FOR OFFICIAL USE ONLY Report No: PAD3327 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED LOAN IN THE AMOUNT OF US$60 MILLION TO THE REPUBLIC OF ANGOLA ON PROPOSED GRANTS IN THE AMOUNT OF SDR 21.8 MILLION (US$30 MILLION EQUIVALENT) TO THE REPUBLIC OF CHAD IN THE AMOUNT OF SDR 10.9 MILLION (US$15 MILLION EQUIVALENT) TO THE CENTRAL AFRICAN REPUBLIC IN THE AMOUNT OF US$75 MILLION (SDR 54.6 MILLION EQUIVALENT) TO THE DEMOCRATIC REPUBLIC OF CONGO IN THE AMOUNT OF US$10 MILLION TO THE ECONOMIC COMMUNITY OF CENTRAL AFRICAN STATES AND PROPOSED CREDITS IN THE AMOUNT OF US$75 MILLION TO THE DEMOCRATIC REPUBLIC OF CONGO IN THE AMOUNT OF EUR 13.5 MILLION (US$15 MILLION EQUIVALENT) TO THE REPUBLIC OF CONGO FOR THE REGIONAL DISEASE SURVEILLANCE SYSTEMS ENHANCEMENT PROJECT (REDISSE) IN CENTRAL AFRICA, PHASE IV September 16, 2019 Health, Nutrition and Population Global Practice Africa 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 (Central African Currency Unit CFA Franc - XAF) XAF 578 = US$1.00 US$1.00 = SDR 0.72 US$1.00 = EUR 0.89 FISCAL YEAR January 1 - December 31 Regional Vice President: Hafez M.H. Ghanem Africa Regional Integration Director: Deborah L. Wetzel Global Practice Director: Muhammad Ali Pate Practice Manager: Magnus Lindelow Task Team Leaders: Enias Baganizi, Andy Chi Tembon ABBREVIATIONS AND ACRONYMS ACDC Africa Centres for Disease Control and Prevention ACDCP Africa Centers for Disease Control Project (P167916) ADM Accountability and Decision making AMR Antimicrobial Resistance AU-IBAR African Union Inter-african Bureau for Animal Resources AWPB Annual Work Plan and Budget CAGF Cellule d’Appui et de Gestion Financière (Coordination and Financial Management Unit) CAR Central African Republic CAT-DDO Catastrophe Risk Deferred Drawdown CDC US Center for Disease Control and Prevention CERC Contingent Emergency Response Component CFA Coopération Financière en Afrique Centrale (Financial Cooperation in Central Africa) CGPMP Projets et Marchés Publics (Procurement Management Unit) CPF Country Partnership Framework DA Designated Account DEP Département des Études et de la Planification (Director of the Department of Studies and Planning) DGLM Director General of Disease Control Management DRC Democratic Republic of Congo DON Disease Outbreak Notification DRM Disaster Risk Management E&S Environmental and Social EAPHLN East Africa Public Health and Laboratory Networking Project ECCAS Economic Community of Central African States ECOWAS Economic Community of West African States EID Emerging and Re-emerging Infectious Diseases EOC Emergency Operating Centre in Public Health ESCP Environmental and Social Commitment Plan ESF Environmental and Social Framework ESMF Environmental and Social Management Framework ESS Environmental and Social Standard EVD Ebola Virus Disease FAO Food and Agriculture Organization FCV Fragile, Conflict and Violence FETP Field Epidemiology Training Program FELTP Field Epidemiology and Laboratory Training Program FM Financial Management FMS Financial Management Specialist FY Fiscal Year GBV Gender Based Violence GDP Gross Domestic Product GEPE Gabinete de Estudos, Planeamento e Estatistica (Department of Studies, Planning, and Statistics) GHG Greenhouse Gas GIIP Good International Industry Practice GRM Grievance Redress Mechanism GRS Grievance Redress Service H1N1 Hemagglutinin (H) and Neuraminidase (N) H5N1 Asian Avian Influenza A, also known as “Bird Flu” IBRD International Bank for Reconstruction and Development ICR Implementation Completion and Results Report ICT Information and Communication Technology IDA International Development Association IDSR Integrated Disease Surveillance and Response IEG Independent Evaluation Group IHR International Health Regulation IP/SSAHUTLC Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities IPF Investment Project Financing ISP Implementation Support Plan iSOP Interdependent Series of Projects IWG International Working Group IWN JEE Joint External Evaluation M&E Monitoring and Evaluation MERS-CoV Middle East Respiratory Syndrome Coronavirus MoH Ministry of Health MoPH Ministry of Public Health MoPHP Ministry of Public Health and Population MTR Mid-term Review NAPHS National Action Plan for Health Security NGOs Non-governmental Organizations NPF New Procurement Framework NSC National Steering Committee OH One Health OHADA Organization for Harmonization of Corporate Law in Africa (Organisation pour l’Harmonisation en Afrique du Droit des Affaires) OHS Health and Safety OIE Office International des Epizooties (World Organization for Animal Health) PASS Health System Support Project PCT Project Coordination Unit PDO Project Development Objective PDSS Health System Strengthening for Better Maternal and Child Health Results Project (P147555) PHEIC Public Health Emergency of International Concern PIM Project Implementation Manual PIU Project Implementation Unit PMU Project Management Unit PNHF Programme National d’Hygiène aux Frontières (National Hygiene Program at the Borders) PPSD Project Procurement Strategy for Development PVS Evaluation of the Performance of Veterinary Services (OIE tool) RAHC Regional Animal Health Center RCCs Regional Collaborating Centers REDISSE Regional Disease Surveillance Systems Enhancement Program RI Regional Integration RoC Republic of Congo RSC Regional Steering Committee R-PCU Regional Project Coordination Unit SARS Severe Acute Respiratory Syndrome SCD Systematic Country Diagnostics SEA Sexual Exploitation and Abuse SENI Health System Support and Strengthening Project SEP Stakeholder Engagement Plan SoE Statement of Expenditure SRP Strategic Response Plan STEP Systematic Tracking of Exchanges in Procurement ToR Terms of Reference UCC Central Coordination Unit (Unidade Central de Coordenação) UEP Unité d’Exécution du Projet UN United Nations UNICEF United Nations Children’s Fund WAHO West African Health Organization WBG World Bank Group WHO World Health Organization WHO/AFRO World Health Organization Africa Regional Office XAF Central African CFA Franc The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Contents DATASHEET ........................................................................................................................... 1 I. STRATEGIC CONTEXT .................................................................................................... 13 A. Regional and Country Context ........................................................................................................ 13 B. Sectoral and Institutional Context .................................................................................................. 17 C. Relevance to Higher Level Objectives............................................................................................. 21 II. PROJECT DESCRIPTION.................................................................................................. 23 A. Project Development Objective ..................................................................................................... 26 B. Project Components ....................................................................................................................... 27 C. Project Beneficiaries ....................................................................................................................... 30 D. Results Chain .................................................................................................................................. 31 E. Rationale for World Bank Involvement and Role of Partners......................................................... 31 F. Lessons Learned and Reflected in the Project Design .................................................................... 32 III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 35 A. Institutional and Implementation Arrangements .......................................................................... 35 B. Results Monitoring and Evaluation Arrangements......................................................................... 36 C. Sustainability................................................................................................................................... 36 IV. PROJECT APPRAISAL SUMMARY ................................................................................... 37 A. Technical, Economic and Financial Analysis ................................................................................... 37 B. Fiduciary.......................................................................................................................................... 40 C. Climate change (co-benefits) .......................................................................................................... 42 D. Legal Operational Policies .............................................................................................................. 43 E. Environmental and Social ............................................................................................................... 44 V GRIEVANCE REDRESS SERVICES ......................................................................................... 48 VI. KEY RISKS ....................................................................................................................... 49 VII. RESULTS FRAMEWORK AND MONITORING ................................................................... 51 ANNEX 1: Implementation Arrangements and Support Plan ................................................. 96 ANNEX 2: DETAILED PROJECT DESCRIPTION ....................................................................... 119 ANNEX 3: Economic and Financial Analysis ........................................................................ 133 ANNEX 4: Technical Priority DRC NAPHS Activities Eligible for REDISSE IV Financing ........... 148 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) LIST OF TABLES Table 1: Breakdown of Project Financing Table 2: Estimated Project Budget Allocations by Component Table 3: Estimated Country funding by Component Table 4: Estimated Country funding by component and sub-component Table 5: Historical cost of Ebola, Yellow Fever, Influenza and Cholera in REDISSE 4 countries Table 6: Risk Categories Table A1.1: Types of projects auditors and audit types Table A1.2: Project Bank Accounts Table A1.3: Financial Management Action Plan Table A1.4: Implementation support plan and resources required Table A3.1: Estimated economic benefits of preventing cholera, Ebola, influenza and yellow fever outbreaks within REDISSE 4 countries, 2019-2023 Table A3.2: Summary of total and per capita project cost Table A3.3: Estimated cost (US$ million 2019) of historical cholera outbreaks in REDISSE 4 countries, 2000-2016 Table A3.4: Estimated economic benefit (US$ million 2019) of preventing cholera within REDISSE 4 countries, 2019-2023 Table A3.5: Summary of estimates of economic cost of 2014-15 Ebola outbreak Table A3.6: Estimated cost (US$ million 2019) of historical Ebola outbreaks in REDISSE 4 countries, 2000- 2019 Table A3.7: Estimated economic benefit (US$ million 2019) of preventing Ebola within REDISSE 4 countries, 2019-2023 Table A3.8: Estimated cost (US$ million 2019) of seasonal influenza and H1N1 in REDISSE 4 countries Table A3.9: Estimated economic benefit (US$ million 2019) of preventing seasonal influenza and H1N1 within REDISSE 4 countries 2019-2023 Table A3.10: Estimated cost (US$ million 2019) of historical yellow fever outbreaks in REDISSE 4 countries, 2000-2018 Table A3.11: Estimated economic benefit (US$ million 2019) of preventing Yellow Fever within REDISSE 4 Countries, 2019-2023 Table A3.12: Cost benefit analysis results Table A3.13: Sensitivity Analysis LIST OF FIGURES Figure 1: Areas at risk for Ebola Emergence Figure 2: The Region of the Economic Community of Central African States (ECCAS) Figure 3: One health framework Figure A1: Institutional and Implementation arrangements at regional level. Figure A2.1: Angola Flow of Funds Figure A2.2.: ECCAS Flow of Funds Figure A2.3.: DRC – RoC Flow of Funds Figure A2.4.: CAR Flow of Funds Figure A2.5.: Chad Flow of Funds LIST OF BOXES Box 1: Complementarity of REDISSE 4 with the Africa CDC Project The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Box 2: EVD Outbreaks in DRC Box 3: Why a Regional Approach to Disease Surveillance and Response in Central Africa The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Central Africa, Angola, Central African Republic, Congo, Regional Disease Surveillance Systems Enhancement Project (REDISSE) Phase IV Republic of, Chad, Congo, Democratic Republic of Environmental and Social Risk Project ID Financing Instrument Process Classification Urgent Need or Investment Project P167817 Substantial Capacity Constraints Financing (FCC) 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 01-Oct-2019 31-Jul-2024 Bank/IFC Collaboration No Page 1 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Proposed Development Objective(s) The project development objectives are: (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the Participating Countries; and (ii) in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. Components Component Name Cost (US$, millions) Component 1: Strengthening Surveillance and Laboratory Capacity to Rapidly detect 126.45 Outbreaks Component 2: Strengthening Emergency Planning and Management Capacity to 66.45 Rapidly respond to Outbreaks Component 3: Public Health Workforce Development 47.60 Component 4: Institutional Capacity Building, Project Management, Coordination and 39.50 Advocacy Organizations Borrower: Republic of Chad Republic of Angola Central African Republic Democratic Republic of Congo ECCAS Republic of Congo Implementing Agency: ECCAS Secretariat Ministry of Health and Population - Republic of Congo Ministry of Public Health - Chad Ministry of Public Health and Population - Central African Republic Ministry of Public Health - DRC Ministry of Health - Angola PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 280.00 Total Financing 280.00 of which IBRD/IDA 280.00 Financing Gap 0.00 Page 2 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 60.00 International Development Association (IDA) 220.00 IDA Credit 90.00 IDA Grant 130.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount Central African Republic 0.00 15.00 0.00 15.00 National PBA 0.00 5.00 0.00 5.00 Regional 0.00 10.00 0.00 10.00 Congo, Republic of 15.00 0.00 0.00 15.00 National PBA 5.00 0.00 0.00 5.00 Regional 10.00 0.00 0.00 10.00 Chad 0.00 30.00 0.00 30.00 National PBA 0.00 10.00 0.00 10.00 Regional 0.00 20.00 0.00 20.00 Congo, Democratic 75.00 75.00 0.00 150.00 Republic of National PBA 25.00 25.00 0.00 50.00 Regional 50.00 50.00 0.00 100.00 Central Africa 0.00 10.00 0.00 10.00 Regional 0.00 10.00 0.00 10.00 Total 90.00 130.00 0.00 220.00 Expected Disbursements (in US$, Millions) WB Fiscal Year 2020 2021 2022 2023 2024 2025 Annual 14.22 44.67 67.76 70.00 71.08 12.27 Page 3 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Cumulative 14.22 58.89 126.65 196.65 267.73 280.00 INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Agriculture and Food 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 ⚫ Substantial 2. Macroeconomic ⚫ High 3. Sector Strategies and Policies ⚫ Moderate 4. Technical Design of Project or Program ⚫ Substantial 5. Institutional Capacity for Implementation and Sustainability ⚫ High 6. Fiduciary ⚫ High 7. Environment and Social ⚫ Substantial 8. Stakeholders ⚫ Substantial 9. Other ⚫ Substantial Page 4 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 10. Overall ⚫ Substantial COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [✓] No Does the project require any waivers of Bank policies? [ ] Yes [✓] No Environmental and Social Standards Relevance Given its Context at the Time of Appraisal E & S Standards Relevance Assessment and Management of Environmental and Social Risks and Impacts Relevant Stakeholder Engagement and Information Disclosure Relevant Labor and Working Conditions Relevant Resource Efficiency and Pollution Prevention and Management Relevant Community Health and Safety Relevant Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Relevant Biodiversity Conservation and Sustainable Management of Living Natural Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Relevant Local Communities Cultural Heritage Relevant Financial Intermediaries Not Currently Relevant NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review Summary (ESRS). Page 5 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Legal Covenants Sections and Description ANGOLA: SCHEDULE 2. Section I.A.2. Technical Committee. The Borrower shall, not later than three (3) months after the Effective Date, establish under terms of reference satisfactory to the Bank, and thereafter maintain throughout Project implementation, the Technical Committee comprising a focal point from each of the Borrower’s ministries responsible for health, finance, agriculture, environment, and territorial administration, the General Project coordinator and other partners. The Technical Committee shall report to the Inter-ministerial Commission for Epidemic Control and shall meet quarterly, with the responsibility of drafting the Annual Work Plan and Budget, reporting on activities carried out within the framework of the Project and archiving Project documentation. Sections and Description ANGOLA:SCHEDULE 2. Section I.A.3.(b). The PIU shall be headed by the General Project Coordinator and its composition shall include the following specialists, all under terms of reference, and with qualifications and experience satisfactory to the Bank: (i) a Project coordinator for REDISSE with expertise in human health; (ii) a monitoring and evaluation specialist; (iii) a financial management specialist; (iii) an accountant and an accountant assistant; and (v) a procurement specialist, and the following staff to be recruited to the PIU not later than three (3) months after the Effective Date: (i) an animal health specialist ; and (ii) an environmental and social safeguards specialist. The Project Implementation Unit shall be further supported by technical staff of the MoH assigned to each specific technical area of the Project, such as health financing, public health, human resources for health, health information systems, epidemiology, among others, as further detailed in the PIM. Sections and Description ANGOLA.: SCHEDULE 2. Section. I.C.4. The Borrower shall establish, not later than three (3) months after the Effective Date, and thereafter maintain and publicize throughout Project implementation the availability of a grievance mechanism, in form and substance satisfactory to the Bank, to hear and determine fairly and in good faith all complaints raised in relation to Parts 1.1, 1.2, 1.3 (a), 1.3 (b)(i), 1.3 (c), 1.3 (d), 1.4, 2, 3 and 4.1 of the Project, and take all measures necessary to implement the determinations made by such mechanism in a manner satisfactory to the Bank. Sections and Description CAR: SCHEDULE 2. Section I. A.3 (b) To that end, the Recipient shall, at all times during Project implementation, maintain the PIU functioning under a mandate and with staffing and resources acceptable to the Association, headed by the Director of Cabinet in the MoPHP and with a composition including, inter alia, the assistant technical coordinator and following staff, each with terms of reference, qualifications and experience satisfactory to the Association, to be recruited not later than two (2) months after the Effective Date: (i) a monitoring and evaluation specialist; (ii) a procurement specialist; and (iii) a social safeguards specialist. Sections and Description ANGOLA: SCHEDULE 2. Section. I.G. The Borrower shall, not later than two (2) months after the Effective Date: (i) develop a financial management manual, in form and substance satisfactory to the Bank, to supplement the Project Implementation Manual; (ii) customize the accounting software of the MoH to enable it to maintain separate records and ledger account of the Project and thereby allow the Recipient to comply with its obligations under this Agreement; and (iii) recruit an internal auditor under terms of reference and with experience and qualifications satisfactory to the Association. Page 6 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Sections and Description CAR: SCHEDULE 2. Section I. A. 2 (a) The Recipient shall, not later than three (3) months after the Effective Date, establish, and thereafter maintain throughout Project implementation maintain, the Project Technical Committee. Sections and Description CAR: SCHEDULE 2. Section I.C.3. The Recipient shall, not later than three (3) months after the Effective Date, establish, and thereafter maintain and publicize throughout Project implementation, the availability of a grievance mechanism, in form and substance satisfactory to the Association, to hear and determine fairly and in good faith all complaints raised in relation to Parts 1.1, 1.2, 1.3 (a), 1.3 (b)(i), 1.3 (c), 1.3 (d), 1.4, 2, 3 and 4.1 of the Project, and take all measures necessary to implement the determinations made by such mechanism in a manner satisfactory to the Association. Sections and Description CAR: SCHEDULE 2. Section I.G (a) not later than two (2) months after the Effective Date, acquire a a multi-project license of for the accounting software (TOMPRO) satisfactory to the Association, so as to allow the Recipient to comply with its obligations under this Agreement; and Sections and Description CAR: SCHEDULE 2. Section I. G. (b) not later than three (3) months after the Effective Date: (i) develop a financial management manual, in form and substance satisfactory to the Association, to supplement the Project Implementation Manual; and (ii) recruit an internal auditor under terms of reference and with experience and qualifications satisfactory to the Association. Sections and Description CHAD: SCHEDULE 2. Section I.A.3 (b). To that end, the Recipient shall, at all times during Project implementation, maintain the existing PCU functioning under a mandate and with staffing and resources acceptable to the Association, headed by a Project Coordinator and with a composition including, inter alia, an administrative and financial manager, a procurement specialist, a senior accountant, an internal auditor, a communication specialist, an monitoring and evaluation specialist, and the following additional staff, each with terms of reference, qualifications and experience satisfactory to the Association, to be recruited not later than three months after the Effective Date: (i) a technical assistant coordinator; (ii) an expert in public health or education; (iii) a social and gender expert; (iv) an environmental expert; (v) a procurement assistant; and (vi) an accountant. Sections and Description CHAD: SCHEDULE 2. Section I.A.1. The Recipient shall establish, not later than three (3) months after the Effective Date, and thereafter maintain throughout Project implementation, the National Steering Committee on Health represented by the One Health platform in the Office of the Minister, Secretary General in the Recipient’s Presidency, with the objective of providing strategic and policy guidance to the PCU and approving the AWP&B. In order to ensure cross-cutting effectiveness, the National Steering Committee on Health shall be headed by the Minister of State, Secretary General of the Recipient’s Presidency and shall include ministers of the concerned departments and the Recipient’s Ministry of Planning. Sections and Description Page 7 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) CHAD: SCHEDULE 2. Section I.A.2.(a). The Recipient shall, not later than three (3) months after the Effective Date, establish, and thereafter maintain within the MoPH throughout Project implementation maintain, the Project Technical Committee to be responsible for reviewing and approving Progress Reports and providing guidance to the PCU. For such purpose, the PTC shall meet every three months. Sections and Description DRC: SCHEDULE 2. Section I.C.3. The Recipient shall establish, not later than two (2) months after the Effective Date, and thereafter maintain and publicize during Project implementation, the availability of a grievance mechanism, in form and substance satisfactory to the Association, to hear and determine fairly and in good faith all complaints raised in relation to Parts 1.1, 1.2, 1.3 (a), 1.3 (b)(i), 1.3 (c), 1.3 (d), 1.4, 2, 3 and 4.1 of the Project, and take all measures necessary to implement the determinations made by such mechanism in a manner satisfactory to the Association. Sections and Description CHAD: Schedule 2. Section I.C.3. The Recipient shall establish, not later than three (3) months after the Effective Date, and thereafter maintain and publicize throughout Project implementation, the availability of a grievance mechanism, in form and substance satisfactory to the Association, to hear and determine fairly and in good faith all complaints raised in relation to Parts 1.1, 1.2, 1.3 (a), 1.3 (b)(i), 1.3 (c), 1.3 (d), 1.4, 2, 3 and 4.1 of the Project, and take all measures necessary to implement the determinations made by such mechanism in a manner satisfactory to the Association. Sections and Description DRC: SCHEDULE 2. Section I.A. 2. (a). The Recipient shall, not later than three (3) months after the Effective Date, establish, and thereafter maintain throughout Project implementation maintain, the Project Technical Committee (PTC) within the Directorate General for Disease Control, under terms of reference and with representation satisfactory to the Association, including, inter alia, the secretaries general of the relevant ministries and technical assistants in animal, human and plant health and environmental and social safeguards. Sections and Description DRC: SCHEDULE 2. Section I.A. 3 (b). To that end, the Recipient shall, at all times during Project implementation, maintain the existing PDSS PCT functioning under a mandate and with staffing and resources acceptable to the Association, headed by the Project Coordinator and with a composition including, inter alia, a Project manager/focal point and the following staff, each with terms of reference, qualifications and experience satisfactory to the Association, to be recruited not later than one (1) month after the Effective Date: (i) a procurement specialist; (ii) a financial management specialist; (iii) an accountant; (iv) a monitoring and evaluation specialist; (v) a social safeguards specialist; (vi) an environmental safeguards specialist; and (vii) four (4) technical specialists. Sections and Description DRC: SCHEDULE 2. Section I.G. The Recipient shall, not later than three (3) months after the Effective Date: (i) develop a financial management manual, in form and substance satisfactory to the Association, to supplement the Project Implementation Manual; (ii) acquire a multi-site and multi-project version of the management accounting software satisfactory to the Association, so as to allow the Recipient to comply with its obligations under this Agreement; and (ii) appoint an internal auditor under terms of reference and with experience and qualifications satisfactory to the Association. Page 8 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Sections and Description ROC: SCHEDULE 2. Section I.A.1.The Recipient shall establish, not later than three (3) months after the Effective Date, and thereafter maintain throughout Project implementation, that the National Steering Committee with the objective of providing strategic and policy guidance to PMU and approving the AWP&B. In order to ensure cross- cutting effectiveness, the National Steering Committee shall be chaired by the Recipient’s Minister of Planning, Statistics and Regional Integration and shall comprise representatives from all Project beneficiary Ministries, while the Project Coordinator shall act as the secretary. Sections and Description ROC: SCHEDULE 2: Section I. A.2. (a). The Recipient shall, not later than three (3) months after the Effective Date, establish, and thereafter maintain throughout Project implementation, the Project Technical Committee within the Directorate of Planning of the MoHP, under terms of reference and with representation satisfactory to the Association. The PTC shall serve as the One Health committee at the central level and shall be vested with responsibility for providing technical design of tools and management documents, developing and concurring with the AWP&B, and monitoring its implementation. For such purpose, the PTC shall meet at least once every quarter. Sections and Description ECCAS: SCHEDULE 2. Section I.A.2. (a) The Recipient shall carry out Parts 1.3 (b)(ii) and 4.2 of the Project through the Regional Project Coordination Unit. To that end, the Recipient shall maintain the RPCU throughout Project implementation under terms of reference approved by the Association and adequately provided with financial resources and staffed with personnel with qualifications and experience satisfactory to the Association. The RPCU shall be headed by a Project Coordinator and is composition shall comprise, inter alia, a financial management specialist, a procurement specialist, a monitoring and evaluation specialist, and the following staff to be recruited not later than three (3) months after the Effective Date, all under terms of reference and with qualifications and experience satisfactory to the Association: a Project manager, an accountant, four senior health/ infectious diseases specialists, a senior environmental specialist, a senior social specialist, and an administrative assistant. Sections and Description ROC: SCHEDULE 2. Section I. A.3. (b). The PMU shall be headed by the Project coordinator and its composition shall include, inter alia, a financial management specialist, a procurement specialist, an accountant, and the following staff to be recruited, not later than three (3) months after the Effective Date, under terms of reference and with qualifications and experience satisfactory to the Association: (i) a monitoring and evaluation specialist; and (ii) a social and environmental safeguards specialist. Additional specialists in other sectoral fields shall be recruited as needed upon the Association’s recommendation thereon. Sections and Description ROC: SCHEDULE 2. Section I.C.3. The Recipient shall establish, not later than three (3) months after the Effective Date, and thereafter maintain and publicize throughout Project implementation, the availability of a grievance mechanism, in form and substance satisfactory to the Association, to hear and determine fairly and in good faith all complaints raised in relation to Parts 1.1, 1.2, 1.3 (a), 1.3 (b)(i), 1.3 (c), 1.3 (d), 1.4, 2, 3 and 4.1 of the Project, and take all measures necessary to implement the determinations made by such mechanism in a manner satisfactory to the Association. Sections and Description Page 9 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ROC: SCHEDULE 2. Section I.G. The Recipient shall, not later than three (3) months after the Effective Date: (i) develop a financial management manual, in form and substance satisfactory to the Association, to supplement the Project Implementation Manual; (ii) upgrade the existing software in the MoHP and training the PMU fiduciary staff on the use of such software, so as to allow the Recipient to comply with its obligations under this Agreement; and (iii) recruit an internal auditor under terms of reference and with experience and qualifications satisfactory to the Association. Sections and Description ECCAS: SCHEDULE 2. Section I.B.3. The Recipient shall establish, not later than two (2) months after the Effective Date, and thereafter maintain and publicize throughout Project implementation, the availability of a grievance mechanism, in form and substance satisfactory to the Association, to hear and determine fairly and in good faith all complaints raised in relation to Parts 1.3 (b)(ii) and 4.2 of the Project, and take all measures necessary to implement the determinations made by such mechanism in a manner satisfactory to the Association. Sections and Description ECCAS: SCHEDULE 2. Section I.F. The Recipient shall, not later than two (2) months after the Effective Date: (i) develop a financial management manual, in form and substance satisfactory to the Association, to supplement the Regional Project Implementation Manual in the area of financial management (including financial, administrative and accounting procedures, internal controls, and audits); and (ii) customize the existing multi projects accounting software currently used by the RPCU to fit the Project accounting and reporting needs, so as to allow the Recipient to comply with its obligations under this Agreement. Conditions Type Description Effectiveness ANGOLA: ARTICLE V.5.01.(a). The Borrower, through the PIU, shall have updated the Project Implementation Manual in form and substance satisfactory to the Bank. Type Description Effectiveness ANGOLA: ARTICLE V.5.01.(b). The Borrower shall have recruited to the PIU a Project coordinator for REDISSE with expertise in human health, under terms of reference and with experience and qualifications satisfactory to the Bank. Type Description Effectiveness ANGOLA: ARTICLE V.5.01.(c). The Borrower shall have furnished to the Bank documentary evidence, in form and substance satisfactory to the Bank, of the establishment of the necessary arrangements, in form and substance satisfactory to the Bank, for purposes of compliance with the provisions of Section 6.02 of the General Conditions under existing loan agreements between the Borrower and the Bank. For purposes of this paragraph (c), “General Conditions” means the “International Bank for Reconstruction and Development General Conditions for Loans”, dated March 12, 2012, with the modifications set forth in Section II of the Appendix to the Loan Agreement dated July 9, 2015 between the Borrower and the Bank for the First Fiscal Management Development Policy Loan (Loan No. 8526-AO). Page 10 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Type Description Effectiveness CAR: ARTICLE V.5.01.(a) .The Recipient, through the PIU, shall have updated the Project Implementation Manual in form and substance satisfactory to the Association. Type Description Effectiveness CAR: ARTICLE V.5.01.(b). The Recipient shall have recruited to the PIU a technical assistant coordinator under terms of reference and with experience and qualifications satisfactory to the Association. Type Description Effectiveness CHAD: ARTICLE V.5.01.(a). The Recipient, through the PCU, shall have updated the Project Implementation Manual in form and substance satisfactory to the Association. Type Description Effectiveness ROC: ARTICLE V. 5.01. (b).The Recipient shall have adopted the Project Implementation Manual in form and substance satisfactory to the Association. Type Description Effectiveness CHAD: ARTICLE V. 5.01. (b). The Recipient shall have developed a financial procedures manual, in form and substance satisfactory to the Association. Type Description Effectiveness CHAD: ARTICLE V. 5.01. (c). The Recipient shall have customized the PCU’s multi-project accounting software to fit the Project accounting and reporting needs Type Description Effectiveness DRC: ARTICLE V. 5.01. (a). The Recipient, through the PCT, shall have updated the Project Implementation Manual in form and substance satisfactory to the Association. Type Description Effectiveness DRC: ARTICLE V. 5.01. (b).The Recipient shall have recruited to the PCT a Project manager/focal point under terms of reference and with experience and qualifications satisfactory to the Association. Type Description Effectiveness ROC: ARTICLE V. 5.01. (a) The Recipient shall have: (i) established the PMU, under terms of reference and with a composition satisfactory to the Association; and (ii) appointed to the PMU the Project coordinator, a financial management specialist and a procurement specialist, all under terms of reference and with qualifications and experience satisfactory to the Association. Type Description Effectiveness ECCAS: ARTICLE V. 5.01. The Additional Condition of Effectiveness consists of the following, namely, that the Recipient shall have adopted the Regional Project Implementation Manual in form and substance satisfactory to the Association Page 11 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Page 12 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) I. STRATEGIC CONTEXT A. Regional and Country Context 1. The Ebola Virus Disease (EVD) epidemic in West Africa in 2014-2015, multiple outbreaks in 2016-20191, and the ongoing EVD outbreak in North Kivu, Democratic Republic of Congo (DRC) highlight both the threat of epidemic prone diseases in the Africa region and the importance of strong disease surveillance and response systems and inter-country collaboration to minimize economic costs and the loss of human lives in an outbreak. 2. The Regional Disease Surveillance Systems Enhancement Program (REDISSE) is multi-sectoral and aims to strengthen national and regional capacity to address disease threats at the human, animal, and environmental interface which is the source of most known epidemic-prone and novel pathogens. The REDISSE program addresses the gaps and weaknesses in disease surveillance, preparedness and response systems across all participating countries and supports country-led efforts to increase the resilience of the animal and human health systems of countries in the sub-region to better prevent and control infectious disease outbreaks. 3. The regional benefits and positive externalities of effective disease surveillance and response are substantial. Collective action and cross-border collaboration are essential elements of the REDISSE program which: (i) supports countries’ efforts to harmonize policies and procedures; (ii) empowers countries to engage in joint planning, implementation and evaluation of program activities across borders at regional, national and district levels, and; (iii) promotes resource sharing of high-cost specialized assets such as reference laboratories and specialized training and research institutions. The surveillance and response capacity of the regional systems depends on open collaboration and the combined strength of individual national systems from central to community-level. Thus, the REDISSE program proposes to strengthen the full “value-chain” of disease surveillance and response from the lowest community level through district, province/state, national, and Regional levels. 4. The REDISSE Program was designed as an interdependent Series of Projects (iSOP) to allow the program to expand as a function of both need and demand. It was originally designed to assist countries in West Africa to prevent, detect and respond to disease threats both individually and through regional collaboration and collective action. At present there are 11 West African countries participating in three effective projects under the REDISSE program2. The proposed project REDISSE Phase IV: Central Africa is the next step in the geographic expansion of the REDISSE Program. This expansion is both logical and urgent for the following reasons: (i) the countries of West and Central Africa are geographically proximate and epidemiologically similar, with hotspots for the emergence of epidemic prone diseases; (ii) health systems in both sub-regions have comparable weaknesses and will benefit from similar interventions; (iii) the trade and cultural connections among the countries of West and Central Africa increase the risk of cross border disease transmission; and, (iv) high and urgent demand from the Central African Government for financial support for disease surveillance and response and an interest in working across borders consistent with the REDISSE program approach. 1 There were significant outbreaks of Lassa fever, Rift Valley fever, Yellow fever, dengue hemorrhagic fever, Marburg virus disease (MVD), meningitis, monkeypox, cholera and plague in Africa between 2016 -2019. 2 REDISSE I was approved in June 2016 and includes Guinea, Sierra Leone and Senegal; REDISSE II was approved in March 2017 and includes Guinea Bissau, Liberia, Nigeria and Togo; REDISSE III was approved in May 2018 and includes Benin, Mali, Mauritania and Niger. Page 13 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 5. The countries in the Central African region are at very high-risk3 for infectious disease outbreaks, particularly those of animal origin (zoonotic diseases). Models have shown that countries in Central Africa, and especially DRC, contain geographic areas where animal populations maintain infection with the EVD4 (Figure 1). The drivers of emerging and re-emerging infectious diseases5 in the sub-region include land use, deforestation, and encroachment on previously remote rainforest habitats where humans may be exposed to new pathogens and wildlife reservoirs of diseases such as EVD.6 Figure 1: Areas at Risk for Ebola Emergence7 6. Applying the REDISSE model to the Central Africa sub-region also entails some challenges specific to this 3 Allen et al., 2017 “Global Hotspots and Correlates of Emerging Zoonotic Diseases.” 10.1038/s41467-017-00923-8. 4 A new model created at Oxford University shows areas where the Ebola virus is most likely prevalent in animal populations. These areas may be at risk for outbreaks of Ebola due to animal-human transmission. Viewed October 11, 2018 - https://www.siitube.com/articles/ethiopia-at-risk-of-animal-to- human-transmission-of-ebola-oxford-study_745.html. 5 Richardson et al., 2016 “Drivers for Emerging Issues in Animal and Plant Health.” 10.2 903/j.efsa. 2016.s0512. 6 Daszak P. 2000. Emerging Infectious Diseases of Wildlife - Threats to Biodiversity and Human ealth. Science 287:443–449. doi: 10.1126/science.287.5452.443. 7 A new model created at Oxford University shows areas where the Ebola virus is most likely prevalent in animal populations. These areas may be at risk for outbreaks of Ebola due to animal-human transmission. Viewed October 11, 2018 - https://www.siitube.com/articles/ethiopia-at-risk-of-animal-to- human-transmission-of-ebola-oxford-study_745.html. Page 14 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) sub-region: (i) a high proportion of countries classified as fragile, conflict and violence prone (FCV) with significant institutional and human capital constraints; (ii) high risk of transmission of diseases from animals to humans (zoonoses) associated with rapid changes in land use and high mammal biodiversity in the world’s second largest rainforest; and (iii) the relative weakness of regional coordinating institutions in Central Africa as compared to West Africa. 7. These challenges demand some experimentation and innovation in the application of the REDISSE model; however, the core structure of the new Phase IV, including the technical components and results framework, remains the same. The preparation of REDISSE Phase IV is based on the experience and lessons learned during the preparation and early implementation of the first three projects in the series. Details on lessons learned and reflected in the project design are given under Section F of this document. 8. REDISSE Phase IV will contribute to regional and global health security by assisting countries in Central Africa to (i) meet obligations under the International Health Regulations (IHR 2005) through implementation of the Integrated Disease Surveillance and Response (IDSR) strategy; and, comply with the World Organization for Animal Health (Office International des Epizooties, OIE) international standards. The project is also in line with the Global Health Security Agenda 2024 (GHSA) objectives and is structured to contribute to four of the key action packages defined in the GHSA strategy: (i) surveillance and reporting; (ii) laboratory capacity; (iii) health workforce; and (iv) epidemic preparedness and response. 9. REDISSE Phase IV will support five countries in Central Africa to establish and maintain a coordinated approach to detecting and swiftly responding to disease outbreaks and public health threats of regional and international consequence: Angola, the Central African Republic (CAR), Chad, the Republic of Congo (RoC), and the DRC. These countries belong to the Economic Community of Central African States (ECCAS), a sub-region of Africa with a total population of more than 192 million people (Figure 2). Involvement of these countries in the project was based, above all, on the expressed interest of the national governments in participating in the project. Epidemiologic considerations and the needs and assets of the project countries were also considered. The REDISSE Program could expand to include other ECCAS member countries when demand and resources become available. 10. The proposed operation will play a critical role in protecting the human capital of the population of the Participating Countries. Human capital—the knowledge, skills, and health that people accumulate over their lives that enables them to realize their potential as productive members of society—is one of the first things to suffer when there is an outbreak of disease. The World Bank’s Human Capital Index measures the productivity of the next generation of workers relative to the benchmark of complete education and full health. This project will play a critical role in protecting the human capital of the five project countries by enhancing health security and reducing the risk of future loss of lives and disruption of essential services such as education, social protection and health that might otherwise be large. Of the five project countries, four are already part of the Human Capital Project (Angola, CAR, Chad, and RoC). REDISSE Phase IV will help participating countries integrate national and cross-border health security actions into their national human capital plans. 11. The REDISSE Phase IV project is complementary to the Africa Centers for Disease Control project (P167916), which is managed by the Africa Centres Disease Control and Prevention (ACDC), a specialized technical institution of the African Union charged with the responsibility of promoting the prevention and control of diseases in Africa. Its mission is to strengthen Africa’s public health institutions’ capacities, capabilities and partnerships to detect and respond quickly and effectively to disease threats and outbreaks based on science, Page 15 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) policy, and data-driven interventions and programs (Box1). Figure 2: The Region of the Economic Community of Central African States (ECCAS)8 8 Meyer, A., Institute for Security Studies (ISS), August 2016. Central Africa Report: Preventing conflict in Central Africa - ECCAS caught between ambitions, challenges and reality. Page 16 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Box 1: Complementarity of REDISSE Phase IV with the Africa CDC Project Alongside the REDISSE IV Project, the World Bank Group (WBG) is also investing in a new Regional Integration (RI) operation to strengthen disease surveillance and response on the African continent through the Africa Centers for Disease Control Project (ACDCP) (P167916) to be implemented in coordination with the Africa Centres for Disease Control and Prevention (ACDC) based in Addis Ababa, Ethiopia. The ACDCP has a continental scope and a three-tiered administrative structure. The first tier is the Africa CDC Secretariat, which is based at the African Union headquarters in Addis Ababa, Ethiopia. The second tier consists of five regional collaborating centers (RCCs) based in Egypt, Gabon, Kenya, Nigeria, and Zambia. The third tier comprises the National Public Health Institutes (NPHIs) and Centers of Excellence based in the African Union’s 55-member countries. Whilst the REDISSE projects focus on the bottom tier, strengthening NPHIs, and promoting a culture of regional cooperation and coordination in specific sub-regions (ECCAS, Economic Community of West African States (ECOWAS)), the ACDCP will focus primarily on the strengthening of the upper tiers of the Africa-wide public health institutional architecture, as well as network alignment, pandemic preparedness, and response capacity across geographic sub-Regions. The REDISSE IV Project and ACDCP will operationally exploit opportunities of complementarity and synergy in supporting disease surveillance and response at the regional (i.e. establishment of regional networking platform) and national (i.e. support to emergency planning and management capacity to rapidly respond to outbreaks, public health workforce development) levels. The two projects will also facilitate the exchange of information in order to minimize the chances of duplication and maximize their synergy effect. They will build on what each is doing through permanent collaborative channels of communication. In addition, the REDISSE IV project will promote and support a network alignment of national laboratories it will support with continental reference laboratory that ACDCP will identify and support. The ACDCP will complement and enhance other IDA-financed regional integration initiatives, including the REDISSE Program, the East Africa Public Health Laboratories Network (EAPHLN) (P111556), the Southern Africa Tuberculosis Health Systems Strengthening Project (SATBHSS) (P155658) and the Regional Integrated Surveillance and Laboratory Networks (RISLNET) platform. B. Sectoral and Institutional Context Human Health 12. Over the past three and half decades at least 30 new infectious pathogens have emerged worldwide.9,10;11 More than 70 percent of emerging infectious diseases that affect humans have their origins in wildlife. Infectious disease outbreaks can have a devastating impact on the social and economic situation of countries, particularly in FCV settings. The pandemic of Hemagglutinin (H) and Neuraminidase (N) (H1N1); epidemics of severe acute respiratory syndrome (SARS), Asian Avian Influenza A, also known as “Bird Flu” (H5N1) and Middle East Respiratory Syndrome Coronavirus (MERS-CoV); and recent outbreaks of EVD are reminders of the persistent risk of infectious, zoonotic diseases and the heavy human toll and economic losses they cause.12 The World Bank estimates that the cost of the 2014-2015 EVD outbreak in West Africa was US$2.8 billion.13 However, a recent study estimated the 9. Nicholas Israel Nii-Trebi, 2017. Emerging and Neglected Infectious Diseases: Insights, Advances, and Challenges. Biomed Res Int. 2017; doi: 10.1155/2017/5245021 [Last accessed on 2018 July 09] (Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5327784/) 10 .Shuvankar Mukherjee. 2017. Emerging Infectious Diseases: Epidemiological Perspective. Indian J Dermatol. 2017 Sep-Oct; 62(5): 459–467. doi: 10.4103/ijd.IJD_379_17 [Last accessed on 2018 July 09] (Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5618832/) 11 Jonathan Runstadler, 2018. Influenza’s wild origins in the animals around us. [Internet]. Available from: https://theconversation.com/influenzas-wild- origins-in-the-animals-around-us-91058. 12 World Bank, 2012 – People Pathogens and our Planet. Volume 2 – economic analysis. 13 2014-2015 West Africa Ebola Crisis: Impact Update. Accessed October 30, 2018. http://www.worldbank.org/en/topic/macroeconomics/publication/2014-2015-west-africa-ebola-crisis-impact-update. Page 17 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) comprehensive economic and social burden from the 2014 EVD outbreak in West Africa to be US$53.19 billion (in 2014 US dollars)14. This includes US$18.8 billion estimated to be the cost of the deaths from non-Ebola causes. Additionally, a recent analysis by the World Bank shows that a severe pandemic such as the 1918 Spanish Flu could cost approximately US$3 trillion globally15, an estimate comparable to the impact of the 2008 global financial crisis. 13. In June 2007, the World Health Organization (WHO) via the IHR, 2005 mandated governments to develop, strengthen and maintain the core capacities of national public health systems to detect, assess, notify, and respond promptly and effectively to health risks and public health emergencies of international concern (PHEICs)16. In the WHO Africa Regional Office (WHO/AFRO), the IDSR strategy serves as a framework to fulfil this mandate. However, to date, IDSR has not been fully implemented in most countries in the region17 and health systems remain limited for systematic collection, analysis, confirmation, and interpretation of disease surveillance data, in addition to insufficient capacity for preparedness and rapid response. 14. Most of the countries in the ECCAS region are hotspots for epidemic-prone infectious diseases. In this region, emerging and re-emerging diseases at the interface of human-animal-ecosystems occur with increased frequency. In DRC, for example, there have been 10 EVD outbreaks since the virus was first discovered in DRC in 1976 (Box 2). These add to the ongoing burden of neglected and endemic human and animal diseases, including zoonoses. Of 1,307 epidemic events between 2011 and 2017 for which data was available, 105 were within the eleven ECCAS countries. REDISSE Phase IV countries accounted for 65.7 percent of the events in the ECCAS sub- region. Box 2: EVD Outbreaks in DRC Recent Ebola virus outbreaks in DRC in May (EVD9) and August (EVD10) 2018 had the potential to become regional epidemics through cross-border transmission. EVD9 was rapidly controlled by the DRC Government with support from development partners, including the World Bank. EVD10 and the efforts to contain and end the epidemic began in August 2018 and are still ongoing. It is now ranked as the second deadliest EVD outbreak after the West Africa epidemic. The outbreak is occurring in an area where conflict and violence are hampering public health efforts to end it. This illustrates the complex operational environment and challenges in the region and underlines the urgent need for this project. The response activities underway to address the emergency, need to be complemented and followed by purposeful investment in technical and human capacity for prevention and preparedness. This project is aimed at further building surveillance and emergency response capacities in the countries over the medium-term. 15. There is also increasing concern over the threat to human and animal health from antimicrobial resistance (AMR).18 Sub-Saharan African countries, including the REDISSE countries, not only lack systems to collect and 14 Caroline Huber, Lyn Finelli, Warren Stevens; The Economic and Social Burden of the 2014 Ebola Outbreak in West Africa, The Journal of Infectious Diseases, , jiy213, https://doi.org/10.1093/infdis/jiy213. Accessed October 30, 2018. https://academic.oup.com/jid/advance- article/doi/10.1093/infdis/jiy213/5129071?rss=1. 15 Burns et al. (2008) Evaluating the economic consequences of avian influenza (http://siteresources.worldbank.org/EXTAVIANFLU/Resources/EvaluatingAHIeconomics_2008.pdf). 16 IHR, 2005 is a legally binding document set forth by the WHO that mandates country governments to develop, strengthen and maintain the core capacities of national public health systems to detect, assess, notify, and respond promptly and effectively to health risks and PHEICs World Health Organization (2008). 17 Report to the Director-General of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation. World Health Organization (2014). 18 Adeyi, Olusoji O.; Baris, Enis; Jonas, Olga B.; Irwin, Alec; Berthe, Franck Cesar Jean; Le Gall, Francois G.; Marquez, Patricio V.; Nikolic, Irina Aleksandra; Plante, Caroline Aurelie; Schneidman, Miriam; Shriber, Donald Edward; Thiebaud, Alessia. 2017. final report. Washington, D.C.: World Bank Group, http://documents.worldbank.org/curated/en/323311493396993758/final-report. Page 18 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) analyze data on AMR, but also lack the resources and capacity19 to prevent and adequately treat infectious diseases. Furthermore, weak laboratory infrastructure and lack of trained laboratory and clinical personnel are factors that impact negatively on surveillance. Since countries that fail to prevent, detect, inform, react or control sanitary issues such as infectious diseases or AMR place other countries at risk, it is essential to take a regional approach to address these challenges. Within the Central African region, the extent of the AMR problem is not well known because surveillance of drug resistance is not carried out in most countries. 16. Country capacity to implement IHR 2005 is measured and monitored by the WHO using the Joint External Evaluation (JEE) Tool.20 The JEE is a data gathering instrument designed to evaluate a country’s capacities for health security, including all IHR and GHSA-relevant capacities across all relevant sectors at a national level. The tool has 19 technical areas arranged according to the IHR and GHSA mandates to prevent detect and respond to disease threats. JEEs have been conducted in four of the five project countries in the ECCAS region21 (CAR, Chad, DRC and RoC). The assessments revealed some common and key weaknesses in health systems for infectious disease surveillance, epidemic preparedness and response, including: • limited availability of laboratory infrastructure for timely and quality diagnosis of epidemic-prone diseases; • lack of interoperability of different information systems that hampers analysis and use of information for decision making and disease mitigation measures; • generally inadequate infection prevention and control standards, infrastructure and practices; • weak and inefficient management of the supply chain system; • significant gaps in regional level surge capacity for outbreak response, stockpiling of essential goods, information sharing and collaboration; • lack at each level of the health pyramid of a fit-for-purpose health workforce for disease surveillance, preparedness and response; • community level surveillance and response structures either do not exist or need significant improvement; and • Lack of capacity for self-assessment. Animal Health 17. Within the animal sector, there is a high incidence and prevalence of infectious communicable diseases, both zoonotic and non-zoonotic. This situation impacts animal and human health, food safety, trade, and economic and rural development. Improvement of animal health requires increased and sustained investments in national veterinary services to meet international standards of quality defined by the OIE Code. Insufficient government funding and limited interest from donors to support veterinary services have not allowed significant progress to date in addressing systemic issues. 19 Dar OA, Hasan R, Schlundt J, Harbarth S, Caleo G, Littmann J et al. Exploring the evidence base for national and regional policy interventions to combat resistance. Lancet. 2016; 387:285–95. 20 The World Health Organization, together with other partners, has developed a Joint External Evaluation Tool-IHRs (2005) (JEE-IHR) to assess country capacity to prevent, detect, and rapidly respond to public health threats. The tool allows countries to identify the most urgent needs within their health security system, to prioritize opportunities for enhanced preparedness, response and action, and, through regular evaluations, will help monitor the progress by country in implementation of the IHRs (2005) (http://www.who.int/ihr/publications/WHO_HSE_GCR_2016_2/en/). The JEE makes use of the PVS evaluation missions’ results which provide an assessment of the strengths and weaknesses of the national Veterinary Services (http://www.oie.int/support-to-oie-members/pvs-evaluations/oie-pvs-tool/). 21 Angola has planned to carry out its JEE later in 2019. Page 19 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 18. Movement of live animals is a major risk factor for the spread of livestock diseases and zoonotic infections. The frequent cross-border animal movement and livestock trade between countries in the region further increase the risk of the occurrence and spread of disease. Disease outbreaks in animals may threaten human health directly through infection or indirectly through loss of livelihood, increased poverty and food insecurity. In most of the countries in the sub-region, animal disease surveillance and animal health care delivery systems are inadequate, and there is no regional strategy for prevention and control of significant animal diseases22 such as the outbreak of highly pathogenic avian influenza A (H5N8) in DRC between October 2016 and July 2018. 19. The OIE Performance of Veterinary Services (PVS) Pathway is a global program for sustainable improvement of a country's veterinary services and the OIE PVS Pathway evaluation tool is, more or less, the animal health equivalent to the JEE tool. OIE has evaluated the performance of veterinary services in only two of the five REDISSE Phase IV countries (Angola and CAR) since 2010. Although these countries have epidemiological surveillance systems for animal health in place, their use is hampered by a shortage of human resources, a weak information system and a lack of financial resources for implementation. 20. Regional leadership for animal health and veterinary services has historically been weak in the Central Africa sub-region. To help address this, during the fifteenth ordinary session of the ECCAS Conference of Heads of State and Governments held in N'Djamena on May 25, 2015, it was agreed that Chad would host a specialized technical center for animal health for Central Africa. The Regional Animal Health Center for Central Africa (Centre regional de santé animale pour l’Afrique centrale, CRSA-AC) became operational in N’Djamena on January 24, 2019. The Center will contribute to the improvement of border movements of animals, the circulation of veterinary medicines and animal products in the sub-region and reduce the risks of the emergence of trans- boundary animal diseases (TADs) and zoonoses. The Center will be supported by governments in the Sub-region and partners, including the OIE. REDISSE Phase IV will assist the Center to develop the One Health (OH) agenda in the sub-region and develop the Integrated Regional Coordination Mechanisms (IRCM) for the control of trans- boundary animal diseases. One Health Approach 21. The OH approach recognizes the connectedness of human, animal and environmental health and the need to address challenges in a collaborative, multi-sectoral and trans-disciplinary approach. Within the ECCAS region, there is a lack of multi-sectoral coordination to support implementation of such an approach. According to JEEs carried out in Chad and the CAR in August 2017 and January 2019 respectively, it was found that a lack of standard operating procedures hampers the functioning of the national OH focal point in Chad (the national focal point for CAR had not yet been officially nominated) and limits implementation of the IHR 2005 and, by implication, the PVS Pathway. 22. The situation in other countries of the region is not very different. It is important, therefore, to strengthen the PVS Pathway and epidemiological surveillance network for animal health, to improve analytical capacity and exchange of information. The establishment of standard operating procedures clarifying the coordination mechanisms between sectors should improve the reporting procedures to WHO and OIE. 22Awa, D. N; Achukwi M. D. 2009. Review of livestock pathology in the central African region: epidemiological considerations and control strategies. In : L. SEINY-BOUKAR, P. BOUMARD (éditeurs scientifiques), 2010. Actes du colloque « Savanes africaines en développement : innover pour durer », 20-23 avril 2009, Garoua, Cameroun. Prasac, N'Djaména, Tchad ; Cirad, Montpellier, France, cédérom. [Available from: https://www.researchgate.net/publication/43076207_Review_of_livestock_pathology_in_the_central_African_region_epidemiological_considerations_a nd_control_strategies]. Page 20 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 23. Given the trans-boundary nature of infectious diseases and the fact that a significant number of these pathogens can be transmitted between animals and humans (more than 70 percent of 1,450 known infectious diseases in humans are of animal origin), there is a critical need for coordination and exchange of knowledge and information between sectors involved with animal and human health at both national and regional levels. The response to the highly pathogenic avian influenza virus H5N1 crisis since 2005 contributed to enhancing cooperation between the human and veterinary health sectors in many countries in the region and lessons learned from successful regional programs for the control of selected priority diseases have demonstrated the efficiency of such coordination. Despite such evidence, in the absence of an ongoing high-profile crisis, routine collaboration has failed to take hold and there is still a need for a dedicated program incentivizing such a joint approach to break down the silos that hamper effective coordination. 24. As with the preceding three phases of REDISSE, this fourth phase project will promote the OH approach to combat epidemics prone and major endemic diseases. OH is a collaborative approach that recognizes the linkages between human, animal and environmental health and the fact that stressors in any one of these domains impacts the others and increases the likelihood of deadly outbreaks (Figure 3). OH focuses on training veterinarians, nurses and hospital workers on infection control measures, investing in health and animal information and surveillance systems, stimulating cross-border emergency preparedness exercises, equipping laboratories and supporting development of multi-sectorial standard operation procedures to combat zoonotic disease outbreaks. Figure 3: One Health Framework Source: CDC, Center for Disease Control and Prevention. National Center for Emerging and Zoonotic infectious diseases (https://www.cdc.gov/onehealth/images/multimedia/ one-health-def.jpg) C. Relevance to Higher Level Objectives Page 21 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 25. The project is aligned with the WBG Strategy for Africa (Resilience to shocks and climate change impacts), and the Africa RI (RI) and Cooperation Assistance Strategy for the period FY18-FY23.23 More specifically, alignment is with Africa’s RI Strategic Priority 4, to “promote collective action to address risks of regional economic contagion, fragility, epidemic, and climate “hot spots”. This strategic priority rests on three arguments: (i) some of Africa’s development challenges and potential risks do not stop at national borders and require collective effort on the part of multiple countries; (ii) ensuring effective and collective action requires clear understanding of the advantages and disadvantages of addressing these risks, including possible asymmetry of benefits for the parties involved and ensuring strong regional platforms that bring together key stakeholders; and (iii) over time, it will be important to make such collective action efforts more sustainable from a financing and institutional point of view Box 3: Why a Regional Approach to Disease Surveillance and Response in Central Africa The World Bank criteria for regional projects and access to Regional Integration financing require that projects: • Involve three or more countries, all of which need to participate for the project’s objectives to be achievable (that is, the project would not make sense without the participation of all of these countries). • Produce benefits, either economic or social, that spill over country boundaries (that is, projects that generate significant positive externalities or mitigate negative ones). • Involve clear evidence of country or regional (ECCAS) ownership and demonstrate commitment of the majority of participating countries. • Provide a platform for a high level of policy harmonization among countries (this is key to the success of a regional initiative) and are part of a well-developed and broadly supported regional strategy. REDISSE IV complies with the IDA regional projects criteria: • The REDISSE IV Project in Central Africa will be implemented in five ECCAS countries: Angola, Chad, Central African Republic, the Democratic Republic of Congo and the Republic of Congo. These countries have prioritized this initiative and allocated their national IDA and IBRD financing to meet obligations under the International Health Regulations and the Terrestrial Animal Health Code. • The project will be implemented in the context of the African IDSR Strategy and the OH approach, based on regional best practices and guidance from ACDC, WHO, OIE and FAO. • The project will support the countries to establish a coordinated approach to detecting and swiftly responding to regional public health threats. Cooperation among Central African countries to prevent and control potential cross-border diseases is a regional public good. The regional benefits and positive externalities of effective disease surveillance and response are substantial. • The project will prioritize (i) control and prevention of cross-border spread of communicable disease; (ii) harmonized policies, standardized technical guidelines as well as information collection and sharing, and (iii) research, including targeted research and development. • Until the ACDC Central Africa Sub-regional Coordinating Center in Libreville is functional, the day-to-day oversight of the Project will be managed by the ECCAS Secretariat in Libreville, and the RAHC in Ndjamena, Chad. The Project will encourage collective action and cross-border collaboration by (i) empowering countries to engage in joint planning, implementation and evaluation of program activities across borders at regional national and district levels; (ii) supporting countries’ efforts to harmonize policies and procedures and; (iii) promoting resource sharing of high cost specialized assets such as reference laboratories and training centres and pooled procurement of difficult to access commodities. Source: Adapted from REDISSE I, II & III. and less reliant on development financing (Box 3). 23 Supporting Africa’s Transformation: Regional Integration and Cooperation Assistance Strategy for the Period FY18-23 dated December 15, 2017 (p. 37). Page 22 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 26. This project is aligned with the Pillar 3 of the broader corporate engagement through the Human Capital Project launched by the World Bank in 2018. This project will assist the governments of the participating countries to tackle some of the worst diseases which are both barriers and threats to human capital development, thereby increasing life expectancy and survival rates of adults. This strategic priority responds to sub-regional, regional or global risks that could impact the continent and compromise the development gains made so far. 27. The project is in line with the WBG mission to end extreme poverty and boost shared prosperity. REDISSE Phase IV is also aligned with the Country Assistance Strategy (CAS) of the Republic of Congo24 under Pillar 2: vulnerability and Resilience under the outcome for strengthening health service delivery, the Country Partnership Strategy (CPF) of CAR25 under Axis 2: rehabilitation and development of socio-economic infrastructure Outcome 8: improved access to quality education and health services, the Country Partnership Framework (CPF) for Chad26 under Engagement Theme 3: building human capital and reducing vulnerability and DRC27 under the third strategic objective to improve social services delivery and increase human development indicators, and the Performance and Learning Review (PLR) of Angola28 under Pillar 2: enhancing quality service delivery and deepening social protection under revised CPS focus area two: increasing efficiency of social program and strengthening social protection. The World Bank is currently drafting a new CPF for DRC for the period 2019-2021 and a Systematic Country Diagnostic for CAR was completed on June 2019. II. PROJECT DESCRIPTION 28. The project will contribute to: (i) ensure more efficient collaboration and synergies between human and animal epidemiological surveillance and response networks at country and regional levels via the OH platform; (ii) facilitate country and regional compliance with international standards for veterinary services, with a particular focus on early detection and rapid response capacity, as adopted by the OIE members states in the Terrestrial Animal Health Code, and use the findings and recommendations from the OIE PVS Evaluation Tool; (iii) develop national and regional capacity to fully implement IHR 2005 through the IDSR strategy, which calls for the continuous monitoring of mortality and morbidity, to identify and respond to threats before they can develop into large scale or trans-boundary epidemics. 29. The project financing in the amount of US$280 million equivalent is considered the fourth Investment Project Financing (IPF) of the iSOP approach of the REDISSE Program, in an effective and sustainable regional surveillance network in Central Africa. Project financing will be mobilized via contributions from individual country allocation of IDA and IBRD funds and a regional integration funding mechanism (Table 1), presented by components in Tables 2 and 3, and by sub-components in Table 4. 24Country Assistance Strategy (CAS) for the RoC, FY2013-2016, September 24, 2012, Report No.71713-CG. There is a CPF under preparation to be delivered in November 2019. 25Joint Country Partnership Strategy (CPS) for the CAR, FY2009-2012, July 31, 2009, Report No.49583-CF. A Systematic Country Diagnostic for CAR was completed on June 2019, Report No.125268-CF. 26 Country Partnership Framework (CPF) for the Republic of Chad, FY2016-2020, November 3, 2015, Report No.95277-TD. 27 CAS for the DRC, FY2013-2016, April 12, 2013, Report No.66158-ZR. The World Bank is currently drafting a new CPF for DRC for the period 2019-2021. 28 Performance and Learning Review of the CPS for the Republic of Angola, FY2014–2016, March 29, 2018. Report No.100988-AO. Page 23 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Table 1: Breakdown of Project Financing Country IDA Regional IDA IBRD Total Country/Regional Institution (US$ Million) (US$ Million) (US$ Million) (US$ Million) Angola 60.0 60.0 Chad 10.0 20.0 30.0 CAR 5.0 10.0 15.0 Congo Republic 5.0 10.0 15.0 DRC 50.0 100.0 150.0 ECCAS Secretariat 10.0 10.0 TOTAL 70.0 150.0 60.0 280.0 30. The estimated budget allocation by component is presented in Tables 2 and 3 below. Table 2: Estimated Project Budget Allocations by Component Budget % of Total Project Components Allocation Budget (US$ million) 1: Strengthening Surveillance and Laboratory Capacity to Rapidly 126.45 45.16 Detect Outbreaks 2: Strengthening Emergency Planning and Management Capacity to 66.45 23.73 Rapidly Respond to Outbreaks 3: Public Health Workforce Development 47.60 17.00 4: Institutional Capacity Building, Project Management, Coordination 39.50 14.11 and Advocacy Total 280.00 100.00 Table 3: Estimated Country Funding by Component Project Components Angola CAR Chad DRC RoC ECCAS Total 1: Strengthening Surveillance and Laboratory Capacity to Rapidly Detect 29.70 6.75 17.5 60.00 7.50 5.00 126.45 Outbreaks 2: Strengthening Emergency Planning and Management Capacity to Rapidly 9.80 2.25 6.00 45.00 1.50 1.90 66.45 respond to Outbreaks 3: Public Health Workforce 7.30 3.15 3.50 30.00 2.25 1.40 47.60 Development 4: Institutional Capacity Building, Project Management, Coordination and 13.20 2.85 3.00 15.00 3.75 1.70 39.50 Advocacy Page 24 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Table 4: Estimated Funding by Component and Sub-component Project Components Angola CAR Chad DRC RoC ECCAS Total Component 1: Strengthening Surveillance and 29.70 6.75 17.50 60.00 7.50 5.00 126.45 Laboratory Capacity to Rapidly Detect Outbreaks Sub-component 1.1. National and sub-national 11.90 2.25 2.60 17.16 0.90 1.36 36.17 surveillance system Sub-component 1.2. Health information and 4.50 0.75 1.93 7.77 1.35 0.08 16.38 reporting systems Sub-component 1.3. Laboratory diagnosis 4.50 3.75 10.10 21.95 5.25 0.72 46.27 capacity Sub-component 1.4. Supply chain management 8.90 0.00 2.97 13.28 0.00 2.84 27.99 systems Component 2: Strengthening Emergency Planning and 9.80 2.25 6.00 45.00 1.50 1.90 66.45 Management Capacity to Rapidly Respond to Outbreaks Sub-component 2.1. Emergency management 5.10 0.92 2.70 22.34 1.05 0.88 32.99 system Sub-component 2.2. 1.40 0.45 1.90 9.88 0.30 0.66 14.59 Medical countermeasures Sub-component 2.3. Non- pharmaceutical 1.20 0.15 1.31 6.52 0.15 0.30 9.63 interventions Sub-component 2.4. 1.00 0.75 0.08 4.01 0.00 0.08 5.92 Research and evaluation Sub-component 2.5. Contingent emergency 1.20 0.00 0.01 2.52 0.00 0.00 3.73 response Component 3: Public Health Workforce 7.30 3.15 3.50 30.00 2.25 1.40 47.60 Development Sub-component 3.1. 4.70 1.20 0.76 12.8 0.75 0.10 20.31 Public health staffing Page 25 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Project Components Angola CAR Chad DRC RoC ECCAS Total Sub-component 3.2. Enhance public health 2.60 1.50 1.83 14.31 1.50 0.97 22.71 workforce training Sub-component 3.3. 0.00 0.45 0.91 2.88 0.00 0.33 4.57 Regulation Component 4: Institutional Capacity Building, Project 13.20 2.85 3.00 15.00 3.75 1.70 39.50 Management, Coordination and Advocacy Sub-component 4.1. Project coordination, fiduciary management, monitoring and evaluation 9.90 0.90 2.20 9.48 2.25 0.23 24.96 (M&E), data generation, and knowledge management Sub-component 4.2. Institutional support, capacity building, 3.30 1.95 0.80 5.52 1.50 1.47 14.54 advocacy, and communication at the regional level A. Project Development Objective PDO Statement 31. The project development objectives are: (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the participating countries; and (ii) in the event of an eligible crisis or emergency, to provide immediate and effective response to said eligible crisis or emergency. PDO Level Indicators29 32. The following key indicators will be used to track progress towards the PDOs: a. Laboratory testing capacity for detection of priority diseases: number of countries that achieve a JEE score of 4 or higher; 29 Indicators (a) through (e) are based on JEE progress monitoring for the implementation of the WHO IHR (2005), as well as OIE PVS assessments. Indicator (f) is based on self-assessment by the region and individual countries. Page 26 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) b. Progress in establishing indicator and event-based surveillance systems: number of countries that achieve a JEE score of 4 or higher; c. Availability of human resources to implement IHR core capacity requirements: number of countries that achieve a JEE score of 3 or higher; d. National multisectoral Multi-hazard emergency preparedness measures including emergency response plans are developed, implemented, and tested: number of countries that achieve a JEE score of 4 or higher); e. Progress on cross-border collaboration and exchange of information across countries: Number of countries that achieve a score of 4 or higher; f. Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint priorities: number of countries that achieve a JEE score of 3 or higher. B. Project Components 33. REDISSE IV was elaborated after extensive consultation in the five project countries. The project will reinforce the capacities of the human and veterinary public health systems of Angola, CAR, Chad, DRC and RoC. This was done through a regional focus promoting the OH approach and supporting implementation of IIHR and OIE standards. 34. The project will be comprised of four components that will collectively strengthen preparedness and response to emerging public health threats across the region. For a detailed description of the project, see Annex 2. All proposed activities will directly contribute to realizing commitments under IHR and demonstrating achieved capacity through JEE, and the OIE PVS l Evaluation Tool. The four project components are as follows: Component 1: Strengthening Surveillance and Laboratory Capacity to Rapidly detect Outbreaks (US$126.45 million equivalent) 35. Early detection of disease outbreaks and laboratory confirmation of the etiologic agents/pathogens responsible will be enhanced through the planning and implementation of coordinated surveillance, laboratory, information and reporting systems in the human and animal health sectors. This component will focus on the regional, national and sub-national levels to establish and scale-up systems that are both sensitive and of high quality and can be sustainably implemented and managed by national and regional authorities. These systems are vital both to ensuring these countries can adapt to climate change and do so in a way which minimizes greenhouse gas (GHG) emissions. This component will enhance the national surveillance and reporting systems and their interoperability at the different tiers of the human and animal health systems. 36. This component will support: enhancement of national surveillance and reporting systems and their interoperability at the different tiers of the health systems; cross-border coordination in the surveillance of priority diseases, and timely reporting of human public health and animal health emergencies in line with the IHR (2005) and the OIE Terrestrial Animal Health Code. This component will strengthen the linkages of surveillance and response processes at all levels of the health system. It will identify and/or establish networks of efficient, high quality, accessible public health and veterinary laboratories as well as support the establishment of a regional networking platform to improve collaboration for laboratory investigations. It will also contribute towards Page 27 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) strengthening the capacities of national veterinary and public health laboratories in the areas of surveillance, pathology, diagnosis of priority infectious disease pathogens and AMR. The four sub-components of this component are: (i) national and sub-national surveillance system; (ii) health information and reporting systems; (iii) laboratory diagnosis capacity; and (iv) supply chain management systems. 37. Under this component, the project will support the integrated disease surveillance and response (IDSR) strategic goals to improve availability of quality information by investing in the development of the required information and communication technology (ICT) infrastructure for cross-sectoral interoperability of surveillance and reporting systems at the country and regional level. 38. In addition, the project through this component, will make investments in renovating and upgrading existing facilities, in ensuring adequate supplies and in strengthening supply chain management. Networking of laboratories will be supported for (i) sharing timely information across countries; and (ii) contributing to joint investigations of disease outbreaks. Networks will ensure improved capacity to diagnose diseases, identify public health threats, and conduct surveillance. Networks will also serve as effective platforms for learning and knowledge sharing. 39. This component will also support strengthening specimen management including the: (i) streamlining of the laboratory specimen referral process, including use of sub-national laboratories rather than having all specimens coming to a central laboratory, where possible; and (ii) improvement of efficiency of specimen transport and disposal systems including through the use of private sector partnerships. 40. This component will finance consultants’ contracts, training and meetings, travel costs, procurement of vehicles for supervision, production and dissemination of disease surveillance materials, communication and computer equipment and software, development of incentives-based early reporting mechanisms for human and animal health; renovation and rehabilitation of facilities, laboratory equipment and reagents, logistics and materials for sample collection, preservation and shipment to the laboratory; and partnership with the private sector for enhanced disease surveillance and reporting. 41. Under this component, the project will fund activities aimed at strengthening the human, animal, and environmental disease surveillance systems of the participating countries and at regional level. It will also encompass the provision of works, goods, consulting services, non-consulting services, and training and the financing of operational costs. Component 2: Strengthening Emergency Planning and Management Capacity to Rapidly Respond to Outbreaks (US$66.45 million equivalent) 42. Proactive planning, testing and financing of emergency management systems is critical to launching a rapid outbreak response. This component will focus on the technical, personnel, legal, infrastructure and community elements that are required to build an effective incident management system and support activation of the system to respond to outbreaks. This component will enhance the scientific base for improving outbreak response by strengthening national and regional capacities for research and evaluation, as well as responding to climate change related events. 43. In particular this component will: (i) enhance cross-sectoral coordination and collaboration for Page 28 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) preparedness and response; (ii) strengthen capacity to prepare for and respond effectively to animal and human disease outbreaks; (iii) improve country and regional surge capacity to ensure both a rapid response and continuity of essential services during an emergency, and (iv) ensure contingency emergency response; by improving the Government’s response capacity in the event of an emergency, following the procedures governed by World Bank Policy, IPF Section III, paragraphs 12 and 13 (Projects in Situations of Urgent Need of Assistance or Capacity Constraints). The five sub-components are: (i) emergency management systems including planning, legal, facilities and communications requirements; (ii) medical countermeasures; (iii) non-pharmaceutical interventions; (iv) research and evaluation; and (v) contingent emergency response. 44. This component will support the (i) updating and/or development of cross-sectoral emergency preparedness and response plans (national and regional) for priority diseases; (ii) regular testing, assessment, and improvements of plans; (iii) expansion of the health system surge capacity including the allocation and utilization of existing pre-identified structures and resources (at the national and regional level) for emergency response, infection prevention and control (IPC); (iv) regional exchange of best practices and lessons learned in preparedness and response across countries in the region; and (v) establishment of national and regional financing mechanisms for animal health and public health emergencies. Component 3: Public Health Workforce Development (US$47.60 million equivalent) 45. A strong public health workforce is the foundation for any region or individual country to effectively detect and respond to disease threats. However, most human resource systems lack plans for a multi-disciplinary health personnel that includes epidemiologists, data managers, laboratory technicians, emergency management and risk communications specialists, and public health managers. 46. This component will focus on activities that support recruitment, training and retention of qualified staff for routine and emergency public health functions including, where possible, coordination with the private sector health workforce. The increased capacity will be critical to having an agile system which can respond to threats, including those resulting from climate change. 47. In particular this component will support: (i) the healthcare workforce mapping, planning and recruitment; and (ii) enhance health workforce training, motivation and retention. The three sub-components of this component will include the following: (i) public health staffing; (ii) enhance public health workforce training; and (iii) regulations. 48. The component will finance consultant contracts for providing the training, computers, training supplies and materials, communication equipment, travel costs, and workshop costs. Component 4: Institutional Capacity Building, Project Management, Coordination and Advocacy (US$39.50 million equivalent) 49. This component focuses on all aspects of project management, including financial management (FM) and procurement; M&E; knowledge generation and management; communication; and capacity building, M&E of social and environmental safeguard mitigation measures. It also provides for critical cross-cutting institutional support, meeting capacity-building and training needs identified in the five countries and specific technical capacity-building activities undertaken within the three technical components. Page 29 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 50. It will support the routine external independent assessment of critical animal and human health capacities of national systems using reference tools (such as OIE PVS and JEE) to identify weaknesses and monitor progress. More specifically, this component will support: (i) project coordination, fiduciary aspects (FM and procurement), M&E, data generation, and knowledge management; and (ii) institutional support, capacity building, advocacy, and communication at the regional level; and (iii) management (capacity building, M&E) of social and environmental safeguard mitigation measures. The two sub-components are: (i) project coordination, fiduciary management, M&E, data generation, and knowledge management; and (ii) institutional support, capacity building, advocacy, and communication at the regional level. This component will build on and complement other projects and initiatives such as REDISSE I, II and III implemented in ECOWAS countries. 51. This component will finance consultant contracts, including contracts with United nations (UN) Agencies and other international and regional organizations and non-governmental organizations (NGOs); training activities; regional meetings; travel costs; procurement of vehicles for supervision; and office equipment and supplies; including computer equipment and software. 52. Across all components, the project will promote partnership with the private sector to improve areas of known weakness in the provision of public goods. Such partnerships will focus on areas in which the private sector has a comparative advantage, or is complementary to, activities in the public sector. These include logistics and supply chain management, information communication and technology development, and improvement of specimen transportation systems. Private medical practitioners, veterinarians and veterinary paraprofessionals may be entrusted with official tasks through contractual arrangements. Under similar contractual mechanisms, the project will explore possible partnerships, with identified centers of excellence and private laboratories with the appropriate capacity to play a critical role in the provision of diagnostic and reporting services for diseases of national, regional and/or global importance. C. Project Beneficiaries 53. The populations of the five REDISSE IV countries (141 million people) will benefit directly from the strengthening of national health systems in Angola, CAR, Chad, DRC, and RoC. There are also beneficiaries from service providers including national and regional institutions that cater for animal and human health. The regional animal health center based in Ndjamena, Chad will also benefit from the project. The capacity of the service providers and regional institutions will be strengthened to prevent, detect and respond to public health events, whenever required. As indicated, ECCAS will house the regional implementing entity, benefiting from REDISSE IV. Page 30 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) D. Results Chain E. Rationale for World Bank Involvement and Role of Partners 54. The economic rationale for investing in REDISSE IV interventions is strong, given that success can reduce the economic burden suffered both by individuals and countries. Communicable and non-communicable diseases are a major constraint on the health, education and potential earnings of people in the Central Africa region. These diseases exacerbate certain factors that contribute to poverty, which impacts negatively on vulnerable populations. Most of the countries in this sub-region do not have enough resources to provide healthcare to vulnerable populations. Compounding the threats in this reality is climate change, which will put pressure on already weak systems, displace populations, and create environmental conditions more favorable for disease transmission. Further, as part of the IDA 18 commitments, the World Bank will assist at least 25 countries in pandemic preparedness efforts, including countries in Central Africa. The project complements both WBG and development partner investments in strengthening health systems, disease control and surveillance, attention to changing individual and institutional behavior, and citizen engagement. 55. Role of partners: At the global level, the project will be implemented collaboratively with partners including WHO, OIE and Food and Agriculture Organization (FAO), who will provide the normative guidance and frameworks for action in their respective areas of concentration. The OIE and FAO will provide support in the area of animal health; and the WHO will be responsible for providing support to countries for the JEE through scheduling, coordinating and organizing the JEEs, working across and in collaboration with all levels of the WHO as well as with FAO, OIE and other partners in countries by the JEE Secretariat of the WHO Emergency Page 31 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Programme.30 A regional African Union Inter-African Bureau for Animal Resources (AU-IBAR) organization would be expected to provide support at regional level Regional Animal Health Center (RAHC). The project will also work with other UN agencies, multilateral and bilateral technical providers, academic and research universities and institutions, NGOs, and the private sector. The JEE Secretariat, part of the WHO Emergency Programme, is responsible for scheduling, coordinating, and organizing the JEEs, working across and in collaboration with all levels of the WHO as well as with FAO, OIE, and other partners in countries. 56. To ensure transparency, regular reporting on progress in meeting project objectives will be shared with partners. As the implementation of the project progresses, the various coordination and collaborating partners at the sub-regional and country levels will be brought together by the national and RSCs to review the progress of the project and identify lessons learned. F. Lessons Learned and Reflected in the Project Design 57. REDISSE IV will benefit from lessons learned in earlier REDISSE projects, most of which have already been reflected in the project design. Such lessons include: • Using the JEE, National Action Plan for Health Security (NAPHS) and Benchmarking tool in country level planning: (i) The JEE assessment identifies strengths and weaknesses in 19 different domains relevant to implementation of the IHR. Like earlier REDISSE projects, REDISSE IV is prioritizing a subset of four (surveillance, labs, outbreak readiness and human resources); (ii) The JEE process is meant to stimulate the development of a NAPHS to address the weaknesses identified in the JEE and help countries increase their JEE scores (some of which we are using as project indicators). However, there has been a lack of clarity on what exactly needs to be done for any given indicator to move the score to the next higher level. To address this, the WHO has recently issued a benchmarking document which we hope to use for dialogue in the countries with respect to their overall and World Bank project specific planning. All of this except the JEE was invented post earlier REDISSE design, but we are recommending in REDISSE IV full use of these tools at national level. This will help mitigate two of the challenges faced by the REDISSE Program during implementation in West Africa: 1) Poor coordination of partner funded or implemented activities that leads to duplication of effort or gaps in support for critical activities; and 2) Mission creep and loss of focus – Many stakeholders around the table trying to get their activities funded whether or not they contribute to the achievement of the PDO. The NAPHS can serve as the “Overall coordination tool or master plan” but this requires a strong coordinating entity in government and willingness of development partners to conform to the plan. • The REDISSE IV results framework reflects an evolution of the REDISSE Program’s approach to M&E. REDISSE found certain indicators to be of little value whilst others were not included in the first two projects which are now being restructured to modify the monitoring framework. More specifically, the REDISSE IV results framework excludes the indicators that were found to add no value in the earlier REDISSE Projects (“dropped indicators”) and added indicators on laboratory progress towards accreditation and medical countermeasures. 30 Joint External Evaluation (JEE). https://www.jeealliance.org/global-health-security-and-ihr-implementation/joint-external-evaluation-jee (Accessed on May 31, 2019). Page 32 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) • During REDISSE implementation in West Africa, two issues have emerged as critical but not adequately addressed by the program: AMR and capacity for clinical research in the context of emergency response. These issues have been highlighted in REDISSE IV. • The importance of a working with a regional institution which (a) has convening power backed by an agreed mandate; (b) can manage regional resources through sub-contracting or direct management (e.g. West African Health Organization (WAHO) has contracts with two universities to provide advanced Field Epidemiology Training Program (FETP); and (c) has the ability to leverage legal action that may be required (WAHO is able –in theory—to get items before the ECOWAS Council of Ministers such as cross border transport of pathogenic specimens. Working with a regional institution has proven important for the earlier REDISSE projects, hence REDISSE IV is working with ECCAS, a regional institution with the suggested characteristics. • A participatory project preparation process helps ensure ownership and commitment. As cross-border regional collaborations are essential in the context of public health emergencies, countries participating in the project have been collectively convened to ensure buy-in and commitment. In addition, the project has benefited from high-level support from senior leadership of Ministries of Finance; Ministries of Environment, Agriculture, Livestock; Ministers of Health, and senior Ministry of Health (MoH) management in moving the design forward and bringing together key actors at regional and national levels. • Use of a standardized monitoring framework will be in place to monitor outcome indicators. An overreliance on a complex M&E 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. • Prepositioned contracts with institutions or vendors likely to be called upon in an emergency. In the Nigeria CERC activation for Lassa Fever in 2018 the Government wanted to engage WHO and the United Nations Children’s Fund (UNICEF) to undertake containment, control and recovery activities but the contracting time was extremely long and inefficient, and one contract was not even signed until after the epidemic was declared over. The CERC allows funds to be reallocated but it does not allow ignoring World Bank procedures. • Many outbreaks can be effectively managed through project components and it is not necessary to activate the CERC for every outbreak. If a government wishes to activate the CERC it is important to look carefully at the proposed activities in the Strategic Response Plan (SRP). If they are activities that can be financed through other project components there might be no need to activate the CERC. • The OH (multi-sector) approach dramatically increases project complexity. One of the key challenges is priority setting in the planning process which requires both time and good planning tools. Another challenge is quality control of documentation relate to procurement as not all stakeholders have the capacity to produce high quality tenders, technical specifications, terms of reference, etc. The need for cross-sectoral interventions towards long-term capacity building to support health systems identified as appropriate following the Global Program for Avian Influenza (GPAI). Individual countries are central to ensuring a Page 33 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) coordinated regional program that addresses the threats posed by infectious diseases, hence the need for cross-sectoral interventions, which emphasizes the adoption of the “OH” approach as necessary for promoting cross-sectoral interventions. • Simplify implementation arrangements and carefully assign project implementation roles based on comparative advantages. The proposed arrangements were informed by Independent evaluation Group (IEG) recommendations on regional projects, specifically with respect to simplifying when possible within the context of a regional project and minimizing multiple layers of accountability. Further, 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. • External financing for financing preparedness activities should prioritize capital investments and regional spending on shared resources. 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. • Gender and field epidemiology training: The importance of a country-driven approach to building resilience to health emergencies in synergy with the WBG’s gender strategy and to resolve gender disparity in the percentage of female participants in training (Field Epidemiology and Laboratory Training Program - FELTP, FETP) in disease surveillance, infection control, and emergency response. In Africa, we have found that in-country trainings are more “female friendly” than regional level trainings for FETP as the latter require candidates to be away from home for long periods. It may be more difficult to reach gender parity in intermediate level and advanced level FELTP training. REDISSE IV adopted a gender disaggregated approach to monitoring training in field epidemiology given observations from WARDS and other REDISSE projects that women had little access to training programs. The team agreed with the countries to ensure that all training organized within the project includes female participants and to ensure this is done, an indicator has been included in the result framework. Page 34 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) III. IMPLEMENTATION ARRANGEMENTS A. Institutional and Implementation Arrangements 58. The REDISSE Phase IV Project will be implemented at both regional and national levels with Steering Committees at each level. At the regional level, REDISSE considered other alternative regional Project Implementation Units (PIUs), including (i) using the Organization for Coordination of the fight against Endemics in Central Africa which was created in 1963 and serves as a specialized institution of the Central African Economic and Monetary Community which does not cover all the ECCAS countries; (ii) WAHO was dropped since it does not have the legal standing to directly intervene in Central Africa; (iii) the Africa CDC project, was dropped based on: a) its limited health expertise; and b) the regional coordination center (RCC) (Gabon is yet to be functional). REDISSE Phase IV was left with the General Secretariat of ECCAS, which has a health division headed by a Medical Doctor. The health division has been involved in the elaboration of the 2016 – 2020 ECCAS medium-term strategic plan in which there is a discussion about Strengthening the ECCAS health system including the management of prevention and response to epidemics, medical and humanitarian emergencies.31 Furthermore, in 2003 in Maputo, the Heads of State and Governments stressed that regional integration and co-operation, the mission of ECCAS, should not be geared solely towards economic, trade or political purposed bit also to the social sector as well. REDISSE Phase IV will therefore be implemented by the General Secretariat of ECCAS whose objective is supporting the facilitation of the Member States policies and programs to best contribute to the overall objectives of ECCAS – achieving regional integration and poverty alleviation through harmonious cooperation. These arrangements will be in place until such a time when the capacity of the RCC is built for ECCAS to sub-contract with the RCC to perform activities in member states. Transition from ECCAS to RCC will be evaluated at the mid- term review of this project. 59. While existing REDISSE projects are managed by the WAHO, there is no equivalent institution in Central Africa. REDISSE Phase IV will be managed by the health unit within the ECCAS Secretariat. In the most recent past, the ECCAS Secretariat has received funding from World Bank trust funds to manage some World Bank funded projects. These projects include (i) an agriculture project (P121913) financed with a grant of US$3.9 million from the Comprehensive African Agriculture Development (CAADP) from 2011-2016 and (ii) a disaster risk management (DRM) project (P166648) financed with a grant from the Global Facility for Disaster (GFDRR) of US$1.2 million until 2020, when the project ends. 60. Implementation risk: ECCAS has managed several projects funded by the World Bank Trust Fund, European Union, and African Development Bank (AfDB), and there has not been any reported major implementation issue. Currently the autonomous implementation unit that will handle overall coordination and implementation responsibility under the project does not have all the necessary staff. To reduce the implementation risk, this project will provide resources to increase the ability of ECCAS to sustain staff and consultants during the period the project is being implemented. Furthermore, the project will update the existing project manual of procedures to include a clear description of roles and responsibilities that prevent any misuse of funds and segregation of duties. Finally, intensive training of staff, especially on FM and disbursement compliance and procedures issues will be undertaken. 31Section 2.3.3.1 – Pillar 3 – Program – Strengthening Human capital; Point 4 – Strengthening of ECCAS health system. …Management of prevention and response to epidemics, medical and humanitarian emergencies. Page 35 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 61. At the national level in all the countries, the project will be implemented through the same project implementation units (PIU) in the ministries of health as for ongoing projects in the health sector, supported by the ECCAS General Secretariat. The PIU will be adapted to work across sectors to improve efficiency and alignment in the implementation of project interventions. The project complements but does not duplicate ongoing and new portfolio projects in all five participating countries. Given the multi-sectoral nature of the proposed activities, PIUs will be further strengthened when necessary, enabling resource sharing and more effective, efficient and timely management of implementation of all the projects in the sector. A national Steering Committee supported by a Technical Committee will be put in place to oversee yearly planning and monitoring of the project. The Technical Committee will be made up of representatives of the concerned departments from the Ministries that are involved in the project. The PIUs will coordinate implementation of the various project components by the sectoral ministries and NGOs and will be responsible for monitoring the use of funds by other implementing ministries and partners. B. Results Monitoring and Evaluation Arrangements 62. M&E arrangements will vary from country to country. However, the results framework looks at both the PDO and intermediate indicators. In order not to create parallel systems, the divisions in the Ministries responsible for disease control, in Angola, CAR, Chad and the DRC will be responsible for monitoring project implementation in each country and reporting to the PIU. The PIU will turn in report to the ECCAS General Secretariat. 63. The PIU in the ECCAS General Secretariat will be responsible for collating country information and facilitating regional reporting and review by the Regional OH Committee. WHO and OIE will work with the countries to conduct operational research/evaluations to complement and validate the results. The regional PIU will harmonize methods and tools to facilitate collection, consolidation, and sharing of information. 64. The monitoring of the project involves the consolidation of M&E indicators, training and capacity building at regional and national levels for staff responsible for data collection, processing and analysis. The regional level will organize annual program evaluation and joint strategic planning. Studies, and surveys will be conducted regarding the impact of the project. Finally, every year, the countries and regions will submit a technical report on project implementation results achieved. C. Sustainability 65. Sustainability is an issue of importance to the project especially when WBG funding is fully disbursed. Project sustainability is a challenge, given the fragile and conflict context of the countries in this region. Two approaches will be used to mitigate the risks associated with such a context: the regional approach of the project and advocacy activities. The ECCAS General Secretariat will have responsibility for coordinating regional integration in the ECCAS sub-region and advocacy activities will ensure that the gains of the project remain at the top of the agendas of Heads of State and Governments, and Ministers of the sub-region. Project sustainability will depend on ECCAS government commitments to treat this as a high priority area that is reflected in policies, programs, and increase in domestic financing. 66. Disease outbreaks affect economic activity by decreasing demand (as personal income, investment and exports fall) and supply (as agriculture production falls and businesses in many sectors close). Outbreaks also reduce labor, capital, and productivity, all of which are major components of growth. As indicated in other REDISSE Page 36 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) projects, preventing and controlling zoonotic disease outbreaks yields large economic benefits by reducing the threats of epidemics and pandemics. Such benefits of disease surveillance go well beyond the health benefits of reducing the number of infections, reducing mortality and morbidity, and healthcare costs. 67. This project will generate sustainable impact on the capacity for disease surveillance and response at country and regional levels through the following interventions: • Building capacity in animal, human and environmental sectors; regional dialogue and identification of best practices for health workforce development; motivation and retention to make sure that critical posts for public human and animal health systems will be filled; and gender considerations will be taken into account. Managerial capacities within the involved ministries will be enhanced to better manage resources (human and financial) and operations; The capacity building will ensure technical sustainability. For example, Component 3, training of human and animal health personnel will take place at all levels of the human and animal health sectors. Furthermore, implementation of activities will be done by personnel from the ministerial departments involved with the project from both animal and human health sectors. This will enable the departments to be technically autonomous by the time the project comes to an end. • Advocating for prevention, detection and response to diseases with epidemic potential especially emerging and re-emerging diseases. Raising awareness, risk communication materials will be tailored to strategic audiences, with an emphasis on political leaders and decision makers. • Updating standard operating procedures and technical guidelines as well as disease surveillance and response policies. • Assessment of the burden of diseases and prioritization of disease surveillance and control will be done in each country. The findings of the assessment will assist with streamlining the disease surveillance program and improve targeting. IV. PROJECT APPRAISAL SUMMARY A. Technical, Economic and Financial Analysis 68. The technical case for investing in disease surveillance and epidemic preparedness through REDISSE Phase IV is to prevent cases, morbidity, mortality and disability that would result from a future outbreak in the region. 69. Within the sub-region, there is a need to establish or reinforce and maintain strong collaboration between the human and animal health systems at national, cross-border, and regional levels to better manage risks that arise at the animal-human-ecosystem interface (the ‘OH’ concept). The project will strengthen the priority core public functions (veterinary public health and human public health) that would reduce these risks. Assessing these core functions, bridging divides among systems and ministries and reducing capacity gaps would constitute a critical element of the program. Countries will establish a OH national platform for inter-sectoral collaboration, planning and monitoring, and, when desirable and possible, joint implementation. At the regional level, project will implement interventions that will support the establishment of a network of those country OH platforms. The Project will implement activities within human and animal public health surveillance, where the activities in the Page 37 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) following four domains which have been identified as core areas for both country and regional levels include: (i) surveillance and information systems; (ii) strengthening of laboratory capacity; (iii) epidemic preparedness and emergency response capacity; and (iv) workforce development. 70. Provision of the capacity either in-country or regionally to detect outbreaks and public health threats in time to implement an appropriate, relevant and coordinated response will be through the surveillance systems. Strong surveillance, supported by modern information technology, will support the timely recognition of the emergence of relatively rare or previously undescribed pathogens in specific countries. 71. Laboratory: A national laboratory system or network is needed to ensure the safe and accurate detecting and characterizing of pathogens causing epidemic diseases, including both known and new threats, from all parts of the country. Laboratory quality which can be defined as accuracy, reliability and timeliness of reported test results is necessary to identify emergent public health threats and to implement appropriate interventions. Although it is important to strengthen laboratory capacity at all levels of each country’s health system, higher - level laboratory functions will be a shared resource at regional level for purposes of efficiency and quality. 72. Preparedness and emergency response capacity: this involves promoting local emergency awareness and response expertise, creating interconnected, robust public health emergency management programs, surveillance platforms to support planning and decision making, and a trained public health workforce to respond. Public health rapid response teams will need to be established and supported. Similarly, veterinary rapid response teams would have to be prepared to intervene for animal disease outbreaks of major importance. Involvement of other key sectors and actors (such as law enforcement, customs, military) for emergency response should also be ensured when cases of zoonotic outbreaks are suspected, collaboration between public health and veterinary services would be warranted. 73. Workforce development: for prevention, detection, and response activities to be conducted effectively in response to both public health routine functions and emergencies, there is need for a multi-sectoral workforce that is fully trained and competent, coordinated, evaluated, and equipped. While developing additional capacity in participating countries for workforce in surveillance, laboratory, and preparedness and emergency response is necessary, workforce resources, especially in specialized fields, can be leveraged regionally as needed and appropriate. 74. Aligned with the objectives of the project, the economic analysis examines the implications of preventing a disease outbreak in the ECCAS sub-region. The economic implications of an outbreak are widespread. Direct costs are linked to excess morbidity and mortality, use of medical services, and implementing emergency disease control measures. Indirect costs include lost productivity, economic downturns due to behavior changes in wider society, decreased trade, investment and tourism, restrictions on travel and increased political tension. 75. To estimate the benefit of preventing an outbreak in REDISSE Phase IV countries, the project used historical data to estimate the costs of cholera, Ebola, influenza and yellow fever in the region since 2000 (Table 5). These diseases were selected because they have resulted in major morbidity and mortality in the REDISSE IV region and Africa more widely. The cost of each condition considers the cost of diagnosis and standard treatment for each disease; the cost borne by households to pay for health services; and the productivity losses associated with hospitalization time for severe cases, reduction in performance for mild cases, time spent by family members caring for those who are ill, and time lost due to premature death. The historical cost of each disease ranges from Page 38 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) a low of US$27 million for yellow fever to a high of US$3,6 billion for influenza. Details on estimation methods are presented in Annex 4. Table 5: Historical Cost of Ebola, Yellow Fever, Influenza and Cholera in REDISSE IV Countries Number of Number of Estimated cost (US$ Condition Years cases deaths million, 2019) Ebola 2000-2019 1552 1,039 36 Yellow Fever 2000-2018 7,570 404 27 Influenza 2000-2019 N/A 127,547 3,637 Cholera 2000-2016 525,852 15,662 1,046 N/A = Not available. Data not available for REDISSE IV countries. 76. In addition to historical estimates, the economic benefit of preventing an “average outbreak” and “major outbreak” is projected for the life of the REDISSE IV project. The average outbreak scenario uses historical data from 2000-2019 to model the annual average number of cases and deaths for cholera (30,932 cases and 921 deaths), Ebola (91 cases and 61 deaths), influenza (6,713 deaths) and yellow fever (13 cases and one death) for each year of the project. The major outbreak scenario uses the average number of cases for each year of the REDISSE IV Project, except for year three, when the number of cases and deaths from a recent major outbreak in Sub-Saharan Africa is modeled. The major outbreak scenarios used are the 2009 cholera outbreak in Zimbabwe (98,588 cases and 4,287 deaths), the 2014-15 West Africa Ebola outbreak (28,616 cases and 11,310 deaths), the 2009 H1N1 pandemic (16,417 deaths in REDISSE IV countries) and 2015-16 yellow fever outbreak in Angola and DRC (7,334 cases and 393 deaths). 77. The estimated benefits of the REDISSE IV Project are conservative. The average outbreak scenario considers only four diseases and the number of cases and deaths in REDISSE IV countries are likely under-reported. Furthermore, the analysis does not account for major death and disability from other causes when the health system is overburdened by an outbreak including decreased investment, reduced trade and tourism, death of health workers, or time away from school. Furthermore, it does not consider the funds allocated from international donors during an emergency response. 78. The economic benefits of the REDISSE IV Project vary depending on the proportion of cases prevented. Examining the “average outbreak” scenario, which is the most conservative scenario, the benefit-cost ratio (BCR) of the project is 1.3, the net present value (NPV) is US$83 million and IRR is 4.7 percent if 25 percent of cases are prevented. The BCR, NPV and IRR increase to 5.0, US$1,054 million and 20.6 percent respectively if the project prevents 95 percent of cases and deaths. The economic benefits increase when considering the prevention of a major outbreak of cholera, Ebola, H1N1 or yellow fever. The results of this analysis indicate that investing in disease surveillance and preparedness through the REDISSE IV Project is justified on economic grounds (Table A3.1, Annex 3). 79. There are three primary rationales for a publicly-provided regional approach to disease surveillance and response network in Central Africa. The first rests on the status of a disease surveillance system as a global public good, which is both non-rival and non-exclusive. These benefits accrue to all countries and thus describe a ‘pure’ global public good. The second rationale is simply the overwhelming economic burden that infectious diseases, individually and collectively, place on the region, constraining regional and national economic development. The Page 39 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) third rationale is based on the sharing of resources to enhance efficiency. Examples of resurgent polio, meningitis, cholera and yellow fever in West African countries that were thought to have been eliminated or controlled demonstrate the need for a coordinated regional response. Costly high-level resources, such as level 3 reference laboratories, specialized research institutions, and advanced training facilities may efficiently serve the needs of more than one country. B. Fiduciary (i) Financial Management 80. FM assessments were carried out by the World Bank to evaluate the adequacy of FM arrangements to support project implementation. The objective of the assessments was to review whether: (i) the budgeted expenditures are realistic, prepared with due regard to relevant policies, and executed in an orderly and predictable manner; (ii) reasonable records are maintained and financial reports produced and disseminated for decision-making, management, and reporting; (iii) adequate funds are available to finance the project; (iv) there are reasonable controls over project funds; and (v) independent and competent audit arrangements are in place.32 81. Based on the assessment and project design, fiduciary risk is considered high, due to the following aspects: i) project requires implementation across different sectors with subsequent coordination challenges, that may also impact the operation of FM arrangements in terms of budgeting, flow of funds and reporting; ii) while most entities are familiar with World Bank requirements, in order to properly support management of an additional project, they need to be strengthened in terms of staffing, tools and procedures; iii) FM weaknesses identified in the performance of the Ministry of Public Health (MoPH)-PCU in Chad; and iv) in most cases, the accounting systems, while adequate for World Bank-financed projects, are not prepared for supporting the accounting of two separate projects, and the issuance of completely separated financial statements; in addition to country fiduciary risks in CAR, Chad and DRC. 82. Mitigating measures have been discussed and strengthening measures have been agreed. Those measures refer to: i) recruitment of finance and internal audit staff to strengthen existing capacity; ii) definition of coordination mechanisms between the MoH-PIUs and other sector entities, as well as clear procedures for the financing of specific activities; and iii) the acquisition or upgrade of accounting software; and by effectiveness, preparation or update the FM section of the PIM. (ii) Procurement 83. Applicable Procurement Regulations: In all countries, as well as for the ECCAS, procurement of goods, works, non-consulting and consulting services will be carried out in accordance with the “World Bank Procurement Regulations for IPF Borrowers” (Procurement Regulations), dated July 2016 and revised November 2017 and August 2018 under the New Procurement Framework (NPF) and the World Bank’s “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by International World Bank for Reconstruction and Development (IBRD) Loans and IDA Credits and Grants” (dated July 2016), as well as provisions stipulated in the financing agreement. 32 FM assessments were carried out in compliance with OP/BP 10.00 and related Directives and Guidance Notes, including Bank Directive: Financial Management Manual for World Bank IPF Operations issued February 4, 2015 and effective from March 1, 2010; and the Bank Guidance: Financial Management in World Bank IPF Operations Issued and Effective February 24, 2015 Page 40 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 84. In each country, a Project Procurement Strategy for Development (PPSD) has been developed with support and guidance from the World Bank procurement team. The PPSD provides the basis and justification for procurement decisions, including the approach to market and selection methods in the Procurement Plan. It describes procurement arrangements enabling the delivery of value for money in each country under a risk-based approach. The World Bank has reviewed the six PPSD and agreed to the Procurement Plan prior to loan negotiations. World Bank procurement specialists based in each country will provide continuous support to their respective project as well as regular clinics to smoothen project procurement implementation. For the sake of coordinating the designated procurement specialists in each country, one of them is nominated as the procurement specialist with accountability and decision making (ADM) responsibility during preparation. However, during implementation, each country procurement specialist will have ADM responsibility for the country she/he covers. Procurement arrangements 85. The procurement arrangement for each country is presented below. Based on the Borrower/Recipient assessment, and if need be, the units that require additional capacities in term of staffing will need to hire additional procurement staff. Angola 86. Procurement activities for the project will be managed by the (PIU) within the MoH under the Department of Studies, Planning, and Statistics (Gabinete de Estudos, Planeamento e Estatistica, GEPE). The PIU is comprised of an experienced team currently responsible for procurement functions under the Angola HSPSP (P160948) and the Angola Child Health Expansion Project (P168956). The team comprises a senior international procurement specialist supported by a procurement officer and an assistant. The MoH has put in place a structure to provide fiduciary, including procurement, support to all projects funded by the World Bank in the health sector, based on its extensive experience. While procurement capacity has been assessed as “satisfactory”, the risks have been rates as “substantial” due to the increased workload for the procurement team. CAR 87. Procurement activities for the project will be carried out by the PIU under Ministry of Public Health and Population (MoPHP). This PIU is already familiar with World Bank guidelines, procedures, and procurement documents since it is currently managing two existing World Bank-funded health projects (Health System Support Project (PASS – P1198150 and the Health System Support and Strengthening Project (SENI – P164953). The PIU will be reinforced with one additional senior procurement specialist and one technical coordinator/focal point dedicated to day-to-day implementation of procurement and management for the project. It is proposed that both positions be filled by competitive recruitment. The recruitment process would start as early as possible to ensure that the project team is completed as soon as possible. In addition, the PIU will benefit from short-term technical experts, procurement training and guidance on the World Bank’s NPF, contract management and Systematic Tracking of Exchanges in Procurement (STEP) to ensure clean procurement transactions and timely project implementation. The procurement risk is rated as “high”, based on the country context and associated risks, the increased workload for the PIU under the MoPHP that will require recruitment of one additional senior procurement specialist, and the fact that this project will be implemented under the NPF. Page 41 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) DRC 88. Procurement activities for the project will be carried out by the PIU under MoPH with the support of the Procurement Management Unit (Projets et Marchés Publics, CGPMP) within the MoPH. This PIU is already implementing procurement activities under the Health System Strengthening for Better Maternal and Child Health Results Project (P147555) with the support of an international procurement specialist recruited by the project. It has the capacity and experience to be responsible for procurement for the project. The CGPMP will benefit from support and coaching by the international procurement specialist. The procurement risk is rated “high” based on the country context and associated risks, the increased workload for the PIU under the MoPH that will require recruitment of one additional procurement specialist, and the fact that this project will be implemented under the NPF. RoC 89. Procurement activities for the project will be carried out by the PIU to be set up under the MoHP. The PIU will be staffed with, among others, one procurement specialist and one procurement assistant recruited through transparent selection procedures acceptable by the Word Bank. The PIU will be responsible for carrying out donor- financed procurement activities for MoHP. The procurement risk is rated “high”, based on the country context and associated risks, the PIU will be set up by newly recruited staff and the fact that the project will be implemented under the NPF. Chad 90. Procurement activities for the project will be carried out by the PIU under the Ministry of Public Health (MoPH). This PIU was created 10 years ago and is familiar with World Bank’s procurement guidelines and procedures and has gained capacity to be responsible of the procurement for the project. The overall procurement risk is rated “high” before mitigation measures; this is based on the current country situation and associated risk; delays in approval of bid evaluation reports for various World Bank-financed projects; and long delays in contract approvals. ECCAS 91. The ECCAS will house the regional coordination of the project. Assessment of the procurement capacity of ECCAS has concluded that the project will use and co-finance the existing procurement specialist of the DRM Project being implemented by ECCAS until 2020. The procurement specialist has experience working with relevant procurement regulations and is trained in PPSD and STEP. A procurement assistant may be recruited during project implementation if the need arises. The procurement risk is rated as “substantial”, based on the increased workload for the procurement team with the addition of a new project. C. Climate change (co-benefits) 92. REDISSE is a multi-country program covering Southern, Central and North Central Africa, with both landlocked and coastal countries. As such there are no summary climatic changes which can be expected across all countries. The World Bank climate country briefs identify extreme precipitation, sea level rise, strong winds and drought as climate risks for the five countries involved in this project. For example, in the north, in the Republic Page 42 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) of Chad, there has been an increase in temperature of 0.7° C since 1960. The desert has been advancing at 3 km/year in the north of the country and Lake Chad is expected to disappear in the next 20 years. At the southern end of this project in Angola, sea level rise of up to half a meter by the end of the century is projected to have a significant impact on coastal settlements where half of the country’s population lives, whilst recurrent flooding over the last ten years has most seriously affected the Cuanhama basins, and the city of Ondjiva. REDISSE IV has been screened for climate and disaster risk. This identified exposure of the project locations and target beneficiaries as moderate risk due to the likelihood of extreme temperatures, precipitation and flooding and drought. Also, the screening assessed the project as having a moderate risk in terms of its potential impact on women due to communicable disease effects. 93. Each of the identified climatic changes are associated with important potential health impacts. Some of these health impacts may include changes to infectious disease ranges and transmission patterns. Vector-borne diseases are susceptible to changes in temperature, humidity and precipitation; water-borne diseases are correlated with precipitation and flooding; animal migration patterns vary according to climatic conditions affecting water and feed resources. Consequent human displacement can result in novel disease emergence due to geography or population density. Periods of heavy rainfall favor the development of competent mosquito vectors, which in drier regions such as Chad, drives epidemics in both ruminants and people. All REDISSE IV countries are characterized as “hotspots” for climate-sensitive health impacts, meaning they occur in climate- vulnerable geographic regions, have vulnerable populations, and have pre-existing burdens of infectious diseases that are likely to increase with climate change. 94. REDISSE IV responds to the threats posed by climate change in a number of ways. The project will contribute to climate adaptation under Component 1 (total ~US$116.45 million) by significantly increasing the capacity of systems to monitor communicable diseases associated with climate change, such as malaria and dengue. This will ensure early detection of changing conditions and disease patterns at both the national and sub- national levels allowing the identification of gaps in information systems to facilitating timely action. Component 2 (total US$67.20 million) will enhance the scientific base needed to improve context relevant research and knowledge and the outbreak response capacity in each of the five countries. This will enable them to respond to early warnings and mount effective and timely emergency responses to climate related events. Component 3 (US$46.85 million) will develop the public health workforce. Public health professionals are key to strengthening preparedness and response to health emergencies including those due to climate change. They are also key to advocating for the necessary resourcing and establishment of governance mechanisms needed for the prevention of such eventualities. Overall, because of all the above investments, institutional capacity will increase across the communicable disease infrastructure of the five countries. This will ensure that information can be used most effectively in decisions around health resources and supply chains, capacity development, and early warning systems to adapt to changing climate risk for health. 95. REDISSE IV adopts important mitigation measures to reduce net greenhouse gas emissions. Under Component 1 (~US$10 million) any laboratory building, and refurbishment will include the use of climate-smart infrastructure (i.e. solar panels, thermal insulation, the use of modern and efficient water supply and treatment as well as low energy lighting), and the purchase of equipment that is low carbon in manufacture and energy efficient in operation. .D. Legal Operational Policies . Page 43 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . . E. Environmental and Social . The project is likely to result in a range of impacts associated with the civil works and transport. This will include environmental impacts associated with any rehabilitation activities such as air and noise emissions, impacts on water quality and disposal and management of waste (including chemicals and medical waste). Impacts to biodiversity and living natural resources are not anticipated. Impacts to people are also anticipated again associated with civil works including to community health and safety as a result of traffic movements and the presence of workers (GBV, SEA and disease transmission). In addition, the working conditions of those employed to undertake rehabilitation activities will need to be managed in order to protect the workforce and meet GIIP in relation to occupational health and safety. Land acquisition is not anticipated as all civil works are planned to be on existing government land, but if the project has land acquisition leading to economic and/or physical displacement, a RPF or RAP will be prepared, consulted upon, cleared by the Bank and disclosed. All 5 countries are home to IP/SSAHUTLC who will need to be considered during project implementation in particular in relation to public health campaigns. Stakeholder Engagement will need to be undertaken both at the national level in relation to the overall program and the local level in relation to civil works and to . ensure that public health campaigns are appropriately designed and implemented. 96. Approval to defer the preparation of Environmental and Social Framework (ESF) safeguards instruments under IPF Policy, paragraph 12 “Projects in Situations of Urgent Need of Assistance or Capacity Constraints” was obtained from the Regional Vice President of the Africa Region. This is due to the ongoing Ebola Virus Disease outbreak in DRC which has placed a serious strain on key policy, technical, and implementing entities who are critical for the preparation of the proposed project both in DRC as well as in some other participating countries such as CAR which are vulnerable to potential cross-border infection. At the same time, there is an urgent need to prepare and deliver this regional project without delay given the direct relation its development objective of strengthening disease surveillance systems has with building the capacity of the participating countries to be better prepared to detect future Ebola and other diseases earlier and respond more swiftly and effectively than they can do today. REDISSE IV countries have prepared and disclosed (On May 31, 2019 for DRC, on June 3, 2019 for CAR and Chad, on June 5, 2019 for Angola and RoC), and on June 11, 2019 for ECCAS) the Environmental and Social Commitment Plans (ESCP) and Stakeholder Engagement Plans (SEP). 97. Environmental Social Standard (ESS)1: Assessment and Management of Environmental and Social Risks and Impacts. The project will result in a range of environmental and social risks and impacts in the five countries, all of which will need to be mitigated. While these impacts may be varied, no irreversible impacts are expected. Potential risks and impacts are associated with rehabilitation of laboratories; emergency interventions; and the handling, management, transportation and storage of drugs, chemicals, specimens and vaccines. Key environmental concerns are related to potential risks and impacts from civil works, management of emergency operations, handling of drugs, biological specimens, chemicals and vaccines. While the Project does not involve activities with a high potential to harm the population nor would it exacerbate social risks, it will be carried out in a context of fragility and growing tension within communities about managing disease outbreaks, such as the Ebola crisis in DRC. Key social concerns relate to civil works, including to community health and safety as a result of traffic movements; the presence of workers (gender based violence (GBV)/Sexual Page 44 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Exploitation and Abuse - SEA - and disease transmission); working conditions of those employed to undertake rehabilitation activities will need to be managed in order to protect the workforce and meet Good International Industry Practice (GIIP) in relation to occupational health and safety; potential involuntary resettlement; presence of Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities (IP/SSAHUTLC) in the project area; and, social conflict about managing the disease in a culturally appropriate manner. Mitigation measures for site-specific impacts will be managed through the implementation of required environmental and social risk management documents that will be prepared within the four months of project implementation, as the proposed operation has been prepared under emergency procedures per World Bank IPF Policy. 98. Environmental and Social Management System. Due to the multi-country nature of the project and limited existing frameworks, reliance on the Environmental and Social (E&S) Framework of the Borrowers/ Recipients is not considered to be appropriate. 99. Environmental and Social Assessment. To manage potential risks and impacts, each participating country will prepare and consult upon an Environmental and Social Management Framework (ESMF) for activities for which the exact location is not yet known, or an Environmental and Social Impact Assessment (ESIA) for activities of which the location is known. 100. Environmental and Social Commitment Plan. The required environmental and social instruments along with the timing for their preparation is captured in the ESCPs for each of the participating countries and ECCAS, which has been prepared and disclosed. Additionally, the ESCP set out a summary of measures (including the preparation of environmental and social instruments) and actions to address potential environmental and social risks and impacts of the project, as well as targeted training and support to the environmental and social specialists. The ESCP will be updated to take into account findings of the subsequent environmental and social assessment, the World Bank’s environmental and social due diligence, and results of engagement with stakeholders. 101. Organizational Capacity and Competency. The PIUs in all participating countries within the health ministries have been working with the World Bank for a number of years. However, an assessment of the organizational capacity and competency will be undertaken, and staff recruited when appropriate. For example, in the PIUs, there are dedicated fiduciary, administrative and environmental and social staff. However, an assessment for the need for addition specialists will be made and if needed staff hired as project implementation nears. The project will also recruit Stakeholder Engagement Specialists to oversee SEP activities with responsibility for interfacing between stakeholders and the project. The PIUs will work closely with selected laboratories and hospitals to ensure that Quality Control and Occupation Health and Safety plans are in place and meet World Bank’s requirements. World Bank specialists will work closely with any recruited staff to strengthen their capacity. 102. Monitoring and Reporting. The ESMF will include monitoring commitments. The environmental and social management plan (ESMP) will be elaborated for contractors/subcontractors to be hired for the rehabilitation of laboratories will also include monitoring commitments. The World Bank will require E&S monitoring performance reporting during implementation. 103. Stakeholder Engagement and Information Disclosure. SEPs for each of the participating countries have Page 45 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) been developed and disclosed. 104. ESS2: The project will mainly use existing government employees within the five countries who will work under their existing terms and conditions. Workers hired for the project as well as contractors employed to construct or rehabilitate facilities will be subject to the requirements of ESS2. Labor Management Procedures will be developed for each of the countries reflecting the different types of workers that will be employed. The project will also include a grievance redress mechanism (GRM) for labor-related complaints. We have also included dated covenants on GRMs. 105. Occupational Health and Safety (OHS). OHS will be considered during implementation both in relation to construction/rehabilitation of facilities and operation. Contractors and selected laboratories will commit to a safe worksite. During operation, a Quality Control Plan for OHS will be developed with detailed requirements for the transport, handling and disposal of infectious disease specimens, chemicals/reagents and other hazardous materials. The OHS plan will include procedures on incident investigation and reporting, recording and reporting of non-conformances, emergency preparedness and response procedures and continuous training and awareness to workers. 106. Child Labor/Forced Labor and Minimum Age. Contractors (construction/rehabilitation of facilities), primary suppliers of drugs/vaccines and subcontractors must commit to not using child labor or forced labor. This commitment will be explained to affected communities. 107. Contracted Workers/Workers Engaged by Third Parties. Contractor and subcontractor recruitment plans will be critical to ensure transparency in local hiring and in meeting project labor procedure requirements. 108. ESS3. During rehabilitation/construction of facilities and emergency interventions, mitigation measures at rehabilitation and emergency intervention sites will include standard pollution prevention and control measures in accordance with the mitigation hierarchy. They will include (i) solid and hazardous waste handling and disposal; (ii) wastewater treatment; (iii) storage and handling of hazardous materials; (iv) housekeeping; (v) control of erosion and storm water runoff; and (vi) noise, vibrations, and dust abatement measures; among others. Management of Hazardous and Non-hazardous Waste 109. The main risks are associated with disposal of health care waste and chemical and hazardous waste (and transportation) of samples. Medical Waste Management Plans (MWMP) and a plan for the management of hazardous waste will be prepared taking into account WBG Environmental, Health and Safety guidance, as well as GIIP. Additionally, the ESMF and site-specific instruments will include (i) guidance related to transportation and management of expired chemical drugs and vaccines during emergency interventions and surveillance of diseases; and (ii) management of waste during rehabilitation of facilities/laboratories. The Project will identify a certified healthcare waste handler prior to start of activities and E&S mitigation measures will be outlined in agreements with participating laboratories and hospitals. 110. Water consumption, energy use and raw material use. The project will use a significant amount of energy but not significant amounts of water and raw material. Contractors and institutions involved in emergency interventions will be encouraged to do more with less water and energy. In addition, rehabilitation Page 46 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) works will include emergency/fire management in laboratory facilities and energy consumption and wastewater treatment. Laboratory facilities require high ventilation rates and the associated air conditioning loads. The ventilation rates are typically required to maintain safety and containment levels and meet the relevant risk management guidelines. 111. Management of air pollution. Purchase of air conditioners using R-22 refrigerant is prohibited for laboratories to be constructed/rehabilitated. R-22 is a hydro-chlorofluorocarbon that contributes to ozone depletion. In 2010, it was discontinued for use in new air conditioning systems. 112. Management of pesticides. Elements for managing pesticides will be included in the ESCP and ESMF for any sub-project involving pest or vector management issues (such as migratory locust control, mosquito or other disease vector control, bird control, or rodent control). 113. ESS4: Community exposure to health issues and workplace safety. Risks and impacts to community health and safety may result from construction/rehabilitation of laboratories, and from transportation of samples, chemicals etc. Risks may also result from emergency interventions and lab operation. Potential impacts will be identified, and mitigation measures presented in the ESMF, and the Medical Waste Management Plan. The project will undertake GBV/SEA Assessments in each country and prepare measures for addressing such risks, including GRM. An appropriate protocol/quality control plan will be set up for the collection, packaging, transportation and storage of biological samples. It will include pre-transportation measures, transportation measures including emergencies (spills, accidental exposures; power/utility failures; fire) and control access to areas where specimens are used and stored. Work involving biological agents is usually carried out in safety offices, which provide a safe process and protection to the user. An OHS plan will be prepared for selected laboratories as part of the readiness and preparedness and response mechanisms imbedded in the project design. The plan will include standard lab practices, limited access, biohazard warning sign, sharps/needle precautions, etc. Contractors and subcontractors will be required to prepare OHS plans 30 days before starting work and to commit to worksite safety. 114. Safety of services. In case of emergency interventions, the project will provide services to communities such as treatment of diseases during outbreaks. A Quality Control Plan will be established and implemented as part of the response plan (imbedded in the project design) to anticipate and minimize risks and impacts that such services may have on community health and safety. The concept of universal access whereby unimpeded access for people of all ages and abilities in different situations and under various circumstances (when possible) will be applied. 115. Traffic and road safety. Access to laboratory facilities will be restricted during rehabilitation and emergency interventions. In addition, during disease outbreaks borders and transhumance routes may be closed. Measures related to traffic and road safety during disease outbreaks will be incorporated in the SEP and national multi-risk preparedness and response plans. 116. ESS5: Economic or physical displacement resulting from land acquisition is not expected in any of the countries as the project will finance the refurbishment of existing laboratories. As part of the ESMF there will be a requirement to screen all sites/facilities to ensure economic or physical displacement does not occur. In those cases where it is necessary, appropriate instruments (compensation at replacement cost and/or other assistances, RPF or RAP) will be prepared, consulted upon, cleared by the World Bank and disclosed. Page 47 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 117. ESS6: Potential impacts to biodiversity will be captured in the ESMF to ensure that impacts are minimized during any emergency response and as a result of any rehabilitation work. In addition, the national and local surveillance system and the sanitary information system will include ecological risk factors (wildlife corridor between countries, parks, reserves, and classified forests). 118. ESS7: As the project will improve disease surveillance and undertake public health awareness campaigns, including around veterinary health and livestock, consultation will need to be designed which reflects needs and ensures benefits from the project to IP/SSAHUTLCs. Indigenous Peoples Planning Framework(s) will be developed to address the risks in Angola, CAR, DRC, and RoC; a screening will be undertaken in Chad to determine if there are IP/SSAHUTLCs in the project area. 119. ESS8: Impacts to cultural heritage associated with the excavation works are expected to be minimal. Measures to mitigate this risk, notably a chance finds procedure that sets out how chance finds associated with the project will be managed, will be captured in the relevant ESMF. 120. ESS10: SEPs for each of the participating countries have been developed and disclosed. The SEPs are aimed at ensuring that the views and interests of all stakeholders, including the local communities, are taken into consideration throughout the project. A key aspect is the engagement of civil society to help monitor the spread of diseases and work with local and health authorities to manage impacts. This will include development of a Grievance Redress Mechanism for all stakeholders. In addition, transparent reporting to and ongoing involvement of affected communities will also be addressed. 121. It is important to include citizens in the preparation, elaboration, implementation, and monitoring and evaluation of projects like REDISSE IV as they will advocate and assist to ensure that public institutions are more transparent, effective and accountable. Citizen’s involvement will also improve community ownership, social and environmental performance of the project and its sustainability. REDISSE IV was designed and prepared after several in-country consultations that were undertaken in each of the participating countries. The stakeholders’ engagement plan (SEP) and the environmental and social commitment plan (ESCP) were developed for each of the 5 participating countries after an extensive consultation with the government and other partners including non-governmental and faith-based organizations. Validation and public disclosure of the ESCP and the SEP for each of the countries was done so as to ensure broad public engagement. It is expected that the remaining environmental and social instruments will also be developed in an inclusive and consultative way after project approval and effectiveness. As concerns project implementation, each country is putting in place a project steering committee that will be responsible for the review of the workplan and budget on an annual basis and provide guidance to the project implementing unit. Consultation and participation is an iterative process, and this process will be undertaken throughout the lifecycle of the project. The Project Implementation Manual will include a specific section on citizens’ engagement. V GRIEVANCE REDRESS SERVICES 122. Communities and individuals who believe that they are adversely affected by a World Bank (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 Page 48 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 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. VI. KEY RISKS 123. The overall risk rating for the project is categorized as “substantial” due to “substantial” risks in political and governance issues, technical design of the project, environmental and social, stakeholders, and conflict and displacement, and as well as “high” rated risks in macroeconomic, institutional capacity for implementation and sustainability, and fiduciary. 124. Political and governance risks are rated as “substantial.” The Central Africa Region is becoming “more democratic” than a few decades ago. However, establishment of real political stability that offers room for peaceful nation building and autonomous development of country states has been difficult. Some of the project countries in the sub-region have been plagued with crises including contested elections and civil unrest. In such conditions, there is a risk of mismanagement of project resources. To mitigate the impact of these risks, the project will put an emphasis on the participation of beneficiaries (committees at regional and national levels) to reduce potential fraud and it will also be necessary to coordinate with other partners in the health and animal sectors. 125. Macroeconomic risk is rated as “high.” In the sub-region, commodity prices have declined since 2014. Since the economies of most of the countries in the sub-region depend on oil, the fall in world oil prices has resulted in macro-economic instability that could negatively impact on allocation of resources to disease surveillance. Though oil prices have been increasing, the immediate outlook for the regional economy looks bleak. This project will advocate to the Government the importance of the support of government to this project for human capital development in countries of the sub-region. 126. The risks associated with technical design of projects and programs are considered “substantial.” Although some of the interventions funded through the project have already been implemented within the sub- region, this has not always been done collaboratively by the animal and human health sectors. There is generally a lack of coordination between the different government ministerial departments and this may result in duplication of activities. This risk will be mitigated through close support by the World Bank team and strong technical assistance from organizations within and outside of the sub-region that have experience working with the two sectors. The project will assist the Government to put in place multi-sectoral coordinating committees. 127. Institutional capacity for implementation and sustainability risks are rated as “high .” As indicated earlier, this region has been plagued with crisis that has resulted in out-migration of most professionals. To address this risk, the project will build the capacity of government staff as necessary, relying initially on skilled consultants and UN agencies to support project implementation and also ensure that non-state-actors (civil society, communities and the private sector) are involved in project implementation. 128. Fiduciary risks are “high.” The project may be put at risk by poor budget management and weak procurement capacity of government. To mitigate these risks and to ensure smooth implementation of activities Page 49 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) and management of funds, the project will make use of an experienced coordination team within the Ministries of Health that have successfully managed other World Bank projects. The existing FM arrangements will contribute to building capacity within the ministries. The project will also follow the World Bank’s New Procurement Policy and the NPF. To further mitigate risks in this area, the PPSD has been prepared to support and guide the fiduciary risks. 129. The social and environmental risks are “substantial”. REDISSE IV will proceed under the new ESF and has been classified as moderate for environmental and substantial for social risks. Though the risks are manageable, the capacity to address and manage these risks is weak. To mitigate the risks, environmental and social safeguard specialist are being recruited in each of the countries to assist the clients on a day-to-day basis. Nine of the ten environmental and social standards are relevant for this project: ESS1 (Assessment and Management of Environmental and Social Risks and Impacts); ESS2 (Labor and Working Conditions); ESS3 (Resource Efficiency and Pollution Prevention and Management); ESS4 (Community Health and Safety); ESS5 (Land Acquisition, Restrictions on Land Use and Involuntary Resettlement); ESS6 (Biodiversity Conservation and Sustainable Management of Living Natural Resources); ESS7 (Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Local Communities); ESS8 (Cultural Heritage); and ESS10 (Stakeholder Engagement and Information Disclosure). ESS9 (Financial Intermediaries) is not relevant for the project since no activity will involve financial Intermediaries. 130. Stakeholder risk is “substantial.” Given the number of ministerial departments and other partners in the different countries that are involved, there is a risk that coordination efforts may not be adequate to ensure the success of proposed project interventions. To manage these risks, support would be provided to establish multisectoral committees at national and regional levels for coordination to ensure effective participation of all stakeholders. Furthermore, there are interventions within the project focusing on citizen engagement and community-based capacity building. 131. Conflict and displacement risk are rated as “substantial.” The Central Africa region has been plagued with crisis that has resulted in people emigrating out of the countries of the region. Most of the project countries are classified as FCV prone. It is also a region which is epidemic-prone. People fleeing conflict would often cross borders increasing the risk of disease transmission. Due to the displacement, people may find it difficult to access care due to the lack of services, distances from health facilities and even lack of financial resources. To manage this risk, the project will work closely with partners that have expertise dealing with displaced people; and with . the beneficiaries. Page 50 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) VII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Africa Regional Disease Surveillance Systems Enhancement Project (REDISSE) Phase IV Project Development Objectives(s) The project development objectives are: (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the Participating Countries; and (ii) in the event of an Eligible Crisis or Emergency, to provide immediate and effective response to said Eligible Crisis or Emergency. Project Development Objective Indicators RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target strengthen national and regional cross-sectoral capacity for collaborative disease surveillance Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that achieve a 0.00 4.00 JEE score of 4 or higher) (Number) ANGOLA: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that 1.00 4.00 achieve a JEE score of 4 or higher) (Number) CAR: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that 1.00 4.00 achieve a JEE score of 4 or higher) (Number) CHAD: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that 1.00 4.00 achieve a JEE score of 4 or higher) (Number) DRC: Laboratory testing capacity for detection of priority 3.00 4.00 Page 51 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target diseases (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) (Number) (Number) RoC: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that 1.00 4.00 achieve a JEE score of 4 or higher) (Number) Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of countries that 1.00 4.00 achieve a JEE score of 4 or higher) (Number) ANGOLA: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of 1.00 4.00 countries that achieve a JEE score of 4 or higher) (Number) CAR: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of 2.00 4.00 countries that achieve a JEE score of 4 or higher) (Number) CHAD: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of 2.00 4.00 countries that achieve a JEE score of 4 or higher) (Number) DRC: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of 3.00 4.00 countries that achieve a JEE score of 4 or higher) (Number) (Number) RoC: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of 2.00 4.00 countries that achieve a JEE score of 4 or higher) (Number) Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of countries 0.00 3.00 that achieve a JEE score of 3 or higher) (Number) ANGOLA: Availability of human resources to implement IHR 2.00 3.00 Page 52 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target core capacity requirements (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) (Number) CAR: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of 2.00 3.00 countries that achieve a JEE score of 3 or higher) (Number) CHAD: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of 2.00 3.00 countries that achieve a JEE score of 3 or higher) (Number) DRC: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of 2.00 3.00 countries that achieve a JEE score of 3 or higher) (Number) (Number) RoC: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of 3.00 3.00 countries that achieve a JEE score of 3 or higher) (Number) National multisectoral Multi-hazard emergency preparedness measures including emergency response plans are developed, 0.00 4.00 implemented, and tested (nat capacity scores) (No of countries that achieve 4or hi (Number) ANGOLA: Multi-hazard national public health emergency preparedness and response plan is developed and 1.00 4.00 implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or highe (Number) CAR: Multi-hazard national public health emergency preparedness and response plan is developed and 1.00 4.00 implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) (Number) CHAD: Multi-hazard national public health emergency 1.00 4.00 Page 53 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target preparedness and response plan is developed and implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) (Number) DRC: Multi-hazard national public health emergency preparedness and response plan is developed and 1.00 4.00 implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) (Number) RoC: Multi-hazard national public health emergency preparedness and response plan is developed and 1.00 4.00 implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher (Number) Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of 0.00 3.00 countries that achieve a score of 4 or higher) (Number) ANGOLA: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) 0.00 3.00 (Number of countries that achieve a score of 4 or higher) (Number) CAR: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of 0.00 3.00 countries that achieve a score of 4 or higher) (Number) CHAD: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of 0.00 3.00 countries that achieve a score of 4 or higher) (Number) DRC: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of 0.00 3.00 countries that achieve a score of 4 or higher) (Number) RoC: Progress on cross-border collaboration and exchange of 0.00 3.00 information across countries (Likert scale 1 - 5) (Number of Page 54 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline End Target countries that achieve a score of 4 or higher) (Number) Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint 0.00 3.00 priorities: no of countries that achieve a JEE score of 3 or higher (Number) ANGOLA: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens 1.00 3.00 identified as joint priorities: no of countries that achieve a JEE score of 3 or hi (Number) CAR: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens 1.00 3.00 identified as joint priorities: no of countries that achieve a JEE score of 3 or highe (Number) CHAD: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens 3.00 4.00 identified as joint priorities: no of countries that achieve a JEE score of 3 or high (Number) DRC: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens 3.00 4.00 identified as joint priorities: no of countries that achieve a JEE score of 3 or highe (Number) RoC: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens 1.00 3.00 identified as joint priorities: no of countries that achieve a JEE score of 3 or hig (Number) PDO Table SPACE Page 55 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Intermediate Results Indicators by Components RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Strengthening Surveillance and laboratory capacity to rapidly detect outbreak Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries that achieve a 0.00 4.00 JEE score of 4 or higher (Number) (Number) ANGOLA: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: 1.00 4.00 number of countries that achieve a JEE score of 4 or higher (Number) (Number) (Number) CAR: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries 2.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) CHAD: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries 1.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) DRC: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries 1.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) RoC: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries 2.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) Laboratory systems quality: number of countries that achieve a 0.00 4.00 JEE score of 4 or higher (Number (Number) ANGOLA: Laboratory systems quality: number of countries 1.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) CAR: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) (Number) 1.00 4.00 CHAD: Laboratory systems quality: number of countries that 1.00 4.00 achieve a JEE score of 4 or higher (Number) (Number) DRC: Laboratory systems quality: number of countries that 1.00 4.00 Page 56 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target achieve a JEE score of 4 or higher (Number) (Number) RoC: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) (Number) 1.00 4.00 Specimen referral and transport system: number of countries 0.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) ANGOLA: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) 1.00 4.00 (Number) CAR: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) 1.00 4.00 (Number) CHAD: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) 2.00 4.00 (Number) DRC: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) 2.00 4.00 (Number) (Number) RoC: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) 1.00 4.00 (Number) Systems for efficient reporting to WHO, OIE/FAO: number of 0.00 4.00 countries that achieve a JEE score of 4 (Number) (Number) ANGOLA: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4(Number) 2.00 4.00 (Number) CAR: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) 2.00 4.00 (Number) CHAD: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) 2.00 4.00 (Number) Page 57 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target DRC: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) 3.00 4.00 (Number) RoC: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) 3.00 4.00 (Number) Progress towards establishing an active, functional regional One Health platform (Number based on 5-point Likert scale) of 1.00 3.00 countries that achieve a score of 4 or higher (Number) Strengthening Emergency planning and management capacity to rapidly respond to outbreaks Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries 0.00 4.00 that achieve a JEE score of 4 or higher (Number) (Number) ANGOLA: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher 1.00 4.00 (Number) (Number) CAR: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of 1.00 4.00 countries that achieve a JEE score of 4 or higher (Number) (Number) CHAD: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of 2.00 4.00 countries that achieve a JEE score of 4 or higher (Number) (Number) DRC: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher (Number) 1.00 4.00 (Number) RoC: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of 1.00 4.00 countries that achieve a JEE score of 4 or higher (Number) Page 58 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target (Number) Regional surge capacity and stockpiling mechanisms established (capacity based on 5-point Likert scale) (Number) 1.00 3.00 System in place for activating and coordinating regional medical countermeasures and health personnel during a public health 0.00 4.00 emergency. ( target score of 5 for sustainable capaci (Number) Public health workforce development Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE score of 4 or higher 0.00 4.00 (Number)) (Number) ANGOLA: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE 1.00 4.00 score of 4 or higher (Number)) (Number) CAR: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE 1.00 4.00 score of 4 or higher (Number)) (Number) CHAD: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE 2.00 4.00 score of 4 or higher (Number)) (Number) DRC: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE 3.00 4.00 score of 4 or higher (Number)) (Number) RoC: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE 2.00 4.00 score of 4 or higher (Number)) (Number) FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher (Number) 1.00 4.00 (Number) ANGOLA: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or 2.00 4.00 higher (Number) (Number) Page 59 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target CAR: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher 2.00 4.00 (Number) (Number) CHAD:FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or 2.00 4.00 higher (Number) (Number) DRC: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher 4.00 4.00 (Number) (Number) RoC: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher 1.00 4.00 (Number) (Number) Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve 0.00 3.00 a JEE score of 4 or higher (Number) (Number) ANGOLA: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve a JEE score of 4 or higher (Number) 1.00 3.00 (Number) CAR: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries 1.00 3.00 that achieve a JEE score of 4 or higher (Number) (Number) CHAD: Human resources are available to ensure the main skills required for implementation of the IHR: number of 3.00 3.00 countries that achieve a JEE score of 4 or higher (Number) (Number) DRC: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries 3.00 3.00 that achieve a JEE score of 4 or higher (Number) (Number) RoC: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries 3.00 3.00 that achieve a JEE score of 4 or higher (Number) (Number) Page 60 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target Percentage of people trained in applied epidemiology who are 0.00 0.00 female (all categories) (Percentage) ANGOLA: Percentage of people trained in applied 0.00 0.00 epidemiology who are female (all categories) (Percentage) CAR: Percentage of people trained in applied epidemiology who are female (all categories) (Percentage) 0.00 0.00 CHAD: Percentage of people trained in applied epidemiology 0.00 0.00 who are female (all categories) (Percentage) DRC: Percentage of people trained in applied epidemiology 0.00 0.00 who are female (all categories) (Percentage) (Percentage) RoC: Percentage of people trained in applied epidemiology 0.00 0.00 who are female (all categories) (Percentage) Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female (Percentage) 0.00 0.00 ANGOLA: Percentage of people trained in basic/short-term (3 0.00 0.00 months) applied epidemiology who are female (Percentage) CAR: Percentage of people trained in basic/short-term (3 0.00 0.00 months) applied epidemiology who are female (Percentage) CHAD: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female (Percentage) 0.00 0.00 DRC: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female (Percentage) 0.00 0.00 (Percentage) RoC: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female (Percentage) 0.00 0.00 Percentage of people trained in advance (2 years) applied 0.00 0.00 epidemiology who are female (Percentage) ANGOLA: Percentage of people trained in advanced (2 years) 0.00 0.00 applied epidemiology who are females (Percentage) CAR: Percentage of people trained in advanced (2 years) 0.00 0.00 Page 61 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target applied epidemiology who are females (Percentage) CHAD: Percentage of people trained in advanced (2 years) applied epidemiology who are females (Percentage) 0.00 0.00 DRC: Percentage of people trained in advanced (2 years) applied epidemiology who are females (Percentage) 0.00 0.00 (Percentage) RoC: Percentage of people trained in advanced (2 years) 0.00 0.00 applied epidemiology who are females (Percentage) Percentage of people trained in intermediate (9 months) applied 0.00 0.00 epidemiology in the country who are females (Percentage) ANGOLA: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females 0.00 0.00 (Percentage) CAR: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females 0.00 0.00 (Percentage) CHAD: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females 0.00 0.00 (Percentage) DRC: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females 0.00 0.00 (Percentage) (Percentage) RoC: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females 0.00 0.00 (Percentage) Institutional Capacity Building, Project Management, Coordination and Advocacy Citizens and/or communities involved in planning/implementation/evaluation of development programs No Yes (Yes/No) (Yes/No) ANGOLA: Citizens and/or communities involved in No Yes planning/implementation/evaluation of development programs Page 62 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline End Target (Yes/No) (Yes/No) CAR: Citizens and/or communities involved in planning/implementation/evaluation of development programs No Yes (Yes/No) (Yes/No) CHAD: Citizens and/or communities involved in planning/implementation/evaluation of development programs No Yes (Yes/No) (Yes/No) DRC: Citizens and/or communities involved in planning/implementation/evaluation of development programs No Yes (Yes/No) (Yes/No) (Yes/No) RoC: Citizens and/or communities involved in planning/implementation/evaluation of development programs No Yes (Yes/No) (Yes/No) 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 Capacity graded on a score JEE (IHR and of 1-5 where: 1 = no GHSA), and capacity (National Laboratory testing capacity for detection OIE PVS Self-assessments by laboratory system is not Participating countries, of priority diseases (national capacity Annual evaluation at countries in capable of conducting any JEE and OIE PVS experts scores) (Number of countries that achieve year 3 and intermediary years. core tests); 2 = limited a JEE score of 4 or higher) end of capacity (national project laboratory system is capable of conducting 1-2 (of 10) Page 63 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) core tests); 3 = developed capacity (national laboratory system is capable of conducting 3-4 (of 10) core tests); 4 = demonstrated capacity (national laboratory system is capable of conducting 5 or more (of 10) core tests); and 5 = sustainable capacity (In addition to capability of conducting 5 or more core tests, country has national system(s) for procurement and quality assurance) ANGOLA: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) CAR: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) CHAD: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) DRC: Laboratory testing capacity for detection of priority diseases Page 64 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) (Number) RoC: Laboratory testing capacity for detection of priority diseases (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) ANGOLA: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) CAR: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) CHAD: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) DRC: Progress in establishing indicator and event-based surveillance systems Page 65 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) (Number) RoC: Progress in establishing indicator and event-based surveillance systems (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) Capacity graded on a score of 1-5 where: 1 = no capacity (country doesn’t have multidisciplinary HR capacity required for implementation of IHR core capacities); 2 = limited capacity (country has multidisciplinary HR capacity JEE (IHR and (epidemiologists, GHSA), and Availability of human resources to veterinarians, clinicians and OIE PVS Self-assessments by implement IHR core capacity Participating countries, laboratory specialists or Annual evaluation at countries in requirements (national capacity scores) JEE and OIE PVS experts technicians) at national year 3 and intermediary years (Number of countries that achieve a JEE level); 3 = developed end of score of 3 or higher) capacity (multidisciplinary project HR capacity is available at national and intermediate level); 4 = demonstrated capacity (multidisciplinary HR capacity is available as required at relevant levels of public health system (e.g. epidemiologist at national level and intermediate level Page 66 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) and assistance epidemiologist (or short course trained epidemiologist) at local level available); 5 = sustainable capacity (country has capacity to send and receive multidisciplinary personnel within country (shifting resources) and internationally) ANGOLA: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) CAR: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) CHAD: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) DRC: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) Page 67 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) (Number) RoC: Availability of human resources to implement IHR core capacity requirements (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) National multisectoral Multi-hazard emergency preparedness measures including emergency response plans are developed, implemented, and tested (nat capacity scores) (No of countries that achieve 4or hi ANGOLA: Multi-hazard national public health emergency preparedness and response plan is developed and implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or highe CAR: Multi-hazard national public health emergency preparedness and response plan is developed and implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) CHAD: Multi-hazard national public health emergency preparedness and response plan is developed and implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) Page 68 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) DRC: Multi-hazard national public health emergency preparedness and response plan is developed and implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) RoC: Multi-hazard national public health emergency preparedness and response plan is developed and implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher Progress graded on a score of 1-5 where: 1 = no capacity (no formal/informal agreements related to cross border collaboration/information exchange, and no standard operating procedures in Progress on cross-border collaboration place); 2 = limited capacity and exchange of information across Self- (informal agreements on Annual Self-assessment Participating Countries countries (Likert scale 1 - 5) (Number of assessment cross-border collaboration/ countries that achieve a score of 4 or information exchange and higher) standard operating procedures drafted); 3 = developed capacity (formal agreements on cross-border collaboration/information exchange, and standard operating procedures adopted); 4 = demonstrated Page 69 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) capacity (formal agreements on cross border collaboration/information exchange and standard operating procedures implemented and routinely monitored); 5 = sustainable capacity (normal agreements on cross-border collaboration/information exchange and standard operating procedures) implemented, routinely monitored and financed from domestic budget. ANGOLA: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of countries that achieve a score of 4 or higher) CAR: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of countries that achieve a score of 4 or higher) CHAD: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of countries that achieve a score of 4 or higher) DRC: Progress on cross-border collaboration and exchange of Page 70 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) information across countries (Likert scale 1 - 5) (Number of countries that achieve a score of 4 or higher) RoC: Progress on cross-border collaboration and exchange of information across countries (Likert scale 1 - 5) (Number of countries that achieve a score of 4 or higher) 1 = Some capacities for surveillance of Zoonoses exist but not organize between animal and human health; 2 = A list of five priority zoonoses / pathogens agreed between the sectors as the most threatening for national public health but has not Coordinated Surveillance Systems in place put in place any specific in animal and human health sectors for system for their zoonotic diseases/pathogens identified as surveillance; 3= Zoonotic joint priorities: no of countries that surveillance systems are in achieve a JEE score of 3 or higher place for one to four of the most threatening zoonoses / pathogens for public health; 4 = Zoonotic surveillance systems are in place for at least five of the most threatening zoonoses / pathogens for national public health; 5 = Systematic sharing of information Page 71 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) between sectors ensures a confirmed surveillance system for priority zoonoses and / or others. ANGOLA: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint priorities: no of countries that achieve a JEE score of 3 or hi CAR: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint priorities: no of countries that achieve a JEE score of 3 or highe CHAD: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint priorities: no of countries that achieve a JEE score of 3 or high DRC: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint priorities: no of countries that achieve a JEE score of 3 or highe RoC: Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint Page 72 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) priorities: no of countries that achieve a JEE score of 3 or hig ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Capacity graded on a score of 1-5 where 1 = no capacity (no interoperable, interconnected, electronic real-time reporting system exists; 2 = limited capacity (country is developing an interoperable, interconnected, electronic JEE (IHR and real-time reporting system, GHSA), and Use of electronic tools: Interoperable, for either public health or OIE PVS Self-assessments by interconnected, electronic real-time Participating countries, veterinary surveillance Annual evaluation at countries in reporting system: number of countries JEE and OIE PVS experts systems); 3 = developed year 3 and intermediary years that achieve a JEE score of 4 or higher capacity (country has in end of (Number) place an inter-operable, project interconnected, electronic reporting system, for either public health or veterinary surveillance systems. The system is not yet able to share data in real-time); 4 = demonstrated capacity (country has in place and interoperable, Page 73 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) interconnected, electronic real-time reporting system, for public health and/or veterinary surveillance systems. The system is not yet fully sustained by the host government); and 5 = sustainable capacity (country has in place an inter-operable, interconnected, electronic real-time reporting system, including both the public health and veterinary surveillance systems which is sustained by the government and capable of sharing data with relevant stakeholders according to country policies and international obligations). ANGOLA: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries that achieve a JEE score of 4 or higher (Number) (Number) CAR: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries that achieve a JEE score of 4 or higher (Number) Page 74 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) CHAD: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries that achieve a JEE score of 4 or higher (Number) DRC: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries that achieve a JEE score of 4 or higher (Number) RoC: Use of electronic tools: Interoperable, interconnected, electronic real-time reporting system: number of countries that achieve a JEE score of 4 or higher (Number) Capacity graded on a score of 1-5 where 1 = no capacity (there are no national laboratory standards); 2 = limited capacity (national JEE (IHR and quality standards have been GHSA), and developed but there is no OIE PVS Self-assessments by Laboratory systems quality: number of system for verifying their Participating countries, Annual evaluation at countries in countries that achieve a JEE score of 4 or implementation); 3 = JEE and OIE PVS experts year 3 and intermediary years higher (Number developed capacity (a end of system of licensing of health project laboratories that includes conformity to a national quality standard exists but it is voluntary or is not a requirement for all laboratories); 4 = Page 75 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) demonstrated capacity (mandatory licensing of all health laboratories is in place and conformity to a national quality standard is required); and 5 = sustainable capacity (mandatory licensing of all health laboratories is in place and conformity to an international quality standard is required). ANGOLA: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) CAR: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) CHAD: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) DRC: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) RoC: Laboratory systems quality: number of countries that achieve a JEE score of 4 or higher (Number) Capacity graded on a score EE (IHR and Self-assessments by Specimen referral and transport system: of 1-5 where 1 = no capacity GHSA), and Participating countries, Annual countries in number of countries that achieve a JEE (i.e. aside from ad hoc OIE PVS JEE and OIE PVS experts intermediary years score of 4 or higher (Number) transporting, no system is in evaluation at place for transporting year 3 and Page 76 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) specimens from district to end of national level); 2 = limited project capacity (system is in place to transport specimens to national laboratories from less than 50% of intermediate level/districts in country for advanced diagnostics); 3 = developed capacity (system is in place to transport specimens to national laboratories from 50- 80% of intermediate level/districts within the country for advanced diagnostics); 4 = demonstrated capacity (system is in place to transport specimens to national laboratories from at least 80% of intermediate level/districts within the country for advanced diagnostics; and 5 = sustainable capacity (system is in place to transport specimens to national laboratories from at least 80% of districts for advanced diagnostics; capability to transport specimens to/from other Page 77 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) labs in the region; and specimen transport is funded from domestic budget). ANGOLA: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) CAR: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) CHAD: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) DRC: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) (Number) RoC: Specimen referral and transport system: number of countries that achieve a JEE score of 4 or higher (Number) Capacity graded on a score JEE (IHR and of 1-5 where 1 = no capacity GHSA), and (no national IHR focal point, OIE PVS Self-assessments by Systems for efficient reporting to WHO, Participating countries, OIE Delegate and/or WAHIS Annaul evaluation at countries in OIE/FAO: number of countries that JEE and OIE PVS experts National Focal Point has year 3 and intermediary years achieve a JEE score of 4 (Number) been identified and/or end of identified focal project point/delegate does not Page 78 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) have access to learning package and best practices as provided by WHO, OIE and FAO); 2 = limited capacity (country has identified National IHR Focal Point, OIE delegates and WAHIS National Focal Points; focal point is linked to learning package and best practices as provided by WHO, OIE and FAO); 3 = developed capacity (country has demonstrated ability to identify a potential PHEIC and file a report to WHO based on an exercise or real event, and similarly to the OIE for relevant zoonotic diseases); 4 = (demonstrated capacity (country has demonstrated ability to identify a potential PHEIC and file a report to WHO within 24 hours and similarly to the OIE for relevant zoonotic disease, based on an exercise or real event); and 5 = sustainable capacity (country has demonstrated ability to identify a potential PHEIC Page 79 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) and file a report within 24 hours, and similarly to the OIE for relevant zoonotic disease, and has a multisectoral process in place for assessing potential events for reporting). ANGOLA: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4(Number) CAR: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) CHAD: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) DRC: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) RoC: Systems for efficient reporting to WHO, OIE/FAO: number of countries that achieve a JEE score of 4 (Number) Progress towards establishing an active, functional regional One Health platform (Number based on 5-point Likert scale) of countries that achieve a score of 4 or higher Mechanisms for responding to infectious Capacity graded on a score Annual JEE (IHR and Self-assessments by Participating countries, zoonoses and potential zoonoses are of 1-5 where 1 = no capacity GHSA), and countries in Page 80 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) established and functional: number of (i.e. no mechanism in place); OIE PVS intermediary years JEE and OIE PVS experts countries that achieve a JEE score of 4 or 2 = limited capacity evaluation at higher (Number) (national policy, strategy or year 3 and plan for the response to end of zoonotic events is in place); project 3 = developed capacity (a mechanism for coordinated response to outbreaks of zoonotic diseases by human, animal and wildlife sectors is established); 4 = demonstrated capacity (timely* and systematic information exchange between animal/wildlife surveillance units, human health surveillance units and other relevant sectors in response to potential zoonotic risks and urgent zoonotic events); and 5 = sustainable capacity (timely** response to more than 80% of zoonotic events of potential national and international concern) *timeliness is judged and determined by country ** time between detection and response as defined by regional/national standards. Page 81 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ANGOLA: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher (Number) CAR: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher (Number) CHAD: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher (Number) DRC: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher (Number) RoC: Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional: number of countries that achieve a JEE score of 4 or higher (Number) Regional surge capacity and stockpiling Capacity graded on a score Annual Survey ECCAS mechanisms established (capacity based of 1 -5 where: 1 = no Page 82 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) on 5-point Likert scale) capacity (no regional surge capacity and stockpiling mechanisms exist); 2 = limited capacity (regional stockpiling mechanism is in place with limited surge capacity); 3 = developed capacity (regional surge capacity and stockpiling mechanism has been established); 4 = demonstrated capacity (regional surge capacity and stockpiling mechanism has been established and tested); 5 = sustainable capacity (effective regional surge capacity and stockpiling mechanism has been established with sustainable funding arrangements from country budget). 1 = No regional countermeasures or System in place for activating and personnel plan has been coordinating regional medical drafted; 2= A regional countermeasures and health personnel countermeasures and during a public health emergency. ( target personnel plan has been score of 5 for sustainable capaci drafted; 3 = Tabletop exercises have been conducted to demonstrate Page 83 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) decision making and protocols are in place for send or receiving countermeasures and personnel in the region. Training and equipment is in place for emergency responders; 4 = At least one response or formal exercise has been conducted in the previous year demonstrating countermeasures and personnel were sent or received in the region. Evidence of emergency management deployer capacity is in place; 5 = Regional/international partnerships or formal agreements are in place that outline criteria for sending and receiving countermeasures and equipment and at least one response or formal exercise has been conducted in the previous year demonstrating countermeasures and personnel were sent or received in the region. Page 84 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Emergency management staff that are classified as internationally deployable EMTs by WHO are in place Capacity graded on a score of 1-5 where 1 = no capacity (no health workforce strategy exists); 2 = limited capacity (a healthcare workforce strategy exists but does not include public health professions e.g. epidemiologists, veterinarians and laboratory technicians); 3 =developed EE (IHR and capacity (a public health GHSA), and Workforce Strategy: An updated workforce strategy exists, OIE PVS Self-assessments by Participating countries, multisectoral staff strategy is in place but is not regularly Annual evaluation at countries in JEE and OIE PVS experts (number of countries that achieve a JEE reviewed, updated, or year 3 and intermediary years score of 4 or higher (Number)) implemented consistently); end of 4 = demonstrated capacity project (a public health workforce strategy has been drafted and implemented consistently; strategy is reviewed, tracked and reported on annually); and 5 = sustainable capacity (“demonstrated capacity” has been achieved, public health workforce retention is tracked and plans are in Page 85 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) place to provide continuous education, retain and promote qualified workforce within the national system). ANGOLA: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE score of 4 or higher (Number)) CAR: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE score of 4 or higher (Number)) CHAD: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE score of 4 or higher (Number)) DRC: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE score of 4 or higher (Number)) RoC: Workforce Strategy: An updated multisectoral staff strategy is in place (number of countries that achieve a JEE score of 4 or higher (Number)) Capacity graded on a score JEE (IHR and FETP or Applied epidemiology training Self-assessments by of 1-5 where 1 = no capacity GHSA), and Participating countries, program in place: number of countries Annual countries in (no FETP or applied OIE PVS JEE and OIE PVS experts that achieve a JEE score of 4 or higher intermediary years epidemiology training evaluation at (Number) program established or no year 3 and Page 86 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) access to such a program in end of another country); 2 = project limited capacity (no FETP or applied epidemiology training program is established within the country, but staff participate in a program hosted in another country through an existing agreement (at Basic, Intermediate and/or Advanced level); 3= developed capacity (one level of FETP (Basic, Intermediate, or Advanced) FETP or comparable applied epidemiology training program in place in the country or in another country through an existing agreement); 4 = demonstrated capacity (two levels of FETP (Basic, Intermediate and/or Advanced) or comparable applied epidemiology training program(s) in place in the country or in another country through an existing agreement); and 5 = sustainable capacity (three levels of FETP (Basic, Page 87 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Intermediate and Advanced) or comparable applied epidemiology training program(s) in place in the country or in another country through an existing agreement, with sustainable national funding). ANGOLA: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher (Number) CAR: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher (Number) CHAD:FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher (Number) DRC: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher (Number) RoC: FETP or Applied epidemiology training program in place: number of countries that achieve a JEE score of 4 or higher (Number) Human resources are available to ensure Capacity graded on a score JEE (IHR and Self-assessments by Participating countries, Annual the main skills required for of 1-5 where 1 = no capacity GHSA), and countries in JEE and OIE PVS experts implementation of the IHR: number of (country has no animal OIE PVS intermediary years Page 88 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) countries that achieve a JEE score of 4 or health workforce capable of evaluation at higher (Number) conducting One Health year 3 and activities); 2 = limited end of capacity (country has animal project health workforce capacity within the national public health system); 3 = developed capacity (animal health workforce capacity within the national public health system and less than half of sub-national levels); 4 = demonstrated capacity (animal health workforce capacity within the national public health system and more than half of sub- national levels); and 5 = sustainable capacity (animal health workforce capacity within the public health system and at all sub- national levels; this includes a plan for animal health workforce continuing education). ANGOLA: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve a JEE score of 4 or higher (Number) Page 89 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) CAR: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve a JEE score of 4 or higher (Number) CHAD: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve a JEE score of 4 or higher (Number) DRC: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve a JEE score of 4 or higher (Number) RoC: Human resources are available to ensure the main skills required for implementation of the IHR: number of countries that achieve a JEE score of 4 or higher (Number) For percentage calculation, Numerator (number of women trained in applied Percentage of people trained in applied epidemiology in the country epidemiology who are female (all in all categories); categories) Denominator (Total number of people trained in applied epidemiology in the country for all categories ANGOLA: Percentage of people trained in applied epidemiology who are female (all categories) Page 90 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) CAR: Percentage of people trained in applied epidemiology who are female (all categories) CHAD: Percentage of people trained in applied epidemiology who are female (all categories) DRC: Percentage of people trained in applied epidemiology who are female (all categories) (Percentage) RoC: Percentage of people trained in applied epidemiology who are female (all categories) For percentage calculation, Numerator (number of women trained in basic/short-term (3 months) Percentage of people trained in applied epidemiology in the basic/short-term (3 months) applied country ; Denominator epidemiology who are female (Total number of people trained in basic/short-term (3 months) applied epidemiology in the country. ANGOLA: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female CAR: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female CHAD: Percentage of people trained in basic/short-term (3 months) Page 91 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) applied epidemiology who are female DRC: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female (Percentage) RoC: Percentage of people trained in basic/short-term (3 months) applied epidemiology who are female For percentage calculation, Numerator (number of women trained in advanced (2 years) applied Percentage of people trained in advance epidemiology in the (2 years) applied epidemiology who are country); Denominator female (Total number of people trained in advanced (2 years) applied epidemiology in the country ANGOLA: Percentage of people trained in advanced (2 years) applied epidemiology who are females CAR: Percentage of people trained in advanced (2 years) applied epidemiology who are females CHAD: Percentage of people trained in advanced (2 years) applied epidemiology who are females DRC: Percentage of people trained in advanced (2 years) applied epidemiology who are females (Percentage) Page 92 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RoC: Percentage of people trained in advanced (2 years) applied epidemiology who are females percentage calculation, Numerator (number of women trained in intermediate (9months) applied epidemiology in the Percentage of people trained in country); Denominator intermediate (9 months) applied (Total number of people epidemiology in the country who are trained in intermediate females (9months) applied epidemiology in the country) ANGOLA: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females CAR: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females CHAD: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females DRC: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females (Percentage) Page 93 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) RoC: Percentage of people trained in intermediate (9 months) applied epidemiology in the country who are females The existence/inexistence of citizens and grassroots Citizens and/or communities involved in organizations trained, ECCAS/Participating Annual Survey planning/implementation/evaluation of engaged and incentivized to countries development programs (Yes/No) contribute to the achievement of the project’s objectives. ANGOLA: Citizens and/or communities involved in planning/implementation/evaluation of development programs (Yes/No) CAR: Citizens and/or communities involved in planning/implementation/evaluation of development programs (Yes/No) CHAD: Citizens and/or communities involved in planning/implementation/evaluation of development programs (Yes/No) DRC: Citizens and/or communities involved in planning/implementation/evaluation of development programs (Yes/No) (Yes/No) RoC: Citizens and/or communities involved in planning/implementation/evaluation of development programs (Yes/No) Page 94 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ME IO Table SPACE Page 95 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ANNEX 1: Implementation Arrangements and Support Plan COUNTRY: Africa Regional Disease Surveillance Systems Enhancement Project (REDISSE) Phase IV Project Institutional and Implementation Arrangements 1. To the extent possible, the PIU will be set up using existing staff from World Bank financed projects within ECCAS. REDISSE IV will co-finance existing administrative staff in the DRM project implementation unit (a Financial Management Specialist (FMS), a Procurement Specialist, an Accountant, and a M&E Specialist). A Project Coordinator will be appointed from within ECCAS with responsibility for day-to-day project implementation and management of the PCU. The Coordinator will also be responsible for reporting to the World Bank, leading coordination activities with project and ECCAS member states, within ECCAS as well as with other program partners. Additional staff to be recruited include a project manager, a senior health/Infectious diseases specialist, experts in environmental and social safeguards and any needed administrative, procurement and FM assistants will be recruited through competitive processes. The recruitment process will start as early as possible before project launch to ensure that the project team is complete to start implementation. Additional specialists in other sectoral fields shall be recruited as needed upon the World Bank’s recommendation thereon. 2. The REDISSE Program, under the REDISSE (Phase IV), will support the ECCAS Health Division in regional coordination and implementation of activities at regional and trans-boundary levels, in line with the 2016–2020 ECCAS Strategic Plan33. However, because the ECCAS General Secretariat does not have all the technical expertise in disease surveillance, such required expertise will be from UN agencies such as WHO/AFRO, and regional academic institutions. ECCAS will delegate responsibility for operational coordination and implementation of regional animal health activities to RAHC, an entity of ECCAS, with the support of OIE. 33 Section 2.3.3.1 – Pillar 3 – Program – Strengthening Human capital; Point 4 – Strengthening of ECCAS health system. …Management of prevention and response to epidemics, medical and humanitarian emergencies. Page 96 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Figure A1.1: Institutional and Implementation Arrangements at Regional Level. ECCAS General Secretariat Dept Human Dept Program, Dept of Physical, Integration, Peace, Budget, Adm & Econ & Monetary Security & Stability Human Resources Integration Health Unit: Project Sub-contract to expert Coordinator institutions like WHO/AFRO, OIE, etc; RCC – Africa CDC . Project Manager M & E Specialist Environ Specialist Co-finance existing Disaster Risk management (DRM) PIU with DRM Project FM specialist Social safeguards Health specialist PS specialist ( Infectious Diseases) 3. At the national level in all the countries, Country-level activities will be implemented according to individual country implementation arrangements. In each participating country, implementation will be the responsibility of the health ministries under the direction of a National Steering Committee (NSC). The NSC will comprise representatives of relevant technical ministries and partners and will oversee yearly planning and monitor project implementation. The project will be implemented through the same PIU in the ministries of health as for ongoing projects in the health sector, supported by the ECCAS General Secretariat. The PIU will be adapted to work across sectors to improve efficiency and alignment in the implementation of project interventions. The project complements but does not duplicate ongoing and new portfolio projects in all five participating countries. Given the multi-sectoral nature of the proposed Page 97 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) activities, PIUs will be further strengthened when necessary, enabling resource sharing and more effective, efficient and timely management of implementation of all the projects in the sector. A national Steering Committee supported by a Technical Committee will be put in place to oversee yearly planning and monitoring of the project. The Technical Committee will be made up of representatives of the concerned departments from the Ministries that are involved in the project. 4. The national (N-PIU) or national project coordination units (N-PCU) in the Ministries of Health will be responsible for (i) coordinating project activities; (ii) ensuring sound FM for project activities in all components by the implementing ministries (agriculture, livestock health, environment) and partners, and (iii) preparing consolidated annual work plans, budgets, M&E, and elaborating implementation reports to be submitted to the Steering Committee and the World Bank. Since this is a multi-sectoral project, it is critical to work across sectors to improve efficiency and alignment in the implementation of project interventions. Specific arrangements have been agreed with each country as follows: Angola 5. The MoH will have overall responsibility for project implementation. The existing committee, the Inter-Ministerial Commission for Epidemic Control will be adapted to serve as the National "OH" committee. This committee will include representatives from the ministries responsible for health, planning, agriculture, environment, and communications as well as representatives of local, regional and international partners. The REDISSE IV Project will be overseen by the National “OH” Committee. The committee will provide strategic and policy guidance to the PIU, known as the Central CoordinationUnit (Unidade Central de Coordenação in Portuguese, UCC), and approve the AWP&B. It will report to the National Council on Civil Protection. 6. A Technical Committee comprising a focal point from each of the Recipient’s ministries responsible for health, finance, agriculture, environment, and territorial administration, the General Project coordinator, the project coordinator responsible for REDISSE IV and other partners will be designated to closely monitor the project, not later than three months after date of effectiveness. The Technical Committee will meet quarterly and will be responsible for drafting the budget and annual work plans, reporting on activities carried out within the framework of the project and archiving project documentation. The Technical Committee will report to the national “OH” Committee. It will meet every quarter. 7. The project will be managed by an existing PIU established within the MoH for the World Bank- funded Angola Health System Performance Strengthening Project (HSPSP) (P160948). Within the MoH, the PIU is located under the GEPE. This department will oversee the project and ensure that efforts are coordinated across the ministry and with other partner-supported initiatives. The PIU will be managed by a General Project Coordinator who will oversee the World Bank-financed health, nutrition and population (HNP) portfolio of projects. The General Project Coordinator is supported by the PIU (UCC). In addition to the General Project Coordinator existing staff from the existing HSPSP PIU that include specialists in M&E, procurement, FM environmental and social and safeguards will serve REDISSE IV. The MoH will recruit before the date of effectiveness, a project coordinator responsible for REDISSE IV who should have expertise in health to oversee the REDISSE IV portfolio and lead the day-to-day implementation of the project and will report to the Director of the DNSP for the technical coordination of activities financed Page 98 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) under the project. One additional environment and social safeguards specialist, an animal health specialist under the guidance of the General Project Coordinator will be recruited not later than three months after the date of effectiveness to strengthen the PIU. The Angolan PIU environmental and social safeguards specialists will work closely with the regional ECCAS safeguards specialist. The PIU Administrative and Financing Manual of Procedures will be updated before the date of effectiveness to detail the roles and responsibilities of the various parties and make explicit any adjustments to national procedures required by IDA. Central African Republic (CAR) 8. The MoPHP will have overall responsibility for project implementation. In coordination with the Minister and the Cabinet Director, technical activities will be undertaken by the relevant directorates and units within the ministry, as well as other relevant ministries. 9. The existing Project National Health Steering Committee will be adapted to become the National “OH” Committee to oversee achievement of the project’s objectives. It will be made up of representatives of the participating Ministries (the MoPHP, the Ministry of Livestock and Animal Health, the Ministry of Environment and Sustainable Development and the Ministry of Water, Forests, Hunting and Fishing). It will be chaired in rotation by the Ministers of the participating ministries. It will be responsible for defining project implementation strategies and validating the annual work plan and Budget. 10. A Technical Committee will be established not later than three months after the date of effectiveness comprising a focal point from relevant ministries, a project coordinator and other project partners. Focal points will be appointed from the MoPHP, the Ministry of Livestock and Animal Health, the Ministry of Environment and Sustainable Development and the Ministry of Water, Forests, Hunting and Fishing. The Technical Committee will meet quarterly and will be responsible for drafting the budget and annual work plans, reporting on activities carried out within the framework of the project and archiving project documentation. The Technical Committee will report to the national “OH’ Committee. 11. The SENI PIU34 will be responsible for day-to-day management of REDISSE IV. REDISSE IV will be coordinated by the Cabinet Director, as with the World Bank-funded Health System Support and Strengthening (SENI) Project (P164953). The Administrative and Financial Manual of Procedures will be updated before the date of effectiveness to detail the roles and responsibilities of the various parties and make explicit any adjustments to national procedures required by IDA. The Capacity of the PIU will be strengthened with a Technical Coordinator before the date of effectiveness, and an accountant and a social safeguard specialist to complement the existing environment specialist, M&E specialist, and a procurement specialist not later than two months after the date of effectiveness. Chad 12. The general principle of this project is to support government efforts to better organize national disease surveillance systems for greater efficiency (responsiveness). The project will support the Government to strengthen the surveillance system by considering the concept of "OH". The REDISSE IV Project in Chad will be coordinated by the MoPH. 34 This is the National Technical Unit (NTU). Page 99 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 13. The national multisectoral Steering Committee will be represented by the OH platform which will be set up by the Office of the Secretary General in the Presidency. It will meet once a year to approve budgeted work plans and provide guidance for the implementation of the project. The chair of the Steering Committee will be the Minister of State, Secretary General of the Presidency. The Steering Committee is composed of the Ministers of the concerned departments and the Ministry of Planning as well as the partners. 14. A Technical Committee comprising of the Director General of the Ministerial departments concerned by the project, the heads of the national diagnostic laboratories and surveillance systems, the officers responsible for the M&E of the projects and programs, technical and financial partners: WHO, FAO, CRSA, OIE, CEBEVIRHA, EU, AFD and Swiss Cooperation, and any natural or legal person whose skills are deemed useful and needed. Focal points appointed by the participating ministries will also be part of the Technical Committee. The Technical Committee will be chaired in rotation by the Director General of the MoPH, Livestock and Environment and of the Territory Administration. It meets every three months to review and approve status reports and provide guidance to the PCU. The committee will be set up by the MoPH. 15. Focal points (one focal point and one assistant per department) will be designated for the ministerial departments and will be the representatives of the PCU to facilitate the implementation of the project in the Ministries of Public Health; Livestock; Territorial Administration; and the Environment. These focal points will work closely with the PCU to draft the budgeted annual work plans, reporting on activities carried out within the framework of the project and archiving project documentation. 16. The existing PCU established to coordinate the implementation of the WBG-funded Mother and child health service strengthening project (PRSSMI – P148052), within the MoPH will be responsible for the coordination and day-to-day management of the project. The PCU will update the project implementation manual and develops financial procedure manual before the date of effectiveness and will inter alia, be responsible for FM and procurement, general planning, internal audit, and monitoring & evaluation responsibilities. In particular, it will therefore be responsible for (i) project management, including M&E; (ii) FM and procurement in accordance with World Bank guidelines and procedures; (iii) internal audit; (iv) the production of national reports on the progress made by the project; and (v) communication about the project. The entities involved in the implementation of the REDISSE project will sign contracts with the PCU. The PCU is presently made up of a coordinator, a technical activities manager, an administrative and financial affairs expert, a procurement specialist, an accountant, an internal auditor, a communication specialist, and a M&E expert. The PCU shall be strengthened by the recruitment of the following experts, not later than three months after the date of effectiveness: A Technical Assistant Coordinator (Epidemiologist), An expert in public health or education; a social and gender expert, an environmental safeguard expert, a procurement assistant, and an accountant for REDISSE IV. 17. The project will rely on animal and human health authorities at the provincial and departmental /health district level to oversee and coordinate activities at the decentralized levels, including data management, disease surveillance. At the provincial, departmental and health districts levels, existing multi-sectoral and multi-disciplinary epidemic and disaster management frameworks will enable stakeholders to share and exchange information as well as good practices. In addition to the actors indicated above, health and veterinary officials, officials of public and private health and veterinary units, Page 100 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) community health workers, heads of administrative units, will be also be involved in disease surveillance and the provision of epidemic/epizootic response services. In addition, they will be involved in the mobilization of communities as most activities will be implemented with the support of the communities, of security officers, communicators and civil society. Democratic Republic of Congo (DRC) 18. The MoPH will have overall responsibility for the project. It will be managed by the NSC which manages other health projects such as the Health System Strengthening for Better Maternal and Child Health Results Project (PDSS) (P147555) and the Multi-sectoral Nutrition Project (PMNE) (P168756), under the responsibility of the Secretary General for Health. In DRC, it has been agreed to strengthen existing structures rather than set up parallel structures. 19. The existing NSC will be responsible for defining project implementation strategies and validating the Annual Work Plan and Budget (AWPB) of the project. The NSC will be chaired by the Minister of Health and made up of representatives from all project beneficiary ministries. 20. A project technical Committee will be put in place under the Directorate General of Disease Surveillance (Direction General de Lutte Contre la Maladie, DGLM). This committee will be chaired by the Director General of Disease control (DGLM) and will include inter alia representatives from the Ministries of Health, Fishery and Animal Husbandry, Environment and Sustainable Development and Agriculture. A Multi-sectoral Secretariat will support the team. This committee will provide overall operational guidance, general oversight of Project implementation, performance monitoring, cross-sectoral coordination and consistency with sector policy and strategies, development of the AWPBs, procurement plans and progress reports. It will report to the national Steering Committee. 21. Project Coordination Team (PCT): To capitalize on the existing expertise and enable quick and efficient implementation, the proposed project will use the existing Health System Strengthening Project PCT. This PCT is already implementing a Health System Strengthening project, and the proposed project will use the existing institutional arrangements and processes in place to support project implementation. The PCT will be expanded to allow for efficient and effective implementation. A separate team will be created within the PCT that will focus on the management of the proposed project. At minimum, the additional PCT staff hired will include: a) a project manager/focal point, who will ensure efficient implementation of the various project components carried out in collaboration with other relevant ministries; b) a FM specialist; c) an accountant; d) a procurement specialist; e) four technical assistants (human health, animal health, plant health and environmental and social safeguards), all of whom will work in close collaboration with the National Border Hygiene Program (Programme National d’Hygiène aux Frontières, PNHF) and the various central sectorial structures); f) a M&E specialist; and g) a project administrative assistant; h) a social safeguards specialist and an environmental safeguards specialist will be recruited by the PCT. Those two staff members will work on the proposed project and on other projects managed by the PCT. The project will finance additional PCT staff, their training, as well as basic equipment and other necessary inputs. The PCT will be recruited through a transparent selection process acceptable to the Government and the World Bank. Page 101 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 22. FM and procurement will be assured by the PDSS according to the existing procedures. Large goods and services procurement will be handled by the Coordination and Financial Management Unit (Cellule d’Appui et de Gestion Financière, CAGF) and with the support of FM and the CGPMP. The team will recruit a procurement expert for reinforcement in this area. The PDSS M&E expert will be responsible this activity for REDISSE IV. 23. The project will be implemented by the PCT within the MoPH under the Director of the Department of Studies and Planning (Département des Études et de la Planification, DEP). The PCT will be responsible for the technical and fiduciary execution of the project and the day-to-day coordination, implementation and communication of activities and results. The PCT will (i) prepare the annual budget and work plans for onward transmission to the NSC; (ii) carry out disbursements and procurement in accordance with World Bank procedures; (iii) prepare and consolidate periodic progress reports; (iv) monitor and evaluate project activities; and (v) liaise with stakeholders on issues related to implementation. Republic of Congo (RoC) 24. The project will be managed by the Project Management Unit (PMU), within the MoHP under the DEP, which must be established before the date of effectiveness. The unit will be responsible for the technical and fiduciary execution of the project and the day-to-day coordination, implementation and communication of activities and results. Before the date of effectiveness, the PMU will update the project implementation manual. The PMU will (i) prepare the annual budget and work plans for onward transmission to the NSC; (ii) carry out disbursements and procurement in accordance with World Bank procedures; (iii) prepare and consolidate periodic progress reports; (iv) monitor and evaluate project activities; and (v) liaise with stakeholders on issues related to implementation. 25. The PIU will have a Project Coordinator, a FMS, a procurement specialist recruited before the date of effectiveness. The Project Coordinator will ensure efficient implementation of the various project components, to be carried out in collaboration with other relevant ministries. The PIU staff members, a M&E specialist, an accountant, social and environmental safeguards specialist, and specialists in other sectors as required will be recruited not later than three months after effectiveness through a transparent selection process acceptable to the Government and the World Bank. 26. An NSC will be put in place with responsibility for defining project implementation strategies and validating the AWPB of the project. The Steering Committee will be chaired by the Minister of Planning, Statistics and RI and made up of representatives from all project beneficiary ministries, including the MoHP, the Ministry of Planning and Economy, the Ministry of Environment, the Ministry of Finance, and the Ministry of Animal Husbandry. 27. A Technical Committee (the "OH" platform) will be anchored in the DEP of the MoHP. It will comprise technical staff of the beneficiary departments and will be supported by the technical and financial partners of the health sector. It will be chaired by the Minister of Health and Population and will meet once every quarter. It will provide technical design of tools and management documents, develop the AWPB and monitor its implementation. Page 102 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Financial Management 28. As part of project preparation, FM assessments were carried out by the World Bank to evaluate the adequacy of FM arrangements to support project implementation. Reviews assessed whether (i) the budgeted expenditures are realistic, prepared with due regard to relevant policies, and executed in an orderly and predictable manner, (ii) reasonable records are maintained and financial reports produced and disseminated for decision-making, management, and reporting, (iii) adequate funds are available to finance the Project, (iv) there are reasonable controls over Project funds, and (v) independent and competent audit arrangements are in place.35 The assessments build significantly on World Bank knowledge of country FM systems, as well as the experience and performance of proposed implementing units through their involvement in other World Bank-financed operations. 29. Based on implementation arrangements for the project, assessments were carried out for the following: Angola: MoH Project PIU established under the GEPE. DRC: MoPH PDSS PIU (established within the MoHP for the implementation of the PDSS. RoC: MoHP - Single Implementing Unit. Chad: MoPH - PCU. CAR: MoPHP-SENI/PASS Project Implementing Unit (Unité d’Exécution du Projet - UEP). Regional: ECCAS R-PIU within the Health Division of the Department of Socio-cultural Integration. 30. Fiduciary risk is considered “high,” due to the following key factors: • the project requires implementation across different sectors—health, agriculture and livestock, environment—thus requiring specific coordination mechanisms, which if not fully in place may cause delays. • most of the proposed implementing units have experience in handling World Bank-financed projects, however, managing a new project poses additional risks and may jeopardize performance if said units are not appropriately strengthened, both in terms of staffing, tools and procedures. Additionally, recent supervision of the proposed PCU in Chad has uncovered shortcomings in project management; significant gaps in the internal audit work carried out; as well as control deficiencies that will need to be addressed. • the coordination of the FM function, budgeting, flow of funds and reporting of project activities might be complex and challenging due to the involvement of other sector entities that will be in charge of implementing certain activities with the subsequent risk of delays in implementation, budgeting, reporting and disbursements. • in most cases, the accounting systems, while adequate for World Bank-financed projects, are not prepared to support accounting of two separate projects, and the issuance of separate financial statements. Thus, upgrading is necessary in order to secure proper accounting; 35FM assessments were carried out in compliance with OP/BP 10.00 and related Directives and Guidance Notes, including Bank Directive: Financial Management Manual for World Bank IPF Operations issued February 4, 2015 and effective from March 1, 2010; and the Bank Guidance: Financial Management in World Bank IPF Operations Issued and Effective February 24, 2015 Page 103 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) • in the case of Angola, the failure by commercial banks to make payments in foreign currency may impact negatively on the implementation of project activities. 31. To mitigate these risks, the following measures have been agreed : (i) existing capacity in finance and internal audit will be strengthened through the recruitment of FM and audit professionals to be financed under the project; (ii) mechanisms for the financing of activities under the responsibility of other sector ministries have been defined and will be reflected in the PIM; (iii) the accounting software will be acquired or upgraded as per the needs identified in each country; and (iv) control weaknesses in Chad will be addressed through a time-bound action plan. By project effectiveness, the FM section of the PIM will be updated for each country. 32. Subject to the successful implementation of measures before project implementation, the proposed FM arrangements, as designed can be considered acceptable to the World Bank. SUMMARY OF FINANCIAL MANAGEMENT ARRANGEMENTS36 33. Country Public Financial Management (PFM) Systems. Most countries are gradually and consistently working to strengthen public FM systems, and the World Bank has been supporting those efforts. However, there are still challenges related to budget execution, internal control and general oversight. Within this framework, the following sections describe country-specific arrangement. ORGANIZATION AND STAFFING 34. Angola: The PIU established under the GEPE will be responsible for fiduciary aspects of the project. Staff in the PIU include an FMS, two Project Accountants and a Project Finance Assistant. The overall responsibility of project FM rests with the FMS who reports to the Project Coordinator. The project FMS and Accountants have experience in FM and disbursement for World Bank-financed operations. The existing staffing is adequate but will be reviewed as implementation advances. 35. DRC: The PDSS PIU will be responsible for project FM tasks. A project dedicated qualified and experienced FM specialist and an accountant to support the accounting division will be recruited and maintained throughout the life of the project. 36. RoC: A single PIU will be put in place within the MoHP that will be responsible for the overall coordination of the project, including the fiduciary aspects. With respect for FM, this unit will build on the PDSS unit that was established with World Bank support to implement the Health Sector Project (P143849). 37. CAR: The UEP established within the MoPHP for the implementation of the SENE and PASS will be responsible for FM of the REDISSE Project. The UEP has developed experience with World Bank requirements and has basic arrangements in place. It will be strengthened with an additional accountant with qualifications and experience satisfactory to the World Bank to be financed under the Project. 36 Detailed FM assessment reports for each of the entities are available in project files. Page 104 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 38. Chad: The PCU of the MoPH that is currently implementing other World Bank-financed projects will also be responsible for the FM, M&E and overall coordination of REDISSE. The PCU’s current financial and accounting team that consists of a FM Specialist is considered adequate. Further training on FM matters and monitoring will also be provided to the team. Beside an accountant, no additional staff will be hired, but job descriptions of existing positions will be updated to include REDISSE. 39. ECCAS: Within the ECCAS Secretariat, existing DRM staff will ensure FM support for the project. An FM Officer and an Accountant of the DRM PIU have been trained in World Bank requirements and will be responsible for recording transactions, monitoring compliance, preparing the Withdrawal Application and financial reports. This situation will be reviewed as implementation advances. PLANNING AND BUDGETING 40. Relevant country and/or institutional budgetary requirements and regulations (budget formulation, execution and monitoring) will be followed in each of the participating countries, as applicable. The PIM will need to define clearly procedures for annual program and budget preparation, especially since project implementation at the national level will require coordination with other sector ministries (i.e., agriculture and livestock, environment and sustainable development). The AWPB will be approved by the respective NSCs will be submitted to the World Bank for approval. Budget execution and analysis of variances will be monitored as part of the quarterly IFRs. 41. Angola: The PIU will prepare annual budgets based on annual work plans and the approved procurement plan. The PIU will produce quarterly variance analysis reports comparing planned with actual expenditures. Arrangements for budget preparation and monitoring of budget execution will be documented in the PIM, which will include FM procedures. The formats for annual budget and monitoring reports will be included as annexes. 42. DRC: The PDSS PIU will prepare an AWPBs for implementation of project activities taking into account project objectives and budget needs of participating sector entities and identifying the role of the respective parties in implementation. The AWPBs (including an annual disbursement forecast) will be submitted to the Steering Committee for approval. The project FM Manual of Procedures will define arrangements for budget preparation and control and the requirements for budgeting revisions and adoption by the Steering Committee. 43. RoC: The AWPBs and budget and the disbursement forecast will be consolidated into a single document by the MoHP. The implementing entities will monitor execution with appropriate accounting software in accordance with budgeting procedures specified in the PIM and will report on variances along with quarterly interim financial reports. 44. CAR: The project coordination together with directors of Health departments will prepare an AWPBs, with a procurement plan for consolidation by UEP who will prepare a related disbursement plan for approval by the Steering Committee. UEP will prepare a budget execution report every quarter with an analyzed of the variances between planned and executed budget. Page 105 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 45. Chad: Project’s transactions will not use the country’s budgeting or expenditure execution procedures. The budgeting process will be defined in the updated FM Procedures Manual. Annual budget will be reviewed and adopted by the project’s "OH" Steering Committee before the beginning of the year, and subsequently submitted for the World Bank’s non-objection. The approved annual budget will be monitored against actual expenditures and variances will be explained and justified through semi-annual IFRs. 46. ECCAS: Budgeting arrangements will be detailed in the manual of FM and administrative procedures (the DRM Project Manual). Annual work plans, and budgets will be approved by the Steering Committee and will describe in a realistic manner activity to be performed during the year and annual budgets. Budget execution will be monitored by a computerized information system and in accordance with budgeting procedures specified in the manual of procedures. ACCOUNTING SYSTEMS, POLICIES AND PROCEDURES 47. Angola: A cash basis for accounting will be used to monitor project funds, expenditures, and resources using existing accounting software. The current accounting software is adequate for producing reliable financial reports to effectively monitor and manage project progress. However, within two months after effectiveness it will be customized to maintain separate records and ledger accounts for financial reporting. 48. DRC: Project accounts will be maintained on an accrual basis, supported with appropriate records and procedures to track commitments and to safeguard assets. The accounting systems and policies, and administrative and financial procedures will be documented in the PIM Administrative, Accounting and Financial Section. Procurement of accounting management software to handle multiple projects, multiple sites, and multiple donor characteristics has been considered, and will be finalized three months after effectiveness. 49. RoC: Since the RoC is a member of the Organization for Harmonization of Corporate Law in Africa (Organisation pour l’Harmonisation en Afrique du Droit des Affaires” (OHADA)), its accounting standards and system (SYSCOHADA) are in line with international standards and will apply to this project. A Code and Chart of Accounts will be developed to meet the specific needs of the project and documented in the Manual of Procedures. There is a need to upgrade the existing accounting software to include a general diary, auxiliary diaries, general balance, cash record and fixed assets record. The system upgrade should be operational no later than three months after project effectiveness. Newly recruited fiduciary staff should be trained in the use of the software by the same date. 50. CAR: The OHADA, assigned accounting system in West and Central African Francophone countries, will be applicable. UEP will customize the existing accounting software (TOMPRO) to have a multi-project software to consider the need for this new project. Additional training will be provided to the FM staff for a better use of the accounting software. 51. Chad: Project will follow SYSCOHADA accounting standards for the recording of project transactions and preparation of annual financial statements. Accordingly, project transactions will be maintained on an accrual basis. Accounting and control procedures will be documented in the Procedures Page 106 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Manual. The existing TOM2PRO Accounting Software which is a multi-project Accounting Software will be able to accommodate the new project. The PCU will therefore be able to record transactions and report project operations in a timely manner, including preparation of withdrawal applications and periodic financial reports (IFRs and annual financial statements). 52. ECCAS: The existing DRM accounting software allows for multi-project and multi-site accounting but will be customized to ensure that accounts of the project activities are kept in an orderly manner and that financial reports are produced on time and in accordance with OHADA accounting principles. INTERNAL CONTROLS AND INTERNAL AUDIT 53. Internal control comprises the whole system of control, financial or otherwise, established by management to: (a) carry out project activities in an orderly and efficient manner; (b) ensure adherence to policies and procedures; (c) ensure maintenance of complete and accurate accounting records; and (d) safeguard the project’s assets. 54. Angola: All finance and administrative procedures will be documented in the FM procedures section of the PIM. This will include (i) budget and budgetary control; (ii) disbursement procedures and banking arrangements; (iii) receipt of goods and payment of invoices; (iv) internal control procedures; (v) accounting system and transaction records; (vi) financial reporting; and (vii) external audit arrangements. The Inspectorate General of Finance (Inspecção Geral das Finanças), based at the Ministry of Finance, is responsible for internal audit functions across the entire government. However, due to limited capacity, the project may not benefit from a review. An internal auditor will be hired for the project. External auditors and to some extent the World Bank supervision will be called in for such a review. 55. DRC: The internal control arrangements for the project will build on the PDSS PIU's Administrative, Accounting and Financial Handbook and will be updated to provide a framework for REDISSE IV implementation. The FM Manual will comply with IDA Directives and will provide for an appropriate separation of tasks and responsibilities. Internal audit will be performed by PDSS PIU's Internal Audit Division and will be strengthened by an internal audit consultant. 56. RoC: The PIU has a FM manual which details key internal control procedures from transaction initiation, review, approval recording, and reporting used for the PSSD project. The manual will be updated within 3 months after the effectiveness to take into consideration specific concerns relating to the REDISSE Project. Additionally, the terms of reference and annual work program of the internal auditors should be reviewed to include specific requirements emerging from project design. Copies of internal auditor’s reports will be submitted to the World Bank. 57. CAR: From a technical point of view, a new national technical unit will be created within the current PCU for REDISSE. That unit will have to work with UEP in the project management with the subsequent risk of delays in decision making and implementation and lack of clarity in terms of roles and responsibilities. Internal controls system and procedures of the project as well as roles and responsibilities will be documented in the project manual. 58. Chad: The PCU’s existing internal control system, which will be applied to the Project, provides for segregation of duties where by: (i) authorization to execute transaction, recording and custody of Page 107 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) assets are performed by different people; and (ii) ordering, receiving, accounting for and paying for goods and services are appropriately segregated. However, there are some deficiencies in implementation that need to be addressed. The existing Procedures Manual will also be updated to fit REDISSE needs, including clear roles and responsibilities of all the stakeholders as well as the coordination mechanisms between the MoPH-PCUs and other sector entities. 59. The internal audit function will also be strengthened through provision of training and developing an annual audit plan using a risk-based approach to closely monitor the implementation of recommended actions. 60. ECCAS: Internal control arrangements will be described in the manual of procedures to ensure that adequate procedures are in place for the preparation, approval and recording of transactions as well as segregation of duties. The manual will be subject to updates as needed. Consideration will be given to involving the financial controller in project activities and follow up of external audit recommendations. FINANCIAL REPORTING 61. Each implementing agency will prepare quarterly unaudited interim financial reports (IFRs), and semi-annual in the case of Chad, to be submitted to the World Bank within 45 days after the end of the quarter. The financial reports will provide quality and timely information to the project management including at a minimum (i) a statement of sources and uses of funds for the reporting and cumulative period (from project inception) reconciled to opening and closing bank balances; and (ii) a statement of expenditure by project component/sub-component comparing actual expenditure against the budget, with explanations for significant variances for both the period and cumulative period. IFR content should be complemented as needed, for instance to include the transfers/advances made to other sector ministries for the implementation of project activities. 62. Annual Project Financial Statements will be prepared reflecting the accounting basis agreed for the project. Financial statements will be subject to external audit. Specific reporting practices are further explained below: 63. Angola: The PIU will prepare annual budgets based on annual work plans and the approved procurement plan. The PIU will produce quarterly variance analysis reports comparing planned with actual expenditures. Arrangements for budget preparation and monitoring of budget execution will be documented in the PIM, which will include FM procedures. 64. DRC. Quarterly reports will include a table on budget execution and will include (i) a statement of sources and uses of funds; (ii) a table summarizing the use of funds by category, activity and by activity component; (iii) an updated procurement plan; (iv) a report on the physical progress of activities; and (v) summaries from internal audits and an update on implementation status of the recommendations of internal or external audit and supervision missions. 65. RoC. Following on the current reporting arrangements, Quarterly IFRs will include tables reflecting: (i) sources and use of funds; (ii) use of funds per activity; (iii) use of funds according to procurement methods and thresholds; and (iv) M&E or physical advance of activities. Financial statements Page 108 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) will be prepared for each financial exercise covering in general twelve months. Interim financial statements will also be prepared and will include: (i) certified status of expenditures; and (ii) an analysis of the Designated Account (DA) management. The format of such reports was discussed and agreed during project negotiations. 66. CAR: UEP will produce quarterly IFRs and project annual financial statements, which will comply with SYSCOHADA and World Bank requirements. The format and generally acceptable content will be described in the project manual. 67. Chad: Semi-annual IFRs will include at a minimum: (a) a statement of sources and uses of funds and opening and closing balances for the semester and cumulative; (b) a statement of uses of fund that shows actual expenditures appropriately classified by main project activities (categories, sub- components) including comparison with budget for the semester and cumulative; (c) a statement on movements (inflows and outflows) of the project DA including opening and closing balances; (d) a statement of expenditure forecast for the next semester together with the cash requirement; (e) notes and explanations; and (f) other supporting schedules and documents. Projects annual accounts/financial statements will be prepared within three months after the end of the accounting year in accordance with SYSCOHADA. 68. ECCAS. The specific format of the IFR was agreed upon during negotiations. Financial Statements will be comprised of: (i) a Statement of Sources and Uses of Funds, including all cash receipts, cash payments and cash balances; (ii) a Statement of Commitments; (iii) Accounting Policies Adopted and Explanatory Notes; and (iv) a Management Assertion that project funds have been expended for the intended purposes as specified in the relevant financing agreements. EXTERNAL AUDIT 69. In accordance with World Bank policy, implementing entities are required to submit annual project financial statements audited in accordance with international standards of auditing (ISAs) by an acceptable external auditor and following terms of reference approved by the World Bank. The auditor will also provide a Management Letter, which will identify deficiencies or weakness in systems and controls, make recommendations for their improvement, and report on compliance with key financial covenants. The costs incurred for the audit will be financed under the project (Table A1.1). Table A1.1: Types of Project Auditors and Audit Types Implementing Country Audit Type Auditor Due Date entity Regional ECCAS Project financial statements; TBC Six months after Management letter the end of each fiscal year Angola MoH – GEPE Project financial statements; Private audit firm Six months after PIU Management letter acceptable to the the end of each World Bank fiscal year DRC MoPH-PDSS Project financial statements; Private audit firm Six months after Page 109 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Implementing Country Audit Type Auditor Due Date entity Unit Report on DA and statement acceptable to the the end of each of expenditures (SoEs); World Bank fiscal year. Management letter RoC MoHP-PDSS Project financial statements; Private audit firm Six months after Unit Report on DA and SoEs; acceptable to the the end of each Management Letter World Bank fiscal year. CAR MoPHP - UEP Project financial statements Private audit firm Six months after Management letter acceptable to the the end of each World Bank fiscal year. Chad MoPH-PCU Project financial statements Private audit firm Six months after Management letter acceptable to the the end of each World Bank fiscal year 70. Disclosure of Audit Report: In accordance with World Bank policies, the Borrower/Recipient is required to disclose the annual audited financial statements in a manner acceptable to the World Bank. In addition, following the World Bank’s formal receipt of these statements from the Borrower/Recipient, the World Bank makes them available to the public in accordance with The World Bank Policy on Access to Information. FUNDS FLOW AND DISBURSEMENT ARRANGEMENTS 71. Disbursement arrangements will comply with World Bank disbursement guidelines and general practice and procedures applicable in each country. Accordingly, the following disbursement methods may be used to withdraw funds from the IBRD loan and IDA credits/grants: (i) advance; (ii) reimbursement; (iii) direct payment; and (iv) special commitment. Under the advance method, a DA will be opened in an acceptable financial institution and will be used exclusively for deposits and withdrawals of DA proceeds for eligible expenditures. Funds deposited into the DA as advances will follow World Bank disbursement policies and procedures, to be described in the Financing Agreement and in the Disbursement and Financial Instructions Letter. Following current practices, advances made to the DA will be documented through the use of SoEs or summary reports (IFRs), and supporting documents defined in the Disbursement and Financial Information Letter (DFIL). Specific arrangements are summarized in the table below: Table A1.2: Project Bank Accounts Supporting Implementing Other Project Bank Country DA (US$) Documents (to be Entity Accounts further detailed in DL) Regional ECCAS DA in Central African TBC before SOEs CFA franc (XAF)* (at effectiveness. commercial bank acceptable to World Bank Page 110 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) MoH-GEPE PIU DA – US$ (at commercial Local currency bank Quarterly IFRs Angola bank acceptable to account (at Six-month cash World Bank) commercial bank forecast acceptable to the World Bank) DRC MoPH-PSSD PIU DA – US$ (at commercial TBC SoE bank acceptable to World Bank) RoC MoHP-PSSD PIU DA – US$ (at commercial TBC SoE bank acceptable to World Bank) Chad MoPH-PCU DA in XAF (at TBC SoE commercial bank acceptable to World Bank CAR MoPHP-UEP DA – XAF (at commercial TBC SoE bank acceptable to World Bank) 72. The arrangements for the financing of activities under the responsibility of other relevant sector ministries will be detailed in the PIM. So far, it has been agreed that in Angola, DRC, RoC and CAR activities would be directly contracted and paid by the PIUs based on terms of reference (ToRs)/technical specifications defined by other sector ministries, but without transfer of funds. In the case of Chad, monthly transfers would be made based on budget estimates and ToRs. Funds transferred to other entities should be reflected as advances in all PIU’s IFRs and annual financial statements. Page 111 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Funds Flow Diagrams Figure A2.1: Angola: Flow of Funds Figure A2.2: ECCAS Flow of Funds Page 112 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Figure A2.3: DRC – RoC Flow of Funds Figure A2.4: CAR Page 113 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Figure A2.5: Chad IDA (Credit/Grant Account) Direct Payment upon Borrower’s request DA (Commercial Bank) IMPLEMENTING MINISTRIES, SUPPLIERS AND SERVICE PROVIDERS (Contractors and other third parties) Flow of documents Flow of funds Page 114 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Table A1.3: Financial Management Action Plan Country/Action Due Date Responsible LEGAL Covenants Recruited an accountant under terms of reference and not later than three ECCAS – PIU Dated with qualifications and experience satisfactory to the months after the Covenant Association Effective Date (i) Develop a FM manual, in form and substance not later than two ECCAS – PIU Dated satisfactory to the Association, to supplement the months after the Covenant ECCAS Regional PIM in the area of FM (including financial, Effective Date administrative and accounting procedures, internal controls, and audits); (ii) customize the existing multi projects accounting software currently used by the RPCU to fit the project accounting and reporting needs, so as to allow the Recipient to comply with its obligations under this Agreement Recruit (i) an FMS; (ii) an accountant and an accountant Dated not later than three assistant all under terms of reference, and with Covenant months after the MoH-GEPE PIU qualifications and experience satisfactory to the World Effective Date Bank (i) Develop a FM manual, in form and substance Dated satisfactory to the World Bank, to supplement the PIM; Covenant ANGOLA (ii) customize the accounting software of the MoHP to enable it to maintain separate records and ledger not later than two account of the project and thereby allow the Recipient months after the MoH-GEPE PIU to comply with its obligations under this Agreement; Effective Date and (iii) recruit an internal auditor under terms of reference and with experience and qualifications satisfactory to the Association (i) Develop a FM manual, in form and substance not later than three PDSS PIU Dated satisfactory to the Association, to supplement the PIM; months after the Covenant (ii) acquire a multi-site and multi-project version of the Effective Date management accounting software satisfactory to the Association, so as to allow the Recipient to comply with its obligations under this Agreement; and (ii) appoint an DRC internal auditor under terms of reference and with experience and qualifications satisfactory to the Association. Recruit (i) a procurement specialist; (ii) a FMS; (iii) an not later than one PDSS PIU Dated accountant each with terms of reference, qualifications month after the Covenant and experience satisfactory to the Association Effective Date Appointed to the PMU a FMS and a procurement Before effectiveness PMU Condition of specialist, all under terms of reference and with effectiveness RoC qualifications and experience satisfactory to the Association. Page 115 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) (i) Develop a FM manual, in form and substance not later than three PMU Dated satisfactory to the Association, to supplement the months after the Covenant PIM; (ii) upgrade the existing software in the MoHP Effective Date and training the PMU fiduciary staff on the use of such software, so as to allow the Recipient to comply with its obligations under this Agreement; and (iii) recruit an internal auditor under terms of reference and with experience and qualifications satisfactory to the Association. Recruit (i) a procurement assistant; (ii) an accountant not later than three MoPH PCU Dated with terms of reference, each with qualifications and months after the Covenant experience satisfactory to the Association Effective Date Customized the PCU’s multi-project accounting Before effectiveness MoPH PCU Condition of CHAD software to fit the Project accounting and reporting effectiveness needs Developed a financial procedures manual, in form and Before effectiveness MoPH PCU Conditions substance satisfactory to the Association. of effectiveness Acquire a a multi-project license of for the accounting not later than two MoPHP – UEP Dated software (TOMPRO) satisfactory to the Association, so months after the Covenant as to allow the Recipient to comply with its obligations Effective Date under this Agreement (i) Develop a FM manual, in form and substance not later than three MoPHP – UEP Dated satisfactory to the Association, to supplement the months after the Covenant CAR PIM; and (ii) recruit an internal auditor under terms of Effective Date reference and with experience and qualifications satisfactory to the Association. Recruit a procurement specialist, with terms of not later than two MoPHP – UEP Dated reference, qualifications and experience satisfactory to months after the Covenant the Association. Effective Date IMPLEMENTATION SUPPORT AND SUPERVISION PLAN 73. The World Bank FM team will provide support for implementation over the project lifetime. The project will be supervised on a risk-based approach. Supervision will cover, but not be limited to, the review of audit reports and IFRs and advice to the task team on all FM issues. Based on current assessed risks, project support missions will be undertaken at least twice a year. The frequency may be adjusted as needed. Strategy and Approach for Implementation Support 74. An Implementation Support Plan (ISP) 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 World Bank to effectively support project implementation. The implementation support team will include specialists in administrative and FM, Page 116 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) procurement; public health (including disease surveillance, and laboratory specialists); animal health; safeguards, management; social mobilization/advocacy, training, M&E, and operations. They will provide “just-in-time” advice and support. The procurement specialist 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 FMS will review all FM reports and audits and take necessary follow-up actions according to World Bank procedures. World Bank team members will also identify capacity building needs to ensure successful project implementation. The ISP has been developed using lessons learned from past REDISSE projects and will be reviewed regularly. 75. The World Bank team will carry out regular implementation performance and progress reviews with the five project implementing units and with ECCAS. The World Bank team will undertake implementation support missions (supervision missions). A mid-term review (MTR) will be organized by the World Bank to take stock of project implementation and to identify corrective actions or adjustments as necessary. In advance of the MTR mission, the implementing agencies under the coordination of ECCAS and the RSC will send to the World Bank a report summarizing project progress and highlighting any issues that require special attention. At project end, the World Bank team will prepare an Implementation Completion and Results Report (ICR) that summarizes achievements made under the project. This report will also include an assessment of the project by the project implementing agencies. This process will also be guided and coordinated by ECCAS. 76. Generally, progress monitoring will focus on: (i) key performance indicators, as identified in the Results Framework; (ii) progress of implementation of the project components; (iii) compliance with key 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 credit funds is required; (vi) compliance with World Bank FM and disbursement provisions; and (vii) compliance with environmental and social safeguards. The World Bank team will also closely monitor completion of the joint external evaluation and the PVS at appropriate points of project implementation (baseline, mid-term and end-term). 77. The implementation support plan and resources required are presented below: Table: A1.4: Implementation support plan and resources required Total Staff Activity Skills Required Number of trips weeks Overall coordination Task Team Leaders (TTLs) Year 1 Project launch Task team: total one for each TTL – health specialists specialist listed Animal health specialists Safeguards specialists Social/mobilization specialists Training programs specialists M&E specialists Operations officers Financial management specialists Procurement specialists Regular implementation Task team: total one for each Page 117 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Total Staff Activity Skills Required Number of trips weeks support mission TTL – health specialists specialist listed Animal health specialists Safeguards specialists Social/mobilization specialists Training programs specialists M&E specialists Operations officers Financial management specialists Procurement specialists Consultants on specialized issues Years 2-5 Bi-annual implementation Task team: total one for each support missions (technical TTL – health specialists specialist listed and fiduciary reviews) Animal health specialists Safeguards specialists Social/mobilization specialists Training programs specialists M&E specialists Operations officers Financial management specialists Procurement specialists Consultants on specialized issues Mid-Term Review March Task team: total one for each 2020 TTL – health specialists specialist listed Animal health specialists Safeguards specialists Social/mobilization specialists Training programs specialists M&E specialists Operations officers Financial management specialists Procurement specialists Consultants on specialized issues ICR Mission June 2023 Task team: total one for each TTL – health specialists specialist listed ICR preparation Animal health specialists M&E Specialists Operations officers ICR Authors Page 118 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ANNEX 2: DETAILED PROJECT DESCRIPTION COUNTRY : Central Africa Regional Disease Surveillance Systems Enhancement (REDISSE) Phase III PROJECT COMPONENTS 1. REDISSE IV seeks to address overall weaknesses of the human and animal health systems that hamper effective disease surveillance and response. The project will: (i) strengthen national capacity to detect and respond to infectious human and animal disease threats; (ii) establish national and regional platforms for collaboration and collective action; and (iii) ultimately, promote a platform to increase engagement across the human health, animal health and environmental sectors 2. The PDOs, key results and indicators under REDISSE remain the same across the SOPs. As adopted under REDISSE I, II and III, the PDOs are: (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in participating countries; and (ii) in the event of an eligible emergency, to provide immediate and effective response to said eligible emergency. 3. REDISSE IV is comprised of four components which include: (i) strengthening surveillance and laboratory capacity to rapidly detect outbreaks; (ii) strengthening emergency planning and management capacity to rapidly respond to outbreaks; (iii) public health workforce development; and (iv) institutional capacity building, project management, coordination and advocacy. Component 1: Strengthening surveillance and laboratory capacity to rapidly detect outbreaks (US$126.45 million equivalent) 4. Early detection of disease outbreaks will be enhanced through planning and implementation of coordinated surveillance, laboratory, information, and reporting systems in the human and animal sectors. The four sub-components of this component are: (i) national and sub-national surveillance system, (ii) health information and reporting systems, (iii) laboratory diagnosis capacity, and (iv) supply chain management systems. 5. Component 1 will focus on the regional, national and sub-national levels to establish and scale-up multi-sectoral systems that are both sensitive and of high quality and can be sustainably implemented and managed by national and regional authorities. These systems are vital both to ensuring these countries can adapt to climate change and do so in a way which minimizes GHG emissions. This component will strengthen existing networks of efficient, high-quality, accessible public health and veterinary laboratories. It will also strengthen the human and animal disease surveillance systems of Angola, CAR, Chad, DRC, and RoC; the development of regional interconnected human and animal platforms to promote collective action, and cross-border and cross-sectoral collaboration in surveillance. It will establish a regional networking platform to improve collaboration for laboratory investigation. Component 1 will also finance the timely reporting of human public health and animal health emergencies in line with the IHR (2005) and the OIE Terrestrial Animal Health Code, thereby enhancing the national surveillance and reporting systems and their interoperability at the different tiers of the health systems. Page 119 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 6. In particular this component will (i) assess epidemic-surveillance systems and networks; (ii) develop harmonized procedures for the surveillance, reporting, diagnosis of and response to prioritized diseases including zoonotic ones within the countries of the sub-region; (iii) use surveillance data for risk management (decision making on disease prevention and control across the sub-region), and risk communication; and (iv) scale-up of the use of ICT including for disease risk mapping, data analysis, and reporting purposes. Component 1 will be made up of four sub-components. Sub-Component 1.1: National and sub-national surveillance system 7. Under this sub component the project will carry out a program to strengthen national and subnational level surveillance structures and processes where gaps exist for detecting events at all levels of the human and animal health systems, through the provision works, goods, consulting services, non- consulting services, training and the financing of Operational Costs required for: a) Strengthening by the Participating countries of its national and subnational level surveillance structures and processes where there are gaps for detecting events at all levels of the human and animal systems, through the renovation and equipment of laboratories, health facilities, the delivery of training to health workers, laboratory technicians and animal and environmental health workers including veterinarians, and community-level workers, the elaboration of a plan to ensure national coverage for surveillance from community to national levels (national communicable disease surveillance strategy) and under this component the project will carry out simulation exercises; b) Establishing by the Participating countries of a system for capturing and reporting events at all levels of its systems and ensuring that reported cases or events with outbreak potential are investigated and linked to laboratory results, through this component the project will carry out a review and development of the required information communication and technology infrastructure to facilitate cross-sectoral interoperability of surveillance and reporting systems and national and sub-national levels; c) Increasing the surveillance capacity of the Participating countries at all levels of the animal and human health systems, for active, passive and rumor surveillance, including in cross-border areas, through this component the project will carry out of assessment of training needs, elaboration of procedure manuals, the delivery of training and workshops for surveillance officers, and the establishment of a regional networking platform to improve collaboration; and d) Strengthening the Participating countries’ surveillance and reporting action for Ports of Entry and at land cross-border crossings, through this component the project will carry out of rehabilitation and equipping of Points of Entry and the delivery of training of workers and simulation exercises. Sub-Component 1.2: Health information and reporting systems 8. Under this sub component the project will carry out a program to improve the availability of quality information with and among the Participating Countries through the development of the required information and communications technology infrastructure for cross-sectoral interoperability of Page 120 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) surveillance and reporting systems at the country and regional level, and encompassing the provision of goods and consulting services required for: a) Developing by the Participating countries of a strategy for an integrated paper-based and electronic real-time reporting system to link among the Participating Countries for public health surveillance, including operational plans and data standards; b) Developing by the participating countries of training materials and implementing of a training plan for surveillance and data management staff on health management information system and data management, analysis and use; c) Establishing by the participating countries of a process for routine monitoring, evaluation and quality improvement of national and sub-national surveillance system, entailing the development and dissemination of guidelines, tools and operating procedures; d) Implementing by the participating countries of interoperable, interconnected, electronic reporting systems at least at the national and sub-national level, entailing the elaboration of an integrated reporting strategy and the needed equipment; e) Establishing by the participating countries of a timely, high-quality reporting at community, facility, sub-national and national levels, encompassing identifying sentinel sites, provision of equipment, training and workshops for data collectors; f) Establishing by the participating countries of a process to ensure that data from case investigations is managed and reported in a standardized way in the Participating Country, through the development and dissemination of harmonized guidelines, protocols and tools, training and workshops, reviewing and updating the national disease priorities; g) Linking by the participating countries of laboratory data management and reporting systems from the Participating Country with its surveillance reporting systems, through the development and dissemination of operating procedures, and the delivery of training and workshops for health workers in animal and human health and laboratory technicians; and h) Establishing linkages by the participating countries between the surveillance and reporting systems in the Participating Country to its national incident management systems, involving the provision of communication technology equipment and the development of guidelines, protocols and tools. Sub-Component 1.3: Laboratory diagnosis capacity 9. Under this sub component the project will carry out a program to develop the participating countries’ public health and veterinary laboratories ability to respond to disease outbreaks in a coordinated manner, and encompassing the provision works, goods (including reagents), consulting services, non-consulting services and training and the financing of Operational Costs required for: Page 121 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) a) Developing and upgrading by the participating countries of a functional country network of public health and veterinary laboratories aimed to strengthen capacities and collaboration of national veterinary and health laboratories and public health institutes, most notably in the areas of surveillance, pathology for the early identification and diagnosis of priority infectious disease pathogens, and antimicrobial resistance, and for sharing timely information across the participating countries and learn and share knowledge, consisting of this component the project will carry out by the Participating countries of an assessment of the existing human and animal health laboratories and networks and the provision of supplies and equipment to support integrated laboratory information systems and the interoperability with disease surveillance and reporting systems, entailing: (i) the assessment of existing national human and animal health surveillance systems and networks for prioritization of interventions within and across key sectors; (ii) the review and update of the participating countries’ national and regional disease priorities, and the review and development of harmonized guidelines, protocols and tools to enhance surveillance and reporting processes at national and regional levels; (iii) the development at national and regional levels of common and harmonized methodologies and protocols (applicable to both public and private actors involved in disease surveillance) for efficient flow and utilization of surveillance data; (iv) the development of the required information communication and technology infrastructure to facilitate cross-sectoral interoperability of surveillance and reporting systems at the national and regional level; and (v) the improvement of procedures and of information and communications technology with a view to establish the necessary linkage of surveillance and reporting systems to national incidence management systems; b) (i) Improving the Participating countries’ data management and specimen management systems by linking national laboratory networks in each of the participating countries through this component the project will carry out by the participating countries of a streamlining laboratory specimen referral process, the delivery of capacity building to laboratory technicians to analyze and use laboratory surveillance data and laboratory data management systems to report either “up or down”, and the strengthening of the quality assurance systems through training and workshops; and (ii) establishing by ECCAS of networks of human and animal regional reference laboratories through (A) the strengthening by ECCAS of regional networking and information sharing between participating countries through a common information platform; and (B) the harmonization by ECCAS of laboratory quality assurance policies across the participating countries on the basis of international standards, notably through the development of common standards, quality assurance systems, procedures and protocols, the introduction of peer review mechanisms, the application of the five-step accreditation process of the WHO’s regional office for Africa and support of the accreditation of laboratories, under this component the project will carry out an external quality assessment on inter-laboratory, and recruitment of additional personnel to provide mentorship to laboratories. c) Renovating and upgrading of the participating countries’ existing networking laboratories facilities, ensuring adequate supplies and strengthening supply chain management and improved capacity to diagnose diseases, identify public health threats, and conduct surveillance with a view to serve as effective platforms for learning and knowledge sharing; and Page 122 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) d) Developing and implementing by the participating countries of a national laboratory strategic plan for point-of-care and laboratory diagnosis of priority human pathogens aimed to establish regional and international networks for testing and reporting on specific pathogens, improving quality management and external quality assurance systems, including accreditation, and establishing laboratory specimen collection, referral and transportations systems at national, sub- national and facility levels. Sub Component 1.4: Supply chain management systems 10. Under this sub component the project will carry out a program aimed at: (i) improving the supply chain management in the participating countries to support disease detection and diagnosis, including establishing efficient inventory tracking and management systems, through the establishment of efficient inventory tracking and management systems; and (ii) establishing public-private partnerships in the participating countries, to improve supply chain logistics management and planning through, inter alia, the provision of logistic and supply chain management, training, and laboratory services. Component 2: Strengthening emergency planning and management capacity to rapidly respond to outbreaks (US$66.45 million equivalent) 11. Under this component the project will carry out by the participating countries a program to improve the participating countries’ local, national and regional capacities to prepare for impending epidemics and respond effectively to human and animal disease outbreak threats including the resulting mortality risks posed by infectious diseases, and entailing: Sub-Component 2.1: Emergency management systems 12. Under this sub component the project will carry out through participating countries and ECCAS a program to strengthen coordination and communication in outbreak preparedness and response, including: (i) coordinating capacity building in risk reduction and emergency preparedness and response across clinical and public health systems; (ii) introducing regular testing of the systems through response to public health events and after-action reviews or through simulations exercises; and (iii) conducting risk analyses at national, sub-national and district/provincial levels including Ports of Entry and prioritizing public health risks, through the provision of works, goods, consulting services, non-consulting services and training and the financing of Operational Costs as required for: a) Establishing and/or strengthening of the participating countries’ management, technical and legal capacity to respond to a public health event including a longer-term health emergency, through the establishment and/or strengthening, as the case may be, of a national public health institute, including the construction or renovation/refurbishment and equipping of the required buildings and the hiring and/or training of personnel; b) Strengthening the participating countries’ Emergency Operations Centers and surge capacity at the national and regional levels, to ensure the implementation of established control measures under national and regional emergency response plans at the community, district, regional and national levels, and encompassing: (i) the establishment and management by the participating countries of a Page 123 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) database of multidisciplinary rapid response teams for rapid deployment, ensuring they are adequately equipped and trained; (ii) the development and management by the participating countries of stockpiling mechanisms (virtual and physical) to ensure availability of supplies during an emergency response; and (iii) the study and testing by the participating countries of mechanisms for the swift mobilization and deployment of resources in response to major infectious disease outbreaks to limit the need for reallocation of resources and the consequent burden on the health system; c) Developing, upgrading, and testing of the participating countries’ operational communication mechanisms; d) Developing by the participating countries of risk communication strategies and training of spokespersons; e) Preparing and test-running by the participating countries of communication materials prior to an outbreak to ensure local acceptance and understanding of contents; f) Improving and harmonizing the participating countries’ policies, legislation, and operating procedures, ensuring the inclusion of representation from other relevant sectors such as environment, customs/immigration, education, and law enforcement; and g) Elaborating by the participating countries of the legal frameworks for disease surveillance systems strengthening to enhance collaboration with the private sector in order to maximize the impact of implementing the OH approach; h) Introducing by the participating countries of regular testing of the systems through response to public health events and after-action reviews or through simulations exercises; i) Conducting of risk analyses by the participating countries at national, sub-national and district/provincial levels, including Ports of Entry and prioritization of public health risks; j) Coordinating by the participating countries of the capacity building in risk reduction and emergency preparedness and response across clinical and public health systems for animals and humans, through developing, testing and updating the participating countries’ contingency plans for major predicted health hazards including infectious disease outbreak and other forms of public health events. Sub-Component 2.2: Medical countermeasures 13. Under this sub component the project will carry out a program to address the weaknesses in surge capacity of the Participating Countries’ healthcare system hindering the roll-out of effective response interventions during emergencies, encompassing the provision of goods, non-consulting services, consulting services and training as required for: a) Developing by the participating countries of strategies for, and providing relevant vaccinations to, at risk populations during an infectious disease outbreak when appropriate and available; Page 124 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) b) Developing by the participating countries of strategies for, and providing relevant drugs for prophylactic use to, at risk populations during an infectious disease outbreak when appropriate and available; c) Developing by the participating countries of strategies for recruitment, deploying and managing of regional and international surge staff; and d) Developing and managing by the participating countries of stockpiling mechanisms (virtual and physical) to ensure availability of supplies in the participating countries’ territory during an emergency response. Sub Component 2.3: Non-pharmaceutical interventions 14. Under this sub component the project will carry out provision of goods, consulting services, non- consulting services and training to assist the participating countries in: a) Developing risk communication and community sensitization strategies specific to cultural and language groups in the participating countries’ territory; b) Identifying of ethical strategies that limit personal and population movement but are sensitive to reducing personal, social and economic hardships, through the development and testing of culturally sensitive communication materials and the provision of nutrition supplements in case of outbreaks; c) Developing strategies to promote social distance in work, educational and social environments; d) Developing and assessment of plans for necessity for the closure of schools, daycare and other mass gathering locations during outbreaks; and e) Identifying support mechanisms to provide home care for ill persons and inpatient care for household members. Sub Component 2.4: Research and evaluation 15. Under this sub component the project will carry out a program by the participating countries to develop plans for implementing and managing research and evaluation activities in participating countries’ territory during an outbreak, develop protocols, and identify and train new staff to conduct research in emergency settings, entailing the provision of goods, consulting services, non-consulting services and training and the financing of Operational Costs as required for: a) Supporting the design and implementation of research of the participating countries, including the use of epidemic-surveillance surveys and use of surveillance data for risk management, the delivery of training of personnel and the provision of reagents, equipment and other laboratory materials; and Page 125 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) b) Strengthening the existing capacity of the participating countries for research and support to the management of operational research in public health emergencies in an outbreak setting, consisting of the training of personnel and the provision of reagents, equipment and other laboratory materials. Sub Component 2.5: Contingent emergency response 16. Under this component the project will carry out provision by the Participating countries of immediate response to an Eligible Emergency, as needed. 17. Each of the project countries will prepare a CERC Operational Manual as an annex to the PIM within three months of project launch. Triggers for the CERC will be clearly outlined in the PIM. Disbursements will be made against an approved list of goods, works, and services required to support crisis mitigation, response and recovery. Component 3: Public Health Workforce Development (US$47.60 million equivalent) 18. Under this component the project will carry out a program by the participating countries to develop its institutional capacity for planning and managing workforce training, leveraging existing training structures and programs, and entailing: Sub-Component 3.1: Public health staffing. 19. Strengthening of the participating countries’ capacity to plan, implement and monitor human resource interventions, building long-term capacity for improved management of human resources, and including the provision of goods, non-consulting services, consulting services and training required for: a) Implementing by the participating countries of a national human resource for health plan that includes multi-disciplinary technical and management public health cadres in surveillance, laboratory, emergency management and risk communications, through the assessment of current workforce (quantity, geographical distribution and capacity), the establishment and management of a database of multidisciplinary technical and management public health cadres; elaboration of an operation manual, guidelines, and evaluation tools; b) Assessment by the participating countries of institutional capacity for planning and managing workforce training, and strengthening of the participating countries’ capacity building in its recruitment and retention of public health workers in the government sector; c) Establishing the participating countries’ surge capacity to respond to a public health event, including longer term emergencies, for clinical, epidemiological, laboratory, communications, social mobilization and management of surge staffing, through stock-taking of existing staff with the human and animal health systems, the development and dissemination of guidelines, protocols and tools (terms of reference) and the testing of the participating countries’ mechanism for swift mobilization and deployment of resources; and Page 126 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) d) Using private actors in the participating countries’ territory to deliver public sector activities through the delegation of power for planning and managing workforce training programs and, on the basis thereof, provision of the technical assistance required for improved efficiency for surveillance, preparedness and response from the human and animal health systems. Sub Component 3.2: Enhance public health workforce training 20. Under this sub component the project will carry out provision of goods, non-consulting services, consulting services and training to the Participating countries to enable it: (i) to assess needs of the participating countries and provide appropriate technical assistance to improve its institutional capacity for planning and managing continuing workforce training programs; and (ii) to deliver training to public health workers, veterinarians, laboratory technicians and clinicians to strengthen surveillance, preparedness and response at the various levels, including the participating countries’ community, district, regional and national and regional level, specifically addressing training: (A) for OH community agents in community-based surveillance and response, technical support and supervision of community agents; (B) to support to inter-sectoral interventions combining animal and human health service providers within the systems; and (C) to health workers in core skill sets. Sub Component 3.3: Regulations 21. Under this sub component the project will carry out by the participating countries of regulatory mechanisms to oversee the public health workforce, consisting of elaboration or revision of legislation on workforce, on integration of training related to surveillance, preparedness and response to epidemics into curriculum of national training schools, and including the provision of goods, consulting services, non- consulting services and training and the financing of Operational Costs as required. Component 4: Institutional Capacity Building, Project Management, Coordination and Advocacy (US$39.50 million equivalent) 22. Under this component the project will carry out by the participating countries of a technical capacity program focused on all aspects of project management, including, inter alia, FM, procurement, M&E, knowledge generation, and social and environmental safeguard aspects, ensuring the delivery of technical capacity-building activities under Parts 1, 2 and 3 of the Project, critical cross-cutting institutional support, and capacity-building and training needs in the participating Countries, encompassing: Sub Component 4.1: Project Coordination, fiduciary management, monitoring and evaluation, data generation, and knowledge management 23. Under this sub component the project will carry out the strengthening of the PCT to support timely and efficient implementation of the Project, and encompassing the provision of works, goods, non- consulting services, consulting services and training and the financing of Operational Costs required for: (i) strengthening the capacities of the participating countries’ national and regional institutions to efficiently perform core project management functions including operational planning, FM, procurement arrangements, and environmental and social safeguards policies; (ii) enhancing M&E systems, including routine health- and animal-management information systems and other data sources; (iii) managing the Page 127 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) operational research program implemented by national and regional institutions under Parts 1, 2 and 3 of the Project; (iv) promoting the design and under this component the project will carry out the impact evaluation studies to measure impact of project interventions; and (v) refurbishing and equipping of the PCT office space as needed. Sub Component 4.2: Institutional support, capacity building, advocacy, and communication at regional level 24. Under this sub component the project will carry out the enhancement of the services of the Regional Project Coordinating Unit, the RAHC and other cross-cutting regional and international institutions or organizations relevant to animal and human health sector development, and encompassing the provision of works, goods, non-consulting services, consulting services, training and the financing of Operational Costs required for: (i) establishing cross-border surveillance of diseases with epidemic potential in humans and animals, through the setting up of a “OH” multi-sector regional committee, validating regional annual plan of work, and organizing cross-border meetings; (ii) designing regular consultation mechanisms for disease surveillance officers in the participating countries; (iii) developing a regional plan to respond to epidemics and other health emergencies; (iv) drafting and adopting common quality assurance standards, procedures and protocols for the regional human and animal health laboratories in the participating countries; (v) putting in place regional (virtual and physical) stock of medicines, vaccines and consumables for emergencies; (vi) developing with national central medical stores or other viable institutions at the regional level collaboration arrangements for the regional stockpiling platform for the effective management of essential stocks and supplies during an emergency response; (vii) harmonizing regional diagnostic procedures for epidemic-prone diseases among the participating countries; (viii) developing regional standards for laboratory accreditation, and quality assurance among the participating countries; (ix) conducting capacity gap analyses (including staffing, skills, equipment, systems, and other variables); (x) implementing advocacy and communication activities that sustain the OH approach; (xi) organizing regional exchange of best practices and lessons learned in preparedness and response across the participating countries; (xii) the study and testing by ECCAS of mechanisms for the swift mobilization and deployment of resources in response to major infectious disease outbreaks; and (xiii) refurbishing and equipping of the Regional PCU and RAHC office space as needed. Disaggregation of activities at the national level 25. All the countries implementing the project, except Angola have recently completed a JEE. JEE is a mechanism to measure progress towards IHR 2005 implementation. The results of these JEES are considered as baselines of the public health capacities of the countries in this project (see Results Framework), and it identifies gaps within the animal and health systems that prevents countries from being able to prevent, detect and respond to disease outbreaks across all sectors. Even though Angola has not completed the JEE, the Angolan authorities in the Animal and Human health sectors have been able to identify some of the gaps. While countries are refining their action plans, this project, REDISEE 4, will assist governments to address some of the identified gaps by implementing the following priority activities in each of the countries as presented below: Page 128 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Chad - Chad will put in place an Emergency Operating Centre in Public Health (EOC) with well-defined roles and responsibilities as well as develop its strategic plan and its standard operating procedures. - Simulation exercises will be organized on a regular basis to test elaborated plans. - Put in place at all levels of the systems a multisectoral emergency intervention team as well as map national resources (logistics, experts, financial etc). - Strengthen the reference laboratory with qualified staff and diagnostic capabilities. - Establish a regular supply strategy for laboratory reagents and consumables. - Rehabilitate of human and animal health laboratories. - Develop a national plan involving the relevant sectors (animal health, human health and the environment sector) for the prevention and control of zoonoses. - Establish the interoperable and interconnected real-time electronic notification system at all levels of the surveillance system. - Develop and implement a training program in human and animal health and field epidemiology. - Develop protocols, procedures, legislation/regulations governing notification to WHO, OIE and FAO. Strengthen the collaboration between the human and animal health surveillance based on the OH approach. - Put in place a functional national focal point for IHR 2005. Central African Republic (CAR) 26. The CAR is just coming out of a long internal crisis where there was destruction of infrastructures, migration of trained staff in animal and health care systems. REDISSE IV will fund the following activities to enable the country to be in a position to prevent, detect and respond to most epidemics: - Organize and strengthen the Emergency Operations Center (COUSP) and define clearly its missions and responsibilities, and develop its strategic plan and allocate human resources and - financial requirements for its operation. - Elaborate emergency plans, Standard operating procedures for monitoring the most common epidemic-prone diseases in the country; for approval and notification for any public health emergency of potential international concern to WHO, OIE, and FAO. - Rehabilitate laboratories for human and animal health systems. - Develop and share widely within the country the list of priority zoonoses specific to RCA. - Elaborate and implement the multisectoral surveillance plan for priority zoonoses. - Elaborate and disseminate a plan for the detection of the priority diseases including the priority zoonoses in all public health and animal health laboratories. - Put in place a sustainable mechanism for supplying equipment, reagents and consumables in all sectors. - Ensure a functional national network of laboratories in both animal and human health. - Conduct simulation exercises to test to enhance detection capabilities, alert and management of public health emergencies surveillance system, as well as test the operational procedures of the national focal point which should be put in place. Page 129 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) - Develop and implement a training plan in field epidemiology for staff from all sectors that are responsible for surveillance, investigation, and response to epidemics. Republic of Congo (ROC) - One of the first thing that Congo will do to quickly assess the national legal framework for the implementation of the IHR (2005), under the effective coordination of the legal services of the ministerial departments and sectors involved in the implementation of the IHR (2005) and adjust accordingly. - Elaborate and disseminate the list of priority zoonoses which are specific to Congo and put in place the National Multisectoral Committee for the surveillance of zoonoses, as well as a formal multisectoral policy for collaboration between the ministerial departments involved on zoonoses. - Rehabilitate the laboratories for animal and human health and provide the needed equipment, reagents and human resources as well as put in place a laboratory equipment maintenance system at all levels. - Strengthen the capacity of the National Public Health Laboratory and other reference laboratories. - Reactivate the national network of functional laboratories for both animal and human health. - Put in place the legal framework for a secure transport and transfer mechanisms for samples in and out of the country. - As concerns animal health, there will be capacity building for animal health, and putting in place an electronic notification system for animal health, as well as improving the collaboration between the OIE and IHR 2005 National focal points. - Develop and implement a plan for field epidemiology training. Democratic Republic of Congo (DRC) 27. The DRC is the largest in size and population of the five countries involved in the implementation of REDISSE IV. DRC is a country that is subject to the occurrence of several epidemic outbreaks and epidemics that compromise the health and life of large segments of the population. To link REDISSE IV to the DRC NAPHS, activities from the technical areas common to the NAPHS and REDISSE IV perceived as potentially eligible for funding under the REDISSE IV financing were identified and aligned with the structure of components and sub-components of the REDISSE IV Project. These activities were costed using the WHO costing tool designed for costing NAPHS. These activities, some of which are presented below, are presented in Annex 4: - Develop the capacity of veterinary laboratories for the diagnosis of priority zoonoses. - Establish regular supply mechanisms for reagents and laboratory consumables. - Strengthen the capacity of the National Institute for Biomedical Research (Institut National de Recherche Biomédicale in French) (INRB). - Put in place a network of reference laboratories to be capable of conducting at least five of the 10 core tests of priority diseases and create a national specimen referral and transport system within the network. - Rehabilitate laboratories at the national and subnational levels. Page 130 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) - Put in place Emergency Operation Centers at all the levels of the health care delivery systems. - Strengthen community-based epidemiological surveillance. - Identify, train, and maintain a rapid respond team capable of responding to an epidemic. - Reinforce the field epidemiology training. - Establish a national electronic real-time, interoperable and interconnected, using the OH approach. - Phased approach will be implemented to establish the CDC-DRC (Box A2.1). Box A2.1: Spotlight on DRC-CDC The frequent epidemics in DRC and the need to consolidate existing, but disconnected, public health programs under one structure to minimize fragmentation and promote efficient systems, highlight the need for the establishment of a National Public Health Institute (NPHI) in DRC: the CDC-DRC. The CDC-RDC aims to be the center of expertise and public health and safety in the Democratic Republic of Congo, with a proposed mission to promote the health of all Congolese by coordinating priority public health functions and resources and prevent, detect and respond quickly and effectively to infectious disease threats. A phased approach will be implemented to establish the CDC-DRC given the country’s vast size, complex public health profile and system. As such, the CDC-DRC will build on the existing systems that have been put in place during responses to Ebola outbreaks and strengthened around the core pillars of a disease outbreak. This expertise will then be integrated into the larger, comprehensive CDC-DRC structure, that will expand essential public health functions using a One Health approach for disease control, prevention, and detection. CDC-DRC will aim to use a ‘horizontal approach’ to link key public health functions, including laboratory and surveillance systems, emergency management, and strong capacities across the country managed by a sustainable home for public health. Similar efforts at supporting NPHIs are being developed for all participating countries. ANGOLA 28. Angola is a country that is subject to the occurrence of several epidemic outbreaks and epidemics that compromise the health and life of large segments of the population. REDISSE IV will support the Government of Angola in implementing the following operational activities: - Strengthen the national public health institute to diagnose and confirm potentially epidemic diseases; - Train the technicians of the national network of laboratories on the collection, packaging and transportation of samples; - Standardize the various types of tests and reagents in the country; - Strengthen the National Institute of Public Health to detect and confirm potentially epidemic diseases; Page 131 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) - Strengthen the National Coordinating Committee for Potentially Epidemic Diseases; - Formally set up the EOC, specifying its missions and the definitions of responsibilities; - Strengthen the Emergency Operations Center (Equipping of the EOC); - Train a national multidisciplinary team for investigation of emergencies; - Reinforce the field epidemiology training; - Develop standard operating procedures for monitoring priority zoonoses, and for multi-sectoral coordination; - Develop and disseminate a plan for the detection of priority diseases in all human and animal public health laboratories; - Map and evaluate existing laboratory facilities, networks and laboratory information management. ECCAS - ECCAS will be responsible for coordination at the regional level. ECCAS will therefore put in place a regional multi-sectoral coordination body which will discuss issues related to epidemiological surveillance using the "OH" approach. - Create a regional network of reference laboratories for animal human health. - Identify regional reference laboratories for diagnostic confirmation of epidemics in both animal and human health sectors. - Develop a regional strategic plan to respond to epidemics and other health emergencies. - Promote the sharing of surveillance information between the countries of the region. - Put in place a regional multisectoral team for regional emergency preparedness and response. - Create a regular consultation framework between disease surveillance officers; laboratory staff and M & E officer in the countries of the region involved in project implementation. - Harmonize regional diagnostic procedures for epidemic-prone diseases. Page 132 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ANNEX 3: Economic and Financial Analysis COUNTRY: Central Africa Regional Disease Surveillance Systems Enhancement Project (REDISSE) Phase IV Project development objective and link with economic evaluation 1. As Table A3.1 illustrates, the economic benefits of the REDISSE IV Project vary depending on the proportion of cases prevented. Examining the “average outbreak” scenario, which is the most conservative scenario, the benefit-cost ratio (BCR) of the project is 1.3, the NPV is US$83 million and the internal rate of return (IRR) is 4.7 percent if 25 percent of cases are prevented. The BCR, NPV and IRR increase to 5.0, US$1,054 million and 20.6 percent respectively if the project prevents 95 percent of cases and deaths. The economic benefits increase when considering the prevention of a major outbreak of cholera, Ebola, H1N1 or yellow fever. The results of this analysis indicate that investing in disease surveillance and preparedness through the REDISSE IV Project is justified on economic grounds. Table A3.1: Estimated Economic Benefits of Preventing Cholera, Ebola, Influenza and Yellow Fever Outbreaks within REDISSE IV Countries, 2019-2023 Proportion Benefit-cost Net present Internal rate Outbreak of cases ratio value (US$ of return (IRR) prevented (BCR) million) (NPV) Average outbreak scenario 25% 1.3 83 4.7% 50% 2.6 429 10.8% 75% 3.9 776 16.3% 95% 5.0 1,054 20.6% Major cholera outbreak 25% 1.5 140 5.5% 50% 3.1 545 11.6% 75% 4.6 950 17.1% 95% 5.8 1,273 21.5% Major Ebola outbreak 25% 2.0 264 9.4% 50% 4.0 792 26.5% 75% 6.0 1,319 58.8% 95% 7.6 1,742 91.4% Major H1N1 outbreak 25% 1.9 227 7.1% 50% 3.7 717 14.3% 75% 5.6 1,208 21.1% 95% 7.1 1,601 26.6% Major yellow fever outbreak 25% 1.3 89 4.8% 50% 2.7 441 10.9% 75% 4.0 794 16.4% 95% 5.1 1,076 20.7% 2. The estimated benefits of the REDISSE IV Project are conservative. The average outbreak scenario Page 133 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) considers only four diseases and the number of cases and deaths in REDISSE IV countries are likely under- reported. Furthermore, the analysis does not account for major death and disability from other causes when the health system is overburdened by an outbreak including decreased investment, reduced trade and tourism, death of health workers, or time away from school. Furthermore, it does not consider the funds allocated from international donors during an emergency response. 3. There are three primary rationales for a publicly-provided regional approach to disease surveillance and response network in Central Africa. The first rests on the status of a disease surveillance system as a global public good, which is both non-rival and non-exclusive. These benefits accrue to all countries and thus describe a ‘pure’ global public good. The second rationale is simply the overwhelming economic burden that infectious diseases, individually and collectively, place on the region, constraining regional and national economic development. The third rationale is based on the sharing of resources to enhance efficiency. Examples of resurgent polio, meningitis, cholera and yellow fever in West African countries that were thought to have been eliminated or controlled demonstrate the need for a coordinated regional response. Costly high-level resources, such as level 3 reference laboratories, specialized research institutions, and advanced training facilities may efficiently serve the needs of more than one country. 4. REDISSE will enhance ECCAS member states’ capacity to rapidly detect and respond to public health threats of national and international concern, thereby reducing the burden of diseases, particularly among poor and vulnerable populations, mitigating the public health and economic risks posed by infectious diseases in humans and animals, and decreasing the threats of future disease outbreaks. This will in the long run result in stronger growth and development prospects in ECCAS sub-region. 5. Aligned with the PDO of the project, the economic analysis examines the implications of preventing a future outbreak in the sub-region. The economic implications of an outbreak are widespread. Direct costs are associated with excess morbidity and mortality, use of medical services, and the cost of implementing emergency disease control measures. Indirect costs include lost productivity, economic downturns due to behavior changes in wider society, decreased trade, investment and tourism, restrictions on travel and increased political tension. 6. The project will benefit the overall population in each of the five target countries. In addition, the project will strengthen the institutional capacity of the ECCAS secretariat to monitor disease outbreaks and to coordinate with national governments to mitigate diseases. Since diseases do not respect national boundaries, the overall sub-region benefits from pandemic prevention. REDISSE will enable ECCAS member states to contribute to a global public good, which increases global health security. 7. This cost-benefit analysis assesses the potential benefits of the REDISSE IV program and quantifies them in monetary terms. The benefits include preventing cases and deaths due to disease contagion. The benefits are then compared to the cost of establishing and maintaining an integrated disease surveillance and response system in the sub-region. 8. Globally, there have been a limited number of economic evaluations to assess the costs, benefits or efficiency of disease surveillance and response systems. However, findings across existing studies are consistent: integrated disease surveillance and response systems result in major cost benefits. For the Page 134 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) one study conducted in a low-income country, Burkina Faso, the authors determined that the national disease surveillance and response system saved US$23 per case and US$98 per death of meningitis adverted (Somda et al., 2010). Cost of the REDISSE IV Project 9. Table A3.2 presents the marginal cost of the REDISSE IV Project compared to the status quo, assuming constant disbursement across each year. The table also presents the marginal cost per capita invested in scaling up disease surveillance systems in the sub-region. Table A3.2: Summary of Total and per Capita Project Cost Total project cost (million) US$280 Annual project cost (million) US$56 Population covered (million) 136 Annual per capita cost US$0.41 10. In 2017, the International Working Group (IWG) on Financing Preparedness estimated that, in countries with a well-functioning underlying health system, establishing a system to improve pandemic preparedness could cost less than US$1 per person per year (IWG on Financing Preparedness, 2017). A different study (Somda et al. 2009) concluded that implementing an integrated disease surveillance and response system could cost even less, at US$0.16 per capita in Eritrea, US$0.04 in Burkina Faso and US$0.02 in Mali. REDISSE will invest annual per capita amount of US$0.41, which is within the range of the IWG’s recommendation and the cost associated with implementing a system in other countries in Africa. Benefits of the REDISSE Project 11. Since 2000, the countries covered by the REDISSE IV project have had outbreaks of cholera, Ebola, hepatitis E, Marburg hemorrhagic fever, meningococcal disease, plague, polio, shigellosis, typhoid fever and yellow fever (WHO, 2018). An estimate of the benefits of adverting or rapidly responding to an outbreak can be generated using both historical data within the five REDISSE countries and Africa more generally, or by making projections about the likelihood and expected costs of future outbreaks. This analysis uses historical data to make projections about the potential benefits of having an effective integrated disease surveillance and response system in Angola, CAR, Chad, DRC and RoC. 12. The first step of this analysis is to examine historical data from four major disease outbreaks in the sub-region – cholera, Ebola, influenza and yellow fever. These diseases have resulted in morbidity and mortality in the REDISSE IV sub-region and Africa more widely between 2000 and 2019. Using historical data, an estimate is generated for the economic burden of these diseases in the sub-region. In addition, data on the number of cases and deaths from a major global outbreak of cholera, Ebola, H1N1 and yellow fever is used to estimate the cost of such an occurrence the REDISSE IV countries during the life of the project. The approach to estimate the potential economic losses in the REDISSE IV countries is: 1) Determine the number of cases and deaths associated with cholera, Ebola, influenza and yellow Page 135 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) fever in the five REDISSE IV countries between 2000 and 2019, as recorded in the WHO Database on Disease Outbreaks (WHO, 2019). 2) Calculate the unit cost of hospitals and health centers, including personnel, capital, utilities and maintenance, using standard WHO unit costs for each country (WHO, 2008). 3) Determine the cost of diagnosis and standard treatment for each disease (both mild and severe cases) using WHO treatment guidelines and an international medicines price indicator list (Management Sciences for Health, 2016). 4) Estimate the out-of-pocket cost borne by households to pay for health services. 5) Determine productivity losses associated with hospitalization time for severe cases, reduction in performance for mild cases, time spent by family members caring for those who are ill, and time lost due to premature death. Losses were calculated by multiplying the estimate of productive years lost (including any time lost between the age of 18 and weighted average life expectancy across the five countries) by GNI per capita (also taken as the weighted average across the five countries) discounted at a rate of 3 percent (NICE, 2014). 13. The estimated losses calculated using this approach are conservative. They do not incorporate other factors, such as the cost of deploying resources from outside the outbreak region/district, costs associated with deaths when resources are diverted away from the delivery of core health services to confront an outbreak, costs associated with school closures during an outbreak or care for children who are orphaned due to an outbreak, and costs associated with behavior changes during an outbreak. Cholera 14. In 2007, there were 178,677 cases of cholera globally resulting in 4,033 deaths. However, the global cholera burden is not distributed evenly – the Africa region accounts for 62 percent of cholera cases and 57 percent of deaths (Kirigia, 2009). One of the worst cholera outbreaks in the Africa region occurred in Zimbabwe between August 2008 and July 2009, where there were 98,585 reported cases and 4,287 deaths (Mukandavire, 2011). 15. Between 2000 and 2016, there were a reported 525,852 cholera cases and 15,662 deaths in the REDISSE IV countries, resulting in an annual average of 30,932 cases and 921 deaths. Based on prior studies, 51 percent of the cases were considered among children under five years of age, 25 percent among children 5 to 14 years of age, and the remaining 23 percent among people 15 years and older (Ali et al. 2012). An assumption was also made that 10 percent of surviving cases were severe, whereas the remaining cases were mild. Mild cases were assumed to last four days, require one outpatient visit and be treated with oral rehydration salts for three days (Kirigia, 2009). Severe cases were assumed to last six days, require 3 days of inpatient care and treatment with ringer lactate, erythromycin and doxyclin (exact treatment and quantities varied by age category, as recommended by WHO guidelines). One family caregiver was assumed to lose productive time equal to the duration of illness. Table A3.3 presents the historical cost of cholera in REDISSE IV countries. Between 2000 and 2016, it is estimated that the sub- region spent US$1,046 million on cholera (which includes the cost of treating cases, lost productivity of affected individuals and one care taker, and the cost associated with productivity due to premature death). Page 136 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Table A3.3: Estimated Cost (US$ million 2019) of Historical Cholera Outbreaks in REDISSE IV Countries, 2000-2016 Year Angola CAR Chad DRC RoC Total Est. Cost Cases Death Cases Death Cases Death Cases Death Cases Death Cases Death (million) 2000 14,995 941 9 2 15,004 943 US$64 2001 5,244 226 5,728 390 10,972 616 US$42 2002 31,658 1,979 31,658 1,979 US$134 2003 55 7 27,272 989 27,327 996 US$68 2004 320 48 5,531 272 7,665 228 13,516 548 US$19 2005 90 14 13,430 244 13,520 258 US$18 2006 67,257 2,722 1,668 71 20,642 426 175 10 89,742 3,229 US$219 2007 18,422 513 28,269 600 7,785 133 54,476 1,246 US$85 2008 10,511 243 30,150 548 156 4 40,817 795 US$54 2009 2,019 88 67 6 22,899 237 93 0 25,078 331 US$23 2010 1,484 30 6,395 175 13,884 182 21,763 387 US$27 2011 1,810 110 117 15 17,267 458 21,700 584 40,894 1,167 US$79 2012 1,215 98 21 0 33,661 819 1,181 37 36,078 954 US$65 2013 6,655 86 26,944 491 1,624 221 35,223 798 US$55 2014 213 3 22,203 372 22,416 375 US$26 2015 19,182 276 19,182 276 US$19 2016 78 3 28,093 759 15 2 28,186 764 US$52 Total 109,664 3,896 458 63 36,317 1,229 368,375 10,065 11,038 409 525,852 15,662 US$1,046 Page 137 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 16. Table A3.4 reports the estimated economic benefit of preventing cholera for an “average outbreak” scenario and a “major outbreak” scenario. The average outbreak scenario assumes that there are 30,932 cases and 921 cholera deaths each year of the REDISSE VI project (taken as the annual average number of cases in the sub-region between 2000 and 2016). The major outbreak scenario assumes the same number of cases and deaths as the average scenario, except during year three, when there are 98,585 cases and 4287 deaths. The major outbreak scenario is modeled after the 2008-09 Zimbabwe outbreak. If the systems established through the REDISSE program prevents 25 percent of cases, the economic benefit is estimated at US$80 million in the average outbreak scenario, and US$137 million in the major outbreak scenario. If the systems prevent 95 percent of cases, the economic benefit is US$302 million in the average outbreak scenario and US$522 million in the major outbreak scenario. Table A3.4: Estimated Economic Benefit (US$ million 2019) of Preventing Cholera within REDISSE IV Countries, 2019-2023 Scenario Cases per year Deaths per year Proportion of Total benefits (2019-2023) (2019-2023) cases (US$ million) prevented Average Outbreak 30,932 921 25% 80 50% 189 75% 239 95% 302 Major Outbreak 2021: 98,585 2021: 4287 25% 137 All other years: Other years: 921 50% 264 30,932 75% 412 95% 522 Ebola 17. The 2014-15 Ebola outbreak in West Africa demonstrates the potential loss associated with a major outbreak in the West Africa sub-region. The outbreak resulted in an estimated 28,616 cases and 11,310 deaths in Guinea, Liberia and Sierra Leone (CDC, 2016). The West African outbreak was unique in that the disease emerged in major metropolitan cities, whereas beforehand, Ebola outbreaks in DRC had been largely concentrated in remote and rural areas. Ebola in West Africa quickly reversed much of the recent economic growth in the sub- region due to a sharp decrease in private sector investment and cross border trade. For example, a recent study of economic activity in Liberia before and after the Ebola outbreak, indicated that 12 percent of firms had closed, more than double the annual firm closure rate of 5 percent per year in Africa (Bowles, 2016). 18. Multiple studies have estimated the economic loss associated with the 2014-15 West Africa Ebola crisis, as summarized in Table A3.5. In a 2018 analysis of the economic and social burden of the Ebola outbreak in West Africa, Huber, Finelli and Stevens argue that most of these estimates do not consider the broader social costs of the outbreak. The authors estimated that the combined economic and social burden of the outbreak was much higher, at US$53.19 billion (2014 US$). Their estimate considers the cost of Ebola related deaths (US$6.74 billion), the impact on the health workforce (US$11.31 billion), the cost of deaths from non-Ebola causes (US$18.78 billion), the cost of long-term Ebola sequelae (US$0.07 billion) the cost of treatment, infection control and screening in the sub-region (US$0.29 billion), the cost of deploying human resources from outside the sub-region Page 138 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) (US$1.26 billion), the cost of social factors related to school closures and orphaned children (US$0.37 billion) and direct economic costs (US$14.04 billion). 19. As compared to the macroeconomic and social approach used in other estimates, Bartsch, Gorham and Lee (2015) examined the cost of a case of Ebola from a different perspective. They considered the costs of supportive care, personal protective equipment, personnel wages and productivity losses for mortality and absenteeism, and estimated that the cost per case of Ebola ranged from US$480 to US$912 when a patient fully recovered, and from US$5,929 to US$18,929 when a patient died, varying by age and country. Their estimate of the total cost in West Africa ranged from US$82 million to US$356 million. Table A3.5: Summary of Estimates of Economic Cost of 2014-15 Ebola Outbreak Estimate Direct cost of controlling Impact on economic Impact on economic outbreak (US$) output growth World Bank 2014 US$18 million preparation 0.1-3.3 percent US$3.8-US$32.6 billion costs in Senegal and Nigeria reduction in investment lost gross domestic (2015) product (GDP) (affected 2-3.4 percent reduction countries, 2014-15) in exports (2014) World Bank 2015 US$6.8 billion lost GDP (affected countries, 2014-15) US$550 million lost GDP (non-affected sub- Saharan African countries 2015) World Bank 2016 40 percent decrease in US$2.8 billion lost GDP working Liberians (2014- (2014-16) for Guinea, 16) Liberia and Sierra Leone UN Economic 290.6 million for Sierra Leone, US$335.3 million US$716 million lost PPP Commission for Guinea, Liberia (2014-15) reduction in Sierra Leone (2014) for Guinea, Liberia Africa 2015 US$5.4 million preparation exports (2014) and Sierra Leone costs in CAR, DRC, Sao Tome and Principe (2014) UN FAO (2015) 12 percent reduction in crop volume (2014) UN Development Loss of exports (2014): Programme (2014) 30 percent in Guinea 14 percent in Liberia 10 percent in Sierra Leone UN Development US$4.7 billion lost GDP Page 139 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Estimate Direct cost of controlling Impact on economic Impact on economic outbreak (US$) output growth Programme (2015) (2017) for Guinea, Liberia and Sierra Leone Office of the UN US$5.9-US$8.9 billion global Special Envoy for support (2015) Ebola (2015) African US$1.4 billion lost PPP Development Bank (2014) for Guinea, Liberia (2015) and Sierra Leone Summary table from Huber, Finelli and Stevens, 2018. 20. To generate an estimate of the historical cost of Ebola in REDISSE IV countries, as well as an estimate for a worst-case scenario, the same age distribution from the West African outbreak for the cases that recovered/ (died) were used: 13 (14) percent of children under 15 years, 73 (57) percent of people age 15 to 44 years, and 14 (29) percent of people above 45 years. The estimates were generated using a similar approach to Bartsch, Gorham and Lee. For people who recovered, Ebola cases lasted an estimated 16.4 days, with patients spending 11.8 days in inpatient treatment. For cases that died, the duration of illness was an estimated 7.5 days with 4.2 days spent in inpatient treatment. Treatment differed for children and adults, with children receiving paracetamol, ORS, morphine, diazepam, ringer lactate, and adults receiving a higher dosage of the same treatment plus metoclopramide and ceftriaxone. Treatment lasted for the same duration as inpatient care, and one family caregiver lost productive time equal to the entire duration of illness. To account for the cost of health worker deaths due to infection, the cost of a doctor and nurse emigrating was applied (Huber, Finelli, Stevens, 2018). Health worker deaths were only applied in the major outbreak scenario. 21. Since 2000, there have been Ebola outbreaks in two of the REDISSE IV countries – RoC and DRC. There has been a total of 1,552 cases and 1,039 deaths, amounting to an average of 91 cases and 61 deaths per year. The current outbreak in DRC is the largest recorded in the country (and second largest only after the 2014-15 West Africa crisis) with 894 cases and 561 deaths as of March 2, 2019. Table A3.6 presents the estimated cost per year to the sub-region. Since 2000, the cost of Ebola (which includes the cost of treating cases, lost productivity of affected individuals and one care taker, and the cost associated with productivity due to premature death) is an estimated US$35.5 million. Table A3.6: Estimated Cost (US$ million 2019) of Historical Ebola Outbreaks in REDISSE IV Countries, 2000-2019 Year DRC RoC Total Est. Cost Cases Deaths Cases Deaths Cases Deaths (US$ million 2002 59 43 59 43 1.44 2003 178 157 178 157 5.26 2005 12 10 12 10 0.34 2007 264 187 264 187 6.28 2009 32 15 32 15 0.51 2012 36 13 36 13 0.44 Page 140 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Year DRC RoC Total Est. Cost Cases Deaths Cases Deaths Cases Deaths (US$ million 2014 69 49 69 49 1.65 2017 8 4 8 4 0.14 2018 591 357 591 357 12.63 2019 303 204 303 204 6.86 Total 1303 829 249 210 1552 1039 35.54 22. Table A3.7 presents the economic benefit of preventing Ebola for an “average outbreak” and “major outbreak” scenario. The average outbreak assumes that there are 91 Ebola cases and 61 deaths each year of the project. A major outbreak scenario makes the same assumptions as the average outbreak scenario, except that during year three, there are 28,616 cases and 11,310 deaths, modeled after the 2014-15 West Africa outbreak. For the average outbreak, the economic benefit ranges from US$3 million when 25 percent of cases are prevented to US$12 million when 95 percent of cases are prevented. For the major outbreak scenario, the economic benefit ranges from US$123 million when 25 percent of cases are prevented to US$467 million when 95 percent of cases are prevented. Table A3.7: Estimated Economic Benefit (US$ million 2019) of Preventing Ebola within REDISSE IV Countries, 2019-2023 Scenario Cases per year Deaths per Proportion of Total benefits (2019-2023) year cases prevented (US$ million) (2019-2023) Average Outbreak 91 61 25% 4 50% 8 75% 13 95% 16 Major Outbreak 2021: 28,616 2021: 11,310 25% 184 Other years: 91 Other years: 61 50% 369 75% 553 95% 700 Influenza 23. Influenza pandemics have resulted in major loss of life and negative economic impacts. Using historical examples, the IWG on Financing Preparedness (2017) estimated that a mild flu pandemic (like the 1968 flu pandemic) would cost 0.7 percent of global GDP, a moderate pandemic (like the 1958 flu pandemic) would cost 3.1 percent of global GDP, and a severe pandemic (like the 1918 flu pandemic) would cost 4.8 percent of global GDP. Like other disease outbreaks, the recent H1N1 influenza pandemic in 2009 hit Africa harder than other regions. While globally, there was an estimated 201,200 respiratory deaths and 83,300 cardiovascular deaths attributed to H1N1, 51 percent occurred in Africa and southeast Asia (Dawood, 2012). However, seasonal influenza also results in major loss of life on an annual basis. In 2018, Luliano and colleagues estimated the excess mortality rate of country specific influenza for 33 countries, which represent 57 percent of the global population Page 141 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) (Lulian, 2018). They estimated that there were between 291,243 and 645,823 seasonal influenza associated respirator deaths per year, and that mortality rates were the highest in sub-Saharan Africa (2.8 to 16.5 deaths per 100,000 individuals). 24. Influenza pandemics have economic implications beyond the loss of human life. A case study of the potential economic impacts of Avian Influenza in Nigeria estimated that in a worst-case scenario, Nigerian chicken production would decrease by 21 percent and farmers would lose US$250 million (You & Diao, 2006). While Avian Influenza has been controlled in many parts of the world, since 2006, outbreaks have occurred in Burkina Faso, Cameroon, Ghana, Niger and Nigeria. 25. Estimates of the number of deaths from seasonal influenza-associated respiratory mortality and the global H1N1 pandemic in 2009 were used to assess the cost of influenza associated deaths in the REDISSE IV countries (Luliano, 2018; Dawood, 2012). Due to data limitations, only the number of influenza deaths (and not cases) were considered. The age distribution of seasonal influenza deaths was 68 percent among people less than 65 years of age, and 32 percent among people greater than 65 years of age (Luliano, 2018). For the H1N1 pandemic, age distribution was assumed to be 29 percent among people under 18 years old, 64 percent among people aged 18 to 64 years, and 8 percent among people above 65 years old (Dawood, 2012). All deaths were associated with illness of eight days and required a four-day inpatient stay. A family caregiver lost productive time equal to the entire duration of illness. Both the low and high range estimates of the number of H1N1 deaths estimated by Dawood et al. were modeled. 26. There are an estimated 6,716 respiratory related deaths from seasonal influenza in the REDISSE IV countries in a given year. The low estimate of the number of H1N1 deaths in REDISSE IV countries in 2009 was 4,503 and the high estimate was 16,417 deaths. As table A3.7 presents, the annual cost of seasonal influenza deaths is estimated at US$191 million. The estimated cost associated with deaths from the 2009 H1N1 ranged from US$177 million to US$648 million. Table A3.8: Estimated Cost (US$ million 2019) of Seasonal Influenza and H1N1 in REDISSE IV Countries Country Number of influenza-associated respiratory deaths Seasonal Influenza H1N1 2009 H1N1 2009 (Annual estimate) (Low estimate) (High estimate) Angola 1,279 1,442 5,321 CAR 290 124 463 Chad 717 409 1,481 DRC 4,157 2,388 8,641 RoC 270 140 511 Total 6,713 4,503 16,417 Estimated Cost 191 per year 178 649 US$ (millions) 27. Table A3.9 presents the results of preventing deaths from seasonal influenza, as well as an outbreak scenario modeled using the low and high estimates of the number of deaths during H1N1 in 2009. The economic Page 142 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) benefits associated with preventing 25 percent to 95 percent of seasonal influenza deaths range from US$264 million to US$1,003 million. The low (high) estimates of preventing 25 to 95 percent of deaths associated with seasonal influenza, as well as an outbreak like H1N1 range from US$288 (408) million to US$1,096 (1,550) million. Table A3.9: Estimated Economic Benefit (US$ million 2019) of Preventing Seasonal Influenza and H1N1 within REDISSE IV Countries, 2019-2023 Scenario Deaths Proportion of Total benefits cases prevented (US$ million) Seasonal Influenza 6,713 deaths per 25% 264 year 50% 528 75% 792 95% 1,003 Major Outbreak – 6,713 deaths per 25% 288 low range estimate year 50% 577 4,503 additional 75% 865 deaths in 2021 95% 1,096 Major Outbreak – 6,713 deaths per 25% 408 high range estimate year 50% 816 16,417 additional 75% 1,224 deaths in 2021 95% 1,550 Yellow fever 28. Yellow fever, a vaccine preventable disease, is a mosquito-borne virus disease. Symptoms of yellow fever, which range from non-specific illness to jaundice, hemorrhage and death, are difficult to distinguish from other conditions, leading to major under-reporting. A 2014 study estimated the burden of yellow fever in Africa at 130,000 cases and 78,000 deaths (Garske, 2014). The authors estimated that vaccination campaigns across the continent had reduced cases and deaths by 27 percent, but this figure was much higher at 82 percent in countries that were specifically targeted by yellow fever campaigns. One of the largest yellow fever outbreaks in recent history was in Angola and DRC between December 2015 to November 2016. The outbreak resulted in 7,334 suspected cases (only 962 confirmed) and 393 deaths (Kraemer, 2017). 29. To estimate the historic and projected cost of yellow fever, 90 percent of cases were assumed to be mild, whereas 10 percent were assumed to be severe (with half of the severe cases resulting in death). Mild cases were assumed to last four days and require one outpatient visit to a health clinic, whereas severe cases were assumed to last 14 days and require 10 days of inpatient care (CDC, 2019). Family caregivers lost productivity for a duration equal to the duration of illness. Sixty-three percent of cases were assumed to be among people below 20 years old, whereas the remaining 37 percent of cases were among people older than 20 years (WHO, 2019). For deaths, 61 percent were assumed to be among children under five years of age, with remaining among people older than five years of age (WHO, 2018).37 There is no standard treatment for yellow fever. Hence, the treatment regimen costed as the delivery of ORS for mild cases and ringer lactate for severe cases. 37 Due to unavailability of age distribution of deaths, the age distribution of malaria deaths was used – World Malaria Report, 2018. Page 143 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) 30. Table A3.10 presents the economic burden of yellow fever across the REDISSE IV countries since 2000. The economic burden, which was estimated at US$27 million, is likely a gross underestimation due to the under- reporting of yellow fever cases and deaths. Table A3.10: Estimated Cost (US$ million 2019) of Historical Yellow Fever Outbreaks in REDISSE IV Countries, 2000-2018 Year Angola/DRC CAR Chad RoC Total Cost Cases Deaths Cases Deaths Cases Deaths Cases Deaths (US$ million) 2008 2 0 2009 4 3 1 0.20 2010 12 2 0.13 2012 1 0 2013 6 2 0 2014 139 6 0.40 2016 7,334 393 25.99 2018 69 0 Total 7,491 401 6 3 2 0 71 0 26.72 31. Table A3.11 projects the cost of yellow fever cases and deaths in the REDISSE IV countries during the life of the project. The “average outbreak” scenario takes the average number of yellow fever cases and deaths in the sub-region between 2000 and 2018, excluding the outbreak in Angola and DRC between 2015 and 2016. The “major outbreak” scenario models an outbreak in year three of the project using the same number of cases and deaths as the 2015-16 outbreak in Angola and DRC. In the average (major) outbreak scenario, the total benefit ranges from US$0.07 million (US$6 million) if 25 percent of cases were prevented to US$0.29 million (US$23 million) if 95 percent of cases were prevented. Table A3.11: Estimated Economic Benefit (US$ million 2019) of Preventing Yellow Fever within REDISSE IV Countries, 2019-2023 Scenario Cases per Deaths per year Proportion of Total benefits year (2019- (2019-2023) cases prevented (US$ million) 2023) Average 13 1 25% 0.07 Outbreak 50% 0.15 75% 0.23 95% 0.29 Major 2021: 7,334 2021: 393 25% 6 Outbreak Other years: Other years: 1 50% 12 13 75% 18 95% 23 Page 144 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Summary of Benefits and Costs of REDISSE IV 32. The economic benefits of the REDISSE IV Project are summarized in Table A3.12. The estimates assume that a major outbreak of Cholera (modeled after the Zimbabwe 2008-09 outbreak), Ebola (modeled after the 2014- 15 West Africa Outbreak), H1N1 (modeled after the 2009 outbreak) and yellow fever (modeled after the 2015-16 Angola and DRC outbreak) will occur during the third year of the project. For the remaining years of the project, the average annual number of cases and deaths between 2000 and 2019 for each condition were used. In all scenarios, the benefits of the project outweigh the costs. 33. Examining the “average outbreak” scenario, which is the most conservative scenario, the benefit-cost ratio (BCR) is 1.3, the net present value (NPV) is US$83 million and the internal rate of return (IRR) is 4.7 percent if 25 percent of cases are prevented. The BCR, NPV and IRR increase to 5.0, US$1,054 million and 20.6 percent respectively if the project prevents 95 percent of cases and deaths. These estimates are conservative – they consider only the economic impact of four diseases. Furthermore, only the direct cost of treating each disease, the cost born by the household, and the cost of premature death and disability is modelled. Finally, the number of cases and deaths for each disease is likely under-reported due to the existing challenges within REDISSE IV countries for early identification and reporting. Table A3.12 Cost Benefit Analysis Results Outbreak Proportion of Benefit-cost ratio Net present value Internal rate of cases prevented (US$ million) return Average 25% 1.3 83 4.7% 50% 2.6 429 10.8% 75% 3.9 776 16.3% 95% 5.0 1,054 20.6% Major Cholera 25% 1.5 140 5.5% outbreak 50% 3.1 545 11.6% 75% 4.6 950 17.1% 95% 5.8 1,273 21.5% Major Ebola 25% 2.0 264 9.4% outbreak 50% 4.0 792 26.5% 75% 6.0 1,319 58.8% 95% 7.6 1,742 91.4% Major H1N1 25% 1.9 227 7.1% outbreak 50% 3.7 717 14.3% (high estimate) 75% 5.6 1,208 21.1% 95% 7.1 1,601 26.6% Major yellow 25% 1.3 89 4.8% fever outbreak 50% 2.7 441 10.9% 75% 4.0 794 16.4% 95% 5.1 1,076 20.7% Page 145 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Sensitivity analysis 34. The results of this analysis are subject to the many assumptions made in key parameters. The sensitivity analysis varies some of these key parameters to examine their impact on results. Table A3.13 presents the baseline scenario, which assumes that the project prevents 50 percent of cases and deaths. The discount and GDP growth rates are then changed. In each scenario, the benefits of the project continue to outweigh the costs. 35. The main conclusion of the analysis does not change: investing in disease surveillance and preparedness through the REDISS IV project is justified on economic grounds. Table A3.13: Sensitivity Analysis Average Major Cholera Major Ebola Major H1N1 Major Yellow outbreak outbreak outbreak Fever outbreak Baseline BCR: 2.6 BCR: 3.1 BCR: 4.0 BCR: 3.7 BCR: 2.7 (50% of cases NPV: US$429 M NPV: US$545 M NPV: US$729 M NPV: US$717 M NPV: US$441 M prevented) IRR: 10.8% IRR: 11.6% IRR: 26.5% IRR: 14.3% IRR: 10.9% Discount rate 0% BCR: 5.1 BCR: 6.4 BCR: 7.3 BCR: 7.5 BCR: 5.2 NPV: US$1,057 M NPV: US$1,403 M NPV: US$1,654 M NPV: US$1,710 M NPV: US$1,087 M IRR: 10.8% IRR: 11.6% IRR: 26.5% IRR: 14.3% IRR: 10.9% 5% BCR: 1.9 BCR: 2.2 BCR: 3.1 BCR: 2.7 BCR: 2.0 NPV: US$235 M NPV: US$298 M NPV: US$521 M NPV: US$422 M NPV: US$242 M IRR: 10.8% IRR: 11.6% IRR: 25.5% IRR: 14.3% IRR: 10.9% GDP growth 0% BCR: 1.4 BCR: 1.5 BCR: 2.3 BCR: 1.9 BCR: 1.4 NPV: US$102 M NPV: US$139 M NPV: US$350 M NPV: US$233 M NPV: US$107 M IRR: 6.0% IRR: 6.7% IRR: 20.7% IRR: 9.2% IRR: 6.1% 5% BCR: 3.3 BCR: 3.9 BCR: 4.9 BCR: 4.7 BCR: 3.4 NPV: US$603 M NPV: US$773 M NPV: US$1,027 M NPV: US$985 M NPV: US$620 M IRR: 12.3% IRR: 13.0% IRR: 28.2% IRR: 15.8% IRR: 12.4% Page 146 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) References: Ali, M., Lopez, Ann L., You, Y.A., Kim, Y.E., Sah, B., Maskery, B., Clemens, J. 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World Bank and Welcome Trust: Washington, DC, 2017. Kirigia, J.M., Sambo, L.G., Yokouide, A., Soumbey-Alley, E., Muthuri, L.K., Kirigia, D.G. Economic burden of cholera in the WHO African region. BMC International Health and Human Rights. 2009;9(8). Kraemer, MU et al. 2017. Spread of yellow fever virus outbreak in Angola and the DRC 2015-16: a modeling study. Lancet Infect Dis; 17:330-38. Luliano, AD, et al. 2018. Estimates of global seasonal influenza-associated respiratory mortality: a modelling study. Lancet; 391: 1285-300. Management Sciences for Health. International Medical Products Price Guide. MSH: Medford, MA, 2016. Mukandavire, Z., Liao, S., Wang, J., Gaff, H., Smith, D.L., Morris, J.G. Estimating the reproductive numbers for the 2008-2009 cholera outbreak in Zimbabwe. PNAS. 2011;108(21)8767-8772. NICE International. 2014. Methods for Economic Evaluation Project: Final Report. 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Accessed January 14, 2019 at https://www.who.int/choice/en/ WHO. 2018. World Malaria Report. WHO: Geneva. You, L., Diao, X. Assessing Potential Impact of Avian Influenza on Poultry in West Africa – A Spatial Equilibrium Model Analysis. IFPRI: Washington, DC, 2006. Page 147 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) ANNEX 4: Technical Priority DRC NAPHS Activities Eligible for REDISSE IV Financing Components / Sub- Actions (ou activities) Components / JEE Title JEE # Summary of NAPHS Indicators Component 1: Strengthening surveillance and laboratory capacity to rapidly detect outbreaks SC 1.1. National, provincial and local surveillance system Organize the work for drafting a legal act Establishment of a surveillance system Real-time D.2.1 based on events Surveillance Support the operation of the multisectoral framework and indicators Strengthening the consultation framework for monitoring zoonoses / priority pathogens Set up sentinel sites for joint surveillance in high-risk areas (passive Surveillance and active outbreaks of priority zoonoses / pathogens) system in place for Zoonoses P.4.1 Support the operation of sentinel sites for monitoring zoonotic zoonoses/priority pathogens diseases / priority pathogens Organize sessions to develop and harmonize tools and training modules on zoonotic surveillance PoE 1 Effective public health action at PoE Capacity Building at 18 Designated PoEs (Infrastructure and People) Elaboration of emergency plans Point of Entry Organization of 4 Status Missions of 18 PoEs designated in 7 PoE 2 Provinces Implementation of the first two required minimum capacities (medical centers, personnel and ambulances) System for efficient Put in place an integrated notification system based on the "one reporting to FAO, Notification D.3.1 health" approach OIE and WHO SC 1.2 Health information system (human et animal) Real-time, Equip all 4 sectors with electronic monitoring system (Server, interoperable, Real time VSAT, Telephone) D.2.2 interconnected, Surveillance Strengthen the capacities of the actors in the IDSR / surveillance of electronic animal diseases and response ( SMAR) Page 148 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) reporting system Ensure M&E SC 1.3 Laboratory diagnosis capacity National Regulation of the quality system Quality of laboratory D.1.4 Laboratory Quality Assurance for Human and Animal Biological laboratory systems system Analysis Strengthening of multisectoral consultation framework (human health, animal health and environment) for coordination and collaboration of laboratories. Laboratory analysis Updating and / or drafting legal texts, multisectoral strategies, National capacities for the strategic plans and operational plans at all levels laboratory D.1.1 detection of Dissemination of legal and regulatory texts system priority diseases Interconnection of databases and exchange of information in real time Rehabilitation of provincial laboratories SC 1.4 Supply chain management systems Development of SOP for collection, storage and transport of System for sending National samples and transporting laboratory D.1.2 laboratory samples system Strengthening the operational capacity of network laboratories Component 2: Strengthening emergency planning and management capacity to rapidly respond to outbreaks SC 2.1 Emergency management systems Mechanisms for Develop SOPs for the response to zoonotic diseases the control of infectious Organise training workshop zoonoses and Zoonoses P.4.3 potential zoonoses Capacity building of personnel established and functional A multi-hazard Strengthening Public Health Emergency Preparedness and National Public Response Capacity Health Emergency Preparedness and Preparation R.1.1 Strengthening preparedness capacities and responses to public Response Plan has health emergencies (functioning of the CEE / CDC DRC) been established and implemented. Collaboration and TBD exchange of REDISSE IV N/A information between countries SC 2.2 Medical countermeasures and staff deployment Establishment of a legal framework for collaboration and Medical R multisectoral coordination for the sending and receiving of means 4.1 medical means in public health emergencies situations Page 149 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Deployment of personnel and medical means in case of crisis Establishment of international partnerships for the deployment of medical personnel and resources in the event of a crisis Establishment of regional "Surge Preparation Capacity" and and medical N/A storage means mechanisms SC 2.3 Non-pharmaceutic Intervention Capacity building of human resources in risk communication Dotation du PNCPS multisectoriel en matériels et équipements à tous les niveaux Formally establish a multisectoral coordination framework for Coordination, risk communication communication Risk Communi- P and promotion of cation 2.1 Improving the quality of health communication on risks IHR Establishment of an intermediate and local committee for the implementation of standard procedures on risk communication Develop a rumor management strategy SC 2.4 Research and evaluation SC 2.5 Contingent emergency response Component 3: Public health workforce development SC 3.1 Existing staff / Staff recruitment Staff Rationalization by HR Staffing Standards in Relevant Sectors and at All Levels Availability of HR to Implement Key Dvpt of D.4.1 Update and / or development of multi-sectoral strategies, IHR Capabilities personnel strategic plans and operational plans at all levels (multi-sector required Human Resources Development Plan based on recommendations from the HR Situation Report) SC 3.2 Training Applied Sustained FELTP and Applied Epidemiology at All 3 Levels Epidemiology Dvpt of Training Program D.4.2 personnel in place such as FETP Staff Number of people REDISSE IV N/A Master 2years 32000/ Candidate (Gap to fill 2193) Page 150 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) trained in Frontline three months/ US5000/ Candidate (Gap to fill 334113) intervention epidemiology (front line, intermediate, advanced) including percentage of women SC 3.3. Regulation Harmonization of Sector Incentive Plans for Retention and loyalty Development of Agents Staff Strategy D.4.3 of personnel Capacity building Component 4: Institutional capacity building, project management, coordination and advocacy SC 4.1 Project Coordination, M&E, Data Generation and knowledge management Creation of an active and TBD REDISSE IV N/A functional "OH" platform Harmonization of existing consultation frameworks with a view to "One health" Dissemination of the IHR (2005) at the level of the authorities and all the sectors involved Evaluation of the communication, promotion of the IHR (2005) at Coordination the level of the authorities and all the sectors involved. Implementation and evaluation of NAPHS & REDISSE IV project Organisation of supervision missions Ensure the institutional support of the PFNRSI Establishment of a multisectoral committee for monitoring legal texts Update of legal texts for an efficient implementation of the IHR (2005), dissemination, M&E of the application of the texts. Legislation / Development of the domestic and external resource mobilization finance plan; mobilization of domestic and external resources for the implementation of the IHR Identification of official and unofficial points of entry of the country Project Management of project management Page 151 of 152 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Project in Central Africa, Phase IV (P167817) Citoyens et/ou TBD communautés participant à REDISSE IV N/A planification/mise en œuvre/évaluation Page 152 of 152