Document of The World Bank FOR OFFICIAL USE ONLY Report No: ICR00005541 IMPLEMENTATION COMPLETION AND RESULTS REPORT TF0B3767 ON A SMALL GRANT IN THE AMOUNT OF USD 3,787,433 TO THE UNITED REPUBLIC OF TANZANIA FOR THE COVID-19 PANDEMIC EMERGENCY FINANCING FACILITY PROJECT (P174366) August 31, 2021 Health, Nutrition & Population Global Practice Africa East Region Regional Vice President: Hafez M. H. Ghanem Country Director: Mara K. Warwick Regional Director: Amit Dar Practice Manager: Ernest E. Massiah Task Team Leader(s): Mariam Ally Juma ICR Main Contributor: Josine Umutoni Karangwa ABBREVIATIONS AND ACRONYMS COVAX COVID-19 Vaccines Global Access COVID-19 Coronavirus Disease of 2019 CPF Country Partnership Framework EAPHLNP East Africa Public Health Laboratory Network Project ESCP Environmental and Social Commitment Plan ESMF Environmental and Social Management Framework ESMP Environment and Social Management Plans FM Financial Management GDP Gross Domestic Product GoT Government of Tanzania ICR Implementation Completion and Results Report IDA International Development Association IFR Interim Financial Report IHR International Health Regulations IRI Intermediate Results Indicator ISR Implementation Status and Results Report M&E Monitoring and Evaluation MoHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children MS Moderately Satisfactory MU Moderately Unsatisfactory NEMC National Environmental Management Council NPHL National Public Health Laboratory PDO Project Development Objective PEF Pandemic Emergency Financing Facility PMT Project Management Team RRH Regional Referral Hospital SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2 SEP Stakeholder Engagement Plan SPRP Strategic Preparedness and Response Program STEP Systematic Tracking of Exchanges in Procurement TOC Theory of Change WBG World Bank Group WHO World Health Organization TABLE OF CONTENTS DATA SHEET ....................................................................... ERROR! BOOKMARK NOT DEFINED. I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................... 4 II. OUTCOME ...................................................................................................................... 8 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ................................ 13 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 15 V. LESSONS LEARNED AND RECOMMENDATIONS .............................................................. 17 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ........................................................... 19 ANNEX 2. PROJECT COST BY COMPONENT ........................................................................... 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) DATA SHEET BASIC INFORMATION Product Information Project ID Project Name COVID-19 Pandemic Emergency Financing Facility P174366 Project Country Financing Instrument Tanzania Investment Project Financing Original EA Category Revised EA Category Organizations Borrower Implementing Agency Ministry of Health, Community Development, Gender, United Republic of Tanzania Elderly and Children Project Development Objective (PDO) Original PDO To strengthen capacity for laboratory diagnosis and management of COVID-19 cases. Page 1 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) FINANCING FINANCE_TBL Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) Donor Financing TF-B3767 3,787,433 3,787,433 3,787,433 Total 3,787,433 3,787,433 3,787,433 Total Project Cost 3,787,433 3,787,433 3,787,433 KEY DATES Approval Effectiveness Original Closing Actual Closing 01-Sep-2020 22-Sep-2020 31-Jan-2021 28-Feb-2021 RESTRUCTURING AND/OR ADDITIONAL FINANCING Date(s) Amount Disbursed (US$M) Key Revisions 29-Jan-2021 3.79 Change in Loan Closing Date(s) Change in Implementation Schedule 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 29-Jan-2021 Moderately Satisfactory Moderately Satisfactory 3.79 ADM STAFF Role At Approval At ICR Regional Vice President: Hafez M. H. Ghanem Hafez M. H. Ghanem Page 2 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) Country Director: Mara K. Warwick Mara K. Warwick Director: Amit Dar Amit Dar Practice Manager: Ernest E. Massiah Ernest E. Massiah Task Team Leader(s): Mariam Ally Juma Mariam Ally Juma ICR Contributing Author: Josine Umutoni Karangwa Page 3 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES Country Context 1. Tanzania’s population in 2019 was estimated at 57.6 million, growing at a rate of 3.1 percent per annum. The economy was stable with the gross domestic product (GDP) growing at an estimated rate of 7 percent between 2013 and 2018.1 In July 2020, with gross national income per capita of US$1,080, the World Bank reclassified Tanzania as a Lower Middle-Income Country. Despite sustained economic growth and a declining poverty level,2 the absolute number of the poor increased from 12.3 million in 2011 to about 14 million in 2018.3 Sectoral Context 2. As the global Coronavirus Disease of 2019 (COVID-19) pandemic spread rapidly across the world, Tanzania responded with key mitigation measures, but initial public policy decisions around COVID-19 prevention and response quickly changed. In early 2020, the Government of Tanzania (GoT) implemented critical measures aimed at containing the spread of COVID-19 and encouraged people to avoid unnecessary movements, practice hand hygiene and social distancing, and identified several public and private hospitals that would serve as isolation centers for people infected with COVID-19. The Government reported COVID- 19 cases up to April 28, 2020 when it stopped acknowledging the presence of COVID-19 cases. Since March 2021, the new, Sixth Phase Government is implementing a new strategy to contain the pandemic, urging the public to take precautionary measures against the spread of infectious diseases, including COVID-19, and promoting measures such as the wearing of masks, and avoiding overcrowding in hospitals. The Government is also encouraging the continued education of the population by health professionals. In July 2021, the Government started implementing the COVID-19 National Vaccine Deployment Plan. Tanzania has joined the COVAX Facility, and the authorities are exploring other options for acquiring vaccines, including through the African Union’s Africa Vaccine Acquisition Trust. In addition, the GoT has resumed sharing COVID-19 data with WHO, reporting a total of 5,679 confirmed cases of COVID-19 from May 1, 2020 to August 21, 2021. 3. The GoT had conducted a number of assessments for COVID-19 preparedness, which were later transformed into a response plan. Between February and April 2020, GoT conducted a rapid assessment on critical COVID-19 preparedness and response gaps, which revealed key challenges in case management, including: (i) inadequate number of trained staff to provide care for Ebola virus disease and COVID-19; (ii) inadequate capacity for screening, triaging, and isolation in most health facilities; and (iii) limited production, distribution and use of oxygen. The study indicated severe shortage and unreliable supply of oxygen in 1 https://www.nbs.go.tz/index.php/en/census-surveys/national-accounts-statistics/na-statistics-by-subject 2 Household Budget Surveys 2011/12 and 2018, Tanzania National Bureau of Statistics 3 Ibid. Page 4 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) regional hospitals as well as capacity needs in the provision of oxygen therapy. 4. The pandemic severely disrupted economic activity in Tanzania, and the World Bank’s latest firm-level data suggest that the situation had only modestly improved by the end of 2020. The GDP growth rate slowed to an estimated 2.0 percent in 2020, as shocks to export-oriented sectors such as tourism, manufacturing, and related services diminished business revenue and labor income, which adversely affected domestically oriented firms of all sizes across all sectors. The World Bank’s December 2020 COVID-19 Business Pulse Survey (COV-BPS) indicated that the situation had improved since the previous survey in June, but overall business sentiment and expectations indicators remained weak, reflecting both the vast scale of the shock and the sluggish anticipated recovery. Moreover, many firms remain financially precarious and highly vulnerable. In December 2020, 35 percent of surveyed firms expected to experience severe financial problems, down slightly from 40 percent in June. 5. The COVID-19 Pandemic Emergency Financing Facility (PEF) Project, covering both the Mainland and Zanzibar, was developed to provide emergency support to the GoT in the COVID-19 response, by prioritizing evidence-based and cost-effective interventions, mainly to meet the needs of oxygen supply and testing capacity. The PEF – housed at the World Bank – was launched in 2016 to provide an additional source of financing to the world’s poorest countries facing cross-border, large-scale outbreaks. PEF financing consists of funding provided by Australia, Germany, IDA, and Japan as well as insurance coverage provided in 2017 through catastrophe bonds issued by the World Bank and sold to capital market investors as well as insurance- linked swaps executed by the World Bank with insurance companies. Countries eligible for PEF financing are members of the IDA, the World Bank’s institution that provides concessional finance for the world’s poorest countries. PEF operations are overseen by a steering body composed of donors (Australia, Germany, Japan), international organizations (including the World Health Organization, UNICEF, and the World Bank), and two IDA-eligible countries. The PEF can provide financing through either its cash or insurance window. The triggers for the PEF insurance window were chosen in close coordination with the World Health Organization, based on historical data available for the diseases covered. As of April 22, 2020, The PEF Steering Body had allocated the entire amount of US$195.84 million to 64 of the world’s lowest income countries that are members of the World Bank’s IDA with reported cases of COVID-19. The Tanzania COVID-19 PEF project was approved by the Bank on September 1, 2020 and became effective on September 22, 2020. As PEF is a facility that finances surge response, the project implementation timeframe was very short. The total project budget amounted to US$3.79 million. This Project was focused on filling in critical gaps in capacity for laboratory diagnosis and management of COVID-19 cases through procurement of seven oxygen plants. It was also aligned with the World Bank’s support for national plans and global commitments to strengthen pandemic preparedness. 6. The project was consistent with the World Bank’s Country Partnership Framework (CPF, Report No. 121790 - TZ, FY18-FY22), particularly focus area 2: "Boost human capital and social inclusion - A life cycle approach to human development challenges", aimed at improving the quality of health care services, and other global and country-specific strategies. The project contributed to the implementation of the IHR (2005) and the Global Health Security Agenda and complemented the development partners’ investments in health systems strengthening, disease control and surveillance. Finally, the project built on the recent World Bank support to the East Africa Public Health Laboratory Network Project (EAPHLNP, P111556, 2010-2020) which Page 5 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) supported strengthening of laboratory diagnosis capacity and the Tanzania Strengthening Primary Health Care for Results Program (P152736, 2015-2021) which focused on provision of primary health care services and played a vital role in disease outbreaks detection, prevention and response. Finally, the project was aligned with World Bank Group (WBG) strategic priorities, particularly the WBG’s mission to end extreme poverty and boost shared prosperity. The project’s focus on preparedness is also critical to achieving Universal Health Coverage. Theory of change (Results Chain) ACTIVITIES OUTPUTS OUTCOMES LONG-TERM OUTCOMES Strengthening Laboratory Diagnosis Capacity Increased number of laboratory Component 1: Delivery of training of laboratory staff trained in laboratory staff in SARS-CoV-2 testing diagnosis of SARS-CoV-2 Strengthened testing capacity of the Distribution of laboratory Increased availability of National Public equipment, supplies and reagents laboratory supplies, reagents, Health Laboratory for testing COVID-19 specimens and equipment (NPHL) Installation of liquid oxygen Increased number of biomedical Decreased deaths and Management of COVID-19 Cases generating plants and oxygen supply staff in the targeted regional human capital and systems at seven regional referral Component 2: Improving referral hospitals trained in economic loss due to hospitals medical oxygen generation COVID-19 Delivery of training for biomedical Increased number of health care technicians on production and workers trained on the management of oxygen plants Strengthened COVID- provision of oxygen therapy 19 case management Delivery of training of health Increased number of oxygen capacity workers on proper provision of cylinders refilled in the targeted oxygen therapy regional referral hospitals Distribution of COVID-19 essential medicines and supplies Project Development Objectives (PDOs) 7. The Project Development Objective was to strengthen capacity for laboratory diagnosis and management of COVID-19 cases. Key Expected Outcomes and Outcome Indicators Key Expected Outcomes 8. The project was developed in line with the GoT’s National COVID-19 Plan to help fill critical gaps in responding to the COVID-19 crisis. Key expected outcomes of the project were to: (a) increase testing capacity of the National Public Health Laboratory (NPHL); and (b) increase COVID-19 treatment capacity at targeted healthcare facilities through improved availability and access to functional oxygen therapy and capacity building of healthcare providers. They were to be achieved by providing training to laboratory staff and laboratory equipment and supplies, installing liquid oxygen generating plants and oxygen supply systems at Page 6 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) selected hospitals, and training biomedical technicians on production and management of oxygen plants and health workers on proper provision of oxygen therapy. Outcome indicators 9. The achievement of the PDO was measured through the following indicators: (a) Targeted hospitals with functional oxygen generation plants (b) SARS-CoV-2 tests carried out at the National Public Health Laboratory Components The project had three complementary components: 10. Component 1: Strengthening Laboratory Diagnosis Capacity (US$1.33 million). The objective of Component was to strengthen capacity for diagnosis and testing of SARS-CoV-2 at the National Public Health Laboratory with the aim of reaching capacity to conduct 500 tests per day by the end of the project. This was to be achieved through: (a) training of laboratory staff; and (b) procurement and distribution of required equipment, reagents, and supplies for testing COVID-19 specimens. 11. Expected outputs of Component 1: (i) At least 60 laboratory staff trained on COVID-19 diagnostics; (ii) provision and distribution of required equipment; (ii) At least 10,000 SARS-CoV-2 tests carried out at the NPHL. 12. Component 2: Improving Case Management (US$2.37 million). Under this component, the project aimed to improve capacity for the case management of COVID-19 through: (i) procurement and installation of oxygen generating plants and manifolds in 7 regional referral hospitals (RRHs) as well as supply of oxygen cylinders to 126 neighboring health facilities; (ii) procurement of essential medicines and supplies; and (iii) training of biomedical technicians on production and management of oxygen plants and nurses on proper provision of oxygen gas. 13. Expected outputs of Component 2: (i) 7 targeted hospitals with functional oxygen generation plants; (ii) 20 biomedical staff in the targeted RRHs trained in medical oxygen generation; (iii) 5,040 oxygen cylinders refilled in the targeted regional referral hospitals; and (iv) 40 healthcare workers trained on the provision of oxygen therapy. 14. Component 3: Implementation Management and Monitoring and Evaluation (M&E) (US$0.09 million). This component supported the strengthening of the existing structures for coordination and management of the project, including arrangements for financial management (FM) and procurement. Specifically, it supported: (i) project coordination/operational costs; (ii) environmental and social activities, including stakeholder engagement and waste management; and (iii) monitoring of implementation progress to track achievements against targets and address implementation challenges as well as organizing evaluation workshops. Page 7 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) 15. Expected outputs of Component 3 included: (i) availability of space in the 7 RRHs for installation of oxygen plant; (ii) supportive supervision during and after installation of oxygen plants; (iii) conduct an Environmental and Social Management Framework (ESMF); and (iv) Evaluation workshops. Significant changes during implementation 16. The project was restructured on January 28, 2021 to extend the Closing Date. The initial Closing Date of the project was January 31, 2021, but due to delays in the delivery of one of the procurement items caused by the global supply chain and logistics challenges resulted from COVID-19 pandemic, the Bank approved a one- month extension of the Closing Date to February 28, 2021. This allowed the project to complete one of the main activities under the project, the installation of the seven oxygen plants. II. OUTCOME Assessment of Achievement of Each Objective/Outcome RELEVANCE The relevance of the project is rated as High. 17. The project objectives were and remain highly relevant and are aligned with country and sector policies and priorities, as well as the World Bank’s COVID-19 strategic preparedness and response program (SPRP). The project and PDOs were and are still: (i) consistent with the World Bank’s CPF, particularly focus area 2: “Boost human capital and social inclusion – A life cycle approach to human development challenges�, aimed at improving the quality of health care services; (ii) fully aligned with the GoT’s most recent National Health Policy (2007) and the draft National Health Policy 2020 and Policy Implementation Strategy 2020-2030, which focus on addressing health security threats and preventing and controlling epidemics through resilient and sustainable systems; (iii) contributing to the implementation of the National Response Plan for COVID-19 (July 2021-June 2022) which prioritizes ten pillars including Laboratory and Diagnostics, Case Management, and Infection Prevention and Control. Furthermore, the project (i) is aligned with the WB’s COVID-19 SPRP, particularly the focus on detection and response to the threat posed by COVID-19 and (ii) contributed to the implementation of the IHR (2005) and the Global Health Security Agenda and complemented the development partners’ investments in health systems strengthening, disease control, and surveillance. 18. As the third wave of the COVID-19 infection spreads in several African countries, including Tanzania, the project PDOs remain relevant, and the project achievements will continue to be leveraged to limit the spread. The GoT has now officially started sharing COVID-19 data with WHO according to the IHR, and the Minister of Health announced the latest number of cases since the third wave of infection began with several patients in need of oxygen. In addition, since the time of project preparation, Tanzania has had only one laboratory (the NPHL) with capacity to conduct COVID-19 testing. Enhancing capacity of the NPHL was critical to improve COVID-19 testing as the Government continues to work on decentralizing this process. Adherence to preventive measures, highly performant testing capacity, and increase in medical oxygen production, will continue to be critical for a swift response to the ongoing COVID-19 outbreak and help decrease community spread. Page 8 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) EFFICACY The overall achievement of the PDO is rated as Substantial. 19. As shown in the theory of change, the PDO is composed of two key outcome areas: (i) to strengthen capacity for laboratory diagnosis; and (ii) to strengthen management of COVID-19 cases. The project achieved both PDO- level indicators. Two intermediate results indicators (IRIs) achieved their target, and two were not achieved. The project has achieved commendable results in a short implementation period. The performance of each outcome area and the achievement of related outputs and indicator targets are described in detail below. 20. Outcome area 1: Strengthen capacity for laboratory diagnosis. [Rating: Substantial]. The PDO indicator measuring the achievement of this part of the PDO is the “Number of SARS-CoV-2 tests carried out at the National Public Health Laboratory�. At the project closure, 66,743 tests had been conducted at the NPHL (from September 2020 to February 2021), surpassing the set target of 10,000, and on average 1,200 tests were being performed per day, against the original objective of reaching capacity to conduct 500 tests per day by the end of the project. 21. The IRI that contributed to the achievement of the first part of the PDO is “Number of laboratory staff trained in laboratory diagnosis of SARS-CoV-2 target�. This indicator was not achieved due to budget constraints as trainings were more expensive than anticipated. The project budget was not sufficient and could only cover half the number of participants – 30 medical laboratory scientists were trained (50 percent of target). 22. To strengthen capacity for laboratory diagnosis, the project procured laboratory reagents and supplies for COVID-19 testing (467 purchased compared to 495 planned), as well as laboratory equipment (5 purchased compared to 6 planned), in addition to conducting trainings of medical laboratory scientists on molecular diagnosis of COVID-19. Although the project’s outputs for laboratory supplies/equipment procured and laboratory staff trained were lower than anticipated due to budget constraints (mix of price fluctuations and under-budgeting of activities which, in the end, made the available project budget insufficient), these activities and outputs were sufficient to fill in the gap for testing and strengthen capacity of the NPHL. 23. Outcome area 2: strengthen management of COVID-19 cases. [Rating: Substantial]. The PDO indicator measuring the achievement of this part of the PDO is the “Number of targeted hospitals with functional oxygen generation plants�. This indicator achieved its target (all 7 liquid oxygen generating plants for Amana, Manyara, Geita, Dodoma, Mbeya, Ruvuma and Mtwara have been installed). Currently, all installed oxygen plants are functional with different output levels depending on demand. 24. The IRIs that contributed to the achievement of this second part of the PDO are the following: Number of Biomedical staff in the targeted regional referral hospitals trained in medical oxygen generation (100% of the target achieved), Number of health care workers trained on the provision of oxygen therapy (100% of the target achieved), Number of oxygen cylinders refilled in the targeted regional referral hospitals (2,400 oxygen cylinders were refilled at project closing in six hospitals, about 48 percent of the end target of 5,040). This target was set at project preparation based on daily oxygen demand and oxygen plant capacity. The low outputs of this indicator are in part due to the delay in oxygen plant procurement as well as variability in oxygen demand overtime. Page 9 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) 25. To strengthen management of COVID-19 cases, the project procured and installed: (i) 7 liquid oxygen generating plants in targeted hospitals (Amana, Manyara, Geita, Dodoma, Mbeya, Ruvuma and Mtwara); and (ii) piping of manifold systems in the 7 regional referral hospitals. In addition, the project supported procurement and delivery of 516 oxygen cylinders as well as procurement of essential medicines for Tanzania Mainland and Zanzibar. Finally, the project conducted working sessions to prepare the oxygen plant management plan in addition to training healthcare workers in the generation and provision of oxygen therapy. Due to delays in the oxygen plants installations, the trainings were conducted in Hydom hospital in Manyara region which had a similar plant to those procured by this project. Table 1: Achievement of PDO Indicators and Intermediate Results Indicators No Indicator name Baseline Achievement Target % at project achievement closure against target Outcome area 1: strengthen capacity for laboratory diagnosis PDO Indicator for outcome area 1 1 SARS-CoV-2 tests carried out at the National Public 0 66,743 10,000 667 Health Laboratory (Number) IRIs for outcome area 1 2 Laboratory staff trained in laboratory diagnosis of SARS- 0 30 60 50 CoV-2 (Number) Outcome area 2: strengthen management of COVID-19 cases PDO Indicator for outcome area 2 3 Targeted hospitals with functional oxygen generation 0 7 7 100 plants (Number) IRIs for outcome area 2 4 Biomedical staff in the targeted regional referral 0 20 20 100 hospitals trained in medical oxygen generation (Number, Custom) 5 Oxygen cylinders refilled in the targeted regional 0 2,400 5,040 48 referral hospitals (Number, Custom) 6 Health care workers trained on the provision of oxygen 0 40 40 100 therapy (Number, Custom) 26. Considering the two PDO indicators fully achieving the end target and half of IRIs fully achieving the target, with the two underachieved IRIs making sufficient contributions to fill the gaps to achieve the PDO, the rating for efficacy is Substantial, especially in view that these accomplishments were made under an extremely tight implementation timeline. The achievements were directly attributable to the project’s interventions. Page 10 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) EFFICIENCY Economic efficiency 27. The project prioritized evidence-based and cost-effective interventions informed by global experience and the needs at the country level to help in the efficient detection and response to COVID-19 cases. According to global experience, well-equipped laboratories with trained staff could ensure rapid and accurate confirmation of cases, which would enable adequately protected clinical staff to triage and treat urgent cases timely as well as facilitate effective tracing and isolation of suspected cases. Strengthening capacity of the NPHL was an economically sound decision since this was and is still the only laboratory in Tanzania conducting COVID-19 tests. 28. The project contributed to the overall increase in oxygen production in the country and decreased oxygen cost. Adding seven oxygen plants at regional hospitals brought a constant supply of oxygen at the health facilities which would lead to reduced procurement and logistics costs of filling oxygen cylinders. These oxygen plants were equitably and efficiently allocated to the seven rural regions with the highest COVID-19 burden and oxygen demand while serving additional communities in the surrounding regions. For treating severe positive COVID-19 cases, oxygen therapy remains the most cost-effective intervention. Oxygen is on WHO’s list of essential medicines, and medical oxygen is a key treatment for severe pneumonia, malaria, sepsis, and meningitis. However, access remains inadequate and/or unaffordable in developing countries for vulnerable populations. The increased demand for medical oxygen to treat COVID-19 exacerbated preexisting gaps in medical-oxygen supplies. Investing in oxygen is also key in maintaining essential health services: medical oxygen is the treatment for viral and bacterial pneumonia that is currently the leading cause of death for children and claims over 800,000 lives each year worldwide.4 Modeling revealed that improving oxygen access could avert 148,000 deaths of children under 5 each year in the 15 countries that have the highest pneumonia burden.5 In 2019, Tanzania ranked as the 9th country with highest number of deaths due to pneumonia and diarrhea in children under 5 years.6 29. There is a strong economic rationale for investing in the project’s activities to mitigate large income losses due to COVID-19. Investing early in health security by focusing on preparedness is not only highly cost-effective, but an integral part of the broader universal health coverage agenda. The positive economic impact of the project included: (i) preventing loss of human capital (loss of life, time and income by vulnerable households, and direct expenditure on medical care and supporting services was mitigated by the project); and (ii) systemic benefits - measures supported by the project had sustainable economic benefits through building capacity to respond to recurrent outbreaks of COVID-19 or other infectious diseases that may emerge. Implementation/Operational efficiency 30. The project design was simple, straight forward and focused on key essential activities to maximize impact. The project team used project funds to focus on key interventions that would fill specific gaps in the country’s COVID- 19 response. During project preparation, the Government of Tanzania stopped sharing official data on the COVID- 4 World Bank Blog. Oxygen for all, during COVID-19 (coronavirus) and beyond. https://blogs.worldbank.org/health/oxygen-all-during-covid-19-coronavirus-and-beyond 5 Graham H, Bakare A, Fashanu C, Wiwa O, Duke T, Falade A. Oxygen therapy for children: A key tool in reducing deaths from pneumonia. Pediatric Pulmonology. 2020; 55:61–64. https://doi.org/10.1002/ppul.24656 6 2019 Pneumonia & Diarrhea Progress Report Card. IVAC at Johns Hopkins Bloomberg School of Public Health. Page 11 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) 19 situation, which restricted evidence-based decision making. The project team relied on earlier studies and assessments, the recently developed COVID-19 response plan, the leadership of the MoHCDGEC, and collaboration with partners. In addition, once key interventions were selected, budgeting was challenging due to fluctuating medical commodities prices in the COVID-19 context, which had negative effects on anticipated project outputs. 31. Though the project was implemented in a difficult political and logistical environment the resources of the project were fully utilized in a short implementation period (5 months from effectiveness to closure). Political leaders influenced the course and supported nonscientific based intervention. This project focused on a few specific activities which were accepted and received technical support. In addition, the project team is to be commended for the results achieved while operating in a challenging environment which resulted in delayed disbursements and procurement procedures. However, excellent coordination among the team members and with the partners contributed to the efficient implementation of the project. At project closure, 100% of the resources were disbursed. 32. Although project activities were carried out within the project ’s initial timeframe except for the procurement and installation of the 7 oxygen plants which were delayed due to shortages in the global supply, procurement challenges and under-budgeting of key activities resulted in lower outputs than initially planned . A total of 467 laboratory reagents were procured compared to 495 planned, 5 laboratory equipment were procured compared to 6 planned, only 50% of laboratory staff were trained on COVID-19 diagnosis, and only 48% of oxygen cylinders were refilled in the targeted hospitals. 33. The project restructuring did not lead to any changes to the initial allocation of budget for the different components. Details of project costs and disbursement by component can be found in Table 2 below. Table 2: Original Allocation and Actual Amount Disbursed (US$ million) Original Allocation at Actual Disbursed Allocation Restructuring Component 1: Strengthening US$1.33 US$1.33 US$1.33 Laboratory Diagnosis Capacity Component 2: Improving US$2.37 US$2.37 US$2.37 Management of COVID-19 Cases Component 3: Implementation US$0.09 US$0.09 US$0.09 Management and Monitoring and Evaluation (M&E) 34. Considering the simple project design coupled with short implementation period (operational efficiency) and the prioritization of evidence-based and cost-effective interventions (economic efficiency) amid the challenging environment in which the project was implemented, efficiency of the project is rated Substantial. Overall Outcome Rating 35. The overall outcome rating for the project is Satisfactory based on the High rating for relevance, Substantial rating for efficacy, and Substantial rating for efficiency. Page 12 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) Other Outcomes and Impacts 36. The project, through procurement of oxygen plants has contributed to boosting oxygen production capacity in the country. Furthermore, by bringing oxygen plants to additional healthcare facilities, more oxygen cylinders are being filled on-site, thereby reducing oxygen costs. Medical oxygen is an essential commodity and will be used for management of other medical conditions such as severe children pneumonia as well. Similarly, other project interventions such as (i) training of health sector workers and (ii) provision of essential basic medical equipment will also contribute to overall health system strengthening, maintenance of essential health services, and bring positive economic returns even in the absence of a major pandemic. III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME Key factors during preparation 37. The project design, monitoring plan and results framework were clear, and the selection of interventions was aligned with GoT COVID-19 response Plan and complementary to the support provided by other partners. Each component had clear objectives aligned to the overall project development objective. The results framework was well designed including baselines and realistic targets. A designated experienced project management team (PMT) was responsible for collecting, compiling, and reporting on the data to inform achievements of results with the support from an M&E focal person. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) already had experience in implementing World Bank-financed projects and had a track record of having the capacity to adapt, learn and improve during project implementation. 38. All risks and mitigation measures were assessed. During project preparation, the project team recognized several risks associated with sector strategy and policy, namely: (i) the challenges related to the implementation of the project activities under a limited implementation period; (ii) potential capacity constraints of the PMT due to competing demands; and (iii) lack of recent data on the COVID-19 situation in Tanzania making it difficult to ensure that interventions are adapted to epidemiological trends. It was suggested that these risks would be mitigated through continued dialogue with the GoT and support provided for data collection on COVID-19 testing and cases at the NPHL. Fiduciary risks were substantial due to potential procurement failure because of insufficient global supply for essential medical consumables and equipment. Environmental risks were also considered since activities under the project were anticipated to generate additional biohazard/healthcare wastes. Social risks included the exposure of health and construction workers to COVID-19 in case of poor management of personal protective equipment in addition to community health and risks associated with construction and operation of health facilities. Stakeholder risks were low during project preparation since collaboration and coordination platforms were put in place across the two implementing Ministries (MoHCDGEC and Local Government) and all development partners were well coordinated: (i) The National Technical Committee was chaired by the Permanent Secretary and responsible for providing oversight to COVID-19 response while ensuring maintenance of essential health services and coordination of the response and resources; and (ii) development partners, under the leadership of WHO established a coordination framework. The World Bank was expected to work closely with the GoT to mitigate the identified risks. Page 13 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) Key factors during implementation Factors subject to Government control and/or implementing entity 39. The Government maintained a leadership role throughout project implementation, ensuring smooth administrative procedures within their control in the COVID-19 context and country-specific challenging environment in which the project was implemented. The implementation arrangements were built on existing systems and structures to further enhance national capacity to respond to COVID-19 and other public health emergencies at national and subnational levels. 40. There was a short lag in the submission of required reports such as the updated Stakeholder Engagement Plan (SEP), the ESMF, and the Initial Environmental Audit reports. However, considering the fast pace of project preparation and short project implementation period, the commitment, close follow-up of the GoT, and collaboration with the World Bank team were commendable and ensured reporting compliance in a timely manner. Factors subject to World Bank control 41. Adequacy of supervision: The World Bank team had to use innovative approaches to project monitoring given travel restrictions and inability to hold face-to-face meetings with Government and other partners. Despite these challenges, the World Bank team provided adequate close monitoring of the project implementation progress with the task team leader based in the country and available for constant virtual consultations, to support the Government in maintaining commitment and leadership. The task team included all relevant technical experts to ensure adequate support and guidance. 42. Adequacy or reporting: Due to the short project implementation period, the World Bank team was only able to conduct one supervision mission and file one implementation status and results report (ISR). The Aide-Memoire of the mission provided quality reporting on the activities progress while being transparent on the issues encountered and proposed mitigation measures/solutions. Factors outside the control of Government and/or implementing entities 43. The World Bank team and the Government faced multiple challenges during project preparation and implementation monitoring due to the global COVID-19 context. Given World Bank-mandated home-based work and other restrictions, the team had to be innovative in providing virtual implementation support which included live video calls with implementing entities to discuss progress in lieu of field missions. In addition, delays were observed with procurement and delivery of medical supplies due to disruptions in the global supply chain, increased demand for COVID-19-related equipment, medicines, reagents and supplies, and budget constraints (a mix of fluctuating prices due to the COVID-19 context and under-budgeting). The GoT acted swiftly in requesting and obtaining a one-month extension to the project’s Closing Date to allow time for the oxygen generation plants to be delivered and installed. Page 14 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME A. Bank Performance Rating: Satisfactory 44. Bank Performance at project preparation is rated as Satisfactory. The Bank responded quickly to the GoT’s request for emergency assistance. The project was well aligned with the GoT’s response to COVID-19 pandemic. The task team worked closely with the technical groups at the MoHCDGEC and other technical agencies and development partners to ensure that the project was aligned with key priorities identified by the rapid need assessment conducted by the MoHCDGEC. The assessment revealed severe shortage and unreliable supply of oxygen in the regional hospitals and highlighted the need to strengthen local capacity in the provision of oxygen therapy. The team maintained a good balance between meeting some of these needs while complementing existing interventions. 45. The team’s approach to risk assessment was thorough and candid. Risks were identified and mitigation measures agreed in consultation with the Government during appraisal, which were built into the design of the project. The procurement related risks were well articulated. 46. The Bank supervision is rated as Satisfactory. The Bank team comprised of technically strong in-country specialists in relevant areas, including experienced health specialists, environmental and social specialists, and procurement and FM specialists. All team members had deep understanding of Bank policies, which facilitated timely support and guidance to the GoT. A virtual supervision mission was conducted on January 21, 2021. The team monitored the progress, identified challenges in Project implementation including underlying causes, discussed solutions and action points with a feasible timeline, all of which were documented in a detailed Aide-Memoire. B. Quality of Monitoring and Evaluation (M&E) Rating: Substantial 47. M&E design is rated as Substantial. The results framework was clearly defined with key PDOs, PDO indicators, IRI indicators, baseline figures and targets, and sources of data. The Project Results Framework was measurable and fit for purpose with PDOs indicators aligned to the two outcome areas and IRI indicators aligned with project activities, which combined, reflect an incremental improvement in diagnosis, case management, and outbreak response. However, two indicators (number of COVID-19 tests conducted at the NPHL and number of oxygen cylinders refilled) could have benefited from more refined definitions in anticipation of the variability/unclarity of the data. 48. M&E Implementation is rated as Substantial. Data was collected from various data sources including training reports, hospital records and laboratory records through the PIU, to monitor both the PDO and intermediate results indicators. The regular reporting on these indicators helped to improve the efficiency and guide project implementation to ensure the PDO is achieved. Given the short period of project implementation, the task team has produced one ISR only, and achievements of PDO indicators and IRIs were reported only for the ISR. Additional close follow-up on project activities progress was done through regular meetings between the project team and Government counterparts. During the last two months of project implementation the teams had weekly meetings Page 15 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) to discuss urgent actions regarding the delayed procurement of the oxygen plants. 49. M&E utilization is rated as Substantial. Findings from M&E were used to improve project implementation. Challenges and issues identified during the virtual supervision mission were documented in the aide memoire by the Bank team and shared with key stakeholders and implementers. Recommendations and actions plans were made, reinforced and monitored to improve project implementation. Close project monitoring allowed for a timely request for restructuring to ensure all activities were completed at project closure. However, closer monitoring of results framework indicators progress could have prevented non-achievement of two IRIs. During project restructuring, the project team missed an opportunity to review indicators targets. Compliance 50. Environmental: the environmental performance was considered satisfactory as adequate measures were implemented as proposed in the Environment and Social Management Plans (ESMP). The environmental risks associated with the project included (i) the occupational health and safety issues related to testing and handling COVID-19 samples; and (ii) medical waste management and community health and safety issues related to the handling, transportation and disposal of healthcare waste. ESMF was developed by the recipient and submitted to the Bank with some delays. The ESMF was later disclosed by MoHCDGEC. As agreed with the Bank, MoHCDGEC conducted an environmental audit for the seven project sites where the oxygen plant was planned to be installed and reports were submitted to the National Environmental Management Council (NEMC) for review and certification. However, some of construction activities had commenced without the required documentations in place contrary to the requirements stipulated in the Environmental and Social Commitment Plan (ESCP); later it was ensured that the activities were conducted in line with the ESMF and the ESMP. 51. Social: the social safeguards performance was considered satisfactory. An initial SEP was developed and disclosed prior to project’s appraisal. Participants were oriented on the purpose of the project and the related benefits. The Government-imposed restrictions on gatherings of people during project implementation has limited the project’s ability to update and submit the SEP to the Bank on-time. The updated SEP was re-disclosed by the MoHCDGEC. 52. Financial Management: During appraisal, the FM risk rating for the grant was rated as Substantial. The key FM initial risk anticipated at project preparation was the lack of separate audit trail for the project financed expenditure and procurement contracts since the short implementation period could result in certain processes being streamlined and impact application of some internal controls. During implementation, the task team conducted routine supervision on FM aspects. The project team worked closely with the PMU to ensure the completion of all contractual activities by the closing date particularly due to the short disbursement deadline date of one month after the project closure date to settle all payments of eligible expenditures. Based on the March 31, 2021 Interim Financial Report (IFR), the project had fully disbursed funds for implementation. The project will submit audit report on the due date. 53. Procurement: During appraisal, the initial procurement risk was rated as Substantial. The key procurement risk anticipated at project preparation was failed procurement due to lack of sufficient global supply of essential medical consumables and equipment needed to address the health emergency and significant disruption in the supply chain. Despite adopting the mitigation measures identified during project preparation, which included working closely with the Government, the project had to be restructured to extend the Closing Date to allow adequate time to complete the delayed procurement of the oxygen generation plants, which accounted for 50 Page 16 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) percent of the grant value. During the project’s implementation support mission conducted in January 2021, procurement performance was downgraded from Moderately Satisfactory (MS) to Moderately Unsatisfactory (MU), reflecting the procurement delays. The remaining seven procurement contracts were all delivered on-time, though quantities of laboratory equipment and reagents procured were lower than planned due to budget constraints and price fluctuations. 54. Bank’s procurement procedures were properly followed. The PMT has experience in management of procurement using the World Bank procedures through the recently closed EAPHLNP which involved all categories of procurement (goods, works, non-consulting and consulting services) using various methods through the Systematic Tracking of Exchanges in Procurement (STEP). 55. Overall, the risks to development outcomes are estimated to be low. The project has significantly improved the capacity for laboratory diagnosis and COVID-19 case management, particularly for oxygen therapy, through training of laboratory staff and health workers and procurement of oxygen plants and supplies, which will continue to support the delivery of essential health services in the post-COVID-19 future. V. LESSONS LEARNED AND RECOMMENDATIONS Lessons learned through the project are the following: 56. During an outbreak such as the COVID-19 pandemic, a project with small emergency funding with a short implementation period should be simple and focus on key evidence-based interventions. At project preparation, the project team was able to use country level assessments and identified needs combined with global experience that was already available to inform project objectives and activities and maximize implementation success in a short timeline. 57. Close monitoring and engagement are key, especially for a project with a short implementation period. Close monitoring under Government leadership and support of the project team allowed for a timely request of restructuring to ensure the finalization of the procurement and installation of the 7 oxygen plants. This is an example of when an event outside the control of the World Bank and the Government can be mitigated to ensure achievement of results. 58. Strong commitment and transparency of the implementing entity and coordination with development partners are crucial for delivering an emergency operation. The commitment of the MoHCDGEC and open communication with the project team as well as close and frequent coordination of partners amid physical restrictions were conducive to project success. Below are the Recommendations from this ICR: 59. Project restructuring could have been used as an opportunity to review the results framework data and revise targets as needed. Even though the restructuring of the project was mainly due to the delay in procurement and installation of the oxygen plants, it could have also provided an opportunity for re-assessing indicators targets, in particular for the two IRIs that were lagging behind due to budget and logistical challenges. However, it is important to recognize that the project team was under pressure to process restructuring in a short period of time and within the restrictions in timeline of the PEF funding. Page 17 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) 60. It is important to lower expectations for outcomes for emergency operations of a short duration. The emergency COVID-19 context in which the project was being implemented in addition to the short implementation timeline contributed to the reduced outputs of some project activities. The procurement of the seven oxygen plants would not have been completed without the one-month extension of the project Closing Date and intense day-to-day monitoring by the project team and the Government. Only a few outcomes and outputs that are simple and manageable would facilitate adequate monitoring and learning during implementation. This also impacted on ability of the client to procure consultants in time to prepare and implement the necessary safeguard documents for the activities financed under the project. Thus, implementation duration should take cognizance of procurement, processing and implementation timelines of safeguard documents. . Page 18 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS A. RESULTS INDICATORS A.1 PDO Indicators Objective/Outcome: Strengthening Laboratory Diagnosis Capacity Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion SARS-CoV-2 tests carried out at Number 0.00 0.00 10000.00 66743.00 the National Public Health Laboratory 29-Jul-2020 28-Aug-2020 31-Jan-2021 28-Feb-2021 Comments (achievements against targets): Objective/Outcome: Improving Case Management Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Targeted hospitals with Number 0.00 0.00 7.00 7.00 functional oxygen generation plants 29-Jul-2020 28-Aug-2020 31-Jan-2021 28-Feb-2021 Page 19 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) Comments (achievements against targets): A.2 Intermediate Results Indicators Component: Strengthening Laboratory Diagnosis Capacity Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Laboratory staff trained in Number 0.00 0.00 60.00 30.00 laboratory diagnosis of SARS- CoV-2 29-Jul-2020 28-Aug-2020 31-Jan-2021 28-Feb-2021 Comments (achievements against targets): Component: Improving Case Management Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Biomedical staff in the targeted Number 0.00 0.00 20.00 20.00 regional referral hospitals trained in medical oxygen 29-Jul-2020 28-Aug-2020 31-Jan-2021 28-Feb-2021 generation Comments (achievements against targets): Page 20 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Oxygen cylinders refilled in the Number 0.00 0.00 5040.00 2400.00 targeted regional referral hospitals 29-Jul-2020 28-Aug-2020 31-Jan-2021 28-Feb-2021 Comments (achievements against targets): Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Health care workers trained on Number 0.00 0.00 40.00 40.00 the provision of oxygen therapy 29-Jul-2020 28-Aug-2020 31-Jan-2021 28-Feb-2021 Comments (achievements against targets): Page 21 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) B. ORGANIZATION OF THE ASSESSMENT OF THE PDO Objective/Outcome 1: Strengthened testing capacity of the National Public Health Laboratory (NPHL) 1. Number of tests conducted at the National Public Health Laboratory (NPHL) Outcome Indicators Intermediate Results Indicators 1. Number of laboratory staff trained in laboratory diagnosis of SARS-CoV-19 Key Outputs by Component 1. Increased number of laboratory staff trained in laboratory diagnosis of SARS-CoV-2 (linked to the achievement of the Objective/Outcome 1) 2. Increased availability of laboratory supplies, reagents, and equipment Objective/Outcome 2: Strengthened COVID-19 case management capacity Outcome Indicators 1. Number of targeted hospitals with functional oxygen generation plants 1. Number of biomedical staff in the targeted regional referral hospitals trained in medical oxygen generation Intermediate Results Indicators 2. Number of oxygen cylinders refilled in the targeted regional referral hospitals 3. Number of health care workers trained on the provision of oxygen therapy 1. Increased number of biomedical staff in the targeted regional referral hospitals trained in medical oxygen generation Key Outputs by Component (linked to the achievement of the 2. Increased number of oxygen cylinders refilled in the targeted regional referral hospitals Objective/Outcome 2) 3. Increased number of health care workers trained on the provision of oxygen therapy Page 22 of 23 The World Bank COVID-19 Pandemic Emergency Financing Facility Project (P174366) . ANNEX 2. PROJECT COST BY COMPONENT Amount at Approval Actual at Project Percentage of Approval Components (US$M) Closing (US$M) (%) Strengthening Laboratory 1.33 1.33 100 Diagnosis Capacity Improving Management of 2.37 2.37 100 COVID-19 Cases Implementation Management and Monitoring 0.09 0.09 100 and Evaluation (M&E) Total 3.79 3.79 100.00 Page 23 of 23