Document of The World Bank PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT TO THE ISLAMIC REPUBLIC OF PAKISTAN FOR A PARTNERSHIP FOR POLIO ERADICATION

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Human Development Unit South Asia Regional Office Document of The World Bank PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 14.7 MILLION (US $20.0 MILLION EQUIVALENT) TO THE ISLAMIC REPUBLIC OF PAKISTAN FOR A PARTNERSHIP FOR POLIO ERADICATION APRIL 21,2003 Report No: PK

2 CURRENCY EQUIVALENTS (Exchange Rate Effective December 1,2002) Currency Unit = PK Rupees (Rs) Rupees 1 = US$ US$1 = Rupees FISCAL YEAR July 1 -- June 30 AFP CAS CDC DFID EPI EU FATA FMOH GDP GOP GF GPEI ICC IDA I-PRSP IPV JICA NGO NID NIH NPI NPV NWFP OPV PEI RI SAPP SIA SNID UNICEF UNF UNFPA USAID VVM WHO WPV ABBREVIATIONS AND ACRONYMS Acute flaccid paralysis Country Assistance Strategy Centers for Disease Control and Prevention (USA) Department of International Development (UK) Expanded Program for Immunization European Union Federally Administered Tribal Areas Federal Ministry of Health Gross Domestic Product Government of Pakistan Bill & Melinda Gates Foundation Global Polio Eradication Initiative Inter-Agency Coordinating Committee International Development Agency Interim Poverty Reduction Strategy Paper Inactivated Polio Vaccine Japan International Cooperation Agency Non-governmental Organization National Immunization Day National Institute of Health National Programme for Immunization Net Present Value North Westem Frontier Province Oral Polio Vaccine Polio Eradication Initiative Rotary Intemational Social Action Program Project Supplemental Immunization Activities Sub-National Immunization Day United Nations Children s Fund United Nations Foundation United Nations Population Fund United States Agency for Intemational Development Vaccine Vial Monitor World Health Organization Wild Polio Virus Vice President: Country ManagedDirector: Sector Director: Task Team Leader: Mieko Nishimizu John W. Wall Charles Griffin Jagmohan S. Kang

3 PAKISTAN PARTNERSHIP FOR POLIO ERADICATION CONTENTS A. Project Development Objective 1. Project development objective 2. Key performance indicators Page 2 2 B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project 2. Main sector issues and Government strategy 3. Sector issues to be addressed by the project and strategic choices C. Project Description Summary 1. Project components 2. Key policy and institutional reforms supported by the project 3. Benefits and target population 4. Institutional and implementation arrangements D. Project Rationale 1. Project alternatives considered and reasons for rejection 2. Major related projects financed by the Bank and/or other development agencies 3. Lessons learned and reflected in the project design 4. Indications of borrower commitment and ownership 5. Value added of Bank support in this project E. Summary Project Analysis 1. Economic 2. Financial 3. Technical 4. Institutional 5. Environmental 6. Social 7. Safeguard Policies

4 F. Sustainability and Risks 1. Sustainability 2. Critical risks 3. Possible controversial aspects G. Main Conditions 1. Effectiveness Condition 2. Other H. Readiness for Implementation I. Compliance with Bank Policies Annexes Annex 1: Annex 2: Annex 3: Annex 4: Annex 5 : Annex 6: Annex 7: Annex 8: Annex 9: Project Design Summary Detailed Project Description Estimated Project Costs Economic Analysis Financial Summary (A) Procurement Arrangements (B) Financial Management and Disbursement Arrangements Project Processing Schedule Documents in the Project File Statement of Loans and Credits Annex 10: Country at a Glance Annex 11: IDA Buy-Down Mechanism Annex 12: Supervision Plan, FY

5 BORROWER [DA JAPAN: JAPAN INTERNATIONAL COOPERATION AGENCY [JICA) LJN CHILDREN S FUND 1 I I Total: I I Borrower: ISLAMIC REPUBLIC OF PAKISTAN Responsible agency: MINISTRY OF HEALTH Expanded Program on Immunization (EPI) Address: National Institute of Health, Islamabad, Pakistan Contact Person: Dr. Rehan Hafiz, Program Manager, EPI Tel: Fax: drrehan@mail.comsats.net.pk Estimated Disbursements ( Bank FYlUS$m): FY I 2004 [ 2005 I 2006 [ Annual I I 3.40 I Cumulative I I 2 I Project implementation period: Expected effectiveness date: Expected closing date: 06/30/2006 _PS*O/ Ra Y M ZcCO

6 A. Project Development Objective 1. Project development objective: (see Annex 1) The project purpose is to assist the Government of Pakistan (GOP) in eradicating Poliomyelitis from Pakistan. The project objective is to support the supply of the additional oral polio vaccine (OPV), needed during , for the country s supplementary immunization activities (SIAs), i.e., for conducting National Immunization Days (NIDs), Sub-National Immunization Days (SNIDs) and mop-up operations. The project is part of a World Health Organization (WHO) led, multi-country effort and will contribute to a global public good, Le., the eradication of Polio from the world by Key performance indicators: (see Annex 1) The following two indicators will be used to measure project performance: Timely arrival of the OPV at the central stores of GOP s Expanded Program on Immunization (EPI), Islamabad, Le., at least five weeks before each of the SIAs; and SIA coverage of 80% achieved in the remaining endemic provinces during The timely arrival of the vaccine will be measured through the EPI s vaccine arrival reports. SIA coverage will be measured through a cluster sampling survey according to a WHO approved methodology. Achievement of these indicators will be a trigger for the IDA buy-down. (See section D.5). Also the number of reported polio cases will be an outcome of interest and will be reported through the Acute Flaccid Polio (AFP) Surveillance System. The details of key indicators for measuring the achievement of the development objectives are described in Annex 1. B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1) Document number: PAK Date of latest CAS discussion: May 15, 2002 General CAS Goals and Health Sector Related Objectives: The CAS, in support of GOP s Interim Poverty Reduction Strategy (I-PRSP), seeks to focus on the reforms to (i) strengthen macroeconomic stability and government effectiveness; (ii) improve the business environment for growth; and (iii) improve equity through support for pro-poor and pro-gender equity policies. In the social sectors, the CAS supports the core I-PRSP objectives of empowering people by creating opportunities for increasing incomes, promoting education, improving access to health services, and implementing safety net programs. In health, it seeks to support the key program interventions of immunization, communicable disease control, and maternal and child health programs. It also supports achievement of improved governance and increased efficiency of public sector expenditures through devolution of powers to local governments; strengthening of district health systems; improvement of monitoring and evaluation; and development of partnerships with the private sector. The proposed project supports the CAS objective of improving equity through supporting pro-poor policies, and CAS S health sector priorities. The poor are at greatest risk from polio due to their unsanitary and crowded living conditions, lower health status, and low immunization coverage. Polio creates both short and long term impoverishment, severely limits the children s future potential and reduces capacity to benefit from education and employment opportunities. The project seeks to eradicate polio from Pakistan and contribute to its eradication from the world. -2-

7 2. Main sector issues and Government strategy: While Pakistan s health indicators have improved in the nineties, they remain weak relative to its per capita income of $440. The infant mortality rate of 82/1000 live births in (Pakistan Integrated Household Survey 2001/02) is among the highest in South Asia. Total fertility rate of 4.8 children per woman (Pakistan Reproductive Health and Family Planning Survey 2000/01) is also highest except for Bhutan. One out of 30 women dies in childbirth, and malnutrition among women and children continues to be a major cause of morbidity. Much of this mortality and morbidity is caused by preventable or readily treatable diseases, with 40% of total disease burden related to communicable disease. (Pakistan: Towards Health Sector Strategy, World Bank 1996). The health system, with an urban and curative bias, is characterized by (i) low (0.7% of the GDP) and inefficient public spending; (ii) uneven public and private service quality; (iii) lack of consumer protectiodeducation; (iv) lack of risk-pooling mechanisms; and (v) a weak regulatory framework. People s dissatisfaction with public services is evident from their seeking 80% of the outpatient care from the private sector. The government tried to address several of the above weaknesses though the multi-donor supported, , Social Action Program Project (SAPP), that focused on programmatic and management reforms, communicable disease control and maternal health. SAPP achieved limited success in improving the quality of health services. However, health outcomes improved with increased resource allocation for preventive and promotive program, especially immunization coverage of children which, for polio, is still around 58% against the at-least 80% needed. Weakly implemented reforms, staff absenteeism, weak outputloutcome monitoring and deficient supervision impeded progress. Government s Current Health Agenda: GOP s broader devolution initiative aims at addressing key health issues by improving staff accountability, efficiency, service quality and coordination with the private sector. The medium-term human development strategy, outlined in the I-PRSP and in the 2001 Health Policy, focuses on (i) strengthening preventive health services including immunization, communicable disease control, maternal and child health, and family planning; (ii) improving the quality of hospital services at the tehsil (sub-district) and district headquarters hospitals; and (iii) strengthening management capacity at the district level. GOP has increased financing for immunization and the routine immunization program is being strengthened. 3. Sector issues to be addressed by the project and strategic choices: The WHO-launched 1988 Global Polio Eradication Initiative (GPEI), the largest public health effort in history, has been highly successful. By 2002, polio cases had decreased by 99%, from 350,000 in 125 countries to 480 in 9 countries. However, ridding the world of this disease by immunizing the final 1% potential cases, involves reaching the remotest and most unreachable populations and convincing those who doubt the vaccine s benefits. On the other hand, because the number of polio cases is presently small in any one country, national governments tend to see polio as a lesser priority relative to more pressing health issues, such as rapid population growth or high infant mortality. Also exhaustion has set in among the governments, donors and communities because of the frequent, large-scale polio campaigns. However, polio eradication remains a global priority because a single infected child puts all the world s children at risk of contracting the disease. Pakistan is, after India and Nigeria, the world s third largest poliovirus reservoir. The Global Polio Eradication Initiative (GPEI) has identified ten countries that would require intense and sustained efforts to interrupt polio transmission; Pakistan i s one of these. Achieving polio eradication in Pakistan will be a -3-

8 major contribution to achieving eradication worldwide. Pakistan initiated polio immunization as part of the Expanded Program on Immunization (EPI) in It started supplemental immunization activities (SIAs) in 1994 first with National Immunization Days (NIDs). It intensified these efforts from 1999, introducing house-to-house immunization by trained vaccinators in 2000 and reaching five NID rounds that year, each round covering over 30 million children. It has conducted cross-border immunization activities with Afghanistan and Iran since SIAs were further intensified with the introduction of a round of sub-national immunization days (SNIDs). The success of the program is reflected in the declining number of confirmed Polio cases. These have decreased from 1803 in 1993 to 98 cases in 2002 (see graph 1). I PAK1STAN:Confirmed Polio Cases 1 Years Pakistan has the following eradication strategy: reaching and maintaining the highest possible routine polio immunization coverage (90% minimum) with at least three dozes of OPV; NIDs to deliver additional supplemental doses of OPV to all children below five years of age; surveillance to detect and investigate every case of acute flaccid paralysis (AFP) in children below 15 years of age, and all suspected polio cases regardless of age; SNIDs in areas with low immunization coverage and districts with persistent polio transmission; and limited mop-up rounds each year depending upon the circulation of virus earlier in the year The intensified efforts include the development of UNICEF-supported community mobilization and a WHO-supported international-quality surveillance system. The latter has enabled the identification of specific districts with persistent virus circulation which has formed reservoirs, harboring the virus through the low transmission winter season, and re-infecting other areas in the high summer season. The distribution of cases indicates circulation of wild polio cases in only 25 of the 120 districts of the country. The clear identification of high-risk districts facilitates the targeting of these districts with the SNIDS. The country has also identified and targeted high-risk populations of Afghan refugees and inner city infants. -4-

9 Polio An effective polio eradication program is in place in Pakistan. The Technical Advisory Group (TAG), which consists of reputed international and national experts and advises GOP on polio eradication, has noted (i) a sharp reduction of transmission in the reservoir areas; (ii) improvement in surveillance quality; (iii) successful implementation of SIAs high-risk area approach; and (iv) continued improvement in the quality of NIDs and SNIDS. It has also noted that high quality surveillance and laboratory data is driving the program, and that a solid structure is in place with the potential to provide broader benefits to immunization. Pakistan needs to make a final, strong push to achieve polio free status. It has the capacity and clear plans in place to achieve this through intensified efforts during The government is maintaining strong commitment and support to polio eradication, but given the pressures on its economy, requires external assistance to maintain the momentum. IDA would support the Pakistan Polio Eradication Initiative (PEI), and the global eradication efforts, in partnership with Bill and Melinda Gates Foundation, the Rotary International and the United Nations Foundation. -5-

10 Strategic Choices: Polio can be eradicated through effective routine immunization services or through well-executed vaccination campaigns. The routine services have not proved equal to the task, and strengthening these services is a medium to long-term effort. So far, such efforts have met with mixed success in Pakistan. Routine coverage for OPV is about 58% against the over 80% needed to achieve interruption of transmission. At the present stage of eradication efforts, routine services can control the disease, prevent outbreaks and facilitate eradication. But the only strategy to interrupt poliovirus transmission and achieve eradication is the short-term, focused, high quality supplementary immunization activities (SIAs). During the last two years, SIAs have been effective in reaching out to the hard-to-reach and resistant populations. Accordingly, this project will support the SIAs to achieve polio free status in Pakistan by The Government of Pakistan, supported by GAVI and other development partners, best supports strengthening of routine immunization through the on-going initiatives. IDA can support polio eradication in Pakistan through a normal IDA credit or the special IDA buy-down arrangement adopted for this project, and other similar projects in polio-endemic countries. This arrangement, on satisfactory project implementation, will reduce the IDA credit to grant terms. The buy-down arrangement is preferred over normal IDA credit because the decision to eradicate polio is a global decision and a global responsibility, and not only of the last few polio-endemic countries. Investing in eradicating the last few cases is less attractive than investing in programs with larger national pay-offs, such as reduced mortality or fertility. The additional support in grant funding will provide the incentive needed to address a disease with greater cross-border or global benefits than national ones. Further, the eradication of an infectious disease is a global public good. Once a disease is eradicated, every child born in the world is protected. Also the IDA buy-down mechanism, which will convert the credit into a grant only on satisfactory implementation, will encourage the government to focus on implementation and results. IDA can support OPV procurement or some or all components of SIAs. It will, however, finance only the OPV procurement and supply. A vaccination campaign, apart from the vaccines, has several components including social mobilization, logistics, monitoring and evaluation and program management. In Pakistan, these other components are financed by GOP and its other development partners including DFID, Government of Japan, the Netherlands, USAID, Center for Disease Control, Atlanta (CDC) and Rotary International. For the additional OPV needed for the SIAs, however, only partial financing is expected to be available from the Government of Japan, and CDC through UNICEF. Also given the planned timeframe of stopping transmission by the end of 2003, it will be simpler and quicker to prepare, implement and monitor a single-component project, especially when other elements for successful SIAs are already in place. C. Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): The project will support Pakistan's Polio Eradication Initiative (PEI) which has three components: (i) the procurement of OPV; (ii) supplemental operations comprising three main areas: cold chain, social mobilization and training; and (iii) surveillance. It will assist GOP to eradicate polio by the end of 2005, with an IDA support of $20.0 million. This project will provide financing for only one component i.e. the procurement of OPV for immunizing all children up to five years of age, under Pakistan's PEI. IDA support will ensure timely procurement -6-

11 and adequate supply of OPV needed for the PEI during the period Vaccines will be procured through UNICEF for use in the NIDs, SNIDs and possible mop-up operations carried out during this period. UNICEF is an established agency for vaccine procurement and is already procuring the OPV for Pakistan. Pakistan will conduct four rounds of NIDs; three rounds of SNIDs and one round of mop-activities in 2003, two rounds of NIDS and SNIDs and one mop-round in 2004, and two NIDs in The estimated need for the SIAs is for approximately 393 million doses at an estimated cost of $40.8 million. IDA will finance OPV for $20.0 million as the remaining $16.0 million and $4.8 million is expected from the Government of Japan and CDC through UNICEF respectively. The total OPV budget for January 2003 to June 2005 is as follows: OPV cost (US$) Funds expected from Japan OPV funding gap/ Funds to be mobilized through the World Bank Partnership $21,746,320 $10,918,483 $8,164,555 $40,829,358 $8,000,000 $8,000,000 $ $16,000,000 $13,746,320 $2,9 18,483 $8,164,555 $24,829,358 The second component of the PEI i.e. Supplemental Operations has three main activities: maintenance of cold chain, social mobilization, and training. It seeks to reach every child up to five years of age, through expanded fixed-site and house-to-house OPV delivery, with special attention to reach the remotelresistant populations. Organizing such eradication campaigns is a complex logistical exercise. In Pakistan, the scale of the operation (over 30 million children to be immunized on an NID), the very short time frame (three days) with over 90% of the immunization posts outside the primary health care facilities (schools, mosques, etc.) makes it even more challenging. Before each round of immunization, extensive micro-planning, social mobilization campaigns, cold chain maintenance, and training of the participants is conducted to ensure effective implementation. The needed infrastructure is in place and a streamlined system functions well. These operations almost regularly reach over 95% of the target group. WHO, with its 117 member national and international staff, and UNICEF with its sizeable field presence support the polio eradication activities. -7-

12 The budget for the Supplemental Immunization Activities (SIAs) is given below: Polio Eradication Initiative: Cost by Components Component Oral Polio Vaccine Procurement I Indicative Yo of costs (US$M) Total (US$M) financing Supplemental Operations I Surveillance Total costs The third component provides support for epidemiological and laboratory surveillance. A Technical Advisory Group (TAG) of national and international experts meets periodically, and provides to the govemment a detailed analysis of program performance, its status, and recommended actions. These reports, along with periodic assessments on the quality of eradication campaigns, are available for monitoring and evaluation. The project is also monitored through regular WHO reports. Upon completion of project activities, WHO will conduct a performance audit of the project within three months of its closing. The performance audit will report on the timely vaccine procurement, use and coverage of children immunized. It will report its findings to GOP, with a copy to IDA. The WHO performance audit will be reviewed by IDA to trigger the IDA buy-down. Component Indicative costs (US$M) Bank- % of % of financing Bank- Total (US$M) financing Oral Polio Vaccine Procurement Total Project Costs Total Financing Required Key policy and institutional reforms supported by the project: The project does not aim at major policy and institutional reform. IDA supports policy and institutional reforms in different sectors, including health, through the federal and provincial Structural Adjustment Credits (NWFP and Sindh). Also, the proposed HNIAIDS Prevention Project, to be financed by the IDA, envisages addressing important sector issues including: controlling spread of HIV/AIDS to avoid it becoming a drain on scarce health resources; introducing a systematic approach to quality assurance, and establishing effective mechanisms for the govemment, NGO, and private sector collaboration. The present project basically finances the supply of oral polio vaccine (OPV) to support intensified supplemental immunization activities (SIAs) for polio eradication. It could, however, indirectly support the following reforms: 0 Expansion of the routine immunization coverage to remote and disadvantaged areas and hard-to-reach populations; 0 Increased resource allocation for proven, cost-effective interventions for child health such as immunization; 0 Promotion of public private partnerships; and 0 Management and implementation strengthening through the participation of numerous functionaries -8-

13 in large and technically well-supported eradication campaigns. 3. Benefits and target population: The project will benefit all Pakistani children below the age of five. It will benefit especially poor and disadvantaged children, eventually all the world s children, and the Pakistani population at large. The project has a strong poverty focus because those living in poor and unsanitary conditions are particularly susceptible to polio, and immunization coverage is lowest among these groups. The project, by supporting the NIDs and SNIDs, will target poor, remote and underprivileged communities. It will especially benefit children whose mothers are unable to take them to health facilities due to socio-cultural restrictions on female mobility. The participation of Lady Health Workers in these campaigns will ensure that the poorest and the most vulnerable, especially the girls, get immunized against polio. Even children who do not receive immunization during the SIAs will benefit from the herd immunity that results from the SIAs when a coverage of 80% is achieved. The project will assist Pakistan in eliminating polio as a public health problem and free scarce resources for use on addressing other important sector issues. The prevention of disability would alleviate human suffering, and decrease economic loss and social burden caused by the disease. However all the above benefits can be achieved only if the SIAs are implemented effectively and, as planned, Pakistan achieves WHO poliofree certification. The repeated SIAs campaigns in Pakistan have led to the development of substantial capacity in planning and managing community based interventions, epidemiology, social mobilization, diagnostic services to support public health interventions and other technical areas. This capacity will eventually strengthen the health system through more effective implementation of other public health interventions and thereby benefit the general population. Vitamin A is distributed during the NIDs in Pakistan. Provision of Vitamin A reduces the blindness incidence among children and reduces infant mortality generally. Combining Vitamin A with the NIDs increases their benefit to poor children who are most at-risk of the Vitamin A deficiency. The project is part of a global effort to eradicate polio world-wide. Such eradication is a global public good. Therefore the benefits of this project go far beyond the national target group, and will include the present and future world populations. 4. Institutional and implementation arrangements: The project will be implemented and monitored through the existing government structures that implement the Pakistan Polio Eradication Initiative (PEI), i.e., through the Expanded Program on Immunization (EPI). To ensure timely procurement and supply of the OPV to the EPI and to monitor its effective use, the following arrangements will be in place. Procurement: OPV will be procured and supplied to the EPI by UNICEF under an agreement between the GOP and UNICEF. A draft agreement for the purpose has been finalized. 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 in Islamabad and for its in-country storage, distribution, administration and use. Vaccine requirements are forecast by the National Program Manager EPI based on the latest estimates of the population of children under five years, and the number of doses to be given per child during a given year. The requirements are estimated with technical support from WHO, UNICEF and TAG and are endorsed by the Inter-Agency Coordination Committee (ICC). The program requirements of OPV for the -9-

14 years are 209 million doses for 2003, 105 million dozes for 2004, and 79 million dozes for Financial Management: Simplified financial management arrangements are appropriate for this project. The project does not envisage direct involvement of the Borrower in the management and accounting of funds. UNICEF will be responsible for these functions under the agreement for OPV supply. The credit proceeds will be disbursed directly to UNICEF on receipt of withdrawal applications from the Borrower. Expenditure will be incurred only on items laid down in the agreement including OPV costs, freight, and handling charges. UNICEF will submit semi-annual financial reports to GOP, with a copy to IDA, in an agreed format that tracks funds disbursed, vaccines purchased and number of children immunized. IDA will use these reports to monitor the outstanding balance and the funds received and spent by UNICEF. Also, these reports will enable IDA to verify the expenditures before subsequent disbursements. GOP will be able to confirm to IDA the receipt of the quantities of OPV indicated in these reports. GOP will also submit to IDA semiannual utilization of the vaccines received. GOP is not required to appoint an independent external auditor or to submit an audit report of the annual financial statements. However, the Association retains the option to request for an audit. Supplemental Immunization Activities (SIAs): The OPV procured and supplied under the project will be used for the SIAs which are organized and implemented as follows. Polio eradication is integrated within the Expanded Program on Immunization (EPI). The Federal Ministry of Health implements the program at the national level through the Federal EPI Cell, and with technical support from WHO and UNICEF. The National Program Manager, EPI, is responsible for implementing the Polio Eradication Initiative (PEI) and SIAs. A WHO team consisting of a CDC seconded senior epidemiologist, a senior program administrator, an NID controller, an EPI expert, a statistician, a social mobilization expert and a logistician, assists the National Program Manager, EPI. The Provincial Program Manager, EPI provides the technical and managerial leadership under the guidance of the Director-General, Health Services, and is responsible for planning, implementing, monitoring and evaluating the SIAs at the provincial level. At the District level, the program is implemented through the district health services under the supervision of the Executive District Health Officer (EDHO). EDHO and the district EPI officers undertake detailed micro planning to ensure that volunteers, health and other department staff and transport are available on the day of the vaccination campaign. They also verify that calculations on the logistics forms with regard to the target population, number and location of NID posts, cold chain needs, and ice requirements are accurate. This process i s facilitated and supported by the Provincial and Federal Program Managers and by WHO and UNICEF local consultants. 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 donors. The Federal MOH is responsible for the procurement, storage and supply of vaccines, cold chain equipment, syringes, needles, social mobilization (air time costs) and for transport. The Provincial Departments of Health bear the cost of staff, training, health education, stationary, POL (petrol, oil, lubricants), and contingencies. A national level Inter-Agency Coordination Committee (ICC), chaired by the Secretary Health coordinates partner agency and national support to the EPI and polio eradication activities, mobilizes resources for polio eradication, advises the government on polio related policies and reviews progress towards polio er'adication. Similar committees function at the provincial level chaired by the provincial -10-

15 Secretaries or Directors General Health Services. At the district level, Coordination Committees are chaired by the EDHO, and attended by the District Coordination Officer and staff from other departments. District-level committees meet monthly, and more frequently close to the actual campaigns. The polio eradication campaigns require efficient organization and mobilization of resources. The mass media, religious and community leaders play a key role in raising awareness and mobilizing the public. Schoolteachers, community members and Lady Health Workers are all involved in giving oral vaccine. UNICEF provides strong support to the social mobilization component of the campaigns. Monitoring and Evaluation: SIA coverage is monitored by an analysis of tally sheets recording the number of children immunized against the number in the target group. The 1998 population census figures are used along with growth rate projections to arrive at a fairly accurate target group number. Output monitoring is undertaken at the provincial level and the impact is monitored at the national level through the AFP surveillance system. Third party monitoring is undertaken through an independent agency which monitors the quality of SIAs in the high-risk and other selected districts. The Technical Advisory Group (TAG) meets periodically and assesses progress. It analyses the polio eradication situation and provides recommendations to give strategic directions to the operations. These reports along with the periodic assessments of the quality of SIAs are also used for monitoring and evaluation purposes. Surveillance: Surveillance quality in Pakistan has achieved and maintained international standards for quality in key indicators since This is largely due to the deployment of WHO supported surveillance officers (SOs) throughout the country, now totaling nearly 60. They visit key reporting sites; undertake advocacy meetings with physicians, unregistered health care practitioners and faith healers; and conduct training workshops for district surveillance coordinators and vaccinators. Surveillance goes through periodic international quality reviews. D. Project Rationale 1. Project alternatives considered and reasons for rejection: The project is one of several similar projects aimed at polio eradication in polio-endemic countries, to be financed through a partnership among the World Bank, the Bill & Melinda Gates Foundation, Rotary International and the United Nations Foundation. Bank s partners will buy down the net present value of the credit once the credit has been satisfactorily used. Different project alternatives, such as financing a different component, some or all of the components of the Pakistan s Polio Eradication Initiative, were considered. These were rejected in favor of financing the OPV procurement and supply for the following reasons: Other components, such as surveillance, social mobilization and logistics, are being well supported and other multilateral agencies are better positioned to continue financing those components. WHO receives large sums annually from bilateral donors for those components. UNICEF, the other main partner, supports logistics and operations. A clear financing gap exists for the OPV needed for the SIAs during Rotary International, a key partner and co-financier of this project, preferred this specific use of the funds. Simplicity of project design i s especially important given the IDA buy-down mechanism and the limited time frame for preparation and implementation of the project

16 The alternative of procuring the vaccines through the government was considered. Because this project is one of an international series, and because specific financing arrangements have been agreed among the partners, it was decided to organize procurement and supply through UNICEF, an agency well recognized for its expertise in vaccine procurement. An alternative would be to invest in strengthening the routine program. Routine immunization coverage remains low in Pakistan and it is known that the high and increasing coverage of supplemental activities has contributed to the rapid decline in polio cases. The project builds on that strength. Also strengthening routine immunization is a longer-term, program type intervention and not the most appropriate for polio eradication, where immediate results are sought. SAPP-2 is a more suitable vehicle for that approach and is already addressing the strengthening of routine immunization. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned). Sector Issue Bank-financed Health Sector Reform Other development agencies Other development agencies DFID, EU, the Netherlands, USAID, WHO, UNFPA, etc. WHO UNFPA, ADB UNICEF Project SAPP-I1 Northern Health, completed Population Welfare, completed Family Health I, completed Family Health 11, completed Technical Assistance to PEI, EPI, Blood Transfusion Services Strengthening and TB Control Contraceptive Supply Women's Health and Health Sector Reforms Social Mobilization, Various, support of NGOs, TA to PEI md EPI Latest Supervision (PSR) Ratings (Bank-f/nance projects only) Implementation Progress (IP) S S S S S Development Objective (DO) U S S S S UNAIDS TA to HIV/AIDS Program and Support to NGOs and UN system for HIV P/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisk ory) - 12-

17 3. Lessons learned and reflected in the project design: Globally polio eradication is benefiting from some of the important lessons learnt from smallpox eradication. While the objective is eradication, the program focus i s more on disease surveillance than on immunization coverage. Flexible eradication strategies are driven by regular and good quality surveillance data. For example, Pakistan is employing SIAs flexibility, based on surveillance data indicating the main disease pockets. A similar approach is planned for "mopping-up" the final cases as eradication nears. The project design reflects the lessons from earlier IDA-supported HNP projects in the South Asia region: Keep the project design simple and well-defined. IDA support will focus on a single component of the polio eradication program. Use of a Project Coordination Unit may undermine the regular structures in a Ministry. The project will be implemented using the existing structures and institutions in place for implementation of routine immunization and PEI activities. Establish good coordination with the other partners. The Resident mission has a senior health specialist who will provide technical support locally and participate in the Inter-Agency Coordination Committee meetings Other relevant lessons from the completed projects in Pakistan, especially from the SAPP, are: Focus on aualitv: SIAs provide house-to-house, convenient immunization services; the objective itself is to achieve a coverage of over 90% of children in the targeted districts. Decentralize, streamline and shift to community control: The project involves repeated, large-scale efforts through full involvement of the community. Without such community support, this project can not be successfully implemented. Improve monitorinp and evaluation and the value and timeliness of feedback: The project seeks to achieve polio eradication through focused, large-scale campaigns that utilize surveillance data as the basis of planning. Strong monitoring and evaluation of on-going campaigns using third party drives PEI activities. Address sustainabilitv: Sustainability will not be an issue in this project aimed at eradication of the disease, polio, which will also contribute to its eradication from the world. Build political will throughout the society: Repeated community participation in campaigns beside the government officials is likely to be conducive to the promotion of such political will in the society. 4. Indications of borrower commitment and ownership: The EPI program, established in 1985 in Pakistan, is a high priority program of the Federal Ministry of Health and the Provincial Departments of Health. EPI was one of the seven federally-funded public health programs included in the Second Social Action Program Project (SAPP-2), supported by the Bank and other development partners. PEI is implemented through the existing EPI program. The government is fully committed to eradicating polio. Recent financial constraints that cut into public health expenditure largely spared the EPI program. President Musharraf personally participated in the 2002 spring round of the National Immunization Day (NID). The Minister of Health, participated in the ICC meeting and high-level advocacy meetings to champion the eradication initiative. Overall the PEI enjoys a high degree of political and community support

18 5. Value added of Bank support in this project: Pakistan s Polio Eradication Initiative has been a major national effort since 1994, and has been supported by several donors. WHO and UNICEF are the lead technical partners for polio eradication globally and in Pakistan. Through them, the donors are providing grant funds for the operations, surveillance and vaccine costs. An additional $20.0 million is needed to meet the vaccine requirements for IDA will meet this gap through a normal credit that will be reduced to grant funding through an innovative IDA Buy-down mechanism. Following an appeal from the Global Polio Eradication Technical Advisory Committee, the Bank, in partnership with the Gates Foundation (GF), Rotary International (RI) and UN Foundation, has developed the IDA Buy-down financing mechanism to support intensified polio eradication activities in polio-endemic countries. These countries are: Afghanistan, Pakistan and India in South Asia and Nigeria and Angola in the Africa Region. A Polio Eradication Trust Fund, to be financed by GF and RI and managed by the World Bank, has been established. The Trust Fund will pay the service fee for the Credit during the implementation and buy down the net present value of the IDA Credit, reducing it to grant terms, when the projects are successfully completed. Thus IDA Credit to Pakistan will in effect be a grant for polio eradication. Since the partners will buy the credit at the Net Present Value, it enables them to leverage their funds for financing polio eradication in Pakistan and elsewhere: they need about a third of the funds they would otherwise need to finance the same goods and services. Through the partnership, they are also able to access the rigor of Bank s project preparation and supervision in support of their efforts for polio eradication. Bank will pilot, through this project, a new financing approach to encourage urgent action on a global public good with significant externalities. This approach will enable the Bank to engage public and private partners in a common global cause. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic (see Annex 4): NPV=US$ million; ERR = % (see Annex 4) 0 Cost benefit 0 Cost effectiveness 0 Other (specify) Justifzcation: Using standard public finance criteria, public involvement in and financing of the Supplementary Immunization Activities to eradicate polio is justified. Control of an infectious disease is a classic example of a public good for health. Global eradication is a global public good with high externalities. Because of the diversity of the communities, government administrative levels and partners that have contributed to the implementation of the Global Polio Eradication Initiative (GPEI), it is not possible to accurately quantify the value of the financial and in-kind expenditures within a country. After quantifying the number of NIDs volunteer hours per country, wage rates from the year 2000 World Development Indicators statistical database were applied to establish a monetary value for the volunteer effort. Based on these calculations, according to a forthcoming WHO study, between 1988 and 2005, world-wide polio endemic countries will have contributed at least US$2.35 billion in volunteer time alone for polio eradication activities. These calculations do not account for the opportunity cost of the volunteer time. They also do not reflect the substantial government resources used at the national, provincial, district and community levels to pay for petrol, social mobilization, training and other -14-

19 activities. Between 1988 and 2005, external sources will have provided at least US$2.75 billion to polio endemic countries to support eradication strategy implementation cost. This included OPV procurement and operational costs for supplemental immunization activities including cold chain refurbishment, training and social mobilization. The strengthening of surveillance has absorbed external resources for vehicles, computers, other equipment, supplies, training, personnel and related costs. External resources are also used for the certification and containment processes, advocacy and resource mobilization, documentation, meetings and administration. Different mechanisms are used to channel these resources to polio-endemic countries, primary ones being multilateral funding through WHO and UNICEF, and direct bilateral funding. Normal cost-benefit analysis does not easily apply to disease eradication. While the costs of eradicating the last case of polio are very high in relation to the by then very low burden of the disease, the benefits of successful eradication are infinite. The disease will be extinct from the world for-ever, unless a man-made mistake or a disaster causes it to reappear. However, ceasing immunization seems no longer a straightforward option. The recent increase in terrorist threats has impacted the development of post-eradication certification strategies. WHO estimates that if eradication is not achieved, even with improved routine immunization coverage, the burden of disease due to polio would be significant. Between 2001 and 2040 there would be 10.6 million new cases of polio worldwide, representing the loss of 60 million DALYs (discounted at 3%), nearly all of which would occur in low-income developing countries. Eradication would result in cost savings in all countries in which OPV is currently used, if polio vaccination were to stop in Even in the worst case scenario, in which OPV may be replaced with a universal IPV strategy, the cost per DALY saved would be low, at approximately US$50 per discounted DALY saved in developing countries. 2. Financial (see Annex 4 and Annex 5): NPV=US$ million; FRR = % (see Annex 4) Present efforts to eradicate polio world-wide are financially supported by a large group of bilateral and private donor agencies, mainly under the coordination of WHO and UNICEF. These two agencies also provide technical support in the implementation of the eradication efforts. The polio-endemic countries provide about 50 percent of the financing, mainly through human resources and recurrent costs. The project will support the procurement of the OPV. The quantity of vaccine procured will depend on the needs identified by the polio surveillance. There remains a risk that eradication will be delayed, requiring additional funds in the future. In that case, additional funds will also be needed for the program support. Commitment to polio eradication is high and continuous future support from the global community is likely. Fiscal Impact: Financial sustainability is not an issue since the supplementary activities of the polio eradication program will end with the disease. Improved surveillance systems set up for poliomyelitis will need to be integrated in regular operations of the health sector, in terms of functioning and financing. There is anecdotal evidence of positive synergies between the polio eradication program and health systems, but these have not yet been fully exploited. -15-

20 3. Technical: There are several reasons why polio can and should be eradicated: (i) there is no animal reservoir to sustain the disease; (ii) the virus has a limited persistence in the environment; (iii) there is no long-term camer state; (iv) permanent immunity is provided following infection; and (v) a safe, highly effective, and easily administered vaccine is available. Polio causes paralysis, most frequently in children, and between 5-10% of cases die when the breathing muscles are paralyzed. Polio is incurable and its effects are largely irreversible. There has been a delay in meeting the global eradication target for the year This is not unlike similar experiences in the Americas (9 months late, 1991) or the Western Pacific Regions (2 years late, 1997). Pakistan i s still on target to meet the Global Strategic Plan s revised target of The eradication strategies are proving successful. At this point in the initiative, the most significant risks are: (1) weaknesses of the routine immunization services; (2) the possibility that political support may decline; and (3) uncertainty about continued funding. GOP s three year strategic plan for the Polio Eradication Initiative, was reviewed during the appraisal together with WHO and other donors. The review clearly indicated that the government is keen on improving routine EPI services, that political commitment to polio eradication both at the federal and provincial levels remains strong, and that donors are willing to support the program, with the needed funds, through its final push to achieve eradication. 4. Institutional: 4.1 Executing agencies: The project will be implemented through the existing federal, provincial, and district structures implementing the routine immunization and the Polio Eradication Initiative (PEI). No new structures will be created. The Federal EPI cell manages the national immunization program and will be responsible for project execution at the national level. It is a relatively strong unit with adequate technical support, from WHO and UNICEF, for program planning, surveillance, social mobilization and monitoring and evaluation. Other partners supporting the PEI, such as DFID, have carried out institutional reviews of the federal, provincial and local structures involved in the execution. They support capacity building and overall program strengthening activities. The Bank will work closely with the partners and will keep informed of the relevant institutional issues. 4.2 Project management: No new management structures will be created for the project. 4.3 Procurement issues: OPV will be procured through UNICEF. The Bank has accepted that UNICEF will use its own procedures for the procurement and delivery of the OPV. Government of Pakistan and UNICEF have finalized the text of a draft agreement, to be entered into between them, for this purpose. There are no significant procurement issues. 4.4 Financial management issues: - 16-

21 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, there are no significant financial management issues. Assurance 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. Upon receipt of a direct 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. Although the Borrower is not required to carry out annual audits, the Association retains the option to request for an audit. WHO coordinates program support provided by a group of bilateral donors and private foundations. These funds provide a large part of the recurrent budget for the SIAs. It is expected that WHO will release funds speedily to facilitate project implementation. This aspect was assessed during the appraisal and it was found that there have been no instances of delayed release of funds by WHO for project implementation of SIAs. GOP is fully satisfied with the way WHO is handling the release of funds for polio eradication activities in Pakistan. 5. Environmental: Environmental Category: C (Not Required) 5.1 Summarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. The project will contribute in a significant way to the eradication of wild poliovirus from the environment and will contribute to worldwide eradication of poliomyelitis. The project s methodology, stimulating oral vaccination with the attenuated virus, has no significant negative environmental impact. The appraisal mission observed supplemental immunization activities in action, as the January sub-national immunization days (SNIDs) coincided with the mission dates, and came to the conclusion that no significant negative environmental issues would need to be addressed under the project. The key stakeholders of the project are children below 5 years of age receiving the vaccines. Their parents, especially their mothers, have been the targets, for the last several years, of IEC campaigns for the ongoing polio eradication efforts. Other stakeholders are the provincial and federal health authorities responsible for the implementation of the campaign. The international community is another important stakeholder, given that disease eradication i s a global public good. Therefore, the polio eradication campaigns have seen an extraordinary cooperation from many donors, governments and communities. The Bank s contribution, towards the end of the campaign, is coupled with that of the Gates Foundation, Rotary International and the United Nations Foundation. 5.2 What are the main features of the EMP and are they adequate? NA 5.3 For Category A and B projects, timeline and status of EA: Date of receipt of final draft: NA 5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EA report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted? NA 5.5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? NA - 17-

22 6. Social: 6.1 Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes. The project specifically aims at benefiting vulnerable and previously neglected groups by providing polio immunization. Poor families, particularly their children, would be the primary beneficiaries of the project. Quantitative studies have found low utilization rates at public health facilities catering to the poor. Qualitative assessments of other health projects indicate that lack of physical access to services is a problem in some areas. A larger problem seems to be the 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 address these issues in respect of polio eradication by developing specific strategies and by using surveillance data to reach the "hard-to-reach" populations. 6.2 Participatory Approach: How are key stakeholders participating in the project? The Polio Eradication Initiative (PEI) has established a framework for broad, on-going participation largely through the Inter-Agency Coordination Committee. This mechanism includes representatives from: (i) key government ministrieddepartments; (ii) multilateral agencies (UNICEF and WHO); (iii) bilateral agencies including the Government of Japan, the Netherlands, EU, DFID, USAID, CDC, etc.; (iv) NGOs; and (v) community mobilization and media experts. The ICC meets regularly to review needs and strategies of the national polio eradication program, and to assess the performance of supplemental immunization activities (SIAs). The PEI has achieved a coverage of over 90% during the last few years by placing high priority on mobilizing participation of the beneficiaries as well as of the key stakeholders. Traditional and religious leaders have been sensitized and are now very committed to the cause. Rejection of polio vaccination now concerns only a very small percentage of the population. 6.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? The Program holds consultations with partner NGOs and community groups which actively participate in social mobilization activities for SIAs. NGOs and community groups are represented in the ICC described above, and they participate with government representatives in joint training workshops for the micro planning of polio activities. 6.4 What institutional arrangements have been provided to ensure the project achieves its social development outcomes? The current institutional arrangements for the PEI have been effective in increasing the number of Pakistani children immunized against polio, and in reaching certification-level acute flaccid polio (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% of AFP cases within 14 days of onset of paralysis. This project will reinforce these arrangements to promote interaction and coordination between the government departments, international agencies, NGOs and community groups at the national, state and local levels. 6.5 How will the project monitor performance in terms of social development outcomes? The project seeks to contribute to polio eradication in Pakistan and globally through the supply of oral polio vaccine to the Expanded Program on Immunization in Pakistan. It will do so by providing the oral polio vaccine for use in the supplemental immunization activities (SIAs) which target all children below - 18-

23 the age of five. Even if some children are left out, they benefit from the "herd" immunity once a coverage of above 80% is achieved. The project's monitoring indicator requires a SIA coverage of 85% in each province in This will be measured through a WHO performance audit to be conducted within three months of the close of the project. 7. Safeguard Policies: 7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies. A part of the proposed project will be carried out in Azad Jammu Kashmir, an area over which Pakistan and India have been in dispute since By financing the credit, IDA does not intend to make any judgement as to the legal or other status of the disputed territory or to prejudice the final determination of the parties' claim. F. Sustainability and Risks 1. Sustainability: The supplementary immunization activities will end with polio eradication and there will be no need to sustain these. Also donors and technical agencies are committed to eradicating polio in Pakistan and globally. Polio eradication benefits are infinite because the disease will be extinct, unless a man-made mistake or disaster makes it reappear. Risk From Outputs to Objective Larger than expected funding gap may occur. The funding gap is based on the present estimates. These estimates may need to be revised based on the Technical Advisory Group recommendations. Risk Rating M Risk Mitigation Measure Estimated were made on the basis of international experience and at the high end of possible scenarios. Also, World Bank participation in the global eradication efforts may make additional funds available by motivating other donors to contribute more. The accelerated strategy with additional M A large effort goes into social mobilization and - 19-

24 NIDs and SNIDs each year may not increase coverage sufficiently to interrupi polio transmission by the end of This would delay global polio eradication. Weaknesses of the routine immunization services may impede polio eradication efforts. Political support for polio eradication may decline. M N achieves active involvement of local, religious and political leaders to facilitate acceptance of vaccination by the population. Routine immunization is receiving strong attention from GOP. Several external partners, amongst them the Bank, are addressing the strengthening of routine immunization through SAPP-2. GOP is strongly committed to polio eradication. Also, the international community will strongly promote eradication in the last few remaining countries and could generate political support. Different partners may not coordinate their activities and may not cooperate h From Components to Outputs N Coordination among the partners engaged in supporting polio eradication has been and remains optimal, and there is little likelihood that they may not cooperate. Inter-Agency Coordination Committee mechanism is effective in ensuring coordination and cooperation among the partners. Overall Risk Rating I Risk Rating - H (High Risk), S (Substantial Ris M (Modest Risk), Ni The risk of Pakistan not achieving polio eradication is modest. health programs in the country. M legligible or Low Risk) The PEI is among the most successful 3. Possible Controversial Aspects: Special support for vertical projects, such as the present project, through the IDA buy-down arrangements, may be perceived as distracting from other, broader and urgent local priorities. Also it may add to funding instruments for specific, limited interventions, which runs counter to Bank's preference to provide budgetary or sector-wide support. Such special support in this case, however, is justified as the Global Polio Eradication Initiative started in 1988 and is close to successful completion. G. Main Loan Conditions 1. Effectiveness Condition OPV Procurement Agreement has been executed by the Borrower and UNICEF and all conditions precedent to its effectiveness have been met. 2. Other [classify according to covenant types used in the Legal Agreements.]

25 H. Readiness for Implementation E 1. a) The engineering design documents for the first year's activities are complete and ready for the start of project implementation. 1. b) Not applicable. 2. The procurement documents for the first year's activities are complete and ready for the start of project implementation. 3. The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. 4. The following items are lacking and are discussed under loan conditions (Section G): 1. Compliance with Bank Policies x 1. This project complies with all applicable Bank policies. E' 2. The following exceptions to Bank policies are recommended for approval. The project complies with all other applicable Bank policies. Sector ManagerlDirector ntry ManagerlDirector -21 -

26 Hierarchy of Objectives jector-related CAS Goal: Annex 1: Project Design Summary PAKISTAN: Partnership for Polio Eradication Key Performance Indicators Sector Indicators: Data Collection Strategy Sector1 country reports: Critical Assumntions [from Goal to Bank Mission) Political Stability Successful eradication programs globally 'olio Eradication: 'olio eradicated world-wide )y 2005 of polio cases after 2003 for the next three years Vational Surveillance system WHO certification process Continuing global commitment and support Jroject Development lbjective: ;upply to Government of 'akistan (GOP) OF 50% of he additional Oral Polio Outcome I Impact Indicators: Coverage of SIAs of 80% achieved in the remaining endemic provinces in 2005 Jroject reports: VHO Performance Audit ising Cluster Sampling vlethodology (from Objective to Goal) Availability of the remaining needed OPV (about 50%) ieports of independent nonitors rechnical Advisory 3roup's SIA assessment,eports Continuing (i) cooperation among government, political leaders, NGOs and the community; (ii) inter-sectoral coordination; (iii) effective cold chain system; and (iv) quality surveillance and monitoring and evaluation systems Planned funds for SIAs from other development partners are available Adequate GOP financing for SIAs continues to be available

27 htput from each :omponent: rimely provision of OPV o GOP Output indicators: Procurement of UNICEF certified OPV and delivery to GOP s Expanded Program on Immunization (EPI) for use in the SIAs: five weeks of before each round of SIAs Data Collection Strategy Project reports: EPI s Vaccination Arrival Reports Critical Assumptions (from Outputs to Objective) Continuing effective coordination between GOP, UNICEF and other Inter-Agency Coordination Committee partners UNICEF s quarterly financial reports International vaccine market is stable GOP s quarterly financial reports Regional peace and political stability Technical Advisory Group s assessment reports Bank s bi-annual and other supervision reports

28 Hierarchy of Objectives Jroject Components I Sub-components: Key Performance Indicators Data Collection Strategy Critical Assumptions from Components to Iutputs) 3ood cooperation amongst he partners Timeliness o f government s request for funds: First request within three weeks of credit effectiveness and each subsequent request: Six months prior to each round o f SIAs GOP financial reports Timeliness o f disbursement of IDA funds to UNICEF for OPV procurement: Within three weeks of receipt o f GOP request Bank supervision reports

29 Annex 2: Detailed Project Description PAKISTAN: Partnership for Polio Eradication The project will support the Pakistan Polio Eradication Initiative (PEI), which seeks to eradicate polio by the end of 2005, with an IDA support of $20.0 million. This will make a significant contribution to the eradication of polio from the world. The PEI is implemented at the national level by the Federal EPI (Expanded Program on Immunization) Cell under the overall guidance of the Federal Ministry of Health and supported by a well-established structure at the provincial and district levels. PEI has three components: (i) the procurement, supply and use of OPV; (ii) supporting supplemental operations; and (iii) surveillance. IDA will support only the first component. Supplemental Immunization Activities (SIAs), in which the OPV will be used, require supporting activities such as logistics, social mobilization, training, surveillance, monitoring and evaluation. WHO and UNICEF will support these activities through bilateral donor and private agency contributions. The following indicators will measure the project s success: 0 Arrival of OPV at the EPI cold rooms in Islamabad at least five weeks before each of the SIAs, to be measured through the EPI s vaccine arrival reports; and 0 SIA coverage of 80% achieved in the remaining endemic provinces during 2005, to be measured through a cluster sampling survey according to a WHO-approved methodology. Government s achievement of the above indicators will be a trigger for the IDA buy-down (see section D.5). Distribution arrangements and storage of vaccines in the EPI cold rooms at the national, provincial, and district levels are functional. During the planning and implementation of SIAs, transport of these vaccines through vaccine carriers to the children i s 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 are carried out to make the public aware of the program benefits and to motivate them to receive the vaccination teams. Mobilization of community leaders, health staff, and volunteers for planning and implementation of SIAs is a key activity. In Pakistan, about 700,000 personnel are needed for each campaign of whom 150,000 are MOH employees, including 10,000 vaccinators and 42,000 Lady Health Workers. The remaining, about 550,000 include other government staff, NGO staff and community members. 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. By Component: Project Component 1 - US$2 million The first and the only component that the project will support is the timely provision of part supplies of OPV needed for eradication campaigns to immunize all children below five years. It will also monitor the appropriate use of this OPV under the PEI. IDA will finance the procurement of about 50 % of the OPV needed for the SIAs to be carried out from UNICEF will supply the vaccine under an agreement between GOP and UNICEF. The Bank has accepted use of UNICEF procurement procedures for the OPV procurement

30 The component s success will be measured by the following indicators: Timeliness of GOP s request for funds for procurement of the OPV: GOP will send, within three weeks of project effectiveness, a withdrawal application to the Bank requesting payment to UNICEF. 0 Timeliness o f disbursement of WB funds to UNICEF for OPV procurement: Bank will transfer funds to UNICEF within 30 business days of the date on which the Withdrawal Application is received by the Bank. 0 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. 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 quarterly 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. 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. WHO will evaluate this component within three months of the project closing, focusing on the timeliness of OPV procurement and supply, and vaccination coverage. WHO will submit its report to GOP with copies to Bank

31 Annex 3: Estimated Project Costs PAKISTAN: Partnership for Polio Eradication Local Project Cost By Component US $million Oral Polio Vaccine Procurement Total Baseline Cost Physical Contingencies Price Contingencies Total Project Costs Total Financing Required Foreign Total US $million US $million Project Cost By Category Local US $million Goods Works Services Trainina 1 Total Project Costs Total Financing Required Foreign US $million Total US $million Note: Total project costs including contingencies. I Identifiable taxes and duties are 0 (USSm) and the total project cost, net of taxes, is 40.8 (US$m), Therefore, the project cost sharing ratio is 49.02% of total project cost net of taxes

32 Annex 4: Cost Benefit Analysis Summary PAKISTAN: Partnership for Polio Eradication GLOBAL HEALTH STRATEGEES VERSUS LOCAL PRIMARY HEALTH CARE PRIORITIES - A CASE STUDY OF NATIONAL IMMUNTSATION DAYS IN SOUTHERN AFRICA B Schreudcr, C Kostermans luildrng on thp succasful eradication of smallpox, the World Iealth Organisation, together with other agencies, is tiow ntiving quickly to the eradicatlon of poliomyelitis, originally imed for the year 2WO Plans for the subsequent global bradication of measles are in an advanced stage txadication jt both polio and measles incorporate ab LI fundamental tsatcgy high rouhne coverage, surveillancc and special iatronal immunisation days (NIUsf, which are supplemenary to routine vaccination services There has been a Itvely debate on whether punr countrieb, hith many health prohtems that could be contmiled, should livert their limited resources for a global goal of eradication hat may have low priority for their children From a cost- :ffectiveners pcrspective, NIDY are fully justifiable -Towever, icld observations in sub4~aran Africa show that KIDS Iivert resources and, to a certain extent, attenhon from the ievelopmcnt of comprehensive prunary health care (PHCI l he routine immunisation coverage rates dropped on JvPragc since the introductton of NIDs tn 1996, which is contrary to what was obserttd m the western Paafir and tither regions The additional investment to be made when moving from disease control to cradication may exceed the financial capacity of an individual country Since the industrialwed countries benefit most from eradicahon, they shouid take responsihility for covering the needs of those countries that cannot afford the inveshnent. The W1IO s trequcnt argument that NIDs $?re promotive to PHC 19 not contfrmed in the sitiithrm African region The authors think that the CVl 10 should, therefore, focus its attention on diminishing the negative side-effects of KID5 and on gettq the positive 5idr effects incorporated in the integrated health services in a siistdinablc way 5 itr kid *? )

33 i I In disease control one can dishn@h between effective control, eliniinat~on, global erz~dication, and extinction All require deliherate eftorts Effectii e wntrol is the reduction of disease inadcnce, pre calence morbidity or mortality to a locally acceptable le\ el, while ehminahon of tiiscaw or infection 15 the wduclioii to Lero (if the Incidence in a defined geographical area Both mntrol and clinimahon require continued control measure6 Glnhd eradication is the reduchoii to two of the woridwide iricillence ot infection caused hy a specihc agent, inter\ ention measure< are no loner needed. Extinction occiirs when the specific agent no longer exists in nature or the lauorator:, From an economic point of blew, elimination 19 generdll) considered tu be Ins cost-effective than ciiseast, cctntm!, since the cost per case controlled usually follows tne iavi of diminishing returns E1 adicatlon L\ espccia11> attractwe, 6mce an) specific iiiterveiition can be stopped after global ~ertification that transmission of infection has ceased Huildmg on the sticcessf~il eradication u! smallpox in 1979, the World Health Organisat~on (WiO), United Nations Children s Furid (UKICEF) and other agencies are no& mavin!: quickly touards the eradicahcm of poliomyel~tis, whxh they hqw to achieve by the year 2000 Plans for the global ale in an advanced stage The cradicabon programme5 for polio and measles incorporate the folio% ing three fundamental strategies high routine coverage, supplenicntal vaccination (national ininiunisatioii dam (EvIDs)) and active suneillmce In particular the hids have occasioned In ely dchate, with proponents and opponent5 sometimes laking dogmatic posi tlnnb In the southern Africm siib-region, the strategy for polio is to hate 2 annual NKh 1 month apart in the cold beason, i 1 wntinuing for up to 3 years. The taiget group for vaccinahon is all children below the age ot 5 >ears, regardless of their I taccination status i v ith regard to measles, countries have done campaigi5 among children aged between 9 monthr; and 14 1 ears Malawi rmp1cmcritt.d its campaign In September 1998 and Suaziland ant1 South Mrica did mathematical miid~lling to show when the follow-up campaigns must be held On the line hand, proponents of NID. il.iim that eradication cannut he schiebed through routine sersiccs ahie They demonstrate the enormou r savings that can be* achieved alter cradiration, owing to the highly fakourablc co~t-effecti~enw (C/ El ratios Im On the other hand, opponents claim that the almost niilitarv bertical approach of WID5 competes with and riegatit elv affect3 comytretiensivr primary health Cart (PI IC) de\clopment Some alw feai thdt eiadicahon btrategies are bccoming thcl public health strategies for the coming century, diserting fu dtention from the continuous care of x ulncinble ~ndividrial~ In their vieti Strenpthenmg rovhnc immiinisatitxi wrviccb 14 mrorc. sustainable lhis article attempt< tit bring both partis togetlier h\ considering puinh ot mutual agreement It has been r$ritten from personal partiapetion in the first rounds of Nllh as well as patkipation in the southem 4frican sub-regional planning and ctaluation meeting\ of n.iticinal Eqxnded Prngnmme fur Ininiunisaticm (EPI) managers, orfiani ed bt the W!1014frica Acgianal Otfice (AFRO) Costs and operationaf aspects of Nflk in southern Africa are also analysed in thii study Finaliy, the study includes replies or subscriherc. to the Afro-h et discuszion group on X1Ds Replies were to thc foflowing questions (1) CVhat are the direct costs ibotli human and mcvictary) {rii Can an indi%idual countq atford not tu participate in a glnbal initiatitc7 (iiii I-low docs an indiviriual poor cnuntr) benefit from MDs (iv) What are the negative effccts of KIDS on suztainability of PHC (P) Can the% effects he minimised THE DILEMMAS OF ERADICATION ln their article cntitlrd Ethical dilemmas in current planning for polio eradicatiim, Taylor cf ti! looked at the dilemm~s nf polio eradiration at Slobal level Tlir authors expressed their concern at the intcnsi:ication of worldwide cradrcation ctfort. UI particular the organication ot h1lh The authors also raise questions regarding the balance between g1obal goalls and Ioc pnorihe3 and the resulting ethical implicaiicinz. Probabl) the most important qucstion raised bj the author 15 bvhethcr pmr countneb, M ith many cni?ttollahle health problems, shouid divert their lrntitcd reiourceb tctwards a global goal that ha3 low priorit); for theii rluldren Cnfortunately the author5 do not pro.i.!de a clear-cut answer this yueshon Ths article attempts to provide curti dn answe for smithern At rica What are the costs of NIDs? A cost study of \IDS in the sctulhem Africm \VI 10 sub-rep showed that thc aicragc direct cnst per saicinated child of f\ round5 of pcilio vaccint wili dio:rnd L SS0.92 Thrz iriduded cost of vaccines, training. logisticb, and social niobiiisation V;iccines, at 48O0 (if the total, ctsn&tuted the niajot cost 7hc cnst ~l a single mea4cs \nccin;ltion dnring a cantpaign, gi\ en with a disposahlc synizgc that is properlj destr close to US1 %me sal ings can be mde h) gi and plio vacc.ncs at the 5 d m bme, ~ hut the dr operatima1 strategrez tnr polio acid 1iiea4~ ~ twdicaticin ma! not a ways allow tor thi\ The total cwts of NIB in thc sub-region ha\ e been calculaled. For polici $\e ~ssirmr.d thc maximum xio three annual ranipaips of tw) rnunds for all children a& under 5 >ears For mcaslcs \be aizuined three campaigns initial campaign for all childicn appd between 4 month% d Marih 2U01, \<>I i)i \c! 3 5AMJ

34 tear i ana two campaigns (for children in the mne age group) ai 4-vear iritcnals thereafter A : I dddi:iotral royt for intenvrymg epidemialol;ical survcillance is included in the clslcuiations Table J shows that the total cost 1% around US$ 114 imilllon In hith 1996 and 1997 expenditure on XIUS in the region \%a\ mostly prcivided bv external funds The exception l+as Eouth.\tr$ca, which paid the tu]! amount ~ ith internal funds 501-1J1 costs paid by the comniunity to parhcipatc in NIUs are not included in the above calculations. A cosnng stud) in Malawi calculated that a mother ~pends 3 hours and 20 minutes to bring her child to one round of NIDs Tahng a rural salary ai L SW 5 per day, the mother b hme for two rounds of polio adds approximatelv SO 3 to ;he direct costs The hidden cog of w1arie.i and operational costs uf health care facilities, ais\+ s covered by internal funda, \+ere also excluded from ~tir Can countries afford to pay for NIDs? Suciet i has to balance cxpendituro on NIDs with expenditure on other piewng needs In South iitrica, NIh annually comume les- than 1, 1 OMl of the totai rrcurtmt budget fur 21th In wiitiast, a poor country such a i hlozainbiquc with intcmal health budget ot rough11 L SS30 million per annum S51 7 per capita), would hate to spend L553 million (or %I of its annual health budget on one national polio mp ugn tvith all the goodwill in the world, there 13 probabl) countr) that can suddcnlp increase its health budget by < % External financial support in the torn1 of loan, credit, or ant IS tireretore indispensable in practice, such support has fordability o! hunian resources IS a potenhally more uc izwt kaccmatlon teams usuallv consist of tmo to four <)pie a\ least me of thenr a protessional In practiie, health rkers are withdrawn from their normal dutm fnr between 2 ys and 2 weeks As no countr! has found it ditficult to recruit basic health work rorn the pot11 of availablc staff OT trainees, KIDS have not substantially aifeckxl the norni il d,tily exemtion of other PHC services. The time spent by district. provincial, md central staff is, however, much more substantial. District staff are diverted for I ~ 2 months to plan, mubilise, support, train, organise logisrics, and evaluate a campaign. At pruvincial level this time may easily double, and at central level it may require up to half of the total asailnhlc time of the national EPI manager and his/licr staff. Consequently, central aid provincial staff can pay much less attention to routine services. What are the side-effects of NIDs? Eradiction strategies cannot be =en in isolation - both positive and ncgative side4fects have been extensively docuniented. The propunents of eradication frequently claim that experience in the Americas has shown that vaccination campaigns can have a positive impart cin the developmcnt of PZiC and thatkocial mnbilisntion reduced distrust between health wrvices staff and cwnni unities and hstercd a new awarelies of health and preventicin. The polio eradication initiaiive has had a positivr impart on the quality of cpideinicilogical surveillance systems in niwt countries in the southern African suh-region. By imprnsing surveillance of suspected polio (acute Claccid paralysis (AFI )), attention was focused on the importance of disease surveillance syslrms. u#hich were strengthened accordingly. It is nttt clear whether this improvement will be sustainablc mcc the extra rcwurces put in for polio surveillance are withdrawn. Sot only did the sensitisih; of the reporting of cases of suspcctcd polio (Am) increase, but it also contributed to the quality of the,tern and called attenticin to the importance of 1 surwillance as such. While if is nu! y t clex, it is hoped that the impact of NlUs will go further than that of the polio initiative alone, and that improvements to surveillance will be made in sustainable ways, a

35 llte NlDs for measles have drawn attention to the need to improve injechon safety. countries have introduced autodestruct syringes and needles during campaihms. Countrit5 also had tc rec(igniw the need to set lip a waste diymsa! system, including ctdiection in boxes and proper incineration. To date, auto-destruct syringes and needles have mostly been used only during the NIDs, and not for routine vaccinations or curatise services. Also, it is still not clear if the impact of NIDs on injection safet! wilf be sustaindbie. On the negative side, the posihve impart of campaigns on the coverage rates of routine imii~unisaticins in the western Pacific, as described by Aylward?! 01.: could not be confirmed in the southem African region. On the cctntrary, tlic coverage rates oi the most important antigens have, on average, declined since the introduction of the NlDj in 1496 (Fig. 1). Opponents ut NIDs do not al>*ash make the necessary distinctim hehvffn the ~lobal goal ot eradication and thc goat of prosiding dails caw to the indrvidual through PHC Opponmts frequently t~iiscoiicei~e XIUS as being an altcmativc way to improve rouhnc cmera rrlect \li)s on grounds of ~nefiicienry National perspective versus global responsibilities Eradication ot a disease is the ultiinate goa. in terms uf wstainablc impart on that disease There is no doubt that the current glcbal strateg~es fur the eradication of botb puiio and meazles can paw the cost-etfcrtivenes (CICI test with honour (see Fig 2) If the \+torid does not embark on eradicatiun of polio and measles. it will face a gradual11 tncreasmg IC\ el of cost5 per disability-adjusted life-year (UALY) gained The f/f rahos for conwol will, in the hnal phase, reach unacceptahlv high lebels Against this, CIF iatios for eradication strategies become, withm the rather Short time of less than 10 vears of concluding the investment, more fasourablc than those tor control alone Fig 2 d~picts the cost-effectwenesz rahob of control and eradicativn strategies for both pol10 and measles Polio em salton Measles ersdl60op 70 EO Many countries iii subsaharati Africa claim that campaigns are temporarily disritptire. A South African study' claimed that campaigns divert attention from the rierelclpinent of routinc services B;irrcm* suggr*sted that mass campaigns are only acceptable as a catalyst to build PIX services and mobilise community a~arenes~ of health issues. kle concludes that bitice this usually does not happen, campaigns have a negative impact on roctinc senices. I'erscmal obsenrationr; in the fiold and reactions sent by cmfirm the competitive anti disruptive effect of X'S on building sustainable PfiC services. Si) far nobody in southern Africa has argued thd KIDS support PIK. Contrary to claims in other parts of the world, NlDs have to some extent disrupted thc development of integrated PHC structiire in the southern African region. This IS mainly at management level, tshcre time spent organking NtDs competes with tinie spent on routine tasks I'arricipation in NlDs is also usually paid for and this may create envy in those who are excluded, causing tensions among the staff. h'ib may iilso undermine corifidencr lwel care. As ICB heard oiic mother say: 'If we come it? becausc wc are folliming the Rcmi chart, why do we suddenly need extra vaccinatici S[mclhing must be wning with the matemdl and chiid health services in the health centre,' s 2 ma Fig. 2. Cosi-eJrectiocrtm ratios,&or s/r~boi /ich iid I~:L*~IEI erodicatioir aiid co,tt.rd in ii f!rw prrspectix The average annual costs per DALY gained hy control strategies will gra&aally rise a5 a result of the inweasin$ number of children to be vaccinated and the declining number oi DALYs gained because of the erer-lower transmission ratr of the disease, llie COS& per vaccinatcd child in thc control strategy will vary greatly by continent, but for rea3ons of simplicity we applied an aniount of US51 as the average cost per vaccinated child in the control scenario for both diseases. Costs assume IUO?c vaccination coverag?. The averagc annuc~l costs per I)hI.,Y g'iined in an cvxiication strategy are based on the total rnsts ctl the eradication strategy divided by the number of DALI's gained since the start of thc eradicaiivn. Total costs ot pcilio eradication arc estiinatcd at

36 l"+j hrllion, and that tor measle> at LES3 7 billion (L'NICEF IYV) The,irerage,iiinunl costa arc the result of the dirisioii ni the total usts by tw number ot wars since tht, start of eradication A Y', annual dtscountinji has bcwt 'ipplied to ~cirrect for utility in the future It 15 assumrd that tor both polit) and measles all routine \ accinatiors ; be 5wpended rf a w-odd free of polio or mea5 e\perted numbers of DALYs ga trend? presented in the tlihil Burden of Diseasffi sericb ' Bart e: ol demonstrated that enormous savings pa:ticuiarl> 1 the iiidurtrialiieci wcvld, would be ma& after the global tvtiirrat" ui a world free ot polio The future savings matie investirig nu\+ in erdication efforts are suh.t.mtia1 rhese vings shotld be used tt) Support the iurthcr development of tegrated PHC, and to compensate for the d:wuphon to these nwes that RlUs are currently provoking Initiative5 for global eradication of disease are comparable tt) thcr globdl apementc between ctmntnei on i$sucs sitch ab an r gilt'. and the banning of land rnines anrl nuciear wtu Gibe11 its great impact, such an agreement should ke ared with the greatest poswhlccari and on11 c ndord if xpcctcd contribution of each indiridmt couiitrj IC defined e eradmtion of polio wa5 endoiwd bc a 1Q6R global lution of dl member states of the WHO and was rmed at the Woild Summit for C hildren in 1090 On both ims the endorsement of polio eradication wac bawd > on technical fcasib~ltty anti expected future benefits icatioiis itf hlu5 un health s?stcms and I'IiC were not greatw resiti~rces should he prcpared to a prnvidinp vaccines Cir covering recurrent One can qucsticxi ivhether NlDs arc an absoiiitc requirement for cradicating polio, lii fact, NIB have neve: been undertaken in the USA and Canada. Other countries with high routine ctrverage ratcs and R reliable sunseillance system in place (including %u:h Africa) decided not to complete the tiill set of *i years of two rctunds of NICs, relying rather on their surveillance ytem as a prerequisite for the 'Free of polict' certification, fioweuer, the arrent coverage rates of the rtiutine El3 services in.some countries in the southern Atriian sub-region 'Ihble 11) do not proside a solid basis for achieving tht: target or globdl eradication of polio in d reasonable time period. Comidering that upgrading the roiltitie EPI services implies a major efftrrt. in the short term it is much organisc NlUs. The impart of NIDs on d probably greatest in those coiintries whew routine coverage is lowest. As a result of their weak infrastructure, these are probably the very countries that will evperieiice rwst disruption from NlD5. To minimise the negative side-effects in thest: countries, NiUs must be planned s e carefully ~ and well in advance. Instead of persisting in pmtirig out the positive impit NlDb have on PllC, the bi'ji0 would dtr better lo pay more attention to the negative side-effects of KIDS. If PHC hits to be stren#hened, there are mom appropriate ways of doing $0. nce eradication 13 J. global inltiati\e, coninutmcnth 4iould h a d according to capaat~ between the 'iid\cs' and 'has e- Ah long a& there 15 no consensus regding their rtance, eradicatwn inihatites mal not receive the sar) hroad support and funding If the initialite is not hr~d bv denors it becomes an empty statement, and the e-rwts' can only adopt H pozturr nf ~FISSIVC re5istanct: '1 iiorictan pint oi \ iew the indu5tria 5 most trom rapid rradication J1t:~evcv the heneiits in reduction dre greater in developing countries where the ce ut new cases of both polin and measles is higher or rt.i] raise the question i:1 wliethcr poor coiirtrie5 ant hcalth pr&iem? should divert their limited 15 tohard$ d p,hhal giial that hd\ ]OM [~ri(irit> for their idii.ri Bc cieiinitiim, global eradication mitiati\-e- tiwd -port of all counbies tit the 'oiintrv could lpopardi.-e tn ~ndii iduai countr> refu.es ntimi it wwid not he iuirtthicni to cxciciw wnie re on t iat coiintrr Ii that cnui~tr~, Ii~~\et PI, wttcr5 froni lntc in implementation, thcn com:iiittcd cuii~itric~ \ i o Tne rrcation of vertical SIDs structure s hdd not he bluntly reiected. It scrves a conipleteiy different obj indi\kluai care pro\*ided hy the integrated Peridic campa1gn5 can never repiace the ctmtjniious rare of I'T-JC The discirssicin sht.iiiid, therefore. not he about whc-ther nhtjons should be administered thrrrugh routine servicei or through h'll)s. Sucicty needs integrated I'tlC, and it nt)ed;i 1% on a tcmpnr,iry Insis to eradiciitr di i