FOR OFFICIAL USE ONLY Report No: ICR00056 IMPLEMENTATION COMPLETION AND RESULTS REPORT (5822-LS; 5823-ZM; 5863-MZ; 5864-MW; 6695-LS; D117-MW; D118-MZ; D659-MW; D660-AFR; D661-AFR) ON CREDITS IN THE AMOUNTS OF SDR 11.4 MILLION (US$15 MILLION EQUIVALENT) and US$21 MILLION TO THE KINGDOM OF LESOTHO SDR 5.7 MILLION (US$7.5 MILLION EQUIVALENT) TO THE REPUBLIC OF MALAWI SDR 17.1 MILLION (US$22.5 MILLION EQUIVALENT) TO THE REPUBLIC OF MOZAMBIQUE SDR 34.2 MILLION (US$45 MILLION EQUIVALENT) TO THE REPUBLIC OF ZAMBIA AND GRANTS IN THE AMOUNTS OF SDR 7.2 MILLION (US$9.5 MILLION EQUIVALENT) AND SDR 20.5 MILLION (US$27 MILLION EQUIVALENT) TO THE REPUBLIC OF MALAWI SDR 17.1 MILLION (US$22.5 MILLION EQUIVALENT) TO THE REPUBLIC OF MOZAMBIQUE SDR 3.8 MILLION (US$5 MILLION EQUIVALENT) TO THE EAST, CENTRAL AND SOUTHERN AFRICAN HEALTH COMMUNITY (ECSA-HC) SDR 2.3 MILLION (US$3 MILLION EQUIVALENT) TO THE AFRICAN UNION DEVELOPMENT AGENCY – NEW PARTNERSHIP FOR AFRICA’S DEVELOPMENT (AUDA-NEPAD) FOR AFR RI-SOUTHERN AFRICA TUBERCULOSIS AND HEALTH SYSTEMS SUPPORT PROJECT DECEMBER 20, 2024 Health, Nutrition and Population Global Practice Eastern and Southern Africa The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT CURRENCY EQUIVALENTS (Exchange Rate Effective Nov 30, 2024) SDR 0.76 = US$1 US$ 1.31 = SDR 1 FISCAL YEAR January 1 - December 31 Regional Vice President: Victoria Kwakwa Country Director: Boutheina Guermazi Regional Director: Daniel Dulitzky For Official Use Only Practice Manager: Ernest E. Massiah Humberto Albino Cossa, John Bosco Makumba, Kavita Phyllis Task Team Leaders: Watsa ICR Main Contributor: Miriam Schneidman The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ABBREVIATIONS AND ACRONYMS AF Additional Financing Africa CDC Africa Centers for Disease Control and Prevention AI Artificial Intelligence AIDS Acquired Immunodeficiency Syndrome AMR Antimicrobial Resistance ASLM African Society for Laboratory Medicine AUDA-NEPAD African Union Development Agency—New Partnership for Africa’s Development CDC United States Centers for Disease Control and Prevention CoE Center of Excellence CoP Communities of Practice COVID-19 Coronavirus Disease 2019 CRI Corporate Results Indicator DALYs Disability Adjusted Life Years DOTS Directly Observed Treatment Short-Course ECSA-HC East, Central and Southern Africa Health Community EBS Event-Based Surveillance For Official Use Only ESMF Environmental and Social Management Framework GDP Gross Domestic Product GRM Grievance Redress Mechanism HIV Human Immunodeficiency Virus IBRD International Bank for Reconstruction and Development ICR Implementation Completion and Results Report ICWM Infection Control and Waste Management IDA International Development Association IEG Internal Evaluation Group ILO International Labor Organization IHR International Health Regulations IOI Intermediate Outcome Indicator IOM International Organization for Migration ISR Implementation Status and Results Report JEE Joint External Evaluation MDR-TB Multidrug-Resistant Tuberculosis M&E Monitoring and Evaluation NCDs Non-Communicable Diseases OHC Occupational Health Center OHS Occupational Health and Safety OHSI Occupational Health and Safety Institute OOP Out of Pocket OP Operational Policy PAD Project Appraisal Document PDO Project Development Objective PIU Project Implementation Unit The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT POI Project Outcome Indicator QER Quality Enhancement Review QI Quality Improvement RAC Regional Advisory Committee RF Results Framework SADC Southern African Development Community SATBHSSP Southern Africa Tuberculosis and Health Systems Support Project SLIPTA Stepwise Laboratory Improvement Process Towards Accreditation SOPs Standard Operating Procedures TB Tuberculosis TEBA The Employment Bureau of Africa The Union The International Union Against Tuberculosis and Lung Disease WHO World Health Organization For Official Use Only The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT TABLE OF CONTENTS DATA SHEET ................................................................................................................................................. i I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................................................2 II. OUTCOME ...................................................................................................................................................9 III. KEY FACTORS AFFECTING IMPLEMENTATION AND OUTCOME ................................................................. 22 IV. BANK PERFORMANCE, COMPLIANCE, AND RISK TO DEVELOPMENT OUTCOME ....................................... 25 V. LESSONS AND RECOMMENDATIONS .......................................................................................................... 28 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ........................................................................................ 31 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT AND SUPERVISION ................................................ 37 ANNEX 3. PROJECT COST BY COMPONENT ......................................................................................................... 41 ANNEX 4. EFFICIENCY ANALYSIS ........................................................................................................................ 42 ANNEX 5. BORROWER, CO-FINANCIER, AND OTHER PARTNER AND STAKEHOLDER COMMENTS ......................... 46 For Official Use Only ANNEX 6. SUMMARY TABLES OF INDICATOR ACHIEVEMENT .............................................................................. 53 ANNEX 7. NATIONAL TRENDS IN KEY TUBERCULOSIS INDICATORS...................................................................... 59 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT DATA SHEET @#&OPS~Doctype~OPS^dynamics@icrbasicdata#doctemplate BASIC DATA Product Information Operation ID Operation Name AFR RI-Southern Africa Tuberculosis and Health Systems P155658 Support Project Product Operation Short Name Investment Project Financing (IPF) Southern Africa TB and Health Systems Operation Status Approval Fiscal Year Closed 2016 For Official Use Only Original EA Category Current EA Category Partial Assessment (B) (Restructuring Data Sheet - 21 Dec Partial Assessment (B) (Approval package - 28 Jul 2016) 2023) CLIENTS Borrower/Recipient Implementing Agency East, Central and Southern African Health Community (ECSA-HC), Kingdom of Lesotho - Ministry of Finance and Republic of Zambia - Ministry of Health (MOH), Republic Development Planning (MoFDP), Republic of Malawi - of Mozambique - Ministry of Health (MISAU), Republic of Ministry of Finance and Economic Affairs (MOFEA), Malawi - Ministry of Health (MOH), Kingdom of Lesotho - Republic of Mozambique - Ministry of Economy and Ministry of Health, African Union Development Agency Finance (MEF), Republic of Zambia - Ministry of Finance (AUDA-NEPAD) and National Planning (MOFNP) DEVELOPMENT OBJECTIVE Original Development Objective (Approved as part of Approval Package on 28-Jul-2016) A. Proposed Development Objective(s) The overall objectives of the project are to: (i) improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of the participating countries; and (ii) strengthen regional capacity to manage the burden of TB and occupational diseases. Current Development Objective (Approved as part of Restructuring Package Seq No 1 on 06-May-2020) i The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT The overall objectives of the project are to: (i) improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of the participating countries; and (ii) strengthen regional capacity to manage the burden of TB and occupational lung diseases; (iii) strengthen country-level and cross-border preparedness and response to disease outbreaks s s s s s s s s s @#&OPS~Doctype~OPS^dynamics@icrfinancing#doctemplate FINANCING Financing Source Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing 178,000,000.00 178,000,000.00 174,673,396.00 IDA-66950 21,000,000.00 21,000,000.00 20,976,024.20 IDA-D1180 22,500,000.00 22,500,000.00 21,774,023.58 IDA-D1170 9,500,000.00 9,500,000.00 9,471,417.86 IDA-58230 45,000,000.00 45,000,000.00 44,303,765.68 IDA-58220 15,000,000.00 15,000,000.00 14,836,140.60 For Official Use Only IDA-58640 7,500,000.00 7,500,000.00 6,801,159.10 IDA-58630 22,500,000.00 22,500,000.00 22,032,041.36 IDA-D6610 5,000,000.00 5,000,000.00 5,022,171.58 IDA-D6600 3,000,000.00 3,000,000.00 2,958,194.45 IDA-D6590 27,000,000.00 27,000,000.00 26,498,457.59 Total 178,000,000.00 178,000,000.00 174,673,396.00 RESTRUCTURING AND/OR ADDITIONAL FINANCING Amount Disbursed Date(s) Type Key Revisions (US$M) • Development Objective • Components 06-May-2020 Portal 85.25 • Results • Reallocations • Components • Results • Legal Covenants 14-Dec-2022 Portal 148.14 • Disbursement Estimates • Reallocations • Implementation Schedule • Results 21-Dec-2023 Portal 162.35 • Loan Closing Date Extension ii The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT • Implementation Schedule @#&OPS~Doctype~OPS^dynamics@icrkeydates#doctemplate KEY DATES Key Events Planned Date Actual Date Concept Review 26-Jun-2015 26-Jun-2015 Decision Review 12-Feb-2016 12-Feb-2016 Authorize Negotiations 04-Apr-2016 04-Apr-2016 Approval 26-May-2016 26-May-2016 Signing 26-Jul-2016 Effectiveness 05-Dec-2016 ICR/NCO 29-Dec-2024 20-Dec-2024 For Official Use Only Restructuring Sequence.01 Not Applicable 06-May-2020 Restructuring Sequence.02 Not Applicable 14-Dec-2022 Restructuring Sequence.03 Not Applicable 21-Dec-2023 ICR Sequence.01 (Final) -- 19-Dec-2024 Operation Closing/Cancellation 30-Jun-2024 30-Jun-2024 @#&OPS~Doctype~OPS^dynamics@icrratings#doctemplate RATINGS SUMMARY Outcome Bank Performance M&E Quality Satisfactory Satisfactory Substantial ISR RATINGS Actual Disbursements No. Date ISR Archived DO Rating IP Rating (US$M) 01 07-Sep-2016 Satisfactory Satisfactory 0.00 02 21-Mar-2017 Satisfactory Satisfactory 7.21 iii The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT 03 02-Nov-2017 Satisfactory Moderately Satisfactory 18.75 04 06-Jul-2018 Satisfactory Moderately Satisfactory 36.47 05 08-Feb-2019 Moderately Satisfactory Moderately Satisfactory 50.52 06 10-Oct-2019 Satisfactory Satisfactory 76.72 07 21-Apr-2020 Satisfactory Satisfactory 85.25 08 27-Oct-2020 Satisfactory Satisfactory 102.34 09 20-May-2021 Satisfactory Satisfactory 110.61 10 24-Dec-2021 Satisfactory Satisfactory 125.07 11 30-Jun-2022 Satisfactory Satisfactory 140.19 12 06-Jan-2023 Satisfactory Satisfactory 148.21 13 29-Jun-2023 Satisfactory Moderately Satisfactory 155.21 14 10-Jan-2024 Satisfactory Satisfactory 162.35 For Official Use Only 15 27-Jun-2024 Satisfactory Satisfactory 171.99 @#&OPS~Doctype~OPS^dynamics@icrsectortheme#doctemplate SECTORS AND THEMES Sectors Adaptation Mitigation Major Sector Sector % Co-benefits (%) Co-benefits (%) FY17 - Mining 15 0 0 FY17 - Energy and Extractives FY17 - Public Administration - 6 0 0 Energy and Extractives FY17 - Health 76 0 0 FY17 - Health FY17 - Public Administration - 3 0 0 Health Themes Major Theme Theme (Level 2) Theme (Level 3) % FY17 - Human FY17 - HIV/AIDS 10 Development and FY17 - Disease Control Gender FY17 - Tuberculosis 40 iv The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT FY17 - Health System FY17 - Health Systems and Policies 40 Strengthening FY17 - Social FY17 - Participation and Development and FY17 - Social Inclusion 10 Civic Engagement Protection For Official Use Only v The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ADM STAFF Role At Approval At ICR Practice Manager Magnus Lindelow Ernest E. Massiah Regional Director Daniel Dulitzky Global Director Timothy Evans Juan Pablo Eusebio Uribe Restrepo Practice Group Vice President Mamta Murthi Country Director Ahmadou Moustapha Ndiaye Boutheina Guermazi Regional Vice President Makhtar Diop Victoria Kwakwa ADM Responsible Team Leader Ronald Mutasa Humberto Albino Cossa John Bosco Makumba, Kavita Phyllis Co-Team Leader(s) Watsa ICR Main Contributor Miriam Schneidman For Official Use Only Page 1 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES A. CONTEXT AT APPRAISAL Context 1. At the time of the preparation of the Southern Africa Tuberculosis and Health Systems Support Project (SATBHSSP), the sub-region had some of the highest tuberculosis (TB) case rates on the continent and was at the epicenter of the global human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic. Eight of the 14 countries in the world with the highest TB incidence (at least 400 cases per 100,000) were in southern Africa, including Lesotho, Malawi, Mozambique, and Zambia. The sub-region also had some of the highest rates of TB/HIV coinfection (50-70 percent) and the worst treatment outcomes in the world. While the HIV/AIDS epidemic contributed significantly to the high TB burden, the mining sector in the sub-region was associated with unprecedented rates of TB cases. The southern Africa sub-region also had a growing problem with multidrug-resistant (MDR)-TB, which was more costly to treat and had high rates of case fatality and treatment failure. The countries were off track to achieve the World Health Organization (WHO) End TB Strategy 2016-2035 targets of reducing TB incidence and mortality by 90 and 95 percent, respectively, by 2035. 2. High levels of poverty, inequality, and migration created a fertile ground for the spread of TB and other communicable diseases, requiring targeted, coordinated action. Given that TB is a disease of poverty, as people who live and work in poorly ventilated and overcrowded conditions are more susceptible, there was a clear For Official Use Only justification for the pro-poor, targeted approach that included miners and their communities. The high levels of intraregional economic activity also increased the risk of the spread of diseases across porous borders, requiring a regional response. The historical patterns of migration in the sub-region, from labor-sending countries such as Lesotho, Malawi, and Mozambique to South Africa, generated important economic opportunities but exacerbated the spread of communicable diseases. Many migrant miners lived and worked in precarious conditions, placing them at high risk of developing TB and other occupational lung diseases. Informal cross- border trade, although an important source of livelihood, contributed to the spread of other infectious diseases such as cholera and hemorrhagic fevers, underscoring the importance of robust health systems and cross-border health programs. 3. At the time of project preparation, the sub-region had inadequate health system capacity for the effective prevention and management of TB and occupational lung diseases. As noted in the Project Appraisal Document (PAD), the systems had multiple weaknesses, including weak, non-standardized TB prevention and treatment strategies and protocols; gaps in occupational health systems and services; inadequate mine-health regulatory capacity; weak laboratory capacity; shortages of human resources; financing gaps; demand-side barriers; and modest involvement of private mining companies and private health care providers in TB and other occupational lung diseases. These weaknesses underscored the need to strengthen health systems and introduce select high- impact, multisectoral interventions. 4. The PAD provided strong rationales for World Bank engagement and selection of participating countries. The project reflected the World Bank’s institutional commitment to regional public goods, including control of communicable diseases, which disproportionately affect the poor, with serious impoverishing effects. The regional rationales were clearly stated: avoid negative spillover effects and maximize positive externalities; support delivery of public goods, including generating evidence of what works in control of TB and occupational lung diseases; reap economies of scale through coordinated, harmonized interventions; and foster regional accountability, with the project serving as a platform for advancing the Southern African Development Community Declaration on Tuberculosis (2012), signed by heads of state, and the Maputo Declaration on Health Laboratory Systems (2008). The four participating countries (Lesotho, Malawi, Mozambique, Zambia) were Page 2 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT selected based on clear criteria, including burden of disease, strong government commitment, and large-scale (Zambia) or growing (Lesotho, Malawi, Mozambique) mining sectors. 5. Preparation involved a rigorous process of selecting regional and global partners, with a clear division of labor among institutions. The regional institutions were identified based on their mandates and capacities to strengthen health systems, enhance cross-country collaboration, and support knowledge sharing (East, Central, and Southern Africa Health Community, ECSA-HC), building and leveraging on platforms established for TB control, laboratories, and disease preparedness and response under other Bank- and donor-funded projects and to support regional economic development, including on occupational health and mining (New Partnership for African Development Planning and Coordinating Agency, which was later renamed the African Union Development Agency, AUDA-NEPAD). Recognizing the need for multisectoral engagement and specialized technical expertise, design and preparation of the regional project involved premier global and regional agencies.1 6. The PAD included a results chain, providing a graphic description of the links between the key outputs, intermediate and coverage outcomes, and health and development outcomes. For this Implementation Completion and Results Report (ICR), a detailed theory of change was constructed to include the socioeconomic and health system determinants, highlighting the multisectoral and systems approach inherent in the design. The theory of change has been retrofitted to include the results framework (RF) for both the original project, the additional financing (AF), and the long-term goals to which the project was contributing (Figure 1). For Official Use Only FIGURE 1: SOUTHERN AFRICA TUBERCULOSIS AND HEALTH SYSTEMS SUPPORT PROJECT: THEORY OF CHANGE Contribu ons to Income Weak and non ine ualit standardi ed improved health MDR TB pa ents bene ed from Intra regional TB preven on ps chosocial nutri onal support and development Roll out a package of TB case no ca on rate economic and treatment standardi ed TB preven on and IV pa ents screening for TB outcomes in the TB treatment success rate ac vit strategies treatment interven ons TB pa ents tested using W O four countries TB cases iden ed through ac ve case Labor mobilit in aps in Roll out a standardi ed package recommended diagnos cs Reduced TB nding sub region occupa onal of occupa onal health services Miners and e miners referred and burden health s stems and mine safet standards screened for TB occupa onal diseases TB cases bacteriologicall con rmed towards mining Enhanced abilit to sector in South and services Miners eligible for compensa on due to deal with outbreaks Africa Inade uate occupa onal diseases receiving it Miners and e miners successfull screened for occupa onal lung diseases and pandemics Migra on mine health Improved mine regulator Countries with harmoni ed clinical towards mining protocols for occupa onal health safet areas within capacit Direct bene ciaries females par cipa ng Weak People who received essen al NP countries laborator Provide training related to project services Corporate Indicator diagnos c ac vi es capacit E pand microscop networks, roll Shortages of out new technologies, and ealth personnel trained human strengthen surveillance capacit ealth facili es renovated e uipped resources pdate dra occupa onal health Laboratories rated stars original or Laboratories compliant with regionall and safet legisla on Demand side higher on SLIPTA assessment harmoni ed SOPs for MDR TB barriers to Outbreaks for which crossborder surveillance accessing TB inves ga on undertaken care ndertake opera onal research Rise in MDR TB and knowledge sharing ac vi es Establish enters of e cellence for Mines inspected at least twice a ear for TB and occupa onal lung diseases compliance Support regional coordina on, New legisla on amendment to mine health polic advocac and harmoni a on and safet legisla on dra ed Opera onal research studies commissioned, and ndings disseminated Centers of e cellence established 1This included the U.S. Centers for Disease Control and Prevention (CDC), African Society for Laboratory Medicine, International Labor Organization, and WHO. Page 3 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Project Development Objective 7. The overall objectives of the project were to: (i) improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of the participating countries and increase regional capacity to manage the burden of TB and occupational lung diseases. Expected Outcomes and Outcome Indicators 8. There were five original outcome indicators to assess achievement of the project, as noted below. The project also included 15 intermediate outcome indicators (IOIs) which were to contribute to the project development objective (PDO). The PAD included an annex on the project outcome indicators (POIs) and the IOIs by country and aggregated, with baseline and targets for the original implementation period from 2017 to 2021. • Objective 1: Improve coverage and quality of TB control and occupational lung disease services. POI 1: TB case notification in target geographic areas (number) POI 2: TB treatment success rate in target geographic areas: new and relapsed TB cases (%) POI 3: TB cases identified through active TB case finding (screening) among TB-vulnerable populations in targeted geographic areas (number) POI 4: Direct beneficiaries (number) and share of females among them (%) For Official Use Only • Objective 2: Strengthen regional capacity to manage the burden of TB and occupational lung diseases. POI 5: Project-supported laboratories compliant with regionally harmonized standard operating procedures for surveillance of MDR-TB (number) Components 9. Component 1: Innovative Prevention, Detection, and Treatment of TB (US$45.49 million). This component had two subcomponents. • Subcomponent 1.1: Enhancing case detection and treatment success (US$37.52 million). This subcomponent financed demand- and supply-side interventions to enhance early case detection and improve treatment success rates through the rollout of a package of standardized TB services across the four countries. On the demand side, the project supported interventions to improve community knowledge and awareness and address barriers to accessing care, including social and behavior change communication activities and nutritional support for MDR-TB patients. On the supply side, the project aimed to improve the clinical quality of services and ensure that international standards for TB care are met across countries by providing training and mentorship for front-line workers, improving patient referral and follow-up, and scaling up community TB screening and TB/HIV services; and strengthen specimen transportation and management by establishing community sputum collection points, introducing agile sample transport mechanisms, and improving transmission of laboratory results. • Subcomponent 1.2: Rolling out a standardized package of occupational health services and mining safety standards across the four countries (US$7.97 million). This subcomponent aimed to strengthen the capacity of public sector agencies responsible for mine safety to conduct inspections and assess mine dust levels; expand screening and referral for occupational lung diseases and other diseases; and develop or strengthen programs for occupational lung diseases. 10. Component 2: Regional Capacity for Disease Surveillance, Diagnostics, and Management of TB and Occupational Lung Diseases (US$43.19 million). This component had three subcomponents. Page 4 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT • Subcomponent 2.1: Improving quality and availability of human resources in the targeted areas (US$15.24 million). This subcomponent aimed to support development of a skilled health workforce related to project activities (TB case detection and management, mine health regulation and occupational health services, disease surveillance). • Subcomponent 2.2: Strengthening diagnostic capacity and disease surveillance (US$23.02 million). This subcomponent aimed to strengthen diagnostic capacity by expanding microscopy networks in targeted areas; rolling out newer, more efficient diagnostic technologies; and scaling up the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) and the companion training and mentorship program; and networking national TB laboratories at the country and regional levels. To strengthen disease surveillance, the subcomponent aimed to upgrade surveillance capacity for MDR-TB and laboratory-based monitoring of antimicrobial resistance, support establishment of cross-border committees for disease outbreak investigations and tabletop simulations, and establish and reinforce information and reporting systems across project districts and border areas. • Subcomponent 2.3: Strengthening mine health regulation (US$4.93 million). This subcomponent supported countries to update or draft occupational health and safety (OHS) legislation, develop mine inspection guidelines, and develop information systems for compliance monitoring and mine health surveillance. 11. Component 3: Regional Learning and Innovation and Project Management (US$33.32 million). This component included four subcomponents. • For Official Use Only Subcomponent 3.1: Occupational research and knowledge sharing (US$3.61 million). This subcomponent included funding for key baseline surveys and studies related to project activities. • Subcomponent 3.2: Centers of excellence (CoEs) on TB and occupational lung disease control (US$5.76 million). This subcomponent supported the participating countries to establish CoEs and generate and share knowledge in strategic areas (Lesotho: community-based management of TB; Malawi: community TB care and integrated disease surveillance; Mozambique: MDR-TB and childhood TB management; Zambia: OHS). • Subcomponent 3.3: Regional coordination, policy advocacy, and harmonization (US$13.42 million). This subcomponent supported ECSA-HC to undertake regional activities by convening technical experts and policymakers, commissioning and coordinating research on TB control and health systems strengthening (e.g., studies on out-of-pocket spending on TB; cost-benefit and health impact of investing in TB control), facilitating knowledge sharing, providing implementation support, facilitating capacity building and training, and coordinating cross-border disease surveillance. The subcomponent also supported AUDA-NEPAD to carry out the following activities related to the private sector and OHS: regional research on private sector opportunities in TB control, the state of mine health regulation, and dissemination of key findings; mobilization of political commitment and domestic financing; and coordination of policy advocacy, including with the Southern African Development Community on regional matters that required harmonization. • Subcomponent 3.4: Project management (US$10.54 million). This subcomponent supported the project implementation units (PIUs) to conduct financial management, procurement, and monitoring and evaluation (M&E). B. SIGNIFICANT CHANGES DURING IMPLEMENTATION 12. The project had four level 2 restructurings, including one AF (Table 1). The overall design remained broadly the same during the implementation period. 13. The first level 2 restructuring (April 10, 2020) involved a modification to the PDO to add a third objective (i.e., strengthen country-level and cross-border preparedness and response to disease outbreaks), reflecting activities increasingly supported under the project and the growing importance of disease outbreak Page 5 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT preparedness.2 The first restructuring also involved modifications to the RF, with the improved availability of baseline data and enhanced implementation experience. 14. The second level 2 restructuring (June 19, 2020) provided AF to expand the scope, scale, and impact of the project. To this end, AF of US$56.0 million from the International Development Association (IDA) was approved, including a US$21 million credit to the Kingdom of Lesotho, a US$27 million grant to the Republic of Malawi, a US$5 million grant to ECSA-HC, and a US$3 million grant to AUDA-NEPAD. Mozambique and Zambia did not seek AF, continuing to implement their respective credits and participating in regional activities. The closing date was extended by two years to December 31, 2023, to allow time to implement the additional interventions in Lesotho and Malawi and to undertake key activities at the regional level across all four countries. The second restructuring also included a new subcomponent focused on the coronavirus disease 2019 (COVID-19) response and comorbidities with TB and modifications to the RF. 15. The third level 2 restructuring (December 1, 2022) included a reallocation of funds across disbursement categories to adjust for overspent categories and to make modifications to the RF. 16. The fourth level 2 restructuring (December 15, 2023) included a six-month extension of the closing date to June 30, 2024, to allow Lesotho, Malawi, and AUDA-NEPAD to use the remaining US$13.5 million and to modify the RF in line with the proposed extension. TABLE 1: SUMMARY OF CHANGES DURING PROJECT IMPLEMENTATION Change World Bank Objectives or rationale Legal agreement For Official Use Only approval date Restructuring Level 2 April 10, 2020 -Modify project development objective to include outbreak preparedness and response -Modify RF, dropping, adding, or modifying indicators -Reallocate funds under Lesotho credit Restructuring Level 2 June 19, 2020 -Provide AF (Lesotho, Malawi, East, Lesotho (Credit 6695-LS; Additional financing Central and Southern Africa Health Amendment to Credit 5822- Total: US$56 million Community, AUDA-NEPAD) LS) August 25, 2020 Lesotho: US$21 million -Change closing date to December 31, Malawi (Credit 5864-MW; Malawi: US$27 million 2023 Grant D1170) April 23, 2020 ECSA-HC: US$5 million -Modify RF to reflect updated targets ECSA-HC (Grant D661) June AUDA-NEPAD: US$3 million -Add new subcomponent to focus on 29, 2020 COVID-19 and comorbidities AUDA-NEPAD (Grant D660) -Remove subcomponent 3.3 on regional June 29, 2020 coordination, policy advice, and harmonization with activities funded under grants to the two regional organizations -Modify procurement arrangements (Zambia) Restructuring Level 2 December 1, -Update RF to reflect exhaustion of funds 2022 and imminent closing in Zambia and Mozambique, increase targets for Lesotho and Malawi, and consider the impact of COVID-19 -Reallocate expenditures for Malawi and Zambia 2The datasheet lists the date on which the signed notification letter was sent to the World Bank Financing and Accounting unit as the date of restructuring (May 6, 2020). Page 6 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Restructuring Level 2 December 15, -Extend closing date by six months for 2023 Lesotho, Malawi, and AUDA-NEPAD -Revise RF indicators to reflect extension of closing date Revised POIs and Outcome Targets 17. The POIs were refined to formally add outbreak preparedness and response, reflecting ongoing support of these activities under the project. The revised POIs were to: (i) improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of the participating countries; (ii) strengthen regional capacity to manage the burden of TB and occupational lung diseases; and (iii) strengthen country-level and cross-border preparedness and response to disease outbreaks. The addition of POI (iii) was broadly in line with the original design, which included support for disease surveillance. 18. The POIs were modified at the time of the first restructuring (April 10, 2020), and three new POI indicators were added to better align with project activities, use more robust measures, and set more ambitious targets, building on achievements and enhanced data availability. The addition of the three POIs below was well justified. • POI 4: Pulmonary TB cases that are bacteriologically confirmed was added to enhance TB detection and notification (%). • POI 5: Miners and ex-miners successfully screened for occupational lung diseases was added to reflect the For Official Use Only project’s focus on occupational health and safet (number). • POI 7: Countries with multi-hazard preparedness plans developed was added to align with the new POI objective focused on disease outbreak preparedness (number). Revised Components 19. The original components were maintained throughout the entire implementation period, although some changes were introduced at the subcomponent level to better reflect evolving priorities. With the AF approved on June 19, 2020, a new subcomponent was added to the Lesotho credit and Malawi grant to focus on the COVID-19 response and comorbidities (Subcomponent 2.4). The new subcomponent aimed to reap synergies between project-supported activities and the COVID-19 pandemic response by adding critical activities: screening TB patients for COVID-19, given their greater vulnerability; screeningCOVID-19 patients for TB; leveraging achievements in TB sputum transportation networks for COVID-19 samples; and strengthening infection control. 20. Although the project components were not changed, selective activities were scaled up to expand geographic coverage and consolidate achievements. With the approval of the AF to the two regional organizations, critical activities were expanded to maximize development impact in all participating countries. For ECSA-HC, the focus was on expanding support for disease outbreak preparedness and response capacity, laboratory systems, and regional learning.3 For AUDA-NEPAD, the focus was on providing capacity-building and technical assistance to strengthen and scale up primary prevention of occupational lung diseases and improve compensation of miners 3 This included providing technical support and training to scale up key activities such as screening and surveillance at points of entry, preparing threat and hazard identification and risk assessments, conducting laboratory-based surveillance and antimicrobial resistance stewardship, strengthening infection control and bio-risk management, promoting One Health approaches, conducting cross-border simulations and investigations, designing early outbreak warning systems, rolling out integrated disease surveillance and response activities, strengthening laboratory quality systems towards accreditation, expanding uptake of new diagnostic testing, integrating COVID-19 screening with TB and occupational lung diseases, continuing to support knowledge sharing across countries, and providing technical assistance to CoEs. Page 7 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT and ex-miners. 4 Unlike the original project, under which financing to the two regional organizations was channeled through the IDA credits and grants, these organizations received individual grants as part of the AF to support their respective activities, with grant agreements signed directly with the World Bank, with the task team taking advantage of the availability of grants through the regional integration unit. Hence, Subcomponent 3.3 (regional coordination, policy advocacy, harmonization) was removed from the project, with all activities retained and funded under the two grants to the regional institutions and changes made only to the legal and finance agreements. Other Changes 21. The IOIs were also revised to ensure alignment with the PDO and the POIs, reflect greater data availability, and introduce better measures of project achievements. The original project had 15 IOIs. During the first restructuring in April 2020, two were dropped due to the lack of reliable data to track progress (proportion of miners eligible for compensation due to occupational diseases, number of countries with harmonized clinical protocols for occupational health in compliance with international best practices). With approval of the April and June 2020 restructurings, two IOIs were added (suspected outbreaks that are laboratory investigated; and TB patients tested using WHO-recommended diagnostics) to better track the effectiveness of project interventions. Likewise, the new corporate results indicator, people who have received essential health, nutrition, and population services, was added, replacing the POI on direct beneficiaries and the share of females among them.5 In 2020, minor changes were also introduced to the several IOIs to further clarify results attained For Official Use Only and better track progress. After the restructurings, the project included 13 IOIs. 22. The final targets for select indicators were adjusted toward the end of the project implementation period. The third level 2 restructuring (December 1, 2022) included revisions to select end targets to align them with what could be realistically achieved by project completion. These changes were necessitated by various implementation delays stemming from the COVID-19 pandemic that impeded case detection and screening activities and exhausted funds and procurement-related delays. The third restructuring also included tweaks to the RF indicators to correct minor errors. Rationale for Changes and Their Implications for the Original Theory of Change 23. The rationale for the four restructurings was clear and sound: adding a third objective (cross-border preparedness and response to disease outbreaks) that reflected activities increasingly supported under the project, including response to the COVID-19 pandemic; providing AF to Lesotho and Malawi to expand the scope, scale, and impact of the project and to the two regional organizations to expand their activities; modifying the RF to reflect greater availability of data and implementation experience; and providing a final six- month extension to use remaining funds and consolidate results. 24. The AF leveraged the initial achievements of the project and expanded its impact. The 2019 mid-term review found that 80 percent of the POIs and IOIs were on track. Nevertheless, implementation progress across the four countries was variable, with some countries absorbing funds more rapidly than others (Lesotho: 87 percent; 4 This included technical support and mentorship to strengthen the CoEs on OHS, conduct risk assessments in mining, roll out innovative dust-control measures, strengthen human resources on occupational health practices, accelerate revision of legislation and regulations, improve compensation systems, adopt occupational exposure limits, develop and adopt workplace guidelines to respond to COVID-19, publish and disseminate study results, facilitate knowledge sharing, and support advocacy at the national and regional levels. 5 The new corporate results indicator is a composite indicator that is measured as a sum of three sub indicators: number of children immunized, number of deliveries attended by skilled health personnel, and number of women and children who have received basic nutrition services. As noted in the Restructuring Paper (April 20, 2020), given the interventions supported under the project, only the third sub indicator was to be tracked. Page 8 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Malawi: 91 percent) and requesting AF. The approval of the AF to the two regional organizations in 2020 enabled all four countries to benefit from scale-up of select interventions, with an increased focus on disease outbreak preparedness and an expanded set of regional training and mentoring activities, reaping economies of scale and cost efficiencies. 25. Changes made during the restructurings were also necessitated by various implementation challenges. Delays stemmed from both the COVID-19 pandemic and general bottlenecks, such as difficulties undertaking inherently complex civil works, procuring specialized equipment (e.g., negative pressure equipment provided by few suppliers), and complying with safeguards requirements. There were also country-specific delays.6 26. The original theory of change remained highly relevant during the implementation phase, with reasonable modifications and tweaks introduced over time. The focus on strengthening health systems and promoting a multisectoral approach was maintained throughout the entire implementation period. The results chain was reviewed periodically for continued relevance, with appropriate adjustments to the POIs and IOIs indicators to introduce better measures of the project’s achievements using globally tracked indicators (e.g., TB patients using WHO-recommended diagnostics, TB cases bacteriologically confirmed, suspected outbreaks which are laboratory investigated, countries with multi-hazard preparedness plans), raise the level of ambition (e.g., laboratories rated 4+ (rather than 2+) stars on the SLIPTA assessment), and drop indicators that did not capture project activities well or proved impractical to collect based on implementation experience (e.g., miners eligible for compensation due to occupational diseases receiving it, countries with harmonized clinical protocols for For Official Use Only occupational health). II. OUTCOME A. RELEVANCE OF POIs 27. The relevance of the POIs is rated High. The project was fully aligned with the World Bank Regional Integration Assistance Strategy, April 2008 (Coordinated Interventions to Provide Regional Public Goods) and remains relevant and aligned with two strategic objectives (Scaling up Access to Quality Public Services and Entrepreneurship through Complementary Regional Solutions; Promoting Collective Action to Address Risks of Regional Economic Contagion, Fragility, Epidemic, and Climate Hot Spots) of the latest strategy.7 The project remained aligned with the Africa Regional Strategy (fiscal years (FY)2021-23), which aimed to reinforce the importance of strengthening disease surveillance and pandemic preparedness and aligning strategic goals with the World Bank COVID-19 response. A recent World Bank Independent Evaluation Group evaluation of the World Bank COVID-19 response highlighted the importance of regional projects, such as the SATBHSSP, in building health systems for preventing and responding to pandemics.8 28. The focus of the POIs on addressing public goods and promoting collective action was highly relevant and remained a priority throughout the entire implementation period. With TB becoming the leading cause of death from infectious disease in 2015, MDR-TB posing an increasing threat to health and development gains 6 Mozambique faced systemic challenges with issuing payments during the first two years of implementation that affected other projects in the health sector portfolio. Zambia experienced lengthy delays in securing contract approval from the attorney general’s office, with contractors unable to initiate civil works during the final years, which required that the number of civil works activities be reduced. Malawi encountered delays stemming from sluggish absorption of funds affecting other Bank-funded operations, as well as macroeconomic-related problems (e.g., shortages of foreign exchange). 7 Supporting Africa’s Transformation Regional Integration and Cooperation Assistance Strateg 018 -2023, approved on May 7, 2018. 8 The World Bank’s Earl Support to Addressing COVID -19 Health and Social Response: An Early-Stage Evaluation, November 15, 2022. Page 9 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT and skyrocketing TB infection rates in the mining sector in the sub-region, the POIs were highly relevant. Given that TB and other communicable diseases know no borders and considering the migration patterns in the sub- region, it was critical to adopt a regional approach, which ultimately proved its effectiveness. Collective action to manage TB and occupational lung diseases and to strengthen disease outbreak response capacity complemented and reinforced investments at the national level. 29. The project was aligned with the original country partnership strategies, recent country partnership frameworks, and national policies of the participating countries, which aimed to strengthen health systems, bolster human capital, and build resilient institutions.9 To this end, the project supported investments in health systems to build regional capacity for enhanced management of both TB and occupational lung diseases. The use of CoEs was well aligned with an assessment of the regional integration strategy that the Independent Evaluation Group conducted, which found that the most promising outcomes of regional operations were an increase in knowledge sharing and enhanced client understanding of regional issues and benefits.10 During the September-October 2023 ICR mission to the four countries, various stakeholders expressed appreciation for the knowledge-sharing activities supported under the project, noting considerable benefits of the peer-to-peer learning activities. B. ACHIEVEMENT OF POIS (EFFICACY) Assessment of Achievement of Each Objective/Outcome For Official Use Only 30. The project substantially achieved the three PDO parts. As discussed below, all POIs and IOIs were systematically compared against the latest baseline and target figures, by country and overall (total or average). Achievement of each PDO part was assessed against a standard rating system.11 A split rating was not applied given that the overall level of ambition was broadly maintained or expanded over time, with only minor reductions to some targets toward the end of the project implementation period.12 Objective 1: Improve coverage and quality of TB control and occupational lung disease services in targeted geographic areas of participating countries. 31. PDO 1 was substantially achieved, as indicated by both POIs and IOIs. Two POIs were fully achieved or surpassed (TB case notification in target geographic areas; miners and ex-miners successfully screened for occupational lung diseases), two were substantially achieved (TB treatment success rate [POI 2]: 83 percent; TB cases identified through active case finding [POI 3]: 88 percent), and one was not achieved (pulmonary TB cases that are bacteriologically confirmed [POI 4]: 8 percent). These results are directly attributable to the project given the focus on strengthening TB case detection, finding missing cases, and improving treatment success rates using newer, more efficient technologies (e.g., GeneXpert machines, digital x-rays), developing community-based models, and providing nutritional support for MDR-TB patients. The results on occupational 9 Lesotho: The World Bank Group Country Partnership Framework, FY24-28; Malawi: Country Partnership Framework, FY21-25, April 2, 2021; Mozambique: Country Partnership Framework, FY23-28, January 25, 2023; Zambia: Country Partnership Framework, FY19- 23, September 20, 2018. 10 Independent Evaluation Group. 2019. “Two to Tango—An Evaluation of World Bank roup’s Support for Regional Integration.” 11 The rating system used is as follows: surpassed/achieved: 100 percent+; substantially achieved: 80-99 percent; partially achieved: 65-79 percent; not achieved: <65 percent. For surpassed indicators, a weighted scale was used to reflect the degree of over- achievement. See Annex 6 for results. 12 When analyzing the initial and revised targets for the POIs the majority (nearly 60 percent) remained unchanged or increased, and the rest were reduced only slightly (1-6 percent). For the IOIs, the targets remained the same or increased for about 72 percent and were revised downwards for 28 percent, reflecting mainly unrealistic initial target setting (e.g., health facilities renovated, laboratories rated 4+ stars). The targets were adjusted to reflect exhaustion of funds or imminent closing of the project in Zambia (December 2022) and Mozambique (June 2023), increase targets for Lesotho and Malawi, and consider COVID-19 restrictions in 2020/21 that impeded case finding and screening activities (December 2022 restructuring). Annex 6 provides further details. Page 10 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT lung disease services are also attributable to the project, which established or strengthened occupational health centers (OHCs) and supported screening of miners and ex-miners and referral for treatment with complementary investments in capacity to bolster coverage and quality of services.13 The shortfall on the target for bacteriological confirmation of pulmonary TB cases reflects the continued overdependence on clinical diagnosis in Lesotho, Mozambique, and Zambia. 32. Performance on the IOIs contributing to PDO 1 was substantial, with many contributing directly to the results attained. Uptake of WHO-recommended diagnostics (IOI 4) was a key achievement, with the target substantially achieved (81 percent) and with most participating countries performing better than the African region average of 48 percent (Annex 7). 14 Accurate diagnosis is a fundamental component of TB care, with the roll-out of rapid molecular diagnostics supporting early detection, prompt treatment, and better quality. Indicators that are proxies for quality were fully achieved or surpassed, such as proportions of HIV patients routinely screened for TB (IOI 3), TB patients satisfied with services (IOI 2), and countries with established electronic health systems for TB case management such as Malawi’s E-Health-TEST system) or laboratory management (IOI 7). The proportion of MDR-TB patients benefiting from nutritional support, which contributed to treatment adherence, was partially achieved (78 percent). Overall, the number of women and children who received nutrition support (IOI 1b, corporate results indicator) surpassed the end target, with one country falling short. 15 IOI 12 on number of miners and ex-miners successfully referred for continuity of treatment for TB and other occupational lung diseases between and within participating countries was achieved overall except for Malawi, which set an excessively ambitious target. Objective 2: Strengthen regional capacity to manage the burden of TB and occupational lung diseases. For Official Use Only 33. PDO 2 was also substantially achieved. The only POI (project-supported laboratories compliant with regionally harmonized standard operating procedures for MDR-TB surveillance) for PDO 2 was surpassed. Most of the IOI end targets contributing to PDO 2 were achieved or surpassed (health facilities equipped, number of personnel receiving training, proportion of mines inspected at least twice a year complying with national mine health regulations, number of countries in which new legislation or amendment to existing mine health and safety legislation drafted and submitted to relevant authority, operational research studies commissioned and findings disseminated) or partially achieved (proportion of mines inspected at least twice a year, laboratories rated 4+ stars16). The IOI on health facilities renovated was not achieved as some countries scaled back these activities based on remaining funds and delays stemming from the COVID-19 pandemic but did not revise the end targets.17 34. These results are directly attributable to the project, given that institutional capacities were weak or non- existent at project inception, particularly for occupational lung diseases. The project supported activities that increased regional capacity to manage TB and occupational lung diseases, including harmonizing standard operating procedures, providing training, expanding diagnostic capacity, enrolling laboratories in the SLIPTA scheme, with six reaching international accreditation, and bolstering occupational health legislative and regulatory capacity, as discussed in greater detail in the institutional capacity section below. The cross-country 13 The introduction of harmonized clinical protocols for occupational lung diseases did not prove feasible, and the indicator was dropped after the mid-term review, so no direct measure of quality was tracked. 14 WHO Global TB Report, 2023. 15 Mozambique reached only 61 percent of the end target, mainly because of funding-related problems. As noted in the government’s ICR, discussions were initiated with the National Institute of Social Action to include people with MDR-TB in the social support program. 16 The percentage of targeted laboratories rated 4+ stars on the SLIPTA checklist reached only 77 percent because several made progress but experienced setbacks. With the benefit of hindsight, raising the target from 2+ to 4+ stars may have been excessively ambitious. 17 With the benefit of hindsight, some IOI targets on number of facilities renovated were excessively ambitious (Zambia: 45; Malawi: 108) and should have been revised during the earlier restructurings. Zambia and Malawi reached only 44 and 51 percent, respectively, of the end targets, whereas Lesotho reached 263 percent, and Mozambique reached 100 percent. Page 11 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT learning and knowledge sharing through the CoEs, communities of practice (CoPs), and collaborative platforms 18 and the support of the two regional coordinating organizations to manage TB (ECSA-HC) and occupational lung diseases (AUDA-NEPAD) also helped increase regional institutional capacity. Objective 3: Strengthen country-level and cross-border preparedness and response to disease outbreaks. 35. Achievement of PDO 3 is rated high overall. The only POI (number of countries with multi-hazard preparedness plans) for PDO 3 was fully achieved. The target on the proportion of suspected outbreaks that were laboratory investigated (IOI 5b) was surpassed, and the target on the number of outbreaks for which cross-border investigations were undertaken (IOI 5a) was achieved overall and partially achieved in Lesotho. These results are directly attributable to the project, which redoubled efforts to prevent and respond to disease outbreaks, which occurred with increasing frequency. This included establishing cross-border committees and implementing event-based surveillance. The cross-border committees, which did not exist before, have led joint responses to major outbreaks (e.g., COVID-19, 2017/18 cholera outbreak) and joint tabletop simulations (e.g., Ebola virus, anthrax).19 36. There was variation in some results across countries given the variable capacities, different epidemiological profiles, and unique country contexts. Lesotho and Malawi experienced setbacks in TB case notifications during the COVID-19 pandemic because of lockdowns and restricted population movements, and were able to partly recover in subsequent years. Malawi also experienced a 37 percent drop in new TB cases during 2015 to 2022, which made it increasingly difficult to find cases. On balance, the countries with stronger, more-resilient health systems— Mozambique and Zambia—were better able to mitigate the impact FIGURE 2: Tuberculosis For Official Use Only of the COVID-19 pandemic and make solid progress on virtually all Treatment Success Rate in POIs, 20 but with support from the two regional institutions, all New and Relapse Cases countries have bolstered institutional capacity and developed or 90 94 92 100 88 introduced innovative models of TB and occupational health, as 77 discussed below. 80 60 37. Overall, the project has contributed significantly to strengthening TB control programs in the participating countries, with solid 40 progress made toward the End TB Strategy targets (Annex 7). 20 Although most countries with a high TB burden globally were not on 0 track to reach the End TB targets (20 percent reduction in incidence and 35 percent reduction in deaths between 2015 and 2022), the four participating countries have performed relatively well. Malawi and Zambia met or surpassed both targets, and Lesotho and Mozambique met the mortality target. 21 Likewise, three of the four Source: 2023 Global TB Report countries met the WHO End TB treatment target (at least 90 percent of TB patients successfully treated) by project completion, with 18 Four CoPs operated throughout the entire implementation period and were led by different countries: M&E and research (Lesotho), laboratory and surveillance (Mozambique), TB continuum of care (Malawi), and OHS and mine health regulations (Zambia), with ECSA-HC supporting Lesotho, Malawi, and Mozambique and NEPAD-AUDA supporting Zambia. Likewise, a collaborative drug-resistant TB platform established to support cross-country learning played a significant role in accelerating uptake of WHO recommendations. 19 The geographic scope of the cross-border committees was expanded beyond the participating countries to include other zones (Tanzania/Malawi, Mozambique/Zimbabwe, Mozambique/Tanzania, Zambia/Democratic Republic of Congo). 20 For example, Mozambique adopted a comprehensive set of interventions to improve early detection and treatment outcomes. From 2017 to 2022, the TB notification rate rose from 84 to 95 percent, and the treatment success rate increased from 90 to 94 percent. With systematic screening of TB patients for HIV and a steep rise in TB preventive therapy among people living with HIV, TB/HIV co-infection rates fell from 40 to 25 percent. 21 WHO 2023 Global TB Report. Page 12 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Lesotho continuing to make progress (Figure 2). The treatment success rate for MDR-TB in all participating countries (Lesotho: 74 percent; Malawi: 76 percent; Mozambique: 75 percent; Zambia: 79 percent) surpassed the African average (71 percent). 22 The solid progress on treatment success is an important achievement because high-quality TB care is essential to prevent suffering and death from TB and to reduce transmission. Justification of Overall Efficacy Rating 38. The overall efficacy of the Southern Africa TB and Health Systems Support Project is rated Substantial. On balance, the scale of the achievements was considerable, given that the project targeted the most vulnerable groups and hard-to-reach geographic areas and was implemented during a pandemic. Four POIs met or exceeded their targets, two were substantially achieved, one was not achieved, and more than 81 percent of all IOI targets were fully or substantially achieved. C. EFFICIENCY Assessment of Efficiency and Rating 39. A cost-benefit analysis and an implementation efficiency analysis were conducted to evaluate the efficiency of the project, with the key results summarized below. Annex 4 provides details on the cost-benefit analysis. Cost-Benefit Analysis 40. A cost-benefit analysis was conducted to determine whether the project yielded greater benefits than costs. For Official Use Only The model and key assumptions used in the analyses at project appraisal23 and the AF and second restructuring of the project24 were replicated for the ICR. The basic assumption was that investing in cost-effective TB control and treatment interventions could reduce morbidity and mortality, which would reduce health care costs associated with TB treatment for the various governments, mining companies and other employers, communities, and family members; increase labor productivity and therefore increase revenue for mining companies and other employers; and provide a steady source of income for families of mine workers and others that could otherwise have been forfeited during illness or death. Collectively, these income gains are expected to increase gross domestic product (GDP) per capita for the participating countries. To estimate the benefits, the initial cost-benefit analyses used life years rather than disability-adjusted life years (DALYs), meaning that the initial analyses examined only mortality and not the quality of life of TB patients during and after the illness. To address this, DALYs were included in the cost-benefit analysis for the ICR. Furthermore, considering that several studies on the cost-effectiveness of TB interventions use DALYs as outcomes of interest, triangulating the results from the ICR with those of existing studies was possible. 41. The cost-benefit analysis was conducted for the combined set of project interventions, not for specific interventions. In each of the four countries, only the areas where the project was implemented were included in the analysis. It is worth noting that the project sought to promote shared prosperity and equity by focusing on the most disadvantaged areas and groups: mining and peri-mining regions; underserved populations; high incidence of poverty; high incidence of TB-HIV and MDR-TB; cross-border areas and transportation corridors; and labor-sending areas. 22 WHO 2023 Global TB Report. 23 World Bank. 2016. “Project Appraisal Document for the Southern Africa Tuberculosis and Health Systems Support Project (Report No. PAD1716).” World Bank, Washington, DC. 24 World Bank. 2020. “Project Paper. Additional Financing for the Southern Africa Tuberculosis and Health Systems Support Project (Report No. PAD3723).” World Bank, Washington, DC. Page 13 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT 42. Using the above assumptions, implementation experiences, and observed data, the number of DALYs averted during project implementation (2016–24) was calculated and costed. To guide the analysis, reference case guidelines for benefit-cost analysis in global health and development 25 and the Copenhagen consensus framework26 for evaluating the cost-effectiveness of health interventions were used. Each DALY averted through project interventions was converted to a monetary value by equating it to the GDP per capita over the implementation period. Project costs and benefits were discounted at 3 percent, and 5 and 10 percent were used for sensitivity analyses. 43. For the four countries combined, the project prevented 332,451 TB deaths (equivalent to 4,022,656 DALYs). At a 3 percent discount rate, the net present value of the project's benefits and costs were estimated at US$2.4 billion and US$153 million, respectively. It was estimated that the benefit-cost ratio (BCR) at the end of the project was 15.5:1, which implies that each US$1.0 invested in the project generated US$15.5. These results were compared with estimates at appraisal, recommended cost-effectiveness thresholds from within- and cross-country studies, and the 2023 GDP per capita for each country. The BCR at completion was much higher than the BCR of 6.3:1 at AF or second restructuring of the project,27 as well as the estimated BCR for sustained TB treatment in sub-Saharan Africa from a previous study (11.1).28 The estimated cost per DALY averted of US$45 is much less than the US$100 per TB DALY averted in low- and lower-middle income countries.29 The estimated cost per DALY averted of US$45 is highly cost-effective because it represents a fraction of the 2023 GDP per capita in the four countries: Lesotho (5 percent of US$878), Malawi (7 percent of US$673), Mozambique (7 percent of US$608), and Zambia (3 percent of US$1,369). Interventions that are less than the GDP per capita For Official Use Only in countries with low and medium Human Development Indexes are highly cost-effective.30 44. Based on the above results, the project was a highly viable investment for the four countries. The analysis used very conservative assumptions because other key investments were not included in the analysis, including investments in pandemic preparedness and response, control and mitigation of cholera outbreaks in Zambia and Malawi, COVID-19 response activities, and project benefits beyond the project implementation period. Consequently, it is likely that the analysis is an underestimation of the total benefits from the project. Implementation Efficiency Analysis 45. The regional design of the project led to economies of scale and cost efficiencies in delivery of key activities. Notable examples include regional training on a wide range of topics related to TB control, occupational health, and disease outbreak preparedness; joint operational research studies; harmonization of protocols and 25 Lisa A. Robinson, James K. Hammitt, Michele Cecchini, Kalipso Chalkidou, Karl Claxton, Maureen Cropper, Patrick Hoang-Vu Eo enou, David de Ferranti, Anil B. Deolalikar, Frederico uanais, Dean T. Jamison, Soonman Kwon, Jerem A. Lauer, Luc O’Kee ffe, Damian Walker, Dale Whittington, Thomas Wilkinson, David Wilson, and Brad Wong. 2019. “Reference Case Guidelines for Benefit- Cost Analysis in Global Health and Development.” https://content.sph.harvard.edu/wwwhsph/sites/2447/2019/05/BCA-Guidelines- May-2019.pdf. 26 https://copenhagenconsensus.com/copenhagen-consensus. 27 World Bank. 2020. “Additional Financing for the Southern Africa Tuberculosis and Health Systems Support Project (Report No. PAD3723).” World Bank, Washington, DC. 28 Ramanan Laxminarayan, Eili Y Klein, Sarah Darley, and Olusoji Adeyi. 2009. “Global Investments in TB Control: Economic Benefits.” Health Affairs 28 (Suppl 1): .w730-w742. 29 Maria Wang and Regina Osih. (2014). Benefits and Costs of the TB Targets for the Post-2015 Development Agenda. A Working Paper produced for the Copenhagen Consensus Centre for the Post-2015 Consensus. https://copenhagenconsensus.com/sites/default/files/health_viewpoint_tb_-_wang.pdf. 30 Rajabali Daroudi, Ali Akbari Sari, Azin Nahvijou, and Ahmad Faramarzi. 2021. “Cost per DALY Averted in Low, Middle-and High- Income Countries: Evidence from the Global Burden of Disease Study to Estimate the Cost-Effectiveness Thresholds. Cost Effectiveness and Resource Allocation 19: 7. https://doi.org/10.1186/s12962-021-00260-0. Page 14 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT guidelines and focus on best-buy TB interventions; and coordinated cross-border disease surveillance and outbreak preparedness activities. The pro-poor focus, with targeted geographic areas and vulnerable groups, directed resources to areas of greatest need, promoting allocative efficiency. 46. The technical support provided by the two regional organizations represented added value and resulted in efficiency gains. ECSA-HC and AUDA-NEPAD: (i) leveraged global evidence to design and develop the CoEs and co-managed the CoPs; (ii) documented results and facilitated knowledge sharing across countries; (iii) synthesized and provided policy and programmatic recommendations to decision makers, and (iv) brokered partnerships with specialized agencies.31 The two institutions prepared a wide range of technical documents, guidelines, and tools that were highly valuable in supporting countries improve the performance of their TB and occupational lung disease programs, as described in greater detail in the regional evaluation of the project.32 All stakeholders appreciated the value that the two regional organizations added, as noted during the ICR mission and at the final Regional Advisory Committee meeting in Livingstone, Zambia, in October 2023. 47. The roll-out of WHO-recommended diagnostic technologies supported more rapid diagnosis of TB, containing the spread of lethal MDR strains. Rapid diagnosis of MDR-TB has strong positive externalities, facilitating prompt treatment and averting its spread. As documented in a study on regional investments, placement of GeneXpert machines at a decentralized level averts more deaths and DALYs.33 The equipment acquired under the project to screen for occupational lung diseases fostered efficiencies by reducing turnaround time for results, increasing testing accuracy, and starting individuals on treatment more rapidly.34 The equipment was For Official Use Only instrumental in diagnosing TB and silicosis. The multi-platform technologies also increased diagnostic capacity during the COVID-19 pandemic, as GeneXpert machines were used for SARS-COV-2 testing. Although introduction of the new diagnostic technologies (e.g., GeneXpert, TrueNet in Lesotho, TB-Lamp in Zambia) increased efficiency, additional efforts are needed to expand coverage and ensure equipment maintenance. 48. Disease outbreak preparedness and response interventions mitigated the impact of outbreaks. It is well recognized that prompt, efficient management of outbreaks and pandemics can have large socioeconomic benefits. Conversely, as seen during the recent COVID-19 pandemic, these events can produce staggering losses in terms of lives and livelihoods.35 Hence, activities funded under the project to prevent and contain outbreaks enabled countries to respond in a timely fashion and minimize fatalities. For example, the project played a key role supporting the COVID-19 response. This included deploying trained surveillance teams across border zones; establishing COVID-19 testing centers; leveraging GeneXpert capability for SARS-COV-2 testing; expanding training of multisectoral rapid response teams at points of entry; supporting contact tracing, case management, and infection prevention and control measures; and conducting community awareness-raising campaigns. The ECSA-HC team played a pivotal role organizing cross-border surveillance and response activities and providing virtual training, leveraging its expertise in conducting similar interventions under Bank-funded regional 31 A few notable examples include mentorship of laboratory personnel by the African Society for Laboratory Medicine; technical supported from the Uganda TB Supranational Laboratory, which mentored the TB reference laboratories in the four countries; roll out of event-based surveillance in collaboration with the Africa CDC; and training on operational research through the International Union Against Tuberculosis and Lung Disease. 32 Regional Implementation Completion and Results Report, ECSA-HC, December 2023. 33 Simone Peart Boyce, Andrés A. Berruti, Helen Connolly, and Miriam Schneidman . 2015. “Evaluating the Economic and Health Impacts of Investing in Laboratories in East Africa: Development and Application of a Conceptual Framework .” World Bank, Washington, DC. 34 The introduction of digital x-ray equipment has reduced turnaround time for submitting results to clinicians from hours to minutes, accelerated preparation of workers’ medical reports with rapid electronic transmission , and reduced the cost of x-ray consumables. 35 Benoit Decerf, Francisco H. G. Ferreira, Daniel G. Mahler, and Olivier Sterck . 2020. “Lives and Livelihoods: Estimates of the Global Mortality and Poverty Effects of the COVID-19 Pandemic.” Policy Research Working Paper 9277. World Bank, Washington, DC. Page 15 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT projects.36 Support for the pandemic response allowed participating countries to quickly roll out surveillance of COVID-19 with personnel trained under the project providing valuable support to promptly test, trace, and isolate positive cases. Project-supported platforms such as the TB Situation Room played a key role in identifying and addressing bottlenecks early and mitigating the impact of the COVID-19 pandemic on case notification. 49. The project experienced some implementation delays and cost overruns. These delays stemmed from difficulties and delays in carrying out civil works (e.g., laboratories, health facilities, CoEs); procurement of specialized equipment, including preparing technical specifications; and compliance with environmental and social safeguards requirements (as discussed in greater detail in paragraphs 82 and 85). 50. Based on the cost-benefit and implementation efficiency analyses, overall efficiency is rated Substantial. D. JUSTIFICATION OF OVERALL OUTCOME RATING 51. The overall outcome is rated as Satisfactory. This is based on the project’s continued high relevance and substantial ratings on efficacy and efficiency. E. OTHER OUTCOMES AND IMPACTS Gender 52. The project’ pro-poor focus, which targeted the most-vulnerable groups and households, benefited both men and women. Targeting men was important given that most miners and ex-miners are male. Although the project did not explicitly track the number of women benefiting from greater access to TB services, women For Official Use Only benefited directly from expanded access to TB services and indirectly from improvement in TB outcomes in men. Moreover, following the mid-term review, a new corporate results indicator was added to track progress on provision of nutrition services (number of women and children who received nutrition services), which are critical for increasing adherence to TB treatment and, more generally, to mitigate the impact of high out-of- pocket spending. Institutional Strengthening 53. The project played an important role in strengthening human resources. This included training in TB control, laboratory systems, occupational health, private sector engagement in TB control, and disease outbreak preparedness and response—critical areas that were previously under-resourced. In total, roughly 24,600 personnel were trained, surpassing the project’s cumulative end target. Numerous stakeholders cited the mentorship activities for laboratory staff as an example of good practice during the ICR mission, as the regionally certified mentors provided practical, hands-on support. In Malawi, Mozambique, and Zambia, the project also supported master’s level training, with a greater impact in terms of strengthening the labor force. The human resources built under the project bolstered the capacity of the national TB programs, strengthened occupational health, and played important roles during the COVID-19 pandemic and other outbreaks. Despite the number of people trained, there remains a need to assess what knowledge providers have and whether they use that knowledge systematically, as the quality of TB care needs continual improvement. 54. The project contributed substantially to building regional capacity to manage both TB and occupational lung diseases with support of the two regional institutions (Box 1Error! Reference source not found.), which contributed to the results attained. Establishing and increasing institutional capacity was a key achievement of the project and part of its legacy, highlighting multiple innovations achieved through strong multisectoral national and regional collaboration. Notable examples include Malawi’s E-HEALTH-TEST System (Box 2Error! 36 The experience gained under the East Africa Public Health Laboratory Networking Project was leveraged to establish additional cross-border committees, conduct tabletop simulations, and carry out joint investigations. Page 16 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Reference source not found. ; Zambia’s TB Situation Room Error! Reference source not found.); Lesotho’s community-based TB management model (Error! Reference source not found.); and Mo ambi ue’s MDR-TB CoE. 37 With support of AUDA-NEPAD, the project raised the visibility of occupational health issues and strengthened capacity by producing occupational health policies, legislation, and regulations. A notable example is the recent enactment of the Lesotho Occupational Safety and Health Act 2024, which is designed to foster a national culture of preventative safety and health and ensure compliance with and enforcement of related measures. These institutional capacit efforts contributed to strengthening mine safet and protecting workers’ rights. The project also established or strengthened capacity to provide good-quality occupational health services to previously under-served groups. Notable examples include Zambia’s CoE on Occupational Health and Safety (Box 5) and Mo ambi ue’s O Cs (Box ), increasing miners’ and ex-miners’ access to screening for TB, occupational lung diseases, and comorbidities and improving access to compensation. BOX 1: GOOD PRACTICE IN LEVERAGING REGIONAL INSTITUTIONS The Bank team conducted a careful selection process and clearly delineated the roles and responsibilities of the two regional institutions based on their expertise and experience in tuberculosis (TB) control, laboratory systems, and disease outbreak preparedness and response (East, Central and Southern Africa Health Community, ECSA-HC) and occupational health and safety, private sector engagement, and related legislative and regulatory reforms (African Union Development Agency —New Partnership for Africa’s Development, A DA-NEPAD). For Official Use Only The two institutions added value to national investments by promoting evidence-based interventions, facilitating knowledge sharing in their respective areas, providing technical support to participating countries given variable capacities, coordinating or commissioning regional research and synthesizing findings and policy recommendations, reviewing innovative models and identif ing lessons e.g., Lesotho’s communit TB care model , and ensuring standardi ation of data ECSA -HC). They also leveraged specialized support from other agencies (e.g., African Society for Laboratory Medicine, Africa Centers for Disease Control and Protection, International Labor Organization, World Health Organization). Institutional structures were established to support coordination at the regional level (Regional Advisory Committee) and facilitate multisectoral collaboration at the national level (interministerial committees), which enabled stakeholders to discuss emerging challenges, address capacity constraints, and identify solutions. The Bank team took advantage of the availability of grant funding for regional institutions to eliminate the need for funding from the countries, which freed up resources to expand the scope of national activities. The regional institutions built their capacity with ECSA-HC subsequently selected to manage the new Africa Multiphase Programmatic Approach Regional Project and AUDA-NEPAD institutionalizing several initiatives through other programs. The regional institutional arrangements leveraged and deepened lessons learned from other regional projects (e.g., East Africa Public Health Laboratory Network Project, which ECSA-HC coordinated) and, in turn, informed the design of other World Bank–funded regional projects in Africa (Regional Disease Surveillance Systems Enhancement, Multiphase Programmatic Approach) and in Latin America and the Caribbean with continual refinements and improvements. A notable example is how ECSA-HC established a strong partnership with the Uganda Supranational TB Laboratory established under the East Africa Public Health Laboratory Network Project to assist the four countries build external quality assessment systems and develop strategic plans. 37 Mozambique constructed a state-of-the-art facility under the project to provide specialized medical, psychosocial, and nutrition support to patients suffering from this lethal strain of the disease and to increase treatment adherence. The MDR-TB CoE is working with stakeholders in rural areas to improve patient follow-up. The facility is an important public health asset that will assist Mozambique to expand coverage and improve the quality of the MDR-TB program, which is already generating important results. Page 17 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT 55. The project bolstered laboratory capacity, which was one of the weakest areas of health systems. Project- supported laboratories were enrolled in the SLIPTA scheme and its companion training and mentorship program (Strengthening Laboratory Management towards Accreditation), which allowed them to measure and increase quality and capacity, benchmark performance, identify bottlenecks, and introduce remedial measures, with the goal of progressing toward accreditation through a 5-star certification system. ECSA-HC developed a unique peer review mechanism to enable experts from participating countries to evaluate each other’s laboratories, building regional capacity and fostering knowledge sharing. 56. The project strengthened disease outbreak preparedness and response capacity. With technical support from ECSA-HC, participating countries bolstered their core preparedness and response capacities in line with the 2005 International Health Regulations, which included conducting International Health Regulations capacity assessments to measure preparedness readiness, identify gaps, and track progress;38 carrying out risk profiling using the WHO Strategic Tool for Assessing Risks to focus resources on priority hazards; establishing the Africa Centers for Disease Control and Prevention (CDC)–recommended event-based surveillance systems; strengthening antimicrobial resistance surveillance capacities; establishing or strengthening cross-border committees and capacities at ports of entry; developing multi-hazard public health emergency plans; conducting simulation exercises and intra- and post-action reviews; and strengthening human resources using the gold standard Field Epidemiology and Training Program. Project-supported facilities and trained personnel played a vital role in early detection of and rapid response to the outbreaks and public health disasters that hit the region, preventing transmission and minimizing case fatality rates. Examples include the 2018 cholera outbreak in For Official Use Only Malawi, Mozambique, and Zambia. 57. The project supported capacity building in operational research. The World Bank team mobilized support of the International Union Against Tuberculosis and Lung Disease, which trained representatives from the participating countries. Forty-eight operational research studies were completed, covering a wide range of thematic areas,39 with findings disseminated nationally, regionally, and globally. Three studies were conducted in all countries: cost-benefit analyses of the impact of TB, to document the high rate of return on these investments;40 a survey on out-of-pocket expenditures, to document the impoverishing effects of TB-related spending and identify mitigation measures;41 and opportunities for private sector participation in TB, including 38 This included support for the WHO Peer States Party Self-Assessment Annual Reporting Tool and the Joint External Evaluation, which consists of 24 indicators for the 13 International Health Regulation capacities needed to detect, assess, notify, report, and respond to public health risks and acute events of domestic and international concern. 39 Notable examples include Lesotho: TB Mortality in Health Facilities (2022); National TB Prevalence Survey (2019); workers’ exposure and control to silica dust and related occupational safety and health knowledge, attitudes and practice survey; and TB Drug Resistance Survey; Malawi: prevalence of pulmonary TB and TB/HIV among miners; assessment of TB measures in mining sector; and baseline mine health and occupational health; Mozambique: optima TB modeling; epidemiological profile of TB in domestic mine workers; TB service readiness survey; seroprevalence survey of COVID-19; and drug resistance survey; and Zambia: TB prevalence surveys; baseline assessment of silicosis; mine regulations and dust sampling study; assessment of TB under-reporting; and mapping of miners and ex-miners. 40 The Lesotho Benefit Cost Study demonstrated the benefits of the TB best-buy interventions supported under the project. The incremental cost-effectiveness ratio was estimated at US$196 per quality-adjusted life year saved, compared with GDP per capita of US$1,181, making the interventions cost-effective, with a rate of return of about US$9 for every US$1 invested under the project. The study found that productivity losses declined from 42 to 11 percent for drug-susceptible TB, although deaths remained high, and that the TB/HIV detection rate improved but that the treatment success rate was stable. 41 The out-of-pocket spending study in Mozambique was instrumental in documenting the magnitude of the problem and developing policy recommendations. The study found that a TB diagnosis decreased household income, productivity, and employment status; quantified medical and non-medical costs, with roughly 30 percent of patients experiencing catastrophic health spending (>20 percent of household income); and identified the main barriers to accessing TB treatment (e.g., transportation and other costs). Key Page 18 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT innovative public-private partnerships and regulatory capacity needs.42 Selection of the three main topics was strategic, as these are highly relevant and potentially transformative; for example, eliminating catastrophic spending on TB is one of the three Global End TB targets. The operational research studies were well done and proved useful in generating information about the TB burden and the situation in the mining sectors, producing evidence of what works and how it can be scaled up; identifying bottlenecks and proposing remedial actions, understanding the impact of high out-of-pocket spending on TB, and exploring opportunities for private sector engagement. BOX 2: M W ’ HEALTH SYSTEM Introduction of an innovative digital reporting system in 15 high TB burden districts resulted in: • Better TB management with the introduction of a digital dashboard that facilitated real-time tracking of test samples • Greater adherence as patients received short message service alerts reminding them to take their medications • Improved reporting as data is generated digitally and patients have unique barcodes BOX3: LESSONS LEARNED FROM ZAMBIA TUBERCULOSIS (TB) SITUATION ROOM For Official Use Only Zambia’s innovative TB Situation Room, a World ealth Organi ation–recommended good practice, mitigated the impact of the COVID-19 pandemic on TB services and ensured that the country remained on track to attain several 2020 End TB targets. TB incidence and mortality dropped by 25 and 72 percent, respectively, with the country surpassing its national targets (2015 – 22). With TB case notification hitting a low of about 35,000 in 2018, Zambia redoubled efforts in subsequent years and managed to sustain and increase notifications even during the COVID-19 pandemic, with notifications rising to 40,000 in 2020 and more than 50,000 by 2022. The TB Situation Room brought together national and provincial TB coordinators to monitor the situation and swiftly address emerging bottlenecks. Key data were tracked weekly, including TB patients notified, bacteriologically confirmed patients, mortality rates, and contacts traced. These reviews allowed for early detection of problems (e.g., stockouts of GeneXpert cartridges) and identification of solutions. Main lessons learned from the virtual TB Situation Room are related to the importance of enhanced communication (e.g., peers sharing ideas and solutions, interactions with national leadership, problem solving), strategic management (e.g., greater participation of provincial teams, identification of performance gaps), and increased ownership (e.g., bolstered accountability among stakeholders, proactive management). Sources Quick Brief Lessons from Zambia’s TB Situation Room, World Bank, March 0 3; ICR mission, October 0 3. strategies to reduce catastrophic spending were incorporated into the national TB control program (improve quality of services to ensure patients are diagnosed and treated promptly, develop monitoring systems to track barriers and costs), and a technical working group was established to explore opportunities for including patients in social protection schemes. 42 A notable example is the flagship study on Mine Health Regulation and Occupational Health and Safety Services in Southern Africa, which compared the legal frameworks and management systems for occupational health and safety in the four countries with international best practice; reviewed the engineering and management systems in place for dust control and monitoring practices in mines; and made recommendations that led to development of in-country OHS policies in Zambia and Lesotho, OHS profiles in Lesotho and Malawi, and development of occupational exposure limit guidelines and an occupational health management code of practice. Page 19 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT BOX 5: ZAMBIA’S CENTRE OF EXCELLENCE (COE) ON OCCUPATIONAL HEALTH AND SAFETY (OHS) Zambia served as the CoE on OHS, sharing good practices and lessons with the other countries. Even though Zambia’s Occupational Health and Safety Institute (OHSI) dates to 1945, there were persistent gaps in service delivery that stemmed from lack of specialized equipment, dilapidated infrastructure, and inadequate human resources capacity. Given that Zambian legislation requires pre-employment and annual screening of all mine workers for occupational lung diseases, it was critical to bolster screening and diagnostic capacity. To this end, the project supported Zambia to strengthen prevention, detection, and surveillance of occupational lung diseases, increase human resource capacity, introduce state-of-the-art diagnostic equipment, and modernize information systems. The OHSI has benefited from state-of-the-art equipment, including digital x-ray machines, spirometry machines for pulmonary function testing, B reading machines (a specialized chest x-ray used to identify occupational health diseases), and dust sampling and analysis technologies. These technologies have increased the accuracy of testing and reduced turnaround time for results. The OHSI has served as a regional training facility benefiting other countries, with Zambia being the only country to have the International Labor Organization–recommended B reading capacity to benchmark and validate screening results. The project supported the upgrading and renovation of OHSI centers and laboratories (Kitwe, Solwezi) to ensure that they comply with standards. Capacity building on OHS has involved both short-term training and degree programs to improve performance and expand labor force capacity. The CoE involved a collaborative, multisectoral effort of three ministries (Health, Mines and Mineral Development, Labour and Social Security), with each contributing according to its comparative advantage, breaking silos, and working toward a common goal. Joint mine inspections were conducted regularly, with roughly 265 mining companies inspected nationwide, to improve compliance with health and safety regulations and strengthen collaboration on crafting new policies and laws. The CoE has also established For Official Use Only collaborative arrangements with Copperbelt University to support research and training, hosted experts from more than 20 countries, and trained roughly 155 doctors and radiologists. An evaluation conducted by ECSA-HC and AUDA-NEPAD found that there has been a paradigm shift in provision of occupational health services, with progressive decentralization to additional provinces (e.g., Lusaka Solwezi) to expand access and coverage. The CoE has also supported outreach activities using well-equipped mobile trucks to reach additional underserved groups. The number of miners and ex-miners reached increased from about 68,000 in 2017 to nearly 73,000 in 2022. From 2017 to 2022, case notification for occupational lung diseases rose by nearly 57 percent. With improvements in screening, certification, and mine inspections, the number of ex-miners compensated through the Workers Compensation Fund Control Board has increased by 40 percent, but the total number remains low. The evaluation found that ex-miners were very satisfied with improved services tailored to their needs and provided in a confidential manner, reducing stigma. Although initial results are encouraging, the focus needs to be on institutionalizing and mainstreaming activities. Key priorities include adopting the five-year implementation strategy developed with support from AUDA-NEPAD, including plans to expand the scale and scope of activities to reach more beneficiaries; finalizing and adopting the sustainability plan, including innovative income- generating activities; clarifying the roles and responsibilities of each institution through a simple memorandum of understanding; ensuring adequate operating budgets for equipment calibration and procurement of reagents and supplies; and adopting recently prepared legislation to allow mine workers who have completed TB treatment to return to work and compel employers in non- mining sectors to bring their workers for screening. Page 20 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT BOX 6: OCCUPATIONAL HEALTH SCREENING (OHS) FOR MOZAMBICAN MINERS AND MIGRANT WORKERS The Mozambican Ministry of Health contracted the International Organization of Migration, a specialized nongovernmental organization with a strong track record of addressing the needs of migrant workers to establish and manage three OHC institutes (OHCIs; Ressano Garcia, Marien Ngouabi, Mandlakazi). As a result, Mozambiquan miners and ex-miners now have access for the first time to a comprehensive program of health services provided in a confidential setting and tailored to their needs, including earlier screenings, more-accurate diagnosis, and follow-up. The OHCIs also played a key role supporting ex-miners gain access to compensation packages from the Employment Bureau of Africa, a company that was originally established to recruit labor for the gold mines in South Africa. The OHCIs were established in strategic cross-border areas to reach a maximum number of migrant workers and were well integrated with other health services. The OHCIs are near the Employment Bureau of Africa offices, which manage contracts of miners seeking work in South Africa, to facilitate the screening and certification process. Over a three-year period, nearly 37,000 individuals were screened. This included TB screening using digital chest x-rays and screening for comorbidities (e.g., human immunodeficiency virus, hypertension, diabetes, hearing and vision loss), with referral for treatment. Roughly 2 percent of people screened for TB were found to be positive. In terms of occupational lung diseases, silicosis was the leading cause of morbidity, followed by TB. Nearly 160 individuals received compensation, amounting to 9,209,393 million rand (US$505,386). A recent evaluation found that community-level interventions led by community health workers were key to raising awareness of TB and occupational lung diseases, collecting sputum samples, and bolstering treatment adherence; OHCI activities were well organized, and the facilities were adequately staffed and equipped; and multisectoral workshops and coordination activities were effective in bringing stakeholders together. Several areas were identified as requiring an intensified effort, including equipment maintenance, sub-optimal treatment initiation for comorbidities, and speed of processing compensation claims. Likewise, continual For Official Use Only effort is needed to encourage miners to be screened, given fears of dismissal if they are diagnosed with a communicable disease. Health authorities and providers expressed satisfaction with the technical support provided by IOM as well as commitment to the transition plan. Community members appreciated the role played by community health workers, who provided knowledge and support to strengthen treatment adherence and facilitate access to care. Key stakeholders noted that the project raised the visibility of occupational health diseases that was lacking in the health system. The OHCIs are a good example of multisectoral collaboration between the public and private sectors and could serve as a model for other provinces in Mozambique to emulate, particularly those with rapidly growing informal or artisanal mining activity. Poverty Reduction and Shared Prosperity 58. Given that TB is a disease of poverty and that the project targeted some of the most vulnerable groups in the region, the project contributed to poverty reduction and shared prosperity. Targeting of both vulnerable groups (TB-affected individuals and households, miners and ex-miners and their families) and impoverished geographic areas (e.g., high TB burden regions; high HIV/AIDS burden regions, transport corridors, cross-border areas) focused attention on the neediest, maximizing the impact on poverty reduction. With enhanced TB case detection and treatment in target geographic areas, the project improved access and treatment outcomes of poor and underserved groups. Likewise, interventions supported under the project to screen miners and assist them access compensation directly affected some of the most vulnerable groups in these countries, who for the first time, were assisted to document their conditions and be compensated, even though the amounts received by some ex-miners were not always commensurate with the level of suffering. Unintended Outcomes and Impacts 59. COVID-19 Pandemic Response and Leprosy Diagnosis Capacity Building. Health system strengthening and capacity- building activities under the project played a pivotal role during the COVID-19 pandemic, before the PDO was revised to incorporate pandemic preparedness and response. As noted above, the project was one of the first in the sub- region to provide resources to respond rapidly to the pandemic, leveraging investments in disease surveillance, laboratory systems, and human resources. The emergence of clinical cases of leprosy necessitated an intensified Page 21 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT effort , with ECSA-HC playing an important role in rebuilding testing capacity for this neglected tropical disease in Malawi, Mozambique, and Zambia by leveraging its strong laboratory expertise.43 Private Sector Engagement 60. Given the pivotal role of the private sector in TB control, the project supported a flagship study to assess challenges and opportunities for broadening engagement. The study, conducted under the leadership of AUDA-NEPAD, informed development of a strategic framework for regional private sector engagement in TB control (2022–25) and a two-year action plan (2022–23) for each country. An assessment conducted at project completion cited several achievements: (i) enhanced regulatory capacity; regular joint mine inspections; training of private sector providers and traditional healers; signing of memoranda of understanding with private sector providers whereby governments provide drugs, reagents, and sputum collection services; and (v) enhanced coordination mechanisms. The assessment noted persistent challenges (e.g., inadequate incentives for private sector, negative provider attitudes, voluntary data reporting, weak referral mechanisms) and the need to intensify support and pilot innovative strategies (e.g., performance-based financing, extension of patient-based electronic system to private sector). Overall, AUDA-NEPAD provided excellent leadership in this area—supporting development of foundational policies and strategies, positioning countries to assume greater ownership of this agenda, and paving the way for greater private sector engagement. 44 III. KEY FACTORS AFFECTING IMPLEMENTATION AND OUTCOME For Official Use Only A. KEY FACTORS DURING PREPARATION Assessment of Project Design 61. Project design was informed by experiences of other regional operations. Key lessons were drawn from the East Africa Public Health Laboratory Networking Project (P111556), the first regional health project in the regional integration portfolio, that was successfully coordinated by ECSA-HC over a 10-year period. 45 The rationale for a regional project was clearly articulated, with good division of roles and responsibilities between national and regional institutions. Countries were designated to serve as CoEs, CoPs co-led by the respective country, and one of the regional organizations. The CoPs provided an opportunity to establish a pool of regional experts who collaborated on preparing annual work plans, monitoring results, and conducting joint periodic reviews. The CoPs combined with the CoEs to offer multiple opportunities for cross-country learning. 62. The design was bold and holistic in terms of vision. The project aimed to tackle major public health challenges (e.g., high rates of TB and occupational lung diseases) and adopted an ambitious multisectoral approach. Although the design may have taxed the capacities of national governments during the initial years, the task team mobilized high- level support for the project at the national and regional levels, and over time, coordination increased considerably. 63. The design was supported by specialized technical agencies and experts both internally and externally. Internally, the task team mobilized the support of specialists from mining and social development global practices. Externally, 43 ECSA-HC provided in-country training on the slit-skin smear microscopy method to 68 participants. After the training, 23 percent of 380 people screened for leprosy were found to have the disease. Rebuilding capacity to test for leprosy has been instrumental in enhancing management of this neglected disease. A am, K., et. al., “Reviving the Slit-Skin Smear Microscopy for Accurate Leprosy Diagnosis in Malawi, Mozambique, and Zambia.” ECSA-HC. 44 In an ongoing effort to sustain this work, AUDA-NEPAD developed the Programme for Investment and Financing in Africa’s Health and mobilized US$20 million, including for continuous support of the African Union Private Sector Engagement Framework and the Southern Africa Development Community Private Sector TB Strategy. 45 As noted in the East Africa Public Health Laboratory Networking Project ICR (September 15, 2021), based on its experience and performance in coordinating laboratory, surveillance, and cross border activities and interventions and sharing good practices, ECSA- HC was selected to manage the SATBHSS Project. Page 22 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT the team garnered support from numerous partners, such as the African Society for Laboratory Medicine, Africa CDC, and WHO and those specialized in OHS (see para. 66), which provided specialized expertise in their respective areas. Assessment of Project Risks 64. The PAD included a detailed discussion of risks. The project was viewed as high risk–high reward, given the numerous risks and yet the potential for impact. The main risks were appropriately identified: complexity of multisectoral work involving the ministries of Health, Mining, and Labor; capacity constraints at the national level, including on fiduciary issues; and coordination challenges between national and regional stakeholders. The risk ratings were well assessed, and the mitigation measures were appropriate. With the benefit of hindsight, the environmental and social risk should have been rated as Substantial rather than Moderate, given limited national capacity in this area. Overall, the Substantial risk rating was appropriate. Assessment of Institutional Arrangements 65. At the country level, implementation arrangements were well integrated into national structures . The goal was to leverage country systems, use implementing entities based on their comparative advantages, and rely on performance-based agreements to ensure accountability between the lead ministry (Ministry of Health) and implementing institutions. The national TB programs provided technical leadership, and existing PIUs were responsible for fiduciary arrangements. An interministerial national technical committee was responsible for ensuring coordination and for reviewing and approving annual work plans and budgets. These arrangements worked For Official Use Only generally well, even though there were some delays in staff recruitment. 66. At the regional level, the two coordinating organizations were selected competitively and carefully. ECSA-HC had a mandate to work on regional public health and a solid track record of coordinating similar regional projects for the World Bank and other institutions (e.g., Global Fund). It established a small, agile team with critical expertise in key areas (e.g., TB control, laboratory systems, M&E), which provided sustained support from inception to completion. AUDA-NEPAD was selected to manage occupational health activities and mine health regulation and to facilitate related cross-country learning. To this end, it leveraged global expertise from specialized agencies (e.g., International Congress on Occupational Health, International Hygiene Association, International Labor Organization, International Occupational Hygiene Association, Medical Bureau for Occupational Diseases, National Institute for Occupational Health, National Institute for Occupational Safety and Health, South African Institute for Occupational Hygiene); led analytic work; and supported countries strengthen their policy, institutional, and regulatory environments. B. KEY FACTORS DURING IMPLEMENTATION Factors Subject to Control of Government and Implementing Agencies 67. Commitment and Leadership: National and regional authorities demonstrated high-level support for the project, which was given flagship status at the heads of state meeting (July 2016), with the African Union confirming its commitment to the United to End TB goal. 68. Coordination and Engagement: Although there were teething problems in the first two years, coordination of activities across components, stakeholders, and countries improved substantially in subsequent years. By completion, key informants noted appreciation for the multisectoral activities and results on the ground, acknowledging the excellent collaboration at both the national and regional levels. Appropriate mechanisms were established to promote coordination and engagement. All participating countries established national interministerial technical committees to ensure engagement of key stakeholders from different sectors. At the regional level, ECSA-HC established a strong regional advisory committee to provide strategic leadership and oversight and ensure coordination with other projects. ECSA-HC and AUDA-NEPAD promoted high-level engagement of policymakers through annual meetings where key achievements were disseminated and commitments to policy Page 23 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT and institutional reforms were made. At the national level, there was strong ownership and engagement of key stakeholders, who led design and implementation of the innovative TB and OHS models of care. 69. Human Resources and Technical Capacity: To address capacity constraints identified at appraisal, all implementing agencies recruited additional personnel and received technical support. Recruitment encountered some difficulties and delays. Despite the technical support received, all participating countries faced difficulties in the design of civil works for laboratories, OHCs, TB wards, or MDR-TB CoEs and in procurement of specialized equipment. 70. Fiduciary: Although the project was implemented through existing PIUs, there was a need to further strengthen capacities in procurement and financial management. There were various delays in participating countries in recruiting fiduciary personnel, which contributed to procurement delays. There were some country-specific constraints, which also impeded implementation (see Factors Outside the Control of the Government and Implementing Agencies, below). 71. Environmental and Social Safeguards: National capacity to comply with environmental and social safeguards requirements was limited, a common problem found in similar operations. Safeguards specialists were recruited two years after effectiveness in most countries. Despite support from the World Bank and ECSA-HC teams, this remained a problem throughout implementation. Nevertheless, the ICR mission found some positive developments on social safeguards, with several countries introducing innovations (see Section III.B). 72. Monitoring and Evaluation: National authorities recognized the importance of strong M&E, as the project was For Official Use Only supporting various innovations, and there was a need to track progress, draw lessons, and make cross-corrections. Although all participating countries made concerted efforts to rely on national information systems whenever possible, there were delays in conducting baseline surveys (except in Malawi), which impeded monitoring in the early years. Nevertheless, once completed, the baseline surveys provided evidence of progress made and allowed some performance ratings to be upgraded to satisfactory. ECSA-HC played an important role in conducting regular data- quality audits and consolidating results at the regional level. With the combined efforts of countries through the CoPs and the technical support of the two regional organizations, there was a concerted effort to monitor and track results, use evidence-based indicators, and continually improve data quality and reliability. Factors Subject to World Bank Control 73. Adequacy of Supervision: The World Bank team was proactive and responsive during implementation, addressing emerging issues, identifying new opportunities, and brokering partnerships. Implementation support was strong, with good division of labor between headquarters-based and country office staff. At an early stage, the task team brought to management’s attention the need for ade uate budgets to supervise the regional operation. There was continuity in management of the project, with one task team leader leading the process from preparation through the mid-term review. The transition was timely and seamless, with intensification of supervision efforts during the COVID-19 pandemic and the last year of the project. Use of country-based co-task team leaders proved effective, as it allowed for hands-on support and enhanced coordination with other Bank-supported health operations in these countries. 74. Adequacy of Reporting: The timeliness and quality of reporting were excellent, with supervision missions conducted twice a year. The Implementation Status and Results Reports (ISRs) were comprehensive, with detailed information on implementation progress in countries and at the regional level. Key bottlenecks and issues were clearly identified in ISRs, which captured well the nature and scope of problems and included reasonable ratings—adjusted as implementation slipped and upgraded as it improved. Page 24 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Factors Outside Government and Implementing Agency Control 75. The main exogenous factor that impeded implementation was the COVID-19 pandemic, The pandemic resulted in disruptions in service delivery, with TB patients unlikely to seek care and more likely to have a negative outcome, particularly in Lesotho and Malawi. At the same time, as noted above, the project provided valuable support to respond to the pandemic in a timely manner in all four countries. 76. Macroeconomic and other country-wide issues also affected implementation. Notable examples include glitches in country systems that prevented timely disbursements across the portfolio, which blocked payments to suppliers (Mozambique); delays in contract approval from the attorney general’s office Zambia ; and devaluation of the currency or lack of foreign exchange (Malawi). 46 IV. BANK PERFORMANCE, COMPLIANCE, AND RISK TO DEVELOPMENT OUTCOME A. QUALITY OF M&E M&E Design 77. M&E was well designed. The PAD included a results chain with a good depiction of inputs, outputs, and outcomes. The POIs and IOIs for improving coverage and quality of TB control services were in line with international good practices and included standardized indicators that WHO recommended and tracked. IOIs were relied upon to monitor progress on occupational lung diseases (e.g., mines inspected twice a year for compliance, new legislation For Official Use Only or amendments to health and safety legislation drafted). To rectify this, one of the IOIs (miners and ex-miners referred and screened for TB and occupational lung diseases) was tracked as a POI after the restructuring. The IOIs related to the three main components were well identified and comprehensive (Figure 1). M&E Implementation 78. At the midterm review, the RF was carefully reviewed, and amendments were introduced. This included dropping some indicators that proved impractical to monitor, adding other indicators to better capture the explicit focus on disease outbreak preparedness and response capacity, and tweaking some targets to expand the scale (Figure 1). M&E was impeded by delays in completing baseline surveys, with most data available two years after effectiveness. Concerns over data reporting, quality, and effective monitoring were flagged by the World Bank team during the first two years, but implementation improved after the midterm review. M&E Utilization 79. The ECSA-HC played a key role in regularly consolidating and sharing results. The consolidated data were used to identify lagging areas that required attention and to take remedial action. The ECSA-HC data audits combined with the quality improvement initiatives were highly useful in identifying weaknesses and proposing corrective actions, with hands-on support to the respective country to remedy issues.47 80. The World Bank implementation support missions systematically assessed progress in achieving the POIs and IOIs. Aide memoires and ISRs provided detailed assessments of progress in meeting quarterly, annual, and cumulative targets; identifying bottlenecks; and recommending practical remedial actions. 46 In addition, toward project completion, the Malawi Ministry of Finance introduced a policy establishing a ceiling on salaries of contractors working at the PIU, which resulted in a huge drop in salaries and staff turnover. 47 For example, in Lesotho, introduction of a quality improvement initiative involved systematic review of implementation bottlenecks and identification of remedial actions, which increased TB case detection rates, with the national TB program now scaling up the initiative. In Malawi and Zambia, the quality improvement initiative was effectively used to improve TB case finding. Page 25 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Justification of Overall Rating of Quality of M&E 81. The overall rating for M&E is Substantial. Although the M&E framework was generally strong, there were some moderate shortcomings, particularly in the early years (e.g., delays in completing baseline surveys; concerns with reporting, quality, and monitoring). B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE 82. Environmental Safeguards. The project triggered Operational Policy 4.01 due to the renovation and construction of laboratories, OHCs, specialized CoEs; generation of infectious medical waste; and OHS concerns, including environmental health. The project was assigned an environmental category of B. Each country prepared an infection control and waste management plan and an environmental and social management framework (ESMF). Although the PAD noted that all participating countries had health projects that the World Bank has supported and were therefore familiar with safeguards requirements, there was recognition that capacity building and institutional strengthening would be needed. To this end, the PIUs in Lesotho, Malawi, and Mozambique contracted safeguards specialists to conduct safeguards screening in accordance with the environmental and social management framework. Site-specific environmental and social management plans were prepared for laboratories, OHCs, and incinerators, albeit with delays. After training by Africa CDC and ECSA-HC, implementation of measures in the infection control and waste management plans improved. Overall, the project complied with the environmental safeguard requirements, but there were recurrent difficulties and delays in compliance, with a Moderately Satisfactory rating during the entire period. For Official Use Only 83. Social Safeguards. Each participating country prepared a grievance redress mechanism (GRM). During the initial years, project teams finalized client feedback surveys to capture beneficiary perspectives. During project implementation, all countries tracked patient satisfaction with TB services. Lesotho systematically incorporated social safeguards measures and strategies in all components, serving as an example of good practice. 48 Malawi also introduced innovations in the GRM mechanism.49 All GRMs aimed to capture both complaints from patients and suppliers. Several complaints were noted during implementation, and all were successfully addressed, as noted in ISRs. The records of these complaints were well documented, and the World Bank team was kept well informed. No allegations of gender-based violence were raised. Overall, the social safeguards were rated Moderately Satisfactory during the implementation period. 84. Financial Management. The project’s financial management arrangements were rated Satisfactor for the entire implementation period. The participating countries and regional institutions maintained appropriate financial management arrangements, including ensuring staffing and conducting audits. There were a few exceptions flagged in ISRs, such as internal control weaknesses, problems with management of per diems, and poor record management on staff allowances (Zambia), but the overall Satisfactory rating was maintained. 85. Procurement. Performance on procurement arrangements and compliance was hindered by difficulties and delays encountered by the countries and regional institutions. Overall, performance was rated Moderately Satisfactory throughout virtually the entire period, with a few exceptions. Key issues which impeded implementation were delays 48 Key actions taken included assessing health care workers to review the impact of COVID-19 on their wellbeing and developing strategies for using the hospital-based wellness program to address concerns, conducting focus group discussions to improve TB knowledge and health-seeking behavior and to understand reasons for nonadherence (e.g., stigma), mobilizing key stakeholders (e.g., local chiefs, district health management teams, civil society) to ensure good participation at community-based integrated screenings, and using the GRM to monitor and resolve complaints. 49 The GRM was mainstreamed into the hospital ombudsman grievance redress system, which increases the likelihood of sustainability; potential users were sensitized on how to use the GRM; and multiple uptake channels (e.g., telephone hotlines, call centers) were established. Malawi also developed a contractor’s code of conduct. Page 26 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT in recruitment of procurement specialists (Lesotho, Mozambique, Zambia) and difficulties retaining qualified staff (Mozambique, Zambia), delays in processing high-value contracts, difficulties in designing inherently complex specialized infrastructure and elaborating technical specifications, and problems adhering to the World Bank’s Systematic Tracking of Exchanges in Procurement system. World Bank procurement specialists conducted regular assessments to track progress and made recommendations, as described in aide memoires. C. BANK PERFORMANCE Quality at Entry 86. The project was highly relevant, and the design was innovative. The participating countries had some of the highest TB incidence rates in the world, including in the mining sector. The health systems approach to TB proved its utility during the COVID-19 pandemic, when investments made under the project were leveraged to respond rapidly and efficiently. WHO-recommended technologies improved diagnostic capacity overall, and the trained frontline health care workers and public health officers were mobilized during both the pandemic and during frequent outbreaks. The partnerships established under the project helped leverage specialized expertise in TB control, occupational health, and operational research. The project was well aligned with country strategies and priorities. 87. The project benefited from a high-quality quality enhancement review. The quality enhancement review team endorsed the bold vision and the regional rationale, commending the team for the extensive work done. The task team addressed the key recommendations of the quality enhancement review: sharpening the health systems For Official Use Only approach to maximize the impact of investments and reap potential synergies, clearly describing activities to be supported under each component, and clarifying the roles and responsibilities of national and regional stakeholders. Quality of Supervision 88. The Bank team provided strong support throughout the 7.5 years of implementation, with intensified assistance during challenging periods. The team kept a consistent focus on the development impact of the project, ensuring its continued relevance and addressing emerging issues. The quality and candor of the performance ratings were high. Implementation support missions were conducted regularly and were well staffed to cover both technical and fiduciary aspects. Ratings were adjusted carefully to reflect performance. The task team kept the respective Country Management Units informed about bottlenecks and sought their support to resolve portfolio-wide issues. Throughout the implementation phase, the Bank team also ensured close collaboration and coordination with other development partners to minimize risk of duplication. Changes in task teams were managed carefully to minimize disruption to implementation support, and the co-management arrangements for the task team leader role represented good practice. In the final stage of the project, the Bank team secured six-month extensions for Lesotho and Malawi to enable them to consolidate achievements and fully utilize remaining funds.50 The Bank team also worked closely with counterparts to develop plans and strategies for the sustainability of investments. Justification of Overall Rating of Bank Performance 89. W k’ . The World Bank team prepared an innovative project, provided strong support, and brokered strategic partnerships. During the ICR mission, government counterparts expressed satisfaction with the World Bank’s support and collaboration. 50 With the extension, Lesotho rolled out an ambitious community-based TB campaign that targeted high-risk groups and tested nearly 27,000 individuals. Drawing on lessons learned during implementation, the campaign used the four symptoms test, x-rays, and laboratory diagnostic testing. An evaluation (quantitative and qualitative) of the campaign found that deployment of mobile teams and leveraging of community structures was critical to increasing case detection and prevention. The evaluation also identified corrective actions (Lesotho District Campaign Report, Ministry of Health, 2024). Page 27 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT D. RISK TO DEVELOPMENT OUTCOME 90. The main risk to maintaining the gains made under the project lies in ensuring continued availability of human and financial resources. Although the project has left important public health assets (e.g., CoEs, public health laboratories, OHCs), these require adequate staffing and operating budgets. The human resources trained under the project are also important assets, and the new multi-platform diagnostic technologies have proven their usefulness for rapid, accurate diagnosis of TB and other infectious diseases. There is a need for participating countries to provide adequate recurrent funding to maintain staffing levels, procure reagents, and maintain equipment to ensure optimal functioning of project-supported facilities. Furthermore, it is essential to ensure that providers systematically use the knowledge acquired. Other exogenous risks that may hinder the project’s development impact are related to frequent public health events, which can divert staff and resources. At project completion, the World Bank teams discussed options and strategies for enhancing prospects of sustainability with counterparts, including transfer of key activities to other development partners or to other Bank-funded investment operations (e.g., Eastern and Southern Africa Health Emergency Preparedness, Response and Resilience Project using the multiphase programmatic approach);51 absorbing personnel paid by the project; making OHCs self-sufficient; and mobilizing support for MDR-TB patients through social safety net programs. V. LESSONS AND RECOMMENDATIONS 91. The main lessons are summarized as follows. For Official Use Only • Regional investments generate economies of scale and foster synergies. Recognizing that countries may not always have the incentive to invest in public goods, given that benefits accrue to other countries, a coordinated regional approach was adopted and proved its added value. Regional investments require a rigorous process for selecting coordinating organizations and clearly delineating roles and responsibilities, as was done in the selection of ECSA-HC and AUDA-NEPAD. Sustained support to regional institutions is critical for strengthening knowledge sharing, reaping economies of scale, building capacity on the continent, and providing technical support to participating countries to address variable capacities. A notable example is ECSA- C’s engagement in regional projects, which now spans more than 15 years, with important capacity established and with continual learning and knowledge sharing across investment operations and countries. For example, peer-to-peer learning was effectively used to facilitate mentorship, with countries with greater capacities supporting others to accelerate implementation, such as Lesotho learning from Zambia’s successful TB Situation Room, Malawi sharing its promising event-based surveillance system with Mozambique, and all four participating countries benefiting from mentoring and support from Ken a’s Medical Laborator E uipment Maintenance and Calibration Centre established under the EAPHLNP. • Empowering countries to innovate and share good practices promotes ownership and helps build a regional pool of experts working together to solve common problems. The CoEs and innovations supported under the project (e.g., Lesotho’s community-based management of TB and wellness centers, Zambia’s TB Situation Room and OHSI, Mo ambi ue’s occupational health screening centers for miners and migrant workers, Malawi’s E- Health-Test System) are good examples of investments that will continue beyond the life of the project. • Health systems and multisectoral approaches to TB and occupational health are highly effective. Investing in health systems to tackle communicable diseases not only enhances management of testing and treatment, but also can have potential benefits for other public health problems. Investments in new technologies, laboratory systems, OHCs, and isolation wards represent important public health assets for future disease outbreaks and for the rising burden of noncommunicable diseases. The multisectoral collaboration on occupational health was 51 Both Malawi and Zambia have recently received funding to increase health system resilience and multisectoral preparedness and response to health emergencies, which includes, inter alia, continued support for human resources, laboratory systems, and new technologies with a view to providing patient-centered health care that will draw on lessons learned in provision of TB and occupational health services under the project. Page 28 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT innovative, with countries demonstrating the benefits of coordinated action and strong interministerial committees. • TB control efforts are challenging and require coordinated action and continual training. The most cost-effective TB interventions are well known, but an intensified effort is needed for their successful implementation. TB control requires collaboration of many actors (e.g., community health workers, clinicians, laboratory technicians, district authorities). The risk of patients dropping out along the TB care cascade remains high as they face multiple barriers such as stigma, affordability, and geographic access. Health care workers require continual training and mentoring in use of best-buy interventions and new technologies, as supported under the project. Countries need to better track and monitor progress using innovative tools (quality improvement initiatives; TB Situation Room; Service Delivery Indicator surveys that assess provider knowledge, effort, and ability) while learning, innovating, and taking corrective actions. The project served as a strong platform from which to share good practices in TB control and occupational health. • Operational research underpins the design of a good project. The studies supported under the project were critical to adopting evidence-based approaches. The studies addressed priority issues, documented good practices, identified bottlenecks, and helped monitor and track progress. Study findings were well disseminated, and forward-looking plans were produced to translate recommendations into actions. Having two regional institutions with expertise in different areas was helpful in producing high-quality operational research. • Partnerships are critical. Brokering strong partnerships can help mobilize specialized expertise, minimize risk of duplication, and maximize development impact. The project served as an example of good practice, with multiple partnerships and collaborative arrangements at the national and regional levels. The interministerial platforms demonstrated how various sectoral ministries—Health, Labor, Mining—can work in new ways to address long- For Official Use Only standing public health and occupational health issues. With the enhanced availability of resources for neglected occupational health diseases, stakeholders increasingly appreciated the benefits of collaborative efforts. The use of two regional institutions with expertise and comparative advantages in different fields contributed immensely to the strong coordination and engagement of multiple sectors and stakeholders. The judicious selection of the regional institutions was critical to the successful implementation. Although joint efforts are typically associated with high transaction costs, the project illustrated that the benefits of leveraging specialized expertise outweighed the cost of coordination between ECSA-HC and AUDA-NEPAD. The Regional Advisory Committee served as a strong platform for coordinating activities between the two regional institutions. The collaborative efforts with the private sector on occupational health were innovative, with good results in terms of increasing mine inspections, expanding screening of miners and ex-miners, and facilitating access to compensation from South Africa. • Planning for sustainability from an early stage is crucial. Given that investment operations have a limited lifespan, it is advisable to seek government commitment from the inception to take over operational costs progressively to foster continuity and ensure long-term sustainability. 92. The key recommendations are summarized as follows. • Expand use of regional investments for other public health problems. In addition to pandemic preparedness and response, regional investments need to give a greater focus to the rising burden of noncommunicable diseases. The recently approved Eastern and Southern Africa Health Emergency Preparedness, Response, and Resilience Program Using the Multiphase Programmatic Approach (P180127) is an example of such an innovative operation that can be potentially transformative by addressing health threats from outbreaks, communicable diseases such as TB, and noncommunicable diseases. • Use TB outcomes to measure health system performance. Given the complex, challenging nature of TB control efforts, countries and development partners should consider using TB control outcomes as proxies for measuring health system performance and progress toward universal health coverage. • Enhance accountability at all levels. The WHO-recommended Multi-Sectoral Accountability Framework to Accelerate Progress to End TB by 2030 can be used more systematically to mobilize and hold accountable multiple stakeholders (e.g., public sector, civil society, private sector). Implementation of Regional Private Sector Engagement TB Strategic Framework action plans can enhance chances of sustainability. • Strengthen metrics for ongoing evaluation of the impact of investments. Although knowledge of tools for measuring progress is widespread, more needs to be done to systematically monitor the impact of investments. Page 29 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Two examples are worth noting. First, the impact of training and mentoring needs to be continually evaluated to determine provider knowledge, effort, and ability. Second, during public health events, there is a need to measure how quickly countries respond and how this affects case fatalities. • Request that governments provide modest levels of counterpart funding from the inception and gradually increase funding during the life of an investment operation. This would ensure that the investments made under Bank-funded operations would be adequately sustained by completion. For Official Use Only Page 30 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS @#&OPS~Doctype~OPS^dynamics@icrresultframework#doctemplate A. RESULTS FRAMEWORK PDO Indicators by Outcomes Not Categorized Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year 679,703.00 Jun/2024 734,025.00 Jun/2024 TB case notification in target Comments on achieving targets Lesotho: 46,955/ 61,629 (76%) Mozambique: 413,349/ 359,103 (115%) Zambia: 198,201/ 175,749 (113%) geographic areas (Number) Malawi: 75,520/ 83,222 (91%) TB Treatment success rate among 93.00 Jun/2024 new and relapse TB cases in target Comments on achieving targets Lesotho: 81%/ 90% (53%) Mozambique: 97% 90% (333%) Zambia: 93%/ 95% (80%) Malawi: 91%/ 95% (68%) geographic areas (Percentage) TB cases identified through active TB 11,932.00 Dec/2014 104,582.00 Jun/2024 case finding (screening) among TB Comments on achieving targets Lesotho: 168,188/ 29,322 (55%) Mozambique: 10,228/ 9,860 (104%) Zambia: 58,150/ 54,000 (108%) Malawi: vulnerable population in target 7,805/ 11,400 (68%) geographic areas (Number) Proportion of pulmonary TB cases 68.00 Jun/2024 55.00 Jun/2024 that are bacteriologically confirmed Comments on achieving targets Lesotho: 45%/ 80% (-192%) Mozambique: 44% 55%/ (42%) Zambia: 60%/ 72% (43%) Malawi: 69%/ 65% (157%) (Percentage) Number of miners and ex-miners 45,453.00 Aug/2019 256,100.00 Jun/2024 363,892.00 Jun/2024 successfully screened for Comments on achieving targets Lesotho: 12,833/ 5,100 (252%) Mozambique: 41,528/ 31,000 (134%) Zambia: 295,684/ 214,000 (138%) Malawi: occupational lung diseases 13,847/ 6,000 (231%) (Number) Page 31 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Number of project supported Comments on achieving targets Lesotho: 1/ 1 (100%) Mozambique: 49/ 61 (80%) Zambia: 48/ 30 (160%) Malawi: 57/ 50 (114%) laboratories compliant with regionally harmonized SOPs for surveillance of MDR-TB – national and sub national levels (Number) Number of countries with multi 4.00 Jun/2024 hazard preparedness plans Comments on achieving targets Lesotho: 1/ 1 (100%) Mozambique: 1/ 1 (100%) Zambia: 1/ 1 (100%) Malawi: 1/ 1 (100%) developed (Number) Intermediate Indicators by Components Not Categorized Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Proportion of MDR-TB patients in 47.00 Jan/2016 84.00 Jun/2024 target geographic areas benefitting Comments on achieving targets Lesotho: 100%/ 97%/ (250%) Mozambique: 52%/ 85% (61%) Zambia: 0%/ 95% (NA) Malawi: 100%/ 100% (100%) from nutritional support during the treatment period (Percentage) People who have received essential 18,142.00 Jun/2024 27,113.00 Jun/2024 health, nutrition, and population Comments on achieving targets Lesotho: 23,178/ 14,300 (162%) Mozambique: 1,477/ 2,523 (59%) Zambia: 1,483/ 939 (158%) Malawi: 975/ 380 (HNP) services (Number) (257%) Number of women and 4,262.00 Oct/2020 18,142.00 Jun/2024 27,113.00 Jun/2024 children who have received Comments on achieving targets Lesotho: 23,178/ 14,300 (162%) Mozambique: 1,477/ 2,523 (59%) Zambia: 1,483/ 939 (158%) Malawi: 975/ 380 basic nutrition services (257%) (Number) Proportion of TB patients satisfied with TB services as per patient exit Comments on achieving targets Lesotho: 89%/ 90% (94%) Mozambique: 0%/ 85% (703%) Zambia: 94%/ 84% (350%) Malawi: 98%/ 100% (52%) surve s or “drop bo ” feedback in target geographic areas (Percentage) Percentage of HIV patients routinely 83.00 Dec/2015 95.00 Jun/2024 screened for TB in targeted Comments on achieving targets Lesotho: 95%/ 95%/ (100%) Mozambique: 100%/ 90%/ (140%) Zambia: 97%/ 97% (100%) Malawi: 99%/ 99% geographic areas in the four (100%) Page 32 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT participating countries (Percentage) Proportion of new and relapse TB 76.00 Jun/2024 patients tested using WHO- Comments on achieving targets Lesotho: 93%/ 90% (175%) Mozambique: 79%/ 65%/ (193%) Zambia: 85%/ 100% (15%) Malawi: 41%/ 50% (50%) recommended diagnostics at the time of diagnosis. (Percentage) Outbreaks of infectious diseases for 3.00 Dec/2015 38.00 Jun/2024 43.00 Jun/2024 which cross-border investigations Comments on achieving targets Lesotho: 6/ 8 (75%) Mozambique: 9/ 9 (100%) Zambia: 13/ 10 (130%) Malawi: 15/ 11 (136%) undertaken (Number) Proportion of suspected outbreaks of 94.00 Jun/2024 communicable diseases that are Comments on achieving targets Lesotho: 100%/ 100% (100%) Mozambique: 100%/ 100% (100%) Zambia: 100%/ 100% (100%) Malawi: 100%/ laboratory investigated 75% (200%) (Percentage) 167.00 Jun/2024 102.00 Jun/2024 Number of health facilities renovated (Number) Comments on achieving targets Lesotho: 21/ 8 (263%) Mozambique: 6/ 6 (100%) Zambia: 20/ 45/ (44%) Malawi: 55/ 108 (51%) 0.00 Aug/2019 Health facilities equipped (Number) Comments on achieving targets Lesotho: 50/ 30 (167%) Mozambique: 392/ 400 (98%) Zambia: 274/158/ (173%) Malawi: 104/ 107 (97%) Number of countries scaling up 4.00 Jun/2024 Electronic Health Systems for TB case Comments on achieving targets Lesotho: 1/ 1 (100%) Mozambique: 1/ 1 (100%) Zambia: 1/ 1 (100%) Malawi: 1/ 1 (100%) management or laboratory management (Number) Number of targeted labs rated 4 stars 0.00 Dec/2016 13.00 Jun/2024 10.00 Jun/2024 and above in SLIPTA assessment Comments on achieving targets Lesotho: 3/ 3 (100%) Mozambique: 1/ 3 (33%) Zambia: 3/ 3 (100%) Malawi: 3/ 4 (75%) (Percentage) 59.00 Jun/2024 Proportion of mines inspected at least twice a year (Percentage) Comments on achieving targets Lesotho: 100%/ 90% (125%) Mozambique: 42%/ 50% (84%) Zambia: 28%/ 70% (-20%) Malawi: 67%/ 90% (74%) Proportion of mines inspected at least twice a year complying with Comments on achieving targets Lesotho: 57%/ 72% (79%) Mozambique: 84%/ 50% (168%) Zambia: 83%/ 52% (160%) Malawi: 68%/ 60% (113%) national mine health regulations (Percentage) 230.00 Dec/2015 13,156.00 Jun/2024 Page 33 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Number of personnel receiving Comments on achieving targets Lesotho: 8,399/ 876 (959%) Mozambique: 3,373/ 4,040 (83%) Zambia: 5,989/ 4,200 (143%) Malawi: 6,848/ training (Number) 4,040 (170%) Number of countries in which new 1.00 Jan/2016 4.00 Jun/2024 legislation or amendment to existing Comments on achieving targets Lesotho: 1/ 1/ (100%) Mozambique: 1/ 1/ (100%) Zambia: 1/ 1/ (100%) Malawi: 1/ 1/ (100%) mine health and safety legislation are drafted and submitted to relevant authority (Number) Number of miners and ex-miners 8,361.00 Jun/2024 8,597.00 Jun/2024 successfully referred for continuity of Comments on achieving targets Lesotho: 179/ 135 (133%) Mozambique: 7,943/ 7,500 (106%) Zambia: 408/ 466 (88%) Malawi: 67/ 260/ (26%) treatment for TB and other occupational lung diseases between participating countries and within participating countries (Number) Operational research studies 44.00 Jun/2024 commissioned and findings, lessons Comments on achieving targets Lesotho: 7/ 8 (88%) Mozambique: 9/ 11 (82%) Zambia: 12/ 12 (100%) Malawi: 20/ 13 (154%) learnt disseminated through national and regional platforms (Number) Operational research studies 3.00 Jun/2024 commissioned and findings, lessons Comments on achieving targets 3/ 3 (100%) learnt disseminated through national and regional platforms (ECSA-HC) (Number) Operational research studies 0.00 Aug/2019 commissioned and findings, lessons Comments on achieving targets 2/ 2 (100%) learnt disseminated through national and regional platforms (AUDA- NEPAD) (Number) For Official Use Only For Official Use Only Page 34 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT B. KEY OUTPUTS Improve coverage and quality of TB control and occupational lung disease services in targeted areas POI indicators • TB case notification in target geographic areas • TB treatment success rate among new and relapsed TB cases in target geographic areas • TB cases identified through active TB case finding (screening) among in TB-vulnerable populations in target geographic areas • Proportion of pulmonary TB cases that are bacteriologically confirmed • Number of miners and ex-miners successfully screened for occupational lung diseases For Official Use Only For Official Use Only Key outputs • Proportion of MDR-TB patients in target geographic areas benefiting from nutritional (linked to support during the treatment period achievement of • Number of women and children who have received basic nutrition services POI outcome) • Percentage of HIV patients routinely screened for TB in targeted geographic areas in the four participating countries • Proportion of new and relapsed TB patients tested using World Health Organization– recommended diagnostics at the time of diagnosis • Number of miners and ex-miners successfully referred for continuity of treatment for TB and other occupational lung diseases between participating countries and within participating countries Strengthen regional capacity to manage the burden of TB and occupational diseases POI indicators • Number of project supported laboratories compliant with regionally harmonized standard operating procedures for surveillance of MDR-TB at the national and sub national levels Key outputs • Number of personnel receiving training (linked to • Number of countries in which new legislation or amendments to existing mine health and achievement of safety legislation are drafted and submitted to relevant authority POI outcome) • Number of health facilities renovated • Number of health facilities equipped • Number of countries scaling up Electronic health systems for TB case management or laboratory management • Number of targeted labs rated 4+ stars on Stepwise Laboratory Improvement Process Towards Accreditation assessment • Proportion of mines inspected at least twice a year • Proportion of mines inspected at least twice a year complying with national mine health regulations Strengthen country-level and cross-border preparedness and response to disease outbreaks POI indicators Number of countries with multi hazard preparedness plans developed Key outputs • Outbreaks for infectious diseases for which cross-border investigation undertaken (linked to • Proportion of suspected outbreaks of communicable diseases that are laboratory achievement of confirmed POI outcome) Regional learning and innovation and project management Page 35 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Intermediate • Operational research studies commissioned and findings and lessons learned disseminated results through national and regional platforms indicators • Operational research studies commissioned and findings and lessons learned disseminated through national and regional platforms (East, Central and Southern Africa Health Community) • Operational research studies commissioned and findings and lessons learned disseminated through national and regional platforms (African Union Development Agency—New Partnership for Africa’s Development) Note: POI, project outcome indicator; TB, tuberculosis. Page 36 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT AND SUPERVISION A. TASK TEAM MEMBERS Name Role Humberto Albino Cossa Team Leader John Bosco Makumba Team Leader Kavita Phyllis Watsa Team Leader Paul Welton Financial Management Specialist Tandile Gugu Zizile Msiwa Financial Management Specialist Henry Amena Amuguni Financial Management Specialist Trust Chamukuwa Chimaliro Financial Management Specialist Joao Tinga Financial Management Specialist Baison Banda Financial Management Specialist Patrick Kabuya Financial Management Specialist Wedex Ilunga Procurement Specialist Amos Martinho Malate Procurement Specialist Gisbert Kinyero Procurement Specialist Tesfaye Ayele Procurement Specialist Komana Rejoice Lubinda Procurement Specialist George Daniel Procurement Specialist Raymond Joseph Mbishi Procurement Specialist Eliot Kalinda Procurement Specialist Anthony Aggrey Msendema Procurement Specialist Antonio Laquene Chamuco Procurement Specialist Christopher Mark Ingoe Environmental Specialist Samantha Germaine Braid Environmental Specialist Paulo Jorge Temba Sithoe Environmental Specialist Ntaoleng Mochaba Environmental Specialist Bruno Nhancale Environmental Specialist Mercy Chimpokosera-Mseu Environmental Specialist Njavwa Namposya Chilufya Social Specialist Kudakwashe Dube Social Specialist Page 37 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Keeena Malefane Social Specialist Davies Madalitso Luhanga Social Specialist Isabella Micali Drossos Counsel Maria Nhassengo-Massingue Peer Reviewer Nikolai Alexei Sviedrys Wittich Procurement Team Mohammad Ilyas Butt Procurement Team Gloria Sindano Procurement Team Yvette M. Atkins Procurement Team Blessing Karadzandima Procurement Team Kutemba Chilila Kambole Procurement Team Matsemane Seitebatso Tsemane Procurement Team Lebekoane Ntoi Procurement Team Chalwe Shanice Chisenga Procurement Team Noel Chisaka Team Member Celia Jose Amosse Team Member Peter Boere Team Member Elvis Teodoro Bernado Langa Team Member Jonathan Aspin Team Member Maiada Mahmoud Abdel Fattah Kassem Team Member Jaime Nicolas Bayona Garcia Team Member Imma Ismaily Killasama Team Member Collins Owen Francisco Zamawe Team Member Saba Gheshan Team Member Thulani Clement Matsebula Team Member Nilsa Ricardina Joao Come Team Member Ana Carolina Leguizamo Baquero Team Member Esther Angellah Lozo Team Member Liying Liang Team Member Diana Jimena Arango Team Member Jose C. Janeiro Team Member Masekeleme Esdorine Sekeleme Team Member Page 38 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Grace Anselmo Mayala Team Member Keneuoe Francoise Mofolo Team Member Wisdom E. Mulenga Team Member Precious Zikhali Team Member Diana Theresa Trindade Team Member @#&OPS~Doctype~OPS^dynamics@icrannexstafftime#doctemplate B. STAFF TIME & COST Staff Time & Cost Stage of Project Cycle No. of Staff Weeks US$ (including travel and consultant costs) Preparation FY15 36.795 203,425.64 FY16 97.764 569,297.72 Total 134.56 772,723.36 Supervision/ICR FY17 66.099 284,602.22 FY18 88.252 426,953.17 FY19 104.442 742,164.83 FY20 101.856 507,529.56 FY21 66.160 264,807.17 FY22 92.622 303,377.30 FY23 51.716 295,318.55 FY24 69.314 515,964.88 FY25 8.240 42,886.10 Total 648.70 3,383,603.78 Page 39 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT For Official Use Only For Official Use Only Page 40 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 3. PROJECT COST BY COMPONENT Amount at approval Actual at project Component (US$ million) closing (US$ million) Innovative prevention, detection, and treatment of TB 60.6 Regional capacity for disease surveillance and diagnostics and 61.2 management of TB and occupational lung diseases Regional learning and innovation and project management 56.2 Note: TB, tuberculosis. Page 41 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 4. EFFICIENCY ANALYSIS 1. 1. The Southern Africa Tuberculosis and Health Systems Support (SATBHSS) project was implemented from May 26, 2016, to June 30, 2024. The aim of the project was to: (i) improve coverage and quality of tuberculosis (TB) control and occupational lung disease services in targeted geographic areas of the participating countries; and (ii) strengthen regional capacity to manage the burden of TB and occupational lung diseases; (iii) strengthen country-level and cross- border preparedness and response to disease outbreaks. To evaluate the efficiency of the SATBHSS project, a cost- benefit analysis and an assessment of implementation efficiency were conducted. Based on these two analyses, the overall efficiency of the SATBHSS project is rated Substantial. Below is a detailed description of the results of the cost-benefit analysis. The results from the implementation efficiency analysis are in the main body of this report. 2. A cost-benefit analysis was conducted to determine whether the benefits of the project were greater than the costs. The model and key assumptions used in the analyses at project appraisal52 and at the additional financing or second restructuring of the project53 were replicated for the Implementation Completion and Results Report (ICR). The basic assumption was that investing in cost-effective TB control and treatment interventions could reduce morbidity and mortality, which would decrease health care costs associated with TB treatment for governments, mining companies and other employers, communities, and family members; increase labor productivity and thereby increase revenue for mining companies and other employers; and provide a steady source of income for families of mine workers and other employees that might otherwise have been forfeited during illness or upon death. Collectively, these income gains are e pected to increase the countries’ gross domestic product DP per capita. To estimate the benefits, the initial cost-benefit analyses used life years rather than disability-adjusted life years (DALYs), meaning that the initial analyses examined only l mortality and did not consider the quality of life of TB patients during and after the illness. To address this, DALYs were included in the cost-benefit analysis for the ICR. Furthermore, considering that several studies on the cost-effectiveness of TB interventions use DALYs as outcomes of interest, triangulating the results from the ICR to existing studies was possible. 3. The cost-benefit analysis was conducted for the combined set of project interventions and not for specific interventions. In each of the four countries, only the areas where the project was implemented were included in the analysis. The project was designed to promote shared prosperity and equity by focusing on the most disadvantaged areas within the countries. These were geographic areas with a high burden of TB: mining and peri-mining regions, areas with underserved populations, areas with a high incidence of poverty, areas with a high incidence of human immunodeficiency virus (HIV) coinfection and of multidrug-resistant TB, cross-border areas and transportation corridors, and labor-sending areas. The interventions implemented across the four countries were largely similar, but each country implemented one or two unique interventions in line with its context. 4. The results show that, for the four countries combined, the SATBHSS project prevented 332,451 TB deaths during the project implementation period (2016–24). Using empirical data from the project implementation period (2016– 24), the number of deaths averted was calculated and converted to DALYs. The lifetime burden of disease attributable to each incidence of TB is 12.1 DALYs (6.3 DALYs from the disease episode, 5.8 DALYs from post-TB).54 Therefore, each 52 World Bank. 2016. “Project Appraisal Document for the Southern Africa Tuberculosis and Health Systems Support Project. ” Report No. PAD1716. World Bank, Washington, DC. 53 World Bank. 2020. “Project Paper. Additional Financing for the Southern Africa Tuberculosis and Health Systems Support Project. ” Report No. PAD3723. World Bank, Washington, DC. 54 Nicolas A. Menzies, Matthew Quaife, Brian W. Allwood, Anthony L. Byrne, Anna K. Coussens, Anthony D. Harries, Florian M. Marx, Jamilah Meghji, Debora Pedrazzoli, Joshua A. Salomon, Sedona Sweeney, Sanne C. van Kampen, Robert S. Wallis, Rein M.G.J. Houben, Page 42 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT TB death averted during the SATBHSS implementation period was multiplied by 12.1 to obtain the total number of DALYs averted. Consequently, the project contributed to the prevention of 332,451 TB deaths, which is equivalent to 4,022,656 DALYs across the four countries (Lesotho, 323,313; Malawi, 471,592; Mozambique, 2,483,323; Zambia, 744,427) (Figure A1). Each DALY averted through project interventions was converted to monetary value by equating it to the GDP per capita from 2016 to 2023 for each country. Project costs and benefits were discounted at 3 percent, whereas 5 and 10 percent were used for sensitivity analyses. Figure A1: Number of Disability-Adjusted Life Years Averted, 2016–24 500,000 3,000,000 2,483,323 450,000 2,500,000 400,000 350,000 2,000,000 300,000 250,000 1,500,000 200,000 744,427 1,000,000 150,000 471,592 100,000 323,313 500,000 50,000 0 0 Mozambique Zambia Malawi Lesotho 2016 2017 2018 2019 2020 2021 2022 2023 2024 TOTAL 5. The results of the cost-benefit analysis shows that the SATBHSS project was cost-effective (Table A1). To guide the analysis, reference case guidelines for benefit-cost analysis in global health and development55 and the Copenhagen consensus framework56 were used to evaluate the cost-effectiveness of health interventions. At a 3 percent discount rate, the net present values of the project's benefits and costs were estimated at US$2.4 billion and US$153 million, respectively. The benefit-to-cost ratio (BCR) at the end of the project is estimated to be 15.5:1, indicating that each dollar invested in the project generated US$15.5. These results were compared with estimates at appraisal, recommended cost-effectiveness thresholds from within- and cross-country studies, and the 2023 GDP per capita for each country. The BCR at completion was much higher than the BCR of 6.3:1 at the additional financing or second Ted Cohen. 2021. “Lifetime Burden of Disease due to Incident Tuberculosis: A Global Reappraisal Including Post-Tuberculosis Sequelae.” Lancet Global Health 9 (12): e1679-e1687. 55 Lisa A. Robinson, James K. Hammitt, Michele Cecchini, Kalipso Chalkidou, Karl Claxton, Maureen Cropper, Patrick Hoang-Vu Eo enou, David de Ferranti, Anil B. Deolalikar, Frederico uanais, Dean T. Jamison, Soonman Kwon, Jerem A. Lauer, Luc O’Kee ffe, Damian Walker, Dale Whittington, Thomas Wilkinson, David Wilson, and Brad Wong. 2019. “Reference Case Guidelines for Benefit- Cost Analysis in Global Health and Development.” https://content.sph.harvard.edu/wwwhsph/sites/2447/2019/05/BCA-Guidelines- May-2019.pdf. 56 Copenhagen Consensus Center. https://copenhagenconsensus.com/copenhagen-consensus. Page 43 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT restructuring of the project57 and of the findings from a study that estimated the BCR for sustained TB treatment in sub-Saharan Africa to be 11:1.58 The cost per DALY averted, estimated to be US$45, was much less than the US$100 per TB DALY averted in low- and lower-middle-income countries.59 The cost per DALY averted, estimated to be US$45, was highly cost-effective because it was a fraction of the 2023 GDP per capita in the four countries (Lesotho, 5 percent of US$878; Malawi, 7 percent of US$673; Mozambique, 7 percent of US$608; Zambia, 3 percent of US$1,369). Interventions that are less than the GDP per capita in countries with low and medium Human Development Index scores have been found to be highly cost-effective.60 Table A1: Summary of Benefits and Costs of the Southern Africa Tuberculosis and Health Systems Support Project Year Total deaths averted Total DALYs averted Total benefits (US$) Project cost (US$) 2016 0 0 0 0 2017 17,810 215,499 136,381,955 19,501,250 2018 23,746 287,333 203,281,097 18,471,250 2019 47,493 574,665 427,901,185 41,001,250 2020 53,430 646,498 456,457,758 26,371,250 2021 59,366 718,331 434,780,682 23,481,250 2022 59,366 718,331 488,530,615 15,871,250 2023 41,556 502,832 386,929,337 15,771,250 2024 29,683 359,166 279,586,481 17,531,250 TOTAL 332,451 4,022,656 2,813,849,110 178,000,000 Net present values at different discount rates Discount Total deaths averted Total DALYs averted Total benefits (US$) Total Costs (US$) Rate 3% 280,348 3,392,207 2,369,580,627 152,918,930 5% 251,355 3,041,392 2,122,728,839 138,815,637 10% 194,124 2,348,897 1,636,320,241 110,564,716 Costs and benefits at discounted rates Discount Cost per life saved Cost per DALY averted Benefit-cost ratio Rate (US$) (US$) 3% 545 45 15.5 5% 552 46 15.3 10% 570 47 14.8 57 World Bank. 2020. “Additional Financing for the Southern Africa Tuberculosis and Health Systems Support Project. ” Report No. PAD3723. World Bank, Washington, DC. 58 Ramanan Laxminarayan, Eili Y Klein, Sarah Darley, and Olusoji Adeyi. 2009. “Global Investments In TB Control: Economic Benefits.” Health Affairs 28 (Suppl1): w730-w742. 59 Maria Wang and Regina Osih. (2014). Benefits and Costs of the TB Targets for the Post-2015 Development Agenda. A Working Paper produced for the Copenhagen Consensus Centre for the Post-2015 Consensus. https://copenhagenconsensus.com/sites/default/files/health_viewpoint_tb_-_wang.pdf. 60 Rajabali Daroudi, Ali Akbari Sari, Azin Nahvijou, and Ahmad Faramarzi. 2021. “Cost per DALY Averted in Low, Middle-and High- Income Countries: Evidence from the Global Burden of Disease Study to Estimate the Cost-Effectiveness Thresholds. Cost Effectiveness and Resource Allocation 19: 7. https://doi.org/10.1186/s12962-021-00260-0. Page 44 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT 6. The results of the sensitivity analysis (Table A1) show that investments from the project remain viable at the 5 and 10 percent discount rates. Therefore, the project was a highly viable investment in the four countries, although the analysis used conservative assumptions because other key investments were not included in the analysis. These include investments in pandemic preparedness and response, control and mitigation of cholera outbreaks in Zambia and Malawi, COVID-19 response activities, and project benefits beyond the project implementation period. Consequently, it is likely that the analysis underestimated the total benefits of the project, although not all the health benefits over the project implementation period (2016–24) can be attributed to the SATBHSS project. Several development partners also contributed to the health benefits through financial and technical support over the same period. Page 45 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 5. BORROWER, CO-FINANCIER, AND OTHER PARTNER AND STAKEHOLDER COMMENTS Summary of Regional Implementation Completion and Results Report 1. The regional Implementation Completion and Results Report (ICR) prepared for the East, Central and Southern Africa Health Community (ECSA-HC) provides a comprehensive evaluation covering all aspects of the main ICR. This summary highlights key achievements, challenges, and lessons. Achievements 2. The project design was highly relevant from inception to completion. The country-led approach fostered government leadership, ownership, and empowerment. The regional institutions played a key role in promoting use of standardized guidelines and protocols and quality improvement interventions for enhanced management of tuberculosis (TB) and occupational lung diseases. ECSA-HC provided demand-driven technical assistance, conducted data quality audits, and used its convening power to support national TB, laboratory, and disease surveillance efforts, and the African Union Development Agency—New Partnership for Africa’s Development (AUDA-NEPAD) made major strides in supporting occupational health and safety and private sector engagement. ECSA-HC proved especially agile, flexible, and innovative in supporting the pandemic response, brokering new partnerships for collective action. The project leveraged innovations and good practices from other Bank-funded regional projects, and, in turn, informed the design of new regional initiatives and projects with continual learning and knowledge sharing. The public health assets (laboratories, centers of excellence (CoEs) on multidrug-resistant (MDR)-TB and occupational health) and personnel supported under the project were leveraged during the COVID-19 pandemic and will contribute to future outbreak and pandemic responses. 3. Overall performance as of September 2023 was considered solid, with a 92 percent achievement rate (fully or partially achieved project outcome indicators and intermediate outcome indicators), using a slightly different scale from the main ICR. The systematic review found good progress on most interventions, with some shortcomings and country variations (e.g., TB case notification and treatment success rates, bacteriologically confirmed pulmonary cases). The ICR noted solid progress in building regional capacity, including strengthening the quality and availability of human resources, conducting cross-border disease surveillance and response activities; rolling out new molecular diagnostics and mobile diagnostic units, initiating pioneering work on occupational health and safety, and bolstering laborator capacit toward international accreditation. Several innovations were noted, such as Zambia’s TB Situation Room, Lesotho’s and Malawi’s communit -based TB models, Malawi’s mobile electronic s stems, and Mozambi ue’s MDR-TB CoE. Challenges 4. The ICR identified several factors that impeded implementation, including procurement-related difficulties that resulted in delays in completion of civil works and equipment installation; inefficiencies in government procedures in some countries that delayed staff recruitment, release of funds, and legislative approvals; inadequate sustainability plans and underfunding of national programs; and exogenous factors (COVID-19 pandemic, cyclones, disease outbreaks). Lessons Learned 5. Notable examples of lessons learned include that regional approaches should be promoted, including communities of practice and centers of excellence (CoEs), which foster peer-to-peer learning and knowledge sharing with potential Page 46 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT economies of scale and cost efficiencies; quality improvement strategies should be incorporated into the design and deployment of all interventions for better health system delivery; innovative ways to sustain regional platforms and national investments through cost-recovery and income-generating strategies and greater private sector involvement should be identified; an all-of-government approach mobilizing other key stakeholders (e.g., Ministry of Finance, decentralized entities) should be adopted; strategies for optimization of laboratory investments (e.g., equipment leasing; in-house capacity for basic laboratory equipment) should be adopted; rapid assessment tools to evaluate quality of training activities should be introduced; opportunities for expanding digital health innovations (e.g., e-learning, data sharing) should be explored; more-action-oriented research should be conducted; and greater domestic resource mobilization for TB and occupational health should be advocated for. Summary of Lesotho ICR Achievements • Adopted a strong design that incorporated important lessons and best practices in TB control, including targeting the most vulnerable groups and high-burden areas, decentralizing care and treatment, and establishing cross- border disease surveillance and response committees. The project was highly relevant to national, regional, and global priorities and well aligned with the National Tuberculosis Strategic Plan 2018–22, National Acquired Immunodeficiency Syndrome Strategic Plan 2018/19–2022/23, and the World Health Organization(WHO) End TB Strategy 2025 milestones. • Accelerated TB control and surveillance; strengthened institutional capacities; promoted multisectoral collaboration, with the project supporting all districts in a difficult mountainous environment with solid results on the ground despite multiple shocks (e.g., COVID-19 pandemic, supply chain constraints and inflation due to the Ukraine conflict). • Established a strong project implementation unit that demonstrated resilience in managing shocks; adopting appropriate mitigation measures to remain on track; conducting regular annual supervision missions; and efficiently and effectively managing key functions, including monitoring and evaluation, fiduciary, and social safeguards. • Performed well on the End TB Strategy targets (comparing results in 2022 with 2015), surpassing the mortality target and making solid progress on the incidence target, as reflected in the 2023 WHO Global TB Report. • Established an innovative integrated patient-centered TB care and treatment model, promoting early screening and preventive therapy, providing nutritional support for MDR-TB patients; strengthening treatment monitoring through phone calls and home visits, promoting home-based treatment administration with family members or village health workers serving as supporters, and strengthening management of comorbidities (initially combining TB and COVID-19 screening and later providing integrated screening for noncommunicable diseases). • Strengthened institutional capacity, which was one of the main achievements of the project and part of its legacy and enhanced prospects for sustainability. For example, well-ventilated coughing booths were established at 50 health care facilities; CoEs on occupational health were refurbished or equipped, and access to services with improved compensation of ex-miners was expanded; (iii) wellness centers were introduced at hospitals; TB triage clinics were established at 10 hospitals, and five TB community clinics were supported (e.g., the Berea Community TB Care Clinic ; TB services were revamped at the countr ’s premiere correctional institute, including a state -of- the-art clinic and eight isolation rooms, with representatives from neighboring countries participating in learning visits; state-of-the-art technologies for enhanced diagnosis (e.g., mobile digital x-ray machines; artificial intelligence diagnostics) were introduced; regulatory capacity in the mining sector was improved; laboratory capacity was strengthened; and multisectoral collaboration on occupational health and safety (OHS) reforms and service delivery was promoted with the adoption of new guidelines, regulations, and bills. Page 47 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT • Leveraged technical support of regional institutions, which played an instrumental role in supporting peer-to-peer knowledge sharing, helping adopt evidence-based TB approaches, establishing cross-border committees (ECSA- HC), and conducting studies and revamping legislation on OHS (AUDA-NEPAD), with both institutions demonstrating commitment and excellence. • Developed a plan to improve prospects for financial sustainability, including arrangements for continuing mentoring by Africa Centers for Disease Control and Prevention, mobilizing domestic resources, absorbing personnel recruited under the project, and transferring key activities to the Global Fund. Key Challenges • Exogenous shocks disrupted service delivery, with lockdowns and supply chain difficulties disrupting the TB program during the early years of the project, requiring an intensified, accelerated response during the final six months that improved performance (e.g., improved TB case finding). • High attrition at senior management levels and organizational management issues impeded implementation with mitigation measures introduced, which improved performance. • Human resource constraints, staff turnover, and motivation-related problems intermittently affected implementation. Recommendations • Leverage the project's achievements to continue and intensify TB control efforts. • Focus on accountability, advocacy, decentralization, and innovative approaches. • Mitigate risks to development outcomes by addressing continuing capacity constraints and coordination challenges to ensure long-term project sustainability. • Enhance gender mainstreaming by promoting inclusiveness and ensuring equitable participation of women, girls, and young men. • Encourage the World Bank to maintain and strengthen its strategic partnership with the Kingdom of Lesotho, providing post-project support to consolidate gains. • Adopt ambitious design but ensure realism in setting targets and mobilize technical support of specialized regional institutions, which proved their utility and effectiveness. Summary of Malawi ICR The Malawi ICR provides a succinct analysis of the main achievements, implementation challenges, and lessons learned, as summarized here. Key Achievements • Surpassed both the End TB strategy incidence (37 percent) and mortality (52 percent) targets compared to 2015) and made substantial progress on treatment success reaching 90 percent). • Scaled up of active case finding to find missing cases, deploying multiple strategies (mobile diagnostic units that offer one-stop screening and diagnostic services) with solid overall progress in increasing TB case notification rates (despite the drop during the COVID-19 pandemic) in a country experiencing a steep annual decline in incidence rate. • Expanded access to WHO-recommended diagnostic tools to improve accuracy of screening and accelerate access to treatment. • Mobilized broad-based support of a wide range of stakeholders and promoted a multisectoral approach to improve coordination of TB and occupational health services. Page 48 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT • Rolled out an innovative e-health system that has helped strengthen community TB efforts, as described in the main ICR. • Established O S services, providing training to healthcare workers at Zambia’s Occupational ealth and Safet Institute (OHSI), conducting regular joint mine inspections, strengthening mining sector regulations and laws, and improving access to compensation. • Strengthened capacity through short- and long-term training for enhanced management. • Improved disease outbreak preparedness, setting up cross-border committees and developing a multi-hazard emergency response plan for public health emergencies. Main Challenges • Perennial series of natural disasters (cyclones) and disease outbreaks (polio) combined with the COVID-19 pandemic, which disrupted services as personnel were redirected to other activities. • Capacity constraints, especially at the local level to manage TB and OSH services, including inadequate skills and numbers. • Quality and reliability of data, with underreporting in some districts, not giving a full picture of overall progress, as well as lack of disaggregated sub-national estimates, which made it more challenging to adapt responses to variable epidemiological contexts. Key Lessons • Continuous capacity building, mentoring, and supervision of implementing entities is critical for performance and greater impact. • Partnerships with civil society and communities facilitate expansion of services in rural areas. • Coordination with other partners and the private sector generates synergies and cost efficiencies. Notable examples include complementarities with activities funded by the Global Fund and the U.S. Agency for International Development and use of the People’s Progressive Movement secretariat to reach out to private health care providers to find missing cases. • Regional institutions play an important complementary role, building capacity, facilitating knowledge sharing, and supporting monitoring and evaluation of national activities. • Flexible financing from the World Bank, combined with timely technical support, contributed to efficient implementation of the project. • Innovative strategies need to be developed to sustain and scale up the project’s achievements, given persistent funding gaps. Summary of Mozambique ICR Key Achievements • Adopted a highly relevant design that addressed critical health issues in Mozambique and the Southern African Development Community region, including high TB and TB/human immunodeficiency virus (HIV) co-infection rates and weak health systems. • made substantial progress toward project objectives, with most targets met or exceeded, particularly TB case notification, treatment success rate, and screening of miners for occupational lung diseases. • Strengthened institutional capacity for enhanced TB case management; adopted a comprehensive package of TB community interventions (e.g., contact tracing, referral of presumptive cases, specimen transport, direct Page 49 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT observation of TB treatment); and expanded coverage of rapid TB diagnostic tests, which substantially increased the TB case notification rate, treatment success rate, and cases identified through active case finding. • Prioritized outreach activities for vulnerable population groups and others identified as having a higher TB burden, namely miners and former miners and their relatives, health care workers, and household contacts, including children and people with HIV and acquired immunodeficiency syndrome. • Introduced innovations in the care and treatment of people with TB, in particular MDR-TB, such as the inauguration in 2022, of the CoE for Management of Multidrug Resistant Tuberculosis; initiation of new all-oral treatment regimens; provision of social support to MDR-TB patients, and establishment of the MDR-TB Therapeutic Committee, with a significant improvement in the MDR-TB success rate from 43 (2016) to 75 percent (2022). • Developed a package of standardized occupational health services, including elaboration of the National Occupational Health Strategy; equipped six medical examination centers and trained clinicians to offer spirometry, audiometry, and visual acuity testing services; installed one occupational health center (OHC); and installed or equipped one (Ressano Garcia Health Center) and operationalized two health centers (Marien Ngoabi Health Center [in Xai-Xai], Manjacaze Health Center) . This included the introduction of digital x-ray machines at medical examination centers in the priority provinces to strengthen capacity to diagnose occupational diseases. • Expanded screening and diagnosis of TB, HIV, and occupational health diseases for Mozambican miners and ex- miners on the border with South Africa and organized a high-level workshop with representatives from South Africa to discuss options for continuity of care and access to compensation schemes with improved coverage. • Strengthened national surveillance policies and established cross-border committees with neighboring countries (Malawi, South Africa, Tanzania, Zambia, Zimbabwe) for coordinated action (e.g., polio vaccine campaign and joint investigations), including elaboration of the Multi-Risk Contingency Plan for Public Health Emergencies, the Multisectoral and Multidisciplinary Plan for the "One Health" approach, and the Evidence-Based Surveillance Manual. • Established a mechanism for interinstitutional coordination on occupational health and safety in the mining sector that brought together key ministries (Ministry of Labor and Social Security, Ministry of Health, Ministry of Mineral Resources and Energy) to conduct joint mine inspections, with about 70 percent of companies inspected able to reduce dust emissions, and strengthened the policy and regulatory environment (e.g., elaboration of National Guidelines for Occupational Health and Safety Inspection, completion of the Code of Practice for Occupational Lung Diseases in Minas Gerais, development of a National Strategy for Public-Private Mix-TB) with the support of AUDA-NEPAD. • Contributed to gender-related actions and institutional capacity building and provided timely support for public health emergencies such as COVID-19 and natural disasters. Main Challenges • Procurement-related challenges, limited technical capacity, and inadequate specialized human resources delayed some activities. • Delays and constraints in implementation, particularl in the first half of its life c cle, hindered the project’s operational efficiency. • Macroeconomic instability and potential cuts in domestic spending may jeopardize continuation of project gains. Key Recommendations • Strengthen procurement and contracting processes to avoid delays in future projects by hiring experienced staff and advocating for streamlined procedures. • Define the statute of the Machava CoE to clarify its role and ensure that it fulfills its intended functions effectively. • Mobilize resources to ensure sustainability of project gains, including the operation of the CoEs and OHCs, and continuation of cross-border meetings. Page 50 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT • Continue advocacy efforts to improve coordination with South Africa for referral and compensation of eligible miners. • Address challenges of high staff turnover, and limited capacity for training to maintain quality of health services. • Engage community actors in TB case finding and ensure continuation of community-based TB activities for high- risk groups. • Expand and maintain the GeneXpert network and involve local organizations in mapping project beneficiaries. • Transfer key activities that depend on the project to other funding sources, such as the Global Fund, to ensure post-project continuity. Summary of Zambia ICR The Zambia ICR provides an in-depth analysis of the achievements, challenges, and lessons of the project. This section below provides selective highlights. Key Achievements • Provided critical support to assist Zambia achieve or surpass both the End TB strategy incidence (22 percent) and mortality (65 percent) targets compared to 2015), with the country recognized by the WHO as one of the top performers. • Prioritized 19 high-TB-burden mining districts, which benefited from the latest TB technologies (e.g., mobile diagnostic units with digital x-ray and artificial technology), upgraded facilities, and innovative approaches to active case finding through an initiative dubbed “marching towards finding 45,000 and 55,000 TB patients in 2020- 0 1.” • Bolstered human resources through training, capacity building, and mentoring of health care workers, laboratory staff, and program managers involved in TB control, mine health regulation and occupational services, and disease surveillance. • Supported 19 laboratories improve their performance and enroll in the national accreditation and certification program, with some reaching international accreditation and others at the mentorship or application stage. • Supported development and enhancement of health information systems for TB surveillance, monitoring, and reporting and application of innovative digital platforms. • Contributed to establishment of the innovative TB Situation Room, which has served as a model for other countries (as described in the main report). • Established a strong OHS program for miners and ex-miners; increased access to and coverage and quality of services at OHS clinics; deployed mobile screening units and served as the Center of Excellence for the region on occupational lung diseases, provided training; and refurbished the OHSI, which benefited from state-of-the-art diagnostic equipment. • Promoted multisectoral collaboration, with key government institutions (Mining Safety Department, OHSI, Workers Compensation Fund,) and the private sector working closely together to reduce workplace injuries, accelerate compensation, ensure legal compliance, and safeguard communities and the environment. • Strengthened legal and policy environment, including adoption of the National Occupational Safety and Health Polic and an amendment to the Workers’ Compensation Act to allow TB patients to return to work after successful treatment. • Reinforced disease outbreak preparedness capacity, including establishment of cross border surveillance committees and training of rapid response teams, which played a key role during the COVID-19 pandemic and during frequent outbreaks such as the 2018 cholera outbreak. • Conducted 12 operational research studies that strengthened the evidence base for TB and occupational health and safety interventions. Page 51 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT • All outcome indicators and 14 of 17 intermediate outcome indicators have been fully or partially achieved. Despite these numerous achievements, the project also faced various challenges. ● Delays in project effectiveness, staff recruitment, and release of funds that delayed start-up. ● Procurement-related delays due to various factors such as lengthy approval processes both at the national level and by the World Bank; suspension of the procurement department for nearly one year; underbudgeting of activities, which necessitated lengthy discussions to seek new authorizations; and change in government, which put procurement on hold during a transition period. ● Lack of funds to sustain the nutritional support and mining inspections towards the end and beyond the lifetime of the project. Key Lessons ● Early TB case detection and routine screening are essential to reducing transmission, and accurate, timely diagnosis is key to ensuring proper patient care and an appropriate public health response. ● Combination of training and mentorship proved effective in ensuring that learning took place and was cascaded to lower levels. Need to shift toward competence-based curriculum, e-learning platforms, and periodic evaluations to measure impact. ● Future research needs to be more oriented toward resolving operational challenges, with broader dissemination of results to lower levels to inform programmatic action. ● Knowledge sharing accelerated implementation and provided platforms for exchanging experiences and lessons with the other participating countries. ● Roll out of digital health technologies and the transformative TB Situation Room bolstered decision making and enhanced the effectiveness of the TB program. ECSA-HC played a supportive role in training countries on utilizing data for decision making. ● Digital health innovations and the multi-disease approach have strengthened the OHS program in mining areas and enhanced its visibility. Access to medical surveillance helps determine the effectiveness of the intervention measures by the inspectorate team. ● Public health assets established under the project (e.g., upgraded laboratories with state-of-the-art equipment, TB wards for drug-resistant patients), combined with cross-border disease surveillance committees, have demonstrated the importance of investing early to enhance outbreak preparedness and response capacity and contain public health threats more quickly. Page 52 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 6. SUMMARY TABLES OF INDICATOR ACHIEVEMENT Table 6.1: Summary of Indicator Achievement by PDO Part PDO Part 1 PDO Part 2 PDO Part 3 OVERALL Improve coverage and Strengthen the regional Strengthen country-level quality of TB control and capacity to manage the and cross-border occupational lung disease burden of TB and preparedness and services occupational lung response to disease diseases outbreaks Rating POIs IOIs POIs IOIs POIs IOIs POIs IOIs Fully achieved 2.5 5.0 1.1 8.4 1.0 3.1 4.6 16.5 or surpassed (100%+) Substantially 2.0 1.0 2.0 1.0 achieved (80%+) Partially 1.0 2.0 3.0 achieved (65- 79%) Not achieved 1.0 1.0 1.0 1.0 (<64%) Total 5.5 7.0 1.1 11.4 1.0 3.1 7.6 21.5 Surpassed or 81.8 85.7 100.00 73.7 100.0 100.0 86.8 81.4 substantially achieved (%) Sub-rating Substantial Substantial High Modest High High Substantial Substantial OVERALL SUBSTANTIAL SUBSTANTIAL HIGH SUBSTANTIAL RATING Note: For surpassed indicators a weighted scale was used to reflect the degree of over-achievement. Page 53 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Table 6.2: Summary of Achievement of POIs in the Four Participating Countries Objective POI Indicator Baseline Original Target Final Target Achievement Improve coverage POI#1: TB case Lesotho: 9,854 Lesotho: 57,628 Lesotho: 61,629 Average: 109% -- Surpassed and quality of TB notification in target control and geographic area Malawi: 9,430 Malawi: 77,998 Malawi: 83,222 Lesotho: 76%-- Partially achieved occupational lung (number) Mozambique: Mozambique: 359,103 Mozambique: 359,103 Malawi: 91% --Substantially achieved disease services 40,059 Zambia: 191,548 Zambia: 175,749 Mozambique: 115% -- Surpassed Zambia: 25,752 Cumulative: 686,277 Cumulative: 679,703 Zambia: 113% --Surpassed Cumulative: 85,095 POI#2: TB treatment Lesotho: 71% Lesotho: 90% Lesotho: 90% Average: 83% --Substantially achieved success rate among new and relapse TB Malawi: 83% Malawi: 95% Malawi: 95% Lesotho: 53% --Not achieved cases in target Mozambique: 87% Mozambique: 90% Mozambique: 90% Malawi: 68% --Partially achieved geographic area (%) Zambia: 85% Zambia: 95% Zambia: 95% Mozambique: 333%-- Surpassed Average: 81% Average: 93% Average: 93% Zambia: 80% --Substantially achieved POI#3: TB cases Lesotho: 4,676 Lesotho: 27,922 Lesotho: 29,322 Average: 88% -- Substantially achieved identified through active TB case finding Malawi: 118 Malawi: 12,150 Malawi:11,400 Lesotho: 55% -- Not achieved among TB vulnerable Mozambique: 130 Mozambique: 9,860 Mozambique: 9,860 Malawi: 68% -- Partially achieved population in target geographic area Zambia: 7,008 Zambia: 60,000 Zambia: 54,000 Mozambique: 104% --Surpassed (number) Cumulative: 11932 Cumulative: 109,932 Cumulative: 104582 Zambia: 108%--Surpassed POI#4: Pulmonary TB Lesotho: 68% Lesotho: 80% Lesotho: 80% Average: 8% --Not achieved cases that are bacteriologically Malawi: 58% Malawi: 65% Malawi: 65% Lesotho: -192%-- Not achieved confirmed (%) Mozambique: 36% Mozambique: 55% Mozambique: 55% Malawi: 157%-- Surpassed Zambia: 51% Zambia: 73% Zambia: 72% Mozambique: 42% -- Not achieved Average: 53% Average: 68% Average: 68% Zambia: 43%-- Not achieved POI#5: Miners and ex- Lesotho: 3,500 Lesotho: 12,300 Lesotho: 5,100 142% -- Surpassed miners successfully screened for Malawi: 0 Malawi: 7,500 Malawi: 6,000 Lesotho : 252% --Surpassed occupational lung Mozambique: Mozambique: 39,000 Mozambique: 31,000 Malawi : 231% --Surpassed diseases (number) 2,413 Zambia: 214,000 Zambia: 214,000 Mozambique : 134% --Surpassed Zambia: 39,540 Cumulative: 272,800 Cumulative: 256,100 Zambia : 138% --Surpassed Cumulative: 45,453 -Strengthen POI#6: Project Lesotho: 1 Lesotho: 6 Lesotho: 1 109% --Surpassed regional capacity supported to manage TB and laboratories compliant Malawi: 24 Malawi: 50 Malawi: 50 Lesotho: 100% --Fully achieved occupational with regionally Mozambique: 14 Mozambique: 30 Mozambique: 61 Malawi: 114% --Surpassed diseases harmonized SOPs for MDR-TB surveillance Zambia: 3 Zambia: 30 Zambia: 30 Mozambique: 80% --Substantially (number) achieved Cumulative: 42 Cumulative: 116 Cumulative: 142 Zambia: 160% --Surpassed -Strengthen POI#7: Countries with Lesotho: 0 Lesotho: 1 Lesotho: 1 100%-- Achieved disease outbreak multi-hazard preparedness preparedness plans Malawi: 0 Malawi: 1 Malawi: 1 Lesotho: 100% -- Achieved response capacity (number) Page 54 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Mozambique: 1 Mozambique: 1 Mozambique: 1 Malawi: 100% --Achieved Zambia: 0 Zambia: 1 Zambia: 1 Mozambique: 100% --Achieved Cumulative: 1 Cumulative: 4 Cumulative: 4 Zambia: 100% --Achieved Table 6.3: Summary of Achievements of IOIs in the Four Participating Countries Objective IOI Indicator Baseline Original Revised Target Achievement Target Improve IOI #1: Proportion Lesotho: 95.0 Lesotho: 97.0 Lesotho: 97.0 Lesotho: 250.0-Surpassed coverage and of MDR-TB Malawi: 43.0 Malawi: Malawi: 100.0 Malawi: 100.0-Achieved quality of TB patients in target Mozambique: 0 100.0 Mozambique: Mozambique: 61.0-Not achieved control and geographic areas Zambia: 49.0 Mozambique: 85.0 Zambia: NA [no funds were provided in occupational benefiting from Average: 47.0 85.0 Zambia: 95.0 2023] lung disease nutritional Zambia: 95.0 Average: 94.0 Average:78.0-Partially Achieved services support during Average: 94.3 treatment IOI #1b: Number Lesotho: 3568 Lesotho: NA Lesotho: 14300 Lesotho: 162.0- Surpassed of women and Malawi: 67 Malawi: NA Malawi: 380 Malawi: 257- Surpassed children who Mozambique: 0 Mozambique: Mozambique: Mozambique: 59.0- Not achieved have received Zambia: 627 NA 2523 Zambia: 158.0 - Surpassed basic nutrition Cumulative: Zambia: NA Zambia: 939 Average: 149.0 - Surpassed services 4262 Cumulative: Cumulative: 11110 18142 IOI #2: Proportion Lesotho: 73.0 Lesotho: 90.0 Lesotho: 90.0 Lesotho: 94.0 -Substantially achieved of TB patients Malawi: 95.8 Malawi: Malawi: 100.0 Malawi: 52.0 -Not achieved satisfied with TB Mozambique: 100.0 Mozambique: Mozambique: 65.0 - Partially achieved services in target 99.0 Mozambique: 85.0 Zambia: 350.0 - Surpassed geographic areas Zambia: 80.0 85.0 Zambia: 84.0 Average: 193.0 - Surpassed Average: 87.0 Zambia: 85.0 Average: 90.0 Average: 90.0 IOI #3: Lesotho: 95.0 Lesotho: 95.0 Lesotho: 95.0 Lesotho: 100.0 - Achieved Percentage of HIV Malawi: 98.0 Malawi: 99.0 Malawi: 99.0 Malawi: 100.0 - Achieved patients routinely Mozambique: Mozambique: Mozambique: Mozambique: - 140.0 Surpassed screened for TB in 66.0 90.0 90.0 Zambia: 100.0 -Achieved target geographic Zambia: 74.0 Zambia: 97.0 Zambia: 97.0 Average: 119.0 – Surpassed areas Average: 83.0 Average: 95.3 Average: 95.0 IOI #4: Proportion Lesotho: 86.0 Lesotho: 90.0 Lesotho: 90.0 Lesotho: 175.0 - Surpassed of new and Malawi: 32.0 Malawi: 50.0 Malawi: 50.0 Malawi: 50.0 -Not achieved relapse TB Mozambique: Mozambique: Mozambique: Mozambique: 193.0 --Surpassed patients tested 50.0 65.0 65.0 Zambia:—Not achieved [achieved 85.0 using WHO- Zambia: 100.0 Zambia: Zambia: 100.0 percent coverage which was lower than recommended Average: 67.0 100.0 Average: 76.0 baseline] diagnostics at Average: 76.3 Average: 81.0 Substantially achieved time of diagnosis IOI #7: Number of Lesotho: 0 Lesotho: 1 Lesotho: 1 Lesotho: 100.0 - Achieved countries scaling Malawi: 0 Malawi: 1 Malawi: 1 Malawi: 100.0 - Achieved up Electronic Mozambique: 0 Mozambique: Mozambique: Mozambique: 100.0 - Achieved Health Systems Zambia: 0 1 1 Zambia: 100.0 -Achieved for TB case Average: 0 Zambia: 1 Zambia: 1 Average: 100.0 - Achieved Page 55 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT management or Average: 4 Average: 4 laboratory management IOI #12: Number Lesotho: 19 Lesotho: NA Lesotho: 135 Lesotho: 133.0 - Surpassed of miners and ex- Malawi: 0 Malawi: NA Malawi: 260 Malawi: 26.0 –Not achieved miners Mozambique: Mozambique: Mozambique: Mozambique: 106.0 - Surpassed successfully 1251 NA 7500 Zambia: 88.0 – Substantially achieved referred for Zambia: 81 Zambia: NA Zambia: 466 Achieved: 103.0 - Surpassed continuity of Cumulative: Cumulative: Cumulative: treatment for TB 1351 13541 8361 and occupational lung diseases between participating countries and within participating countries Strengthen IOI #6a: Health Lesotho: 0 Lesotho: 12.0 Lesotho: 8.0 Lesotho: 263.0 - Surpassed the regional facilities Malawi: 0 Malawi: Malawi: 108.0 Malawi: 51.0 – Not achieved capacity to renovated Mozambique: 0 238.0 Mozambique: Mozambique: 100.0 - Achieved manage the Zambia: 0 Mozambique: 6 Zambia: 44.0 -Not achieved burden of TB Cumulative: 0 4 Zambia: 45.0 Average: 61.0 – Not achieved and Zambia: 83.0 Cumulative: occupational Cumulative: 108 lung diseases 337 IOI #6b: Health Lesotho: 0 Lesotho: 25.0 Lesotho: 30.0 Lesotho: 167.0 - Surpassed Facilities Malawi: 0 Malawi: Malawi: 107.0 Malawi: 97.0 -Substantially achieved equipped Mozambique: 0 355.0 Mozambique: Mozambique: 98.0 – Substantially achieved Zambia: 0 Mozambique: 400.0 Zambia: 173.0 - Surpassed Cumulative: 0 25 Zambia: 158.0 Average: 118.0 – Surpassed Zambia: Cumulative: 228.0 695.0 Cumulative: 633 IOI #8: Number of Lesotho: 1 Lesotho: 6 Lesotho: 3 Lesotho:100.0 -Achieved targeted Malawi: 2 Malawi: 20.0 Malawi: 4.0 Malawi: 75.0 – Partially achieved laboratories rated Mozambique: 1 Mozambique: Mozambique: Mozambique: 33.0 -Not achieved 4 stars and above Zambia: 3 3 3 Zambia: 100.0 - Achieved in SLIPTA Cumulative: 7 Zambia: 3 Zambia: 3 Average: 77.0 – Partially achieved assessment Cumulative: Cumulative: 32 13.0 IOI #9a: Lesotho: 50.0 Lesotho: 90.0 Lesotho: 90.0 Lesotho: 125.0 - Surpassed Proportion of Malawi: 0 Malawi: 90.0 Malawi: 90.0 Malawi: 74.0 -Partially achieved mines inspected Mozambique: 0 Mozambique: Mozambique: Mozambique: 84.0 -Substantially achieved at least twice a Zambia: 35.0 50.0 50.0 Zambia: -20.0 -Not achieved year Average: 21.0 Zambia: 30.0 Zambia: 70.0 Average: 71.0 -Partially achieved Average: 65.0 Average: 75.0 IOI #9b: Lesotho: 0 Lesotho: 72.0 Lesotho: 72.0 Lesotho: 79.0 -Partially achieved Proportion of Malawi: 0 Malawi: 60.0 Malawi: 60.0 Malawi: 113.0-Surpassed mines inspected Mozambique: 0 Mozambique: 168.0 -Surpassed Page 56 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT at least twice a Zambia: 0 Mozambique: Mozambique: Zambia: 160.0 -Surpassed year complying Average: 0 50.0 50.0 Average: 125.0 -Surpassed with national Zambia: 20.0 Zambia: 52.0 mine health Average: 50.5 Average: 59.0 regulations IOI #10: Number Lesotho: 230 Lesotho: 806 Lesotho: 876 Lesotho: 959.0 -Surpassed of personnel Malawi: 0 Malawi: 3740 Malawi: 4040 Malawi: 170.0 -Surpassed receiving training Mozambique: 0 Mozambique: Mozambique: Mozambique: 83.0 -Substantially achieved Zambia: 0 4040 4040 Zambia: 143.0- Surpassed Cumulative: 230 Zambia: 4400 Zambia: 4200 Average: 187.0-Surpassed Cumulative: Cumulative: 12986 13156 IOI #11: Number Lesotho: 0 Lesotho: 1 Lesotho: 1 Lesotho: 100.0- Achieved of countries in Malawi: 0 Malawi: 1 Malawi: 1 Malawi: 100.0 - Achieved which new Mozambique: 0 Mozambique: Mozambique:1 Mozambique: 100.0 -Achieved legislation or Zambia: 1 1 Zambia: 1 Zambia: 100.0-Achieved amendment to Cumulative: 1 Zambia: 1 Cumulative: 4 Average: 100.0 -Achieved existing mine Cumulative: 4 health and safety legislation are drafted and submitted to relevant legislative authority IOI #13a: Lesotho: 0 Lesotho: 9.0 Lesotho: 8.0 Lesotho: 88.0-Substantially achieved Operational Malawi: 0 Malawi: 20.0 Malawi: 13.0 Malawi: 154.0- Surpassed research studies Mozambique: 0 Mozambique: Mozambique: Mozambique: 82.0- Substantially achieved commissioned Zambia: 0 12.0 11.0 Zambia: 100.0- Achieved and findings, Cumulative: 0 Zambia: 10.0 Zambia: 12.0 Average: 109.0- Surpassed lessons learnt Cumulative: Cumulative: disseminated 51.0 44.0 through national and regional platforms IOI #13b: 0 3 3 100.0- Achieved Operational research studies commissioned and findings, lessons learnt disseminated through national and regional platforms (ECSA- HC) IOI #13b: 0 2 2 100.0-Achieved Operational research studies commissioned and findings, Page 57 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT lessons learnt disseminated through national and regional platforms (AUDA- NEPAD) Strengthen IOI#5a: Outbreaks Lesotho: 2 Lesotho: NA Lesotho: 8 Lesotho: 75.0- Partially achieved country-level for infectious Malawi: 1 Malawi: NA Malawi: 11 Malawi: 136.0- Surpassed 61 and cross- diseases for Mozambique: 0 Mozambique: Mozambique: Mozambique: 100.0- Achieved border which cross- Zambia: 0 NA 9 Zambia:130.0- Surpassed preparedness border Cumulative: 3 Zambia: NA Zambia: 10.0 Average: 113.0- Surpassed and response investigation Cumulative: Cumulative: to disease undertaken 41 38.0 outbreaks IOI #5b: Lesotho: 100.0 Lesotho:100. Lesotho: 100.0 Lesotho: 100.0- Achieved Proportion of Malawi: 50.0 0 Malawi: 75.0 Malawi: 200.0-Surpassed suspected Mozambique: Malawi: 75.0 Mozambique: Mozambique: 100.0- Achieved outbreaks of 100.0 Mozambique: 100.0 Zambia: 100.0-Achieved communicable Zambia: 100.0 80.0 Zambia: 100.0 Average: 200.0-Surpassed diseases that are Average: 88.0 Zambia: Average: 94.0 laboratory 100.0 investigated Average: 89.0 Note: 1/ Baseline figures of zero imply that the intervention was not supported prior to the project. Page 58 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT ANNEX 7. NATIONAL TRENDS IN KEY TUBERCULOSIS INDICATORS Table 7.1: Change in Key Global Tuberculosis Targets in Four Participating Countries, 2015-2022 ---------------------% Change------------ Incidence Rate Total number of deaths Lesotho -15.00 -41.00 Malawi -37.00 -52.00 Mozambique 0.00 -64.00 Zambia -25.00 -72.00 Global average (actual) -8.70 -19.00 Sub-Saharan Africa (actual) 38.00 End TB Strategy -20.00 -35.00 Source: 2023 Global Tuberculosis Report, WHO Figure 7.1: New and relapse tested with rapid diagnostics (%) 100 91 90 79 80 70 70 60 55 48 50 40 30 20 10 0 Lesotho Malawi Mozambique Zambia SSA Avg Source: 2023 Tuberculosis Global Report, WHO. Page 59 The World Bank AFR RI-Southern Africa Tuberculosis and Health Systems Support Project (P155658) ICR DOCUMENT Figure 7.2: Tuberculosis treatment success rate among new and relapse TB cases (%) 100 94 92 90 88 90 77 80 70 60 50 40 30 20 10 0 Lesotho Malawi Mozambique Zambia SSA Avg Source: 2023 Global Tuberculosis Report, WHO. Figure 7.3: Pulmonary tuberculosis cases that are bacteriologically confirmed (%) 80 70 60 50 40 30 20 10 0 Lesotho Malawi Mozambique Zambia SSA Avg Source: 2023 Global TB Report, WHO. Page 60