FOR OFFICIAL USE ONLY Report No: PAD3148 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON PROPOSED CREDITS TO THE COMMONWEALTH OF DOMINICA IN THE AMOUNT OF SDR 2.2 MILLION (US$3 MILLION EQUIVALENT) GRENADA IN THE AMOUNT OF US$6 MILLION SAINT LUCIA IN THE AMOUNT OF US$6 MILLION SAINT VINCENT AND THE GRENADINES IN THE AMOUNT OF US$6 MILLION AND PROPOSED GRANTS TO THE CARIBBEAN PUBLIC HEALTH AGENCY (CARPHA) IN THE AMOUNT OF SDR 4.8 MILLION (US$6.6 MILLION EQUIVALENT) ORGANISATION OF EASTERN CARIBBEAN STATES (OECS) IN THE AMOUNT OF SDR 2.2 MILLION (US$3 MILLION EQUIVALENT) FOR AN OECS REGIONAL HEALTH PROJECT August 8, 2019 Health, Nutrition & Population Global Practice Latin America And Caribbean Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective May 31, 2019 Currency Unit = Eastern Caribbean Dollar (EC$) EC$2.70 = US$1.00 US$1.00 = SDR 0.72 FISCAL YEAR July 1 – June 30 Commonwealth of Dominica January 1 – December 31 Grenada April 1 - March 31 Saint Lucia January 1 – December 31 Saint Vincent and the Grenadines Regional Vice President: Axel van Trotsenburg Country Director: Tahseen Sayed Khan Senior Global Practice Director: Muhammad Ali Pate Practice Manager: Michele Gragnolati Task Team Leader(s): Carolyn J. Shelton, Neesha Harnam ABBREVIATIONS AND ACRONYMS CARICOM Caribbean Community CARPHA Caribbean Public Health Agency CDC Centers for Disease Control and Prevention CDEMA Caribbean Disaster Emergency Management Agency CERC Contingent Emergency Response Component CPF Country Partnership Framework CPU Central Procurement Unit EOC Emergency Operations Center ESMF Environmental and Social Management Framework ESMP Environmental and Social Management Plan EU European Union FETP Field Epidemiology Training program FM Financial Management GDP Gross Domestic Product GIS Geographic information systems GNI Gross National Income GRS Grievance Redress Service HCWM Health Care Waste Management HIS Health Information Systems HIV Human Immunodeficiency Virus HNP Health, Nutrition & Population HPU Head of Procurement Unit HSI Hospital Safety Index HSSP Health System Strengthening Project IBRD International Bank for Reconstruction and Development ICT Information and communication technology IDA International Development Association IEG Independent Evaluation Group IHR International Health Regulations IPF Investment Project Financing JEE Joint External Evaluation MISP Minimal Initial Service Package MOF Ministry of Finance MOH Ministry of Health MOHW Ministry of Health and Wellness MTR Mid-term review OECS Organisation of Eastern Caribbean States OP/BP Operations Policy/Bank Procedures PAHO Pan-American Health Organization PBA Projected Budgetary Allocation PDO Project Development Objective PEF Pandemic Emergency Facility PHC Primary Health Care PIU Project Implementation Unit PPS Pharmaceutical Procurement Service PPSD Project Procurement Strategy for Development PSM Procurement and Supply Management RPAC Regional Project Advisory Committee RPS Regional Partnership Strategy SCD Systematic Country Diagnostic SDR Special Drawing Rights SOP Standard Operating Procedure SRH Sexual and Reproductive Health STEP Systematic Tracking and Exchanges in Procurement system SVG Saint Vincent and the Grenadines TA Technical Assistance TOR Terms of Reference UHC Universal Health Coverage WB World Bank WHO World Health Organization The World Bank OECS Regional Health Project (P168539) TABLE OF CONTENTS DATASHEET ................................................................................. Error! Bookmark not defined. I. STRATEGIC CONTEXT ...................................................................................................... 1 A. Regional and Country Context .......................................................................................................... 1 B. Sectoral and Institutional Context .................................................................................................... 2 C. Relevance to Higher Level Objectives............................................................................................... 5 II. PROJECT DESCRIPTION.................................................................................................... 6 A. Project Development Objective ....................................................................................................... 6 B. Project Components ......................................................................................................................... 7 C. Project Beneficiaries ....................................................................................................................... 12 D. Results Chain .................................................................................................................................. 12 E. Rationale for Bank Involvement and Role of Partners ................................................................... 13 F. Lessons Learned and Reflected in the Project Design .................................................................... 14 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 15 A. Institutional and Implementation Arrangements .......................................................................... 15 B. Results Monitoring and Evaluation Arrangements......................................................................... 18 C. Sustainability................................................................................................................................... 19 IV. PROJECT APPRAISAL SUMMARY ................................................................................... 19 A. Technical, Economic and Financial Analysis ................................................................................... 19 B. Fiduciary.......................................................................................................................................... 21 C. Safeguards ...................................................................................................................................... 22 V. KEY RISKS ..................................................................................................................... 24 VI. RESULTS FRAMEWORK AND MONITORING ................................................................... 26 ANNEX 1: Implementation Arrangements and Support Plan .......................................... 54 ANNEX 2. Project Preparation Team .............................................................................. 64 ANNEX 3. Map .............................................................................................................. 65 The World Bank OECS Regional Health Project (P168539) DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Caribbean, Dominica, Grenada, St. Lucia, St. OECS Regional Health Project Vincent and the Grenadines Project ID Financing Instrument Environmental Assessment Category Investment Project P168539 B-Partial Assessment Financing Financing & Implementation Modalities [ ] Multiphase Programmatic Approach (MPA) [✓] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [ ] Fragile State(s) [ ] Disbursement-linked Indicators (DLIs) [✓] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a non-fragile Country [ ] Project-Based Guarantee [ ] Conflict [ ] Deferred Drawdown [ ] Responding to Natural or Man-made Disaster [ ] Alternate Procurement Arrangements (APA) Expected Approval Date Expected Closing Date 29-Aug-2019 31-Jul-2024 Bank/IFC Collaboration No Proposed Development Objective(s) The objective of the Project is to improve preparedness capacities of health systems for public health emergencies in the OECS region. i The World Bank OECS Regional Health Project (P168539) Components Component Name Cost (US$, millions) Improved Health Facilities and Laboratory Capacity 17.42 Strengthening Public Health Surveillance and Emergency Management 9.27 Institutional Capacity Building, Project Management and Coordination 3.91 Contingency Emergency Response Component (CERC) 0.00 Organizations Borrower: Commonwealth of Dominica Grenada Saint Lucia Saint Vincent and the Grenadines Caribbean Public Health Agency (CARPHA) Organisation of Eastern Caribbean States (OECS) Implementing Agency: Dominica - Ministry of Health and Social Services Grenada - Ministry of Health, Social Security and International Business St. Lucia - Ministry of Health and Wellness St. Vincent and the Grenadines - Public Sector Investment Programme Management Unit (PSIPMU) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 30.60 Total Financing 30.60 of which IBRD/IDA 30.60 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 30.60 IDA Credit 21.00 ii The World Bank OECS Regional Health Project (P168539) IDA Grant 9.60 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Dominica 3.00 0.00 0.00 3.00 National PBA 1.00 0.00 0.00 1.00 Regional 2.00 0.00 0.00 2.00 Grenada 6.00 0.00 0.00 6.00 National PBA 2.00 0.00 0.00 2.00 Regional 4.00 0.00 0.00 4.00 St. Lucia 6.00 0.00 0.00 6.00 National PBA 2.00 0.00 0.00 2.00 Regional 4.00 0.00 0.00 4.00 St. Vincent and the 6.00 0.00 0.00 6.00 Grenadines National PBA 2.00 0.00 0.00 2.00 Regional 4.00 0.00 0.00 4.00 Caribbean 0.00 9.60 0.00 9.60 Regional 0.00 9.60 0.00 9.60 Total 21.00 9.60 0.00 30.60 Expected Disbursements (in US$, Millions) WB Fiscal Year 2020 2021 2022 2023 2024 2025 Annual 1.33 3.24 6.05 8.45 8.51 3.02 Cumulative 1.33 4.57 10.62 19.07 27.58 30.60 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population iii The World Bank OECS Regional Health Project (P168539) Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of Yes country gaps identified through SCD and CPF b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or Yes men's empowerment c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  Moderate 2. Macroeconomic  Moderate 3. Sector Strategies and Policies  Moderate 4. Technical Design of Project or Program  Substantial 5. Institutional Capacity for Implementation and Sustainability  Substantial 6. Fiduciary  Substantial 7. Environment and Social  Moderate 8. Stakeholders  Moderate 9. Other 10. Overall  Substantial COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No iv The World Bank OECS Regional Health Project (P168539) Does the project require any waivers of Bank policies? [ ] Yes [✓] No Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 ✔ Performance Standards for Private Sector Activities OP/BP 4.03 ✔ Natural Habitats OP/BP 4.04 ✔ Forests OP/BP 4.36 ✔ Pest Management OP 4.09 ✔ Physical Cultural Resources OP/BP 4.11 ✔ Indigenous Peoples OP/BP 4.10 ✔ Involuntary Resettlement OP/BP 4.12 ✔ Safety of Dams OP/BP 4.37 ✔ Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Legal Covenants Sections and Description REGIONAL PROJECT ADVISORY COMMITTEE Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines: Schedule 2, Section IA.1. The Recipient shall, at all times during the implementation of Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project, ensure adequate representation and participation in the Regional Project Advisory Committee, and shall maintain such representation with resources satisfactory to the Association as set forth in the Project Operations Manual. CARPHA: Schedule 2, Section IA.1. The Recipient shall not later than sixty days after the Effective Date establish and thereafter convene with the frequency set forth in the POM, the Regional Project Advisory Committee, chaired by the Recipient and composed of two representatives from each of the Participating Countries, and one representative from OECS, and with a mandate and functions set forth in the POM, in form and substance satisfactory to the Association. OECS: Schedule 2, Section IA.1. The Recipient shall, at all times during the implementation of the Project, ensure participation and adequate representation to the Regional Project Advisory Committee, and shall maintain such representation with resources satisfactory to the Association as set forth in the Project Operations Manual. Sections and Description v The World Bank OECS Regional Health Project (P168539) PROJECT IMPLEMENTATION UNIT Commonwealth of Dominica: Schedule 2, Section IA.2. (a) The Recipient shall maintain, at all times until the completion of Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project, the PIU within the MOH assisted by an implementation support team as set forth in the POM, with management and staff, terms of reference, mandate and resources satisfactory to the Association with experience, qualifications, expertise and terms of reference acceptable to the Association; and.(b) Without limitation to paragraph (a), the Recipient shall not later than sixty days after the Effective Date recruit the Project officer with experience, qualifications, expertise and terms of reference acceptable to the Association. Grenada: Schedule 2, Section IA.2. (a) The Recipient shall maintain, at all times until the completion of Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project, the PIU within the MOHSSIB with management and staff, terms of reference, mandate and resources satisfactory to the Association with experience, qualifications, expertise and terms of reference acceptable to the Association; and (b) Without limitation to paragraph (a), the Recipient shall not later than sixty days after the Effective Date recruit the Project coordinator and appoint the financial management and procurement specialists all with experience, qualifications, expertise and terms of reference acceptable to the Association. Saint Lucia: Schedule 2, Section IA.2. The Recipient shall maintain, at all times until the completion of Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project, the PIU within the MOH with management and staff, terms of reference, mandate and resources satisfactory to the Association with experience, qualifications, expertise and terms of reference acceptable to the Association. Saint Vincent and the Grenadines: Schedule 2, Section IA.2. The Recipient shall maintain, at all times until the completion of Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project, the PSIPMU with management and staff, terms of reference, mandate and resources satisfactory to the Association with experience, qualifications, expertise and terms of reference acceptable to the Association. CARPHA/OECS: Schedule 2, Section IA.2. The Recipient shall maintain, at all times until the completion of the Project a Project Implementation Unit (PIU) with staff, terms of reference, mandate and resources satisfactory to the Association; including a Project manager, a financial management specialist, and a procurement specialist, all with experience, qualifications, expertise and terms of reference acceptable to the Association. Sections and Description PROJECT OPERATIONS MANUAL Commonwealth of Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines: Schedule 2, Section IB. 1. The Recipient shall carry out Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project in accordance with the POM. 2. Except as the Association shall otherwise agree, the Recipient shall not amend, waive or fail to enforce the POM, or any provision thereof. 3. In case of any conflict between the provisions of this Agreement and those of the POM, the provisions of this Agreement shall prevail. CARPHA/OECS: Schedule 2, Section IB. 1. The Recipient shall carry out the Respective Part of the Project in accordance with the POM. vi The World Bank OECS Regional Health Project (P168539) 2. Except as the Association shall otherwise agree, the Recipient shall not amend, waive or fail to enforce the POM, or any provision thereof. 3. In case of any conflict between the provisions of this Agreement and those of the POM, the provisions of this Agreement shall prevail. Sections and Description SAFEGUARDS Commonwealth of Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines: Schedule 2, Section IC. 1. The Recipient shall ensure that: (a) the Respective Part of the Project is carried out with due regard to appropriate health, safety, social, and environmental practices and standards, and in accordance with the Safeguards Instruments; (b) for each activity under Parts 1.1(a), 1.2(a), 2.1(a), 2.2(a) and 3 of the Project for which the ESMF provides for the preparation of an ESMP: (i) proceed to have such ESMP as appropriate: (A) prepared and disclosed in accordance with the ESMF; (B) consulted upon adequately with people affected by Parts 1.1(a), 1.2 (a), 2.1(a), 2.2 (a) and 3 of the Project as per the ESMF, and submitted to the Association for review and approval; and (C) thereafter adopted, prior to implementation of the activity; and (ii) take such measures as shall be necessary or appropriate to ensure compliance with the requirements of such ESMP in a manner satisfactory to the Association. 2. The Recipient shall ensure that: (a) all consultancies related to technical assistance, design and capacity building under the Respective Part of the Project, the application of whose results could have environmental, social and health and safety implications, shall only be undertaken pursuant to terms of reference reviewed and found satisfactory by the Association; and (b) such terms of reference shall require the technical assistance, design and capacity building activities to take into account the requirements of the applicable Bank Safeguards Policies and EHS Guidelines. CARPHA/OECS: Schedule 2, Section IC. The Recipient shall ensure that: (a) all consultancies related to technical assistance, design and capacity building under the Respective Part of the Project, the application of whose results could have environmental, social and health and safety implications, shall only be undertaken pursuant to terms of reference reviewed and found satisfactory by the Association; and (b) such terms of reference shall require the technical assistance, design and capacity building activities to take into account the requirements of the applicable Bank Safeguards Policies and EHS Guidelines. Sections and Description CONTINGENCY EMERGENCY RESPONSE COMPONENT (CERC) Commonwealth of Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines: Schedule 2, Section ID. 1. The Recipient shall: (a) prepare and furnish to the Association for its review and approval, a CERC Manual which shall set forth vii The World Bank OECS Regional Health Project (P168539) detailed implementation arrangements for the CERC Part, including: (i) designation of, terms of reference for and resources to be allocated to, the entity to be responsible for coordinating and implementing the CERC Part (“Coordinating Authority”); (ii) specific activities which may be included in the CERC Part, a sound and actionable country-level response plan, Eligible Expenditures required therefor (“Eligible Emergency Expenditures”), and any procedures for such inclusion; (iii) financial management arrangements for the CERC Part; (iv) procurement methods and procedures for Eligible Emergency Expenditures to be financed under the CERC Part; (v) documentation required for withdrawals of Eligible Emergency Expenditures; (vi) environmental and social safeguards management frameworks for the CERC Part, consistent with the Association’s policies on the matter; and (vi) any other arrangements necessary to ensure proper coordination and implementation of the CERC Part; (b) afford the Association a reasonable opportunity to review said proposed CERC Manual; (c) promptly adopt such CERC Manual for the CERC Part as shall have been approved by the Association; (d) ensure that the CERC Part is carried out in accordance with the CERC Manual; provided, however, that in the event of any inconsistency between the provisions of the CERC Manual and this Agreement, the provisions of this Agreement shall prevail; and (e) not amend, suspend, abrogate, repeal or waive any provision of the CERC Manual without prior approval by the Association. 2. The Recipient shall, throughout the implementation of the CERC Part, maintain the Coordinating Authority, with adequate staff and resources satisfactory to the Association. 3. The Recipient shall undertake no activities under the CERC Part (and no activities shall be included in the CERC Part) unless and until the following conditions have been met in respect of said activities: (a) the Recipient has determined that an Eligible Emergency has occurred, has furnished to the Association a request to include said activities in the CERC Part and an action plan in order to respond to said Eligible Emergency, and the Association has agreed with such determination, accepted said request and notified the Recipient thereof; (b) the Recipient has prepared and disclosed all safeguards instruments required for said activities, in accordance with the CERC Manual, the Association has approved all such instruments, and the Recipient has implemented any actions which are required to be taken under said instruments; and (c) the Recipient has ensured that no activities under the CERC Part fall under the prohibited activities mentioned in CERC Manual. Commonwealth of Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines: Schedule 2, Section IE. The Recipient shall procure the Emergency Expenditures required for the CERC Part of the Project in accordance with the procurement methods and procedures set forth in the CERC Manual. Sections and Description OTHER UNDERTAKINGS Commonwealth of Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines: Schedule 2, Section IF. The Recipient shall cooperate with CARPHA and OECS as required for implementation by CARPHA and OECS within the Recipient’s territory of the regional activities included in the Project and enable CARPHA and OECS to discharge their respective coordination obligations set forth in Section I. F of Schedule 2 to the CARPHA Financing Agreement and the OECS Financing Agreement. CARPHA: Schedule 2, Section ID. The Recipient shall: (a) serve as the lead technical entity to oversee the design, planning and technical assistance for the implementation of selected Regional Level Activities and identified in the POM; (b) provide technical advice to the Participating Countries related to the national level activities with a regional viii The World Bank OECS Regional Health Project (P168539) dimension to be implemented by the Participating Countries, such as compliance with common standards for laboratories of Participating Countries; and (c) (i) cooperate and coordinate with OECS as required for the implementation of the Regional Level Activities of the Project and to meet the Project objectives; and (ii) inform the Association of the arrangements made to ensure such cooperation and coordination. OECS: Schedule 2, Section ID. The Recipient shall: (a) cooperate and coordinate with CARPHA as required for the implementation of the Regional Level Activities of the Project and to meet the Project objectives; and (b) inform the Association of the arrangements made to ensure such cooperation and coordination. Sections and Description PROJECT REPORTING Commonwealth of Dominica, Grenada, Saint Lucia, Saint Vincent and the Grenadines, CARPHA and OECS: Schedule 2, Section II. The Recipient shall furnish to the Association each Project Report not later than forty-five days after the end of each semester, covering the semester. Conditions Type Description Effectiveness Section 4.01. The Financing Agreement of at least two of the Participating Countries and of OECS and CARPHA have been executed and all conditions precedent to the effectiveness of said Financing Agreements have been fulfilled. Type Description Disbursement Commonwealth of Dominica: Schedule 2 Section B. No withdrawal shall be made: (a) for payments made prior to the Signature Date; except that withdrawals up to an aggregate amount not to exceed SDR 110,000 equivalent may be made for payments made prior to this date but on or after June 14, 2019, for Eligible Expenditures; or (b) under Category (2), for Emergency Expenditures under Part 4 of the Project, unless and until the Association is satisfied, and has notified the Recipient of its satisfaction, that all of the following conditions have been met in respect of said activities: (i) the Recipient has determined that an Eligible Emergency has occurred, has furnished to the Association a request to include said activities in the CERC Part and an action plan in order to respond to said Eligible Emergency, and the Association has agreed with such determination, accepted said request and notified the Recipient thereof; (ii) the Recipient has prepared and disclosed all safeguards instruments required for said activities, and the Recipient has implemented any actions which are required to be taken under said instruments, all in accordance with the provisions of Section D of this Schedule; (iii) the Recipient's Coordinating Authority has adequate staff and resources, in accordance with the provisions of Section D of this Schedule, for the purposes of said activities; and (iv) the Recipient has adopted the CERC Manual in form, substance and manner acceptable to the Association and the provisions of the CERC Manual remain or have ix The World Bank OECS Regional Health Project (P168539) been updated in accordance with the provisions of Section D of this Schedule so as to be appropriate for the inclusion and implementation of said activities under the CERC Part. Type Description Disbursement Grenada: Schedule 2 Section B. No withdrawal shall be made: (a) for payments made prior to the Signature Date, except that withdrawals up to an aggregate amount not to exceed $300,000 equivalent may be made for payments made prior to this date but on or after June 17, 2019, for Eligible Expenditures; or (b) under Category (2), for Emergency Expenditures under Part 4 of the Project, unless and until the Association is satisfied, and has notified the Recipient of its satisfaction, that all of the following conditions have been met in respect of said activities: (i) the Recipient has determined that an Eligible Emergency has occurred, has furnished to the Association a request to include said activities in the CERC Part and an action plan in order to respond to said Eligible Emergency, and the Association has agreed with such determination, accepted said request and notified the Recipient thereof; (ii) the Recipient has prepared and disclosed all safeguards instruments required for said activities, and the Recipient has implemented any actions which are required to be taken under said instruments, all in accordance with the provisions of Section D of this Schedule; (iii) the Recipient’s Coordinating Authority has adequate staff and resources, in accordance with the provisions of Section D of this Schedule, for the purposes of said activities; and (iv) the Recipient has adopted the CERC Manual in form, substance and manner acceptable to the Association and the provisions of the CERC Manual remain or have been updated in accordance with the provisions of Section D of this Schedule so as to be appropriate for the inclusion and implementation of said activities under the CERC Part. Type Description Disbursement Saint Lucia and Saint Vincent and the Grenadines: Schedule 2 Section B. No withdrawal shall be made: (a) for payments made prior to the Signature Date; or (b) under Category (2), for Emergency Expenditures under Part 4 of the Project, unless and until the Association is satisfied, and has notified the Recipient of its satisfaction, that all of the following conditions have been met in respect of said activities: (i) the Recipient has determined that an Eligible Emergency has occurred, has furnished to the Association a request to include said activities in the CERC Part and an action plan in order to respond to said Eligible Emergency, and the Association has agreed with such determination, accepted said request and notified the Recipient thereof; (ii) the Recipient has prepared and disclosed all safeguards instruments required for said activities, and the Recipient has implemented any actions which are required to be taken under said instruments, all in accordance with the provisions of Section D of this Schedule; (iii) the Recipient’s Coordinating Authority has adequate staff and resources, in accordance with the provisions of Section D of this Schedule, for the purposes of said activities; and (iv) the Recipient has adopted the CERC Manual in form, substance and manner acceptable to the Association and the provisions of the CERC Manual remain or have x The World Bank OECS Regional Health Project (P168539) been updated in accordance with the provisions of Section D of this Schedule so as to be appropriate for the inclusion and implementation of said activities under the CERC Part. Type Description Disbursement OECS: No withdrawal shall be made for payments made prior to the Signature Date, except that withdrawals up to an aggregate amount not to exceed SDR 220,000 equivalent may be made for payments made prior to this date but on or after June 13, 2019, for Eligible Expenditures. Type Description Disbursement CARPHA: No withdrawal shall be made for payments made prior to the Signature Date, except that withdrawals up to an aggregate amount not to exceed SDR 240,000 equivalent may be made for payments made prior to this date but on or after June 13, 2019, for Eligible Expenditures. xi The World Bank OECS Regional Health Project (P168539) I. STRATEGIC CONTEXT A. Regional and Country Context 1. The Organisation of Eastern Caribbean States (OECS) consists of twelve small open economies, including three British Overseas Territories and three overseas departments and regions of France. The population of the OECS member countries ranges widely from approximately 5,000 (Montserrat) to 400,000 (Martinique). OECS member states are generally highly open economies heavily dependent on tourism, which contributes at least one quarter of total economic output, except for Grenada and Saint Vincent and the Grenadines (SVG), where the contribution is much lower. Of the member countries, Dominica, Grenada, Saint Lucia, and SVG will participate in the OECS Regional Health Project though other members may benefit indirectly from regional activities.1 2. The OECS region faces several key challenges, including low growth, high debt, fiscal deficits, and vulnerabilities to external shocks. This region exhibits substantial volatility in Gross Domestic Product (GDP) growth rates, with fiscal policies tending to exacerbate output volatility.2 In the period since 2013, economic growth has varied widely among the four participating countries with Grenada being the only country to sustain growth above two percent. In 2017, the most recent year for which data is available, GDP growth ranged from 5.1 percent (Grenada) to -9.5 percent (Dominica).3 Gross National Income (GNI) per capita in the four countries ranges from US$6,590 in Dominica to US$9,180 in Grenada (2017).4 Despite the limited fiscal space for public investment due to high ratios of debt to GDP, there is a high level of need for building ex-ante resilience to climate change, natural disasters, and public health emergencies. 3. Interconnected hazards such as extreme weather events and disease outbreaks, exacerbated by climate change, threaten to erode development gains. Climate change projections for the OECS region include higher temperatures, changing rainfall patterns, rises in sea level, and increased intensity and frequency of natural disasters. The International Monetary Fund notes that vulnerability to natural disasters is one of the main economic challenges facing Caribbean states. Hurricanes are a major natural hazard and pose significant destructive potential due to high wind speeds, heavy rains, and powerful storm surges that produce flooding, which may increase the threat from vector-borne diseases. Average annual losses from hurricanes alone are estimated at US$835 million in the Caribbean region.5 Dominica most recently experienced substantial damages and losses estimated at 226 percent of 2016 GDP following Hurricane Maria in 2017 while other countries were also affected in 2013 and 2016, mainly from extensive flooding. Going forward, climate change is expected to lead to rising temperatures, changes in rainfall patterns, and an amplification of extreme weather events6 with implications for increasing the incidence of water-borne and vector-borne diseases. 1 Reference to the OECS going forward refers exclusively to the four project-participating countries, namely Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines. 2 OECS Regional Partnership Strategy: 2019-2023. Report Number 127046-LAC. World Bank. 2018. 3 World Development Indicators. World Bank. 2019. 4 Ibid. 5 GFDRR (2015) Small Island States Resilience Initiative. Washington, DC: Global Facility for Disaster Reduction and Recovery. 6 World Bank. 2018. Global Crisis Risk Platform (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/762621532535411008/Global-Crisis-Risk-Platform 1 The World Bank OECS Regional Health Project (P168539) 4. Official poverty data in the region are limited and outdated, but consumption-based poverty rates range from 20 to 30 percent for the four participating countries.7 Available evidence suggests that extreme poverty rates are low while moderate poverty rates are high. Nonetheless, there have been considerable gains in human development, and life expectancy averages 75 years. Meanwhile, unemployment rates are high, at around 20 percent in Saint Lucia (2016), 28.6 percent in Grenada (2016), and 25.1 percent in SVG (2015). B. Sectoral and Institutional Context 5. Faced with limited capacity and fiscal space, as well as high levels of exposure to economic and climate related risks, the four participating countries have had limited success in adequately preparing for public health emergencies. Recent extreme weather events such as Hurricanes Irma and Maria (2017) and regional outbreaks of Chikungunya (2014) and Zika (2016) highlighted the consequences of weaknesses in public health emergency preparedness. Assessments conducted by the Pan-American Health Organization (PAHO) since 2015 under its Smart Health Facilities Initiative8, which aims to ensure that health facilities are environmentally friendly and resilient to disasters (mainly extreme weather events), found that in some countries more than 75 percent of health facilities scored in the Category C range, indicating they would no longer be operational after a disaster. In Dominica, Hurricane Maria caused extreme damage to health facilities, disrupted access to health services and increased vulnerability to outbreaks of gastroenteritis and vector borne diseases while compromising treatment of chronic diseases. For example, the main hospital, Princess Margaret Hospital, sustained severe damage and was only able to function at 53 percent while bed capacity decreased by 43 percent.9 At the same time, a 40 percent increase in persons seeking care was reported. Severe weather events are thus notable for their impact on the health sector, as they may induce a demand for services while damaging health facilities and further impairing the delivery of health services. Meanwhile, the rapid spread of disease in the region can be seen with the Chikungunya outbreak, which spread to over 350,000 people between December 2013 and July 2014. Two years later, the Zika outbreak exposed gaps in public health preparedness and response that had not been adequately addressed following the 2014 Chikungunya outbreak. The vector-borne nature of these recent outbreaks, and the ease with which vectors cross national borders underscores the importance of well- coordinated country and regional responses and containment strategies to avoid the high costs associated with outbreaks, including productivity and investment opportunity (tourism) loss. 10 6. Preparedness in the context of this regional project refers to a range of health and non-health capabilities and operational capacities put in place at national and regional levels to ensure prevention, protection, response and recovery from public health emergencies, such as infectious disease outbreaks, 7 OECS Regional Partnership Strategy: 2019-2023. Report Number 127046-LAC. World Bank. 2018. 8 The PAHO Smart Health Facilities Initiative is co-financed by the United Kingdom’s Department of International Development (DFID) to support the retrofitting of selected health facilities in the Caribbean region. This project will complement current investments to fill critical gaps. 9 Post-Disaster Needs Assessment. Hurricane Maria, September 18, 2017. Report by the Government of the Commonwealth of Dominica. 10 While a One Health approach (which recognizes that human health is connected to the health of animals and the environment) was considered, the small size of the livestock industry, high degree of mobility and substantial needs of the human health sector in the project-participating countries indicated that it would be more appropriate to focus on human health at this time. While recent estimates of the agriculture sector in project-participating countries are not available, evidence suggests that the agriculture industry is relatively small ranging from 11 percent (2008, Grenada) to 40 percent of the labor force (2002, Dominica) and is mainly focused on crops (CIA World Factbook). More recent estimates suggest that these figures have fallen to 6 percent of the labor force in Saint Vincent and the Grenadines (ILO 2018). 2 The World Bank OECS Regional Health Project (P168539) extreme weather events and other climate change risks. Natural disasters and disease outbreaks have demonstrated the cross-boundary nature of public health emergencies, underlining the need for resilient health systems and stronger inter-country collaboration. A regional approach is thereby warranted, whereby investments in preparedness are harmonized at the country level and complemented at the regional level. As part of strengthening health security for the OECS region, this project intends to build resilience and mitigate cross- border transmission of disease outbreaks and disruptions in the aftermath of an extreme weather event and climate change impacts. This project responds to the demand for financial support for preparedness for public health emergencies expressed by Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines, and is expected to enhance their capacity to adapt to and mitigate climate change and have spillover benefits across the OECS region. 7. The health systems of the four participating countries are similarly structured and have overlapping gaps in preparedness capacity. In 2005, in response to an increase in global mobility, emergence and reemergence of diseases, nearly 200 countries across the world signed on to implement the International Health Regulations (2005) (IHR). The objective of this legally binding instrument is “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." The IHR require countries to strengthen core surveillance and response capacities. Current IHR core capacity implementation status among the four participating countries ranges between 63-77 percent, suggesting room for improvement. Rapid needs assessments following the Zika outbreak carried out by the World Bank (WB) in collaboration with PAHO in all four project-participating countries revealed the following shortcomings in infectious disease surveillance, epidemic preparedness, and response: (i) lack of an adequately trained health workforce for disease surveillance, preparedness, and response across the different levels of health services; (ii) nonexistent or insufficient facility level surveillance and response structures; (iii) limited laboratory infrastructure for timely and quality diagnosis of epidemic-prone diseases; (iv) lack of interoperability of information systems hampers analysis and utilization of information for decision-making and disease mitigation measures; (v) inadequate infection, prevention and control standards, infrastructure, and practices; (vi) significant gaps in regional level surge capacity for emergency response, stockpiling of essential goods, information sharing, and collaboration. At the same time, areas of heterogeneity across countries in terms of the availability of adequately trained public health specialists (e.g. epidemiologist, entomologist, etc.) suggested opportunities for sharing of human resources and expertise across countries. 8. Under the proposed project, investments in health systems strengthening will have a direct impact on improving IHR core capacities in the participating countries, particularly in the areas of surveillance, laboratories, workforce development, and emergency management. Furthermore, project investments will contribute to sustainable, effective and efficient regional collaboration for mitigating and/or preventing public health risks and the economic consequences associated with infectious diseases while also improving continuity of care following a disaster. At present, many health facilities lack the resilient infrastructure to withstand extreme weather events. Related to this is the vulnerability of health facilities to climate change, where previously unaffected facilities may be vulnerable to rising sea levels, floods, and mudslides. At the primary health facility level, typically the first point of contact with the health system, current disease surveillance and response protocols are inadequate. Laboratory confirmation of diagnoses is challenging due to limited laboratory infrastructure at the national level, while laboratory infrastructure at the regional level has not been able to cope with the surge in demand during outbreaks. Although all four countries have some form of health information systems (HIS), these are not updated in real time, have limited interoperability, and are poorly connected at the regional level. These shortcomings subsequently translate to weaknesses in supply chain management and surge 3 The World Bank OECS Regional Health Project (P168539) level capacity at the national and regional levels, making it difficult for countries and the OECS region to mount a coordinated response to public health emergencies. 9. Project activities will leverage existing platforms and institutions for public health preparedness, which indicate a high level of regional commitment (Box 1). These regional collaborations have been instrumental in addressing the health needs of the population and play an important role in driving the health agenda forward. The OECS has a longstanding history of regional cooperation in health. In 1986, OECS Governments decided to pool the procurement and management of pharmaceuticals and medical supplies to achieve economies of scale through the Pharmaceutical Procurement Service (PPS). In 2011 with the Revised Treaty of Basseterre, the OECS Economic Union was established which allows for the free movement of persons, goods and services across OECS countries. This has a direct impact on the level of regional cooperation in health, including the movement of health professionals, and sharing of health services. In 2016, the OECS Commission Health Unit was established to drive regional functional cooperation to implement the OECS Growth and Development Strategy Health Agenda 2017- 2030. With the 1984 adoption of the first Caribbean Cooperation in Health Initiative (now in its fourth iteration) and the 2011 legal establishment of the Caribbean Public Health Agency (CARPHA) by an inter-governmental agreement (IGA)11 signed by the Caribbean Community (CARICOM) Member States, CARPHA became the single regional public health agency for the Caribbean. 10. CARPHA, as well as other agencies operating in the region, have clearly defined roles and responsibilities and a high degree of coordination. As part of its mandate, CARPHA serves as the Caribbean Reference Laboratory, coordinates regional public health surveillance, provides support to countries in surveillance and disease control, conducts specialized training for health workers, and defines quality standards and standard operating procedures. Overall coordination of Disaster Management in the CARICOM region is led by the Caribbean Disaster Emergency Management Agency (CDEMA). The OECS Commission, CARPHA and PAHO work closely with CDEMA in any disaster response. PAHO maintains an Emergency Operations Center (EOC) for the Latin America and Caribbean region that collects, monitors, and disseminates information about health crises and disasters and facilitates an effective health response in emergencies. The United States Centers for Disease Control and Prevention (CDC) has focused on strengthening laboratory information systems and surveillance capacity (mainly for Human Immunodeficiency Virus (HIV) and Tuberculosis), with support to the construction of a new climate resilient national public health laboratory in Barbados that will serve other parts of the eastern Caribbean. Despite this new reference laboratory, there continues to be a gap in laboratory services for specialized tests. Other gaps in laboratory services were identified as part of the Rapid Needs Assessments conducted in 2016/2017, and an in-depth regional laboratory assessment will be conducted under the project to inform program priorities. Small population sizes mean that due to low volumes certain tests will remain unavailable at the national level. In addition to strengthening lab policy and quality assurance, ensuring a robust and responsive system for lab sample transportation as needed for surveillance and in emergencies is an important part of the project. 11 As per article 4 of the IGA, CARPHA’s core functions to its member states include: (i) provision of support and coordination of the development of regional standards and networks related to laboratory practice; (ii) coordination of effective responses to public health crises in the Caribbean; and (iii) provision of leadership in defining effective public health interventions in the Caribbean and development and adaptation of relevant models for various circumstances. The IGA is available at http://carpha.org/Portals/0/docs/CARPHA_IGA.pdf 4 The World Bank OECS Regional Health Project (P168539) Box 1. A Regional Approach to Addressing Public Health Emergencies  A regional challenge: The eastern Caribbean remains vulnerable to extreme weather events and climate change while frequent disease outbreaks in recent years have highlighted weaknesses in health systems’ preparedness for public health emergencies. Capacity constraints and limited fiscal space have hampered the ability of the OECS region to adequately strengthen preparedness efforts. Promotion of strategic and complementary investments at the regional level can help mitigate the disruptions and health consequences associated with extreme weather events and contain cross-border spillovers of communicable disease beyond what countries can achieve by acting alone.  A regional solution: Regional frameworks and institutions exist to facilitate coordination and cooperation but have not been sufficiently leveraged to improve public health emergency preparedness. Clear policy commitment to a regional approach is seen through the 2011 Revised Treaty of Basseterre and the 2017 Ministers of Health Forte de France Declaration on Health, for which the OECS PPS is a manifest of this commitment. The Caribbean Cooperation in Health is the regional framework through which CARICOM member states have set agreed targets for health cooperation, and for regional institutions and development partners to improve the health status of the Caribbean people. During the 17th special session of the CARICOM Heads of Government meeting in November 2014, a ten-point plan of action was adopted to manage the spread of infectious and vector-borne diseases in the region. Creation of the Regional Coordinating Mechanism on Health Security (RCMHS), for which CARPHA serves as the Chair, was an integral part of the 10-point action plan. Regional entities such as CARPHA and the OECS provide platforms for policy harmonization. A regional approach confers economies of scale, which are particularly important given the relatively small national populations across the OECS. Regionalization of certain aspects of public health emergency preparedness will result in lower costs per unit for select public health activities.12 Finally, a regional approach is appropriate given the positive externalities associated with the public goods nature of strengthening preparedness for public health emergencies.  Achievement of regional-level results: Through the activities supported by the project, improvements are expected in laboratory services, regional harmonization of policies and procedures, regional collaboration on public health surveillance and emergency response efforts, and resource sharing of high-cost specialized assets such as reference laboratories, training programs, HIS, pooled procurement of difficult-to-access commodities, and sharing of human resources. C. Relevance to Higher Level Objectives 11. The proposed project is consistent with the World Bank Group’s strategies for the Organisation of Eastern Caribbean States. The proposed Project is fully aligned with the World Bank Group’s FY2015-19 Regional Partnership Strategy (RPS) for the OECS, discussed by the Executive Directors on November 13, 2014, and extended through FY2020 by the Performance and Learning Review of the RPS, discussed by the Executive Directors on May 23, 2018, in particular with its Pillar 2: Enhancing Resilience. 13 The proposed project is aligned with this Pillar given its focus on strengthening health systems in the target countries and enhancing regional 12 Bernet PM, Singh S. (2015) Economies of scale in the production of public health services: an analysis of local health districts in Florida. American Journal of Public Health;105(S2). 13 Performance and Learning Review of the RPS for the OECS, Report No. 118511-LAC, May 1, 2018. 5 The World Bank OECS Regional Health Project (P168539) health security which is the key building block for a health system to prepare for extreme weather events and disease outbreaks. Finally, collaboration and collective action across borders to promote preparedness for health emergencies are one of the clearest examples of a global public good, as described in Box 1. 12. The proposed project is in line with the World Bank Group’s twin goals of eliminating extreme poverty and boosting shared prosperity as well as the growing priority placed on management of crisis risks for WB support.14 The poor are often the first and worst-affected by a health crisis, especially in an epidemic. The project contributes to the region’s progress in meeting obligations under the International Health Regulations (IHR 2005) and is in line with the strategy and objectives of the Global Health Security Agenda. The project is also fully aligned with the Bank’s efforts to accelerate the achievement of Universal Health Coverage (UHC) – investing in public health emergency preparedness is a key core element of UHC, and an integral part of health systems. The proposed project reflects the World Bank’s recent efforts to improve support to pandemic preparedness. Under IDA 18, a commitment was made to support 25 IDA countries (mainly in Africa except for Guyana and Haiti) to develop pandemic preparedness plans and frameworks for health emergency preparedness, response, and recovery. Furthermore, the proposed project complements the Global Pandemic Emergency Financing Facility15 (PEF) by: (i) focusing on capacity for disease surveillance and epidemic preparedness so that countries will be better able to detect and contain outbreaks before they develop into a Public Health Emergency of International Concern and trigger the PEF; and (ii) including a Contingency Emergency Response Component (CERC), so that countries will be able to mobilize funds quickly from within the project in the event of an outbreak. Lastly, the proposed project is aligned with and supportive of the World Bank Group Climate Change Action Plan and recently announced new set of climate targets for 2021-2025, including an effort to strengthen action on climate and health. II. PROJECT DESCRIPTION A. Project Development Objective PDO Statement: The objective of the Project is to improve preparedness capacities of health systems for public health emergencies in the OECS region. PDO Level Indicators: The PDO level indicators will be measured at the country/regional entity-level16 as well as aggregated as a summary indicator. The summary indicators are presented below, and the complete Results Framework, including sub-indicators, is provided in Section VI. (i) Number of project-participating countries with health system capacity to withstand extreme weather events based on A-70 rating on Smart Health Facility standards17 14 World Bank. 2018. Global Crisis Risk Platform (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/762621532535411008/Global-Crisis-Risk-Platform 15 Established in 2017 by the World Bank Group with the support of Japan, Germany and the WHO, the PEF is a quick- disbursing financing mechanism that provides surge funding to IDA eligible countries to enable a rapid and effective response to a large-scale disease outbreak. 16 The project-participating countries are Dominica, Grenada, Saint Lucia and Saint Vincent and the Grenadines. The regional bodies are CARPHA and the OECS. 17 The Smart Health Facility/Hospital is defined as HSI A and minimum Green 70 percent, simplified as A-70. Low HSI scores such as low B and C, generally correspond to facilities with low structural and non-structural scores. Therefore, a target of an 6 The World Bank OECS Regional Health Project (P168539) (ii) Number of project-participating countries/regional entities with laboratory testing capacity for detection of priority diseases based on achievement/sustainment of a Joint External Evaluation (JEE) score of 4.0 or higher18 (iii) Number of project-participating countries/regional entities with indicator- and event-based surveillance19 established based on achievement/sustainment of a JEE score of 4.0 or higher (iv) Number of project-participating countries with emergency operations capacity strengthened based on achievement/sustainment of a JEE score of 4.0 or higher B. Project Components Component 1: Improved Health Facilities and Laboratory Capacity (US$17.42 million) 13. This component focuses on improving the resilience and capacity of select health facilities and laboratories to provide services to manage a public health emergency, including an emerging disease outbreak, extreme weather event or other disaster. The component will support the refurbishment and equipping of select health facilities to ensure continuity of care and improve laboratory infrastructure and equipment with corresponding training. 14. Subcomponent 1.1 Health Facilities Infrastructure and Referral Networks. This component will focus on the development of: (i) resilient health facilities in participating countries; and (ii) a facility inventory at the regional level, which will inform the development of an emergency coordination mechanism at the regional level. At the national level, activities focused on health facility resilience will build on the Smart Health Facilities Initiative implemented by PAHO. Under this initiative, in-depth assessments of health facilities in all four participating countries have been conducted.20 Using the assessment findings, select health facilities will be upgraded to improve their resilience to climate change and extreme weather conditions.21 Examples of climate resilient and energy-efficient upgrades include structural improvements, roofing, electrical safety, improvements in lighting, telecommunications, plumbing and water storage as well as the inclusion of ramps to facilitate access for people who are disabled. The number of facilities to be upgraded in each country is reflected in the Results Framework. 15. At the regional level, an emergency and critical care facilities inventory, including information on human resources, will be developed by the OECS to document the available resources for an emergency response. As the project scope does not allow upgrading of all facilities, the facilities inventory and geographic information systems HSI score of an A and a green score of 70 percent is combined as A-70. This indicator reflects the Smarting of facilities conducted under this project. 18 A Joint External Evaluation (JEE) is a voluntary, collaborative process that is intended to assess country capacity to prevent, detect and rapidly respond to public health threats independently of whether they are naturally occurring, deliberate or accidental. The purpose of the external evaluation is to measure country-specific status and progress in achieving as well as maintaining the targets. Evaluations are carried out by a panel of subject matter experts. For more information, see https://www.who.int/ihr/procedures/joint-external-evaluations/en/ 19 WHO defines public health surveillance as the continuous, systematic collection, analysis and interpretation of health- related data needed for the planning, implementation, and evaluation of public health practice. Indicator-based surveillance involves reports of specific diseases from healthcare providers to public health officials. Event-based surveillance focuses on news stories, rumors, reports and other information about health events that may pose a threat to public health. Investment in routine “fair weather” public health surveillance is an important element of a health securi ty strategy. 20 Assessments in Dominica will need to be updated to reflect the post-hurricane context. 21 Facility upgrades are expected to apply universal access and design approaches with respect to persons with disabilities. 7 The World Bank OECS Regional Health Project (P168539) (GIS) mapping is expected to provide useful guidance on available resources and possible referral networks22 to ensure continuity of care following a public health emergency, particularly an extreme weather event. These investments are expected to improve the continuity of care in the context of a public health emergency, reducing the need for medical evacuations. 16. Subcomponent 1.2 Laboratory Infrastructure and Capacity Building. The project will also support investments in laboratory infrastructure and capacity with the aim of improving the efficiency and quality of the laboratory network in the region. New infrastructure will include climate-resilient and energy-efficient design where possible. An underdeveloped laboratory network has hindered the region’s capacity to confirm and respond in a coordinated manner, as recently seen with the 2016 Zika outbreak. At the national level, this subcomponent will include: (i) expansion of national laboratory services, including provision of equipment and reagents; (ii) improvements in specimen handling and supply chain management (including cold chain transport equipment such as icebox coolers for shipping samples as well as solar powered refrigerators); (iii) technical support for laboratory data management systems and interoperability with health and surveillance information systems at national and regional levels; (iv) training and capacity building for laboratory services; and (v) strengthened laboratory quality management systems. 17. At the regional level, a corresponding set of activities will be conducted, where project activities implemented by CARPHA will include: (i) assessment of national laboratory capacity in project-participating countries to provide the needed laboratory services (e.g. collect, test, process, diagnose, and confirm cases); (ii) technical support to improve the link between national laboratory networks and the regional reference laboratory; (iii) enhancements to the regional reference laboratory capacity in order to provide the region with the necessary capacities in processing, diagnosing and confirming priority infectious diseases including in the context of growing climate change impacts; and (iv) improved laboratory safety and specimen transportation. A regional quality assurance program will also be supported with the implementation of common standards for national laboratories, including policies, standard operating procedures (SOPs) and related training. Recognizing the small country context and high level of integration, support will be provided to the OECS under the project to: (i) develop a pooled procurement system for laboratory equipment, service contracts, and laboratory parts and reagents; (ii) develop and implement laboratory specimen transportation agreements; and (iii) support development of laboratory budget processes. Component 2. Strengthening Public Health Surveillance and Emergency Management (US$9.27 million) 18. This component will support efforts to strengthen public health preparedness, including surveillance23 and emergency response through improvement of national and regional capacities and promotion of cross- border collaboration. This component would improve the completeness and quality of the reporting chain for surveillance activities from the national to regional level, including improvements in interoperability and the development of a regional dashboard to monitor trends. The project would also address vulnerabilities at the national level, in areas such as port health and development of national health emergency response mechanisms and operations centers. Similar efforts would be made in regional preparedness and response, including the 22 The referral network refers to a health network at the facility level where a Smart health facility is networked with facilities that have not been retrofitted to ensure continuity of care following an extreme weather event. 23 According to WHO, public health surveillance is the continuous, systematic collection, analysis and interpretation of health- related data needed for the planning, implementation, and evaluation of public health practice. Such surveillance can serve as an early warning system for impending public health emergencies; document the impact of an intervention, or track progress towards specified goals; and monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategies. 8 The World Bank OECS Regional Health Project (P168539) development of an emergency health services coordinating mechanism. Improved surveillance activities will allow for better monitoring of climate-sensitive diseases and their evolution over time, thereby reducing the vulnerability of the population to climate change. 19. Subcomponent 2.1 Public Health Surveillance. At the national level, activities under this subcomponent will focus on: (i) improving the information base for surveillance through training and investments in HIS (e.g. strengthening case detection and reporting, mapping communicable diseases using GIS to identify high-risk areas); (ii) addressing points of vulnerability through improved surveillance in targeted areas (e.g. food safety, port health and inspection) and high-risk groups (e.g. pregnant women); and (iii) support to national vector control programs and implementation of the Frontline and Basic Field Epidemiology Training Program (FETP). At the regional level, project activities to be implemented by CARPHA include: (i) the expansion and roll-out of the Intermediate and Advanced FETP;24 (ii) improvements in surveillance reporting to and from the regional level, including protocols for communication and data sharing and the development of a regional dashboard; and the (iii) development of an information and communication platform for surveillance and management including GIS. As part of efforts to improve surveillance reporting, the project will support in-country assessments by CARPHA of participating countries’ ability to report and use surveillance information. 20. Subcomponent 2.2 Emergency Management. This subcomponent will support strengthening of national and regional emergency management and response capacities to respond swiftly and effectively to outbreak threats. In addition, project interventions will provide support to improve country and regional surge capacity to ensure rapid response during an emergency, including those induced by climate change. Activities to be supported at the national level include: (i) development and/or updating of health emergency preparedness and response plans; (ii) establishment of isolation facilities for response and containment capacity in the event of an outbreak; (iii) setup and equipping of national health emergency response systems and/or operations centers (e.g. staff, protocols and procedures, communications, equipment); and (iv) management of biomedical waste. Investments at the national level will also seek to address weaknesses in compliance with the 2005 IHR, and where necessary, will include training. At the regional level, CARPHA will focus on the: (i) development of regional preparedness and response action plans for public health emergencies (including simulation exercises); (ii) support to countries in their JEE self-assessments and development of National Action Plans for Health Security; and (iii) establishment of a contingency emergency response funding mechanism. Also, at the regional level, the OECS will focus on the development and implementation of an OECS health emergency services coordinating mechanism to strengthen regional capacity for mobilizing first responders and moving critical health supplies to affected areas, including strengthening of systems facilitating patient movement and specialized health human resources. Finally, the project will also support training on a minimal initial service package (MISP) in sexual and reproductive health (SRH) in the context of public health emergencies. Component 3: Institutional Capacity Building, Project Management and Coordination (US$3.91 million) 21. Component 3 will support the critical building blocks for strong implementation and coordination required for implementing this regional project. Specific institutional capacity building activities include technical assistance for contract management, procurement, financial management (FM), environmental and social safeguards, construction supervision (e.g. engineer and/or architect), monitoring and evaluation, and project audits. With respect to project management and coordination, this component will finance personnel for project execution 24 The FETP represents one area through which investments at the national level can be leveraged. While training participation costs for basic FETP will come out of the respective country project budgets, participation costs for the advanced modules of the FETP will be covered by CARPHA. 9 The World Bank OECS Regional Health Project (P168539) and regional coordination platforms for knowledge sharing among the implementing entities and collective monitoring of implementation status. Finally, related operating expenses and equipment will also be financed. Component 4. Contingency Emergency Response Component (CERC) (US$0 million) 22. This zero-cost component aims to provide immediate surge funding in the event of a public health emergency, such as a disease outbreak. The CERC is only triggered in the case of a public health emergency and when certain actions, as agreed by the Government and Bank teams, are met. These actions can include: (i) the country declares a national public health emergency; and (ii) presents a sound and actionable country-level response plan. Having the CERC in place provides a compelling platform for country-level discussions on the importance and need for country-level readiness to respond to disease outbreaks. Once triggered, the CERC is implemented following the exceptional policy requirements set out in Paragraph 12 of the IPF Policy (Projects in Situations of Urgent Need of Assistance or Capacity Constraints) and enables rapid reallocation of funds between project components following an emergency. Together with the operational, fiduciary, procurement, disbursement and financial management arrangements that underpin its implementation, the CERC provides a conduit for flow of PEF funds (in the form of grant funds) into the project. Details on triggering the CERC in terms of definition of a public health emergency will be defined in the respective Financing and Grant Agreements as well as described in a CERC Operations Manual. Project Financing Table 1. Financing by Component and Country/Regional Organization (US$ million) Components/Countries Dominica Grenada St. Lucia SVG CARPHA OECS Component 1. Improved Health Facilities and Laboratory Capacity 2.44 4.09 4.40 3.40 2.16 0.93 (US$17.42 million) Component 2. Strengthening Public Health Surveillance and Emergency 0.38 1.45 1.13 2.03 2.95 1.33 Management (US$9.27 million) Component 3. Institutional Capacity Building, Project Management and 0.18 0.46 0.47 0.57 1.49 0.74 Coordination (US$3.91 million) Component 4. Contingency Emergency 0.00 0.00 0.00 0.00 0.00 0.00 Response Component (US$0) Total 3.00 6.00 6.00 6.00 6.60 3.00 23. Gender dimensions are important aspects of the proposed project in light of critical health services requiring continuity during and following a public health emergency. During natural disasters and other emergencies, SRH needs are often not met: pregnant women risk life-threatening complications without access to obstetric care, access to family planning services is disrupted, and vulnerability to gender based sexual violence, exploitation and/or HIV infection increases. To deal with these gaps, the project will support training in a MISP for SRH in disasters. The MISP, developed by the Inter-Agency Working Group on Reproductive Health in Crises25, is a 25 http://iawg.net/ 10 The World Bank OECS Regional Health Project (P168539) series of actions required to respond to reproductive health needs at the onset of a crisis. These activities must be implemented in a coordinated manner by appropriately trained staff and help to ensure that quality reproductive health services are available in even the worst scenarios. In order to adequately monitor how well countries are equipped to offer the MISP, this activity will be monitored as an intermediate indicator in the Results Framework. Finally, given the gender aspects of infectious diseases, such as exposure to pathogens and response to illness,26 the project will seek to develop protocols for gender-specific surveillance of priority infectious diseases, such as Zika, as it poses a greater risk to pregnant women. 24. Climate co-benefits of the project are expected to be significant, largely due to climate mitigation and adaptation activities outlined under Components 1 and 2. The project is expected to improve the health systems’ capacity to detect and respond to disease outbreaks; and resiliency to extreme weather events in the OECS region. Strengthened disease surveillance mechanisms and development of national health preparedness response plans supported by the project explicitly address climate vulnerabilities related to tracking patterns of diseases as a result of changing climatic conditions. The climate co-benefits from a strengthened surveillance system lie in the availability of a mechanism in the OECS region through which to monitor the potential threat of a disease outbreak following a natural disaster and curtail its potential regional spread, thereby improving the health systems’ resilience to climate change. Climate change resilience and mitigation measures will also be incorporated, as they relate to the refurbishment of health facilities by including energy efficient improvements in lighting, appliances and equipment, incorporating climate resilient designs, and improving health care waste management (HCWM). Civil works supported by the project will follow the Green Checklist, utilized under the Smart Health Facilities Initiative, which incorporates climate smart actions for health infrastructure. Renovations to existing health facilities will benefit, when possible, from energy-efficient ventilation and air conditioning systems which reduce these related costs and enhance infection control, as well as energy efficient and cost saving investments such as light-emitting diode (LED) lights, and lighting control measures (e.g., dimming, occupancy sensors, daylighting). Reductions in dioxins, a greenhouse gas, are expected with the promotion of an autoclave/grinder instead of an incinerator to dispose of medical waste,27 which also eliminates potential HCWM issues from the outset and reduces the volume of medical waste to be managed and treated. Finally, project-participating countries will apply the OECS Building Code, which focuses on climate resilient infrastructure standards and is also referred to by the Smart Health Facilities Initiative. 25. Disability and Inclusion. Including persons with disabilities and expanding equitable opportunities is at the core of World Bank Group’s goals to end extreme poverty and promote shared prosperity. One billion people, or 15 percent of the world’s population28, experience some form of disability, and disability prevalence is higher in developing countries. Persons with disabilities on average are more likely to experience adverse socioeconomic outcomes than persons without disabilities, and often have limited access to basic services. Under Component 1, the project will aim to remove some of the barriers that individuals with disabilities face when seeking health care services, such as inability to reach or enter health care establishments and lack of accessible equipment. Efforts to improve continuity of care for mental health and other psychosocial services will also be supported. 26 WHO has elaborated an analytical framework on considering sex and gender in emerging infectious disease programs and will be used as a starting point to identify potential areas for the development of protocols. This is available at http://www.wpro.who.int/topics/gender_issues/Takingsexandgenderintoaccount.pdf Accessed April 8, 2019. 27 WHO- Health – Care Waste http://www.who.int/mediacentre/factsheets/fs253/en/ https://www.healthcare-waste.org/ 28 Disability Inclusion and Accountability Framework, 2018 International Bank for Reconstruction and Development / The World Bank. 11 The World Bank OECS Regional Health Project (P168539) 26. Citizen Engagement. Community dialogue and cooperation, and principles of consultation were prioritized during project preparation, for example with the development of the Environmental and Social Management Framework (ESMF) in each country. These efforts will continue during implementation through project support to countries’ efforts to develop, streamline and/or consolidate existing public health emergency management plans. Involvement of citizens and/or communities in this process will be monitored with an intermediate indicator included in the Results Framework to ensure that feedback received from key populations is incorporated in public health emergency management plans. The project has also established a Grievance Redress Mechanism (GRM) as outlined in each country’s ESMF, which have been publicly disclosed in each country. C. Project Beneficiaries 27. The main project beneficiaries are an estimated 1.5 million people29 covering the entire OECS region given the public goods nature of public health emergency preparedness and response. The population of the four participating countries numbers 470,491. Furthermore, CARPHA member states include countries outside the OECS, which may also indirectly benefit from the project. Secondary beneficiaries include service providers as well as national and regional institutions participating in the Project. While four of the seven full member countries are participating in the Project, country-level activities are expected to yield positive regional spillovers, and investments made through the project are expected to improve health security in the region. D. Results Chain 28. The proposed project will finance critical, high-priority and high-impact investments to improve the preparedness capacities of health systems for public health emergencies in the OECS region. In line with safe health facility and climate smart initiatives, the project will finance critical renovations and refurbishments to support the Smarting (defined as the implementation of Smart Health Facility recommendations) of priority facilities. To address capacity constraints in laboratory services, the project will invest in improvements to laboratory capacity. The project will also support the regional harmonization of laboratory specimen transportation policies and capacity building of key health personnel and laboratory technicians in advanced field epidemiology and laboratory training. As part of strengthening core technical capacities for surveillance and emergency management, the project will also support the updating of clinical protocols and harmonized procedures for infectious disease surveillance, including support to laboratory quality assurance, interoperability of health and laboratory information systems, and the establishment of health emergency operations centers. Figure 1 illustrates the flow of the desired changes expected including short-, mid-, and long-term goals. The achievement of project objectives over the course of the project will be monitored using the Results Framework as described in Sections III.B (Results Monitoring and Evaluation Arrangements) and VI (Results Framework and Monitoring). Improvements in the preparedness capacities of health systems for public health emergencies in the OECS region are expected beyond the participating countries as the regional entities serve, at a minimum, all OECS member states.30 29 All population estimates obtained from 2017 World Development Indicators, with the exception of Anguilla and Montserrat (2018, CIA World Factbook). Recent estimates for Guadeloupe and Martinique were not available, and thus 2013 estimates were used (PAHO). 30 CARPHA membership includes OECS and non-OECS countries. 12 The World Bank OECS Regional Health Project (P168539) Figure 1: Results Chain and Expected Outcomes • Upgrade health facilities and their networks, and improve laboratory capacity (e.g. facilities, data management systems) • Develop regional lab quality assurance, reference lab, its interoperability, and transportation and cold chain • Develop/update protocols and harmonized procedures on infectious disease surveillance • Strengthen HIS for national data collection, GIS for regional mapping, and regional ICT platform for surveillance Activities • Update emergency plans, biohazard waste management systems, and EOCs • Develop training and simulation curriculum for country-level health workforce, lab technicians, FETP • Resilient health facilities and improved laboratory capacity through implementation of Smart Health Facility recommendations at select health facilities and laboratories • Technical capacities in place through progress in achieving the IHR core capacities with a focus on capacities 4 Outputs (response) and 5 (preparedness) • Coordinated regional and national preparedness and response action plans for priority infectious diseases • Improved preparedness capacities of health systems for public health emergencies in the OECS region Expected Outcomes • Rapid detection and response of priority infectious diseases • Coordinated public health emergency management Expected • Continuity of care following a public health emergency Project Impact E. Rationale for Bank Involvement and Role of Partners 29. The Bank’s value-added to the OECS region’s efforts to improve preparedness capacities of health systems for public health emergencies stems from the provision of a regional platform and dedicated resources for coordination and implementation of high-impact activities. The project design is expected to foster improved regional coordination efforts, harness cost efficiency gains, and reinforce ongoing regional and national health sector dialogue. Harmonization of policies and procedures for preparedness across the OECS region such as streamlined handling of laboratory specimen transport capacity and a coordination mechanism for emergency health services will help strengthen response mechanisms to public health emergencies. The project design also builds on the commitments reflected in the Caribbean Region Global Health Security Agenda Five Year Roadmap (2017-2021). 30. The Bank’s value-added lies in its ability to support governments in facilitating dialogue required to align stakeholders around a set of priority actions. The project will support efforts to strengthen capacity of the health workforce in the OECS region to better manage disease outbreaks and develop harmonized policy regulation to facilitate smoother coordination and timely action. As a global convener, the Bank will contribute to strengthening existing knowledge-sharing and coordination platforms across the region for continued capacity building to effectively respond to public health emergencies. The proposed project also leverages the Bank’s substantial experience in responding to the Ebola outbreak and its aftermath in West Africa, where the Bank is using its expertise to support countries in their efforts to strengthen preparedness and response to public health threats in those countries. The proposed project design also builds on lessons from the Bank’s experience with regional approaches to strengthening health systems: ranging from the Ebola outbreaks in West Africa, 13 The World Bank OECS Regional Health Project (P168539) strengthening public health laboratory networks across East Africa, and improving the capacity to manage the burden of tuberculosis in southern Africa. 31. In the case of public health emergencies, the rationale for public sector investment is based on the externalities associated with pandemic preparedness, and the overwhelming economic burden that extreme weather events and infectious diseases, individually and collectively, place on the OECS region, which in turn, constrains economic development. Furthermore, the global public good nature of key investments is clear, such as a robust disease surveillance system, as it is both non-rival and non-exclusive. Within the context of pandemics, a 2016 IEG assessment of WB support to pandemic preparedness outlines that priority should be placed on the control and prevention of cross border spread of communicable disease and sharing of resources to enhance efficiency such as pooled procurement of key commodities and health workforce development which could result in financial savings due to economies of scale. In addition, costly high-level resources such as reference laboratories are expected to efficiently serve the needs of more than one country. Delays between the onset of the epidemic and the implementation of control measures are costly. This is particularly significant in the Caribbean given the high volume of travel within the region and the ease by which disease-carrying vectors cross borders. Too often, detection, diagnosis, and control of disease outbreaks are attempted only with delay and when contagion grows exponentially, the cost of controlling the epidemic outbreaks rise in tandem. 32. Finally, the Bank has a long history of health sector engagement in the Caribbean region. Starting in 2001, the Bank supported the Caribbean Multi-Country HIV/AIDS Action Program and more recently the Barbados Second HIV/AIDS Project, which closed in 2015. Through the Caribbean Program, the Bank provided a total financing of US$157 million through twelve projects to support the Caribbean region in addressing HIV/AIDS and health system strengthening. In 2014, with the threat of Ebola, CARICOM requested the Bank’s assistance in assessing the region’s preparedness to address the threat of Ebola and other public health emergencies with simulation and training activities supported through technical assistance funding benefiting the region. F. Lessons Learned and Reflected in the Project Design 33. The project design incorporates lessons learned from previous and ongoing WB and donor-financed projects supporting preparedness of health systems for public health emergencies, WB experience in disaster vulnerability reduction in the Caribbean as well as IEG reviews of regional projects.31 Some of these lessons include:  The interconnectedness32 and capacity constraints of small island states, especially those in the OECS region, necessitates a regional approach to addressing public health emergencies. While specific activities vary by country depending on need and priority, harmonization of country and regional level activities to ensure complementarity is a key focus of the project design.  External financing for financing preparedness activities should prioritize capital investments and 31 World Bank Group Support to Health Services: Achievements and Challenges (2018); Crisis Response and Resilience to Systemic Shocks: Lessons from IEG Evaluations (2017); World Bank Group Engagement in Small States (2016); The Development Potential of Regional Programs: An Evaluation of World Bank Support of Multi-country Operations (2007). 32 This high degree of interconnectedness brings benefits but also presents challenges in the context of public health emergencies. On the one hand, this could result in the rapid spread of diseases, as seen with selected vector-borne diseases. At the same time, following a natural disaster, neighboring countries often step in to help the affected country. 14 The World Bank OECS Regional Health Project (P168539) regional spending on shared resources.33 The project design reflects recommendations from the 2017 International Working Group on Financing Pandemic Preparedness by ensuring that investments in infrastructure and equipment are complemented by health systems strengthening and technical capacity building support.  A participatory project preparation process helps ensure ownership and commitment. As cross-border regional collaborations are essential in the context of public health emergencies, project-participating entities were collectively convened multiple times to ensure buy-in and commitment. In addition, the project has benefited from high-level support from senior leadership of Ministries of Finance, Ministers of Health and senior MOH management in moving the design forward and bringing together key actors at regional and national levels.  Simplify implementation arrangements and carefully assign project implementation roles based on comparative advantages. The proposed arrangements were informed by IEG’s recommendations on regional projects, specifically with respect to simplifying when possible within the context of a regional project and minimizing multiple layers of accountability. Furthermore, IEG notes that best practice is to rely on national institutions for execution and implementation of program interventions at the country level, and on regional institutions for supportive services that cannot be performed efficiently by national agencies, such as coordination, data collection, and specialized technical assistance.  Use of a standardized monitoring framework to monitor outcome indicators. An overreliance on a complex monitoring and evaluation framework can lead to delays in tracking project results. Thus, this project will rely on standardized indicators measuring public health system capacities with existing collection and assessment tools, and routine reporting practices, such as the JEE. This approach not only avoids placing additional burden on project-participating countries, but also facilitates tracking of national performance indicators that can easily be aggregated at a regional level. III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 34. The project will be implemented primarily through the MOH Planning Units based in each respective country, with the exception of Saint Vincent and the Grenadines where it will be implemented by the PSIPMU on behalf of and in close collaboration with the MOH. National-level implementation arrangements will seek to build on existing project implementation experience and capacities both within the MOH and centralized fiduciary functions housed within Ministries of Finance. Regional level implemented activities will be housed within existing project execution and technical units of CARPHA and the OECS respectively. Project Coordination and Management functions across each implementing entity will be accountable for: (i) development of annual workplans; (ii) monitoring and reporting on the Results Framework; (iii) coordination of project activities; (iv) coordination and close follow-up on project fiduciary matters. Table 2 summarizes the proposed implementation arrangements by country and each regional body, with details outlined in the following paragraphs. 33 International Working Group: From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level. 2017. 15 The World Bank OECS Regional Health Project (P168539) 35. In Dominica, the project will be housed in the existing MOH project management unit (PMU), established in December 2016 through Cabinet decision. Since hurricane Maria in 2017, the PMU has been mandated to manage all health infrastructure projects as well as implementation of donor supported projects in the health sector, namely the PAHO Smart Health Facility Initiative, Green Climate fund “smarting” of health facilities, Americares, Electricians without Borders for solar panel installations, CDEMA, and the United Nations Development Programme. The PMU is staffed with a Coordinator, Administrative Assistant, Engineer, Architect, Project Officer and a Secretary. The project will finance a dedicated Project Officer and a Procurement Assistant. Procurement functions will be handled by the MOH PMU with supervision from the Ministry of Finance (MOF) Procurement Unit. FM functions will be handled by the MOH Accounting Unit. 36. In Grenada, project coordination and management will be housed in the MOH Planning Unit led by the Chief Health Planner and assisted by a Project Coordinator financed by the project. Project fiduciary functions will be carried out by the dedicated MOF procurement and financial management units, both of which have experience managing WB projects currently under implementation. The newly established Ministry of Implementation and Infrastructure will likely provide inputs to the procurement processes related to the civil works to be financed under the project in Grenada. 37. In Saint Lucia, the regional project will be implemented through a newly established PIU within the Ministry of Health and Wellness (MOHW), which is currently implementing the 2018 approved Health Systems Strengthening Project (P166783). This newly established MOHW PIU is recruiting a Project Manager, FM Specialist, Procurement Specialist and Monitoring and Evaluation Coordinator. The national project coordination unit (PCU) is currently providing mentorship to the MOHW to ensure capacity building and knowledge transfer. Through a memorandum of understanding (MOU) this national PCU is expected to manage the fiduciary functions until adequate capacity has been established at the MOHW PIU as assessed by the World Bank. 38. In Saint Vincent and the Grenadines, the project will be housed in the Ministry of Finance, Economic Planning, Sustainable Development and Information Technology in the Public Sector Investment Project Management Unit (PSIPMU). A Project Officer from the MOH Planning Unit will be assigned as the Project Coordinator and will relocate to the PSIPMU. The Project Coordinator will be under the guidance and supervision of the Director of Planning. A Procurement and Contract Management Specialist and a Financial Management Specialist will be recruited to support the PSIPMU. All procurement and financial functions will be undertaken by the current fiduciary staff in PSIPMU until the relevant personnel is recruited. The Project Coordinator will work alongside staff in the MOH Planning Unit to implement project activities, monitor project progress, and build long- term capacity for project and fiduciary management in the MOH. In-house expertise from an engineer to provide inputs to technical specifications and support the monitoring of works will also be necessary. The MOF confirmed that such experience was available in the Ministry in the form of engineers and quality specialists given the recent experience with renovations to health facilities under the European Development Fund. 16 The World Bank OECS Regional Health Project (P168539) Table 2. Implementation arrangements by Country and Regional Entities Countries/Functions Project Management Procurement Financial Management and Coordination Dominica Existing MOH Project Existing MOH Project Existing MOH Accounting Management Unit that Management Unit with Unit with support from will include a recruited supervision from MOF MOF Implementation dedicated Project Officer Procurement Unit and Support Team Implementation Support Team Grenada Recruited Project MOF Procurement Unit MOF Accountant General Coordinator to be housed in MOH Planning unit Saint Lucia Existing MOH PIU with Existing MOH PIU with Existing MOH PIU with dedicated Project MOF mentoring through MOF mentoring through Coordinator financed by MOU MOU HSSP (P166783) Saint Vincent and the Appointed Project Officer Recruited Procurement Recruited Financial Grenadines within the MOH Planning and Contract Management Specialist Unit assigned as Project Management Specialist to be housed in MOF Coordinator to be to be housed in MOF (PSIPMU) housed in the MOF (PSIPMU) (PSIPMU) CARPHA Existing Project Execution Existing Procurement and Existing Finance Unit Unit supported by a Supply Management recruited Project Officer Team assisted by a recruited Procurement Officer OECS Existing Health Unit Existing Procurement Existing Finance and supported by a recruited unit assisted by a Accounting Unit Project Manager and recruited Procurement Project Assistant Officer 39. Implementation of regional level activities will be carried out by CARPHA and the OECS. CARPHA will serve as the lead technical body to oversee the design, planning, and technical assistance for the implementation of select regional level activities. CARPHA would also provide technical advice to select country-level activities with a regional dimension, such as compliance with regional standards. The OECS Health Unit will implement regional level activities related to the development of regional policies and legislation (e.g. cross-border laboratory specimen transportation), and regional coordination mechanisms (e.g. coordination of emergency and critical care services; pooled procurement of laboratory equipment, service contracts, and laboratory reagents). 40. A dedicated regional coordination platform will be established for the duration of project implementation in the form of a Regional Project Advisory Committee (RPAC). The RPAC will advise on and monitor the overall strategic direction of the project and review project implementation. Convened by CARPHA, the RPAC will include two representatives from each of the project-participating countries, one representative 17 The World Bank OECS Regional Health Project (P168539) from the OECS Health unit, and at least one World Bank representative as an observer. The RPAC will provide technical advice on project activities, facilitate and coordinate knowledge transfer, resolve potential implementation bottlenecks and offer solutions to implementation challenges. For the first year of implementation, the RPAC will meet quarterly and have at least one face-to-face meeting. For the remaining project implementation period, the RPAC will meet twice a year – once in person and once virtually. 41. Fiduciary arrangements and funds flow. Project funds will flow directly from IDA to the individual countries for country-level activities. Country-level arrangements would entail having Financing Agreements signed between the national government authority and the World Bank. At the regional level, the Regional IDA grant funds for specifically identified activities would flow directly to CARPHA and the OECS respectively. 42. Legal Arrangements. Based on the proposed implementation arrangements, each participating country would enter into a Financing Agreement directly with IDA while the regional bodies would do the same through their respective Grant Agreements. B. Results Monitoring and Evaluation Arrangements 43. The proposed Results Framework includes pre-existing indicators from the PAHO Smart Health Facilities Checklist and indicators that measure progress toward the achievement of the International Health Regulations (IHR) as assessed by the Joint External Evaluation (JEE). The PAHO Smart Health Facilities Checklist has two dimensions, namely the Hospital Safety Index (HSI) and Green Checklist, with high scores required on both dimensions to be considered Smart. A facility that is found to be safe (Category A on the HSI) and green (at least 70 percent on the Green Checklist) is considered Smart.34 The JEE Tool, currently in its second edition, draws on the original IHR core capacities to monitor laboratory, surveillance and emergency management program implementation.35 The JEE measures the capacities of a “One Health” approach, namely that programs are implemented as part of integrated plans across human, animal, environmental and other sectors. This project will focus primarily on the human sector with some environmental components, so appropriate JEE capacities in human health will be assessed separately, particularly in laboratory and surveillance. Countries will conduct annual self-assessments using the JEE tool as will CARPHA and OECS jointly. CARPHA will conduct capacity building aimed at improving the JEE self-evaluations of participating countries. In addition, a formal JEE will be conducted at least once in each participating country by project closing, which will serve as a validation exercise for the self- evaluations. In 2016, CARPHA and other key stakeholders conducted a regional self-assessment based on the JEE tool, and the findings were used to develop the Caribbean Region Global Health Security Roadmap (2017-2021) which identifies actions to strengthen regional health security. More recently in 2018, a formal JEE with external evaluators was carried out in Grenada. Other participating countries will work with the WB and other development partners towards formally validating their self-assessment scores over the life of the project. While indicators will be monitored annually, in many cases depending on the specific capacity, a small improvement often has the potential for transformational impact such that the indicator could easily move from a “1” for example to a “3” in just over a one-year period. 34 A detailed description of this initiative is available at: https://www.paho.org/disasters/index.php?option=com_docman&view=download&category_slug=smart-hospitals- toolkit&alias=2141-a-model-policy-for-smart-health-facilities&Itemid=1179&lang=en. Accessed April 16, 2019. 35 For more detailed information, see https://www.who.int/ihr/publications/WHO_HSE_GCR_2018_2/en/ 18 The World Bank OECS Regional Health Project (P168539) C. Sustainability 44. The project’s sustainability will be enhanced by the choice of project activities and the regional aspect of the project. The project will support: (i) climate-smart refurbishments to prioritized health facilities (including laboratories); (ii) technical and institutional capacity; (iii) establishment of regional standards, policies and protocols with buy-in at country and regional level; (iv) training on the use of equipment and inclusion of warranties; and (v) establishment of new and reinforcement of existing citizen engagement mechanisms. Climate smart refurbishments made to health facilities are expected to improve their long-term sustainability and contribute to efficiency gains through more efficient utilization of water and energy. Going forward, it is expected that the improved energy efficiency will result in reduced power consumption, and savings obtained will be re- invested into maintenance costs. Select investments aim to address regional challenges in a sustainable manner, such as addressing the shortage of medical technologists in the region through the establishment of a national training program for medical technologists for example. Several indicators in the Results Framework rely on the JEE Tool which requires that demonstrated capacity (i.e. achieving a JEE score of 4) meet key technical criteria as well as sustainability criteria as measured by their inclusion in the national health sector plan with a secure funding source. Sustainability at the national level will be further enhanced through the regional aspect of the project. This includes encouraging national-level investments in basic FETP training through provision of regional level support for higher level training. Findings, knowledge sharing, and lessons learned will also be communicated through the RPAC as well as other technical working groups convened by CARPHA that include countries across the Caribbean region. Finally, development of harmonized efforts at the regional level, such as the use of standard protocols and procedures, as well as initiatives to encourage cross-country collaboration, such as pooled procurement for laboratory services, are also expected to contribute to the sustainability of project investments. IV. PROJECT APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 45. The project is relevant and consistent with the aim of improving preparedness capacities for public health emergencies in the OECS region. Project activities fall under two technical components, which have been harmonized at the regional level. Through close collaboration, activities will be sequenced appropriately during project implementation, including at the country and regional levels. Further, the two regional bodies have been working closely to align activities and ensure that their areas of focus are suited to their comparative advantages. Finally, there is a degree of standardization across project activities to ensure a regional scope, as reflected in the Results Framework. 46. The economic case for investing in preparedness for public health emergencies in the OECS region focuses on two types of public health emergencies, namely extreme weather events and epidemics. Communicable diseases are a major constraint on the health, education, and potential earnings of people living in the Caribbean region. Weak preparedness and response capacity to handle extreme weather events and communicable disease outbreaks is exacerbated by the imminent threat of climate change, which is expected to impact already weak regional and national systems, displace populations, and create environmental conditions more favorable for extreme weather events and disease. Hence, the economic rationale for investing in strengthening the region’s ability to mount a robust response to these crises is key to mitigating the economic burden not only on individuals, but also on the countries and the region as a whole. 19 The World Bank OECS Regional Health Project (P168539) 47. While the size of damages to health facilities have been limited as a share of total damages following extreme weather events, the importance of health facilities providing services in the aftermath of these events cannot be underestimated.36 The Smart Health Facilities Toolkit provides guidance for cost-benefit analysis, allowing policymakers to determine whether or not to invest in the Smarting of health facilities, and to compare different projects.37 Under the Smart Health Facilities Initiative, all healthcare facilities in the four participating countries were assessed for disaster safety and water and energy consumption. Based on these assessments, health facilities were identified for improvement, and the scope of works to be conducted were detailed and costed. Prioritization was determined based on catchment population, current safety level, number of facilities in the area, services offered, and HSI and Green Scores, with each of these aspects weighted according to importance. Consideration was also given to the cost of retrofitting. Investments in several facilities have already been made under initial phases of the Smart Health Facilities initiative. An in-depth cost benefit analysis of the Georgetown Hospital in Saint Vincent and the Grenadines, completed under Phase I of retrofitting works, illustrates the possible economic impact of Smarting a health facility.38 Two scenarios were compared, a ‘do nothing’ scenario and retrofitting of the facility. Under the retrofitting scenario, the cost of improvements and sustainability over time were weighed against possible savings from areas such as efficient utilization of water (10 percent more efficient), efficient consumption of energy (10 percent) and rainwater harvesting (approximately 200,000 gallons per year). Initial results suggest that the savings were much greater than initially expected. Following the Smarting of Georgetown Hospital, a 58 percent reduction in electrical consumption was observed, and the return on investment of the photovoltaic system is expected to be about 4-6 years. In addition, there was an increase in the patient load by 34 percent following refurbishment. Thus, the Smarting of Health Facilities can result in substantial benefits. 48. At the global level, the return on country system investments and operations to reduce pandemic risk are more than tenfold. On a per annum basis, the estimated return at the global level ranges from 50 to 123 percent per annum. The recent International Working Group report on financing pandemic preparedness (From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level) estimates the expected annual loss due to an influenza pandemic at 1.13 percent of GNI in Grenada, Saint Lucia, and Saint Vincent and the Grenadines.39 This does not capture the impact of pathogens such as Severe Acute Respiratory Syndrome (SARS) and Ebola (which have been linked to larger losses), the effect of smaller scale outbreaks, or of emerging diseases that become endemic. Meanwhile, the short-term economic impact of the Zika epidemic in Latin America and the Caribbean has been estimated at 0.06 percent of regional GDP (World Bank 2016), but these estimates were predicated on a swift international response, and do not include the cost of caring for individuals with microcephaly and Guillain-Barre Syndrome, which have both been confirmed to be linked to Zika. While country-specific estimates are not available, the cost of caring for an individual with microcephaly in the United 36 For example, following Hurricane Maria in Dominica, the damage and losses in the health sector was less than 2 percent of total damages and losses. Post-Disaster Needs Assessment. Hurricane Maria, September 18, 2017. A Report by the Government of the Commonwealth of Dominica. 37 An overview of the Cost-Benefit Analysis Methodology is available at: https://www.paho.org/disasters/index.php?option=com_docman&view=download&category_slug=smart-hospitals- toolkit&alias=2178-smart-hospitals-toolkit-cost-benefit-analysis-cba&Itemid=1179&lang=en. Accessed April 2, 2019. 38 This is described in the PAHO Cost-Benefit Analysis Methodology. The savings associated are presented here: https://www.apha.org/- /media/files/pdf/membergroups/phn/paho_webinar_slides.ashx?la=en&hash=B637962F0BEACAFC475181C072D9CE98CA8 66531. Accessed April 2, 2019. 39 Figures for Dominica were not available. 20 The World Bank OECS Regional Health Project (P168539) States is estimated to be as high as US$10 million over their lifetime. The economic impact of an outbreak may thus vary in the short- and long-term, with some outbreaks associated with high short-term costs (such as Ebola) and others associated with high long-term costs (such as Zika). Strengthening of public health preparedness efforts are thus likely to yield returns over the short- and long-term as a result of improvements in health security. 49. Table 3 shows the comparison of the marginal cost per capita in investing in public health emergency preparedness relative to the expected annual pandemic loss per capita. Investments made under this project are low compared to the potential benefit, and low considering the potential loss to GNI in the event of a pandemic, which could lead to productivity loss, loss from travel/transport bans, loss from consumer confidence and spending, and the cost of response and recovery. Table 3. Total and per capita project cost Item Figure Total project cost (millions) 30.6 Estimated annual project cost (millions) 5.4 Population covered40 1,469,451 Annual per capita cost $4.12 Minimum expected annual pandemic loss per capita41 $76.00 B. Fiduciary 50. Fiduciary risk is assessed as Substantial due to the nature of the project and involvement of six implementing entities for successful execution of the project. 51. Financial Management. An FM assessment of the project was conducted in accordance with OP/BP 10.00 and Financial Management Manual for World Bank IPF Operations (OPCS5.05-DIR.01 issued February 10, 2017). The assessment concluded that the respective implementing entities responsible for implementation of the FM arrangements in various countries have adequate FM arrangements that should be able to provide, with reasonable assurance, accurate and timely information on the status of the funds as required by the World Bank. 52. The World Bank has agreed to receive separate sets of interim financial reports (IFRs) and annual audit reports from the participating implementing entities. Each implementing entity will submit (a) quarterly IFR to the WB within 45 days after the close of each quarter; and (b) annual audit report within six months of the close of the financial year. All internal controls are detailed in the FM section of the project operational manual (POM), which has been formally adopted by all implementing entities. The POM describes the FM procedures for the project as well as agreed roles and responsibilities of various agencies involved in project implementation. FM risks and compliance will be monitored during the World Bank’s six-monthly implementation support missions as well as through annual external audits. FM aspects of the project will be executed by the designated implementing 40 As the project is expected to benefit the OECS region, the total population of member countries is included here. CARPHA member states include countries outside the OECS, which may also indirectly benefit from the project. 41 Expected loss is the average annual economic loss arising from pandemics over an extended period. Figures are presented for Saint Vincent and the Grenadines; estimates for Grenada and Saint Lucia were higher and estimates for Dominica were not available. Data obtained from the International Working Group: From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level. 2017. 21 The World Bank OECS Regional Health Project (P168539) entities as detailed in Annex 1. 53. Procurement. Procurement responsibilities will rest with the Ministries of Health in Dominica, Saint Lucia, and SVG, the MOF Central Procurement Unit (CPU) for Grenada, at CARPHA, the Procurement and Supply Management team, and the Procurement Unit in the OECS Commission. Given the limited exposure to World Bank Procurement across implementing entities, some project-participating countries will rely on transitory arrangements until the procurement capacities are assessed as satisfactory by the World Bank, specifically with respect to Saint Lucia and SVG. The OECS is already implementing a WB-financed project and the actual capacities are assessed as adequate for the project. CARPHA has extensive experience in procurement under different Multilateral Development Banks (MDB) or International Donors, but not with the World Bank. 54. Procurement will be carried out in accordance with the World Bank’s “Procurement Regulations for Investment Project Financing (IPF) Borrowers” (Procurement Regulations) dated July 2016 and revised in November 2017 and August 2018, with due consideration to “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants,” dated July 1, 2016, and other provisions stipulated in the Financing Agreements. In accordance with paragraph 5.9 of the Procurement Regulations, the WB’s Systematic Tracking and Exchanges in Procurement (STEP) system will be used to prepare, clear, and update Procurement Plans and monitor all procurement transactions for the Project. 55. A simplified Project Procurement Strategy for Development (PPSD) has been developed and defines the applicable procurement arrangements, appropriate selection methods, including market approach, and type of review to be conducted by the WB. The PPSD describes how procurement in this operation will support the PDO and deliver value for money using a risk-based approach. The PPSD provides adequate supporting market analysis for the selection methods detailed in each implementing entities’ Procurement Plan. Mandatory Procurement Prior Review Thresholds detailed in Annex I of the WB’s Procurement Procedures are applied. All procurement procedures, including roles and responsibilities of different participating entities and units are defined in the POM which has been formally adopted by all implementing entities. 56. Most project activities will be carried out through national or international competition. The World Bank’s Standard Procurement Documents shall be used for all contracts subject to international competitive procurement. For contracts subject to national competitive procurement, the Borrowers should use Procurement Documents agreed with and found acceptable by the Bank. Procurement of goods, services and consulting services will include rehabilitation works for health facilities, laboratory equipment, IT modules for Health Management system and so on. The consultancy category will include capacity building activities for health management units, among other technical assistance. The procurement methods, thresholds and prior review thresholds will be detailed in the PPSD. A more detailed assessment of the procurement capacity is provided in Annex 1. C. Safeguards 57. The project is classified as category B and triggers the WB policy on Environment Assessment (OP/BP 4.01). No social safeguards have been triggered for this project. The safeguards risks stem primarily from risks related to activities during civil works, waste from civil works and rehabilitation, and the management of waste from laboratories and health care facilities. 22 The World Bank OECS Regional Health Project (P168539) (i) Environmental Safeguards 58. This project only triggers O.P/BP 4.01 in terms of safeguards for national level activities. For regional level activities, currently there are no safeguards implications. Component 1 focuses on improving preparedness of health facilities and improved laboratories in the four OECS countries to ensure they are able to provide services in any public health emergency or extreme weather event. Supported activities include upgrading of health facilities, focusing on the refurbishment of existing health facilities, and of laboratories. In the case of SVG, a new public health laboratory will be constructed. Works could range from low risk activities (painting, grouting, tiling) to low-medium risk activities (roofing, internal wall construction, electrical works, etc.). The risks related to these activities are generally small, highly localized and easily mitigated. Negative environmental impacts are likely to include noise, dust, waste management issues (solid largely, and some liquid) and operational Health and Safety concerns. To address construction risks, each country has prepared an Environmental and Social Management Framework (ESMF) to cover risks related to construction that cover renovation risks in health facilities and laboratories. ESMFs prepared for each of the four countries in this project have been consulted on and disclosed as follows: Dominica (May 13, 2019), Saint Lucia (June 3, 2019), SVG (June 6, 2019) and Grenada (June 13, 2019). 59. Component 2 will (a) establish an isolation facility for response and containment in the event of a health crisis and (b) strengthen the health facilities' internal mechanisms for managing biohazardous waste materials. The project will not finance any improvements outside health facility buildings that are related to the processing of that waste (i.e. incineration facilities, or landfills etc.). The project would promote the use of autoclaves/grinders where appropriate. This aspect of the project will focus on aspects that improve the safe handling and in-house disposal of biomedical hazardous waste (sharps, etc). The isolation facility will not be new but reconstructed from an already existing wing/section of the health facility. If the project determines that it is better to build a new isolation facility outside of an existing health facility, an Environmental and Social Management Plan (ESMP) will be prepared prior to construction. Likewise, the project will prepare a biohazardous medical waste plan to ensure that the waste is properly handled from source to destination when necessary and applicable. This plan will need to be prepared, approved, consulted and disclosed prior to implementation. Policies and practices on the management of biohazardous waste will also be addressed at the national level in some countries, and not limited to a specific health facility. (ii) Social Safeguards 60. With respect to the facilities to be renovated, there is no intention to acquire additional land from what the Government already owns. It is not expected that the footprint of existing facilities will increase. The displacement of people from their land or livelihood in the process of renovation or civil works is not envisioned. As such, the policy on Involuntary Resettlement (OP/BP 4.12) is not triggered. 61. Physical Cultural Resources (OP/BP 4.11) has not been triggered as the works are in existing facilities and do not include or impact important physical cultural resources. The scope of work requires precautions related to unanticipated cultural heritage discoveries, as such the project will establish chance find procedures with construction contractors during all civil works activities and this will be managed by the respective PIUs. 62. The safeguard pertaining to Indigenous Peoples (OP/BP 4.10) has not been triggered because the project area is limited to established health facilities and laboratories. 23 The World Bank OECS Regional Health Project (P168539) (iii) Grievance Redress Mechanisms 63. A grievance redress mechanism (GRM) is built into the project by adapting existing feedback mechanisms as needed and as described in each country’s ESMF. The GRM process and mechanism is described in the country- specific ESMFs and will be in place prior to project implementation. 64. Communities and individuals who believe that they are adversely affected by a WB supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org. V. KEY RISKS 65. The overall risk rating for the project is rated Substantial. According to the Systematic Operations Risk- rating Tool, the project has three substantial risks. 66. Technical Design of Project. The technical design of the project faces substantial risk considering the complexities of coordinating national and regional level activities to ensure they align and build on each other. Further, the project has two technical components, each with several interventions at country and regional levels. Strategic prioritization and harmonization of interventions among the various participants is the core challenge. To mitigate this risk, (i) the team engaged in substantial engagement with participating countries and regional bodies to ensure a level of standardization of activities across countries during project preparation; and (ii) a Regional Project Advisory Committee will conduct one face-to-face meeting and at least one virtual meeting (convened by CARPHA with the WB participating as an observer) each year during project implementation. 67. Institutional Capacity of Implementation and Sustainability. As a result of generally weak institutional capacity at the country level for implementation and sustainability of the project, this risk is rated Substantial. Within two participating countries (Grenada and Saint Lucia), proposed implementation arrangements will rely on new structures housed in the MOH. Cross ministry collaboration with respect to fiduciary management and/or supervision and mentoring is taking place in some form across all countries. To mitigate the risks associated with setup of new institutional arrangements, temporary mentoring and support from national PIUs (housed in the MOF) will be provided together with close supervision from the WB team. In the case of Grenada, a steering committee will be set up to facilitate inter-ministerial coordination. Meanwhile, at the regional level, both CARPHA and the OECS have been assessed as having sufficient fiduciary capacity to manage regional activities, and each have extensive experience managing donor financed programs. Further, these regional entities have demonstrated cross-border collaboration in the context of public health preparedness activities (e.g. CARPHA) and regional initiatives (e.g. OECS). The OECS has experience implementing both WB-supported projects as well 24 The World Bank OECS Regional Health Project (P168539) as other donor financed initiatives. Likewise, CARPHA has extensive experience implementing grant financing from development partners such as the European Union, Global Fund and the United States CDC, although no direct experience implementing a WB-financed project. 68. Fiduciary Risks. Fiduciary risk is assessed as substantial given limited recent institutional fiduciary experience of the respective MOHs in Bank-funded projects, the need to set up new structures, and limited capacity within existing central implementation units. To mitigate risks associated with financial management and procurement, temporary mentoring and support from the national PIU, formalized through an MOU, will be provided in Saint Lucia until fiduciary capacity is assessed to be satisfactory by the WB. Customized training will be provided to all participating countries and the two regional entities where existing units will be used for . fiduciary aspects of project implementation. 25 The World Bank OECS Regional Health Project (P168539) VI. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Caribbean OECS Regional Health Project Project Development Objectives(s) The objective of the Project is to improve preparedness capacities of health systems for public health emergencies in the OECS region. Project Development Objective Indicators RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target Public health emergency preparedness Number of countries with health system capacity to withstand extreme weather events based on A-70 rating on Smart Health 0.00 4.00 Facility standards (Number) Dominica: Health system capacity to withstand extreme weather events based on SMART Health Facility standards 0.00 3.00 (Number) Grenada: Health system capacity to withstand extreme weather events based on SMART Health Facility standards 0.00 5.00 (Number) Saint Lucia: Health system capacity to withstand extreme weather events based on SMART Health Facility standards 0.00 14.00 (Number) Saint Vincent and the Grenadines: Health system capacity to withstand extreme weather events based on SMART Health 0.00 3.00 Facility standards (Number) 26 The World Bank OECS Regional Health Project (P168539) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target Public health emergency preparedness Number of countries/regional entities with laboratory testing capacity for detection of priority diseases based on 1.00 5.00 achievement/sustainment of a JEE score of 4.0 or higher (Number) Dominica: Laboratory testing capacity for detection of priority 2.00 4.00 diseases based on JEE score (Number) Grenada: Laboratory testing capacity for detection of priority 3.00 4.00 diseases based on JEE score (Number) Saint Lucia: Laboratory testing capacity for detection of 3.00 4.00 priority diseases based on JEE score (Number) Saint Vincent and the Grenadines: Laboratory testing capacity 3.00 4.00 for detection of priority diseases based on JEE score (Number) CARPHA: Laboratory testing capacity for detection of priority 4.00 4.00 diseases based on JEE score (Number) Public health emergency preparedness Number of countries/regional entities with indicator and event- based surveillance established based on 1.00 5.00 achievement/sustainment of JEE score of 4.0 or higher (Number) Dominica: Indicator and event-based surveillance established 3.00 4.00 based on JEE score (Number) Grenada: Indicator and event-based surveillance established 2.00 4.00 based on JEE score (Number) Saint Lucia: Indicator and event-based surveillance 3.00 4.00 established based on JEE score (Number) Saint Vincent and the Grenadines: Indicator and event-based 3.00 4.00 27 The World Bank OECS Regional Health Project (P168539) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target surveillance established based on JEE score (Number) CARPHA: Indicator and event-based surveillance established 4.00 4.00 based on JEE score (Number) Public health emergency preparedness Number of countries with emergency operations centre (EOC) capacities, procedures, and plans in place based on 0.00 4.00 achievement/sustainment of JEE score of 4.0 or higher (Number) Dominica: Emergency operations center (EOC) capacities, 1.00 4.00 procedures, and plans in place based on JEE score (Number) Grenada: Emergency operations center (EOC) capacities, 1.00 4.00 procedures, and plans in place based on JEE score (Number) Saint Lucia: Emergency operations center (EOC) capacities, 3.00 4.00 procedures, and plans in place based on JEE score (Number) Saint Vincent and the Grenadines: Emergency operations center (EOC) capacities, procedures, and plans in place based 1.00 4.00 on JEE score (Number) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Component 1: Improved Health Facilities and Laboratory Capacity Number of countries with 100% of proposed facility upgrades completed to withstand extreme weather events based on Smart 0.00 100.00 Health Facility standards (Percentage) 28 The World Bank OECS Regional Health Project (P168539) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Dominica: Completed proposed facility upgrades to withstand extreme weather events based on Smart Health Facility 0.00 100.00 standards (Percentage) Grenada: Completed proposed facility upgrades to withstand extreme weather events based on Smart Health Facility 0.00 100.00 standards (Percentage) Saint Lucia: Completed proposed facility upgrades to withstand extreme weather events based on Smart Health 0.00 100.00 Facility standards (Percentage) Saint Vincent and the Grenadines: Completed proposed facility upgrades to withstand extreme weather events based 0.00 100.00 on Smart Health Facility standards (Percentage) Number of countries/regional entities that complete 100 percent of proposed laboratory upgrades (Percentage) 0.00 5.00 Dominica: Completed proposed laboratory upgrades (Percentage) 0.00 100.00 Grenada: Completed proposed laboratory upgrades (Percentage) 0.00 100.00 Saint Lucia: Completed proposed laboratory upgrades (Percentage) 0.00 100.00 Saint Vincent and the Grenadines: Completed proposed 0.00 100.00 laboratory upgrades (Percentage) CARPHA: Completed proposed laboratory upgrades (Percentage) 0.00 100.00 Number of countries/regional entitites with specimen referral and transportation systems based on achievement/sustainment 0.00 5.00 of JEE score of 4.0 or higher (Number) Dominica: Specimen referral and transportation systems based on JEE score (Number) 2.00 4.00 Grenada: Specimen referral and transportation systems based on JEE score (Number) 3.00 4.00 29 The World Bank OECS Regional Health Project (P168539) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Saint Lucia: Specimen referral and transportation systems based on JEE score (Number) 1.00 4.00 Saint Vincent and the Grenadines: Specimen referral and transportation systems based on JEE score (Number) 3.00 4.00 CARPHA/OECS: Specimen referral and transportation systems based on JEE score (Number) 3.00 4.00 Number of countries/regional entitites with quality laboratory systems based on achievement/sustainment of JEE score of 4.0 1.00 5.00 or higher (Number) Dominica: Quality laboratory systems based on JEE score (Number) 2.00 4.00 Grenada: Quality laboratory systems based on JEE score (Number) 2.00 4.00 Saint Lucia: Quality laboratory systems based on JEE score (Number) 3.00 4.00 Saint Vincent and the Grenadines: Quality laboratory systems based on JEE score (Number) 3.00 4.00 CARPHA: Quality laboratory systems based on JEE score (Number) 4.00 4.00 CARPHA/OECS: System in place for activating and coordinating medical countermeasures during a public health emergency 3.00 4.00 (Number) Component 2: Strengthening Public Health Surveillance and Emergency Management Number of countries/regional entities that use electronic tools for surveillance based on achievement/sustainment of JEE score 1.00 5.00 of 4.0 or higher (Number) Dominica: Use of electronic tools for surveillance based on JEE 3.00 4.00 score (Number) Grenada: Use of electronic tools for surveillance based on JEE score (Number) 2.00 4.00 30 The World Bank OECS Regional Health Project (P168539) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Saint Lucia: Use of electronic tools for surveillance based on JEE score (Number) 3.00 4.00 Saint Vincent and the Grenadines: Use of electronic tools for surveillance based on JEE score (Number) 3.00 4.00 CARPHA: Use of electronic tools for surveillance based on JEE score (Number) 4.00 4.00 Number of countries/regional entitites receiving FETP or other applied epidemiology training based on 1.00 5.00 achievement/sustainment of JEE score of 4.0 or higher (Number) Dominica: Basic/frontline FETP training or other applied epidemiology training received based on JEE score (Number) 2.00 4.00 Grenada: Basic/frontline FETP training or other applied epidemiology training received based on JEE score (Number) 4.00 4.00 Saint Lucia: Basic/frontline FETP training or other applied epidemiology training received based on JEE score (Number) 3.00 4.00 Saint Vincent and the Grenadines: Basic/frontline FETP training or other applied epidemiology training received 2.00 4.00 based on JEE score (Number) CARPHA: Regional (intermediate/advanced) FETP training or other applied epidemiology training provided based on JEE 2.00 4.00 score (Number) Number of countries/regional entities with multi-sectoral, multi- hazard emergency preparedness measures, incl emergency response plans based on achievement/sustainment of JEE score 0.00 5.00 of 4.0 or higher (Number) Dominica: Multi-sectoral, multi-hazard emergency preparedness measures, incl emergency response plans, 1.00 4.00 based on JEE score (Number) Grenada: Multi-sectoral, multi-hazard emergency preparedness measures, incl emergency response plans, 2.00 4.00 based on JEE score (Number) 31 The World Bank OECS Regional Health Project (P168539) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Saint Lucia: Multi-sectoral, multi-hazard emergency preparedness measures, incl emergency response plans, 1.00 4.00 based on JEE score (Number) Saint Vincent and the Grenadines: Multi-sectoral, multi- hazard emergency preparedness measures, incl emergency 1.00 4.00 response plans, based on JEE score (Number) CARPHA/OECS: Multi-sectoral, multi-hazard emergency preparedness measures, incl emergency response plans, 2.00 4.00 based on JEE score (Number) Citizen Engagement Number of public health emergency plans that document incorporation of feedback from key populations (Number) 0.00 4.00 Gender CARPHA: Protocols developed for gender-specific surveillance of priority infectious diseases (Yes/No) No Yes OECS: Number of countries with training in the Minimum Initial Service Package for sexual and reproductive health in 1.00 4.00 emergencies and disasters (Number) IO Table SPACE UL Table SPACE Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of countries with health system This indicator reflects a Hospital External and internal Ministry of Health capacity to withstand extreme weather combined value of the Annual Safety Index experts using Planning Units events based on A-70 rating on Smart Hospital Safety Index (HSI) (HSI) and standardized tools Health Facility standards and Green Score based on Green Score developed and in use 32 The World Bank OECS Regional Health Project (P168539) the Smart Hospital/Health Checklist by the PAHO Smart Facilities Index developed by Health Facilities PAHO. HSI category A Initiative reflects a facility that is able to continue functioning following a disaster. A Green Score of 70 reflects achievement of 70 percent on the Green checklist. This reflects the total number of countries that have Smart Health Facilities supported by the OECS Regional Health Project. External and internal Indicator based on Smart experts using Dominica: Health system capacity to Hospital/Health Facilities HSI and standardized tools Ministry of Health withstand extreme weather events Index. This reflects the Annual Green Score developed and in use Planning Unit based on SMART Health Facility number of health facilities Checklist by the PAHO Smart standards Smarted under the OECS Health Facilities Regional Health Project. Initiative External and internal Indicator based on Smart experts using Grenada: Health system capacity to Hospital/Health Facilities HSI and standardized tools Ministry of Health withstand extreme weather events Index. This reflects the Annual Green Score developed and in use Planning Unit based on SMART Health Facility number of health facilities Checklist by the PAHO Smart standards Smarted under the OECS Health Facilities Regional Health Project. Initiative 33 The World Bank OECS Regional Health Project (P168539) External and internal Indicator based on Smart experts using Saint Lucia: Health system capacity to Hospital/Health Facilities HSI and standardized tools Ministry of Health withstand extreme weather events Index. This reflects the Annual Green Score developed and in use Planning Unit based on SMART Health Facility number of health facilities Checklist by the PAHO Smart standards Smarted under the OECS Health Facilities Regional Health Project. Initiative External and internal Indicator based on Smart experts using Saint Vincent and the Grenadines: Hospital/Health Facilities HSI and standardized tools Ministry of Health Health system capacity to withstand Index. This reflects the Annual Green Score developed and in use Planning Unit extreme weather events based on number of health facilities Checklist by the PAHO Smart SMART Health Facility standards Smarted under the OECS Health Facilities Regional Health Project. Initiative JEE Question D.1.1. Capacity graded on a scale of 1-5 where: 1 = no capacity (laboratory surveillance system is not capable of conducting any Number of countries/regional entities core tests) Ministry of Health with laboratory testing capacity for JEE and self- External and internal 2 = limited capacity Annual Planning Units and the detection of priority diseases based on assessments experts using JEE tool (laboratory system is PIU in CARPHA achievement/sustainment of a JEE score capable of conducting 1-2 of 4.0 or higher out of 10 core tests) 3 = developed capacity (laboratory system is capable of conducting 3-4 of 10 core tests) 4 = demonstrated capacity 34 The World Bank OECS Regional Health Project (P168539) (laboratory system is capable of conducting 5 or more of 10 core tests) 5 = sustainable capacity (laboratory system is capable of conducting 5 or more of 10 core tests and quality assurance systems are in place and tested) Dominica: Laboratory testing capacity Capacity graded as JEE and self- External and internal Ministry of Health Annual for detection of priority diseases described in JEE Question assessments experts using JEE tool Planning Unit based on JEE score D.1.1. Grenada: Laboratory testing capacity Capacity graded as JEE and self- External and internal Ministry of Health Annual for detection of priority diseases described in JEE Question assessments experts using JEE tool Planning Unit based on JEE score D.1.1. Capacity graded as Saint Lucia: Laboratory testing JEE and self- External and internal Ministry of Health described in JEE Question Annual capacity for detection of priority assessments experts using JEE tool Planning Unit D.1.1. diseases based on JEE score Saint Vincent and the Grenadines: Capacity graded as JEE and self- External and internal Ministry of Health Laboratory testing capacity for Annual described in JEE Question assessments experts using JEE tool Planning Unit detection of priority diseases based D.1.1. on JEE score Capacity graded as described in JEE Question D.1.1. It is important to note CARPHA: Laboratory testing capacity that while the baseline and JEE and self- External and internal Annual PIU in CARPHA for detection of priority diseases targets are the same, IHR assessments experts using JEE tool based on JEE score capacities also refer to maintaining all essential public health functions needed to apply and comply 35 The World Bank OECS Regional Health Project (P168539) with the IHR. In other words, efforts need to continuously be made to maintain higher scores achieved. JEE Question D.2.1. Capacity graded on a scale of 1-5 where: 1 = no capacity (no indicator or event-based surveillance system exists) 2 = limited capacity (indicator or event-based surveillance system established in next year) Number of countries/regional entities 3 = developed capacity Ministry of Health with indicator and event-based (indicator or event-based JEE and self- External and internal Annual Planning Units and surveillance established based on surveillance system in place) assessments experts using JEE tool PIU in CARPHA achievement/sustainment of JEE score of 4 = demonstrated capacity 4.0 or higher (indicator and event-based surveillance system in place) 5 = sustainable capacity (indicator and event-based surveillance system in place and regularly evaluated and updated, and country/regional entity contributes to regional/international surveillance networks) 36 The World Bank OECS Regional Health Project (P168539) Dominica: Indicator and event-based Capacity graded as JEE and self- External and internal Ministry of Health Annual surveillance established based on JEE described in JEE Question assessments experts using JEE tool Planning Unit score D.2.1. Grenada: Indicator and event-based Capacity graded as JEE and self- External and internal Ministry of Health Annual surveillance established based on JEE described in JEE Question assessments experts using JEE tool Planning Unit score D.2.1. Saint Lucia: Indicator and event-based Capacity graded as JEE and self- External and internal Ministry of Health Annual surveillance established based on JEE described in JEE Question assessments experts using JEE tool Planning Unit score D.2.1. Saint Vincent and the Grenadines: Capacity graded as JEE and self- External and internal Ministry of Health Indicator and event-based Annual described in JEE Question assessments experts using JEE tool Planning Unit surveillance established based on JEE D.2.1. score Capacity graded as described in JEE Question D.2.1. It is important to note that while the baseline and targets are the same, IHR capacities also refer to CARPHA: Indicator and event-based JEE and self- External and internal maintaining all essential Annual PIU in CARPHA surveillance established based on JEE assessments experts using JEE tool public health functions score needed to apply and comply with the IHR. In other words, efforts need to continuously be made to maintain higher scores achieved. Number of countries with emergency JEE Question R.2.2. Capacity Ministry of Health operations centre (EOC) capacities, graded on a scale of 1-5 JEE and self- External and internal Annual Planning Units and the procedures, and plans in place based on where: assessments experts using JEE tool PIU in CARPHA achievement/sustainment of JEE score of 1 = no capacity (no EOC 4.0 or higher structure or 37 The World Bank OECS Regional Health Project (P168539) plans/procedures in place) 2 = limited capacity (EOC structure in place and responds to emergencies on ad hoc basis) 3 = developed capacity (EOC structures, plans, resources and trained staff in place. Not yet capable of responding to an alert within 120 minutes) 4 = demonstrated capacity (National EOC system in place and able to respond to emergency within 120 minutes, functions have been tested and updated in past 2 years. Structures and plans available at sub- national level.) 5 = sustainable capacity (All national and sub-national systems tested and updated regularly. EOC operations can be sustained for large- scale or concurrent emergencies.) Dominica: Emergency operations Capacity graded as JEE and self- External and internal Ministry of Health Annual center (EOC) capacities, procedures, described in JEE Question assessments experts using JEE tool Planning Unit and plans in place based on JEE score R.2.2. 38 The World Bank OECS Regional Health Project (P168539) Capacity graded as Grenada: Emergency operations JEE and self- External and internal Ministry of Health described in JEE Question Annual center (EOC) capacities, procedures, assessments experts using JEE tool Planning Unit R.2.2. and plans in place based on JEE score Saint Lucia: Emergency operations Capacity graded as JEE and self- External and internal Ministry of Health Annual center (EOC) capacities, procedures, described in JEE Question assessments experts using JEE tool Planning Unit and plans in place based on JEE score R.2.2. Saint Vincent and the Grenadines: Capacity graded as JEE and self- External and internal Ministry of Health Emergency operations center (EOC) Annual described in JEE Question assessments experts using JEE tool Planning Unit capacities, procedures, and plans in R.2.2. place based on JEE score ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Ministry of Number of countries with 100% of Percentage of facilities Health Ministry of Health proposed facility upgrades completed to Annual Progress report completed according to Planning Planning Units withstand extreme weather events based program plans Units on Smart Health Facility standards Dominica: Completed proposed Ministry of Percentage of facilities Ministry of Health facility upgrades to withstand Annual Health Progress report completed according to Planning Unit extreme weather events based on Planning Unit program plans Smart Health Facility standards Grenada: Completed proposed facility Ministry of Percentage of facilities Ministry of Health upgrades to withstand extreme Annual Health Progress report completed according to Planning Unit weather events based on Smart Planning Unit program plans Health Facility standards 39 The World Bank OECS Regional Health Project (P168539) Saint Lucia: Completed proposed Ministry of Percentage of facilities Ministry of Health facility upgrades to withstand Annual Health Progress Report completed according to Planning Unit extreme weather events based on Planning Unit program plans Smart Health Facility standards Saint Vincent and the Grenadines: Ministry of Completed proposed facility upgrades Percentage of facilities Ministry of Health Annual Health Progress report to withstand extreme weather events completed according to Planning Unit Planning Unit based on Smart Health Facility program plans standards Ministry of Ministry of Health Number of countries/regional entities Percentage of facilities Annual Health Progress report Planning Units and that complete 100 percent of proposed completed according to Planning Unit the PIU in CARPHA laboratory upgrades program plans Ministry of Percentage of facilities Health Ministry of Health Dominica: Completed proposed Annual Progress report completed according to Planning Planning Unit laboratory upgrades program plans Units Ministry of Percentage of facilities Ministry of Health Grenada: Completed proposed Annual Health Progress report completed according to Planning Unit laboratory upgrades Planning Unit program plans Ministry of Percentage of facilities Ministry of Health Saint Lucia: Completed proposed Annual Health Progress report completed according to Planning Unit laboratory upgrades Planning Unit program plans Ministry of Saint Vincent and the Grenadines: Percentage of facilities Ministry of Health Annual Health Progress report Completed proposed laboratory completed according to Planning Unit Planning Unit upgrades program plans CARPHA: Completed proposed Percentage of facilities Annual PIU in Progress report PIU in CARPHA laboratory upgrades completed according to CARPHA 40 The World Bank OECS Regional Health Project (P168539) program plans JEE Question D.1.2. Capacity graded on a scale of 1-5 where: 1 = no capacity (no system in place to transport specimens from sub- national to national labs; transportation is ad hoc) 2 = limited capacity (system is in place to transport specimens to national labs from <50% of sub-national labs for advanced Number of countries/regional entitites diagnostics) Ministry of Health with specimen referral and transportation JEE and self- External and internal 3 = developed capacity Annual Planning Units and the systems based on assessments experts using JEE tool (system is in place to PIU in CARPHA achievement/sustainment of JEE score of transport specimens to 4.0 or higher national labs from 50-80% of sub-national labs for advanced diagnostics) 4 = demonstrated capacity (system is in place to transport specimens to national labs from at least 80% of sub-national labs for advanced diagnostics) 5 = sustainable capacity (systems in place to transport specimens to/from other labs in the 41 The World Bank OECS Regional Health Project (P168539) region and funded from host country budget) Dominica: Specimen referral and Capacity graded as JEE and self- External and internal Ministry of Health Annual transportation systems based on JEE described in JEE Question assessments experts using JEE tool Planning Unit score D.1.2. Grenada: Specimen referral and Capacity graded as JEE and self- External and internal Ministry of Health Annual transportation systems based on JEE described in JEE Question assessments experts using JEE tool Planning Unit score D.1.2. Saint Lucia: Specimen referral and Capacity graded as JEE and self- External and internal Ministry of Health Annual transportation systems based on JEE described in JEE Question assessments experts using JEE tool Planning Unit score D.1.2. Saint Vincent and the Grenadines: Capacity graded as JEE and self- External and internal Ministry of Health Annual Specimen referral and transportation described in JEE Question assessments experts using JEE tool Planning Unit systems based on JEE score D.1.2. CARPHA/OECS: Specimen referral and Capacity graded as JEE and self- External and internal Annual PIU in CARPHA/OECS transportation systems based on JEE described in JEE Question assessments experts using JEE tool score D.1.2. JEE Question D.1.4. Capacity graded on a scale of 1-5 where: 1 = no capacity (no national laboratory standards) Number of countries/regional entitites 2 = limited capacity (quality Ministry of Health JEE and self- External and internal with quality laboratory systems based on standards developed but no Annual Planning Units and the assessments experts using JEE tool achievement/sustainment of JEE score of system for verifying their PIU in CARPHA 4.0 or higher implementation) 3 = developed capacity (system of licensing laboratories including conformity to national standards exists but is 42 The World Bank OECS Regional Health Project (P168539) voluntary or is not a requirement for all laboratories) 4 = demonstrated capacity (mandatory licensing of all laboratories is in place and conformity to national standards is required) 5 = sustainable capacity (mandatory licensing of all laboratories is in place and conformity to an international standard is required) Capacity graded as JEE and self- External and internal Ministry of Health Dominica: Quality laboratory systems Annual described in JEE Question assessments experts using JEE tool Planning Unit based on JEE score D.1.4. Capacity graded as JEE and self- External and internal Ministry of Health Grenada: Quality laboratory systems Annual described in JEE Question assessments experts using JEE tool Planning Unit based on JEE score D.1.4. Capacity graded as JEE and self- External and internal Ministry of Health Saint Lucia: Quality laboratory Annual described in JEE Question assessments experts using JEE tool Planning Unit systems based on JEE score D.1.4. Saint Vincent and the Grenadines: Capacity graded as JEE and self- External and internal Ministry of Health Annual Quality laboratory systems based on described in JEE Question assessments experts using JEE tool Planning Unit JEE score D.1.4. Capacity graded as described in JEE Question JEE and self- External and internal CARPHA: Quality laboratory systems D.1.4. It is important to note Annual PIU in CARPHA assessments experts using JEE tool based on JEE score that while the baseline and targets are the same, IHR capacities also refer to 43 The World Bank OECS Regional Health Project (P168539) maintaining all essential public health functions needed to apply and comply with the IHR. In other words, efforts need to continuously be made to maintain higher scores achieved. JEE Question R.4.1. Capacity graded on a scale of 1-5 where: 1 = no capacity (no national countermeasure plans in place) 2 = limited capacity (plans have been drafted, but no exercises have been conducted) CARPHA/OECS: System in place for 3 = developed capacity JEE and self- External and internal activating and coordinating medical (plans are in place, and Annual PIU in CARPHA/OECS assessments experts using JEE tool countermeasures during a public health tabletop exercises have emergency been conducted to demonstrate sending or receiving of medical countermeasures during a public health emergency) 4 = demonstrated capacity (plans are in place, and at least one response/formal exercise/simulation within the previous year in which medical countermeasures 44 The World Bank OECS Regional Health Project (P168539) were sent or received) 5 = sustainable capacity (Country participates in a regional/international partnership or has formal agreement with another country or international organization that outlines criteria and procedures for sending and receiving medical ountermeasures and has participated in an exercise or response within the past year to practice deployment or receipt of medical countermeasures) JEE Question D.2.2. Capacity graded on a scale of 1-5 where: 1 = no capacity (no electronic tool to collect, report or analyze Number of countries/regional entities Ministry of Health surveillance data) JEE and self- External and internal that use electronic tools for surveillance Annual Planning Units and the 2 = limited capacity (ad hoc assessments experts using JEE tool based on achievement/sustainment of JEE PIU in CARPHA electronic tools have been score of 4.0 or higher developed to collect, report or analyze surveillance data or the country is developing an integrated electronic real-time reporting system for public health 45 The World Bank OECS Regional Health Project (P168539) surveillance) 3 = developed capacity (integrated electronic real- time reporting system for public health surveillance in place at all levels of health system, but system is not able to share data in real time) 4 = demonstrated capacity (integrated electronic real- time reporting system for public health surveillance in place at all levels of health system, and data can be shared in real time) 5 = sustainable capacity (integrated electronic real- time reporting system for public health surveillance in place at all levels of health system, and system is linked to with other regional and/or international systems to promote data sharing) Capacity graded as JEE and self- External and internal Ministry of Health Dominica: Use of electronic tools for Annual described in JEE Question assessments experts using JEE tool Planning Unit surveillance based on JEE score D.2.2. Capacity graded as JEE and self- External and internal Ministry of Health Grenada: Use of electronic tools for Annual described in JEE Question assessments experts using JEE tool Planning Unit surveillance based on JEE score D.2.2. 46 The World Bank OECS Regional Health Project (P168539) Capacity graded as JEE and self- External and internal Ministry of Health Saint Lucia: Use of electronic tools for Annual described in JEE Question assessments experts using JEE tool Planning Unit surveillance based on JEE score D.2.2. Saint Vincent and the Grenadines: Use Capacity graded as JEE and self- External and internal Annual Participating countries of electronic tools for surveillance described in JEE Question assessments experts using JEE tool based on JEE score D.2.2. Capacity graded as described in JEE Question D.2.2. It is important to note that while the baseline and targets are the same, IHR capacities also refer to JEE and self- External and internal CARPHA: Use of electronic tools for maintaining all essential Annual PIU in CARPHA assessments experts using JEE tool surveillance based on JEE score public health functions needed to apply and comply with the IHR. In other words, efforts need to continuously be made to maintain higher scores achieved. JEE Question D.4.4. Capacity graded on a scale of 1-5 where: 1 = no capacity (no FETP or Number of countries/regional entitites applied epidemiology Ministry of Health receiving FETP or other applied JEE and self- External and internal training established at Annual Planning Units and the epidemiology training based on assessments experts using JEE tool national level) PIU in CARPHA achievement/sustainment of JEE score of 2 = limited capacity (no FETP 4.0 or higher or applied epidemiology training established at national level, but staff participate in training in 47 The World Bank OECS Regional Health Project (P168539) other countries) 3 = developed capacity (one level of FETP – basic, intermediate or advanced - or applied epidemiology training in place at national level or in another country through an existing agreement) 4 = demonstrated capacity (two levels of FETP – basic, intermediate or advanced - or applied epidemiology training in place at national level or in another country through an existing agreement) 5 = sustainable capacity (three levels of FETP – basic, intermediate or advanced - or applied epidemiology training in place at national level or in another country through an existing agreement, and there is sustainable national funding) Dominica: Basic/frontline FETP Capacity graded as JEE and self- External and internal Ministry of Health training or other applied Annual described in JEE Question assessments experts using JEE tool Planning Unit epidemiology training received based D.4.4. on JEE score 48 The World Bank OECS Regional Health Project (P168539) Capacity graded as described in JEE Question D.4.4. It is important to note that while the baseline and targets are the same, IHR capacities also refer to Grenada: Basic/frontline FETP training JEE and self- External and internal Ministry of Health maintaining all essential Annual or other applied epidemiology assessments experts using JEE tool Planning Unit public health functions training received based on JEE score needed to apply and comply with the IHR. In other words, efforts need to continuously be made to maintain higher scores achieved. Saint Lucia: Basic/frontline FETP Capacity graded as JEE and self- External and internal Ministry of Health training or other applied Annual described in JEE Question assessments experts using JEE tool Planning Unit epidemiology training received based D.4.4. on JEE score Saint Vincent and the Grenadines: Capacity graded as JEE and self- External and internal Ministry of Health Basic/frontline FETP training or other Annual described in JEE Question assessments experts using JEE tool Planning Unit applied epidemiology training D.4.4. received based on JEE score CARPHA: Regional (intermediate/advanced) FETP Capacity graded as JEE and self- External and internal Annual PIU in CARPHA training or other applied described in JEE Question assessments experts using JEE tool epidemiology training provided based D.4.4. on JEE score Number of countries/regional entities JEE Question R.1.2. Capacity Ministry of Health with multi-sectoral, multi-hazard graded on a scale of 1-5 JEE and self- External and internal Annual Planning Units and the emergency preparedness measures, incl where: assessments experts using JEE tool PIU in CARPHA emergency response plans based on 1 = no capacity (no national achievement/sustainment of JEE score of multi-sectoral, multi-hazard 49 The World Bank OECS Regional Health Project (P168539) 4.0 or higher emergency preparedness plan in place) 2 = limited capacity (national multi-sectoral, multi-hazard emergency preparedness plan is in place. SOPs for core emergency response coordination functions have been developed in past two years) 3 = developed capacity (emergency preparedness measures are implemented at national level including points of entry and mass gathering events. Response plans have been exercised or used in actual response operations in past two years.) 4 = demonstrated capacity (preparedness measures are implemented at national, sub-national and local levels. Multi-sectoral, multi- hazard response plans in place at sub-national and local levels as well as points of entry. Response plans have been exercised or used in actual response 50 The World Bank OECS Regional Health Project (P168539) operations in past two years) 5 = sustainable capacity (dedicated human resources and regular budget funding to support coordination and implementation of emergency preparedness measures. Dedicated resources in place form implementation of multi- sectoral, multi-hazard response plans, contingency plans and SOPs at national, sub-national and local levels. Systems are regularly tested, reviewed and updated.) Dominica: Multi-sectoral, multi- Capacity graded as JEE and self- External and internal Ministry of Health hazard emergency preparedness Annual described in JEE Question assessments experts using JEE tool Planning Unit measures, incl emergency response R.1.2. plans, based on JEE score Grenada: Multi-sectoral, multi-hazard Capacity graded as JEE and self- External and internal Ministry of Health emergency preparedness measures, Annual described in JEE Question assessments experts using JEE tool Planning Unit incl emergency response plans, based R.1.2. on JEE score Saint Lucia: Multi-sectoral, multi- Capacity graded as JEE and self- External and internal Ministry of Health hazard emergency preparedness Annual described in JEE Question assessments experts using JEE tool Planning Unit measures, incl emergency response R.1.2. plans, based on JEE score 51 The World Bank OECS Regional Health Project (P168539) Saint Vincent and the Grenadines: Multi-sectoral, multi-hazard Capacity graded as JEE and self- External and internal Ministry of Health Annual emergency preparedness measures, described in JEE Question assessments experts using JEE tool Planning Unit incl emergency response plans, based R.1.2. on JEE score CARPHA/OECS: Multi-sectoral, multi- Capacity graded as JEE and self- External and internal hazard emergency preparedness Annual PIU in CARPHA described in JEE Question assessments experts using JEE tool measures, incl emergency response R.1.2. plans, based on JEE score Number of national public health emergency plans that document incorporation of feedback obtained through Public public consultations with consultations key populations. Key with key populations could include populations isolated communities, World Bank review of Number of public health emergency plans as Ministry of Health women of reproductive age, Annual national public health that document incorporation of feedback documented Planning Units or other to be defined. A emergency plans from key populations in national minimum of one public public health health emergency plan is emergency expected per country, with plans all four project-participating countries expected to develop public health emergency plans by the end of the project. Inclusion of gender-specific CARPHA: Protocols developed for gender- PIU in considerations in Annual Progress report PIU in CARPHA specific surveillance of priority infectious CARPHA surveillance protocols for diseases priority infectious diseases. 52 The World Bank OECS Regional Health Project (P168539) A Minimum Initial Service Package for sexual and reproductive health in emergencies and disasters OECS based on OECS: Number of countries with training has been defined, but OECS work countries where this in the Minimum Initial Service Package for Annual Technical unit in OECS training has only been program activity has been sexual and reproductive health in conducted in 1 country at conducted emergencies and disasters this time. This indicator will ensure that training has been provided to all countries. ME IO Table SPACE 53 The World Bank OECS Regional Health Project (P168539) ANNEX 1: Implementation Arrangements and Support Plan COUNTRY: Caribbean OECS Regional Health Project Implementation Arrangements 1. The project will be implemented primarily through the MOH Planning Units based in each respective country, with the exception of Saint Vincent and the Grenadines where it will be implemented by the PSIPMU on behalf of and in close collaboration with the MOH. National-level implementation arrangements will seek to build on existing project implementation experience and capacities both within the MOH and centralized fiduciary functions housed within Ministries of Finance. Regional level implemented activities will be housed within existing project execution and technical units of CARPHA and the OECS, respectively. Project Coordination and Management functions across each implementing entity will be accountable for: (i) development of annual workplans; (ii) monitoring and reporting on the Results Framework; (iii) coordination of project activities; and (iv) coordination and close follow-up on project fiduciary matters. 2. Implementation of regional level activities will be carried out by CARPHA and the OECS. CARPHA will serve as the lead technical body to oversee the design, planning, and technical assistance for the implementation of select regional level activities. CARPHA would also provide oversight for select country-level activities with a regional dimension. The OECS Health Unit will implement regional level activities related to the development of regional policies and legislation and regional coordination mechanisms. Implementation Support Plan 3. An Implementation Support Plan for the project has been developed based on the assumption that project activities will require intensive support during implementation, especially during the first year. A broad range of skills is required for the Bank to effectively support project implementation. The implementation support team will include specialists in public health (including disease surveillance, and laboratory specialists); financial management, procurement, environmental and social safeguards, architect and/or biomedical engineer, monitoring and evaluation, and WB operations. These functions will provide “just-in-time” advice and support. The procurement specialist(s) will carry out annual ex-post review of procurement that falls below prior review thresholds and will have separate focused missions depending on the procurement needs that arise. The FM specialist(s) will review all FM reports and audits and take necessary follow-up actions according to Bank procedures. Bank team members will also identify capacity building needs to ensure successful project implementation. The Implementation Support Plan has been developed using lessons learned from previous regional projects in the health sector and will be reviewed regularly. 4. The Bank team will carry out routine implementation performance and progress reviews with the six project implementing entities through implementation support missions and virtual dialogue (e.g. videoconference). A mid-term review (MTR) will be organized by the WB to take stock of project implementation and identify corrective actions or adjustments as necessary. In advance of the MTR, the implementing agencies and the RPAC will send to the Bank a report summarizing project progress and highlighting issues that require special attention. At project closure, the Bank team will prepare an Implementation Completion and Results Report that summarizes achievements made under the project. This report will also include an assessment of the 54 The World Bank OECS Regional Health Project (P168539) project by the project implementing agencies. This process will also be guided by the RPAC. 5. Generally, progress monitoring will focus on: (i) key performance indicators, as identified in the Results Framework; (ii) progress of implementation across project components; (iii) compliance with legal conditions and covenants; (iv) progress in relation to implementation and procurement plans; (v) whether estimated project costs are sufficient to cover planned activities and whether reallocation of funds is required; (vi) compliance with WB fiduciary and disbursement provisions; and (vii) compliance with environmental and social safeguards. The Bank team will also closely monitor status of the JEE at appropriate points of project implementation (baseline, mid- term and end-term). Table 1: Implementation Support Plan and estimated resources required Total Number of Activity Skills Required estimated trips staff weeks Overall coordination Task Team Leaders (TTLs) Year 1 Project launch Task team: total 8-10 1 for each TTL – health specialists specialist Safeguards specialists (2) listed Monitoring and Evaluation specialists FM specialists Procurement specialists Operations support Regular Task team: total 12-16 2 for TTLs implementation TTL – health specialists support mission Safeguards specialists (2) At least 1 for Architect and/or biomedical engineer each Monitoring and Evaluation specialists specialist FM specialists listed Procurement specialists Operations support Consultants on specialized issues as needed Years 2-5 Bi-annual Task team: total 18-22 At least 2 for implementation TTL – health specialists each support missions Safeguards specialists (2) specialist (technical and Architect and/or biomedical engineer listed fiduciary reviews) Monitoring and Evaluation specialists FM specialists Procurement specialists Operations support Consultants on specialized issues as needed Mid-Term Review Task team: total 10-12 1 for each TTL – health specialists specialist 55 The World Bank OECS Regional Health Project (P168539) Total Number of Activity Skills Required estimated trips staff weeks Safeguards specialists (2) listed Architect and/or biomedical engineer Monitoring and Evaluation specialists FM specialists Procurement specialists Operations support Consultants on specialized issues as needed Implementation Task team: total 8-12 1 for each Completion Review TTL – health specialists specialist Mission and Monitoring and Evaluation Specialists listed Preparation Operations support Implementation Completion Review Authors Financial Management (FM) 6. Financial management and accountability arrangements. FM aspects of the project in various countries will be executed by the designated implementing entities and are detailed in Table 2. 7. Planning and Budgeting: The respective implementing entities will designate a financial management staff to undertake the record keeping for the project. Each implementing entity will prepare an overall budget for the life of the project, which will be revisited periodically and updated, as needed, to reflect the implementation progress. An annual work plan and annual budget will be derived from this overall budget, which will be agreed with the WB and then included in respective ministries’ annual budget for approval by the parliament (except for CARPHA, where it will be included in the entity’s budget for approval by CARPHA’s Board). 8. Funds Flow: Advances will be disbursed by the WB to a segregated Designated Account (DA) opened at an agreed bank. DA account will be used to finance the US currency expenditures. Funds will be periodically transferred from DA to segregated local currency operating account, which will also be maintained at the agreed bank. The local currency operating account will be used to finance local currency expenditures. Disbursement methods available to the project will be: Advance, Reimbursement and Direct Payment. 9. Accounting and Internal Controls: The respective implementing entities will use their existing FM systems to record and maintain all project transactions. The annual budget for the World Bank project, once approved, will be the guiding factor for recording all the project transactions. The respective FM systems will allow capturing of the project transactions by categories, components, subcomponent and activities, as needed. All implementing entities will prepare a project financial manual guidance for staff, which is an integral part of the POM. 10. Reporting: Advances will be disbursed to the respective implementing entities based on a six-month cash forecast and each implementing entity will be submitting quarterly unaudited financial reports to the World Bank in the form of IFRs within 45 days after the close of each quarter. The IFRs will be generated from the physical accounting records and variance analysis (actual versus budgeted expenditures) will also be included. The agreed upon IFR format is included in the disbursement and financial information letter. The World Bank will document 56 The World Bank OECS Regional Health Project (P168539) expenditures from the IFRs, which will also include additional request for funds. 11. External Auditing: The external audit of the project will be conducted by the agreed audit entities (referred as external auditors) as detailed in the table below. The project will produce annual financial statements which will be submitted to the external auditors to be audited as per Terms of Reference (TORs) agreed between the project and the World Bank. The project budget will include cost of the technical support to be obtained by the Supreme Audit Institution, if needed. The project will submit the Audit Report along with the Audited Financial Statements and the Management Letter to the World Bank no later than six months after the close of the year. 12. The World Bank’s fiduciary team will provide the project staff training on specific World Bank policies and guidelines. FM risks and compliance will be monitored during the World Bank’s six-monthly implementation support missions as well as through annual external audits. With the implementation of these measures, the respective implementing entities will have in place a FM system that should be able to provide, with reasonable assurance, accurate and timely information on the status of the funds as required by the World Bank. 13. The overall disbursement arrangements will follow standard disbursement policies and procedures included in the Disbursement and Financial Information letter and as established in the Disbursement Guidelines for Investment Project Financing, dated February 2017. The minimum application size for Direct Payments and Reimbursements will be recorded in the Disbursement and Financial Information letter. Table 2. FM arrangements at the respective implementing entities: FM element St. Lucia42 OECS Grenada43 Dominica SVG44 CARPHA (National Commission (Accountant (MOH (PSIPMU, PCU) General, MOF) accounting MOF) unit) Responsible Accounting Accounting Senior Accounting Financial Project FM staff for Officer in Assistant and Certified staff under the Management Accountant the project National PCU Accountant Accountant oversight of Specialist under the under under the under Accountant under the supervision of supervision of Business supervision of heading MOH supervision of Financial Finance Partner Accountant Accounting Finance Controller Manager Manager General unit Manager Designated Bank of Saint First National Grenada An acceptable Bank of Saint Royal Bank of US$ and local Lucia Bank of St. Cooperative commercial Vincent and Canada currency bank Lucia Bank bank the accounts Grenadines 42 In Saint Lucia, FM aspects, at the outset, will be implemented by the National PCU in the Department of Economic Development, Transportation and Civil Aviation, which has experience managing WB projects. MOHW is in the process of setting up a new PIU. Once this PIU is ready, its FM capacity will be assessed by the WB and under an agreed MOU, the implementation of the current project will be transferred to this PIU. 43 The MOF Accountant General’s Department set up a new project ac counts unit in January 2019. While FM arrangements are deemed adequate, it is imperative that the functions, responsibilities and procedures of the MOH, Ministry of Infrastructure and Implementation, MOF CPU and the MOF Accountant General’s Department are outlined in the POM. 44 In Saint Vincent and the Grenadines, the FM aspect of the project will be implemented by the existing PSIPMU unit, which is familiar with WB financed projects and cognizant of WB policies and guidelines. As the PSIPMU is currently overstretched with implementation of multiple donor financed projects, recruitment of a finance officer for the project will be conducted. 57 The World Bank OECS Regional Health Project (P168539) FM element St. Lucia42 OECS Grenada43 Dominica SVG44 CARPHA (National Commission (Accountant (MOH (PSIPMU, PCU) General, MOF) accounting MOF) unit) Accounting Quickbooks SAGE 50 Quickbooks Smartstream Peachtree QuickBooks/FI software used Sage 50 V NICS for record (accounting keeping software) IFRs to be April – June July – January – July – January – January – submitted for September March September March March the quarter July – ended September October – April – June October – April – June April - June December December October – July – July – July – December January – September January – September September March March January – October – October - October - March April - June December April - June December December Annual April - March July – June January – July – June January – January – external audit December December December reports to be submitted for Audit report to Project audit Project audit Project audit Project audit Project audit Entity audit be submitted report to be report to be report to be report to be report to be report with submitted by submitted by submitted by submitted by submitted by adequate 30 September 31 December 30 June 31 December 30 June disclosure on use of funds from the WB project to be submitted by 30 June Selection of Auditor An audit firm Auditor The Office of An audit firm CARPHA’s external General of St. deemed General of the Director of deemed statutory auditor (SAI) Lucia (SAI) acceptable to Grenada (SAI) Audit (SAI) acceptable to auditor45 the Bank and the Bank and appointed as appointed as per WB per WB procurement procurement procedures procedures 14. Procurement. A detailed assessment of the procurement capacity by implementing entity is provided below. Due to the complexity of the project and lack of extensive procurement experience at the country level, the overall procurement risk in all participating countries is assessed as Substantial. 45 CARPHA’s present statutory auditor is BDO Trinidad. In case, CARPHA plans to change the statutory auditor, the WB will be duly consulted. 58 The World Bank OECS Regional Health Project (P168539) Procurement Arrangements: Dominica 15. In April 2019, a capacity assessment was conducted of the MOH Project Management Unit as the implementing agency to carry out procurement actions for the project. The assessment concluded that MOH has insufficient procurement capacity to carry out the activities envisaged in the project. Although the PMU may be familiar with national procurement rules and procedures, none has experience in conducting procurement processes guided by WB procurement rules, nor previous experience implementing a WB-financed project. Therefore, procurement training on WB procurement rules is needed and the project will finance at least one procurement officer with experience in implementing WB-financed projects and familiar with WB procurement rules. 16. Implementation of procurement activities will require coordination between technical and fiduciary staff, given that technical staff will need to provide technical inputs for key steps of the procurement activities, such as TORs, Technical Specifications, Designs, Qualification Requirements and Evaluation Criteria for Procurement Documents, Evaluation of Expressions of Interest, Evaluation of Bids/Proposals and so on. 17. In addition, potential lack of MOH technical capacity to respond to various phases of the procurement cycle such as the preparation of TORs, evaluation of bids/proposals, contract management, etc. may lead to delays in the implementation of the WB-financed contracts, which would undermine implementation. Therefore, the Government should monitor this situation closely. For Dominica, the overall procurement risk in the country is assessed as Substantial. Procurement Arrangements: Grenada 18. An assessment of the capacity of the implementing agency to implement procurement actions for the project was carried out in March 2019 for the MOF CPU. The assessment concluded that CPU has potential capacity to carry out the procurement activities envisaged in the project, but some improvements are required and welcome. Although the CPU is well established, and its procurement officers are very familiar with national procurement rules and procedures, few have experience in conducting procurement processes guided by the World Bank’s procurement rules, while some do not have experience in implementing a Bank-financed project. On the other hand, the CPU’s workload is heavier than it was earlier in 2019, as this unit is now in charge of all procurement activities carried out by the Government, including contracts financed by own funds, WB funds and other donors’ funds. Therefore, the unit needs additional procurement training and could also benefit from additional support. 19. Key issues/risks concerning procurement identified during the assessment are as follows: (a) After dissolving the PCU in charge of the integrated coordination and implementation of all WB-financed projects, including procurement functions, the Government recently decided that the MOF CPU is now in charge of all procurement processes related to the WB portfolio in Grenada. Although these procurement arrangements are not unusual, as they reflect how procurement functions and activities are assigned and carried out by the Government on a regular basis, they make the CPU’s workload heavier, as predictable, because this unit is also in charge of all procurement activities carried out by the Government, including contracts financed by own funds, WB funds and other donors’ funds. Such a heavier workload may lead to delays in the implementation of WB-financed contracts, which would undermine the implementation 59 The World Bank OECS Regional Health Project (P168539) of the whole WB portfolio. This needs to be monitored closely and the CPU should give priority to WB financed contracts, as they are linked to short and quite inflexible deadlines. In addition, the Government should consider extra support to the CPU, which would include hiring an additional procurement consultant familiar and experienced in WB procurement rules and procedures. (b) In general, the MOF CPU is well established and familiar with public procurement procedures. The CPU comprises 5 (five) procurement officers: Chief Procurement Officer, 2 (two) Senior Procurement Specialists and 2 (two) Procurement Specialists, and some administrative staff. The 5 (five) procurement officers are familiar with national procurement policies and procedures, but only one is familiar with WB procurement policies and procedures. Therefore, additional procurement training is needed, and the CPU could benefit from additional support to be provided by a team member with solid experience in procurement processes guided by WB procurement rules and procedures; (c) Given that the MOH is in charge of project coordination and implementation, while the Ministry of Implementation and Infrastructure provides oversight, the CPU shall interact closely with these entities, mainly because they have to provide technical inputs (Technical Specifications, TORs, Bid/Proposal Evaluation, etc.) for procurement processes to be conducted by the CPU. Given that any uncertainty on the coordination among the CPU, the MOH and the Ministry of Implementation and Infrastructure may lead to delays in the implementation of WB-financed contracts that could undermine project implementation, the Government should ensure smooth coordination to avoid implementation delays; (d) Potential lack of technical capacities from MOH to respond to various phases of the procurement cycle such as preparation of TORs, evaluation of bids, contract management, etc. may lead to delays in the implementation of WB-financed contracts. Therefore, the Government should closely monitor this situation. For Grenada, the overall procurement risk is assessed as Substantial. Procurement Arrangements: Saint Lucia 20. An assessment of the capacity of the implementing agency to implement procurement actions for the project was carried out in February 2019 for the MOH and the MOF PCU. The assessment concluded that MOH has insufficient procurement capacity to carry out the activities envisaged in the project. MOH has no previous experience in implementing a WB-financed project and therefore a dedicated PIU will be established. The PIU will be equipped with an experienced procurement officer that will be hired through an individual consultant selection. The existing MOF PCU will conduct procurement activities until the new MOH PIU demonstrates it has acquired adequate expertise. The MOF PCU comprises a diverse team of procurement specialists with experience with WB procurement. 21. Key procurement issues/risks for project implementation identified during the assessment are as follows: (a) Although, at the moment, the MOF PCU is able to smoothly manage the additional work the project will bring, the situation may change as the PCU is expected to handle new projects currently in the pipeline. This needs to be monitored and if necessary will be reviewed and adapted to reflect any changes. (b) The selection process for the new MOH PIU procurement specialist may not conclude with a desired outcome; (c) Point (a) will be assessed and reviewed during implementation until the transfer of the procurement function is made to the MOHW PIU; 60 The World Bank OECS Regional Health Project (P168539) (d) Lack of technical capacities from MOH to respond to various phases of the procurement cycle such as preparation of TORs, evaluation of bids, contract management, etc. For Saint Lucia, the overall procurement risk is assessed as High. Procurement Arrangements: Saint Vincent and the Grenadines 22. Project implementation will rely on the existing PSIPMU of MOF, which is currently supporting other WB projects.46 The capacity of the PSIPMU has been assessed, and the project will support necessary strengthening of the PSIPMU to ensure smooth implementation of the project without the creation of additional organizational units. 23. The PSIPMU will be responsible for all procurement activities under the Project. It will be directly Responsible for the procurement of goods, works, and consulting and non-consulting services. The PSIPMU has experience in procurement of consulting services, goods, works and training, and has been trained in the new World Bank Procurement Regulations for IPF Borrowers. However, lack of experience with the new procurement regulations warrants increased initial support from the World Bank, which is expected to be reduced with time as the PSIPMU staff becomes more familiar with the practical implications of these new regulations. 24. Key procurement issues/risks for project implementation identified during the assessment are as follows: (a) The selection process for the additional PSIPMU procurement specialist may not conclude with a desired outcome; (b) Lack of technical capacities from MOH to respond to various phases of procurement cycle such preparation of TORs, evaluation of bids, contract management etc. (c) Point (a) will be assessed and reviewed during implementation; (d) The Project will require coordination and communication between the MOH and fiduciary staff from MOF PSIPMU. This may impact timelines for procurement activities; and (e) The PSIPMU has experience in the implementation of World Bank-funded projects (including through the procurement of consulting services, works, goods and training) and has been trained in the new procurement regulations. However, the absence of experience in the new regulations warrant additional support from the World Bank which is expected to be reduced with time as the procurement staff becomes more familiar with the practical implications of the new regulations. The overall Procurement risk rating is Substantial, based on the assessment of the PSIPMU capacity, considerations, and complexity of the procurement arrangements reviewed and exposed. The Procurement Accredited Staff assigned to this project will monitor the procurement risk during implementation and will support, train and guide the Borrower’s procurement team assigned to the Project. For Saint Vincent and the Grenadines, the overall procurement risk is assessed as Substantial. 46 These include the Human Development Service Delivery Project (P154253); the Solar PV Demonstration and Scale-up (P153404); the OECS Regional Agriculture Competitiveness Project (P158958); the Regional Disaster Vulnerability Reduction Project (P117871) and the OECS Regional Tourism Competitiveness Project (P152117). 61 The World Bank OECS Regional Health Project (P168539) Procurement Arrangements: Caribbean Public Health Agency (CARPHA) 25. An assessment of the capacity of the implementing agency (CARPHA) to implement procurement actions for the project was carried out in March 2019. CARPHA is a well-structured agency with extensive exposure to MDBs and International Donors (PAHO, WHO, EU, Inter-American Development Bank). The Procurement and Supply Management team (PSM) comprises two procurement specialists, two procurement assistants and an inventory officer. The PSM team is coordinated by a procurement manager (Head of Procurement team) who develops and manages all aspects of procurement within CARPHA and is responsible for establishing the organizations’ approach to procedures, policies, standards, and monitoring for procurement activities. The PSM team’s responsibilities include managing and leading the procurement staff, providing technical guidance, training, coaching, and mentoring. 26. Procurement activities are well specified in a consolidated procurement manual with clear roles and responsibilities. Key procurement issues/risks for project implementation identified during the assessment are as follows: (a) Although CARPHA has procurement experience, it lacks exposure to WB procurement. The previous procurement activities were relatively smaller in value and complexity as the ones envisaged under this project. Therefore, close WB support and tailored training needs to be in place to ensure smooth implementation of the Procurement Plan. (b) Although a fully dedicated Procurement Officer is not envisaged for this project, CARPHA will appoint a dedicated Procurement Officer who will support the project in the procurement function. Based on the assessment of CARPHA’s capacity, and complexity of the project, the overall procurement risk rating is Substantial. Procurement arrangements: OECS Commission 27. A capacity assessment of the implementing agency (OECS Commission) to implement procurement actions for the project was carried out in February 2019. The OECS Commission is moving toward a centralized procurement function. The main functions of the centralized office are to work in collaboration with key partners to successfully undertake OECS organization-wide procurement, ensuring adherence to all applicable procedures and internal processes. This will entail a more integrated approach compared to the decentralized model. 28. Procurement is coordinated by a procurement officer (Head of Procurement Unit - HPU) who develops and manages all aspects of procurement within the OECS and is responsible for establishing the organizations’ approach to procedures, policies, standards, and monitoring for procurement activities. The HPU responsibilities include managing and leading the procurement staff, providing technical guidance, training, coaching, and mentoring. A key aspect of the procurement function is the provision of oversight/compliance checks and reviews of procurement documentation, which will be undertaken by the procurement officer. 29. The HPU has 14 years’ experience of implementing WB-financed projects. The HPU gained significant experience within the Project Coordination Unit in Saint Lucia through on-the-job training in implementation of WB-financed projects and through attending regional trainings on WB procurement policies, including the workshop concerning the Procurement Regulations for IPF Borrowers, held in Grenada in October 2016. 62 The World Bank OECS Regional Health Project (P168539) 30. Key issues/risks concerning procurement identified during the assessment are as follows: (a) While the OECS Commission has experience in WB-financed projects, it will benefit from close WB support and tailored training needs to be in place to ensure smooth implementation of the Procurement Plan. (b) The OECS Commission will identify within their existing structure a Procurement Assistant who will support the project in the procurement function. The WB Procurement Specialist will continue to provide ongoing support on the application of the World Bank’s Regulations during implementation. (c) Procurement oversight will be undertaken by the HPU, who also has the procurement function of other projects currently implemented by the OECS Commission. This may lead to capacity constraints and needs to be monitored closely during project implementation. (d) Because of the nature of the procurement involved, strong collaboration and input from the technical team needs to be in place, specifically in the preparation of technical aspects of the Procurement Documents. This close support needs to be provided to avoid implementation delays and ensure successful procurement outcomes. (e) The above will be monitored during implementation supervisions and additional measures will be discussed and implemented if deemed necessary. Based on the assessment of the OECS Commission’s capacity, and complexity of the project, the overall procurement risk rating is Substantial. 31. The project will use the WB’s online tool STEP for all procurement transactions. 32. Frequency of procurement supervision. Supervision of procurement will be carried out primarily through prior review supplemented by supervision missions at least twice a year. 33. Training costs. The project will finance training (workshops, etc.), as needed. Training will be carried out according to training plans, which the implementing entities will revise semi-annually and as needed and submit to the WB for ‘no objection’ before implementation. Expenses will be covered under the training category and disbursed based on the statements of expenditures. 34. Operating costs. ‘Operating Costs’ means incremental operating costs incurred by the implementing entities on account of project implementation, management, and monitoring, including dissemination of project- related information and publications, office rent and utilities, office and equipment insurance, maintenance and repair, vehicle insurance, local travel, communication, translation and interpretation, bank charges, and other miscellaneous costs directly associated with the project. All operating costs are based on periodic budgets and procured using the implementing agencies’ administrative procedures acceptable to the WB. Operating costs do not include salaries of government officials and civil servants. 35. Advertisements. A General Procurement Notice will be published online on the United National Development Business website. Specific Procurement Notices will be published as the corresponding bid documents become available. 36. Debarments. The Borrower will respect debarment decisions by the WB and will exclude debarred firms and individuals from the participation in the competition for Bank-financed contracts. Current listing of such firms and individuals can be found at the following website address: http://www.worldbank.org;/debarr 63 The World Bank OECS Regional Health Project (P168539) ANNEX 2. Project Preparation Team NAME ROLE SPECIALIZATION Carolyn J. Shelton Task Team Leader (ADM Responsible) Senior Health Specialist Neesha Harnam Task Team Leader Health Specialist Arun Manuja Financial Management Specialist Senior Financial Management (ADM Responsible) Specialist Manjola Malo Procurement Specialist (ADM Procurement Specialist Responsible) Nyaneba E. Nkrumah Environment Specialist (ADM Senior Natural Resources Responsible) Management Specialist Christopher Mays Johnson Social Specialist (ADM Responsible) Senior Social Development Specialist Marta Elena Molares- Counsel Consultant Halberg Carmen Carpio Team Member Senior Health Specialist Sara Halstead Hersey Team Member Senior Health Specialist Marize de Fatima Santos Team Member Program Assistant Jose C. Janeiro Team Member Senior Finance Officer Ruth Jo Goorman Team Member Finance Analyst Shonell Jodian Robinson Team Member Financial Management Specialist Vinicius Lima Moura Team Member Senior Procurement Specialist Amadou Konare Team Member Consultant Barbara Donaldson Team Member Consultant Elizabeth Joana Graybill do Team Member Consultant Nascimento 64 The World Bank OECS Regional Health Project (P168539) ANNEX 3. Map 65