World Bank Reproductive, Maternal and Child Health Services 2017-21

Summary of key results and implementation status Overall: By the time of the latest ISM most of the project activities had been either concluded or were nearing completion. The components still grappling with delays are the civil works component and the roll out of the Birth Death and Adoption Order Registration (BDAR) solution, none of which are supported by the Swedish funding. As of 31 December 2022, progress towards achievement of the Project Development Objectives (PDO) and implementation progress were both rated as moderately satisfactory. The rating on the latter is a downgrade from the annual report 2021/22. The mission's assessment is however that the project is on track to achieve the PDOs with most of the project activities have been satisfactorily concluded and most PDO indicators have either been fully or substantially achieved. At the same time, the aide memoire highlights the risk of sustainability of results due to the discontinuation of several of the complementary systems strengthening interventions that have been implemented as part of the project. This was also discussed at length in the April meeting. Some mitigating actions have however been taken by the Bank and MoH by integrating some of the interventions in other WBsupported projects. Some will also be supported by a USAID funded health activity. Component 1: Resultsbased financing for primary health care services The RBF program concluded in June 2022 after having continuously scaled up during implementation. At the end, 1,425 health facilities were reached in 131 of the countrys 135 districts, meaning a theoretical coverage of 92 % of the national population. Analysis of performance shows significant increase in both quantity of outputs (utilization of the incentivized indicators) and a general increase in quality scores over time for the targeted facilities (although with some variation depending on in which phase facilities were enrolled). Examples of increased utilization is antenatal care visits, facilitybased deliveries (live births), uptake of family planning and child immunization. The annual report describes the linkages between RBF and broader system strengthening as follows: The observed improvements in both the quantity and quality of services relate to the various pathways in which RBF impact service delivery including the autonomy for health facility staff to use the additional resources to address the most pressing services delivery and demand generation challenges including procurement of stocked out medicines, equipment, and facilitation of engagement with community actors through Village Health Teams. There has been progressive interaction between the RBF program and other interventions under the project such as quality improvements e.g., institutionalization of Maternal and Perinatal Death Surveillance and Response, scale up of the mentorship program across the country, and adolescent health activities targeting minimization of teenage pregnancies. Further mainstreaming of the RBF principles should maintain the momentum on ensuring these synergies. In the April meeting with the WB, it was also emphasized that the performance improvement as a result of the RBF programme is supported by different studies including one of the studies from the Operational Research Programme within the project (fully funded by Sweden) and a joint study by MoH and ThinkWell. Interestingly, the ISM aide memoire also notes an immediate dip in the incentivized indicators following the end of the programme. This illustrates the sustainability challenges highlighted above and that result from of a wide range of complex and interacting factors from the overall low level of domestic funding of the health sector to mindsets among individual decision makers. The Ministry of Finance is a strong advocate for resultsbased financing and has committed to the principle of mainstreaming RBF into the governments primary health care system. For that purpose 9MUSD is provided in the 23/24 budget. MoH has in spite of the demonstrated benefits of RBF, to date not shown a matching level of enthusiasm for its continuation but is requested to prepare for the mainstreaming agenda including an increase in related human resources. The ISM underscored the criticality of adequate preparations to ensure success of the reform and provided several recommendations to support that work. The WB has also offered technical support. Component 2: Strengthen health systems to deliver RMNCAH services This component consists of five subcomponents of which the Embassy funds three (in bold): (i) improving availability of essential drugs and supplies, (ii) improving availability and management of the health workforce, (iii) improving availability and functionality of medical equipment in health facilities, Sammanfattande resultatuppdatering Conclusion on Performance Contribution ID: 10191 4 (13) (iv) improving health infrastructure at Primary Health Care (PHC) facilities, and (v) improving quality of care and supervision. Improving access to adolescent health services and overall health promotion also falls under component 2 and is an area of focus that the Embassy has pushed for as a priority since before the onset of the programme (see CoP 19/20 for history), and has emphasized in followup throughout. In the April meeting, the WB expressed thanks to the Embassy for pushing on ADH, insisting that it had made a difference, while admitting challenges with getting MoH to give ADH sufficient attention. It has also been noted by GFF in previous dialogue that for supply-side RBF programs there is limited evidence on using facility incentives for ADH. The ISM also noted that the ADH interventions to date have been too much focused on training and not having sufficient reach. The ISM aide memoire however reports several activities implemented during the review period with the aim to improve access and quality of SRH services at health facilities and other institutions such as schools and universities. These are in addition to a number of activities reported in the 21/22 annual report such as mobilizing 960 men and boys through male action groups, to champion teenage pregnancy prevention in selected communities in 30 districts. The ISM recommends MoH to: (i) continue empowering and engaging communitybased groups and CSOs to reach more adolescents, (ii) scale up effective models for training competent adolescent health service providers including through fellowship programs, and (iii) engage research institutions like Makerere University School of Public Health (MakSPH) to undertake implementation research on high impact solutions for scaling up the delivery and uptake of adolescent services. On the sub-components supported by Sweden the ISM notes progress particularly when it comes to human resources for health, where scholarships and mentorships has contributed to improving the quality of the health workforce. While the sub-component was heavily delayed by COVID19, 1,250 health workers have been awarded scholarships since the inception, of which 1,190 have completed their studies. The beneficiaries include 401 critical care nurses trained to support functionality of intensive care units in both public and private hospitals contributing to both COVID19 and EVDresponse. Additionally, 4,600 health workers have benefited from inservice mentorships across the country with a focus on emergency obstetric care, newborn care, postpartum family planning, long-acting reversible contraceptives, postabortion care, and infection prevention control in the context of COVID19 and EVD. For sustainability purposes the programme has also trained 353 master mentors to sustain the mentorship programme beyond the lifetime of URMCHIP. Availability of essential medicines and commodities remains a major challenge in Uganda. The project has however supported procurement and supplies at facility level through RBF payments and MoH has also procured RMNCAH medicines and supplies worth 5,1mUSD under the project. In addition to quality of care improvements as a result of RBF and through scholarship and mentorship Sammanfattande resultatuppdatering Conclusion on Performance Contribution ID: 10191 5 (13) activities, this sub-component also includes MoH senior level support supervision to regional referral hospitals, general hospitals and selected HC IVs supported by the project. Strengthening of maternal and perinatal death surveillance and response also falls under this subcomponent with an improvement being seen especially for maternal death reviews, while perinatal death reviews lag behind although also significantly improved. Operational Research Program The OR program which is fully funded by the Embassy has two objectives: (i) to assist Uganda in generating practical and actionable evidence for RMNCAH implementation and (ii) to further strengthen the capacity of Ugandan researchers in operational research. The program concluded successfully in December 2022 following a dissemination event at which the the Embassy participated and delivered remarks. A summary report of the programme is available online and with the Embassy. There is also a separate meeting report form the dissemination event. WB reports the following in the ISM aide memoire: World Bank, through the RMNCAH OR Advisory Committee has recommended formal publication of the studies under the International Development in Focus Series of the Bank. It is hoped that the findings of this program will inform future studies, and the ongoing policy discourse on RMNCAH and human capital development. Some of the early findings have already proved useful in informing the updated RMNCAH Sharpened Plan, the design of some of the areas on continuity of essential health services in UCREPP, and the draft of the Human Capital Development and Growth Review. The Bank, Sweden, and the Advisory Committee appreciate the Ministry of Healths support in the design and execution of the OR program, and hope recommendations from the study are taken up moving forward. Additionally, from the meeting report on the implementation of research recommendations: Most of the research recommendations are in line with ongoing policy reform priorities of MoH. Additionally, the MoH committed to advancing the shortterm recommendations, including leveraging the existing and new development projects to strengthen and enhance investments in governance and managerial capacity development, service delivery competency development, mentorship and support supervision of providers, and emergency medical services and referrals for RMNCAH services. A compendium with all the studies coupled by related policy briefs was to be finalised during the first quarter of 2023, but has been delayed and is now expected to be published in June 2023 according to the WB.