Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Report Number: ICRR0024161 1. Project Data Project ID Project Name P159040 REDISSE 2 Country Practice Area(Lead) Western and Central Africa Health, Nutrition & Population L/C/TF Number(s) Closing Date (Original) Total Project Cost (USD) IDA-59670,IDA-59680,IDA-59690,IDA- 31-Aug-2023 107,009,058.95 59700,IDA-D1700 Bank Approval Date Closing Date (Actual) 01-Mar-2017 31-Aug-2023 IBRD/IDA (USD) Grants (USD) Original Commitment 147,000,000.00 0.00 Revised Commitment 106,870,963.69 0.00 Actual 107,014,016.64 0.00 Prepared by Reviewed by ICR Review Coordinator Group Salim J. Habayeb Jenny R. Gold Susan Ann Caceres IEGHC (Unit 2) 2. Project Objectives and Components DEVOBJ_TBL a. Objectives The objectives of the project (Phase II of the Regional Disease Surveillance Systems Enhancement Program, termed as REDISSE II project) were: (a) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa, thereby addressing systemic weaknesses within the animal and human health sectors that hinder disease surveillance and response; and Page 1 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) (b) in the event of an Eligible Emergency, to provide immediate and effective response to said Eligible Emergency (Financing Agreement, April 5, 2017, p. 6). Financing Agreements were entered between the International Development Association (IDA) and the four countries (Guinea Bissau, Liberia, Nigeria, and Togo) participating in this second phase of the regional operation. The overall REDISSE program was planned to follow a phased approach (Series of Projects) that allowed countries to join each phase at their own discretion and readiness, while the West Africa Health Organization (WAHO), an affiliate organization of the Economic Community of West African States (ECOWAS), would support all participating countries as the regional project coordinator and main provider of technical assistance. During implementation, some country-specific outcome-level targets were either increased, maintained, or reduced. Initial values for baseline and target scores were estimated during project preparation, and, as envisaged, the project updated estimated values once the countries completed their first round of assessments (ICR, p. 33). Hence, the revisions were unrelated to changes in overall project ambition. Notwithstanding the above, original and revised targets were achieved or substantially achieved. Therefore, this ICR does not apply a split evaluation which would be inconsequential to deriving the overall efficacy rating and project outcome rating. b. Were the project objectives/key associated outcome targets revised during implementation? Yes Did the Board approve the revised objectives/key associated outcome targets? No c. Will a split evaluation be undertaken? No d. Components The project adopted the overall design of the REDISSE Program in defining its components. I. Surveillance and Information Systems (Original Cost: US$45.3 million; Actual cost: US$34.1 million). Component I aimed to enhance national surveillance and reporting systems at different levels of the health system. It supported national and regional efforts in the surveillance of priority diseases and timely reporting of human and animal public health emergencies in line with the International Health Regulations (IHR 2005) and the OIE Terrestrial Animal Health Code. It sought to strengthen the linkages of surveillance and response systems at local level. It had three subcomponents: (1.1) Support coordinated community-level surveillance systems and processes across the animal and human health sectors; (1.2) Develop capacity for interoperable surveillance and reporting systems; and (1.3) Establish an early-warning system for infectious disease trends protection. II. Strengthening of Laboratory capacity (Original Cost: US$30.9 million; Actual Cost: US$22 million). This component involved the identification and/or establishment of networks of efficient, high quality, accessible public health and veterinarian laboratories for the diagnosis of infectious human and animal diseases and the establishment of a regional networking platform to improve collaboration for laboratory investigation. It had three subcomponents: (2.1) Review, upgrade and network laboratory facilities; (2.2) Page 2 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Improve data management and specimen management systems; and (2.3) Enhance regional reference laboratory networking functions. III. Preparedness and Emergency Response (Original Cost: US$20.4 million; Actual Cost: US$20.9 million). Component III was meant to support national and regional efforts to enhance infectious disease outbreak preparedness and response capacity, improving local, national and regional capacities. It aimed at improving country and regional surge capacity to ensure a rapid response during an emergency. It sought to provide educating and change behavior and prepare communities for outbreaks and emergencies. It had the following sub-components: (3.1) Enhance cross-sectoral coordination and collaboration for preparedness and response; (3.2) Strengthen capacity for emergency response, and (3.3) Contingency Emergency Response Component (CERC). IV. Human resource management for Effective Disease Surveillance and Epidemic Preparedness (Original Cost: US$22.6 million; Actual Cost: US$13.5 million). This component was cross-cutting and aimed to strengthen government capacity to plan, implement and monitor human resource interventions. It supported the development of institutional capacity for planning and managing workforce training, leveraging existing training structures and programs across countries in the region. It had two subcomponents: (4.1) Healthcare workforce mapping, planning and recruitment; and (4.2) Enhance health workforce training, motivation and retention. V. Institutional Capacity Building, Project Management, Coordination and Advocacy (Original Cost: US$22.1 million; Actual Cost: US$16.3 million). This component focused on all aspects related to project management. It provided cross-cutting institutional support to meet the additional capacity building and training needs, on top of the support provided in the other four technical components. It supported the independent external assessments of critical animal and human health capacities of national systems using reference tools [Joint External Evaluation (JEE) and World Organization for Animal Health (OIE) Performance of Veterinary Services (PVS)] to identify weaknesses and monitor progress. It had two sub- components: (5.1) Project coordination, fiduciary management, monitoring and evaluation, data generation and knowledge management; and (5.2) Institutional support, capacity building, advocacy, and communication at the regional level. e. Comments on Project Cost, Financing, Borrower Contribution, and Dates At appraisal, the original cost was estimated at US$147 million, to be funded by a combination of IDA Credits and Grants allocated from country and regional IDA resources (regional integration matching fund mechanism), including resources from the multi-donor trust fund (MDTF) associated with the REDISSE Program. The breakdown of allocations was as follows: Original financing allocations (in US$ million) Country Country IDA Regional IDA Total Guinea Bissau 7.0 14.0 21.0 Liberia 5.0 10.0 15.0 Nigeria 45.0 45.0 90.0 Page 3 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Togo 7.0 14.0 21.0 Total 64.0 83.0 147.0 The above allocations were complemented by an existing grant commitment of US$20 million made available in 2016 to WAHO through ECOWAS, in support of regional level activities and coordination among all countries participating in the REDISSE program. There were funding cancellations of US$40.1 million in 2023 (see third restructuring below), and the actual cost was US$107 million. The project had three level-2 restructurings: The first restructuring was approved on February 13, 2020 to reflect two key events: completion of JEE rounds undertaken between 2017 and 2019; and activation of the CERC related to an outbreak of Lassa fever in Nigeria in 2018. The CERC's approved amount was US$2.5 million. Its activation was approved by the Africa Regional Vice-President on April 6, 2018. Funds were reallocated from the Credit No. IDA-59700- NG disbursement categories 1 and 2 to the CERC category 3 to address the most urgent needs, including: scaled up action for detection, diagnosis, infection control, and case management to reduce the chances of the disease spreading across borders. The restructuring also introduced revisions to the results framework with updated baseline data, an indicator to reflect CERC results, and an indicator to monitor the training of women. The second restructuring of June 1, 2023, reflected Liberia’s triggering of the CERC on March 20, 2020 in response to the COVID-19 pandemic and allocation of US$8 million from the project funds to finance the response. The restructuring was delayed by the havoc caused by the COVID-19 pandemic itself (Task Team clarifications, August 16, 2024). The Task Team also clarified that the three other participating countries did not trigger the CERC for COVID-19 because they were able to build upon and enhance existing activities to provide an additional focus on COVID-19. The restructuring entailed: (i) normalizing the reallocation of funds due to the activation of the CERC (under which a total of US$5.2 million was utilized); and (ii) revising the results framework to incorporate intermediate results indicators to monitor performance of activities related to COVID-19. The third restructuring of August 25, 2023, reflected cancellations and reallocations of funds in Guinea- Bissau, Nigeria, and Togo prior to project completion. Cancellations were spread over all components and aggregated at US$40.11 million (ICR, p. 15). By 2022, discussions about extension of the closing date were already ongoing in view of cumulative delays, including political instability in Guinea Bissau, delayed project effectiveness in Nigeria, and the impact of the COVID-19 pandemic. However, it was envisaged that a new Bank-supported Multi-Phased Programmatic Approach (MPA) operation, the Health Security Program in West and Central Africa, P179078, that was under preparation, would continue funding activities initiated by the project. Given the information available at the time, a decision was made to close the original project as scheduled on August 31, 2023, while continuing to support health security through the new operation. However, the MPA preparation was delayed. The ICR reported (p. 15) that there was insufficient time to utilize the remaining funds by the closing date, and 27% of the original project funding was cancelled. 3. Relevance of Objectives Page 4 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Rationale The project was prepared in the aftermath of the 2014-2016 West Africa Ebola outbreak, which illustrated the critical importance of strengthening national disease surveillance systems and inter-country collaboration in order to detect disease outbreaks earlier and to respond more swiftly and effectively to disease outbreaks. The ICR reported that at entry and at project completion, objectives were aligned with the Country Partnership Strategies and Frameworks for all four participating countries during the period FY 2017-2023, as they focused on strengthening health systems’ capacity, including disease surveillance, to improve health outcomes and to reduce vulnerability. The PDOs were also aligned with the Regional Integration and Cooperation Assistance Strategy for the period FY21–FY23, which explicitly underlined a focus on pandemic response and disease surveillance. The PDOs were also consistent with the objectives of country plans for disease surveillance, preparedness, and emergency response. In Nigeria, PDOs aligned with the country’s multi-sectoral National Action Plan for Health Security 2018-2022. In Liberia, PDOs were aligned with key objectives of the country’s Pro-poor Agenda for Prosperity and Development, the Liberia Incident Action Plan for COVID-19 response, and the National Action Plan for Health Security 2018-2022. In Togo, objectives aligned with the Accelerated Growth Strategy and Employment Promotion, the National Health Development Plan, and the National Program for Agricultural Investment and Food Security. In Guinea- Bissau, objectives were consistent with the Second National Plan for Health Development. Objectives were aligned with and built on international guidelines and agendas, namely, the International Health Regulations coordinated by the World Health Organization (WHO), the One Health Agenda that integrates human and animal health aspects, the Global Health Security Agenda, Universal Health Coverage, the OIE Terrestrial Animal Health Code and Manual, and the Sustainable Development Goals. At the regional level, PDOs were aligned with the goals set by ECOWAS Member States to design a regional and national One Health Coordination Mechanism. Importantly, health security is bolstered by collective approaches for building preparedness and response capacities along with mutualization of resources rather than unilateral actions. Strengthening national, regional, and global systems for infectious disease outbreaks preparedness, alert, and response are global public goods that extend beyond the reinforcement of the first line of defense at the country level, but to the region and ultimately to the global level, as infectious disease outbreaks can transcend national borders. Rating Relevance TBL Rating High 4. Achievement of Objectives (Efficacy) EFFICACY_TBL OBJECTIVE 1 Objective Page 5 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa, thereby addressing systemic weaknesses within the animal and human health sectors that hinder disease surveillance and response Rationale Surveillance and epidemic preparedness are closely interlinked, notably in aspects related to laboratory capacities, information systems, human resources, and ultimate goals. They are also assessed in tandem by the WHO Joint External Evaluation tool and methodology (see below). Therefore, surveillance and preparedness are addressed under one objective. Concurrently, there are also close linkages with Objective 2, as Objective 1 promotes the overall capacities and readiness to respond to health emergencies. The theory of change (ICR, p. 9) envisaged the following: that surveillance and information systems strengthening activities to:  harmonize protocols and guidelines;  establish linkages between surveillance information systems (human and animal; sub-national, national and regional);  develop/enhance early warning systems for surveillance, inc. analysis and predictions;  implement collaborative activities in cross-border surveillance;  train human and animal health community/field level staff for detection and reporting;  conduct Field Epidemiology Training for staff at different levels and across sectors (human and animal health); and  strengthen infrastructure and equipment of health facilities; would be reasonably expected to result in the following outputs and intermediate results:  improved collaboration and exchange of information across countries;  strengthened community/local-level surveillance and response processes;  establishment of event-based surveillance systems;  better integration/ interconnection of surveillance and information/reporting systems across animal and human health sectors;  improved surveillance processes across the human and animal health sectors (progress towards operationalizing the One Health approach);  improved systems for effective reporting to relevant organizations; and  improved capacity to analyze/predict epidemic trends; that laboratory capacity strengthening activities to:  improve laboratory infrastructure, equipment and supplies, and networks;  increase laboratory services;  strengthen laboratory information systems;  strengthen integration of laboratory information systems and reporting; and  improve sub-national, national and regional laboratory specimen referral and transportation; and strengthen quality assurance systems and accreditation processes; Page 6 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) would be reasonably expected to result in the following outputs and intermediate results:  laboratory facilities upgraded and connected as a network;  increased laboratory testing capacity for detection of priority diseases;  improved specimen management systems; and  enhanced networking functions of regional reference laboratories; that preparedness and emergency response activities to:  develop/update National Emergency Preparedness and Response Plans;  strengthen Emergency Operating Centers infrastructure;  strengthen risk communication mechanisms;  conduct simulation exercises; and  deploy resources for outbreak response; would be reasonably expected to result in the following outputs and intermediate results:  multi-hazard emergency preparedness and response plans implemented;  mechanisms for responding to known infectious zoonoses and potential zoonoses established and operational; and  surge capacity of Emergency Operating Centers and stockpiling mechanisms established at national and regional levels; that human resources management for surveillance and preparedness to:  carry out human resources mapping and gap analysis;  train personnel in surveillance, preparedness, response, and One Health at central and decentralized levels; and  recruit surveillance and laboratory staff; would be reasonably expected to result in the following:  increased availability and human resources capacity to implement IHR core capacities; and  increased capacity and competency of public health and veterinary health workforce; and that institutional capacity building, coordination, and advocacy activities would be reasonably expected to result in the following outputs:  One Health established and functional as an institutional collaboration mechanism;  improved cross-border collaboration and information exchange; and  strengthened regional public health institutions. The above outputs and intermediate results would plausibly contribute to the following outcomes that would be reflective of the project stated objectives: Page 7 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040)  Increased collaboration and integration for surveillance and preparedness across sectors, countries and the regional level.  Increased effectiveness in disease surveillance, early detection, and reporting.  Systemic weaknesses in human and animal health sectors (human resources, quality data, planning) are reduced.  Increased capacity for immediate and effective response to an eligible public health emergency at sub-national, national and regional levels. The ICR (p. 10) noted that the overall REDISSE program would benefit the population of ECOWAS countries and that REDISSE II was expected to benefit over 191 million people whose livelihoods might be affected by diseases outbreaks. Secondary beneficiaries would include public and private providers and national and regional institutions involved in human and animal health. The ICR also suggested that, in the long run, the above intended outcomes would contribute to two long-term impacts: improved health outcomes and reduced vulnerability; and mitigation/reduction of human and economic burden of disease outbreaks. Explanatory Note on WHO Joint External Evaluation Tool (JEE) used by the project: The international community coalesced around the notion that a more objective measure of country preparedness capacities had to be developed. Hence, in 2016, WHO, together with member states and partners, developed and launched a Joint External Evaluation Tool-International Health Regulations (JEE- IHR) as a standardized, independent, transparent, objective, and multisectoral assessment that enables countries to determine their ability to be prepared for and address infectious disease risks through a coordinated response (ICR, p. 129). The JEE examines capacities across 19 technical areas to establish an objective baseline assessment, enabling countries to have a greater understanding of their gaps and weaknesses in health security. Various countries and development partners embraced JEE as the globally accepted tool, methodology and process to monitor, measure and strengthen health security. Under the REDISSE series of projects, a decision was made to use several of JEE indicators to develop the results framework. REDISSE II project drew most of its Results Framework indicators from the WHO JEE tool (ICR, p. 17). The JEE evaluation process would help monitor country progress in implementing the International Health Regulations (PAD, p. 5). The JEE tool is organized around four components (Prevent, Detect, Respond, and address other related IHR hazards and Points of Entry), and each core capacity is assessed using 5-level scores which reflected advancements ranging from no capacity to sustainable capacity. Self-assessments were conducted as part of the project preparation. Countries were responsible for conducting annual self-assessments using the tools of JEE, complemented by OIE PVS for animal health. Subsequently, JEE would be carried out by external experts biennially to validate the findings and data quality of the national self-assessments. While the project was expected to contribute to improved JEE scores, the latter cannot be fully attributed to the project only, as there may be other progress made by countries in improving and strengthening their disease surveillance and epidemic preparedness capacities, regardless of the project. On the other hand, progress in particular areas may not be included in JEE scores, hence such progress may not be accounted for. For instance, REDISSE contributed to strengthening core IHR core capacities related to military doctors, Page 8 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) maritime health, and food safety personnel to support the regional and national integration of the One Health approach. Nevertheless, JEE measures important aspects of preparedness and are used as a proxy to measure the overall level of such preparedness. Main outputs and intermediate results Outputs related to surveillance and information Systems: Countries that achieve a JEE score of 4 or higher in terms of an interoperable, interconnected, electronic real- time reporting system: In all countries (Liberia, Nigeria, Guinea Bissau, and Togo), the JEE score increased from a baseline score of 2.0 in February 2020 to a score of 3.0 in December 2023, short of, but substantially achieving the target of 4-point score. Countries that achieve a JEE score of 3.0 or higher in terms of surveillance systems in place for priority zoonotic diseases/pathogens:  In Liberia, the score increased from a baseline score of 2.0 in February 2020 to 3.0 in December 2023, achieving the target of 3.0.  In Nigeria, the score remained at the baseline score of 3.0, short of the target of 4.0.  In Guinea Bissau, the score increased from a baseline score of 2.0 in February 2020 to 3.0 in December 2023, short of, but substantially achieving the target score of 4.0.  In Togo, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2023, achieving the target score of 3.0. Countries achieving a JEE score of 4 or 5 in terms of systems for efficient reporting to WHO, OIE/FAO:  In Liberia, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2023, short of the target score of 5.0.  In Nigeria, the score remained at the baseline of 3.0, short of the target of 4.0.  In Guinea Bissau, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December Liberia, short of the target of 4.0.  In Togo, the score increased from a baseline of 2.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0. Outputs related to strengthening laboratory capacities: Countries that achieve a national capacity score of 4 or higher in laboratory systems quality:  In Liberia, the score increased from a baseline of 1.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0  In Nigeria, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2023, short of the target of 4.0.  In Guinea Bissau, the score increased from a baseline of 1.0 in February 2020 to 2.0 in December 2023, short of the target of 4.0.  In Togo, the score increased from a baseline of 2.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0. Page 9 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Countries that achieve a JEE score of 4 or higher in specimen referral and transport system:  In Liberia, the score increased from a baseline of 3.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Nigeria, the score increased from a baseline of 1.0 in February 2020 to 2.0 in December 2023, short of, but substantially achieving the target of 3.0.  In Guinea Bissau, the score increased from a baseline of 1.0 in February 2020 to 2.0 in December 2023, short of the target of 4.0.  In Togo, the score increased from a baseline of 1.0 in February 2020 to 3.0 in December 2023, achieving the target 0f 3.0. Outputs related to preparedness and emergency response: National capacity scores in mechanisms for responding to infectious zoonoses and potential zoonoses are established and functional:  In Liberia, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2023, short of, but substantially achieving the target of 4.0  In Nigeria, the score increased from a baseline of 1.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Guinea Bissau, the score increased from a baseline of 1.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Togo, the score increased from a baseline of 2.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0. Outputs related to human resources management for effective disease surveillance and epidemic preparedness: Countries that achieve a JEE score of 3, 4, or higher in workforce strategy:  In Liberia, the score remained at the baseline score of 2.0, short of the target of 4.0.  In Nigeria, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2013, achieving the target of 3.0.  In Guinea Bissau, the score increased from a baseline of 1.0 in February 2020 to 2.0 in December 2023, short of the target of 4.0.  In Togo, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2023, short of, but substantially achieving the target of 4.0. Countries that achieve a JEE score of 3, 4, or higher in having applied epidemiology training program in place:  In Liberia, the score increased from a baseline of 3.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Nigeria, the score remained at the advanced level of the baseline score of 4.0.  In Guinea Bissau, the score increased from a baseline of 3.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0. Page 10 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040)  In Togo, the score increased from a baseline of 3.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0. The percentage of females among people trained in epidemiology for all categories was 29.7 percent, short of the target of 35 percent.  The percentage of females among people trained in basic applied epidemiology was 27.8, short of the target of 40 percent.  The percentage of females among people trained in intermediate applied epidemiology was 31 percent, moderately short of the target of 35 percent. And,  The percentage of females among people trained in advanced applied epidemiology was 27 percent, exceeding the target of 25 percent. The project set voluntary targets for training in field epidemiology as noted above. During the ICR interviews, country representatives explained some of the obstacles (beyond the project’s control) which prevented them from reaching the set targets for women’s training, including: (a) the COVID-19 pandemic; (b) the challenges that women in the region faced to move away from their cities and families to participate in training; and (c) shortage of candidates applying for the training. Countries that achieve a JEE score of 3, 4, or higher in veterinary health workforce:  In Liberia, the score increased from a baseline of 2.0 in February 2020 to 3.0 in December 2023, achieving the target of 3.0.  In Nigeria, the score remained at the baseline score of 3.0.  In Guinea Bissau, the score increased from a baseline of 2.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Togo, the score increased from a baseline of 2.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0. Outputs related to institutional capacity building, project management, coordination and advocacy:  All four countries had citizens and communities involved in planning/implementation/evaluation of development programs.  Additional information on country-specific activities and outputs was provided by the ICR (pp. 83-88). Outcomes By completion, results showed that REDISSE II had strengthened disease surveillance, preparedness, and response capacities in the four participating countries. Results showed that participating countries strengthened their laboratory capacity, surveillance capacity, preparedness and response capacity, and the capacity of their human resources to address IHR requirements. Countries also strengthened regional-level collaboration in terms of facilitating knowledge and information sharing, regional coordination in terms of aligned policies and technical strategies, and resource sharing in terms of training institutions and the use of reference laboratories. The results showed that countries either fully met their intended JEE scores or made substantial progress in meeting them. The ICR (p. 18) noted that the investments were expected to continue yielding further results after project completion. The main shortcoming was the mixed progress in advancing Page 11 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) the One Health agenda. Challenges and inefficiencies encountered in the operationalization of One Health are noted in section 5. Improved national capacity scores for laboratory testing capacity for detection of priority diseases:  In Liberia, the score increased from a baseline of 2.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Nigeria, the score remained at the baseline of 3.0, short of the target of 4.0  In Guinea Bissau, the score increased from a baseline of 1.0 to 3.0, short of, but substantially achieving the target of 4.0.  In Togo, the baseline of 4.0 was maintained as intended. Establishment of an active and functional One Health Platform (measured on 5-point Likert scale): The indicator was meant to be monitored at the regional level (Task team clarifications, August 16, 2024). From a baseline of 1-point in February 2020, a 3-point level was achieved in December 2023, short of the 4- point target. The project helped in establishing the foundational elements for the One Health Approach in participating countries, but its implementation was complex and challenging (see sections 5 and 8) and its full operationalization was partly achieved. Establishment of an indicator and event-based surveillance systems:  In Liberia, the score was maintained at 4.0 as intended.  In Nigeria, the score increased from a baseline of 3.0 in February 2020 to 4.0 in December 2023, achieving the target of 4.0.  In Guinea Bissau, the score increased from a baseline of 1.0 to 2.0, short of the target of 4.0.  In Togo, the score increased from a baseline of 3.0 to 4.0, achieving the target of 4.0. Availability of human resources to implement IHR core capacity requirements:  In Liberia, the score increased from a baseline of 1.0 in February 2020 to 3.0 in December 2023, short of, but substantially achieving the target of 4/0.  In Nigeria, the score increased from a baseline of 3.0 to 4.0, achieving the target of 4.0.  In Guinea Bissau, the score increased from a baseline of 1.0 to 4.0, achieving the target of 4.0.  In Togo, the score increased from a baseline of 2.0 to 4.0, achieving the target of 4.0. Cross-border collaboration and exchange of information across countries:  In Liberia, the score increased from a baseline 0f 1.0 in February 2020 to 3.0 in December 2023, achieving the target of 3.0.  In Nigeria, the score increased from a baseline of 1.0 to 4.0, achieving the target of 4.0.  In Guinea Bissau, the score of 3.0 remained at the baseline of 3.0, short of the target of 4.0. Page 12 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040)  In Togo, the score increased from a baseline of 1.0 to 3.0, short of, but substantially achieving the target of 4.0. Rating Substantial OBJECTIVE 2 Objective In the event of an eligible emergency, to provide immediate and effective response to said Emergency Rationale The theory of change is the same as that of Objective 1, as the pathway elements toward intended outcomes are intertwined, and complemented by the actual response. The ICR (p. 21 and 22) emphasized the importance of having overall preparedness and response plans in place to facilitate effective responses to health emergencies, and that existing engagement support prior to the advent of emergencies was key to the timeliness and effectiveness of the COVID-19 response. Outputs and intermediate results The same outputs discussed under Objective 1 above are applicable to Objective 2, and are complemented by the actual response outputs. In the context of rollout by governments of organizational arrangements focused on further strengthening disease surveillance and response to the COVID-19 epidemic, outputs included the provision of laboratory equipment and supplies, medicines and supplies, including personal protective equipment, ambulances, vehicles and motorcycles, and electric incinerators. Further granular Information about country-specific activities and outputs was provided by the ICR (pp. 85-88). Outcomes Development and implementation of a multi-hazard national public health emergency preparedness and response plan:  In Liberia, the score increased from a baseline of 1.0 in February 2020 to 3.0 in December 2023, achieving the target of 3.0.  In both Nigeria and Guinea Bissau, the score increased from a baseline of 1.0 to 3.0, short of, but substantially achieving the target of 4.0.  In Togo, the score increased from a baseline of 2.0 to 4.00, achieving the target of 4.0. Cross-border collaboration and exchange of information across countries: The targets were fully or substantially achieved, as shown under Objective 1, above. Page 13 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Actual response to eligible emergencies: During project implementation, the COVID-19 pandemic constituted the main health emergency. Other emergencies in participating countries included Lassa fever, rabies, and avian flu (see below). The ICR (p. 21) reported that REDISSE II was critical to all four countries at the onset of the COVID-19 pandemic in 2020, as it provided the required financing to prepare for and to respond to the crisis. The project also served as an operational and financial bridge until the approval of projects in each country under the COVID-19 Strategic Preparedness and Response Program (SPRP). By project completion, and building on capacities that were already being strengthened prior to the COVID-19 crisis, participating countries, supported by WAHO, were able to provide immediate and effective response to COVID-19 from March 2020 onwards, as confirmed by the ICR’s mission interviews that captured the role of REDISSE II in operationalizing a fast response given the availability of designated laboratories for COVID-19 diagnostic testing, resources, and arrangements that were already in place through the ongoing work to strengthen surveillance and preparedness capacities. The number of suspected cases of COVID-19 reported and investigated per approved protocols in Liberia reached 15,229 investigated cases, exceeding the target of 300 cases, although the adequacy of the target was questionable. The ICR (p. 23) reported that WAHO coordinated the COVID-19 response which included implementation of national action plans, training of front-line workers and clinical staff, provision of laboratory reagents, and personal protective equipment, all resulting in a timely response. The ICR (p. 22) also noted that the project findings were in line with IEG 2019 findings in “IDA’s Crisis Response Window: Lessons from Independent Evaluation Group” about the importance of activities that strengthen surveillance and preparedness systems, where newly acquired capacities and newly improved systems were used to respond to health emergencies. In addition to the COVID-19 pandemic, REDISSE II supported the response to other outbreaks. In Nigeria, REDISSE II supported the response to Lassa fever outbreak with effective management of 8,101 cases of Lassa fever versus a target of 1,914 cases. The ICR reported that, due to the effective response in 2018, the Lassa case fatality rate showed a decrease from 27 percent to 20.4 percent when compared to outbreaks in previous years. The project also supported the national response to rabies outbreak, and conducted mass anti-rabies vaccination campaign in hotspot areas. Rating Substantial OVERALL EFF TBL OBJ_TBL OVERALL EFFICACY Rationale Page 14 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Both objectives (to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness; and to provide immediate and effective response to an eligible emergency) were almost fully achieved, indicative of a substantial rating for overall efficacy. Overall Efficacy Rating Substantial 5. Efficiency The PAD’s economic analysis (pp. 185-202) presented compelling arguments for investing in integrated disease surveillance and response systems, as the prevention and control of disease outbreaks yields large economic benefits. Considering that the estimates of the required investments to build a well-functioning global disease surveillance system and response are relatively modest, the expected returns on investment of avoiding large losses are very high – as high as 123 percent annually (World Bank, 2012). This is far above expected returns on nearly all other public and private investments. The PAD’s economic analysis provided three primary rationales for a publicly-provided regional approach to disease surveillance and response network in West Africa. The first was the overwhelming economic burden that infectious diseases place on the region. The second rested on the status of a disease surveillance system as a global public good whose benefits accrue to all countries. The third rationale was based on the sharing of resources to enhance efficiency. Using results of economic benefits produced under Markov Chain Monte Carlo simulations that considered economic parameters in West Africa, the total annual benefit of controlling an outbreak in West Africa was, on average, equal to US$7.2 billion (PAD, p. 197). The net present value of project costs was estimated at US$313 million. By applying the estimated average annual impact constant for the five first years of the project, it was possible to calculate a benefit-cost ratio equal to US$108.7, i.e. for each US$1 invested through the project, there will be an expected return of US$109. The estimated benefit-cost ratio under various scenarios of the sensitivity analysis remained robust. The ICR’s economic analysis re-emphasized the arguments of significant potential returns on investments related to impact on health outcomes, the economy at large, health system, and global health security. It also explained how the West Africa Ebola outbreak illustrated why responding to outbreaks was far more expensive—in lives and money—than investing in preparedness. By the end of 2015, US$3.6 billion were spent on fighting the Ebola epidemic, and Liberia, Sierra Leone and Guinea collectively sustained an estimated loss of US$2.8 billion in GDP that year. On the other hand, Nigeria already had an epidemic response infrastructure in place when Ebola struck. The country had an established contact tracing method, an advanced virology laboratory, experienced epidemiologists, and strong clinical governance, which helped prevent substantial loss of human lives, limit the costs of responding to the outbreak and lessen the financial losses to the country’s economy. The economic cost of US$186 million incurred by Nigeria was much lower than other affected countries in the region. Since COVID-19 was a novel outbreak, and with no data on case fatality rates available prior to 2020, the economic analysis examined the outbreak of Lassa fever in Nigeria while using actual project costs (ICR, p. 113) and a discount rate of 3 percent. The benefit-cost ratio was 43.1, i.e., each US$1 invested Page 15 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) through the project yielded an expected discounted benefit equivalent to US$43 in terms of averted human and economic losses due to outbreaks caused by one pathogen. In terms of implementation efficiency, WAHO provided strong regional coordination that contributed to enhancing efficiency, reducing duplication of efforts, promoting sharing of assets, and facilitating the implementation of standardized guidelines and protocols across countries, thus reducing the time it took for countries to start their response efforts. WAHO brokered pooling of resources such as expertise, equipment, and funding, which led to economies of scale. The project upgraded national laboratories to serve as regional laboratories, allowing countries to access diagnostic services without investing in costly infrastructure, and reducing turnaround times by avoiding the need to send samples overseas to Europe. In addition, regional collaboration facilitated pooled procurement of reagents and consumables for COVID-19 testing, which led to bulk purchasing and better pricing. Concurrently, there were aspects of implementation that moderately reduced overall efficiency. Project implementation had a slow start due to delayed effectiveness in various countries, and up to one year in Nigeria due to the required parliamentary approval. The operationalization of the One Health approach was difficult as the concept was still nascent, and it implied working with multiple ministries in each country, which until that point, had worked independently. The challenges of One Health were exacerbated by that fact that in most countries, the animal and environmental sectors had been historically underfunded, and the availability of REDISSE financing was seen as an opportunity to tackle what was most urgent to them, not necessarily what was most strategic under the One Health lens. The implementation of the One Health approach was complex and challenging. The ICR (p. 31) reported that the approach was not fully understood by countries. Identifying areas where the human, animal and environmental sectors would collaborate proved to be a lengthy and contentious process. There was also a high turnover of Project Coordination Units (PCUs) staff resulting in disrupted continuity, loss of institutional knowledge, and delays as new staff required time to get up to speed. This issue was pronounced in Guinea Bissau in view of the continuous changes in government and a lack of qualified personnel. Upon the introduction of the new STEP system for procurement by the World Bank, procurement staff required time to familiarize themselves with the new processes and adjusted procurement procedures. In 2020, the COVID-19 pandemic created substantial implementation challenges with widespread disruptions, lockdowns and travel restrictions. Nevertheless, core implementation was completed during its original five-year time frame, although there were substantial fund cancellations. In view of high value for money, but with moderate shortcomings in implementation efficiency, the overall project efficiency is rated substantial. Efficiency Rating Substantial a. If available, enter the Economic Rate of Return (ERR) and/or Financial Rate of Return (FRR) at appraisal and the re-estimated value at evaluation: Rate Available? Point value (%) *Coverage/Scope (%) Page 16 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) 0 Appraisal 0  Not Applicable 0 ICR Estimate 0  Not Applicable * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome Relevance of objectives was rated high, as objectives supported a regional public good by addressing disease threats and preventing their negative impacts. Objectives remained consistent with Country Partnership Frameworks of the four participating countries, with the Regional Integration and Cooperation Assistance Strategy for the period FY21–FY23, which explicitly mentions a focus on pandemic response and disease surveillance, and with WHO International Health Regulations. Efficacy was rated substantial, as objectives were almost fully achieved. Efficiency was also rated substantial in view of the high value for money, but with some negative aspects of implementation that moderately reduced overall project efficiency. These findings are consistent with a satisfactory overall outcome rating. a. Outcome Rating Satisfactory 7. Risk to Development Outcome Several factors are likely to contribute to sustaining development outcomes. The regional working modality that promoted collaborative efforts and efficiency aspects was institutionalized to a certain extent. Capacities for surveillance and laboratories have been strengthened and are likely to be sustained through the intermediate future, including with continued support from development partners who remain committed to health security, and the participatory nature of the operation has strengthened the collaboration on health security among governments, development partners, and the World Bank. The ICR (p. 39) noted that the new regional MPA operation (The Health Security Program in West and Central Africa Project, P179078) would contribute to sustaining achievements over time. However, only Liberia was included in the first phase of the MPA and delays in project preparation beyond the control of the Bank resulted in gaps in the continuity of activities as originally envisioned. Nevertheless, the regional Health Security MPA demonstrates the Bank’s commitment to provide continued support to this agenda both at the regional level and for those countries that opt to join the Program (ICR, p. 38). Concurrently, there are risks that development outcomes may not be fully maintained and they are largely related to financial factors, with insufficient national resources to continue recurrent activities at the same level as with REDISSE II financing. The project financed the hiring of staff and the cost of maintaining logistics and operational support for countries to undertake routine activities of surveillance, laboratory and response efforts. For example, REDISSE II financed the daily transportation of staff working in the national reference laboratory in Liberia, ensuring regular attendance of lab staff to perform their duties, and financed the salaries of veterinary staff in all four countries, but only a portion of them were absorbed by the Page 17 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) governments at project closure. As for One Health, the foundational elements of the One Health Platforms were established, but countries still require funds to effectively operationalize them. 8. Assessment of Bank Performance a. Quality-at-Entry The ICR (p. 36) reported that the World Bank Team worked closely with the governments of participating countries and with development partners to engage sectoral stakeholders and ensure ownership from inception. Preparation included a wide group of technical staff and built on previous work carried out under REDISSE I project (the first phase of the regional program). The Team considered WAHO’s role at the regional level as a driving force and provider of technical support, aiming to ensure that none of the ECOWAS countries would be left behind. The ICR reported that project preparation was inclusive and participatory. According to the PAD (pp. 38-40), the project benefitted from a rich set of lessons drawn from World Bank-supported operations in health systems strengthening, extensive literature review of regional disease surveillance and response networking arrangements from other regions, best practices and lessons learned from international initiatives and development partner projects with similar objectives, and lessons learned from major infectious disease outbreaks. Salient lessons also included the need to build institutional capacity at both national and regional levels, addressing weaknesses in M&E, improving cooperation across sectors, promoting engagement with the private sector, and promoting ownership and sustainability. Apart from One Health readiness issues discussed below, institutional and implementation arrangements were adequate both at the regional and national levels, and were in line with those of REDISSE I project. WAHO would act as the regional project coordinator, hosting the regional secretariat of REDISSE. At the country level, Guinea Bissau had a Project Steering Committee that included Representation from multiple ministries and a PCU in the office of the Director General of Health. Liberia had a One Health Steering Committee that would serve as the advisory and oversight body for the project and a Project Implementation Unit (PIU) housed at the Ministry of Health. Nigeria had a National Steering Committee with oversight responsibilities for the project, including planning, management and monitoring of project activities, and a PCU housed at the Nigeria Centre for Disease Control. Togo had a Project Management Unit (PMU) at the Ministry of Health and Social Protection, responsible for general planning, fiduciary management, internal audit, procurement and the M&E. This PMU was pre-existing under the World Bank-assisted Maternal and Child and Nutrition Services Support Project (P143843). Overall financial management arrangements were considered by the financial management assessment as adequate to meet the Bank’s minimum fiduciary requirements under OP/BP10.00. Arrangements included a financial management action plan, and arrangements for dealing with fraud and corruption, staffing and training, budgeting, accounting procedures, internal control and internal auditing, financial reporting and monitoring, external auditing, fund flows and disbursement arrangements, procurement, Page 18 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) and implementation support plan (PAD, pp. 53-60). M&E arrangements were also adequate (PAD, p. 43) and built on existing processes for JEE assessments guided by WHO. The project was classified under category B for Environmental Assessment, and each country had suitable arrangements to address safeguard policies, and prepared three sets of documents: a national Healthcare Waste Management Plan, an Integrated Pest and Vector Management Plan, and an Environmental and Social Management Framework (PAD, p. 61) In terms of fragility aspects, the ICR (p. 37) noted that, at the time of preparation, Guinea-Bissau, Liberia, and Togo were included in the World Bank’s Harmonized List of Fragile Situations for FY17. In FY20 the list became the World Bank’s List of Fragile and Conflict-affected Situations, which then included Nigeria but excluded Togo. In FY22 Liberia was removed from the list, but Guinea-Bissau and Nigeria remained on the list. There was insufficient preparation and effective mitigation measures to address the risks related to the operationalization of the One Health approach. The Systematic Operations Risk-rating Tool (SORT) identified the overall risk as Substantial (PAD, p. 207), including the complexity of the project and the implementation environment, and correctly identified the risk related to Institutional Capacity for Implementation and Sustainability as high. The PAD noted that the project required active engagement and collaboration between the Ministries of Health, Agriculture, Education, and Technology & Communications and the local governments. The ICR (p. 41) reported that it was critical for the successful design and implementation of projects that promote One Health to dedicate sufficient time during preparation, and to continue during early implementation to jointly define priorities and identify the activities to be supported by the project. As previously discussed in section 5, the operationalization of the One Health approach was not fully understood by the countries, and the project subsequently faced substantial challenges in implementing One Health. The ICR noted that the level of effort required for One Health was underestimated by the project team. Its lessons also noted the importance of putting emphasis on planning One Health interventions during preparation and early implementation to avoid the experience of REDISSE II. Quality-at-Entry Rating Moderately Satisfactory b. Quality of supervision According to the ICR (p. 37), World Bank supervision focused on development impact and proactively focused on supporting countries in overcoming obstacles that undermined achieving intended results and outcomes. Also, the Bank Team swiftly provided support in moments of greater risks or deteriorating country or international contexts, such as in the case of the Lassa Fever outbreak in Nigeria in 2018 and Guinea Bissau’s socio-political turmoil from 2019 onwards. The Bank Team responded to Client requests to either reallocate project funds or trigger the CERC for Lassa fever (Nigeria) and COVID-19 (Liberia). The Bank was proactive in restructuring the project three times to adapt the project to changing implementation contexts. The Bank Team carried out regular and adequately staffed supervision and implementation Page 19 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) support missions throughout the life of the project while overcoming the challenges related to the multi- country and multi-sector nature of the project. Originally REDISSE had a team of two TTLs at headquarters, and, as implementation progressed, the World Bank added co-TTLs based in the field in each country. This positive development reportedly strengthened but also introduced a degree of fragmentation in supervision. In-country and Headquarters TTLs worked jointly to achieve coordination and resolve supervision issues, which was not always easy according to the ICR. Guinea Bissau, which had a very fragile context throughout the project, could have benefited from more frequent implementation support missions. The Bank rules for TTL-ship at the time only allowed the appointment of one TTL ADM and one co-TTL, which presented challenges as the REDISSE program grew. The project was jointly prepared by the Health and Agriculture Global Practices, with a Health TTL and an Agriculture co-TTL having been appointed. For a period, both REDISSE I and REDISSE II were under the supervision of a single TTL ADM, with centralized clearance of all ‘No Objections’ for seven countries and one regional organization. While this contributed to significant bottlenecks in the early stages of project implementation, it was eventually resolved with the introduction of country co-TTLs. Supervision was challenging during the COVID-19 pandemic. The Bank Team adapted and introduced regular virtual supervision support meetings, until travel resumed. Supervision and support to fiduciary, environmental and social safeguards were reputedly adequate. The Bank Team regularly provided training and technical assistance to the PCU teams. The Bank Team was reportedly candid in its dialogue with the countries and reporting on project performance. Back-to office reports, ISRs, Aide Memoires, and effective Mid-Term Review in 2021 provided adequate assessments and identification of implementation challenges. The Bank Team maintained its dialogue and collaboration with development partners to facilitate the achievement of the PDOs and the higher-level objectives of the global security agenda. In terms of post-project transition, the World Bank opted to continue supporting countries under a new regional MPA operation (see section 2e) that was already under preparation. But, as noted in section 7, there were delays in MPA preparation beyond the control of the Bank, resulting in gaps in the continuity of activities as originally envisioned (ICR, p. 38). . Quality of Supervision Rating Satisfactory Overall Bank Performance Rating Moderately Satisfactory 9. M&E Design, Implementation, & Utilization Page 20 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) a. M&E Design Objectives were clearly stated. The design of the M&E system of the project followed the framework of the overall REDISSE Program and REDISSE I project. The PAD (p. 43) noted that most indicators relied on existing international tools for evaluating IHR and OIE compliance and progress, namely the JEE and PVS tools, minimizing the burden of data collection on the four participating countries. The latter would conduct annual self-assessments using the above tools, followed by JEE assessments carried out by external experts biennially to validate the findings of national self-assessments and the quality of their data. JEE indicators were aligned with core aspects of health security and with the stated PDOs, and they were also relevant because participating countries were entering the project at different levels of capacity and consequently had different baseline levels in terms of IHR capacities or JEE scores. During preparation, and based on self-assessments, tentative values of baseline and target scores were estimated with the understanding that they would be updated when countries complete their JEE. The PAD did not include an explicit theory of change, as it was not required at the time of preparation, but it clearly established the activities and intended results under each component. Other ongoing efforts by national governments and development partners also contributed to the achievement of JEE scores. This was in line with the REDISSE Program intent to provide significant contributions that complement other efforts seeking to enhance health security and to increase JEE scores without necessarily focusing on full attribution aspects. b. M&E Implementation All participating countries regularly monitored the results framework indicators and provided regular updates to the World Bank. Tracking of indicators was systematic and facilitated by the PCUs, which had an M&E specialist. Since indicators were part of the JEE and self-assessment processes, data were collected and analyzed as part of the regular work of a National Technical Working Group responsible for reporting on IHR capacities, including JEE, and extending beyond the REDISSE project. Hence, monitoring of the results framework indicators was not exclusively project-based, and was part of a collective effort by governments and development partners, including the World Bank. In addition, given that JEE was a national process conducted under the guidance of WHO, existing arrangements spared the countries from the burden of setting up parallel M&E systems (ICR, p. 34). Concurrently, the use of JEE created some challenges. As the JEE tool evolved, changes were introduced, and benchmarks were made more stringent. c. M&E Utilization The ICR (p. 35) reported that M&E findings were used to inform program management and decision making. Data were used to monitor and support the progress in activities that were behind intended scores and to inform annual workplans. Findings were shared with the regional level and with stakeholders. M&E Quality Rating Substantial Page 21 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) 10. Other Issues a. Safeguards Overview: The ICR (p. 35) reported that participating countries in REDISSE II project fully complied with the World Bank’s safeguards policies and procedures. The overall safeguards rating was consistently rated as satisfactory, including in the final ISR, as also recorded in the Operations Portal. The project was classified as category B for Environmental Assessment, as it triggered two safeguard policies: Environmental Assessment (OP 4.01) and Pest Management (OP 4.09). The countries prepared National Healthcare Waste Management Plans, Integrated Pest and Vector Management Plans, and Environmental and Social Management Frameworks. These documents addressed potential risks, provided implementation budget, and explained implementation arrangements. The documents provided guidance for site-specific waste management plans. Supervision visits were conducted to assess environmental, health and safety using standardized checklists for rehabilitation and minor construction works. In Togo, REDISSE II developed and implemented two tools for bio-medical waste, pesticide, and zoonoses waste management. In addition, a regional roadmap for the operationalization of the sustainable management of healthcare waste in West Africa was developed with WAHO’s support. The roadmap included two major activities: (i) the development of a regional strategic plan to strengthen the management of healthcare waste; and (ii) the development of a directive for the harmonization of regulations on the sustainable management of healthcare waste in West Africa, which was adopted as a regulation by the 22nd Ordinary Meeting of Assembly of Heath Ministers in ECOWAS in 2021. The project developed a Grievance Redress Mechanism (GRM) in all four countries. Its functioning varied among countries, for example, in Guinea Bissau, most complaints were related to the lack of health infrastructure, strikes in the health sector, and lack of medicines, and many of these complaints could not be resolved under the GRM. b. Fiduciary Compliance Financial Management: As noted in section 8, financial management arrangements were adequate at entry, and financial management performance was also largely adequate during implementation. For the four countries, audit reports were presented on time, without auditor qualifications. Countries complied with legal covenants (ICR, p. 36). Procurement: Moderate shortcomings were observed, largely resulting from weak institutional capacity, lack of previous experience with World Bank-supported operations, and from staff turnover. The introduction of the World Bank STEP system for procurement was associated with delays, but related issues were overcome with time. While the development and approvals of procurement plans were timely, subsequent procurement processes were slow, including because of the need for intersectoral consultations. Challenges were dealt with through additional training and collaboration among teams. c. Unintended impacts (Positive or Negative) Page 22 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) None reported. d. Other -- 11. Ratings Reason for Ratings ICR IEG Disagreements/Comment Outcome Satisfactory Satisfactory The project had insufficient preparation for introducing the One Health approach and lacked effective risk mitigation measures for its operationalization, which was not fully understood by participating countries. One Health presented considerable challenges throughout implementation. According to the ICR, the level of effort required Bank Performance Satisfactory Moderately Satisfactory for the development of One Health was underestimated by the project team. The ICR noted that it was critical to dedicate sufficient time during preparation and early implementation to One Health for a successful design and implementation. It also recommended placing greater emphasis on planning One Health interventions to avoid the experience of REDISSE II. Quality of M&E Substantial Substantial Quality of ICR --- High 12. Lessons The ICR (pp. 40-41) offered several lessons and recommendations, including the following lessons slightly restated by IEG Review: Page 23 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) Regional approaches maximize the benefits of projects promoting health security. Under this regional operation, participating countries followed common standards and approaches for preparedness and response to health emergencies, and the ensuing cohesive and collaborative approach for responding to COVID-19 pandemic helped countries to implement mutually agreed best approaches and to follow defined standards developed through a participative effort, thus contributing to a greater buy-in and adoption of standardized approaches. This lesson illustrates the merits of a regional approach for future operations supporting health security, and it corroborates previous IEG findings (World Bank. 2022. The World Bank’s Early Support to Addressing COVID-19: Health and Social Response. An Early-Stage Evaluation. Independent Evaluation Group. Washington, DC: World Bank) indicating that “Regional projects facilitated knowledge sharing and were particularly helpful for countries with limited capacity to respond independently to COVID-19. Regional projects supported technical cooperation between ministries and public health institutes, encouraged leadership, developed human capacity, and coordinated technical sharing and financing for COVID-19 responses in countries. Longer-running regional projects had more established networks, which had successfully built some preparedness before the pandemic to support COVID- 19 responses, although even newer regional projects added value, mainly through convening and technical and learning support.” Despite the large cancelation of funds, the regional approach enabled the project to achieve its outcomes substantially, providing for efficient implementation. Adopting globally accepted indicators can provide an objective assessment of preparedness capacities. Under the project, the adoption of the Joint External Evaluation tool facilitated alignment of stakeholders and development partners in support of compliance aspects with IHR requirements and reduced the M&E burden on countries. Nevertheless, there is a downside to such an adoption, as WHO’s updates to the Joint External Evaluation indicators and benchmarks became increasingly stringent. Projects that support the establishment of One Health approach require time and extensive planning during preparation and early implementation. REDISSE sought to establish One Health in countries where the concept was novel, and where implementation required major structural and behavioral changes. Under the project, all four countries experienced challenges and delays in implementation, and there was competition among the health, animal, and environmental sectors to get financing for their sectoral priorities. The level of efforts required for promoting One Health was underestimated. 13. Assessment Recommended? No 14. Comments on Quality of ICR The ICR was focused on results. It was well organized, and presented a complete and substantiated critique of the project. It was candid. The theory of change was adequately illustrated with logical links along the pathway between activities, outputs, and intended outcomes. The quality of overall evidence was adequate and the quality of the ICR’s analysis was high, including in addressing attribution issues. Its narrative and observations were aligned with the stated objectives. The lessons were derived from project experience, and were Page 24 of 25 Independent Evaluation Group (IEG) Implementation Completion Report (ICR) Review REDISSE 2 (P159040) underpinned by evidence presented in the ICR. Lessons are poised to inform future regional operations aimed at advancing health security. The ICR was internally consistent, and aligned with the guidelines. a. Quality of ICR Rating High Page 25 of 25