Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) Report Number : ICRR0021395 1. Project Data Project ID Project Name P113102 RY-Schistosomiasis Control Project Country Practice Area(Lead) Yemen, Republic of Health, Nutrition & Population L/C/TF Number(s) Closing Date (Original) Total Project Cost (USD) IDA-H5420 30-Jun-2016 20,518,971.64 Bank Approval Date Closing Date (Actual) 17-Dec-2009 31-Jan-2018 IBRD/IDA (USD) Grants (USD) Original Commitment 25,000,000.00 0.00 Revised Commitment 25,000,000.00 0.00 Actual 22,420,508.64 0.00 Prepared by Reviewed by ICR Review Coordinator Group Salim J. Habayeb Judyth L. Twigg Eduardo Fernandez IEGHC (Unit 2) Maldonado 2. Project Objectives and Components a. Objectives According to the Financing Agreement dated 1/6/10, the objectives of the project were to decrease the prevalence and intensity of infection of both urinary and intestinal schistosomiasis among school-age children by 2015 in endemic regions of Yemen. The statements of objectives in the Financing Agreement, Project Appraisal Document (PAD), and ICR were identical. Explanatory note on schistosomiasis from World Health Organization (WHO) references: Page 1 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) Schistosomiasis is a disease caused by parasitic worms, which affect the urinary tract and/or intestines. Symptoms include abdominal pain, diarrhea, bloody stools, or blood in the urine. The disease progresses to renal failure and bladder cancer in urinary schistosomiasis, and liver fibrosis and portal hypertension in intestinal schistosomiasis. Infected water snails act as intermediate hosts releasing schistosomiasis parasites in fresh water bodies, lakes or rivers, and which in turn penetrate the skin of the human host. People are infected when they are exposed to infested water, such as in routine agricultural and occupational activities. School-age children who play, swim, or fish in infested water make them especially vulnerable to infection. Schistosomiasis is prevalent in tropical and subtropical areas, especially in poor communities without access to safe drinking water and adequate sanitation. Notes on objectives and associated outcome targets: • The statement of objectives specified the date of the intended achievement “by 2015”. But the closing date was extended and the project closed on 1/31/18. Since achievements are more appropriately assessed upon the completion of project activities, this ICR Review will assess the reported project achievements around project closing, when the impact evaluation was undertaken. • The methodology for measuring schistosomiasis intensity by numbers of parasitic eggs was revised in 2014 from numbers to percentages for technical reasons. Hence, outcome targets for the intensity of infections were also modified to fit the calculation methodology. The revisions were unrelated to project ambition. b. Were the project objectives/key associated outcome targets revised during implementation? No PHEVALUNDERTAKENLBL c. Will a split evaluation be undertaken? No d. Components Original Components 1. Preventive Chemotherapy for Schistosomiasis Control (Appraisal US$22.65 million; Actual US$21.1 million). The component consisted of activities for campaign-based preventive chemotherapy using fixed and temporary sites; routine preventive chemotherapy; and information, education and communication. Provision of drugs, laboratory equipment, goods, consultant services and training. Page 2 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) 2. Independent Monitoring, Audit and Project Administration (Appraisal US$2.35 million; Actual US$1.2 million). (a) Support to technical and financial audits, and monitoring and evaluation (M&E) preventive chemotherapy interventions; and (b) support to the project administration unit, including implementation, external audits and M&E. Revised Components A project restructuring on 3/14/13 maintained the original two components and added the following third component: 3. Output-Based Deworming and Control of Other Neglected Tropical Diseases (Approved amount US$5 million; Actual US$0.11 million). The new component was meant to support school-based deworming for the treatment of soil-transmitted helminths, and to the control of onchocerciasis, trachoma, and other neglected tropical diseases. e. Comments on Project Cost, Financing, Borrower Contribution, and Dates Cost and financing. The original overall project cost was reported in the ICR (p. 2) at US$28.8 million, comprising contributions of US$25 million from an International Development Association (IDA) Grant, US$2.14 million from the government, US$1.46 million from WHO, and US$0.2 million from foreign universities (Imperial College London). Actual total cost at closing was reported in the ICR as US$23.5 million, covering US$22.4 million in disbursements from the IDA Grant, US$0.9 million from WHO, and the full US$0.2 million from Imperial College London (the ICR, p. 18, stated that Imperial College London's actual contribution was in the range of US$1.5-2 million). The ICR reported that some drug procurement (in the amount of US$0.5 million) was not completed, and these funds were returned to the Bank (see Section 10b). Note on other support provided to the project. WHO support to the project included quality assurance of drugs, procurement of praziquantel for the treatment of schistosomiasis, training, and design of sentinel surveys. The Schistosomiasis Control Initiative of the Imperial College London provided technical assistance in designing impact evaluation and financed its implementation. The END Fund (a private philanthropic organization registered in the United States and United Kingdom, dedicated to ending common neglected tropical diseases) supported an additional mass drug administration round. Dates. The project was approved on 12/17/09 and became effective on 8/3/10. A level 2 restructuring was undertaken on 3/14/13 to revise the results framework and allocations between categories, and to add deworming and other tropical disease activities. The Mid-Term Review was carried out on 6/30/16. Three closing date extensions aggregating at 19 months were undertaken on 6/21/16, 5/26/17, Page 3 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) and 9/2/17 to complete project activities. The project closed on 1/31/18, 19 months after the original closing date of 6/30/16. 3. Relevance of Objectives Rationale At appraisal, schistosomiasis was among the significant public health problems in Yemen, where 42% of the population lived in poverty. About three million people were infected with either urinary schistosomiasis or intestinal schistosomiasis, or with both, corresponding to an estimated prevalence of about 15 percent. At least 600,000 school-age children and adults suffered from severe morbidity resulting from the parasitic worm disease, where the severity of clinical symptoms increases with the worm burden. 15 million individuals were living in schistosomiasis endemic areas, and, as noted in Section 2a, school-age children bathing or participating in recreational activities in contaminated water were most at risk. The project was linked to the third strategic objective for fostering human development under the FY10-FY13 Country Assistance Strategy, which specifically noted the priority of reducing the prevalence of schistosomiasis (ICR, p. 6). At closing, the objectives remained fully relevant to the Bank’s Country Engagement Note (CEN) FY17-18, which was prepared in lieu of a Country Partnership Framework because of the volatile country situation. The CEN defined two objectives for engaging and supporting the country during the conflict and post-conflict period: (1) provide emergency support to preserve local service delivery capacity to support conflict-affected families and communities; and (2) prepare for post-conflict recovery and reconstruction, with due attention to state and institution building and laying the foundation for a more inclusive and resilient development framework in the future. The schistosomiasis control project was included as an integral part of CEN activities under its objective to preserve local service delivery to support conflict-affected communities. At the same time, in its discussion on investment choices, the ICR (p. 17) referred to the Global Burden of Disease (2010) that estimated Yemen’s top three causes in disability-adjusted life years (DALYs) - lower respiratory infections, diarrheal diseases, and congenital anomalies - while the burden of schistosomiasis accounted for only 3.16% of the total DALYs in Yemen. However, since relevance of objectives is largely qualified by alignment with the Bank's partnership and engagement strategy with the country, relevance of objectives is rated High. Rating High 4. Achievement of Objectives (Efficacy) PHEFFICACYTBL Page 4 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) Objective 1 Objective Decrease the prevalence of infection of urinary and intestinal schistosomiasis among school-age children in endemic regions. Rationale The implementation of campaign-based preventive chemotherapy, supported by technical assistance, training and health education, could reasonably be expected to increase program coverage of drug administration in targeted endemic districts and among enrolled and non-enrolled school-age children. In turn, it was reasonable to anticipate a decrease in the prevalence of infections. Intermediate results • The project covered 275 endemic districts through mass drug administration campaigns, attaining 100% geographic coverage, exceeding the target of 90% for geographic coverage. • The program of distribution of praziquantel for enrolled and non-enrolled school-age children in all 275 endemic districts covered 6 million children out of a total of 7 million school-age children, reflecting program coverage of 86%, exceeding the target of 75%. The program of drug distribution for enrolled school-age children reached coverage of 100% by 1/1/18, exceeding the target of 80%. The ease of reaching school-enrolled students might explain the universal coverage for this sub-group, while program coverage for non-enrolled school-age children reached 70.7%, slightly above the target of 70%. • 11,711 health personnel received training, including doctors, nurses, midwives, pharmacy staff, laboratory staff, and health administrators. The project also trained teachers and volunteers, and the total number of persons trained under the project reached 36,732 persons. • The number of all direct project beneficiaries was 11.4 million at the end of the project, exceeding the target of 6 million beneficiaries. Outcomes The prevalence of infection with any form of schistosomiasis among school-age children decreased from a baseline of 17.3% in 2013 to 7.4% in 2017, exceeding the target of 10%. Also, overall prevalence (all ages) decreased from a baseline of 16.7% in 2013 to 6.9% in 2017, exceeding the target of 10%. Rating High PHREVDELTBL PHEFFICACYTBL Page 5 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) Objective 2 Objective Decrease the intensity of infection of urinary and intestinal schistosomiasis among school-age children in endemic regions. Rationale The implementation of campaign-based preventive chemotherapy, supported by technical assistance, training and health education, could reasonably be expected to increase program coverage of drug administration in targeted endemic districts and among enrolled and non-enrolled school-age children. In turn, it was reasonable to expect a decrease in the intensity of both urinary and intestinal schistosomiasis infections. Outputs were as listed under Objective 1. Outcomes Urinary schistosomiasis: Heavy infections of urinary schistosomiasis among school-age children decreased from a baseline of 3.1% in 2014 to 1.3% in 2017, short of the target of 1%. Also, the overall percentage (all ages) of heavy infections decreased from a baseline of 2.7% in 2014 to 1.2 % in 2017, short of the target of 1%. Intestinal schistosomiasis: The ICR (p. 29) stated that the impact evaluation did not report on the disaggregated rate of intensity of infection specific to school-age children, but on the decrease in the overall rate (all ages) for heavy and medium infection of intestinal schistosomiasis from a baseline of 4.1% in 2014 to 1% in 2017, exceeding the target of 2.5%. The ICR, p. 29, stated that the overall target of 2.5% could not be applied to children's data, including because the children’s baseline of 0.7% was already below the overall target of 2.5%. The TTL (11/1/18) stated that a sample (of unknown size and methodology) was reviewed in collaboration with partners to identify the children-specific rate in heavy infections, which was denoted by the ICR in the results framework's comments as 0.3% (and that a related target of 0.3% was achieved, ICR, p. 12), having decreased from a baseline of 0.7%. Rating Substantial PHREVDELTBL PHOVRLEFFRATTBL Rationale Page 6 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) The aggregation of one fully achieved objective on disease prevalence with one almost fully achieved objective on disease intensity indicates an overall efficacy rating of Substantial. Overall Efficacy Rating Substantial 5. Efficiency The PAD’s economic analysis calculated DALYs to assess cost-effectiveness. The analysis estimated that the cost of avoiding one DALY ranged between US$25.8 and US$48.3 (PAD, p. 68). The estimates compared favorably with US$25 to US$100 per DALY, which is the range considered to be cost-effective in developing countries. The PAD also compared its estimates with an alternative scenario, under which treatment is provided only to those actually infected after their identification by screening, and where the cost per DALY was estimated at US$346. The alternative scenario was not deemed to be cost-effective because the cost of screening is high. The PAD concluded that, given high screening costs and low drug costs for mass chemotherapy, large-scale preventive chemotherapy in endemic areas, as undertaken by the project, would be cost-effective (PAD, p. 81). The ICR carried out a cost-benefit analysis, assessing the benefits arising from the reduction in disease prevalence: reduced mortality, reduced cost of care due to reduced morbidity, reduced loss of productivity, and increased health personnel productivity, all aggregating at US$125.54 million. The time period used was eight years with costs starting in 2010 and benefits starting in the third year. With an investment cost of US$22.7 million over eight years, the net present value was estimated at US$49.7 million using a discount rate of 3%. The benefit-cost ratio was estimated at 12.44 and the internal rate of return at 43.13% (ICR, p. 40). The ICR did not provide a sensitivity analysis that would have shown estimated values under higher discount rates. Also, as stated in Section 3, the burden of schistosomiasis accounted for only 3.16% of the total disability-adjusted life years in Yemen. Some aspects of implementation contributed to efficiency, such as the inclusion of activities to reach out-of- school children (ICR, p. 14) and leveraging of partnerships (ICR, p. 18). But there were shortcomings related to other aspects of implementation and design. The project allocated US$5 million to the addition of a new component (Output-Based Deworming and Control of Other Neglected Tropical Diseases) described by the ICR (p. 21) as extremely ambitious, as there was insufficient capacity in managing output-based financing in the Ministry of Public Health and Population (MoPHP). The component had minimal progress and a negligible expenditure (US$0.1 million) used for printing materials. Also, the ICR (p. 18) stated that the project entered into a technical assistance agreement with WHO that focused solely on the implementation of mass drug administration campaigns, and hence other activities were no longer financed. Financial management shortcomings were noted throughout the implementation period. According to the ICR, hygiene education and behavior change interventions did not receive much consideration, and yet, they could have enhanced Page 7 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) the results gained from mass drug administration (ICR, p. 24). The ICR (p. 18) noted that there was lack of attention to integration aspects with the regular health system such as the use of existing platforms for drug distribution and integrated supply chain and monitoring, and referred to IEG's Portfolio Review of World Bank Lending for Communicable Disease Control, Working Paper 2010/3, which stressed that investments for strengthening health systems are an essential means to controlling disease outcomes, especially for the poor, and should not be viewed as alternative investments in communicable disease control. In view of the conflict situation in the country, disbursements were suspended twice in 2011 and 2015 for a cumulative period of 15 months. There were periods of severe restrictions to operate the project administration unit due to the lack of operating costs and salaries (ICR, p. 15). The Bank Office in Yemen was closed in February 2015, and interaction with the project administration unit was undertaken from a distance through virtual meetings. Three project extensions were needed to complete project activities. However, within the broad context of overall efficiency, these shortcomings are considered relatively moderate and efficiency is rated Substantial. Efficiency Rating Substantial a. If available, enter the Economic Rate of Return (ERR) and/or Financial Rate of Return (FRR) at appraisal and the re-estimated value at evaluation: Rate Point value (%) *Coverage/Scope (%) Available? 0 Appraisal 0 Not Applicable 100.00 ICR Estimate  43.13 Not Applicable * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome Relevance of objectives is rated High as the objectives were fully consistent with the Bank’s Country Engagement Note. Efficacy is rated Substantial, as the project almost fully achieved its objectives. Efficiency is rated Substantial because of moderate shortcomings. Therefore, the overall Outcome is rated Satisfactory. a. Outcome Rating Satisfactory Page 8 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) 7. Risk to Development Outcome The continued conflict situation in the country constitutes a major risk that development outcomes may not be maintained, although the government remains committed to schistosomiasis control with continued support from partners, and remains specifically committed to continue the implementation of preventive drug therapy. Transitioning from an intensive phase to a future maintenance phase to prevent resurgence of schistosomiasis transmission would require health systems that function effectively, inclusion of non-medical and environmental measures, and overall improvement in living conditions and sanitation. 8. Assessment of Bank Performance a. Quality-at-Entry An important element of the project design was the appropriate focus on mass drug administration to rapidly reduce schistosomiasis infections and their morbidity in endemic areas. But there were shortcomings. According to the ICR (p. 18), due attention was not provided during project preparation to health education and behavior change interventions for water and sanitation, as they are known to play an important complementary role in the interruption of disease transmission. Environmental interventions for snail control were not included, and the TTL (11/1/18) clarified that such interventions would have required a rigorous assessment and the involvement of multiple sectors, with extensive training beyond the MoPHP, and that the project constituted a first phase focusing on preventive chemotherapy. On the other hand, the ICR (p. 18) stated that the National Schistosomiasis Control Program regretted during the preparation of the ICR that there were no substantial steps taken during implementation to control snails. The ICR also noted that snail control was expected to be considered at the Mid-Term Review. Eventually, such complementary strategies along with mass drug administration will be needed to interrupt disease transmission. The project considered lessons learned from country and global experience, including the importance of a single purpose public health intervention; the value of expanding targeting to reach non-enrolled school- age children and other pockets of underprivileged populations; securing drug procurement to support large- scale drug administration campaigns; and adequate technical support to the line ministry in charge of the national control program (PAD, p. 10). Since the procurement of drugs was a major part of the project, it was secured through direct contracting with WHO. Risks were well identified, including considerable risks of political instability and unrest (PAD, p. 18). Mitigation measures for other risks were put in place, including the contracting of an Independent Technical and Internal Audit Firm to provide fiduciary support and independent verification of mass drug administration campaigns. M&E design and arrangements were adequately prepared, but with shortcomings related to school-age children data, as disaggregation of results and targets were not specified by the PAD (ICR, p. 11), and it Page 9 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) was not clear whether the three PDO indicators measured progress in school-age children in endemic areas or the entire population that was treated in those areas. The ICR (p. 18) stated that the project could have paid more attention to related health system strengthening aspects such as existing platforms for drug distribution and integrated supply chain to facilitate the eventual integration of the vertical program into the regular health system to ensure long term sustainability and impact. Quality-at-Entry Rating Moderately Satisfactory b. Quality of supervision During accessible periods, all supervision missions were jointly undertaken with partners and the MoPHP (ICR, p. 22). The Bank team’s engagement was reportedly solid during implementation with a maintained focus on achieving results on the ground. According to the ICR (p. 25), counterparts valued Bank implementation support, including hands-on support in fiduciary aspects. Frequent virtual meetings with government officials and partners were conducted remotely to discuss progress and challenges. The Bank team and Country Management Unit were pro-active in lifting the disbursement suspension in 2015. Coordination with partners was reportedly strong, including WHO and the Schistosomiasis Control Initiative of the Imperial College London, along with the MoPHP and its National Schistosomiasis Control Program. Partnership with the END Fund enabled the national program to conduct an additional mass drug administration campaign. However, there were shortcomings. Deficiencies in the team's reporting were noted. According to the ICR, the Implementation Status Reports (ISRs) always reported overall figures (ICR, p. 11) without disaggregating data for school-age children, even though such data were collected and available (ICR, p. 25). Also, according to the ICR, the ISRs' reporting on implementation status and results monitoring was not systematic, and data for some indicators, namely geographic and program coverage, were erratic (ICR, p. 22). The ICR (p. 25) stated that the addition of deworming and control of other neglected tropical diseases at the 2013 restructuring was too ambitious in view of limited capacity in implementing output-based financing, and that, at the Quality at Entry Review, the team had proposed the testing of output-based financing, but this was not recommended, as it would bring complexity to project implementation. A revision of the project's environmental assessment category at the 2013 restructuring was not undertaken (see Section 10a and ICR, p. 22). Quality of Supervision Rating Moderately Satisfactory Overall Bank Performance Rating Moderately Satisfactory Page 10 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) 9. M&E Design, Implementation, & Utilization a. M&E Design The objectives were clear and measurable, although it was unusual to set an achievement date in the statement of objectives. The selection of indicators was appropriate. The results framework was aligned with the theory of change. Building on the National Schistosomiasis Control Program M&E system, which was already in place, and on sentinel site surveys, impact evaluation was adequately planned in collaboration with WHO and the Schistosomiasis Control Initiative of the Imperial College London. There were no baselines at entry, and these were collected in 2013 (ICR, p. 21). But disaggregation of data by adults and school-age children should have been specified in the PAD to avoid potential confusion during project implementation (ICR, p. 21) and to facilitate the assessment of objectives that were specific to school-age children. b. M&E Implementation Overall, M&E implementation was adequate. Data collection and analysis for the impact evaluation were conducted for the baseline, mid-term and end-line surveys. Data for intermediate results indicators were collected by the National Schistosomiasis Control Program. After each of the 13 mass drug administration campaigns, the collected data were independently verified by a third-party agency. Difficulties were encountered in assessing the intensity of intestinal schistosomiasis in school-age children because of M&E gaps, and the lack of a relevant target. c. M&E Utilization According to the ICR (p. 22), data were utilized by MoPHP to recategorize the districts in terms of endemicity. The baseline and mid-line surveys of the impact evaluation informed the planning for subsequent mass drug administration campaigns in targeting vulnerable districts. M&E Quality Rating Substantial 10. Other Issues a. Safeguards Page 11 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) At entry, no safeguard policies were triggered by the project which was classified as Category C under the Environmental Screening Category. However, the ICR (p. 22) stated that the 2013 restructuring included surgical treatment for trachoma (with an intermediate result indicator on the number of persons benefiting from trachoma surgery), thus generating a potential medical waste risk. The ICR stated that a change in the project's environmental category was not discussed by the team. b. Fiduciary Compliance Financial Management. Relevant arrangements were put in place, and the Independent Technical and Internal Audit firm verified that mass drug administration campaigns were properly conducted and constituted a reliable base for fund disbursements. The ICR stated that the independent audit firm was instrumental in fiduciary capacity building at the project administration unit, and the firm contributed to enhancing the confidence of the Bank and partners during inaccessible periods caused by the conflict in the country (ICR, p. 23). There were shortcomings, many of which were related to weak capacities. Quarterly interim financial reports presented to the Bank required revisions throughout the implementation period. Independent financial auditors reported a number of observations, such as missing documentation, delays in settling advances, and discrepancies in the information provided. Procurement. There were delays related to the preparation of technical specifications, incorrect preparation of procurement documents, and centralized decision-making at MoPHP, notably in the early stages of implementation. Post procurement reviews were carried out annually by the Bank and were used for improving the quality of procurement documentation, specifications, and filing. Suspension of disbursement; and procurement through UN agencies. Following civil unrest in 2015, the Bank suspended disbursement for all Bank-financed projects in the Yemen portfolio on 3/11/15, in line with OP/BP 7.30 on dealing with de facto governments. In December 2015, the Bank team obtained exceptions to lift disbursement suspension for both this Schistosomiasis Control Project and the Health and Population Project (P094755) in view of the dire needs for basic health services (ICR, p. 9). The policy exception was granted subject to entering into Operational and Technical Assistance Agreements with UN agencies to further ensure that the funds were properly used for their intended purposes. The project administration unit was sustained through its access to the project’s designated account to continue the discharge of its duties. Near the end of project, procurement of praziquantel worth US$0.5 million was planned to be utilized under the Yemen Emergency Health and Nutrition Project (P1618109). However, procurement was not completed before project closing, including because of shifting attention to the cholera epidemic in the country, and related funds were returned to the Bank. c. Unintended impacts (Positive or Negative) None reported. Page 12 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) d. Other -- 11. Ratings Reason for Ratings ICR IEG Disagreements/Comment The ICR rated efficacy as High, and this ICR Review rated efficacy as Substantial because the objectives were almost fully achieved. The Outcome Highly Satisfactory Satisfactory ICR rated efficiency as High, and this ICR Review rated efficiency as Substantial because of moderate shortcomings. This ICR Review rated both quality at entry and supervision as Moderately Moderately Satisfactory because of Bank Performance Satisfactory Satisfactory shortcomings discussed in Section 8, including shortcomings in monitoring and the quality of reporting. Quality of M&E Substantial Substantial --- Quality of ICR Substantial --- 12. Lessons The ICR (pp. 26-27) offered several lessons, restated by IEG: Leveraging comparative strengths of partners under clear terms of reference maximizes partnership effectiveness. Partnerships that were developed by the project under clear terms of reference with the World Health Organization, the Schistosomiasis Control Initiative of the Imperial College - London, and the End Fund leveraged the core comparative strengths of these agencies in the interest of the project. Integrating relevant health system strengthening activities with a vertical disease approach promotes sustainability and resilience. The project focused primarily on immediate needs, but could have dealt with Page 13 of 14 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review RY-Schistosomiasis Control Project (P113102) relevant health system strengthening aspects such as the integration of drug distribution for schistosomiasis with the regular health system. When a vertical approach for a disease control project is adopted, maintaining its single disease purpose maximizes the likelihood of its progress and cost-effectiveness. Although primary attention to schistosomiasis was temporarily diluted by the introduction of deworming and other neglected tropical diseases, the project was focused on attaining its stated objectives and maintained its primary attention on schistosomiasis control. 13. Assessment Recommended? No 14. Comments on Quality of ICR The ICR established and illustrated the theory of change in a lucid and convincing manner. It was aligned to development objectives. The ICR was very candid and clear overall, with some gaps in its presentation of results. The quality of the evidence was adequate, but with moderate shortcomings related to the project M&E and not to the ICR's sound analysis. The narrative, findings, and evidence supported the ICR's conclusions, but not its ratings. Lessons and recommendations were related to project experience and should prove useful to future projects in countries with fragility, conflict and violence situations. The ICR's discussion in highlighting the value of UN partnerships and the identification of alternative supervision arrangements in conflict environments was noteworthy. The ICR was consistent with the guidelines. a. Quality of ICR Rating Substantial Page 14 of 14