Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD5660 INTERNATIONAL DEVELOPMENT ASSOCIATION ACTING AS ADMINISTRATOR OF THE PANDEMIC FUND THE PALESTINIAN UMBRELLA FOR RESILIENCE SUPPORT TO THE ECONOMY MULTI DONOR TRUST FUND AND THE STATE AND PEACEBUILDING FUND PROJECT PAPER ON A PROPOSED ADDITIONAL GRANT IN THE AMOUNT OF US$45 MILLION TO THE PALESTINE LIBERATION ORGANIZATION (FOR THE BENEFIT OF THE PALESTINIAN AUTHORITY) FOR AN ADDITIONAL FINANCING TO HEALTH SYSTEM EFFICIENCY AND RESILIENCE PROJECT MAY 7, 2024 Health, Nutrition & Population Global Practice Middle East And North Africa Region This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s policy on Access to Information. CURRENCY EQUIVALENTS (Exchange Rate Effective May 1, 2024) Israeli New Currency Unit = Sheqalim (ILS) ILS 3.74 = US$1 US$ 0.27 = ILS 1 FISCAL YEAR January 1 - December 31 Regional Vice President: Ousmane Dione Country Director: Stefan W. Emblad Regional Director: Fadia M. Saadah Practice Manager: Michele Gragnaloti Task Team Leader(s): Denizhan Duran ABBREVIATIONS AND ACRONYMS AF Additional Financing AM Accountability Mechanism AS Assistance Strategy CERC Contingency Emergency Response Component DA Designated Account DFIL Disbursement and Financial Information Letter EHSO Environmental and Health and Safety Officer ESF Environmental and Social Framework ESMF Environmental and Social Management Framework E&S Environmental and social ESCP Environmental and Social Commitment Plan FAO Food and Agriculture Organization of the United Nations GBV Gender-Based Violence GHG Greenhouse Gas Emissions GM Grievance Mechanism GRS Grievance Redress Service HbA1C Hemoglobin A1c IDP Internally Displaced People IP Implementation Progress IPF Investment Project Financing ISR Implementation Status and Results Report MENA Middle East and North Africa Region MHPSS Mental Health and Psychosocial Support Services NDC Nationally Determined Contributions NGO Non-governmental Organizations OHS Occupational Health and Safety OMR Outside Medical Referral PA Palestinian Authority PDO Project Development Objective PHC Public Primary Health Care PMOH Palestinian Authority Ministry of Health PMU Project Management Unit POM Project Operations Manual PPR Pandemic Prevention, Preparedness and Response PRCS Palestine Red Crescent Society PURSE Palestinian Umbrella Resilience and Resilience Support to the Economy Multi-Donor Trust Fund SEA/SH Sexual Exploitation and Abuse, and Sexual Harassment SOP Standard Operating Procedures SPF State Peacebuilding Fund TPM Third-Party Monitoring UN United Nations UNICEF United Nations Children’s Fund UNMAS United Nations Mine Action Service UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East UXO Unexploded Ordnance VAC Violence against children WA Withdrawal Application WHO World Health Organization West Bank and Gaza Additional Financing to Health System Efficiency and Resilience Project TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ........................................ 7 II. DESCRIPTION OF ADDITIONAL FINANCING .................................................................... 16 III. KEY RISKS ..................................................................................................................... 30 IV. APPRAISAL SUMMARY .................................................................................................. 31 V. WORLD BANK GRIEVANCE REDRESS .............................................................................. 36 VI SUMMARY TABLE OF CHANGES .................................... ERROR! BOOKMARK NOT DEFINED. VII DETAILED CHANGE(S) ................................................... ERROR! BOOKMARK NOT DEFINED. VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 41 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) BASIC INFORMATION – PARENT (Health System Efficiency and Resilience Project - P180263) Country Product Line Team Leader(s) West Bank and Gaza Special Financing Denizhan Duran Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P180263 Investment Project HMNHN (9320) MNC04 (5562) Health, Nutrition & Financing Population Implementing Agency: Ministry of Health ADD_FIN_TBL1 Is this a regionally tagged project? No Bank/IFC Collaboration No Expected Approval Date Closing Date Guarantee Environmental and Social Risk Classification Expiration Date 07-Apr-2023 31-May- Substantial 2028 Financing & Implementation Modalities Parent [ ] Multiphase Programmatic Approach [MPA] [✓] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] 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) [ ] Hands-on Expanded Implementation Support (HEIS) May 6, 2024 Page 1 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Development Objective(s) To support the Palestinian Authority in improving the quality, efficiency, and resilience of public health service delivery. Ratings (from Parent ISR) RATING_DRAFT_NO Implementation Latest ISR 23-Jun-2023 08-Feb-2024 Progress towards achievement of PDO S S Overall Implementation Progress (IP) S S Overall ESS Performance S S Overall Risk S S Financial Management S S Project Management S S Procurement S S Monitoring and Evaluation S S BASIC INFORMATION – ADDITIONAL FINANCING (Additional Financing to Health System Efficiency and Resilience Project - P181529) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P181529 Additional Financing to Cost Overrun/Financing Yes Health System Efficiency Gap, Restructuring, Scale Up and Resilience Project Financing instrument Product line Approval Date Investment Project Recipient Executed 02-May-2024 Financing Activities Projected Date of Full Bank/IFC Collaboration Disbursement 16-Jun-2028 No May 6, 2024 Page 2 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Is this a regionally tagged project? No Financing & Implementation Modalities Child [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Performance-Based Conditions (PBCs) [ ] 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) [ ] Hands-on Expanded Implementation Support (HEIS) [✓] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments Grants 10.00 9.09 0.91 91 % PROJECT FINANCING DATA – ADDITIONAL FINANCING (Additional Financing to Health System Efficiency and Resilience Project - P181529) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 10.00 45.00 55.00 Total Financing 10.00 23.80 33.80 Financing Gap 0.00 21.20 21.20 DETAILS - Additional Financing NewFinEnh1 May 6, 2024 Page 3 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Non-World Bank Group Financing Trust Funds 23.80 Special Financing 23.80 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ] Yes [ ✔ ] No May 6, 2024 Page 4 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) ESStandards 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 Not Currently Relevant Biodiversity Conservation and Sustainable Management of Living Natural Not Currently Relevant Resources Indigenous Peoples/Sub-Saharan African Historically Underserved Traditional Not Currently Relevant Local Communities Cultural Heritage Not Currently Relevant Financial Intermediaries Not Currently Relevant ESStandardsNote 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). INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas PROJECT TEAM Bank Staff Name Role Specialization Unit Denizhan Duran Team Leader (ADM Senior Economist, Health HMNHN May 6, 2024 Page 5 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Responsible) Ala' Abd Minem Procurement Specialist (ADM Procurement Specialist EMNRU Mohammad Turshan Responsible) Mohammad Ali Mousa Financial Management Financial Management EMNGU Jaber Specialist (ADM Responsible) Specialist Environmental Specialist (ADM Manal M F Taha Environmental Specialist SMNEN Responsible) Social Specialist (ADM Sr. Social Development Najm-Ul-Sahr Ata-Ullah SMNSO Responsible) Specialist Ma Dessirie Kalinski Team Member Disbursement Officer WFACS Manon Yvonne Haemmerli Team Member Economist, Health HMNHN Mariam William Guirguis Team Member Operations Analyst HMNHN Mariana Margarita Montiel Counsel Sr. Counsel LEGAM Salwa G A Massad Team Member Health Specialist HMNHN Samira Ahmed Hillis Team Member Program Leader HMNDR Sayed Ramin Ziwary Team Member Economist, Health HMNHN Severin Rakic Team Member Health Specialist HMNHN Zein Azzam Ibrahim Team Member Program Assistant MNCGZ Daqqaq Zeyad Abu-Hassanein Environmental Specialist Sr. Environmental Specialist SMNEN Extended Team Name Title Organization Location May 6, 2024 Page 6 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING 1. This project paper seeks the approval of the World Bank Middle East and North Africa (MENA) Regional Vice President for a proposed Additional Financing (AF) and restructuring for the West Bank and Gaza Health System Efficiency and Resilience Project (P180263). The proposed AF of US$45 million will be financed by a US$14.8 million grant from the Pandemic Fund, a US$5 million grant from the State and Peacebuilding Fund (SPF), and a US$4 million grant from the Palestinian Umbrella for Resilience Support to the Economy Multi-Donor Trust Fund (PURSE), with a financing gap of US$21.2 million.1 The purpose of the restructuring and the AF is to respond to the changed context on the ground following the beginning of the conflict in October 2023, and to accordingly scale-up activities undertaken as part of the Parent Project to improve the quality, efficiency, and resilience of public health service delivery. The project also aims to address critical gaps in pandemic prevention, preparedness and response (PPR) such as surveillance, laboratory capacity, and human resources. The AF is processed under Condensed Procedure applying Paragraph 12 of Section III of the Bank Operations Policy “Investment Project Financing� (IPF) related to the Situations of Urgent Need of Assistance or Capacity Constraints. 2. The proposed AF responds to critical emergency and early recovery health needs in West Bank and Gaza, which have been further exacerbated by the ongoing conflict. Since October 2023, the Palestinian health system has been grappling with the impact of the conflict, with over 34,000 killed and 76,000 injured, and 1.7 million displaced (75 percent of the population).2 90 percent of the assets in the health system was damaged or destroyed since the conflict began. Only about a quarter of primary health facilities and less than a third of hospitals remain operational, leading to a halt in essential service delivery. A famine is imminent. Large-scale displacement, coupled with communicable disease outbreaks, are putting a further strain on the already weakened system. Obstructions to the entry of humanitarian aid, especially for key inputs of fuel and water, are further complicating service delivery, and the health response faces a substantial financing gap. According to work done by the World Bank, United Nations (UN), and the European Union as part of the Interim Damage Assessment published on April 2, 20243, urgent additional financing is needed to enable emergency and early recovery efforts, with humanitarian emergency and early recovery needs for Gaza for the next 9 months at US$550 million, and infrastructure and reconstruction needs estimated at another additional US$554 million. Through three components, which mobilize US$23.8 million and can absorb up to US$21.2 million as a financing gap, this proposed AF supports the emergency and early recovery phase, but not the reconstruction phase, given the limited resources. Activities across each of the components focus on ensuring the resilience of the health system in West Bank, while implementing emergency and early recovery response in Gaza, in alignment with the design principles of the parent project while reflecting the changed context. In addition to providing direct financing, the proposed AF will enable the World Bank to lead a coordinated aid response, pooling donor resources to enable emergency and early recovery response to the conflict while scaling up pandemic preparedness and health system resiliency strengthening efforts. Since the beginning of the conflict, the World 1 Pandemic Fund finances critical investments to strengthen pandemic prevention, preparedness, and response capacities at national, regional, and global levels, with a focus on low- and middle-income countries. State and Peacebuilding Fund is the World Bank’s largest multi-donor trust fund providing catalytic financing to help prevent conflict, support rapid crisis response, and build long-term resilience in situations of fragility, conflict, and violence. Palestinian Umbrella for Resilience Support to the Economy (PURSE) is a platform to harness development partners’, World Bank’s, and the Palestinian Authority’s efforts to address development challenges at a strategic level. 2 Health Cluster of Occupied Palestinian Territory 3 Gaza Interim Damage Assessment, 2024. thedocs.worldbank.org/en/doc/14e309cd34e04e40b90eb19afa7b5d15-0280012024/original/Gaza- Interim-Damage-Assessment-032924-Final.pdf May 6, 2024 Page 7 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Bank has mobilized US$10 million for emergency implementation under the Gaza Health Emergency Response Project, and reallocated US$10.2 million from existing available resources for emergency health response in Gaza and West Bank4; the proposed AF complements these efforts for both emergency and early recovery.5 3. The proposed restructuring of the project includes the following: i) revision of the Project Development Objective (PDO) to incorporate the current context and the activation of the Contingent Emergency Response Component (CERC); ii) changes to project components and costs; iii) reallocation between disbursement categories; iv) changes to disbursement arrangements; v) changes to the results framework; vi) update of the technical and economic analysis; and vii) update of the environmental and social analysis and risks. A. Parent Project Design 4. The PDO of the Parent Project is to support the Palestinian Authority (PA) in improving the quality, efficiency, and resilience of public health service delivery. The Parent Project includes the following components: Component 1 (Scaling up cost-effective public primary health care (PHC) services - US$4 million) supports increasing the availability and quality of public PHC services across the West Bank; Component 2 (Improving public hospital service delivery, US$5.3 million) supports improving public hospital capacity in both West Bank and Gaza; Component 3 (Project Implementation and Monitoring, US$0.7 million) supports the coordination, implementation, and management of project activities including the human resources and running costs of the Project Management Unit (PMU) and; Component 4 (CERC, US$0.0 million) to respond to emergencies. The Parent Project, a US$10 million grant provided by the Trust Fund of Gaza and the West Bank (TF0C0976), was approved by the World Bank Board of Executive Directors on April 7, 2023, and declared effective on June 8, 2023. The project closing date is set for May 31, 2028. B. Parent Project Implementation Status 5. The progress towards achieving the PDO and overall Implementation Progress are rated Satisfactory in the last Implementation Status and Results Report (ISR) of February 2024. The implementing agency is the Palestinian Authority Ministry of Health (PMOH), and a fully operational PMU is effectively implementing the project. The Project Operations Manual (POM) was prepared and received the World Bank’s non-objection. The Fiduciary and Environmental and Social performances are rated Satisfactory and all aspects of the Environmental and Social Framework are compliant. Following the beginning of the conflict in October 2023 and the receipt of a request by the PA Ministry of Finance and the PMOH, the CERC was activated on December 15, 2023 for the totality of the undisbursed and uncommitted funds of US$8.3 million. The following paragraphs describe Parent Project implementation status by component. 6. Component 1: Scaling up cost-effective public primary health care (initially US$4 million). Following 4 This includes US$8.3 million from the parent project and US$1.9 million from the Improving Early Childhood Development Project, as described in forthcoming sections. 5 Gaza Health Emergency Project (P503036) was approved by the Regional Vice President of the World Bank on December 2023 and became effective January 2024; it is entirely disbursed and procurement under the project is underway through WHO and UNICEF for the procurement and delivery of essential medicines and medical equipment. The reallocation of US$10.2 million includes US$1.9 million from the Improving Early Childhood Development in the West Bank and Gaza project (P168295), and US$8.3 million from the Parent Project through CERC activation, as described in section B. May 6, 2024 Page 8 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) effectiveness in June 2023, the procurement process of mammography machines was immediately launched (US$1 million), and the remaining uncommitted US$3 million was reallocated from this component to the CERC. The delivery and installation of the mammography machines are expected to be completed by May 2024, in alignment with the parent project objectives and timelines. 7. Component 2: Improving public hospital service delivery (initially US$5.3 million). While preparatory work was underway for each of the activities under this component, none of the activities were launched prior to the beginning to the conflict; therefore, the totality of the US$5.3 million was reallocated to the CERC for immediate emergency response. 8. Component 3: Project implementation and monitoring (initially US$0.7 million). The PMU was fully capacitated, with staff maintained to enable project implementation and monitoring across key roles of Health Specialist, Procurement Specialist, Financial Management Specialist, Environmental and Social Specialist, and Administrative Assistant. The recruitment of a consultant to focus on gender-based violence (GBV), sexual exploitation and abuse and sexual harassment (SEA/SH) issues is also finalized. 9. Component 4: CERC (initially US$0 million). Following CERC activation in December 2023, the following contracts were signed: i) a contract with the World Health Organization (WHO) for US$4 million for procurement of medicines and kits to manage trauma and other emergency services, as well as management of non- communicable diseases (NCD) in Gaza, for which the first items are expected to arrive in April 2024; ii) a contract with the United Nations Children’s Fund (UNICEF) for US$2.3 million for emergency procurement of vaccines in West Bank, given the stockouts emerging from the current fiscal crisis; and iii) a contract for US$2 million to support the procurement of medical equipment in West Bank with local suppliers focusing on strengthening emergency and trauma management capacity in governorates that are the most substantially impacted by the current situation, with contracts expected to be signed by end-April 2024.6 10. Given the significant unmet needs in the context of the conflict, the PA has requested additional financing to replenish the resources allocated to the CERC and to support emergency and early recovery efforts. The need for additional resources to replenish the CERC and respond to the dire situation in Gaza and the West Bank was conveyed by the PA in April 2024. The proposed AF will form part of an expanded health response for early recovery efforts which is being supported by development partners under the coordination of PMOH. Since the beginning of the conflict, the World Bank has been playing a key role in emergency response, with an additional US$10 million mobilized for the Gaza Health Emergency Project approved by the World Bank in December 2023, in addition to the aforementioned CERC activation of US$8.3 million from the Parent Project and the allocation of US$1.9 million from the Improving Early Childhood Development Project (P168295) which is supporting the procurement commodities for maternal, newborn, and child health and nutrition in Gaza. The proposed AF will build on these efforts in supporting emergency and early recovery efforts, and be informed by ongoing analytical work conducted by the World Bank on damage, loss, and needs assessments. 6As of April 2024, PMOH has signed three contracts with UN agencies financed by the World Bank: i) US$1.9 million with UNICEF for procurement of emergency maternal, newborn and child health supplies, vaccines, and nutrition commodities in Gaza, through the Improving Early Childhood Development in the West Bank and Gaza project (P168295), 85 percent of which has been shipped or delivered; ii) US$4.0 million with WHO for procurement of emergency, trauma, and non-communicable disease supplies, for which procurement process has been finalized; and iii) US$2.3 million with UNICEF for vaccine procurement in West Bank, procurement has been finalized for 10% of supplies and is ongoing for the rest. May 6, 2024 Page 9 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) C. Rationale for Additional Financing 11. As of April 22, 2024, more than 34,000 people including over 10,000 children were killed during the conflict, with over 76,000 injured, resulting in a catastrophic humanitarian situation. Since its beginning in October 2023, the conflict has resulted in an unprecedented direct and indirect health and human impact in the totality of Gaza strip. Table 1 provides an overview of the impact through both the direct impact of the conflict, through injuries requiring rehabilitative and reconstructive surgery, through malnutrition-related health conditions given the fact that 95 percent of the population is suffering from food insecurity and a famine is projected to unfold anytime until May 20247, and through a massive outbreak of communicable diseases. Indirectly, the conflict has interrupted essential service delivery for maternal, newborn and child health services, as well as those suffering from NCD and mental health conditions. Estimates suggest that even with an immediate ceasefire, there could be an additional death toll of 6,600-12,000 due to the impact of disrupted services.8 The conflict has created an unprecedented level of displacement in Gaza: more than three quarters of Gaza’s 2.2 million population are internally displaced, with more than a million in Rafah, which is having difficulty absorbing a population that has grown fivefold since the beginning of the conflict. The majority of the displaced population lives in temporary emergency or informal shelters, as well as 154 health facilities or schools operated by the United Nations Relief and Work Agency for Palestine Refugee in the Near East (UNRWA) and other non- governmental organizations (NGOs). This has resulted in the further exacerbation of the food and sanitary situation, further posing a strain on health service delivery9. There is an urgent need to scale up emergency and early recovery delivery of essential health services. Table 1: Direct and indirect health impact of the conflict in Gaza10 Direct impact on health service delivery Fatalities 34,049 Injuries 76,901; over 80% estimated to require reconstructive surgery Number of people facing acute food security 2,130,000 Phase 5 (catastrophic) 677,000 Phase 4 (emergency) 876,000 Phase 3 (crisis) 578,000 Phase 2 (stressed) 96,327 Number of people suffering from mental health conditions 485,000 Communicable disease outbreaks Acute jaundice 43,200 7 Palestine Food Security Cluster, Acute Food Insecurity Situation, 15 February-15 March 8 Zeina Jamaluddine, Zhixi Chen, Hanan Abukmail, Sarah Aly, Shatha Elnakib, Gregory Barnsley et al. (2024). Crisis in Gaza: Scenario-based health impact projections. Report One: 7 February to 6 August 2024. London, Baltimore: London School of Hygiene and Tropical Medicine, Johns Hopkins University. The higher end is based on assumptions of infectious disease epidemics. 9 Resilience Amidst Chaos: 100 Days of UNRWA Health Response to the Humanitarian Crisis in the Gaza Strip - January 2024 10 Last updated: 22 April 2024. Sources: Health Cluster of Occupied Palestinian Territory; Palestine Food Security Cluster, Acute Food Insecurity Situation, 15 February-15 March. Data is based on reporting and surveillance systems from UNRWA and other partners and can be underreported due to interruptions in data collection. May 6, 2024 Page 10 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Acute respiratory infections 673,900 Bloody diarrhea 6,700 Diarrhea 359,400 Meningitis 287 Skin diseases 100,600 Indirect impact on health service delivery Number of internally displaced people 1,700,000 Number of pregnant women 52,000 Number of monthly babies born 5,500 Number of premature infants on incubators 130 Patients in kidney dialysis 1,100 Patients living with diabetes 71,000 Patients living with hypertension 225,000 Patients living with cancer 2,000 Patients living with cardiovascular diseases 45,000 12. The conflict has resulted in the dismantlement of the Gazan health system, with attacks disrupting delivery of essential health services, and an estimate of over US$550 million to rebuild the damaged infrastructure. Prior to the beginning of the conflict, Gaza’s health system was already suffering from resource constraints, shortages of health workers and essential medicines, as well as the limited availability of key chronic disease management services; driven by the near-blockade in Gaza.11 Since the beginning of the conflict, ongoing destructions and incursions into health facilities, as well as military operations in the vicinity of facilities have resulted in the dismantlement of the health system in Gaza. As of April 22, 2024, there have been 435 incidents in Gaza that WHO refers to as attacks on health care12, resulting in 722 people killed and 924 injured. 490 health workers have been killed since the beginning of the conflict. 99 health facilities and 104 ambulances destroyed or damaged; 25 hospitals, 16 UNRWA clinics, and 44 Ministry of Health primary health centers are not functioning.13 The conflict has negatively impacted the availability of safe spaces for women and girls surviving GBV, while referral mechanisms and service providers for survivors are severely strained and lack capacity and support. Ongoing destructions combined with lack of fuel and essential inputs have dismantled the Gazan health system: as of April 22, 2024, only 39 percent of hospitals and 30 percent of primary health facilities are partially or completely functioning.14 According to work done by the World Bank and UN agencies as part of the Interim Damage Assessment15, 29 of the 38 hospitals and 42 of the 52 public primary health centers have been partially damaged or completely destroyed, resulting in reconstruction needs of US$554 million of pure infrastructure (Table 2). This figure is likely an underestimate given the continued conflict, as well as the uncertainty surrounding the extent of damage to medical equipment and specialized services in hospitals, which can further drive up the costs on infrastructure; it is important to note that the data also excludes economic and social losses 11 World Bank, 2024 (forthcoming). Public Health Expenditure Review for West Bank and Gaza: Health Chapter. 12 Health attacks, or attacks on health care, are defined by WHO as “any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access and delivery of curative and/or preventive health services during emergencies.� 13 World Health Organization, March 2024. Impact of health attacks in the Gaza strip https://www.emro.who.int/images/stories/Impact_of_health_attacks_in_the_Gaza_Strip_12_Mar.pdf?ua=1 14 Health Cluster of Occupied Palestinian Territory 15 Gaza Interim Damage Assessment, 2024. thedocs.worldbank.org/en/doc/14e309cd34e04e40b90eb19afa7b5d15-0280012024/original/Gaza- Interim-Damage-Assessment-032924-Final.pdf May 6, 2024 Page 11 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) from the conflict as well as the needs and costs associated with the restoration of service delivery and recovery and reconstruction. Destruction and damage of hospitals has impacted the delivery of specialized services and reconstructive and rehabilitative surgery, highlighting the need for rapid interim solutions for scaling up acute and chronic case management. Despite the mobilization of resources and humanitarian response, the lack of fuel, limited specialty human resources, shortages of essential medicines and medical equipment, and limited access to clean water and sanitation services continue to remain as bottlenecks to facility-based health service delivery. Referrals out of Gaza for emergency procedures have been severely constrained.16 Table 2: Financial estimations of damage to health infrastructure in Gaza17 Asset Types Baseline Partially Damaged Completely destroyed Total Cost $222,532,827 Hospitals 38 10 19 Non-public health centers/practices 188 88 63 $193,901,719 Public primary health centers 56 16 26 $63,975,720 UNRWA health centers 22 4 16 $34,752,243 Laboratories 1 0 1 $98,728 Dentist 62 31 23 $3,494,970 Maternity Services 10 3 5 $12,242,267 Optician 12 5 6 $789,824 Pharmacy 383 189 146 $21,878,116 Total infrastructure damage $553,666,414 13. Service delivery is primarily taking place through field hospitals or primary care delivery points operated by UN agencies or NGOs. As a result of the collapse of the health care system, three field hospitals have been deployed, and service delivery for primary health services is taking place through 185 delivery points, most of which are operated by UNRWA, Palestinian Medical Relief Society, Juzoor, and Palestinian Red Crescent Society. Over 55 local and international NGOs, such as MedGlobal and MSF, also provide specialized services through temporary delivery points. In addition to shelter delivery points, mobile units in Gaza also deliver services, especially for immunization and chronic conditions; however, gaps remain in terms of coverage due to funding and security constraints. Despite these difficult circumstances, over 20,000 medical consultations a day are provided across 185 delivery points. Given the scale of destruction and dismantlement of the fixed health system, it is likely that UN agencies and NGOs will continue to deliver services in Gaza for the foreseeable future. Needs assessment and service delivery arrangements are coordinated closely by the Health Cluster. 14. The conflict has resulted in a substantially increased prevalence of mental health disorders in West Bank and Gaza. Due to protracted violence including the current conflict, the West Bank and Gaza has one of the highest levels of mental health burden in the MENA region. With over 1.7 million displaced people seeking shelter in Rafah, the lack of privacy, with multiple families sharing accommodations in the host communities and 16 According to WHO, as of April 2024, almost 10,000 cases requested evacuation from Gaza, with only 50 percent approved and evacuated. 36 percent of these cases were due to war injuries, 32 percent to cancer, 27 percent for other severe diseases, and 5 percent for kidney disease requiring dialysis. 17 Source: Gaza Interim Damage Assessment, 2024. thedocs.worldbank.org/en/doc/14e309cd34e04e40b90eb19afa7b5d15- 0280012024/original/Gaza-Interim-Damage-Assessment-032924-Final.pdf Assumptions based on reconstruction cost of a hospital at US$10 million including medical equipment and the reconstruction cost of a primary health center at US$2 million including medical equipment. These assumptions will be further validated and discussed in the process of the ongoing damage, needs, and loss assessment process. May 6, 2024 Page 12 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) overcrowded , has left women and girls vulnerable to gender-based violence, harassment, and abuse.18 Some 543,000 children were already in need of mental health and psychosocial support (MHPSS) services, and two- thirds of the population were showing signs of psychological distress.19 Neurotic disorders, mood disorders, and schizophrenia were among the most prevalent mental health disorders in West Bank.20 Symptoms of depression and post-traumatic stress disorder are more frequent in Gaza than in West Bank.21 The impact of worsening mental health during the current conflict is most apparent among Palestinian children. Over 17,000 children in Gaza are now unaccompanied and more than a million children require ongoing MHPSS for conflict-related trauma.22 A growing number of children who have been separated from their families and are particularly vulnerable to various forms of GBV, including exploitation and abuse, are also in need of specialized mental health and psychosocial support.23 Given the destruction and damage faced by the health system, family and mental health services are delivered at a mix of facilities and service delivery points in Gaza, including additional 71 UNRWA delivery points (almost all at shelters), 25 delivery points run by NGOs and 20 public delivery points, with a high volume of services delivered since the beginning of the conflict.24 Scaling up of the MHPSS services in Gaza requires mobilization and training of additional providers of outreach services and provision of medical and non-medical inputs for service delivery in health facilities and shelters. Conflict in Gaza, settlers’ violence, raids, and restrictions on movements are taking a toll on mental health in the West Bank. Though the mental health services in West Bank continue to be provided by 16 specialized psychiatric and community health clinics in collaboration with NGOs, insufficient funding reduces availability of services and psychotropic drugs. 15. With over 75,000 injuries caused by explosive weapons in Gaza, there is an urgent need for large-scale surgical capacity to conduct rehabilitative surgery. This is essential to avoid functional limitations and permanent disability in patients. Most cases require multiple operations including limb reconstruction, plastic surgery, and long-term physical therapy. However, due to insufficient medical supplies and surgical infrastructure because of destruction, as well as shortages of highly skilled expertise, most injured individuals, including children, are undergoing amputation without anesthesia. Moreover, the majority of amputees still have open wounds, untreated burns, fractures, and shrapnel due to difficulties accessing care during ongoing conflicts. The lack of resources and disruption of services severely limits the ability to provide the complex and specialized rehabilitative procedures that are desperately needed. Improving surgical capacity through training, medical supplies and equipment, as well as restoration of the healthcare infrastructure to perform surgical procedures, are high priority interventions for the early recovery phase. 16. The health system in West Bank is also under threat, with increased violence and severely reduced access to health services. Since the beginning of the conflict, 469 Palestinians have been killed and 4,800 have been injured across the West Bank and east Jerusalem.25 412 incidents in the West Bank – including obstruction of access, use of force, and militarized searches, have been recorded since the beginning of the conflict. These incidents, referred to by WHO as attacks on health care, have impacted 275 ambulances, 48 health facilities, and 18 UNFPA Palestine Situation Report #6 – 1 March 2024 19 Mental Health and Psychosocial Support Technical Working Group Advocacy Statement, November 23, 2023. 20 Ministry of Health (2023) Health Annual Report: Palestine 2022. PHIC. 21 https://documents1.worldbank.org/curated/en/099153502102330181/pdf/P17925303fca130e30936d016a378b6a1e9.pdf 22 https://www.juzoor.org/cached_uploads/download/2024/03/12/03-2024-a-war-on-health-gaza-juzoor-report-1710245501.pdf 23 WHO situational report, February 2024 24 Since the onset of the conflict, it is estimated that 570,000 IDPs, including over 300,000 children, have benefited from a total of 150,407 PSS sessions/activities. During the period 18-25 March, 21,768 IDPs, including 13,946 children, benefited from these services. https://www.unrwa.org/resources/reports/unrwa-situation-report-98-situation-gaza-strip-and-west-bank-including-east- Jerusalem?__cf_chl_rt_tk=mUhWThglc1YyQYAok_b06ZPj.Gpfl3jNPRiW2kjE4UM-1712248683-0.0.1.1-1749 25 Health Cluster of Occupied Palestinian Territory May 6, 2024 Page 13 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) 16 mobile clinics impacted, causing substantial disruptions to essential health service delivery.26 With persistent and increased incidences of confrontations in the West Bank, there is an increased need for trauma and emergency services. GBV, including physical and sexual violence, remains a daily threat to women and girls, constituting targeted assaults on their rights, identity, and dignity. Rising hostilities are creating operational challenges as patients experience difficulties in accessing health service points. Insecurity, movement restrictions, and disruptions to health care services (attacks on health care) limit access to sexual and reproductive health services and NCD services in the West Bank and distribution of medicines and supplies. Outside medical referrals (OMR) from the West Bank are severely impacted due to the Israeli Authorities closing all crossings from the West Bank into Israel, as well as ad-hoc closures between governorates and cities within the West Bank, necessitating the acceleration of investments for public hospitals within West Bank to ensure service continuity.27 In order to ensure service delivery despite obstructions to care, there are 172 mobile clinics operated by the Health Cluster in West Bank, supported by 33 partners; there is a need to scale up coverage and ensure continued financial support for these clinics for continuous service delivery. 17. Despite efforts to mobilize funding and provide medical supplies since the conflict began, substantial needs remain, in particular given the constrained macroeconomic environment. Humanitarian response has been slowed down substantially by Israeli movement restrictions into the entry of trucks, a lengthy pre-approval process with bans on various items, imminent threat of conflict in the south of Gaza (Rafah) making distributions and humanitarian missions dangerous, as well as ongoing escalations of violence in the north of Gaza. The estimated need of 500 trucks daily to enter Gaza with humanitarian supplies has not been reached since the beginning of the conflict, with 161 trucks daily on average entering Gaza in March 2024.28 US$101 million for health response has been mobilized in Gaza since the beginning of the conflict.29 US$53 million of drugs, medical supplies, and medical equipment have already arrived into Gaza, with another US$10 million arrived to the border, and US$13.1 million in the pipeline. This includes average weekly supplies for over 200,000 people in need, with as much as 440,000 people reached weekly.30 As of end-March 2024, Health Cluster estimates an additional US$549 million is needed to deliver services to 2.2 million people in need in Gaza through the end of 2024: the highest needs are for delivering trauma and emergency care services (US$189 million), health system strengthening including minor civil works to ensure service delivery but excluding reconstruction (US$81 million), delivering primary health services (US$80 million); and treatment/surveillance for communicable disease outbreaks (US$77 million).31 The economy in Gaza contracted by 86 percent and the economy in West Bank contracted by 22 percent in the last quarter of 2023 on top of an already constrained scenario, demonstrating 26 https://www.emro.who.int/images/stories/Impact_of_health_attacks_in_the_WestBank_12_Mar.pdf?ua=1; 27 Outside medical referrals (OMR) are referrals from public hospitals in Gaza and West Bank to private and non-governmental organization (NGO) hospitals in Gaza, West Bank, east Jerusalem, and Israel. These referrals are associated with access barriers for patients, given lengthy permit processes, and a significant financial burden for the Palestinian Authority, as OMR cost higher than service delivery in public hospitals, and there is substantial room for additional cost controls. More information: “Racing Against Time: World Bank Economic Monitoring Report to the Ad Hoc Liaison Committee (English). Washington, D.C. : World Bank Group. http://documents.worldbank.org/curated/en/099638209132320721/IDU0e8b2e87e098b004a7a09dcb07634eb9548f4� 28 18,542 trucks have entered Gaza as of April 1, 2024; daily trucks range from a minimum of 8 to a maximum of 300 which entered during the ceasefire in November; UNRWA dashboard. Challenges with humanitarian response are described in weekly UN OCHA reports; https://www.ochaopt.org/content/humanitarian-needs-and-response-update-19-25-march-2024 & UNRWA reports https://www.unrwa.org/resources/reports/unrwa-situation-report-98-situation-gaza-strip-and-west-bank-including-east-Jerusalem 29 https://app.powerbi.com/view?r=eyJrIjoiZDA2NmZiNDYtNDA1Ni00Nzg4LWFkNDItNDI3YmM3ZjMyYjA4IiwidCI6IjBmOWUzNWRiLTU0NGYtNGY2 MC1iZGNjLTVlYTQxNmU2ZGM3MCIsImMiOjh9 30 Health Cluster of Occupied Palestinian Territory - Dashboard 31 Gaza Health Cluster bi-weekly partners update, 20 March 2024. Subsequent investment needs include maternal, newborn, and child health (US$61 million), non-communicable diseases (US$27 million), mental health and psychosocial support (US$10 million), emergency preparedness (US$10 million), multi-disciplinary rehabilitation (US$7.4 million), and child health (US$7 million). May 6, 2024 Page 14 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) the substantial impact of the conflict and the impossibility of raising public expenditures on health in the short- or even medium run.32 18. Beyond the need for emergency response and recovery from the current conflict, pandemic preparedness continues to be a top priority of the Palestinian health sector. The COVID-19 pandemic has imposed a protracted shock to the health system, with high morbidity and low vaccination rates, and it has revealed several gaps in the Palestinian health’s system’s ability to prevent, prepare for, and respond to health shocks, including those related to climate changes. During the COVID-19 pandemic, the response was severely hindered by the inability to procure enough personal protective equipment and other essential supplies. Although there are national guidelines for surveillance, they are only implemented at the national and district levels, not at the community level, and have not been updated. While the guidelines for indicator-based surveillance are implemented, there is a lack of standard operating procedures and guidelines for event-based surveillance systems. Moreover, electronic surveillance and reporting is not functional across all levels of surveillance. The risk of disease threats combined with health vulnerabilities put the population at high risk of epidemics and consequent morbidity and mortality. A Pandemic Preparedness and Health System Resilience Assessment, conducted in 2022, resulted in the identification of the following priority areas for PPR strengthening: (i) development of strategies to support allocations for public health and preparedness to assure continuous service provision in case of future pandemics; (ii) development of policies and strategies for emergency preparedness including One Health approaches33; (iii) strengthening institutional capacity with staff training on health protection and emergency response, as well as expanded epidemiological surveillance capacity; (iv) development of communication protocols tested before emergencies; (v) strengthening health information systems and early warning systems; and (vi) conducting simulation exercises and forecasting scenarios for a variety of hazards (e.g., climate event, conflict, refugee crisis, biohazard, political crisis, and financial crisis) to inform decision-making. Pandemic preparedness and infectious disease prevention is of particular concern in Gaza, where over 600,000 cases of infectious disease have been identified since October 2023, and outbreak risks continue to be a concern. 19. Following the Pandemic Fund’s first call for proposal, the PMOH has successfully obtained approval for funds of US$20 million. The Pandemic Fund provides a dedicated stream of additional, long-term funding for critical pandemic PPR functions. The overall objectives of the approved project are to (i) strengthen preparedness and response to future health emergencies and pandemics, in accordance with the One Health approach, and (ii) enhance the availability of resources for PPR in West Bank and Gaza. The funding will be channeled through four implementing entities: (i) World Bank will receive US$15.5 million; US$14.8 million of which is planned to be executed by the PMOH, (ii) Food and Agriculture Organization of the United Nations (FAO) will receive US$3.0 million, (iii) World Health Organization will receive US$1.0 million, and (iv) UNICEF will receive US$0.5 million. Activities by each of the implementing agency will be implemented in complementarity. Following the approval received in July 2023 by the Pandemic Fund and the finalization of administrative processes by the Fund Secretariat in December 2023, the World Bank task team has submitted a request for reallocation of activities in 32 World Bank Economic Monitoring Report: https://thedocs.worldbank.org/en/doc/db985000fa4b7237616dbca501d674dc- 0280012024/original/PalestinianEconomicNote-Feb2024-Final.pdf 33 One Health is a collaborative approach that aims to balance and optimize the health of people, animals, and ecosystems. It recognizes that these groups are closely linked and interdependent. One Health works across sectors and disciplines to help with protecting health; addressing health challenges such as infectious diseases, antimicrobial resistance, and food safety; and promoting the health and integrity of ecosystems. https://www.who.int/health-topics/one-health May 6, 2024 Page 15 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Gaza to reflect the current context, which was approved in February 2024. 20. The proposed AF is aligned with the West Bank and Gaza Assistance Strategy (AS) for FY22-25 (Report No. 156451-GZ) and the World Bank Group’s enlarged MENA Regional Strategy (March 2019). The AF directly contributes to the first focus area of the AS on achieving better human development outcomes by focusing on prioritizing investments in health to promote human capital, particularly in a fragility, conflict and violence context and on achieving better human development outcomes and strengthening resilience across the health system34. It is also aligned with the World Bank Group enlarged MENA Regional Strategy which emphasizes human capital development as well as the World Bank Group Goals to end extreme poverty and promote shared prosperity. 21. The AF is also aligned with the Strategy for Fragility, Conflict, and Violence (2020-2025),35 particularly Pillar II which emphasizes “Remaining engaged during conflicts and crisis situations� to build resilience, protect essential health sector institutions, and deliver critical health services. It also helps ensure the provision of essential health services, and, thus, preserves human capital gains. 22. The project is aligned with the goals of the Paris Agreement on both mitigation and adaptation. The AF underwent “disaster and climate risk screening� to identify potential risks. While climate exposures risks are considered high due to droughts and extreme temperatures, the impact on project activities is considered low due to the short-term nature of activities and alignment with the West Bank and Gaza Nationally Determined Contributions (NDCs).36 The project activities will not result in an increase in greenhouse gas (GHG) emissions levels or create any persistent barriers to transition to low GHG emissions over existing levels. From a mitigation perspective, these activities are considered Universally Aligned as they are human health activities (UAL#37) or temporary and timebound activities associated with emergency preparedness and immediate response in the aftermath of a crisis or disaster (UAL #40). By improving the resilience of the West Bank and Gaza health systems, this project will ensure that the health system can adapt to the adverse impacts of climate change. This is all in line with the Paris Agreement’s objective of enhancing adaptive capacity, as it recognizes the importance of ensuring access to healthcare services for vulnerable populations in the face of climate-related challenges. II. DESCRIPTION OF ADDITIONAL FINANCING A. Scope 23. In response to the humanitarian emergency in Gaza and the continued need to strengthen the resilience of the health system in West Bank, the proposed AF and restructuring will mobilize urgent financing for priority 34 https://documents1.worldbank.org/curated/en/627701619710823261/pdf/West-Bank-and-Gaza-Country-Assistance-Strategy-for-the-Period- FY22-25.pdf 35 World Bank. 2020. World Bank Group Strategy for Fragility, Conflict, and Violence 2020 –2025. http://documents.worldbank.org/curated/en/844591582815510521/World-Bank-Group-Strategy-for-Fragility-Conflict-and-Violence-2020- 2025. Washington, DC: World Bank. 36 http://www.palestinecabinet.gov.ps/WebSite/Upload/Documents/%D8%A7%D9%84%D8%A7%D8%B3%D8%AA%D8%B1%D8%A7%D8%AA%D9 %8A%D8%AC%D9%8A%D8%A9%20%D8%A7%D9%84%D9%82%D8%B7%D8%A7%D8%B9%D9%8A%D8%A9%20%D9%84%D9%84%D8%B5%D8% AD%D8%A9%202021-2023.pdf May 6, 2024 Page 16 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) emergency and early recovery activities, while maintaining the principles and the initial component design of the Parent Project. The Parent Project was designed at a point where catalytic investments were needed across Gaza and West Bank to improve access to high quality care, efficiency of health services, and resilience of service delivery. Investments within the scope of the Parent Project were selected to reduce the reliance on costly OMR which posits access and financing barriers, and instead to strengthen integration of services for NCDs through a patient-centered approach; to improve technical efficiency of hospital services through provision of effective, lower-cost services at public hospitals; and to improve the capacity of service delivery at all levels given the health system’s vulnerability to shocks. Given the eruption of the conflict four months into the effectiveness of the project, almost none of the initially planned activities have been implemented, with the CERC activation and subsequent changes described in section I-B implying most of the funds planned for initially designed activities were allocated to emergency response. Through three recipient-executed trust fund grants, the proposed AF will therefore a) finance the scale up of project activities across the first two components to support emergency and early recovery efforts to ensure the continuity of health service delivery, with required changes to sub- components design based on the context; and b) introduce a new component to strengthen the quality, efficiency, and resiliency of public health and PPR services. Original project design is therefore retained at the component level, with the first component continuing to support cost-effective primary health care services, and the second component focusing on public hospital service delivery; as described in the subsequent paragraphs, sub-component design and activities are modified to respond to the current crisis. 24. This AF and restructuring also provide a platform for scalable and continued emergency response and early recovery of the health system across three principles, with financing gaps for various components. As described in section I-C, current estimates of health sector needs for emergency response, early recovery, and reconstruction exceed US$1 billion, a figure which will continue to increase up to and following a ceasefire and is substantially above the available funding portfolio. Regardless of the available financing, the scope of activities to strengthen the health system remains the same, with activities to strengthen service delivery in PHC and hospital levels, and to strengthen public health and disease surveillance capacities. Therefore, this restructuring adds a financing gap for priority activities where investments can be scaled up immediately and for which there is absorptive capacity within this project. This provides agility for the project to rapidly absorb and scale up funds for the designed activities, and enables the development of a mechanism, through the PMOH, to coordinate and strengthen emergency and early recovery investments across different financing sources. The scope of activities within each component and sub-component would be determined based on three principles: i) strengthening the Palestinian health system in a phased and coordinated approach in alignment with pre-conflict health system priorities; ii) scalability in terms of number of beneficiaries and health facilities that can be reached; and iii) providing a flexible platform for a range of implementing modalities through the PMOH, including contracting of UN agencies and NGOs as pertinent, particularly during the period of the recovery of the health system in Gaza. Acknowledging the different context driven by a complete dismantlement of the health system in Gaza and the need to improve the resilience of the health system in West Bank, the project will finance investments across both areas, with investments within each territory determined by the same principles, and investments across the two determined by timing of fund availability and any requirements associated with the funding. The amount of the financing gap for this additional financing has been determined as a function of external resources that can be mobilized and absorbed by the Project in the short-term. Discussions are underway with a range of bilateral and multilateral development partners to close the financing gap around specific activities and contributions that are of pertinence. If the total $45m is not received during the span of the project, the project would be restructured to reflect the actual funding received. May 6, 2024 Page 17 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) 25. Beyond the activities and the financing gap in this project, substantial needs remain for the recovery and reconstruction of the Palestinian health system, necessitating further resources and a long-term approach. Regardless of the conflict’s trajectory, the health system will need sustained investments for the years to come, transitioning from emergency response to recovery, reconstruction, and ultimately resilience. Given the current level of funds and the uncertainty associated with future phases of the conflict, this proposed AF only includes interventions – through the secured financing as well as the financing gap – for emergency and early recovery efforts to ensure continuity of essential health services. Effective delivery of emergency and early recovery interventions financed through this project will ensure a strong foundation for reconstruction and resilience efforts. Across these four phases, there will be four different categories of interventions, some of which are financed by this project, but for others additional resources would be needed: i) ensuring continuity for delivery of essential health services, with a priority on primary health and public health services, through medical equipment, drugs and other medical supplies, mobile/temporary units, financing of service delivery at non- governmental organizations and community providers during the transition period, evacuation of patients as needed, and minor civil works; ii) strengthening human resources for health, through scaling up both in-service and pre-service training of health workers, provision of psychosocial support for health workers, and arrangements for bringing in health workers from outside; iii) reconstruction of the health infrastructure in Gaza through a prioritized and phased approach, with a focus on building capabilities in particular for emergency, trauma, and NCD management as well as key specialty areas for which there exist access challenges; and iv) governance and sustainable health financing, through strengthening institutions for planning and decision- making, as well as defining a roadmap for a transition towards a sustainable financing of the Palestinian health system. 26. Given these changes, the original PDO will be modified to reflect the context. The PDO will change to reflect the ability to respond promptly and effectively to eligible crisis and emergencies, following the activation of the CERC in the Parent Project. The revised PDO will read “to support the Palestinian Authority (PA) in improving the resilience and efficiency of the health system, and in case of an Eligible Crisis or Emergency, respond promptly and effectively to it.� May 6, 2024 Page 18 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) B. Project Components and Proposed Changes under the AF/Restructuring 27. The US$45 million AF has been designed and appraised for the full US$45 million, including results that match the allocated amount. The component design outlines activities that will be implemented within the US$45 million funding envelope, with US$23.8 million already confirmed as well as additional activities to be financed by an additional resource mobilization of US$21.2 million. These additional funds are expected to be filled from subsequent World Bank and donor funding. With the full US$45 million designed and appraised, the process of incorporating additional funds as more financing becomes available will be significantly simplified, as no changes to the original design are required. Any further change in project scope or increase of financing beyond US$45 million will entail a separate AF processing and restructuring. In the event that anticipated resources falls short, the project will undergo restructuring to realign indicator targets accordingly. The four components of the project cover both emergency and early recovery activities in Gaza and West Bank. Emergency activities in Gaza can be implemented immediately; as indicated in section C, a range of essential humanitarian interventions are already being delivered in Gaza despite the very difficult conditions. Many early recovery activities in Gaza, such as those that would be financed by the Pandemic Fund, would be implemented following a durable ceasefire. All activities in West Bank seek to further strengthen the resilience of the health system and can be implemented immediately. Activities within each component would be selected based implementation of May 6, 2024 Page 19 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) needs assessments, rapid surveys, use of remote data as feasible, and ongoing engagement with third-party monitoring (TPM) agencies. The focus of each component, including financing sources and gaps, are described below, with further details on activities for subcomponents described in Annex 1. 28. Component 1: Scaling up cost-effective primary health services (original cost US$4M; post-CERC cost US$1M; additional financing of US$16.8M with a US$10M financing gap). Aligned with Parent Project design, this component will continue to finance catalytic investments to improve the availability and quality of cost- effective primary health services. To reach this objective, the Parent Project design included planned investments to procure medical equipment, such as digital mammography machines and hemoglobin A1c (HbA1C) analyzers (subcomponent 1.1, delivery of NCD prevention and control services through public primary health centers), strengthening health information systems, as well as scaling up the family health model (subcomponent 1.2, strengthening information systems and quality of PHC). The procurement of digital mammography machines is already underway, and the procurement of HbA1c analyzers will not proceed as it was completed with other financing resources. While the exact scope of activities to strengthen health information systems at the primary care level is not yet determined due to changes in government strategy and investments by other partners, the project is expected to retain the scope on this domain. This component will support restoration of the PHC network to address essential healthcare needs of the population. The following paragraphs describe the scope of the restructuring and additional financing for both sub-components under this component. 29. Subcomponent 1.1 Delivery of essential primary health services at public PHC (original cost US$2.2M; post-CERC cost US$1M; additional financing of US$7M with a US$5M financing gap). This sub-component will finance medical equipment investments, essential and complementary medicines, any minor civil works, temporary PHC such as mobile units, as well as costs associated with human resources for health, health information systems, and any other investments required to deliver essential services at public PHC. This expansion of scope is due to the extensive damage and disruption to the PHC services in Gaza and the West Bank. 30. The scalable activities within this subcomponent will be financed by a US$2 million contribution through PURSE which will finance strengthening the primary health care system in the West Bank, and a US$5 million financing gap is included to scale up the aforementioned activities particularly in Gaza. 31. Subcomponent 1.2: Strengthening mental and family health services (original cost US$0M; post-CERC cost US$0M; additional financing of US$9.9M with a US$5M financing gap). Given the substantial impact of the conflict on the destruction of the public primary health infrastructure in Gaza and increased obstructions of access to public facilities in West Bank, investing only in public PHC is insufficient. This is particularly important for MHPSS services: due to the high burden, a facility-based delivery system is insufficient. There is an urgent need to scale up MHPSS across both Gaza and West Bank, where many services are offered by NGOs and often in a fragmented way. Engaging community and non-governmental organizations will enable the delivery of health services for the whole family in an integrated way, with a focus on the delivery of a package focusing on prevention as well as treatment (named “family health�), integrated with MHPSS. Ensuring that service providers are equipped to provide safe, effective, and survivor-centered MHPSS to women, girls, and children who have experienced GBV will be critical in both cases of self- disclosure and where needs are acute. This subcomponent is newly added to support service delivery continuity by ensuring effective delivery of mental and family health services at the community-level and at non-public health facilities such as those operated by NGOs or temporary service delivery points, primarily to internally displaced persons (IDPs). This will take place through the PMOH May 6, 2024 Page 20 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) contracting UN agencies and/or NGOs with a focus on training for MHPSS service providers, provision of community-level integrated outreach MHPSS and family health services, and strengthening of integrated MHPSS and family health service delivery for IDPs. 37 32. The scalable activities within this subcomponent will be financed by US$4.9 million two-year grant from the SPF, which will finance the delivery of family and mental health services at the community level in Gaza. This financing will contribute to the timely and effective response to crises while strengthening resilience of health system. A US$5 million financing gap is included to scale up the aforementioned activities, particularly in West Bank. 33. Component 2: Strengthening hospital service delivery (original cost US$5.3M; post-CERC cost US$0M; additional financing of US$13.2M with a US$11.2M financing gap). In continued alignment with the Parent Project’s design, investments under this component will continue to strengthen the delivery of lifesaving and cost-effective priority hospital services. Priority investment domains for hospitals will continue to be determined by the criteria outlined in the parent project, which are: geographic access, potential to reduce OMR costs, and availability of operating capacity within the hospitals (physical and human resources). 38 Based on this criteria, the Parent Project included investments to launch radiotherapy for cancer treatment in Gaza; for scaled up cancer diagnostic capacity, maternal and newborn care in West Bank; and for interventions to strengthen the management and quality of care in hospitals. None of these activities were launched prior to the beginning of the conflict in October 2023, and the available resources were reallocated to the procurement of emergency medical equipment in Gaza and West Bank. The design of this component in the Parent Project will be largely maintained, with investments replenishing the financing which was allocated to the CERC ; however, various changes will be made to expand the scope of activities in light of the current context. While investments based on the Parent Project criteria to increase access and reduce the reliance on OMR are still pertinent for Gaza (such as radiotherapy), the current funding envelope necessitates prioritizing emergency and priority investments to reconstruct the health system following its dismantlement. The following paragraphs describe the scope of the AF and restructuring for both sub-components under this component. 34. Subcomponent 2.1 Delivery of essential services at public hospitals (original cost US$4.8M; post-CERC cost US$0M; additional financing of US$4.7M with a US$3.7M financing gap). This subcomponent will support the purchase of drugs, medical supplies, medical equipment, as well as support for other inputs for delivery of essential services at public hospitals. Selection of services and interventions will be based on an ongoing medical equipment and hospital capacity assessment, implemented as described under subcomponent 1.1. 35. The scalable activities within this subcomponent will be financed by a US$1 million contribution through PURSE, which will target investments in public hospitals in West Bank, and a US$3.7 million financing gap is included to scale up the aforementioned activities in both Gaza and West Bank. 36. Subcomponent 2.2 Strengthening management and quality of care in hospitals (original cost US$0.5M; post-CERC cost US$0M; additional financing of US$2.5M with a US$1.5M financing gap). While the 37Implementation and fiduciary arrangements pertaining to UN agency and NGO contracting are described under section E. 38These criteria are: (i) geographic access: given the movement restrictions and the political context, substantial infrastructure investments are needed to improve the resilience of the tertiary care system in the West Bank and Gaza; (ii) potential to reduce OMR costs: conditions which constitute the largest total and unit costs of OMR will be targeted for medical equipment and capacity strengthening investments; and (iii) availability of operating capacity May 6, 2024 Page 21 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) procurement of medical equipment is crucial for high-quality service delivery and improved access, it is insufficient on its own. The activities under the Parent Project will be retained, and this subcomponent will support targeted investments and capacity-building efforts to enhance health workforce competencies, integrate population-based cancer registries, and improve hospital management. Priority investments from this subcomponent will include hardware and software purchases, and trainings to strengthen information systems on OMR and their integration with the Bisan financial accounting system. This aims to ensure effective tracking of revenues, service billing, and system integration. Additionally, health worker training will address the critical gap in cardiovascular care, particularly in cardiac catheterization, to reduce referrals and enhance service delivery in the West Bank. Furthermore, the subcomponent will support ongoing capacity building in hospital quality improvement, cancer registration, and referrals, including targeted studies and interventions for the PMOH Services Purchasing Unit, audits, public-private partnerships, and training for the use of cancer registries. The scalable activities within this subcomponent will be financed by a US$1 million contribution through PURSE, and a US$1.5 million financing gap is included to scale up the aforementioned activities. 37. Subcomponent 2.3 Delivering rehabilitation and reconstructive surgery services (original cost US$0M; post-CERC cost US$0M; additional financing of US$6M with a US$6M financing gap). This subcomponent is newly added to address the large backlog of reconstructive surgery needs while developing sustainable local capacity for managing both chronic and acute rehabilitation cases in Gaza. First, this subcomponent will include procurement of specialized medical equipment for rehabilitation centers and surgery units at key public hospitals. Equipment will include physiotherapy devices, prosthetics and orthotics tools and materials, microsurgery sets, craniomaxillofacial surgery kits, etc. Second, it will finance relevant health workers’ training needs such as surgeons and surgical nurses, physiotherapists, prosthetists/orthotists and other specialists in advanced techniques for complex reconstructive procedures, both for initial trauma management and post- surgical rehabilitation therapies. Third, in light of the large number of patients that need to be evacuated from Gaza for trauma care, this subcomponent will support patient travel/evacuation and costs of advanced surgical procedures not available in Gaza, as well as for provision of procedures at non-governmental facilities as pertinent. Priority will be given to limb salvage/reconstruction and management of severe burn injuries. 38. While no financing is secured for this sub-component as of the processing of this proposed AF, activities are included to be scaled up as a priority following on the availability of funding. 39. Component 3: Strengthening key public health functions of pandemic prevention, preparedness, and response (PPR) (original cost US$0M; post-CERC cost US$0M; additional financing of US$14.50M with a US$0M financing gap). This component is introduced under the proposed AF to strengthen prevention, preparedness and response to future health emergencies. Beyond the current crisis, these health shocks are expected to become more prevalent due to climate change. The totality of the component will be financed through a three- year grant from the Pandemic Fund, and it will contribute towards building resiliency by increasing the resources available for the PMOH to invest in PPR actions, leveraging future financing in PPR in West Bank and Gaza, and supporting formulation of the policy commitments, data sharing, and communication in the areas of One Health and PPR. The following three subcomponents will be added to the project, all financed by the Pandemic Fund, implemented in both Gaza and West Bank, and without a financing gap39: 40. Subcomponent 3.1. Strengthening of surveillance, early warning systems and multisectoral collaboration (original cost US$0M; post-CERC cost US$0M; additional financing of US$5M with a US$0M 39 Activities will be implemented as included in the original Pandemic Fund proposal, with a 60-40% split between West Bank and Gaza. May 6, 2024 Page 22 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) financing gap). The subcomponent will address challenges with surveillance of diseases with epidemic potential in the health sector, while strengthening intersectoral collaboration in accordance with the One Health approach. The subcomponent will support: i) the purchase of medical equipment, hardware and telecommunication equipment, as well as the provision of technical assistance, and training required for the establishment of a cross- sectoral One Health platform for West Bank; ii) development of One Health strategy; development and implementation of surveillance action plans, technical guidance, and standard operating procedures (SOPs) aligned with the strategy; iii) upgrade of applications that enable electronic disease notification and cross- sectoral surveillance efforts; iv) preparation and implementation of desk review exercises for communicable disease outbreak scenarios; expansion of after/intra-action review and implementation of new approaches, such as 7-1-7 for outbreak detection, reporting and response; development of formal partnerships supporting One Health strategy implementation; and v) promotion of One Health approach through public awareness campaigns. 41. Subcomponent 3.2. Strengthening national laboratory systems (original cost US$0M; post-CERC cost US$0M; additional financing of US$5.60M with a US$0M financing gap). The subcomponent will address challenges with laboratory capacity and timely detection of suspected outbreaks, including but not limited to specimen transport vehicles, central public health laboratories’ diagnostic capacities – missing equipment, supplies, SOPs, and quality management systems, lack of national diagnostic networks, and inconsistent application of the biosafety measures. The subcomponent will support i) procurement of goods (specimen transport vehicles, laboratory equipment, hardware and telecommunication equipment, laboratory information management system, diagnostic kits, reagents, and consumables) to strengthen central laboratories in both West Bank and Gaza; ii) technical assistance and training required for the development of tier-specific cross- sectoral diagnostic testing strategy; iii) refurbishment/reconstruction of public health laboratories involved in the PPR, including related unexploaded ordnance (UXO) assessment and clearance in accordance to United Nations Mine Action Service (UNMAS) guidelines, and rubble removal in Gaza; iv) implementation of quality management systems in the central public health laboratories and antimicrobial resistance laboratories; development and implementation of SOPs and protocols, including those for sampling, samples transport and storing; v) implementation of biosafety and biosecurity measures, including those for the infectious waste disposal; and vi) (re)accreditation of the central public health laboratories. 42. Subcomponent 3.3. Improving response to health emergencies (original cost US$0M; post-CERC cost US$0M; additional financing of US$3.9M with a US$0M financing gap). The subcomponent will address challenges with vaccine access and delivery, emergency logistic, and supply chain management, including gaps in cold chain system and lack of prepositioned emergency stocks of the personal protective equipment (PPE) and other relevant supplies. It will support i) development of capacities for effective mobilization for outbreak and health emergency response; ii) purchase of consumables, equipment, training, and technical assistance required to establish and refill stocks of PPE and emergency supplies for detection, response, and treatment of communicable diseases; iii) procurement to ensure functioning of the cold chain in the vaccine stock management in collaboration with UNICEF; iv) review of the list of essential medical countermeasures for the management of high-risk emergencies; and v) development of SOPs and plans for storage, deployment, logistical and administrative support related to the prepositioned stocks. 43. Component 4: Project Implementation and Monitoring (original cost US$0.7M; post-CERC cost US$0.7M; additional financing of US$0.50M with a US$0M financing gap). This component, previously named under the Parent Project as Component 3, will continue financing necessary human resources and running costs for the PMU at the PMOH, including: (i) staffing, (ii) data collection, aggregation, and periodic reporting on the May 6, 2024 Page 23 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) project’s implementation progress; (iii) monitoring of the project’s key performance indicators; and (iv ) overall project operating costs, audit costs and monitoring and compliance with the Environmental and Social Commitment Plan (ESCP). Additionally, it would support the PMU in performing the role of the PPR Steering Committee secretariat under the Pandemic Fund’s part of additional financing, including: (i) monitoring and evaluation activities and (ii) collation of inputs from PMOH, WHO, UNICEF, and FAO into joint progress reports for the Pandemic Fund. Given the expanded scope of the project to focus on emergency response and coordination, pandemic preparedness, and mental health, additional health specialist staff would be recruited as pertinent. The component would also finance the recruitment of TPM or additional staff to oversee project implementation and contracting as needed, as described under section E. To support this expansion of scope, US$0.20M from SPF and US$0.30M from the Pandemic Fund are added to this component. 44. Component 5: Contingent Emergency Response Component (CERC) (original cost US$0M; post-CERC cost US$8.3M; additional financing of US$0M with a US$0M financing gap). The CERC, previously named under the Parent Project as Component 4, will be maintained under the AF as Component 5, to provide immediate response, as needed, to support the PA’s ability to respond effectively in the event of an emergency in line with World Bank procedures on disaster prevention and preparedness. Table 3: Summary of revised component costs and financing sources Items in italics are added with this AF; item in * are dropped Project Components Original Revised cost AF (US$, Financing Total financing cost after CERC millions), gap (US$, (US$, millions) (US$, activation including millions) (b)+(c)+(d) millions) (US$, source (d) (a) millions) (c) (b) Component 1: Scaling up cost-effective 4.00 1.00 6.80 10.00 17.80 primary health care services 1.1 Delivery of essential primary health 2.20 1.00 2.00 5.00 8.00 services at public PHC PURSE 1.2 Strengthening information systems and 1.80 0.00 0.00 0.00 0.00 quality of PHC* 1.2 Strengthening mental and family health 0.00 0.00 4.80 5.00 9.80 services SPF Component 2: Strengthening hospital service 5.30 0.00 2.00 11.20 13.20 delivery 2.1 Delivery of essential services at public 4.80 0.00 1.00 3.70 4.70 hospitals PURSE 2.2 Strengthening management and quality of 0.50 0.00 1.00 1.50 2.50 care in hospitals PURSE 2.3 Delivering rehabilitation and 0.00 0.00 0.00 6.00 6.00 reconstructive surgery services Component 3: Strengthening key public 0.00 0.00 14.5 0.00 14.50 May 6, 2024 Page 24 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) health functions of pandemic prevention, preparedness, and response (PPR) 3.1 Strengthening of surveillance, early 0.00 0.00 5.00 0.00 5.00 warning systems and multisectoral Pandemic collaboration Fund 3.2 Strengthening national laboratory systems 0.00 0.00 5.60 0.00 5.75 Pandemic Fund 3.3 Improving response to health emergencies 0.00 0.00 3.90 0.00 3.90 Pandemic Fund Component 4: Project Implementation and 0.70 0.70 0.50 0.00 1.20 Monitoring 0.30 – Pandemic Fund 0.20 - SPF Component 5: Contingent Emergency 0.00 8.30 0.00 0.00 8.30 Response Component Total Project Costs 10.00 10.00 23.80 21.20 55.00 C. Changes to the Results Framework 45. The Results Framework will be adjusted to account for scale-up of project interventions. Given the change in the activity scope, almost the totality of the results framework is modified, as indicated in Table 3, Section VII and Annex 2. The PDO-level indicator on OMR reductions will be maintained but the target will be revised downwards40, whereas the indicators on the medicines information system and diabetes control will be dropped given the change in scope, replaced instead by indicators on number of people benefiting from project interventions. For component 1, while the indicator on number of women undergoing mammography examination will be retained, other indicators will be dropped and replaced with number of people and health facilities benefiting from project-supported interventions, including for mental health. For component 2, the patient satisfaction indicator will be retained, and the indicators on cancer, cardiovascular, maternal, newborn, and child health will be dropped, replaced instead by indicators on number of people and hospitals benefiting from project-supported interventions, similar to component 1. Two intermediate indicators on the number of PHCs and hospitals receiving project investments will be used to measure CERC outcomes during its 18-month implementation period. Three new intermediate indicators are added for component 3, in line with the approved Pandemic Fund proposal. Given the scalable nature of the project and the ongoing fundraising efforts as part of the financing gap, intermediate targets are not included for indicators, and end-targets are based on the complete additional financing cost of US$45 million; if the financing gap is not closed prior to project closing date, 40 Given the destruction of the health system in Gaza, it is likely that OMR out of Gaza will increase substantially over the course of the Project following the end of hostilities. Even as the project-financed medical equipment investments would aim to reduce medical referrals from West Bank, given the reduced scope on the initially anticipated investments, as well as the broader macro-fiscal situation, the rate of reduction will likely be lower than initially anticipated within the scope of the project. Given the uncertainty around the access considerations around OMR, the new target will be ‘no change in the OMR annual average rate of growth.’ May 6, 2024 Page 25 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) a restructuring will be conducted to revise targets downward, as per the US$23.8M scenario provided in Annex 2. D. Other Changes 46. This restructuring records the activation of the CERC and the corresponding reallocation of funds among disbursement categories. The CERC activations responded to a request made by the Ministry of Finance on December 6, 2023 to reallocate US$8.3 million of the project’s undisbursed funds to address emergency needs in the West Bank and Gaza, including the procurement of essential drugs, medical supplies, and other medical and non-medical inputs to respond to the conflict which erupted on October 7, 2023. Specifically, the allocation involved: (i) US$4 million from Subcomponent 2.1 (Purchasing of medical equipment to expand hospital capacity in high-need areas) to support emergency supplies and equipment in Gaza; (ii) US$1.2 million from sub- component 1.1 (Delivery of NCD prevention and control services through public primary health care centers); (iii) US$1.8 million from Sub-component 1.2 Strengthening information systems and quality of PHC: (iv) US$0.75 million from Subcomponent 2.1 (Purchasing of medical equipment to expand hospital capacity in high-need areas); and (v) US$0.55 million from Sub-component 2.2 (Strengthening management and quality of care in hospitals) to support vacancies, emergency supplies and equipment in the West Bank. The World Bank approved the CERC Operations Manual and the Emergency Action Plan (EAP) on December 5, 2023, outlining the CERC’s implementation modalities and environmental and social implications, including the Procurement Plan. Amendments were made to the ESCP and the Stakeholders Engagement Plan (SEP) to reflect CERC activities to be implemented. The CERC activation was approved by the World Bank on December 15, 2023. 47. The CERC is Paris Aligned on both adaptation and mitigation. Paris Agreement goals were considered in the preparation of the CERC Manual. The activities under the EAP focuses on procurement of emergency medical supplies and medical equipment. These activities will be implemented under emergency circumstances, and will be temporary and timebound for 18 months. Hence, these will be universally aligned as per UA#40 - Activities associated with emergency preparedness and immediate response in the aftermath of a crisis or disaster. On adaptation, the risk from identified climate hazards to delivery of these activities is low due to the CER C’s short term nature. 48. Changes to Disbursement Categories. As a result of the AF and restructuring, the following changes will be made to the Disbursement Categories of the Grant Agreement: i. Reallocation between disbursement categories. Through the CERC activation, US$8.3 million will be reallocated from Disbursement Category 1 to cover activities related to Emergency Expenditures under Part 4 of the Project (Disbursement Category 2). ii. Inclusion of severance payment. Due to the PA’s constrained fiscal situation and pursuant to the Ministerial Council’s decree issued on April 5, 2021 stipulating that severance payments for consultants and temporary employees hired by the PA under donor-financed projects are to be financed through the respective project’s budget, the restructuring of the project will include severance payments for eligible temporary staff of the PMU. These payments are equivalent to one month’s salary for each year of service, calculated based on the last received salary as well as monetary compensation for annual leave not taken (a maximum of two years accumulated leave of up to 14 days per year). iii. Inclusion of Civil Works under Disbursement Category 1. With the AF expanded scope to finance minor May 6, 2024 Page 26 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) civil works under components 1 and 3, Disbursement Category 1 covering “Goods, non-consulting services, consulting services, training, and operating costs� will be revised to include these activities. E. Institutional and Implementation Arrangements 49. As under the Parent Project, the PMOH will continue to be the implementing agency for the AF. The existing PMU has been established previously for other projects, including the ongoing COVID-19 Emergency Project (P173800), and the Health System Resilience and Strengthening Project (P150481) closed in 2023, and its technical and implementation capacity were assessed and deemed satisfactory. As part of the HSERP, the PMU has been further capacitated with a designated Health Specialist, who provides technical support for the implementation of activities in both West Bank and Gaza, as well as ensures effective monitoring and evaluation. The POM will be updated to reflect AF activities and specify their implementation arrangements. Due to the ongoing conflict, the PMOH will work in close collaboration with UN agencies to facilitate access, conduct procurement, and deliver services in areas affected by the conflict. TPM will be utilized where it is feasible and provides additional value. TPM agency would, as needed, provide monitoring and evaluation support to the project PMU on the performance of implementation agencies contracted to carry out project activities in Gaza. TPM would report on the achievement of results, beneficiary experience, and the Environmental and Social Framework (ESF) compliance as agreed for each component of the project. TPM reports would be shared with the PMU and the World Bank. The PMU would be required to investigate and address any issues reported by the TPM. Additional expertise will be recruited for the PMU as necessary to reflect the additional scope of the project, especially on PPR and mental health, as well as contracting and monitoring procurement and financial management progress as needed. 50. Due to the destruction of the public health infrastructure in Gaza and the obstruction of access to health services in the West Bank, the PMOH will consider contracting NGOs in addition to UN agencies. This contracting could take place either through UN agencies or directly between the PMOH and NGOs. This is pertinent for family health and mental health service delivery activities in subcomponent 1.2, and the delivery of tertiary services under component 2 including for rehabilitative surgery. NGOs in Gaza have reached an average of 69,000 beneficiaries weekly since the beginning of the conflict, with interventions that are scalable with additional financing.41 Palestine Red Crescent Society (PRCS)42 and Palestinian Medical Relief Society (PMRS)43 have been at the forefront of the health humanitarian response in Gaza and providing key health services to the entire population, including in North Gaza, via dedicated outreach medical teams. Despite constraints, medical teams have been providing emergency and non-emergency services through mobile clinics in the West Bank as well as in multiple medical points in Gaza IDP shelters. They provide key emergency response operations through imbedded programs encompassing emergency medical service- pre-hospital health care, disaster risk management, psychosocial support, rehabilitation services, primary and secondary health care and community- based programming. These organizations also have been establishing partnerships and cooperation with UN agencies on the ground. In the mental health area, the Gaza Community Mental Health Program (GCMHP) 41Health Cluster of Occupied Palestinian Territory - Dashboard 42PRCS is an officially recognized independent Palestinian National Society. It enjoys legal personality and is part of the International Red Cross and Red Crescent Movement 43 PMRS was founded in 1979 by a group of Palestinian doctors and health professionals seeking to supplement the decayed and inadequate health infrastructure caused. PMRS made a significant contribution to the creation of a Palestinian national health infrastructure, replacing the fragmented health. PMRS now extends its services to over 1.5 million Palestinians in the West Bank and Gaza Strip, providing improved models of healthcare that are built on sound evidence-based practice and specifically adapted to the Palestinian context. May 6, 2024 Page 27 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) provides specialized mental health services and key mental health services in shelters. It is also the focal point organization for the Mental Health Cluster in Gaza, therefore coordinating with all key organization as well as the PMOH. These NGOs, as well as others, will be considered for contracting by the PMOH for the delivery of essential family and mental health services, as well as tertiary services where relevant. PMOH’s contracting capacity will be strengthened through Bank-executed ongoing technical assistance to the Services Purchasing Unit (SPU) as well as other stakeholders, and good practices on defining a core list of services and prices will be followed. The World Bank is conducting an assessment of NGOs and service delivery networks to assess NGO service delivery networks and capacity. NGO to be contracted will be selected based on the needs and absorptive capacity following the assessment, and adherence to fiduciary and operational safeguards criteria will be assured. Climate change 51. Climate change is going to cause an additional burden on the Palestinian health system. West Bank and Gaza will be significantly affected by climate change risks related to increasing temperatures and heatwaves, variability of rainfall, floods, increased aridity, and drought.44 Climate variability is likely to compound existing challenges such as water scarcity, extreme heat, wildfires, and landslides. The risk of increased intensity and frequency of heat waves is particularly troubling for vulnerable groups and patients with NCDs, the burden of which has been increasing in West Bank and Gaza. The climate extremes could overwhelm the Palestinian healthcare system, especially combined with an eruption of conflict. High temperatures can cause severe adverse health impacts, especially on vulnerable groups such as IDPs, outdoor laborers and agricultural workers, the elderly, infants and children, pregnant women, and those with cardiovascular diseases. Women are also adversely affected as primary caretakers in this context, since they will need to work harder to secure household livelihoods, leaving them with fewer opportunities to develop skills and work in the formal economy. Exposure to high temperatures has increased by 17 percent between 1990 and 2019, impacting morbidity and mortality from cardiovascular disease, diabetes, and kidney diseases.45 52. Electricity and water shortages affect access to health services, particularly in Gaza. Interruptions in energy supply due to chronic electricity shortages have created a substantial challenge for the health sector in Gaza, putting lives of the most vulnerable patients at risk. In 2023, electricity supply was expected to cover 39.6 percent of overall demand. Electricity shortages directly impacted intensive care units, in which the bed occupancy rate was 84 percent, as well as dialysis patients, as 923 patients performed dialysis sessions on 131 machines per month.46 Prior to the conflict, hospitals in Gaza relied on backup generators to sustain critical life- saving services when electricity was unavailable from the main electricity grid. Access to safe water has also been a challenge, particularly in Gaza.47 While 94.7 percent of Gaza households used piped water as their main source for domestic purposes before the current conflict, only 3.2 percent of households used it for drinking, indicating that tap water was generally not potable or safe for consumption. Due to weak surveillance capacity in Gaza, the number of cases of water borne diseases attributed to the low quality of water provided by the water network was unknown. The Humanitarian Response Plan 2023 listed Gaza as a priority area and intended to focus on flood-prone areas, areas with limited access to water, sanitation and hygiene services, and areas exposed to public/environmental health risks.48 44 The State of Palestine’s First Nationally Determined Contributions (NDCs) “Updated Submission� October 2021. 45 Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. https://doi.org/10.1016/S0140-6736(20)30752-2. 46 WHO, Gaza Public Health Situational Analysis, October 2023 47 WHO, Gaza Public Health Situational Analysis, October 2023 48 https://www.ochaopt.org/content/humanitarian-response-plan-2023 May 6, 2024 Page 28 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) 53. The project will contribute to the adaptation of the Palestinian health system to the adverse impacts of climate change through improving its resilience and efficiency. The project aims to enhance the resilience and efficiency of the Palestinian health system in response to climate change impacts, including rising temperatures, heatwaves, variable rainfall, and increased aridity by expanding comprehensive public primary healthcare to address both communicable and non-communicable diseases which are expected to become more prevalent due to climate change. By maintaining essential health services for communicable and non-communicable diseases in Gaza, this project aims to ensure the continuation of basic healthcare services and prevent collapse of the health system. By strengthening the national public health laboratories, the project intends to support the strengthening of capacities needed to implement recommendations from the Country Climate and Development Report for West Bank and Gaza49 and achieve one of the NDC actions. Laboratory strengthening will facilitate collaboration between the PMOH and local authorities in monitoring of environmental risk factors. While climate co-benefits are not formally assessed as the project is a special financing, the project intends to prioritize the procurement of energy-efficient equipment, such as laboratory and cold chain equipment, to support climate change mitigation efforts where feasible. Citizen Engagement 54. Citizen engagement arrangements for the Parent Project will be maintained for the AF. The HSERP builds on the work done under the citizen engagement approach of the ongoing COVID-19 Emergency Response Project (P173800). The project includes activities to strengthen citizen engagement such as involvement of civil society, consultations, the use of national multi-stakeholder committees with civil society representatives and establishing a grievance redress mechanism for the project. Citizen engagement for the AF will be tracked through an existing beneficiary feedback indicator on the percentage of “Patients that are satisfied with the treatment received in hospitals� which will track beneficiary satisfaction amongst those utilizing hospital services. Gender 55. The escalating crisis and mass displacement in Gaza has resulted in additional challenges for women and adolescent girls in Gaza, especially related to maternal needs, sexual and reproductive health as well as concerns around safety and GBV. Pregnant women are among vulnerable groups, exposed to lack of comprehensive primary care and access to safe deliveries. The health services will consider and respond to the different needs of women, men, boys, and girls, while supporting provision of family and mental health services under subcomponent 1.2, including i) antenatal care, ii) reproductive and postnatal care, and iii) emergency gender-based violence care. Training on administration of the MHPSS interventions will be provided to both female and male service providers. Mental health needs of patients will be addressed with awareness of gender- sensitive approach, with attention given to GBV, both in terms of training and service provision. The project will track the numbers of males and females among the beneficiaries, to assess the extent to which both men and women are being sufficiently reached by the services. 56. Moreover, the project will maintain the gender tag pathway of the Parent Project. The project will maintain focus on increasing the use of breast cancer screening by procuring specialized equipment, such as mammograms, in the governorates with highest unmet demand and the indicator on “Annual number of women 49 https://openknowledge.worldbank.org/entities/publication/ece9f50d-cec0-465c-9e92-7281eff7634f May 6, 2024 Page 29 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) undergoing mammography examination� will be maintained to measure the gender tag under the Parent Project. III. KEY RISKS 57. The overall risk rating remains Substantial. The risks deemed High or Substantial are summarized below. 58. Political and governance and sector strategies and policies risks are deemed “High�. The political instability in the territories, particularly the ongoing conflict in Gaza, poses significant risks on project implementation. The prevailing political context and ongoing security concerns may lead to substantial challenges in delivering drugs and medical supplies into Gaza, potentially causing delays in project implementation, interrupting service delivery. This challenging environment also poses sector strategies/policy risks due to the constraints in the stewardship function of the health system in Gaza and potential difficulty in coordination with the PMOH in the West Bank. To help mitigate these risks, the project design allows for direct contracting between the PMOH and active partners on the ground, such as UN agencies as well as NGOs, to facilitate entry of goods during the active conflict and the provision of service delivery in Gaza. To manage this risk, TPM would be utilized where pertinent to strengthen monitoring and evaluation and address issues related to governance. Furthermore, the project will maintain the CERC under the AF to provide flexibility in reallocating funds and responding to emerging needs promptly. 59. Macroeconomic risk is rated “Substantial�. Macroeconomic risks remain Substantial due to the large fiscal deficit predominantly financed by donor grants and a sharp decline in the Palestinian economy in 2023, expected to persist in 2024. Availability of recurring expenditures to ensure service continuity can be at risk. To mitigate these effects, the project is designed in close coordination with development partners and will serve as a means to reassure donors of the World Bank ongoing commitment to supporting the PA during these challenging circumstances. Such effort could potentially encourage additional donor participation to bridge the financing gap and further mitigate risks. 60. Technical design risks are deemed “Substantial�. This risk stems from the unpredictability of the conflict situation, particularly due to ongoing damage and distruction of healthcare infrastructure, disruptions in service delivery and, uncertainties regarding funding. The technical design of the project operates under the assumption of full funding availability. However, there is a risk that end results of the project will not be possible to achieve without addressing the resource mobilization needs and identified financial gap. This risk has been factored into the project’s design, including scalability of activities based on confirmed financing and potential resources mobilization. In the event that anticipated resources will not materialize as expected, the project will be restructured accordingly. 61. Institutional Capacity for Implementation and Sustainability and Stakeholders risks are considered “Substantial�. The deteriorating security conditions and restrictions on the movement of health sector workers pose significant challenges to the coordination and delivery of health services, especially in Gaza. To address this risk, the project would build on the existing implementation arrangements between the PMOH and UN agencies as relevant, which have been scaled up and implemented strongly since the beginning of the conflict. These agencies maintain a strong presence in both the West Bank and Gaza and are currently engaged in implementing May 6, 2024 Page 30 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) activities related to the CERC in close coordination with the PMOH, demonstrating implementation capacity even during peak hostilities. Collaborating with local and international NGOs to streamline emergency response efforts will enhance access to and delivery of services. Furthermore, an intersectoral logistics cluster is facilitating coordination and ensuring rapid exchange on issues regarding the entry of goods and services to hard-to-reach areas. Additionally, the World Bank is playing a crucial role in the health cluster and will continue leveraging this platform to maximize coordination among stakeholders. As described in the previous sections, the project covers both emergency and early recovery interventions in Gaza and West Bank. Emergency health interventions have been implemented by development partners in Gaza even during the peak of hostilities despite substantial barriers, demonstrating that the activities within the scope of this project should also be implemented in a reasonable manner. Early recovery interventions can already be implemented in West Bank, and would be launched at a feasible time in Gaza. 62. Fiduciary risk is rated “Substantial�. The rating for FM risk is Substantial, and the procurement risk is also Substantial. The PMU at PMOH has extensive experience working with World Bank projects and is currently implementing the Parent Project. FM risk, initially assessed as High, will be mitigated through the project specific mitigating measures and adequate financial management arrangements that will be replicated from the Parent project. The residual FM risk is therefore rated Substantial after mitigation measures. The procurement risk for the parent project was Moderate and has been elevated to Substantial due to the prevailing security conditions in West Bank and Gaza, and the complex mechanism for entering the goods to Gaza due to the ongoing conflict. The PMU, with support from the World Bank, UN agencies and other stakeholders, will work on special arrangements to facilitate the project’s implementation and mitigate the risks associated with the evolving security situation. 63. Environmental and Social (E&S) risks are rated Substantial. The identified E&S risks and impacts would be mitigated through the project’s Environmental and Social Framework (ESF) instruments including the ESCP, SEP addendum, Labor Management Procedures (LMP), in addition to the Environmental and Social Management Framework (ESMF), which will be updated within two months of effective date. Additional elaboration on the E&S risks and mitigation measures are listed in section F. 64. “Other� risk is rated “High� given the ongoing conflict. The High rating for other risks acknowledges the complexity and the unknown trajectory of the ongoing high intensity conflict and its impact on the delivery of health services that are not directly supported by the project, such as reduced working hours and reductions in the salary of health workers. It also factors in the indirect risks associated with systems collapsing and which may further expose the proposed implementation arrangements in a manner that is not accounted for under the established risk categories above. IV. APPRAISAL SUMMARY A. Economic Analysis 65. Given the nature of the project as a response to urgent needs and the uncertainty concerning cost and benefits, a qualitative economic analysis of the proposed project has been conducted to identify the main development benefits and confirm that the expected associated costs are appropriate, based on existing May 6, 2024 Page 31 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) evidence and estimates. The analysis suggests the Project will have a very concrete impact in terms of preventing disruptions in essential services, scaling-up new services critically needed in the current context (mental health, rehabilitation and reconstructive surgery, pandemic preparedness, and infectious disease control). The technical and economic analysis of the parent project remains relevant, especially regarding investments in medical equipment to reduce OMR and scale up cost effective interventions. 66. Gaza’s health system has been dismantled by the conflict, with an estimated total financial impact of damage estimated at about US$533 million, highlighting the immense financial need for reconstruction. This estimate has reached an unprecedented level, as it already stands at least more than 6 times the estimated values of damages and losses in the 2021 conflict. The impact of the ongoing conflict on the health sector is both direct, through damage to health infrastructure, as well as indirect, through the losses incurred due to interruptions in service delivery. The largest economic burden is due to hospitals’ destructions, estimated at least more than US$222 million, although this is likely underestimated. Public primary health centers and private health facilities also represent an important share of the economic burden, with damage costs estimated at US$63 million and US$193 million respectively. The municipality of Gaza bears the highest burden of the destruction, with an estimated US$ 274 million worth of damages, among which US$133 million due to the destructions of hospitals. Outside the city of Gaza, North Gaza governorate remains the most affected area, with an estimated US$83 million worth of damages in that area. Therefore, the amount of need regarding reconstruction justifies the activities under this project regarding civil work in Gaza to rehabilitate and maintain healthcare infrastructure such as water and electricity plumbing and provision of essential utilities such as fuel, generators, and procurement and installation of communication devices to sustain facility operations.50 B. Technical 67. Recent research has highlighted that infection diseases will be the leading cause of death in Gaza in the coming months, pointing to the need to invest in infectious disease control and surveillance. Over the next six months projections of excess deaths due to the conflict (additional to the current number of deaths) will rise to up to 85,750.51 The projections suggest that epidemics would be one of the main causes of excess deaths, with between 5,000 and 11,000 deaths due to epidemics52. Projections suggest that cholera, measles, polio (both wild- type and vaccine-derived) and meningococcal meningitis pose the greatest mortality threat, with substantial mortality potentially occurring under the three scenarios, owing to ongoing disruptions including overcrowding, inadequate WASH, and an ongoing nutritional emergency. Measles is expected to cause moderate-size epidemics at most due to the very high vaccination coverage prior to October 2023, which is projected to afford considerable (but falling) herd immunity protection. The need for robust health surveillance and intervention strategies is compelling, especially in absence of laboratory capacity in Gaza, therefore it is expected that activities under this project will be highly cost-effective. 68. Given the dire mental health situation, activities to improve MHPSS are expected to be highly effective. There is growing, but still limited, evidence from intervention studies on the effectiveness of community-based 50 All damage figures are from the aforementioned Gaza Interim Damage and Needs Assessment 51 Zeina Jamaluddine, Zhixi Chen, Hanan Abukmail, Sarah Aly, Shatha Elnakib, Gregory Barnsley et al. (2024). Crisis in Gaza: Scenario-based health impact projections. Report One: 7 February to 6 August 2024. London, Baltimore: London School of Hygiene and Tropical Medicine, Johns Hopkins University. The higher end is based on assumptions of infectious disease epidemics. 52 Crisis in Gaza: Scenario-based health impact projections. Report One: 7 th of February to 6 th of August 2024 May 6, 2024 Page 32 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) mental health interventions among conflict-affected populations in lower- and middle-income countries; mental health interventions are cost-effective and essential health services with economic returns. Importantly, the treatment gap for mental health services among conflict-affected people is very high, with studies showing more than 80 percent of those who report symptoms of mental disorders do not receive mental health care. A key challenge is therefore to scale up effective community-based mental health interventions to benefit more people and reduce the treatment gap53. Interviews with mental health experts in Gaza highlighted that it is expected that 1 million people will need at least basic mental health services following the conflict, showing the need to train and capacitate community-level responses while continuing to invest in specialized services. In the West Bank, psychosocial distress and deterioration in mental well-being is associated with the political situation, insecurity and violence, including threats of home demolitions, arrests, night raids and settler violence, in addition to loss of income. 69. Pandemic PPR is a highly cost-effective investment for protecting both health and economic well-being. By allocating resources to develop robust healthcare infrastructures, early detection systems, and rapid response capabilities, governments and organizations can reduce the spread of infectious diseases, minimize disruptions to economies and societies, and save lives. The COVID-19 pandemic has underscored the importance of preparedness, demonstrating how a lack of investment can lead to widespread loss of life and economic downturns. A systematic review of relevant studies showed that every US$1 invested yields a median return of US$14.54 C. Financial Management 70. The Financial Management (FM) assessment for the PMU at PMOH that was carried out during the preparation and supervision of the Parent Project is deemed adequate for the AF. The assessment evaluated the institutional capacity of the PMU to implement the FM and Disbursement arrangements in line with World Bank guidelines and found it to be Satisfactory. 71. The existing FM and disbursement arrangements established for the Parent Project will be replicated for the AF. The AF primarily involves scaling up of the existing activities of the project components and subcomponents with additional US$ 45 million which will be financed by a US$14.8 million from the Pandemic Fund, US$5 million from the SPF, and US$4 million from the PURSE trust fund through a contribution by Norway, with a financing gap of US$21.2 million. The PMU at PMOH will continue to be responsible for project implementation, financial recording, and compliance with the World Bank FM and disbursements guidelines. 72. Parent Project’s fiduciary reporting arrangements will be retained. The PMU at PMOH will ensure that an adequate computerized financial system is in place and qualified financial staff, including a Finance Manager. Semi-annual Interim Financial Reports (IFRs) will continue to be submitted in excel format in a timely manner, within 45 days from the end of each reporting period. The financial statements of the project will continue to be audited by a qualified and reputable private audit firm acceptable to the World Bank. 53Scaling up mental health interventions in conflict zones. The Lancet 2019 54WHO and World Bank (2022) Analysis of Pandemic Preparedness and Response (PPR) architecture, financing needs, gaps and mechanisms. Paper prepared for the G20 Joint Finance & Health Task Force May 6, 2024 Page 33 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) 73. The AF will continue utilizing the same disbursement arrangements and guidelines as stipulated in the Parent Project Disbursement and Financial Information Letter (DFIL), in accordance with the World Bank’s disbursements guidelines, with minor changes. The AF will continue using “Reporting-Based Disbursement� with IFRs that include cash forecasts covering one or two quarters, as deemed necessary. In addition to the existing US Dollar Designated Account (DA) opened at the Bank of Palestine, the AF will require opening additional three DAs at the Bank of Palestine - one for each of the three new Trust Funds. In case the financing gap will be funded by new Trust Funds, additional DAs will be opened for each new TF. Other disbursement arrangements including using proper Withdrawal Applications (WA) and E-disbursement will be replicated from the Parent project. The POM will be updated to reflect changes in the FM section. All other FM and Disbursement arrangements will remain the same as those of the Parent Project. D. Procurement 74. Procurement of new activities under the AF will be carried out in accordance with the World Bank’s Procurement Regulations for Borrowers under IPF dated September 2023. Furthermore, the “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by International Bank for Reconstruction and Development (IBRD) Loans and International Development Association (IDA) Credits and Grants�, dated October 15, 2006 and revised in January 2011 and as of July 1, 2016 shall apply to the AF. 75. Given the emergency nature of this AF, simplified procurement procedures for goods and selection procedures for consultants’ services may apply in accordance with the Bank Guidance: Procurement in Situations of Urgent need of Assistance or Capacity Constraints, dated March 7, 2019. The PMU at PMOH will update the project POM to include changes made to the procurement section and submit it for the World Bank’s review and clearance. Other than the emergency procedure, procurement for the AF will follow the same arrangements in place for the parent project. The proposed simplified procurement procedures may include (i) direct contracting of UN Agencies to supply goods and services as specified in Section VI (Para 6.47 and 6.48) and Section VII (Para 7.27 and 7.28) of the applicable Procurement Regulations respectively; (ii) direct contracting of firms as appropriate; (iii) increasing the threshold for using “Request for Quotations� of Works and Goods; (iv) shortening the period for preparation of bids under National Competitive Bidding; and (v) other procedures defined in accordance with the Bank Guidance: Procurement in Situations of Urgent need of Assistance or Capacity Constraints. 76. The PMU at PMOH, which has adequate capacity and experience in the World Bank’s Procurement Regulations, will continue to retain overall responsibility for procurement and contract management under the AF. The AF will finance minor works, goods, non-consulting services, and consultants’ services under the AF activities which mainly includes the scaling up of the existing activities of the Parent Project. The PMU will update the Project Procurement Strategy for Development (PPSD) and the Procurement Plan, to include additional activities to be financed under the AF, during the early stages of the implementation of the AF due to the emergency nature of the AF. E. Legal Operational Policies . Triggered? May 6, 2024 Page 34 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No . F. Environmental and Social 77. The overall environmental and social (E&S) risk for the Additional Financing is rated Substantial. The environmental risk is assessed as Substantial and includes issues related to the parent project and the AF: (i) Occupational Health and Safety (OHS) due to testing and handling of supplies and equipment during treatment, as well as due to the minor works for installation of equipment in the existing hospitals and health care facilities, (ii) hazardous materials that must be managed in terms of their use, storage, and handling, (iii) production and management of medical healthcare waste resulting from the different components, and (iv) managing and handling of waste and end-of-life waste of equipment. In addition to risks related to minor rehabilitation, and reconstruction activities including UXO assessment and clearance in accordance with UNMAS guidelines and procedures, removal, rubble removal and waste management, health and safety, community health and safety). 78. The social risk is Substantial. Risks pertain to i) social exclusion or inequitable access of comparatively marginalized or vulnerable groups (e.g. persons with disabilities, the elderly, women headed households, the poor, people in Area C, Bedouin communities, communities in relatively rural/remote locations etc.) to project benefits; ii) management of labor (also including potential incidents of sexual exploitation and abuse and sexual harassment (SEA/SH) and working conditions; iii) community health and safety issues; and iv) potential social tension and increase in stigma of people seeking treatment for mental health concerns or incidents of GBV and violence against children (VAC). The engagement of local NGOs and community-based organizations for service delivery will also help mitigate this risk: primary, secondary, and tertiary level services will be designed and prioritized with community engagement and inputs. 79. The SEA/SH rating is substantial due to (but not limited to) the potential exposure of women and vulnerable groups (e.g. persons with disabilities, elderly, unaccompanied children or orphans) to SEA/SH during provision of project services; potential of sexual harassment among project actors working to manage and/or deliver goods and/or services; the limited capacity and lack of availability of trained health service providers in addressing or managing GBV prevention and response; scarce resources and facilities and weak referral systems; lack of support systems and absence of knowledge and training of aid staff in issues related to SEA/SH/GBV and VAC; lack of enforcement when it comes to protocols on how to respond to survivors of GBV and VAC seeking care; and lack of clarity in grievance mechanism, GBV referral systems and existing gender norms that serve as barriers for women/children to report and/or seek care for GBV and/or VAC. Health service providers themselves may also face stigma and backlash when addressing survivors of GBV. The specialist for the preparation of the SEA/SH action plan has been recruited and will start work in May 2024. 80. The E&S risks and impacts have been assessed and requisite mitigation measures have been included in the parent project’s E&S instruments, where the ESMF will be adopted for the AF, until the update of ESMF addressing the AF E&S requirements is prepared, consulted and disclosed within two months of effective date. An update to the project SEP has been prepared and will be disclosed prior to appraisal. A standalone ‘SEA/SH Action Plan’ (in line with the ESF Good Practice Note (GPN) for Addressing Sexual Exploitation and Abuse and Sexual Harassment (SEA/SH) in Human Development Operations, September 2022) will be prepared, disclosed and implemented to cover both the parent project and AF activitiesby June 30, 2024. Commitments to implement May 6, 2024 Page 35 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) the project in accordance with the requirements of the Bank’s ESF, including maintaining the ES staffing, defining contractor (including UN agencies) management and reporting, updating the ESMF to cover the Project AF E&S requirements have been included in the updated ESCP which has been prepared by MoH, reviewed, and publicly disclosed on April 16th, 2024 81. The PMU has engaged and will maintain an Environmental and Health and Safety Officer (EHSO) and an Environmental and Social Focal Point in Gaza (once the situation on the ground allows) to ensure implementation of E&S requirements. The World Bank’s in-country and MENA regional teams have provided capacity building for the EHSO to further strengthen compliance with the ESF. The EHSO will also support the implementation of the SEA/SH Action Plan and will receive requisite training during the project to ensure proper implementation of this Plan. Further training to strengthen ESF implementation will be provided to the EHSO, the Focal Point in Gaza and other staff and commitments in this regard are included in the ESCP. 82. Functioning grievance mechanisms (GMs) are in place for both project beneficiaries and workers. These GMs can be strengthened further (e.g. in line with actions proposed in the SEA/SH Action Plan) during project implementation as required. Details of the beneficiary and workers’ GMs are included in the project SEP and LMP respectively, and commitments to ensure that GMs remain operational throughout the project are included in the ESCP. V. WORLD BANK GRIEVANCE REDRESS 83. Grievance Redress. Communities and individuals who believe that they are adversely affected by a project supported by the World Bank may submit complaints to existing project-level grievance mechanisms or the Bank’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 Bank’s independent Accountability Mechanism (AM). The AM houses the Inspection Panel, which determines whether harm occurred, or could occur, as a result of Bank non-compliance with its policies and procedures, and the Dispute Resolution Service, which provides communities and borrowers with the opportunity to address complaints through dispute resolution. Complaints may be submitted to the AM at any time after concerns have been brought directly to the attention of Bank Management and after Management has been given an opportunity to respond. For information on how to submit complaints to the Bank’s Grievance Redress Service (GRS), please visit http://www.worldbank.org/GRS. For information on how to submit complaints to the Bank’s Accountability Mechanism, please visit https://accountability.worldbank.org. May 6, 2024 Page 36 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) VI SUMMARY TABLE OF CHANGES Changed Not Changed Project's Development Objectives ✔ Results Framework ✔ Components and Cost ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Implementing Agency ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ VII DETAILED CHANGE(S) PROJECT DEVELOPMENT OBJECTIVE Current PDO To support the Palestinian Authority in improving the quality, efficiency, and resilience of public health service delivery. Proposed New PDO To support the Palestinian Authority in improving the resilience and efficiency of the health system, and in case of an Eligible Crisis or Emergency, respond promptly and effectively to it. May 6, 2024 Page 37 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Component 1: Scaling Up 4.00 Revised Component 1: Scaling 16.80 Cost-effective Public Up Cost-Effective Primary Health Care Primary Health Services Services Component 2: Improving 5.30 Revised Component 2: 13.20 Public Hospitals Service Strengthening Hospital Delivery Service Delivery Component 3: Project 0.70 Revised Component 4: Project 0.50 Implementation and Implementation and Monitoring Monitoring Component 4: Contingent 0.00 Revised Component 5: 0.00 Emergency Response Contingent Emergency Component Response Component 0.00 New Component 3: 14.50 Strengthening key public health functions of pandemic prevention, preparedness, and response TOTAL 10.00 45.00 REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed REALLOCATION NEW TF-C0976-001 | Currency: USD iLap Category Sequence No: 1 Current Expenditure Category: G NCS CS T IOC Excp P4 10,000,000.00 0.00 1,700,000.00 100.00 100.00 iLap Category Sequence No: 2 Current Expenditure Category: Emergency Expenditures P4 0.00 0.00 8,300,000.00 100.00 100.00 May 6, 2024 Page 38 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Total 10,000,000.00 0.00 10,000,000.00 DISBURSEMENT ARRANGEMENTS Change in Disbursement Arrangements Yes Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2023 0.00 0.00 2024 9,087,619.82 9,087,619.82 2025 5,912,380.18 15,000,000.00 2026 15,000,000.00 30,000,000.00 2027 15,000,000.00 45,000,000.00 2028 10,000,000.00 55,000,000.00 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ High ⚫ High Macroeconomic ⚫ Substantial ⚫ Substantial Sector Strategies and Policies ⚫ Substantial ⚫ High Technical Design of Project or Program ⚫ Moderate ⚫ Substantial Institutional Capacity for Implementation and ⚫ Moderate ⚫ Substantial Sustainability Fiduciary ⚫ Substantial ⚫ Substantial Environment and Social ⚫ Substantial ⚫ Substantial Stakeholders ⚫ Moderate ⚫ Substantial Other ⚫ High Overall ⚫ Substantial ⚫ Substantial May 6, 2024 Page 39 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) LEGAL COVENANTS2 LEGAL COVENANTS – Additional Financing to Health System Efficiency and Resilience Project (P181529) Sections and Description OPS_LEGAL_CONVENANT_CHILD_NODATA No information available Conditions May 6, 2024 Page 40 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: West Bank and Gaza RESULT_NO_PDO Additional Financing to Health System Efficiency and Resilience Project Project Development Objective(s) To support the Palestinian Authority in improving the resilience and efficiency of the health system, and in case of an Eligible Crisis or Emergency, respond promptly and effectively to it. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Delivery of quality health services (Action: This Objective has been Revised) Percentage of diabetes patients with good glycemic 23.00 23.00 25.00 30.00 40.00 50.00 control (Percentage) Action: This indicator has been Marked for Deletion Number of people receiving quality health, nutrition, 0.00 477,910.00 population services (Number) Action: This indicator is New May 6, 2024 Page 41 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) RESULT_FRAME_TBL_ PD O Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improved efficiency of health system system (Action: This Objective has been Revised) Average growth rate of total OMR expenditures in the preceding 3 years for 16.00 16.00 conditions targeted by the project (Percentage) Action: This indicator has been Revised System for monitoring stock outs of essential NCD medicines in place in public PHC (Action: This Objective has been Marked for Deletion) System for monitoring stock outs of essential NCD medicines in place in public NO YES PHC centers (Text) Action: This indicator has been Marked for Deletion Improve resilience of the health system (Action: This Objective is New) Percentage of scores maintained or improved for targeted indicators within the 0.00 20.00 States Parties’ Annual Report/Joint External Evaluation (Percentage) Action: This indicator is New PDO Table SPACE May 6, 2024 Page 42 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Intermediate Results Indicators by Components RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Component 1: Scaling up cost-effective primary health care services (Action: This Component has been Revised) Percentage of public PHC centers using the unified 11.70 11.70 20.00 25.00 35.00 40.00 electronic patient records (Percentage) Action: This indicator has been Marked for Deletion Proportion of level 3 and level 4 public PHC centers equipped with essential equipment for 14.00 15.00 50.00 65.00 70.00 75.00 NCD services as per national standards (Percentage) Action: This indicator has been Marked for Deletion Number of health staff trained in family health care practice 114.00 130.00 150.00 170.00 190.00 200.00 (Number) Action: This indicator has been Marked for Deletion Percentage of patients with diabetes who are routinely 40.00 40.00 50.00 55.00 65.00 70.00 monitored in public PHC facilities (Percentage) Action: This indicator has been Marked for Deletion Number of women undergoing mammography examination 5,864.00 20,000.00 (Number) May 6, 2024 Page 43 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Number of people receiving project supported quality 0.00 175,610.00 primary health services (Number) Action: This indicator is New Number of people receiving project supported quality mental health and psychosocial 0.00 247,500.00 247,500.00 support services (Number) Action: This indicator is New Number of public PHC facilities and service delivery points 0.00 280.00 280.00 receiving investments from the project (Number) Action: This indicator is New Number of service delivery points provided with equipment or medical/non- medical supplies for provision 0.00 20.00 20.00 of integrated MHPSS and family medicine services (Number) Action: This indicator is New Number of referrals from outreach teams to health facilities providing integrated 0.00 30,000.00 30,000.00 MHPSS and family medicine services (Number) May 6, 2024 Page 44 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator is New Number of service providers recruited and trained to 0.00 200.00 200.00 administer MHPSS interventions (Number) Action: This indicator is New Component 2: Strengthening hospital service delivery (Action: This Component has been Revised) Public hospitals with expanded cancer detection and management capacity 0.00 0.00 1.00 2.00 3.00 3.00 expanded in high-need areas (Number) Action: This indicator has been Marked for Deletion Public hospitals with expanded cardiovascular disease detection and management 0.00 15.00 capacity in high-need areas (Number) Action: This indicator has been Marked for Deletion Number of public hospitals strengthened with equipment to deliver maternal, newborn, 0.00 0.00 2.00 4.00 8.00 10.00 and child health services in high-need areas (Number) Action: This indicator has been Marked for Deletion May 6, 2024 Page 45 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Percentage of patients that are satisfied with service availability at hospitals 0.00 75.00 targeted by the project (Percentage) Number of people receiving project supported quality 0.00 18,800.00 tertiary care services (Number) Action: This indicator is New Number of people receiving project supported 0.00 6,000.00 rehabilitation surgery (Number) Action: This indicator is New Number of public hospitals receiving investments from the 0.00 30.00 project (Number) Action: This indicator is New Component 3: Strengthening key public health functions of PPR (Action: This Component is New) Number of after/intra-action reviews or simulation exercises 0.00 5.00 performed utilizing the 7-1-7 approach (Number) Action: This indicator is New Number of diagnostic tests 0.00 4.00 added to the central public May 6, 2024 Page 46 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) RESULT_FRAME_TBL_ IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 health laboratories (Number) Action: This indicator is New IO Table SPACE Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of patients with type 2 diabetes mellitus with good glycemic control at the last clinical visit to the level 3 and level 4 public PHC centers in the last 12 months (HbA1c <7.0% or 53 mmol/mol)/number of Percentage of diabetes patients with good Annual PHIPH DHIS2 reports MOH patients with type 2 glycemic control diabetes mellitus registered in the level 3 and level 4 public PHC centers over during the last 12 months. The indicator will cover patients with type 2 diabetes mellitus (code E11 under ICD10 or code 5A11 under ICD11). May 6, 2024 Page 47 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) The indicator will be gender disaggregated and monitored in West Bank. This indicator measures the sum of the number of people (millions) benefitting directly and indirectly from the full continuum of health prevention, promotion, curative, rehabilitative and palliative care that is safe, effective, and patient- MOH reports and Number of people receiving quality Annual MOH MOH centered, due to project documents health, nutrition, population services activities during the intervention period. The indicator will be disaggregated by gender. The baseline is 0 to capture the fact that the indicator only refers to project- supported beneficiaries. OMR expenditures for cancer, cardiovascular, neonatal and maternal Average growth rate of total OMR e-Referral conditions will be tracked Annual e-Referral analysis PMOH expenditures in the preceding 3 years for data based data from MOH conditions targeted by the project eReferrals database. Reduction in OMR growth was an average of 16% in May 6, 2024 Page 48 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) the three years between 2019-2021. In order to avoid any year-on-year fluctuations, the calculation relies on the average growth rate of the preceding three years. The essential NCD medicines are the core medicines for primary health care facilities for treatment of NCDs, as System for monitoring stock outs of defined in the WHO-PEN Annual PHIPH DHIS2 reports MOH essential NCD medicines in place in public interventions for primary PHC centers health care. The system will be considered in place if it is setup and functional. This indicator will be monitored in West Bank. 15 indicators targeted in West Bank (JEE D1.1, JEE D1.2, JEE D1.3, JEE D.1.4, JEE D2.1, JEE D2.3, JEE D3.3, JEE P2.1, JEE P2.2, JEE MOH will be reporting MOH will be reporting Percentage of scores maintained or P4.2, JEE P5.1, JEE P7.1, JEE through the Pandemic through the Pandemic improved for targeted indicators within Annual MOH P7.2, JEE P8.3, and JEE Fund steering Fund steering the States Parties’ Annual Report/Joint R1.5) with total baseline committee committee External Evaluation score: 17 (baseline scores from SPAR 2023 reduced to account for impact of the conflict); 4 indicators targeted in Gaza (JEE D1.1, May 6, 2024 Page 49 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) JEE D1.3, JEE D2.1, and JEE R1.5) with the total baseline score: 4 (all indicators reduced to level 1). Calculated by (total score at end of the project- total baseline score)/total baseline score ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Number of PMOH PHC center in West Bank in which DHIS2 was fully Semiannua PNIPH reports and Percentage of public PHC centers using PNIPH MOH implemented/total number l documents the unified electronic patient records of PMOH PHC centers in West Bank (excluding mobile clinics) Number of level 3 and level 4 public PHC centers in West Bank fully equipped for provision of essential Proportion of level 3 and level 4 public NCD interventions (WHO- MOH reports and PHC centers equipped with essential Annual MOH MOH PEN) for primary health documents equipment for NCD services as per care system in low- national standards resource settings/total number of level 3 and level 4 PMOH PHC centers in West Bank May 6, 2024 Page 50 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) Number of health staff who completed family medicine residency program (doctors), diploma course MOH Reports and Number of health staff trained in family in family medicine Annual MOH MOH documents health care practice (doctors, nurses/midwives, and pharmacists), or family medicine transitional training program (doctors and nurses/midwives). Number of patients with diabetes mellitus (E10 and E11) who had HbA1c measured and recorded in PNIPH and Percentage of patients with diabetes who its patient file in last 12 NCD PNIPH and MOH reports Annual MOH are routinely monitored in public PHC months/total number of supervisors at and documents facilities patients with diabetes. The district level indicator will be disaggregated by gender and monitored in West Bank. The number of women undergoing mammography Number of women undergoing Annual MOH MOH MOH examination in public mammography examination health facilities in West Bank Cumulative number of primary health care MOH reports and Number of people receiving project services, including family Annual MOH MOH documents supported quality primary health services health services beneficiaries in West Bank and Gaza, across public May 6, 2024 Page 51 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) facilities, NGO facilities, and temporary delivery points. Cumulative number of mental health services Number of people receiving project beneficiaries in West Bank MOH reports and Annual MOH MOH supported quality mental health and and Gaza across all delivery documents psychosocial support services points. This indicator will be disaggregated by gender. Cumulative number of Number of public PHC facilities and public PHC facilities that MOH reports and Annual MOH MOH service delivery points receiving benefitted from the project documents investments from the project investment in West Bank and Gaza. Number of service delivery points Cumulative number of provided with equipment or medical/non- project supported service WHO reports and Annual MOH MOH medical supplies for provision of delivery points that documents integrated MHPSS and family medicine benefitted from project services investments Cumulative number of Number of referrals from outreach teams WHO reports and project supported referrals Annual MOH MOH to health facilities providing integrated documents from outreach teams to MHPSS and family medicine services health facilities in Gaza. Cumulative number of the Number of service providers recruited WHO reports and providers recruited and Annual MOH MOH and trained to administer MHPSS documents trained under the project interventions in Gaza. Number of public hospitals Public hospitals with expanded cancer MOH reports and in West Bank and Gaza Annual MOH MOH detection and management capacity documents where cancer detection expanded in high-need areas and management capacity May 6, 2024 Page 52 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) were expanded Number of public hospitals in West Bank where Public hospitals with expanded MOH reports and cardiovascular disease Annual MOH MOH cardiovascular disease detection and documents detection and management capacity in high-need areas management capacity was expanded Number of public hospitals in West Bank where additional medical Number of public hospitals strengthened equipment has been MOH reports and with equipment to deliver maternal, purchased to improve the Annual MOH MOH documents newborn, and child health services in delivery of maternal, high-need areas newborn, and child health services, including delivery beds and neonatal incubators Number of hospital patients satisfied with the treatment/total number of hospital patients that Percentage of patients that are satisfied completed survey. The MOH reports and Annual MOH MOH with service availability at hospitals indicator will be documents targeted by the project disaggregated by West Bank and Gaza. Results of the survey will be disclosed and disseminated to the public. Number of people MOH reports and Number of people receiving project Annual MOH MOH receiving health services documents supported quality tertiary care services across public and NGO May 6, 2024 Page 53 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) delivery points. Based on average unit cost of US$250 per patient of standard inpatient services in hospitals. Number of people receiving rehabilitative surgery. MOH reports and Number of people receiving project Annual MOH MOH Based on average unit cost documents supported rehabilitation surgery of US$1,000 per patient of rehabilitative and reconstructive surgery Number of public hospitals in Gaza and West Bank receiving project investments including medical supplies, Annual MOH Documents and Number of public hospitals receiving MOH MOH equipment and minor civil reports investments from the project works. There are 51 hospitals in West Bank (15) and Gaza (36). Assuming targeting all hospitals in West Bank 40% in Gaza. As per agreement with stakeholders during Pandemic Fund application Number of after/intra-action reviews or process. MOH reports and Annual MOH MOH simulation exercises performed utilizing Number of summaries of documents the 7-1-7 approach the after/intra action review or simulation exercise reports performed under the project. May 6, 2024 Page 54 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) As per agreement with stakeholders during Pandemic Fund application process. MOH reports and Number of diagnostic tests added to the Annual MOH MOH Number of new diagnostic documents central public health laboratories tests for communicable diseases introduced in central public health laboratories. ME IO Table SPACE May 6, 2024 Page 55 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) ANNEX 1: Supplemental Information on Activities per Subcomponent Subcomponent 1.1: Delivery of essential primary health services at public PHC • Medical supplies that will be procured include medications for managing non-communicable diseases like diabetes, hypertension and cardiovascular diseases. Maternal and newborn health kits containing supplies for antenatal care, childbirth, postnatal care and newborn care will also be supported. Routine childhood vaccines to protect against preventable diseases and medicines for common childhood illnesses will be procured. This subcomponent will also finance antibiotics and drugs for managing infectious diseases, as well as medical equipment necessary at PHC facilities such as examination tables, blood pressure monitors and stethoscopes. Facilities to receive supply and medicine investments from this project will be determined through an ongoing assessment being conducted by the World Bank and the PMU which seeks to assess baseline capacity and needs of medical equipment across public PHC facilities in West Bank. In Gaza, the needs for service delivery in public PHC facilities will be assessed when the situation allows. • In Gaza, minor rehabilitation works will help re-establish basic water, electricity and waste systems at health centers to ensure service continuity. Generators, fuel and communication devices will be installed to restore operations. Where facilities have been completely destroyed, temporary prefabricated medical clinics will be set up with necessary fittings, equipment and staff to continue serving communities including support for (or to) safe spaces for women and girls specialized services in coordination with the GBV Subcluster. • Mobile clinics, mobile medical teams and community outreach activities will be supported through the provision of vehicles, equipment and supplies. Mobile clinics will allow healthcare workers to travel to populations in need and will be equipped with essential medical supplies and equipment tailored for outpatient care on the road, such as examination equipment, basic diagnostic tools, medications and maternal/child health commodities as well as mobile support for GBV survivors. Subcomponent 1.2: Strengthening mental and family health services • Recruitment and training of MHPSS service providers: Given the need for additional mental health practitioners, additional staff needs to be trained on how to provide basic mental health care, including health workers who are not delivering family health services, and non-specialist respondents such as religious leaders, community leaders, social workers, and educators. To increase the number of mental health providers, a training of trainers approach will be followed, using WHO mental health Gap Action Program Humanitarian Intervention Guide (mhGAP HIG guideline) and child protection, GBV MHPSS guidelines55 (GWI & Trocaire) in coordination with the GBV Subcluster. This training will also be contextualized according to the diverse needs of key sub population groups in need, such as IDPs, children and health professionals. • Provision of community-level integrated outreach MHPSS and family health services, including services for children and adolescents: Upon receiving brief training modules including on foundational elements of survivor centered care and referral, non-specialist respondents could provide active listening to those impacted, recognize those in need of professional assessment and/or care, and know where and when to refer those assessed as requiring a higher level of MHPSS support, in line with the WHO Psychological first 55Supporting Uptake of Survivor-Centered Practice: Building Consensus Between GBV And MHPSS Workers Around Shared Guiding Principles and Recommendations for Progressing Practice https://gbvaor.net/node/1878 May 6, 2024 Page 56 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) aid: Guide for field workers. Educators can be critical players to provide MHPSS particularly to children and adolescents (for whom the psychological trauma has been accumulating since early age) in schools and supportive child-friendly spaces where recreational activities to raise their awareness on their mental health and safe space to express their feelings. Interventions will include brief training on mental health first aid for educators, as well as supporting documentation for parents, and may be further supported by south-south learning activities sharing evaluated models for community level mental health support building.56 • Strengthening of integrated MHPSS and family health services delivery for IDPs including safe spaces for women and girls in coordination with the GBV Subcluster at fixed service delivery points such as shelters and other service delivery points through provision of medical (e.g., medicines, referral forms, portable emergency medical equipment) and non-medical inputs (e.g. utilities for health facilities, printed assessment and screening tools, information materials, personal protective equipment) for the delivery of family and mental health services, including for survivors of GBV, and support to existing family health care teams in shelters and facilities. Subcomponent 2.1 Delivery of essential services at public hospitals • In Gaza, given the substantial dismantlement of the health system, investments will be selected in a prioritized manner, with scale-up of services which need to be the most urgently restored. As a first priority, equipment will be procured to strengthen diagnostic, surgical and intensive care capacities of public hospitals for cross-cutting inpatient and emergency management. This would include the procurement of operating theatre equipment, anesthesia machines, emergency resuscitations supplies, X-rays and ultrasounds, amongst other items. Devices to support emergency obstetric and neonatal care will also be prioritized, such as neonatal incubators. Following the restoration of essential and high priority functions, based on the available funding, investments will be expanded to finance other priority conditions aligned with the parent project, such as cardiovascular conditions, cancers, and kidney conditions. In addition to medical equipment investments, where necessary, essential medicines, medical supplies, fuel, generators, communications devices, and other non- medical inputs would also be procured, and minor civil works would be financed to allow for service delivery. Finally, depending on the context, temporary hospitals and field hospitals would also be supported. • In the West Bank, medical equipment, medical supply, vehicle, and other medical and non-medical inputs for ensuring service delivery for hospital care will be procured in accordance with the criteria outlined in the parent project. 56Programs such as from Rwanda, https://ubuntucenterforpeace.org/blog/building-more-rigorous-evidence-a-big-step-on-the-path-to-scaling- up May 6, 2024 Page 57 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) ANNEX 2: Provisional Scalability of Project’s Results Indicator Baseline US$23.8M scope US$45M scope Methodology and PDO indicators assumption 1. Average growth rate (percentage) of total OMR expenditures Described in parent in the preceding 3 years for conditions targeted by the 16.00 16.00 16.00 project PAD project The sum of intermediate 2. Number of people receiving quality health, nutrition, 0.0057 213,268 477,910 indicators Component population services 1 - #1/#2/#7 & Component 2 - #1/#2 15 indicators targeted in West Bank: 11 indicators reported annually in the SPAR (JEE D1.1, JEE D1.2, JEE D1.3, JEE D.1.4, JEE D2.1, JEE D2.3, JEE P2.1, JEE P2.2, JEE P7.1, JEE P7.2, and JEE R1.5), and 4 indicators from the JEE (JEE D3.3, JEE P4.2, JEE P5.1, and JEE P8.3); total 3. Percentage of scores maintained or improved for targeted baseline score: 17 indicators within the States Parties’ Annual Report/Joint 0% 20% 20% (baseline score from External Evaluation SPAR 2023 reduced to account for impact of the conflict) 4 indicators targeted in Gaza (JEE D1.1, JEE D1.3, JEE D2.1, and JEE R1.5) with the total baseline score: 4 (all indicators reduced to level 1). Calculated by (total score at end of the project-total baseline score)/total baseline score Intermediate Indicators Component 1 Average unit cost of 1. Number of people receiving project supported quality 0.00 29,268 175,610 PHC service per primary health services patient: US$68 The sum of: (i) 140,000 2. Number of people receiving project supported quality mental psychosocial support 0.00 150,000 247,500 health and psychosocial support services beneficiaries in Gaza under US$23.8M scope and 200,000 57 The baseline is 0 as the indicator captures number of people supported by the project May 6, 2024 Page 58 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) under US$45M (additional 0.5M to be allocated to the psychosocial support), (ii) number of beneficiaries of mental health services to be provided in Gaza US$23.8M scope: 10,000 patients referred to health facilities; average unit cost of mental health service per patient (12 visits*US$30): US$360; and (iii) number of beneficiaries of mental health services to be provided in West Bank under US$45M scope: 37,500 patients; average unit cost of mental health service per outpatient per year (4 visits*US$30): US$120; There are 491 public PHC facilities (441 in West Bank/145 level 3 and 4, 52 in Gaza/all level 3 and 4), and 3. Number of public PHC facilities and service delivery points 0.00 140* 280 almost 200 delivery receiving investments from the project points. Assuming targeting 20% of all with US$23.8M scope and 40% of all with US$45M scope 4. Number of service delivery points provided with equipment Based on the existing or medical/non-medical supplies for provision of integrated 0 20 20 public delivery points MHPSS and family medicine services in south of Gaza (20) 5-9% of population to be reached by PSS outreach services in Gaza (indicator #2 under this component) 5. Number of referrals from outreach teams to health facilities 0 30,000 30,000 would need referral to providing integrated MHPSS and family medicine services a health facility (7,000- 12,600 under US$23.8M scope; 10,000-20,000 under US$45M scope) 6. Number of service providers recruited and trained to 100 new providers to 0.00 200 200 administer MHPSS interventions be trained annually May 6, 2024 Page 59 of 60 The World Bank Additional Financing to Health System Efficiency and Resilience Project (P181529) during the first two years. The number will include training of the existent providers engaged by MOH, UNRWA and NGOs. Described in parent 7. Number of women undergoing mammography examination 0.00 30,000 30,000 project PAD Component 2 Based on average unit cost of US$250 per 1. Number of people receiving project-supported quality 0.00 4,000 18,800 patient of standard tertiary care services inpatient services in hospitals Based on average unit cost of US$1,000 per 2. Number of people receiving project-supported rehabilitation 0.00 0.00 6,000 patient of surgery rehabilitative and reconstructive surgery There are 51 hospitals in West Bank (15) and Gaza (36). Assuming targeting all hospitals 3. Number of public hospitals receiving investments from the 0.00 22* 30 in West Bank under project both scenarios, and 20% in Gaza with US$23.8M & 40% in Gaza with US$45M 4. Percentage of patients that are satisfied with service Described in parent 0.00 75% 75% availability at hospitals targeted by the project project PAD Component 3 1 review/exercise performed every 6 4. Number of after/intra-action reviews or simulation exercises months. Details on the 0.00 5.00 5.00 performed utilizing the 7-1-7 approach indicator available in the Pandemic Fund’s Result Framework. Introduction of each new test requires adequate space, equipment, trained personnel, operating 5. Number of diagnostic tests added to the central public health 0.00 4.00 4.00 procedures, and laboratories availability of consumables. List of diagnostic tests is to be proposed by the MOH. Indicators with a * capture the impact of CERC activation. May 6, 2024 Page 60 of 60