The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Tunisia COVID-19 Response project (P173945) MIDDLE EAST AND NORTH AFRICA | Tunisia | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2020 | Seq No: 8 | ARCHIVED on 23-Nov-2023 | ISR58045 | Implementing Agencies: Ministry of Health, Ministry of Health, Republic of Tunisia Key Dates Key Project Dates Bank Approval Date: 30-Apr-2020 Effectiveness Date: 01-Jun-2020 Planned Mid Term Review Date: 01-Jun-2022 Actual Mid-Term Review Date: 01-Jun-2022 Original Closing Date: 30-Jun-2021 Revised Closing Date: 31-Mar-2025 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) To improve COVID-19 detection and infection control in Tunisia through increasing the availability of COVID-19 equipment and supplies. Has the Project Development Objective been changed since Board Approval of the Project Objective? Yes Board Approved Revised Project Development Objective (If project is formally restructured) To prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness. Components Table Name Emergency COVID-19 Response:(Cost $102.85 M) Implementation Management and Monitoring and Evaluation:(Cost $2.10 M) Support Health Systems Strengthening:(Cost $38.50 M) Contingency Emergency Response Component Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Satisfactory Overall Risk Rating Substantial Substantial Implementation Status and Key Decisions The Tunisia COVID-19 Response project Parent project was approved by the World Bank's Executive Board on April 30, 2020 and was declared effective on June 1st, 2020. The project is financed by a US$20 million loan under the Multiphase Programmatic Approach supported by the Fast Track COVID-19 Facility. An additional financing of a US$100 million loan has was been approved by the World Bank’s Executive Board on March 26, 2021 and was declared effective on May 26, 2021. A second additional financing of a US$22 million loan and a US$1.8 million grant has been was approved by the Regional Vice President on May 24, 2022 and was declared effective on October 12, 2022. A total of US$111.55 million (or 79 11/23/2023 Page 1 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) percent) of the project has been disbursed. The project has enabled purchase and deployment of COVID-19 vaccines to contribute to Tunisia’s high vaccination rate (over 60 percent of adults), as well as the purchase of medical equipment to expand care capacity. MPA Program Development Objective MPA PDO Table The Program Development Objective is to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness MPA Table Multiphase Programmatic Approach (MPA) Status MPA Table Body COVID-19 MPA - ISR Write-up as of October 16, 2023 Sustained efforts continue to be made to advance the implementation of the 87 MPA operations. After a great deal of activity (restructurings and disbursements) processed at the end of FY23 when several operations were restructured just before or on June 30, 2023, the past two months have seen a slower period of disbursements. The overall level of disbursements is being affected by three main reasons: (i) low disbursements in six countries, (ii) pausing of disbursements in three other countries – Afghanistan, Myanmar, and Sudan, and (iii) processing of refunds to the project accounts at this late stage of project implementation. In addition, (i) a large refund from the UN to the project account of the Myanmar operation was processed in late March due to the inability to implement the project, and (ii) Loans and Credits denominated in SDRs and Euros have been affected because of fluctuations between the SDRs and Euros against the US dollar. As of October 16, 2023, 88 MPA-projects had been approved with a total commitment of US$4.27 billion. One operation (Guatemala) was cancelled in mid-September 2021, at the request of the Government. Total disbursements as of October 16, 2023, amount to US$3.96 billion or 93% of overall commitments. This amount does not include disbursements under MPA-V operations which are reported together with AF-V operations. Ten operations closed by the end of CY22 and nine operations closed on June 30, 2023. While there are sixteen (16) operations with closing dates by the end of CY23, there are plans for several projects to process extensions so this number will change. As with the Mid Term Review (MTR) issued on March 25, 2023, no individual COVID-19 MPA operation will need an ICR. Only one ICR will be prepared upon completion of the SPRP COVID-19 MPA Program, which closes on December 31, 2025. The Global ICR will be based on final ISRs packages prepared by country operations’ teams. A template for the final ISR was issued by OPCS on March 25, 2023. Several operations have/are preparing final ISR packages. The overall conclusion of the MTR was that: (i) the COVID-19 MPA Program embodied a rapid, innovative approach to new lending for human health response; (ii) the COVID-19 MPA has been successful, notwithstanding considerable uncertainty and multiple constraints in the early stages of the pandemic; (iii) the Bank’s emergency response was remarkably swift in the most vulnerable countries facing human capital losses and development setbacks; and (iv) notwithstanding the challenges, the MPA is on track to achieve its PrDO, “prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness.“ Seventy three (73) country projects or 86 percent of projects approved have reached 70-100+ percent disbursement (reasons for >100% disbursements relate to fluctuations between the Euro and the SDR against the US$). Out of the 73 operations, 63 operations or 86 percent have disbursed 90+ percent of commitments. Out of the 73 operations, 49 operations or 67 percent are fully disbursed and ten (10) operations have disbursed 95-99 percent of commitments. There are four operations with disbursements of 50 percent or less. Out of these four operations, one operation has disbursed 35 percent (AFW), two operations in EAP have disbursed 46-48 percent and one operation in SAR has disbursed 49 percent. The projects are benefitting about 3.7 billion people or 50% of the global population. When countries with AF-V operations are counted, the projects are benefitting about 4.1 billion of 51 percent of the global population. This is because some countries that do not have a parent project have AF-V operations. All projects approved are disbursing. Operations in ECA and MNA are fully disbursed. In other regions, operations have reached: (i) SAR 94 percent, (ii) LAC 93 percent, (iii) EAP 86 percent, (iv) AFW 84, and (v) AFE 78 percent. Disbursements for EAP operations are being affected by low disbursements in three countries. AFE lower disbursements compared to other regions are a result of low 11/23/2023 Page 2 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) disbursements under two operations, which have disbursed 54-66 percent respectively. In the case of AFW low overall disbursements are a result of low disbursements under one operation. Retroactive Financing (RF) represents 19 percent of commitments. SAR has the highest percentage of RF at 37 percent, followed by ECA at 18 percent. IDA continues to represent 40 percent and IBRD 60 percent of disbursements. Streamlined procedures, delegated approvals, coupled with flexible project design and intensified efforts across the Bank have contributed to the progress. Implementation is being guided by Bank teams working in parallel with other health related projects, including Additional Financing operations supporting vaccine procurement and deployment efforts. COVID-19 MPA AF-V - ISR Write-up – October 16, 2023 As of October 16, 2023, the Bank has approved 117 operations (including MPA-V operations) to support vaccine procurement and rollout in 78 countries amounting to $9.24 billion. The Senegal AF2 operation for $15 million financed by a Grant from The Global Finance Facility was approved on June 30, 2023. Also, a Second AF (IDA Grant of $1.50 million) was approved on August 31, 2023 for Sao Tome and Principe. One hundred and nineteen (119) operations had been approved amounting to $10 billion, but the: (i) Costa Rica operation ($120 million), and (ii) Peru operation ($500 million) were cancelled at the request of both governments. Also, (i) the Gabon ($12 million) reported in July as closed is still in the process of being closed, and (ii) the Afghanistan operation commitment of $113 million was reduced to $60 million. Partial cancellations have been processed in the past weeks under other operations, thereby the overall commitment has decreased in the past months. Of the 117 approved operations: (i) 67 are in Africa – 31 in AFE and 36 in AFW; (ii) 10 in East Asia and the Pacific; (iii) 11 in Europe and Central Asia; (iv) 11 in Latin America and the Caribbean; (v) 9 in Middle East and North Africa; and (vi) 9 in South Asia. The 117 operations approved, include 6 operations that involved restructuring of parent projects (Bhutan, Cameroon, North Macedonia, Philippines, and Pakistan) and in the case of Lebanon, restructuring of the Health Resilience Project. Thirty-two (32) operations are being implemented in Fragile and Conflict-affected situations. IDA represents 45 percent and IBRD 55 percent of disbursements. Total disbursements under these projects as of October 16, 2023, amount to US$6.27 billion or 68 percent of overall commitments. Disbursements under MPA-V operations are included in this total while disbursements under the six restructured projects are counted under parent projects. With less than planned demand for IDA/IBRD funds for vaccine procurement because, inter alia, over supply of vaccines from donations from various sources, several projects have been/are being restructured and more will need to be restructured to reallocate funds allocated for procurement of COVID-19 vaccines and deployment. Guidance was issued under an Email from Juan Pablo Uribe of July 7, 2023, which provided direction for the use of undisbursed funds under COVID-19 operations. Four (4) operations are fully disbursed (Argentina, Indonesia, Sri Lanka AF-V 1, and Ukraine AF-V 3). Forty-seven (47) operations or 40 percent of operations approved have disbursed over 70 percent of their commitments. Out of the 47, eighteen (18) operations or 38 percent have disbursed 90+. Nine operations have disbursed 95-99 percent of commitments (Cabo Verde, Ecuador AF-V 1, Gambia AF-V 1 and 2, Iraq, South Sudan AF-V 2, Sierra Leone AF-V 1, Turkey, and Yemen). Ninety-five (95) operations or 81 percent of total operations approved are disbursing. ECA has the highest percentage of disbursements at 86 percent, followed by SAR and MNA at 77 percent, LAC at 76 percent, EAP at 74 percent, AFE at 58 percent and AFW at 57 percent. As of August 1, 2023, the World Bank had purchased 635.4 million doses of the COVID-19 vaccine of which 506.8 million had been delivered to client countries and 500.7 million administered. Retroactive Financing (RF) represents 36 percent of overall commitments. High levels of RF have been authorized under different operations - Ukraine (100%), Panama and Turkey (90%), Argentina and Guyana (80%), and Belize, and Sri Lanka (70%). One hundred and fifteen (115) loan/financing agreements or 99 percent of projects approved have been signed and 114 or 99 percent have become effective. As with the COVID-19 MPA operations, streamlined procedures, delegated approval, wide use of Bank Facilitated Procurement (BFP), coupled with flexible project design, and intensified efforts across the Bank have contributed to the rapid design, processing, and implementation of the AF-V operations. 11/23/2023 Page 3 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Moderate High High Macroeconomic Substantial High High Sector Strategies and Policies Moderate Moderate Moderate Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and Substantial Substantial Moderate Sustainability Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Moderate Substantial Substantial Other -- -- -- Overall Moderate Substantial Substantial Results PDO Indicators by Objectives / Outcomes To prevent, detect and respond to the threat posed by COVID-19 IN01347589 ►Number of health facilities and laboratories provided with personal protective equipment under the project (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 228.00 228.00 228.00 Date 30-Apr-2020 18-Jun-2022 18-Jun-2022 30-Jun-2021 IN01347590 ►Percentage of priority populations vaccinated based on targets defined in national plan, total (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 54.00 54.00 50.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347656 Percentange of priority populations vaccinated based on targets defined in national plan by gender (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target 11/23/2023 Page 4 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Value 0.00 54.00 54.00 50.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347657 ►Number of hospitals equipped with chronic case management equipment (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 25.00 Date 03-May-2022 18-Jun-2022 18-Jun-2022 30-Jun-2023 IN01347658 ►Number of hospitals with strengthened emergency care capacity (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 10.00 Date 03-May-2022 18-Jun-2022 18-Jun-2022 30-Jun-2023 Intermediate Results Indicators by Components Emergency COVID-19 response IN01347659 ►Percentage of Project supported health facilities and laboratories confirming receipt of equipment within 14 days of in-country delivery of such equipment (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 100.00 100.00 100.00 Date 30-Apr-2020 18-Jun-2022 18-Jun-2022 30-Jun-2021 Supporting Health System Strengthening IN01347660 ►Functional National Coordinating Committee (or the engagement of an existing committee) for COVID-19 vaccine introduction is in place (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target No committee with clear terms of reference, roles, Committee established Committee established Committee established Value responsibilities and and operational and operational and operational regular meetings defined Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347661 ►COVID-19 vaccine delivery strategies to reach identified target groups are defined and include women in hard to reach areas and frontline health workers (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 11/23/2023 Page 5 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Operational strategies Operational strategies Operational strategy defined to identify and defined to identify and defined to identify and No specific strategies Value deliver vaccines to deliver vaccines to deliver vaccines to defined targeted groups to targeted groups to targeted groups to ensure high coverage ensure high coverage ensure high coverage Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347662 ►Percentage of people reached by messages and/or materials to explain the vaccination campaign, total (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 97.00 97.00 70.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 According to the Iterative Beneficiary Monitoring (IBM) survey finalized in May 2022, 97 percent of the Comments: sample has reported having received sufficient information regarding the vaccination campaign. IN01347663 Percentage of people reached by messages and/or materials to explain the vaccination campaign by gender (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 97.00 97.00 70.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347664 ►Percentage of beneficiaries reporting that community engagement processes were effective (transparent, inclusive, responsive), total (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 39.00 39.00 70.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 According to the Iterative Beneficiary Monitoring (IBM) survey, 39 percent of the population was aware of Comments: engagement processes, including on reporting of grievances. IN01347665 Percentage of beneficiaries reporting that community engagement processes were effective (transparent, inclusive, responsive), by gender (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 39.00 39.00 70.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347666 ►Functional health management and information system to deploy the COVID-19 vaccine is in place, including identification, registration and follow up with recipients by gener age and locality (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target No functional health Information system for Information system for Information system for management and COVID-19 vaccine COVID-19 vaccine COVID-19 vaccine Value information system for deployment is in place deployment is in place deployment is in place COVID-19 vaccine in and functional and functional and functional place 11/23/2023 Page 6 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 IN01347667 ►Number of of freezers, fridges, cold boxes, and vaccine carriers procured to upgrade the national cold chain to support delivery of COVID- 19 vaccines and improve national capacity (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 2,939.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 13 -80 freezers, 33 -20 freezers, 300 PQS fridges, 627 vaccine carriers, over 2000 fridge tags, and 26 refrigerated vehicles were either purchased with government funds are donated from FADES, Gavi, Japan, US, EU, or UNICEF. Discussions during the January 2022 mission have confirmed that World Comments: Bank project resources will not be utilized for cold chain procurement at this point, given the fact that all national gaps have been closed by these efforts. IN01347668 ►Percentage of female community workers (as a share of total community workers) providing vaccine information compared to baseline (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 60.00 60.00 60.00 Date 01-Feb-2021 02-Aug-2021 02-Aug-2021 31-Mar-2025 No new data was available on this since August 2021. Comments: IN01347669 ►Share of people agreeing with the importance of the vaccine, total (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 41.00 75.00 75.00 70.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Mar-2025 A Facebook survey which was implemented in December 2021 - January 2022 demonstrated 85 percent of the population agreeing with the importance of the vaccine, the rate being identical for men and women; ie no gender gap regarding coverage. Results from the Iterative Beneficiary Monitoring (IBM) survey Comments: conducted in May 2022 point to a slight decline in this, with 78 percent of women and 72 percent of men agreeing with the importance of the vaccine (75 percent overall). IN01347670 Share of people agreeing with the importance of the vaccine, by gender (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 41.00 78.00 78.00 70.00 Date 01-Feb-2021 18-Jun-2022 18-Jun-2022 31-Dec-2025 Performance-Based Conditions Data on Financial Performance 11/23/2023 Page 7 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P173945 IBRD-91120 Effective USD 20.00 20.00 0.00 20.52 0.00 100% P173945 IBRD-92230 Effective USD 100.00 100.00 0.00 70.32 25.19 74% P173945 IBRD-94110 Effective USD 22.00 22.00 0.00 22.13 0.43 98% P173945 TF-B8616 Effective USD 1.80 1.80 0.00 0.30 1.50 17% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P173945 IBRD-91120 Effective 30-Apr-2020 11-May-2020 01-Jun-2020 30-Jun-2021 31-Mar-2025 P173945 IBRD-92230 Effective 26-Mar-2021 31-Mar-2021 26-May-2021 31-Mar-2025 31-Mar-2025 P173945 IBRD-94110 Effective 24-May-2022 13-Jun-2022 12-Oct-2022 31-Mar-2025 31-Mar-2025 P173945 TF-B8616 Effective 10-May-2022 13-Jun-2022 13-Jun-2022 31-Mar-2025 31-Mar-2025 Cumulative Disbursements 11/23/2023 Page 8 of 9 The World Bank Implementation Status & Results Report Tunisia COVID-19 Response project (P173945) Restructuring History Level 2 Approved on 18-Jun-2021 Related Project(s) P175785-Additional Financing for Tunisia COVID-19 Response Project ,P178540-Second Additional Financing to Tunisia COVID-19 Response Project 11/23/2023 Page 9 of 9