32 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 35 A. Institutional and Implementation Arrangements .......................................................................... 35 B. Results Monitoring and Evaluation Arrangements......................................................................... 36 C. Sustainability................................................................................................................................... 36 IV. PROJECT APPRAISAL SUMMARY ................................................................................... 37 A. Technical, Economic, and Financial Analysis (if applicable) ........................................................... 37 B. Fiduciary.......................................................................................................................................... 38 C. Safeguards ...................................................................................................................................... 40 V. KEY RISKS ..................................................................................................................... 43 VI. RESULTS FRAMEWORK AND MONITORING ................................................................... 44 ANNEX 1. IMPLEMENTATION ARRANGEMENTS AND SUPPORT PLAN ................................... 53 ANNEX 2. SPECIAL FOCUS ON HUMAN RESOURCES FOR HEALTH .......................................... 66 ANNEX 3. SPECIAL FOCUS ON ADOLESCENT HEALTH IN SENEGAL ......................................... 68 ANNEX 4. DESIGN OF THE UNIVERSAL HEALTH INSURANCE IN SENEGAL ............................... 71 ANNEX 5. ACCOUNTABILITY MECHANISMS IN THE PROJECT ................................................. 73 ANNEX 6. ECONOMIC ANALYSIS ........................................................................................... 75 ANNEX 7. CLIMATE SCREENING AND CLIMATE CO-BENEFITS FOR SENEGAL........................... 84 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Senegal Investing in Maternal, Child and Adolescent Health Project ID Financing Instrument Environmental Assessment Category Investment Project P162042 B-Partial Assessment Financing Financing & Implementation Modalities [ ] Multiphase Programmatic Approach (MPA) [✓] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Disbursement-linked Indicators (DLIs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made Disaster [ ] Alternate Procurement Arrangements (APA) Expected Approval Date Expected Closing Date 26-Sep-2019 31-Dec-2024 Bank/IFC Collaboration No Proposed Development Objective(s) The proposed Project Development Objective is to improve utilization of essential reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) services meeting quality standards in Priority Regions. Components Component Name Cost (US$, millions) Page 1 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 1. Improving availability of RMNACH-N services of adequate quality 60.00 2. Promoting adolescent health and women’s empowerment 25.00 3. Supporting reforms to strengthen governance, equity, and financing sustainability 65.00 in the health sector 4. Contingency Emergency Response Component (CERC) 0.00 Organizations Borrower: Republic of Senegal Implementing Agency: Ministry of Health and Social Action PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 150.00 Total Financing 150.00 of which IBRD/IDA 140.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 140.00 IDA Credit 140.00 Non-World Bank Group Financing Trust Funds 10.00 Global Financing Facility 10.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Senegal 140.00 0.00 0.00 140.00 Page 2 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) National PBA 140.00 0.00 0.00 140.00 Total 140.00 0.00 0.00 140.00 Expected Disbursements (in US$, Millions) WB Fiscal Year 2020 2021 2022 2023 2024 2025 Annual 10.00 24.96 37.85 35.08 29.13 12.97 Cumulative 10.00 34.96 72.81 107.89 137.03 150.00 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of Yes country gaps identified through SCD and CPF b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or Yes men's empowerment c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance ⚫ Moderate 2. Macroeconomic ⚫ Moderate 3. Sector Strategies and Policies ⚫ Moderate Page 3 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 4. Technical Design of Project or Program ⚫ Substantial 5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial 6. Fiduciary ⚫ Substantial 7. Environment and Social ⚫ Moderate 8. Stakeholders ⚫ Moderate 9. Other 10. Overall ⚫ Moderate COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [ ] Yes [✓] No Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✔ Performance Standards for Private Sector Activities OP/BP 4.03 ✔ Natural Habitats OP/BP 4.04 ✔ Forests OP/BP 4.36 ✔ Pest Management OP 4.09 ✔ Physical Cultural Resources OP/BP 4.11 ✔ Indigenous Peoples OP/BP 4.10 ✔ Involuntary Resettlement OP/BP 4.12 ✔ Safety of Dams OP/BP 4.37 ✔ Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Page 4 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Legal Covenants Sections and Description SCHEDULE 2. Section I.A.9. The Recipient shall, no later than three (3) months after the Effective Date, update the existing PIM to include the Project specifications, in substance and form satisfactory to the Association. Sections and Description SCHEDULE 2. Section I.A.10. The Recipient shall, no later than four (4) months after the Effective Date: (a) update the accounting and reporting system and fix software link issues; and (b) select and hire an external auditor, project coordinator, and a procurement specialist, all with qualifications and experience satisfactory to the Association. Conditions Type Description Disbursement No withdrawal shall be made for payments made under Category 1, until and unless the Recipient has fully disbursed under Category 1 of the GFF Grant Agreement in accordance with Section III.B.1. (b) of Schedule 2 of the Legal Agreement. Type Description Disbursement No withdrawal shall be made for payments made under Category 2, until and unless the Recipient has prepared and adopted the human resources contracting and incentive program manual, in form and substance acceptable to the Association in accordance with Section III.B.1. (c) of Schedule 2 of the Legal Agreement. Type Description Disbursement No withdrawal shall be made for payments made under Category 4 , until and unless: (i) the Recipient has prepared and adopted the respective Cash Transfer Manual: (ii) the Recipient has hired and entered into a contract with a Payment Agency as set forth in Section I.B.1 of this Schedule; and (iii) the payments are made in accordance with the procedures and eligibility criteria set forth in the respective Cash Transfer Manual and the contracts with the respective Payment Agency in accordance with Section III.B.1. (d) of Schedule 2 of the Legal Agreement. Type Description Disbursement No withdrawal shall be made for payments made under Categories 5 and 6, until and unless the Recipient has updated the CBH Grant Manual and the maternal health voucher manual, in form and substance acceptable to the Association in accordance with Section III.B.1. (e) of Schedule 2 of the Legal Agreement. Type Description Effectiveness The GFF Grant Agreement shall not become effective until evidence satisfactory to the World Bank has been furnished to the World Bank that the following condition has been satisfied, namely that the execution and delivery of this Agreement on behalf of the Recipient have been duly authorized or ratified by all necessary governmental action. Page 5 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Page 6 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) I. STRATEGIC CONTEXT A. Country Context 1. Located in the westernmost part of Africa’s Sahel region, Senegal is one of the most stable and politically open countries in Africa. It has a national territory that spans 196,712 km2, with 700 km of coast by the Atlantic Ocean and a population estimated at 15.7 million in 2018. Approximately half of the population lives in urban areas, with 23 percent of the total population living in the greater Dakar region, which accounts for 0.3 percent of the country’s geographic territory. Senegal is a stable democracy and has strengthened its democratic structures in recent years (three peaceful political transitions and four presidents since its independence in 1960). The country’s political system was further strengthened by the 2016 constitutional referendum that reduced presidential mandates from seven to five years and by the recent peaceful presidential elections (Macky Sall was reelected in February 2019). 2. With a real gross domestic product (GDP) per capita estimated at US$1,410 in 2018 (recent GDP rebasing), Senegal has recently been classified by the World Bank as a lower-middle-income country (LMIC), after several decades of being a low-income country. The pace of economic growth has recently improved, following long periods of volatility. Senegal’s GDP growth reached 6.8 percent in 2018 (slightly lower than the rate of 7.1 percent in 2017), while inflation remains under control. According to official estimates, all sectors contributed significantly to growth in 2018, but the primary sector continues to be the fastest growing, mainly due to agriculture. This is linked to ongoing support programs and the robust external demand. The secondary sector remains dynamic with construction, processed food, and chemicals still growing robustly. Hospitality and financial services are the key drivers of the tertiary sector. The economic outlook is favorable with progressively higher growth rates expected in the coming years. 3. Senegal has developed an ambitious plan to reduce poverty and accelerate growth: Emerging Senegal Plan (Plan Senegal Emergent, PSE) 2014–2035. The PSE established a framework for the country’s economic and social policy over the medium to long term. The PSE focuses on three pillars: ( a) structural transformation of the economy to achieve strong and sustainable growth; (b) human capital, expansion of access to social services and social protection, and preservation of conditions for sustainable development; and (c) enhancement of governance and security through institutional strengthening and promoting peace. The services sector is also growing rapidly, helped by advances in transport and communications. 4. The share of Senegalese people considered poor has declined (living below the US$1.90 a day threshold) from 38.0 percent in 2011 to 33.5 percent according to the latest projections,1 but inequalities are rising. Poverty is highly concentrated in rural areas. The rural poor are mostly working in the agricultural industry and suffer from multiple deprivations and chronic poverty. In contrast, in urban areas, the poor are mainly unemployed or working in the informal sector, typically in commerce and other services, and construction growth for the bottom 40 has been considerably slower than the average, indicating that the share of consumption for the poorest is continuing to shrink, confirming a trend started 1 Macro Poverty Outlook, World Bank, 2019. Page 7 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) in 2005. Geographical disparities are also pronounced: 40 percent of rural households live in precarious dwellings compared to less than 10 percent in urban areas. B. Sectoral and Institutional Context 5. To benefit from a demographic dividend, Senegal needs to accelerate its fertility decrease. Despite a decreasing dependency ratio and an increasing labor force, Senegal is only partially taking advantage of its incipient demographic dividend, which accounted for a mere 0.5 percentage point of the per capita GDP growth since 2000. Indeed, the fertility rate is still high and decreases only at a slow pace (from 6.4 children per woman in 1986 to five in 2010/2011 and 4.6 children per woman in 2017). Senegal is a pre-demographic dividend country due to its high fertility, declining mortality (under-five mortality decreased from 121 deaths per 1,000 live births in 2005 to 56 in 2017), and young age structure (half of the population under 24 years). Slow job creation among the youth is another key constraint for Senegal to leverage its demographic transition. As many as 300,000 young people enter the labor market every year, but their productive contribution to the economy is stifled, as they face very limited economic opportunities, showing the highest unemployment rate at 9 percent (against the national average of 6.1 percent), as well as high inactivity and underemployment rates, respectively, at almost 60 percent and 22 percent. The demographic dividend is equally constrained by lagging, although improving, results in maternal and reproductive health, as well as important and persistent gender inequalities in accessing basic services and productive inputs, hampering women’s capacity to accumulate human capital and pursue economic opportunities (Systematic Country Diagnostic [SCD] for Senegal). Early pregnancies and early marriages are major concerns: 9.5 percent of girls are married before the age of 15 and 32 percent before the age of 18 (Demographic and Health Survey [DHS] 2017), with adolescent girls living in rural areas, with a low level of education, and from poor households being the most vulnerable. Adolescent health service coverage remains weak: indeed, health services do not specifically target this age group and less than 2 percent of adolescents have access to modern contraception methods. Investing in adolescents is at the heart of the potential for demographic dividend. 6. While Senegal has seen substantial progress in infant mortality over the last decade, more needs to be done to accelerate reductions in stunting (that is, children being too short for their age) and neonatal mortality. The country has made tremendous strides in diminishing infant and under-five mortality rates, which, respectively, decreased from 61 to 42 and 121 to 56 deaths per 1,000 live births from 2005 to 2017. Such improvements are the result of better access to malaria treatment and prevention and enhanced vaccine coverage (which increased from 59 percent in 2004 to 75 percent in 2017). Yet, progress in nutrition is mixed: while Senegal has one of the lowest stunting rates in Africa (that is, 17 percent in 2017), the prevalence of underweight children only decreased from 14.2 percent in 2005 to 13.5 percent in 2016 (DHS 2005, 2016). Furthermore, the neonatal mortality rate has only decreased modestly, compared to the under-five and infant mortality rates, from 35 deaths per 1,000 live births in 2005 to 19 (the lowest level reached) in 2014 (DHS) but increased again to 28 deaths per 1,000 live births in 2017. Neonatal conditions are the leading cause of death for children under five (45 percent), followed by pneumonia (12 percent) and diarrhea (9 percent). 7. Improvements in maternal health are modest, despite marked improvements in modern contraceptive prevalence. The maternal mortality ratio (MMR), while still high, has steadily declined, from 401 deaths per 100,000 live births in 2005 to 236 in 2017 (DHS 2017). Owing to a well-performing national program on family planning, the modern contraception rate increased from 10 percent in 2005 Page 8 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) to 26 percent in 2017 (DHS), which has certainly contributed to decreasing the MMR. Despite a rapid progress in family planning availability, the fertility rate has remained stable over the last decade (4.7 in 2016 and 5.3 in 2005) and particularly high among women from the lowest wealth quintile (7.1). Malnutrition is also a major risk factor in maternal mortality with over a fifth of all maternal deaths associated with undernutrition, particularly iron-deficient anemia. Additionally, the rate of births assisted by trained personnel remains low at 68 percent (DHS 2017) and has improved only slowly since 2012 (51 percent). Skilled birth attendance also varies significantly across socioeconomic gradients: 56 percent in rural areas versus 90 percent in urban areas, with skilled birth attendance at only 30 percent of births among women from the lowest wealth quintile. Figure 1. Selected Health Indicators of Senegal and Comparator Countries Senegal has good life expectancy… Rather low infant mortality… Life expectancy at birth (both sexes), 2015 Infant mortality (per 1,000 live births), 2016 LMIC SSA SSA 76 LMIC 66 62 65 67 67 67 68 53 36 40 41 34 23 26 12 Cote Ghana Tanzania Kenya Senegal Mauritius Cambodia Morocco Mauritius Morocco Cambodia Senegal Kenya Tanzania Ghana Cote d'Ivoire d'Ivoire But still relatively high maternal mortality… …which can be partially explained, among others, by a low rate of births attended by professional staff Maternal mortality (national estimate per 100,000 Births attended by skilled personnel, live births), latest available year latest available year LMIC SSA 614 100 89 460 494 74 68 71 362 59 61 236 44 170 110 53 Mauritius Morocco Cambodia Senegal Kenya Ghana Tanzania Cote Kenya Cote Tanzania Senegal Ghana Morocco Cambodia Mauritius d'Ivoire d'Ivoire Source: World Development Indicators (WDI) 2015-2016-2017, Senegal SCD 2018. Note: SSA = Sub-Saharan Africa. 8. Chronic malnutrition or stunting has fallen from a rate of more than 20 percent in 2005 to approximately 17 percent in 2017, thus making Senegal one of the top performers in this area across continental Sub-Saharan Africa. Malnutrition is expected to fall to or below 10 percent by 2025. Such progress was achieved largely due to synergy of interventions from different sectors, including, among others, the effective community-based approach of the Unit of Fight against Malnutrition (Cellule de Lutte contre la Malnutrition, CLM) and capacity strengthening at the operational level. The Senegal success rests on its mainstreaming nutrition across sectors with coordination from the CLM, decentralizing program delivery, using a community-based approach, and strengthening capacity. The program currently intervenes in 400 communes (municipalities) and aims to expand to all 571 and reach full coverage of nutrition services in all children under five, as well as to intensify services for those mothers and children in the first 1,000 days in the communes where it currently intervenes. However, climate change is expected to hamper the progress made on reducing undernutrition, and in particular, stunting. This is Page 9 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) mainly due to how climate change will impact food (i.e., quantity and quality of food produced) and non- food factors (i.e., decreased incomes, destruction of water and sanitation infrastructure and other public services). Therefore, ensuring climate-related health promotion activities, particularly among women and adolescent girls, will be essential to help reduce the multiple risk factors that can lead to stunting. 9. Notwithstanding the progress, Senegal still has a low Human Capital Index (HCI) of 0.42 and significant geographical inequities exist in maternal, reproductive, and child health and nutrition, aligned with the poverty map, as illustrated in figure 2. Figure 2. Inequalities in Maternal, Reproductive and Child Health Outcomes Aligned with Poverty Map Source: DHS data 2017. Senegal Reforms toward Universal Health Coverage 10. Senegal’s strategy to reach universal health coverage (UHC) is summarized in the four strategic directions stated in the Health Financing Strategy (HFS): (a) improve the availability of quality health services; (b) extend financial protection against health-related risks; (c) strengthen high-impact multisectoral interventions; and (d) increase resource mobilization. The HFS was finalized in 2017 and was followed by a high-level forum chaired by the President on health financing in November 2017. 11. The Government of Senegal launched its ambitious Universal Health Insurance (Couverture Maladie Universelle, CMU) program in 2013 and created an autonomous agency under the Ministry of Health and Social Action (MoHSA) to manage this program in January 2015 (Agency for Universal Health Insurance [Agence Nationale pour la Couverture Maladie Universelle, ANACMU]). Most of the program features were designed (and sometimes piloted) between 2009 and 2012. But the major boost came in 2012 when the President (Macky Sall) made the launch of the UHC a formal commitment during his political campaign. The objective of the UHC is to cover 75 percent of the population by the end of 2021, and the ultimate goal remains the coverage of the entire Senegalese population. The ANACMU intends to provide coverage to members of the informal sector, including the most vulnerable. To do so, it relies on Page 10 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) a well-developed network of community-based health insurances (CBHIs) (at least one per municipality), and the central level (ANACMU) is the ultimate payer, guaranteeing a high level of risk pooling. In addition, enrollment is either partly or fully subsidized. Senegal’s poorest families—300,000 households or about 20 percent of the population—benefit from the National Family Safety Net Program (Programme National de Bourses de Sécurité familliales, PNBSF), which is implemented by the General Delegation for Social Protection in Senegal (Délégation Générale à la Protection Sociale au Sénégal, DGPSN) and provides support to families to invest in the development of their young children, including through cash transfers and social promotion/information sessions. Enrollment of these families in CBHIs is supposed to be fully subsidized by the state budget. Annex 4 provides details on the design of the CMU in Senegal. In April 2019, the ANACMU became an autonomous agency under the Ministry of Community Development and Social and Territorial Equity, hence institutionalizing a complete split between functions of provision and financing of care. 12. Overall, as a result of the introduction of the CMU, Senegal demonstrated a significant increase in financial health protection coverage (including all schemes) of the population from 20 percent in 2010 to 47 percent in 2017. The coverage rate by CBHIs has increased over the same period from 4 percent in 2010 to 12 percent in 2014 and 17 percent in 2017. The ANACMU is indeed also subsidizing access to limited sets of intervention for specific population groups through the management of the free health care policies. Free health care policies have been implemented targeting specific groups to increase access to care: free delivery care for pregnant women (2005), free health services for the elderly (Plan Sésame 2006), and free services at the primary level for children under five (2013). However, these free health care programs have some limitations. Benefit packages are limited, and there are frequent issues of availability of drugs and delays of reimbursements to health facilities, leading to their limited effectiveness in some regions (for example, for the Plan Sésame). 13. However, critical challenges for the CMU program need to be addressed for impact and sustainability of the approach: (a) the scheme is currently voluntary, and to increase health insurance coverage (and with the issue of weak quality of care in public health facilities), it is crucial to develop strategies to have a large pool of resources and limit adverse selection, including a potential move toward more mandatory approaches; and (b) the different mechanisms of care coverage for the population, especially the most vulnerable groups, need to be better integrated to ensure greater efficiency and sustainability of the CMU program. 14. Using public-private partnerships to achieve UHC by making essential inputs available at facilities is critical, but challenges remain. Through the National Supply Pharmacy, Senegal is adopting the ‘last mile’ model (Yeksi Naa) as part of supply chain reforms. This approach focuses on improving distribution to ‘last mile’ health facilities through the Informed Push Model (IPM), which relies on third- party private logistics providers to deliver contraceptives directly to health facilities, based on practices adapted from the commercial sector. Within three years, the model was scaled nationwide, dramatically reducing stock-outs to less than 2 percent of all public facilities. This model is now extending beyond contraceptives to include more than 100 essential medicines but is facing financial sustainability issues. 15. Fostering data quality and data use through digital health is essential to reach UHC. Senegal has developed a National Digital Health Strategy 2018–2023, also aligned with the orientations of the Plan Digital Senegal 2025 and the PSE. The vision is to use the digital tool for a more efficient health system. By 2023, the objective is to contribute substantially to the UHC and to ensure decision making by Page 11 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) stakeholders based on quality and secure information. Areas of focus of the digital health strategy are to (a) promote access to quality care through e-health solution; (b) promote the prevention and management of health risks through a wider dissemination of digitized health information through digitalization of the CMU; (c) strengthen the performance of health personnel through the optimal use of information and communication technologies in day-to-day work; and (d) improve health governance through the availability of quality and secure information at all levels of the health system. To strengthen its health information system, the MoHSA launched the deployment of the District Health Information Software 2 (DHIS2), a platform for reporting and analyzing health and social data that is already operational at hospital, health center, and health post levels. Additionally, the ANACMU is setting up an integrated management information system for UHC. Major Constraints to Achieve UHC and Trigger the Demographic Dividend 16. A health system bottleneck analysis2 conducted in 2017 showed that clinical quality, financial access, and cultural acceptability are the top three barriers to effective coverage of the reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) package. Governance and financing issues in the sector are additional constraints that limit the impact of available resources to improve health outcomes. Further studies show that the following obstacles limit the accessibility to quality health services: (a) the density of health centers is low, reducing their geographical accessibility and capacity for outreach activities; (b) qualified health workers prefer to work in urban areas, especially Dakar; (c) the performance of health workers is weak; and (d) health facilities have limited funding for ensuring the availability of drugs and supplies. At the national level, care competence, organization, and management are the dimensions of the quality of care with the worst performance. Financial access is also an issue: 65 percent of total health expenditures for primary health care (PHC) services are paid by households. Furthermore, issues with cultural acceptance negatively affects key priority interventions, including family planning, antenatal care, assisted deliveries, and emergency obstetric and neonatal care (EmONC). Figure 3 summarizes key PHC performance indicators. 2Conducted by the Global Financing Facility (GFF) for Every Woman Every Child Platform with support from the Primary Health Care Performance Initiative. Page 12 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Figure 3. Vital Signs Profile for PHC Performance in Senegal Source: Primary Health Care Performance Initiative (PHCPI) 2018. 17. Despite the great strides made by Senegal to improve its overall PHC system, potential benefits remain largely dependent on having sufficient numbers of competent human resources geographically well distributed to deliver PHC services. In 2018, the PHCPI’s performance index for Senegal remained quite low regarding its workforce and inputs (2.1 on a maturity scale of 1 to 4). This situation is due essentially to three factors: insufficient number of students admitted for health training in universities, lack of adequate management of the hiring process for civil servants, and insufficient incentives to retain personnel and foster a better distribution of human resources. In addition, the low level of competence of health care workers remained one of the top three hurdles identified to improve quality of care. Overall, only 22 percent of PHC workers adhered to clinical practice guidelines for services (Services Delivery Indicators 2010). For example, only 7 percent of parents/caregivers are informed about their child’s diagnosis (Service Provision Assessment [SPA] 2016). Some barriers also persist in terms of geographical accessibility of health services, notably in regions that remain marginalized due to distance from urban centers and lack of adequate transport infrastructure. Overall, 68.5 percent of patients indicate that they had ‘no barrier due to distance’. Senegal needs to maintain efforts to strengthen the foundations of the system, by consolidating infrastructure density and basic equipment. Indeed, there are clear disparities by region, with better coverage in Ziguinchor, Fatick, Saint-Louis, Dakar, and Kedougou, while the regions of Diourbel, Kaffrine, Kolda, and Louga remain the least covered (National Sanitary Development Plan [Plan National de Development Sanitaire, PNDS] 2018). 18. Social, cultural, and religious norms, including persistent gender inequalities, contribute to constrain improvements on reproductive health outcomes, as they affect women’s capacity to accumulate human capital and weaken their agency and result in high fertility rates, including among adolescent girls. While net enrollment for girls and boys has reached parity for both primary and Page 13 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) secondary cycles, girls are still more likely to drop out early, mainly due to cultural practices, such as early marriages. This is also due to lack of acceptability of use of family planning for unmarried women and economic incentives for a girl to be married early. As a result, and despite the encouraging intergenerational progress, adult women are systematically less educated than men, which, together with their lower access to productive inputs and discrimination, weighs heavily on their agency and access to opportunities.3 About 46 percent of women (15–49 years old) received no education (with major disparities as 78 percent of women in Tambacounda region have no primary-level education, 64 percent in rural areas, and 74 percent for women in the lowest economic quintile). According to DHS 2017, 74 percent of women do not decide for themselves about health care, and 20 percent of the poorest women do not seek care because their husband would not approve of it. Regional inequities are striking: only 1 percent of women in Tambacounda, 2 percent in Kolda, and 2 percent in Kaffrine are involved in three major decision-making processes (national average 14 percent).4 The traditional role attributed to women in Senegal has consequences for their agency and for adolescents’ ability to take their own fertility decisions. Increasing women’s empowerment is thus key to improve maternal and reproductive health. 19. Despite commitment to reach UHC by 2030, there is a low prioritization of health in the Government budget and direct payments remain a burden for households. Total annual health expenditure in Senegal is approximately 4 percent of GDP (Global Health Expenditures Database [GHED] 2015). The share of domestic general government health expenditure (GGHE) as a percentage of general government expenditure (GGE) dropped from 8 percent in 2005 to 4 percent in 2015 (GHED). This is a large reduction in the prioritization of health. In 2014, the GGHE/GGE ratio was below the median of LMICs of 9.7 percent. Private spending on health care is mostly supported by out-of-pocket (OOP) payments from households. According to the National Health Accounts (NHA) for Senegal, OOP payments represented 44 percent of the total health expenditure in 2014 and 2015, down from 45 percent in 2015 (GHED), which however still hints at a low level of financial protection of Senegalese citizens against health-related financial risks. The latest analysis report of catastrophic health expenditure and its impact on impoverishment and use of services in Senegal in 2005 and 2011 (MoHSA, WHO, and ANSD 2013, using poverty surveys) found that the proportion of OOP expenditure in the total household expenditures was higher for the poor. Nevertheless, at the national Forum on Health Financing in end-2017, the President affirmed the commitment of the Government to reach the Abuja declaration target of 15 percent of the budget dedicated to health by 2022. 20. Governance issues and limited efficiency in the health sector jeopardize efforts to ask for more resources from the Ministry of Finance. First, there are issues in allocative efficiency: the latest NHA shows an insufficient allocation of funds to primary care and preventative services: Senegal spends half of the total health expenditure on preventive care (15 percent) but double on curative care (30 percent) while most causes of diseases could be prevented by preventive health measures. On the technical efficiency side, little is known about the productivity or number of visits per medical personnel. A study examined technical efficiency of hospitals, but the sample size was limited and did not highlight correlates of low or high productivity. Finally, donor coordination mechanisms are limited and aid at the regional level is fragmented while external funds finance a substantial share of total health expenditures in Senegal (21 percent). On the one hand, donors complement each other by supporting different regions, but this 3 Atuesta and Marzo F., 2017. Breaking Out the Productivity Trap: how gender inequalities lock Senegal’s women into lifetimes of lower income. World Bank. 4 DHS 2017; the three decisions are health care for the woman, major purchases for the households, and visits to family. Page 14 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) contributes to fragmentation, with several systems being used, increasing transaction costs and inefficiencies. Furthermore, only 45 percent of participating development partners have communicated their resources for the next three years to the MoHSA (IHP+, 2016 scorecard). 21. Thus, the health system does not provide an equitable access to quality health services. This is due to the inequity in allocation of resources between regions as well as for rural and vulnerable areas. The results of the 2013 NHA show that the southeast regions (with the highest child mortality rates in the country) are receiving fewer resources, and an important part of the financing for RMNCAH-N services is concentrated in the Dakar, Thiès and Kaolack triangle—regions with the lowest maternal and child mortality rates. Senegal is engaged in prioritizing Interventions and Regions of Focus to Improve Equity and Maternal, Adolescent, and Child Health Outcomes 22. As part of the GFF in support of Every Women Every Child, Senegal is engaged in prioritizing interventions and regions of focus to improve equity and maternal and child health outcomes, using the available resources. The GFF is a global partnership that supports the improvement of the health and well-being of women, children, and adolescents. The objective is to strengthen the dialogue among key stakeholders under the leadership of governments and support the identification of a clear set of priority results that all partners commit their resources to achieving: (a) getting more results from existing resources and increasing the total volume of financing from four sources (Domestic government resources, financing from IDA, aligned external financing, and private sector resources) and (b) strengthening systems to track progress, learn, and course-correct. 23. Through the GFF process, Senegal has developed an RMNCAH Investment Case (IC) based on a thorough analysis of the system bottlenecks and evidence-based interventions; strengthened coordination with its financial and technical partners; and built a strong consensus on the priorities the country should focus on to significantly improve maternal, child, and adolescent health outcomes. A GFF platform was created (building on the existing RMNACH group) with representatives from key ministries (Health, Finance, Interior, and Education), partners, civil society organizations, and the private sector. The GFF platform delivered an RMNCAH IC in 2018 (validated technically in March 2018). Partners and the Government are engaged and have a better understanding of where the gaps are and where to realign. The GFF IC focuses on the following five key priority areas: (a) provision of a high-impact RMNCAH package; (b) enhanced financial access to and sociocultural acceptability of the RMNCAH package through demand side financing; (c) improved adolescent health through multisectoral approaches; (d) strengthened supply of health care services by scaling up high-impact human resources and supply chain interventions to address low effective service coverage of RMNCAH; and (e) strengthening of health system governance. 24. The IC took an equity lens by focusing on the regions with the weakest health and socioeconomic indicators. The Senegal IC targets five priority regions based on a composite index comprising the following indicators: poverty rate, neonatal mortality, under-five mortality, assisted delivery, contraceptive prevalence, proportion of adolescents with active sexual life, and antenatal care coverage. The regions in the south of the country, for example, Sedhiou, Kolda, Tambacounda, Kedougou, and Kaffrine, have the lowest index. Increasing quality and accessibility of adolescent, maternal, and child Page 15 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) health services will support Senegal in its efforts to reap the benefits of the demographic dividend. The IC is aligned with the domestic resources’ mobilization agenda of the HFS and its related HFS work plan. Current Health Portfolio and Complementarity with Other Sectors 25. The World Bank supports the Government to strengthen the health system and each UHC through lending operations and analytical work. The proposed project will build on lessons learned from the current Health and Nutrition Financing Project (Projet Financement de la Santé et de la Nutrition, PFSN) (closed in June 2019, details on links between current and proposed operations in table 3 under section F: Lessons learned and reflected in project design) and be complementary to other operations. • The PFSN (P129472) is a five-year US$40.8 million project that closed on June 30, 2019. The objective of the project was to increase the utilization and quality of maternal, neonatal, and child health and nutritional services, especially among the poorest households in targeted areas of Senegal. The project contributed to support Senegal in reaching UHC, by improving financial accessibility for health and protection for the poorest (through the extension of CBHI, a community nutrition program, and maternal vouchers) and improving the quality of care (through a results-based financing [RBF] scheme). • The Regional Disease Surveillance Systems Enhancement (REDISSE) Project (P154807) is a US$30 million regional and multisectoral project, effective since December 2016. It supports Senegal to address systemic weaknesses within animal and human health systems that hinder effective disease surveillance and response. Its specific objective is to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa and, in the event of an eligible crisis or emergency, to provide immediate and effective response to said eligible crisis or emergency. • An Advisory Services and Analytics (ASA) task ‘Support to UHC and Pandemic Preparedness’ (P164017) provides support for Senegal’s UHC agenda by (a) monitoring Senegal’s progress reaching UHC and health-related Sustainable Development Goals (SDGs) and (b) strengthening pandemic emergency response capacities, especially coordination. This US$1 million World Bank-executed ASA is funded by the Policy and Human Resources Development Trust Fund (TF). • Additionally, the World Bank-executed GFF TF (TF0A7148) supports analytical work on adolescent health, health financing and efficiency, health system performance at the primary level, human resources for health (HRH) and health information system. • The PHCPI is a World Bank-executed TF (TF0A5254) supporting the Government of Senegal on international performance comparisons and analytics, access to global knowledge and best practices related to performance improvement, and multicountry learning for the PHC system. • Cross-cutting ASAs such as the Policy Note on Equity of Social Spending (P168261) that was finalized in 2018 and Public Expenditures Review (P170349) that includes the health sector (to be delivered in FY20) will also support the interventions proposed in the project. Page 16 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 26. The proposed operation will also complement interventions of the Early Years, Education and Social Protection Projects, as well as the potential Development Policy Operation on Equity and Sustainability in the pipeline for FY21–24 and interventions from other health partners in Senegal. C. Relevance to Higher Level Objectives 27. Through strengthening availability of quality health services, improving adolescent health and women’s empowerment, and improving financial protection, the proposed project is fully aligned with the Government Strategy. One of the three pillars of the PSE is related to human capital, (with the objective to expand access to social services and social protection, and preservation of conditions for sustainable development) and Senegal’s Government aims to reduce fertility rate from 5 to 3 by 2035 (PSE), by investing in family planning programs, empowerment of women, and initiatives to reduce child mortality. Specifically, the three strategic objectives of the 2018 PNDS are: (a) improving governance in the sector; (b) improving quality of health services; and (c) increasing social protection. 28. The proposed project will also directly address some of the binding constraints identified in the 2018 SCD (report number: 130660), especially the inequity of social public policies and expenditures. As indicated in the SCD, lagging outcomes in child, maternal, and reproductive health undermine Senegal’s ability to build a strong and inclusive human capital base for its long-term development. 29. Building on the SCD, the interventions under the project remain consistent with, and aligned to, the emerging framework of the Country Partnership Framework (CPF, FY20–24) (currently under development5), which focuses on (a) building human capital throughout the life cycle; (b) optimizing social development; and (c) creating an ecosystem for innovation. More particularly, under the first focus area, this project will support the World Bank approach on providing universal access to health care, increasing resilience among the poorest households (through health insurance and financial protection), and reducing dependency ratio to leverage the demographic dividend (by improving access to quality health care, especially reproductive health and family planning and nutrition services). 30. The proposed project is also fully in line with the World Bank Group’s twin objectives of reducing poverty and promoting shared prosperity and with the SDGs), in particular Goal 3: Ensure healthy lives and promote well-being for all at all ages. Goal 3 of the SDGs has several targets that the proposed project directly supports: reduction of maternal mortality (Target 3.1), reduction of under-five and neonatal mortality (Target 3.2); achieving universal access to sexual and reproductive health care services (Target 3.7); achieving UHC (Target 3.8); and increasing health financing and the recruitment, development, training, and retention of the health workforce (Target 3.c). The project also supports achievement of Goal 1: End poverty in all its forms everywhere, through its links with social safety nets programs and improved financial protection from health expenditures among the poor and vulnerable, and Goal 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture, through its activities related to supporting high-impact nutrition interventions. 31. The project is also fully aligned with the Human Capital Project, with a view to contributing to improving the three health ultimate outcomes indicators (probability of survival to age 5, stunting, and 5 To be delivered FY20. Page 17 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) adult survival rate to age 60) included in the World Bank HCI. Senegal is one of the 60 trailblazer countries for the Human Capital Project. II. PROJECT DESCRIPTION A. Project Development Objective PDO Statement 32. The proposed Project Development Objective (PDO) is to improve utilization of essential reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) services meeting quality standards6 in Priority Regions. 33. The proposed PDO indicators are the following: (a) The following indicators will be used to measure increased utilization of RMNCAH-N services in the targeted regions: (i) Utilization of health services by patients covered by an insurance mechanism (percentage) (ii) Percentage of children under 5 suffering from childhood stunting (percentage) (iii) Utilization rate of modern contraceptive methods by adolescent girls in a relationship, aged 15-19 (percentage) (b) The following indicators will be used to measure achievements of quality health care services in the targeted regions: (iv) Quality index of health services (percentage) (v) Percentage of pregnant women having 4 antenatal care visits at standard quality (percentage) 34. The full list of indicators is presented in section VI. 6 Quality standards are defined as compliance with the official World Health Organization (WHO) quality standards of clinical care for RMNCAH-N services that Senegal has adopted. WHO standards have been defined through a series of published guidelines including (a) standards for improving quality of maternal and newborn care in health facilities (https://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/) and (b) standards for improving the quality of care for children and young adolescents in health facilities (https://www.who.int/maternal_child_adolescent/documents/quality-standards-child-adolescent/en/). In Senegal, the SPA survey allows a regular monitoring (every year) of compliance to those standards of quality of clinical care. Page 18 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) B. Project Components 35. The proposed five-year project would cover the regions with the poorest health outcomes (and very high levels of poverty) with interventions to address major bottlenecks (availability and quality of basic maternal, child, and nutrition services; financial access to health services; cultural and social norms) to improve health outcomes and support key governance reforms. The project is aligned with the priority interventions identified in the GFF IC to improve maternal, child, and adolescent health and will be focused on six priority regions (five defined through an in-depth prioritization exercise, Kédougou, Kolda, Kaffrine, Tambacounda, and Sédhiou, as well as the region of Ziguinchor). Building on lessons learned from the existing portfolio (PFSN closed on June 30, 2019), analytical work, and international and regional experience (the Sahel Women Empowerment and Demographic Dividend [SWEDD] Project- P150080), the proposed project will • Scale up successful interventions to improve maternal and child health and nutrition (community nutrition platform, health insurance for the poorest, cash transfer for poor pregnant women and ensure availability of critical maternal and child health inputs) and • Pilot (for two years) with technical assistance, evaluate, and scale up innovative approaches (on adolescent health and quality of care). A significant learning agenda will also be integrated in the operation. 36. The project intends to achieve its objective through interventions at the community, primary, regional, and central levels that are organized into three complementary components addressing the major bottlenecks in the sector: (1) Improving availability of RMNACH-N services of adequate quality (US$60 million); (2) Promoting adolescent health and women’s empowerment (US$25 million); and (3) Supporting reforms to strengthen governance, equity, and financing sustainability in the health sector (US$65 million). A fourth component is a Contingency Emergency Response Component (CERC) that will allow for rapid reallocation of project proceeds in the event of a natural or man-made disaster or crisis. The Results Chain presented in section D provides an overview of the impact expected from the project’s interventions on major bottlenecks. Component 1: Improving availability of RMNACH-N services of adequate quality (US$60 million equivalent: IDA US$55 million and GFF TF US$5 million) 37. This component will support key interventions to overcome bottlenecks identified as major constraints for health system performance and effective delivery of RMNCAH-N services in the six targeted regions.7 Subcomponent 1.1: Supporting the availability and distribution of human resources and other key inputs in Priority Regions (IDA US$30 million) 38. This subcomponent will include investment to support the Government in improving the availability of qualified health care professionals as well as ensuring the availability and efficient distribution of key health inputs (drugs, equipment, emergency, and maternal and child health 7 Kaffrine, Kedougou, Kolda, Sedhiou, Tambacounda and Ziguinchor. Page 19 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) equipment) in the regions targeted by the project. The aim of this subcomponent is to increase availability and improve the quality and efficiency of the supply of health care services. Annex 2 provides details on the situation of HRH in the six regions and proposed strategies. 39. Availability and distribution of qualified health workers. Under this subcomponent, the project will help overcome the staffing gaps identified in the Health Care Mapping Strategy (Carte Sanitaire 2017– 2021) for the six priority regions. To do so, the project will finance contracts with skilled personnel in marginalized areas. Priority personnel to be recruited include medical specialists (gynecologists- obstetricians, pediatricians, anesthesiologists), midwives, nurses, pharmacists, nutritionists, maintenance specialists, and technicians. Furthermore, the project will support the Human Resources Directorate of the MoHSA in the development of an incentive program that aims at retaining skilled personnel (medical specialists) in marginalized and difficult areas. The project will also involve the private sector within this subcomponent, by promoting increased partnership between the MoHSA and the private sector to improve access to quality care, through the recruitment and distribution of unemployed midwives and health care workers. The project will finance the recruitment and retention of health care professionals for the first three years of the project. The Government will then integrate them on the MoHSA payroll and finance the cost for Years 4 and 5 of the project to ensure the long-term sustainability of the investment (commitment letter to be signed by the MoHSA, as it was done successfully in the past for other qualified health workers contracted by projects then integrated in the national payroll). 40. To improve the availability of qualified human resources, this subcomponent will also finance the implementation and scaling-up of the strategy for mobile midwives (Sages-femmes Itinérantes, SAFI). The strategy is to increase the availability of qualified health workers in health posts. Certified midwives (called SAFIs) devote more of their work time to reach the most remote populations at community sites and public gathering places (weekly markets and so on). The tasks of the SAFIs are to deliver quality curative, preventive, and promotional services and plan outreach in collaboration with the community. The SAFI strategy has proven successful in the past in Senegal in the regions of Matam and Sedhiou to help increase the recruitment of midwives, as well as their availability in outposts. The initiative will finance investments such as motorcycles and small clinical equipment to ensure that midwives are mobile and can connect with the populations that are the most remote, at a community level. 41. Under this subcomponent, the project will support the availability of key drugs, commodities, and equipment for maternal and child health, as the weakness of the drug supply chain was identified as one of the key health system bottlenecks during the development of the GFF IC. Following a pilot approach funded by partners, the Government of Senegal chose the IPM as its national strategy for supply chain management. The National Pharmacy Agency (Pharmacie Nationale d’Approvisionnement, PNA) is scaling up the push model approach. The PNA transports supplies to the district level and contracts private operators for last-mile delivery to provide medicines to health facilities. The PNA has done extensive financial analysis of the budget and cost recovery involved in scaling up the PM and foresees that it will be self-sustaining after a transition period. The project will support the PNA to ensure the transition and the sustainability of the approach, for example, in financing the contracts of the private operators in priority regions. 42. Additionally, the project will procure key equipment for maternal and neonatal health services (for emergency obstetric care services and emergency pediatric services) that are essential to avoid maternal and neonatal deaths. Specific trainings to use this equipment will also be provided. Investments Page 20 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) will also ensure the quality of medical products delivered at the facility level and the availability of blood products, which is critical to save lives of mothers and children during emergency birth deliveries. The project will also ensure the availability and distribution of micronutrients and other inputs required to improve nutrition services. Finally, the project will support the procurement of equipment improving accessibility of health care services for disabled persons. 43. This subcomponent will also support the electrification with solar panels of health facilities that are not connected or have interrupted electricity access in the six regions. Costs of solar panels for the health facilities in need have been estimated at US$1.8 million. Maintenance of electricity and water equipment as well as consumption payments will also be supported by the project during the first three years of the project and transitioned to the Government for Years 4 and 5, and it will be monitored as part of the local quality scorecards. Subcomponent 1.2: Strengthening clinical competence and capacity of health care professionals and regional planning services to deliver quality care to mothers, children, and adolescents (US$15 million: IDA US$10 million and GFF TF US$5 million) 44. To improve the clinical quality of health care services at the community and PHC levels, it is proposed to implement a multipronged strategy addressing gaps in the quality of care. This is critical to improve clinical and health outcomes for mothers, children, and adolescents. Under this subcomponent, the project will fund (a) in-service trainings of health care professionals and regional planners, workshops, consultants, and communication strategies related to quality of care (US$4 million); (b) efforts to strengthen the capacity of medical regions to manage and organize integrated networks of quality health services (US$5 million); (c) the development and pilot of an accreditation process in two pilot regions with a view to scaling up after the pilot has been evaluated (US$2 million); and (d) interventions to strengthen local accountability for better quality of care, for example, through the release of local quality scorecards about maternal, child, and adolescent health and nutrition services (US$4 million). 45. Training programs will be supported to help improve current care competency levels with a focus on antenatal care (including detection and management of anemia), family planning, and sick child care and ensure that staff in the field have received adequate training and support. In-service training programs focus on quality of clinical care and inter-relational quality including patient experience and include training for better management of antenatal care, neonatal care management, pediatric emergencies, integrated management of childcare diseases, family planning, and better care of disabled persons. Core training on capacity for continuous quality improvement and care integration will also be delivered. To strengthen preservice training, the project will also support the collaboration between the Minister of Health, the university, and the Center of Excellence for Mother and Child Health. Trainings will also support the scale-up of antenatal group consultations to the priority regions. 46. The project will support medical regions to organize and manage integrated networks of quality health services with the development and implementation of quality improvement plans at regional and health facility levels (financial transfers for quality improvement activities, including medical waste management) and set up quality assurance mechanisms for drugs and integrated supervision. 47. The project will finance the development of standards of care for maternal, child, and adolescent care and will pilot the implementation of an accreditation process in two pilot regions. The Page 21 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) project will also evaluate the effectiveness of introducing accreditation of facilities as well as its impact, with a view to scaling up accreditation in other parts of the country. The accreditation standards and process will be developed in Year 1, piloted in Years 2–3, evaluated in Year 4, and ready for rollout by the end of the project to the entire country. 48. Local accountability for better quality of care will be strengthened by implementing local scorecards for maternal, child, and adolescent health including quality of care indicators, by engaging the community in the design of provider plans of continuous quality improvement and by training community volunteers in quality of care and equipping them with processes and instruments to share complaints with health care providers and districts. Innovative models of community engagement related to quality of care will be tested such as the model of health defenders successfully implemented in Guatemala.8 The project will ensure that reliable information about quality of care including clinical quality and effective coverage is available throughout the duration of the project. Subcomponent 1.3: Supporting nutrition services at community and health facilities levels (IDA US$15 million) 49. Community nutrition. The project will support the community-based interventions of the CLM to enhance demand for nutrition services (nutrition enhancement grants). This subcomponent will support the CLM to carry out the demand-side activities of the current successful nutrition program in Senegal. As currently done, local non-governmental organizations (NGOs) (Agences d’Exécution Communautaire, AEC) are contracted by the CLM to implement the different community-based nutrition services. One ‘AEC’ covers approximately one health district. AECs work closely with local councils to implement the package of nutrition services and activities at the community level. Three kinds of activities would be implemented: (a) growth promotion and monitoring for children between 0 and 24 months of age in communities; (b) behavioral change communication activities; and (c) detection and community care of malnutrition. Thus, contracts with local NGOs to implement these activities will be funded. Community nutrition interventions will be complementary (geographically) to the interventions supported by the Early Years Project (P161332) that became effective in April 2019 and benefit from the interventions developed under this project to remain efficient. Regarding the nutrition package, the proposed project will focus exclusively on Kedougou, Sedhiou, and Zinguichor as the Early Years Project will intervene in the remaining regions (Diourbel, Fatick, Kaffrine, Kaolack, Kolda, Matam and Tambacounda). 50. Supporting health posts, health centers, and district hospitals to better promote nutrition activities and the management of malnutrition. To strengthen links between community and health posts/centers and hospitals for nutrition management, the project will support improvement in management of malnutrition cases as well as nutrition promotion for pregnant mothers, adolescents, and children. 8Community defenders are volunteers elected by their own communities to implement monitoring and evaluation (M&E) of public policies and health care services. They also collect complaints and evidence of right to health violations in their communities and translate it to corresponding authorities. Community defenders also engage in strategic advocacy with municipal, provincial, and national government with explicit demands to eliminate barriers to access and the discrimination experienced by rural indigenous families when seeking health care. Page 22 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Component 2: Promoting adolescent health and women’s empowerment (IDA US$25 million equivalent) 51. Investing in adolescent health is at the heart of the potential for demographic dividend and increased population well-being in Senegal. One of the contributors to high fertility rates is the early age at which women start their reproductive life. Younger age at childbirth for women is associated with negative outcomes for both women and their children, such as higher risk of complications at birth, poorer health, lower educational attainment, and poverty. 52. This component aims to alleviate barriers due to social and cultural norms that limit women's and adolescent girls’ access to health and nutrition services. Beyond the constraints related to the availability and quality of health and nutrition services (which are supported under Component 1) and the financial constraints (which are targeted by interventions funded under Component 3), certain social and cultural norms as well as low levels of women’s empowerment negatively affect adolescent girls and women’s health. This component will therefore finance interventions (a) promoting behavioral change through awareness and communication and community mobilization and (b) empowering adolescent girls and women including through pilot cash transfer initiatives. Interventions under this component are multisectoral and address different groups of the Senegalese population. The overall objective of this component is to (a) increase the demand for and use of quality RMNCAH-N services; (b) improve sexual and reproductive health knowledge and practices; (c) enhance women and girls’ autonomy and decision power; and (d) delay marriage and pregnancy. Operational research will also support implementation, by including insights from behavioral science in the design and evaluation of selected multisectoral interventions to empower adolescent girls and improve their reproductive health. Lessons learned and evidence produced by the SWEDD Project will also be integrated in the design of the proposed interventions. 53. The proposed interventions are based on promising local experience and international evidence and complementarity with other partners (the United Nations Population Fund (UNFPA), the Women’s Integrated Sexual Health (WISH) program funded by the U.K. Department for International Development, and so on); some are summarized in table 1 (details in annex 3). Table 1. Global Evidence and Senegal Experience to Improve Adolescent Health and Women’s Empowerment Promising Experience in Type of Interventions Global Evidence Senegal Mass media approaches TV show ‘C’est la vie’ promotes Evaluations in a number of countries (Ethiopia, through entertainment Mali, The Gambia, and so on) have shown knowledge on reproductive increased knowledge and improved attitudes health, personal skills, and so about family planning, approval of family on. planning, and use of reproductive health services. Social and behavior Tostan program in Senegal Rigorous evaluations of programs in Bangladesh change at community focuses on community and India indicate that community-based level education and mobilization, approaches have been effective and have and engages communities to resulted in increases in use of modern family pledge public declarations planning methods, discussions with husbands against harmful practices such about family planning, and continuation of as early marriage. method use. Page 23 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Promising Experience in Type of Interventions Global Evidence Senegal Safe spaces for women’s leadership in Senegal (UNFPA). To improve school performance and keep girls in school, the program establishes safe spaces for girls in school and community space. Life skillsa and jobs skills Life skills training has been Life skills and livelihoods trainings help reduce training implemented by DGPSN as part child marriage and increase engagement in of the Yok Kom Kom program. income-generating activities. The Bangladeshi Results of the Impact Association for Life skills, Income, and Evaluation will be available in Knowledge for Adolescents (BALIKA) program early 2020. targeted girls ages 12–18 with safe spaces, education support with tutoring, life skills and livelihoods training in generic skills and exposure to a variety of income-earning activities. The program helps reduce child marriage (by 23 percent for the girls involved in the livelihoods activities) and increase engagement in income- generating activities (35 percent). Cash transfers for No experience in Senegal In Malawi, the Zomba Cash Transfer Program adolescent girls (to keep targeting adolescent girls. (ZCTP) gave incentives (school fees and cash them in school or bring transfers) to keep girls in school and to them back to encourage them to return to school. An Impact school/vocational Evaluation showed that the likelihood of ever training) being pregnant or married was reduced by 27 percent and 44 percent, respectively.b Note: a. These interventions are designed to teach a broad set of social and behavioral skills including decision making, community living, and personal awareness and management with the aim of developing young peoples’ abilities and motivations. b. ‘The short-term impacts of a schooling conditional cash transfer program on the sexual behavior of young women’, Baird et al. 2010. Subcomponent 2.1: Supporting behavioral change through communication, community, and individual interventions (IDA US$7 million) 54. Strong social and behavioral change communication is a critical part of community mobilization which is necessary to address social norms, attitudes, and practices, especially for sustainability of results. The objective is to increase sociocultural acceptability and behavior change through an inclusive process that involves all relevant stakeholders and to change perception on adolescent reproductive health issues by focusing on its overall benefits and by putting the accent on health, well-being, and capacity to engage in schooling or productive activities to help lift their families out of poverty rather than just sexual and reproductive health. Several types of social and behavioral change interventions will be financed by the project targeting different groups (religious and traditional leaders, health workers and teachers, youth counselors and young leaders, adolescent girls and boys, men and husbands) and at different levels (national, community, individual), making them complementary approaches to support Page 24 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) the development of positive behaviors toward adolescents and women. Boys will also be targeted as they play a key role in women and girls’ empowerment. 55. At the national level, the project will fund national mass media campaigns, promoting messages regarding gender issues and adolescent health on television, radio, and social networks. The content would be locally generated with support from experts, involving religious leaders and civil society representatives to be most relevant and culturally appropriate. At the community level, the project will scale up several successful interventions such as creating community forums with religious and community leaders to foster dialogue between parents and adolescents and promoting intergenerational and intragenerational dialogue platforms. The project will also contribute to improve existing health promotion activities linked to adolescent health such as Counseling Centers (Centre Conseil Adolescent) managed by the Ministry for the Youth. 56. To promote an enabling environment for adolescent health and women’s empowerment, ‘champions’ (such as young leaders, youth associations representatives, journalists, teachers, bloggers, and so on) will benefit from activities to strengthen their advocacy capacities. Training and discussions among peers with religious and community leaders (SWEDD approach and manual), as well as traditional ‘communicators’ and teachers, would also be supported for adolescent health and women’s empowerment. Finally, health workers’ capacities in terms of interpersonal communication, women’s and adolescents’ rights, building self-confidence, and so on will be strengthened to create a more positive environment at health facilities for adolescents. Subcomponent 2.2: Strengthening adolescent and women’ s empowerment (IDA US$18 million) 57. Several factors are drivers of teenage pregnancies and early marriage, including persistence of traditional social norms, religious beliefs, economic incentives, education, socioeconomic background, tradition of child marriage, and inadequate sexual health service provision. This subcomponent will fund interventions to address issues related to economics incentives and education, as Subcomponent 2.1 is supporting alleviation of traditional social norms and religious beliefs. Indeed, a low level of empowerment of adolescent girls and women prevents them from effectively achieving their desired fertility and affects their health (constraints on access to information, disempowered within the household on health seeking decisions, and interactions with health providers) and the development of their children (health and education), thus hindering Senegal’s human capital improvement. Addressing these gender gaps early on is crucial as adolescent outcomes can have long-term effects throughout the life cycle, and it is key to reach young women before they have children to break the inter-generational transmission of poverty and its associated outcomes. 58. Levels of education and poverty play a significant role in adolescent pregnancies and early marriage in Senegal. Low levels of school enrollment for girls (especially at the secondary level and in rural areas) and low bargaining power to make informed decisions about fertility and contraception within the household, explained partially by the low economic power of women, are major gender issues affecting adolescent and women’s health. To address these issues, the project will support the implementation of strategies for (a) enhanced access of girls to secondary school and (b) improved economic empowerment of women (including out-of-school girls) while strengthening multisectoral coordination mechanisms to ensure effectiveness and sustainability of these strategies. Page 25 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 59. Two cash transfer programs will be supported by the project: (a) one for enhancing access and retention of adolescent girls in secondary schools and (b) one to support access of out-of-school girls in vocational training. Girls’ access to schools is hindered by cost issues: transportation and accommodation when the school is further away from home reinforce decisions to marry them early rather than sending them to school. Based on international and regional evidence, a cash transfer program for vulnerable adolescent girls (based on the Unique Registry that is already used for targeting beneficiaries of the country’s safety net program) in secondary school will be piloted and then scaled up in the six regions after refining the design for two years with results from the evaluation. For the two-year pilot, one district in each region will be selected and around 100 girls per district will benefit from cash transfers. An NGO/firm will be contracted to support the MoHSA, in coordination with the Ministry of Education, to implement this program and a research agenda and evaluation will be conducted. The second cash transfer program will support out-of-school adolescents to ensure their enrollment in vocational training, with a similar approach: six pilot departments (around 50 girls per department) and appropriate accompanying measures and evaluation before scaling up the intervention in all six regions. The evaluation would include a baseline survey in the selected areas and control areas and an end line survey after two years. In the pilot phase, these cash transfer programs will benefit 900 girls per year. The total adolescent girls’ population (girls ages between 10 and 19) in the six poorest regions of Senegal is estimated at around 400,000, and the cash transfer programs would target 10 percent of them each year from Year 3 of the project. Thus, it is estimated that around 115,000 girls will benefit from cash transfers by the project. 60. The project will also support interventions to empower girls and young women with life skills and jobs skills training. These trainings will target women and girls who never entered or have fallen out of the school system or even girls in school whose needs the education sector alone cannot meet (for example, married girls). These trainings will be based on curricula already developed in Senegal (through the Yok Kom Kom program with DGPSN). Such trainings will include, among others, functional alphabetization centered on health and nutrition, development of leadership skills, self-confidence, negotiations skills, reproductive health knowledge, and so on. Component 3: Supporting reforms to strengthen governance, equity, and financing sustainability in the health sector (US$65 million equivalent: IDA US$60 million and GFF TF US$5 million) 61. This component aims to support the Government of Senegal in necessary reforms to strengthen governance to improve equity, efficiency, and sustainability in the financing of health sector. Indeed, some inefficiencies in the utilization of existing resources as well as the low level of domestic resources for health and low strategic management of the sector limit improvements of health outcomes for the Senegalese population, especially for the most vulnerable. To increase equity, this component will support interventions to overcome financial barriers encountered by the most vulnerable to access essential health services, including RMNCAH-N. In doing so, it provides a strong incentive for the utilization of services improved as part of Component 1. This component also aims to bring more efficiency overall: in the way health insurance for the most vulnerable is managed, in the way providers are incentivized to deliver care in an efficient manner with strategic purchasing mechanisms, and finally in the general governance of the health system (health information systems, stewardship, health financing reforms). Page 26 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Subcomponent 3.1: Improving financial protection against health risks (IDA US$37 million) 62. Waiving financial barriers to access to care to reach a greater level of equity. These financial barriers and resulting inequity pertain to two types of costs: direct (cost of services, cost of medicines) and indirect costs (transportation to facilities especially). These two types of costs require separate sets of interventions. As part of this subcomponent, direct financial barriers will be addressed through an enhancement of the CMU scheme (details on the scheme in annex 4) and indirect barriers will be addressed through an extension of the maternal health voucher pilot. 63. Tackling the direct cost issue while enhancing efficiency through support to the CMU. The project will contribute to expand coverage of CMU for greater equity and develop strategic purchasing and new institutional arrangements for greater efficiency and sustainability of CMU. The following activities will be financed: (a) contribute to promote and finance the enrollment in CBHI, including of the poorest (as identified in the national unified registry) and more vulnerable (children under five years old), through the integration of the free health care scheme into the CBHI (CBH Grants); (b) support the development of strategic purchasing by the ANACMU, for instance, through strengthening of the integrated information system for management of the CMU (Système d’Information de Gestion Intégré de la CMU, SIGICMU) and building capacities for informed decisions to manage the health insurance (control, equalization, costs, and so on); and (c) promote greater efficiency in internal processes of the CMU scheme. 64. More equity through subsidization of the enrollment in the CMU contributory scheme, including of the poorest and most vulnerable populations (children under five years old), hence resulting in the integration of the free health care scheme into the insurance scheme of the CMU. To improve efficiency in the management of the very fragmented set of benefits under its responsibility, the agency plans to progressively integrate free health care schemes into the CBHI. The agency will therefore subsidize enrollment in the CBHI and hence access to a broader package of care, moreover with more efficiency than when reimbursing discrete interventions on a fee-for-service basis with the free health care scheme. This integration effort is currently piloted in one district and has been supported over the last eight months as part of the PFSN, through partial subsidization of the enrollment. This support is meant to continue as part of the new project, as well as to be scaled up to additional districts of intervention of the project. In doing so, the project will contribute to open access to a wider package of care9 for the poor and children under five years old in intervention districts that are known for a low level of utilization of health services. In addition, while subsidizing access of the most vulnerable, this financial support will also provide a steady flow of funds, which will allow the CMU to focus on additional reforms. This will, for instance, enable the introduction of new purchasing mechanisms to fund health services in a more strategic way, as well as testing new institutional arrangement at district and regional levels. This will ultimately result in greater efficiency and sustainability of the CMU scheme at the end of the project (these innovations are described in the following paragraphs). The bulk of related interventions will take the form of direct subsidization by the project’s funds, as a complement to domestic funding, of the enrollment of the beneficiaries of PNBSF and free health care scheme for a total amount of US$28 million. 9 UHI schemes, including population covered, modalities of subsidization, and packages of care are described in annex 4. Page 27 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 65. Strengthening equity even further through communication geared toward potential net contributors. Although the focus is put on the most vulnerable and their health needs, in a voluntary scheme such as the Senegalese CMU, it is crucial to develop strategies to attract net contributors,10 hence enlarging the pool and countering adverse selection. The project will support the development and implementation of a communication strategy including interventions at both national and community levels. As the voluntary nature of enrollment is a well-known factor of midterm slowdown in the enrollment rate of the CBHI, the project may also provide technical assistance to facilitate the shift to a more mandatory approach. Project support for these interventions will consist of technical assistance/consultants and workshops for the preparation of the communication strategy and communication campaigns as well as financing of community-level events and payment of broadcasting fees. Communication-related intervention will amount to US$1 million. 66. More health for money through better efficiency. As a means to seek greater efficiency of the CMU scheme, the project will support institutional change and strategic purchasing11 reforms to render the management of the CMU system more agile and more efficient. This is the purpose of the planned support to the professionalization of CBHI agents and to the progressive transfer of part of the CBHI roles to the departmental and even regional levels. The project will also provide technical assistance in areas such as alignment and improvement of packages of care currently managed by the ANACMU (and especially the alignment of the benefit package with priority interventions determined in the IC, to make sure that essential RMNCAH services are actually free at the point of service). The project will also support the design and implementation of new purchasing mechanisms (for instance, per capita funding for PHC) in collaboration with the MoHSA. As a prerequisite for the CMU to purchase health care services strategically, it requires adequate data and the capacity to use the data to inform decision making. While the previous operation supported the design of the SIGICMU, this project will support its deployment and operationalization at the local and facility levels, including the training of relevant staff to properly feed the system with data and interpret them to make evidence-based decisions. Aside from being essential to tasks such as claims management and control of the effectiveness of care, the system is indeed expected to feed a data warehouse that will centralize very granular (down to the individual level) information on utilization and funding flows from every CBHI, hence allowing real-time interpretation and policy adjustments. Interventions related to efficiency gains and strategic purchasing will amount to US$5 million. 67. Tackling inequity of access beyond direct cost of treatment. As far as indirect costs are concerned, the project will support interventions to overcome barriers and hence boost demand for maternal health services. This subcomponent will expand the maternal health voucher pilot intervention that is currently implemented under the PFSN by the CLM and identified in the GFF IC as successful to increase demand for maternal services. Two services are incentivized through these vouchers: (a) four antenatal care visits by poor pregnant women and (b) assisted deliveries at the health center level. Cash transfers to pregnant women and operational costs of local NGOs (managing of the cash transfer, verification, and communication) will be funded (US$3 million). 10Net contributors are enrollees who contribute more than they receive from the insurance scheme. 11As defined by the WHO, “Strategic purchasing means active, evidence-based engagement in defining the service-mix and volume and selecting the provider-mix to maximize societal objectives. Improving the strategic purchasing of health services is central to improving health system performance and making progress towards UHC.” Page 28 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 68. Seeking synergies between health financing and service delivery policies. Interventions of Subcomponent 3.1 will be implemented in synergy with activities conducted as part of other components and subcomponents. On the one hand they will waive barriers of access to health services improved as part of Component 1, and on the other they will be implemented, monitored, and improved as part of the broader governance improvement led in Subcomponent 3.2. Pilot activities of Subcomponent 3.1 can actually be considered as proofs of concept for a future scale-up of policies aiming at more equity and efficiency in health financing. Subcomponent 3.2: Improving governance of the health system (US$28 million: IDA US$23 million and GFF TF US$5 million) 69. The objective of this subcomponent is to improve transparency and accountability in health policy implementation, with a focus on resources utilization. This will be achieved by (a) improving how financial resources for health are managed and tracked; (b) improving how health information is produced and analyzed to generate more robust evidence; and (c) improving stewardship and accountability, especially through a greater role of the civil society. 70. Improving how financial resources for health are managed and tracked. The project will support improvement in public finance management in health. In cooperation with the World Bank Governance team in Senegal, it will support the MoHSA to implement program budgeting, which will allow tracking of resources in the health sector and measurement of the efficiency of domestic resources. It will then allow taking corrective measures in case of misalignment between priorities and financial resources allocation as, for instance, revealed in a previous BOOST (public expenditure database tool) in the case of RMNCAH. 71. As a complement to enhancing program budgeting, the project will also support the development of a fiduciary unit to manage resources of external partners. Several donors (Global Fund, Gavi, the U.S. Agency for International Development [USAID], the World Bank) are already strengthening their partnership in support of a common work plan to build capacities of the fiduciary unit at the MoHSA (Direction de l’Administration Générale et de l’Equipement, DAGE), at central and regional levels, to manage resources of external partners with respect to RMNCAH-N. This unique work plan aims to strengthen the alignment of partners and strengthen the capacities of the DAGE and the internal audit function within the MoHSA. Moreover, it will also support the implementation of a unique work plan leading to a virtual pooling of external resources by the MoHSA to support the funding of the RMNCAH-N package in the long term. The project will also continue to support the promotion of a public-private partnership in the sector, on the basis of current World Bank support to the establishment and function of the alliance of the private health sector. Activities in support of better management and tracking of financial resources for health will amount to US$3 million. 72. Improving how health information is produced and analyzed. The project aims to support the production of more timely, comprehensive, and accurate data on how health services perform and how they are funded (by domestic and external resources alike). This will be achieved through the development of an integrated health management information system (especially creating interoperability between several information systems, including those of the MoHSA and of the CMU) and of a resource tracking tool on the basis of existing sources on financial flows (the NHA and integrated financial management [FM] information system). The national capacity to interpret compiled information and formulate it in policy recommendation will also be strengthened through support to dedicated units Page 29 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) at the CMU and at the MoHSA Department of Planning. Evidence-generation activities will mostly consist in procurement of equipment, technical assistance, training, and capacity-building workshops and will amount to US$10 million. 73. Improving stewardship and accountability. This subcomponent will support the coordination mechanism for the implementation of the IC, including the development of implementing tools at the regional level. Civil society organizations will also be supported to play their role of monitoring and citizen participation in the health sector. Special attention will also be given to the role of civil society organizations (organized with the civil society organizations for the GFF) for (a) the functionality of the civil society organization platform for the GFF; (b) the implementation of a community scorecard for monitoring commitments and accountability of stakeholders as well as the setup of the grievance redress mechanism (GRM) for the project (as described in section IV related to the GRM); (c) the development and implementation of watch and alert tools; and (d) the development and implementation of a communication plan on the GFF. Interventions under this subcomponent will therefore include contracts with civil society organizations and will amount to US$10 million. 74. Project coordination. This includes day-to-day management of project activities including recruitment of necessary staff to ensure smooth coordination and implementation of the project (coordinator, FM specialist, procurement specialist, M&E specialist) and related expenses. Expenses related to this subcomponent will cover technical assistance, consultants, equipment, workshops, formal trainings, on-the-job trainings, and study tours, as well as coordination and communication activities (US$5 million). Component 4: Contingent Emergency Response Component (US$0 equivalent) 75. The CERC will be included under the project in accordance with World Bank Investment Project Financing (IPF) Policy, paragraphs 12 and 13, for projects in Situations of Urgent Need of Assistance or Capacity Constraints. This will allow for rapid reallocation of project proceeds in the event of a natural or man-made disaster or crisis that has caused, or is likely to imminently cause, a major adverse economic and/or social impact. C. Project Beneficiaries 76. The primary beneficiaries of the project will be women, adolescents, and children through increased access to higher quality RMNCAH-N services, as well as vulnerable populations and the poorest households of the six priority regions. This represents a total of more than 2.3 million annual beneficiaries targeted by the project, out of a total population of 3.5 million in the six priority regions. Beyond its overall support for the improvement of the coverage and quality of RMNCAH-N services for women, adolescents, and children and the implementation of the CMU scheme, the project will financially contribute to the enrollment of the poorest and most vulnerable in a Health Insurance Scheme. As part of the support for the different interventions, the project will also target key stakeholders involved in the access and provision of services to the main beneficiaries: parents, community and religious leaders, health care workers, and so on. Page 30 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) D. Results Chain Figure 4. Results Chain Note: HR = Human resources; TA = Technical assistance. E. Rationale for World Bank Involvement and Role of Partners 77. The value added of the World Bank support to Senegal lies in addressing both critical demand- and supply-side bottlenecks to the delivery of RMNCAH-N services and supporting the reform agenda in the health sector, particularly health financing reforms. The comparative advantage of the World Bank includes its technical input based on international experience on health system strengthening, including HRH, quality, and health financing system, and capacity to mobilize a wide range of technical expertise to support key strategies and reforms (for example, health financing system assessments, health financing strategy, RMNCAH IC). 78. The PHCPI partnership. The PHCPI partnership, which gathers the World Bank Group, the WHO, and Bill and Melinda Gates Foundation in collaboration with two think tanks, Ariadne Labs and Research for Development, aims to catalyze improvements in PHC in low- and middle-income countries through better measurement and knowledge sharing. The PHCPI supports the Government of Senegal on international performance comparisons and analytics, access to global knowledge and best practices related to performance improvement, and multicountry learning for the PHC system. Page 31 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 79. Catalytic role and complementarities with other partners in the GFF approach. As previously highlighted, the proposed project is aligned with the priorities identified in the GFF IC. As part of the GFF IC development, a mapping of the resources of partners and the Government has been done (by priorities, sub-priorities, and regions) to avoid duplication in funding (the resources mapping is available in the GFF IC). The IDA/GFF TF financing is also a way to catalyze the mobilization of additional public and private resources to fill funding gaps identified in priority regions and interventions to achieve RMNACH targets (a resource mapping and costing exercise for these priorities is being undertaken). Through the GFF, the national platform (including representatives of the MoHSA, Ministry of Finance, partners, civil society, the private sector) will facilitate transparency, dialogue, and synergies of interventions, identify unfunded priority interventions, and avoid duplication. Thus, the World Bank, with its expertise, is playing a convening role in the various dimensions of UHC. F. Lessons Learned and Reflected in the Project Design 80. The project draws on best practices and innovative approaches from Senegal and lessons learned from countries that have successful programs to health system performance challenges. Key international lessons that have informed the design and lessons learned from the PFSN (closed in June 2019) are presented in table 2. Page 32 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Table 2. Lessons Learned from International Evidence and the PFSN Global Lessons Lessons Learned from the PFSN Proposed Project Improving quality Using the results-based mechanism and Implementation of RBF in Senegal Tools developed as part of RBF will be of care at the increasing accountability at the local level. has been challenging, due to lack of adapted and used (quality checklist, results primary level In different settings, results-based leadership and ownership from the monitoring, linking results to payments, web- approaches have demonstrated that they MoHSA and lack of capacity of the based platform) and staff retention will be can enhance performance and national program implementing it. strengthened in difficult areas. accountability, especially if there is increased Therefore, results have been This project will build on the best practices autonomy to develop local initiatives. disappointing so far. The approach and continue to develop new tools and has been too centralized. methodologies to strengthen results-based approaches and quality of care. Strengthening Availability of qualified human resources and Interventions added as part of the Human resources interventions (mobile health system drugs is the first step to ensure quality of 2018 restructuring; identified as key midwives), as well as ongoing supply chain care. bottlenecks for health system reforms, will be supported. performance. Nutrition and Community nutrition interventions are Support to the CLM community Continued support, complementarily to the community-level crucial to improve human capital. platform and maternal health Early Years Project and domestic funding, demand-side vouchers pilot. Successful approach adding interventions developed under the interventions to reduce malnutrition issues in Early Years Project. (maternal Senegal. vouchers) Health information Governance and evidence-based decision Support to develop the health Continue supporting health information system/digital making needs a robust health information information system and health system and strengthening capacities to better health system. insurance information system analyze data produced and evidence-based decision. CMU Although free health care schemes are an Challenge of sustainability of the Support reforms to ensure the CMU will play effective initial way to provide a limited Health Insurance Scheme and a strategic purchasing role and the package of care to selected population financial accessibility sustainability of the scheme. The purpose of groups, often these schemes increase the support is to merge free health care fragmentation of the health financing system schemes into the general state-subsidized and are not purchased in a strategic way. CBHI scheme and strengthen control They tend to create sustainability issues and mechanisms. negative incentives (for example, over The project aims to support the agency in consultations or prescriptions for people three complementary directions to address who have no co-payment). Theory and voluntarily approach to enrollment: Page 33 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Global Lessons Lessons Learned from the PFSN Proposed Project empirical evidence demonstrated the communication campaigns to boost voluntary limitations of community health insurance enrollment in the medium term, exploration when it comes to reaching a critical level of of policy options to move toward more pooling. This is mainly due to the voluntary obligation, and support to the nature of enrollment in the traditional CBHI institutionalization of CBHI at a district rather model and, institutionally, the fact that CBHIs than municipality level. remain local institutions. Adolescent health Investing in adolescent health, especially of Interventions proposed to support adolescent interventions adolescent girls, is at the heart of the health in Senegal are based on a potential for demographic dividend and comprehensive diagnostic of the context increased population well-being. (using behavioral economics) and Multisectoral interventions for adolescents international evidence (see table 2 and annex are more successful (combining health 3 for more details). information and incentives for school retention). Religious and traditional leaders can also play a key role in changing social norms that constrain adolescent girls’ well- being; there are therefore important gains to be expected from raising their awareness. Page 34 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 81. The MoHSA will be the implementing ministry of the project. In coordination with the Minister and Secretary General, technical activities will be undertaken by the relevant directorates and agencies (the CLM and ANACMU). The General Secretariat (SG) of the MoHSA will be the unit responsible for the overall technical coordination of implementation of the project. The DAGE will have the overall fiduciary responsibility and it will rely on the existing fiduciary arrangements in place for the ongoing REDISSE project. 82. Overall governance of the project will be provided by the multisectoral Steering Committee of the GFF (GFF platform). All entities involved in the project’s implementation will be overseen by a Steering Committee. In accordance with aid harmonization and alignment, the proposed project will be implemented by the MoHSA, in close collaboration with the CLM and the ANACMU. Other ministries and institutions will also support the project and facilitate implementation (Ministry of Education; Ministry of Women, Family and Gender; Ministry of Community Development and Social and Territorial Equity; General Delegation of Social Protection and National Solidarity). A technical committee will also be set up at the MoHSA to ensure regular monitoring of project implementation. It is proposed that this committee should meet once a month during first year of the project and then once a quarter. 83. A specific Project Coordination Unit (PCU) will be put in place. A dedicated project coordinator (that is, coordinating only this project) will be appointed. Fiduciary support to the DAGE will be mutualized with support provided through the two other projects (Health Financing and Nutrition Project closed in June 2019 and REDISSE project closing in January 2023). Additional staff may be recruited within the PCU, such as an M&E specialist, technical specialist (public health), and FM and procurement specialists to support the DAGE. The PCU will be responsible for the day-to-day management of the project and will (a) coordinate the project activities; (b) ensure the FM of the project activities in all components under oversight of the DAGE; and (c) prepare consolidated annual work plans, budgets, M&E, and the implementation report of the project to be submitted to the Steering Committee and the World Bank. The proposed institutional arrangements are based on lessons learned from coordination and implementation of the two ongoing health projects. 84. Through the project, support will continue to be provided to the DAGE and internal inspection, jointly with other partners (Global Fund, Gavi, USAID, LuxDev). The objective is to set up a center of mutualized fiduciary management (Centre de Gestion Mutualisée) to manage donor financing in the midterm. Thus, fiduciary arrangements may be revised at the midterm review of the project if this center is operational and functional. Page 35 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Figure 5. Institutional Arrangements Note: ISMEA =Investing in Maternal, Child and Adolescent Health Project (Acronym in French: Investir dans la Santé de la Mère, de l’Enfant et de l’Adolescent). B. Results Monitoring and Evaluation Arrangements 85. A detailed Results Framework is included in section VI. The progress and results of project implementation will be monitored on a routine basis throughout the life of the project, to provide timely information on implementation status and effectiveness of the interventions. 86. The general principle underlying the M&E approach is the alignment with routine health data systems of the MoHSA DHSs conducted by the National Statistics and Demography Agency (Agence Nationale de Statistiques Démographiques, ANSD) and alignment with the GFF IC results framework. Indeed, as part of the GFF approach in Senegal, it is also planned to have a web-based dashboard to monitor all interventions at the regional level as well as the funding allocated. Additionally, specific tools would be adjusted to monitor quality of care improvements. 87. As part of the institutional arrangement option selected, an M&E specialist will be identified to coordinate and liaise with the different implementing units. The M&E specialist will ensure the monitoring of all the indicators and facilitate the production of a scorecard in the DHIS2 to gather all the DHIS2 indicators relevant for the project. As part of standard monitoring, the PCU will regularly gather information and report on the implementation of components. C. Sustainability 88. Sustainability of the project investments is based on (a) interventions supported by the project as part of the different sectorial strategies of the Government of Senegal (HFS, Sectorial Investment Plan, GFF IC, and so on); (b) strong commitment of the Government for UHC; and (c) some activities that support reforms to increase efficiency of public expenditures. Page 36 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 89. Senegal has experienced a steady GDP growth rate of over 6.7 percent in the last two years, which is likely to be continued in 2019 and 2020 and even accelerated in 2020 (WDI 2018). However, domestic public resources allocated to health stagnated at 4 percent of GGHE (NHA as reflected in GHED). This level of public health expenditure is clearly not sufficient to deliver on the high-level political promise of UHC. 90. In addition, and as reflected in the stakeholders’ (government and civil society alike) deep involvement in the development of the GFF IC in 2017–2018, there is a strong impetus from all actors and a renewed commitment of the state for a greater priority for health in the coming years. Moreover, this strong political commitment already materialized in the creation of strong institutions such as the ANACMU, which is a key building block of a pro-UHC Senegalese social protection system in health. In addition, efficiency gains can be made in a service delivery system that still favors hospital care over primary care (hospitals still capture two-thirds of government health expenditure). While advocating for more domestic resources mobilization for health, the project contributes in many ways to this move toward greater efficiency, through the promotion of high-impact, PHC-based health intervention and the introduction of strategic purchasing mechanisms. 91. The project will bring US$150 million to the sector over five years, compared to a domestic GGHE amounting to US$165 million in 2015 (NHA as reflected in the GHED). This is substantial yet unlikely to further crowd out government investment in health. First, some interventions are multisectoral (especially Component 2). Second, specific discussions took place to ensure that funds from the project come as a temporary complement to substantial budget resources. This was specifically the case for the measure of subsidization of the enrollment of the most vulnerable in the social health insurance scheme. For all these political, institutional, macroeconomic, and sectoral reasons, there are positive prospects for the sustainability of the interventions supported by this project past its term, for which the national part insisted on the fact that the project should only partly subsidize enrollment, with the state budget taking the greater share, hence allowing proper scale-up and sustainability in the longer run. IV. PROJECT APPRAISAL SUMMARY A. Technical, Economic, and Financial Analysis (if applicable) 92. The economic analysis of the project draws on empirical evidence to demonstrate that the expected benefits outweigh the costs of the proposed interventions in terms of health, poverty, and social impacts. A detailed economic and financial analysis was conducted during project preparation and includes (a) a cost-effectiveness analysis of the project (what is the incremental cost-effectiveness ratio?); (b) a cost-benefit analysis of the project (how much does the project cost per saved life year?); and (c) a financial analysis (how financially sustainable is the project?). Economic Analysis 93. The proposed project will seek to improve the health status of the Senegalese population and to promote equity in access to quality health care service with a specific focus on women and children and on the poor population. Project investments will contribute to strengthen the performance of the health system in Senegal. The implementation of the project will increase the effective coverage of RMNCAH-N. The investment in RMNCAH-N is a pillar for capturing the demographic dividend. Page 37 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 94. In addition, support for the scale-up, strengthening, and rationalization of the CMU scheme is likely to decrease the incidence of catastrophic health expenditure, hence freeing up household resources for other essential goods and assets and increasing their well-being as soon even in the medium term. Jointly, demand- and supply-side interventions embedded in the project are likely to have a long-term positive impact on productivity and hence have a positive macroeconomic impact. 95. The rationale for public intervention in health is well established both theoretically and empirically. First, health interventions are public goods and would be provided in insufficient quantity if only provided by unregulated private actors, hence creating a problem of equity of access. Second, health interventions create externalities: the societal benefit of delivering these interventions exceeds their costs. Likewise, the negative externalities of not providing these interventions is a risk for all members of the society. Finally, asymmetry of information, which occurs on both demand- and supply-side interventions, is all-pervasive in health. 96. Global evidence shows that high-impact RMNCAH-N interventions retained in the project are cost-effective. For instance, community management of severe and acute malnutrition is a cost-effective intervention with US$26–39 per disability-adjusted life year (DALY) averted; participatory women’s groups on health outcomes or training of community health workers and midwives show a cost of US$150–1,000 per DALY averted depending on the national context and so do safe motherhood initiatives based on a package combining antenatal and postnatal care by trained health attendants (all figures, as reported in DCP312,2016). 97. A cost-effectiveness analysis was conducted to assess the foreseen impact of the project. It included all (discounted) project costs as all jointly contribute to the objectives of the project. By using the Lives Saved Tool (LiST), averted deaths by the project are valued at almost US$5,000, for an average cost of US$30,000 per averted death over the time span of the project. Detailed methodology, results, and limitations for this cost-effectiveness analysis are presented in annex 6. B. Fiduciary (i) Financial Management 98. The overall FM responsibility for the project lies with the DAGE and the coordination unit, which will be established in the MoHSA, including the preparation of the consolidated financial reports, the withdrawal requests, and the project audits. 99. An assessment of the FM arrangements under the MoHSA DAGE was carried out in September 2018. The assessment entailed a review of its capacity and its ability to record, control, and manage all the project resources and produce timely, relevant, and reliable information for the key stakeholders. The objective of the assessment was to determine whether the FM arrangements in place are acceptable. The FM assessment was carried out in accordance with the Financial Management Practices Manual issued by the Financial Management Board on March 1, 2010 and retrofitted on February 4, 2015. 12 Black, R. E., R. Laxminarayan, M. Temmerman, and N. Walker. 2016. Disease Control Priorities, third edition, Volume 2. Reproductive, Maternal, Newborn, and Child Health. Washington, DC: World Bank. Page 38 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 100. This new project will be managed through the existing FM arrangements in place for the PFSN that was closed in June 2019 and ongoing REDISSE projects under the MoHSA DAGE responsibility. These arrangements include (a) an FM team fully dedicated to the two projects’ activities and familiar with World Bank procedures and region-based interventions (this FM team comprising an administrative and financial officer and two accountants remains adequate for this new project); (b) a multi-project accounting software, which will easily integrate the proposed project’s accounts; (c) an internal auditor recruited in September 2018 to conduct ex post reviews of all projects; and (d) an administrative and FM manual in place. The overall FM performance of REDISSE has been rated satisfactory for the following reasons: (a) the quarterly interim financial reports (IFRs) are timely submitted and the quality is satisfactory and (b) the external auditors have issued an unqualified opinion (clear opinion) on the 2017 financial statements of REDISSE. The accounting software presents a weak network between computers used by accountants that delays consolidation of financial information and timely bookkeeping. 101. As a result of the assessment, the MoHSA DAGE will be required: (a) No later than three months after effectiveness to update the existing project financial and administrative manual to include this new project specifications; and (b) No later than four months after effectiveness to fix the software link issues and recruit an external auditor with qualification and experience satisfactory to the World Bank. 102. Conclusion of the FM assessment. The conclusion of the assessment is that the FM arrangements in the MoHSA DAGE are adequate and satisfy the World Bank’s minimum requirements under the World Bank Policy and Directive on IPF effective in 2017. The overall risk for the project is rated Moderate. An FM action plan including proposed mitigation measures will be put in place focusing on action listed earlier. (ii) Procurement 103. The Borrower will carry out procurement for the proposed project in accordance with the World Bank’s ‘Procurement Regulations for IPF Borrowers’ (Procurement Regulations), dated July 2016 and revised in November 2017 and August 2018 under the New Procurement Framework (NPF); the ‘Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants’, dated October 15, 2006, and revised in January 2011 and as of July 1, 2016; and other provisions stipulated in the Financing Agreement. The procurement assessment carried out by the World Bank is summarized in annex 1. 104. As part of the preparation of the project, the MoHSA (with support from the World Bank) has prepared the Project Procurement Strategy for Development (PPSD), which describes how fit-for- purpose procurement activities will support project operations for the achievement of the PDO and deliver value for money (VfM). The PPSD considers institutional arrangements for procurement, roles and responsibilities, thresholds, procurement methods, prior review, and any other requirement for carrying out procurement. It also includes a detailed assessment and description of state government capacity for carrying out procurement and managing contract implementation, within an acceptable governance structure and accountability framework. Other issues to be considered will include the behaviors, trends, and capabilities of the market (that is, Market Analysis) to inform preparation of the Page 39 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Procurement Plan. The strategy includes a summary on procurement risk, Mitigation Action Plan, and Procurement Implementation Support and Supervision plan (detailed in annex 2). C. Safeguards (i) Environmental Safeguards 105. The project is not likely to have significant negative effects on Senegal’s environment, forests, or other natural resources. The project includes investment components to increase utilization and improve the quality in priority regions with a focus on RMNCAH-N services and thus triggers OP/BP 4.01 Environmental Assessment. None of the activities are expected to have significant, long-term, or irreversible impacts on the natural environment; therefore, the project is classified as Environmental Category B. 106. Environmental Assessment (OP 4.01) and MWMP. An MWMP has been prepared. The purpose of this plan is to specify the procedures used to handle and dispose of medical waste. The MWMP proposes technically feasible, economically viable, and socially acceptable waste management systems. The potential beneficiaries (public and private), modalities of interventions, transport logistics, costs of the chain of values, follow-up, and evaluation system should be an integral part to align the plan with the project national health vision. The document has been approved and was published in the country and on the World Bank’s external website in June 2019. 107. Subproject sites are not all identified, in particular the electrification with solar panels of health facilities, but the civil works at all sites are expected to be small-scale and very limited. These small-scale constructions will be covered by a Checklist Environmental Management Plan for any subproject where there are no unusual risk factors. The plan will be prepared and disclosed by the Borrower and attached to the construction contracts once construction sites will be identified. (ii) Social Safeguards 108. The project does not trigger any social safeguard policy. Design of the project has been developed in a participatory process, including representative members of civil society organizations. Moreover, during project implementation, civil society organizations (members of the GFF platform) will be contracted to monitor implementation of project interventions with a scorecard to follow commitments and accountability of stakeholders. Results from the scorecards will be shared at local, regional, and national levels. A citizen engagement indicator that will be monitoring the beneficiary feedback is included in the results framework: number of scorecards made and disseminated annually at regional and national level. Scorecards reports will include feedback from beneficiaries and civil society, as well as monitoring the effectiveness of the responses to GRM and satisfaction surveys (details on annex 5). 109. Additionally, communities will be involved in quality improvement of health services as part of interventions funded under Component 1 of the project. It will ensure that they participate in the development of quality improvement proposals and their capacities will be strengthened to ensure that they have the adequate information to understand the quality of health care services received by the community and have mechanisms to hold health care providers accountable. Additionally, under Page 40 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Component 3, the GFF civil society organizations will play a monitoring role and the project will include a GRM and satisfaction surveys to ensure that reclamations are effectively and promptly addressed and beneficiaries are satisfied. 110. The project direct beneficiaries are the most vulnerable in Senegal (poorest, under-five children, women, and adolescent) and the project will support their access to quality health care services. Interventions will also contribute to increase gender equality and women’s empowerment. 111. The project’s gender-responsive interventions help close the gender gap and promote inclusive growth. The project focuses on first generation issues where closing the gender gap in maternal mortality and improving women’s access to health services still remain priorities.13 112. A GRM will be set up that implies an inclusive process including the civil society, the beneficiaries, the health personnel, and the Project Management Unit. The building blocks of GRMs will include six principles: fairness, objectiveness and independence, simplicity and accessibility, responsiveness and efficiency, speed and proportionality, and participation and social inclusion. The GRM is an inclusive process where beneficiaries are informed on the GRM procedures and dedicated GRM personnel receive continuous training and learning. Finally, the GRM will be based on analysis to regularly review and act upon grievances data, trends, and systemic issues. A specific procedure will have to be put in place for the management of gender-based violence and all forms of abuse and exploitation of children and vulnerable persons. Additionally, for cash transfers to adolescent girls, GRMs to be put in place in the schools may also be used (through World Bank education project). (iii) Grievance Redress Mechanisms 113. 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. (iv) Climate screening and co-benefits 114. As per the assessment conducted, total climate co-benefits in this project amount to US$12.1 million (8.6 percent) with potential for further increase. Please refer to annex 7 for information on climate screening and climate co-benefits. This project has been screened for climate change and the following vulnerabilities were identified through the process. The potential risks are assessed as 13 ‘Implementing the World Bank Group’s Gender Strategy in Health, Nutrition, and Population’, 2016. Page 41 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ‘moderate’ in the Summary Climate and Disaster Risk Screening Report. Senegal, particularly the Dakar, Thies, and Kaolack triangle, is categorized as ‘high exposure’ due to extreme temperature, precipitation and flooding, drought, sea level rise, 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 women 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. 115. The project will support Senegal through the following adaption activities: • Component 1 (US$60 million equivalent). The main objective is to improve the availability of RMNACH-N services. This will include strengthening human and institutional capacities to ensure sustainable access to health services even during natural disasters such as flooding and droughts. To address this issue, this project will increase the number of qualified health workers and mobile midwives who will be trained on various skills to improve care competency levels as well as how to cope with working in higher temperatures that can lead to heat stress/exhaustion and other climate-associated events. • Component 2 (US$25 million equivalent). The main objective is to promote adolescent health and women’s empowerment. The behavioral change and communication activities under this component will attempt to change the perceptions of adolescent health as well as provide knowledge about the impacts of climate change on women’s health. This project will ensure that women are aware of their nutritional needs and how to adapt to climate- induced food shortages without compromising their own health through various awareness and communication campaigns. The activities in this component will also empower women to reduce post-traumatic stress and the gender-based violence that some women encounter before and in the aftermath of a natural disasters. • Component 3 (US$65 million equivalent). It aims to support reforms to strengthen equity and financing sustainability in the health sector. This project will recommend the use of mandatory rather than voluntary approaches to access health insurance, which will enable service users, particularly women who are generally the household’s caregivers, to reduce OOP expenditures. An integrated management information system will be established enabling an improved monitoring of disease outbreaks and disaster risk management. 116. The project will support Senegal through the following mitigation activities: • Component 1 (US$60 million equivalent). The project will install solar panels on various health facilities, which will help provide sustainable access to electricity for cooling, refrigeration, and other essential functions. This project will also ensure access to safe water sources in the health centers to minimize climate-induced infection transmission. Furthermore, to facilitate access to health services, midwives will be mobile and will connect with populations who are most remote, mitigating the emissions from journeys of service users replaced by more efficient travel by midwives. Moving care closer to home also tends to be more efficient, thereby further reducing emissions. Page 42 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) • Component 2 (US$25 million equivalent). Under this component, women will be provided with more information on how to prevent certain health hazards such as shifting from using biomass fuels for cooking to cleaner technologies reducing the environmental impact as these technologies are also more energy efficient, reduce local deforestation impacts, as well as improve indoor air quality and thus the health status of women and children. • Component 3 (US$65 million equivalent). It will reduce the cost of health care as part of moving toward UHC, thereby improving women’s social safety nets and increasing their ability to own other assets that can aid in mitigating impacts of climate change. V. KEY RISKS 117. The overall risk of the proposed operation is rated ‘Moderate’. The key risks and proposed mitigation measures are described in this section. 118. These will include the key areas of technical assistance required by the implementing entities, especially central-level regulatory bodies to manage project funds, as well as entities at the decentralized level. The task team will closely coordinate with the Government and key development partners to mobilize and harmonize financing. 119. Technical design of projects and programs risk is considered Substantial. Although some of the interventions funded through the project have already been implemented in Senegal at a small or large scale (such as community nutrition, CBHI, demand-side RBF, mobile midwives, public-private partnership for supply chain, and so on), the project intends to support key reforms on health financing and implement innovative interventions to strengthen quality of care and promote adolescent health. This risk is being partially mitigated through close support by the World Bank team and strong technical assistance to be recruited from the start of the project. 120. Institutional capacity for implementation and sustainability risk is rated Substantial. Capacities at the MoHSA to implement and monitor some of the project’s interventions (on quality of care and mutisectoral interventions on adolescent health) are limited. To address this risk, the project will rely on skilled consultants to support the different entities of the MoHSA and build capacities as necessary, as well as for some interventions to contract with non-state actors (civil society organizations, communities, and the private sector). 121. Fiduciary risks are Substantial. Although significant progress on fiduciary management has been made in Senegal, some challenges remain, including the need to strengthen a reliable budget monitoring system or reinforcing internal and external controls. To ensure smooth implementation of the project and management of the project funds, a dedicated coordination team within the MoHSA will be recruited (with a coordinator, M&E specialist, and so on) and will use the existing fiduciary unit while strengthening it (with a dedicated procurement specialist, other as needed). Complementarily, and jointly with other partners (Gavi, USAID, Global Fund), capacities of the DAGE will be strengthened. . Page 43 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) VI. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Senegal Investing in Maternal, Child and Adolescent Health Project Development Objectives(s) The proposed Project Development Objective is to improve utilization of essential reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) services meeting quality standards in Priority Regions. Project Development Objective Indicators RESULT_FRAME_TBL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Increased utilization of RMNCAH-N services in the targeted regions Utilization of health services by patients covered by an 15.00 20.00 25.00 30.00 35.00 40.00 insurance mechanism (Percentage) Percentage of children under 5 suffering from childhood 17.00 15.00 13.75 12.50 11.25 10.00 stunting (Percentage) Utilisation rate of modern contraceptive methods by adolescent girls in a 8.00 12.50 14.00 15.50 17.00 18.50 relationship, aged 15-19 (Percentage) Improved quality of health services in the 6 priority regions Quality index of health services 70.00 72.00 75.00 77.00 80.00 82.00 Page 44 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 (Percentage) Percentage of pregnant women having 4 antenatal 52.00 72.00 78.00 84.00 87.00 89.00 care visits (at standard quality) (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 1. Improve availability of RMNCAH and nutrition services People who have received essential health, nutrition, and 0.00 2,466,625.00 population (HNP) services (CRI, Number) People who have received essential health, nutrition, and population (HNP) 0.00 1,404,809.00 services - Female (RMS requirement) (CRI, Number) Number of children 0.00 546,590.00 immunized (CRI, Number) Number of women and children who have received basic nutrition services (CRI, 0.00 1,577,041.00 Number) Number of deliveries attended by skilled health 0.00 342,993.00 Page 45 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 personnel (CRI, Number) Percentage of births in health centers with a functional 14.90 16.00 16.50 17.10 17.70 18.30 EmONC base (Percentage) Percentage of newborns who benefited from an immediate care package at birth 83.00 85.00 88.00 91.00 94.00 97.00 (Percentage) Percentage of births delivered in high capacity health facilities 20.00 22.00 24.00 26.00 28.00 30.00 (Percentage) 2. Promote adolescent health and women’s empowerment Number of adolescent girls who benefited from cash 0.00 780.00 38,231.00 76,462.00 114,693.00 191,155.00 transfers (Number) Adolescent girls pregnancy rate among the beneficiaries of cash transfer initiatives 16.00 14.00 12.00 10.00 7.00 4.00 (Percentage) Contraceptive prevalence rate 26.00 28.00 30.00 32.00 34.00 36.00 (Percentage) Support reforms to strengthen equity and financing sustainability in the health sector Number of beneficiaries of the 816,393.00 2,283,108.00 2,564,461.00 2,650,520.00 2,742,365.00 2,837,532.00 CBHIS (Number) Number of vulnerable beneficiaries (children aged 0-5 0.00 227,030.00 302,707.00 378,383.00 416,222.00 454,060.00 and pregnant women) covered by the CBHIS (Number) Completion rate of health facilities data reports 91.50 93.00 94.50 96.00 97.50 99.00 (Percentage) Page 46 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) RESULT_FRAME_TBL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Number of Scorecards made and disseminated annually at 0.00 14.00 28.00 42.00 56.00 70.00 regional and national level (Number) IO Table SPACE UL Table SPACE Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection The baseline was Numerator: number of estimated using the people covered by an 2011 EPSS – that insurance mechanism that number represents the ACMU have used at least once the average consultation Utilization of health services by patients Yearly Annual ACMU health services over the last rate in health facilities. covered by an insurance mechanism Reports year A new baseline should Denominator: number of be defined at the people covered by an beginning of the insurance mechanism project. Numerator: Number of children aged 0 to 59 Percentage of children under 5 suffering months suffering from Yearly EDS-c ANSD & CLM/DSME from childhood stunting stunting in the three regions of the initiative (Ziguinchor, Sedhiou, Kedougou) Page 47 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Denominator: Number of children aged 0 to 59 months in the three regions of the initiative Current baseline and targets are based on EDS-c.The indicator has been included in the Numerator: Number of DHIS-2 parameters, but adolescents girl in a the first results will be relationship aged 15-19 Utilisation rate of modern contraceptive available CY20 onwards using modern contraceptive Yearly EDS-c DSME methods by adolescent girls in a only. DHIS2 is not methods relationship, aged 15-19 reliable for family Denominator: Number of planning data. In a adolescent girls in a relationship is relationship aged 15-19 translated by "en union" in the French version of the indicator. Average quality score of Every two EDS-c DSME Quality index of health services health services across 12 years core indicators Numerator: Number of pregnant women having 4 For the baseline, data DHIS2 Percentage of pregnant women having 4 antenatal care visits at Yearly from DHIS2 2018 was DSME antenatal care visits (at standard quality) standard quality used Denominator: Total number of pregnant women ME PDO Table SPACE Page 48 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection People who have received essential yearly DHIS-2 ANSD, DSME, CLM health, nutrition, and population (HNP) services People who have received essential ANSD, CLM, health, nutrition, and population yearly Cumulative number CLM, ANSD, DSME DHIS2 (HNP) services - Female (RMS requirement) Cumulative number of children DP aged 0-11 DHIS2 Number of children immunized months completely immunized CLM Project Number of women and children who yearly CLM report have received basic nutrition services Number of deliveries attended by skilled health personnel Nominator: Number of births in health centers with a functional EmONC base in Percentage of births in health centers Yearly DHIS2, ANSD DSME the six regions of the project with a functional EmONC base Denominator: Total number of expected births in the 6 regions Page 49 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Numerator: Number of newborns who receive immediate care after birth Project Percentage of newborns who benefited according to MOHSA Yearly Records & DSME from an immediate care package at birth guidelines DHIS2 Denominator: Number of newborns during the reference period Numerator: number of deliveries taking place in Percentage of births delivered in high health facilities with more yearly DHIS2, ANSD DSME, ANSD capacity health facilities than 500 births a year Denominator: total number of expected births Number of adolescent girls who benefited from credits and cash transfers. Cumulative number. Cash Project and Number of adolescent girls who benefited transfers targeting the Yearly Government DSME from cash transfers poorest adolescent girl Records quintile, with year 1 being the pilot project implemented in 6 districts only. Numerator: Number of beneficiaries of cash transfer who report a Adolescent girls pregnancy rate among Project pregnancy in the calendar Yearly DSME the beneficiaries of cash transfer records year. initiatives Denominator: Total number of girls who benefited from a cash transfer in that Page 50 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) calendar year. Numerator: Total number of women aged 15 to 49 years using a modern method of Yearly EDS-c DSME Contraceptive prevalence rate contraception Denominator: Total number of women aged 15 to 49 years ANACMU Bi- Number of people covered Bi-Annual Annual ANACMU Number of beneficiaries of the CBHIS by a Community Based reports Health Insurance Scheme Number of vulnerable beneficiaries (children aged Number of vulnerable beneficiaries ANACMU Bi- 0-5 and pregnant women) Bi-Annual ANACMU (children aged 0-5 and pregnant women) Annual covered by the Community covered by the CBHIS reports Based Health Insurance Scheme Numerator: number of reports provided by health facilities (health centers and Completion rate of health facilities data health posts) that report Quarterly DHIS2 DSIS reports SRSE health data for the 6 regions of the project Denominator: number of expected reports Cumulative number of Project Scorecards made and records, Civil Number of Scorecards made and disseminated annually at Yearly society DPRS disseminated annually at regional and regional and national level reports, national level (2 at the national level and 2 Government per region annually). The records Page 51 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) scorecards include feedback from beneficiaries and the civil society, as well as monitoring the effectiveness of the responses to the GRM and satisfaction surveys. ME IO Table SPACE Page 52 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 1. IMPLEMENTATION ARRANGEMENTS AND SUPPORT PLAN Project Institutional and Implementation Arrangements 1. The MoHSA will be the implementing ministry of the project. Under coordination from the Minister and Secretary General, technical activities will be undertaken by the relevant directorates and agencies (the CLM and ANACMU). The SG of the MoHSA will be the unit responsible for the technical coordination of implementation, and the DAGE will be responsible for FM and procurement related to the project. 2. The proposed institutional arrangements are based on lessons learned from coordination and implementation of the two health projects and also the ongoing support to the DAGE by different partners (Global Fund, Gavi, USAID, LuxDev) to set up a center of mutualized fiduciary management (Centre de Gestion Mutualisée) to manage donor financing. A specific PCU will be put in place. A dedicated project coordinator (that is, coordinating only this project) will be appointed, and the PCU will also include an M&E specialist and a fiduciary team to support the DAGE. The PCU will be responsible for the day-to-day management of the project and will (a) coordinate the project activities; (b) ensure the FM of the project activities in all components; and (c) prepare consolidated annual work plans, budgets, M&E, and the implementation report of the project to be submitted to the Steering Committee and the World Bank. 3. Overall governance of the project will be provided by the multisectoral Steering Committee of the GFF (GFF platform). All entities involved in the project’s implementation will be overseen by a Steering Committee. In accordance with aid harmonization and alignment, the proposed project will be implemented by the MoHSA, in close collaboration with the CLM and the ANACMU. Other ministries and institutions will also support the project and facilitate implementation (Ministry of Education; Ministry of Women, Family and Gender; and Ministry of Community Development and Social and Territorial Equity, General Delegation of Social Protection and National Solidarity). 4. A project Designated Account (DA) will be opened by the Ministry of Finance and managed by the MoHSA’s DAGE. Subaccounts could be created for the DAGE, CLM, and ANACMU. The project will use the scheme already existing at the MoHSA to implement the PFSN. 5. A Project Preparation Funds Advance (US 1 million) is supporting the government to implement the preparatory activities prior to project effectiveness. Activities to be financed through the advance include: (a) technical support (consultants) for operational, administrative and FM and technical manuals and procedures (review of the project implementation manuals and the M&E guidelines; review and update of the Nutrition grant, Maternal Health vouchers and Community-Based health Insurance manuals; development of the cash transfer manual for the adolescent girls and women’s empowerment interventions; preparation of the manual for the recruitment and the management of the HRH in the underserved areas and the revision of the project administrative and FM manual); (b) recruitment of experts in charge of project coordination; procurement, M&E and communication in order to support the day to day operation in the MoHSA; (c) purchase of office equipment (including IT equipment) and furniture for project implementation, including divisions and units within the MoHSA to meet their logistical needs to effectively carry out their tasks for the project; and (d) training and workshops for actors Page 53 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) at central and decentralized levels (regional and district health authorities, community health workers, etc. Table 1.1. Overview of Components and Financing by Component in US$, millions Total Project Components IDA GFF TF Project 1. Improving availability of RMNCAH-N services of adequate quality 60 55 5 1.1 Supporting the availability and distribution of human resources 30 30 — and other key inputs in Priority Regions 1.2 Strengthening clinical competence and capacity of health care 15 10 5 professionals and regional planning services to deliver quality care to mothers, children, and adolescents 1.3 Supporting nutrition services at community and health facility 15 15 — levels 2. Promoting adolescent health and women’s empowerment 25 25 — 2.1 Supporting behavioral change through communication, 7 7 — community and individual interventions 2.2 Strengthening adolescent and women’ s empowerment 18 18 — 3. Supporting reforms to strengthen governance, equity, and financing 65 60 5 sustainability in the health sector 3.1 Improving financial protection against health risks 37 37 — 3.2 Improving governance of the health system 28 23 5 4. CERC 0 0 0 Total Project Cost 150 140 10 Financial Assessment Report: Senegal Investing in Maternal, Child and Adolescent Health (P162042) (September 2018) Introduction 6. A specific PCU will be put in place to implement the project under the oversight of the MoHSA in close collaboration with the SG, CLM, and the ANACMU. The DAGE of the MoHSA will have the overall FM responsibility. The DAGE already has the overall FM responsibility of two World Bank-funded projects: PFSN (closed in June 2019) and the P154807 Regional Disease Surveillance Systems Enhancement (REDISSE). It will rely on FM arrangements in place for the two projects. Country Issues 7. The inherent risk of the PFM system in Senegal is rated Substantial. Senegal has embarked on major reforms to strengthen the institutional framework of PFM and shift toward performance-based budgeting, with budget programs and the devolution of commitment authority to line ministries. These reforms are under way and will be implemented gradually until 2020. Although significant progress has been made, a number of challenges remain, including (a) setting a comprehensive and transparent budget management system which takes into account payments related to state-owned enterprises and national agencies; (b) developing a reliable budget monitoring system to limit budget deviations; and (c) reinforcing the internal and external controls of budget execution. Page 54 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) 8. The ongoing PFM Technical Assistance Project (P122476) funded by the World Bank aims at addressing the key weaknesses related to the budget and accounting systems and the internal and external controls. However, these country issues would not materially affect the project as it is being implemented through a specific PCU under the oversight of the MoHSA. Financial Management Risk Assessment and Mitigation 9. Table 1.2 summarizes the inherent and control risks and mitigation measures. Table 1.2. FM Risks and Mitigation Measures Initial Condition of Residual Risk Mitigation Measures Incorporated Description of Risk Risk Effectiveness Risk (Risk during Project Implementation Rating (Yes/No) Rating) INHERENT RISKS Country Level PFM system is weakened S Remedial measures are being taken to No S mainly by bottlenecks in address the weaknesses of the budget budget execution and execution procedures, accounting system, payment procedures. and internal and external controls through the ongoing PFM TA (P122476). Entity Level Issues of coordination due to H A project Steering Committee will provide the No S implication of multiple main strategic direction and oversee the entities involved implementation. Project Level Delays in implementation S The technical committee involving all relevant No S due to activities in 6 regions directorates and agencies will monitor the and involvement of the project’s implementation. Roles and MoHSA’s SG and 2 responsibilities will be clearly defined in the autonomous agencies, the revised administrative and FM manual. CLM and ANACMU Overall Inherent Risk S Residual Risk: S CONTROL RISK Internal control Lack of clarity on roles and S The existing manual of administrative and No M responsibility of the new PCU financial procedures will be updated to and the other entities directly include all specificities of the project and involved in the project clearly define roles and responsibilities. Weak internal audit S An internal auditor was recently recruited to No M environment carry out ex post reviews. Page 55 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Initial Condition of Residual Risk Mitigation Measures Incorporated Description of Risk Risk Effectiveness Risk (Risk during Project Implementation Rating (Yes/No) Rating) Budget Delay in budget preparation S The existing manual includes budget No M and approval as well as lack preparation calendar and monitoring of budget monitoring process procedures that will be applied to the project. and control mechanism Periodic reports of budget monitoring and resulting from the implication recommendations will be required for the of multiple technical entities project. involved Accounting Lack of adequate FM team M FM team in place remains adequate for the No L new project. Delay in recording due to S Delays in recording consolidation of activities No S weak links of the software will be fixed. Funds Flow Funds may be diverted or S FM team and internal auditor will ensure that No M used for non-project-eligible funds are used for purposes intended. purposes. Lessons learned on poorly documented expenditures related to the PFSN will be used to give clear indication on documentation of expenses. Monthly replenishment will be sent to ensure sufficient funds. Financial Reporting Delays in the submission of M The MoHSA’s DAGE FM team has experience No M agreed IFRs and annual in IFR preparation. They will prepare and project financial statements agree with the World Bank on the format and content of the IFRs to be used during implementation. Auditing Poor-quality audit S An external auditor with experience and No M qualifications acceptable to the World Bank will be recruited. Overall Control Risk S M Overall Risk S Note: H = High; S = Substantial; M = Medium; L = Low. Financial Management and Disbursements Arrangements 10. The following are the FM arrangements for the project: (a) Internal Control and Internal Auditing Arrangements (i) Internal control arrangements. The existing manual of administrative and financial procedures will be updated to include all specificities of the project. Page 56 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) (ii) Internal auditing arrangements. An internal auditor with satisfactory experience and qualification was recently recruited to carry out ex post reviews. (b) Accounting Arrangements 11. The current SYSCOHADA accounting standards in use for ongoing World Bank-financed projects will be applicable to this project. Annual financial statements will be prepared by the MoHSA DAGE in compliance with SYSCOHADA standards. The MoHSA DAGE is equipped with a multiproject accounting software, which will easily integrate the proposed project’s accounts. However, it presents weak links between computers used by accountants that delays recording of consolidation of activities and should be fixed. The FM team in place is adequate to handle the new project activities. (c) Budgeting Arrangements 12. The project will prepare an annual budget and Procurement Plan based on the agreed annual work program. The budget will be adopted by the Steering Committee before the beginning of the year, and its execution will be monitored on a quarterly basis. The budgeting calendar, process, and monitoring have been clearly defined in the Administrative and FM Manual of Procedures. Annual draft budgets will be submitted to the World Bank’s no-objection after adoption by the Steering Committee and implementation no later than November 30 every year. Periodic reports of budget monitoring and variance analysis will be prepared by the DAGE. (d) Financial Reporting Arrangements 13. Each quarter, the DAGE will prepare and consolidate IFRs for the project, in form and content satisfactory to the World Bank. These IFRs will be submitted to the World Bank within 45 days after the end of the quarter to which they relate. The FM team will prepare project financial statements in compliance with SYSCOHADA and World Bank requirements. (e) External Auditing Arrangements 14. The Disbursement and Financial Information Letter (DFIL) will require the submission of audited financial statements of the project to IDA within six months after the end of each fiscal year-end. The audit report should reflect all the activities of the project. An external auditor with qualifications satisfactory to the World Bank will be appointed to conduct annual audits of the project financial statements in accordance with audit terms of reference (ToR) agreed with IDA. In accordance with the World Bank Policy on Access to Information, the Borrower is required to make its audited financial statements publicly available in a manner acceptable to the Association; following the World Bank’s formal receipt of these statements from the Borrower, the World Bank also makes them available to the public. (f) Flow of Funds and Disbursement and Banking Arrangements (i) Banking Arrangements 15. DAs for the project will be opened in commercial banks acceptable to IDA, managed by the scheduling and public spending directorate (Direction de l’Ordonnancement et Dépenses Publiques), the Page 57 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) entity assigned with the overall responsibility of payments. Arrangements for the management of the DA will be described in the updated manual and in the DFIL. Subaccounts may be opened for the CLM and ANACMU activities, depending on financial evaluation from the World Bank and authorization from the Ministry of Finance. (ii) Disbursement Arrangements 16. Disbursements would be transactions based whereby withdrawal applications will be supported with Statement of Expenditures. The following disbursement methods may be used under the project: reimbursement, advance, direct payment, and special commitment, as specified in the DFIL and in accordance with the Disbursement Guidelines for IPF, dated February 2017. Documentation will be retained at the MoHSA DAGE FM team for review by the World Bank staff and auditors. The DFIL provides details of the disbursement methods, required documentation, DAs’ ceiling, and minimum application size. (iii) Flow of Funds Arrangements 17. Flow of funds arrangements for the project is as follows: Figure 1.1. Funds Flow Chart Credit Account at the World Bank Funds (Direct Payments) Designated Account MFB Subaccount (CLM, ANACMU, and DAGE) Government Implementing entities, suppliers, Ministry of Finance consultants, and contractors and Budget Direct payments Transfer of funds Transmission of documents (report invoice, Withdrawal Application, audit report, IFR, and so on) Page 58 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Table 1.3. Eligible Expenditure under IDA Credit Category Amount of the Credit Percentage of Expenditures Allocated to be Financed (expressed in EUR) (inclusive of Taxes) (1) Goods, works, non-consulting services, and consulting 58,022,000 100% services, including training and operating costs, for the project, except contracting and incentive program under Part A.1(a), Nutrition Enhancement Grants under Part A.3(a), Cash Transfers under Part B.2(a), CBH Grants under Part C1(a), and maternal health vouchers under Part C1(c)(i) of the project (2) Human resources contracting and incentive program 22,000,000 100% under Part A.1(a) of the project (3) Nutrition Enhancement Grants under Part A.3(a) of the 4,400,000 100% project (4) Cash Transfers under Part B.2(a) of the project 10,500,000 100% (5) CBH Grants under Part C1(a) of the project 24,600,000 100% (6) Maternal health vouchers under Part C1(c)(i) of the 2,600,000 100% project (7) Emergency Expenditures under Part D of the project 0 (8) Refund of Preparation Advance 878,000 Amount payable pursuant to Section 2.07 of the General Conditions TOTAL AMOUNT 123,000,000 Table 1.4. Eligible Expenditure under GFF Grant Category Amount of the Credit Percentage of Expenditures Allocated to be Financed (expressed in US$) (inclusive of Taxes) (1) Goods, works, non-consulting services, and consulting 10,000,000 100% services, including training and operating costs, for the project, except contracting and incentive program under Part A.1(a), Nutrition Enhancement Grants under Part A.3(a), Cash Transfers under Part B.2(a), CBH Grants under Part C1(a), and maternal health vouchers under Part C1(c)(i) of the project (2) Human resources contracting and Incentive program 0 under Part A.1(a) of the project (3) Nutrition Enhancement Grants under Part A.3(a) of the 0 project (4) Cash Transfers under Part B.2(a) of the project 0 (5) CBH Grants under Part C1(a) of the project 0 (6) Maternal health vouchers under Part C1(c)(i) of the 0 project (7) Emergency Expenditures under Part D of the project 0 TOTAL AMOUNT 10,000,000 Page 59 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Financial Management Action Plan 18. The following actions need to be taken to enhance the FM arrangements for the project: Table 1.5. FM Action Plan Action Date due by Responsible Entity 1 • Update the project’s administrative and FM manual. Not later than MoHSA DAGE three months after effectiveness 2 • Update the accounting and reporting system and fix link issues. Not later than MoHSA • Select the external auditor. four months DAGE/Project • Recruit an external auditor with qualification and experience after Implementation Unit satisfactory to the World Bank. effectiveness 3 • Prepare a human resource contracting and incentive program Disbursement MoHSA manual. conditions DAGE/Project • Prepare a Cash Transfer Manual. Implementation Unit • Recruit a Payment Agency for cash transfers programs. • Update the CBH manual. • Update the maternal health voucher manual. Implementation Support Plan 19. Based on the outcome of the FM risk assessment, the following implementation support plan is proposed. The objective of the implementation support plan is to ensure the MoHSA DAGE maintains a satisfactory FM system throughout the project’s life. Table 1.6. Implementation Support Plan FM Activity Frequency Desk reviews IFRs’ review Quarterly Audit report review of the project Annually Review of other relevant information such as interim internal Continuous, as they become available control systems reports On-site visits Review of overall operation of the FM system Every semester for Implementation Support Mission and annual when the risk becomes Moderate Monitoring of actions taken on issues highlighted in audit reports, As needed auditors’ management letters, internal audit, and other reports Transaction reviews (if needed) As needed Capacity-building support FM training sessions During implementation and as and when needed Page 60 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Procurement 20. Procurement under this project will be carried out in accordance with the World Bank’s Procurement Regulations, dated July 2016 and revised in November 2017 and August 2018 under the NPF, and the ‘Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants’, dated October 15, 2006, and revised in January 2011 and as of July 1, 2016. 21. Advertisement. The Borrower shall prepare and submit to the World Bank a General Procurement Notice (GPN) and the World Bank will arrange for the publication of the GPN in United Nations Development Business (UNDB) online and on the World Bank’s external website. The Borrower may also publish it in at least one national newspaper. 22. The Borrower shall publish the Specific Procurement Notices (SPNs) for all goods, works, non- consulting services, and the Requests for Expressions of Interest on their free-access websites, if available, and in at least one newspaper of national circulation in the Borrower’s country and in the official gazette. For open international procurement and selection of consultants using an international short list, the Borrower shall also publish the SPN in UNDB online and, if possible, in an international newspaper of wide circulation, and the World Bank arranges for the simultaneous publication of the SPN on its external website. 23. Procurement documents. In the event of international competitive procurement of goods, works, non-consulting services, and consulting services, the Borrower shall use the applicable World Bank standard procurement documents with minimum changes, acceptable to the World Bank, as necessary to address any project-specific conditions. 24. Procurement information and documentation filing and database. Procurement information will be recorded and reported as follows: (a) Complete procurement documentation for each contract, including bidding documents, advertisements, bids received, bid evaluations, letters of acceptance, contract agreements, securities, related correspondence, and so on, will be maintained at the level of the respective ministries in an orderly manner and will be made readily available for audit. (b) Contract award information will be promptly recorded, and contract rosters as agreed will be maintained. 25. PPSD and Procurement Plan. As part of the preparation of the project, the Borrower (with support from the World Bank) prepared its PPSD, which describes how fit-for-purpose procurement activities will support project operations for the achievement of the PDO and deliver VfM. The procurement strategy is linked to the project implementation strategy at the regional level, ensuring proper sequencing of the activities. It considered institutional arrangements for procurement, roles and responsibilities, thresholds, procurement methods, and prior review and the requirements for carrying out procurement. It also included a detailed assessment and description of state government capacity for carrying out procurement and managing contract implementation, within an acceptable governance structure and accountability framework. Other issues taken into account included the behaviors, trends, Page 61 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) and capabilities of the market (that is, market analysis) to inform the Procurement Plan. The finalized versions were approved on July 24, 2019. 26. The Procurement Plan covering the first 18 months of project implementation was prepared and submitted to the World Bank and approved by the World Bank on July 24, 2019. The Procurement Plan will be updated by the procuring entity on an annual or as-needed basis to reflect actual project implementation needs. Updates of the Procurement Plan will be submitted to the World Bank for ‘no- objection’ and the PPSD updated accordingly. 27. Operational costs financed by the project, if any, would be incremental expenses, including communication costs, rental expenses, utilities expenses, transport and accommodation, per diem, workshop, supervision costs, and salaries of locally contracted support staff. Such service needs will be procured using the procurement procedures specified in the Project Implementation Manual accepted and approved by the World Bank. 28. The MoHSA will be the implementing ministry of the project. Under coordination from the Minister and Secretary General, technical activities will be undertaken by the relevant directorates and agencies (the CLM and ANACMU). The SG of the MoHSA will be the unit responsible for the technical coordination of implementation, and the DAGE will carry out overall procurement activities. The DAGE is implementing two projects (Health Financing and Nutrition Project closed in June 2019 and REDISSE project closing in January 2023), with the ‘Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants’ dated January 2011 and revised in July 2014. However, the new project will increase the workload of the staff, which may have a negative impact on the efficiency and efficacy of the procurement processes and hence cause project implementation delays. In addition, this project will be implemented under the NPF. The following measures are proposed to mitigate these risks and reduce their classification from Substantial to Moderate: (a) Recruit staff with strong experience in World Bank process. (b) Develop an administrative and financial procedures manual which includes procurement procedures, including the new provisions of the World Bank Procurement Regulations. (c) Have an acceptable procurement filing system in place during project implementation. Table 1.7. Procurement for Key Contracts of the First 18 Months Risk Description Description of Mitigation Responsibility Deadline The project will be Ensure close collaboration with the MoHSA and Client Continuous implemented with many other stakeholders for all the processes. stakeholders. The project will be Develop an administrative and financial Client Immediate implemented under the NPF. procedures manual which includes the new provisions of the World Bank Procurement Regulations. Recruit a procurement specialist with strong experience in World Bank processes. Delay in implementation of Manage the procurement process, identify each Client Continuous activities responsibility, and manage the timing. Page 62 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Risk Description Description of Mitigation Responsibility Deadline Evaluation of cost Make reasonable evaluation of activities. Client Continuous Delay in bid evaluation Improve the procurement process in terms of Client Continuous process and other timing. procurement stages Table 1.8. Details of PPSD Estimated Review No. Description of the Contract Amount Method (Prior or (US$) Post) 1 Selection of operators for distribution of health 493,459 Request for Bid (national) Post products at the level of health posts 2 Acquisition of inputs for the care and prevention of 3,436,406 Direct with the United Prior malnutrition Nations Children’s Fund 3 Acquisition of inputs for drugs quality control 429 553 Request for Bid (national) Post 4 Acquisition of equipment for EmONC, pediatric 5,154,639 Request for Bid Prior emergencies, and the care of disabled people (international) 5 Acquisition of logistical vehicles (20 supervision 2,491,409 Direct with the United Prior vehicles, 20 motorbikes, and 25 ambulances) Nations Office for Project Services 6 Networking of medical ambulances 10,309 Shopping Prior 7 Acquisition of incubators 103,092 Request for Bid (national) Post 8 Radio telecommunication system 214,776 Request for Bid (national) Post 9 Increase community demand for quality of care 343,643 Request for Bid (national) Post 10 Selection of specialized providers for mass awareness 1,580,756 Request for Bid (national) Post interventions (talks, posters, forums, and so on) 11 Selection of payment agency for cash transfers to 116,843 Request for Bid (national) Post adolescents 12 Improvement of the SIGICMU 1,111,683 Request for Bid Post (international) 13 Acquisition of computer equipment for the health 327,319 Request for Bid (national) Post and social information system 14 Selection of consultant for accreditation process of 996,564 QCBS Post EmONC 15 Convention with the CLM to increase community- 7,847,246 Direct Prior based nutrition interventions 16 Recruitment of consultants for training of 171,820 IC Post stakeholders and adolescents for behavioral change and women’s empowerment 17 Studies to improve financial protection 1,119,801 QCBS Prior 18 Consultant for midterm evaluation of National Health 6,872 IC Post Plan 19 Acquisition of registers and printed materials to 125,000 Request for Bid (national) Post regularize unregistered children and management tools (individual cards) 20 Deployment of the SIGICMU 862,069 Request for Bid (national) Post Page 63 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Estimated Review No. Description of the Contract Amount Method (Prior or (US$) Post) 21 Selection of a consultant for operational research on 142,857 QCBS Post quality innovation and maternal and neonatal deaths audits 22 Recruitment of a consultant firm for strategic 862,069 QCBS Post development 23 Rehabilitation of EmONC (standard norms) 1,724,138 Request for Bid (national) Post 24 Acquisition of solar panels 996,563 Request for Bid (national) Post Note: IC = Selection of Individual Consultants; QCBS = Quality- and Cost-Based Selection. 29. Frequency of procurement reviews and supervision. The World Bank’s prior and post reviews will be carried out based on thresholds indicated in Table 1.. IDA will conduct supervision missions every six months and annual postprocurement reviews; the standard postprocurement reviews by World Bank staff should cover at least 20 percent of contracts subject to postreview. Postreviews consist of reviewing technical, financial, and procurement reports on project procurement actions by World Bank staff or consultants selected and hired by the World Bank according to procedures acceptable to the World Bank. Project supervision missions shall include a World Bank procurement specialist or a specialized consultant. IDA may also conduct an independent procurement review at any time until two years after the closing date of the project. 30. Based on the assessment carried out during the implementation of the other projects, from the Procurement Risk Assessment Management System, the procurement risk is rated Substantial. Table 1. summarizes the procurement prior review for ‘substantial risk’. These prior review thresholds can evolve according to the variation of procurement risk during the life of the project. Table 1.9. Procurement Prior Review Thresholds (US$) Procurement Categories Thresholds Works (including turnkey projects, supply and installation, and public-private partnerships) 10,000,000 Goods, information system services, and non-consulting (not intellectual) services 2,000,000 Consultant services (firms) 1,000,000 Individual consultant 300,000 Strategy and Approach for Implementation Support 31. The proposed project will require intensive support during implementation, especially during the first 12 months and for interventions related to Component 2 (Adolescent Health). A broad range of skills is required for the World Bank to effectively support project implementation. Some skills will be needed on a regular basis while others will be required more intermittently or on an ad hoc basis. 32. The implementation support team will include technical, financial, procurement, and operational specialists. The supervision team will include the following members: (a) Task Team Leader (b) Health economist based in Dakar Page 64 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) (c) FM specialist who would review adherence to World Bank procedures with regard to fiduciary responsibilities (d) Procurement specialist, responsible for procurement (e) Operations specialist, responsible for M&E (f) GFF focal point (g) Technical team (health insurance specialist, quality of care specialist, and others as needed) (h) Safeguards specialists Table 1.10. Implementation Support Plan and Resource Requirements Resource Time Focus Skills Needed Partner Role Estimate Project management. Recruitment of Project management six staff weeks — PCU staff, update of Project Implementation Manual, and development of annual work program and budget Procurement. Development and timely Procurement six staff weeks — execution of the Procurement Plan; development and review of ToRs, bidding documents, call for proposals, First 12 and manifestation of interest months Disbursement and FM. Opening of FM three staff — account, client connection platform, weeks withdrawal requests, and timely reporting M&E M&E four staff — weeks Technical support for health insurance, Health specialists and 12 staff weeks Technical quality, adolescent health, HRH, and health economists and six assistance health financing consultant weeks Procurement. Timely and correct Procurement four staff — implementation of the Procurement weeks Plan FM. Timely and quality reporting FM three staff — weeks Project management. Implementation Project management six staff weeks — 12 months– support project Safeguards Social and four staff — completion environmental weeks safeguards Technical support for health insurance, Health specialists and 12 staff weeks Technical quality innovation financing, health economists and six assistance and adolescent health, HRH, and health consultant policy dialogue financing weeks Page 65 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 2. SPECIAL FOCUS ON HUMAN RESOURCES FOR HEALTH 1. Insufficient availability of qualified health workers is one of the main obstacles to the effective coverage of RMNCAH-N in the project’s target regions. Achieving maternal and child health goals will require enough competent and geographically well-distributed human resources to provide services. 2. The analysis carried out in the preparation of the project highlighted that (a) qualified health workers prefer to work in urban areas, especially in Dakar; and (b) the performance of health workers is weak. This situation depends on three factors: insufficient number of students admitted for health training in universities; lack of adequate management of the hiring process for civil servants; and insufficient incentives to retain personnel and foster a better distribution of human resources. In addition, the low level of competence of health care workers remained one of the top three hurdles identified to improve quality of care. 3. To ensure the continuous availability of qualified human resources at all levels, particularly in difficult-access areas, the 2017 evaluation of the national human resources development plan for 2011– 2018 recommended the following interventions: (a) Operationalize a plan to integrate contract health workers into the public service. (b) Develop and enforce regulations to delegate recruitment capacity. (c) Ensure that a valid HRH recruitment plan is available. (d) Meet the needs of health workers at all levels, especially in areas of difficult access. (e) Adopt and implement a plan to motivate health workers to increase retention. (f) Validate and implement incentives for health workers in difficult-access areas. (g) Adopt and implement a mobility guide for health workers. 4. Despite recruitment efforts in recent years, the gap remains large and there is also an inequitable distribution of HRH in the regions; rural and isolated areas are being abandoned in favor of urban areas considered more attractive in terms of living and working conditions and opportunities for advancement; the prospects for change are not very optimistic with a growing burden of chronic disease and morbidity. Through the HRH development plan, the MoHSA planned to recruit approximately 877 doctors; 1,178 senior technicians, 10,337 nurses, and 4,781 midwives, but until 2014, only 19 percent of these positions were filled (state and contract staff combined). These recruitment efforts were reinforced in 2017 by the strategy of placing the ‘midwife and nurse’ couple in each health post in Senegal with the support of the Government of Japan. However, with the 2017 evaluation of this plan, it was concluded that the perception at the regional/district level is that the situation of staff in difficult areas has not improved. This situation illustrates the fact that recruitment efforts without a good retention strategy in difficult areas did not solve problems in areas where the need is the greatest. The lack of decentralization of recruitment functions was cited as a reason. 5. In the new PNDS, strengthening the availability and quality of HRH is one of the main priorities. With the support of partners, major efforts have been made to improve the availability of human resources, especially in difficult areas, and to improve the governance of human resources management. Page 66 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) The main HRH governance tools have been developed: the HRH mobility guide, the guide to harmonize contracting procedures between the MoHSA and partners; capacity building for the development of job descriptions; strengthening the functionality of the iHRIS software for HRH management; the development of the HRH mapping and the development of a directory of human resources statistics. 6. In line with the new PNDS, the three priority interventions proposed in this project are (a) recruitment and retention of human resources in the difficult-access areas targeted by the project; (b) capacity building for health professionals (develop in the first year and scale up from the second year); and (c) strengthening of the human resources management system. To ensure the sustainability of the intervention, the salaries of the staff recruited in this project will be aligned with the salaries of the MoHSA’s contract personnel. The Government is committed to gradually integrating these contract workers among the civil servants by the fourth year of the project. For specialties (gynecologist, pediatricians, and anesthetists), the availability of the required number of personnel is uncertain. To strengthen the training capacities of these specialties, the project will support the collaboration between the Minister of Health, the university of Dakar, and the Centre of Excellence for Mother and Child Health. It is also planned to reinforce collaboration with the Army Health Service to facilitate the mobilization of human resources of the army’s health personnel in difficult-access areas. Page 67 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 3. SPECIAL FOCUS ON ADOLESCENT HEALTH IN SENEGAL Characteristics of Adolescent Health in Senegal 1. Investing in adolescent health is at the heart of the potential for demographic dividend and increased well-being of the population in Senegal. Indeed, one of the contributors to high fertility rates is the early age at which women start having sexual relations. Younger age at childbirth for women is associated with negative outcomes for both women and their children, such as higher risk of complications at birth, poorer health, lower educational attainment, and poverty. Delaying marriage and childbearing by five years can reduce the growth of population by 15–20 percent. Every other teenage girl (50 percent between ages 15 and 19) has had sexual relations with a partner at least 10 years older, over the previous 12 months. 2. Adolescent mothers face higher maternal and neonatal mortality risks than women in their twenties. On average, young mothers experience higher rates of anemia, life-threatening blood loss, infection, seizures, and complicated labor.14 These factors contribute to a higher risk of maternal death among adolescents and of neonatal death for their babies. Perinatal deaths are 50 percent more frequent among infants born to mothers under the age of 20 than among those born to mothers ages 20–29. Infants of adolescent mothers are also more likely to be born with low birth weight, which has associated negative long-term effects on the infant’s development. Unwanted pregnancies may end in abortions, which are more likely to be unsafe in this age group than in higher age groups.15 3. In the Senegalese context, the phenomenon of child16 marriage is connected to a tradition of polygyny. The practice of men marrying several women is very prominent: almost half of all married women are married to polygynous husbands—73 percent of married women in rural areas. Of married female adolescents (ages 15–19), 25 percent are in polygamous marriages. Senegal’s family code reflects the strong tradition of child marriage below the minimum legal marriage age. Overall, Senegal’s adolescent health service coverage is very weak. Health services do not specifically target this age group, even though 42 percent of the Senegalese population is under 15 years. Teenage pregnancies are a key determinant of adolescent health. Of all 15–19-year-old girls in Senegal, 15.6 percent have either already had a child or are pregnant (DHS). For rural girls in this age group, over 22.2 percent of them have had a child or are pregnant, and for girls without education, this indicator is at 32.5 percent. Overall, by the time they are 18 years old, 24.3 percent Senegalese girls have already had one child (DHS). 4. Several factors are drivers of teenage pregnancies, including persistence of traditional social norms, religious beliefs, economic incentives, education, socioeconomic background, tradition of child marriage, and inadequate sexual health service provision. Teenagers in rural areas (22.2 percent) have a much higher fertility rate than teenagers living in urban surroundings (7.8 percent). Level of education also plays a significant role: 33 percent of the young girls (ages 15–19) who have started their procreative 14 Conde-Agudelo A., Belizan J., Lammers C., 2008. ‘Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study’, American Journal of Obstetrics & Gynecology, Vol. 192, Issue 2, p342–349, 2005. 15 World Health Organization, 2011, ‘Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008’, WHO, Geneva. 16 The word ‘children’ is used to refer to persons below the age of 18; ‘adolescents’ for persons between the ages of 10 and 19, as defined by UN-DESA (2011). Teenagers is synonymous to adolescent. Page 68 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) life have not received instruction, 17 percent only have the primary level, and only 6 percent have reached middle school or higher. Poverty has a strong impact on this issue as well: in the households in the lowest quintile, one out of three women (34 percent) has started her procreative life against 3 percent of the women in the highest quintile. Another core issue is early marriage, as 38 percent of adolescent girls are married before the age of 18 (DHS 2015). Other issues relate to the topic as well, such as female genitalia mutilation, which concerns 16.9 percent young adolescent girls (ages 10–14). 5. Lack of access to modern contraception is another key factor that has detrimental consequences on adolescent health. It is estimated that less than 2 percent of adolescents have access to a modern type of contraception. Over 86 percent of teenagers ages 15–19 have heard about different contraceptive methods, but among the teenagers sexually active in this age group, only 2.2 percent use a method of contraception (DHS). Furthermore, it is estimated that 25.5 percent of married women who want to delay pregnancy do not know how to use family planning methods effectively. The unmet need for contraception is 26.4 percent for 15–19-year-old girls (DHS). Attendance at youth centers for counseling is limited, despite the increasing availability of such services. An obstacle that teenagers face when accessing information is the attitude of the service providers. Unmarried adolescents seeking counseling may be turned down if they are unaccompanied or stigmatized by their community because of a lack of confidentiality in counseling centers. 6. Ultimately, poor health and education outcomes can have long-lasting consequences in the lives of teenagers and are often linked with poverty and social vulnerability. Mindful of this, and the pressure that population growth puts on achieving development goals, Senegal’s Government aims to reduce fertility rate from 5 to 3 by 2035 (PSE), by investing in family planning programs, empowerment of women, and initiatives to reduce child mortality. Another core initiative puts the attention on education attainment for girls to secondary level at least, as well as reducing teen and child marriage. Senegal’s Family Planning 2020 strategy is to create demand for family planning, improve service delivery, provide quality services, and facilitate access. National Experience and Global Evidence 7. In Senegal, some pilot programs have been implemented and demonstrate promising results, as follows: • Girls’ education: safe spaces for women’s leadership in Senegal (UNFPA). To improve school performance and keep girls in school, the program establishes safe spaces for girls in school and community space; emphasizes informing the various actors of the educational community (parents, opinion leaders/decision makers, and so on) on the issues of girls’ education; and helps deconstruct stereotypes and sociocultural prejudices that devalue the role of girls in the community through gender training of facilitators of safe spaces, teachers, and the control body, for better consideration of gender equality and equity in teaching learning strategies. • Tostan program on life skills training and community mobilization. The program supported life skills training on human rights, problem resolution, basic hygiene, and personal health. Women are the main beneficiaries, but men also participated. Emphasis was placed on harmful traditional practices (early marriage, frequent pregnancies, and circumcision). Page 69 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) • TV show ‘C’est la vie’ (It’s life) based on communication for development is an education tool through entertainment. Mobile projections in eight regions were organized in August 2016, reaching around 2,000 people, and some discussions were held at Adolescent Centers (Centre Conseils Adolescents) on reproductive health. Global Evidence on Adolescent Health and Women’s Empowerment (Summary) • Impact of cash transfers to keep girls in school and delay pregnancy and marriage. In Malawi, the ZCTP gave incentives (school fees and cash transfers) to keep girls in school and to encourage them to return to school. An Impact Evaluation showed that the likelihood of ever being pregnant or married was reduced by 27 percent and 44 percent, respectively.17 • Developing negotiations skills for girls reduces the likelihood of becoming pregnant. A study was conducted in Zambia, where girls participated in after-school sessions with female coaches, consisting of training on negotiation and interpersonal communication. It significantly reduced the likelihood of becoming pregnant (by 17 percentage points).18 • Life skills and livelihood trainings help reduce child marriage and increase engagement in income-generating activities. The BALIKA program targeted girls ages 12–18 with safe spaces, education support with tutoring, life skills on sexual and reproductive health, gender-based violence, decision making, critical thinking, negotiation, and gender rights awareness, as well as livelihoods training in generic skills and exposure to a variety of income-earning activities. The program helps reduce child marriage (by 23 percent for the girls involved in the livelihoods arm) and increase engagement in income-generating activities (35 percent). • Engaging men in issues related to adolescent and women’s health is crucial. In Niger, the Husbands’ Schools (Ecole de Maris) were designed to get men actively involved in the promotion of reproductive health and to foster behavioral change at the community level. Evidence has shown that husbands have taken a more active role in the health care of their families and are communicating better with their wives, and some have even attended the births of their children. Significant increases have also been recorded in deliveries assisted by skilled personnel, prenatal and postnatal consultations, and use of family planning. 17 Baird, S., Berk O. et al., 2010. ‘The short-term impacts of a schooling conditional cash transfer program on the sexual behavior of young women’. 18 Ashraf N., Bau N., Low C., McGinn K., 2018. "Negotiating a Better Future: How Interpersonal Skills Facilitate Inter-generational Investment." University of Pennsylvania Population Center Working Paper (PSC/PARC) , 2018. Page 70 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 4. DESIGN OF THE UNIVERSAL HEALTH INSURANCE IN SENEGAL 1. The ANACMU was created as an autonomous agency under the MoHSA in January 2015, in charge of managing a social health insurance scheme dedicated to the coverage of members of the informal sector. It was later put in charge of the management of a separate group of noncontributory free health care scheme, for selected groups of the population (children below five years, pregnant women, and elderly). In April 2019, the ANACMU became an autonomous agency under the Ministry of Community Development and Social and Territorial Equity, hence institutionalizing a complete split between the functions of provision and financing of care. Design of the CMU Social Insurance Schemes of the ANACMU • Rural and informal groups are targeted through a voluntary and subsidized CBHI program (nearly 80 percent of the population works in the informal and rural sectors). • At least one ‘mutuelle’ (that is, CBHI) created in each local council in Senegal (commune or communauté villageoise). To date, 676 CBHIs are functional. • Premiums highly subsidized by the Government (50 percent of the premium amounts). Annual individual premium: CFAF 7,000 (that is, around US$13). • Full subsidy for premiums and copayments for the poorest households (identified by a national methodology in the unique registry and beneficiaries of PNBSF and the disabled people (beneficiaries of equal opportunity cards, that is, Carte d’Égalité des Chances, CEC). 1,482,942 PNBSF beneficiaries enrolled in CBHIs (65 percent of CBHI members). • The package of care is as depicted in Table 4.1: Table 4.1. The Basic Package to be Subsidized with the CMU (No Co-payments for Beneficiaries of PNBSF and CEC Enrolled in CBHIs) Copayment rates (%) At Health Center At Hospital Level Level Outpatient care (including general services, dental services, antenatal 20 20 care, postnatal care, family planning, laboratory exams, echography, and minor surgeries) in Government-run facilities Immunization 0 — Generic drugs 20 20 Specialty drugs (including at private-contracted pharmacies) 50 50 Inpatient care (hospitalization, simple delivery, complicated delivery, 20 0 and so on) (but only for the accommodation costs) C-section — 0 Transport (for referrals) 20 20 Page 71 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Free Health Care Schemes of the ANACMU • There are three separate schemes, for three separate groups (children under age five years, pregnant women, and elderly). • There are three separate and very limited packages of care. • Care is purchased on a fee-for-service basis with limited visibility on the effectiveness of care. 2. The multiplicity of schemes managed by the ANACMU generates both equity and efficiency issues (in internal management and in-service delivery). As a result, the agency is currently taking steps to integrate free health care schemes in the social health insurance scheme. 3. As a result of the introduction of CMU, Senegal has demonstrated significant increase of financial health protection coverage (including all schemes) of the population from 20 percent in 2010 to 47 percent in 2017, as follows: • 11 percent from formal sector in private health insurances (for private sector workers, Instituts de Prévoyance Médicale) and through budget allocations for civil servants and retirees from public sector (both of these formal sector schemes are managed separately and independently of the ANACMU). • 17 percent of the population in CBHIs (rural and informal groups and the poorest identified with the unified registry), that is, CMU. The coverage rate by CBHIs has increased over the same period from 4 percent in 2010, to 12 percent in 2014, and to 17 percent in 2017. • 19 percent with free health care initiatives for specific vulnerable groups (children under age of five years, pregnant women, and elderly). Page 72 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 5. ACCOUNTABILITY MECHANISMS IN THE PROJECT 1. The project will strengthen accountability in the health sector through three different types of interventions: (a) By supporting civil society organizations in playing their role of project implementation monitoring and of fostering citizen participation in the health sector (b) By igniting demand for better quality of care for mothers, children, and adolescents by making tailored, current, high-quality information on quality of care available on a regular basis through the release of local quality scorecards on maternal, child, and adolescent health and nutrition services (c) By improving how financial resources for health are managed and tracked in the sector (a) Supporting Civil Society Organizations 2. The project will aim at strengthening the role of civil society organizations (organized with the civil society organizations for the GFF) by (i) Ensuring the functionality of the civil society organization platform for the GFF, (ii) Supporting the implementation of a community scorecard for monitoring commitments and accountability of stakeholders, (iii) Financing the development and implementation of watch and alert tools, and (iv) Financing the development and implementation of a communication plan on the GFF. (b) Strengthening Local Accountability through Quality of Care Scorecards for Mothers, Children, and Adolescents 3. Local accountability for better quality of care will be strengthened by implementing local scorecards for maternal, child, and adolescent health including quality-of-care indicators, by engaging the community in the design of provider plans of continuous quality improvement, and by training community volunteers in quality of care and equipping them with processes and instruments to share complaints with health care providers and districts. Innovative models of community engagement related to quality of care will be tested such as the model of health defenders successfully implemented in Guatemala. In Guatemala, community defenders are volunteers elected by their own communities to implement M&E of public policies and health care services. They also collect complaints and evidence of right-to-health violations in their communities and translate them to the corresponding authorities. 4. Specifically, the complaints will be managed by a GRM that will be set up through an inclusive process including the civil society, the beneficiaries, the health personnel, and the Project Management Unit. The building blocks of GRMs will include six principles: fairness, objectiveness and independence, simplicity and accessibility, responsiveness and efficiency, speed and proportionality, and participation and social inclusion. The GRM is an inclusive process, with beneficiaries informed on the GRM procedures and dedicated GRM personnel, providing continuous training and learning. Finally, the GRM will be based on analysis to regularly review and act upon grievances data, trends, and systemic issues. A specific Page 73 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) procedure will have to be put in place for the management of gender-based violence and all forms of abuse and exploitation of children and vulnerable persons. Additionally, for cash transfers to adolescent girls, GRMs to be put in place in the schools may also be used. 5. Community defenders also engage in strategic advocacy with municipal, provincial, and national governments with explicit demands to eliminate barriers to access and the discrimination experienced by rural indigenous families when seeking health care. Engaging with patients in local accountability mechanisms has proven important in the implementation of strong PHC models: communities with stronger local governance mechanisms and patient engagement were able to reduce avoidable mortality faster in Brazil compared to communities with weaker local governance.19 The project will ensure that reliable and timely information about quality of care including clinical quality and effective coverage is available throughout the duration of the project, at least on a yearly basis. Other potential interventions to augment demand for quality of care include a national commitment to a quality guarantee; charters of rights for patients; and expanded opportunities for recourse, complaints, and participation in local governance systems. (c) Improving Transparency and Effectiveness of PFM in Health 6. Finally, the project will support improvement in PFM in health. This will be achieved by (a) improving how financial resources for health are managed and tracked; (b) improving how health information is produced and analyzed to generate more robust evidence; and (c) improving stewardship and accountability, especially through a greater role of the civil society. The project will also support the development of a fiduciary unit to manage resources of external partners. 19 Hone T., Rasella D., Barreto M., Atun R., Majeed A. and Millet C., 2016. Large Reductions In Amenable Mortality Associated With Brazil’s Primary Care Expansion And Strong Health Governance, Health Affairs 36, no.1 (2017):149-158. Page 74 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 6. ECONOMIC ANALYSIS Introduction 1. The proposed project will seek to improve the health status of the Senegalese population and to promote equity in access to quality health care service with a specific focus on women and children and on the poor population. Project investments will contribute to strengthen the performance of the health system. The implementation of the project will increase the effective coverage of RMNCAH-N. The investment in RMNCAH-N is a pillar for capturing the demographic dividend. 2. In addition, support for the scale-up, strengthening, and rationalization of the CMU scheme is likely to decrease the incidence of catastrophic health expenditure, hence freeing up household resources for other essential goods and assets and increasing their well-being as soon as in medium term. 3. Jointly, demand- and supply-side interventions embedded in the project are likely to have a long- term positive impact on productivity and hence have a positive macroeconomic impact. 4. The rationale for public intervention in health is well established both theoretically and empirically. First, health interventions are public goods and would be provided in insufficient quantity if only provided by unregulated private actors, hence creating a problem of equity of access. Second, health interventions create externalities: the societal benefit of delivering these interventions exceeds their costs. Likewise, the negative externalities of not providing these interventions is a risk for all members of the society. Finally, asymmetry of information, which occurs on both demand- and supply-side interventions, is all-pervasive in health. 5. Global evidence shows that high-impact RMNCAH-N interventions retained in the project are cost-effective. For instance, community management of severe and acute malnutrition is a cost-effective intervention with US$26–39 per DALY averted; participatory women’s groups on health outcomes or training of community health workers and midwives show a cost of US$150–1,000 per DALY averted depending on the national context and so do safe motherhood initiatives based on a package combining antenatal and postnatal care by trained health attendants (all figures, as reported in DCP3, volume 2, chapter 17). Cost-effectiveness Analysis 6. The purpose of an economic analysis is to assess to what extent the gains resulting from the implementation of a project exceed the related increase in costs. The most straightforward approach would therefore be to monetize all gains to be able to compare them directly, dollar per dollar, with the related costs, and this is what is done through a cost-benefit analysis. As human development-focused projects often include a great share of ‘soft’ interventions, this valuation is nevertheless far from straightforward. For such projects, it is therefore recommended to adapt a cost-effectiveness approach, which has been retained for the present economic analysis of a health project. Page 75 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Methodology 7. A cost-effectiveness analysis toolkit for RBF projects was developed by the World Bank in 2015 and will be used as the methodological reference for the present analysis. It will allow to weight benefits (expressed in terms of effectiveness) and costs (expressed in monetary units). Costs will include costs related to the interventions included in the three components of the project. Gains will be expressed in terms of lives saved as a consequence of the supported interventions. To determine this gain, the expected number of lives saved by the project will be compared to a status quo scenario (that is, what would happen if the project were not to take place?). The output of a cost-effectiveness analysis is hence an incremental cost-effectiveness ratio (ICER), which reflects the change in cost divided by the change in the amount of lives saved as a result of the implementation of the project (that is, what was the cost of a life saved as part of this project?). It hence offers a convenient way to compare the project with similar ones. Figure 6.1 describes the structure of a cost-effectiveness analysis as proposed in the 2015 World Bank toolkit. Figure 6.1. Structure of the Cost-effectiveness Analysis of Health Programs Note: QALYs = Quality-adjusted life years; HMIS = Health management information system. Determining Incremental Costs 8. The first step of the cost-effectiveness analysis is to determine incremental costs, that is, costs of the targeted interventions had the project not existed versus cost of the interventions with the actual support of the project. As interventions supported by the project are new, the full cost of the project will be considered as the incremental costs. Cost categories hence include payments made as part of the quality fund mechanism, subsidies for the enrollment in the CMU scheme, cost of health inputs procured through the program, cost of trainings, verification, and so on. The implementation pace of the project is linear, and the annual cost of the project is US$30 million per year, over a five-year implementation period. However, it is recommended to apply a discount rate of 3 percent for all costs incurred in the future. The total present value of the project will hence be US$141.3 million (see table 6.1). Page 76 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Table 6.1. Discounted Program Costs (US$) Year Actual Cost Present Value FY20 30,000,000 30,000,000 FY21 30,000,000 29,100,000 FY22 30,000,000 28,227,000 FY23 30,000,000 27,380,190 FY24 30,000,000 26,558,784 Total 150,000,000 141,265,974 Note: Yearly discount rate: 3 percent. 9. The ISMEA project as a whole contributes to a PDO, either through direct interventions or through broader health-system-strengthening activities. As a result, it was decided to include all interventions and all related costs in the cost-effectiveness analysis. Determining Incremental Gains from the Project 10. The cost-effectiveness analysis measures project effectiveness in terms of deaths averted as a result of the health interventions supported by the project, preventive or curative. LiST was used for the cost-effectiveness analysis. LiST was preloaded with • Senegal demographic data imported from the 2017 UNFPA database; • Data on nutrition and mortality and morbidity; • Impact Matrix: LiST links selected RMNCAH-N health interventions with their impact in terms of deaths averted. Baselines and target values for the coverage of interventions supported by the project were inputted in line with the project’s Result Framework, where possible; and • Default values from the LiST tool for effectiveness of health services. 11. Table 6.2 summarizes the results of the LiST projections only for interventions of the ISMEA project, which directly supported maternal and child health services. The incremental number of lives saved as compared to status quo amounts to 991. Page 77 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Table 6.2. Incremental Number of Lives Saved as Compared to Status Quo Neonatal (0–1 month) Child (1–59 months) Maternal Deaths Total Deaths Deaths Averted Deaths Averted Averted Averted 2020 106 223 24 353 2021 209 422 46 677 2022 309 591 66 966 2023 406 737 84 1227 2024 501 862 99 1462 Total 1,531 2,835 319 4,685 Limitations 12. A significant number of lives are saved, which may however be underestimated, for the following reasons: • For some indicators of the performance framework, the reported coverage is already rather high, with limited potential for progress. This is, for instance, the case of assisted deliveries or access to the essential package of postnatal care. The main issue lies in the quality of care actually offered and the way it is measured, and this is precisely what this project aims to tackle through innovations such as the quality innovation fund. • Many interventions of the present have only a distal impact on coverage, which cannot be measured using LiST. This is, for instance, the case of Subcomponent 1.1 interventions, especially of subsidies to enrollment of children under five in the CBHI scheme. This intervention is expected to have a significant impact on financial risk protection and hence utilization of a broad package of curative and preventive care by children, but it is not possible to directly measure it. It is one of the main reasons for the little measured impact of the project on children using LiST. This is more generally the case of all health-system- strengthening activities, which represent a large share of the costs of this project. • In addition, a number of interventions have an impact beyond RMNCAH-N, for the general population, which is measurable through LiST. • In compliance with the Project Appraisal Document development guidelines, the number of interventions included in the performance framework was limited, due to which the baseline/targets were not determined. Determination of the ICER 13. As a result of the abovementioned limitations, the calculated ICER for the present project is rather high (US$30,152.82 per life saved on average) if all costs are taken into account. However, once all components on both the demand and the supply side of the project synergize in the interventions, it is expected that the actually observed ICER will be much more favorable during implementation. Page 78 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Table 6.3. ICER (US$ per Death Averted) Neonatal Maternal Child Deaths Total Deaths Discounted ICER (US$ per Deaths Deaths Averted Averted Costs (US$) Death Averted) Averted Averted 2020 106 223 24 353 30,000,000 84,985.84 2021 209 422 46 677 29,100,000 42,983.75 2022 309 591 66 966 28,227,000 29,220.50 2023 406 737 84 1,227 27,380,190 22,314.74 2024 501 862 99 1,462 26,558,784 18,166.06 Total 1,531 2,835 319 4,685 141,265,974 30,152.82 Macroeconomic Situation 14. In 2018, Senegal was classified by the World Bank as an LMIC. The pace of economic growth has recently improved, following long periods of volatility. Senegal’s GDP growth reached 6.7 percent in 2016 and 7.1 percent in 2017, while inflation remained under control. According to official estimates, all sectors contributed significantly to growth in 2017, but the primary sector continues to be the fastest growing, mainly due to agriculture. This is linked to the ongoing support programs and the robust external demand. The secondary sector remains dynamic, with construction, processed food, and chemicals still growing robustly. Hospitality and financial services are the key drivers behind tertiary sector. The economic outlook is favorable with progressively higher growth rates expected in the coming years. Page 79 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Figure 6.2. Growth Accelerated in 2015 and 2016, Making Senegal One of Sub-Saharan African Fastest-growing Economies GDP Growth (%) Real GDP Growth in Africa (%), 2015 10 8 6 4 2 0 -2 -4 -6 -8 -10 Note: UEMOA= Union Economique et Monétaire Ouest Africaine (West African Economic and Monetary Union). 15. The International Monetary Fund (IMF) projects that the economy of Senegal will grow at a high rate of 6.7 percent annually, with quite a stable growth and low inflation rates. In 2014, the country Page 80 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) released the PSE, an ambitious plan to boost economic growth in the country and accelerate poverty reduction. The 2016 IMF press release highlights the commitment of the country to implementing the PSE—that is, the continued efforts to improve competitiveness and satisfactory results in the country’s plans to enhance tax collection and transparency, increase electricity service distribution, and boost private sector initiatives to attract foreign direct investment from China, Europe, and the United-States. Given the country’s efforts to rationalize spending and close the revenue deficit, the country’s risk of debt distress is kept at the level ‘low’. The outlook concludes on potential structural risks, which are considered ‘manageable’ in the context of Senegal. Figure 6.3. GDP Growth Rates (Historical and Forecast) 8 7 6 5 4 growth rate 3 2 1 0 2018 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2019 2020 2021 Growth rate Projected growth rate Source: WDI data combined with IMF forecasts (IMF 2016). 16. Senegal does relatively well in collecting and spending government revenues as a share of GDP. In 2014, the overall GGE amounted to 30 percent of GDP, above the median ratio for the group of L-LMICs (28.5 percent). This ratio has been improving steadily since the end of the 1990s, mainly as a result of an increase in the tax revenues (excluding grants): in 1997, tax revenues were only 15.3 percent of the GDP, and in 2014, they represented 20.1 percent. Senegal’s revenue base has grown increasingly diversified in the recent years. Senegal relies to a large extent on the collection of value added tax. Interestingly, the contribution of rents from the extractive industry or energy sector is much lower than other countries in the region (Organisation for Economic Co-operation and Development, 201620). Health Sector Expenditure 17. The share of government domestic resources allocated to the health sector decreased by half between 2006 and 2012 and stabilized at around 4 percent until 2015. With the continuous increase in health spending, the contribution of household health expenditure remains the main source of health funding. In addition, the practice of allocating resources to health programs and services on a historical basis is the reason for disparities between programs and regions in financing of the health system. The results of the 2013 NHA show that the southern regions of the country where the child mortality rate is 20 Organisation de Coopération et Développement Economique, Forum africain sur l’administration fiscale et Commission de l’Union africaine, 2016. Page 81 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) the highest benefit from fewer resources. To contribute to a more efficient allocation of sector funding, this project prioritizes the six southern regions and PHC. Figure 6.4. Domestic GGHE as Percentage of GGE 10 8 6 4 2 0 Source: WHO GHED. 18. Since 2012, the structure of health expenditure has not changed much despite the implementation of the health insurance program in 2013. These results are not surprising because the implementation of the program only started in 2015 with the creation of ANACMU. The evolution of external financing has been fluctuating a little, from 12 percent in 2010 to 16 percent in 2013 to 12 percent in 2015. Expenses for voluntary health insurance have been stable since 2008 at 12 percent. Direct payments from households are the main source of health expenditure, and their share of health expenditure has been about 44 percent since 2010. Figure 6.5. Health Financing Sources (2010–2015) % Current Health Expenditure 120 Out-of-pocket (OOPS) 100 Voluntary Health Insurance 80 60 Compulsory Health Insurance 40 External Health Expenditure 20 0 Domestic General Government Health Expenditure 2000 2005 2010 2012 2013 2014 2015 Source: WHO GHED. 19. In recent years, Senegal has made significant progress on health insurance coverage, from 20 percent coverage in 2010 to 47 percent in 2017. These results should make it possible to strengthen the financial protection of households against the financial risks associated with illness and the reduction of financial burden related to health problems. The strong political commitment of the Government and the Page 82 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) programmatic framework for the implementation of the national health financing strategy and the GFF investment file make for better ownership and strong government leadership in the implementation of this project. In addition, the alignment of partners on the GFF IC's government priorities and funding strategy and the Government's commitment to increase the sector resources to reach the Abuja declaration target of 15 percent are positive factors for the achievement of project objectives and more efficient use of project resources. Page 83 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) ANNEX 7. CLIMATE SCREENING AND CLIMATE CO-BENEFITS FOR SENEGAL 1. According to the assessment conducted, total climate co-benefits in this project amount to US$12.1 million (8.6 percent) with potential for further increase. This project has been screened for climate change, and the following vulnerabilities were identified through the process. The overall potential risk in the Summary Climate and Disaster Risk Screening Report is assessed as Moderate. Senegal, and in particular, the Dakar, Thiès, and Kaolack triangle, is categorized as having ‘high exposure’ due to extreme temperature, precipitation and flooding, drought, sea level rise, 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 women 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. 2. Senegal is vulnerable to climate change with more intense rainfall in shorter periods leading to frequent flooding and drier seasons leading to food insecurity. These climatic events have grave consequences on health such as nutrition-related effects and waterborne illnesses. In particular, it is projected that risks will increase 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 agricultural output. It is important to note that there will be regional differences; the Dakar, Thiès, and Kaolack triangle where the project will take place is at increased risk of waterborne diseases such as cholera and diarrheal diseases due to flooding and overcrowding. For instance, in 2009, the floods that affected the project region and Saint Louis caused over US$100 million of damage and loss, with damages to health centers, and it was reported that there were approximately 2,000 cases of diarrhea and 3,300 cases of malaria following the flood.21 3. The project will support Senegal through the following adaptation activities: • Component 1 (US$60 million equivalent). The main objective is to improve the availability of RMNCAH-N services. This will include strengthening human and institutional capacities to ensure sustainable access to health services even during natural disasters such as flooding and droughts. There is insufficient availability of quality health services, which makes access difficult particularly with more extreme climatic conditions. To address this issue, this project will increase the number of qualified health workers who will be trained on various skills to improve care competency levels as well as how to cope with working in higher temperatures that can lead to heat stress/exhaustion and other climate-associated events. This will be particularly important for the mobile midwives as they will spend much time in the communities. • Component 2 (US$25 million equivalent). The main objective is to promote adolescent health and women’s empowerment. The behavioral change and communication activities under this component will attempt to change the perceptions of adolescent health as well as provide knowledge about the impacts of climate change on women’s health. For instance, 21 USAID. 2018. Technical Report - Climate Change and Health Risks in Senegal. Page 84 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) women, in general, feed the men and children in the household first, which has been known to increase malnutrition. During climate-induced food shortages, women’s nutritional status can be further negatively affected. Therefore, this project will ensure that women are aware of their nutritional needs and how to adapt to climatic changes without compromising their own health through various awareness and communication campaigns. More studies have also found that natural disasters that devastate communities’ economic activities can lead to post-traumatic stress and in some cases can leave women vulnerable to gender-based violence. The activities in this component will empower women to alleviate barriers due to social and cultural norms. • Component 3 (US$65 million equivalent). It aims to support reforms to strengthen equity and financing sustainability in the health sector. This is key as girls and women are the most vulnerable in many communities, and this project aims to improve their access to quality health services while increasing their adaptive capacity to climate change. For instance, this project will recommend the use of mandatory rather than voluntary approaches to access health insurance. Women are generally the household’s caregivers and will also potentially have to pay OOP to ensure family members are taken care of. The ANACMU is also setting up an integrated management information system, which will enable improved monitoring of disease outbreaks and disaster risk management. 4. The project will support Senegal through the following mitigation activities. • Component 1 (US$60 million equivalent). To address the challenge of electrification and refrigeration of medical drugs for the ‘last-mile of delivery’, the project will install solar panels on various health facilities which will help provide sustainable access to electricity for cooling, refrigeration, and other essential functions. This project will also ensure access to safe water sources in the health centers to minimize climate-induced infection transmission. To address the challenge of the ‘last-mile of delivery’ for health services access, midwives will be mobile and will connect with populations who are most remote at the community level. This will mitigate the emissions from journeys that service users will no longer need to make which are replaced by more efficient travel by midwives. Moving care closer to home also tends to be more efficient, thereby further reducing emissions. • Component 2 (US$25 million equivalent). Under this component, women will be provided with more information on how to prevent certain health hazards such as shifting from using biomass fuels for cooking to cleaner technologies. This will reduce the impact on the environment as these technologies are also more energy efficient, reduce local deforestation impacts, and improve indoor air quality and thus the health status of women and children. • Component 3 (US$65 million equivalent). It will reduce the cost of health care as part of moving toward UHC, thereby improving women’s social safety nets and increasing their access to other assets and networks that can aid in mitigating impacts of climate change. Page 85 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Table 7.1. Detailed climate co-benefit assessment Adaptation Mitigation Total IDA Component/Prior Co- Co- Financing Reason for Assigning Potential to Improve Action/Disbursement- benefits benefits (US$, Climate Co-benefit Climate Co-benefit linked Indicator (US$, (US$, millions) millions) millions) 1. Improving 55.00 5.5 1.8 Adaptation co-benefits are — availability of assigned for improving the RMNCAH-N services availability of quality of adequate quality health services that can directly help the population cope with various climate change- induced health risks. Installation of solar panels is eligible for mitigation co- benefits under 1.3: Measures to facilitate integration of renewable energy into grids of the MDB List of Eligible Mitigation Activities. 2. Promoting 25.00 0.0 0.7 Use of clean cookstoves is Category I adolescent health and eligible for mitigation co- (c) Adaptation: Link to women’s benefits under 3.2: Energy project activities empowerment efficiency improvements in Potential for adaptation existing commercial, public co-benefits if more and residential buildings of information can be the MDB List of Eligible provided on the Mitigation Activities. nutrition-related awareness-raising activities that promote climate change adaptation and under which subcomponents the activities will be carried out. Page 86 of 87 The World Bank Investing in Maternal, Child and Adolescent Health (P162042) Adaptation Mitigation Total IDA Component/Prior Co- Co- Financing Reason for Assigning Potential to Improve Action/Disbursement- benefits benefits (US$, Climate Co-benefit Climate Co-benefit linked Indicator (US$, (US$, millions) millions) millions) 3. Supporting reforms 60.00 4.0 0.09 (Climate co-benefits for — to strengthen project governance, equity, coordination/management and financing are prorated based on the sustainability in the overall project’s climate health sector co-benefits) Adaptation co-benefits are assigned for improving the access to health services that can directly help the population cope with various climate change- induced health risks. 4. CERC 0.00 — — Not applicable — TOTAL 140 9.5 2.6 Total climate finance: US$12.1 million (8.6 percent) Page 87 of 87