The World Bank Haiti COVID-19 Response (P173811) REPORT NO.: RES57942 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HAITI COVID-19 RESPONSE APPROVED ON APRIL 2, 2020 TO REPUBLIC OF HAITI HEALTH, NUTRITION & POPULATION LATIN AMERICA AND CARIBBEAN Regional Vice President: Carlos Felipe Jaramillo Country Director: Lilia Burunciuc Regional Director: Jaime Saavedra Practice Manager: Tania Dmytraczenko Task Team Leader(s): Marie Isabelle Simeon, Nicolas Collin Dit De Montesson The World Bank Haiti COVID-19 Response (P173811) ABBREVIATIONS AND ACRONYMS AF Additional Financing AFE Africa, East and South countries AF-V Additional Financing for Vaccine AFW Africa, West and Central countries BFP Bank Facilitated Procurement DINEPA National Directorate for Drinkable Safe Water and Sanitation (Direction Nationale de l’Eau Potable et de l’Assainissement) DP Direct Payment EAP East Asia and the Pacific Region ECA Europe and Central Asia E&S Environment and Social ESRC Environmental and Social Risk Classification FM Financial Management GFF The Global Finance Facility IBRD International Bank for Reconstruction and Development ICR Implementation Completion Results Report IDA International Development Association ISR Implementation Status and Results LAC Latin America and the Caribbean Region MEF Ministry of Finance (Ministère de l’Economie et des Finances) MNA Middle East and North Africa MPA Multiphase Programmatic Approach MSPP Ministry of Public Health and the Population MTR Mid Term Review OPCS Operations, Policy and Country Services Vice Presidency PDO Project Development Objective PIU Project Implementation Unit RF Retroactive Financing SAR South Asia SDR Special Drawing Rights UCNPV National Coordination Unit for the Vaccination Program UGP Unite de Gestion de Projet, Ministry of Public Health and the Population UN United Nations WB World Bank The World Bank Haiti COVID-19 Response (P173811) BASIC DATA Product Information Project ID Financing Instrument P173811 Investment Project Financing Environmental and Social Risk Classification (ESRC) Substantial Approval Date Current Closing Date 02-Apr-2020 30-Mar-2024 Organizations Borrower Responsible Agency Republic of Haiti Multiphase Programmatic Approach (MPA) Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness Multiphase Programmatic Approach (MPA) Status (Public Disclosure) Status and Key Decisions (Public Disclosure) COVID-19 MPA Considerable efforts continue to be made to advance the implementation of the 87 MPA operations. The past two months have seen good efforts to accelerate implementation reflected in the number of disbursement applications processed. However, as noted in the past months, the overall level of disbursements is being affected by three main reasons: (i) low disbursements in seven countries (Bangladesh, Kiribati, Nigeria, Samoa, Solomon Islands, Uganda, and Zambia); (ii) pausing of disbursements in two other countries – Afghanistan, and Myanmar; and (iii) processing of refunds to the project accounts at this late stage of project implementation. In addition, (i) a large refund from the UN to the project account of the Myanmar operation was processed in March 2023 due to the inability to implement the project, and The World Bank Haiti COVID-19 Response (P173811) (ii) the amounts of Loans and Credits denominated in SDRs and Euros have been affected because of fluctuations between the SDRs and Euros against the US dollar. As of February 16, 2024, 88 MPA-projects had been approved with a total commitment of US$4.25 billion. One operation (Guatemala) was cancelled in mid-September 2021. Total disbursements as of February 16, 2024, amount to US$3.99 billion or 94% of overall commitments. This amount does not include disbursements under MPA-V operations which are reported together with AF-V operations. Closing dates for MPA operations have been as follows: (i) ten operations closed by the end of CY22, (ii) nine operations closed on June 30, 2023, (iii) thirteen operations closed on December 31, 2023. Twenty-eight operations are scheduled to close by June 30, 2024. However, this number will change as extension of closing dates are being processed under some operations. As with the Mid Term Review (MTR) issued on March 25, 2023, no individual ICR will be required for COVID-19 MPA operations. Only one ICR will be prepared upon completion of the SPRP COVID-19 MPA Program, which closes on December 31, 2025. The Global ICR will be based on final ISRs packages prepared by country operations’ teams. A template for the final ISR was issued by OPCS on March 21, 2023. Several operations have/are preparing final ISR packages. The overall conclusion of the MPA MTR was that: (i) the COVID-19 MPA Program embodied a rapid, innovative approach to new lending for human health response; (ii) the COVID-19 MPA has been successful, notwithstanding considerable uncertainty and multiple constraints in the early stages of the pandemic; (iii) the Bank’s emergency response was remarkably swift in the most vulnerable countries facing human capital losses and development setbacks; and (iv) notwithstanding the challenges, the MPA is on track to achieve its PrDO, “prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness.“ Seventy-five (75) country projects or 86 percent of projects approved have reached 70-100+ percent disbursement (reasons for >100% disbursements relate to fluctuations between the Euro and the SDR against the US$). Out of the 75 operations, 66 operations or 87 percent have disbursed 90+ percent of commitments. Out of the 75 operations, 51 operations or 68 percent are fully disbursed, and ten (10) operations have disbursed 95-99 percent of commitments. There are seven operations with disbursements of 65 percent or less. Out of these four operations, one operation has disbursed 35 percent (AFW), two operations in EAP have disbursed 48-62 percent and one operation in SAR has disbursed 52 percent. The operation in AFW is in the process of being restructured to: (i) extend the closing date by four months, (ii) cancel a large amount under the parent project, (iii) reallocate funds under the various components and activities that will remain, and (iv) revise the Results Framework. Processing of the restructuring is becoming urgent as the current closing date is February 29, 2024. The projects are benefitting about 3.7 billion people or 50% of the global population. When countries with AF-V operations are counted, the projects are benefitting about 4.1 billion of 51 percent of the global population. This is because some countries that do not have a parent project have AF-V operations. All projects approved are disbursing. Operations in ECA and MNA are fully disbursed. In other regions, disbursements have reached: (i) LAC 98 percent, (ii) SAR 95 percent, (iii) EAP 88 percent, (iv) AFW 85 percent, and (v) AFE 82 percent. Disbursements for EAP operations are being affected by low disbursements in three country projects that have disbursed between 48 and 62 percent. AFE lower disbursements compared to The World Bank Haiti COVID-19 Response (P173811) other regions are a result of low disbursements under two operations, which have disbursed 62-66 percent respectively. In the case of AFW low overall disbursements are a result of low disbursements under one operation (35 percent). Retroactive Financing (RF) continues to represent 20 percent of commitments. SAR has the highest percentage of RF at 37 percent, followed by ECA at 18 percent. Direct Payment (DP) disbursements represent 22 percent of commitments. EAP has the highest level of disbursements using DP – 80 percent, followed by AFW at 38 percent. IDA continues to represent 40 percent while IBRD represents 60 percent of disbursements. Streamlined procedures, delegated approvals, coupled with flexible project design and intensified efforts by counterparts and Bank teams have contributed to the progress. Implementation is being guided by Bank teams working in parallel with other health related projects, including Additional Financing operations which have supported vaccine procurement and deployment efforts. COVID-19 MPA AF-V Good progress is being made in the implementation of AF-V operations. As of February 16, 2024, the Bank has approved 117 operations (including MPA-V operations) to support vaccine procurement and rollout in 78 countries amounting to $8.70 billion. Four operations have been approved in the past months including: (i) Senegal AF2 operation for $15 million financed by a Grant from The Global Finance Facility (GFF) approved on June 30, 2023; (ii) a Second AF (IDA Grant of $1.50 million) approved on August 31, 2023 for Sao Tome and Principe, (iii) a Grant of $3.94 approved for Chad on July 23, 2023; and (iv) Zimbabwe AF2 operation for $15 million financed by a Grant from the GFF approved on December 7, 2023. 121 operations had been approved amounting to $10 billion, but partial cancellations have been processed in the past months under several operations. In addition, four operations were cancelled: (i) Costa Rica loan ($120 million), (ii) Peru loan ($500 million), (iii) Gabon loan ($12 million), which loan agreement lapsed, and (iv) Philippines AF2 loan of $300 million. The Afghanistan operation commitment of $113 million was reduced to $60 million. Of the 117 approved operations: (i) 67 are in Africa – 32 in AFE and 35 in AFW; (ii) 10 in East Asia and the Pacific; (iii) 11 in Europe and Central Asia; (iv) 11 in Latin America and the Caribbean; (v) 9 in Middle East and North Africa; and (vi) 9 in South Asia. The 117 operations approved, include 6 operations that involved restructuring of parent projects (Bhutan, Cameroon, North Macedonia, Philippines, and Pakistan) and in the case of Lebanon, restructuring of the Health Resilience Project. Partial cancellations have been/are being processed under several operations -- Afghanistan, Bangladesh, Belarus, Benin, Cabo Verde, Cameroon, Ethiopia, Gabon, Georgia, Lao, Madagascar, Mali, Nepal, Nigeria, Pakistan, Philippines, PNG, Sierra Leone, South Africa, Sudan, ROC AF2, and Togo. Thirty-two (32) operations are being implemented in Fragile and Conflict-affected situations. IDA represents 45 percent and IBRD 55 percent of disbursements. Total disbursements under these projects as of February 16, 2024, amount to US$6.51 billion or 76 percent of overall commitments. Disbursements under MPA-V operations are included in this total while disbursements under the six restructured projects are counted under parent projects. With less than planned demand for IDA/IBRD funds for vaccine procurement because, inter alia, over supply of vaccines from donations from various sources, several projects have The World Bank Haiti COVID-19 Response (P173811) been/are being restructured and more will need to be restructured to reallocate funds or partially cancel funds allocated to procurement of COVID-19 vaccines and deployment. Guidance was issued under an Email from Juan Pablo Uribe of July 7, 2023, which provided direction for the use of undisbursed funds under COVID-19 operations. Five (5) operations are fully disbursed (Argentina, El Salvador AF1, Indonesia, Sri Lanka AF-V 1, and Ukraine AF-V 3). Sixty (60) AF-V/MPA-V operations or 51% of operations approved have disbursed over 70% of their commitments. Out of 60, twenty-five (25) operations or 42% have disbursed 90+. Ninety-eight (98) operations or 84 percent of total operations approved are disbursing. EAP has the highest percentage of disbursements at 96 percent, followed by ECA at 88 percent, LAC at 84 percent, SAR at 81 percent, MNA at 78 percent, AFE and AFW at 62 percent. Retroactive Financing (RF) represents 37 percent of overall commitments. ECA has the highest level of RF at 74 percent, followed by SAR at 68 percent, LAC at 59 percent, MNA and AFE at 29 percent and AFW at 13 percent. Disbursements to UN agencies represent 22 percent of overall disbursements, while Direct Payment represents 16 percent of disbursements. As with the COVID-19 MPA operations, streamlined procedures, delegated approval, wide use of Bank Facilitated Procurement (BFP), coupled with flexible project design, and intensified efforts from counterparts and Bank staff have contributed to the rapid design, processing, and implementation of the AF-V operations. OPS_TABLE_PDO_CURRENTPDO Project Development Objective (PDO) Original PDO To respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Haiti. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-E0620 23-May-2022 04-Aug-2022 31-Oct-2022 30-Mar-2024 35.00 5.38 28.38 IDA-D6010 02-Apr-2020 03-Apr-2020 15-Apr-2020 30-Mar-2024 20.00 19.60 .43 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? Yes The World Bank Haiti COVID-19 Response (P173811) Explanation Due to the overdue financial audit (for 2022), a waiver has been processed to proceed with the restructuring involving the extension of the Project closing date notwithstanding overdue audit reports based on the recent improvements and corrective action plan agreed with the Government. Has the waiver(s) been endorsed or approved by Bank Management? Yes Explanation On January 2nd and January 4th 2024, WFA and FM managers provided clearance to proceed with the restructuring involving the extension of the Project closing date notwithstanding overdue audit reports based on the recent improvements and corrective action plan agreed with the Government. I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. Introduction 1. This restructuring paper seeks the World Bank (WB) Country Director’s approval for a Level II Restructuring of the Haiti COVID-19 Response Project (P173811) to: (i) reallocate IDA Grant E062-HT proceeds corresponding to vaccine procurement to strengthening patient care capacity, immunization systems, and pandemic preparedness and response capacity, given vaccines donations received from other donors, persisting low incidence and demand for COVID-19 vaccines, and more pressing priorities for the health system; (ii) extend the Project’s closing date by 20 months (from March 30, 2024 to November 30, 2025) to allow for the implementation of these revised activities; and (iii) adjust the Project’s Results Framework, implementation schedule, and disbursement estimates to reflect the shift in activities and the extended implementation period. These changes are described in more detail below. If approved, this would be the second restructuring of the Project1 and the first extension of the closing date. 2. The proposed revisions to the Project’s scope are in response to the changing operational environment and government priorities and are expected to significantly improve the Project’s future performance. The proposed 20-month closing date extension is necessary to ensure that the Government of Haiti has sufficient time to fully execute the IDA grant resources, particularly given the ongoing fragile and conflict-affected context of Haiti. It would also allow for an orderly closure of the Project prior to the December 31, 2025 closure of the COVID-19 Multiphase Programmatic Approach, under which this Project was prepared. B. Project Background 3. The Haiti COVID-19 Response Project (P173811), prepared under the Strategic Preparedness and Response Program, was initially financed by a US$20 million IDA grant (D601-HT), approved by the WB Board of Directors on April 2, 2020, and declared effective on April 15, 2020. An Additional Financing (AF) of US$35 million (IDA 1 The project was first restructured in May 2022 when the AF was processed. The World Bank Haiti COVID-19 Response (P173811) Grant E062-HT) to support the Government of Haiti with the procurement and deployment of COVID-19 vaccines, and further reinforce preparedness and response activities, was approved by the WB’s Regional Vice President for Latin America and the Caribbean on May 23, 2022, and declared effective on October 31, 2022. The Project aims to strengthen epidemiologic surveillance and diagnostic capacity of the Ministry of Public Health and the Population (MSPP) and strengthen public health services to cope with the increased demands posed by COVID- 19. The Project consists of three components: (i) Emergency COVID-19 response and (ii) Health System Strengthening; and (iii) implementation management and monitoring and evaluation. C. Project Status and Performance 4. In the last Implementation Status and Results (ISR) Report filed December 22, 2023, the Project’s progress towards achievement of the Project Development Objective (PDO) and overall Implementation Progress were rated Moderately Satisfactory and Moderately Unsatisfactory respectively. Overall implementation progress remains uneven with some activities yielding good results on the first phase of the pandemic response, including for strengthening epidemiological surveillance and reinforcement of healthcare services provision capacity and health system strengthening whereas COVID-19 vaccination activities remain stalled due to the lack of demand, low incidence rates, and unfavorable country context. Three out of the Project’s four PDO indicators have been achieved, with two surpassing final targets, whilst the remaining PDO indicator on COVID-19 vaccination has not been achieved. The operational environment continues to deteriorate, with widespread insecurity and access barriers, massive emigration and brain drain all presenting challenges for implementation of Project-financed activities. 5. Under Component 1, Project-financed activities have been implemented quickly under the Parent Project and have contributed to limited COVID-19 mortality and incidence. These activities include: (i) infection prevention and control (including procurement of personal protective equipment for the entire health system); (ii) oxygen therapy equipment for patient care (over 515 oxygen concentrators installed to date); (iii) lab and surveillance capacity (including testing for COVID-19); (iv) communications activities; and (v) overall response coordination at the central and local levels. No hospitalized case has been reported for COVID-19 within the last six months. In 2023, the Project achieved a major milestone with the completed installation of renewable energy systems in five major health facilities, as well as in the country’s main laboratories in Les Cayes and Cap-Haitien. These systems, jointly financed by the Haiti Renewable Energy for All Project (P156719), are expected to strengthen patient treatment capacities of these facilities. Fuel consumption decreased between 50 percent and 100 percent depending on the size of the hospital, freeing up an average of US$1,200 per hospital each month. Before the investment, the lack of electricity (due to scarcity of fuel in the country or lack of financial resources to buy fuel) generated up to three months of cumulative days of service disruption per year. As a result of the installation of the renewable energy, two of the five hospitals can provide uninterrupted services, and the other three have the battery autonomy to provide services well into the nighttime without using fuel. Personal protective equipment distribution continues in response to emerging needs, and more than 92 percent of this equipment has been distributed. 6. COVID-19 vaccination activities have stalled due to very low COVID-19 incidence since 2020 and persisting lack of demand for COVID-19 vaccines. As of December 20, 2023, only 2.3 percent of the population has been vaccinated and Haiti remains among the ten countries with the lowest COVID-19 vaccination coverage in the The World Bank Haiti COVID-19 Response (P173811) world.2 COVID-19 vaccination activities were also slowed by widespread insecurity and by the refocusing of the MSPP efforts towards responding to more pressing needs, including the cholera epidemic response that started in October 2022 and falling routine immunization rates. The country is now facing a rise in diphtheria cases and is highly vulnerable to imported cases of measles. As a result, the National Coordination Unit for the Vaccination Program (UCNPV) at MSPP plans to strengthen its routine immunization systems and to conduct vaccination campaigns aimed at reducing its vulnerability to vaccine preventable diseases and averting future outbreaks. Additionally, UCNPV’s vaccination strategy has shifted from mass community outreach for COVID-19 vaccination to the integration of COVID-19 vaccines into the national program of immunization with the aim of using resources more efficiently, and to strengthening routine immunization at the facility level, ensuring the availability of COVID- 19 vaccines to people seeking care at the health facilities. 7. Under Component 2, health system strengthening activities continue to show progress. Investments in laboratory capacities have enabled Haiti to strengthen 18 main laboratories (project target: 3 laboratories) with equipment, supplies and training. These laboratories continue to provide COVID-19 testing across the country per the Pan American Health Organization COVID-19 standing recommendation issued in August 2023. Equipment procured under the Project has also expanded the testing volume and scope capacity of these laboratories, which is critical in the current context of cholera and diphtheria epidemics. In addition, the Project supported the establishment of a network of 74 COVID testing sites until 2022, although 11 of them closed in 2023 due to insecurity issues. Identification of replacement sites is ongoing to reestablish a broader capacity for the early detection of COVID-19 cases. The Project continues to surpass the target of having at least 90 percent of suspected COVID-19 cases investigated based on national guidelines despite the diminution of testing sites. As of December 7, 2023, all suspected COVID-19 cases have been investigated despite the large efforts reoriented from COVID-19 response towards the cholera epidemic. Activities to strengthen the deployment of MSPP subnational mobile response teams to a broader range of outbreaks, including cholera and diphtheria, are ongoing. 8. Under Component 3, project implementation has been constrained by widespread insecurity and mass emigration of health workers. While significant progress has been made during the last 18 months with the recruitment of more than 95 percent of the Project Implementation Unit (PIU) staff co-financed with Centers for Disease Control and Prevention and the Global Fund, growing staff retention and recruitment challenges across the health system are affecting not only project implementation, but the broader health system. Frontline health workers as well as central and departmental personnel are leaving the country. As of December 2023, the National Laboratory of Public Health has reportedly lost 60 percent of its human resources, making it increasingly difficult to ensure staff replacement. Across the health system, the departure of doctors, nurses and other MSPP key personnel continue to affect service delivery and core health system functions in the country. However, to mitigate the impact of staff shortages, the MSPP and partners are attempting to adopt a strategy to recruit and invest in building capacity of less experienced workers. 9. Fiduciary. Financial Management (FM) performance is rated Unsatisfactory. Continuous loss of FM staff due to insecurity and disrupted physical access to the PIU office have severely affected the FM performance since 2020, with both the 2021 and 2022 audits marked as overdue. However, the PIU and WB agreed on a corrective action plan to clear the backlog of Interim Financial Reports and overdue audit, and this plan is underway. Over the last six months, the PIU has increased its financial management capacity with the recruitment of two additional staff, as well as a new financial management director. The overdue 2021 audit was submitted and the 2022 audit is 2WHO (2023): World Health Organization emergency dashboard, Haiti COVID-19 vaccination data, as of December 20, 2023. https://covid19.who.int/region/amro/country/ht The World Bank Haiti COVID-19 Response (P173811) expected to be submitted during the first half of 2024. The corrective action plan has also resulted in progress on the general PIU FM performance through the clearance of the backlog of overdue interim financial reports under the Strengthening Primary Healthcare and Surveillance Project in Haiti Project (P167512) managed by the same PIU. Based on the recent improvements and corrective action plan agreed with the Government, on January 4, 2024, WB management provided clearance to proceed with the restructuring involving the extension of the Project closing date notwithstanding the overdue audit report. 10. Procurement. Under the original grant, despite a difficult context and the lack of qualified human resources, the PIU managed to implement activities in a timely manner. As of December 2023, the Project had disbursed US$24.8 million out of the total US$55 million grant proceeds: 98 percent of the original grant and 14 percent of the AF. However, priorities in the country have shifted away from COVID vaccination since approval of the AF, thereby stalling activities related to the deployment of COVID-19 vaccines, impacting the overall disbursement rate and resulting in a revision of the procurement rating from Moderately Satisfactory in November 2022 to Unsatisfactory in the December 2023 ISR to reflect the lack of procurement processes for COVID-19 vaccination activities. It is expected that the proposed restructuring would lead to an improvement in the procurement rating, as procurement processes for new activities could be initiated. 11. Environment and Social (E&S). The E&S performance was assessed as Moderately Unsatisfactory in the December ISR given on inadequate reporting by Project E&S specialists. However, project activities under the original grant have largely been completed and the remaining activities present minor E&S risks. The E&S capacity of the PIU has been considerably strengthened through the hiring of field-based consultants (which are pending mobilization) who will monitor E&S performance. Further actions by the PIU to strengthen E&S performance agreed during the last implementation support mission in December 2023 include: (i) the preparation of training/inductions for field based E&S staff; (ii) improvements in E&S reporting including through the preparation of a E&S semester report, in accordance with the Environmental and Social Commitment Plan; (iii) addressing the two pending grievances; and (iv) updating the E&S instruments for AF activities in line with the Environmental and Social Commitment Plan. 12. Project Management. Project Management performance is currently rated Moderately Satisfactory. Current implementation arrangements are deemed appropriate with key human resources in place. Contracts with United Nations agencies will continue to be part of the Procurement strategy to mitigate capacity shortcomings in MSPP. The WB will continue to provide extensive project implementation and supervision support, including through Hands-on Extended Implementation Support. D. Request and Rationale for Restructuring 13. Through the Ministry of Finance’s (Ministère de l’Economie et des Finances, MEF) request No. DEE/BM/WB/245 dated August 14, 2023, the Government of Haiti solicited: (i) the reallocation of SDR$3.7 million under IDA Grant E062-HT from COVID-19 vaccine procurement to other health system priorities, scaling up existing activities under Components 1 and 2; (ii) extending the closing date for both grants (IDA-D601-HT and IDA-E062-HT) from March 30, 2024 to November 30, 2025; and (iii) adjusting the Results Framework to reflect the revised scope and implementation period of the project. 14. The proposed restructuring is necessary to maximize the impact of Project resources and to respond to the changing context, including the need to strengthen MSPP’s capacity to respond to the cholera and diphtheria epidemics and to boost routine immunization coverage rates. The restructuring would enable the scale up of existing Project-financed activities including: (i) enhancing disease reporting systems and laboratory investigation The World Bank Haiti COVID-19 Response (P173811) of priority pathogens; (ii) expanding MSPP subnational mobile response teams to a broader range of outbreaks, including cholera and diphtheria, and their deployment to all departments; and (iii) investing in renewable energy solutions and equipment for three additional health facilities. Under Component 2, the restructuring would also facilitate continued efforts to strengthen surveillance systems (particularly for post-vaccination) at local and national levels; including via (i) strengthening governance for pandemic preparedness and response, notably via support to the coordination of Cholera control interventions with other partners, in particular with the National Directorate for Drinkable Safe Water and Sanitation (Direction Nationale de l’Eau Potable et de l’Assainissement, DINEPA); (ii) information systems, training and supervision to strengthen national systems for public health preparedness; and (iii) the rapid activation of community response and case notification at the community level for Cholera and other infectious pathogens (such as diphtheria or measles). II. DESCRIPTION OF PROPOSED CHANGES 15. Adjustment of Components costs. The cost of Component 1 would be reduced by US$5 million (from US$45.5 million to US$40.5 million) to reflect the prioritization of surveillance and pandemic preparedness and response activities over COVID-19 vaccination activities. Component 2 costs would be increased by US$5 million accordingly (from US$7 million to US$12 million) to account for the proposed scale up of successful health system strengthening activities. Table 1. Proposed reallocation across Project Components Current Current Proposed Cost Component Name Cost (US$M) (US$M) Component 1: Emergency COVID-19 Response 45.5 40.5 Component 2: Health System Strengthening 7 12 Component 3: Implementation Management and Monitoring and Evaluation 2.5 2.5 Total 553 55 16. Reallocation across disbursement categories. The Government requested a reallocation of SDR$3.7 million from Expenditure Category 2 of IDA Grant E062-HT (Goods under Part 1.(b)(vi) of the Financing Agreement, which refers to acquisition, storage and distribution of Project COVID-19 Vaccines) to Expenditure Category 1 (goods, works, non-consulting services, and consulting services, training and operating costs for the Project, except for goods under Part 1.(b)(vi)), to support activities that respond to more urgent health system needs under Components 1 and 2, as described above. With this reallocation, all remaining Project resources would be supporting activities under Category 1 (See Table 2). Table 2. Proposed reallocation of project funds across categories for IDA-E062-HT Category Current Current Requested Amount Requested Amount of Percentage of of the Financing Percentage of the Financing Expenditures to Allocated after Expenditures to be Allocated be Financed restructuring Financed (expressed in (inclusive of (expressed in SDR) after restructuring SDR) Taxes) (inclusive of Taxes) 3The difference between the current costing shown here and the costing in Section III. Summary of Changes is due to the US$35 million additional financing approved in 2022. The World Bank Haiti COVID-19 Response (P173811) (1) Goods, works, non- consulting services, consulting 21,700,000 100% 25,400,000 100% services, Training and Operating Costs under the Project (2) Acquisition, storage, and distribution of Project COVID-19 3,700,000 100% 0 - Vaccines under Part 1.4 (vi) of the Project TOTAL AMOUNT 25,400,000 25,400,000 17. Results Framework. To reflect the reprioritization of activities, the PDO indicator “Population fully vaccinated disaggregated by sex” would be deleted. A new PDO indicator “primary health care facilities with a functional solar powered system (number)” is added to capture the health facilities’ uninterrupted capacity to maintain cold chain for vaccines and essential medicines and contribute to a strengthened and resilient system. New intermediate results indicators would also be added: (i) “cholera alerts and outbreaks investigated and acted on by mobile rapid response teams within 48 hours of onset (percentage)” to capture the surveillance and community response to cholera epidemics; (ii) “call centers which are operational (percentage)” will help to capture the patients’ complaints and early detection of any adverse events that may occur following immunization; (iii) “health facilities reporting vaccination data (percentage)” will measure the number of health facilities able to report vaccination date on the Ministry’s information system; and (iv) “medical waste incinerators meeting the WHO standards functional in public health facilities (number)”. Several intermediate indicators are proposed for deletion as they are not linked to the updated strategy of integration of COVID vaccination into the routine immunization program. All the changes are captured in the Results Framework. 18. Closing date, disbursement estimates, and implementation schedule. As the political context and security environment in the country continue to be volatile and unpredictable, the resulting uncertainty poses potential risks of delays in the implementation of Project activities as planned. To provide the Government with sufficient time to implement the proposed Project activities and achieve the revised PDO indicators, the closing date for both grants would be extended by 20 months, from March 30, 2024 to November 30, 2025. The Project’s disbursement estimates and implementation schedule would also be adjusted accordingly to reflect this closing date extension. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Reallocation between Disbursement Categories ✔ Disbursement Estimates ✔ Implementation Schedule ✔ The World Bank Haiti COVID-19 Response (P173811) Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ MPA Program Development Objective ✔ MPA Expected Results and Indicators ✔ PBCs ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Overall Risk Rating ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) MPA PROGRAM DEVELOPMENT OBJECTIVE Current MPA Program Development Objective The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness EXPECTED MPA PROGRAM RESULTS Current Expected MPA Results and their Indicators for the MPA Program Progress towards the achievement of the PDO would be measured by outcome indicators. Individual country-specific projects (or phases) under the MPA Program will identify relevant indicators, including among others: The World Bank Haiti COVID-19 Response (P173811) • Country has activated their public health Emergency Operations Centre or a coordination mechanism for COVID-19; • Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents; • Number of acute healthcare facilities with isolation capacity; • Number of suspected cases of COVID-19 reported and investigated per approved protocol; • Number of diagnosed cases treated per approved protocol; • Personal and community non-pharmaceutical interventions adopted by the country (e.g., installation of handwashing facilities, provision of supplies and behavior change campaigns, continuity of water and sanitation service provision in public facilities and households, schools closures, telework and remote meetings, reduce/cancel mass gatherings); • Policies, regulations, guidelines, or other relevant government strategic documents incorporating a multi- sectoral health approach developed/or revised and adopted; • Multi-sectoral operational mechanism for coordinated response to outbreaks by human, animal and wildlife sectors in place; • Coordinated surveillance systems in place in the animal health and public health sectors for zoonotic diseases/pathogens identified as joint priorities; and • Mechanisms for responding to infectious and potential zoonotic diseases established and functional; and • Outbreak/pandemic emergency risk communication plan and activities developed and tested OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Component 1: Emergency Component 1: Emergency 16.00 Revised 40.50 COVID-19 Response COVID-19 Response Component 2: Health System Component 2: Health System 3.00 Revised 12.00 Strengthening Strengthening Component 3: Implementation Component 3: Implementation Management and Monitoring 1.00 Revised Management and Monitoring 2.50 and Evaluation and Evaluation TOTAL 20.00 55.00 OPS_DETAILEDCHANGES_LOANCLOSING_TABLE The World Bank Haiti COVID-19 Response (P173811) LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IDA-D6010 Effective 30-Mar-2024 30-Nov-2025 30-Mar-2026 IDA-E0620 Effective 30-Mar-2024 30-Nov-2025 30-Mar-2026 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IDA-E0620-001 | Currency: XDR iLap Category Sequence No: 1 Current Expenditure Category: G W NCS CS T IOC 21,700,000.00 1,840,848.71 25,400,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: A,S,D COVID 19 Vacc Part 1.4(vi) 3,700,000.00 0.00 0.00 100.00 100.00 Total 25,400,000.00 1,840,848.71 25,400,000.00 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 0000 0.00 0.00 2020 17,460,954.00 17,460,954.00 2021 2,160,423.65 2,160,423.65 2022 0.00 0.00 2023 1,334,043.71 1,334,043.71 2024 23,000,000.00 16,000,000.00 The World Bank Haiti COVID-19 Response (P173811) 2025 11,000,000.00 18,000,000.00 . The World Bank Haiti COVID-19 Response (P173811) . Results framework COUNTRY: Haiti Haiti COVID-19 Response Project Development Objectives(s) To respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness in Haiti. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 Emergency COVID-19 Response Suspected cases of COVID-19 cases reported and investigated based on national guidelines 0.00 90.00 (Percentage) Rationale: Action: This indicator has been Revised The end target date of this indicator has been revised to reflect the new project closing date. Country has activated their public health Emergency Operations Centre or a coordination 0.00 11.00 mechanism for COVID-19 (Number) Population fully vaccinated disaggregated by sex 1.00 5.00 10.00 (Percentage) Action: This indicator has been Marked for Deletion Health System Strengthening Number of designated laboratories with 0.00 3.00 diagnostic equipment, test kits, and reagents for The World Bank Haiti COVID-19 Response (P173811) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 diseases with mandatory immediate notification per MSPP norms (Number) Health care facilities with a functional solar 5.00 8.00 powered system (Number) Action: This indicator is New PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Component 1: Emergency COVID-19 Response Individuals reached with tailored information (e.g., individuals and decision makers in different sectors — travel and 0.00 3,000,000.00 4,500,000.00 6,000,000.00 tourism, food and agriculture, healthcare workers and businesses . . .) (Number) Rationale: This indicator has been revised to take into account individuals reached with tailored information about both COVID-19 vaccines and routine Action: This indicator has been Revised immunization. Targets and dates have been revised to align with the new project closing date. Mobile units established in rural areas to strengthen the COVID-19 vaccination 0.00 12.00 22.00 campaign (Number) Action: This indicator has been Marked for Deletion The World Bank Haiti COVID-19 Response (P173811) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Actions taken in vaccine deployment and distribution based on feedback from 0.00 3.00 5.00 beneficiaries (Number) Action: This indicator has been Marked for Deletion Target areas employing female health care workers to serve women and girls 0.00 75.00 75.00 for vaccine delivery (Percentage) Action: This indicator has been Marked for Deletion Mobile Vaccination Units with a Female 0.00 75.00 75.00 Vaccinator (Percentage) Action: This indicator has been Marked for Deletion Call centers collecting citizen feedback on COVID-19 vaccination, which are 50.00 80.00 100.00 functional (Percentage) Action: This indicator is New Component 2: Health System Strengthening Specimens of diseases with mandatory immediate notification submitted for laboratory testing confirmed within WHO 35.63 60.00 100.00 standard time at reference laboratories supported by the project (Percentage) Rationale: Action: This indicator has been Revised Formulation and targets have been revised to reflect the project's new closing date The World Bank Haiti COVID-19 Response (P173811) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 Health facilities reporting essential 0.00 70.00 vaccination supplies data (Percentage) Action: This indicator is New Medical waste incinerators meeting WHO standards functional in a public health 0.00 4.00 facility (Number) Action: This indicator is New Cholera alerts and outbreaks investigated and acted on by mobile rapid response 40.00 80.00 100.00 teams within 48 hours of onset (Percentage) Action: This indicator is New IO Table SPACE The World Bank Haiti COVID-19 Response (P173811)