Pakistan - Third Partnership for Polio Eradication Project. Project Appraisal Document

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized FROM: Vice President and Corporate Secretary OFFICIAL USE ONLY IDA/R /1 Streamlined Procedure For meeting of Board: Thursday, June 18, 2009 Pakistan - Third Partnership for Polio Eradication Project Project Appraisal Document June 1, 2009 Attached is the Project Appraisal Document regarding a proposed credit to the Islamic Republic of Pakistan for a Third Partnership for Polio Eradication Project (IDA/R ). This project will be taken up at a meeting of the Executive Directors on Thursday, June 18, 2009 under the Streamlined Procedure. Distribution: Executive Directors and Alternates President Bank Group Senior Management Vice Presidents, Bank, IFC and MIGA Directors and Department Heads, Bank, IFC and MIGA 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 Group authorization.

2 Document of The World Bank FOR OFFICIAL USE ONLY Report No: PK PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 50.2 MILLION (US$74.68 MILLION EQUIVALENT) TO THE ISLAMIC REPUBLIC OF PAKISTAN FOR A THIRD PARTNERSHIP FOR POLIO ERADICATION PROJECT May 20,2009 Human Development Unit South Asia Regional Office 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.

3 CURRENCY EQUIVALENTS (Exchange Rate Effective April 30,2009) Currency Unit = PKR US$1 = PKR80.47 US$1 = SDR0.67 FISCAL YEAR July01 - June30 ABBREVIATIONS AND ACRONYMS AFP ACPE BMGF CAS CDC CIDA DFID ED0 (H) EPI FATA GAVI GNP GOP GPEI HNP IACC IDA LHW MDG MOH MTDF NGO NID NIH NPV NWFP OPV PDO PEI PHC PRS(P) S IA SNID TA TAG TPPEP Acute Flaccid Paralysis Advisory Committee for Polio Eradication Bill & Melinda Gates Foundation Country Assistance Strategy Centres for Disease Control and Prevention (USA) Canadian International Development Agency Department for International Development (UK) Executive District Officer (Health) Expanded Program on Immunization Federally Administered Tribal Areas Global Alliance for Vaccines and Immunization Gross National Product Government of Pakistan Global Polio Eradication Initiative Health, Nutrition and Population Inter-Agency Coordinating Committee International Development Association Lady Health Worker Millennium Development Goal Ministry of Health Medium Term Development Framework Non-governmental Organization National Immunization Day National Institute of Health Net Present Value North-West Frontier Province Oral Polio Vaccine Project Development Objective Polio Eradication Initiative Primary Health Care Poverty Reduction Strategy Supplemental Immunization Activities Sub-National Immunization Day Technical Assistance Technical Advisory Group Third Partnership for Polio Eradication Project

4 UNF UNICEF USAID VAR WE3 WHO WPV FOR OFFICIAL USE ONLY United Nations Foundation United Nations Children s Fund United States Agency for International Development Vaccine Arrival report World Bank World Health Organization Wild Polio Virus Vice President: Country Director: Sector Manager: Task Team Leader: Isabel M. Guerrero Yusupha B. Crookes Julie McLaughlin Inaam ul haq This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.

5 PAKISTAN Third Partnership for Polio Eradication Project CONTENTS Page I. STRATEGIC CONTEXT AND RATIONALE... 1 A. B. C. Country and sector issues... 1 Rationale for Bank involvement... 4 Higher level objectives to which the project contributes... 5 I1. PROJECT DESCRIPTION... 5 A. Lending instrument... 5 B. Project development objective and key indicators... 5 C. Project Components... 6 D. Lessons learned and reflected in the project design... 7 E. Alternatives considered and reasons for rejection... 8 I11. IMPLEMENTATION... 8 A. Partnership arrangements B. Institutional and implementation arrangements... 8 C. Monitoring and evaluation of outcomeshesults... 9 D. Sustainability E. Critical risks and possible controversial aspects F. Credit conditions/covenants IV. APPRAISAL SUMMARY A. Economic and Financial Analysis B. Technical C. Institutional D. Fiduciary E. Social F. Environment G. Safeguard policies H. Policy Exceptions and Readiness... 15

6 Annex 1: Polio Eradication Initiative. Detailed Project Description. 16 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies Annex 3: Results Framework and Monitoring Annex 4: Oral Polio Vaccine Requirement Annex 5: Project Costs Annex 6: Financial Management and Disbursement Arrangements Annex 7: Procurement Arrangements Annex 8: IDA Buy-Down Mechanism Annex 9: Project Preparation and Supervision Annex 10: Documents in the Project File Annex 11: Statement of Loans and Credits Annex 12: Country at a Glance Annex 13: Map IBRD

7 . PAKISTAN THIRD PARTNERSHIP FOR POLIO ERADICATION PROJECT Date: Monday, May 20,2009 Country Director: Yusupha B. Crookes Sector ManagedDirector: Julie McLaughlid Michal Rutkowski Project ID: PI Lending Instrument: SDecific Investment Loan " PROJECT APPRAISAL DOCUMENT SOUTH ASIA SASHD Project Financing Data [ ] Loan [XI Credit [ ] Grant [ ] Guarantee [ ] Other: Team Leader: Inaam ul haq Sectors: Health (100%) Themes: Child health (P);Other communicable diseases (P) Environmental screening category: Category C For Loans/Credits/Others: Total Bank financing (US$m.): Proposed terms: Standard IDA terms with 35 years maturity including a grace period of 10 years with a special provision for third party funded Trust Fund to purchase the credit at its net present value once the project has been successfully completed in accordance with the terms of Financing Agreement c _I --. -".-- Source Local Foreign Totag BORROWEIURECIPIENT International Development Association (IDA) JAPAN: Government of Japan World Health Organization UNICEF Total: Borrower: ISLAMIC REPUBLIC OF PAKISTAN Economic Affairs Division, Government of Pakistan, Islamabad, Pakistan Tel: Fax: Responsible Agency: Expanded Program on Immunization (EPI) Ministry of Health, National Institute of Health, Chak Shehzad, Islamabad, Pakistan Tel: Fax: altaf%osan@nmail.com

8 I._-.I-_ Y i 2010 I 2011 I r 4nnual Zumulative I The project will assist the GoveGnent of Pakistan s Polio Eradication Initiative (PEI) in decreasing the number of polio cases and ultimately eradicating the disease in Pakistan. The development objective is to assist Pakistan s efforts to eradicate polio through procurement, supply and effective use of the oral polio vaccine in the country s supplementary immunization activities (SIAs) during The objective is consistent with the original project development objective. Project description Re$ PAD II.D., Technical Annex 4 Pakistan s PEI has three components: (i) procurement, supply and effective use of oral Polio vaccines, (ii) supplemental immunization activities; and (iii) surveillance. The project with an International Development Association support of US $74.68 million will finance only the first component i.e. procurement, timely supply and effective use of Oral Polio Vaccines during SIAs. Which safeguard policies are triggered, if any? Re$ PAD IKF., Technical Annex 10 No safeguard policies triggered. Significant, non-standard conditions/covenants, if any, for: Re$ PAD III. F. Credit effectiveness: OPV procurement agreement has been executed by the Borrower and UNICEF and all conditions precedent to its effectiveness (other than the effectiveness of the Financing Agreement) have been met. Covenants applicable to project implementation: 1. Provide to the Association a revised PEI strategy (based on the findings of the independent assessment undertaken by the WHO on inter alia, the PEI) as approved by the Technical Advisory Group within four months from the date of the WHO assessment report; 2. Maintain, the Inter-Agency Coordination Committee at the national level; Provincial Coordination Committees at the provincial level; and at the district level, District Coordination Committees; 3. Carry out the SIAs organized under the PEI with due diligence and efficiency; and 4. The disease surveillance systems established under the PEI will be maintained throughout the period of project implementation.

9 I. STRATEGIC CONTEXT AND RATIONALE A. Country and sector issues 1. Pakistan is making slow progress towards the health related Millennium Development Goals (MDG) compared to most of its South Asian neighbors and is not on track to achieve most MDG targets by Factors internal and external to the health sector contribute to this slow progress. The public health sector performs inadequately with low levels of coverage of essential services due to poor quality of implementation; weak management and governance challenges; and persisting low and inefficient public spending. External factors contributing to poor health outcome include illiteracy, unemployment, gender inequality, social exclusion, increasing urbanization, and lack of access to safe drinking water and inadequate sanitation. The poor health status of a large part of the population remains an obstacle to Pakistan s economic growth. 2. The Government of Pakistan (GOP) is cognizant of the above challenges. Its mediumterm health strategy, outlined in Poverty Reduction Strategy (PRS) and Medium Term Development Framework envisages increasing public sector health expenditures focusing on prevention and control of diseases, reproductive health and addressing nutrient deficiencies. Results of Pakistan Social and Living Standards Measurement Survey indicate that during , intermediate health outcomes have shown some improvements including: increasing antenatal care from 35 percent to 61 percent, skilled attendance at birth increased from 24 percent to 36 percent, proportion of fully immunized children has increased from 53 percent to 76 percent. In addition, TB case detection rate at 69 percent and cure rates at 87 percent are almost at 2010 targets. Despite these improvements, challenges remain, e.g., one fourth of children remain unimmunized, two thirds of women deliver without skilled attendance and there is a large unmet need for family planning. 3. Global Polio Eradication Initiative (GPEI): Poliomyelitis (polio) is a highly infectious disease caused by a virus mainly affecting children under five years of age. The virus invades the nervous system, and can cause irreversible paralysis. The GPEI launched by the World Health Organization (WHO) has been highly successful: the incidence of polio cases has decreased by 99 percent globally since 1988 with only new cases in 2007 in the four endemic countries and 12 re-infected countries. It is estimated that 5 million children are walking who would have been paralyzed if not immunized against polio. However, the number of polio cases increased to 1652 worldwide in 2008 (91 percent in four endemic countries - Pakistan, India, Afghanistan and Nigeria) due to persisting virus transmission. In 2009, 328 cases have been reported to date. GPEI has focused on the remaining four countries with an intensified campaign with use of new technologies, such as the use of monovalent vaccine which resulted in decrease in incidence of Type I polio virus by 81 percent in last three years. The Global Strategic Advisory Group of Experts on Immunization and Advisory Committee on Polio Eradication reviewed the intensified effort in 2008 and affirmed that interruption of polio virus was still achievable despite increased transmission. WHO has called for an independent assessment of the program due to slow progress towards eradication. The review is likely to be completed by June/July The program strategy will be reviewed and changed (if needed) based on the findings of the Independent review in all countries including Pakistan. Polio eradication is a global public good, and remains a priority because a single infected child puts unvaccinated children everywhere at risk of contracting the disease. 1

10 4. Status of Polio Eradication in Pakistan and Remaining Challenges: Pakistan's Polio Eradication Initiative (PEI) has made satisfactory progress in its efforts to eradicate polio since The numbers of confirmed polio cases decreased substantially from around 1,147 in 1997 to 32 in 2007 with decreasing number of infected districts. The transmission of polio virus was restricted to three zones of the country and large part of the country was polio free. Overall, PEI worked satisfactorily and Pakistan continued to organize, nationwide Supplemental Immunization Activities (SIAs) with an average coverage of more than 97 percent during the last four years. Acute Flaccid Paralysis (AFP) surveillance has remained satisfactory for all indicators of quality at the national and provincial levels, meeting WHO performance-indicator targets. SIA monitoring and surveillance system continues to provide quick feedback to identify high risk areaddistricts and communities besides investigating more than 4000 suspected cases of polio for AFP during last four years. Pakistan: Confirmed Polio Cases 1400 ' I : ? m 6 ~ ~ 8 ~ ~ ~ td v ) ( o l c o o m m m m m o o o o o o o o o o F F r r N N N N N N N N N N Years 5. SIAs have been implemented effectively across the country with high OPV coverage of targeted population during the last four years, however Pakistan has seen upsurge in virus transmission across the country during 2008 resulting in 117 confirmed cases (50 percent from the known transmission zones and 50 percent from other zones). By end April, 11 cases have been confirmed in The 2008 cases have been reported from all four provinces (Punjab 31; Sindh 18; North-West Frontier Province (NWFP) and Federally Administered Tribal Areas (FATA) 52; Balochistan 1 1 ; and Islamabad Capital Territory 5) with majority of cases from NWFPBATA (44 percent) and Punjab (27 percent). According to the Advisory Committee on Polio Eradication (APCE), the recent upsurge of transmission is due to polio virus type I. It concluded that despite Pakistan having a sound program it faces a number of serious challenges some of which need to be immediately addressed to make progress towards eradication. These include: a) An efficient virus transmission: The transmission of the polio virus is particularly efficient in Pakistan due to a number of factors including hygiene and climate. The coverage targets set for Pakistan PEI for the first two buy-down projects were appropriate in light of understanding of population immunity levels and polio transmission in the early 2000s. However, more recent analyses by Imperial College, London demonstrate that in fact transmission is much more efficient in Pakistan and requires a much higher level of 2

11 population immunity than previously thought (in the range of percent) to interrupt type 1 virus and an only slightly lower level for type 3 virus; Unstable security situation: The coverage of population especially in known transmission zones is being hampered by the unstable security situation (mainly in NWFP, FATA and Balochistan). The unstable security situation is resulting in large scale population movements and it limits access of polio teams to approximately 675,000 of the targeted children. This situation also explains the spread of polio from known transmission zones to previously polio-free areas. Insecurity in southern Afghanistan also has direct bearing on Pakistan especially in Sindh, NWFP and Balochistan; Afghanistan and Pakistan are part of one polio transmission block. In 2008 Afghanistan also witnessed an upsurge of Polio cases (increasing from 17 in 2007 to 3 1 in 2008) in provinces along the Pakistan border. This necessitates the need for coordinated action against polio in the border areas of Pakistan and Afghanistan ensuring coverage of all population traveling between the two countries during immunization days and routinely; Lapses in campaign quality: Although the average coverage of the targeted populations has been high, there are lapses in campaign quality due to weak management and lack of close supervision in selected districts of the country; Coverage of routine immunization: The immunization coverage through the routine immunization program has improved but remains low with Diphtheria, Polio, Tetanus (DPT) coverage of about 75 percent; and SociaYreligious resistance: Social and religious factors contribute to negative perceptions about immunization in general and the polio campaigns specifically which limits the populations acceptance or seeking out of services. With growing security challenges, the above issues need special communication strategies to involve the local populations and informal, unofficial and tribal leadership and authorities. Despite the upsurge and increased transmission, APCE and the technical partners (WHO and UNICEF) recently judged that Pakistan can still interrupt transmission of polio if the above challenges are addressed by revising the PEI strategy and addressing implementation bottlenecks. The PEI strategy has been revised with a particular focus on: intensifying SIAs (increasing the number of rounds and proportion of population covered in sub national rounds), improve campaign quality and strengthening micro planning at local level with increasing technical support from UNICEF and WHO; using innovative ways to improve coverage in security compromised areas by working closely with local communities, religious and traditional leaders; ensuring coverage of internally displaced populations; strengthening the response and coordination with Afghanistan including expanding border immunization centers and immunizing 1.2 million children; strengthen communication and community mobilization including effective engagement of local and religious leaders to deal with social/religious resistance; involvement of highway police and using mobile telephone networks. Additional steps are being taken to enhance routine immunization coverage with Global Alliance for Vaccines and Immunization (GAVI) assistance which include targeting poorly performing districts with technical support; strengthening micro planning and using community based lady health workers to provide immunization services. 7. The independent assessment by the WHO of the Global and Pakistan s PEI program was planned to be completed by May 2009, however it has been delayed and is most likely to be completed by June/July The findings of the assessment will guide further revision of the program strategy (if needed). GoP will share with the Bank an updated program strategy approved

12 by the Technical Advisory Group (TAG), a group of International and National Experts within four months of the assessment report. B. Rationale for Bank involvement 8. PEI is a major global public health effort actively supported by many development partners with leading technical roles for WHO and UNICEF. As eradication took longer than expected, additional financing was needed to meet the vaccine requirements. To address this need for extra financing, the IDA buy-down financing mechanism (see Annex 8 for details) was developed by the Bank in partnership with the Bill & Melinda Gates Foundation (BMGF), United Nations Foundation (UNF), Centers for Disease Control (CDC), Rotary International and other technical partners, following a request from the Global Polio Eradication Technical Advisory Committee. Under the mechanism the Polio Eradication Trust Funds, financed by BMGF, and UNF and managed by the World Bank, are already established. The Trust Funds will pay the service fee and commitment charges for the Credit during the implementation and buy-down the net present value of the IDA Credit upon successful completion of the project, as determined by a third party. An Independent Evaluation of Performance of the IDA buy-down projects found strong support for use of mechanism by all stakeholders and recommended that the Bank should continue to use the buy-down mechanism. 9. IDA has supported Pakistan s PEI through two Partnership for Polio Eradication Projects since 2003 using the IDA buy-down mechanism. The projects have contributed to GOP s eradication efforts with financing for the procurement of Oral Polio Vaccine (OPV) with support amounting to US$ll2 million. The projects have ensured regular and timely supply of OPV for SIAs and reported high coverage of targeted population during SIAs. Overall project implementation rating for both projects has been satisfactory and progress towards project development objective (PDO) was rated as satisfactory. Based on performance audit, IDA buydown for both projects have been triggered. The project ICR rated project outcome moderately satisfactory, based on substantial relevance of objectives and design. In addition, the Independent Evaluation of Performance of the IDA buy-down acknowledges the simplicity of the design and the well defined focus of the projects as a key to successful implementation and recommended Pakistan should be provided continued access to the buy-down mechanism, given its satisfactory performance of the two projects. 10. Polio eradication is at a critical stage in Pakistan. Interruption or slowing of efforts at this time in Pakistan will very likely lead to large outbreaks of poliomyelitis, the impact of which will be felt in areas far beyond the regions where polio is still endemic. Endemic circulation in Nigeria and India has resulted in re-infection of polio in many countries of the world. The recent upsurge of transmission needs to be addressed by further intensification of the SIA which requires additional resources. GOP with limited resources has been trying to increase its investment in the health sector. It had planned to finance OPV procurement from its own resources after the completion of second IDA polio project. GoP indeed financed and procured OPV during 2008 and will finance procurement of OPV to be used till June However, the deteriorating economic environment arising from external shocks and growing fiscal deficit has forced GoP to seek out other financing sources. IDA financing will add value by: (a) ensuring timely availability of OPV for SIA; (b) maximizing the results of the investments of other donors (who are financing 4

13 operational and surveillance costs); (c) maximizing the achievement of the two IDA projects. The proposed operation will also underline the Bank s continued commitment to the GPEI. C. Higher level objectives to which the project contributes 11. The proposed operation is aligned with the Country Assistance Strategy FY06-09 (CAS) whose primary objective is to assist Pakistan in reducing poverty through improvements in health status and higher productivity levels. Poliomyelitis, a preventable disease causes premature death or lifelong disability that reduces people s capacity to benefit from education and employment opportunities and places a burden on the health care system. The children of the poor, often living in crowded unhygienic conditions and with lower levels of immunization coverage are at greatest risk from infection and severe sequela. Reducing illness and death from polio is fully consistent with the CAS objective to support programs that will help Pakistan implement its PRS and achieve the MDG. 11. PROJECT DESCRIPTION A. Lending instrument 12. The proposed lending instrument is Specific Investment Loan through an IDA credit with a special provision for third party funded Trust Funds to purchase the credit at its net present value once the Project has been successfully completed in accordance with the terms of the Financing Agreement. B. Project development objective and key indicators 13. The Third Partnership for Polio Eradication Project (TPPEP) is a follow up to the two previous Partnership for Polio Eradication Projects in Pakistan. The project will assist GOP s PEI in decreasing the number of polio cases and ultimately eradicating the disease in Pakistan. The project development objective (PDO) is to assist Pakistan s efforts to eradicate polio through procurement, timely supply and effective use of the OPV for the country s SIAs during TPPEP is part of the WHO led multi-country effort, and will contribute to a global public good, Le., the eradication of polio from the world. 14. The indicators to measure project performance include: a) Timely arrival of OPV at the district stores of the Department of Health. Target: vaccines arrive in all the district stores at least three days before each of the SIA; and b) Coverage of targeted population in SIA. Target At least 90 percent verified by finger marking of OPV in the targeted accessible population (children under-five) of all high risk districts during August 2009-June Timely arrival of OPV at the district stores will be measured in all districts for each round by program monitoring teams and measured through review of stock register maintained at the district level. The monitoring teams will collect information, aggregate and report on the indicator to the Expanded Program on Immunization (EPI). SIA coverage will also be measured for each 5

14 round and quarterly reported by the program. WHO will conduct coverage assessment in the first quarter of using cluster sampling survey using standard WHO methodology. Achievement of the two indicators will be a trigger for the IDA buy-down. Vaccine arrival in the country will be measured through EPI s Vaccine Arrival Reports (VAR). The project will also monitor number of confirmed polio cases reported, which is an outcome indicator of the polio eradication program. SIAs are also used for Vitamin A supplementation to the targeted population. It is critical to track vitamin A coverage as well, as child mortality and malnutrition rates remain high in Pakistan. The details of key indicators for measuring the achievement of PDO are described in Annex 3. C. Project Components 16. PEI has three components: (i) procurement, timely supply and effective use of OPV, (ii) supplemental immunization activities; and (iii) surveillance. TPPEP will assist GoP to interrupt virus transmission in Pakistan with the ultimate aim of eradicating polio. TPPEP will finance only the first component of PEI as its predecessor projects i.e., procurement and timely supply and effective use of OPV. The proposed project will benefit all Pakistani children below the age of five especially poor children and has a strong poverty focus because those living in poor and unsanitary conditions are susceptible to polio, and have low immunization coverage. 17. Component 1 -Procurement and timely supply and effective use of OPV: TPPEP will provide financing for only the first component of PEI as the previous projects, i.e., procurement and timely supply and effective use of OPV in SIA between August 2009 and June 2011 during SIAs including several rounds of National Immunization Days (NID) and sub-national immunization days (SNID). The estimated OPV needed for the SIA during the project period is for approximately 551 million doses at an estimated cost of US$92.65 million. IDA will finance OPV procurement for US$74.68 million. The Government of Japan is expected to provide remaining US$7.95 million in parallel financing with GoP expected to finance US$10.02 million (see Annex 4). IDA will finance the procurement of OPV though UNICEF for use in the SIAs as in the predecessor projects. 18. Component 2 - Supplemental immunization activities: These operations consist of: (a) maintaining cold chain; (b) social mobilization; (c) training; and (d) NIDs, SNIDs and mop up operations. All implementation arrangements are in place for these operations. The system functions reasonably well, and during last two years PEI has maintained high coverage of the targeted population. The national, provincial and district units are assisted by WHO and UNICEF through international and national staff to support and oversee the activities in the field as well as at the federal and provincial level. To address the upsurge in transmission and make progress towards eradication, a number of steps are being taken by the program and the program strategy is being revised: (a) increasing number of rounds of NID (one every two months) with additional rounds of SNID in transmission zones and outbreak response in re-infected areas; (b) increased use of monovalent OPV; (c) improve campaign quality by strengthening micro planning at local level with enhanced technical support from UNICEF and WHO; (d) strengthening the response and coordination with Afghanistan including expanding border immunization centers; (e) using innovative ways to improve coverage in security compromised areas by working closely with local communities, religious and traditional leaders and ensuring coverage of internally displaced populations; and (f) strengthened communication including involvement of local and religious 6

15 leaders to deal with social/religious resistance; involvement of highway police and using mobile telephone networks (see details in Annex 1). 19. Component 3 - Surveillance, including laboratory and epidemiological surveillance. The surveillance system is fully fimctional and data is regularly reviewed by TAG in collaboration with the national program, provincial and district managers and technical partners. All district in the country regularly report information and many exceed the global standard on key indicators for quality reporting such as the like timely collection of stool samples, their transportation to the laboratory and the 60 day follow-up. Surveillance, assessment of OPV coverage and quality of campaign form the monitoring and evaluation system for PEI. 20. The total budget needed for PEI during is about US$ million (See Annex 5), of which US$92.65 million is needed for OPV procurement. With the Government of Japan expected to finance US$7.95 million and GOP contribution being US$10.02 million for OPV procurement, IDA will finance the remaining gap of US$74.68 million. The cost of supplemental operations and surveillance will be financed by WHO and UNICEF with support from various partners. 21. The performance audit in two previous projects was undertaken by WHO. The independent review of IDA buy-down projects highlighted possibility of conflict of interest in WHO being the performance auditor being the lead technical agency for Polio eradication and recommended performance audit be undertaken by an independent agency. Upon completion, an independent agency competitively selected by the Bank will conduct a performance audit of the project within three months of project closing. The performance audit will report on timely vaccine procurement, use and coverage of children immunized. The report will be submitted to GOP and IDA to assess if the IDA buy-down can be triggered. 22. Vitamin A is distributed during the SIA in Pakistan. Reduction of Vitamin A deficiency reduces the incidence of blindness among children and reduces infant and child morbidity and mortality in general. Combining Vitamin A with the SIA increases their benefit to the poor children who are most at-risk for Vitamin A deficiency. The project will monitor vitamin A coverage and use the information for policy dialogue to facilitate the post-sia vitamin A supplementation strategy. D. Lessons learned and reflected in the project design 23. The proposed project will implement a tested design implemented by the original projects. In addition, it reflects lessons learnt from IDA-supported Health, Nutrition and Population projects in Pakistan and in the South Asia region specifically by: (a) keeping the design simple and welldefined; (b) using the regular structures for program management rather than separate stand alone Project Management Unit; and (c) working closely and in coordination with the development partners. The proposed project has been developed in close collaboration with technical agencies WHO and UNICEF and other partners through the Inter-Agency Coordination Committee meetings in which all partners including the World Bank participate. 7

16 E. Alternatives considered and reasons for rejection 24. The proposed project will implement a tested design, which worked well in previous projects aiming at polio eradication in polio-endemic countries (Pakistan and Nigeria), using the innovative buy-down financing mechanism. Therefore, other project alternatives, such as financing a different component, were considered and rejected in favor of financing OPV procurement IMPLEMENTATION A. Partnership arrangements 25. The TPPEP will support the PEI which is part of a major global public health effort in which there is a strong partnership of bilateral and multilateral donors, private philanthropic agencies, civil society and governments. The program is actively supported by these partners and most funding is channeled through the technical UN agencies, i.e. WHO and UNICEF. B. Institutional and implementation arrangements 26. As in the original projects, the TPPEP will be implemented and monitored through the existing structures of EPI which is already managing PEI. EPI implements the routine immunization program across Pakistan elaborate arrangements at the federal, provincial and district levels. Implementation arrangement is already in place to ensure timely procurement and supply of OPV to PEI, and to monitor its effective use. SIAs are managed and coordinated by the National Program Manager, EPI at the federal level with technical collaboration of WHO and UNICEF. At the provincial level, the Provincial Program Manager EPI provides the technical leadership under the guidance of the Director General Health Services. At the District levels, Executive District Officer Health (EDOH) coordinates PEI activities supported by the officer responsible for EPI and other Officers working in the District Department of Health in each of the facilities. The District team undertakes detailed micro-planning for each round ensuring all systems are functional for the SIA campaign. 27. Coordination Committees are in place at the federal, provincial and district levels which include government officials of relevant departments, local political and social leaders, and representatives of non government organizations and development partners are in place. An IACC at the national level coordinates overall strategy for the SIA. Social mobilization campaigns are planned and will be executed through mass media, religious and community leader s school teachers, community members and Lady Health Workers with technical support of UNICEF. 28. Surveillance quality in Pakistan is of international standard for key indicators since It operates in close cooperation with Afghanistan s surveillance team by sharing information and data. WHO supports the deployment of Surveillance Officers throughout the country, now totaling nearly 60. Their main activities include visits of key reporting sites; advocacy meetings with physicians, unregistered health care practitioners and faith healers, and training workshops for district surveillance coordinators and vaccinators. Surveillance is subject to periodic international quality reviews. 8

17 29. Procurement: Procurement arrangements agreed under the previous projects will be continued. UNICEF will be the sole procurement agent for OPV due to tight supply and demand of OPV during the final stages of the global eradication effort. OPV will be procured and supplied to GOP under a contract between the GOP and UNICEF, for which a draft agreement has been prepared. UNICEF s international procurement division, based in Copenhagen, will undertake the procurement following UNICEF s procurement procedures. The National Program Manager, EPI will be responsible for receiving the OPV at the National Institute of Health, Islamabad, and for its in-country storage, distribution, administration and use. 30. Vaccine requirements are forecasted by the National Program Manager EPI with support from WHO and UNICEF. This is based on the latest estimates of the population of children under-five, and the number of rounds and doses to be administered per child during a given year. The requirements are endorsed by IACC and TAG based on surveillance data. For the program has forecasted the requirements for OPV which will be discussed and agreed during appraisal and will become final as part of the procurement agreement Financial Management: The project will support a single component, i.e., procurement and timely supply and effective use of OPV in SIA between August 2009 and June UNICEF will procure vaccine for GOP for which the Bank will make direct payments to UNICEF. Financial management arrangements will be the same as used for the previous projects. WHO and UNICEF will manage their share of project expenditure using their own financial management systems including internal and external audit. UNICEF will open a separate ledger account for this purpose in its books of account. GOP will maintain inventory records for vaccine received and utilized. EPI will then ensure that OPV arrival reports are reconciled with the related procurement and dispatch information received fkom UNICEF. UNICEF will provide to GOP and the Bank a statement of funds received from the Bank and payments there from on a six monthly basis. 32. UNICEF s internal controls on use of funds, procurement of vaccine and utilization thereof are considered adequate and no audit reports will be required in respect of the project as was the case for the previous projects. There are no significant unresolved financial problems in respect of the previous projects except for delays in submission of utilization reports. However, the delays did not have any impact on implementation of the project. The implementing agency has assured that there will not be any delays in reporting for the follow up project. 33. Disbursements will be made under a blanket withdrawal application for the full amount of OPV procurement contract to be signed by GoP and UNICEF. UNICEF will submit cost estimates to GoP on a six monthly basis on the basis of which payments will be made by the Bank to UNICEF. C. Monitoring and evaluation of outcomes/results 34. Existing systems of monitoring and evaluation established for PEI and SIA are fully functional and the proposed project will not require any new monitoring or evaluation mechanism. SIA coverage is monitored by an analysis of tally sheets recording the number of children immunized against the number in the target group. Vaccine supply by UNICEF will be monitored through EPI s Vaccine Arrival Reports (VAR). Vaccine availability at the district level will be 9

18 monitored through a District VAR linked with the District vaccine stock register and will be reported by district Department of Health after each NID/SNID and will be consolidated and reported by each province to the federal EPI. EPI will share this report as part of the semi-annual report to the Bank. Output monitoring of SIAs quality and coverage is undertaken at the provincial and district level using District monitoring teams consisting of WHO, UNICEF and GOP staff. SIA coverage will be measured post campaign monitoring using standard WHO methodology. Validity checks already in place including assessment by WHO/UNICEF staff and market surveys will be continued. SIA outcome is monitored at the national, provincial and district level through the AFP surveillance system. TAG meets periodically and assesses progress by analyzing the polio eradication situation and provides strategic directions to the operations. 35. Upon completion of the project, an independent agency competitively selected by the Bank will conduct a performance audit of the project within three months of project closing. The performance audit will report on timely vaccine procurement, its use and the immunization coverage of children. The report will be submitted to GOP and IDA. The performance audit will be used by IDA to assess if the IDA buy-down can be triggered. Details of financial management arrangements and buy-down are contained in annex 6 and 8. D. Sustainability 36. SIAs are likely to end with polio eradication and there will be no need to sustain these after three years of zero reporting of polio. Eradication benefits are infinite because the disease will be extinct forever, unless a man-made mistake or disaster makes it reappear. If eradication is delayed and additional financing is required, it is most likely to be supported by the development partners and technical agencies who are fblly committed to eradicate the disease in Pakistan and globally. E. Critical risks and possible controversial aspects 37. Polio eradication has been delayed due to persisting transmission in four remaining endemic countries. In Pakistan, persisting transmission is being exacerbated by an unstable security situation and on-going conflict resulting in large scale population movements and decreasing access to children in NWFP, FATA and Balochistan. Until global eradication is achieved, all countries will need to maintain polio immunization. Risk From outputs to objective Eradication strategy using SIAs may not interrupt polio transmission, causing delay in achieving polio eradication in Pakistan and internationally Risk Rating H Risk Mitigation Measure Program strategy has been revised by intensifying SIAs; mop up rounds and epidemic response to overcome coverage issues in high risk areas; and use of mono valent OPV to enhance immunity to reduce transmission. A technical review of global program is being undertaken by independent experts to advise WHO and four remaining countries. The results of review Residual Risk S 10

19 Low levels of routine coverage may hamper polio eradication with negative impact on achievement of SIAs From Components to outputs Low levels of access to targeted population in security compromised areas and displaced populations in NWFP, FATA and Balochistan and bordering region of Afghanistan S S will help redefine the strategy. Recent improvements in immunization coverage indicate that intensified efforts with GAVI assistance are yielding some result. The intensified strategy focuses on low performing districts by provision of technical assistance; strengthening micro planning at local level and use of community based workers to provide immunization. Measures being taken include: a) increasing number of SIAs to increase probability of all children being immunized; b) involvement of local traditional and religious leaders to improve access/ acceptance during SIAs; c) increasing coordination with Afghanistan to cover border areas simultaneously; and d) Working with both warring parties to plan for safe time periods for SIAs. S S Timely and adequate availability of resources for organizing SIAs by WHO N WHO has strengthened its ability to generate resources from bilateral to ensure resources are available for SIAs. In addition Department for International Development (DFID) and Canadian International Development Agency (CIDA) have agreed to provide additional SUPD0I-t Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk) N F. Credit conditions/covenants 38. The non-standard credit conditions include: 0 Effectiveness Condition: OPV agreement has been executed by the Borrower and UNICEF and all conditions precedent to its effectiveness (other than the effectiveness o f the Financing Agreement) have been met. 0 Covenants applicable to project implementation: (a) Provide to the Association a revised PEI strategy (based on the findings of the independent assessment undertaken by the WHO on inter alia, the PEI) as approved by the Technical Advisory Group within four 11

20 months from the date of the WHO assessment report; (b) Maintain, the Inter-Agency Coordination Committee at the national level; Provincial coordination committees at the provincial level; and at the district level, district coordination committees; (c) Carry out the SIAs organized under the PEI with due diligence and efficiency; and (d) The disease surveillance systems established under the PEI will be maintained throughout the period of project implementation. IV. APPRAISAL SUMMARY A. Economic and Financial Analysis 39. Using standard public finance criteria, public involvement in and financing of SIAs to eradicate polio is well justified. Control of an infectious disease is an example of a public good for health with high externalities. Between 1988 and 2007, external sources have provided US$6.13 billion to polio-endemic countries for eradication efforts, including for OPV procurement, surveillance and operational costs for SIAs. External resources are also used for the certification, advocacy and resource mobilization, documentation, meetings and administration. Resources are being channeled to polio-endemic countries by bilateral funding through WHO and UNICEF and direct bilateral funding. Efforts are also being financed by national resources to pay for petrol, social mobilization, training and other activities and non-monetary commitments such as the time spent by volunteers. Between 1988 and 2007, it has been estimated that polio-endemic countries will have contributed more than US$2.5 billion in volunteer time alone for PEI. These calculations do not account for the opportunity cost of the public sector staff and volunteer time. 40. In order to achieve global eradication, the focus in is to ensure the interruption of polio transmission. As of January 2009, a total of US$200 million was still needed globally to implement the planned activities to reach that objective. Nigeria, India Afghanistan and Pakistan, which accounted for majority of polio cases worldwide in 2008, account for 60 percent of the financial requirements for that period. 41. Normal cost-benefit analysis does not easily apply to disease eradication, particularly at the level of any given country. While the costs of eradicating the last cases of polio are very high in relation to the very low burden of the disease, the benefits of successful eradication are infinite. To illustrate that point, for instance, a recent WHO report' estimates the foregone treatment and rehabilitation costs after polio has been eradicated globally could exceed US$1 billion annually. A 2007 analysis published in the Lancet also highlighted that as long as it is technically feasible, eradication remains a better alternative - from an economic perspective -than control. If the effort is not sustained and even intensified, the burden and number of cases will continue to rise which in turn decreases the chance of eradication. B. Technical 42. Polio eradication is possible because: (a) there is no animal reservoir for the disease; (b) the virus has a limited persistence in the environment; (c) there is no long-term carrier state; (d) 1 Global polio Eradication Initiative, Financial resource requirements,

21 permanent immunity is provided following infection; and (e) a safe and highly effective vaccine is available. Polio causes paralysis, most frequently in children, and between 5-10 percent of cases die due paralysis of breathing muscles. Polio is incurable and its effects are largely irreversible. More than 99 percent reduction in number of polio cases since launch of the GPEI and significant geographical restriction as number of endemic countries are down from over 125 to only four reinforce the fact that polio eradication is technically as well as operationally feasible if strategies are implemented effectively. Many countries having similar situations as in Pakistan have been successful to eradicate polio. 43. The global eradication of polio eradication by 2000 has been delayed due to persistence of wild polio virus transmission in remaining four endemic countries. Pakistan is most likely to interrupt transmission if it is able address critical issues. The significant risks to eradication include: (a) low coverage of the routine immunization program; (b) increasing unstable security situation; (c) decline of political support; and (d) uncertainty about continued funding. C. Institutional 44. The PEI s institutional arrangements were in place, functional and effective during with an average SIA coverage of 97 percent of the targeted population; in reaching certification-level for AFP surveillance (one case of AFP per 100,000 population under 15) and approaching the international standard for collection of adequate diagnostic specimens from at least 80 percent of AFP cases within 14 days of onset of paralysis. The project will continue to use existing arrangements for effective coordination during SIAs at all levels between the public sector, international agencies, NGOs and community groups. EPI holds consultations with partner NGOs and community groups which actively participate in social mobilization activities for SIA and participate in micro-planning of polio activities at the local level. 45. The project will be implemented through the existing federal, provincial, and district structures already involved in managing EPI. No new structures will be created. EPI will manage the project at the national level. The provincial and district Departments of Health through their EPI units will coordinate activities and implement SIAs. The Bank will work closely with the development partners and lead technical agencies WHO and UNICEF who provide technical support to the program. D. Fiduciary 46. Procurement: OPV will be procured through a sole source agreement between UNICEF and GOP. UNICEF has been designated by the global polio eradication partners to be the sole procurement agent for OPV due to very tight supply and demand of OPV globally. The Bank and UNICEF have agreed on the text of agreement for procurement services, which will be entered between the GOP and UNICEF. The Bank has accepted that UNICEF will use its own procedures for the procurement and delivery of the OPV (See for details Annex 7). 47. Financial management: As this project does not require direct involvement of the Borrower in the disbursement of IDA credit, and IDA funds will be transferred directly to UNICEF. Financial management arrangements for this project are relatively simple. Assurance 13

22 that the Bank's fiduciary requirements are met, especially that funds are used for the purpose intended with due regard to economy and efficiency, will be obtained through the measures discussed in Annex 6 and addressed in the OPV Agreement to be entered into by the Borrower and UNICEF. GOP will send a blanket withdrawal application to the Bank, authorizing the Bank to make direct payments to UNICEF of amounts requested by UNICEF under this Agreement, through an initial, and subsequently semiannual, payment request. Upon receipt of a payment request from the GOP, IDA funds will be transferred to UNICEF for the procurement of OPV. UNICEF's regular financial management system and auditing procedures will be used for this project. WHO coordinates technical and financial support provided by a group of bilateral development partners and private donor agencies to finance SIA operations and surveillance for SIA. E. Social 48. The proposed project directly benefits children under-five. Poor families, particularly their children, would be the primary beneficiaries. Quantitative studies have found low utilization rates of public health facilities especially by the poor. Qualitative assessments of other health projects indicate that lack of physical access to services is a problem in some areas in addition to poor quality of health services. While wealthier groups can purchase health services from the private sector, the poor are unable to afford these services and continue to rely on traditional practitioners. The project would not address these issues but in the context of polio eradication has developed specific strategies to access the "hard-to-reach'' populations. 49. PEI has established a framework for on-going participation largely through the IACC. This mechanism includes representatives from: (a) key government ministrieddepartments; (b) multilateral agencies (UNICEF and WHO); (c) bilateral agencies including the Government of Japan, the Netherlands, the European Union, DFID, CIDA, the United States Agency for International Development, the World Bank etc.; (d) NGOs; and (e) community mobilization and media experts. The IACC meets regularly to review the needs and strategies of the national polio eradication program, and assess the performance of supplementary immunization activities. 50. PEI has achieved success for the last few years through mobilizing participation of the beneficiaries, communities and other stakeholders. Local politicians and religious leaders are regularly sensitized and contribute by mobilizing local communities. Non acceptance of vaccination is very low. The EPI holds consultations with partner NGOs and community groups which actively participate in social mobilization activities for SIA. NGOs groups are represented in the IACC mechanism described earlier, and participate with government representatives in workshops for the micro-planning of polio activities at the district and below level. The current institutional arrangements for PEI have been effective achieving results on the grounds. The project will reinforce arrangements to promote coordination between the government departments, international agencies, NGOs and community groups at the national, provincial and local levels. F. Environment 5 1. The project is not likely to cause any direct or indirect or long term negative environmental impacts which will need to be addressed. The project involves supply and use of OPV in small 14

23 plastic vials which will need to be disposed off. The disposal of the vials will be done in accordance with the WHO guidelines* for immunization campaigns as already being practiced. No sharps such as needles or vial cutters are involved in the oral vaccination methods. It is not deemed necessary that an environmental assessment be carried out. Implementation and following of WHO guidelines for immunization campaigns for waste disposal will facilitate development of safe waste disposal culture in the health sector. G. Safeguard policies Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.0 1) [I [X 1 Natural Habitats (OP/BP 4.04) [I [ XI Pest Management (OP 4.09) [I [ XI Cultural Property (OPN 11.03, being revised as OP 4.1 1) [I [ XI Involuntary Resettlement (OP/BP 4.12) [I [ XI Indigenous Peoples (OD 4.20, being revised as OP 4.10) [ XI [I Forests (OP/BP 4.36) [I [ XI Safety of Dams (OP/BP 4.37) [I [ XI Projects in Disputed Areas (OP/BP/GP 7.60) [I [ XI Projects on International Waterways (OP/BP/GP 7.50) [I [XI 52. No Safeguard policies have been triggered. H. Policy Exceptions and Readiness 53. TPPEP is a follow-on project and all aspects of the program which are part of an on-going operation are ready for implementation The draft procurement document for OPV procurement has been prepared and will be ready at the start of project implementation. The Program Implementation Plan for has been made available to the Bank. It will be appraised whether it is realistic and of satisfactory quality. 2 Management of Wastes for Immunization Campaign Activities: Practical Guidelines for Planners and Managers, WHO (WHO/SDE/WSH 04: 1 1) 15

24 Annex 1 : Polio Eradication Initiative - Detailed Proiect DescriDtion I. Program Background Pakistan: Third Partnership for Polio Eradication Project 1. The proposed project will support Pakistan s PEI, which seeks to eradicate polio and ensure Pakistan becomes polio free till polio fiee certification, with an IDA support of US$74.68 million. PEI is part of the WHO-led GPEI. The proposed project by supporting the PEI will make a significant contribution towards the eradication of polio from the world. 2. The PEI is implemented at the national level by the EPI under the overall guidance of the Ministry of Health. The EPI program is a national program, however, its management and financing is decentralized to provincial and district level. PEI is implemented through the provincial and district Departments of Health as the routine immunization program. EPI has wellestablished structures at the provincial and district level that are responsible for planning, implementation and monitoring of SIAs. The program is implemented with close collaboration with other programs including the Lady Health Workers program and with other departments including education. Besides the three levels of government, technical partners WHO and UNICEF provide technical support and finance SIA operations through bilateral donor and private agency contributions. 3. Pakistan s PEI has three components: (a) the procurement, timely supply and effective use of OPV; (b) supplemental immunization activities; and (c) surveillance. IDA will support only the first component as in the previous projects. SIAs, in which the OPV will be used, require supporting activities such as distribution, storage of vaccines, logistics, social mobilization, training, surveillance, monitoring and evaluation. Distribution arrangements and storage of vaccines in the EPI cold rooms at the national, provincial, and district levels are fully functional and no new arrangements are required for the proposed project. The system works well for routine program and have worked adequately for the first two projects. During the planning and implementation of SIAs, transport of these vaccines through vaccine carriers to the children is coordinated with the vaccination teams. Social mobilization and IEC activities with parents and communities are organized at the local, district, provincial and national levels. Media campaigns in visual, audio, and print form and through mobile phone networks are carried out to make the public aware of the program benefits and to motivate them to get their children immunized. 4. Mobilization of community leaders, health staff, and volunteers for planning and implementation of SIAs is a key activity. In Pakistan, about 750,000 personnel are mobilized for each campaign of who 100,000 are public sector employees, including 10,000 vaccinators. In addition, 98,000 plus Lady Health Workers, the community based workers provide additional support during SIAs. The remaining, about 650,000 include other government staff, NGO staff and community members. Each SIAs round involves organizing these staff into over 80,000 teams including about 70,000 mobile teams, 9,000 fixed teams and 4,600 transit teams to cover about 30 million children across the country. In addition, about 800 campaign support persons, 15,000 local in-charges and 2,700 zonal supervisors supervise and monitor each campaign. Training and advocacy with these groups in micro-planning, supervision, administration of OPV, record keeping, and cold chain maintenance occurs prior to each round of immunization. 16

25 11. Revised PEI Strategy 5. PEI has a well defined technical strategy which has worked in most countries of the world. Pakistan made progress towards eradication however, in 2008, the number of Polio cases increased due to increased transmission of the virus. APCE and the technical partners (WHO and UNICEF) recently judged that Pakistan can still interrupt transmission of polio. However, this will need addressing a number of challenges. The program has updated its implementation strategy with a focus on: intensifying SIA by increasing the number of NID rounds from four to six (one every two month); and undertaking additional rounds of SNIDS in known transmission zones in between NIDs with increased population coverage and outbreak response activities in reinfected areas; increased and strategic use of monovalent OPV to close residual immunity gaps (tri-valent OPV remains the primary tool with monovalent OPV round interspersed in every 3'd round of SIA; enhancing coordination and simultaneous rounds in border areas with Afghanistan including operationalizing permanent border vaccination points in 1 1 strategic positions (recent efforts have ensured coverage of 1.2 million children) to cover migrating nomads and population in border districts besides sharing of information and plans; In security comprise areas access is being enhanced through local community participation and involvement of local and religious leaders through local jirgas (local community assemblies) and strengthening monitoring through hiring local people to undertake monitoring and report missing children. In additional internally displaced populations are being covered in all rounds by providing services in camps; improve campaign quality by strengthening micro-planning at local level with enhanced technical support from UNICEF and WHO; Communication is being strengthened with development and operationalization district and agency specific communication activities and enhanced engagement of media to overcome misreporting and negative propaganda and working with Ministry of Interior to promote immunization and stop broadcast by illegal FM channels. In addition, the program has involved electronic media to report missed children and the motonvay police to ensure children traveling during campaign days on national highways and using mobile telephone networks; and Strengthening of routine immunization program with support from Global Alliance for Vaccines and Immunization (GAVI) assistance include targeting poorly performing districts with technical support; strengthening micro planning at the local level and using community based lady health workers to provide immunization services. Program Components: Component 1: Procurement, Timely Supply and Effective use of OPV As the original project, the proposed project will support PEI by financing only one component that will support procurement, timely supply and effective use of OPV needed for 17

26 SIAs to immunize all children below five years. IDA will finance the procurement of about 85 percent of the OPV needed for the SIAs to be carried out during July 2009-June The remaining 15 percent will be provided by Government of Japan in parallel financing. UNICEF will supply the vaccine under an agreement between GOP and UNICEF as in the original project. The Bank has accepted use of UNICEF procurement procedures for the OPV procurement. The component's success will be measured by the following indicators: a) Timeliness of GOP's request for funds for procurement of the OPV: GOP will send, within three weeks of proj ect effectiveness, a blanket withdrawal application to the Bank requesting payment to UNICEF; b) Timeliness of disbursement of IDA funds to UNICEF for OPV procurement: Bank will transfer funds to UNICEF within 30 business days of the date on which the payment request is received by the Bank; c) Timeliness of procurement and supply by UNICEF; the OPV will arrive at the EPI cold rooms in Islamabad at least 5 weeks before each round of SIAs; and d) Timeliness of supply by GOP; the OPV will arrive at the district stores of the Department of Health at least three days before each of the SIAs. 8. Funds will not be handled by GOP and will be transferred directly to UNICEF. Accordingly only UNICEF will provide financial management and accounting for the funds and provide semi-annual reports to the government with copies to IDA. IDA will use these reports to monitor the outstanding balance and the funds received and spent by UNICEF. a) Component Two: Supplemental Immunization Activities 9. The second component of PEI Le. supplemental immunization activities consists of: (a) maintenance of cold chain; (b) NIDs, SNIDs and mop up operations; (c) social mobilization; and (d) training. All implementation arrangements are in place for these operations. The National, provincial and district units are supported by WHO and UNICEF through international and national staff to support and oversee the activities in the field. The system functions well, and during 2007 and 2008 an average coverage of about 97 percent of the targeted population has been achieved. This component will be financed by WHO and UNICEF with grant financing. 10. SIAs coverage is monitored by an analysis of the tally sheets recording the number of children immunized against the number in the target group. Output monitoring is undertaken at the provincial level through independent monitors, and impact monitoring at the national level through the AFP surveillance system. The Technical Advisory Group meets periodically and assesses progress. Its reports, along with the periodic assessments of the SIAs quality undertaken by WHO and other technical partners, are also used for monitoring and evaluation purposes. An independent firm will evaluate this component within three months of the project closing, focusing on the timeliness of OPV procurement and supply, and vaccination coverage. The independent party will submit its report to GOP with copies to IDA. 18

27 b) Component Three - Surveillance 11. The surveillance component includes laboratory and epidemiological surveillance. The surveillance system is fully functional and collects data from public and private sector. Data is analyzed regularly generating weekly and monthly epidemiological report. It is regularly reviewed by TAG in collaboration with Government counterparts and technical partners. Each district regularly reports above the global standard on key indicators including timely collection of stool samples, 60 day follow up etc. The data from surveillance and assessments of the quality of campaign comprise the monitoring and evaluation system for PEI. The component is financed by WHO with grant support from development partners Institutional and implementation arrangements 12. The PEI is implemented at the national level by the EPI under the overall guidance of the Ministry of Health. The EPI program is a national program, however, its implementation and financing is decentralized to provincial and district level. As EPI, PEI is implemented through the provincial and district Departments of Health. EPI program has well-established structures at the provincial and district level that are responsible for planning, implementation and monitoring of SIAs. The program is implemented with close collaboration with other programs including the Lady Health Workers program and with other departments including education. The technical partners WHO and UNICEF provide technical support and finance SIA operations through bilateral donor and private agency contributions. 13. The proposed project will be implemented and monitored through the existing structures of EPI which is already managing PEI. EPI implements the routine immunization program across Pakistan elaborate arrangements at the federal, provincial and district levels. To ensure timely procurement and supply of OPV to PEI, and to monitor its effective use, implementation arrangements are already in place. The proposed project will support a single component of PEI i.e. procurement, supply and use of OPV in SIAs. SIAs are managed and coordinated as follows: a) The National Program Manager, EPI is responsible for the PEI at the federal level and implements the program with technical collaboration of WHO and UNICEF; b) A WHO team consisting of a WHO seconded Senior Public Health Professional, a senior program administrator, an NID controller, an EPI expert, a statistician, a social mobilization expert and a logistician provide technical support to the National Program Manager, EPI; c) At the provincial level, the DirectorProvincial Program Manager EPI heads the program under the guidance of the Director General Health Services; d) At the District levels, Executive District Officer (Health) (ED0 (H)} supervises the EPI activities. ED0 (H) is supported by the officer responsible for EPI and other Officers working in the District Department of Health in each of the facility. The District team undertakes detailed micro-planning for each round ensuring all systems are functional for the SIA campaign. In addition, it calculates and verifies the target population, number and location of NID posts, cold chain needs, and ice requirements. This process is supported by WHO and UNICEF provincial and district based staff; 19

28 e) MOH is responsible for the overall policy and strategy besides procurement, storage and supply of vaccines, cold chain equipment, syringes and transport for the routine and PEI. The Provincial Departments of Health bear the cost of staff, training, health education, stationary, petrol, oil and lubricants, and other contingencies. WHO and UNICEF assist by supplying the cold chain equipment, vehicles and TA; f) Coordination Committees at the federal, provincial and district levels include government officials of related departments, local political and social leaders, and representatives of the NGOs and development partners; g) A national level IACC, chaired by the Minister/Secretary Health, has the overall responsibility for coordinating the SIAs. Similar committees function at the provincial level chaired by the provincial SecretariesDirector General Health Services. The Provincial Committees are responsible for specifying tasks, developing check lists, monitoring progress of planning and critical steps, delivering clear and simple messages to the community, indenting for vaccine, and ensuring that the cold chain is effectively functioning. The role of the provincial DirectorProgram Manager EPI is to plan, implement, monitor and evaluate the SIA. At the district level, Coordination Committees are chaired by the ED0 (H), and attended by the Deputy Commissioner. These Committees meet monthly, and more frequently close to the actual campaigns; and h) The mass media, religious and community leaders play a key role in raising awareness and mobilizing the public. School teachers, community members and Lady Health Workers are all involved in giving the oral vaccine. UNICEF provides strong support to the social mobilization component of the campaigns. 20

29 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies Pakistan: Third Partnership for Polio Eradication Project Project Bank- financed Health Sector Reform NWFP DPL - multisector including support to health sector reforms Implementation Progress (IP) S Development Objective (DO) S Family HealtWComm unicable disease control HIV/AIDS Prevention Project (ongoing) Partnership for Polio Eradication Project 2"d Partnership for Polio Eradication project MS S S MS S S Other Donors DFID USAID WHO ADB UNICEF AUSAID UNFPA UNAIDS National Health Facility (ongoing) Support to NGOs for consumer protection and reproductive health Maternal and Neonatal Health PAIMAN - Maternal health Technical assistance in multiple areas of health including polio and immunization Women's Health Project Reproductive Health Project Devolved Social Services Project in Sindh and Punjab Punjab MDG Program Maternal and Child Health focusing on immunization, Polio and maternal services Maternal and Neonatal Health through DFID Technical support to RH and Family Planning program Technical support to Enhanced HIV/AIDS program and NGOs IPDO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 21

30 Annex 3: Results Framework and Monitoring Pakistan: Third Partnership for Polio Eradication Project Assist Pakistan s effort to eradicate polio through timely supply and effective use of oral polio vaccine for the country s supplementary immunization activities during Intermediate Outcomes Component One: Timely provision of OPV to Government of Pakistan OPV coverage is at least 90% verified by finger marking in the targeted accessible population (children underfive) of all high risk districts during August 2009-June Number of confirmed polio cases reported Coverage of Vitamin A supplementation of at least 80% in the provinces during July 2009-June Intermediate Outcame Indicators Component One: Procurement of UNICEF certified OPV and delivery to Government of Pakistan s Expanded Program on Immunization for use in the supplemental immunization activities Timely arrival of OPV at the district stores of the Department of Health in all the district stores at least three days before each of the SIAs Use of I Satisfactory performance to trigger IDA buy-down To assess program outcome and guide program strategy To be used for policy dialogue for development of post SIA vitamin A supplementation strategy Component One: Results to be used for: a) planning of SIAs; b) ensuring timely distribution of OPV supplies to various regions of the country; c) to monitor the outstanding balance and the funds received and spent by UNICEF; and d) release of payment request for next six months to UNICEF Satisfactory performance to trigger IDA buy-down 22

31 Arrangements for Results Monitoring Indicator OPV coverage is at least 90% verified by finger marking in the targeted accessible population (children under-five) of all high risk districts during August 2009-June District Monitoring Reports Cluster sampling survey End of each round of NIDdSNIDs First quarter EPI/WHO 90% Confirmed polio cases Procurement and delivery of UNICEF certified OPV in Islamabad Pakistan - three weeks prior to each round AFP surveillance Vaccine Arrival Reports Ongoing (reported on monthly basis) Six monthly EPI EPI 117 in 2008 TBDI Less than 50 cases in weeks prior to each NID/SNID Timely arrival of the OPV at the district stores of the Department of Health in all districts at least three working days before the scheduled dates of the SIA. Coverage of Vitamin A supplementation of at least 80% in the provinces during July 2009-June District Monitoring Reports District Monitoring Reports Quarterly Twice a year EPI EPI TBD days before the scheduled dates of the SIA in all districts 90 3 Baseline to be established by July by data analysis of first two quarter of

32 Annex 4: Oral Polio Vaccine Requirement Year Au~-Dcc 2009 Total target population I 30,000,000 Number of NID rounds l 3 Number of OPV doses for NIDs (A) 105,300,000 Number of SNID rounds 2 Target population for SNIDs (percentage of total target 0.7 DoDulation) NAber of OPV doses for SNIDs 49,140,000 (B) 2010 Jan -J u n 2011 I 30,540,000 I 31,089,720 I -I-. Total I I I ,390,800 72,749, ,440, ,731, ,562,459 I 139,434,259 I I Number of OPV doses for mop up/outbreak response rounds = C OPV Total (no of Doses) A+B+C OPV cost (US$) Funds Expected form GoP (US$) Funds Expected form GoJ (US$) 5,265, ,705,000 26,830,440 10,024, ,932,950 5,456,246 19,654,196 I 259,055, ,768, ,529,199 I 10,024,560 Funding gap to be mobilized through IDA (US$) 16,805,880 24

33 Annex 5: Project Costs Pakistan: Third Partnership for Polio Eradication Project r-- Program Cast by Component Local 1-7Gi&n Total US$ million 1 uss million US$ million Oral Polio Vaccine Procurement Supplemental Operations Cost Surveillance Total Baseline Cost Physical Contingency Price Contingency Total Program Cost4 Y Total Financing Required IDA WHO UNICEF GOP GOJ I_ Projeet Cost by category LocaI Foreign Total tis$ million US% - million US% -- million..-.. Goods Works I I I ~emices Total Program Cost Total Financing Reauired Total Program Cost including contingencies Includes costs on training for workers for each round of SIAs 25

34 Annex 6: Financial Management and Disbursement Arrangements Pakistan: Third Partnership for Polio Eradication Project I. Summary of the Financial Management Assessment 1. Not applicable 11. Overview of Implementation Arrangement 2. IDA has entered into a partnership with the Bill & Melinda Gates Foundation and UN Foundation to support the proposed project. The project will support a single component, i.e., the provision of OPV. The proposed project as the previous projects is using an innovative financing mechanism: although IDA financial resources will be provided to GOP, third party funding from the above partners will "buy down" the service charge, the commitment fee and repayments by financing the net present value (NPV) of the IDA credit upon successful completion of the project. This will, in effect, mean grant funding for the program. 3. The IDA credit will finance a single agreement for the supply of OPV between the GOP and UNICEF for the supply of OPV with the arrangements described below which are similar to original project: a) OPV will be procured by UNICEF following its own procurement procedures. The draft agreement between GOP and UNICEF will be subject to the Bank's prior review and no objection; b) GOP will send a blanket withdrawal application to the Bank, authorizing the Bank to make direct payments to UNICEF of amounts requested by UNICEF under this Agreement, through an initial, and subsequently semiannual, payment requests; c) UNICEF will maintain a separate ledger account, through which all of UNICEF's receipts and expenditures for the purposes of providing the services contemplated under this Agreement will be recorded; and d) UNICEF will report semiannually to GOP, with copy to the Bank, on the use of funds received including: (a) balance at the beginning and end of the reporting period; (b) purchase orders placed by UNICEF during the reporting period; (c) actual quantities of OPV delivered and number of children immunized during the reporting period; and (d) expenditures from the OPV Procurement Account during the reporting period. 4. The above arrangements are based on the proposed agreement for supply of OPV to be entered into between UNICEF and GOP Financial Management Arrangements 5. The proposed project as the previous projects does not require direct involvement of the Borrower in the management and accounting of fimds, which will be the responsibility of UNICEF. The credit proceeds will be disbursed by the Bank directly to UNICEF as stipulated in 26

35 the procurement agreement to be signed between the GOP and UNICEF. The needed quantities of vaccines will be agreed in advance and the price is relatively stable. 6. The Bank will accept semiannual reports from UNICEF as meeting the financial information requirements for Financial Monitoring Reports. EPI will be responsible to reconcile the OPV arrivals with the related information received from UNICEF. The assurance that the Bank's fiduciary requirements are met, and that funds are used for the purpose intended with due regard to economy and efficiency, will be achieved through the following measures: a) UNICEF's procedures for the procurement of OPV will be agreed upon with the Bank; b) All expenses will be on items agreed beforehand (vaccine cost including freight, and UNICEF handling charges); c) The semiannual financial report from UNICEF to GOP, with a copy to the Bank, will allow close monitoring of the outstanding balance and funds received and spent by UNICEF. The Bank will be in a position to verify expenditures before any subsequent disbursements; and d) GOP will be able to confirm receipt of the quantities of goods indicated in the above reports. IV. Audit Arrangements 7. As the funds will be managed by UNICEF, the borrower is not required to submit audited annual financial statements to the Bank. However, the Association retains the option to request for an audit. V. Disbursement Arrangements 8. Disbursements will be made under a blanket withdrawal application for the full amount of OPV procurement contract to be signed by GOP and UNICEF. UNICEF will submit cost estimates to GOP on a six monthly basis on the basis of which payments will be made by the Bank to UNICEF. VI. Allocation of credit proceeds (Table A) Table A: Allocation of Credit Proceeds Total Project Costs Total

36 Annex 7: Procurement Arrangements Pakistan: Third Partnership for Polio Eradication Project I. General 1. Procurement for the proposed project will be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004, revised in October 2006 and the provisions stipulated in the Legal Agreement. 11. Procurement of Goods 2. Goods procured under this project will include OPV only, which shall be procured from UNICEF in accordance with the provisions of Paragraph 3.9 of the Procurement Guidelines. UNICEF has been agreed by the global polio eradication partners to be the sole procurement agent for OPV, given the tight supply and demand of OPV during the final stages of the global polio eradication effort. 3. The Credit will finance OPV for US$74.68 million under a single agreement with UNICEF for the supply of OPV. The procurement will be done using the Bank's agreed procurement contract with UN agencies which will be agreed with or satisfactory to the Bank. The draft agreement has been drafted. IDA will review and clear the draft agreement before UNICEF and GOP sign the agreement Assessment of the agency's capacity to implement procurement 4. As per the Director OPCPR's Memorandum dated October 17,2002, a formal assessment of the procurement capacity of the Federal EPI Cell (Project Implementing Agency) is not necessary according to Procurement Services Policy Group guidelines dated August 11, This is because under the proposed project, UNICEF, and not the implementing agency, will handle procurement. 5. The Federal EPI Cell will be responsible for project execution at the national level. While EPI is a strong program, it has limited capacity for procurement, especially for large scale international procurement. As in the original project, the borrower will enter into an agreement with UNICEF for the supply of OPV. UNICEF will ensure timely supply of OPV to EPI. EPI will be responsible for the in-country storage, distribution and administration of the vaccines. 6. UNICEF will report on a semiannual basis to the Government of Pakistan with a copy to IDA on: (a) purchase orders placed by UNICEF; (b) actual quantities of OPV delivered to NIH; and (c) expenditure from the OPV Procurement Account during the reporting period. Payments to UNICEF will include its standard handling charges for vaccine procurement, an amount not exceeding 6 percent of the vaccine cost, and other non-freight costs, if any. 7. The overall project risk for procurement is low. 28

37 IV. Procurement Plan 8. The quantity of vaccine required is determined by the Technical Advisory Group (TAG). These needs are regularly adjusted based on surveillance findings. If surveillance shows good results, and not all project funds are needed for procurement of OPV for during , through the first quarter 201 1, IDA funds will be reprogrammed for the procurement of OPV needed for If TAG determines that are no longer needed, the available funds could be used for procurement of polio vaccines for the routine immunization program. A TAG recommendation to this effect will be needed. V. Frequency of Procurement Supervision 9. In addition to the prior review supervision to be carried out fiom Bank office, it is recommended that supervision mission take place every 12 months, unless otherwise required. VI. Details of the Procurement Arrangements 10. The credit will finance OPV for US$ million under a single agreement of total US$ million between GOP and UNICEF for the supply of OPV in accordance with Paragraph 3.9 of the Procurement Guidelines. This agreement will be subject to prior review by the Bank before signing Table A: Project Costs by Procurement Arrangements (US$ million equivalent) 1. Works () () () () () 2. Goods () () (74.68) () (74.68) 3. Services () () () () () I Total * () (74.68 ( (74.68) 29

38 Annex 8: IDA Buy-Down Mechanism Pakistan: Third Partnership for Polio Eradication Project I. Introduction 1. This annex describes the arrangements for the implementation of the IDA buy-down mechanism for polio eradication projects, which aims to convert the terms of a normal IDA development credit to grant terms through provision of additional external donor resources under clearly defined performance criteria. In the context of the Pakistan third polio eradication project, resources for the buy-down will become available as a result of an agreement between IDA, the Bill & Melinda Gates Foundation (BMGF) and Centers for Disease Control (CDC) through the UN Foundation (UNF). The buy-down mechanism complies with IDA'S existing financial policies. 11. The Partnership 2. The World Bank's Health, Nutrition & Population Sector Anchor established a partnership with BMGF, UNF and several technical partners to assist polio eradication by providing countries with IDA financial resources but without IDA repayment obligations. The BMGF and UNF agreed to provide funds to IDA-administered trust fund - Polio Eradication Trust Funds (PETFs) that will buy down the debt incurred by recipient countries for successful implementation of polio eradication projects. In addition to making commitment fee and service charge payments to IDA on behalf of the recipients during project implementation, the PETFs will, upon successful project implementation, buy down the net present value of the principal amount of the development credit The Mechanism 3. IDA is extending a development credit to Pakistan. The Financing Agreement will include two special provisions: a) the PETFs will pay the applicable service charges and commitment charges, if any; and b) The PETFs will buy down the principal amount of the credit upon successful completion of the project (as determined by a performance audit conducted by an independent agency competitively selected by the Bank). 4. The buy-down will be funded by two trust funds, one for the contribution of BMGF and second for CDC through UNF. The buy-down mechanism operates in three stages-credit signing, project implementation, and project completion. These stages are described below. IV. At Credit Signing 5. IDA (FRM) determines the discount rate (the prevailing SDR-basket Commercial Interest Reference Rates (CIRR) on the date of credit signing) and the foreign exchange rate (SDR: USD) that will be used to calculate the estimated net present value at final buy-down. The indicated amount is set aside in a special earmarked child-account under the PETFs. The set- 30

39 aside amount equals IDA commitment and service charge payments over the projected implementation period and the estimated amount needed to buy down the principal of the credit at the end of the implementation period. IDA hedges the foreign exchange risk under its existing currency rebalancing mechanism. V. During Project Implementation 6. Under the project, IDA, acting on a request from the recipient country, disburses funds to UNICEF, the agency responsible for procuring the oral polio vaccine. UNICEF in turn supplies the vaccines to the recipient government. Resources in the earmarked child accounts of the PETFs pay the commitment and service charges on the disbursed amounts during the implementation of the project. 7. If the implementation period is substantially longer than initially projected, funds required to pay service charges could exceed the funds set aside. However, the investment income on the set-aside buy-down amount will provide a cushion against this risk. If the implementation period exceeds five years, the responsibility for servicing the credit will revert to the recipient country unless the BMGF and UNF grant an extension. VI. At Project Completion 8. Upon completion of the project, an independent agency competitively selected by the Bank will conduct a performance audit within 3 months of project closing to determine if the IDA funds achieved their intended results. The performance audit measures the results for two indicators: a) Timely arrival of oral polio vaccine at the district stores of the Department of Health at least three days before each of the SIAs; and b) OPV coverage is at least 90 percent verified by finger marking in the targeted accessible population (children under-five) of all high risk districts during August 2009-June If the independent performance audit evaluates the project as satisfactory, the IDA buydown will be triggered. The earmarked h d s in the PETFs will be used to pay off the IDA credit at the net present value of the credit based on the defined foreign exchange and discount rates to buy down the principal of this credit (Repayment Amount). IDA will in turn cancel this credit and release the recipient from any future liability. If the credit is not fully disbursed, the final Repayment Amount will be calculated on a pro-rata basis. If the independent performance audit evaluates the project as unsatisfactory, the recipient will remain obligated to pay back IDA on the terms of the credit. 31

40 Annex 9: Project Preparation and Supervision Pakistan: Third Partnership for Polio Eradication Project Planned Actual Review by Regional Panel October 15,2008 December 12,2008 PCN October 30,2008 January 07,2009 Appraisal May 6-8,2009 May 7-11,2009 Negotiations May18-19,2009 Board approval June 18,2009 Planned date of effectiveness July 15,2009 Planned closing date December 3 1, 2011 Preparation 1. The proposed project was prepared in collaboration with the MOH, UNICEF and WHO staff in Pakistan. The MOH team was made up of staff of the EPI, led by Dr. Altaf Bosan, National Program Manager and included Dr Faisal Mansoor, Deputy Program Manager, Dr Syma Iqbal. Local staff from technical partners WHO and UNICEF have actively participated in the project preparation. The Bank project preparation core team consisted of Inaam Haq, Amie Batson, Asif Ali, Furqan Ahmed Saleem and Laura Kiang. The Peer reviewers were: Romesh Govendraj (AFTH3), and Anthony Meashem (HDNHE). The Bank4staff who worked on the project included: Name Inaam Haq Amie Batson Kees Kostermans Martin Senano Wen-Jun Tan Asif Ali Furqan Saleem Agnes Couffinhal Darren W. Dorkin Laura Kiang Shahzad Sherjeel Zia A1 Jalaly Javiad Afzal Mohammad K. Omar Anwar Ali Bhatti Nasreen Kazmi M. Khalid Khan Supervision Plan Specialty Sr. Health Specialist Sr. Health Specialist Lead Health Specialist Country Lawyer Counsel Sr. Procurement Specialist Sr. Financial Management Specialist Health Economist Senior Operations Officer Operations Officer Sr. External Affairs Officer Social Development Specialist Environmental Specialist Consultant Disbursement Officer Program Assistant Program Assistant UNIT SASHD HDNHE SASHD LEGES LEGES SAWS SARFM SASHD HDNHE SASHD SAREX SACPK SASDI SASDI SASHD SASHD SASHD 2. The proposed project will be supervised as follows: 32

41 a) Through regular participation in the IACC meetings: IACC frequently reviews performance of SIAs and provides advice to the government. It reviews the monitoring reports for every NID and every SNID, as also the assessments of SLA by the Technical Advisory Group. Bank staff based in Islamabad is member of the IACC and will participate in all its meetings and reviews. b) Through regular on-going dialogue and interaction with the implementers including technical partners WHO and UNICEF by the Bank s resident Senior Health Specialist. c) Through bi-annual/annual joint Supervision Mission with UNICEF and WHO: The Task Team Leader will lead bi-annual supervision mission with technical partners. The supervision missions will be undertaken during or soon after the National Immunization Days (NIDS). The program of missions for the duration of the project is as follows: - -- Mission Participating Partner Responsibilities Schedule Organizations October 2009 Bank, UNICEF Bank: Vaccine supply &WHO March 2010 October Bank, UNICEF & WHO I Bank, UNICEF & WHO March Bank, only ICR mission UNICEF: Social mobilization and Cold Chain WHO: Monitoring and Surveillance Bank: Vaccine supply UNICEF: Social mobilization and Cold Chain WHO: Monitoring and Surveillance Bank: Vaccine supply UNICEF: Social mobilization and Cold Chain WHO: Monitoring and Surveillance 33