The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) f Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 29-Jun-2023 | Report No: PIDA35670 Jun 12, 2023 Page 1 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Eastern and Southern Africa P180127 AFE Health Emergency Preparedness, Response and Resilience MPA Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) EASTERN AND SOUTHERN AFRICA 26-Jun-2023 29-Sep-2023 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Intergovernmental Democratic Republic of Authority on Development Sao Tome and Principe - (IGAD), Republic of Kenya, Ministry of Health (MOH), Democratic Republic of Sao Intergovernmental Tome and Principe, Federal Authority on Democratic Republic of Development (IGAD), Ethiopia, East, Central and Kenya BioVax Institute, Southern Africa Health Federal Democratic Community (ECSA-HC) Republic of Ethiopia - Ministry of Health (MOH), Republic of Kenya - Ministry of Health (MOH), East, Central and Southern Africa Health Community (ECSA-HC) Proposed Development Objective(s) The Development Objective (DO) is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in Eastern and Southern Africa. Components Strengthening the Preparedness and Resilience of Regional & National Health Systems to Manage Health Emergencies Improving the Detection of and Response to Health Emergencies Program Management Contingent Emergency Response Component (CERC) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Jun 12, 2023 Page 2 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) Total Project Cost 359.00 Total Financing 359.00 of which IBRD/IDA 359.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 359.00 IDA Credit 120.00 IDA Grant 239.00 Environmental and Social Risk Classification Substantial Decision The review did authorize the team to appraise and negotiate Jun 12, 2023 Page 3 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) A. Introduction and Context Regional Context 1. Home to almost 60 percent of Africa’s population, the Eastern and Southern Africa (AFE) region consists of 26 geographically, culturally, and economically diverse countries. Annual gross domestic product (GDP) growth in the region has averaged 2.3 percent over the last decade, with significant heterogeneity across countries.1 As of 2019, as many as 389 million people (35 percent of the population) in the Sub-Saharan region lived in poverty with less than US$2.15 per day.2 Levels of human capital are similarly low: on average, a child born in AFE today will be 39 percent as productive when s/he grows up as s/he could be if s/he enjoyed complete education and full health.3 Human capital development is particularly challenging for girls and women who face regressive gender norms and gender-specific health risks while having less access than their male counterparts to health, education and other human capital-related services. 2. The Eastern and Southern Africa (AFE) region is a hotspot for emerging and re-emerging infectious disease (EID) outbreaks, endemic diseases, and other complex and inter-related health emergencies (HEs). For the purposes of the proposed Program, health emergencies are defined as any acute or chronic shocks to health systems that by virtue of scale, timing, or unpredictability, overwhelms routine capabilities and hinders the provision of essential health services . Health emergencies are, thus, not restricted to infectious diseases, but include noncommunicable diseases (NCDs), as well as acute or chronic environmental, economic, and political events that compromise health systems. Between 2017 and 2019, a total of 415 disease outbreaks were recorded across the African continent.4 In AFE, recent infectious disease outbreaks have included Ebola Virus Disease (EVD) in the Democratic Republic Congo (DRC) and in Uganda; Marburg virus disease in Uganda, DRC, Angola, and Tanzania; Yellow Fever and Chikungunya outbreaks in Kenya, Ethiopia; Dengue fever in Kenya, São Tomé and Príncipe (STP), and measles and cholera outbreaks in several countries. In Africa, improvements in health outcomes over the last two decades have since stalled due to the coronavirus disease (COVID- 19) related service disruptions, exacerbating the regional burden for existing acute and chronic communicable diseases such as malaria5 and Human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS).6 The increasing rates of pathogen resistance to commonly used antimicrobials—commonly referred to as anti-microbial resistance 1 Ranging from approximately -10 percent in South Sudan to +8 percent in Ethiopia. World Development Indicators (WDI), World Bank. 2 World Bank (2022). Poverty and Shared Prosperity 2022: Correcting Course . Washington DC: World Bank Group. doi:10.1596/978-1-4648-1893-6. License: Creative Commons Attribution CC BY 3.0 IGO 3 Human Capital Index (2020). 4 Implementing epidemic intelligence in the WHO African region for early detection and response to acute public health events (available at: https://pubmed.ncbi.nlm.nih.gov/33985609/). 5 According to the WHO’s World Malaria Report, in the Africa region, malaria cases have increased by 14 million cases (218 to 232 million) and 55,000 deaths (544,000 to 599,000) between 2019 to 2020 as a consequence of COVID-19. As a result of service disruptions due to COVID-19, malaria case incidence increased from 225.5 cases to 233.6 cases in this same time period. While improvements were seen in 2021, progress for malaria cases and deaths have stalled due to COVID-19 and other humanitarian emergencies. 6 According to the UNAID’s Global AIDs Update, HIV incidence rate continues to decline globally, but the progress made against HIV is slowing rather than accelerating as a consequence to COVID-19. While the number of new HIV infections have decreased from 1.7 million (2019) to 1.5 million (2020) to 1.5 million in (2021) globally, this decrease represents 3.6% decrease only - the smallest annual reduction since 2016. Many countries, especially in the Africa region, are left to address the rising HIV infections alongside other health crises. Jun 12, 2023 Page 4 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) (AMR)—globally and regionally have further complicated the situation.7 Overuse, misuse, as well as lack of access to quality-assured antimicrobials are the main drivers of AMR. WHO estimates that AMR could result in 4.1 million deaths across Africa by 2050 and that African countries could lose up to 5% of their GDP as a result of AMR.8 The “epidemic� of the rapidly increasing rates of NCDs (such as Type II diabetes, cardiovascular disease, and respiratory diseases) is another much neglected HE. Data from the World Health Organization (WHO) surveys in Sub-Saharan Africa (SSA) demonstrate the increasing incidence and prevalence of NCDs in the AFE region. Between 1990 and 2017, the proportion of all disability adjusted life years attributable to NCDs in Africa increased from 19% to 30% of the total burden. On this trajectory, NCDs are set to overtake communicable, maternal, neonatal and nutritional conditions and diseases as cause of mortality by 2030.9 At a broader level, widespread NCDs translate to decreased labor outputs, lower returns on human capital investments, and increased health care costs. Other common HEs in the region include floods and droughts (both of which can accentuate hunger and malnutrition), inadequate water supply and waste management (which can lead to a spike in cholera and other water-borne infectious diseases), and environmental degradation. Several contextual drivers increase the risk of HEs in the region, including population growth, rapid unplanned urbanization, displacement, lifestyle changes, as well as climate change, air pollution, conflict, economic distress, and fragility.10 In turn, poorly managed HEs deepen the vulnerability of countries to poverty, fragility, conflict, and violence. HEs also affect vulnerable groups11 unevenly, with forcibly displaced communities and their hosts12, women, and children often bearing the brunt of the adverse impacts. 3. The AFE region is highly vulnerable to climate change with negative impacts on service delivery, infrastructure, and agriculture, jeopardizing development gains. Africa is the most vulnerable continent to climate change despite having contributed the least to atmospheric concentrations of greenhouse-gas emissions.13,14 Within the AFE region in particular, climate change is expected to decrease overall rainfall, particularly in Southern Africa, coupled with an increase in extreme flooding events and overall rainfall increases in Eastern Africa.15,16,17 Climate change is increasing the frequency of climate shocks, for example between 2019 and early 2023, East Africa was impacted by 20 cyclones, 7 Ramanan Laxminarayan, The Overlooked Pandemic of Antimicrobial Resistance, The Lancet, Comment, Volume 399, Issue 10325, P606-607, February 12, 2022. 8 WHO/AFRO AMR Factsheet, https://www.afro.who.int/sites/default/files/ARD%20Cluster/Factsheets/1669121367976%20(1).pdf 9 Kraef C, et al. Fighting non-communicable diseases in East Africa: assessing progress and identifying the next steps. BMJ Global Health 2020;5:e003325. doi:10.1136/ bmjgh-2020-003325 10 World Health Organization, Note on Health Security, WHO, 2022. 11 Vulnerable Groups refer to social or other groups with limited resources and thus higher risks for morbidity and premature mortality than non-vulnerable groups. “Vulnerability� can arise from a range of social, economic, political, and demographic markers, with gender often a cross-cutting marker of vulnerability across other markers ((MacLachlan et al 2011 and Adebisi et al 2021). 12 UNHCR estimates that 30 million internally displaced persons, refugees and asylum-seekers live in Africa, representing almost one-third of the global refugee population. Economic instability, conflict, food insecurity, and climate events have been key triggers of forced displacement in the region (Source: https://www.unhcr.org/about- unhcr/where-we-work/africa). 13 African Development Bank, Climate Change in Africa, 2023. https://www.afdb.org/en/cop25/climate-change-africa 14 Brookings Institute, Africa: Financing Adaptation and Mitigation in the World’s Most Vulnerable Region. https://www.brookings.edu/wp-content/uploads/2016/08/global_20160818_cop21_africa.pdf 15 UNICEF, The Climate Crisis, 2020: https://www.unicef.org/esa/media/7061/file/UNICEF-The-Climate-Crisis-2020.pdf 16 Intergovernmental Panel on Climate Change / University of Oslo, Climate Change in Eastern and Southern Africa, Impacts, Vulnerability, and Adaptation: https://www.ipcc.ch/apps/njlite/srex/njlite_download.php?id=5977 17 Associated Press, March, 2023, “East African States Ail From Too Much, Too Little Rain�: https://apnews.com/article/east-africa-cyclone-drought-la-nina-climate-change-f4e0258e423631cee82c4e041b7f6e8f Jun 12, 2023 Page 5 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) affecting infrastructure and crops and causing injuries and deaths.18 Further, climate change is fueling water scarcity with far reaching implications. These changes in in climactic patterns negatively impact agriculture, 95 percent of which is rain-fed in SSA. In AFE, 59 percent of all employment is estimated to come from agriculture.19 Agriculture losses are projected to drive the negative economic impacts of climate change, which is projected to result in GDP losses of 15 percent in SSA by 2050.20 According to the Intergovernmental Panel on Climate Change (IPCC), vulnerability to climate change in SSA is exacerbated by limited investment in climate change adaptation measures to increase resilience to climate shocks.21 4. Gender-unequal norms in the AFE region continue to impact women and girls more than men and boys. East Africa has some of the highest regional rates of child marriage in the world, the majority involving girls under the age of 18 (with fewer boys subject to early marriage).22 Data from Demographic and Health Surveys (DHS) show a female disadvantage in land ownership, access to banking and finance, as well as to mass media, and higher education.23 . Though the region has shown some progress in reducing maternal mortality, the weak resilience of maternal health systems is reflected in a high it remains high at an average maternal mortality ratio of 391 per 100,000 births in East and Southern Africa, and the region is unlikely to meet the 2030 SDG goals.24 Unequal gender norms contribute to higher risks for women and girls during health emergencies, while hampering their ability to access Universal Health Coverage (UHC), PPR, and other health services. For example, women’s increased exposure to EVD can be attributed at least in part to their responsibility for caring for the sick (e.g., during the 2018 EVD epidemic in the DRC, 56 percent of recorded deaths were among women and girls), while men’s increased vulnerability to the virus can be attributed at least in part to their responsibility for hunting. Gender inequality persists in reported HIV prevalence, being higher for women than men in all countries in the region for which the DHS report data; in some countries, including Ethiopia, girls are more likely to be unvaccinated (20.6 percent) than are boys (17.6 percent). 5. The AFE region has received World Bank support to address the challenges referenced above through national and regional projects. However, recent experiences from the COVID-19 response suggest that systemic weaknesses in health systems, multisectoral collaboration, and overall regional health security capacity remain and therefore require further and better targeted support. AFE’s response to COVID-19, supported inter alia by the World Bank Group’s (WBG’s) COVID-19 Strategic Preparedness and Response Program (SPRP) and the Africa Centers for Disease Control and Prevention (CDC) Regional Investment Financing Project, demonstrated several strengths, including rapid prioritization by the highest levels of government as well as recognition of the need for integrated cross-sectoral responses that work effectively across national boundaries. WBG supported Projects like the East Africa Public Health Laboratories Networking Project (EAPHLN - P111556), the Southern Africa Tuberculosis (TB) and Health Systems Support Project (SATBHSSP - P155658), and the Regional Disease Surveillance Systems Enhancement (REDISSE) portfolio Phases I-4 (P154807, P159040, P161163, P167817) have all played crucial roles in helping countries conduct cross-border disease 18 Associated Press, March, 2023, “East African States Ail From Too Much, Too Little Rain�: https://apnews.com/article/east-africa-cyclone-drought-la-nina-climate-change-f4e0258e423631cee82c4e041b7f6e8f 19 Kwakwa, Victoria. World Bank. “Seizing the Agri -Food Opportunity in East and Southern Africa: https://blogs.worldbank.org/africacan/seizing-agri-food-opportunity-eastern-and-southern- africa#:~:text=The%20agriculture%20and%20food%20sector,86%25%20and%2080%25%20respectively. 20 African Development Bank. “Climate Change Impacts on Africa’s Development Growth�: https://www.afdb.org/sites/default/files/documents/publications/afdb-economics_of_climate_change_in_africa.pdf 21 IPCC Sixth Assessment Report: https://www.ipcc.ch/report/ar6/wg2/chapter/chapter-9/ 22 United Nations Children’s Fund, Child Marriage in Eastern and Southern Africa: A statistical overview and reflections on ending the practice, UNICEF, New York, 2022. 23 Data analysis using Statcompiler: https://www.statcompiler.com/en/ 24 https://africa.unwomen.org/en/where-we-are/eastern-and-southern-africa_africa Jun 12, 2023 Page 6 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) surveillance, activate, and facilitate emergency operations centers, test samples with rapid turn-over of confirmed cases, and investigate suspected cases. These investments—made over the last decade—have helped bolster capacity in a region that was feared to suffer the worst outcomes of COVID-19. That said, while the dire predictions of massive COVID- 19 infection and deaths in Africa did not materialize, the pandemic did show that there is need for enhanced and more strategic long-term regional and national investment in pandemic prevention, preparedness, and response (PPR)—which is a regional (and global) public good. Furthermore, COVID-19 and AFE’s repeated infectious disease outbreaks have exposed continued weaknesses in the regional capacity to prevent and respond to HEs in a proactive, rather than reactive, manner, and reinforced the need for concerted regional action to address a variety of relevant cross-border issues. Beyond the World Bank’s own interventions, the African Union’s (AU) support for a Joint Continental Strategy, and regularly updated guidance to countries from the Africa CDC, have also helped ensure dedicated Task Forces at the country and regional levels. 6. Greater than 75% of emerging infectious diseases globally have been zoonotic in nature, transmitted from animal hosts to humans; multisectoral action is thus an imperative. Zoonotic diseases in Africa range from endemic zoonoses such as brucellosis and leptospirosis, to neglected zoonoses such as rabies and onchocerciasis, to emerging zoonoses such as anthrax, yellow fever, Ebola, Lassa fever and COVID-19. Key anthropogenic drivers of emerging zoonoses include rapid urbanization, armed conflict, and deforestation. The One Health25 approach, which demands collaboration across the three interdependent sectors—animal health (Agriculture sector), human health (Health sector) and ecosystems (Environmental sector)—to prevent, detect and respond to disease threats will be critical to address these growing challenges in Africa. Sectoral and Institutional Context 7. As noted above, although previous investments have had a positive impact in the region’s health sector, multiple assessments find that AFE countries are still not sufficiently prepared to prevent, detect, and respond to HEs. These include assessments against (i) the International Health Regulations (IHR)26; WHO’s Joint External Evaluation (JEE)27; the Global Health Security Index (GHSI)28; and country-led self-assessments, such as the State Party Self- Assessment Annual Reporting (SPAR) tool.29 In each of these assessments, many AFE countries consistently fail to demonstrate adequate HE preparedness and resilience. In some countries, for example, Public Health Acts are outdated and need to be revised to be able to tackle current and future HE risks. Other countries have recently developed national multi-hazard preparedness and response plans and strategies, but many of them remain unfunded and thus not operational. Of particular concern, the most recent GHSI found that preparedness and resilience capacities appear to 25 Operationalizing the One Health approach to maximize the region’s ability to prevent and detect pot ential threats entails (but is not limited to): (i) assessing human and animal health surveillance systems; (ii) supporting the development of regional guidelines for information and data management for both animal and human health (interoperable surveillance systems); and (iii) ensuring that One Health coordination and technical assistance mechanisms are established. 26 The International Health Regulations are a legally binding agreement, providing a framework for national and regional action in preparedness. It can be measured by the Joint External Evaluation (JEE third party assessment) or the Global Health Security Index (GHSI). 27 The Joint External Evaluation (JEE) is a voluntary, collaborative, multisectoral process to assess country capacities across 19 technical areas, to prevent, detect and rapidly respond to HEs. 28 The GHSI measures indicators in 6 dimensions directly related to preparedness, alongside indicators regarding the country context that could shape their abilities to prevent, detect, and rapidly respond to outbreaks, producing a composite score where 100 is the maximum. Africa’s average GHSI score is currently 29.0, compared to a global average of 38.9. 29 The SPAR tool consists of 35 indicators for the 15 IHR capacities needed to detect, assess, notify, report, and respond to public health risk and acute events of domestic and international concern. Jun 12, 2023 Page 7 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) have weakened in recent years, most likely because inadequate investments, further exacerbated by the strain on health systems imposed by COVID-19. 8. Climate change is increasing the burden of vector and water borne diseases while compromising health service delivery in East and Southern Africa. Malaria transmission is expected to increase in geographic scope and seasonality in East and Southern Africa due to climate change, impacting up to an additional 75.9 million people in the region by 2080. 30 Evidence from Eastern and Southern Africa shows that the region is experiencing climate change-induced intense rainfall events triggering catastrophic floods and associated injuries and deaths. In Southern Africa, in 2022 alone, severe storms caused the deaths of more than 890 people. 31,32 Diarrhea is a leading cause of morbidity and mortality in SSA among children under five years of age. 33 In Eastern and Southern Africa, climate change variables including increasing mean temperature and precipitation are associated with increasing diarrheal disease out-breaks. 34,35 Further, climate change impedes health service delivery and destroys health facilities, including those in both the Horn of Africa and South Africa during floods in 2022. 36,37 9. Key aspects of PPR, such as surveillance and maintenance of essential health services during an outbreak, do not systematically address gender gaps. Public health surveillance is a key foundation of PPR as it provides the information with which to track and identify trends in potential outbreaks and plan prevention, preparedness and response accordingly. Yet, standard disease surveillance, including across Africa, does not collect or disaggregate data on cases and deaths by pregnancy status; data on sex and age, while collected at the community and health post level, are rarely incorporated in regular surveillance data and analyses at higher levels of the system. For example, assessments of the surveillance system in Kenya, Zambia and Nigeria have reported minimal – if any – data on sex and age in health registers or in weekly reporting forms. Thus, in the event of an outbreak, gender differences are not immediately known.38 Similarly, essential health services packages developed for health emergencies rarely include comprehensive maternal and reproductive health services and supplies, putting women’s and girls’ health at risk. In Kenya, for example, maternal deaths reportedly rose significantly during the COVID-19 pandemic.39 Evidence from the 30 Ryan, S. J., Lippi, C. A., & Zermoglio, F. (2020). Shifting transmission risk for malaria in Africa with climate change: a framework for planning and intervention. Malaria Journal, 19, 1-14. 31 The International Disasters Database - EM-DAT. (2023) https://public.emdat.be/data 32 Eriksen, S., O’Brien, K., & Rosentrater, L. (2008). Climate change in Eastern and Southern Africa: Impacts, vulnerability, and adaptation. GECHS report, 2, 2008-2. 33 Dunne. D. (October 26, 2022) Analysis: Africa’s unreported extreme weather in 2022 and climate change. https://www.preventionweb.net/news/analysis-africas-unreported-extreme-weather-2022-and-climate-change 34 Boeckmann, M., Roux, T., Robinson, M., Areal, A., Durusu, D., Wernecke, B., ... & Chersich, M. F. (2019). Climate change and control of diarrheal diseases in South Africa: Priorities for action. South African Medical Journal, 109(6), 359-361. 35 Boeckmann, M., Roux, T., Robinson, M., Areal, A., Durusu, D., Wernecke, B., ... & Chersich, M. F. (2019). Climate change and control of diarrheal diseases in South Africa: Priorities for action. South African Medical Journal, 109(6), 359-361. 36 ReliefWeb, South Africa: Floods and Landslides - Apr 2022, https://reliefweb.int/disaster/fl-2022-000201-zaf 37 WHO, The greater Horn of Africa’s climate-related health crisis worsens as disease outbreaks surge, 2022 https://www.afro.who.int/news/greater-horn-africas-climate-related-health-crisis-worsens-disease-outbreaks-surge 38 Mandyata CB, Olowski LK, Mutale W. Challenges of implementing the integrated disease surveillance and response strategy in Zambia: a health worker perspective. BMC Public Health 2017; 17: 746; Ibrahim LM, Stephen M, Okudo I, et al. A rapid assessment of the implementation of integrated disease surveillance and response system in Northeast Nigeria, 2017. BMC Public Health 2020; 20: 600; Ng’etich, A.K.S., Voyi, K. & Mutero, C.M. Assessment of surveillance core and support functions regarding neglected tropical diseases in Kenya. BMC Public Health 21, 142 (2021). https://doi.org/10.1186/s12889-021-10185-1 39 Impact of COVID-19 on gender equality and women’s empowerment in East and Southern Africa. Nairobi: UN Women and UNFPA, East and Southern Africa Regional Offices. March 2021. Jun 12, 2023 Page 8 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) EVD outbreaks in DRC and Sierra Leone, SARS in Asia, H1N1 in South Africa, and COVID-19 in many countries shows that women found it significantly harder to access regular maternal, reproductive health or family planning services during an infectious disease outbreak compared to other time periods.40 10. At the same time, women and girls provide an under-utilized resource to strengthen health system resilience and reach in Eastern and Southern Africa, including for HE. Women are the caretakers of the sick at home, of domestic livestock, and, through their role in water and fuel collection and preservation, central to the interaction of the community with the environment. Most frontline health workers across the region are women, who were at the forefront of COVID-19 response at the community level. Yet, women’s potential in the health system is constrained by their relative lack of access to and use of training opportunities compared to their male colleagues, which can inhibit women from advancing in their careers. Analyses of the sex ratio of participation in training such as the Field Epidemiology Training Program (FETP) among REDISSE countries41 showed that only about one-third of trainees at the advanced level were women, while at frontline levels the proportion of female trainees had dropped from one-third in 2019 to 19 percent in 2021. Ongoing studies in DRC and Sierra Leone point to a several reasons for the inadequate representation of women, including a lack of supervisor and familial support and a lack of awareness. A recent analysis in Guinea suggests a vicious cycle where the lack of women at the levels of technical expertise required for FETP results in fewer women being nominated for the training which, in turn, prevents women from improving skills and progressing in their careers at the same rate as their male colleagues.42 11. The absence of a viable pharmaceutical/vaccine manufacturing capacity among countries in the region has rendered the region almost entirely reliant on imports and international largesse. The pharmaceutical industry in Africa accounts for only 3 percent of the global pharmaceutical market,43 and close to 90 percent of medicines used in Africa are imported. Most of the pharmaceutical companies are in North Africa, with Senegal, Tanzania, Uganda, Kenya, Nigeria, and South Africa being among the few countries in SSA with some pharmaceutical production capacity. Moreover, few pharmaceutical companies in SSA, engage in production of active pharmaceutical ingredients (ibid). A situation—witnessed during the COVID-19 pandemic—where 99 percent of the vaccines and 95 percent of the pharmaceuticals needed at the regional level to combat health emergencies had to be imported is clearly not tenable. The development of regional pharmaceutical manufacturing and logistical capacity is therefore an imperative, which is being supported by a number of international agencies such as WHO and GAVI. Such capacity can only be built on a strong legal and regulatory foundation, as well as public-private collaboration, across the countries in the region for the manufacture, distribution, sale, and export of pharmaceuticals. Furthermore, any decisions on pharmaceutical 40 IRC (2020). Not All That Bleeds is Ebola – how the DRC outbreak impacts reproductive health. https://www.rescue.org/sites/default/files/document/4416/srhebolareport1172020.pdf; Lam CM, Wong SF, Leung TN, et al. (2004). “A case-controlled study comparing clinical course and outcomes of pregnant and nonpregnant women with severe acute respiratory syndrome.� BJOG 111: 771–74; Wong SF, Chow KM, Leung TN, et al. (2004) “Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome.� Am J Obstet Gynecol; 191: 292–97; Klein, S.L., Passaretti, C., Anker, M., Olukoya, P. Pekosz, A. (2010). “The impact of sex, gender and pregnancy on 2009 H1N1 disease.� Biol Sex Differ. 1: 5. 41 REDISSE is a regional multi-sectoral program currently involving sixteen (16) countries in West and Central Africa – 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. 42 Collins, D., Diallo, B.I., Bah, M.B. et al. Evaluation of the first two Frontline cohorts of the field epidemiology training program in Guinea, West Africa. Hum Resour. Health 20, 40 (2022). https://doi.org/10.1186/s12960-022-00729-w 43 IQVIA (2019). Differentiate and win in the African Pharma Market. Available at ttps://www.iqvia.com/locations/middle- east-and-africa/library/white-papers/differentiate-and-win-in-the-african-pharma-market Jun 12, 2023 Page 9 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) manufacture must be premised on a reliable market assessment to avoid a situation where the supply capacity vastly exceeds the demand and creates industrial “white elephants.� 12. A sustainable response to HEs requires moving away from ad-hoc responses towards systemic prevention, preparedness, and resilience, including ensuring the maintenance of essential health services for reproductive, maternal, neonatal, and child health (RMNCH) and NCDs—as well as in increasing investments to reduce gender related risks and those of climate change. Despite the multiple, severe, and long-lasting impacts of HEs, institutions, systems, and policies in AFE are largely designed to react to these events, rather than prevent or prepare for them. Preparedness/response and resilience activities have historically been viewed as two different areas of health sector interventions, and—as such—typical investments have focused on one or the other. Preparedness/response projects tend to focus on delivering essential public health functions, while resilience investments have tended to focus on interventions across the WHO Health System Building Blocks. While theoretically, it is understood that these concepts are interconnected44, in practice, few efforts and large-scale investments integrate both preparedness and resilience in a holistic and sustainable manner. Yet, recent outbreaks prove that the status quo is untenable and unsustainable. Indeed, the COVID-19 pandemic has demonstrated that a focus on one without the other leads to suboptimal health and economic outcomes. In the absence of a systemic focus on resilience, chronic stressors render health systems more fragile, over-exposed to shocks, and liable to long-term disruption. The 2018-2020 EVD outbreak in the DRC, for example, cost US$1.2 billion—twice as much as the country’s entire health budget.45 The outbreak, and response to it, also demonstrated the impacts that such shocks can have on health outcomes for women, with aggravated rates of death and lower access to care among pregnant women compared to the general population .46 In contrast, another analysis of the 10th EVD outbreak response in DRC in 2019-20 demonstrated that combining preparedness in surrounding areas with capacity building, and increased community engagement efforts resulted in a significant reduction in disease transmission and was cost-effective.47 13. Responsibility for HE preparedness and resilience must be shared by governments, partners, sectors, and communities, which must collaborate effectively across the prevention-detection-response continuum, both within and across national borders, implementing actions that are pro-active and sustainable, and possibly far upstream from the HE events themselves. Furthermore, preparedness and resilience should be seamlessly integrated into ‘emergency-ready health systems’ since separate systems are unaffordable and are likely to be less effective. In 44 Brown, G.W., Bridge, G., Martini, J. et al. The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages. Global Health 18, 51 (2022). https://doi.org/10.1186/s12992-022- 00840-6 45 Humanitarian Policy Group (2021). The Democratic Republic of Congo’s 10th Ebola response: Lessons on international leadership and coordination. Retrieved from https://cdn.odi.org/media/documents/The_Democratic_Republic_of_Congos_10th_Ebola_response_lessons_on_internat ional_q0pMdk9.pdf 46 IRC (2020). Not All That Bleeds is Ebola – how the DRC outbreak impacts reproductive health. https://www.rescue.org/sites/default/files/document/4416/srhebolareport1172020.pdfhttps://www.rescue.org/sites/de fault/files/document/4416/srhebolareport1172020.pdf 47 Humanitarian Policy Group (2021). The Democratic Republic of Congo’s 10th Ebola response: Lessons on international leadership and coordination. Retrieved from https://cdn.odi.org/media/documents/The_Democratic_Republic_of_Congos_10th_Ebola_response_lessons_on_internat ional_q0pMdk9.pdf Jun 12, 2023 Page 10 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) recognition of this fact, the WHO developed, in 2021, the Health Systems for Health Security Framework48, intended to guide practitioners on how best to leverage synergies across both concepts to better prevent, detect and respond to health emergencies. 14. A solid regional foundation and multisectoral action is a prerequisite for HE preparedness and resilience in AFE countries. Porous borders, unregulated trans-border commerce, population displacement, travel, and migration increase the risk of cross-border spread of infectious diseases as well as several risk factors for NCDs, necessitate a regional approach to manage these cross-cutting risk factors that may be difficult to address by any individual country alone. Furthermore, mitigation of these risks requires coordination and collaboration across sectoral ministries. Although the regional or global nature of many HEs is now well-recognized, institutions, systems, and policies for coordination between local, national, regional, and global authorities are not adequately developed to deal with them. In particular, there are no well-developed mechanisms for adopting coordinated approaches across sectors at regional level. Strengthening AFE’s regional approach to health emergency preparedness, response, and resilience (HEPRR), by investing in shared activities, resources, regulations, policies, and institutions, will enhance the region’s capacity to prevent, detect, and respond to HEs, while also ensuring that essential health services continue to be provided during emergencies. A regional approach is also efficient, in that the costs involved can be shared. A regional approach will allow countries to share expertise, knowledge, and good practices, and jointly develop public goods such as common frameworks for managing social, environmental, and governance risks as well as health inequities arising from gender inequality, poverty, and other forms of vulnerability. A robust regional foundation will also allow countries to tailor approaches at national and local level, based on specific needs. 15. Recent intergovernmental commissions have called for expanded financing for PPR and more effective global PPR governance that connects health and finance. Most notably, the G20 High-Level Independent Panel (HLIP) called for US$15 billion additional, more predictable, flexible, and sustainable international resources per year to be mobilized for PPR. Part of this funding has been allocated to a new fund that has been established as a Financial Intermediary Fund (FIF) within the World Bank, for which a Health and Finance Task Force has been established. In addition, the International Development Association 2020 (IDA20) replenishment calls for a meaningful operationalization of its funds in Africa on the One Health and preparedness agendas. 16. The proposed Multi-Phased Programmatic Approach (MPA) will complement and expand the scope of key WBG- financed operations. Over the past several years, the WBG has built up a strong global and regional track record on both preparedness and health system strengthening (HSS). A regional MPA is proposed based on lessons learned globally and from regional WBG-financed projects/programs like the REDISSE portfolio Phases 1 to 4, the SATBHSSP, the Africa CDC Regional Investment Financing Project (P167916), the Health Emergency Preparedness and Response Multi-donor Trust Fund (HEPRTF), and—most importantly—the COVID-19 SPRP (P173789). The proposed MPA will ensure a sustained, comprehensive, and transformational impact on both health emergency preparedness/response and resilience, 48 Health systems for health security: A framework for developing capacities for International Health Regulations, and components in health systems and other sectors that work in synergy to meet the demands imposed by health emergencies. Geneva: World Health Organization; 2021. License: CC BY-NC-SA 3.0 IGO. Jun 12, 2023 Page 11 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) emphasizing equity49 and inclusivity50, and building on the many achievements of previous WBG supported projects. The specific vulnerable groups and actions to make health care more equitable and inclusive will be determined contextually within and by each participating country with reference to these widely understood definitions. In addition to vulnerability by gender and poverty status, other key vulnerabilities relevant to the MPA will be identified. B. Proposed Development Objective(s) Development Objective(s) (From PAD) The Development Objective (DO) is to strengthen health system resilience and multisectoral preparedness and response to health emergencies in Eastern and Southern Africa. Key Results 17. The PrDO level indicators are listed below in Table 1, along with baseline and endline targets. PrDO indicators #1 and #4 measure multisectoral preparedness and response, while PrDO indicators #2 and #3 are associated with resilience. The detailed Results Framework (and methodology) (Section VII of the PAD) provides a list of intermediate results indicators (IRIs) for this phase. The indicators are informed by a menu of priority activities in Annex 1. Each indicator in the results framework is linked to a priority I activity in the menu. In order to permit country-specific projects to have flexibility to focus on activities most relevant to their context, while also maintaining coherence in activities across all Program countries, each country under the MPA will be required to collect data on three out of four PDO indicators in the MPA, and five out of nine IRIs. MPA countries will be free to include additional indicators in their country-specific results frameworks in accordance with country-specific activities, but these will not be reported on at the MPA level. The menu of options will ensure cross-country comparability, including on key activities related to gender, equity, and inclusivity, while providing flexibility to countries to implement country-specific activities. To enable attribution, rigorous impact evaluations will be undertaken, where feasible, at midpoint and endpoint to assess the impact of specific interventions on national/regional capacity to prevent, detect, and respond to HEs. 18. The MPA Results Framework comprises four PrDO indicators and nine intermediate indicators. The indicators are informed by a menu of priority activities in Annex 1 of the PAD. The menu of options will ensure cross-country comparability, including on key activities related to gender, equity, and inclusivity, while providing flexibility to countries to implement country-specific activities. Each indicator is linked to a priority I activity that will be undertaken by all MPA countries. MPA countries will be free to include additional indicators in their country-specific results frameworks in accordance with country-specific activities, but these will not be reported on at the MPA level. The MPA Results Framework is defined in such a way that the indicators are scalable as the number of MPA countries increases. For that reason, targets are typically set in terms of the percentage of MPA countries that meet the criteria defined by a given indicator. The Results Framework includes a PrDO indicator related to regional integration (PrDO2), an intermediate indicator related to climate (IRI5), and six intermediate indicators related to gender. In order to mitigate risks of misuse 49 Equity in health care refers to “a state in which everyone has a fair and just opportunity to attain their highest level of health,� and “aims to adjust resources for disadvantaged groups to truly create an even playing field.� https://www.hopkinsacg.org/health-equity-equality-and-disparities/ and CDC 50 Inclusive health care entails health services that are efficacious, equitable and affordable for everyone, especially the most vulnerable. Efficacious means functional, good quality health services, equitable means health services reach everyone (see EQUITY), and affordable means services are provided in the most cost-effective way possible, for the individual and society (MacLachlan et al 2011 and Adebisi et al 2021). Jun 12, 2023 Page 12 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) of funds, the Results Framework requires that for many indicators, the responsibility for reporting is shared between the government (which maintains records of activities) and a third-party monitor (which verifies that the activities took place). The complete Results Framework and methodology is available in Section VII of the PAD. Table 1: PrDO Level Indicators # Indicator Baseline End Target 1 Countries scoring 80% in at least 3 JEE core capacity indicators in each 0% 66% axis (Prevent, Detect, and Respond) 2 Countries that have active cross-border rapid response teams for health 0% 66% emergencies 3 Countries where 60% of detected health emergency events met the 7- 0% 66% 1-7 target, plus adequate reporting data including sex, age, and pregnancy status. 4 Countries where 80% of project-supported laboratories have achieved a 0% 66% 3-star rating or higher during a Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) audit D. Project Description The Program has four components detailed as follows: 19. Component 1: Strengthening the preparedness and resilience of regional and national health systems to manage HEs. This component will support the strengthening of the capacity of essential institutions and activities that directly contribute to the resilience of the health systems to cope with HEs equitably and inclusively and be complimentary to other HSS activities being conducted by other World Bank and partner investments. The component has four subcomponents, namely: • Subcomponent 1.1 will support multisectoral and cross-border planning, financing, and governance for HEs, emphasizing the so-called “essential public health functions� (EPHF)51. • Subcomponent 1.2 will support health workforce development • Subcomponent 1.3 will support the strengthening of local vaccine and pharmaceutical manufacturing capacity. • Subcomponent 1.4 will support delayed onset threats, including AMR, One Health, NCDs, and climate change. 51 Essential Public Health Functions (EPHF) are the capacities of health authorities, at all institutional levels and together with civil society, to strengthen health systems and guarantee the right to health, acting on the risk factors and social determinants that have an effect on population health. The 11 essential functions are framed as institutional capacities that countries must strengthen for appropriate public health action. Jun 12, 2023 Page 13 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) 20. Component 2: Improving early detection of and response to HEs through a multisectoral approach. The ability to detect and respond effectively to HEs at national, regional, and global levels depends on the operational readiness and capacities across the following critical subsystems that will be supported under this component. The component has four subcomponents as follows: • Subcomponent 2.1 will support information systems for HEs and the digitalization of the health sector. • Subcomponent 2.2, building on the investments of Subcomponent 2.1, will support collaborative multisectoral surveillance and laboratory diagnostics. • Subcomponent 2.3 will support emergency management, coordination, and essential service continuity. • Subcomponent 2.4 will support risk communication and community engagement (RCCE), empowerment, and social protection during health emergencies, with a focus on equitable reach to all populations, especially across gender dimensions. 21. Component 3: Program management. This component will consist of three sub-components as follows: • Subcomponent 3.1 will support monitoring and evaluation (M&E) • Subcomponent 3.2 will focus on support for the learning agenda • Subcomponent 3.3 will focus on all other aspects of program management, including equipment and materials, compliance with fiduciary, procurement, and safeguards (environmental and social) requirements. At the national level, these activities will be undertaken by the Project Implementation Units (PIUs). 22. Component 4: Contingent Emergency Response Component (CERC). There is a high probability that during the life of this proposed MPA, countries will experience an epidemic or outbreak of public health importance, or other disaster, which causes a major adverse economic and/or social impact (e.g., Ebola), which will result in a request to the World Bank to support mitigation, response, and recovery in the country(ies) affected by such an emergency. This CERC is included under the MPA in accordance with the World Bank’s Investment Project Financing Policy, paragraphs 12, for situations of urgent need of assistance. This will allow for rapid reallocation of Program proceeds in the event of a natural or man-made disaster or health outbreak or crisis that has caused or is likely to imminently cause a major adverse economic and/or social impact. To trigger this component, the Government of the affected country needs to declare an emergency or provide a statement of fact justifying the request for the activation of the use of emergency funding. To allocate funds to this component, the Government may request the World Bank to re-allocate MPA funds to support emergency response and early recovery. Disbursements would be made against an approved list of critical goods, services and works required to support the immediate response and recovery needs, including for the most vulnerable segments of the population at risk. A CERC Operations Manual will be prepared as an annex to the Project’s Operation Manual outlining triggers for its activation and detailing fiduciary, safeguards, and any other necessary implementation . arrangements. . Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Jun 12, 2023 Page 14 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) Summary of Assessment of Environmental and Social Risks and Impacts . 23. The Program will have considerable positive outcomes as it aims to strengthen the preparedness, response, and resilience of health systems in Eastern and Southern Africa to public health emergencies. However, the Program activities can also have both direct and downstream adverse environmental, health and safety (EHS) risks if there are no appropriate systems for the collection, handling, transportation and disposal of public healthcare/medical wastes in the beneficiary countries as per the requirements of the World Bank EHS guideline for Health Care Facilities (HCF). The potential EHS risks and impacts may mainly result from activities to be financed under : i) subcomponent 1.3 ; ii) subcomponent; 1.4 which deals with data/information technology; iii) subcomponent 1.5 and iv) subcomponent 2.1. 24. There are environmental, health and safety risks associated with the Program pertaining to healthcare facilities and laboratory diagnostics. These include on infectious waste management and potential water contamination. There are also potential occupational and community health safety risks and impacts that may result from the project activities. Health and safety hazards that may affect workers in healthcare facilities/diagnostic laboratories include exposure to infections and diseases, hazardous materials /waste, and radiation. Community hazards include potential infection hazards within the facility, and at waste disposal sites . 25. The Social Risk is rated Substantial. Project activities will be implemented country wide in Ethiopia, Sao Tome Principe (STP), and Kenya. The primary social risks relate to i) security, ii) the possible exclusion of underserved communities; iii) labor and working conditions; iv) Gender-Based Violence, and v) community health and safety. 1) In the context of security, potential conflict, and violence in parts of Ethiopia and Kenya could put project investments, services, and staff at risk and disrupt project implementation, communication, and monitoring. 2) Potential exclusion of underserved communities relates to the risk of inequity in sharing of project benefits due to low capacity, weak infrastructure, and insecurity for communities in historically underserved and inaccessible/remotely located communities. Other vulnerable groups such as internally displaced persons, persons with disability, refugees, women may also be excluded from project benefits. Exclusion can occur in developing plans and strategies systems and approaches under subcomponent 1.5 (vi) on community engagement to develop community-led climate emergency preparedness and response plans and subcomponent 2.3 in developing plans for risk communication, health messages, readiness for and resilient to health emergencies and shocks, , develop social welfare and protection action plans and local mechanisms to ensure food security and access to schooling during PHEs. These activities require tailored approaches that are sensitive to specific socio-cultural needs of underserved and vulnerable communities. 3) Labor and working conditions risks include recruitment and employment discrimination, employer lack of compliance with terms and conditions of employment, occupational health and safety violations, and failure to provide project workers with a dedicated worker grievance mechanism. 4) Sexual Exploitation, Abuse and Harassment (SEA/H/GBV) risks are related to contextual factors, such as unintentional exacerbation of existing insecurity and conflict in both countries, and from project activities, including interactions between project workers and local communities, as well as sexual harassment among project workers. 5) Community health and safety risks involve the transmission of communicable diseases, including HIV/AIDS and COVID-19, due to interactions among project workers and between the project workforce and local communities, risks to local communities related to the activities of project security personnel, and inappropriate disposal of hazardous materials related to project activities. failure to implement operating procedures. The project does not finance construction activities. Only minor renovation of infrastructure for climate resilience and expansion of existing ICU and isolation facilities is envisaged under subcomponent 1.3. 26. The social context in STP is distinct from that of the other participating countries, given the small size of the population and the insularity which characterize STP. The issues relating to security and conflict, or vulnerable groups Jun 12, 2023 Page 15 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) meeting the relevant environmental standards identified above for the other participating countries are not relevant in STP. However, issues such as SEA/SH and GBV and risks relating to labor and working conditions are particularly relevant. E. Implementation Institutional and Implementation Arrangements 27. The proposed MPA will be implemented at the country and regional levels. As noted, Phase I entails projects in three countries, namely Ethiopia, Kenya, and STP. In addition, the Phase I will be supported by two regional entities, namely the ECSA-HC, which will take the lead on health-related regional issues and IGAD, which will be responsible for the multisectoral aspects of the regional program. 28. At the country level, project implementation will be the responsibility of the respective recipients and conducted through either newly established or existing PIUs. PIUs will also be established in the two regional entities to coordinate work on the proposed MPA, with overall coordination among the countries and regional entities being facilitated by a Regional Advisory Committee. In addition, the multisectoral nature of the program’s design implies that at both country and regional level, there will be coordination, collaboration, and partnership across sectors. Given the broad geographic coverage of the proposed Program, the differing scope of country activities, and the varying implementation systems/capacities, the implementation arrangements used by participating countries will necessarily vary. The subsequent sections summarize the institutional and implementation arrangements for each of the implementing entities, as well as the World Bank’s own role in supporting implementation. Jun 12, 2023 Page 16 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) ETHIOPIA 29. The Ministry of Health (MoH) will be the implementing agency for the proposed project in Ethiopia and will oversee the overall implementation of the project. The State Minister for Programs will oversee the overall implementation of the proposed project. The Grant Management Unit (GMU) of the Ethiopian MoH’s Partnership and Cooperation Directorate (PCD) will be responsible for the day-to-day management of project activities, as well as the preparation of consolidated annual workplans and consolidated activity and financial reports for the various project components. The PCD already manages and coordinates several World Bank funded projects in the health sector, including the Africa CDC Regional Investment Financing Project; Ethiopia COVID-19 Emergency Response Project (P173750); Sustainable Development Goal Program for Results (P123531); and Ethiopia Program for Results (Hybrid) for Strengthening Primary Health Care Services (P175167). Strengthening the capacity of the GMU/PCD will be necessary in order to support the project under the proposed MPA. The Ethiopian Public Health Institute (EPHI)52 will serve as the key technical entity for the implementation of the project activities. The MoH will collaborate with other sectors as needed. KENYA 30. The MoH and the Kenya Biovax Institute (KBI) will be the main implementing agencies for the project in Kenya. While the MoH has over two decades of implementing World Bank supported activities, the KBI was established recently, and it is still putting in place institutional structures to guide its operations. Thus, in the first year of project implementation, the MoH will also oversee implementation of activities under the KBI, with possibilities of transitioning over activities related to local manufacturing fully to KBI as the capacity evolves. Activities under the NPHI, Pharmacy and Poisons Board (PPB) will also be implemented through the MoH. The Kenya Medical Supplies Agency (KEMSA)53 will be responsible for procurement and distribution of medical supplies and equipment where applicable. 31. Project management will be the responsibility of a project management team (PMT) established specifically for this project. The PMT will draw on existing structures that have been put in place to oversee the implementation of ongoing projects, include the Transforming Health Systems for Universal Care Project (P152394) and the Kenya COVID-19 Emergency Response Project (P173820). The MoH will be required to: (a) set up a dedicated PMT; (b) designate staff with appropriate skill sets and recruit on exceptional basis to fill skills gaps; (c) build staff capacity; and (d) make resources available to conduct day-to-day functions. 32. The MoH will establish an oversight committee under the leadership of the Principal Secretary. The oversight committee will comprise of key stakeholders in local manufacturing to provide guidance and oversight during implementation. A local manufacturing committee with the mandate of providing leadership on pharmaceutical manufacturing is already in place. The mandate and membership of this committee will be expanded to include vaccine manufacturing. Additionally, a multisectoral oversight group, will be put in place to guide the implementation process. The PMT will work closely with the oversight committee to ensure the objectives of the project are met. SÃO TOMÉ AND PR�NCIPE 53 KEMSA is the government procurement agency for medical supplies and equipment. Jun 12, 2023 Page 17 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) 33. The MoH will be the implementing agency for the project in STP and oversee the overall implementation of the project. The Project Coordination Unit (PCU) that was originally established within the MoH to implement the STP COVID-19 Emergency Response Project (P173783), has performed well, and is expected to also support the project under the proposed MPA. Once the project becomes effective, the PCU will hire short term consultants to support implementation as needed. 34. The MoH will work closely with other health and non-health agencies, including the Ministry of Finance and Fiduciary Agency for Project Management (AFAP), on project implementation. Leveraging its experience in implementation of investment projects (since 2003), the AFAP will be responsible for providing fiduciary support for the project through the PCU. Specifically, AFAP will oversee disbursements, procurement, financial management (FM), and safeguards. 35. The MoH will collaborate, as relevant, with other ministries for technical support on “non -health� determinants of equitable and inclusive health. Additionally, the project will engage key development partners such as the WHO to provide TA and implementation support. REGIONAL BODIES 36. In addition to national level support, the proposed MPA will support regional institutions in coordinating and/or assisting countries across the region as part of the MPA. At the regional level, the program will be supported by ECSA-HC, IGAD, and a RAC established specifically for the Program. The two regional organizations will play separate, but complementary, roles (i.e., IGAD leading the multisectoral activities and ECSA-HC the health-centered aspects) focused on: (i) planning and delivering regional activities; (ii) providing technical assistance to countries; (iii) supporting the implementation of cross-border activities/interventions; (iv) establishing regional policies and procedures; (v) facilitating and implementing a robust regional learning agenda/program; (vi) coordinating relevant actors; and (vii) convening multisectoral stakeholders, political actors and decision makers, governments, and regional economic communities to advance cross-sectoral policies and actions necessary to achieve more resilient systems for HE preparedness and response, as well as disaster risk reduction and responses to disasters and humanitarian emergencies in the context of the health sector. These organizations will support, as needed, routine assessments like JEEs and SPARS at the national level, M&E, and analytical work. Importantly, the regional organizations will coordinate with core public health/technical entities like the Africa CDC and the WHO, both of which are central to the delivery of related activities in the region. 37. The RAC will serve as the bridge between the MPA and the overall regional agenda and priorities. It will provide a forum for broader technical and regional engagement beyond the specific focus of the MPA, with an emphasis on ensuring program alignment with a broader regional agenda and strategic direction. It will include the participation of both regional and global experts and provide a forum for debating and advancing multisectoral policy reforms to shift the regional approach to HE. In addition, the RAC will also provide strategic direction to the implementation of the MPA, ensuring that program interventions are aligned with the regional strategic directions and vice versa. WORLD BANK COORDINATION ROLE Jun 12, 2023 Page 18 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) 38. The MPA will be monitored by a multisectoral World Bank team comprising of an overall Program-level MPA task team, as well as individual task teams for each country and regional entity. The World Bank team will facilitate coordination across country task teams and focal points in operational and technical units as needed. It will also monitor the implementation of individual projects and keep World Bank management and the Board of Executive Directors informed. In doing so, the World Bank team will operate as a unified cross- country/cross sectoral team to address key issues. It may, for example, help align the implementation of different country-level operations leveraging other ongoing World Bank supported projects across sectors, monitor Program achievements and its use of key indicators, facilitate knowledge exchange and communication as integral elements of the learning agenda, develop harmonized reporting mechanisms, and identify gaps in monitoring, report to and coordinate with different partners and stakeholders, and develop adaptive strategies, as and when necessary. . CONTACT POINT World Bank Ramesh Govindaraj Lead Health Specialist Enias Baganizi Senior Health Specialist Ian Forde Senior Health Specialist Joao Verissimo Figueiredo Rodrigues E Pires Senior Health Specialist Borrower/Client/Recipient Democratic Republic of Sao Tome and Principe Alberto Leal Director General AFAP afap2@yahoo.com.br East, Central and Southern Africa Health Community (ECSA-HC) Prof. Yoswa Dambisya Director General yoswa@ecsahc.org Federal Democratic Republic of Ethiopia H.E Ahmed Shide Ministry of Finance ashide@mofed.gov.et Jun 12, 2023 Page 19 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) Intergovernmental Authority on Development (IGAD) Dr Mohamed Elduma Senior Programme Coordinator, Health and Social Development mohamed.elduma@igad.int Republic of Kenya Dr. Chris K. Kiptoo Principal Secretary, the National Treasury pstreasury01@gmail.com Implementing Agencies Democratic Republic of Sao Tome and Principe - Ministry of Health (MOH) Celsio Rodrigues da Vera Crus Junqueira Minister, Ministry of Health msaudestepgeral@gmail.com East, Central and Southern Africa Health Community (ECSA-HC) Martin Matu Project Coordinator mmatu@ecsahc.org Federal Democratic Republic of Ethiopia - Ministry of Health (MOH) Naod Wendrad Abera Strategic Affairs Executive Officer naod.wendrad@moh.gov.et Intergovernmental Authority on Development (IGAD) Dr Mohamed Elduma Senior Programme Coordinator, Health and Social Development mohamed.elduma@igad.int Kenya BioVax Institute Dr. Michael Lusiola Chief Executive michael.lusiola@biovax.go.ke Republic of Kenya - Ministry of Health (MOH) Eng. Peter K. Tum, C.B.S. State Department For Medical Services Principal Secretary pshealthke@gmail.com Jun 12, 2023 Page 20 of 21 The World Bank AFE Health Emergency Preparedness, Response and Resilience MPA (P180127) FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Ramesh Govindaraj Enias Baganizi Task Team Leader(s): Ian Forde Joao Verissimo Figueiredo Rodrigues E Pires Approved By Practice Manager/Manager: Country Director: Boutheina Guermazi 30-Jun-2023 Jun 12, 2023 Page 21 of 21