Document of The World Bank FOR OFFICIAL USE ONLY Report No: ICR00006656 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-59670; IDA-59680; IDA-59690; IDA-59700; IDA-D1700) ON CREDITS IN THE AMOUNT OF EUR 19.9 MILLION (US$21 MILLION EQUIVALENT) TO THE REPUBLIC OF GUINEA BISSAU, SDR 11.2 MILLION (US$15 MILLION EQUIVALENT) TO THE REPUBLIC OF LIBERIA, SDR 66.5 MILLION (US$90 MILLION EQUIVALENT) TO THE FEDERAL REPUBLIC OF NIGERIA, AND EUR 13.3 MILLION (US$14 MILLION EQUIVALENT) TO THE REPUBLIC OF TOGO AND A GRANT IN THE AMOUNT OF SDR 5.3 MILLION (US$7 MILLION EQUIVALENT) TO THE REPUBLIC OF TOGO FOR THE REGIONAL DISEASE SURVEILLANCE SYSTEMS ENHANCEMENT (REDISSE) PHASE II PROJECT June 4, 2024 Health, Nutrition & Population Global Practice Western And Central Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective May 30, 2024) Currency Unit = FCFA, LRD, NGN 605.2 FCFA; 194 LDR; 1,334.4 NGN = US$1 US$1 = SDR 0.756086 US$1 = EUR 0.92267573 FISCAL YEAR July 1 - June 30 Regional Vice President: Ousmane Diagana Country Director: Boutheina Guermazi Regional Director: Trina S. Haque Acting Practice Manager: Carolyn J. Shelton Carolyn J. Shelton, Collins Chansa, Yemdaogo Tougma, Task Team Leaders: Mariam Noelie Hema, Chijioke Samuel Okoro ICR Main Contributor: Maria R. Puech Fernandez ABBREVIATIONS AND ACRONYMS ADM Accountability and Decision Making AFENET African Field Epidemiology Network CDC Center for Disease Control and Prevention CERC Contingent Emergency Response Component CES Center for Epidemiologic Surveillance COUSP Centre des Operations d’Urgences de Sante Public CPF Country Partnership Framework CPS Country Partnership Strategy EBS Event-based Surveillance ECOWAS Economic Community of West African States EOC Emergency Operation Center ESF Environmental and Social Framework ESMF Environmental and Social Management Framework FCT Nigeria – Federal Capital Territory FCV Fragility, Conflict, Violent FETP Field Epidemiology Training Program FELTP Field Epidemiology and Laboratory Training Program GHSA Global Health Security Agency GoGB Government of Guinea-Bissau GoL Government of Liberia GoN Government of Nigeria GoT Government of Togo HCWMP Health Care Waste Management Plan ICR Implementation Completion and Results Report IDA International Development Organization IDSR Integrated Disease Surveillance and Response IHR International Health Regulations (Règlement Sanitaire International) IPC Infection, Prevention and Control IPVMP Integrated Pest and Vector Management Plan ISR Implementation Status Report ITSON Integrated Training for Surveillance Officers in Nigeria JEE Joint External Evaluation MINSAP Ministry of Public Health - Guinea Bissau MOA Ministry of Agriculture MOH Ministry of Health MPA Multiphased Programmatic Approach MTR Mid-term Review NADIS National Animal Diseases Information and Surveillance System - Nigeria NAPHS National Action Plan for Health Security NCDC Nigeria Center for Disease Control NPHIL National Public Health Institute of Liberia NSPRP National Surveillance, Preparedness and Response Plan OH One Health OIE (WOAH) World Organization for Animal Health, formerly called OIE OOAS Organisation Ouest Africaine de la Santé (West Africa Health Organization) PAD Project Appraisal Document PCU Project Coordination Unit PDO Project Development Objective PHEIC Public Health Emergency of International Concern PIU Project Implementation Unit PIM Project Implementation Manual PVS Performance of Veterinary Services (Pathway) RAHC ECOWAS Regional Animal Health Center RCSDC Regional Center for Surveillance and Disease Control REDISSE Regional Disease Surveillance Systems Enhancement RRT Rapid Response Teams SOP Series of Projects SORMAS Surveillance, Outbreak, Response Management and Analysis System - Nigeria STEP Systematic Tracking of Exchanges in Procurement UHC Universal Health Care UNDP United Nations Development Program US CDC United States Center for Disease Control VS Veterinary Services WAHO West Africa Health Organization (Organisation Ouest Africaine de la Santé) WB The World Bank WHO World Health Organization WOAH World Organization for Animal Health, formerly called OIE TABLE OF CONTENTS DATA SHEET .......................................................................................................................... 1 I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................... 6 A. CONTEXT AT APPRAISAL .........................................................................................................6 B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) ..................................... 12 II. OUTCOME .................................................................................................................... 16 A. RELEVANCE OF PDOs ............................................................................................................ 16 B. ACHIEVEMENT OF PDOs (EFFICACY) ...................................................................................... 17 C. EFFICIENCY ........................................................................................................................... 26 D. JUSTIFICATION OF OVERALL OUTCOME RATING .................................................................... 29 E. OTHER OUTCOMES AND IMPACTS (IF ANY) ............................................................................ 29 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ................................ 30 A. KEY FACTORS DURING PREPARATION ................................................................................... 30 B. KEY FACTORS DURING IMPLEMENTATION ............................................................................. 31 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 33 A. QUALITY OF MONITORING AND EVALUATION (M&E) ............................................................ 33 B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE ..................................................... 35 C. BANK PERFORMANCE ........................................................................................................... 36 D. RISK TO DEVELOPMENT OUTCOME ....................................................................................... 39 V. LESSONS AND RECOMMENDATIONS ............................................................................. 40 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ........................................................... 42 ANNEX 1B. KEY OUTPUTS BY COMPONENT ....................................................................... 83 ANNEX 1C. RESULTS FRAMEWORK INDICATOR COMPARISON .............................................. 89 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION ....................... 102 ANNEX 3. PROJECT COST BY COMPONENT ......................................................................... 108 ANNEX 4. ECONOMIC ANALYSIS ......................................................................................... 109 ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS . 118 ANNEX 6. SUPPORTING DOCUMENTS (IF ANY) ................................................................... 127 ANNEX 7. THE JOINT EXTERNAL EVALUATION (JEE) TOOL ................................................... 128 ANNEX 8. THE ONE HEALTH APPROACH ............................................................................. 130 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) DATA SHEET BASIC INFORMATION Product Information Project ID Project Name Regional Disease Surveillance Systems Enhancement P159040 (REDISSE) Phase II Country Financing Instrument Western and Central Africa Investment Project Financing Original EA Category Revised EA Category Partial Assessment (B) Partial Assessment (B) Organizations Borrower Implementing Agency MINISTRY OF HEALTH (MOH) OF LIBERIA, MINISTRY OF HEALTH (MOH) OF TOGO, MINISTRY OF PUBLIC HEALTH Federal Republic of Nigeria, Republic of Guinea Bissau, (MINSAP) OF GUINEA BISSAU, NIGERIA CENTER FOR Republic of Liberia, Republic of Togo DISEASE CONTROL (NCDC), West African Health Organization (WAHO) Project Development Objective (PDO) Original PDO The PDOs are : (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa, thereby addressing systemic weaknesses within the animal and human health systems that hinder effective disease surveillance and response; and (ii) in the event of an Eligible Emergency, to provide immediate and effective response to said Eligible Emergency. Page 1 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) FINANCING Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing 14,000,000 8,898,301 9,570,116 IDA-59670 7,000,000 5,291,548 4,722,150 IDA-D1700 15,000,000 15,000,000 14,765,663 IDA-59690 90,000,000 63,938,990 63,619,094 IDA-59700 21,000,000 13,742,124 14,336,994 IDA-59680 Total 147,000,000 106,870,963 107,014,017 Non-World Bank Financing 0 0 0 Total 0 0 0 Total Project Cost 147,000,000 106,870,964 107,014,017 KEY DATES Approval Effectiveness MTR Review Original Closing Actual Closing 01-Mar-2017 27-Jul-2017 04-Feb-2022 31-Aug-2023 31-Aug-2023 RESTRUCTURING AND/OR ADDITIONAL FINANCING Date(s) Amount Disbursed (US$M) Key Revisions 13-Feb-2020 22.07 Change in Results Framework Change in Components and Cost Reallocation between Disbursement Categories 01-Jun-2023 95.47 Change in Results Framework Change in Components and Cost Reallocation between Disbursement Categories 29-Aug-2023 107.49 Change in Components and Cost Cancellation of Financing Reallocation between Disbursement Categories Page 2 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) KEY RATINGS Outcome Bank Performance M&E Quality Satisfactory Satisfactory Substantial RATINGS OF PROJECT PERFORMANCE IN ISRs Actual No. Date ISR Archived DO Rating IP Rating Disbursements (US$M) 01 28-Jun-2017 Satisfactory Satisfactory 0 02 26-Dec-2017 Satisfactory Satisfactory 1.24 03 21-Jun-2018 Satisfactory Satisfactory 10.55 04 20-Dec-2018 Satisfactory Satisfactory 14.34 05 04-Jun-2019 Moderately Satisfactory Moderately Satisfactory 20.01 06 18-Dec-2019 Moderately Satisfactory Moderately Satisfactory 21.05 07 23-Jun-2020 Moderately Satisfactory Moderately Satisfactory 46.87 08 12-Jan-2021 Moderately Satisfactory Moderately Satisfactory 58.93 09 22-Jul-2021 Moderately Satisfactory Moderately Satisfactory 69.63 10 10-Mar-2022 Satisfactory Satisfactory 75.36 11 06-Dec-2022 Moderately Satisfactory Moderately Satisfactory 86.46 12 13-Sep-2023 Moderately Satisfactory Moderately Satisfactory 108.97 13 17-Jan-2024 Satisfactory Moderately Satisfactory 107.03 SECTORS AND THEMES Sectors Major Sector/Sector (%) Agriculture, Fishing and Forestry 33 Livestock 33 Page 3 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Information and Communications Technologies 5 ICT Infrastructure 5 Health 62 Public Administration - Health 30 Health Facilities and Construction 32 Themes Major Theme/ Theme (Level 2)/ Theme (Level 3) (%) Private Sector Development 31 ICT 31 ICT Solutions 31 Human Development and Gender 100 Health Systems and Policies 100 Health System Strengthening 100 Urban and Rural Development 85 Rural Development 85 Rural Infrastructure and service delivery 85 Disaster Risk Management 33 Disaster Preparedness 33 Environment and Natural Resource Management 50 Climate change 50 Adaptation 50 ADM STAFF Role At Approval At ICR Regional Vice President: Makhtar Diop Ousmane Diagana Country Director: Rachid Ben Messaoud Boutheina Guermazi Director: Timothy Grant Evans Trina S. Haque Practice Manager: Trina S. Haque Carolyn J. Shelton Page 4 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Chijioke Samuel Okoro, Collins Task Team Leader(s): John Paul Clark, Francois G. Le Gall Chansa, Yemdaogo Tougma, Mariam Noelie Hema ICR Contributing Author: Maria R. Puech Fernandez Page 5 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES A. CONTEXT AT APPRAISAL Regional, Sectoral and Institutional Context 1. The countries in the West Africa Region belong to the Economic Community of West African Countries (ECOWAS1), which encompasses 15 countries (with a population of 355 million people) that are heterogenous in terms of cultural, economic, and human development. Overall, countries rank low on the United Nations Development Program (UNDP) human development index. While the ECOWAS countries face different challenges, they also share a set of common risks related to: (i) limited institutional capacity; (ii) economic growth frequently affected by external shocks; and (iii) susceptibility to frequent outbreaks of infectious diseases. This was certainly the case for the four countries – Guinea Bissau, Liberia, Nigeria, and Togo - participating in Phase II of the Regional Disease Surveillance Systems Enhancement (REDISSE) Program. Some of these countries were also affected by political instability2 and vulnerability to natural disasters at the time of project preparation. 2. In the wake of the 2014-16 West Africa Ebola outbreak, the international health community began to coalesce around the goal of strengthening the world’s capacity, particularly in low -income countries, to be better prepared to prevent, detect, and respond to infectious disease outbreaks. The West Africa Ebola outbreak, which began in an area bordering Guinea, Liberia and Sierra Leone, went unnoticed for several weeks before it was identified, mainly due to weak surveillance systems and poor public health infrastructure. Gaps in these countries’ preparedness and response capacities contributed to the outbreak spreading uncontrollably, resulting in more than 28,600 cases, 11,325 deaths, and wiping out many of the recent development gains in the three countries, which had been among the fastest growing economies in the world prior to the crisis. The World Bank estimated that as a result, the three countries lost US$2.2 billion in GDP in 2015 alone. In the aftermath of the Ebola crisis, the World Health Organization (WHO) bolstered its focus on strengthening country surveillance, preparedness and response systems, the Global Health Security Agenda joined efforts with WHO in supporting countries comply with their International Health Regulations (IHR) requirements, and the Joint External Evaluation (JEE) tool to monitor country compliance with IHR was developed. 3. Against this background, and while the Ebola crisis was still unfolding, the World Bank began the preparation of an ambitious and complex operation, the REDISSE Program. The nature of the REDISSE Program was both unique and groundbreaking for the following reasons. First, the size of the program was large, targeting 16 countries in the Africa region, a handful of which were considered FCV countries. As a result, projects covering a batch of countries had to be prepared as a series of operations. Second, the REDISSE program integrated the One Health approach in its implementation, which required cross-sectoral collaboration between the health, agriculture, and environment sectors, which are sectors that had 1ECOWAS is a regional organization which promotes economic integration across the West Africa Region. 2At the time of preparation, Guinea-Bissau, Liberia, and Togo were included in the World Bank’s Harmonized List of Fragile Situations for FY17. In FY20 the list became the World Bank’s List of Fragile and Conflict-affected Situations, which then included Nigeria but excluded Togo. In FY22 Liberia was removed from the list but Guinea-Bissau and Nigeria have remained on the list since. Page 6 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) traditionally worked in silos. Moreover, at the time, this complex approach was still relatively nascent and the concept itself was not yet well established and had not yet been well developed in practice, which meant a steep learning curve by countries. Third, it included a regional dimension, which focused on cross-border collaboration. In addition to the regional aspect, many of the activities involved implementation at local, subnational, and national levels. Fourth, it was comprehensive, covering several core capacities under the IHR (surveillance, laboratories, human resources, and preparedness and emergency response). Lastly, it included the possibility of supporting the response to a health emergency, which proved to be instrumental during COVID-19 and with other outbreaks. 4. The REDISSE Program became the first comprehensive set of projects financed by the World Bank that directly addressed systemic gaps in health emergency preparedness and response capacities at country and regional levels. Before REDISSE, the World Bank’s approach to health emergencies had been mostly one of supporting countries in times of crisis rather than providing steady support pandemic capacities during non- crisis times. In that sense REDISSE was a game-changer. Other projects, particularly in the post-COVID world, have followed in the footsteps of REDISSE. Moreover, the REDISSE projects played a critical role in bridging the financing gap between the onset of the COVID-19 pandemic and the approval and effectiveness of the COVID-19 Strategic Preparedness and Response Program (SPRP), approved on April 2, 2020 for the first group of countries3, which provided funding for COVID-19 response to 33 Sub-Saharan African countries and later extended to 41 countries to support the acquisition of COVID-19 vaccines. Theory of Change (Results Chain) 5. The REDISSE PAD did not include a Theory of Change (ToC)4, therefore the project’s TOC was constructed ex-post, retrofitted from the PAD project description and the Results Framework (RF). The TOC was built on the logic that activities addressing the weaknesses in the human and animal health systems would strengthen national and regional capacity for disease surveillance in the four countries. It was also built on the logic that activities would build cross-sectoral and inter-country collaboration, which would strengthen disease surveillance systems, and preparedness and response capacities. The PAD assessed the overall risks for the four participating countries as substantial, as some were considered FCV countries5. The activities under Component 1 would contribute to strengthening national surveillance and reporting systems, and their interoperability at national, decentralized, and local levels by: (i) supporting coordinated community-level surveillance systems and processes across the animal and human health sectors; (ii) developing capacity for interoperable surveillance and reporting systems; and (iii) establishing an early warning system for infectious disease trends prediction. Activities under Component 2 would contribute to establishing networks of public health and veterinarian laboratories for diagnosis of infectious human and animal diseases and a regional networking platform to improve collaboration on research by: (i) upgrading laboratory facilities, improving data management and specimens’ management systems, and enhancing regional reference laboratory functions. Activities under Component 3 would enhance preparedness and response capacity, improving local, national, and regional level capacity by: (i) enhancing cross-sectoral coordination and collaboration for 3https://www.worldbank.org/en/news/press-release/2020/04/02/world-bank-group-launches-first-operations-for-covid-19- coronavirus-emergency-health-support-strengthening-developing-country-responses 4 As per OPCS guidelines, including the theory of change became mandatory for PADs as of May 2018. The PAD for REDISSE II (P159040) was approved by the World Bank’s Board of Directors on 2 March 2017 5 At the time of preparation, Guinea-Bissau, Liberia, and Togo were included in the World Bank’s Harmonized List of Fragile Situations for FY17 Page 7 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) preparedness and response; and (ii) strengthening the capacity for response. It included a sub-component to support the governments’ immediate response in case of an outbreak. The results chain also included activities under Component 4 to strengthen human resources across the main themes of Components 1, 2 and 3 (surveillance, laboratories and preparedness and response) and to strengthen countries’ capacity to plan for and improve management of human resources. Activities under Component 5 would provide cross- cutting critical institutional support. They would also support the external independent evaluation of critical animal health and human health capacities of national systems using reference tools (JEE, OIE PVS). Figure 1 presents the Theory of Change for the Project. Page 8 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Figure 1: REDISSE - Theory of Change Activities Intermediate Results Outcomes PDO Surveillance and information systems: • Collaboration and exchange of • Establish linkages between surveillance information across countries information systems (human and animal; improved. Increased sub-national, national and regional). • Community/local-level surveillance collaboration and • Develop/enhance early warning systems and response processes are integration for Strengthen for surveillance, inc. analysis and strengthened. surveillance and national and predictions. • Progress towards establishing event- preparedness regional cross- • Implement cross-border surveillance based surveillance systems. across sectors, sectoral collaboration activities. • Better integration/ interconnection across countries capacity for • Train human and animal health of surveillance and and regional level. collaborative community/field level staff for detection information/reporting systems disease and reporting. across animal and human health Increased surveillance • Conduct Field Epidemiology Training sectors. effectiveness in and epidemic Program (FETP) for staff at different • Surveillance work and processes disease preparedness levels and across sectors (human and across the human and animal health surveillance, early in West Africa. animal health). sectors are improved and better detection, and • Improve infrastructure and equipment of coordinated (progress towards reporting. Provide health facilities. operationalizing One Health immediate and • Harmonize protocols and guidelines. approach) Systemic effective Laboratory capacity: • Systems for effective reporting to weaknesses in response to • Improve infrastructure, equipment and relevant organizations are improved. human and animal emergencies. supplies of laboratory facilities and • Capacity to analyze/predict health sectors networks. epidemic trends is improved. (human resources, • Increase laboratory services. quality data, • Strengthen lab information systems. • Laboratory facilities upgraded, planning) are • Strengthen integration of lab info connected as a network (sub- reduced. systems with disease surveillance and nationally, nationally and regionally) reporting syst. • Laboratory testing capacity for Increased capacity • Improve sub-national, national and detection of priority diseases for immediate and regional lab specimen referral and increased. effective response transportation systems. • Specimen management systems to an eligible • Strengthen quality assurance systems improved. public health and accreditation processes. • Regional reference laboratory emergency at sub- Preparedness and Emergency Response: networking functions enhanced. national, national • Develop/update National Emergency and regional Preparedness and Response Plans. levels. • Strengthen Emergency Operating Center • Multi-hazard emergency infrastructure. preparedness and response plans • Strengthen risk communication implemented. Long-term Outcomes mechanisms. • Mechanisms for responding to • Conduct simulation exercises. known infectious zoonoses and Strengthen health systems to • Deploy resources for outbreak response. potential zoonoses established and (i) improve health outcomes and reduce vulnerability HR Management for Surveillance and operational. (ii) mitigate /reduce human and economic burden of Preparedness: • EOC Surge capacity and stockpiling disease outbreaks • Carry out HR mapping and gap analysis. mechanisms established at national • Train human resources at central and and regional levels. decentralized levels (surveillance, preparedness, response, one health). • Availability and capacity of human Inputs Financing, equipment, logistics, technical • Recruitment of surveillance and resources to implement IHR core assistance (WB & WAHO), grievance redress laboratory staff capacities is increased. mechanism, ESF tools. WBG global expertise, Institutional Capacity Building, Coordination • Capacity and competency public convening power and reputation as a fair broker. and Advocacy: health and veterinary health • Build capacities in public health workforce increased. institutions. • Establish One Health coordination • Cross-border collaboration and platforms. information exchange improved. • Regional public health institutions are strengthened. • One Health as an institutional Page 9 of 131 collaboration mechanism established and functional. The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Project Development Objectives (PDOs), Key Expected Outcomes, Components 6. The PDOs were: (a) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa, thereby addressing systemic weaknesses within the animal and human health sectors that hinder disease surveillance and response; and (b) in the event of an Eligible Emergency, to provide immediate and effective response to said Eligible Emergency. 7. The achievement of the PDOs was to contribute to the higher outcome of building coordinated interventions to provide regional public goods; and of improving regional collaboration across borders to address disease threats (a public good). The achievement of the PDOs was expected to contribute to increased growth, ending extreme poverty, and boosting shared prosperity. 8. Project beneficiaries: The main program beneficiaries were the population of ECOWAS countries. REDISSE II was expected to benefit over 191 million people6 whose livelihoods might be affected by diseases. Secondary beneficiaries included public and private service providers and national and regional institutions involved in human and animal health. 9. The main expected Project outcomes, as included in the PAD, were: • PDO 1 - Strengthened capacity at national and regional level, at cross-sectoral level, for collaboratively surveillance and for epidemic preparedness. • PDO 2 - Improved capacity to respond immediately and effectively to an eligible emergency. The Project was also expected to contribute to the following outcomes and achievements: • Developed capacity (national and regional) to fully implement the Integrated Disease Surveillance and Response (IDSR). • Developed capacity (national and regional) to comply with international standards for veterinary services. • Efficient collaboration and synergies between human and animal epidemiological surveillance and response networks, at national and regional levels. 10. The PDO-level results indicators for the REDISSE II project were to be measured primarily using indicators drawn from WHO’s JEE tool as follows: PDO 1: (i) Progress towards establishing an active, functional One Health Platform (Number based on 5- point Likert scale). (ii) Laboratory testing capacity for detection of priority diseases: (number of countries that achieve a JEE score of 4 or higher out of 5), (iii) Progress in establishing indicator and event-based surveillance systems: (number of countries that achieve a JEE score of 4 or higher out of 5), (iv) Availability of human resources to implement IHR core capacity requirements: (number of countries that achieve a JEE score of 3 or higher out of 5), 6 Data from PAD2200: 1.9 million in Guinea Bissau, 4.4 million in Liberia, 177.5 million in Nigeria and 7.3 million in Togo Page 10 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) (v) Progress on cross-border collaboration and exchange of information across countries: (number of countries that achieve a JEE score of 4 or higher out of 5). PDO 2: (vi) Multi-hazard national public health emergency preparedness and response plan is developed and implemented: (number of countries that achieve a JEE score of 4 or higher out of 5), 11. The JEE tool assesses country capacities to prevent, detect, and respond to public health risks, in line with the International Health Regulations (IHR). At appraisal, the Bank made a conscious decision to use the JEE tool for the project, signaling its alignment, along with all development partners, to this newly developed tool and its agreement to work together with partners in contributing to support countries to strengthen their preparedness capacities and progressively achieve higher JEE scores. The consensus was that JEE indicators were adequate to (i) monitor the project’s implementation progress and achievement of the PDOs, (ii) facilitate the dialogue between all relevant partners contributing to the health security agenda in those countries; and (iii) limit the M&E burden on countries by having a single tool. The choice of JEE indicators also reflected the complementary character of the REDISSE program, along with all other ongoing efforts by development partners (see Annex 7 for details). It is important to note, however, that while the project contributed to improved scores, the project alone was not responsible for the achievement of the score. Moreover, the JEE scores themselves were not expected to fully reflect and record all the progress made by countries in strengthening their preparedness capacities. The JEE measures certain aspects of preparedness and are used as a proxy to measure a level of preparedness. See section on Outcomes and on Quality of M&E for more details. 12. The REDISSE II project included five components: 13. Component 1 – Surveillance and Information Systems (Original cost: US$45.33 million. Actual cost: US$ 34.07 million) This component aimed to enhance national surveillance and reporting systems at the different levels of the health system. It supported national and regional efforts in the surveillance of priority diseases and timely reporting of human and animal public health emergencies in line with the IHR (2005) and the OIE Terrestrial Animal Health Code. It sought to strengthen the linkages of surveillance and response systems at local level. It had three subcomponents: (1.1) Support coordinated community-level surveillance systems and processes across the animal and human health sectors; (1.2) Develop capacity for interoperable surveillance and reporting systems; and (1.3) Establish an early-warning system for infectious disease trends protection. 14. Component 2 - Strengthening of Laboratory capacity (Original cost: US$30.89 million equivalent. Actual cost: US$22.03 million). This component involved the identification and/or establishment of networks of efficient, high quality, accessible public health and veterinarian laboratories for the diagnosis of infectious human and animal diseases and the establishment of a regional networking platform to improve collaboration for laboratory investigation. It had three subcomponents: (2.1) Review, upgrade and network laboratory facilities; (2.2) Improve data management and specimen management systems; and (2.3) Enhance regional reference laboratory networking functions. 15. Component 3 - Preparedness and Emergency Response (Original cost: US$20.4 million equivalent. Actual cost: US$20.93 million). This component supported national and regional efforts to enhance infectious disease outbreak preparedness and response capacity, improving local, national and regional capacities. The Page 11 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) project aimed at improving country and regional surge capacity to ensure a rapid response during an emergency. It sought to educate and change behavior and prepare communities for outbreaks and emergencies. It had the following sub-components: (3.1) Enhance cross-sectoral coordination and collaboration for preparedness and response; (3.2) Strengthen capacity for emergency response, and (3.3) Contingency Emergency Response Component (CERC). 16. Component 4 – Human resource management for Effective Disease Surveillance and Epidemic Preparedness (Original cost: US$22.64. Actual cost: US$13.46 million). This component was cross-cutting of the previous three components. It aimed to strengthen government capacity to plan, implement and monitor human resource interventions. It supported the development of institutional capacity for planning and managing workforce training, leveraging existing training structures and programs across countries in the region. It had two subcomponents: (4.1) Healthcare Workforce mapping, planning and recruitment; and (4.2) Enhance Health Workforce training, motivation and retention. 17. Component 5 - Institutional Capacity Building, Project Management, Coordination and Advocacy (Original cost: US$22.05 million. Actual cost: US$16.33 million). This component focused on all aspects related to project management. It provided critical cross-cutting institutional support, to meet the additional capacity building and training needs, on top of the support provided in the other four technical components. It supported the routine independent external assessments of critical animal and human health capacities of national systems using reference tools (JEE and OIE PVS) to identify weaknesses and monitor progress. It had two sub-components: (5.1) Project coordination, fiduciary management, monitoring and evaluation, data generation and knowledge management; and (5.2) Institutional support, capacity building, advocacy, and communication at the regional level. 18. Project Institutional Arrangements were both at regional and national level. At regional level, project implementation was led by WAHO, which hosted a secretariat for regional coordination and was financed exclusively through the REDISSE Phase I Project. Country implementation included several institutions (ministries of health, agriculture, and environment, national institutes of health and/or disease control). In all countries, one implementing agency functioned as un “umbrella ministry”, in charge of coordinating implementation by sectoral ministries (agriculture, livestock, health, etc.) and NGOs. Given the multi-sectoral nature of the project, countries also established national steering and technical committees that involved additional actors (ministries of finance and international development partners). These committees were also established at regional level. B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) 19. Figure 2 below presents the REDISSE II Project timeline and major milestones that took place during the life of the Project. Page 12 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Figure 2: REDISSE II Timeline of Key Events Sep: Liberia completes 1st JEE 2016 Mar: REDISSE II Board Approval Jun: Nigeria completes 1st JEE 2017 Jul: Togo REDISSE II effectiveness Sep: Guinea Bissau REDISSE II effectiveness Nov: Liberia REDISSE II effectiveness Feb: Nigeria REDISSE II effectiveness Apr: Nigeria triggers CERC for Lassa 2018 Apr: Togo competes 1st JEE 2019 Jul: Guinea Bissau completes 1st JEE Feb: 1st REDISSE II Project Restructuring Feb: Nigeria records 1st COVID-19 case Mar: Liberia records 1st COVID-19 case Mar: Liberia triggers CERC for COVID-19 Mar: Guinea Bissau records 1st COVID-19 case 2020 Mar: Togo records 1st COVID-19 case Apr: Liberia COVID-19 MPA Project Board Approval Apr: Togo COVID-10 MPA Project Board Approval Aug: Nigeria COVID-19 MPA Project Board Approval 2021 Jun: Guinea Bissau COVID-19 MPA Project Board Approval May: 2nd REDISSE II Project Restructuring Aug: Nigeria completes 2nd JEE (report not yet public) Aug: 3rd REDISSE II Project Restructuring Aug: REDISSE II Project Closes (31 Aug 2023) 2023 Sep: Liberia completes 2nd JEE (report not yet public) Dec: Health Security MPA Board Approval 20. The REDISSE II project was restructured three times: i) February 2020; ii) June 2023; and iii) August 2023. Table 1 presents key information about each restructuring. Table 1: Summary of REDISSE II Project Restructurings Date Countries Changes made Percent disbursed by relevant country credit/grant 1 13-February-2020 All countries -Results Framework for all countries GB: 17.14% -Component and Costs (for Nigeria) Liberia: 22.5% Nigeria: 10.75% Page 13 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) -Reallocation between Disbursement Togo: 25.85% Categories (for Nigeria) 2 1-June-2023 Liberia -Results Framework Liberia: 87.33 % -Component and Costs GB: 60.5% -Reallocation between Disbursement Nigeria: 61.6 % Categories Togo: 68% 3 25-August-2023 Guinea Bissau -Components and Cost GB:62 % Nigeria -Cancellations Liberia: 91.5% Togo -Reallocation between Disbursement Nigeria: 73.6% Categories Togo: 68% 21. Restructuring No. 1: A First Level II Restructuring was approved on February 13, 2020 to reflect two key events: (a) the first JEE exercises completed between 2017 and 2019; and (b) an outbreak of Lassa fever in Nigeria in February -March 2018, which resulted in the activation of the CERC. The restructuring entailed: (i) reallocations between disbursement categories due to CERC activation in Nigeria; and (ii) updates to the RF as follows: (a) update the baseline scores and targets of indicators with the JEE7 scores, (b) align regional and country-level indicator targets with the baseline data, (c) remove indicators that no longer were pertinent to the Project8; (d) add an indicator to monitor access by men and women to training opportunities; and (e) add an indicator to reflect CERC results. 22. Restructuring No. 2: The Second Level II Restructuring was approved on June 1, 2023 to reflect Liberia’s triggering of the CERC to respond to the COVID-19 pandemic. On March 20, 2020, the Government of Liberia (GoL) requested to activate the CERC by allocating US$8 million from the Project to fund the response. At the GoL’s request, the restructuring entailed: (i) normalizing the reallocation of funds due to the activation of the CERC (a total of US$5.2 million was utilized for the COVID-19 response); and (ii) revising the results framework to incorporate intermediate results indicators to measure the performance of activities for the COVID-199. 23. Restructuring No. 3: The Third Level II Restructuring was approved on August 25, 2023, to reflect a cancellation and reallocation of funds and changes in the costs by components, by Guinea-Bissau, Nigeria, and Togo, prior to the project’s completion. The Project had a closing date of August 31, 2023, and by 2022 there were already discussions and formal requests for its extension. While there was some rationale to justify the extension, including the impact of COVID-19 and issues related to specific country contexts (political instability in Guinea Bissau; delays in effectiveness in Nigeria) which affected implementation, the WB opted for keeping the original closing date. A new Bank-supported Multi-Phased Programmatic Approach (MPA) operation, the Health Security Program in West and Central Africa (P179078), was already under preparation and was meant to continue many of the activities initiated by REDISSE. Given the information available at the time, the decision to close the original project as scheduled and continue supporting health security through the new operation was reasonable. However, delays in MPA project preparation, which were beyond the control of 7 Guinea Bissau was the last of the REDISSE II countries to complete its JEE, in July of 2019 8 As per the Restructuring Project Paper, the removed indicators were: (1) Turnaround time from date of specimen collection to date of results returned for priority diseases; (2) Total number of project beneficiaries; (3) Project beneficiaries of which female; and (4) Number of policy briefings on the status of disease surveillance and response in the region presented at ECOWAS meetings. 9 These were: (1) Number of suspected cases of Covid reported and investigated per approved protocol; (2) Number of designated laboratories with COVID-19 diagnostic equipment, test kits and reagents; and (iii) Outbreak/pandemic emergency risk communication plan and activities developed and tested. Page 14 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) the teams, resulted in a lack of continuation of supported activities as originally envisioned, as countries were unable to sustain many of the REDISSE-financed activities with their own resources. As there was not sufficient time to utilize the project's funds by the closing date, 27% of the original project amount was cancelled. Table 2: Summary of Project Costs Amount Revised Amount at Amount at Amount at Amount After Project Closing as % Component Cancelled Approval Restructurings Closing of Amount at (US$M) (US$M) (CERC) (US$M) (US$M) Approval Component 1: Surveillance and Information Systems 45.33 44.29 10.22 34.07 75.2% Component 2: Strengthening of Laboratory Capacity 30.89 30.17 8.86 21.31 69.0% Component 3: Preparedness and Emergency Response 26.08 30.92 6.12 24.8 95.1% Component 4: Human Resource Management for Effective 22.64 20.62 9.18 11.44 50.5% Disease Surveillance and Epidemic Preparedness Component 5: Institutional Capacity Building, Project 22.06 21 5.73 15.27 69.2% Management, Coordination, and Advocacy TOTAL 147.00 147.00 40.11 106.89 72.7% Revised PDOs and Outcome Targets 24. The PDOs were not revised during the life of the Project. Revised PDO Indicators 25. The First Level II Restructuring in February 2020 introduced one additional PDO indicator for Nigeria to measure the CERC results: “Number of suspected cases actively investigated for Lassa fever and treated if needed”. Revised Components 26. The project components and sub-components were not revised during the life of the Project. Rational for Changes and their Implication on the Theory of Change 27. While there were three restructurings, the results chain between inputs-activities-intermediate results and outcomes was not altered. The rationale for the restructurings is explained above, under the section of significant changes. The results of the JEEs carried out by participating countries provided additional information that was not available during appraisal10. The JEEs provided more accurate and/or realistic data about country capacities, which required adjusting the results framework baselines, targets, and the harmonization of regional and national annual targets21. 10 At the time of appraisal, only Liberia had completed a JEE. The last country to complete a JEE was Guinea-Bissau, in July 2019. Page 15 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) II. OUTCOME A. RELEVANCE OF PDOs Rating: High 28. The relevance of the PDOs is considered high both at appraisal and at completion. At appraisal, the PDOs were highly relevant, as the project was prepared in the aftermath of the 2014-2016 West Africa Ebola outbreak, which had confirmed the critical importance of strengthening national disease surveillance systems and inter-country collaboration in order to detect disease outbreaks earlier and respond more swiftly and effectively. The PDOs aimed to strengthen national disease surveillance systems, strengthen cross-sectoral collaboration within country and regional collaboration as well as to ensure improved preparedness, and response capacity, considering the lessons learned of the Ebola outbreak. At completion, the PDOs remained highly relevant, as strengthening surveillance systems, improving preparedness and response capacity continue to be increasingly pertinent, as proven by the COVID-19 pandemic. 29. The PDOs were aligned with the Country Partnership Frameworks’ (CPF) and Country Partnership Strategies’ (CPS) main goals and pillars for the period FY 2017-2023 for all four REDISSE II countries. These key documents focused on strengthening health systems’ capacity, including disease surveillance, to improve health outcomes and reduce vulnerability. The PDOs were also aligned with the Regional Integration and Cooperation Assistance Strategy for the period FY21–FY23, which explicitly mentions a focus on pandemic response and disease surveillance. 30. At appraisal and completion, the PDOs aligned with and built on international guidelines and health regulations. Namely, the WHO International Health Regulations (IHR 2005), the One Health Agenda, the Global Health Security Agenda, Universal Health Coverage (UHC), the OIE Terrestrial Animal Health Code and Manual, and the Sustainable Development Goals (SDG). At regional level, the PDOs aligned with the goals set by the Economic Community of West African States (ECOWAS) Member States to design a robust regional and national One Health Coordination Mechanism (OHCM)11. 31. The PDOs also aligned with the main objectives of the countries’ disease surveillance, preparedness, and emergency response related strategies and plans. COVID-19 rendered the PDOs even more relevant, as REDISSE’s activities aimed to strengthened surveillance systems, enabling better preparedness and response capacity to face the COVID-19 pandemic. For Nigeria, the PDO aligned with the country’s multi-sectoral National Action Plan for Health Security 2018-2022 (NAPHS). For Liberia, the PDOs were aligned with key objectives of the country’s Pro-poor Agenda for Prosperity and Development, the Liberia Incident Action Plan for COVID-19 response, and National Action Plan for Health Security (NAPHS) 2018-2022. For Togo, the Project aligned with the Accelerated Growth Strategy and Employment Promotion (SCAPE), the National Health Development Plan (NHDP) and the National Program for Agricultural Investment and Food Security (PNIASA). For Guinea-Bissau, the project was aligned with the Second National Plan for Health Development (PNDS II). 11WHO, Report on One Health Technical and ministerial Meeting to Address Zoonotic Diseases and related Public Health Threats, WHO, 2016. View: https://www.afro.who.int/sites/default/files/2018- 02/Report%20of%20the%20One%20Health%20Technical%20and%20Ministerial%20Meeting%20--%20Dakar_.pdf Page 16 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) B. ACHIEVEMENT OF PDOs (EFFICACY) Assessment of Achievement of Each Objective/Outcome 32. The assessment of achievements of outcomes for REDISSE II, as well as for the REDISSE Program as a whole, was a complex exercise. REDISSE II and the REDISSE Program drew most of its Results Framework indicators from the WHO JEE tool. On the one hand, the decision of adopting the JEE framework was a sound one. It was a conscious decision to join a global effort to support countries strengthen their national capacities to prevent, detect, and respond to public health risks in line with the IHR, and progressively improve their JEE scores. On the other hand, it came with some challenges. As mentioned in paragraph 11, the project was contributing to, but was not responsible for, the country’s achievement of a particular score. In addition, the JEE scores alone do not necessarily reflect the real progress made by countries in strengthening capacities. Significant progress may be achieved without achieving a higher JEE score. Scores are dependent on reaching a specific benchmark, which is used as a proxy to determine the level of progression, but does not consider the abundance of related achievements that take place prior to reaching the benchmark. Simply put, if a country has made substantial progress but does not meet the specific criteria for a given score, the score given will be one level below. Moreover, the JEE score, while important, is dependent of several factors including the WHO external evaluators and the version12 of the JEE tool used for the evaluation. Finally, the JEE specific targets associated with the particular score have been updated to push the envelope and promote progress in terms of strengthening preparedness capacity. In some instances, the targets at the start of the project did represent the same target that at the end of the project. Nevertheless, the JEE tool is still well aligned with the spirit of what the REDISSE project was aiming to achieve: strengthening disease surveillance and epidemic preparedness. Therefore, the ICR team agreed that assessing the achievement of outcomes based mainly on reaching the targeted JEE scores would not truthfully represent the achievements made by countries. The ICR reports on the actual progress achieved by countries with REDISSE’s support in each of the key elements of epidemic preparedness: surveillance, laboratories, preparedness and response systems. Annex 1.C presents the JEE scores, showing the progress in national capacities, towards the achievement of the scores. 33. The COVID-19 pandemic, and the urgent response efforts needed to address it, tilted the needle between the two dimensions of the PDO, leaning heavier than originally planned towards response to an eligible emergency. This meant suspending the implementation of many planned activities and shifting the focus to COVID-19 response efforts. At the same time, the COVID-19 pandemic provided a unique opportunity for countries to make use of the surveillance and preparedness capacity recently built with support from the Project. The timing for the capacity built could not have been more opportune. 34. By completion, REDISSE II had succeeded in strengthening disease surveillance, preparedness, and response capacities across human health and animal health sectors in the four participating countries. With REDISSE II’s support, participating countries had strengthened their laboratory capacity, their surveillance capacity, their preparedness and response capacity, the capacity of their human resources for IHR requirements and had strengthened regional-level collaboration (facilitating knowledge and information sharing and exchange), regional coordination (common or aligned policies and technical strategies) and 12 The JEE was first released in 2016. In 2018 WHO issued a version 2.0 which made compliance with scores for a few indicators more stringent. The 3rd edition was launched in 2021. Page 17 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) resource sharing (training institutions and reference laboratories). While not all countries met their target JEE scores per se, there was substantial progress made across most of them. REDISSE II contributions yielded significant results and will continue to yield results and outcomes after the Project’s completion. 35. The achievement of outcomes of REDISSE II was assessed across the two dimensions of the PDO : (i) Strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa and (ii) in the event of an Eligible Emergency, provide immediate and effective response. While the first dimension of the PDO has a national and regional element, and REDISSE II countries benefited from regional-level activities, financing to support the implementation of regional activities (led by WAHO) was channeled exclusively through the REDISSE I project. Thus, assessment of the national and regional elements of the first dimension of the PDO is done jointly. In addition, the assessment of the two elements of the first dimension, disease surveillance and epidemic preparedness, is also done jointly. The reason for the joint assessment is that these two elements are intertwined and cannot be artificially separated. Strengthening epidemic preparedness includes a combination of multiple elements, such as surveillance, laboratories, human resources, information systems, referral systems, etc. Strengthening all of these elements results in a stronger epidemic preparedness. First dimension of the PDO: Strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa. Rating: Substantial 36. The achievement of PDO I is based on the results of five PDO indicators and five IRIs. 37. Surveillance capacity at regional level was strengthened. By completion, under WAHO leadership, surveillance systems for preparedness and response had been strengthened. Regular regional collaboration around health security was established, contributing to lift weaker countries, such as Guinea Bissau, and having stronger countries such as Nigeria sharing their knowledge and experiences. For all participating countries, there was progress achieved on cross-border collaboration and exchange of information across countries (PDO indicator 5). This materialized in harmonization of guidelines, policies, and strategies (laboratory standards, One Health, capacity building, etc.) and in mainstreaming the technical capacity acquired through regional collaboration at national level. All REDISSE II countries actively participated in regional meetings and followed up on the main strategic recommendations and action plans. WAHO was strengthened in its role as regional surveillance coordinator by completion. 38. Surveillance capacity at national level was also strengthened. By completion, the participating countries had strengthened their surveillance systems at all levels (national, decentralized, local), but especially at community level (PDO indicator 3). With REDISSES’s support, surveillance and information systems were improved, resulting in better capacity to detect health events, report them, investigate them, and respond to them. Participating countries made substantial progress in establishing electronic information systems (IRI 1), that better capture and share information, albeit falling short in achieving these systems' interoperability and interconnectedness. Participating countries succeeded in strengthening indicator and event-based surveillance system (PDO indicator 3) and in strengthening surveillance systems for priority zoonotic diseases and pathogens (IRI 3). By completion, countries showed progress from baseline capacity in strengthening their national systems for reporting to WHO, OIE/FAO on health events across sectors (IRI 7). Page 18 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) a. Nigeria strengthened surveillance capacity for human health throughout the country. It established its Integrated Training of Surveillance Officers (ITSON) program. This training targeted Epidemiologist and Disease Surveillance Notification Officers (DSNOs) across the 36 states and 774 local government areas. REDISSE II supported the finalization of IDRS guideline review involving many stakeholders at all levels in two stages. The country deployed the Electronic SORMAS - Surveillance and Outbreak Response Management System to Bauchi, Plateau, River, Delta and Taraba States for case-based reporting and management of disease outbreaks. Nigeria carried out trainings of disease surveillance agents for community-based surveillance of zoonotic and non-zoonotic animal disease as well. It implemented active surveillance of live-bird markets for highly pathogenic avian influenza virus. It supported transportation means for surveillance officers in hard-to-reach areas. It successfully trained officials at Points of Entry (POE). By completion the country was able to deploy the electronic reporting system for Human and Animal health to 36 states and the federal capital territory (IRI 1) and had a joint list of prioritized zoonotic diseases (IRI 3). b. Interestingly, Guinea-Bissau, which was lagging behind in terms of progress due to the significant socio-political turmoil and instability affecting the country, was able to achieve a degree of strengthening thanks to the need to accelerate efforts to respond to COVID-19. Guinea-Bissau piloted the electronic information system during COVID-19, in limited scale and time. 39. Laboratory testing capacity for detection of priority diseases was strengthened, measured by PDO indicator 2, IRIs 2 (Laboratory systems quality) and IRI 5 (System referral and transport system). By completion, Guinea Bissau, Liberia, Nigeria, and Togo had succeed in strengthening laboratory testing capacity for detection of priority diseases, exhibiting developed or demonstrated capacity at completion. With REDISSES’s support, the quality of national laboratory systems was strengthened (IRI 2), with the adoption of protocols and standards agreed at regional and international level. During the ICR mission, Liberia, Nigeria and Togo confirmed the use of these protocols to carry out testing. With the acquisition of equipment and training in both human and animal health laboratories, the national labs could test ten or more priority diseases13. Guinea Bissau relied on regional labs in other countries to carry out the testing it required. By completion, Nigeria had established a National Quality assurance system through an External Quality Assurance (EQA) method and in July 2023, a quality assurance exercise for the national reference laboratories was carried out. 14 laboratories have been accredited using national and international ISO standards. REDISSE II supported these results, financing building of capacity of the lab staff for diagnosis, reporting of diseases in human and animal health, and engaging surge lab staff to improve workforce strength. 40. Specimen referral and transport systems improved in all countries (IRI 5), with Togo and Liberia showing developed and demonstrated capacity. Nigeria had achieved by completion a transportation of specimens that worked well for its geographical and financial reality, which did not comply with the requirements of the target score, but nevertheless fulfilled their needs. Guinea Bissau showed progress in the specimen and transportation system from the country’s baseline. While the turnaround time from date of specimen to date of results return for priority diseases was not monitored under the project14, Liberia, Togo and Nigeria continued monitored it and reported significant improvements. 13 3 of the 4 countries met the original criteria of the JEE version 1 to obtain a score of 4 for PDO indicator 2. However, since countries were measuring capacities using JEE version 2, which raised the criteria for that indicator, only 2 of the 4 countries got a score of 4. Please see M&E section for further details. 14 This was one of the indicators dropped during the first restructuring (Feb 2020). Page 19 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 41. Human Resources to implement IHR core capacity requirements were strengthened (PDO indicator 4). This achievement was the result of the training and hiring of human resources in human health and animal health (IRI 6, 9, 11-14). At project completion, three of the four countries had demonstrated capacity in terms of availability of human resources to implement IHR core capacity requirements. With REDISSE’s support, staff working in Epidemiological Surveillance Centers were trained in all four countries. Participating countries trained their staff in Field Epidemiology Training Program (FETP) at basic, intermediate, and advanced levels (IRI 6). The Project financed training activities, contributing to strengthening of human resources to manage health security interventions. WAHO played a key role in coordinating training and supported countries with the FELTP frontline training of national epidemiology officers and laboratory technicians15. Countries had different levels of achievement but by project completion all four countries had FETP training programs in place. Bothe Guinea Bissau and Liberia succeeded in having an applied epidemiology training program such as FETP in place by completion. Nigeria achieved advanced (44 residents), intermediate (30) and frontline (1,300) FETP training. Togo succeeded in training staff from human, animal and environmental sectors on FETP at all three levels and hired staff for the three sectors with REDISSE II support. The FELTP program was key in materializing interuniversity collaboration and for a better understanding of the One Health Approach for the three sector ministries. All four countries drafted public workforce strategies but only Nigeria and Togo drafted a public workforce strategy that includes public health professions e.g. epidemiologists, veterinarians and laboratory technicians (IRI 4) reaching developed capacity. Guinea Bissau and Togo reached demonstrated capacity with regards to veterinary health workforce (IRI 9) while the other two countries reached developed capacity. 42. REDISSE II helped establish foundational elements for the One Health Approach in participating countries. By project completion, there had been progress in establishing an active, functional regional One Health Platform (PDO indicator 1). An action plan for regional collaboration was developed and endorsed by the participating countries. By completion, all four countries had made progress on establishing active collaboration across sectors (human, animal and environmental) and three countries (Liberia, Nigeria and Togo) had made progress on establishing an active and functional One Health Platform, advancing the One Health agenda. With regional impulse by WAHO, there was progress integrating the One Health Approach in the national processes of strengthening the surveillance, preparedness, and response systems. There was consensus across all four participating countries that REDISSE II was instrumental in establishing the foundations of the One Health approach in those countries. a. Liberia established focal points, working in cross-sectoral collaboration by 2021 it had developed and validated the 2nd Edition of its One Health Platform Governance Manual16. The Governance Manual was later revised with six (6) Technical Working Groups, including Risk Communication and Community Engagement, Surveillance, Laboratory, Antimicrobial Resistance, Emergency Preparedness and Response, and Workforce. The Steering Committee, the technical committee, the National and Epidemic Preparedness committee, and Working Groups were supported by the OH Secretariat at the national level in its day-to-day operations. 15See section on Institutional Strengthening and Annex 1 for details on training. 16It used the Tripartite Joint Risk Assessment Tool (JRA-OT). Three of its prioritized zoonotic diseases (Ebola, Rabies & Lassa Fever) were assessed. The manual is a governing framework that calls for strengthening inter-ministerial linkages, existing national mechanisms for integrated collaboration, agreement on terms of reference (TOR). Other areas included decision-making mechanisms, rooster set-up for leaders and members of the steering and technical committees including other technical working groups. Page 20 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) b. Nigeria prepared a national One Health Strategy in 2019 which was implemented until project completion and established the institutional structure for One Health, endorsed by key stakeholders. The platform was functional at national level, with a sound and well-established road map for information sharing among stakeholders. Some states in Nigeria (Edu, Benue, Nasarawa) also implemented a OH approach, which led to cross-sectoral collaboration. REDISSE II supported the development of national guidelines for Integrated National Environmental Health Surveillance Systems (INEHSS), to include the environmental sector as well. In Nigeria, one of the outcomes was the inter-ministerial collaboration, cooperation, which allowed for effective response to outbreaks. c. Togo established focal points for animal, human and environmental health, initiating the collaborative working modality to strengthening the national surveillance systems. By completion, Togo had approved an inter-ministerial decree, formalizing the institutional arrangements, roles, and responsibilities for the OH platform. During project implementation, monthly meetings were regularly held, with focal points for each of the sectors. The OH approach involved all levels, from community level to the districts (in some aeras as pilots) and to the focal points. The training activities and the university collaboration were key in Togo to instill a better understanding of the OH approach across sectoral ministries, to respond to public health emergencies and brake with the traditional practices of vertical interventions. d. Guinea Bissau was successful in raising awareness and conducting training on the One Health Approach, though it encountered difficulties to make substantive institutional advances. The project contributed to planting the seeds for the OH approach in the country. By completion, there was awareness across the different sector about the OH principles and ways of working. 43. Having a multi-hazard national public health emergency preparedness and response plan (PDO indicator 5) also contributes to strengthening epidemic preparedness. However, since the PAD linked this PDO indicator to the second dimension of the PDO, the assessment of achievements related to the indicator are discussed under the second dimension of the PDO. It is important to note that having preparedness and response plans in place also contribute to effective response to health emergencies (preparedness for response). Second dimension of the PDO: In the event of an eligible emergency, provide immediate and effective response. Rating: High 44. The instrumental role of the REDISSE II project in the countries’ response to COVID-19, particularly at the onset and in the early months of the pandemic, cannot be over-emphasized. REDISSE II was critical to all four countries when the pandemic hit as it provided the required financing to prepare for and to respond to the crisis. REDISSE II served as bridge financing until the approval and effectiveness of the COVID-19 Strategic Preparedness and Response Program (SPRP) projects in each country. Across all countries, individuals interviewed emphasized the fortune and timeliness of having REDISSE II funding available for COVID-19, describing it as “lifesaving”. 45. By completion, with REDISSE’s support, WAHO and all participating countries succeeded in providing immediate and effective response to COVID-19 and other eligible health emergencies17. WAHO and the participating countries built their initial response to COVID-19 on the physical and institutional capacity achieved through the REDISSE project prior to the crisis. WAHO and the countries had made progress in strengthening infectious disease outbreak preparedness and response capacities, which enabled a timely and 17 Outbreaks during implementation in participating countries included Lassa, rabies and avian flu. Page 21 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) adequate response to the COVID-19 pandemic from March 2020 onwards. In fact, the REDISSE project was the first line of financing for response to COVID-19 for the four countries. The ICR interviews captured the impact that REDISSE II had in effectively and immediately responding to the pandemic: activities towards strengthening surveillance and preparedness systems had been or were being implemented, and these newly acquired capacities and newly improved systems were used to respond to the health emergency. The ICR findings were in line with IEG’s findings in their analysis of the WB support to respond to COVID-1918. Prior cross-sectoral engagement, collaboration and previous engagement support were also key in the timeliness and effectiveness of the COVID-19 response. Preparedness for Immediate and Effective Response 46. By completion, the coordination architecture for emergency response across sectors had been improved at regional and national level. All four countries had improved their preparedness and capacity to respond to a health emergency. REDISSE activities were aligned to support each country’s National Action Plan for Health Security (NAPHS). All four participating countries had made progress to develop and implement Multi-Hazard National Public Health Emergency Preparedness and Response Plans (PDO indicator 5). All four countries conducted strategic emergency risk assessments, identified, and mapped emergency resources, which guided their use at the time of a crisis. All four countries had established capacities and coordinating mechanisms for response to zoonotic disease outbreaks. REDISSE’s support ensured that investigation and response to several outbreaks (COVID, rabies, avian flu) was possible. When COVID-19 hit, participating countries implemented these health emergency plans or prepared COVID-specific response plans. 47. Liberia developed tools for a timely health emergency response operation, including an emergency operation manual and a robust emergency management structure for mobilization of resources needed during an emergency19. The country established Emergency Operating Centers (EOCs), activated to respond to the pandemic and other health emergencies. By completion, Liberia was regularly updating national level inventories and maps of multi-sectoral resources for emergency response, demonstrating capacity. Liberia completed a National Vulnerability Risk Assessment and a mapping exercise, validated by its national technical committee. Liberia developed joint field investigations and monitoring tools for zoonotic diseases. It also developed disease-specific plans for Ebola, Lassa Fever, Marburg, Cholera, Rabies and Highly Pathogenic Avian Influenza (HPAI). In addition, by completion, Liberia had built human resource capacity, identified responders, and created Integrated Rapid Response Teams (IRRT) to respond to large health emergencies or pandemics, for relevant priority diseases across sectors, at community, facilities, farms, district, country, and national level. 48. Nigeria developed a national multi-sectoral multi-hazard emergency preparedness plan (NMMEPP). The country revamped the national strategic stockpiling system to support disease investigation, detection, and response. By completion, Nigeria had carried out a national multi-hazard risk profiling and resource mapping at national level and in 18 states, using the Strategic Tool for Assessing Risks (STAR) and the Vulnerability and Risk Analysis and Mapping (VRAM) tools. REDISSE contributed to this effort by supporting the data analysis, report writing, validation of data collected, specifically. Nigeria enhanced the human capacity to respond to 18 Independent Evaluation Group. 2019. IDA’s Crisis Response Window: Lessons from Independent Evaluation Group Evaluations, World Bank, Washington, DC. 5 19 Liberia developed guidelines and actions plans: NAPHS, Revised Public Health Law, National Epidemic Preparedness and Response Committee, which holds weekly meetings, the production of a Weekly Epidemiology Bulletin, Incident Management System, and responsible structures identified and functioning. The country has demonstrated ability to coordinate a joint response across, human, animal, and environmental sectors. Page 22 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) emergencies, through training of Rapid Response Teams (RRTs). The project supported the introduction of public health emergency operations training to all officers in Nigeria’s security agencies. By completion, Nigeria had established a multi-sectoral operational mechanism for coordinated investigation and response to outbreaks of zoonotic diseases across human and animal health sectors20. Nigeria strengthened the Infection Prevention and Control (IPC) and data management and risk communication capacity, improving the timeliness and capacity to report to the national level. Nigeria also developed Lassa fever prevention and control strategies and improved risk communication among stakeholders. 49. Togo, in addition to a National Action Plan for Health Security, the country updated its multi-risk National Health Emergency Preparedness and Response Plan, which was used in the response to COVID-19. Togo also developed specific plans to respond to specific zoonotic diseases (rabies, avian flu, etc.). By completion, Togo had improved coordination and cross-sectoral collaboration for emergency response; it had successfully established RRT and trained them on agreed emergency procedures and protocols in the six health regions in the country. Furthermore, as part of strengthening efforts, and under the One Health umbrella, Togo prepared a National Preparedness and Response to Emergency Plan and carried out annual field simulation exercises to test the plan. Togo also strengthened surveillance capacity for avian flu with the training of 900 avian producers, in five regions of the country, on biosecurity and flu prevention. 50. Guinea-Bissau made progress as well, improving stakeholder’s understanding of inter-sectoral coordination and collaboration on preparedness and response, and strengthening the rapid response capacity. REDISSE supported the implementation of an emergency response mechanism, which was used for the response to COVID-19. 51. The project supported strengthening of Public Health Emergency Operations Centers across all countries. All countries allocated resources to strengthen these capacities before the COVID-19 pandemic hit. The Regional Center for Surveillance and Disease Control (RCSDC) at regional level was already functional at decentralized level and around 100 hundred centers at national level were made operational and strengthened. REDISSE II provided support for managing the emergency operation centers across all participating countries. In collaboration with other partners, it also provided support for rolling out the implementation of the then new WHO Integrated Disease Surveillance and Response (IDSR 2) across all countries. For example, REDISSE II funded two phases of the finalization of the IDSR guidelines. Actual Response to Eligible Emergencies 52. REDISSE II was instrumental in the response to the COVID-19 pandemic. It allowed participating countries to operationalize a fast response, given the availability of resources for health emergency response and the systems and processes that were already in place through the ongoing work to strengthen surveillance and preparedness capacities. For COVID-19, the response from all 4 countries was timely, as funds and human resources were available and already working on surveillance and laboratory testing. WAHO coordinated with countries during the early period of COVID-19 to closely monitor the situation and to share information. With REDISSE funds channeled to the response, the country’s health systems continued to be strengthened throughout all core capacities: surveillance, diagnosis, emergency response, human resources, and institutional framework. In fact, because of the response to COVID-19 many of the activities aimed to 20The effectiveness of this mechanism was ensured thanks to joint training, joint risks assessments, national RRTs, simulation exercises, etc. Page 23 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) strengthen pandemic preparedness and response capacities were accelerated in the early days of the emergency. In February 2020, there were only two labs with capacity in West Africa to test for COVID-19, at the outset of the pandemic. By September 2020, all countries had established multiple laboratories. 53. Liberia response to COVID-19: Liberia triggered the Project’s Contingency Emergency Response Component (CERC), boosting the GOL’s efforts to respond to COVID-1921 under the national preparedness and response plan. REDISSE contributed to a timely and effective response to COVID-19, by providing the necessary resources. Key support in the initial stages of COVID-19 pandemic consisted of (i) training 4,900 frontline workers, including 660 clinical staff assigned to treatment centers; (ii) acquisition of supplies for IPC; (iii) acquisition of laboratory reagents and consumables; and (iv) support for surge teams. These were instrumental in breaking the chain of transmission of the virus. The number of suspected cases of COVID-19 reported and investigated, complying with approved protocols, reached 15,229 (versus a target of 300). The number of designated laboratories with COVID-19 diagnostic equipment test kits and reagents reached seven sites (versus a target of three). Finally, Liberia developed and tested an outbreak/ pandemic emergency risk communication plan and activities for the COVID-19 response. Table 3 presents target and actual values for the CERC-related indicators, which were all achieved. Table 3: CERC-specific indicators for Liberia Baseline End of Project Actual** (2020) Target (September 2021*) Number of suspected cases of COVID-19 reported and 0.00 300 15,229 investigated. investigated per approved protocols. Number of designated laboratories with COVID-19 diagnostic 0.00 3 7 equipment, test kits and reagents Outbreak/pandemic emergency risk communication plan and No Yes YES. Adherence to activities developed and tested protocols tested * The CERC closed in September 2021 ** Reported in March 2023 54. Nigeria response to COVID-19: REDISSE supported timely and early response to COVID-19 pandemic at both national and state level, financing States Incidence Action Plans. With the Project’s support, the government rolled out a series of interventions focused on further strengthening disease surveillance and epidemic preparedness and response, based on the national public health emergency preparedness and response plan. The Nigeria Beneficiary Assessment captured the impact of these interventions in response to COVID-19. Beneficiaries expressed how the project-supported interventions helped them with the COVID-19 response22. 21 The GoL prepared a National Strategic Preparedness and Response Plan (NSPRP) for COVID in February 2020. Some key activities in this plan were implementing using US$1.5 million from REDISSE II in the early stages. On March 16, 2020, the GoL declared a COVID- 19 public health emergency by Decree. An Incident Action Plan valued at US$48.6 million was also developed, with the goal of strengthening the implementation of measures to prevent, detect and mitigate the impact of COVID-19 outbreak in Liberia. To mobilize WB funds, the GoL prepared a Contingency Emergency Response Implementation Plan for 8 million, as a subset of the IAP and the GoL requested the activation of the CERC on March 20, 2020. The CERC was activated on March 26, 2020 and closed on September 26, 2021. 22 Beneficiary Assessment Report. REDISSE. September 2023. Nigeria. Nigeria was able to develop rapid tests kits and optimize GeneXpert tool for the diagnosis of COVID-19 Page 24 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 55. Guinea-Bissau response to COVID-19: REDISSE II supported the country’s National Response Mechanism to respond to the pandemic. The Project financed the acquisition of 8 ambulances, distributed to medical facilities and other locations across the country. This strengthened patient transfer and evacuation capacity. In addition, three double-cabin trucks were delivered to the health regions of Biombi, Oio and Tombali. REDISSE provided support to purchase small medical equipment and critical medical supplies (including PPE), key in the early response times to COVID-19. REDISSE II also supported strengthening Emergency Health Operations Centers’ capacity for emergency preparedness and response with acquisition of computer hardware. Eight electric incinerators were procured and delivered to different locations and institutions. 56. Togo response to COVID-19: REDISSE supported the acquisition of crucial equipment to respond to COVID-19 including ambulances for three health districts and equipping the 15 POE and the 9 Health centers responsible for accepting patients with key medications (chloroquine and Azithromycin). The country prepared and implemented a National Plan for Preparation and Response to COVID-19. REDISSE II also supported the strengthening of surveillance activities during the time of COVID-19 including the acquisition of 31 vehicles and all-terrain motorcycles, medicines and PPE for individuals and collective protection for investigating suspected COVID-19 cases. 57. REDISSE II supported the response of other outbreaks. In Nigeria, REDISSE II supported the national response to rabies outbreak and conducted mass anti-rabies vaccination campaign in hotspots States. In April 2018, Nigeria triggered the CERC to response to an outbreak of Lassa fever. With REDISSE II’s support, the country successfully responded to 8,101 cases of Lassa fever (versus a target of 1,914 cases) in 9 states. REDISSE II provided medicines and equipment, supported building capacity in the areas of surveillance, data management and infection, prevention and control, and supported the constitution and deployment of Rapid Response Teams (RRT), which proved pivotal in limiting the spread of the outbreak within Edo, Ondo, Enugu, Kebbi, Bauchi, Plateau, Delta and Taraba states. With REDISSE II support, Nigeria built significant preparedness and response capacity while simultaneously using the capacity to respond to the Lassa Fever emergency. Thanks to the effective response, the Lassa case fatality rate showed a decrease (from 27 percent to 20.4 percent) compared to outbreaks in previous years. Justification of Overall Efficacy Rating Rating: Substantial 58. The overall rating for efficacy is deemed Substantial in light of the achievements highlighted above: a. Strengthened capacity at national and regional level and at cross-sectoral level, for collaboratively surveillance and for epidemic preparedness, with substantial results for three of the four countries. b. Improved capacity to respond immediately and effectively to an eligible emergency, with the response to COVID-19 as the main epidemic/pandemic but also Lassa and Yellow fever in Nigeria and rabies in Togo and Liberia. The Project also contributed to the following achievements: c. National and regional capacity developed capacity to implement the Integrated Disease Surveillance and Response (IDSR), strengthened at community and decentralized level. d. National and regional capacity developed to a certain degree to comply with international standards for veterinary services. Achievements were affected by COVID-19. Page 25 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) e. Progress in implementing, at national, regional and local levels, effective collaboration and synergies between human and animal epidemiological surveillance and response networks, with an observable change of mentalities and behaviors. C. EFFICIENCY Rating: Substantial 59. The cost of pandemics is on par with other high-profile economic threats that concern heads of state and policy makers, such as climate change and natural disasters. The COVID-19 pandemic sent shock waves through the world economy and triggered the largest global economic crisis in more than a century. The economic impacts of the pandemic were especially severe in emerging economies where income losses caused by the pandemic revealed and worsened preexisting economic fragilities.23 The economic toll of the COVID-19 pandemic is probably incalculable. The World Bank estimated that the world economy shrank by 4.3% in 2020, a setback matched only by the Great Depression and the two world wars.24 The World Bank also estimated that the pandemic pushed nearly 100 million more people into extreme poverty in 2020 alone.25 Some of the economic impacts that COVID-19 had, which are true of many relatively smaller outbreaks, include: (i) reduction in agricultural production and exchange, which reduces domestic supply causing food prices to rise and creates food insecurity; (ii) reduction in public revenues due to less economic activity and lower tax compliance; (iii) rising unemployment and loss of income due to shutdowns; and (iv) reduction in tourism due to border closure and travel restrictions (the year 2020 saw an estimated US$ 1.3 trillion loss in international tourism expenditures.)26. 60. The West Africa Ebola outbreak unequivocally illustrated why responding to outbreaks is "far more expensive—in lives and money—than investing in preparedness”.27 By the end of 2015, US$ 3.6 billion had been spent on fighting the epidemic, and Liberia, Sierra Leone and Guinea collectively sustained an estimated loss of US$ 2.8 billion in GDP that year.28 On the other hand, Nigeria already had an epidemic response infrastructure in place when Ebola struck. They had an established contact tracing method, a highly-skilled virology laboratory, experienced epidemiologists, and strong clinical governance, which helped prevent substantial loss of human lives, limit the costs of responding to the outbreak and lessen the financial losses and impacts on the country’s economy. The economic cost of US$ 186 million incurred by Nigeria was much lower than other affected countries in the region.29 23 World Bank. 2022. World Development Report 2022: Finance for an Equitable Recovery. Washington, DC: World Bank. doi:10.1596/978-1-4648-1730-4 24 https://www.economist.com/finance-and-economics/2021/01/09/what-is-the-economic-cost-of-covid-19 25 World Bank. 2022. World Development Report 2022: Finance for an Equitable Recovery. Washington, DC: World Bank. doi:10.1596/978-1-4648-1730-4 26 https://preventepidemics.org/preparedness/financing/ 27 From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level. Report from the International Working Group on Pandemic Preparedness. World Bank. May 2017 28 WTTC, 2018. Impact of Ebola Epidemic in Travel & Tourism. https://wttc.org/Portals/0/Documents/Reports/2018/Impact%20of%20the%20Ebola%20epidemic%20on%20Travel%20and%20 Tourism%202018.pdf?ver=2021-02-25-182521-103 29 RSLS. Why preparedness is a smart investment. https://resolvetosavelives.org/wp-content/uploads/2024/05/ROI-Why- Preparedness-is-a-Smart-Investment.pdf Page 26 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 61. There are clearly significant potential returns on investment in improving preparedness to infectious diseases, as follows: • Impact on Health Outcomes: First and foremost, investing in preparedness significantly improves the lives of people and their overall livelihoods by decreasing mortality and morbidity, as well as social and psychological impacts which can lead to serious health threats. This in turn directly impacts people’s productivity, averting potential disruptions in their work and the need to care for sick family members. • Economic Impact: The costs associated with pandemics far exceed those of preventive measures. The COVID-19 pandemic, for instance, has resulted in trillions of dollars in losses, whereas investments in preparedness are measured in billions. It's estimated that an additional US$ 4 per person annually could significantly enhance global preparedness, protecting economies from severe downturns.30 • Health System Response: Investing in pandemic preparedness ensures that health systems can respond swiftly and effectively to emerging threats, safeguarding lives and livelihoods. A well-prepared health system can maintain essential services and mitigate economic disruptions during a pandemic, reducing long-term societal impacts. • Global Health Security: Such investments enhance global health security, with all countries contributing to and benefiting from improved health security measures. • Healthcare Sector Benefits: Investments in pandemic preparedness provide significant co-benefits for the healthcare sector. The synergistic relationship between pandemic preparedness and overall health system investment reinforces the need for dedicated resources to strengthen public health capabilities, which are often overlooked in favor of investments with more immediate and visible returns.31 62. From an economic perspective, the investments made by the REDISSE project proved Highly cost- effective, significantly enhancing preparedness and readiness at both national and regional levels. The project strengthened surveillance capacities, allowing countries to establish robust systems for regional collaboration and improve their abilities to detect, report, investigate, and respond to health events. National laboratory testing capabilities were bolstered through upgraded equipment, staffing, training, and improved specimen referral and transport systems. Additionally, regional laboratories were enhanced, providing essential services to countries with less developed national capacities. See Annex 4 for details on the cost- benefit analysis. For example, the cost-benefit ratio for REDISSE investments made to reduce the Case-Fatality Ratio caused by Lassa fever in Nigeria was found to be 1/43.12, i.e., each US$1 invested through the project yielded an expected (discounted) benefit equivalent to US$43.12 in terms of averted human and economic losses. The same calculation could not be done for COVID-19 given its rarity and consequently no comparable before/after data. 63. The project's impact on emergency response coordination was also substantial, improving structures at both national and regional levels. These enhancements proved to be critical during the COVID-19 response, as countries could utilize and expand their newly acquired capacities, supported by project financing. Regional coordination mechanisms established by the project were effectively activated, facilitating information sharing and the use of standardized protocols, which bridged knowledge gaps and reduced response times. 30 Chawla M, Schmunis R, Zindel M. Strategic prioritisation: Three principles for an affordable and essential preparedness package. J Glob Health 2023;13:03052. 31 From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level. Report from the International Working Group on Pandemic Preparedness. World Bank. May 2017 Page 27 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 64. The initial investments of the REDISSE project in training, infrastructure development, and preparedness measures helped mitigate the social and economic burden of COVID-19 and other outbreaks. These upfront costs are far outweighed by the long-term benefits of a region better equipped to manage and mitigate the impact of infectious diseases. The enhanced regional public health infrastructure not only benefits individual nations but also contributes to a more resilient and interconnected West African health landscape. Implementation Efficiency 65. Overall, the project demonstrated High implementation efficiency. The project achieved significant results within its original five-year timeframe and did not require an extension. This accomplishment is particularly noteworthy since it faced substantial challenges posed by the COVID-19 pandemic, which caused widespread disruptions, including lockdowns, travel restrictions, and overburdened health systems. Further, the project was being implemented in FCV32 settings, which inherently involves navigating complex environments with unstable political climates, security risks, limited infrastructure, and constrained access. Implementing adaptive strategies to overcome logistical challenges posed by the pandemic and FCV conditions, the project managed to deliver substantial results using only three-quarters of allocated funding. 66. The strong regional coordination by WAHO also significantly enhanced the operational efficiency of REDISSE investments. WAHO facilitated the development and implementation of standardized guidelines and protocols across countries, ensuring consistency and reducing duplication of efforts. This standardization simplified processes and procedures, which helped reduce the time it took for countries to start their response efforts. Moreover, WAHO brokered pooling of resources such as expertise, equipment, and funding, which led to economies of scale. The project upgraded national laboratories to serve as regional laboratories, allowing countries to access diagnostic services without investing in costly infrastructure, and reducing turnaround times by avoiding the need to send samples to Europe. In addition, regional collaboration facilitated pooled procurement of reagents and consumables for COVID-19 testing, which led to bulk purchasing, better pricing and reduced procurement times. 67. The high levels of operational efficiency are even more noteworthy considering the significant challenges the project faced due to high turnover among the Project Coordination Unit (PCU) staff and in dealing with new procurement processes. High PCU staff turnover disrupted the continuity of operations, loss of institutional knowledge, and delays as new staff required time to get up to speed. The issue was particularly pronounced in Guinea Bissau due to continuous changes in government and a lack of qualified personnel, which posed additional challenges to project implementation in that country. The project faced slow procurement due to the need to familiarize both the involved countries and the Bank with the new STEP system. This learning curve slowed procurement processes as stakeholders required time to understand and effectively use the new system. Moreover, existing procurement procedures had to be significantly adjusted to align with the new system, impacting the speed and efficiency of procurement activities during this transition period. 32 At the time of preparation, Guinea-Bissau, Liberia, and Togo were included in the World Bank’s Harmonized List of Fragile Situations for FY17. In FY20 the list became the World Bank’s List of Fragile and Conflict-affected Situations, which then included Nigeria but excluded Togo. In FY22 Liberia was removed from the list but Guinea-Bissau and Nigeria have remained on the list since. Page 28 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 68. Despite any challenges faced by the project during an unprecedented historic pandemic, Efficiency is rated as High given the very high cost-benefit ratio and the overall implementation efficiency which this project was able to attain. D. JUSTIFICATION OF OVERALL OUTCOME RATING Rating: Satisfactory 69. The overall outcome rating for REDISSE II is considered Satisfactory, based on the High rating of Relevance and Substantial ratings for both Efficacy and Efficiency. E. OTHER OUTCOMES AND IMPACTS (IF ANY) Gender 70. The Project contributed to closing some gender gaps by monitoring the proportion of women’s participation in training and capacity building activities (see Annex 1 for IRIs 11-16). Voluntary targets for training on the FETP were set at 40, 35, and 25 percent for basic, intermediate, and advanced levels for training. Although not all countries reached their targets, there was significant participation of women in FETP trainings, averaging 28% for basic, 31% for intermediate, and 27% for advanced for the four countries. During the ICR interviews, the countries expressed that there had been obstacles beyond the project’s control that prevented them from reaching the agreed targets for the gender training, including (a) COVID-19, (b) the challenges that women in the region face to move away from their cities and their families to get the training, and (c) a shortage of candidates applying for the training, etc. Countries (Guinea Bissau and Nigeria) found that REDISSE contributed to creating awareness around gender issues and disparities among government and key project stakeholders. In addition, Liberia carried out sensitization and awareness sessions on gender across sectors and institutions during the establishment of the One Health Platform, to close gender gaps. Institutional Strengthening 71. REDISSE II contributed to strengthening institutional capacity at regional level and in all four countries. WAHO was strengthened in its regional coordinating role, as the regional umbrella that supports all ECOWAS countries. WAHO enabled networking and connections across countries and institutions, ensuring that ECOWAS countries learn from other countries’ experiences. REDISSE’s institutional arrangements at regional and national level contributed to strengthening the region’s institutional landscape. REDISSE’s Regional Steering Committee and Regional Technical Committee met regularly, facilitating strategic discussions and the provision of technical assistance. At national level, the National Steering Committees (NSC) and National Technical Committees (NTC) also met regularly in the participating countries33, performing similar functions with relevant achievements. 72. There was progress in the establishment of the One Health approach in all participating countries, contributing to institutional strengthening. In all four countries, REDISSE II contributed to establishing coordination across sectors that did not exist before. In the case of Guinea-Bissau, it contributed to a better 33 Guinea-Bissau faced challenges to hold those regular meetings given the political and institutional instability. Page 29 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) understanding of the governance arrangements, roles, and responsibilities in the public and animal health sectors under the One Health approach. Poverty Reduction and Shared Prosperity 73. REDISSE II enabled countries to respond to the COVID-19 pandemic immediately. The project had been under implementation for almost two years and the activities that had been carried out, such as strengthening of laboratories and multiple trainings, as well as activities that were ongoing when the pandemic hit (such as active surveillance) contributed to mitigate the impact of the pandemic, reducing morbidity and mortality. This response benefited the population at large, including rural areas where older and more poor and vulnerable populations reside. People infected with COVID-19 were also treated for free in public health facilities supported by REDISSE II. Countries indicated that improved transport logistics for surveillance enabled prompt outbreak investigation and response in rural communities. This saved rural communities out- of-pocket expenses and other resources for treatment. Nigeria allocated REDISSE II COVID-19 response funds to the states which allowed them to allocate resources to other pressing needs. REDISSE II supported response to the region outbreaks (such as rabies, avian influenza and yellow fever) contributed to save out-of-pocket costs on medications as well. Training of farmers in Togo on avian influenza likely contributed to save animal lives, avoiding culling animals and communities' economic loss. III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME A. KEY FACTORS DURING PREPARATION 74. The West Africa Ebola outbreak motivated countries to strengthen health security. While the Ebola crisis of 2014-2016 was still unfolding, the Bank began preparation of this ambitious and complex operation called the REDISSE Program. Preparation entailed a comprehensive consultation process that sought buy-in from 15 ECOWAS countries and alignment with developing partners supporting health security in Africa. With the Ebola crisis still active in the region, many countries were eager to join REDISSE. However, as the havoc of Ebola started shrinking, countries’ initial excitement began to fade, entering the typical cycle of panic and neglect. This resulted in the Bank team having to invest an exceptional amount of time and effort to sustain momentum and reignite that sense of urgency that was rapidly fading amongst countries. Given this context, the operation changed from a project covering 15 countries to a series of projects (SOP), incorporating countries in phases based on their readiness to join. 75. REDISSE was designed in phases, with new countries joining each phase, and a single regional organization formally associated with the first phase only. The West Africa Health Organization (WAHO) was brought on to the REDISSE program in phase I to support all countries through regional level activities as they joined the different phases. There were multiple discussions during project preparation to determine the best way to engage with a single regional organization that would be working with all the countries under the REDISSE Program. After a series of internal consultations, the widespread recommendation was to have a single financial agreement with WAHO under the 1st phase of REDISSE and increase the financial support as new countries joined the program in subsequent phases. This implementation arrangement worked well as it avoided fragmentation of both the funding and the Bank's implementation support (WAHO had a single team as counterpart, rather than multiple TTLs and teams across phases). The only downside of this arrangement Page 30 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) was the fact that while phase I and II of REDISSE have closed, phase III remains active, with no funding from the REDISSE program to WAHO. 76. In the aftermath of the West Africa Ebola outbreak the international community coalesced around the notion that a more objective measure of country preparedness capacities had to be developed and rolled out. Hence, the JEE was developed and was adopted by the international community as the globally accepted tool and methodology to measure and monitor progress of country compliance with IHR core capacities. Most development partners working on health security adopted the JEE and its indicators, which use a 5-point scale to determine levels of capacity. In this context, the REDISSE program also adopted several JEE indicators as indicators of its results framework. 77. The inclusion of the One Health Approach into the project design represented a new institutional approach, which was complex and challenging. The concept of One Health (OH) had been gaining traction since 2007 and was recognized by the public health and animal health communities as a critical factor in strengthening health security. In that spirit, the REDISSE team understood that OH had to be an integral part of project design. However, operationalization of the OH approach was not fully understood by countries, as the concept was still quite nascent. This presented challenges both during project preparation and implementation. The OH Approach implied working with multiple ministries in each country, which until that point, had worked independently. Identifying areas where the human, animal and environmental sectors would collaborate proved to be a lengthy and contentious process. This was exacerbated by that fact that in most countries the animal and environmental sectors had been historically underfunded and the availability of REDISSE financing was seen as an opportunity to tackle what was most urgent to them, not necessarily what was most strategic under the OH lens. 78. Countries participated and engaged in REDISSE program design, showing ownership. The Project design was highly participatory, engaging national stakeholders in different sectors, encouraged, and led by WAHO and the WB. Countries embraced the PDOs, and the design proposed to achieve them. The design was flexible on the specific activities to be supported by REDISSE II, to adapt to participating countries' realities. Project design focused on defining clear implementation arrangements and on incorporating mitigation measures to support countries during implementation. This reflected the classification of participating countries as FCV and the assessment of risks during preparation.34 B. KEY FACTORS DURING IMPLEMENTATION 79. Project implementation had a slow start. While it took between 4 and 8 months for REDISSE II to become effective in most countries, due to required parliamentary approval in Nigeria, effectiveness in the country took almost one year. After effectiveness, some countries took additional time to begin implementation (Liberia took 7 additional months) as participating countries put together the PCU teams and prepared the Project Implementation Manuals (PIMs). Nigeria also took a longer time than the other three participating countries in approving a final version of the PIM, in 2020. 80. Weak governance and low institutional capacity at national level posed challenges throughout the Project's life. All four countries, to a greater or lesser extent, had weak institutional capacity to implement the Project. The institutional capacity risk assessment at appraisal had to be tackled during implementation. 34 Risks at preparation were assessed overall as substantial and high for institutional capacity to implement the project. Page 31 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Not only were there challenges to staff the PCUs initially, but there was a significantly high staff turnover in all four countries, many of which had to do with salary issues. This meant that at times, activities or processes were halted for months. Togo experienced extremely high PCU staff turnover, also associated with salaries, which brought down staff morale and motivation. Nigeria experienced high turnover of staff as well, as the PCU was meant to be staffed with civil servants who take leave from the regular posts. Identifying an adequate match for projects was a time-consuming endeavor. Guinea Bissau had the most challenges in establishing and keeping capacity at the PCU. With constant changes in government leadership, the PCU in Guinea Bissau also experienced continuous changes in Project coordinators, which affected the initial period of implementation. The political instability in Guinea Bissau not only affected the PCU but also the project counterparts at the different ministries. With every change in government, new leads and teams were put in place, which meant that often activities had to be restarted. An additional factor was that all four PCUs oversaw more than one project at any given point. The PCUs were managing REDISSE, the Bank-financed COVID-19 response projects, and projects with other development partners. PCU staff reported not having enough capacity to adequately manage the project management load. 81. Participating countries were considered FCV35 during implementation: Nigeria experienced violence and conflict in the Northeast part of the country, economic and social turmoil, and climate catastrophes, in addition to a Lassa Fever outbreak in March 2018. Guinea Bissau was considered fragile given the lack of political stability, with constant changes of government, which brought changes of top-level official as well as well as the technical level staff. 82. The inclusion of One Health introduced complexities that had to do with the multi-sectoral and multi- level nature of the approach. Embracing the OH approach brought challenges during implementation. A lot of work was done during preparation to bring together the three sectors in each country to define priorities and agree on areas and activities for collaboration. These discussions continued during the early stages of implementation, and, as with preparation, they continued to be contentious. Significant effort was also made in ensuring that stakeholders understood the concept of One Health, and later, be able to agree on how to operationalize it. The time consumed in these efforts was very significant. All four countries reported planning exercises to be cumbersome. Due to historically low sectoral budget, when project resources became available there was competition among sectors for financial resources. Annual plans and budgets were often delayed for this reason. Moreover, the OH approach requires a fundamental shift in the way these sectors work, which had historically worked independently and were now being asked to collaborate on multiple areas of work. While all stakeholders understood the importance of OH to strengthen health security, the implementation of OH is a complex and lengthy process (see Annex 8 for details). 83. The regional nature of the project brought benefits to countries during implementation but also had its challenges. Being part of a regional effort had significance to countries, particularly those with weaker institutions. All countries saw value in being part of a joint effort and in interacting and learning from their peers in other countries, all of which was brokered by WAHO. The work led by WAHO gave countries a sense of collective work towards the betterment of the African region's capacities for health security. It inspired, particularly the countries with lower capacities, to advance and be at par with stronger countries. The regional aspect of this operation elevated countries and motivated them to be like their peers. 35 At the time of preparation, Guinea-Bissau, Liberia, and Togo were included in the World Bank’s Harmonized List of Fragile Situations for FY17. In FY20 the list became the World Bank’s List of Fragile and Conflict-affected Situations, which then included Nigeria but excluded Togo. In FY22 Liberia was removed from the list but Guinea-Bissau and Nigeria have remained on the list since. Page 32 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 84. The first dimension of the PDO (strengthening disease surveillance and epidemic preparedness) contributed to the second dimension of the PDO (immediate and effective response to an emergency). As explained in the achievement of outcomes sections, prior to the COVID-19 pandemic, participating countries had implemented (to different degrees) activities to strengthen surveillance systems, including hiring and training staff and community workers, acquiring equipment and consumables, improving laboratory services, coordinating across sectors (human health and animal health), etc. While achievements were different in each country, there was a degree to strengthening of capacities that enabled countries to better respond to COVID- 19 and other outbreaks (rabies, avian flu) during project implementation. 85. The COVID-19 pandemic had both a positive and negative impact on Project implementation. On the one hand, the pandemic halted many of the activities that were part of the first dimension of the PDO, especially those that had to do with the animal sector. While many activities in the human health sector could not start or continue due to the health emergency, other activities that were required to support an effective response to COVID-19 were accelerated as they supported the response36. A mentioned above, the COVID-19 pandemic also tilted the needle between the two dimensions of the PDO, leaning heavier than originally planned towards response to an eligible emergency. IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME A. QUALITY OF MONITORING AND EVALUATION (M&E) M&E Design 86. The REDISSE II Project, as well as the entire REDISSE Program, had a unique M&E design. As was previously explained, the REDISSE Program drew most of its Results Framework (RF) indicators from the WHO JEE tool. The REDISSE Program was designed to complement other efforts at country level (by national governments and development partners) to strengthen pandemic preparedness capacities and the JEE indicators were very aligned with the spirit of the Program and its development objectives. Moreover, the JEE tool and its indicators were used by many development partners. In that context, the Program chose to adopt several of the JEE indicators as Project indicators, considering them appropriate to monitor the project’s achievement of the PDOs. 87. The M&E design is considered to be adequate to assess the achievement of the PDOs. The PAD included a set of indicators in the results framework to be monitored, documented and to assess performance and progress. The RF included annual targets for each participant country and a regional target that captured the number of countries (out of 4) that achieved a target score. During preparation estimated values37 of baseline and target scores were included, acknowledging that countries had not completed their first JEE, which would yield more realistic values of their capacities. Once all four countries completed their JEE, the RF was updated in terms of baseline and target scores through a restructuring. The PAD did not include an explicit ToC, as it was not required at the time of preparation. The PAD clearly established the possible activities, results, and 36 Examples of these activities are development of information systems, consolidation of rapid response teams, training for laboratory capacity, IPC, etc. 37 Based on self-assessments, which were considered not to be fully reliable. Page 33 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) outcomes under each component that would contribute to the achievement of the PDOs. While adequate to measure the achievement of the PDO, the RF indicators were not always directly related to project-financed activities. Moreover, there were other ongoing efforts (by national governments and development partners) that were also contributing to achievement of the RF indicators (the JEE scores). This made the assessment of achievements of outcomes a complex exercise, requiring the ICR team to establish the project's contribution to achieving the targets for the indicators. M&E Implementation 88. As established, the M&E arrangements limited the burden on countries for data collection and M&E. Given that the JEE is a national process, conducted under the guidance of WHO, countries set up arrangements at national level to conduct yearly self-evaluations on their IHR core capacities38 and undertake JEEs every four to five years. These arrangements functioned independently of the Project but were linked to it and informed the Project’s M&E. This arrangement limited the burden on the country of setting up parallel M&E systems to monitor project implementation. 89. All REDISSE II countries regularly monitored the RF indicators, providing annual updates to the Bank during supervision missions. There was systematic tracking of RF indicators, and the PCUs had an M&E specialist, responsible for the M&E system for the Project. Since the RF indicators were part of the JEE and self- assessment exercises, data was collected, analyzed, and discussed as part of the work of a National Technical Working Group responsible for reporting on IHR capacities, including JEE exercises, which was broader than the REDISSE project. While this ensured a regular monitoring and evaluation of the progress towards the implementation of the IHRs, the monitoring of the indicators in the RF was not exclusively project based. Monitoring was part of a collective effort by the governments and the development partners, including the WB. 90. Although the use of JEE indicators was positive in the sense that it aligned countries, the Bank and other development partners towards common goals, it presented some challenges for the Project M&E. The JEE scores are dependent on reaching a specific benchmark which is used as a proxy to determine the level of progression but does not consider the abundance of related achievements that take place prior to reaching the benchmark. Moreover, the JEE scores are dependent of several other factors including the WHO external evaluators and the version of the JEE tool used for the evaluation. The JEE tool, first launched in 2016, has evolved over the years to address technical limitations and challenges identified through its application. In early 2018 WHO issued a 2nd edition of the tool (JEE 2.0)39, which introduced changes to the indicators (introduction of some and merging of others) and, in some cases, the benchmarks used to determine a level of capacity were made more stringent. Although the changes were not monumental, they did present some complications for the measurement of a few RF indicators, which countries had to manage. While these changes represented a “moving target” for the Project itself, all countries and development partners, including the Bank, understood the need to stand behind and support the “upgraded indicators” of JEE 2.0. Regardless of the changes, the JEE and its indicators remain well aligned with the spirit of the REDISSE II Project. During the ICR preparation country counterparts highlighted the important contribution of REDISSE II in advancing towards the achievements of results and building of capacities. 38 Reported every year to the World Health Assembly 39 The JEE was updated again in 2021 to incorporate lessons from COVID-19. The tool is currently in its 3rd edition (JEE 3.0) Page 34 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) M&E Utilization 91. The M&E arrangements for the Project were a subset of those used to assess national capacities to prevent, detect, and respond to public health risks, in line with the International Health Regulations (IHR), namely annual self-assessments and full JEE evaluations. Findings from these assessments were used to inform program management and decision making. Data were used to monitor the progress in activities that were behind the scores of the indicators of the results framework. They were used to inform annual workplans and to share information at regional level. Justification of Overall Rating of Quality of M&E Rating: Substantial 92. The overall rating of the quality of the REDISSE’s Monitoring and Evaluation system is rated as Substantial, based on: a. The regular monitoring of the project’s implementation (activities, progress towards the PDO). b. Annual self-assessments and the completion of the JEEs during the project's life, adapting to the evolution of the JEE tool. c. The links established and monitored by the PCUs between the REDISSE II supported activities and the JEE indicators, showing an understanding of REDISSE’s results chain. B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE 93. Environmental and Social Safeguards: Participating countries in REDISSE II fully complied with the Bank’s safeguards policies and procedures, as set at appraisal. REDISSE II was classified as category B operation due to moderate risk of the proposed activities and triggered two safeguard policies: Environmental (OP 4.01) and Pest Management (OP 4.09). Countries prepared national Healthcare Waste Management Plans (HCWMP), Integrated Pest and Vector Management Plans (IPVMP) and environmental and Social Management Frameworks (ESMF). In Nigeria, these documents detailed the potential risks of each activity, define mitigation measures, provided budget for implementation, and describe implementation arrangements for monitoring and supervision. The documents also provided guidance for site-specific waste management plans during implementation. In Liberia, supervisory and monitoring visits were conducted to assess environmental, health and safety which included waste management at various health facilities and laboratories in the country, using standardized checklist for rehabilitation and minor construction works. In Togo, REDISSE II developed and implemented two tools for bio-medical waste and pesticide and zoonoses waste management. In addition, a regional roadmap for the operationalization of the sustainable management of healthcare waste in West Africa was developed with WAHO’s leadership and support. Two major activities were covered: (i) the development of a regional strategic plan to strengthen the management of healthcare waste, and (ii) the development of a directive for the harmonization of regulations on the sustainable management of healthcare waste in West Africa, which was adopted as a regulation by the 22nd Ordinary Meeting of Assembly of Heath Ministers (AHM) in ECOWAS in 2021. 94. A Grievance Redress Mechanism (GRM) was developed in all four countries, but more operational in some countries than in others. In Guinea Bissau, most complaints were related to the lack of health infrastructure, strikes in the health sector and lack of medicines. Few complaints were satisfactorily resolved under the GRM. Page 35 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) In Liberia, a functional Grievance Redress mechanism Committee was set-up at national and ten out of the fifteen counties. 95. Procurement: Procurement activities in all four countries were affected by weak institutional capacity, lack of previous experience working with the WB and staff turnover issues (see section III). Countries mentioned delays in procurement processes with the introduction of STEP, which required a steep learning curve to operate on the platform, but these were overcome with time. While approval of the procurement plan was timely, procurement processes were slow, due to the intersectoral consultations in country and at the WB to prepare and approve procurement documents. Challenges were dealt with through collaboration between teams. Countries perceived their need for additional procurement training and accompanying from the WB. They also expressed their sentiment that the Bank was slow in providing non-objections. Nigeria had issues around staff capacity and the implementation of procurement rules. The evaluation committee did not meet with due regularity and procurement processes faced many bureaucratic steps. Togo indicated that delays in procurement processes were the main reason for low disbursement. Constant changes of procurement specialists caused these delays. 96. Financial Management: Overall, audit reports were presented on time, without auditors’ observations, for the four countries. Countries complied with loan covenants. Togo mentioned that changes in financial specialist affected implementation, and pointed out that, on occasion, the Bank was late in signing the IFRs. C. BANK PERFORMANCE Quality at Entry Rating: Satisfactory 97. The World Bank carried out a sound project preparation. It worked closely with the government of the four participating countries as well as with development partners to engage sectoral stakeholders and ensure ownership from inception. The Bank carried out regular missions, which included a wide group of technical staff. The Bank built on the work carried out to design and implement REDISSE I, while designing REDISSE II as the second phase of the regional program. The Bank saw WAHO’s role as a driving force and provider of technical support, as a key feature of this regional project, to ensure that none of the ECOWAS countries was left behind. By designing a regional project, the Bank ensured access to regional resources to support achieving a “regional public good”. Project design paid attention to implementation arrangements to mitigate risks. 98. The World Bank collaborated extensively with key development partners to define the REDISSE program as a complement the governments and development partners' efforts to achieve strengthen health security. The REDISSE Program was developed jointly by the Health, Nutrition and Population and Agriculture Global Practices to ensure that the human-animal-environment interface addressed under the One Health approach were adequately incorporated. 99. The project preparation was inclusive and participatory. WAHO was brought in as a key implementing stakeholder for REDISSE II as well as for REDISSE I. Emphasis was placed on participation by key stakeholders as REDISSE was a regional program and multi-sectoral at the national level. The Bank and the governments worked together to design implementation arrangements geared to foster collaboration at regional and Page 36 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) national level across sectors not used to working together on a daily basis. The regional consultations allowed for harmonization of priorities and expectations across countries, validating the technical design of the program. 100. Project design was adequate in the choice of PDOs, components and the broad set of activities eligible to achieve each component’s goals. The Project was design to include flexibility, providing a broad spectrum of types of activities to undertake each component, rather than strictly defining the activities to be financed by the project. This allowed countries that were at different levels of preparedness capacities to implement the Project to respond to their own realities. The Bank carried out a sound assessment of risks and proposed mitigation measures to the extent feasible40. At the time of appraisal, all risk categories were deemed substantial, except for institutional capacity risks, deemed high at the appraisal. REDISSE II incorporated activities to strengthen capacity across all project components. Quality of Supervision Rating: Satisfactory 101. World Bank supervision focused on development impact. Supervision proactively focused on supporting countries in overcoming obstacles that undermined achieving the project results and outcomes. The WB provided support in moments of greater risks or deteriorating country or international context. Such were the cases of the Lassa Fever outbreak in Nigeria in 2018 and Guinea Bissau’s socio-political turmoil since 2019 onwards. The Bank responded swiftly to the countries’ requests to either reallocate project funds or trigger the CERC for Lass fever (Nigeria) and for COVID-19 (Liberia). The Bank was proactive in restructuring the project three times, to incorporate key findings from the JEEs to better monitor the project and to adapt the project to the changing implementation context. 102. The World Bank carried out regular and adequately staffed implementation support missions throughout the life of the Project. There were challenges during supervision, given the multi-country and multi-sector nature of the project. Originally REDISSE had a team of 2 TTLs in headquarters. This was a source of bottlenecks during supervision, as mentioned in section III. As implementation progressed, the Bank added decentralized TTLs for each country based in the field. This was a positive change that brought cohesiveness, cross-fertilization, coordination among the four countries under REDISSE II. This change also introduced a degree of fragmentation to each country’s supervision. In-country and headquarters TTLs worked to achieve coordination, resolving issues during supervision, which was not always easy. Guinea Bissau, which had a very fragile context throughout the Project, could have benefited from more frequent implementation support missions. Supervision was challenging during the COVID-19 pandemic. The Bank adapted and introduced regular (sometimes weekly) virtual supervision support missions/meetings, until the time travel resumed. Supervision and support on fiduciary, environmental and social safeguards was adequate as well. The Bank regularly provided training and technical assistance to PCU teams, as requested. Countries did expressed difficulties using STEP and would have liked to have more hands-on support to navigate the system. Countries with more tech-savvy procurement staff had less difficulties. 40At the time of preparation, Guinea-Bissau, Liberia, and Togo were included in the World Bank’s Harmonized List of Fragile Situations for FY17. In FY20 the list became the World Bank’s List of Fragile and Conflict-affected Situations, which then included Nigeria but excluded Togo. In FY22 Liberia was removed from the list but Guinea-Bissau and Nigeria have remained on the list since. Page 37 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 103. The World Bank was candid in its dialogue with the countries and in its reporting on the project performance. Back-to office reports, ISRs, Aide Memoires after supervision missions provided sound assessment of implementation challenges to achieve the PDOs. A good example was the mid-term review (MTR) carried out during the second half of 2021. The Bank was clear in the challenges until project completion and supported defining priorities and transitions, given the time left to close the project. Implementation rhythm improved after that country-Bank work. The Bank continued to collaborate, dialogue and work with development partners to achieve the program PDOs and the higher-level objectives of the global security agenda. 104. The Bank rules for TTL-ship at the time only allowed the appointment of one TTL ADM and one co-TTL, which presented challenges as the REDISSE program grew. The project was jointly prepared by the Health and Agriculture Global Practices so a Health TTL and an Agriculture co-TTL were appointed. For a period, both REDISSE I and REDISSE II were under the supervision of a single TTL ADM, with centralized clearance of all No Objections, for seven countries and one regional organization. While this contributed to significant bottlenecks in the early stages of project implementation, it was eventually resolved with the introduction of country co-TTLs. 105. Minor shortcomings during implementation were identified as follows: a. Countries considered the Bank took a long time to provide non-objections. This was especially true at the early stages of implementation due to the supervision arrangements concentrating in one single TTL ADM (for both REDISSE I and II Projects). However, the multi-sectoral nature of activities also contributed to delays. The Bank required consultation with the technical sector experts outside of HNP, which lengthen issuing the non-objections. b. The Bank fell short in ensuring seamless continuity of support for health security once REDISSE II closed. Initial technical work for a potential extension was carried out up to November 2022. At that time the Bank opted to continue supporting countries under a new regional MPA operation – the Health Security Program in West and Central Africa (P179078) Project – that was already under preparation and would support many of the activities initiated by REDISSE. Unfortunately, only Liberia was included in the first phase of the MPA and delays in project preparation, which were beyond the control of the teams, resulted in gaps in continuation of activities as originally envisioned. Nevertheless, the regional Health Security MPA demonstrates the Bank’s commitment to provide continued financing support to this agenda both at the regional level and for those countries that opt to join the Program. Justification of Overall Rating of Bank Performance Rating: Satisfactory 106. The overall Bank performance is rated as Satisfactory based on the following: a. High relevance of the PDO together with flexibility and adaptability of the project’s design. b. Adequate risk assessment and mitigation measures at appraisal and implementation during supervision. c. Participatory and consultative project design. Page 38 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) d. Proactively restructuring the project when the official JEE evaluations were completed, to update the Results Framework; to respond to the Nigeria Lass fever outbreak in 2018 and to the COVID-19 pandemic in early 2020, working with each of the participating countries to meet their needs to face public health emergencies. e. Timely and regular adequate supervision missions throughout the project's life. D. RISK TO DEVELOPMENT OUTCOME 107. There are several factors that contribute to the sustainability of development outcomes. For example: a. There was a degree of “institutionalization” of a regional way of working that was achieved with the project, through the regular meetings of the Regional Steering and Technical Working Committees. The regional collaboration produced tangible results, after discussions on harmonization of policy, strategies and guidelines around cross-sectoral health surveillance, preparedness, and response. These arrangements were considered valuable. This modus operandi may continue to function to a certain extend (virtually) if funding is not available. b. There was also institutionalization of the One Health approach in several countries and country staff in the different ministries have become accustomed to a new way of working (cross-sectorally). Moreover, development partners support the One Health approach, so the foundation that REDISSE II has helped build will be capitalized on by countries and development partners. c. Capacities for surveillance and laboratories have been strengthened in terms of equipment, processes, training, etc. These capacities will stay in the country in years to come and can be built upon through the support of other development partners and/or other Bank projects, such as the Health Security Program in Western and Central Africa (P179078) Project. d. The inclusive and participatory nature of the Project design and implementation has strengthened the collaboration on health security among the governments, development partners and the Bank. In some cases, development partners are financially supporting some of the activities originally supported by REDISSE II after project closure. 108. Nevertheless, a factor undermining the continuity of the achievements and results would be the lack of sufficient national resources and/or a follow up operation to seamlessly continue recurrent activities at the same level as with REDISSE II financing. REDISSE II financed the hiring of staff and the cost of maintaining the logistics and operational support for countries to undertake routine activities of surveillance, laboratory and response efforts. For example, REDISSE II financed the daily transportation of staff working in the national reference laboratory in Liberia, ensuring regular attendance of lab staff to perform their duties, and financed the salaries of veterinary staff in all four countries, with only a portion of them being absorbed by the governments at project closure. In addition, while the foundational elements of a One Health Platform were established in several countries, at project closing, countries still required funds to continue operationalizing the OH architecture designed with the project. For instance, in Togo, the platform was formally established with the approval of an inter-ministerial decree, with strong institutional positing, but financing was still being identified at project closing. The new regional MPA operation – the Health Security Program in West and Central Africa (P179078) Project – will contribute to sustaining achievements over time, both at the regional level and in countries that opt to join the regional Program. Page 39 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) V. LESSONS AND RECOMMENDATIONS 109. Regional approaches are essential for projects supporting health security. The Ebola epidemic showed the importance of cross-country and regional collaboration to prepare and respond to health emergencies, as pathogens know no borders. In fact, the REDISSE program was designed based on the lessons learned from that and other outbreaks. A common approach and common (minimum) standards to prevent, detect and respond to health emergencies make the health security of the countries in the region as a whole, stronger. The COVID-19 pandemic proved the essential role of a regional approach to tackle health emergencies. Under REDISSE, a regional approach defined standards and policies for prevention, preparedness and response to health emergencies, many of which supported a cohesive response to the COVID-19 pandemic. The cohesive and collaborative approach to the response to COVID-19 helped countries implement best approaches and follow minimum standards. WAHO made the development of these standards and policies a participative effort, which contributed to a greater buy-in and adoption of the standardized approaches. Regional approaches in health security also contribute to common agreements on how countries will work together and support each other during an emergency, whether it affects one or multiple countries. In future, WB projects supporting health security should strongly consider including a regional approach. IEG findings41 corroborate this lesson stating “Regional projects facilitated knowledge sharing and were particularly helpful for countries with limited capacity to respond independently to COVID-19. Regional projects supported technical cooperation (such as for planning and reporting on the response) between ministries and public health institutes, encouraged leadership, developed human capacity, and coordinated technical sharing and financing for COVID-19 responses in countries. Longer-running regional projects had more established networks, which had successfully built some preparedness before the pandemic to support COVID-19 responses, although even newer regional projects added value, mainly through convening and technical and learning support.” 110. Choosing globally accepted indicators can contribute to align to higher level objectives but there is a downside. In the case of the REDISSE program, given the alignment of the development partners around the JEE and its indicators, it made sense to adopt the JEE indicators as part of the RF. This adoption contributed to align multiple development partners to support a set of higher-level objectives (compliance with the IHR requirements). While it made sense at the time, there were challenges at project level with this decision. The updates introduced by WHO to the JEE tool, which changed some of the indicators and their benchmarks, created complications for monitoring and evaluation. This also resulted in some targets not being achieved because of changes in the measurement tool, which made the description of the scores more stringent. Changes in the tool were not anticipated by the Project team and were out of the Project's control. As has been described before, REDISSE's choice of JEE indicators as RF indicators was justified. Moreover, the choice was intended to reduce the M&E burden on countries, which already had in place mechanisms to monitor progress in IHR capacities, as measured by the JEE. In future, teams should carefully consider adopting globally accepted monitoring tools and indicators, as indicators for a Project. This may be especially true for tools that are relatively new. 111. Projects that support the One Health approach's establishment require time and extensive planning during preparation and early implementation. REDISSE sought to establish OH in countries where the 41World Bank. 2022. The World Bank’s Early Support to Addressing COVID-19: Health and Social Response. An Early-Stage Evaluation. Independent Evaluation Group. Washington, DC: World Bank Page 40 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) concept of OH was novel. As described, implementation of OH requires major structural changes, in addition to behavioral changes. Paradigm shifts like these require time and extensive coordination. It is critical for successful design and implementation of project that promote OH to dedicate sufficient time during preparation, and continue during early implementation, to jointly define priorities and identify the activities to be supported by the project. The level of effort required for OH was underestimated by the Project team. In the case of REDISSE II, all four countries experienced delays and competition among the health, animal, and environmental sectors to get financing for their sectoral priorities. Negotiations to define what to include in the annual work plans took time, and annual working plans were often not realistic. While activities, as included in the PAD, were broad to accommodate all different countries, it is important to put emphasis on planning of OH interventions during preparation and at during early implementation, to avoid the experience of REDISSE II. 112. Regional projects involving FCV countries require substantial flexibility in their design and additional implementation support. Flexibility in design of regional projects is key for countries that have different capacities, contexts, and realities to adapt implementation to their needs. Within the overall framework of the REDISSE II Project design, countries were able to implement activities that were best suited to their realities, which helped countries better achieve the PDOs. Furthermore, flexibility in the project design allowed participating countries to quickly escalate ongoing activities to respond to the COVID-19 pandemic. Rapid access to financial resources in times of crises is critical for FVC countries, which often face shocks and lack the ability to mobilize resources in a timely manner. Countries experiencing situations of conflict, violence or fragile states face greater challenges during project implementation, across several dimensions (socio- political context, institutional capacity, natural disasters). This is key when assessing progress and achievements, as achievements, or lack thereof, in such contexts need to be seen through a different lens. All four participating countries in REDISSE II were assessed facing substantial overall risks, with a rating of high for institutional capacity. To mitigate the risks, FCV countries must have appropriate implementation support, with closer follow ups, additional hands-on support and additional missions, all of which requires adequate supervision budgets for teams. 113. Sustainability needs to be thoroughly addressed during implementation: REDISSE II included in the PAD activities designed to foster sustainability of the Project achievements beyond the Project's life. Nevertheless, the focus on sustainability was not kept during implementation. This may be in part due to the effects of the COVID-19 pandemic on project implementation. As a consequence, many REDISSE-supported activities were dropped or discontinued at the end of the Project (such as staff salaries, veterinary positions at local level, fuel for essential staff transportation to labs, etc.). While it seems obvious, more importance needs to be placed on ensuring sustainability, particularly for health security, where most of the costs of maintaining preparedness levels and core IHR capacities are recurrent costs. REDISSE made progress in pushing for change and gaining momentum in health security. However, lack of resources to support continuity of these efforts generates fatigue among stakeholders and loss of credibility that has a cost in future reform and change efforts. Therefore, it is critical to focus on how efforts and investments will be sustained after project closure. . Page 41 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS A. RESULTS INDICATORS A.1 PDO Indicators Objective/Outcome: To strenghen national and regional cross-sectoral capacity for collaborative disease surveillance Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Laboratory testing capacity Number 1.00 3.00 3.00 2.00 for detection of priority diseases (national capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 scores) (Number of countries that achieve a JEE score of 4 or higher) Comments (achievements against targets): The benchmark for achieving a score of 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Progress in establishing Number 1.00 3.00 3.00 3.00 indicator and event-based surveillance systems 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Page 42 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Availability of human Number 0.00 4.00 4.00 4.00 resources to implement IHR core capacity requirements 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) (Number of countries that achieve a JEE score of 3 or higher) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Progress on cross-border Number 0.00 3.00 2.00 1.00 collaboration and exchange of information across 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Page 43 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) countries (Number of countries that achieve a score of 4 or higher) Comments (achievements against targets): Two countries met their targets, but only one got a score of 4. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Progress towards establishing Number 1.00 4.00 4.00 3.00 an active, functional regional One Health platform 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (Number based on 5 point Likert scale) Comments (achievements against targets): Only Liberia and Nigeria monitored this indicator at country level. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Laboratory testing Number 2.00 4.00 4.00 4.00 capacity for detection of priority diseases (national 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 capacity scores) Page 44 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Comments (achievements against targets): The benchmark for achieving a score of 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Progress in Number 4.00 4.00 4.00 4.00 establishing indicator and event-based surveillance 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 systems (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Availability of Number 1.00 4.00 4.00 3.00 human resources to implement IHR core capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 requirements (national capacity scores) Comments (achievements against targets): Page 45 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Progress on cross- Number 1.00 4.00 3.00 3.00 border collaboration and exchange of information 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 across countries Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Progress towards Number 1.00 4.00 4.00 4.00 establishing an active, functional One Health 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Platform Comments (achievements against targets): Indicator not included in the PAD Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 46 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) NIGERIA - Progress towards Number 1.00 3.00 4.00 4.00 establishing an active, functional One Health 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Network Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Laboratory testing Number 3.00 4.00 4.00 3.00 capacity for detection of priority diseases (national 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Progress in Number 3.00 3.00 4.00 4.00 establishing indicator and event-based surveillance 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 systems (national capacity scores) Page 47 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Availability of Number 3.00 3.00 4.00 4.00 human resources to implement IHR core capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 requirements (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Progress on cross- Number 1.00 3.00 4.00 4.00 border collaboration and exchange of information 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 across countries Comments (achievements against targets): Page 48 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Number of Number 0.00 0.00 1,914.00 8,101.00 suspected cases actively investigated for Lassa fever 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 and treated if needed Comments (achievements against targets): Indicator introduced in 1st restructuring (Feb 2020) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Laboratory Number 1.00 4.00 4.00 3.00 testing capacity for detection of priority diseases (national 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 capacity scores) (Number) Comments (achievements against targets): The benchmark for achieving a score of 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Progress in Number 1.00 4.00 4.00 2.00 Page 49 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) establishing indicator and 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 event-based surveillance systems (national capacity scores) (Number) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Availability Number 1.00 4.00 4.00 4.00 of human resources to implement IHR core capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 requirements (national capacity scores) (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Progress on Number 3.00 4.00 4.00 3.00 cross-border collaboration and exchange of information 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 across countries (Number) Page 50 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Laboratory testing Number 4.00 3.00 4.00 4.00 capacity for detection of priority diseases (national 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Progress in Number 3.00 3.00 4.00 4.00 establishing indicator and event-based surveillance 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 systems (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Page 51 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Availability of human Number 2.00 3.00 4.00 4.00 resources to implement IHR core capacity requirements 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Progress on cross- Number 1.00 3.00 4.00 3.00 border collaboration and exchange of information 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 across countries Comments (achievements against targets): Objective/Outcome: In the event of an Eligible Emergency, to provide immediate and effective response to said Emergency Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Multi-hazard national public Number 0.00 3.00 3.00 1.00 health emergency preparedness and response 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 plan is developed and Page 52 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) implemented (national capacity scores) (Number of countries that achieve a JEE score of 4 or higher) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Multi-hazard Number 1.00 4.00 3.00 3.00 national public health emergency preparedness and 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 response plan is developed and implemented (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Multi-hazard Number 1.00 3.00 4.00 3.00 Page 53 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) national public health 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 emergency preparedness and response plan is developed and implemented (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Multi- Number 1.00 4.00 4.00 3.00 hazard national public health emergency preparedness and 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 response plan is developed and implemented (national capacity scores) (Number) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Multi-hazard national Number 2.00 3.00 4.00 4.00 Page 54 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) public health emergency 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 preparedness and response plan is developed and implemented (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 became more stringent in JEE version 2.0 compared to 1.0. A.2 Intermediate Results Indicators Component: Component 1: Surveillance and Information Systems Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Interoperable, Number 0.00 3.00 3.00 0.00 interconnected, electronic real-time reporting system: 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 number of countries that achieve a JEE score of 4 or higher (Number) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 changed in JEE version 2.0 compared to 1.0, but did not necessarily become more stringent. The focus of the indicator was less on interoperable, interconnected systems and more on electronic tools in general. Page 55 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Surveillance Systems in place Number 0.00 4.00 4.00 4.00 for priority zoonotic diseases/pathogens: number 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 of countries that achieve a JEE score of 3 or higher (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Systems for efficient Number 0.00 3.00 4.00 0.00 reporting to WHO, OIE/FAO: number of countries that 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 achieve a JEE score of 5 (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 56 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) LIBERIA - Interoperable, Number 2.00 4.00 4.00 3.00 interconnected, electronic real-time reporting system 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 changed in JEE version 2.0 compared to 1.0, but did not necessarily become more stringent. The focus of the indicator was less on interoperable, interconnected systems and more on electronic tools in general. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Surveillance Number 2.00 4.00 3.00 3.00 Systems in place for priority zoonotic diseases/pathogens 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Systems for Number 2.00 4.00 5.00 3.00 Efficient reporting to WHO, OIE/FAO (national capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 scores) Page 57 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Interoperable, Number 2.00 3.00 4.00 3.00 interconnected, electronic real-time reporting system 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 changed in JEE version 2.0 compared to 1.0, but did not necessarily become more stringent. The focus of the indicator was less on interoperable, interconnected systems and more on electronic tools in general. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Surveillance Number 3.00 3.00 4.00 3.00 Systems in place for priority zoonotic diseases/pathogens 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) Comments (achievements against targets): Page 58 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Systems for Number 3.00 3.00 4.00 3.00 Efficient reporting to WHO, OIE/FAO (national capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Number 2.00 4.00 4.00 3.00 Interoperable, interconnected, electronic 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 real-time reporting system (national capacity scores) (Number) Comments (achievements against targets): The benchmark for achieving a score of 2, 3, 4 & 5 changed in JEE version 2.0 compared to 1.0, but did not necessarily become more stringent. The focus of the indicator was less on interoperable, interconnected systems and more on electronic tools in general. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 59 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) GUINEA BISSAU - Number 2.00 4.00 4.00 3.00 Surveillance Systems in place for priority zoonotic 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 diseases/pathogens (national capacity scores) (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Systems for Number 2.00 4.00 4.00 3.00 efficient reporting to WHO, OIE/FAO (national capacity 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 scores) (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Interoperable, Number 2.00 3.00 4.00 3.00 interconnected, electronic real-time reporting system 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (national capacity scores) Comments (achievements against targets): Page 60 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) The benchmark for achieving a score of 2, 3, 4 & 5 changed in JEE version 2.0 compared to 1.0, but did not necessarily become more stringent. The focus of the indicator was less on interoperable, interconnected systems and more on electronic tools in general. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Surveillance Systems Number 2.00 3.00 3.00 3.00 in place for priority zoonotic diseases/pathogens (national 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Systems for Efficient Number 2.00 3.00 4.00 4.00 reporting to WHO, OIE/FAO (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 61 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) LIBERIA - Number of Number 0.00 300.00 300.00 15,229.00 suspected cases of COVID-19 reported and investigated 26-Mar-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 per approved protocol Comments (achievements against targets): Indicator introduced during 2nd restructuring (May 2023) Component: Component 2: Strengthening of Laboratory Capacity Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Laboratory systems quality: Number 0.00 3.00 3.00 1.00 number of countries that achieve a JEE score of 4 or 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 higher (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Specimen referral and Number 0.00 3.00 2.00 1.00 transport system: number of countries that achieve a JEE 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 score of 4 or higher Page 62 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Laboratory systems Number 1.00 4.00 4.00 3.00 quality (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Specimen referral Number 3.00 4.00 4.00 4.00 and transport system (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Laboratory Number 2.00 3.00 4.00 3.00 Page 63 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) systems quality (national 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Specimen referral Number 1.00 3.00 3.00 2.00 and transport system (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Laboratory Number 1.00 4.00 4.00 2.00 systems quality (national capacity scores) (Number) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 64 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) GUINEA BISSAU - Specimen Number 1.00 4.00 4.00 2.00 referral and transport system (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Laboratory systems Number 2.00 2.00 4.00 4.00 quality (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Specimen referral Number 1.00 3.00 3.00 3.00 and transport system (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Page 65 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Number of Number 0.00 3.00 3.00 4.00 designated laboratories with COVID-19 diagnostic 26-Mar-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 equipment, test kits, and reagents Comments (achievements against targets): Indicator introduced during 2nd restructuring (May 2023) Component: Component 3: Preparedness and Emergency Response Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Mechanisms for responding Number 0.00 3.00 3.00 3.00 to infectious zoonoses and potential zoonoses are 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 established and functional: number of countries that achieve a JEE score of 4 or higher (Number) Comments (achievements against targets): Page 66 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Regional surge capacity and Number 1.00 3.00 3.00 2.00 stockpiling mechanisms established (capacity based 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 on 5 point likert scale) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Mechanisms for Number 2.00 4.00 4.00 3.00 responding to infectious zoonoses and potential 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 zoonoses are established and functional (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Mechanisms for Number 1.00 4.00 4.00 4.00 responding to infectious zoonoses and potential 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Page 67 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) zoonoses are established and functional (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Number 1.00 4.00 4.00 4.00 Mechanisms for responding to infectious zoonoses and 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 potential zoonoses are established and functional (national capacity scores) (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Mechanisms for Number 2.00 3.00 4.00 4.00 responding to infectious zoonoses and potential 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 zoonoses are established and functional (national capacity scores) Page 68 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Yes/No No Yes Yes Yes Outbreak/pandemic emergency risk 26-Mar-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 communication plan and activities developed and tested Comments (achievements against targets): Indicator introduced during 2nd restructuring (May 2023) Component: Component 4: Human Resource Management for Effective Disease Surveillance and Epidemic Preparedness Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Workforce Strategy: number Number 0.00 3.00 3.00 0.00 of countries that achieve a JEE score of 4 or higher 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (Number) Comments (achievements against targets): Page 69 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) The benchmarks for achieving scores did not change significantly between JEE version 1.0 and 2.0. However, for version 2.0 this indicator included (absorbed) the indicator on Veterinary Health Workforce. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Applied epidemiology Number 1.00 3.00 3.00 4.00 training program in place such as FETP: number of 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 countries that achieve a JEE score of 4 or higher (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Veterinary human health Number 0.00 3.00 3.00 2.00 workforce: number of countries that achieve a JEE 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 score of 4 or higher (Number) Comments (achievements against targets): In JEE version 2.0 this indicator was included under (absorbed by) the indicator on Workforce Strategy. Page 70 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Workforce Strategy Number 2.00 4.00 4.00 2.00 (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): The benchmarks for achieving scores did not change significantly between JEE version 1.0 and 2.0. However, for version 2.0 this indicator included (absorbed) the indicator on Veterinary Health Workforce. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Applied Number 3.00 4.00 4.00 4.00 epidemiology training program in place such as 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 FETP (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 71 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) LIBERIA - Veterinary or Number 2.00 3.00 3.00 3.00 animal health workforce (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): In JEE version 2.0 this indicator was included under (absorbed by) the indicator on Workforce Strategy. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Workforce Number 2.00 4.00 3.00 3.00 Strategy (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): The benchmarks for achieving scores did not change significantly between JEE version 1.0 and 2.0. However, for version 2.0 this indicator included (absorbed) the indicator on Veterinary Health Workforce. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Applied Number 4.00 5.00 4.00 4.00 epidemiology training program in place such as 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 FETP (national capacity Page 72 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Veterinary human Number 3.00 4.00 4.00 3.00 health workforce (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): In JEE version 2.0 this indicator was included under (absorbed by) the indicator on Workforce Strategy. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Workforce Number 1.00 4.00 4.00 2.00 Strategy (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): The benchmarks for achieving scores did not change significantly between JEE version 1.0 and 2.0. However, for version 2.0 this indicator included (absorbed) the indicator on Veterinary Health Workforce. Page 73 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Applied Number 3.00 5.00 4.00 4.00 epidemiology training program in place such as 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 FETP (national capacity scores) (Number) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Veterinary Number 2.00 4.00 4.00 4.00 human health workforce (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 (Number) Comments (achievements against targets): In JEE version 2.0 this indicator was included under (absorbed by) the indicator on Workforce Strategy. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 74 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) TOGO - Workforce Strategy Number 2.00 3.00 4.00 3.00 (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): The benchmarks for achieving scores did not change significantly between JEE version 1.0 and 2.0. However, for version 2.0 this indicator included (absorbed) the indicator on Veterinary Health Workforce. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Applied Number 3.00 3.00 4.00 4.00 epidemiology training program in place such as 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 FETP (national capacity scores) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Veterinary or animal Number 2.00 3.00 4.00 4.00 health workforce (national capacity scores) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Page 75 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Comments (achievements against targets): In JEE version 2.0 this indicator was included under (absorbed by) the indicator on Workforce Strategy. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Percentage female of people Percentage 0.00 35.00 35.00 29.65 trained in applied epidemiology (All categories) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Guinea-Bissau Percentage 0.00 35.00 35.00 35.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Liberia Percentage 0.00 35.00 35.00 31.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 NIgeria Percentage 0.00 35.00 35.00 30.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Togo Percentage 0.00 35.00 35.00 22.60 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Page 76 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Indicator introduced during 1st restructuring (Feb 2020) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Percentage female of people Percentage 0.00 40.00 40.00 27.75 trained in applied epidemiology (Basic) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Guinea-Bissau Percentage 0.00 40.00 40.00 38.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Liberia Percentage 0.00 40.00 40.00 30.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Nigeria Percentage 0.00 40.00 40.00 32.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Togo Percentage 0.00 40.00 40.00 11.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Indicator introduced during 1st restructuring (Feb 2020) Page 77 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Percentage female of people Percentage 0.00 35.00 35.00 31.00 trained in applied epidemiology (Intermediate) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Guinea-Bissau Percentage 0.00 35.00 35.00 31.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Liberia Percentage 0.00 35.00 35.00 31.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Nigeria Percentage 0.00 35.00 35.00 48.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Togo Percentage 0.00 35.00 35.00 14.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Indicator introduced during 1st restructuring (Feb 2020) Page 78 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Percentage female of people Percentage 0.00 25.00 25.00 27.00 trained in applied epidemiology (Advanced) 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Guinea-Bissau Percentage 0.00 25.00 25.00 23.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Liberia Percentage 0.00 25.00 25.00 36.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Nigeria Percentage 0.00 25.00 25.00 38.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Togo Percentage 0.00 25.00 25.00 11.00 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Indicator introduced during 1st restructuring (Feb 2020) Indicator Name Unit of Measure Baseline Original Target Formally Revised Actual Achieved at Page 79 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Target Completion NIGERIA: Number of people Text 0.00 0.00 (i) 6; (ii) 75 (i) 6; (ii) 76 trained in (i) Lassa fever surveillance officers diagnostics and (ii) in the use of SORMAS 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 Comments (achievements against targets): Indicator introduced during 1st restructuring (Feb 2020) Component: Component 5: Institutional Capacity Building, Project Management, Coordination and Advocacy Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Citizens and/or communities Yes/No No Yes Yes Yes involved in planning/implementation/ev 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 aluation of development programs (Yes/No) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion LIBERIA - Citizens and/or Yes/No No Yes Yes Yes Page 80 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) communities involved in 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 planning/implementation/ev aluation of development programs (Yes/No) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Citizens and/or Yes/No No Yes Yes Yes communities involved in planning/implementation/ev 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 aluation of development programs (Yes/No) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion NIGERIA - Number of weekly Number 0.00 0.00 3.00 3.00 sensitization programs conducted on national radio 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 network Comments (achievements against targets): Page 81 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Indicator introduced during 1st restructuring (Feb 2020) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GUINEA BISSAU - Citizens Yes/No No Yes Yes Yes and/or communities involved in 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 planning/implementation/ev aluation of development programs (Yes/No) Comments (achievements against targets): Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion TOGO - Citizens and/or Yes/No No Yes Yes Yes communities involved in planning/implementation/ev 13-Feb-2020 31-Aug-2023 31-Aug-2023 15-Dec-2023 aluation of development programs (Yes/No) Comments (achievements against targets): Page 82 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 1B. KEY OUTPUTS BY COMPONENT Objective/Outcome 1 - Strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa. PDOI 1. Progress towards establishing an active, functional OH Platform. PDOI 2. Laboratory testing capacity for detection of priority diseases. PDOI 3. Progress in establishing indicator and event-based surveillance systems. Outcome Indicators PDOI 4. Availability of human resources to implement IHR core capacity requirements. PDOI 6. Progress on cross-border collaboration and exchange of information across countries. IRI 1. Interoperable, interconnected, electronic real-time reporting system. IRI 3. Surveillance systems in place for priority zoonotic diseases/pathogens. IR 7: Systems for efficient reporting to WHO, OIE/FAO. IRI 2. Laboratory systems quality. IRI 5. Specimen referral and transport system. IRI 4. Workforce strategy. IRI 6. Applied epidemiology training program in place such as FELTP/FEPT Intermediate Results IRI 9. Veterinarian human health force. Indicators IRI 11. Percentage female of people trained in epidemiology – all categories. IRI 12. Percentage female of people trained in epidemiology – Basic. IRI 13. Percentage female of people trained in epidemiology – Intermediate. IRI 14. Percentage female of people trained in epidemiology – Advanced. IRI 10. Citizens, communities involved in planning/implementation/evaluation of development. Guinea-Bissau Key Outputs by Component Promotion and dissemination of the OH approach among key stakeholders (Government (linked to the achievement and technical staff): outreach and dissemination activities at national and local level. of the Objective/Outcome Support technical committees (through workshops) to set up and operationalize the OH 1) approach. Page 83 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Support the Public Health Emergency Operations Center (PHEOC). Training liaison officers at community level (bridge between community health workers and livestock breeders). Liberia Information Technology Tool developed (TOT at national level) and piloted in 4 counties for e-reporting in real time. Join prioritized zoonotic diseases list established. Surveillance systems for zoonotic dis, established (human and animal health) Community health volunteers and Community animal health workers designated, at health facility levels. Facility focal points and at PoE (port health staff and quarantine officers) established. External Quality Assurance program for labs was established. System for sample transport in place (facility-district-county-national to referral laboratories). Laboratory Information Management System (LIMS) optimized. Acquisition of laboratory reagents, and supplies for infection, prevention, and control (IPC). Joint workforce needs assessment completed, identifying gaps at national and sub-national levels. 154 health professionals hired (133 human health; 21 animal health) as surveillance officers. Total of 3,743 health care workers trained: 3,508 trained as field epidemiologists and 235 Animal health workers (35 national/county and 200 community) trained (AFENET and University of Liberia Agricultural College). MOA developed a Workforce Strategy by completion. One Health Platform Governance Manual prepared and revised (improved) in 2021. Nigeria Health workers trained on event-based surveillance systems. Printing and distribution of IDSR forms, case investigation forms, contact tracing forms for all 36 states. Information technology tools available (Human health: DHIS2, SitAware, SORMAS. Use of SORMAS in 9 states (disease surveillance strengthened, with real-time electronic reporting and analysis. Support provided to all 36 states and the FCT (supervision and data provision support). Page 84 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) NADIS revamped: equipment and training provided for animal disease surveillance officers in the 36 states and FCT. IDSR technical guidelines reviewed. First Integrated Environmental Health Surveillance technical guideline developed. Health workers hired and trained in 8 PoE. Engagement of 100 veterinarian officers, deployed to States veterinary service departments. FETP training: 30 intermediates and 1,300 frontlines. Support for 44 staff for FETP advance level training. 2019 Yellow Fever Simulation Exercise. Acquisition of reagents, consumables, equipment and alternative power supply for network of laboratories, veterinary teaching hospitals and National Research Laboratory. Togo Component 1/4: Acquisition of IT and office equipment, GPS, and thermal cameras for the main Points of Entry (POE). Acquisition of vehicles for the three sectors. Human Resources Capacity built on surveillance and response (60 focal points for the SIMR trained, 243 surveillance agents trained on surveillance of potential epidemic diseases and on the use of tool to register at POE and 300 operational actors, working on surveillance at community level trained); Recruitment of Five veterinary agents to support surveillance at POE; strengthening surveillance capacity for avian flu (900 avian farmers trained of prevention and bio-security in the five endemic regions. Establishment of a Digital Notification Platform of Diseases/Events at community level for the 3 sectors, at different levels. Component 2/4: Capacity strengthened for store and conservation of labs reagents (acquisition and installation of a Cold chamber at the INH). Transportation and disposal of samples strengthened (4 agents trained abroad and 60 laboratory staff in human and animal health trained on IATA norms; acquisition of wrapping to transport samples provided to INH. Action Plan against AMR prepared and all hospital labs strengthened to carry out anti-bigrams. JEE evaluation (1) and Annual self-evaluations (5) for the four participating countries Objective/Outcome 2 - - In the event of an eligible emergency, provide immediate and effective response to said Eligible Emergency. PDOI 5. Multi-hazard national public health emergency preparedness and response plan Outcome Indicators developed and implemented. Page 85 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) PDOI 6. Progress on cross-border collaboration and exchange of information across countries. PDOI CERC Nigeria: Number of suspected cases actively investigated and treated if needed. IRI 8. Mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional. IRI 15. Regional surge capacity and stockpiling mechanism established. -Nigeria CERC: Number of people trained in Lassa fever diagnostics and in the use of SORMAS. -Nigeria CERC: Number of weekly sensitization programs conducted on national radio Intermediate Results network. Indicators -Liberia CERC: Number of suspected cases of COVID-19 reported and investigated per approved protocol. -Liberia CERC: Number of designated laboratories with COVID-19 diagnostic equipment, test kits, and reagents. - Liberia CERC: Outbreak/pandemic emergency risk communication plan and activities developed and tested. National Action Plans for Health Security in each country established, as a contingency cross-sectoral mechanism response. Guinea Bissau National Response Mechanism strengthened: acquisition of (i) computer hardware (laptops, printers, copiers, scanners, projectors, tablets, power banks). Acquisition of: (i) critical medical supplies (individual and collective PPE); (ii) 8 ambulances Key Outputs by Component (fully equipped), delivered to medical centers; (iii) Three double cabins trucks, equipped for (linked to the achievement the regions of Biombo, Oio and Tombali; (iv) small medical equipment (thermometers); (v) of the Objective/Outcome 8 electric incinerators; (vi) COVID-19 vaccines and medical supplies (for treatment); (vii) 2) Laboratory reagents, GeneXpert systems 4-Module configuration equipment, lab materials. Liberia Joint field investigation/outbreak and monitoring tools for zoonotic diseases developed (including Lassa and rabies): this used as the policy document to initiate the response. Emergency and contingency plans developed for zoonotic diseases. Page 86 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) CERC manual prepared. National EOC established links with sub-nationals EOCs for information exchange among staff. Laboratories designated and equipped for COVID-19 diagnosis: all 15 counties using rapid testing and three sites (National Reference Laboratory included) equipped and providing diagnostic services. Rabies and other strategy plans developed and/or revised. Pandemic emergency risk community plan and activities developed and tested, with specific focus on COVID-19. Disease surveillance interventions at POE and at community levels implemented (COVID-19 response). 4,900 frontline workers trained (frontline and non-frontline), including 660 clinical staff assigned to treatment centers (response capacity). Surge teams supported. Mitigation measures implemented. Nigeria Seasonal calendar developed. Multi-sectoral operational mechanism for coordinated investigation and response to outbreaks of endemic, emerging or re-emerging zoonotic diseases in place. Contingency plans for almost all priority zoonotic diseases. Multisectoral multidisciplinary Public Health Emergency Operating Centers. Technical Working Groups for Rabies, Mpox, Lassa fever, influenza, etc. Acquisition of medicines, consumables, PPEs to respond to diseases in 36 states and FCT. Engagement of logistics and warehousing officers to support medical counter measures activities in NCDC and designated laboratories. Animal health sector: acquisition of anti-rabies campaign materials, production of radio/ television jiggles. Acquisition of seven ambulatory vehicles for VTH in states; state vaccination campaign logistics support provided for at-risk veterinarians. With WAHO support, establishment of 20 CES in Kwara state (15) and FCT (5), during the COVID-19 pandemic. 276,000 ampoules of 200mg/2ml Ribavirin injection and 45,000 Tablets of 500mg of Ribavirin Tablet and 47 thousand pieces of protective equipment Togo Component 2: Laboratories refurbished, equipped for human and animal health. Acquisition of consumables and reagents (for COVID-19 diagnosis) Page 87 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Acquisition of vaccines (rabies and anthrax). Kits for avian flu detection and new castle. Quality of laboratory improved (quality of testing during COVID-19 and avian flu outbreak improved): 2 animal health regional labs and 1 central laboratory equipped. Component 3: -COVID-19: Acquisition of ambulances, medicines to treat patients, PPE individual and collective. -COUSP operational capacities strengthened (TIC equipment central level and 3 regions). -Elaboration and dissemination of key strategic documents: PANSS, national COVID-19 response plan; protocol for medical waste for incinerators M100; Integrated Management Plan for vectors and insecticides (animal health, 500 copies distributed); Strategic Plan for medical waste management (human health, 3000 copies distributed; Management framework for hospital and veterinary fluids; Strategic Plan (PCI). -RRIs (EIR in French) trained in the 6 health regions on standards operational procedures. -Annual simulations (to test the national preparedness and response plan). Page 88 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 1C. RESULTS FRAMEWORK INDICATOR COMPARISON Actual at Original Revised PDO PDO Indicator Measure Baseline completion Target Target (15 Dec 2023) Project Development Objective Indicators PDO 1 Description: Where 1 = no capacity; 2 = governance structure established and endorsed; 3 = an action plan for regional collaboration is developed and endorsed; 4 = action plan is budgeted and implemented; 5 = fifty percent of operational Progress towards establishing an budgets for the implementation of regional action plan comes active, functional One Health from national budgets Additional info: the multi-sectoral aspects 1 4 4 3 Platform of One Health require the establishment of a platform consisting of a governance mechanism, an operational action plan, and M&E framework to determine intersecting areas and responsibilities between human, animal, and environmental health. 1.a: G.Bissau n/a n/a n/a n/a 1.b: Liberia 1 n/a 4 4 1.c: Nigeria 1 3 4 4 1.d: Togo n/a n/a n/a n/a PDO 2 Number of countries achieving JEE score of 4 or higher 1 = no capacity (National laboratory system is not capable of conducting any core tests); 2 = limited capacity (national laboratory system is capable of Laboratory testing capacity for conducting 1-2 (of 10) core tests); 1 3 3 2 detection of priority diseases 3 = developed capacity (national laboratory system is capable of conducting 3-4 (of 10) core tests); 4 = demonstrated capacity (national laboratory system is capable of conducting 5 or more (of 10) core tests); and Page 89 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 5 = sustainable capacity (In addition to capability of conducting 5 or more core tests, country has national system(s) for procurement and quality assurance) 2.a: G.Bissau JEE score 1 4 4 3 2.b: Liberia JEE score 2 4 4 4 2.c: Nigeria JEE score 3 4 4 3 2.d: Togo JEE score 4 3 4 4 PDO 3 Number of countries achieving JEE score of 4 or higher 1 = no capacity (no indicator or event-based surveillance system exists); 2 = limited capacity (indicator and event-based surveillance system(s) planned to begin within one year); 3 = developed capacity (indicator OR event-based surveillance Progress in establishing indicator and system(s) in place to detect public health threats); 1 3 3 3 event-based surveillance systems 4 = demonstrated capacity (indicator AND event-based surveillance system(s) in place to detect public health threats); 5 = sustainable capacity (in addition to surveillance systems in country, using expertise to support other countries in developing surveillance systems and provide well-standardized data to WHO and OIE for the past five years without significant external support) 3.a: G.Bissau JEE score 1 4 4 2 3.b: Liberia JEE score 4 4 4 4 3.c: Nigeria JEE score 3 3 4 4 3.d: Togo JEE score 3 3 4 4 PDO 4 Number of countries achieving JEE score of 3 or higher 1 = no capacity (country doesn’t have multidisciplinary HR capacity required for implementation of IHR core capacities); Availability of human resources to 2 = limited capacity (country has multidisciplinary HR capacity implement IHR core capacity 0 4 4 4 epidemiologists, veterinarians, clinicians and laboratory requirements specialists or technicians) at national level); 3 = developed capacity (multidisciplinary HR capacity is available at national and intermediate level); Page 90 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 4 = demonstrated capacity (multidisciplinary HR capacity is available as required at relevant levels of public health system (e.g. epidemiologist at national level and intermediate level and assistance epidemiologist (or short course trained epidemiologist) at local level available); 5 = sustainable capacity (country has capacity to send and receive multidisciplinary personnel within country (shifting resources) and internationally) 4.a: G.Bissau JEE score 1 4 4 4 4.b: Liberia JEE score 1 4 4 3 4.c: Nigeria JEE score 3 3 4 4 4.d: Togo JEE score 2 3 4 4 PDO 5 Number of countries achieving JEE score of 4 or higher 1 = no capacity (national public health emergency preparedness and response plan is not available to meet the IHR core capacity requirements); 2 = limited capacity (a multi-hazard national public health emergency preparedness and response plan to meet IHR core capacity requirements has been developed); Multi-hazard national public health 3 = developed capacity (national public health emergency emergency preparedness and response plan(s) incorporates IHR related hazards and Points of 0 3 3 1 response plan is developed and Entry AND Surge capacity to respond to public health implemented emergencies of national and international concern is available); 4 = demonstrated capacity (procedures, plans or strategy in place to reallocate or mobilize resources from national and intermediate levels to support action at local response level (including capacity to scaling up the level of response); 5 = sustainable capacity (the national public health emergency response plan(s) is implemented/tested in actual emergency or simulation exercises and updated as needed) 5.a: G.Bissau JEE score 1 4 4 3 5.b: Liberia JEE score 1 4 3 3 5.c: Nigeria JEE score 1 3 4 3 Page 91 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 5.d: Togo JEE score 2 3 4 4 PDO 6 Self-assessment (Likert scale). Number of countries that achieve a score of 4 or higher. Description: Progress graded on a score of 1-5 where: 1 = no capacity (no formal/informal agreements related to cross border collaboration/information exchange, and no standard operating procedures in place); 2 = limited capacity (informal agreements on cross-border collaboration/ information exchange and standard operating procedures drafted); 3 = Progress on cross-border developed capacity (formal agreements on cross-border collaboration and exchange of 0 3 2 1 collaboration/information exchange, and standard operating information across countries procedures adopted); 4 = demonstrated capacity (formal agreements on cross border collaboration/information exchange and standard operating procedures implemented and routinely monitored); 5 = sustainable capacity (normal agreements on cross-border collaboration/information exchange and standard operating procedures) implemented, routinely monitored and financed from domestic budget. 6.a: G.Bissau Self-assessment 3 4 4 3 6.b: Liberia Self-assessment 1 4 3 3 6.c: Nigeria Self-assessment 1 3 4 4 6.d: Togo Self-assessment 1 3 4 3 PDO 7 Nigeria: CERC indicator-No. of suspected cases actively investigated Self-assessment 0 n/a 1,914 8,101 for Lassa fever and treated if needed (added in 1st restructuring Feb 2020) Intermediate Results Indicators Component 1: Surveillance and Information Systems IRI 1 Number of countries achieving JEE score of 4 or higher 1 = no capacity (no interoperable, interconnected, electronic Interoperable, interconnected, real-time reporting system exists; 0 3 3 0 electronic real-time operating system 2 = limited capacity (country is developing an interoperable, interconnected, electronic real-time reporting system, for either public health or veterinary surveillance systems); Page 92 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 3 = developed capacity (country has in place an inter-operable, interconnected, electronic reporting system, for either public health or veterinary surveillance systems. The system is not yet able to share data in real-time); 4 = demonstrated capacity (country has in place and interoperable, interconnected, electronic real-time reporting system, for public health and/or veterinary surveillance systems. The system is not yet fully sustained by the host government); and 5 = sustainable capacity (country has in place an interoperable, interconnected, electronic real-time reporting system, including both the public health and veterinary surveillance systems which is sustained by the government and capable of sharing data with relevant stakeholders according to country policies and international obligations). IRI 2.a: G.Bissau JEE score 2 4 4 3 IRI 2.b: Liberia JEE score 2 4 4 3 IRI 2.c: Nigeria JEE score 2 3 4 3 IRI 2.d: Togo JEE score 2 3 4 3 IRI 3 Number of countries achieving JEE score of 3 or higher 1 = no capacity (no zoonotic surveillance system exists); 2 = limited capacity (country has determined zoonotic diseases of greatest national public health concern but does not have animal zoonotic surveillance systems in place); 3 = developed capacity (zoonotic surveillance systems in place for 1-4 zoonotic diseases/ pathogens of greatest public health Surveillance systems in place for concern); 0 4 4 4 priority zoonotic diseases/pathogens 4 = demonstrated capacity (zoonotic surveillance systems in place for five or more zoonotic diseases/ pathogens of greatest public health concern); and 5 = sustainable capacity (zoonotic surveillance systems in place for 5 or more zoonotic diseases/pathogens of greatest public health concern with systems in place for continuous improvement). Page 93 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) IRI 3.a: G.Bissau JEE score 2 4 4 3 IRI 3.b: Liberia JEE score 2 4 3 3 IRI 3.c: Nigeria JEE score 3 3 4 3 IRI 3.d: Togo JEE score 2 3 3 3 IRI 7 Number of countries achieving JEE score of 5 1 = no capacity (no national IHR focal point, OIE Delegate and/or WAHIS National Focal Point has been identified and/or identified focal point/delegate does not have access to learning package and best practices as provided by WHO, OIE and FAO); 2 = limited capacity (country has identified National IHR Focal Point, OIE delegates and WAHIS National Focal Points; focal point is linked to learning package and best practices as provided by WHO, OIE and FAO); 3 = developed capacity (country has demonstrated ability to Systems for efficient reporting to identify a potential PHEIC and file a report to WHO based on an 0 3 4 0 WHO, OIE/FAO exercise or real event, and similarly to the OIE for relevant zoonotic diseases); 4 = (demonstrated capacity (country has demonstrated ability to identify a potential PHEIC and file a report to WHO within 24 hours and similarly to the OIE for relevant zoonotic disease, based on an exercise or real event); and 5 = sustainable capacity (country has demonstrated ability to identify a potential PHEIC and file a report within 24 hours, and similarly to the OIE for relevant zoonotic disease, and has a multisectoral process in place for assessing potential events for reporting). IRI 7.a: G.Bissau JEE score 2 4 4 3 IRI 7.b: Liberia JEE score 2 4 5 3 IRI 7.c: Nigeria JEE score 3 5 4 3 IRI 7.d: Togo JEE score 2 3 4 4 Page 94 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Liberia Liberia: Number of suspected cases of COVID-19 reported and investigated per approved protocol Self-assessment 0 n/a 300 15,229 (added in 2nd restructuring May 2023) Component2: Strengthening of Laboratory Capacity IRI 2 Number of countries achieving JEE score of 4 or higher 1 = no capacity (there are no national laboratory standards); 2 = limited capacity (national quality standards have been developed but there is no system for verifying their implementation); 3 = developed capacity (a system of licensing of health laboratories that includes conformity to a national quality Laboratory systems quality standard exists but it is voluntary or is not a requirement for all 0 3 3 1 laboratories); 4 = demonstrated capacity (mandatory licensing of all health laboratories is in place and conformity to a national quality standard is required); and 5 = sustainable capacity (mandatory licensing of all health laboratories is in place and conformity to an international quality standard is required). IRI 3.a: G.Bissau JEE score 1 4 4 2 IRI 3.b: Liberia JEE score 1 4 4 3 IRI 3.c: Nigeria JEE score 2 3 4 3 IRI 3.d: Togo JEE score 2 2 4 4 IRI 5 Number of countries achieving JEE score of 4 or higher 1 = no capacity (i.e. aside from ad hoc transporting, no system is in place for transporting specimens from district to national level); Specimen referral and transport 2 = limited capacity (system is in place to transport specimens to 0 3 2 1 system national laboratories from less than 50% of intermediate level/districts in country for advanced diagnostics); 3 = developed capacity (system is in place to transport specimens to national laboratories from 50- 80% of intermediate Page 95 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) level/districts within the country for advanced diagnostics); 4 = demonstrated capacity (system is in place to transport specimens to national laboratories from at least 80% of intermediate level/districts within the country for advanced diagnostics; and 5 = sustainable capacity (system is in place to transport specimens to national laboratories from at least 80% of districts for advanced diagnostics; capability to transport specimens to/from other labs in the region; and specimen transport is funded from domestic budget). IRI 5.a: G.Bissau JEE score 1 4 4 2 IRI 5.b: Liberia JEE score 3 4 4 4 IRI 5.c: Nigeria JEE score 1 3 3 2 IRI 5.d: Togo JEE score 1 3 3 3 Liberia Liberia: Number of designated laboratories with COVID-19 diagnostic equipment, test kits and Self-assessment n/a 3 4 reagents (added in 2nd restructuring May 2023) Component 3: Preparedness and Emergency Response IRI 8 Number of countries achieving JEE score of 4 or higher 1 = no capacity (i.e. no mechanism in place); 2 = limited capacity (national policy, strategy or plan for the response to zoonotic events is in place); 3 = developed capacity (a mechanism for coordinated response Mechanism for responding to to outbreaks of zoonotic diseases by human, animal and wildlife infectious zooneses and potential sectors is established); 0 3 3 3 zoonoses are established and 4 = demonstrated capacity (timely* and systematic information functional exchange between animal/wildlife surveillance units, human health surveillance units and other relevant sectors in response to potential zoonotic risks and urgent zoonotic events); and 5 = sustainable capacity (timely** response to more than 80% of zoonotic events of potential national and international concern) *timeliness is judged and determined by country ** time Page 96 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) between detection and response as defined by regional/national standards. IRI 8.a: G.Bissau JEE score 1 4 4 4 IRI 8.b: Liberia JEE score 2 4 4 3 IRI 8.c: Nigeria JEE score 1 4 4 4 IRI 8.d: Togo JEE score 2 3 4 4 IRI 15 Self-evaluation (5-point likert scale) - Description: Capacity graded on a score of 1 -5 where: 1 = no capacity (no regional surge capacity and stockpiling mechanisms exist); 2 = limited capacity (regional stockpiling mechanism is in place with limited surge capacity); 3 = developed capacity (regional surge capacity Regional surge capacity and and stockpiling mechanism has been established); 4 = 1 3 3 2 stockpiling mechanisms established demonstrated capacity (regional surge capacity and stockpiling mechanism has been established and tested); 5 = sustainable capacity (effective regional surge capacity and stockpiling mechanism has been established with sustainable funding arrangements from country budget) Liberia Liberia: Outbreak/pandemic emergency risk communication plan and activities developed and tested Self-assessment n/a n/a yes yes (added in 2nd restructuring May 2023) Component 4: Human Resources Management for Effective Disease Surveillance and Epidemic Preparedness IRI 4 Number of countries achieving JEE score of 4 or higher 1 = no capacity (no health workforce strategy exists); 2 = limited capacity (a healthcare workforce strategy exists but does not include public health professions e.g. epidemiologists, veterinarians and laboratory technicians); Workforce strategy 0 3 3 0 3 =developed capacity (a public health workforce strategy exists, but is not regularly reviewed, updated, or implemented consistently); 4 = demonstrated capacity (a public health workforce strategy has been drafted and implemented consistently; strategy is Page 97 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) reviewed, tracked and reported on annually); and 5 = sustainable capacity (“demonstrated capacity” has been achieved, public health workforce retention is tracked and plans are in place to provide continuous education, retain and promote qualified workforce within the national system). IRI 4.a: G.Bissau JEE score 1 4 4 2 IRI 4.b: Liberia JEE score 2 4 4 2 IRI 4.c: Nigeria JEE score 2 4 3 3 IRI 4.d: Togo JEE score 2 3 4 3 IRI 6 Number of countries achieving JEE score of 4 or higher 1 = no capacity (no FETP or applied epidemiology training program established or no access to such a program in another country); 2 = limited capacity (no FETP or applied epidemiology training program is established within the country, but staff participate in a program hosted in another country through an existing agreement (at Basic, Intermediate and/or Advanced level); 3= developed capacity (one level of FETP (Basic, Intermediate, or Applied epidemiology training Advanced) FETP or comparable applied epidemiology training 1 3 3 4 program in place such as FELTP/FEPT program in place in the country or in another country through an existing agreement); 4 = demonstrated capacity (two levels of FETP (Basic, Intermediate and/or Advanced) or comparable applied epidemiology training program(s) in place in the country or in another country through an existing agreement); and 5 = sustainable capacity (three levels of FETP (Basic, Intermediate and Advanced) or comparable applied epidemiology training program(s) in place in the country or in another country through an existing agreement, with sustainable national funding). IRI 6.a: G.Bissau JEE score 3 5 4 4 IRI 6.b: Liberia JEE score 3 4 4 4 IRI 6.c: Nigeria JEE score 4 5 4 4 IRI 6.d: Togo JEE score 3 3 4 4 Page 98 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) IRI 9 Number of countries achieving JEE score of 4 or higher 1 = no capacity (country has no animal health workforce capable of conducting One Health activities); 2 = limited capacity (country has animal health workforce capacity within the national public health system); 3 = developed capacity (animal health workforce capacity within the national public health system and less than half of sub- Veterinary human health workforce national levels); 0 3 3 2 4 = demonstrated capacity (animal health workforce capacity within the national public health system and more than half of sub-national levels); and 5 = sustainable capacity (animal health workforce capacity within the public health system and at all sub-national levels; this includes a plan for animal health workforce continuing education). IRI 9.a: G.Bissau JEE score 2 4 4 4 IRI 9.b: Liberia JEE score 2 3 3 3 IRI 9.c: Nigeria JEE score 3 4 4 3 IRI 9.d: Togo JEE score 2 3 4 4 IRI 11 Percentage female of people trained Percentage. For percent calculation: Numerator (Number of in applied epidemiology (All women trained in applied epidemiology in the country in all 0 n/a 35 29.65 categories). (added in 1st categories): Denominator (Total number of people trained in restructuring Feb 2020) applied epidemiology in the country in all categories) IRI 11.a: G.Bissau 0 n/a 35 35 IRI 11.b: Liberia 0 n/a 35 31 IRI 11.c: Nigeria 0 n/a 35 30 IRI 11.d: Togo 0 n/a 35 22.6 IRI 12 Percentage female of people trained Percentage in applied epidemiology (Basic) 0 n/a 40 27.75 (added in 1st restructuring Feb 2020) IRI 12.a: G.Bissau 0 n/a 40 38 IRI 12.b: Liberia 0 n/a 40 30 Page 99 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) IRI 12.c: Nigeria 0 n/a 40 32 IRI 12.d: Togo 0 n/a 40 11 IRI 13 Percentage female of people trained Percentage in applied epidemiology 0 n/a 35 31 (Intermediate) (added in 1st restructuring Feb 2020) IRI 13.a: G.Bissau 0 n/a 35 31 IRI 13.b: Liberia 0 n/a 35 31 IRI 13.c: Nigeria 0 n/a 35 48 IRI 13.d: Togo 0 n/a 35 14 IRI 14 Percentage female of people trained Percentage in applied epidemiology (Advanced) 0 n/a 25 27 (added in 1st restructuring Feb 2020) IRI 14.a: G.Bissau 0 n/a 25 23 IRI 14.b: Liberia 0 n/a 25 36 IRI 14.c: Nigeria 0 n/a 25 38 IRI 14.d: Togo 0 n/a 25 11 Nigeria Nigeria: Number of people trained in (i)6; (ii) 76 (i) Lassa fever diagnostics and ii) in (i) 6; (ii) Self-assessment 0 n/a surveillance the use of SORMAS (added in 1st 75 officers restructuring Feb 2020) Component 5: Institutional Capacity Building, Project Management, Coordination and Advocacy IRI 10 Citizens/communities involved in planning/implementation/evaluation No Yes yes yes of development Yes/No IRI 10.a: G.Bissau Yes No Yes yes yes IRI 10.b: Liberia Yes No Yes yes yes IRI 10.c: Nigeria Yes No Yes yes yes IRI 10.d: Togo Yes No Yes yes yes Page 100 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Nigeria Nigeria: Number of weekly sensitization programs conducted on self-assessment 0 n/a 3 3 national radio network (added in 1st restructuring Feb 2020) Page 101 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION A. TASK TEAM MEMBERS Name Role Preparation John Paul Clark, Francois G. Le Gall Task Team Leader(s) Elzbieta Sieminska, Mohamed El Hafedh Hendah Procurement Specialist(s) Bella Diallo Financial Management Specialist Pooshpa Muni Reddi Team Member Aissatou Chipkaou Team Member Abiodun Elufioye Team Member Hocine Chalal Team Member Alexandra C. Bezeredi Environmental Specialist Vololoniaina N Andrianaivo A Team Member Frode Davanger Team Member Gaston Sorgho Peer Reviewer Alaa Mahmoud Hamed Abdel-Hamid Team Member Fernando Lavadenz Team Member Benjamin P. Loevinsohn Team Member Shiyong Wang Team Member Ruma Tavorath Environmental Specialist Maman-Sani Issa Safeguards Advisor/ESSA Daniel Rikichi Kajang Team Member Page 102 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Adetunji A. Oredipe Team Member Abimbola Adubi Team Member Ayodeji Oluwole Odutolu Team Member Jean Charles Amon Kra Team Member Patrick Lumumba Osewe Peer Reviewer Moustapha Ould El Bechir Team Member Rianna L. Mohammed-Roberts Team Member Esinam Hlomador-Lawson Team Member Mamata Tiendrebeogo Team Member Akinrinmola Oyenuga Akinyele Team Member Haidara Ousmane Diadie Team Member Stephane Forman Peer Reviewer Adewunmi Cosmas Adekoya Team Member Shunsuke Mabuchi Team Member Amos Abu Social Specialist Fatou Fall Samba Team Member Saidu Dani Goje Team Member Adjalou Celestin Niamien Team Member Mathias Gogohounga Team Member Sydney Augustus Olorunfe Godwin Team Member Brahim Sall Team Member Oluwayemisi Busola Ajumobi Team Member Erick Herman Abiassi Team Member Page 103 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Enias Baganizi Team Member Matthieu Louis Bonvoisin Counsel Caroline Aurelie Plante Team Member Edson Correia Araujo Team Member Faly Diallo Team Member Michael Opeyemi Olugbile Team Member Essienawan Ekpenyong Essien Team Member Komana Rejoice Lubinda Team Member Sekou Abou Kamara Team Member Munirat Iyabode Ayoka Ogunlayi Team Member Tolulope Oluseun Idowu Team Member Syed I. Ahmed Team Member Supervision/ICR Carolyn J. Shelton, Collins Chansa, Yemdaogo Tougma, Task Team Leader(s) Mariam Noelie Hema, Chijioke Samuel Okoro Daniel Rikichi Kajang, Bayo Awosemusi, Mary Anika Procurement Specialist(s) Asanato-Adiwu Josue Akre Financial Management Specialist Eucharia Nonye Osakwe Financial Management Specialist MacDonald Nyazvigo Financial Management Specialist Akinrinmola Oyenuga Akinyele Financial Management Specialist Fatou Mbacke Dieng Financial Management Specialist Joyce Chukwuma-Nwachukwu Procurement Team Vololoniaina N Andrianaivo A Team Member Nohra Eugenia Posada Pacheco Team Member Janet Victoria Ngegla Environmental Specialist Papa Ansoumana Moustapha Mane Social Specialist Page 104 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Sophie Lo Diop Environmental Specialist Luis Camilo Osorio Florez Team Member Djacumba Cassama Team Member Akhilesh Ranjan Social Specialist Zinnah S Mulbah Team Member Lucky Erhaze Environmental Specialist Ayodeji Gafar Ajiboye Team Member Gina Cosentino Social Specialist Franck Cesar Jean Berthe Team Member Harende Kpango Team Member Komlan Kpotor Environmental Specialist Ifeoma Clementina Ikenye Team Member Monica Moura Porcidonio Silva Team Member Michael Opeyemi Olugbile Team Member Faly Diallo Team Member Allan Dunstant Odulami Cole Procurement Team Edson Correia Araujo Team Member Zoe Quoi Diggs Duncan Procurement Team Anta Tall Diallo Procurement Team Lemu Ella Makain Team Member Erick Herman Abiassi Team Member Brahim Sall Team Member Sydney Augustus Olorunfe Godwin Team Member Nadia Mireille Zenia Amoudji Agnegue Procurement Team Saidu Dani Goje Team Member Seynabou Thiaw Seye Procurement Team Fatou Fall Samba Team Member Amos Abu Environmental Specialist Luis Corrales Team Member Page 105 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) Rocio Schmunis Team Member Aisha Donald Kaga Team Member Nikolai Alexei Sviedrys Wittich Procurement Team Mamadou Mansour Mbaye Procurement Team Olukayode O. Taiwo Social Specialist Mamata Tiendrebeogo Procurement Team Esinam Hlomador-Lawson Procurement Team Adetunji A. Oredipe Team Member Andre L. Carletto Team Member B. STAFF TIME AND COST Staff Time and Cost Stage of Project Cycle No. of staff weeks US$ (including travel and consultant costs) Preparation FY17 23.173 192,152.69 FY18 3.062 21,306.50 FY19 0 4,920.00 Total 26.24 218,379.19 Supervision/ICR FY17 0 45.04 FY18 27.485 232,247.60 FY19 65.518 321,189.17 FY20 59.275 316,048.07 FY21 54.751 251,498.74 FY22 56.224 272,713.09 FY23 66.652 322,504.84 Page 106 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) FY24 30.294 227,005.25 Total 360.20 1,943,251.80 Page 107 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 3. PROJECT COST BY COMPONENT Revised Amount Amount at Amount at After Amount Cancelled Amount at Project Closing as % of Component Approval (US$M) Restructurings (US$M) Closing (US$M) Amount at (CERC) (US$M) Approval Component 1: Surveillance and 45.33 44.29 10.22 34.07 75.2% Information Systems Guinea Bissau 4.65 4.65 1.79 2.86 Liberia 1.48 1.41 0.00 1.41 Nigeria 35.00 34.03 7.03 27.00 Togo 4.20 4.20 1.40 2.80 Component 2: Strengthening of 30.89 30.17 8.86 21.31 69.0% Laboratory Capacity Guinea Bissau 6.72 6.72 3.02 3.70 Liberia 2.53 1.81 0.00 1.81 Nigeria 19.00 19.00 5.00 14.00 Togo 2.64 2.64 0.84 1.80 Component 3: Preparedness and 26.08 30.92 6.12 24.8 95.1% Emergency Response Guinea Bissau 2.33 2.33 1.19 1.14 Liberia 2.55 6.42 0.00 6.42 Nigeria 10.50 11.47 0.97 10.50 Togo 10.70 10.70 3.96 6.74 Component 4: Human Resource Management for Effective Disease 22.64 20.62 9.18 11.44 50.5% Surveillance and Epidemic Preparedness Guinea Bissau 3.98 3.98 1.16 2.82 Liberia 2.96 0.94 0.00 0.94 Nigeria 14.50 14.50 8.00 6.50 Togo 1.20 1.20 0.02 1.18 Component 5: Institutional Capacity Building, Project 22.06 21 5.73 15.27 69.2% Management, Coordination, and Advocacy Guinea Bissau 3.32 3.32 0.10 3.22 Liberia 5.48 4.42 0.00 4.42 Nigeria 11.00 11.00 5.00 6.00 Togo 2.26 2.26 0.63 1.63 TOTAL 147.00 147.00 40.11 106.89 72.7% Page 108 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 4. ECONOMIC ANALYSIS A. The Context 1. A succession of major disease outbreaks, including SARS, MERS, Avian Influenza, Ebola Virus Disease, Zika, and COVID-19, has inflicted widespread devastation on both societies and economies. Several factors intricately connected to various aspects of contemporary living contribute to the “evolution of microbes and humans coming to a collision course”,42 including the pervasive nature of global travel, the expanding intrusion of humanity into previously untouched natural habitats, and the effects of modernization, such as climate change, urbanization, and overcrowding. These outbreaks have differed from one another in many ways, including their clinical presentation, their degree of severity, and their means of transmission – but all have had one notable thing in common: the outbreaks caught most countries off-guard and exposed huge vulnerabilities in the capacities of countries and regions to respond quickly. 2. Microbes know no borders and aided by large scale movements in an interconnected world, easily transcend national boundaries and cause significant health, social, and economic repercussions that affect multiple countries and regions.43 The recent outbreaks underscore the folly of relying solely on national health capacities and measures, and present a compelling case for strengthening regional and global preparedness in addition to bolstering national capacities to respond rapidly and effectively to disease outbreaks. 3. The World Bank's characterization of healthcare-related entities and actions as “goods” mirrors its economic perspective on human health, wherein healthcare provision is influenced by market dynamics of demand and supply. Economists commonly classify such entities into four types: private goods (e.g., food, medicine, books), club goods (e.g., toll roads, movie theaters), common goods (e.g., natural resources, universal healthcare), and public goods (e.g., environment, culture, pandemic preparedness), depending on specific characteristics related to “excludability” (i.e., the ability to prevent someone from using them) and “rivalry” (i.e., whether their consumption affects availability for others) (figure 1). 44,45 4. The scope of public goods can be local, national, or global. Public fireworks, for instance, are a local public good, as anyone within eyeshot can enjoy the show. On the other hand, national defense is a national public good, as its benefits are enjoyed by citizens of the state. By extension, global public goods are those whose benefits affect all citizens of the world.46 This approach was initially outlined in 1993 when the World Bank articulated its rationale for engaging in health matters, highlighting the control of 42 Payne, Tom (2023) “Infectious Diseases: Are Humans the Dominant Risk?” Alesco Risk Management Services. Accessed on 11/11/23 at https://www.alescorms.com/news/infectious-diseases 43 Osterholm, Michael T and Mark Olshaker (2020): “Chronicle of a Pandemic Foretold: Learning From the COVID -19 Failure— Before the Next Outbreak Arrives,” Foreign Affairs, July/August 2020 44 Kaul I, Grunberg I, Stern MA, eds. Public goods: international cooperation in the 21st century. Oxford University Press, 1999doi: 10.1093/0195130529.001.0001.Google Scholar 45 Moon S, Røttingen J-A, Frenk J. Global public goods for health: weaknesses and opportunities in the global health system. Health Econ Policy Law2017; 358:195-205. doi:10.1017/S1744133116000451 pmid:28332461. 46 Chin, Moya (2021): “What are Global Public Goods?”, Finance and Development, A Quarterly Publication of the International Monetary Fund, December 2021, Volume 58, Number 4 Page 109 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) infectious diseases as a highly efficient and cost-effective “investment” focus.47 Considering pandemic preparedness to be a global public good and viewing health as a catalyst for economic prosperity further justified the substantial financial commitments of over US$16 billion made by the World Bank in combating Ebola.48,49 Figure 1: Categorization of goods 5. For a variety of reasons, public goods are undersupplied. Individuals cannot be charged for consumption of public goods, and once supplied, no one can be prevented from consuming them. Individual producers of public goods cannot profit from them and thus have no incentives to invest in their production. The production of global public goods such as pandemic preparedness poses an even greater challenge since it involves additional layers of cross-border coordination. The consequences of underinvestment in global health functions became very evident in the West African Ebola epidemic of 2014-2016, which challenged the weak surveillance systems and raged unabated for over eighteen months in the absence of rapid diagnostic tests, treatment, and vaccine availability. This episode highlighted the world’s unpreparedness to effectively combat multi-country disease outbreaks and laid the foundation for the Regional Disease Surveillance Systems Enhancement (REDISSE) projects. B. The Regional Disease Surveillance Systems Enhancement (REDISSE) projects 6. REDISSE is a regional multi-sectoral program that aims to strengthen national and regional capacities in West Africa (and select Central African countries) to address disease threats at the human, animal, and environmental interface. It also includes a contingent emergency response component to improve a government’s response capacity in the event of an emergency. Implemented in phases as an series of projects, it covers 16 countries in Africa.50 REDISSE I, the first in the series of projects, was approved in 2016 for three countries – Guinea, Sierra Leone and Senegal, each of which received US$30 47World Bank Group. Development report 1993: investing in health. 1993. https://openknowledge.worldbank.org/handle/10986/5976?show=full 48 World Bank. 2016. World Bank Annual Report 2016. Washington, DC: World Bank. doi: 10.1596/978-1-4648- 0852-4. 49 Kim JY. Speech by World Bank Group President Jim Yong Kim at the annual meetings plenary. 2016. http://www.worldbank.org/en/news/speech/2016/10/07/plenary-speech-by-world-bank-group-president-jim-yong-kim-2016 50 The REDISSE program was approved in four phases in 2016, 2017, 2018, and 2019 respectively with a total financing from the World Bank of U$688.13 million. Countries covered by the REDISSSE program of projects include Angola, Benin, Chad, Central Africa Republic, Congo Republic, Democratic Republic of Congo, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Sierra Leone, Senegal, and Togo. Page 110 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) million – and one regional entity – the West African Health Organization (WAHO),51 a regional health institution established in 1998 by the heads of the 15 ECOWAS States to improve health systems and address the common health challenges faced in the region through coordination, collaboration and cooperation among the member states, which received US$20 million from IDA and US$8.6 million52 in trust fund co-financing from the government of Canada. REDISSE II, the second in the series of projects, was approved one year later in 2017, and covered four countries: Guinea Bissau (US$21 million), Liberia (US$15 million), Nigeria (US$90 million) and Togo (US$21 million). WAHO was designated as the regional agency for purposes of coordination, cooperation and collaboration for all REDISSE-covered countries but only received financing under REDISSE I. C. Economic Justification 7. The REDISSE II project documents emphasize that a compelling economic argument exists for investing in the strengthening of integrated disease surveillance and response systems in ECOWAS countries. Using the West Africa Ebola epidemic as a case in point, the PAD contends that given the adverse effects of slower economic growth in the region, estimated at US$7.35 billion in regional loss of output in 2014, and considering the relatively modest investments needed to establish a robust global disease surveillance and response system, the potential returns on investment are remarkably high, potentially reaching up to 123% annually. Furthermore, given the ease with which viruses cross borders, it concludes that there is a strong economic rationale for enhancing cross-sectoral and inter-country capabilities in integrated disease surveillance and response to rapidly detect and address public health threats. 8. The REDISSE II project documents primarily present three rationales for a publicly provided approach to strengthening disease surveillance and response network: • First, infectious diseases impose a substantial economic burden on the region, hindering both regional and national economic development. The economic losses from pandemics are estimated to be at least US$60 billion annually, and diseases disrupt trade and commerce globally. • Second, disease surveillance is considered a global public good, with benefits extending beyond national borders. The non-excludable and non-rivalrous nature of these benefits necessitates collective funding to address the “free rider” problem. Additionally, the externalities of disease outbreaks, such as discouraging foreign investment and limiting international livestock trade, justify public financing. • The third rationale emphasizes resource sharing for efficiency, avoiding duplication of costly high- level resources across countries. Coordinated regional responses, especially in the face of resurgent diseases, enhance efficiency and cost-effectiveness. Delays in implementing control measures during epidemics incur significant costs, emphasizing the need for timely detection and response to prevent exponential growth in contagion and mitigation costs. D. Benefit-Cost Analysis 51 Aidam, J., Sombié, I. The West African Health Organization’s experience in improving the health research environment in the ECOWAS region. Health Res Policy Sys 14, 30 (2016). https://doi.org/10.1186/s12961-016-0102-7 52 US$3.8 initially, followed by US$4.8 during mid-term review. Page 111 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 9. The economic analysis presented in the REDISSE II project document includes a benefit-cost analysis (BCA), which compares projected benefits and costs of strengthening the surveillance and response systems up to OIE/WHO standards in 15 West Africa countries. The analysis covered 15 diseases, including Ebola and HIV and thirteen other diseases that caused at least one outbreak between 1996 and 2009. A simulation model was used to measure the impacts of disease outbreaks based on an annual probability of an outbreak in West Africa within a range 0.01 to 0.03. The cumulative sum of the economic and health impacts of simulated events was calculated under the scenarios of status quo (no disease surveillance) and intervention, i.e. the REDISSE program. The number of cases and deaths averted were estimated using historical data from previous outbreaks. Potential health benefits included benefits derived from averting cases and deaths, as well as social and psychological benefits stemming from less apprehension and greater peace of mind when large outbreaks of serious infectious diseases are rare or non-existent. Economic impact was inferred from loss in economic output due to reduction in the labor force participation (temporarily or permanently through workers being ill, dying, or caring for the sick), and disruptions in trade, travel, and commerce due to restrictions and shutdowns. Total economic impact was assumed to be within a range of -0.07 to -4.8 percent of GDP. The total annual benefit of controlling an outbreak in West Africa is, on average, equal to US$ 7.2 billion. The net present value of the project costs was estimated at US$ 313 million. By applying the estimated average annual impact constant for the five first years of the project and using a discount rate of 3%, the analysis estimated a benefit-cost ratio equal to US$ 108.73. 10. Since the REDISSE (phases 1 and 2) projects have closed, an ex-post cost-benefit analysis has been conducted for this ICR. Building upon the ex-ante analysis described in the preceding paragraph, the ex- post analysis assesses actual data and results. The retrospective approach allows for a more accurate understanding of the project's impact, as it considers unforeseen factors and real-world complexities that may have influenced outcomes and provides valuable insights for future decision-making and policy development by informing stakeholders about the effectiveness and efficiency of past projects. 11. Health benefits are measured in terms of averted mortality (AM) due to disease “i” in country “j” in year “y” due to investments in strengthening preparedness through the REDISSE projects, as follows: AMi,j,y>2017 = Number of Casesi,j,y>2017 * (CFRi,j,y<2017 – CFRi,j,y>2017) where CFR refers to the Case Fatality Ratio, which is a measure used in epidemiology and public health to quantify the proportion of people diagnosed with a particular disease who die from that disease within a specified period. 12. Total health benefit (BH) is determined as the sum of the benefit from Averted Mortality from all diseases during the REDISSE project period. BH,,y = ∑i,yBH(AM,j,y) The economic benefits (BE) are calculated as in the original BCA: BE =∑(BE,) Page 112 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) where “t” refers to economic sectors (agriculture, transport, manufacturing, and services). 13. Two major disease outbreaks occurred during the REDISSE project period 2017-23. In terms of impact, the most severe outbreak during this period was the COVID-19 pandemic. The first case in the region was recorded in Nigeria at the end of February 2020, and within a month, all countries in the region came to be affected by the pandemic. By the end of 2022, the number of cases recorded had increased to over 950,000 with over 12,000 deaths. The economic consequences were also huge. Extreme poverty in countries of Western Africa increased by nearly 3 percent in 2022, and the proportion of people in the region living with less than US$ 1.90 a day increased from 2.3 per cent in 2020 to 2.9 per cent in 2021. The debt burdens of countries in the region increased due to slow economic recovery, shrinking fiscal space and weak resource mobilization. This worsening economic situation adversely affected the food security and nutrition situation in the region, leaving more than 25 million people unable to meet their basic food needs in the region, an increase of 34% compared to 2020. 14. Since COVID-19 was once in a century outbreak, there is no CFR data for the years before 2020. Therefore, Averted Mortality attributable to the REDISSE investments cannot be estimated. In lieu, it is useful to look at other disease outbreaks for which there is before/after data. 15. The other major outbreak that occurred during the REDISSE project period 2016-23 in one of the project’s countries was Lassa Fever, a viral hemorrhagic fever caused by the Lassa virus. It is primarily found in West Africa and is transmitted to humans through contact with food or household items contaminated with rodent urine or feces, particularly from the multimammate rat (Mastomys species). Lassa Fever was recorded in Nigeria in seven out of eight years between 2016 and 2023 (2021 being the only exception). Table 1 presents the number of cases and CFR in each year. Table 1: Lass Fever Outbreaks in Nigeria, 2016-2023 Date Suspected cases Confirmed cases Deaths Case Fatality Ratio (CFR) January 26, 2016 159 82 51.6 May 27, 2016 273 165 149 56.2 June 28, 2017 501 175 104 59.4 March 1, 2018 1081 317 90 28.4 March 23, 2018 1495 376 119 31.6 April 20, 2018 1849 413 114 27.6 February 14, 2019 327 324 72 22.2 February 20, 2020 472 70 14.8 February 14, 2022 211 40 19.0 May 1, 2023 4702 877 152 17.3 Source: WHO Disease Outbreak News (https://www.who.int/emergencies/disease-outbreak-news) 16. Using exactly the same approach as in the BCA computation presented in the REDISSE II project document, but using actual project costs instead of estimated costs, we compute the benefit-cost ratio to be equal to 43.12, i.e., each US$ 1 invested through the project yielded an expected (discounted) benefit equivalent to US$ 43.12 in one country (Nigeria) in terms of averted human and economic losses due to outbreaks caused by one pathogen (Lassa). Page 113 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) E. Economic Evaluation 17. The REDISSE II project aim to strengthen cross-sectoral and inter-country capacity, contributing to the rapid detection and response to public health threats. By reducing the burden of diseases, the project aims to mitigate public health and economic risks and foster stronger growth and development prospects in the covered countries. Additionally, the REDISSE program position ECOWAS member states to contribute to global health security as a vital public good. 18. The REDISSE II project became active in July 2017 in Togo, September 2017 in Guinea Bissau, November 2017 in Liberia, and February 2018 in Nigeria. However, project implementation was severely impacted by the COVID-19 pandemic which reached all countries by March 2020. First, in accordance with the provisions in the PDO as well as the project components, project resources were redeployed away from planned preparedness activities to surge response. And second, in 3 of the 4 countries, varying amounts of the original credit were canceled due to the disruptions caused by the pandemic, with 27 percent of the original credit amount getting canceled, 28 percent diverted away from preparedness to response, leaving 45 percent only for planned preparedness activities (Table 2).53 Table 2: Distribution of Original Credit Amount (US$, millions) Original Revised Credit Funds used for Funds used Percent Funds Percent Funds Credit (after Planned for used for used for Amount cancellations) Preparedness Response Planned Planned Activities Activities Preparedness Preparedness (% original) (% revised) Nigeria 90 64 39 25 44 62 Liberia 15 15 10 5 67 67 Togo 21 14 7 7 33 50 Guinea 21 14 7 7 33 50 Bissau TOTAL 147 107 64 43 45 60 19. Despite the unforeseen disruption unleashed by the COVID-19 pandemic, the REDISSE II project significantly validate the economic rationale for cross-border investments in the global public good of strengthening pandemic preparedness. First, REDISSE II played a pivotal role in reinforcing both regional and national health security, enhancing national capabilities to prevent, detect, and respond to major disease outbreaks. The project's regional strategy underscored the importance of collective action and cross-border cooperation. This emphasis facilitated information sharing, policy and procedure harmonization, and collaborative planning, implementation, and evaluation of program activities. This form of interaction proved especially crucial for countries with limited capacity, such as Togo, Guinea- Bissau, and Liberia. These nations gained substantial benefits from engaging with counterparts from other countries addressing similar issues, providing a valuable learning experience. In countries where capacity is less extensive, such exchanges nurture a sense of aspiration to match the capabilities of nations with 53Some funds used for response could be counted as preparedness, especially the spending on purchase of laboratory equipment, ambulances, etc. However, in the absence of details, a precise determination is not possible. Page 114 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) greater resources. Consequently, this dynamic contributed to the establishment of essential capacity standards that all countries in the region should strive to achieve. 20. Second, WAHO facilitated the development of a regional laboratory strategy and a regional emergency response strategy. These frameworks were employed as models for nations to formulate their individual national strategies. By utilizing the regional strategy as a foundation for national strategy development, countries guaranteed that their approaches adhered to a predefined minimum standard. Additionally, WAHO extended technical assistance to aid countries in aligning their strategies with these established standards. 21. Third, REDISSE II played a crucial role in the formation of a regional network comprising reference laboratories dedicated to human and animal health. This initiative involved the creation of a collaborative network involving 12 human health laboratories and 2 animal health laboratories. Additionally, at least 2 national laboratories were upgraded to serve as regional facilities. With the support of WAHO, the project facilitated the provision of essential equipment, reagents, and training to enable these laboratories to function as regional reference centers. This development alleviated the reliance on European laboratories for sample testing and quality control during the COVID pandemic, consequently reducing the turnaround time for laboratory testing. 22. Fourth, the adoption of a one-health approach, emphasizing the interconnectedness of human and animal health, has improved the efficiency and coordination of surveillance efforts. Strengthening laboratory capacity, including the acquisition of cold chain logistics for animal health, has contributed not only to elevated diagnostic capabilities but has also contributed to the overall improvement of health infrastructure in the region. 23. Fifth, under the auspices of WAHO, master's level training in regional Field Epidemiology and Laboratory Training Programs (FETP) was undertaken. This specialized training was tailored for a select group of senior epidemiologists, a category with limited representation and poor training opportunities at the national level. By orchestrating a regional training program, WAHO successfully gathered enough students from multiple countries to facilitate the training. The inception of the Advanced Field Epidemiology and Laboratory Training Program in 2018 marked the initiation of master's level training at regional institutions, benefiting over 100 students in two centers of excellence in Abuja (for English speaking candidates) and Bamako (for French speaking candidates). The inaugural cohort of 50 students successfully graduated in 2020. Additionally, WAHO supported the establishment of a network of biosafety associations, with an office in Benin. Additional training with WHO and Association International de Transport Aerien (AITA) was organized to ensure that all countries have at least one AITA-trained and certified person who had the stamp of authority to approve air transportation of medical samples. This resulted in huge reduction of processing time, since DHL was not accepting medical samples unless the person was Institut Pasteur, OOAS or AITA-certified. 24. Sixth, working closely with Fondation Mérieux teams and Santé Monde (Canadian NGO implementing partner in charge of surveillance), the REDISSE project facilitated the establishment of 40 Epidemiological Surveillance Centers (10 in Benin, 20 in Nigeria and 10 in Togo) to integrate laboratory and surveillance units in health districts. This effort significantly strengthened surveillance data analysis and management capabilities. Page 115 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 25. Seventh, REDISSE II resources played a pivotal role in instituting a laboratory certification process within the region, incorporating ISO1589 for human health and ISO7025 for animal health. Supported by WAHO, training sessions were conducted for laboratory personnel in 14 facilities across the region, initiating the Process System Adaptation Program. Special emphasis was placed to enhance quality in the 14 laboratories and move them from 0 and 1 to 4 and 5 stars under a process improvement program known as the Process System Adaptation Program. Upon reaching the 4-star status, the accreditation process was initiated, resulting in accreditation of 1 laboratory in Senegal, 3 in Nigeria and 1 in Ghana. 26. Eighth, WAHO facilitated the exchange of technical assistance among countries, maintaining a roster of health security experts across the region. By promoting and funding the provision of technical assistance between countries, WAHO enabled participating countries to access expertise that might otherwise have been unavailable. Additionally, WAHO organized cross-border simulation exercises, such as the yellow fever simulation between Nigeria and Benin. Following the simulation exercise, these two countries established collaborative mechanisms for cross-border cooperation. 27. Ninth, REDISSE II ensured that participating countries gained swift and early access to World Bank funding for COVID-19 preparedness and response and successfully bridged the financing for response until additional financing tailored to each country was made available through the World Bank's COVID-19 Fast- Track Facility. REDISSE provided comprehensive support for various facets of COVID-19 management, covering surveillance, entry point screening, laboratory testing and diagnosis, infection prevention and control, case management (inclusive of essential medical equipment and materials), and effective risk communication. With backing from WAHO, REDISSE II countries achieved a more coordinated response to the COVID pandemic. Several laboratories in all REDISSE II countries were enhanced and equipped to conduct a large number of PCR tests and genome sequencing. Regular weekly meetings enabled WAHO to stay abreast of the situation in each country, facilitating the provision or coordination of necessary technical assistance. Additionally, WAHO played a pivotal role in harmonizing approaches across countries, including the establishment of a minimum standard for testing and travel bans. Furthermore, the organization facilitated the sharing of high-cost specialized assets such as regional reference laboratories, training institutions, and emergency stockpiles. 28. One of the least appreciated but significant impacts of the project lies in the training initiatives, which have empowered hundreds of health professionals in all countries in surveillance and information systems. By focusing on training human and animal health staff across multiple countries, the project has played a pivotal role in building the capacity to rapidly detect and respond to infectious disease outbreaks. This concerted effort, supported by WAHO with coordination and collaboration, has not only bolstered the individual capacities of the participating countries but has also enhanced the regional public health infrastructure. 29. The proactive response to the Covid-19 pandemic, with staff trained and equipped weeks before the outbreak, exemplifies the preparedness instilled by the project. Additionally, the training modules covering a spectrum of outbreaks, including Lassa Fever, Rift Valley Fever, Monkeypox, Dengue, Avian Flu, Rabies, and Foot and Mouth disease, have contributed to the creation of a robust and versatile public health workforce capable of responding to a wide range of threats. Page 116 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 30. The investment in human resource management for effective disease surveillance and outbreak preparedness, with hundreds of health personnel trained in field epidemiology and laboratory programs at national and regional levels, has contributed to the fortification of the foundation for sustained and effective response mechanisms. The emphasis on capacity building for regional project coordination and regional health security partnership management through WAHO reflects a strategic approach to sustainability and regional collaboration. By strengthening the coordination mechanisms, REDISSE II has contributed to laying the groundwork for continued collaboration, ensuring the longevity and effectiveness of regional health security efforts. F. Conclusion 31. In general, REDISSE II played a pivotal role in enhancing surveillance and response systems in the countries actively involved in the program. REDISSE participating countries are actively integrating and modernizing their disease surveillance systems, bolstering laboratory diagnostic and research capabilities, establishing a resilient health security workforce, implementing emergency response frameworks, fortifying national public health institutions, and effectively responding to real-time public health emergencies, including the challenges posed by COVID-19. 32. In the backdrop of COVID-19, the achievements of the REDISSE II project provide compelling evidence for public financing of pandemic preparedness as a regional/global public good. The experience of the four participating countries underscores the importance of enhanced cross-border surveillance and information-sharing in containing outbreaks, particularly when the microbes are easily transportable across borders, by air or human carriers. It makes the case for regional information sharing to bridge knowledge and treatment gaps, particularly in areas that markets consistently neglect. By coordinating regional efforts through WAHO, REDISSE demonstrated that collective provision of public goods that benefits all countries is more efficient and cost-effective than if individual countries attempted to produce them independently. Despite the disruptions in planned activities by the pandemic, REDISSE II has made substantial contributions to strengthening public goods in the region. 33. From an economic standpoint, REDISSE II can be seen as prudent investments. The upfront costs associated with training, infrastructure development, and preparedness measures are outweighed by the long-term benefits of the countries and of a region better equipped to handle and mitigate the impact of infectious diseases. The enhanced regional public health goods resulting from the project not only contribute to the well-being of individual nations but also foster a more resilient and interconnected West African health landscape. Page 117 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS A. Liberia- Summary of Key Messages from the Country Final Project Report 1. Based on the country report, the main achievements linked to PDO-level indicators are as follows: 2. PDO indicator 1: Progress towards establishing an active, functional One Health Platform: Liberia embraced the One Health guiding principles to facilitate cross-sectoral collaboration to address emerging public health risks, in line with Liberia’s National Action Plan for Health Security 2018-2022 (NAPHS). In June 2017, a One Health Coordination Platform (OHCP) was established to facilitate collaboration among partners, supporting Liberia's NAPHS and the One Health Strategic Plan. Both frameworks serve as guiding documents for coordinated action. The Platform also serves as a mechanism for identifying funding gaps and seeking potential donor support. 3. PDO indicator 2: Laboratory testing capacity for detection of priority diseases: With REDISSE II, Liberia's laboratory testing capacity for detecting priority diseases was significantly enhanced. At completion, the National Reference Laboratory is able to conduct a wide array of serological, microscopy, bacteriology, and molecular tests for diseases including HIV, tuberculosis, malaria, and COVID-19. The Central Veterinary Laboratory tests for various animal diseases such as avian influenza (HPAI), rabies, Salmonella, Brucella, and others. The Environmental Protection Agency Laboratory monitors environmental safety by testing wastewater and drinking water sources for contaminants. Liberia demonstrates substantial progress in strengthening laboratory systems quality, for both human and animal health, with the establishment of a national External Quality Assurance (EQA) program. Strengthening of specimen referral and transport (facility- district-country-national to referral laboratories) in both human and animal health was achieved, despite the sample collection being limited to human health due to health agency funding shortages. 4. PDO indicator 3: Progress in establishing indicator and event-based surveillance systems: Liberia made significant progress in establishing indicator and event-based surveillance systems. It reported 82% proportion of outbreaks detected and investigated, with reports submitted at the national level. The country made progress in integrating disease surveillance and response capabilities within both animal and human sectors. These efforts were facilitated through various initiatives, including the development of an electronic reporting system co-financed by USAID and the REDISSE-II project. Despite challenges in its implementation and roll- out, Liberia has made strides in surveillance for priority zoonotic diseases, with a prioritized list established. Liberia has also shown ability in reporting to international organizations like World Health Organization (WHO), the World Organization for Animal Health, (WOAH) and the Food and Agriculture Organization (FAO) within 24 hours of identifying potential public health emergencies. Surveillance staff, referred as “community health volunteers” and “community animal health workers” were posted in health facilities serving as Point of entry PoE (port health staff and quarantine officers), for informed decision-making processes during public health events and emergencies. 5. PDO 4 indicator: Availability of human resources to implement IHR core capacity requirements: Liberia made considerable efforts to address shortcomings in human resources management capacity. The country established the Field Epidemiology Training Program (FETP) to ensure continuous training across basic, intermediate, and advanced levels, in line with recommendations from a 2018 joint mission by the World Bank Page 118 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) and West Africa Health Organization (WAHO). The Field Epidemiology and Laboratory Training (FELTP) Program trained over 300 healthcare workers within the human health sector over a five-year period. However, due to funding limitations, Liberia sought support from universities and other partners to sustain the program. In relation to veterinary health functions, Liberia reports grappling with significant gaps in Veterinary Services (VS), leading to critical understaffing and hindering its ability to address long-term challenges posed by a growing population. 6. PDO indicator 5: Multi-hazard national public health emergency preparedness and response plan is developed and implemented: With REDISSE’s support, Liberia developed a wide range of tools for a timely health emergency response operation, including an emergency operation manual and the establishment of a robust emergency management structure for mobilization of resources needed during an emergency. Liberia developed guidelines and actions plans: NAPHS, Revised Public Health Law, National Epidemic Preparedness and Response Committee, which holds weekly meetings, the production of a Weekly Epidemiology Bulletin, Incident Management System, and responsible structures identified and functioning. The country has demonstrated ability to coordinate a joint response across human, animal, and environmental sectors. The country established EOCs, activated to respond to the COVID-19 pandemic and other health emergencies. By project completion, Liberia was regularly updating national level inventories and maps of multi-sectoral resources for emergency response, demonstrating capacity. Liberia also completed a National Vulnerability Risk Assessment and a mapping exercise, validated by its national technical committee. Liberia developed joint field investigations and monitoring tools for zoonotic diseases. It also developed disease-specific plans for Ebola, Lassa Fever, Marburg, Cholera, Rabies and Highly Pathogenic Avian Influenza (HPAI). In addition, by completion, Liberia had built human resource capacity, identified responders, and created Integrated Rapid Response Teams (IRRT) for relevant priority diseases across sectors, at community and national level with REDISSE’s support. 7. PDO indicator 6: Progress on cross border collaboration and exchange of information across countries: Three cross-border exercises were conducted for strengthening collaboration and exchange of information at points of entry (PoE), leading to the signing of a Memorandum of Understanding (MOU) among the Mano River Union (MRU) countries, including Côte d’Ivoire, Guinea, Liberia, and Sierra Leone, for information exchange, sample transport, and tracking systems. Regular mid-level meetings involving MRU border countries were conducted to discuss events and issues. While there's a recommendation for establishing a Health Information Exchange (HIE) platform, the concept is still in its early stages but holds promise for facilitating general cross-border information sharing. During the response to COVID-19, the government of Liberia sought financial assistance from development partners to enhance the country's cross-border capacity in disease surveillance, vaccination deployment, and overall health system strengthening. This support encompassed training for Port Health Officers, Quarantine Officers, and members of the Joint Security at designated points of entry to bolster cross-border intervention efforts. Main findings 8. Health system strengthening requires long-term commitments, with sustainability as a key consideration for impactful results. While REDISSE II aimed to promote sustainability ensuring country ownership, country ownership in Liberia proved challenging. As a result, many REDISSE-supported initiatives, including staff salaries and essential logistics, ceased after the project's conclusion due to insufficient funding, which undermines the credibility gained in health security efforts. In the case of Liberia, the project funded Page 119 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) staff transportation to the national reference lab, the country lacked the budget to maintain funding levels after project closure, underscoring the necessity of sustainable financing mechanisms to uphold progress in health security endeavors. Similarly, Liberia’s veterinary sector need comprehensive strengthening to address the long-term challenges of a growing livestock population and its contribution to regional agricultural GPD of 44% according to the OECD. 9. The activation of the CERC under the REDISSE-II project and re-programming of resources in the early stages of the COVID outbreak in 2020 was critical in enhancing Liberia's funding and implementation of the National Surveillance, Preparedness and Response Plan (NSPRP). The resources facilitated training of frontline workers, procurement of supplies for infection prevention and control, establishment of Precautionary Observation Centers (POCs), and setting up testing laboratories across all 15 counties. Moreover, community engagement, surveillance interventions, and support for surge teams were instrumental for COVID-19 response. B. Nigeria- Summary of Key Messages from the Country Final Project Report 10. Based on the country report, the main achievements linked to PDO-level indicators are as follows: 11. PDO 1: Progress towards establishing an active, functional One Health Platform: Nigeria implemented a robust One Health coordination and governance mechanisms, guided by the National One Health Strategic Plan 2019-2023 (NOHSP). This plan is aligned with key national and international legal frameworks, such as the National Action Plan for Health Security (NAPHS), the International Health Regulations (IHR), and the Performance of Veterinary Services (PVS). The REDISSE II project played a crucial role in supporting the implementation of the One Health Agenda, emphasizing the integration of the human-animal-environmental interface for effective disease management. This support included raising awareness of One Health concept within relevant authorities and fostering collaborations among ministries, departments, and agencies (MDAs). The implementation of a One Health Strategy at national and subnational levels allowed for the coordination of multi-sectoral actions to enhance prevention, preparedness, and response capacities. Since 2021, a functional One-Health Platform has been established, providing leadership in the planning, implementation and monitoring of One Health activities. The established governance structure includes: a National One Health Steering Committee (NOHSC), a National One Health Technical Committee (NOHTC) and a National One- Health Coordination Unit (NOHCU). At sub-national level, states like Edu, Benue and Nasawara developed functional One Health teams, leading to better cross-sectoral coordination within those areas. Furthermore, funding from REDISSE II provided support to develop national guidelines for the Integrated National Environmental Health Surveillance System (INEHSS) and capacity building activities in both human and animal health sectors. This support also strengthened inter-ministerial collaboration, which has been recognized as a positive outcome, leading to a more comprehensive response to disease outbreaks. Additionally, REDISSE II facilitated workshops, training sessions, and joint risk assessments across the country, contributing to improved disease surveillance and management. 12. PDO 2: Laboratory testing capacity for detection of priority diseases: Nigeria’s laboratory testing capacity was strengthened for the detection of priority diseases in several areas, with staffing and acquisition of equipment. Nigeria’s Laboratory capacity has been improved through: (i) set up of a molecular laboratory for Lassa Fever diagnosis in one of the three hotspots (Ebonyi State); (ii) recruitment of a biomedical engineer to support the national equipment maintenance in the NRL; (iii) improved operational delivery; (iv) improved Page 120 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) specimen transportation to designated laboratories across the country; and (v) provision of laboratory commodities, reagents and supplies across all laboratory networks for both human and animal health. The diagnosis of animal diseases benefited as a result of the upgrade of animal health laboratories in veterinary teaching hospitals and the National Veterinary Health Institute (NVHI), procurement of ambulances and commodities at the National Reference Laboratory (NRL) and installation of a SCADA machine for the central veterinary diagnostic laboratory. 13. PDO 3: Progress in establishing indicator and event-based surveillance systems: Surveillance capacity for human health improved with the adoption of the Surveillance, Outbreak Response Management and Analysis System (SORMAS) as the prominent tool for event-based reporting and management of disease outbreaks, which was supported by REDISSE II in 9 states. The Integrated Disease Surveillance and Response (IDSR) guidelines were finalized, as a strategy to promote rational use of resources by integrating and streamlining common surveillance activities and training activities on IDSR targeting Epidemiologist and Disease Surveillance Notification Officers (DSNOs) across the 36 states and 774 local government areas (LGA) were conducted. Additionally, NCDC adopted "TatafoBis," an event-based surveillance system, providing timely information on disease outbreaks and events of public health importance. It deployed SItAware, a system for incident and outbreak logging, at a national scale, along with the rollout of mobile platforms like mSERS and SMS-based reporting systems for epidemic-prone diseases in all 774 Local Government Areas (LGAs). Furthermore, the National Animal Diseases Information and Surveillance (NADIS) system to facilitate reporting of animal diseases, including major transboundary events was developed. NCDC also focused on environmental surveillance through the Integrated National Environmental Health Surveillance System and supported the training of surveillance officers at various levels. 14. PDO 4: Availability of human resources to implement IHR core capacity requirements: Nigeria reported progress in the management of human resources for disease surveillance and response. Over 2,495 personnel were trained in various IHR core capacities across human and animal health sectors in Nigeria's 36 states and the Federal Capital Territory (FCT). REDISSE II project played a significant role in workforce training by leveraging existing training structures and programs of epidemiologists, supporting program reviews, and implementing accreditation compliance plans for Nigeria's Field Epidemiology Training Programme (FETP), which as of 2021, has graduated 334 trainees at Advanced level and 1,116 at Frontline level. The Nigerian version of the Frontline level which is called the Integrated Training for Surveillance Officers in Nigeria (ITSON) received support from the REDISSE II in line with Nigeria’s workforce strategy. The project also supported the In-Service Applied Veterinary Epidemiology Training (ISAVET) training. Also, fellowship programmes such as Mathematical modelling, strengthening capacity for AMR surveillance, Qualifying the workforce for AMR surveillance in Africa and Asia (QWArS), Improving Public Health Management for Action (IMPACT), Infection Prevention and Control (IPC) were carried out on a regular basis. In addition, Nigeria has conducted health workforce mapping, planning, and recruitment in both human and animal health sectors. The project engaged laboratory and veterinary staff, deployed personnel to states based on identified gaps, and recruited surge staff to strengthen surveillance at points of entry (PoEs), especially in response to outbreaks like Ebola and Marburg. The project also provided support for staff motivation, reporting, and training, including private animal health service providers. 15. PDO 5: Multi-hazard national public health emergency preparedness and response plan is developed and implemented: The National multi-hazard risk profiling and resource mapping, conducted in 18 states using tools like the Strategic Tool for Assessing Risks (STAR) and Vulnerability and Risks Analysis and Mapping Page 121 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) (VRAM), ensured preparedness for emergencies in Nigeria. Rapid Response Teams were established and trained across all 37 states and 774 LGAs, aiding in disease outbreak responses. Simulation exercises and after- action reviews tested the functionality of International Health Regulations (IHR) capacities. REDISSE II supported local production of anti-rabies vaccines and mass vaccination campaigns. The project facilitated the development of preparedness actions, along with the National multi-sectoral multi-Hazard Emergency Preparedness Plan (NMMEPP), training for frontline health workers, including Virtual Rapid Response Team (RRT) Training, and establishment of a National First Responders (N-First) pool to enhance surge capacity. Public health emergency operations training was extended to Nigeria’s security agencies. Procurement efforts provided medicines, consumables, personal protective equipment (PPE), and ambulatory vehicles for veterinary teaching hospitals (VTHs) nationwide, further strengthening disease response capabilities across Nigeria. 16. PDO 6: Progress on cross border collaboration and exchange of information across countries: The project successfully contributed to achieve progress in this front. Notably, there's a robust communication mechanism between national port health officials and various PoE, facilitating seamless information sharing at borders such as seaports, airports, and ground crossings. The response to the COVID-19 pandemic further enhanced this communication network within the country. Additionally, the project supported the recruitment of surge staff at entry points, improving screening processes and reducing traveler waiting times. WAHO facilitated information exchange among Nigeria, Liberia, and Sierra Leone. Main findings 17. The support provided by the World Bank to Nigeria through the REDISSE II has been pivotal to improve national disease surveillance systems and fostering collaboration between countries to detect disease outbreaks. By institutionalizing One Health structure within relevant line ministries, REDISSE II made a significant contribution for the formulation of a 5-year strategic plan for One Health in Nigeria (2019-2023). This plan underscores Nigeria's commitment to bolstering multi-sectoral collaboration in addressing public health challenges that span the human-animal-environment ecosystem. 18. Coordination provided by the West Africa Health Organization (WAHO) played a pivotal role in strengthening response efforts by facilitating political leadership, technical learning and knowledge exchange for the adoption of plans, messaging, guidelines and policies at regional and national levels. Regional support also facilitated evidence-based and data tools to help countries monitor crisis response actions. This coordination capacity, enhanced through the REDISSE program, enabled WAHO to facilitate exchanges across countries for the COVID-19 response. As an example of this was WAHO’s development of a regional response plan in early 2020, agreed by Ministers, highlighting the effectiveness of regional collaboration in mounting a cohesive response to a disease outbreak. C. Guinea Bissau- Summary of Key Messages from the Country Final Project Report 19. Based on the country report, the main achievements linked to PDO-level indicators are as follows: 20. PDO indicator 1: Progress towards establishing an active, functional One Health Platform: The adoption of the One Health approach helped clarify institutional roles and responsibilities of authorities in charge of programmatic, financial and resources decisions of the country’s health sector. By promoting an integrated Page 122 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) approach and cross-sectoral coordination, progress in implementation of One Health contributed to break sectoral and institutional silos across the human, animal Health, and environmental health sectors, despite the complexity in coordinating stakeholders from various sectors. Support of key government authorities was an enabling factor in the operationalization of the "One Health" approach. Nevertheless, political instability in Guinea Bissau prompted continued changes to the focal points at the different ministries with a result of loss of institutional memory. 21. PDO indicator 2: Laboratory testing capacity for detection of priority diseases: Guinea Bissau encountered difficulties in implementing the actions aimed at enhancing quality control and assurance of laboratory tests, particularly due to the lack of in-country laboratories that could perform human or animal health screenings. Thus, it relied on regional labs in other countries to carry out the required testing. Despite the lack progress to strengthen laboratory capacity, REDISSE II contributed to improve data management and medical/veterinary specimen referral and transport. A key remaining constraint to be resolved is the need for improved capacity to reduce or mitigate AMR (Antimicrobial Resistance), which implies rehabilitating and equipping existing or newly built human and veterinary laboratory facilities. 22. PDO indicator 3: Progress in establishing indicator and event-based surveillance systems: Resources initially allocated for specific components were reallocated to bolster the National Response Mechanism. REDISSE II financed the acquisition of critical medical supplies, including personal protective equipment (PPE) and ambulances, aimed at enhancing epidemic/pandemic surveillance capacity. The project supported the purchase of small medical equipment, computer hardware, electric incinerators, and COVID-19 vaccines and medical countermeasures. Technical specifications for these acquisitions were developed by relevant committees and teams, ensuring suitability and effectiveness. The equipment and supplies were delivered to various institutions and regions to strengthen emergency preparedness and response capacity. 23. PDO indicator 4: Availability of human resources to implement IHR core capacity requirements: The country implemented some measures to boost technical capacity of animal health and human health professionals and other practitioners. WAHO provided support for the country Advanced Field Epidemiology and Laboratory Training Program. 24. PDO indicator 5: Multi-hazard national public health emergency preparedness and response plan is developed and implemented: The Government acknowledges that timely financial and technical support from REDISSE II greatly aided Guinea Bissau's COVID-19 response plan, effectively mitigating the negative social and economic impacts of the pandemic. 25. PDO indicator 6: Progress on cross border collaboration and exchange of information across countries: Guinea Bissau did not report on progress towards cross-border collaboration. Main findings 26. Although the Government of Guinea-Bissau provided the enabling conditions for an inter-sectoral view of health risks by adopting a One Health approach, there still room for further improvement in the platform’s regulatory and institutional frameworks to enable it to effectively become the main forum for the discussion and formulation of public health policies. Page 123 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 27. A major challenge in Guinea Bissau resulted from the lack of an institutional champion for project implementation and constant staff turnover at the Project Implementation Unit (PIU). The lack of a well- functioning PIU was signaled as a contributing factor to project delays that negatively affected project implementation. Considering the political and sectoral context of Guinea-Bissau, future operations need to consider measures to provide sustainability of the PIU’s core staff from changes in government administration. D. TOGO- Summary of Key Messages from the Country Final Project Report 28. Project Relevance. REDISSE II remained relevant considering the Strategic Partnership Framework and the Project’s PDOs, which aligned with Togo’s priorities and needs at closing; in particular, it aligned with needs and priorities around potentially epidemic diseases. The project is aligned with the country’s development strategies, implemented over the last ten years. Moreover, the Project contributed to the implementation of the axis of intervention in the National Plan for Health Development (Plan National de Développement Sanitaire - PNDS, 2017 - 2022). The Project is aligned as well with the World Bank strategic role. 29. Project’s Efficacy: By August 31, 2023, almost all project activities had been carried out and completed. The activities carried over the last weeks were the final country project evaluation, the technical audits (including environmental and social) and the final financial management matters (over the grace period). 30. After 6 years of implementation, the REDISSE II project for TOGO closed with a satisfactory rating for achievements, having achieved the PDOs. There was substantial progress, measured by the PDO indicators and the intermediate results indicators. 31. Assessment of the Efficacy of Stakeholders. Overall, all the stakeholder performed their roles during and in the implementation of REDISSE II, despite the challenges faced during implementation, due to external factors, out of their control. Their performance is deemed satisfactory. Main challenges affecting implementation: • The project started with a six (6) month delay, reducing the implementation period to five years and a half. • The absence of an operational plan from the beginning hindered the implementation of activities. This absence allowed the different implementing institutions to propose each year a plethora of activities, which, for the most part, were not aligned with REDISSE’s II PDO. The time required to carry out studies, arbitrage and validation was substantial, which resulted in discouragement by implementing actors. • The instability in their positions of the World Bank task team leaders. • Human resource problems, especially in the animal health sector, and the workload at central and operation levels for the human and animal health sectors, negatively affecting the implementation of REDISSE II activities. • The rotation of the PCU staff (rotation of 10 managers and staff in the PCU in a period of 3 years) negatively impacted implementation. Page 124 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) • Delays in the approval of the PTBAs and the submission of the TORs for certain activities negatively affected implementation, with contractual delays. • No respect for the deadlines set for evaluations of some large bids. • Difficulties to obtain technical specifications on time and of good quality (deficiencies in the specification that delayed procurement): • Delays in the evaluations and validation (signature), due to the unavailability of some members of the evaluation commission. • Delays in the implementation of the « One Health » platform, specifically the weak ownership of the processes by the sectoral ministries. • The weak visibility of the overall envelop of activities to implement during the life of the project, given the absence of a specific programmatic framework for the project, which did not favor a stronger monitoring and evaluation of the Project activities. Lessons Learned The strengths of the REDISSE II project were the following: • Successfully building capacity of veterinarians, animal health staff, staff in environmental sector strengthening at regional and local level, regarding field epidemiology surveillance at basic, intermediate, and advance levels. • Implementing activities and developing synergies among key actors in the surveillance, preparedness, and response against potentially epidemic diseases. • The implementation of a data base (EMA-I) for capturing and gathering information. • Reinforcing the number and quality of qualified staff to strengthening the health surveillance systems for detection, notification, and investigation of health emergencies. The REDISSE II challenges or weaknesses were the following: • The arrival of the COVID-19 pandemic delayed or put a stop to certain project activities. Specifically, the pandemic put a stop to all activities that required interaction in the field, to prevent contacts. • The absence of a pre-defined operational plan at the beginning of the project and the absence of a pre-defined priorities from the start undermined project implementation, as it did not allow for enough time to anticipate and plan for the execution of project activities. It did not facilitate or contribute to the dialogue and understanding among the national actors responsible for the implementation of the project and the elaboration of the annual working plans. • There were weaknesses in the allocation of the project resources, which had an adverse impact on implementation, negatively affecting disbursements: there were more than optimal resources for component 3 and less than optimal for component 2. • The implementing actors had weak capacity to prepare and complete on time the technical specifications of acceptable quality (weakness in presenting estimates for unit costs, for instance), which delayed project implementation. Recommendations for the World Bank and WAHO: • Making an effort to reduce delays in obtaining the non-objections, which generated lack of motivation among the project’s actors, negatively impacting the achievement of the project’s objectives. Page 125 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) • It would be advisable to prepare a harmonized salary scale, for the staff working in WB projects, to be applied to new staff who will work on a WB-funded project. This would avoid a competition among projects funded by the WB, to avoid staff leaving one WB project for another. • Accompanying actors and beneficiaries to build the skills and competencies in the preparation of terms of reference to meet the guidelines of international development partners and the WB, is key. • The fundamental principal of the participation of key stakeholders and beneficiaries in the process of planning and definition of priorities, in line with their need is key to ensure the sustainability of the project’s achievements. To achieve that, it is important for future projects to provide encouragement and support to the national project team in the preparation of an operational plan, during the project preparation phase. It is key to foster a mechanism to ensure dialogue, consultation among key actors and beneficiaries and create consensus, incorporating needs and points of views from these different actors. This would ensure the definition of activities to be implemented by component, and a common understanding of the project implementation by all actors. Recommendations for the Government: • Elaborate an operational plan for future projects, to facilitate the preparation and submission of the annual working plans, within the time planed in the operation manuals of a project (administrative procedures, financial management and procurement). • Strengthen technical capacity of implementation units to prepare terms of reference and technical specifications and contemplate the possibility of hiring a technical specialist to complete these tasks to ensure shortening the delays around the procurement processes. • Make available counterpart funds to foster commitment from civil servants who work on projects, to capture and disseminate project best practices and experiences, capture and disseminate project achievements and ensure the implementation and sustainability of activities after a project completion. Page 126 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 6. SUPPORTING DOCUMENTS (IF ANY) The following documents were reviewed in preparation to this ICR: 1. Project Appraisal Document - PAD 2. Restructuring Documents 3. Financing Agreements 4. Country Partnership Strategies 5. Country Partnership Frameworks 6. Aide Memoires 2016-2023 7. Mid-term Review Report, February 2022 8. Implementation Status Reports - ISR No. 1-13 9. Country Progress Reports 10. JEE reports 2017-2023 11. Country Presentations. July 2023. Abidjan 12. Nigeria Beneficiary Assessment Report. September 2023 13. Guinea - Bissau Country Final Implementation Report. August 2023 14. Nigeria - Country Final Implementation Report. December 2023 15. Liberia - Country Final Implementation Report 16. Togo - Country Final Implementation Report. November 2023 17. Report on One Health Technical and Ministerial Meeting. Dakar, Senegal, November 2016 18. Rapport de l’evaluation interne. Finale du programme de formation en FELTP-master mis en œuvre par les universites de Ouagadougou et du Ghana sur financement de REDISSE-OOAS. 2018 A 2023. CEDEAO. REDISSE. Bobo Dioulasso. Mai-Aout 2023. 19. World Bank. 2022. The World Bank’s Early Support to Addressing COVID-19: Health and Social Response. An Early-Stage Evaluation. Independent Evaluation Group. Washington, DC: World Bank 20. Vanlangendonck, C., Mackenzie, J. & Osterhaus, A. Highlights from Science Policy Interface sessions at the One Health Congress 2020. One Health Outlook 3, 1 (2021). https://doi.org/10.1186/s42522-020-00033-4 21. Operationalizing One Health in Liberia: Bringing Sectors Together for Resilient Health Services Post-Ebola – presented by Sonpon Blamo Sieh, National Public Health Institute of Liberia, Liberia. 22. Performance of the Public Health System During a Full-Scale Yellow Fever Simulation Exercise in Lagos State, Nigeria, in 2018: How Prepared Are We for the Next Outbreak? - Health Security Volume 17, Number 6, 2019 ª Mary Ann Liebert, Inc. Oyeladun Funmi Okunromade, Virgil K. Lokossou, Ike Anya, Augustine Olajide Dada, Ahmad M. Njidda,Yahya O. Disu, Mahmood Muazu Dalhat, Carlos Faria De Brito, Muhammad Shakir Balogun, Patrick Nguku, Olubunmi Eyitayo Ojo, Chikwe Ihekweazu, and Stanley Okolo. 23. Ahanhanzo C, Johnson EAK, Eboreime EA,et al. COVID-19 in West Africa: regional resource mobilisation and allocation in the first year of the pandemic. BMJ Global Health 2021;6:e004762. doi:10.1136/ bmjgh-2020-004762 24. Putting Pandemics Behind Us Investing in One Health to Reduce Risks of Emerging Infectious Diseases. October, 2022. One Health. World Bank, Technical Report. 25. World Bank (2022a). One Health Case Study: Liberia. Page 127 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 7. THE JOINT EXTERNAL EVALUATION (JEE) TOOL 1. Considering the growth in international travel and trade, the emergence and reemergence of international disease threats, and other public health risks, the World Health Assembly adopted revisions to the International Health Regulations (IHR 2005) that went into effect in June 2007 with the stated goal that all member states would self-assess and report, on an annual basis, on their progress towards complying with the 13 core IHR capacities and that all member states would fully achieve compliance within 5 years (i.e., by mid-year 2012)54. The IHR core capacities for preparedness, detection, and response represent essential national public health functions, which provide health protection for domestic populations and collectively also provide the basis for regional and global health security. Despite two 2- year extensions (2012 and 2014), by 2016, most member states had failed to report annually on their progress toward compliance. Moreover, national self-assessments proved to be unreliable estimates of true country capability55 56. Due to the identified deficiencies and limitations of the self-assessment-based reporting, calls for external assessment of capabilities had been raised several times both by the WHO57 and other actors. 2. In parallel, at the time when the Ebola epidemic was spreading through West African and the wider region and due to the frustration with lack of progress towards IHR implementation, the Global Health Security Agenda (GHSA) was launched in 2014 at the US Department of Health and Human Services. It comprised representatives of 26 nations, WHO, the Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (WOAH), to prevent, detect, and respond to serious infectious disease threats with the capacity for rapid spread and to galvanize national efforts toward IHR 2005 compliance to prevent such diseases. In 2015 the GHSA developed a health security external assessment tool and process, which was piloted in 5 volunteer countries (Georgia, Peru, Uganda, Portugal, and the UK). That same year the IHR Review Committee recommended that the WHO Secretariat “develop, through regional consultative mechanisms, options to move from exclusive self-evaluation to approaches that combine self-evaluation, peer review and voluntary external evaluations involving a combination of domestic and independent experts”. The Executive Board at its 136th session and the 68th World Health Assembly approved implementation of the recommendation. As a result, a global technical consultation meeting on the IHR Monitoring and Evaluation Framework launched an exercise which produced an evaluation tool and process called the JEE, developed based on the experience of national self-assessments, the WOAH Evaluation of Performance of Veterinary Services (PVS), the GHSA external assessment pilots, the CDC’s Public Health Emergency Preparedness Performance Measures, among others. 54 World Health Organization. International Health Regulations (2005). 3rd ed. http://apps.who.int/iris/bitstream/10665/246107/1/9789241580496-eng.pdf 55 World Health Organization, Regional Committee for the Eastern Mediterranean. Global health security —challenges and opportunities with special emphasis on the International Health Regulations (2005). http://applications.emro.who.int/docs/RC61_Resolutions_2014_R2_15554_EN.pdf?ua=1 56 Vong S, Samuel R, Gould P, El Sakka H, Rana BJ, Pinyowiwat V, et al. Assessment of Ebola virus disease preparedness in the WHO South-East Asia Region. Bull World Health Organ. 2016;94:913–24. 10.2471/BLT.16.174441 57 World Health Organization. Implementation of the International Health Regulations (2005). Report of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation. http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_22Add1-en.pdf Page 128 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) 3. The JEE was developed as a standardized, independent, transparent, objective, and multisectoral assessment that enables countries to determine their ability to be prepared for and address infectious disease risks through a coordinated response. The JEE examines capacities across 19 technical areas to establish an objective baseline assessment, enabling countries to have a greater understanding of their gaps and weaknesses in health security, so they can focus efforts to improve in these areas58. The JEE was first launched in 2016 and within a year more than 50 countries had completed an evaluation. The JEE process brings together a multisectoral approach (e.g., animal and human health, food and agriculture, and security and law enforcement), enabling engagement and cooperation, often for the first time, of these disparate but health-related country experts and policy makers. Strengths, vulnerabilities, scores, and 3–5 priority actions for each of the 19 technical areas are jointly developed based on the standards in the JEE tool. The country is expected to use the JEE report to develop a national action plan for health security with associated costs so that compliance gaps can be addressed through domestic resources in collaboration with donors, partners, multilateral agencies, and the private sector through technical assistance, funding support, or both 59. Within this context, countries and development partners embraced the JEE as the globally accepted tool, methodology and process to monitor, measure and strengthen health security. 4. When the REDISSE series of projects (SOP) were under preparation, which involved extensive consultations with countries and partners working in health security, there was a decision to use several of the JEE indicators to develop the SOP’s results framework. This reconfirmed the commitment of the World Bank and other development partners to collectively support countries in improving their JEE scores. 5. The JEE tool has evolved over the years to address technical limitations and challenges identified through the first round of assessments and to incorporate the lessons of the COVID-19 pandemic. In January of 2018, WHO issued the second edition of the JEE tool with relatively minor adjustments. This edition introduced new indicators and merged some other indicators into a single one. The third edition of the JEE was launched in 2021. This edition introduced changes in technical areas and indicators and integrated equity considerations across several areas. Compared to the original JEE, versions 2 and 3 also made adjustments in the description of different levels (scores) across several indicators, making them more stringent to comply with. Countries have been encouraged by WHO and partners alike to rely on the latest version of the JEE to assess their capacities. Since the REDISSE results framework is based on indicators of JEE version 1.0, for countries that used JEE 2.0 or 3.0 to assess their capacities, the scores obtained using the more stringent measurement represent a greater capacity than what is considered in the results framework of the project (using version 1.0 of the JEE). 58https://www.cdc.gov/globalhealth/healthprotection/stories/global-jee-process.html 59Bell E, Tappero JW, Ijaz K, Bartee M, Fernandez J, Burris H, et al. Joint External Evaluation—development and scale-up of global multisectoral health capacity evaluation process Emerg Infect Dis. 2017 Suppl. https://doi.org/10.3201/eid2313.170949 Page 129 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) ANNEX 8. THE ONE HEALTH APPROACH 1. Although the linkages between human and veterinary medicine have been recognized since the mid-1800s, the term ‘One Health’ was first used by the series of strategic goals known as the ‘Manhattan Principles’ derived at a meeting of the Wildlife Conservation Society in 2004, which recognized the link between human and animal health. These principles were a vital step in recognizing the critical importance of collaborative, cross-disciplinary approaches for responding to emerging and resurging diseases, and in particular, for the inclusion of wildlife health as an essential component of global disease prevention, surveillance, control, and mitigation.60 The term One Health continued to be used and promoted as a concept in the years to follow. Since 2007 a series of strategic frameworks, declarations, roadmaps, and action plans for One Heath have been developed, multiple congresses on the topic have been held, and most countries have committed to advance the concepts of One Health.61 While in recent years the One Health concept has gained a lot of recognition in the public health and animal health communities, implementation of the One Health approach in countries is still at a nascent stage. 2. The WHO defines One Health as an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. The One Health approach recognizes that the health of humans, animals (both wild and domestic), plants, and the wider environment are closely linked and interdependent and changes in these relationships can increase the risk of human and animal diseases developing and spreading. Therefore, to address the full spectrum of disease control – from prevention to detection, preparedness, response and management, an approach that relies on shared governance, communication, collaboration, and coordination among all relevant sectors is needed. 62 3. However, collaboration in an integrated manner across sectors and disciplines that have traditionally worked in silos does not come free of challenges. Major structural changes, in addition to substantial behavioral change, are required to integrate the human, animal and environmental health fields to effectively work together. This involves, among other things, integrated databases and information systems; mechanisms for routine coordination; a shared understanding of the risks of spillover of pathogens in the human-animal-environment interface; standardized approaches, frameworks, and methods; and most importantly, the willingness and know-how of relevant actors who have traditionally worked within their own disciplines to work jointly across sectors. 4. A 2019 review of literature found that the most challenging factor in performing One Health initiatives is promoting collaboration between a wide diversity of stakeholders, which is a fundamental aspect of the One Health approach.63 This included challenges in collaboration between multiple actors, multiple domains and at multiple levels. Another important challenge identified was the difficulty to acquire and establish the necessary conditions to start operating under the One Health approach. This 60 Mackenzie JS, Jeggo M. The One Health Approach-Why Is It So Important? Trop Med Infect Dis. 2019 May 31;4(2):88. doi: 10.3390/tropicalmed4020088. PMID: 31159338; PMCID: PMC6630404. 61 https://www.cdc.gov/onehealth/basics/history/index.html 62 https://www.who.int/health-topics/one-health 63 Carolina dos S. Ribeiro, Linda H.M. van de Burgwal, Barbara J. Regeer, Overcoming challenges for designing and implementing the One Health approach: A systematic review of the literature, One Health, Volume 7, 2019, 100085, ISSN 2352-7714, https://doi.org/10.1016/j.onehlt.2019.100085 (https://www.sciencedirect.com/science/article/pii/S2352771418300223) Page 130 of 131 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase II (P159040) included policy support, access to funding, and ability to understand and implement the One Health approach. 5. Successful implementation of the One Health approach involves a paradigm shift in the way of working that requires changes in cultural, social and institutional practices and breaking down the interdisciplinary barriers that still separate human, animal and environmental health. These fundamental changes take time to become established, for them to take root and to become the new norm. Page 131 of 131