Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD1134 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON PROPOSED IDA GRANTS TO THE REPUBLIC OF GUINEA IN THE AMOUNT OF SDR 16.5 MILLION (US$25 MILLION EQUIVALENT) REPUBLIC OF LIBERIA IN THE AMOUNT OF SDR 34.3 MILLION (US$52 MILLION EQUIVALENT) REPUBLIC OF SIERRA LEONE IN THE AMOUNT OF SDR 18.5 MILLION (US$28 MILLION EQUIVALENT) FOR THE EBOLA EMERGENCY RESPONSE PROJECT SEPTEMBER 10, 2014 Health, Nutrition, and Population Global Practice (GHNDR) Africa Regional Integration Department (AFRCI) Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective August 20, 2014) Currency Unit = GNF, LRD, SLL US$1 = 7,030 GNF, 84.50 LRD, 4,375 SLL US$1 = SDR 0.65859666 FISCAL YEAR January 1 – December 31 July 1 – June 30 (for Liberia) ABBREVIATIONS AND ACRONYMS AAA Analytic and Advisory Activities AfDB African Development Bank AU African Union ASEOWA Africa Union Support to Ebola Outbreak CDC US Centers for Disease Control and Prevention CPI Consumer Price Index CRW Crisis Response Window DPT3 Third Diphtheria, Pertussis and Tetanus ECOWAS Economic Community Of West African States EOC Emergency Operation Center ERF Emergency Response Framework E&S Environment and Social ESSAF Environmental and Social Screening Assessment Framework ETC Ebola Treatment Center ETU Ebola Treatment Unit EU European Union EVD Ebola Virus Disease FAO Food and Agricultural Organization of the United Nations FDI Foreign Direct Investment GDP Gross Domestic Product GFD General Food Distribution GNF Guinean Francs GNI Gross National Income GoL Government of Liberia H1N1 Pandemic Influenza HEA Health Emergency Account HIPC Heavily Indebted Poor Countries IBRD International Bank for Reconstruction and Development IDA International Development Association IEG Independent Evaluation Group IMF International Monetary Fund i IPAU Integrated Project Administration Unit IPC Infection Prevention and Control IPF Investment Project Financing LRD Liberian Dollars MERS-CoV Middle East Respiratory Syndrome Coronavirus M&E Monitoring and Evaluation MSF Médecins Sans Frontières MoFED Ministry of Finance and Economic Development MoH Ministry of Health MoHS Ministry of Health and Sanitation MoHSW Ministry of Health and Social Welfare MOU Memorandum of Understanding MRU Mano River Union MMR Maternal Mortality Ratio NaCSA National Commission for Social Action NASSCORP National Social Security and Welfare Corporation NCG National Consultative Group NGO Non-governmental Organization NRC National Response Center NTF National Task Force NTT National Technical Team OCHA United Nations Office for the Coordination of Humanitarian Affairs ODA Official Development Assistance OP/BP Operations Policy/Bank Policy ORAF Operational Risk Assessment Framework PAD Project Appraisal Document PFM Public Financial Management PDO Project Development Objectives PHEIC Public Health Emergency of International Concern PPE Personal Protective Equipment SARS Severe Acute Respiratory Syndrome SDR Special Drawing Rights SLL Sierra Leonean Leones SPL Social Protection and Labor TA Technical Assistance TFR Total Fertility Rate UN United Nations UNICEF United Nations Children’s Fund UNMIL United Nations Mission in Liberia UNOPS United Nations Office for Project Services USAID United States Agency for International Development WAEMU West African Economic and Monetary Union WAHO West Africa Health Organization WFP World Food Program WHO World Health Organization WBG World Bank Group YESP Youth Employment Support Project ii Regional Vice President: Makhtar Diop Country Director: Colin Bruce Practice Senior Director: Timothy G. Evans Practice Manager: Trina Haque Task Team Leader: Shunsuke Mabuchi Co-Task Team Leaders: Sheila Dutta, Patricio V. Marquez iii AFRICA Ebola Emergency Response Project TABLE OF CONTENTS Page I. STRATEGIC CONTEXT .................................................................................................1 A. Country and Regional Context...................................................................................... 1 B. Situations of Urgent Need of Assistance or Capacity Constraints ............................... 3 C. Sectoral and Institutional Context................................................................................. 6 D. Higher Level Objectives to which the Project Contributes .......................................... 9 II. PROJECT DEVELOPMENT OBJECTIVES ..............................................................10 A. Project Development Objective .................................................................................. 10 B. Project Beneficiaries ................................................................................................... 11 C. PDO Level Results Indicators ..................................................................................... 11 III. PROJECT DESCRIPTION ............................................................................................11 A. Project Components .................................................................................................... 12 B. Project Financing ........................................................................................................ 15 C. Lessons Learned and Reflected in the Project Design ................................................ 16 IV. IMPLEMENTATION .....................................................................................................17 A. Institutional and Implementation Arrangements ........................................................ 17 B. Results Monitoring and Evaluation ............................................................................ 20 C. Sustainability............................................................................................................... 20 V. KEY RISKS AND MITIGATION MEASURES ..........................................................21 A. Risk Ratings Summary Table ..................................................................................... 21 B. Overall Risk Rating Explanation ................................................................................ 21 VI. APPRAISAL SUMMARY ..............................................................................................21 A. Economic and Financial Analyses .............................................................................. 21 B. Technical ..................................................................................................................... 23 C. Financial Management ................................................................................................ 24 D. Procurement ................................................................................................................ 25 E. Social (including Safeguards) ..................................................................................... 26 iv F. Environment ................................................................................................................ 27 Annex 1: Technical Brief of Ebola Virus Disease .....................................................................29 Annex 2: Example of Commitments of Selected International Partners Engaged in the Ebola Emergency Response ........................................................................................................30 Annex 3: Results Framework and Monitoring .........................................................................32 Annex 4: Detailed Project Description .......................................................................................35 Annex 5: Additional Lessons Learned on Fighting Disease Outbreak ...................................45 Annex 6: Implementation Arrangements ..................................................................................46 Annex 7: Operational Risk Assessment Framework (ORAF) .................................................57 Annex 8: Implementation Support Plan ....................................................................................60 Annex 9: Procurement Arrangements .......................................................................................62 Annex 10: The Economic Impact of the Ebola outbreak in Guinea, Liberia and Sierra Leone (as of August 27, 2014)......................................................................................................77 Annex 11: Environment and Social Action Plan.......................................................................86 LIST OF TABLES Table 1: Comparative health indicators in Guinea, Liberia and Sierra Leone (2012 data) ............ 3 Table 2: Confirmed, probable, and suspect cases and deaths from Ebola virus disease in Guinea, Liberia, and Sierra Leone, as of 6 September 2014 ........................................................................ 4 Table 3: Proposed Bank support program with indicative instrumentation and amounts .............. 8 Table 4: Estimated Ebola-related food needs & associated costs in the three affected countries 15 Table 5: Initial Estimated Project Cost and Financing Component Allocation and percentage contribution to the broader plan .................................................................................................... 16 Table 6: Country allocation .......................................................................................................... 16 Table 7: Projected Impact of the Ebola Outbreak, 2014 (as of August 29, 2014) ........................ 23 Table 8: Thematic areas and cost items of the Ebola outbreak response plan .............................. 36 Table 9: WFP’s estimate of Ebola-related food needs and associated costs in the three affected countries ........................................................................................................................................ 42 Table 10: Procurement risks and proposed mitigation measures.................................................. 66 Table 11: Procurement and Selection Review Thresholds for Liberia ......................................... 67 Table 12: Procurement risks and proposed mitigation measures.................................................. 70 Table 13: Procurement and Selection Review Thresholds for Sierra Leone ................................ 71 Table 14: Procurement and Selection Review Thresholds ........................................................... 75 Table 15: Projected Impact of the Ebola Outbreak, 2014 ............................................................. 77 v Table 16: Guinea – Estimated GDP Impact of Ebola ................................................................... 78 Table 17: Guinea – Estimated Fiscal Impact of Ebola (US$ million) .......................................... 79 Table 18: Liberia – Estimated GDP impact of Ebola ................................................................... 80 Table 19: Liberia – Estimated Fiscal Impact of Ebola (US$ million) .......................................... 81 Table 20: Sierra Leone – Estimated GDP Impact of Ebola .......................................................... 83 Table 21: Sierra Leone – fiscal operations (US$ million) ............................................................ 84 vi . PAD DATA SHEET . PAD DATA SHEET Africa Ebola Emergency Response Project (P152359) PROJECT APPRAISAL DOCUMENT . AFRICA 0000009074 Report No.: PAD1134 . . Basic Information Project ID EA Category Team Leaders P152359 B - Partial Assessment Shunsuke Mabuchi Sheila Dutta Patricio V. Marquez Lending Instrument Fragile and/or Capacity Constraints [ X ] Investment Project Financing - Fragile within a non-fragile country Financial Intermediaries [ ] Series of Projects [ ] Project Implementation Start Date Project Implementation End Date 16-Sep-2014 30-Sep-2015 Expected Effectiveness Date Expected Closing Date 25-Sep-2014 30-Sep-2015 Joint IFC No Practice Senior Global Practice Country/Regional Regional Vice President Manager/Manager Director Integration Directors Colin Bruce Trina S. Haque Timothy Grant Evans Yusupha B. Crookes Makhtar Diop Ousmane Diagana . Recipients: Republic of Guinea, Republic of Liberia, Republic of Sierra Leone . Safeguards Deferral (from Decision Review Decision Note) Will the review of Safeguards be deferred? [ X] Yes [] No Project Financing Data(in USD Million) [ ] Loan [X] IDA Grant [ ] Guarantee vii [ ] Credit [ ] Grant [] Other Total Project Cost: 105.00 M Total Bank Financing: 105.00 M Financing Gap: 0.00 . Financing Source Amount Borrower 0.00 IDA Grant from CRW 105.00 Total 105.00 . Expected Disbursements (in USD Million) Fiscal 2015 2016 Year Annual 105.00 0 Cumulati 105.00 105.00 ve . Proposed Development Objective(s) The Project Development Objective is to contribute in the short term to the control of the Ebola Virus Disease (EVD) outbreak and the availability of selected essential health services, and mitigate the socio- economic impact of EVD in Guinea, Liberia, and Sierra Leone. . Components Component Name Cost (USD Millions) Component 1: Support to the EVD Outbreak Response Plans 45.00 and Strengthening Essential Health Services Component 2: Human Resources Scale up for Outbreak 38.00 Response and Essential Health Services Component 3: Provision of Food and Basic Supplies to 22.00 Quarantined Populations and EVD Affected Households . Institutional Data Practice Area / Cross Cutting Solution Area Health, Nutrition & Population Cross Cutting Areas [ ] Climate Change [X] Fragile, Conflict & Violence [ ] Gender [ ] Jobs [ ] Public Private Partnership Sectors / Climate Change Sector (Maximum 5 and total % must equal 100) viii Major Sector Sector % Adaptation Mitigation Co-benefits % Co-benefits % Health and other social services Health 80 Health and other social services Other social services 20 Total 100 I certify that there is no Adaptation and Mitigation Climate Change Co-benefits information applicable to this project. . Themes Theme (Maximum 5 and total % must equal 100) Major theme Theme % Human development Other communicable diseases 80 Social protection and risk management Other social protection and risk 20 management Total 100 . Compliance Policy Does the project depart from the CAS in content or in other significant Yes [ ] No [ X ] respects? . Does the project require any waivers of Bank policies? Yes [ X ] No [ ] Have these been approved by Bank management? Yes [ X ] No [ ] Is approval for any policy waiver sought from the Board? Yes [ X ] No [ ] Explanation: Bank management has noted that the exceptional nature of the Ebola outbreak (in terms of its scale, severity, potential further rapid spread and substantial negative economic impact) warrants eligibility for a Crisis Response Window (CRW) allocation to enable a robust World Bank Group response to the Ebola outbreak. Furthermore, this project appraisal document seeks the approval of Executive Directors to provide the financing of the project from the CRW in the amount of USD105 million entirely on grant terms rather than on each country’s standard IDA terms as is prescribed for financing from the CRW. The use of grant financing is appropriate in light of the demonstrable regional and global positive externalities that will flow from mitigating the spread of the deadly virus in the affected countries and reducing the risk of its spreading to at-risk neighboring countries, thereby benefitting the West Africa region as a whole, as well as the rest of the world, by minimizing the socio economic impact of the outbreak and protecting lives and livelihoods of the population. The funds requested under this emergency CRW/IDA operation, complementing the support provided by other international partners under the leadership of the World Health Organization and in coordination with the United Nations, would support the Governments of Guinea, Liberia, and Sierra Leone to control the spread of the deadly Ebola Virus Disease and to mitigate the unprecedented health and socioeconomic impacts of the Ebola epidemic. In view of the rapid acceleration and daily evolution of the epidemic, it needs to be highlighted that the current level of resources may not be sufficient to address the growing Ebola outbreak and its impacts in the near future. As such, there is the possibility that further resources from ix the CRW may be requested. Does the project meet the Regional criteria for readiness for implementation? Yes [ X ] No [ ] . Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 X Natural Habitats OP/BP 4.04 X Forests OP/BP 4.36 X Pest Management OP 4.09 X Physical Cultural Resources OP/BP 4.11 X Indigenous Peoples OP/BP 4.10 X Involuntary Resettlement OP/BP 4.12 X Safety of Dams OP/BP 4.37 X Projects on International Waterways OP/BP 7.50 X Projects in Disputed Areas OP/BP 7.60 X . Legal Covenants Name Recurrent Due Date Frequency Sierra Leone: Project Implementation One month after Manual Effective Date Description of Covenant FA Schedule 2.Section I.B.2 (a). To facilitate efficient implementation of the Project, the Recipient shall, not later than one (1) month after Effective Date: (i) prepare and adopt, in form and substance satisfactory to the Association, a Project Implementation Manual; and (ii) thereafter, ensure that the Project is carried out in accordance with the arrangements, procedures and guidelines set out in the Project Implementation Manual. Name Recurrent Due Date Frequency Sierra Leone: External Auditor Five months after the Effective Date To facilitate the auditing of Financial Statements referred to in FA Section II.B.3 of Schedule 2 to the FA, the Recipient shall, not later than five (5) months after the Effective Date, appoint in accordance with the provisions of Section III of Schedule 2, and thereafter maintain at all times during Project implementation, an external auditor for the Project. Name Recurrent Due Date Frequency Sierra Leone: Internal Audits Quarterly The Recipient shall carry out quarterly internal audits under terms and conditions satisfactory to the Association (mainly in relation to Compensation Benefits and Emergency Operating Costs), and furnish the related internal audit reports to the Association not later than forty-five (45) days after the end of each calendar quarter. Name Recurrent Due Date Frequency x Name Recurrent Due Date Frequency Sierra Leone: Environmental and Social One month after the Screening and Assessment Framework Effective Date Description of Covenant FA Schedule 2. Section I.D.1 (a). The Recipient shall, not later than one (1) month after the Effective date, prepare and disclose in a manner satisfactory to the Association: an Environmental and Social Screening and Assessment Framework or an Environmental and Social Management Framework (as the case may be) detailing: (i) the guidelines, procedures and timetables for carrying out of environmental and social assessments under the Project; (ii) the measures to be taken during the implementation of the Project to eliminate or offset adverse environmental and social impacts, or to reduce them to acceptable levels; and (iii) the actions needed to implement these measures, including monitoring and evaluation, and institutional strengthening. Name Recurrent Due Date Frequency Sierra Leone: Health Care Waste One month after the Management Plan Effective Date Description of Covenant FA Schedule 2. Section I.D.1 (b). The Recipient shall, not later than one (1) month after the Effective date, prepare and disclose in a manner satisfactory to the Association: a Health Care Waste Management Plan (including, inter alia, arrangements for the implementation and monitoring of residual impacts on surrounding environments and persons), all in form and substance satisfactory to the Association (collectively, “Safeguard Instruments”). Name Recurrent Due Date Frequency Liberia: Project Implementation Manual One month after the Effective Date Description of Covenant FA Schedule 2.Section I.B.2 (a). To facilitate efficient implementation of the Project, the Recipient shall, not later than one (1) month after the Effective Date: (i) prepare and adopt, in form and substance satisfactory to the Association, a Project Implementation Manual; and (ii) thereafter, ensure that the Project is carried out in accordance with the arrangements, procedures and guidelines set out in the Project Implementation Manual. Name Recurrent Due Date Frequency Liberia: External Auditor Five month after the Effective Date To facilitate the auditing of Financial Statements referred to in FA Section II.B.3 of Schedule 2 to the FA, the Recipient shall, not later than five (5) months after the Effective Date, appoint in accordance with the provisions of Section III of Schedule 2, and thereafter maintain at all times during Project implementation, an external auditor for the Project. Name Recurrent Due Date Frequency Liberia: Internal Audits Quarterly The Recipient shall carry out quarterly internal audits under terms and conditions satisfactory to the Association (mainly in relation to Compensation Benefits and Emergency Operating Costs), and furnish the related internal audit reports to the Association not later than forty-five (45) days after the end of each calendar quarter. xi Name Recurrent Due Date Frequency Liberia: Environmental and Social One month after the Screening and Assessment Framework Effective Date Description of Covenant FA Schedule 2.Section I.D.1 (a). The Recipient shall, not later than one (1) month after the Effective date, prepare and disclose in a manner satisfactory to the Association: an Environmental and Social Screening and Assessment Framework or an Environmental and Social Management Framework (as the case may be) detailing: (i) the guidelines, procedures and timetables for carrying out of environmental and social assessments under the Project; (ii) the measures to be taken during the implementation of the Project to eliminate or offset adverse environmental and social impacts, or to reduce them to acceptable levels; and (iii) the actions needed to implement these measures, including monitoring and evaluation, and institutional strengthening. Name Recurrent Due Date Frequency Liberia: Health Care Waste Management One month after the Plan Effective Date Description of Covenant FA Schedule 2. Section I.D.1. (b). a Health Care Waste Management Plan (including, inter alia, arrangements for the implementation and monitoring of residual impacts on surrounding environments and persons), all in form and substance satisfactory to the Association. Name Recurrent Due Date Frequency Guinea: Project Implementation Manual One month after the Effective Date Description of Covenant FA Schedule 2. Section I.B.2 (a). To facilitate efficient implementation of the Project, the Recipient shall, not later than one (1) month after the Effective Date: (i) prepare and adopt, in form and substance satisfactory to the Association, a Project Implementation Manual; and (ii) thereafter, ensure that the Project is carried out in accordance with the arrangements, procedures and guidelines set out in the Project Implementation Manual. Name Recurrent Due Date Frequency Guinea: External Auditor Five months after the Effective Date To facilitate the auditing of Financial Statements referred to in FA Section II.B.3 of Schedule 2 to the FA, the Recipient shall, not later than five (5) months after the Effective Date, recruit in accordance with the provisions of Section III of Schedule 2, and thereafter maintain at all times during Project implementation, an external auditor for the Project. Name Recurrent Due Date Frequency Guinea: Financial Management System Two months after the Effective Date To facilitate the proper maintenance of its financial management system referred to in FA Section II.B.1 of Schedule 2 to the FA, the Recipient shall: (a) not later than one (1) month after the Effective Date, recruit a financial management officer and internal auditor and appoint an accountant; and (b) not later than two (2) months after the Effective Date, acquire and thereafter install a computerized xii accounting system, all in accordance with the provisions of FA Section III of Schedule 2 to the FA. Name Recurrent Due Date Frequency Guinea: Internal Audits Quarterly The Recipient shall carry out quarterly internal audits under terms and conditions satisfactory to the Association (mainly in relation to Compensation Benefits and Emergency Operating Costs), and furnish the related internal audit reports to the Association not later than forty-five (45) days after the end of each calendar quarter. Name Recurrent Due Date Frequency Guinea: Environmental and Social One month after Screening and Assessment Framework Effective Date Description of Covenant FA Schedule 2.Section I.D.1 (a). The Recipient shall, not later than one (1) month after the Effective date, prepare and disclose in a manner satisfactory to the Association: an Environmental and Social Screening and Assessment Framework or an Environmental and Social Management Framework (as the case may be) detailing: (i) the guidelines, procedures and timetables for carrying out of environmental and social assessments under the Project; (ii) the measures to be taken during the implementation of the Project to eliminate or offset adverse environmental and social impacts, or to reduce them to acceptable levels; and (iii) the actions needed to implement these measures, including monitoring and evaluation, and institutional strengthening. Name Recurrent Due Date Frequency Guinea: Health Care Waste Management One month after Plan Effective Date Description of Covenant FA Schedule 2. Section I.D.1 (b). A Health Care Waste Management Plan (including, inter alia, arrangements for the implementation and monitoring of residual impacts on surrounding environments and persons), all in form and substance satisfactory to the Association. . Conditions Source Of Fund Name Type IDWT Sierra Leone: Detailed List of Beneficiaries Disbursement Description of Condition FA Section IV. B.1. (a) Notwithstanding the provisions of Section IV.A of Schedule 2 to the FA, no withdrawal shall be made under Category (2), unless and until the Recipient has submitted in form and substance satisfactory to the Association, for each withdrawal, a detailed list of Beneficiaries, in accordance with the provisions of Section II.B.2 of this Schedule 2 and the provisions of Section IV of the Disbursement Letter. xiii Source Of Fund Name Type IDWT Liberia: Detailed List of Beneficiaries Disbursement Description of Condition FA Section IV. B.1 (b). Notwithstanding the provisions of Section IV.A of Schedule 2 to the FA, no withdrawal shall be made under Category (2), unless and until the Recipient has submitted in form and substance satisfactory to the Association, for each withdrawal, a detailed list of Beneficiaries, in accordance with the provisions of Section II.B.2 of this Schedule 2 and the provisions of Section IV of the Disbursement Letter. Source Of Fund Name Type IDWT Guinea: Detailed List of Beneficiaries Disbursement Description of Condition Section IV.B.1 (b) under Category (2), unless and until the Recipient has submitted in form and substance satisfactory to the Association, for each withdrawal, a detailed list of Beneficiaries, in accordance with the provisions of Section II.B.2 of this Schedule 2 and the provisions of Section IV of the Disbursement Letter. Team Composition Bank Staff Name Title Specialization Unit Shunsuke Mabuchi Health Specialist Team Lead GHNDR Patricio V. Marquez Lead Health Specialist Health GHNDR Sheila Dutta Senior Health Specialist Health GHNDR Trina S. Haque Practice Manager Health GHNDR Inguna Dobraja Country Manager Liberia AFMLR Francis Ato Brown Country Manager Sierra Leone AFMSL Cheick Fantamady Kante Country Manager Guinea AFMGN Christine Makori Senior Counsel Legal LEGAM Faly Diallo Financial Officer Finance CTRLA Patrick Piker Umah Tete Sr Financial Financial Management GGODR Management Specialist Xiaoping Li Senior Procurement Procurement GGODR Specialist Nina Rosas Raffo Social Protection Social Protection GSPDR Specialist Emily Weedon Chapman Social Protection Social Protection GSPDR Specialist Daniele A-G. P. Jaekel Operations Analyst Operations GPSOS Tomo Morimoto Operations Officer Operations GHNDR Sybille Crystal Senior Operations Operations GHNDR xiv Officer Rianna L. Mohammed- Senior Health Specialist Health GHNDR Roberts Enias Baganizi Senior Health Specialist Health GHNDR Francisca Ayodeji Akala Senior Health Specialist Health GHNDR Ibrahim Magazi Senior Health Specialist Health GHNDR Yvette M. Atkins Senior Program Operations GHNDR Assistant Renaud Seligmann Practice Manager Financial Management GGODR Adenike Sherifat Sr Financial Financial Management GGODR Oyeyiola Management Specialist Ismaila Ceesay Lead Financial Financial Management GGODR Management Specialist Maimouna Mbow Fam Senior Financial Financial Management GGODR Management Specialist Celestin Adjalou Senior Financial Financial Management GGODR Niamien Management Specialist (Guinea) Saidu Dani Goje Financial Management Financial Management GGODR specialist (Liberia) (Liberia) Sydney Augustus Financial Management Financial Management GGODR Olorunfe Godwin Specialist (Sierra Leone) Bayo Awosemusi Lead Procurement Procurement GGODR Specialist Alpha Mamoudou Bah Senior Procurement Procurement GGODR Specialist Daniel Rikichi Kajang Senior Procurement Procurement GGODR Specialist Charles Taylor Consultant Procurement GGODR Winter M. Chinamale Senior Procurement Procurement GGODR Specialist Mathias Gogohounga Procurement Specialist Procurement GGODR Ousmane Tanou Diallo Consultant Procurement GGODR Sanjay Srivastava Lead Environmental Environmental GENDR Specialist Safeguard Felix Nii Tettey Oku E T Consultant Environmental GENDR Safeguard Demba Balde Senior Social Social Development GURDR Development Specialist Knut Opsal Lead Social Social Safeguard GURDR Development Specialist xv Aissatou Chipkaou Operations Analyst Operations GHNDR Timothy John Bulman Senior Economist Economist GMFDR Safiatou Lamarana Operation Officer Operations (Guinea) AFMGN Diallo Errol George Graham Senior Economist Economist GMFDR Demet Kaya Senior Economist Economist DFIRM Akiko Maeda Lead Health Specialist Health GHNDR Christopher H. Herbst Health Specialist Health GHNDR Raymond Muhula Public Sector Specialist Public Sector GGODR Shiho Nagaki Public Sector Mgmt. Public Sector GGODR Specialist Dinesh Nair Senior Health Specialist Health GHNDR Cyrus P. Talati Senior Economist Economist GMFDR Shiyong Wang Senior Health Specialist Health GHNDR Ali Zafar Senior Economist Economist GMFDR Noel Chisaka Senior Public Health Public Health GHNDR Spec. Ivar J. Andersen Manager, Operations CRW DFIRM Coleen R. Littlejohn Senior Operations Operations AFRDE Officer Thierno Hamidou Diallo Disbursement Assistant Disbursement AFMGN Ousmane Tanou Diallo Consultant GGODR Non Bank Staff Name Title City . Locations Country First Location Planned Actual Comments Administrative Division Guinea Liberia Sierra Leone xvi I. STRATEGIC CONTEXT A. Country and Regional Context 1. This project appraisal document seeks the approval of the Executive Directors to provide a grant of US$105 million equivalent from the IDA Crisis Response Window (CRW). The proposed Ebola Emergency Response Project will support the first phase of the World Bank Group’s (WBG) response to the current and still evolving Ebola Virus Disease (EVD) outbreak in the West African countries of Guinea, Liberia, and Sierra Leone under the funding of IDA’s CRW. Although CRW resources are generally intended to address severe natural disasters and economic crises, the present circumstances in West Africa encompass the characteristics of such natural disasters and economic crises that CRW was established to address. Indeed, since the Ebola virus was first identified in 1976, no previous Ebola outbreak has been as large or persistent as the current epidemic in West Africa, and the recent reported deaths and infection cases highlight the risk of wider spread across Africa and to other continents. 2. The IDA17 replenishment framework specifies that Management consults with the Executive Directors shortly after a disaster occurs to indicate that access to CRW resources would form part of an appropriate response. An Executive Directors’ Seminar on the EVD outbreak in West Africa and the Bank’s proposed emergency recovery and medium-term response took place on August 5, 2014. Executive Directors expressed strong support for the proposed use of CRW resources in addressing the EVD outbreak. Subsequently, on August 19, 2014, in line with the framework for allocating resources from IDA’s CRW, a note was presented to the WBG Board informing the Executive Directors of Management’s intention to allocate an indicative amount of SDR100 million (US$150 million equivalent) to support the West African nations in responding over the short-and medium-terms to the EVD outbreak. 3. Given the nature of the Project as a regional and global public good with positive externalities in containing and mitigating a fast moving epidemic, financing on grant terms is warranted. The proposed Project has long-term regional development impact as it aims to mitigate the spread of a deadly virus in the affected countries and reduce the risk of spreading to at-risk vulnerable neighboring countries. The high mortality rate of EVD and its capacity to spread to other countries in the absence of strong and effective public health systems make it imperative to support an immediate emergency response in the affected countries as part of a coordinated international response led by the World Health Organization (WHO) and the United Nations (UN). As designed, the proposed Project would also benefit the affected countries and the West Africa region as a whole by minimizing the socio economic impact of the outbreak. 4. In view of the rapid acceleration and daily evolution of the epidemic, the current level of resources may not be sufficient to address the growing Ebola outbreak and its impacts in the near future. As such, further resources from the CRW may be requested by the Bank team. Because the initial responses to the Ebola outbreak were uneven and much-delayed, the disease and attendant human and economic costs increased very rapidly over the last nine months. As a result, control of the epidemic and mitigation of its impacts will now require far greater efforts and resources than if the Governments had the requisite capacity to act earlier. Initial commitments of US$200 million made by the WBG President on August 4, 2014, should 1 be considered within the context of an evolving epidemic as it continues to unfold. Since the end of July 2014, WHO’s initial cost estimates have increased significantly by about 400 percent, to US$490 million. 1 Therefore, the immediate response is still significantly under-resourced for the purposes of curbing the outbreak, mitigating its immediate socio-economic effects, rebuilding basic health service delivery capacities, and going further to invest in the fundamental development of a robust health system in the sub-region. Also, the prospect that the epidemic may well extend beyond the 6 months suggested in the WHO’s Roadmap is real. In that scenario, the WBG will develop a proposal for additional investments to meet these challenges based on the most credible data available, the realities at country level, attention to the negative externalities laid bare by the EVD outbreak, assessment of overall resource availability from all other sources, and in consultation with the WHO, UN agencies, and other partners. 5. Guinea: A legacy of political instability, insecurity, and governance challenges has limited the potential for shared prosperity with respect to Guinea’s vast natural wealth. The country’s total population in 2013 was estimated at 11.7 million and the per capita gross national income (GNI) is at US$460. The poverty rate increased from 53 percent in 2007 to 55 percent in 2012. Health sector challenges include deteriorating trends for some key sector indicators. While access to prenatal care and to some child immunizations (DPT3) has significantly increased from 2000 to 2011, infant mortality rate and maternal mortality ratio (at respectively 67 per 1,000 live births and 724 per 100,000 live births) are among the highest in Africa. The total fertility rate (TFR) remains high, although it declined from 6 children per reproductive aged woman in 2000 to 5 children in 2012. In 2008, 71 percent of the population had access to an improved water source. The combination of low health sector budget allocation (less than 1 percent of GDP) and weak execution has undermined the effectiveness of Guinea’s health sector policies. Health expenditures are currently focused on secondary care, tertiary care, and central administration, to the detriment of primary care. 2 6. Liberia: Liberia has recently begun the transition from recovery to development, following fourteen years of civil war. Although a country rich in natural resources, it is beginning its recovery from a 90 percent decline in its GNI per capita that occurred between 1987 and 2003. The country’s total population in 2013 was estimated at 4.2 million and the per capita GNI is at US$410. In 2007, nearly two-thirds of Liberia’s population lived below the poverty line and almost half were living in extreme poverty. Nevertheless, poverty is estimated to have fallen to 56.4 percent more recently. Despite efforts to strengthen overall health systems management and health services delivery since the end of the war, Liberia continues to face significant challenges in improving maternal and child health outcomes, as well as other health outcomes. The maternal mortality ratio (MMR) remains high, but has declined from close to 1,000 per 100,000 live births in 2007 to 770 per 100,000 live births in 2010. While over one in ten children will die before the age of five, infant and under five mortality rates have almost halved over the last 20 years (Table 1), due to improved access resulting from the Government’s free health care policy, 1 and enhanced capacity to deliver essential services such as immunizations. Malaria continues to be a 1 These estimates could further increase when the UN Senior Coordinator submits his forthcoming report. 2 World Bank (2013). Country Partnership Strategy for Guinea for the period FY14-17 and Guinea Social Sector Public Expenditure Review (forthcoming, 2014). 2 major source of morbidity and mortality: at least 33 percent of all in-patient deaths in Liberia and 41 percent of deaths among children under five are attributed to malaria 3. 7. Sierra Leone: A post-conflict country, Sierra Leone has experienced strong growth over the last decade. The country’s total population in 2013 was estimated at 6 million and the per capita GNI is at US$680. The economy has been on a recovery path, averaging 5.8 percent annual per capita growth between 2003 and 2011. 4 Despite this growth, 53 percent of the country’s 6 million inhabitants remained below the poverty line and nearly one million (14 percent) were extremely poor in 2011. The country’s maternal and child health outcomes remain low compared to other countries in Sub-Saharan Africa (Table 1). According to the latest estimates, Sierra Leone’s MMR was the sixth highest in the world at 890 maternal deaths per 100,000 live births in 2010, compared to the regional average of 500 deaths per 100,000 live births. 5 Since the introduction of the Free Health Care Initiative in 2010, 6 the country has made important progress toward increasing access to health services. For example, the percentage of births delivered in a health facility increased from 29 percent in 2007 to 52 percent in 2011.7 In addition, chronic malnutrition for children ages 0-5 is on the rise, increasing from 40 percent in 2005 to 44 percent in 2010. 8 Table 1: Comparative health indicators in Guinea, Liberia and Sierra Leone (2012 data) SSA Sierra Guinea Liberia Regional Leone Average Maternal Mortality Ratio (per 100,000 live births) 724 770 890 500 Health expenditure per capita (current US$) 32 65 96 95 Health expenditure, total (% of GDP) 6 16 15 6 Immunization, DPT (children 12-23 months) 59 77 84 71 Immunization, measles (children 12-23 months) 58 80 80 72 Life expectancy at birth, total (years) 56 60 45 56 Infant mortality rate (per 1,000 live births) 65 56 117 64 Under-five mortality rate (per 1,000) 101 75 182 98 Source: World Bank, Health, Nutrition, and Population Data Dashboard (HNPStats). Accessed online on 8/21/2014). B. Situations of Urgent Need of Assistance or Capacity Constraints 8. West Africa is facing its first documented outbreak of EVD. EVD is a severe acute viral illness of animal origin with a very high case fatality rate that spreads in the human population through human-to-human transmission (see Annex 1 for scientific background of EVD). This evolving outbreak is the largest in the nearly four-decade history of this disease in terms of geographical areas already affected and others at immediate risk of further spread. Table 2 illustrates the rapid increases in cases and deaths of EVD in three months in West Africa. By 3 2011 Liberia Malaria Indicator Survey. 4 IMF World Economic Outlook Databases (2013). 5 World Health Organization (2010). Trends in maternal mortality: 1990 to 2010. 6 This policy abolished all user fees in public facilities for pregnant women, lactating mothers, and under-5 children. 7 Report on the 2011 Integrated National Public Services (INPSS) Survey Public Services, Governance, and Social Dynamics (June 2012). Institutional Reform and Capacity Building Project Evaluations Unit. 8 World Bank (2012) Sierra Leone Draft Social Protection Assessment Report. 3 September 6, 2014, the cumulative number of confirmed, probable, and suspected cases of EVD in West Africa is estimated at 4,269 with 2,288 deaths. The overall case fatality rate (ratio of deaths to cases) is 54 percent, ranging from 37 percent in Sierra Leone to 64 percent in Guinea. However, this estimate is approximate, since some cases and deaths may have been missed, particularly from inadequate contact tracing in Guinea during the initial period of the outbreak that facilitated transmission (Briand, S. et al, NEJM, August 20, 2014). The WHO has warned that infections can rise to 20,000 (WHO, August 28, 2014). 9. The outbreak in West Africa is taking place in areas with fluid population movements over porous borders. Cases are occurring in rural areas which are difficult to access, but also in densely populated capital cities. There is high exposure to the Ebola virus in the community through household care and customary burial procedures in which mourners have direct contact with the body of the deceased person. Also, there is denial, mistrust, and misinformation among the population, leading to rejection of public health interventions and information, contributing to the continued spread of the disease. Close community ties and movement within and across borders has also led to difficulties in tracing and following up of contacts for the three countries. Global air travel could further contribute to the spread of EVD as the result of the boarding and traveling of infected, asymptomatic persons to other countries. The situation is further aggravated by the particularly weak and limited capacity to detect and control infectious disease outbreaks in the affected countries (Science, August 27, 2014). 10. Moreover, health care workers have been infected while treating patients with suspected or confirmed EVD. In six months since the EVD outbreak, more than 225 health workers have fallen ill and nearly 130 have lost their lives to the disease. 9 These infections have been noted to have occurred through close contact with patients when infection control precautions are not strictly practiced. Hence, the lack of preparedness, late detection, and delayed response to the EVD outbreak contributed to magnify the impact and cost of the outbreak in the affected countries. Table 2: Confirmed, probable, and suspect cases and deaths from Ebola virus disease in Guinea, Liberia, and Sierra Leone, as of 6 September 2014 Confirmed Probable Suspect Totals CFR Guinea Cases 664 151 47 862 64% Deaths 400 151 4 555 Liberia Cases 634 969 443 2,046 60% Deaths 508 420 296 1,224 Sierra Leone Cases 1,234 37 90 1,361 37% Deaths 461 37 11 509 Totals 9 WHO (2014). August 24, 2014 WHO Statement. 4 Cases 2,532 1,157 580 4,269 54% Deaths 1,369 608 311 2,288 Source: WHO: Ebola Response Roadmap Situation Report, 8 September, 2014. 11. The inability to contain the EVD outbreak has highlighted the lack of or limited capacity of already weak and under-resourced health systems and the scarcity of health workers in the affected countries. Treatment facilities are over-burdened and this is aggravated by lack of personal protective equipment (PPE) and other basic supplies, training programs, and infection prevention control procedures in the facilities. In the report by US CDC from Liberia dated August 1, 2014 for example, PPE supplies, training, and transportation are inadequate and few health facilities with cases have infection control plans and operational isolation units in place. This situation is placing health workers at risk of contagion. The infection of health care workers has paralyzed the health system - in many areas of affected countries, public hospitals and clinics have closed down with health workers fleeing or abandoning their posts due to fear of contamination. As a result of this situation, essential health services for other diseases are no longer being offered and people are dying from lack of medical care for child deliveries by trained personnel and from otherwise preventable and treatable conditions such as malaria. 12. Underlying the crisis is the weak laboratory diagnostic capacity in the affected countries, not only for EVD diagnosis but for other conditions, as well as cross-border collaboration and networking among laboratories in the sub-region. Security remains a major concern, as in some regions of the affected countries community members have rejected support from burial teams and health workers, leading to the withdrawal of international personnel from the health facilities. Contact tracing 10 does not always appear to be carried out to identify persons who may have been in contact and infected by an EVD infected individual, and symptomatic patients are not always referred to health care providers, contributing to an “invisible caseload”. Nationwide surveillance and data management systems are weak in the affected countries, which also hinders diagnosis and case confirmation. Given the above challenges, WHO has confirmed that under- reporting of cases is a problem, particularly in Liberia and Sierra Leone, currently the two countries most impacted by the EVD epidemic. 13. Countries and the global community have declared emergencies. All three affected countries have declared a state of emergency. The US CDC has issued a Level Three warning to avoid non-essential travel to the West African nations of Guinea, Liberia, and Sierra Leone. This warning, which is the highest level of alertness, is a reflection of the worsening and seriousness of the Ebola outbreak in this region. On August 8, 2014, WHO issued a statement indicating that the ongoing outbreak of Ebola Viral Disease in West Africa constitutes a “Public Health Emergency of International Concern” (PHEIC) and recommended appropriate temporary measures to reduce international spread. This is the third PHEIC ever announced by WHO. On August 1, 2014, the Mano River Union Heads of State issued a declaration of intention for 10 Contact tracing is the method that has been used in the control of endemic contagious disease for decades. A disease investigation begins when an individual is identified as having a communicable disease. An investigator interviews the patient, family members, physicians, nurses, and anyone else who may have knowledge of the primary patient's contacts, anyone who might have been exposed, and anyone who might have been the source of the disease. Then the contacts are screened to see if they have or have ever had the disease. The type of contact screened depends on the nature of the disease. 5 coordinated action and initiated a “sanitary cordon”. In Liberia, security forces have powers to enforce closing of most border crossings and isolation of affected communities, among other measures. All schools have been closed indefinitely, and non-essential Government workers have compulsory leave for 30 days. In Sierra Leone, the Government announced similar measures on July 30, 2014. The army has been deployed to affected communities, and public gatherings have been banned, except for the purpose of communicating preventive measures on Ebola. 14. The restriction of movement is leading to food crises in the quarantined and most affected areas where the three countries intersect. In the Mano River region, food insecurity is spreading rapidly. More than 1 million people in the region are facing a food crisis in the coming months. Furthermore, as the crisis continues to evolve, this threat may spread to other areas due to quarantine or other disruptions in movement of goods and people. The World Food Program (WFP) has declared Guinea, Liberia and Sierra Leone a Level Three food emergency - its highest threat. 15. Rapid Market Analyses conducted by WFP in key markets around the capitals of Sierra Leone and Liberia in mid-August 2014 indicate increases in commodity prices. In Monrovia, the price of essential commodities increased between 13 and 150 percent over a two week period. 11 A similar price assessment of markets in Freetown on August 14, 2014 also found significant increases in the price of local and imported foods since mid-July. These increases are linked to reduced availability of locally and sub-regionally farmed goods as farmers in isolated areas have been unable to harvest crops and traders unable to transport local produce. This, coupled with disruption in entry of goods into the country has led to stockpiling and rationing of goods. At the same time, roadblocks, border closures, and movement restrictions have limited the supply of goods from the centers out to affected rural areas, which rely heavily on this supply for their primary staple. This lack of availability of food, particularly in quarantined areas and “hot zones” is likely to exacerbate the already high food insecurity in the affected countries. C. Sectoral and Institutional Context Responses to the Crisis 16. An emergency response to the crisis has been launched at both national and regional levels. The Governments of Guinea, Liberia, and Sierra Leone, along with the WHO have prepared Ebola outbreak response plans and priority preparedness activities for six months up to the end of 2014 (and revised to end of February 2015) to accelerate the response in the region. The goals of the WHO Roadmap “Strategy for Accelerated Response to Ebola Outbreak in West Africa” prepared in conjunction with the countries are to: (i) stop transmission of EVD in the affected countries through scaling up effective, evidence-based outbreak control measures; and (ii) prevent the spread of EVD to the neighboring at-risk countries through strengthening epidemic preparedness and response measures. To improve coordination and efficiency of the response, each of the three governments established central and district-level committees and emergency response/incident management centers to coordinate the efforts by development partners, NGOs, and the private sector and also created pooled funds to invite contributions and promote streamlined implementation. Furthermore, despite the extremely challenging 11 WFP Regional Emergency Operation Document (OMD West Africa 200761). 6 circumstances, domestic health workers have been providing front-line services to care for Ebola patients as well as continue to provide essential health services, often at great personal risk. 17. The immediate and short-term funding plan, estimated at end-July at US$103 million for six months, and now revised upwards to US$490 million 12 , is geared to ensure coordination among all actors and the delivery of effective support to the affected countries and countries at risk. The plan has three main thrusts: (a) immediate outbreak response interventions; (b) enhancing coordination and collaboration; and (c) scaling up human, logistic, and financial resource mobilization. It does not include amounts for enhanced social protection or mitigation of the impact of fiscal shocks. It also focuses on the immediate objectives at hand rather than the medium term needs for rebuilding and strengthening the capacity of the public health, service delivery and veterinary platforms of these countries. 18. In spite of intensified international support, a large financing and resource gap exists to effectively scale up the emergency response and control the EVD outbreak. Of the estimated US$490 million total cost, cost for the countries with widespread and intense transmission represents US$367 million (75 percent). In contrast, as of September 7, 2014, total committed and contributed international funds recorded in the Financial Tracking Service by OCHA are only US$ 89.4 million. With the recently approved US$60 million by the African Development Bank (AfDB) and US$12 million from the restructured projects from the WBG for Sierra Leone and Liberia, the total international financing remains short of the updated financing requirement. 19. To supplement over-stretched treatment facilities, hundreds of international aid workers (including from Médecins sans Frontières - MSF) and organizations including WHO and US CDC staff are supporting national and regional response efforts (see Annex 2). However, financing is limited, and more health workers, equipment and supplies (including PPEs) and community level interventions are urgently needed to scale up effective outbreak and control measures. To this end, on August 21, 2014, the Peace and Security Council of the African Union (AU) authorized the immediate deployment of AU-led military and civilian humanitarian volunteer health workers from across the continent. The US$25 million operation is expected to run for six months. This will need to be complemented by major scale-up training for both domestic and international health workers along with the provision of PPE and infection prevention and control (IPC) materials. Much more investment is required over the medium term to support countries to rebuild and significantly strengthen the capacity of weak public health systems and services delivery platforms, particularly to revamp and strengthen disease surveillance, public health laboratories, outbreak monitoring, case identification, diagnosis, case confirmation in accordance with WHO’s International Health Regulations, and case management and infection prevention control in health facilities. World Bank Response 20. In response to the call from the West African nations and WHO, the World Bank is proposing a package of short and medium term financing of almost US$230 million in emergency funding that supports country responses. It intends to help Guinea, Liberia, and Sierra Leone contain the spread of Ebola infections, assist their communities to cope with the 12 WHO’s updated Ebola Response Roadmap as of August 28, 2014. 7 economic impact of the crisis, and rebuild and strengthen essential public health systems and service delivery platforms in the region. The Bank’s comprehensive, multi-sectoral approach will include three parts: (i) Part A. Epidemic control, stabilization and mitigation, including immediate support to contain the outbreak and immediate enhancement of the social protection response, (ii) Part B. Enhanced Social Protection to help expand social safety nets to benefit affected communities; and (iii) Part C. Rebuilding and strengthening essential public health systems and service delivery platforms in West Africa to enable a more effective response to infectious disease outbreaks in the future (Table 3). To finance the emergency response and strengthening public health systems capacity, the Bank seeks to make available up to approximately US$80 million from IDA, whilst US$150 million would be allocated from the IDA 17 CRW. As part of the Bank’s immediate response, the two active health sector operations in Liberia and Sierra Leone were restructured on August 8, 2014 to make available US$6 million for each country to support their initial response. Furthermore, a US$6 million Project Preparation Advance (PPA) was provided to Guinea. The US$6 million made available for each country are being disbursed to the Governments and UN agencies supporting the Government, and essential supplies and drugs have been delivered to Liberia and Sierra Leone. Table 3: Proposed Bank support program with indicative instrumentation and amounts Action Amount Source of Instrument (USD Funding million) Part A. Epidemic Control, Stabilization and Social Mitigation Immediate support to Ebola 12 National IDA Restructuring 2 health projects containment (Liberia, Sierra Leone; $6 million each) – Approved August 8, 2014. Emergency Ebola Response: 105 CRW New multi-country emergency Health and Social Protection response health/SP project covering Interventions Guinea, Liberia, Sierra Leone (This Project) Processed under OP 10.00 Para. 12. Part B. Enhanced Social Protection Once outbreak is under control, 15 CRW/ Additional financing for ongoing enhancement of social National IDA social protection programs in all protection response three countries. Part C. Building Public Health System Capacity Strengthening national health 23 National IDA US$12 million additional financing systems in affected countries to health HNP projects in Sierra Leone and Liberia New Health operation of up to US$11 million in Guinea Regional Multi-country Disease 75+ National New regional multi-country project Surveillance and Public Health IDA/ and Veterinary Labs Project Regional IDA/CRW Total 230 Of which US$150 million is from the CRW 21. The proposed operation meets the criteria of OP 10.00 Paragraph 12 (Projects in Situations of Urgent Need of Assistance or Capacity Constraints) and will be processed through condensed procedures: (i) EVD outbreak is a multi-country disaster and public health emergency; (ii) Guinea, Liberia and Sierra Leone face severe capacity constraints with fragile 8 and under-resourced health systems that are unable to respond to the sudden and rapidly evolving epidemic; and (iii) widespread and entrenched poverty in the three countries will likely increase because of the shock from the epidemic. 22. Policy Exception: As noted earlier, Bank Management has acknowledged that the exceptional nature of the Ebola outbreak warrants eligibility for a CRW allocation to enable a robust World Bank Group crisis response. This project appraisal document also seeks the approval of Executive Directors to provide the financing of the project from the CRW in the amount of USD105 million equivalent entirely on grant terms rather than on each country’s standard IDA terms as is prescribed for financing from the CRW. 13 The use of grant financing is appropriate in light of the demonstrable regional and global positive externalities that will flow from mitigating the spread of the deadly virus in the affected countries and reducing the risk of its spreading to at-risk neighboring countries, thereby benefitting the West Africa region as a whole, as well as the rest of the world, by minimizing the socio economic impact of the outbreak and protecting lives and livelihoods of the population. D. Higher Level Objectives to which the Project Contributes 23. The goal of the broader EVD outbreak responses by the countries and the global community is to control the spread of EVD and minimize its impact on the economy, resilience and health services for the population in the affected areas. 24. More broadly, this Project contributes to the World Bank’s dual goal of ending extreme poverty and boosting shared prosperity, by helping to minimize the economic and social impact of the EVD outbreak as described in the Economic and Financial Analyses section below and in Annex 10. 25. The proposed emergency Project is also fully aligned with the respective Country Assistance/Partnership Strategies for Guinea, Liberia, and Sierra Leone, as outlined below. a) Guinea: One of the three areas of strategic engagement outlined under Guinea’s FY14-17 Country Partnership Strategy (CPS, Report No: 76230-GN) addresses the strengthening of human capital. The CPS notes planned Bank support to improve access to basic social services, while continuing to create short-term support to the vulnerable population through safety nets. More specifically, the CPS emphasizes that agreed health targets will aim at strengthening the capacity to provide services and quality care accessible to the entire population, in addition to prevention of malnutrition and both communicable and non- communicable diseases. The CPS emphasizes that its envisioned human development program will enable the Bank to contribute to poverty reduction through improved basic services. The proposed emergency operation consequently is fully aligned with, and contributes to the CPS. 13 Under the CRW’s implementation framework for IDA17, the terms of assistance for CRW financing are identical to those under which regular IDA assistance is provided to a particular country. For FY15, Liberia will receive 100% of its regular IDA financing on credits terms while Sierra Leone and Guinea will each receive 50% of their regular IDA financing on credit terms and the balance of 50% on grant terms. 9 b) Liberia: Pillar II of the Liberia’s FY13-17 Country Partnership Strategy (Report No:74618- LR) focuses on Human Development and noted that better provision of social services and building social safety net to address the needs of extreme poor will allow Liberia to progress towards the MDGs and increase trust in the state. The CPS prioritizes enhancing capacity of the public health sector to deliver quality service. As outlined above, the proposed emergency operation contributes to Liberia’s CPS objectives. c) Sierra Leone: Sierra Leone’s Joint Country Assistance Strategy (JCAS) for fiscal years 2010-2013 (Report No: 9913-SL) is organized around two pillars: growth and human development. The proposed Project contributes to the JCAS by supporting improved access to health service. The JCAS also flags several risks, including social stability risk. The design of the proposed Project will support the mitigation of this social stability risk through its health and social protection components, which address the socio-economic challenges the EVD outbreak poses to vulnerable communities. 26. The proposed emergency project is also fully aligned with Pillar 3 of the Bank Regional Integration Assistance Strategy (RIAS) which makes room for coordinated interventions to provide regional public goods, and in this case a propitious avenue to develop the institutional capacity and an enabling framework for regional and cross-border collaboration to combat EVD. Several factors necessitating regional collaborative measures include: the risk of wider spread across the region, absence of strong national health systems, weak laboratory diagnostic capacity and surveillance and data management systems; lack of personal protective equipment / supplies; absence of coordinated training and infection prevention control procedures; and the occurrence of infections in difficult to access rural areas and densely populated urban communities; and the principal vectors of transmission being household care, customary burial procedures, denial, mistrust and misinformation. II. PROJECT DEVELOPMENT OBJECTIVES A. Project Development Objective 27. The Project Development Objective is to contribute in the short-term to the control of the Ebola Virus Disease (EVD) outbreak and the availability of selected essential health services, and mitigate the socio-economic impact of EVD in Guinea, Liberia, and Sierra Leone. 28. Project components are geared to help operationalize the WHO-led Ebola Response Roadmap and the National Response Plans complementing and working in coordination with other international agencies involved in the emergency response. As such, the support provided under this Project is part of a multi-partner emergency response effort led by the respective countries and coordinated with WHO and the UN. 29. It is important to stress that in addition to Ebola-focused interventions, this operation will serve as the first instalment in a rapidly escalating series of coordinated investments to boost the essential public health systems and service delivery capacity across a range of common ailments. As designed, this operation will strengthen the core elements that support patient care: trained personnel, diagnostic facilities (including essential supplies for basic laboratory functions of hematology, clinical chemistry), and the treatment of common ailments (e.g., malaria, respiratory 10 tract infections, and basic services such as child deliveries). In the medium term, WBG support will aim to build capacity in the three countries to prevent, detect, and respond effectively to future outbreaks of Ebola and other infectious diseases. B. Project Beneficiaries 30. Project beneficiaries include the populations of Guinea, Liberia and Sierra Leone who are infected by the EVD or at risk of the EVD infection. It also directly benefits health workers by providing PPEs, related training on proper use of the PPE and IPC practices, and incentive packages for them to manage the EVD. It will also contribute to fund the salaries of expatriate health workers being mobilized under the AU deployment plan or other initiatives. Further, the food and water distribution to the quarantined population and other Ebola-affected households will benefit the most food insecure and nutritionally vulnerable people. C. PDO Level Results Indicators 31. Achievement of the PDO will be measured through the following indicators: • Availability (at any given time) of at least two weeks needs of PPEs and other required IPC supplies in the Ebola treatment centers (ETCs) and referral centers (measured by WHO logistic report and independent audit). • Number of health workers who received financial incentives 14 to provide medical care to EVD patients and for other essential health needs. • Number of people in the quarantined areas and other Ebola-affected households who received food and other basic supplies. III. PROJECT DESCRIPTION (See Annex 4 for detailed project description) 32. The proposed Project will provide financing for the three countries to: (i) implement their Outbreak Response Plans and concurrently support the countries to provide essential health services during the outbreak (Component 1); (ii) address emerging critical issues of securing sufficient national and international health workers for the outbreak response and the provision of essential health services (Component 2); and (iii) provide essential food and water to the quarantined population and other Ebola-affected households (Component 3). The funds will be utilized by the respective Governments with the support of UN agencies that lead each area of work to ensure the fastest and most efficient implementation. A PPA was provided to Guinea under the Project. 33. The Project will support retroactive financing as governed by Bank policy (OP 10.0, Paragraph 12, revised July 1, 2014). To this end, the following provisions will guide the use of this procedure: (i) the total amount of retroactive financing can be up to 40 percent of the grant amount in accordance with provisions for Projects in Situations of Urgent Need of Assistance or 14 Financial incentives include hazard/indemnity pay to health workers working for Ebola response, and death benefit to families of health workers who die of Ebola. 11 Capacity Constraints; (ii) funding will be made available for eligible payments made by the countries from May 1, 2014 up to the expected date of signing of the legal agreement for the Bank grant; (iii) to be eligible for retroactive financing, expenditures have to be for activities related to the Project’s Development Objectives and included in the Project Description of the Legal Agreement and the Project Appraisal Document (PAD); and (iv) when beneficiary’s capacity to implement the needed activities is insufficient, the Bank may, at the request of the Beneficiary, enter into agreement with relevant international agencies, including UN (using its own procedures), national agencies, private entities, or other third parties. To this end, a list of eligible expenditures will be developed along with clear instructions for Government and participating international agencies to document the eligible expenditures for retroactive financing. 34. The individual country activities to be funded under the Project will help to operationalize some elements that are contemplated as part of the WHO-led and National Emergency Response Plans, complementing, expanding and intensifying the responses rapidly. They will consist of a group of interventions based on the countries’ epidemiological and institutional needs, and assessed options for meeting them. A. Project Components Component 1: Support to the EVD Outbreak Response Plans and Strengthening Essential Health Services 35. This component will contribute to finance critical gaps in ongoing emergency response efforts funded by Governments and development partners in Guinea, Liberia and Sierra Leone. To this end, support will be provided to help implement in the affected countries the “Ebola Response Roadmap” developed by WHO with the aim of achieving full geographic coverage with complementary Ebola response activities in these three countries that are affected by widespread and intense EVD transmission. The Roadmap envisions applying an Ebola intervention package that includes case management, burials, case diagnosis, surveillance, information, communications and education (ICE) and social mobilization, and sub-national coordination and technical/logistical support. 36. Under Component 1, funding will be made available to complement Bank’s funding from the restructured projects and other international partners’ funds, and support Guinea, Liberia and Sierra Leone to provide full Ebola intervention package described above in accordance with the individual needs and priorities of the countries. Given daily updates in the number of EVD cases and fatalities in each of the three countries, it would not be feasible to explicitly earmark use of IDA’s proposed contribution. 37. In addition to the full Ebola intervention package described above, 15 this component will also finance the provision of essential health services to meet other health needs of the population. To strengthen the provision of essential health services, this component will finance PPE, IPC materials and other essential supplies for the non-Ebola focused health facilities, staff 15 Staff cost will be covered in the Component 2. 12 training on the proper use of the PPE and IPC supplies, and essential drugs and equipment for the facilities to operate. 38. The funds for Component 1 will be allocated on the basis of individual country needs and priorities included in the national response action plans and using agreed institutional implementation arrangements through the most efficient channels, including the use of UN agencies and other agencies under Memorandum of Understanding (MOU) or contract between the Government and the UN agencies. Component 2: Human Resources Scale Up for Outbreak Response and Essential Health Services 39. This component will supplement the efforts of Governments and other partners to motivate and reward health workers in the affected countries to work on the EVD emergency response and provide other essential health services. Mobilizing and sustaining sufficient human resources to implement Ebola response interventions is a critical aspect of the EVD response strategy in all three countries. This component will provide a comprehensive package of incentives and activities to motivate health workers and will support the deployment of African and international medical doctors, nurses and other medical and paramedical personnel, including a plan led by the African Union (AU) and WHO. 40. The component will finance the following activities: (a) Provision of hazard/indemnity pay to health personnel that work in ETCs and referral centers. Those eligible includes all cadre of staff in ETCs including volunteers. The amount of the hazard/indemnity pay will be defined as to be consistent with the amounts currently paid by the respective Governments during the crisis. Deliberate efforts will be made to ensure that this new payment arrangement does not distort existing public service remuneration structures. A clear exit strategy will be defined to ensure that those additional payments do not become a burden at the end of the crisis. For instance, beneficiaries will be required to sign a commitment letter notifying them that this arrangement would terminate at the end of the crisis. Third party monitoring mechanisms and internal audit will be instituted to ensure proper documentation of attendance and payments made. For Guinea, where the government and partners have been paying hazard pay, the Project will support an indemnity (e.g., 75 percent of salary) to health workers who provide essential services to encourage them to sustain essential health services. (b) Funding will also be made available for in-country medical care to exposed health workers. This component will also finance necessary logistics or facilities to secure health workers’ access to medical care should they become infected. (c) Payment of death benefit to families of exposed health workers. The amount of compensation for families shall be based on the existing rate where it exists and specific country context where it does not exist. (d) Establishing communication, providing non-financial incentives, and advocating health care workers and volunteers. The component will help develop communication strategies targeting health care workers, provide a range of non-financial incentives (e.g., 13 awards, branded goods and media publication) to benefit health workers involved in the EVD emergency response, and carry out intensive campaigns to change people’s views and attitudes on the health care workers involved in the EVD emergency response. (e) Recruitment, training, and deployment of expatriate medical doctors, nurses and other medical and paramedical personnel. This can include the AU and WHO plan described above. The Project will support the implementing of the plan. The actual estimated needs for health workers are being assessed to make sure that the scale of recruitment meets the needs of each country. 41. Currently, no significant salary payment arrears exist for health care workers in Guinea, Liberia and Sierra Leone. However, the Project will retain the flexibility to finance regular payroll of health workers, if needed, in case of a documented shortfall of government revenues due to the economic impact of the EVD outbreak that may hinder on-time payment of salaries for domestic health workers. As such, the Project under this component could potentially contribute towards the payment of salaries of domestic health workers directly involved in the EVD emergency response and in the provisions of other essential health services in the affected communities. To this end, and subject to an assessment of needs and internal controls, an eligible expenditure under this component of the Project would be the payment of salaries for domestic health workers. Component 3: Provision of Food and Basic Supplies to Quarantined Populations and EVD Affected Households 42. This component aims to improve access to food and other basic supplies for the EVD- affected households in the quarantined areas and other “hot zones” in Guinea, Liberia, and Sierra Leone. Specifically, the component will finance delivery of food and basic supplies (e.g., safe water), as well as related logistical and operational costs to individuals directly and indirectly affected by the EVD crisis in quarantined regions. Funds for this component will primarily be channeled to WFP under contracts between each Government and the WFP. However, depending on the priority of the supplies to be delivered, funds may also be channeled to other agencies with comparative advantage in delivering those items. 43. Initially, this component will target approximately 395,000 individuals affected by the EVD in quarantined areas and other EVD “hot zones”. In particular, this component would target: (i) confirmed and suspected EVD cases at Ebola Treatment Centers; (ii) confirmed and suspected contact cases in quarantine or under observation; and (iii) those living in communities isolated in “hot zones” where availability of and access to food is being affected by the crisis. The Project would finance delivery of food items to approximately one-third of the population with Ebola-related food needs in the highest priority quarantined areas and “hot zones”, as identified in the WFP Regional Emergency Operation. Some priority centers and geographical areas have been identified based on currently available information (see Annex 4); however, these may change depending on the evolution of the EVD crisis. 14 Table 4: Estimated Ebola-related food needs & associated costs in the three affected countries Support from Ebola Emergency WFP Regional Emergency Operation Response Project Country Estimated Estimated Population Total % of total Project Tonnage Project Project requiring food budget beneficiaries financing (mt) beneficiaries tonnage assistance (USD m) per country (USD m) (mt) Guinea 464,000 22,954 24.7 35.3 9.0 140,000 6,500 Liberia 449,000 22,226 24.1 34.0 8.0 135,000 6,500 Sierra Leone 400,000 19,800 20.7 30.5 6.0 120,000 4,000 Total 1,313,000 64,979 69.8 100.0 23.0 395,000 17,000 Source: WFP Regional Emergency operation estimates as of August 19, 2014. Estimates Project beneficiaries and tonnage based on WFP’s country-specific proposals for allocation of Project financing. 44. The intervention package supported under this component is designed to increase the availability of food and safe drinking water to prevent rapid deterioration of the worst- affected population’s food security and nutritional status. The WFP would provide a food package in the form of an enhanced general food ration, which is designed to meet the full caloric and micronutrient requirements of beneficiaries. Provision of other basic supplies (e.g., safe water, chlorine) will be determined on a country by country basis and in line with each country’s evolving needs in the quarantined areas, “hot zones” as well as Ebola-affected households. For patients in hospitals or observation centers, WFP will provide cooked meals through health partners in charge of the facilities. For the rest of the beneficiaries, the WFP would implement General Food Distribution (GFD) through a blanket approach providing take- home dry rations to entire targeted communities. 45. This component will allow some flexibility for the activities to evolve in line with the situation and the particular country context. Any changes to the delivery models will be agreed upon between the individual implementing countries, the WFP, and the Bank. In terms of sustainability, once the crisis is contained, this emergency social protection response is expected to transition to medium-term safety net support to mitigate the impact of shocks on affected households. B. Project Financing 46. The Project instrument is an Investment Project Financing (IPF) in the amount of US$105 million equivalent, to be implemented over a 12-month period. Investment plans will be updated regularly on a weekly/monthly basis to adjust implementation to the changing needs of the affected countries. 15 Table 5: Initial Estimated Project Cost and Financing Component Allocation and percentage contribution to the broader plan Total Cost in Bank WHO Road- financing Project cost IDA % Project Components map and as % of Total $US Financing Financing WFP plan (US$ ) Component 1: Support to the 48 million 48 million 100% EVD Outbreak Response Plans and Strengthening Essential For three Health Services countries 22.6% Component 2: Human 35 million 35 million 100% 367 million Resources Scale up for Outbreak Response and Essential Health Services Component 3: Provision of Food 22 million 22 million 100% WFP Plan 31.4% and Basic Supplies to 70 million Quarantined Populations and Ebola-Affected Households Total Project Costs 105 million 105 million 100% Table 6: Country allocation 16 Sierra Country Allocation Guinea Liberia Leone Total Component 1 11 25 12 48 Component 2 6 19 10 35 Component 3 8 8 6 22 Total 25 52 28 105 C. Lessons Learned and Reflected in the Project Design 47. The proposed Bank response takes into account the lessons learned from previous WBG responses to different health crises, in particular avian influenza (from 2006-2013). Feedback from the Independent Evaluation Group (IEG) underlined that “the proposed WBG response to the Ebola epidemic (discussed in this note) appears to be aligned with many of the key lessons flagged in the learning product on avian influenza”. The following features in particular were noted: • Using the crisis as an entry point for not only immediate emergency interventions but also medium-term risk reduction through public health system strengthening; recognizing that future opportunities to engage may be limited once the crisis has passed. • Going beyond the outbreak of Ebola in humans to also provide support for veterinary agencies and to address other zoonotic diseases—those passed between animals and humans. 16 The above country allocations are preliminary and may change. The tentative figures in the above table are based on the resource requirements for each country, reflected in WHO’s roadmap, countries’ cost estimate, and human resources data. 16 • Ensuring that existing crisis response financing platforms are used for health emergencies, in addition to other disasters. • Working closely with other partners, within the WHO-led strategic framework, with a strong focus on WBG comparative advantage related to building public health system capacity. • Complementing national level investments with regional approaches for cross-boundary collaboration on regional public health goods. • Multi-sectoral collaboration across Global Practices and with the Africa Region. • Incorporation of communication and awareness activities as a key part of emergency interventions. 48. The detailed design of the proposed response will also take into account some of the lessons from the IEG evaluation of the Avian Influenza Response effort, including: • The need for rapid response needs to be balanced with the need for robust design. Deferring key decisions until after approval can lead to long lag times before project effectiveness and initial procurement. Expertise from US CDC and international technical agencies such as WHO, US CDC and the World Organization for Animal Health (OIE) and use of their tools for assessing system performance and identifying capacity gaps could help to guide decisions on system strengthening. • Investments in physical infrastructure, medical equipment, and information systems can outstrip the human capacity of agencies to operate and maintain these investments. Establishing a strategy for funding, procuring, staffing and maintenance of physical infrastructure and equipment is critical to ensure long term financial and technical sustainability of systems. • It can be more effective to work through and expand existing institutions rather than creating new ones in parallel. • Monitoring and evaluation system design should not be neglected in the rush to provide a rapid response. Intermediate outcome indicators that track the performance of particular functions (surveillance, sample collection and transport, diagnosis, and case management) against benchmarks can be useful. Surveys should assess behavioral practice, not just knowledge. 49. The team also noted the expert opinion of 10 leaders of the fights against smallpox, polio, SARS, rinderpest, Guinea worm, and other diseases on how best to fight the outbreak (New York Times, August 29, 2014) (See Annex 5). IV. IMPLEMENTATION A. Institutional and Implementation Arrangements (See Annex 6 for details) Component 1: Support to the EVD Outbreak Response Plans and Strengthening Essential Health Services 50. Detailed use of funds from Component 1 will be determined by the existing country institutional arrangements. Each country has coordination mechanisms led by the government, 17 particularly the Ministry of Health. The following mechanisms will be used to develop quarterly investment plans for the Component 1: • Guinea: The country established: (i) at the strategic level, an Inter-Ministerial Committee headed by the Minister of Health and comprising the Ministers of Budget, Social Services, Communication, and Primary Education; and (ii) at the operational level, a National Coordination Committee located in the Ministry of Health was established to coordinate all the Ebola-related activities and serve as the project implementation unit (PIU) of the Project. The Government will strengthen the PIU initially by seconding the procurement, financial management and other operational staff from the existing PIU for the Bank-funded Village Community Support Program Project. • Liberia: National Consultative Group (NCG) includes non-restrictive members from a wide cross-section of the society, who would be briefed and provided inputs on the status of the anti-Ebola campaign. It meets bi-monthly and works as the overarching group. The Incidence Management System (IMS), led by the Ministry of Health and Social Welfare (MOHSW), coordinates the day-to-day response and makes operational decisions. In this project, IMS will be the overall coordinator and technical lead of the operation. IMS will work closely with the Health Systems Strengthening Project Coordination Office (HSSP Coordination Office) who is responsible for the day-to-day operations, including contracts with UN agencies. The Project Financial Management Unit (PFMU) within the Ministry of Finance and Development Planning will be responsible for the financial management of the project, including the hazard/indemnity pay and death benefit. • Sierra Leone: The Ebola EOC is co-chaired by the Chief Medical Officer (CMO) and the WHO Representative, and benefits from the participation of other Ministries and partners. All the investment plans will be approved by the EOC. The use of funds in this component will be determined by the EOC. In this project, the EOC will be the overall coordinator and technical lead of the operation. EOC will be responsible for coordinating as well as oversight of all the implementation of project activities, in close collaboration with UN agencies. The EOC will be supported by the Integrated Project Administration Unit (IPAU) within the Ministry of Finance for activities that involve procurement and by KPMG as a fiduciary agent to provide accounting and fiduciary arrangements. 51. The project uses contracting by the Government with UN and other agencies. Given the emergency, the Project will select the fastest and most efficient and effective ways of implementation. For example, where an agency has comparative strengths and experience, the Government will contract the agency for the implementation of the part of the plan (for example, UNICEF for the procurement of PPE, IPC materials and supplies, US CDC for surveillance, MSF for running an Ebola treatment center). 52. The financing for Component 1 will be disbursed to the Ministry of Health or national accounts aimed for the coordination, as well as contracted UN agencies (See FM section for details). 18 • Guinea: A Special Account for Ebola outbreak response is in place to facilitate fast disbursement. The Government plans to establish a segregated account for the World Bank such that the Bank’s funding and disbursement can be clearly monitored. • Liberia: The Ebola Trust Fund established at the Central Bank, once strengthened, will be used as a pool fund to manage the fund from the World Bank for recurrent and operational expenses as well as the government and other partners. For procurement by the government, a segregated account for the World Bank will be established within the PFMU. • Sierra Leone: For recurrent and operational expenses, the fund will be channeled to the Ebola EOC’s account with Ministry of Finance and Economic Development (MoFED), Ministry of Health and Sanitation (MoHS) and WHO as signatories, and KPMG as the fiduciary agent. For procurement by the government, a segregated account for the World Bank will be established within the EOC. • UN agencies: Based on the contract between the government and the UN agencies for specific parts of the investment plan, the funds will be channeled into the UN agencies for rapid implementation. Component 2: Human Resources Scale Up for Outbreak Response and Essential Health Services 53. For each country, the management of the hazard/indemnity pay and death benefit will be managed by an independent agency (public or private) that is capable of verifying the attendance (with logistics capacity) and carry out quick payment (e.g., using mobile phone, bank transfer). For example, Liberia plans to use the Project financial management unit (PFMU) established for the existing Project as an independent agency to handle the hazard/indemnity pay and death benefit. The communication, advocacy and non-financial incentives will be managed by the Ministry of Health or contracted to an agency with strong ability on communications. 54. For the recruitment, training and deployment of African and international health workers needed for the emergency response, the Governments of the participating countries under the Project will enter into a MOU or contract with the African Union or other agencies to cover the cost of these workers. 55. The flow of funds for Component 2 will be the same as for Component 1. The funds will be transferred to the contracted agencies in case of hazard/indemnity pay and death benefit. Component 3: Provision of Food and Basic Supplies to Quarantined Populations and EVD Affected Households 56. WFP will ensure the assessment, coordination, programming, planning, monitoring, evaluation and supervision of all activities for this component, in close collaboration with WHO and the Ministries of Health and Ministries of Agriculture in the respective countries. The funds will be directly channeled to WFP, based on contracts between the Governments of the three countries and the WFP. As determined on a country-specific basis, the Governments may adopt separate contracts with UNICEF, or other partners, for the procurement and distribution of other basic supplies (e.g., safe water, chlorine). The allocation of funds from the three countries will be based on the estimated number of beneficiaries (Table 5) – Guinea (35.3 percent), Liberia (34.2 19 percent) and Sierra Leone (30.5 percent) – as identified in the WFP Regional Emergency Operation. 57. The WFP manages two UN Humanitarians Response Depot hubs in the region located in Ghana and the Canary Islands to support procurement and transit as necessary. WFP also maintains warehouses in the port capitals as delivery points as well as in the “hot zone” cross- border areas of Gueckedou, Guinea, and Foya, Liberia, and is in the process of identifying additional strategic locations for local warehouses, which will be financed by their own resources. B. Results Monitoring and Evaluation 58. The World Bank’s task team will monitor all the implementation steps of each component very closely with a timetable to ensure execution with minimum delays. A full range of lead and senior experts including FM and Procurement experts or specialists both in each country and at regional and headquarter level will support the on-time operations. 59. The overall Monitoring and Evaluation (M&E) for Component 1 will be carried out by the Ministries of Health, WHO and UNICEF in each country. WHO will provide progress reports on the overall EVD outbreak responses, which will be used for monitoring progress of the overall outbreak response activities. As needed independent performance audits will be considered to assess the availability of the PPEs and IPC materials in ETCs (PDO indicator 1). 60. For Component 2, a contracted agency for the hazard/indemnity pay and death benefit will report the verification and payment reports, including the number of health care workers who received the hazard/indemnity pay and death benefit. Advocacy to communities and communications and non-financial incentives will be monitored using the reports from the implementing agency. 61. For Component 3, WFP will be responsible for monitoring Project activities and reporting on implementation progress as part of its regular monitoring and reporting arrangements for its Ebola Regional Emergency Operation. WFP will also be responsible for gathering the information necessary to update the Component 3 related indicators in the results framework together with the Ministries of Agriculture and other Ministries collaborating in implementation of this component. The Social Protection and Labor Practice will lead the implementation support from the World Bank. C. Sustainability 62. This Project is an emergency response to the EVD outbreak and the main objective is to support the Governments to control the outbreak and mitigate the socio-economic shocks, especially the food crisis among the quarantined population. Part of the funds will be used to build capacity of local health care workers and officers to detect and manage the Ebola cases. Further, the follow-on additional financing to the existing health systems strengthening project and planned regional multi-country disease surveillance and public health and veterinary labs project will utilize what is built through this emergency response Project and build longer-term regional capacity for surveillance, lab and case management. Similarly, the social protection 20 support provided under this Project will transition to more traditional support through additional financing to expand existing social safety net programs (e.g., cash transfers/public works) to mitigate the impact of socioeconomic shocks on households affected by EVD. V. KEY RISKS AND MITIGATION MEASURES A. Risk Ratings Summary Table Risk Category Rating Stakeholder Risk Moderate Implementing Agency Risk High - Capacity High - Governance High Project Risk Substantial - Design Substantial - Social and Environmental Moderate - Program and Donor Moderate - Delivery Monitoring and Sustainability Substantial - Other (Beneficiaries) High Overall Implementation Risk High B. Overall Risk Rating Explanation 63. Given the exceptional context of this emergency operation and the challenging country/sub- regional context in which implementation will occur, risk during project preparation and implementation is assessed as high. As previously noted, the current EVD outbreak exceeded the capacity of the health systems of the three countries, and quarantine of the highly affected regions can lead to food, nutrition and social crises. To mitigate such risks, the proposed Project will partner with key specialized technical agencies with a demonstrated track record (such as WHO, WFP and other UN agencies) under the Governments’ supervision. It should be noted that although the context of the proposed Project is high risk, the outlined approach is viewed as the only means of ensuring a fully robust and multi-sectoral response to the EVD epidemic in Guinea, Liberia, and Sierra Leone. Although the project design cannot eliminate all programmatic risks associated with this emergency response, the alternatives of inaction or a delayed response can be seen to be more costly from a development perspective. VI. APPRAISAL SUMMARY A. Economic and Financial Analyses 64. Widespread and entrenched poverty in the three countries will likely increase because of the shock from the epidemic, though the magnitude of the impact is yet to be fully estimated as the 21 epidemic is still unfolding. As elaborated in detail in Annex 10, disruption of economic activity is worsening with the closure of many borders, closure of some markets, internal restrictions on movement of people and goods, and expectations that contagion may not begin to subside for some months at best. It should also be noted that the effects will depend on the extent to which the contagion can be contained geographically and in its severity, and the duration of the epidemic. Apart from the loss of human life, in the short and medium terms the main impacts can be expected to result from loss of production (whether from time lost for production or reduced productivity), associated loss of income, and fiscal impacts on both the revenue and expenditure sides, the latter related to the costs of provision of food and social assistance to affected communities, and diversion and increase in resources that will need to be devoted to respond to this serious public health threat. Preliminary estimates done by Bank’s Country Economists of the impact on the economy including GDP from the three directly affected countries are as follows: • The economic impact of Ebola is likely to be significant for the economies of Guinea, Sierra Leone and Liberia, with current estimates for 2014 showing a halving of GDP growth in Liberia and Guinea with an impact of more than 3 percentage points for Sierra Leone. There is also a significant negative impact on fiscal balances ranging from US$80 million to US$120 million.17 These estimates are based on optimistic scenarios of epidemiological containment within the next six to nine months. 18 • The ongoing crisis has substantial impact on the daily lives of millions of people through the tragedy of human loss; the closure of borders and markets; the interruption of agricultural cycles; the restriction on the movement of people; the suspension of regional and international flights; and the delay in public and private investments. The main first- round economic effects have been on agriculture and services, which together accounts for more than half of the total shock to economic activities across the three countries. • The severity of the longer-term impact will depend on the ability of the authorities to curb the epidemic and most importantly, restore confidence so that key global supply chains are not severed. Otherwise, the overall economic impact may be much more severe as the countries become more isolated; with new effects on economic activity from the cessation of large-scale mining and the interruption of international trade. • Assuming containment of the epidemic by end-2014, the post-crisis recovery across these three countries could be accelerated by consistent and credible health responses with the support of international partners. This could reduce the fear factor that is driving many economic decisions, local and international. 17 Estimates do not account for any increases in grants that may result from the responses by international donors. 18 WHO and CDC. 22 Table 7: Projected Impact of the Ebola Outbreak, 2014 (as of August 29, 2014) Country Estimates of GDP Impact Estimates of Fiscal Impact Initial GDP Revised GDP Absolute Change Change in Deficit as a Growth Growth in Deficit (US$ share of initial Projection projection million)1 Revenue (%) (June 2014) Guinea 4.5 2.4 -120.0 5.6 Liberia 5.9 2.5 -92.8 18.6 Sierra Leone 11.3 8.0 -79.0 13.6 Source: World Bank/IMF Staff Estimates Note: Figures do not include any donor response. 65. Fully consistent with Bank’s assessment, initial assessment by the International Monetary Fund (IMF) also evidences that the Ebola outbreak is having an acute macroeconomic and social impact on the three already fragile countries in West Africa. It is estimated that economic growth is likely to slow sharply in all three cases, and significant financing needs are likely to rise. 19 Beyond these economic effects, the IMF expects that the social impact of the crisis will also be significant since the outbreak is likely to lead to increased poverty in food and security among vulnerable groups, as well as an impact on employment, including in the key agriculture sector. To help mitigate the impact of the outbreak, the IMF is considering providing additional financing support to the affected countries. 66. Rationale for Public Provision and Bank Involvement. As differing from a slow-onset disaster such as a drought, where a more thorough preparation of a regular investment project may be preferable, Guinea, Liberia and Sierra Leone are already experiencing the human and socio-economic impact of the still evolving EVD epidemic. What is ominous for West Africa, however, is that even if all EVD transmission could be halted today, the impact of the deaths of the people already infected and the socio-economic consequences will be materialized over the medium term. Given the infectious nature of the EVD, this epidemic needs to be confronted with close, well-coordinated joint efforts, and with the highest priority at the regional level. Otherwise, no matter how successful one country can be in stopping this disease, in the short run it will be afflicted with new cases. Public and external financing on grant terms is therefore justified to support a Regional/Global Public Good. The proposed Project has demonstrable long term regional development impact as it aims to mitigate the spread of a deadly virus in the affected countries and reduce the risk of spreading to at-risk vulnerable neighboring countries. As designed, the proposed Project would also benefit the affected countries and the West Africa region as a whole by minimizing the socio-economic impact and protecting lives and livelihoods of the population. B. Technical 67. This Project will provide rapid funds to the most needed areas in the global and country efforts to respond to the outbreak. The EVD outbreak response plans for the three countries are based on WHO’s collective experiences in response to SARS, pandemic influenza 19 Transcript of a Press Briefing by Gerry Rice, Director, Communications Department, IMF, August 28, 2014. 23 (H1N1), and Middle East respiratory syndrome coronavirus (MERS-CoV). Activities set out in the plans are based on WHO’s Emergency Response Framework (ERF) grading system (Outbreak response plan, 2014). The financial support to the gaps in the plan ensures efficient and coordinated response to the outbreak. 68. The three countries will implement the Project with support from the Health, Nutrition and Population (HNP) and Social Protection and Labor (SPL) teams in the Bank, and with development partners. The Project aims to respond to multi-sector problems by having a joint HNP-SPL team, provide implementation support, and use multi-sector partners such as WHO, WFP and other UN agencies. The proposed implementation arrangements leverage the comparative advantages of each organization. C. Financial Management 69. A Financial Management (FM) assessment was conducted on the FM arrangements for the Ebola Emergency Response Project on all the national implementing entities in Guinea, Liberia and Sierra Leone. Financial Management arrangements for dealing with UN agencies was also determined and the Bank will rely on their financial rules and regulations. The objective of the assessment was to determine whether the implementing entities have acceptable financial management arrangements in place that satisfy the Bank’s Operation Policy/Bank Procedure (OP/BP) 10.00. These arrangements would ensure that the implementing entities: (i) use Project funds only for the intended purposes in an efficient and economical way; (ii) prepare accurate and reliable accounts as well as timely periodic financial reports; (iii) safeguard assets of the Project; and (iv) have acceptable auditing arrangements. The FM assessment was carried out in accordance with the Financial Management Manual issued by the FM Sector Board on March 1, 2010. 70. Budgeting arrangements were found to be adequate. Accounting arrangements for Liberia were adequate, while for Sierra Leone, KPMG will be the fiduciary agent of the EOC for the first six months of implementation hence, there will be need to review the accounting arrangements of the Project at the end of their period of service. With respect to Guinea, MoH will have to acquire a computerized accounting information system to enhance the accountability of Project funds, recruit a Financial Management Officer and appoint a qualified and experienced accountant from the ministry in order to have adequate accounting arrangements. All countries will need to document the Project arrangements including Financial Management in the Project Implementation Manual. Internal Auditors in all the three countries will need to conduct quarterly internal audits and submit their reports to the Bank within 45 days as part of the mechanism of strengthening fiduciary arrangements especially for Component 2 in relation to compensation benefits that include hazard/indemnity pay and emergency operating costs. Further, Guinea’s MoH will need to recruit an internal auditor to strengthen its internal control systems. Interim Financial Reports from national implementing entities will have to be submitted to the Bank on a quarterly basis within 45 days after the end of the quarter. Governance and anti- corruption mechanisms are encouraged to be put in place and they include having a complaint handling mechanisms, involvement of civil society in the supervision of the Project and enhancing transparency and accountability by publically sharing financial information that include budgets, financial reports and audited financial statements as well as displaying clinical and non-clinical staff being paid compensation benefits at the Ebola Treatment Centers/Units. 24 External audits will be done for the national implementing entities while for the UN agencies, the Bank will seek audit elimination in accordance with Bank Policies and Procedures as the Bank receives audit reports for the UN agencies and they are available at their websites. Details of the FM assessments as well as the action plan are included under Annex 6. 71. With respect to disbursements, a report based method of disbursements will be used to make advances to the Governments of Sierra Leone, Guinea and Liberia. Others mechanisms that can be used include direct payments, reimbursements and special commitments. Disbursements to all UN agencies will be made using advances to an official UN organization account upon signing the contracts with the Governments and approval of the disbursement by the national implementing entity. 72. The conclusion of the assessment is that the financial management arrangements in place meet IDA’s minimum requirements under OP/BP10.00, and therefore are adequate to provide, with reasonable assurance, accurate and timely information on the status of the Project required by IDA. The overall Financial Management residual risk rating of the Project is Substantial for Guinea, Sierra Leone and Liberia. D. Procurement 73. Procurement under the Project will be carried out in accordance with the Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers dated January 2011 and revised in July 2014 (“Procurement Guidelines”) and the Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers dated January 2011 and revised in July 2014 (“Consultant Guidelines”) and the provisions in the respective Financing Agreement. Flexibilities and simplifications applicable for FCS operational environment as well as provided in OP 10.00 para. 12 for rapid response to crises and emergencies have been incorporated into the detail procurement arrangements as already agreed with the Governments of three Recipient countries and summarized in Annex 9. 74. Given the fluid situations on the ground, the Procurement Plan for each country will be updated on a monthly basis, at least during the first six months of implementation, to reflect the rapid changing needs of the countries. Updating of the Procurement Plan will be done through the monthly work plan that will be submitted by the Government and agreed by the Bank. 75. UN agencies would be hired by the Governments on sole-source basis for their unique roles and qualifications in responding to the emergency situations. Standard forms of agreement for UN agencies as acceptable to the Bank will be adopted. For those UN agencies, if such forms have not been agreed with the Bank, the Bank team will provide acceptable sample forms for use by the countries. 76. Bank may finance the payment of special Ebola risk premiums (i.e., hazard/indemnity pay) to the health workers of the Ebola treatment centers, as well as providing possible death benefits for those workers. The expenditures under this category will not be subject to the Bank’s procurement procedure but to the requirements for documentation, verification, internal and external audits, as well as the ceiling amounts, pay scale etc., that will be agreed with the Bank 25 prior to disbursing of such expenditures in accordance with the provisions of the respective Financing Agreements. 77. Retroactive financing is allowed up to 40 percent of the Grant for each country, covering the expenditures incurred by the country prior to the signing of the Financing Agreement, but on or after May 1, 2014, under the activities agreed with the Bank. For the UN agencies hired by the Government, certain quick-disbursing arrangements may be agreed upon to finance a positive list of imported or locally produced goods that are required for the Project, further subject to the Bank’s prior agreement on the conditions for the release of the financial tranches and the required documentation and certifications, such as customs and tax certificates or invoices. E. Social (including Safeguards) 78. Since the first cases of the EVD were reported in Guinea-Conakry back in March 2014, EVD has rapidly spread in communities recently affected by conflict in Liberia and Sierra Leone killing hundreds of people and putting millions at risk of contracting the deadly disease. The Ebola epidemic has unprecedentedly shattered post war community rebuilding efforts as it has caused a resurgence of fear and social stigma, mistrust of officials including health professionals, mayhem and loss of livelihood especially in communities at the epicenter of the Ebola outbreak. The alarming increase of EVD-related morbidity and mortality has further undermined the already stretched post-conflict public health resources. Moreover, the Ebola-hit West African countries have been struggling to overcome major socio-cultural barriers that hamper efforts to implement the needed life-saving public health measures to contain the epidemic. 79. In terms of environmental and social safeguards, the Ebola Emergency Response Project will neither involve displacement of population (except on a limited and temporary basis in cases of quarantine and Ebola treatment centers), nor require land acquisition. In addition, in terms of community health and safety, the expected impacts of the proposed Project will result in positive effects. There are no Indigenous Peoples present in any of the Project areas and adverse impacts in terms of cultural heritage are not expected. 80. It is necessary to promote sustainable Ebola health service provision in villages and poor urban areas where local people live and where health posts are ill staffed. Also, sensitization and information programs and assistance in referral to modern health systems to inform local people, particularly women should be introduced alongside implementation of the essential health care package. These sensitization and information activities may be contracted to NGOs which can facilitate stakeholders’ participation in the planning and implementation process in order to prevent social exclusion. 81. Potential issues to address in order to promote participation and inclusion of stakeholders: identifying and exploring methods of overcoming cultural barriers to access to health care; encouraging closer links between traditional and modern health systems; training community health workers from vulnerable groups and underserved communities; training health care staff in cultural sensitivity; identifying geographical social hot spots for extra support from official health systems targeting identified vulnerable groups or communities; and identifying gender dimensions as women may be more impacted economically by EVD consequences. 26 82. A social screening and assessment framework will be prepared as part of the overall ESSAF (see following section) for the three affected countries after the Board approval in order to guide implementation. F. Environment 83. The Project is expected to have a positive environmental impact since the control of the epidemic is a positive impact in and of itself by reducing the risk and controlling the spread of a deadly pathogen from the population and its environment. Implementation of emergency response activities, however, will require proper waste management and disposal to prevent the virus circulating in the environment. 84. Given the Ebola epidemic’s contagion risk and its potential fatal consequences, significant environmental impacts related to the handling and disposal of hazardous and non-hazardous waste generated under the care and support component will be managed by strengthening the existing national guidelines for Health Care Waste Management (HCWM) in each country, in accordance with WHO recommendations to minimize exposure to the virus. Each of the countries currently has a national health care/medical waste management plan which will be updated during Project implementation. WHO protocols for handling Ebola will be annexed to the health care/medical waste management plans and disclosed in-country with an accompanying information campaign. In addition, the Project would support updating the HCWM guidelines, training for health care workers to manage medical waste following these guidelines, the purchase of equipment for proper handling, the disposal of medical waste in participating facilities, and the appropriate handling/burial of Ebola case fatalities. However, it is noted that the three components proposed under this emergency Project are not expected to have a significant environmental footprint. In fact, by actively promoting the use of improved environmental safety measures, the proposed Project would serve to significantly mitigate health-facility based transmission, in addition to reducing risk to communities through health education/outreach efforts. 85. The Project has been assigned an environment Category B, given the above context, with policy on Environmental Assessment (OP4.01) triggered (See Annex 11). The safeguards requirements will be deferred until after the Project approval by the Board of Directors in accordance with OP10.00. 86. Project activities that would be financed under Component 1 are not expected to involve large scale construction or involuntary displacement of people. However, environment and social impacts and risks resulting from infection control interventions, construction of temporary ETCs, possible financing of incinerators for infectious waste disposal (if needed), as well as use and disposal of chemicals and management of healthcare waste within and from healthcare facilities will need to be considered, as the Project may be required to address financial gaps with respect to such critical environmental safeguards measures. 87. Project activities that would be financed under Component 2 are expected to have only moderate environment and social impacts. 27 88. Project activities supported under Component 3 would involve using the existing infrastructure of a partner agency (WFP) and would consequently not involve building either major roads or food storage facilities. Therefore, it is expected that environment and social footprints of such interventions would not be significant. 89. While the environmental risks and impacts associated with the emergency interventions are not expected to be significant, there would be need to systematically assess and analyze these interventions, including institutional capacity to minimize any residual environment and social impacts to the surrounding environment and people in the three affected countries. In particular the following Action Plan is proposed: a) Identify an Environmental Focal point in each of the affected countries, working collaboratively with the Ministry of Health, Ministry of Environment and Ministry of Social works. b) Update the existing Healthcare Waste Management Plan (HCWMP) in each of the three countries consistent with the WHO guidelines. c) Prepare terms of reference to develop an Environmental and Social Screening Assessment Framework (ESSAF), including procedures to identify critical environment and social risks and prepare specific mitigation and monitoring plans. d) The ESSAF to include procedures for assessment of environmental and social risks, coordination of environmental risks mapping and planning across various implementing agencies, identifying critical risks, monitoring and supervision of all environment mitigation measures. e) The ESSAF to include mapping environment, health and safety risks associated with geographical locations, as well as recommend measures to protect community and vulnerable biological environment from future contamination or destruction due to disposal of waste food, chemicals, medical waste or debris from temporary displacement. 28 Annex 1: Technical Brief of Ebola Virus Disease 1. Ebola virus disease (EVD), formerly known as Ebola hemorrhagic fever, is a severe, frequently fatal viral illness that are often characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding. People are infectious as long as their blood and secretions contain the virus. The incubation period (from infection with the virus to onset of symptoms) is 2 to 21 days. No licensed specific treatment or vaccine for EVD is available for clinical use, although several vaccines and new drug therapies are being tested. Severely ill patients require intensive supportive care as patients are frequently dehydrated and require oral rehydration with solutions containing electrolytes or intravenous fluids. 2. Ebola first appeared in 1976 in two simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo (this latter outbreak was in a village situated near the Ebola River, from which the disease takes its name). In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and porcupines found ill or dead or in the rainforest. Fruit bats, a common source of bush meat in West Africa, are considered to be a natural host of the Ebola virus. The West African variant of the EVD likely diverged from Middle African lineages, crossed from Guinea to Sierra Leone in May 2014, and has exhibited sustained human-to-human transmission subsequently, with no evidence of additional zoonotic sources (Science, August 27, 2014). 3. Ebola spreads in the community through human-to-human transmission, with infection resulting from direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola. 29 Annex 2: Example of Commitments of Selected International Partners Engaged in the Ebola Emergency Response 1. WHO has been the lead technical agency coordinating the immediate response in the affected countries. It is establishing a regional coordination center in Conakry, Guinea. On July 31, it issued a Flash Appeal of US$103 million, that was later updated to US$431 million, to fund a 6-month emergency response plan to tackle the epidemic at national and regional levels. Bilateral Assistance: 2. The US Government is providing equipment and technical expertise to the affected countries and to international agencies responding to the outbreak. US CDC has been part of the response efforts providing essential diagnostic tools (e.g. mobile labs) as well as technical expertise. It is currently undertaking a “surge” with 40-50 additional epidemiologists and other personnel joining the containment program in the affected countries. USAID is reprograming ongoing programs to provide US$35 million plus technical assistance and personnel. 3. The Chinese Government provided US$5 million equivalent supplies, including medical protective clothes, disinfectants, thermo-detectors and medicines on August 12, 2014. It also sent three expert teams including disease control specialists. Multilateral Assistance: 4. AfDB: On August 2014, AfDB approved funding of US$60 million in grant resources for funding the emergency response through WHO. 5. DFID has provided a total of US$16.6 million in response to Ebola outbreak. These monies have been provided to UN agencies (WHO, UNICEF, Standby Partnership Team), and to a number of international NGOs (MSF, IFRC, IRC, SCF, Action Aid, Christian Aid, Concern Worldwide, Oxfam, etc.).The range of activities that are being supported include case management and infection prevention control, epidemiology and laboratory equipment, psychosocial support, social mobilization co-ordination and logistics, and provision of expert personnel. 6. The European Union is providing €3.9 million (US$5.2 million) in support of the Ebola response in West Africa, as announced on July 30, 2014 which is being channeled through WHO, MSF and International Federation of Red Cross and Red Crescent Societies (IFRC). On September 5, 2014, the European Commission announced €140 million of funding for the countries currently affected by the Ebola virus in West Africa: Guinea, Sierra Leone, Liberia and Nigeria. €38 million of the new package is specifically designed to help those governments bolster their health services (for example through reinforcing treatment centers or support for health workers), both during the crisis and in the recovery phase. It will also provide support in the areas of food security, water and sanitation, which are essential in terms of safeguarding the health of the population. The rest will be used to reinforce governments’ capacity to deliver public services, and macro-economic stability; as well as providing mobile laboratories for the detection of the virus and training health worker. 30 7. WFP: (i) has raised the Ebola emergency level to level 3 and is reprogramming their current operations to respond to the Ebola outbreak; (ii) will issue a global call for funds for these operations, which will include food distribution, school feeding and nutrition interventions; and (iii) plans to reach the one million people currently isolated in the affected areas. 8. The AU Commission pledged on August 13, 2014 US$1 million to Ebola response and on August 21 announced the immediate deployment of a joint AU-led military and civilian humanitarian mission to tackle the emergency situation caused by the Ebola outbreak. The African Union Support to Ebola Outbreak (Operation ASEOWA) is expected to deploy civilian and military volunteers from across the continent to ensure that Ebola is put under control. The mission will comprise medical doctors, nurses and other medical and paramedical personnel. The operation is expected to run for six months with monthly rotation of volunteers. 9. Note: The commitments listed above are examples of key allocations made to date. This list will be updated as further commitments are announced. 31 Annex 3: Results Framework and Monitoring Africa: Ebola Emergency Response Project (P152359) Project Development Objective (PDO): The Project aims to contribute in the short term to the control of the Ebola Viruse Disease (EVD) outbreak and the availability of selected essential health services, and mitigate the socio-economic impact of EVD in Guinea, Liberia, and Sierra Leone. Target Values Responsi- Description PDO Level Results Unit of Baseline Data Source/ bility for (indicator Core Yr 1 Frequency Indicators* Measure (estimate) Methodology Data definition Collection etc.) % Guinea: Guinea: 6 month WHO logistic WHO Indicator one: 0% 80% report Availability (at any Liberia: Liberia: given time) of at least 0% 80% Independent Independe two weeks needs of Sierra Sierra audit nt audit PPEs and other Leone: Leone: agency required IPC supplies 0% 80% in the Ebola treatment centers (ETCs) and referral centers Indicator two: Number Guinea: 0 Guinea: 6 month Report from MoH Number of health Liberia: 0 2,300 the workers who received Sierra Liberia: independent financial incentives Leone: 0 7,500 agency (hazard/indemnity Sierra responsible pay and death Leone: for hazard/ benefits) to provide 1,460 20 indemnity pay medical care to EVD and death patients and for other benefit essential health needs Indicator three: Number 0 Guinea: 6 month WFP progress WFP 20 Estimated 80% of total number of health workers in ETCs and referral centers in countries’ plan. 32 Number of people in 140,000 report the quarantined areas Liberia: and other Ebola- 135,000 affected households Sierra who received food Leone: and other basic 120,000 supplies Indicator four: % 0 Core Project beneficiaries INTERMEDIATE RESULTS Indicator five: Number 0 Guinea: MoH report MoH 7 Number of expatriate Liberia: health workers who 6 receive salary Sierra payments to provide Leone: 7 medical care to EVD patients and for other essential health needs Indicator six: Metric 0 Guinea: WFP progress WFP Total food ton 6,500 report distribution Liberia: 6,500 Sierra Leone: 4,000 Indicator seven: % 0 Guinea: WHO and WHO 80% UNICEF UNICEF Presence (%) of Liberia: report information, 80% communication and Sierra education programs Leone: per district to raise 80% 33 public awareness and change behaviors to prevent the further spread of EVD 34 Annex 4: Detailed Project Description Component 1: Support to the EVD Outbreak Response Plans and Strengthening Essential Health Services 1. This component will contribute to finance critical gaps in ongoing emergency response efforts funded by Governments and development partners in Guinea, Liberia and Sierra Leone. To this end, support will be provided to help implement in the affected countries the “Ebola Response Roadmap” developed by WHO with the aim of achieving full geographic coverage with complementary Ebola response activities in these three countries that are affected by widespread and intense EVD transmission. The Roadmap envisions applying an Ebola intervention package that includes (WHO, 2014): • Case management: ETCs with full infection prevention and control (IPC) activities; Ebola referral/isolation centers; referral processes for primary health care facilities. This will be complemented with training programs for each category of worker on IPC activities and proper use of PPE. All Ebola workers and other health workers will have access to sufficient quantities of the appropriate PPE, IPC materials and other essential supplies such as disinfectants, tents and body bags. • Burials: supervised burials with dedicated expert burial teams. • Case diagnosis by a WHO-recognized laboratory. • Surveillance: contact tracing and monitoring. • Information, communication, and education and social mobilization: provision to the general public with accurate information on the Ebola outbreak and measures to reduce the risk of exposure, and to promote full community engagement in contact tracing and risk mitigation. • Sub-national coordination and technical/logistical support. 2. A large funding gap exists to effectively scale up the emergency response and control the current EVD outbreak. The EVD outbreak has become widespread quickly, and a “massively scaled and coordinated international response is needed to support affected and at- risk countries” (WHO, 2014). The WHO’s updated Ebola Roadmap as of August 28, 2014 estimates that the US$490 million will be required over the next 6 months. Of the total cost, the cost for countries with widespread and intense transmission involves the largest cost of US$367 million (75 percent). In contrast, as of August 21, 2014, total committed and contributed international funds recorded in the Financial Tracking Service by OCHA are only US$50.7 million. 21 Even by adding to it the recently approved US$60 million by the African Development Bank (AfDB) and US$12 million from the restructured projects from the WBG for Sierra Leone and Liberia, the total international financing is only US$122.7 million, which is well short of the updated financing requirement. 3. To supplement the emergent financing needs, the World Bank sourced US$12 million to Liberia and Sierra Leone, by restructuring the existing health projects. In Liberia, UNICEF 21 This does not include the World Bank’s US$12 million from the restructured existing project for Liberia and Sierra Leone, this project, and the US$60 million pledge from the African Development Bank. 35 and UNOPS will be contracted by the MoHSW for the procurement of PPEs, IPC materials and other essential supplies and ambulances and pick-up vehicles. In Sierra Leone, the funds will be disbursed to the Integrated Project Administration Unit (IPAU) of the Ministry of Finance and Economic Development (MoFED) to finance the immediate gaps in its outbreak response plan with technical assistance from WHO. 4. Under Component 1 of this Project, funding will be made available to complement Bank’s funding from the restructured projects and other international partners’ funds, and support Guinea, Liberia and Sierra Leone to provide the full Ebola intervention package described above and in Table 8 in accordance with the individual needs and priorities of the countries. Given daily updates in the number of EVD cases and fatalities in each of the three countries, it would not be feasible to explicitly earmark use of IDA’s proposed contribution. The proposed operation of this component would consequently take a more programmatic approach. Table 8: Thematic areas and cost items of the Ebola outbreak response plan Thematic area Cost Items (not exclusive) Case management • Ebola treatment centers (facility, staff, etc.). and burials • Personal Protective Equipment (PPEs), medicines and Infection Prevention Control (IPC)/medical supplies. All Ebola workers will have access to sufficient quantities of the appropriate PPE, IPC materials and other essential supplies such as disinfectants, tents and body bags. • International case management experts. • Experienced clinician to supervise health workers. • Monthly allowances for doctors, nurses and other staff (e.g., burial teams) • Training of health workers with a specific accelerated training program for each category of worker that is adaptable to the district/treatment center level and places particular emphasis on IPC activities and proper use of PPE. • Counseling and other psychosocial support. • Incinerators for carcasses and medical equipment, electric generators, water pumps. Case diagnosis • EVD alert management system. and surveillance • Staffing for surveillance, contact tracing, and laboratories. • Outbreak database and epidemiology data analysis. • Minor rehabilitation of lab facilities and equipment. • EVD diagnostic capacity building in laboratories. • Shipment of biological specimen to laboratories. • Mobile laboratories. Social • Support to home-based care, safe burial, early reporting by communities and other local mobilization solutions. • Political/traditional leaders’ engagement. • Staff mobilization. • Training on social mobilization. • Multiple channel communications. Subnational • Ambulance, vehicles, fuels and other logistics. coordination and • Coordination meetings. technical/ • Communications. logistical support Source: Country Ebola Outbreak Response Plans. 36 5. In addition to the full Ebola intervention package described above 22, this component will also finance the provision of essential health services to meet other health needs of the population. The outbreak rendered health facilities dysfunctional due to health workers’ fear of infection when diagnosing and treating patients. To strengthen the provision of essential health services, this component will finance PPE, IPC materials and other essential supplies for the non- Ebola focused health facilities, cost for staff training on the proper use of the PPE and supplies, and essential drugs and equipment for the facilities to operate. The Ministries of Health in each country will map out the essential health facilities in highly affected area that need to resume full operation, and carry out rapid needs assessment. The funds will be utilized based on the results of these assessments. 6. The funds for Component 1 will be allocated on the basis of individual country needs and priorities included in the national response action plans and using agreed institutional implementation arrangements through the most efficient channels. • WHO Ebola Response Roadmap updated the needs for beds/Ebola treatment centers, referral centers, and other resources based on projected case loads and developed a detailed costing of the Ebola response. Under Component 1, pro-rata needs assessment will be used as a "guide" to inform the distribution of program investments. Investment plans at the country level will be updated on weekly and/or monthly basis in accordance with the evolution of the epidemic and the implementation of the response. Initially, it is considered that program funds will be allocated to the three countries based on the cost for each country to provide the full Ebola intervention package. • The Governments (National Crisis Committee in Guinea/MoH, EMS/MoHSW in Liberia and Ebola Emergency Operations Center (EOC) in Sierra Leone) with support from development partners develop monthly investment plans with costing of high priority cost items. The plan specifies the gaps. • Based on agreement with the Bank, the most appropriate channel for implementation will be selected, including the use of UN and other agencies (e.g., contract with UNICEF for the procurement of PPE, IPC materials and other essential supplies) under MOU or contract between the Government and the UN and other agencies. • The funds will be channeled to the special account for Ebola response for Guinea, Ebola Trust Fund for Liberia, and Integrated Project Administration Unit (IPAU) of the MoFED and/or EOC for Sierra Leone. Direct payments can also be channeled to UN agencies or other agencies based on the terms of contracts between each of the three Governments and the agencies where appropriate. Component 2: Human Resources Scale Up for Outbreak Response and Essential Health Services 7. A critical gap in the current EVD response relates to the lack of sufficient number of skilled national health care workers for finding cases and contacts, to manage outbreak detection and response, and to care for patients’ safety. With the escalation of the Ebola outbreak that has resulted in an increasing number of EVD cases, additional health personnel is 22 Staff cost will be covered in the Component 2 37 required not only for EVD case diagnosis and management, surveillance, burials and social mobilization, but also to provide services to address in parallel other health needs of the population in the affected countries. 8. Mobilizing and sustaining sufficient human resources to implement Ebola response interventions requires a comprehensive approach to their remuneration, training, equipment, physical security, and access to health care. Despite the dire need for health care workers, many of them are refusing to work due to anxiety and fear of being infected with EVD by providing care to patients due to the lack of, or limited availability of, personal protective equipment, training and infection control measures, and supplies for health facilities and ambulances. This situation is aggravated by the lack of insurance/death benefit provisions available to health workers. Addressing this situation will help strengthen the capacity of countries to mount an effective response to the EVD outbreak but also to provide essential services to tend other health needs of the population (e.g., child deliveries, malaria control). Component 1, as envisioned above, will fund the procurement of PPE and the undertaking of specific accelerated training programs for each category of worker that is adaptable to the treatment center levels and places, with particular emphasis on infection prevention and control (IPC) and proper use of PPE to reduce the risk of contagion with the Ebola virus among health workers. 9. Under Component 2, funds will be made available to help the Governments provide health care workers an incentive package to supplement the Governments’ ongoing efforts to motivate health care workers to cope with the challenges of the crisis. This package will include: (i) providing hazard/indemnity pay to those who work in Ebola treatment centers and referral centers; (ii) provide death benefits to families of healthcare workers who die, or have died in the line of duty; (iii) in-country provision of medical care to exposed health workers; and (iv) communication, non-financial incentives and advocacy for health care workers. More specifically, under Component 2, support will be provided as follows: (i) Provision of hazard/indemnity pay to health personnel that work in Ebola treatment centers and referral centers: In Liberia, currently 334 clinicians and 358 non-clinicians (Total 692) are working for the Ebola Treatment Units (ETUs). This is expected to surge to around 2,700 according to the WHO’s cost estimate in its latest Ebola Response Roadmap. The rough estimate of the required staff for Sierra Leone and Guinea are 1,400 and 640 respectively. The Component 2 would provide hazard/indemnity pay to such staff to compensate for the high exposure to the risk of EVD infection. The following criteria will guide the allocation of hazard/indemnity pay: • Level of Compensation: The amount of the hazard/indemnity pay will be defined as a percentage of the regular salaries for each health worker and will be agreed in accordance with existing procedures and arrangements, including the payment by development partners. Funding provisions will also be made for in-country provision of medical care to exposed health workers. The government will convene a monthly meeting with development partners to monitor the payment progress hazard/indemnity pay and their rate. • Clear exit strategy: To avoid the distortion of the existing public sector payment reforms in three countries, the system will be managed under a clear exit strategy, including the period 38 of the hazardous work payments, establishing a communication plan, signing of commitment letter by beneficiaries that describes the agreement on terms and conditions and publication of the letter, and non-financial incentives that supplements the hazardous work payment. • Independent verification and on-time payment: The payment will be based on the verification of daily attendance by the health workers to pre-selected facilities in the affected communities. The verification and payment will be administered by an independent agency that can verify attendance and pay on-time. Payment may use the e-payment system by a mobile provider that has been rolled out at scale in some countries (e.g., Sierra Leone) under WBG-funded social projection projects, as well as other e-payment and regular public sector mechanisms as suitable. 10. (ii) Payment of death benefit to families of exposed health workers: There is no insurance coverage for health care workers that can sufficiently compensate them for death or disability due to contagion with the EVD. Moreover, for example in Liberia, the current Civil Service Pension System does not provide compensation for families of staff who die while serving in the Civil Service. To provide insurance to the families of the affected health care workers, this component will finance the provision of death benefits to the families of the health care workers who died of EVD: • The amount of compensation for families shall be based on the existing rate where it exists – e.g., death benefit provided by the National Social Security and Welfare Corporation (NASSCORP) in Liberia. • The payment will be based on the confirmed death by EVD. • The death benefit applies to all public sectors health care workers who work in affected communities and not limited to those who work in Ebola treatment centers. 11. (iii) In-country medical care to exposed health workers: This component will also finance necessary logistics or facility to secure health workers’ access to medical care should they become infected. 12. (iv) Communication, Non-financial incentives and Advocacy for health care workers: Health care workers have been the most affected and traumatized by the Ebola crisis. At the moment, most of them feel unappreciated and segregated by the community, despite the amount of work they are doing and the risk they are confronting. This component will help the government to develop and implement communication strategies targeting health care workers, provide a range of non-financial incentives to benefit health workers involved in the EVD emergency response (e.g., public awards, branded goods), and carry out intensive campaigns to change people’s views and attitudes on the health care workers involved in the EVD emergency response, particularly those health workers providing care to infected patients in selected facilities. Examples include the following: • Intensive information, communication and education campaigns targeting the general population to highlight the heroic work carried out by frontline health workers in helping to prevent the spread of EVD and to keep providing essential health care services during the EVD outbreak. 39 • Communication to health care workers to encourage them to return to health centers, including information about quality control measures adopted in health facilities and availability of protective equipment to minimize the risk of EVD contagion, as well as on the hazardous work compensation package described above. • Communication on the stories of role models, appreciation and rewards to those who demonstrate commitment, selflessness, and high quality of work related to the implementation of the EVD emergency response and in the provision of essential health services. 13. Component 2 will also contribute financing in each affected country towards the deployment of African and other international medical doctors, nurses, and other medical and paramedical personnel under a plan led by the African Union and WHO. The current plan is estimated to cost more than US$25 million. The Project under this component will contribute along with pledges made by the US government and other international partners to support the African Union in implementing this plan. In supporting this effort, the Project will help in filling the existing gap in international efforts and will work with WHO, OCHA, US CDC, EU CDC and other agencies already on the ground. 14. Currently, no significant salary payment arrears exist for health care workers in Guinea, Liberia and Sierra Leone. However, if there is a documented shortfall of government revenues due to the economic impact of the EVD outbreak that may hinder on-time payment of salaries for domestic health workers, the Project under this component could potentially contribute towards the payment of salaries of domestic health workers directly involved in the EVD emergency response (e.g., providing care to infected patients in the selected facilities) and in the provisions of other essential health services in the affected communities. To this end, unallocated grant funds under the Project would be retained to contribute to pay domestic health workers' salaries. Component 3: Provision of Food and Basic Supplies to Quarantined Populations and EVD Affected Households 15. The EVD crisis is expected to have serious consequences for food security in Guinea, Liberia, and Sierra Leone. The Governments’ and neighboring countries efforts to contain the spread of the disease have disrupted trade and are potentially disrupting agriculture activities, which constitute the main source of livelihood in these countries. Traditional national and international supply routes have been interrupted by closing of borders and transportation access points (sea, land, air). Government containment measures have included cordoning off of large geographic areas, roadblocks, and other movement restrictions (e.g., banning of large gatherings such as markets). These measures limit the supply of food and other basic goods from the capitals out to the rural areas. In Sierra Leone and Liberia the epicenters of the disease encompass important agricultural zones, where the highest production of staples (i.e., rice, cassava) takes place. And while robust data are scarce, there is anecdotal evidence that agriculture activity, which is the main source of income for the majority of the population, is being affected, limiting the supply of food available locally. The timing of the EVD crisis also coincided with the beginning of the annual farming season for important crops (i.e., the “lean” season in July to August) when household food stocks are diminished and reliance on markets increases. 40 16. This heightened threat of food insecurity occurs within a context of already high food insecurity and poor nutritional outcomes. Based on the latest estimates from WFP’s comprehensive food security and vulnerability assessments carried out between 2011 and 2013, one in three households in Guinea are affected by severe and moderate food insecurity, one in five households in Liberia, and one in two in Sierra Leone. 23 Chronic malnutrition affects 35 percent of children in Guinea, reaching 42 and 44 percent in Liberia and Sierra Leone respectively. Preventing food insecurity and the resulting deterioration of nutritional outcomes, particularly for those is quarantined areas and “hot zones”, is critical to mitigate the impacts of the EVD crisis on poverty and broader economic development in these countries. 17. This component would therefore aim to improve access to food and other basic supplies (e.g., safe water) for the affected population in the quarantined areas and other “hot zones” in Guinea, Liberia and Sierra Leone. Specifically, the component will finance delivery of food and related logistical and operational costs to improve food access for individuals directly and indirectly affected by the EVD crisis in the three affected countries. Funds for this component will be channeled to the WFP under contracts between the Governments of the three affected countries and the WFP. Provision of other basic services (e.g., safe water, chlorine) will be determined on a country by country basis and in line with each country’s evolving needs in the quarantined areas and “hot zones”, as well as of Ebola-affected households. 18. This component would target approximately 450,000 individuals affected by the EVD in quarantined areas and other EVD “hot zones”. In particular, this component would target: (i) confirmed and suspected EVD cases at hospitals and treatment centers individuals; (ii) confirmed and suspected contact cases in quarantine or under observation; (iii) those living in communities isolated in quarantined areas and “hot zones” where availability of and access to food is being affected by the crisis. The WFP’s rapid estimate of the population requiring immediate food assistance in these areas due to the Ebola outbreak and their corresponding food needs over a three-month period is summarized in Table 9. The Project would finance delivery of food items to approximately one-third of this population in the highest priority areas, in line with WFP’s Regional Emergency Operation (OMD West Africa 200761). Given the evolving nature of the EVD crisis, new priorities may emerge in terms of the specific supplies that are most needed in the quarantined areas and “hot zones”. 23 WFP Comprehensive Food Security and Nutrition Survey, Liberia (2013); WFP Comprehensive Food Security and Vulnerability Assessment, Guinea (2012); WFP Comprehensive Food Security and Vulnerability Assessment, Sierra Leone (2011). 41 Table 9: WFP’s estimate of Ebola-related food needs and associated costs in the three affected countries Support from Ebola Emergency WFP Regional Emergency Operation Response Project Country Estimated Estimated Population Total % of total Project Tonnage Project Project requiring food budget beneficiaries financing (mt) beneficiaries tonnage assistance (USD m) per country (USD m) (mt) Guinea 464,000 22,954 24.7 35.3 9.0 140,000 6,500 Liberia 449,000 22,226 24.1 34.0 8.0 135,000 6,500 Sierra Leone 400,000 19,800 20.7 30.5 6.0 120,000 4,000 Total 1,313,000 64,979 69.8 100.0 23.0 395,000 17,000 Source: WFP estimates. Estimates include cost of regional operations. 19. Based on currently available information, some priority areas have been identified; however, these priority geographical areas may change depending on how the EVD crisis evolves. The specific areas to target will be aligned with the Government’s overall Ebola response action plan and will be agreed upon between the respective Governments, the WFP, and the World Bank, with guidance from other partners such as the WHO. The following areas have been identified as priority areas: i. Guinea: ETCs, isolated communities in border areas, and other “hot zones” within the affected prefectures including but not limited to Gueckoudou, Macenta, Youmou, N’zerekoré, Kissidougou, Fourecariah, Dubreka, Boffa, Conakry, Kourrousa, Siguiri, and Pita. ii. Sierra Leone: ETCs in Kenema, Daru, Kailahun, and Koindu; isolated communities in border areas and other “hot zones” within the affected districts of Kenema, Kailahun, Bombali, PortLoko, Moyamba, Kambia, Tonkolil, Pujehun, Bo, Bonthe, Koinadgu and Western area. iii. Liberia: ETUs, isolated communities in border areas, and other “hot zones” within the affected counties Montserrado, Lofa, Bong, Bomi, Grand Cape Mount, Margibi, Nimba, Grand Bassa, and Rivercess. 20. Funds for this component will primarily be channeled to the WFP, as well as to other agencies as required for delivery of non-food supplies, under contracts between the Governments of the three affected countries and the WFP. The Governments’ national Ebola committees/ taskforces, with support from the ministries of agriculture, health, and other key line ministries in the respective countries, will work with WFP to develop an investment plan for Component 3. The investment plan will include a simple positive list of expenditure items to address the EVD-related food security needs, with costing of high priority items and specifying the funding gaps. For efficiency purposes, it is expected that the majority of the Component 3 funds will be channeled to each country through direct payments to the WFP or other agencies based on the terms of contracts between each of the three Governments and the agencies. In recognition that other agencies may have a higher comparative advantage over WFP in provision of non-food basic supplies; the component could also channel funds to other agencies for delivery of these items. This could be done directly or through sub-contracting by WFP. A portion of the funds would be channeled to the special account for Ebola response for Guinea, 42 Ebola Trust Fund for Liberia, and Integrated Project. Administration Unit (IPAU) of the MoFED and/or EOC for Sierra Leone, to support the Government’s monitoring and supervision of the component activities. 21. The food supply intervention package supported under this component is designed to increase the availability of food to prevent rapid deterioration of the worst-affected population’s food security and nutritional status. The WFP would provide a food package in the form of an enhanced general food ration, which is designed to meet the full caloric and micronutrient requirements of beneficiaries. The food ration is expected to include key staple foods such as rice and will include specific elements tailored toward the needs of women of reproductive age and young children. Provision of other basic supplies such as safe water and chlorine will be determined on a country by country basis and in line with each country’s evolving needs in the quarantined areas, “hot zones” as well as Ebola-affected households. WFP will work with health partners as well as experienced NGOs to deliver these goods. 22. The delivery modalities used would aim to rapidly and effectively deliver the supplies required, while minimizing the health risks associated with large gatherings. For patients in hospitals or observation centers, cooked meals will be provided; in these cases, the food will be directly provided by WFP to the health partner in charge of the facility for preparation. For the rest of the beneficiaries, the WFP would implement General Food Distribution (GFD) through a blanket approach providing take-home dry rations. Such a blanket approach would benefit all members in the targeted community. Ebola treatment and observation centers and communities will be prioritized to receive GFD based on the joint response plan of the WHO and the three affected countries. Targeting at the community level in this way rather than at the household level is considered appropriate for the context, given the already strained capacity on the ground, the heightened potential for social conflict, and the increased risk of disease exposure that staff mobilization brings. To further mitigate the health risks associated with distribution activities, WFP, jointly with the WHO, has developed guidelines on appropriate delivery and distribution modalities. WFP will be responsible for training staff and partners on these risk mitigation measures and providing them with appropriate protective equipment and hygiene materials. 23. To prevent the food and other items from reaching unintended beneficiaries (i.e., “leakage”), WFP has developed specific guidance and operating procedures for the handling and storage of food aid commodities. These procedures cover a range of issues including the selection and design of storage structures, coping with moisture and temperature, food packing, inspections and sampling, food safety, and microbiology. In addition, depending on the context, in particular the specific commodities to be handled and the specific supply chain setting, WFP would develop locally Standard Operating Procedures to address in detail the necessary actions to be performed by each actor within the supply chain (e.g., from transporters to warehouse managers). WFP will provide capacity building to Government and other partners on all of these issues to mitigate against the risk of food “leakages”. 24. To the extent possible, commodities will be procured locally and regionally to limit procurement delays and mitigate disruptions to local markets. Preliminary assessments by WFP indicate that rice and other key nutritional items are available in one or more of the three 43 affected countries and in the region. However, given the situation is in flux, flexibility in the food basket will be maintained to minimize implementation delays. 25. This component will allow some flexibility for the activities to evolve in line with the situation and the particular country context. For example, under the current circumstances certain types of supplementary feeding programs are not viable (e.g., school feeding programs cannot be implemented if schools are closed); however, as the emergency situation begins to improve and schools are reopened, support under this component can be transitioned into more effective, cost-efficient, and more sustainable delivery models. In addition, the geographical priority areas are likely to shift as the crisis evolves. To introduce such flexibility, the contract between the Governments and the WFP is expected to include a positive list of expenditure items that will be allowed to be financed under Component 3. However, any changes to the delivery models will be agreed upon between the individual implementing countries, the WFP, and the Bank. 26. In terms of sustainability, once the crisis is contained, this emergency social protection response is expected to transition to medium-term safety net support. International experience shows that provision of food and basic supplies is preferable only in emergency contexts where supply of these items limited and direct cash transfers would lead bring inflationary pressures or are otherwise impractical. Given the emergency nature of the crisis, provision of food and supplies is considered necessary over the immediate term to prevent nutritional deprivation and households falling further into poverty. However, as the crisis comes under control, it is expected this support will transition to expansion of more traditional safety net mechanisms, such as cash transfers, to mitigate the impact of shocks on households affected by EVD. 44 Annex 5: Additional Lessons Learned on Fighting Disease Outbreak 1. The Bank team noted the expert opinion of 10 leaders of the fights against smallpox, polio, SARS, rinderpest, Guinea worm, and other diseases on how best to fight the outbreak (New York Times, August 29, 2014) as follows: • Unusual tactics and inventive thinking will be needed to beat West Africa’s Ebola outbreak. • Clear, courageous national and regional leadership is essential, along with funding levels commensurate with the changing needs of an evolving epidemic. • Immediate attention needs to be placed in developing strategies to stop the panic caused by quarantined residents of the affected countries being put behind barbed wire and roadblocks in affected regions. The outbreak will not end until average citizens calm down and help their infected neighbors instead of fleeing from them. • To prevent panic, respected leaders must quell rumors. Radio is useful but the key is to get trusted local leaders like chiefs, clerics, midwives and traditional healers to do the job. Ebola survivors “should be publicized,” “so people understand that they don’t have to die if they come in for care.” • The outbreak could be stopped without experimental drugs or vaccines. • The military may be useful, as long as they only deliver supplies, set up field hospitals, provide electricity and communications — and avoid anything that involves brandishing weapons, including enforcing quarantines. • Health workers taking huge risks must be compensated, and so must their families if they die. To find and deploy expatriate doctors, nurses and logistics personnel to support the emergency response will require paying them adequately. Several doctors who helped eradicate smallpox — which had a 30 percent fatality rate — said they sometimes paid victims and their families in food and cash to stay indoors. Whole villages were paid to build quarantine huts where the sick were cared by neighbors who had survived or had been vaccinated. • Also, as the EVD outbreak is like the Severe Acute Respiratory Syndrome (SARS), doctors and nurses are in the highest risk group. Training must be extra-thorough — especially in taking off protective gear that might be smeared with virus. Nigeria, for example, does not let anyone near victims without three days of training on wearing protective gear. • It may initially be wise to quarantine only obviously ill Ebola victims and temporarily abandon isolating their relatives and contacts. Eventually, all will have to be monitored, but seemingly healthy people have been forced into hospitals alongside those dying. That people go into hospitals in good shape only to die makes others flee from health teams. • Rapid diagnostic testing is crucial, because the early symptoms mimic those of common diseases like malaria and typhoid. Quarantining people with easily curable ills alongside Ebola patients is a deadly error. • To build trust and lower death rates, especially because local hospitals are not functioning anymore, the response plan will have to include treating less exotic but still potentially fatal illnesses like malaria and pneumonia. • Areas under quarantine will require food shipments for months. 45 Annex 6: Implementation Arrangements I. Implementation Arrangements Component 1: Support to the EVD Outbreak Response Plans and Strengthening Essential Health Services 1. Guinea: • Inter-Ministerial Committee o Established on April 5, 2014 o Headed by the Minister of Health and comprising the Ministers of Budget, Social Services, Communication, and Primary Education. o Provide strategic level guidance. o This high level committee meets once a week. • National Coordination Committee/PIU o Established with PIU function on September 5, 2014. o The PIU will be supported by secondees from the PIU of the Bank-funded Village Community Support Program Project to boost the implementation capacity for an initial three to six months period. • The National Coordination Committee/PIU will make Project decisions (e.g., on the investment plans for Component 1) and provide oversight of the Project progress. Implementation of Component 1 and day-to-day operation will be led by the PIU and the Ministry of Health and part of the work will be contracted to relevant technical agencies (e.g., WHO, UNICEF). 2. Liberia: • National Consultative Group (NCG) o Includes non-restrictive members from a wide cross-section of the society, who would be briefed and provided inputs on the status of the anti-Ebola campaign. o Works as the overarching group. o The NCG will meet bi-monthly. • The Incidence Management System (IMS) o Headed by Assistant Minister of Health/Deputy Chief Medical Officer as Incident Manager and includes four (4) deputies for the purposes of coordination, medical, and support services. o The Incident Manager is primarily responsible for the management of the outbreak, establishes immediate priorities, objectives and strategies as well as approves action plans, authorizes request and modifies management structure or committees to enhance efficiency and effectiveness. Incident Manager will report directly to the President chair of the NCG and report bi-weekly to the National Consultative Group. o It has sub-groups by topics (e.g., case management) and development partners participate in each sub-group. 46 o The IMS will serve as the central point for all Ebola response related activities and all financial transaction accordingly. o IMS will meet bi-weekly • In this project, IMS will be the overall coordinator and technical lead of the operation. IMS will work closely with the Health Systems Strengthening Project Coordination Office (HSSP Coordination Office) on day-to-day operations, including contracts with UN agencies. The IMS and HSSP Coordination Office will be supported by the Project Financial Management Unit (PFMU) within the Ministry of Finance and Development Planning for activities. 3. Sierra Leone: • Ebola Emergency Operation Center (EOC) o Co-chaired by the Chief Medical Officer (CMO) and WHO Representative, and participated by other Ministries and partners. o The operational structure of the EOC includes a Financial Secretariat and 24/7 call center. o All the investment plans will be approved by the EOC. The use of funds in this component will be determined by the EOC. • The EOC will make project-related decisions (e.g., investment plan for Component 1) and provide oversight of the project progress. The Ministry of Health and Sanitation (MoHS) will lead the implementation of Component 1 with technical support from WHO and other partners. The MoHS will contract out part of the work to technical agencies (e.g., WHO, UNICEF, UNFPA) to ensure the rapid delivery of services. Component 2: Human Resources Scale Up and Deployment for Outbreak Response and Provision of Essential Health Services 4. Description: • For each country, the management of the hazard/indemnity pay and death benefit will be contracted out to an independent agency (public or private) that is capable of verifying the attendance (with logistics capacity) and carry out quick payment (e.g., using mobile phone). • For example, the World Bank’s Youth Employment Support project (YESP) social protection project in Sierra Leone is implemented by the National Commission for Social Action (NaCSA), which handles the mobile payment to the service providers. The same arrangement will be sought for Sierra Leone, as well as for other countries. • In Liberia, the government plans to use the Project Financial Management Unit (PFMU) for the hazard/indemnity payment and death benefit. • The communication, advocacy and non-financial incentives will be managed by the MoH or contracted to an agency with strong ability in communications. • For the deployment of African and international health workers needed for the emergency response, the Governments of the participating countries under the Project will enter into a MOU with the AU or other agencies to cover the cost of these workers. 47 Component 3: Provision of Food and Basic Supplies to Quarantined Populations and EVD Affected Households 5. WFP will ensure the assessment, coordination, programming, planning, monitoring, evaluation and supervision of all activities for this component, in close collaboration with WHO and the Ministries of Health in the respective countries. The funds will be directly channeled to the WFP, based on contracts between the Governments of the three countries and the WFP. As determined on a country-specific basis, the Governments may adopt separated contracts with UNICEF, or other partner, for the procurement and distribution of other basic supplies (e.g., safe water, chlorine). The allocation of funds from each country will be based on the estimated number of beneficiaries (Table 9) – Guinea (35.3 percent), Liberia (34.2 percent) and Sierra Leone (30.5 percent) – as identified in the WFP Emergency Operation. 6. WFP, as the lead agency of the UN system’s global Logistics Cluster and the manager of UN common transport/logistics services, has strong capacity to deliver the food assistance and other logistical services. Transportation routes and borders are open to humanitarian operations and there are provisions for special requests for the transit of goods at the field level, including a dedicated Supply Chain Working Group. The WFP manages two UN Humanitarians Response Depot hubs in the region located in Ghana and the Canary Islands to support procurement and transit as necessary. WFP also maintains warehouses in the port capitals as delivery points as well as in the “hot zone” cross-border areas of Gueckedou, Guinea, and Foya, Liberia, and is in the process of identifying additional strategic locations for local warehouses, which will be financed by their own resources. 7. WFP will work with health partners and health counterparts as well as experienced NGOs and other agencies for the delivery and distribution of the food assistance. WFP, jointly with the WHO, has already developed guidelines on appropriate delivery and distribution modalities to mitigate health risks associated with distribution activities. WFP will also train staff and partners on risk mitigation measures and provide them with the appropriate protective equipment and hygiene materials. More broadly, WFP has put in place specific guidance and operational procedures for the purchase and management of transport, logistics, and related services with the aim of achieving timely, cost-efficient, and quality of delivery of commodities. All major services include insurance coverage, protection and reconditioning of cargo, and legal and related services relating to disputes and recoveries. II. Financial Management, Disbursements and Procurement 8. A Financial Management (FM) assessment was conducted on the FM arrangements for the Ebola Emergency Response Project. The Project, specifically parts of Component 1 and the entire Component 2, will be implemented in Sierra Leone by the Emergency Operations Center (EOC) that is overseen by the Ministry of Finance and Economic Development (MoFED), Ministry of Health and Sanitation (MoHS) and World Health Organization (WHO). The EOC will have KPMG as a fiduciary agent. KPMG entered into an agreement with the Government of Sierra Leone on August 14, 2014 to provide accounting services to the EOC. Services by KPMG will initially be provided free for six months as part of its corporate responsibility to Sierra Leone. In Guinea, parts of Component 1 and the entire Component 2 of the Project will be 48 implemented by the Ministry of Health (MoH) that will have a Project Implementing Unit. In Liberia, the implementing entity will also be the Ministry of Health and Social Welfare that has an Ebola Fund Management Task Force (EFMTF) and Incidence Management System (IMS), which is headed an Assistant Minister. The IMS will coordinate the operations of the Project while operational and procurement procedure will be managed by the HSSP Coordination Office, and FM will be managed by the Project Financial Management Unit (PFMU) that is already established under the Ministry of Finance. UN agencies such as UNICEF, WHO and UNFPA will be implementing parts of Component 1 while WFP will implement Component 3 of the Project. The UN agencies will sign an agreement to implement the Project with the Governments of Guinea, Liberia and Sierra Leone. 9. The objective of the assessment was to determine whether the implementing entities have acceptable financial management arrangements in place that satisfy the Bank’s Operation Policy/Bank Procedure (OP/BP) 10.00. These arrangements would ensure that the implementing entities: (i) use Project funds only for the intended purposes in an efficient and economical way; (ii) prepare accurate and reliable accounts as well as timely periodic financial reports; (iii) safeguard assets of the Project; and (iv) have acceptable auditing arrangements. The FM assessment was carried out in accordance with the Financial Management Manual issued by the FM Sector Board on March 1, 2010. Budgeting Arrangements 10. All national implementing entities of Guinea, Sierra Leone and Liberia will prepare annual budgets, analyzed by quarter, based on the work plans and the procurement plans, including cash flow forecasts for each component and be submitted to the Bank, at least two months before the beginning of the Project fiscal year. The budgets will follow national procedures during the budget preparation process. All UN agencies will have to submit their project budget to the national implementing entities under the timeframe specified under their agreements with the Governments of Guinea, Sierra Leone and Liberia. During the financial year, budgets will be reviewed on a quarterly basis against actual expenditure using interim financial reports for national implementing entities. These interim financial reports will be expected to be submitted within 45 days after the end of the quarter to the Bank. For UN agencies, they will follow their Financial Regulations and rules to provide this information to the national implementing entities and the Bank. Accounting Arrangements 11. Accounting Policies and Procedures: Liberia will use the PFMU Financial Management Manual for the Project as well as the Ebola Trust Fund Financial and Procurement Policies and Procedures for the Project. Sierra Leone will have KPMG as the Fiduciary agent of the Ebola EOC and will have to submit the accounting policies and procedures that KPMG will use for the Project. With respect to Guinea, the MoH will use the national accounting policies and procedures for the Project. In order to strengthen FM arrangements and cover elements of the Project not included in the existing FM Manuals including hazard/indemnity pay guidelines, the Recipients will have to prepare and agree with the Bank, on a Project Implementation Manual within one month after effectiveness as an undertaking to the Financing Agreement. As part of 49 the accountability documents, national implementing entities will be expected to keep records of all clinical and non-clinical staff paid compensation benefits classified under the ETCs/Units as well as compensation letters that show their commitment to provide service to Ebola patients. UN agencies will use their Financial Rules and Regulations to account for the Project funds. 12. Accounting Staff Arrangements: Staffing arrangements for Liberia at the PFMU are adequate for the Project. In Sierra Leone, KPMG will have a team of accountants to account for Project funds. However, this service will be limited to the timeframe of their contract which is six months unless it is extended. After that, the accounting arrangements in Sierra Leone for the Ebola EOC will have to be reviewed by the Bank. In Guinea, the MoH will need to recruit a Financial Management Officer and appoint a qualified accountant from the ministry to account for the Project funds within one month after effectiveness. The MoH PIU will upon effectiveness acquire an accountant from the Village Community Support Program Project to support the project until the PIU recruits the Financial Management Officer and appoints an accountant. UN agencies will ensure that staffing arrangements for the Project are maintained throughout the life of the Project. 13. Accounting information systems: Liberia’s PFMU will use the SUN Accounting system to prepare the Projects’ books of accounts. Sierra Leone’s EOC Fiduciary Agent, that is, KPMG will ensure a proper accounting system is in place for the Project as it prepares the accounts. Guinea’s MoH will have to acquire and set up a computerized accounting system within two months after the Project’s effectiveness. Internal Controls and Internal Audit Arrangements 14. Internal Control: The Project management in each country will maintain adequate internal controls system in place in order to ensure the use of funds for the intended purpose. Fixed assets and contracts registers relating to the Project will be prepared, updated regularly and submitted as Annex to the quarterly IFRs. The accounting policies and procedures described above plus management arrangements put in place, will be used to define the internal control systems for the Project. Internal Audit: In Guinea, Liberia and Sierra Leone, the government will ensure that quarterly internal audits are done on the Project using a risk based approach and the reports provided to the Bank within 45 days after the end of the quarter. This will mainly involve auditing compensation benefits such as hazard/indemnity pay, death benefits and emergency operating costs under Component 2. Internal Auditors at sub-national and national levels are expected to be engaged in the Project to conduct these audits. UN agencies will use their own internal audit arrangements. Internal auditors will have to agree on the work plan/terms of reference of conducting audits related to the Project. The audits will be done using a risk based approach. The PIU in Guinea will need to recruit an internal auditor to coordinate internal audit activities within one month after effectiveness. UN agencies will use their own internal audit arrangements. 50 Financial Reporting Arrangements 15. All national implementing entities of Guinea, Liberia and Sierra Leone will prepare quarterly un-audited IFRs in form and content satisfactory to the Bank, which will be submitted to the Bank within 45 days after the end of the quarter to which they relate. UN agencies will also prepare semi-annual interim financial reports (Fund Utilization Reports) as part of their progress reports and submit them to the national implementing entities and the Bank within 30 days after the end of the reporting period. The formats and contents of the IFR will be agreed between the Bank and the national implementing entities. The contents of the IFR will include a section to report on the accountability of funds utilized and a section to access funds using the report-based method of disbursement. 1. The reporting section includes: • Statement of Sources and Uses of Funds; and • Statement of Uses of Funds by Project Activity/Component. • Listing of clinical and non-clinical staff getting compensation benefits categorized by ETCs/Units. 2. The disbursement section includes: • Designated Account Activity Statement; • Bank statements for both the Designated and Project Account and related bank reconciliation statements; • Summary statement of Designated Account expenditures for contracts subject to prior review; and • Summary statement of Designated Account expenditures not subject to prior review. 16. All national implementing entities will also prepare the Project’s annual accounts/financial statements within three months after the end of the accounting year in accordance with accounting standards acceptable to the Bank. The financial statements will be required to be submitted to the Bank within six months after the end of the fiscal year. The minimum accounting and financial reporting basis will be cash basis. For example Liberia will be using the International Public Sector Accounting Standard cash basis of accounting with additional information on commitments. This information should be provided with additional information on commitments and other obligations. External Audit Arrangements 17. The external audit of the Project’s funds that is implemented by the national implementing entities will be done by the Supreme Audit Institutions of Liberia (General Auditing Commission) and Sierra Leone (Audit Service Sierra Leone). For Guinea, the audit will be done by a private audit firm this is acceptable to the Bank. Supreme Audit institutions can contract private audit firms acceptable to the Bank to conduct the audit of the Project on its behalf. The cost of hiring a private audit firm will be met by the Project. All audits should be carried out in accordance with International Standards on Auditing or International Standards for 51 Supreme Audit Institutions issued by the International Organization for Supreme Audit Institutions. All Terms of Reference for audits of the implementing entities will be agreed with the Bank and the external auditors should be appointed within five months after effectiveness. Terms of reference should ensure there is reasonable audit coverage of expenditures involving compensation benefits such as hazard/indemnity pay and death benefits as well as emergency operating costs. Audit reports together with management letters should be submitted to the World Bank within six months after the end of the government’s fiscal year. Audit reports will be publically disclosed by the World Bank Group in accordance with the Bank’s disclosure policy. 18. For the UN implemented activities under Components 1 and 3, the Bank will pursue audit elimination in accordance with Bank Policy and Procedures as their audits are submitted to the Bank and are available on the UN organization’s website. However, UN agencies will have to avail their audit reports to the Governments of Guinea, Liberia and Sierra Leone based on agreements in place with respect to the Project. Governance and Anti-corruption (GAC) arrangements 19. FM has put measures in place to strengthen GAC arrangements by mitigating any issues arising in the FM arrangements as seen in the action plan. However, in order to ensure proper internal controls are maintained, there will be quarterly internal audits focusing mainly on compensation benefits (hazard/indemnity pay and death benefits) and emergency operating costs and annual external audits done on the Project. In addition, the Bank will conduct regular supervisions with the government based on the risk rating of the Project. 20. In order to strengthen GAC arrangements, it is recommended that the following be done: • Put in place an independent complaint handling mechanism where complaints will be made and responded to with a good recording system to show the related details including the time the complaint was reported and the time the response was made. • Involve civil society in the supervision of Project activities. • Ensure transparency with respect to the Project funding. This will involve disclosing the Project’s amounts received and transferred to the various implementing entities. In addition, public disclosure e.g. on websites of financial reports such as budgets, financial reports and annual audited accounts will enhance transparency and accountability. In addition, public display of clinical and non-clinical staff getting compensation benefits at the ETCs/Units and the national implementing entity websites will also enhance transparency and accountability. Daily press releases to keep the public informed on the Project’s activities will also be useful. In Sierra Leone for example, there are daily press releases done by the EOC that are covered in the national radio and television and they will include disclosure of financial information in relation to the Project. 52 Disbursements and Funds Flow Arrangements Disbursement arrangements 21. All national implementing entities of Guinea, Liberia and Sierra Leone will access funding from the Bank using the report-based disbursement method. The initial disbursement by IDA for the Project will be made after receiving a withdrawal application with a six months cash flow forecast from the Project. These withdrawal applications should be prepared within one month after Project effectiveness. Thereafter, IDA disbursements will be made into the Designated Account based on quarterly Interim Financial Reports (IFRs) which would provide actual expenditure for the preceding quarter (three months) and cash flow projections for the next two quarters (six months). In the case of Liberia and Sierra Leone, funds will be transferred from the Designated Account to the pooled accounts after receiving cash flow projections to confirm what activities will be funded. While for Guinea, funds will be transferred from the Designated Account into the Operations or Project Account (sub-account for transactions paid in Guinea Francs). 22. Other methods of disbursement that can be used by the national implementing entities include direct payments, reimbursements and special commitments. All UN agencies upon signing a contract with the Governments of Guinea, Liberia and Sierra Leone and authorization to disburse by the Governments, will receive funds from the Bank through an advance deposited into an official UN Bank Account, using the Blanket Commitment Form, in accordance with the provisions of the Financial Rules and Regulations of the particular UN Organization. If ineligible expenditures are found to have been made from the Designated and/or Pooled or Project Account or sub account, the borrower will be obligated to refund the same. If the Designated Account remains inactive for more than six months, the Bank may reduce the amount advanced. The Bank will have the right, as reflected in the terms of the Financing Agreement, to suspend disbursement of the funds if significant conditions, including reporting requirements, are not complied with. Additional details regarding disbursement will be provided in the disbursement letters for each of the countries. Funds Flow Arrangements 23. Guinea: A Designated Account (DA) in US$ and a transaction account in Guinea Francs (GNF) will be opened in a commercial bank acceptable to IDA under the responsibility of the Ministry of Health. The payment agency will also open a sub-account for transactions related to Component 2. For compensation benefits (indemnity pay), transfers from the sub-accounts will be sent for clinical and non-clinical staff upon approval by the MoH through micro-finance entities distributed throughout the affected districts. The micro-finance entities will then deposit funds into the staff bank accounts or pay them through mobile money. Clinical and non-clinical staff may also be provided official coupons that they can cash in at the micro-finance institutions. All opened accounts will be managed according to the disbursement procedures described in the Administrative, Accounting and Financial procedures and the Disbursement Letters. Applications for withdrawal of proceeds will be prepared by the Ministry of Health and submitted to the Bank (IDA). Report based method will be used to withdraw funding from the Bank as explained under disbursements above. 53 24. Liberia: IDA will disburse funds for Components 1 and 2 in US$ to the designated account managed by the PFMU for the Project held under the Central Bank of Liberia. Recurrent expenditure once established and approved, will be disbursed into the Trust Fund established for the Ebola Emergency Response Project also at the Central Bank. Report based method of disbursement will be used to withdraw funding from the Bank as explained under disbursements above. 25. Sierra Leone: IDA will disburse the funds in US$ in Designated Account managed by the EOC whose fiduciary agent is KPMG. Recurrent expenditure once established and approved, will be disbursed into the EOC pooled account established for the Ebola Emergency Response Project. There will be two EOC pooled accounts, that is, one in USD and the other in Leones and disbursements from the designated account can be made to either of the accounts. The EOC designated and pooled accounts will be overseen by the MoFED, MoHS and WHO. Both of these accounts will be held at the Bank of Sierra Leone. Report based method of disbursement will be used to withdraw funding from the Bank as explained under disbursements above. 26. All Designated Accounts and pooled or operating bank accounts should be opened in either the central bank or commercial bank acceptable to the Bank (IDA). The accounts should be opened upon the signing of the Financing Agreement and the effectiveness of the Project. The bank account details and signatories to the accounts should also be submitted during this period. UN agencies: Payments to all UN agencies implementing Component 1 (UNICEF, WHO, UNFPA, etc.) and Component 3 (WFP) will be made upon approval by the national implementing entity and having a contract with the Governments of Guinea, Liberia and Sierra Leone. The payment will thereafter be made by the Bank using an advance to an official UN Bank Account. All contracts with UN agencies will have to be cleared by the Bank before they are signed with the governments of Guinea, Liberia and Sierra Leone. All UN agencies will have to submit a Fund Utilization projection (cash flow forecast) for six months of expenditure every three months to the national implementing entity for approval of the disbursement. Disbursements to UN agencies can be up to 100 percent of the contractual amount. UN agencies will have to account for the funds using semi-annual Fund Utilization Reports and annual audited accounts. 27. Counterpart funding: The Governments of Guinea, Liberia and Sierra Leone will be putting in their own funding to fight Ebola outbreak in their respective countries. These will be put into the pooled accounts in the case of Liberia and Sierra Leone or into an operating account in the case of Guinea. 54 Funds Flow Diagram Disbursement funds flow Chart for Guinea, Liberia and Sierra Leone IDA Advances made to UN Agencies under Designated Accounts in USD for Ministry of Health Component 1 (UNICEF,WHO, UNFPA, (Guinea), etc) and 3 (WFP) into UN Official PFMU Liberia) and Account EOC (Sierra Leone) Operational/Transactional Account for Guinea in GNF and Pooled Accounts for Liberia (TF Project Pooled A/C in local currency) and Sierra Leone (EOC Pooled A/C in both USD and Leones) Payment for project eligible expenses (US$) Flow of Funds Financial Management Action Plan Country Action Responsibility Due Date All Agree on Interim Financial Report Formats for MoH, PFMU By September 15, Countries Component 1 and 2 implementers. and KPMG 2014 All Agree on external audit terms of reference. MoH, PFMU By September 30, Countries and KPMG 2014 All Open the Designated Accounts and Operating MoH, PFMU Between the Countries Accounts and provide their account details plus and KPMG signing of the signatories to the Bank. Pooled accounts details and Financing the signatories that will be used by the Project are to Agreement and be provided too. Effectiveness All Have a Project Implementation Manual agreeable to MoH, PFMU One month after Countries the Bank with Financial Management arrangements and KPMG effectiveness detailed related to the Project. Sierra KPMG to submit to the Bank and Government of KPMG One month after Leone Sierra Leone, accounting policies and procedures for effectiveness the Project as part of the Project Implementation Manual. Guinea Appoint a qualified accountant within the Ministry of MoH One month after Health and recruit a Financial Management Officer effectiveness to handle FM tasks of the Project Guinea Recruit a qualified and experienced internal auditor MoH One month after for the project. effectiveness Guinea Acquire and set up an adequate computerized MoH Two months after accounting system effectiveness All Appoint an external auditor for the Project MoH, PFMU Five months after Countries and KPMG effectiveness 55 Supervision Plan 28. Financial Management supervision missions will be carried out twice a year based on the current Substantial residual risk rating of the Project. Supervision will also include desk reviews such as the review of the IFRs and audit reports. In-depth reviews and forensic reviews may be done were deemed necessary. The FM supervision will be an integrated part of the Project’s implementation reviews. It is also envisioned that joint supervision missions with procurement staff to strengthen Bank control and support may be conducted. A review of the Project expenditures will be carried out regularly (as part of the scope of each implementation review mission) to ensure that expenditures incurred under all project are eligible for Project funding. Conclusion 29. The conclusion of the assessment is that the financial management arrangements in place meet IDA’s minimum requirements under OP/BP10.00, and therefore are adequate to provide, with reasonable assurance, accurate and timely information on the status of the Project required by IDA. The overall Financial Management residual risk rating of the Project is Substantial for Guinea, Sierra Leone and Liberia. 56 Annex 7: Operational Risk Assessment Framework (ORAF) Africa: Ebola Emergency Response Project (P152359) 1. Project Stakeholder Risks Rating MODERATE Description: The main stakeholders include government Risk Management: International agencies (such as WHO, CDC, MSF, etc.) are already ministries, particularly the MoH including health facilities at the providing aid coordination, medical care and training of health facility staff. The local level, MSP, CBOs, local and international NGOs, and UN Governments of Guinea, Liberia and Sierra Leone and the donor community are mobilized. agencies involved in implementation. Well-coordinated donor The UN has established a new system-wide coordination initiative to help halt the spread of and Governments implementing agencies efforts will be the EVD. The Governments of Guinea, Liberia and Sierra Leone, with the technical support essential to the success of the Ebola emergency response in the of WHO, developed the EVD Outbreak Response Plan in West Africa and have put in place three affected countries. With the multiple donors financing, an inter-ministerial task force to develop and operationalize the response plan. WHO is multiple sector implementation, and the need for rapid response, setting up an Ebola Response Center in Conakry involving other international agencies; the a key risk is that activities could be implemented in a disorderly center will serve as the main sub-regional operations hub. All donors, including the Bank, fashion wasting time and other precious resources. Key are involved and will continue to be involved in these coordination efforts. Implementing elements such as the provision of financial, technical and agencies, through their respective ministries, will be able to obtain support from the task physical resources to health facilities, health workers, force and the operations hub if and when needed. government officials, etc. could be seriously delayed and thus Stage: Preparation and Status: Resp: Client, UN, Bank Due Date : Project results hampered. Implementation In progress 2. Implementing Agency Risks (including fiduciary) 3.1. Capacity Rating: HIGH Description: Implementation capacity of implementing Risk Management: The inter-ministerial task force and the Ebola Response Center agencies in the three countries is relatively weak, staff is established by WHO as well as Bank and other donors’ technical support will be available to untrained to deal with such difficult circumstances. They only assist with implementation difficulties. To further mitigate the implementation risk including have limited capacity and resources to deal with such a any fiduciary risk, critical emergency activities (and associated funds) will be delegated to multifaceted emergency crisis. UN agencies and international NGOs which have staff already working in the field and can respond immediately. Discussions with Governments and UN agencies have started. Bank will provide close supervision to ensure that contracts between Government and UN agencies (WHO, WFP, UNOPS, etc.) are signed as soon as the legal agreements are signed. UN contracts are paid 100% upfront and, in order to gain time, as soon as the Grant is effective, the contracts or advances can be paid directly into a UN Agency official bank account. With regard to Financial Management, measures have been put in place to strengthen the accountability process. They include having adequate staff or a fiduciary agent (in the case of Sierra Leone) to account for the Project funds, having adequate accounting policies and procedures to strengthen the internal control systems, reporting on expenditure incurred during and at the end of the annual year and ensuring that quarterly internal audits are done as well as annual external audits. Status: Resp: Client Stage: Implementation Due Date : In progress 57 3.2. Governance Rating: HIGH Description: Delays in signing the legal agreements and in Risk Management: The Bank will work closely with Governments to ensure rapid Project start-up including signing of contracts with UN agencies processing and approval of key documentations including contracts with UN agencies, could hamper the timing of the response and therefore its leaning if needed on the inter-ministerial task force and the UN Coordinated operations hub. impact. Weak fiduciary capacity may lead to inefficient use of Weak fiduciary capacity has been mitigated as explained under 3.1 above and in Annex 6. resources. Status: Resp: Client, Stage: Implementation Due Date : In progress 4. Project Risks 4.1. Design Rating: SUBSTANTIAL Description: A key risk concerns the possible delays in start-up Risk Management: The rapid response from the UN, WHO, CDC and MSF has already of implementation and that the current efforts would not contain provided initial coordination, delivered treatments to diagnosed individuals, and provided the spread of the disease. Resources necessary for the essential training of health facilities staff. Governments have cordoned off areas to be quarantined. elements of the emergency response would then become The immediate response, the overall coordination of the response program by the UN and insufficient. Another risk is the possible difficulty of Governments, and the emergency status of the Project which includes delivery of services by coordinating the multi-sector approach in a constantly evolving UN agencies and international NGOs already active in the field should help expedite the and very volatile situation. A third risk is the non-return of key much needed support. In addition, the international community is mobilized and funds health personnel in the local facilities should the planned could be reallocated from other programs/projects towards the Ebola response plans. The incentives not reach them in time, or if fear of contracting the Bank will provide close supervision to ensure implementation bottlenecks are resolved disease is too strong. immediately and resources are distributed as planned. Resp: Client, UN and Status: its agencies, intl NGOs Stage: Implementation Due Date : Ongoing and the Bank 4.2. Social & Environmental Rating: MODERATE Description: This Project being an emergency operation Risk Management: A social screening and assessment framework will be prepared as part processed under OP/BP 10.00, the preparation and disclosure of of the overall ESSAF for the three affected countries after the Board approval in order to safeguards documents is deferred to the implementation stage. guide implementation. While the environmental risks and impacts associated with the However, the safeguards documents will need to be disclosed emergency interventions are not expected to be significant, there would be need to prior to activities concerned by the safeguards plan of action. systematically assess and analyze the interventions, including institutional capacity to minimize any residual environment and social impacts to the surrounding environment and people in the three affected countries. An action plan has been proposed to that effect. Stage: Preparation and Status: Resp: Client and Bank Due Date : Implementation In progress 4.3. Program & Donor Rating: MODERATE Description: With multiple donors and financial support Risk Management: The UN has established a system-wide coordination initiative. ranging from US$5 million to over US$200 million, gaps to be Governments of Guinea, Liberia and Sierra Leone, with the technical support of WHO filled, and potential need for more resources, the key risk is a developed the EVD Outbreak Response Plan in West Africa and have put in place an inter- lack of coordination despite the current established system and ministerial task force has been put in place to develop and operationalize the response plans. potential wastage of resources. WHO is setting up an Ebola response center in Conakry involving other international agencies and which will serve as the main sub-regional operations hub. It will be crucial that all donors remain involved in these aid coordination efforts, and frequently assess the 58 situation and needed shift in support and needed additional resources. Therefore coordination efforts will need to be intensified during implementation. Status: Resp: Donors Stage: Implementation Due Date : In progress 4.4. Delivery Monitoring & Sustainability Rating: SUBSTANTIAL Description: Monitoring and evaluation systems are weak. Risk Management: Sustainability: disease surveillance in the region will be strengthened by the ongoing Bank- Sustainability: Disease surveillance is weak and another similar financed Disease Surveillance project where training is being provided to government situation could arise. disease surveillance teams. The EVD outbreak is resulting in greater human and financial resources allocation for M&E and disease surveillance, in addition to increased focus on capacity development. But this will take time and will need to be sustained once the outbreak is over. Status: Resp: Client, WHO Stage: Implementation Due Date : In progress 4.5. Other : Beneficiaries Rating: HIGH Description: There is denial, mistrust and misinformation Risk Management: Support to the Governments six-month emergency plans, which include among the population leading to the rejection of public health urgent provision of supplies and safety measures to the affected populations, is being interventions and information, contributing to the continued provided by other donors as well as through the restructuring of existing Bank-financed spread of the disease. Misinformation is rampant and cultural projects in Liberia and Sierra Leone. With regards to this Project, the contract with the WFP practices including contact with the deceased during burial will be signed as soon as implementation allows. ceremonies increases exposure to the virus. Another risk is the difficulty of containing the populations of quarantined areas Resp: Client, Bank, Status: In Stage: Implementation Due Date : who lack food and water supplies, creating violent riots in some Donors progress areas. This situation could get out of hand if food supplies are Resp: Stage: Due Date : Status: not promptly delivered to the quarantined populations. Overall Risk Overall Implementation Risk: Rating High Given the exceptional context of this emergency operation and the challenging country/sub-regional context in which implementation will occur, risk during project implementation is assessed as high. As previously noted, the current EVD outbreak exceeded the capacity of the health systems of the three countries, and quarantine of the highly affected regions can lead to food, nutrition and social crises. To mitigate such risks, the proposed Project will partner with key specialized technical agencies with a demonstrated track record (such as WHO, WFP and other UN agencies) under the Governments’ supervision. It should be noted that although the context of the proposed Project is high risk, the outlined approach is viewed as the only means of ensuring a fully robust and multi-sectoral response to the EVD epidemic in Guinea, Liberia, and Sierra Leone. Although the project design cannot eliminate all programmatic risks associated with this emergency response, the alternatives of inaction or a delayed response can be seen to be more costly from a development perspective. 59 Annex 8: Implementation Support Plan 1. The implementation support to the projects in Guinea, Liberia and Sierra Leone, the EVD affected countries, would be a major challenge considering the still evolving nature of the epidemic, travel restrictions to the countries, limitations in the implementation capacities of countries, the multi-sectoral approach of the program, and logistical difficulties. Implementation support will be planned in a way to make it both cost-effective and efficient so that the WBG can be actively and continually involved during the implementation phase to help achieve the program goals. The supervision plan outlined here provides an overall strategy, the co-ordination arrangements with other donors, likely costs, and the staffing composition. Supervision Objectives and Strategy: 2. The objectives of the implementation support for this program in the three countries would be to: a. Ensure that country implementation agencies implement the projects with due diligence to achieve the program development objectives; and also ensure appropriate inter- linkages with broader health sector development objectives; b. Identify problems promptly as they arise during implementation and help the implementing agencies resolve them; c. Adapt the Project to lessons learned during implementation and other relevant changes in order to enhance the prospects of achieving the agreed program objectives; and d. Facilitate collaboration among donors already involved in the emergency response in the three countries. 3. Each country project would define clear benchmark and performance criteria to permit a high degree of self-supervision of input use and results. Existing management information systems in the countries will help capture routine data and information on procurement and financial management aspects in a systematic way to help guide the Project team in suitably executing the Project. The national agencies in charge of Project implementation with the support of international partners and WBG Country Office staff will prepare quarterly reports, including the audited accounts. This will help provide the WBG an overview of Project implementation status on a regular basis. The designated national agencies in charge of Project implementation will play a major role in overseeing and supporting the operations of the sector ministries and the local communities, including periodic field visits. 4. WBG implementation support will be carried out in close coordination with all donors and the regional agencies active in the emergency response in the affected countries. This would include joint supervision missions and full exchange of progress reports and supervision mission reports of donors from their independent missions. To strengthen the countries’ institutional capabilities and increase the cost-effectiveness of WBG supervision, the Project will engage specialized international donor agencies to help carry out Project implementation support. These specialized regional agencies that have technical expertise and experience in the area such as WHO, USCDC, UNICEF, and WFP, are expected to take the lead in providing technical guidance to help implement country projects. 60 5. To get the projects off to a good start and to assure quality implementation, the WBG will be actively involved via videoconferencing and electronic communication, and mobilizing the support of Country Office specialized staff members. Once travel restrictions ease, and adopting the recommended precautions from the UN and WHO, technical supervision missions will be organized and combined for the three countries or largely done by convening county teams together at the WHO-led Regional Response Center in Conakry which will help in considerable cross-fertilization of implementation experience among the countries and learning from each other. This process will also result in substantial cost savings of supervising a program of this nature since a number of repetitious tasks in each country could be eliminated. 6. The main elements of the implementation support for the countries under this program will be as follows: • The designated national agencies in each of the countries will institute a process of systematic supervision of the individual country projects. They will coordinate Project work across agencies in the government, NGOs, and local communities involved in the Project and submit a periodic report to the WBG team of Project progress; • Continuous technical advice will be provided to the Project teams, based on their need, by international and regional agencies involved in the emergency response; • To the extent possible, there will be joint implementation support missions with other key agencies; and • As part of the plan to pool donor efforts, it is envisaged that supervision of and technical support for the country projects will be shared with each donor having primary responsibility for specific areas. 7. The Mid-Term Project Review. Given the very short timeframe of disbursing the entire amount of funds in the FY15, there will not be a Mid-Term Project Review. Project progress will be reviewed on daily basis. 8. Composition of Missions. The supervision missions will include as appropriate at the time, specialists in the following areas: public health, CSR/HR expertise for Component 2, procurement, and financial management. Additional technical staff from international agencies involved in the response will participate as part of the implementation support missions. 9. Supervision outputs/outcome. On the basis of Project monitoring and evaluation, the supervision missions would be geared to ensure that implementation of the projects is progressing as planned and to anticipate or detect any problems (e.g., adequacy of supplies, deployment of health personnel to affected areas). These missions would also focus on determining the degree of progress in meeting set goals or Project performance on the basis of evaluation of inputs (human and capital resources available for Project implementation) and Project operation variables (who is to do what, where, when and how), as well on assessments of impacts and outcomes that may include changes in knowledge, attitudes, behavior, risk factors, disease and socioeconomic impacts. 61 Annex 9: Procurement Arrangements A. General 1. Procurement for the three country projects under the proposed Ebola Emergency Response Project will be carried out in accordance with: (i) "Guidelines: Procurement of Goods, Works, and non-Consulting Services Under IBRD Loans and IDA Credits & Grants by World Bank Borrowers" dated January 2011 and revised July 2014; (ii) "Guidelines: Selection and Employment of Consultants Under IBRD Loans and IDA Credits & Grants by World Bank Borrowers" dated January 2011 and revised July 2014; (iii) “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants” dated October 15, 2006 and revised in January, 2011; and (iv) the provisions methods stipulated in the Legal Agreements. 2. The Bank Project team’s assessment of procurement capacity of the project implementing agencies was carried out through various ways given the restrictions in travelling to the countries, including normal meetings, video & audio-conferences, email exchanges and Bank’s assessments under previous projects. The procurement arrangements for each country are summarized in this annex. 3. Since the three country projects are all considered fragile and conflict-affected states (FCS), the Bank has already been applying relevant procurement flexibilities and simplifications to their FCS operational environments. Further flexibilities as provided under OP 10.00 para. 12 for rapid response to crises and emergencies have been incorporated into the detail procurement arrangements as already agreed with the Governments of three Recipient countries. 4. Given the fluid situations on the ground, it was further agreed with the countries that the Procurement Plan will be updated on monthly basis or as the need arises, during the first six months of implementation in the first instance, to reflect the rapidly changing needs of the respective countries. Updating of the Procurement Plan will be done through the monthly work plan that will be submitted by each country and agreed by the Bank. 5. UN agencies would be hired by the Governments on sole-source basis for their unique roles and qualifications in responding to the Ebola epidemic crisis. Standard forms of agreement for UN agencies as already have been published by the Bank will be adopted. For those UN agencies, if such forms have not been agreed with the Bank, the Bank Project team will provide acceptable sample forms for use by the countries. 6. Subject to the final agreement with the respective countries, Bank may finance the payment of special Ebola risk premiums to the health workers of the Ebola treatment centers, as well as providing possible death benefits to those workers. The expenditures under this category will not be subject to the Bank’s procurement procedure but the requirements for documentation, verification, internal and external audits, as well as the ceiling amounts, pay scale, etc. will be agreed with the Bank prior to making any disbursement of such expenditures. 62 7. Retroactive financing in accordance with the Procurement Guidelines is allowed up to 40 percent of the Grant for each country, covering the expenditures incurred by the country prior to the signing of the Grant Agreement, but on or after May 1st 2014, under the activities agreed with the Bank. For the UN agencies hired by the Government, certain quick-disbursing arrangements may be agreed upon to finance a positive list of imported or locally produced goods that are required for the Project, further subject to the Bank’s prior agreement on the conditions for the release of the financial tranches and the required documentation and certifications, such a s customs and tax certificates or invoices. 8. The general description of various items under different expenditure categories is presented below. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements, and time frame would be agreed between the Recipient and IDA Project team in the Procurement Plan for respective countries. B. Procurement Arrangements for Liberia 9. National Competitive Bidding (NCB) Procedures as set forth in the country’s Public Procurement and Concessions Act dated 2005 and amended and reinstated in September 2010 may be used, further subject to the following conditions: (a) foreign bidders shall be allowed to participate in National Competitive Bidding procedures; (b) bidders shall be given at least one month to submit bids from the date of the invitation to bid or the date of availability of bidding documents, whichever is later; (c) no domestic preference shall be given for domestic bidders and for domestically manufactured goods; and (d) in accordance with paragraph 1.16 (e) of the Procurement Guidelines, each bidding document and contract financed out of the proceeds of the credit shall provide that: (i) the bidders, suppliers, contractors and subcontractors shall permit the World Bank, at its request, to inspect their accounts and records relating to the bid submission and performance of the contract, and to have said accounts and records audited by auditors appointed by the World Bank; and (ii) the deliberate and material violation by the bidder, supplier, contractor or subcontractor of such provision may amount to an obstructive practice as defined in paragraph 1.16(a)(v) of the Procurement Guidelines. 10. A General Procurement Notice (GPN) will be prepared and published in United Nations Development Business (UNDB) online, on the Bank’s external website and in at least one national newspaper after the Project is approved by the Bank Board, and/or before Project effectiveness. Specific Procurement Notices for all goods and works to be procured under International Competitive Bidding (ICB) and Requests for Expressions of Interest (REOIs) for all consulting services to cost the equivalent of US$300,000 and above would also be published in the United Nations Development Business (UNDB) online, Bank’s external website and the national press. For works and goods using NCB procedures, the Specific Procurement Notice (SPN) will only be published nationally. 63 Procurement Methods 11. Procurement of Works: Works contracts for incinerator units and rehabilitation of labs to be financed by IDA under this Project will be procured using shopping procedures based on a model request for quotations satisfactory to the Bank. 12. Procurement of Goods and Non-Consulting Services: Goods and non-consulting services to be procured for the Project activities include: PPEs, medicines and IPC/medical supplies; equipment required for surveillance, contact tracing, and laboratories; ambulances, vehicles; electric generators, water pumps; mobile laboratories, food supplies, water and materials for training on social mobilization. As far as possible, UN agencies will be used, to fast track implementation. 13. The procurement will be done using the Bank’s Standard Bidding Documents (SBDs) for all procurement under International Competitive Bidding (ICB). Bidding documents to be used under NCB procedures shall be acceptable to the Bank. 14. Selection of Consultants: The Project will finance consultancy services such as technical assistance, trainers, surveys, audits, supervision and Project implementation services, etc. Consultancy firms will be selected using the following methods: (a) Quality-and Cost-based Selection (QCBS); (b) Quality Based Selection (QBS); (c) Fixed Budget Selection (FBS); (d) Least Cost Selection (LCS); (e) Selection based on Consultants’ Qualifications (CQS); (f) Single Source Selection of firms; and (g) Selection of UN agencies. Selection of Individual Consultants (ICS) would be followed for assignments which meet the requirements of paragraphs 5.1 to 5.5 of the Consultant Guidelines. Single Source Selection (SSS) of Consultants would be followed for assignments which meet the requirements of paragraphs 3.8 to 3.11 of the Consultant Guidelines for firms; UN agencies may be hired on sole-source basis following paragraph 3.15 of the Consultant Guidelines. Selection of individuals under paragraph 5.6 of the Guidelines will require the World Bank’s prior review if the contract is above US$100,000 equivalent. Short lists of consultants for services estimated to cost less than US$100,000 equivalent per contract may be composed entirely of national consultants. However, if foreign firms have expressed interest, they would not be excluded from consideration. 15. Training, Workshops, Study Tours, and Conferences: Training workshops (including training material and support), conference attendance and study tours, will be carried out based on approved quarterly training and allied activities plan. A detailed training and workshops’ plan giving nature of training/workshop, number of trainees/participants, duration, staff months, timing and estimated cost will be submitted to IDA for review and approval prior to initiating the process. The selection methods will derive from the activity requirement, schedule and circumstance. After the training, the beneficiaries will be requested to submit a brief report indicating what skill have been acquired and how these skills will contribute to enhance their performance and contribute to the attainment of the Project’s objective. 16. Operational Costs: Operational costs financed by the Project would be incremental expenses, including office supplies, vehicles operation and maintenance, maintenance of equipment, communication costs, rental expenses, utilities expenses, consumables, transport and 64 accommodation, per diem, supervision costs, and salaries of locally contracted support staff. Such services’ needs will be procured using the procurement procedures specified in the Project Implementation Manual (PIM) accepted and approved by the Bank. Assessment of the agencies’ (Min. of Health and Social Welfare) capacity to implement procurement 17. The Procurement Unit of the Ministry of Health & Social Welfare (MoHSW) will be responsible for coordinating procurement under the Project. An assessment of the procurement capacity of the MoHSW was based on current procurement implementation arrangements on the on-going Health System Strengthening Project (HSSP) - P128909. During the assessment of the procurement capacity of the MoHSW for HSSP in October 2011, the procurement unit was headed by an experienced and well qualified Director of Procurement with experience in donor funded projects.. Unfortunately, he resigned after working for four months under HSSP. Another procurement officer from the Ministry’s procurement unit was assigned to HSSP but an assessment shows that he has no previous experience in procurement under World Bank financed projects. 18. During the restructuring of HSSP to incorporate an emergency response to the Ebola Crisis in July 2014, it was agreed that there would be need for an experienced Procurement Specialist to be engaged for a short term assignment because it was concluded that the Ministry’s Procurement Unit has staff experienced in handling procurement under the Public Procurement and Concessions Act of Liberia but have limited experience in World Bank procurement procedures. The short term specialist would, not only assist in fast-tracking implementation, but also build capacity in the Procurement unit to carry out procurement using World Bank procedures. To mitigate this risk, it was agreed that the International Procurement Specialist (IPS) attached to the IPFMRP (P127319) should support the HSSP until an experienced procurement specialist is hired for the HSSP. This IPS has agreed to support both the HSSP and this Project in the interim. 19. The Project procurement risk, prior to mitigation measures is High. The risk is reduced to a residual rating of “Substantial” in view of the mitigation measures in place in Table 10 below. 65 Table 10: Procurement risks and proposed mitigation measures No Key Risks Risk Mitigation Actions By Whom By When Inadequate experience of (a) Use of the IPS from IPFMRP Ministry of Health Immediately procurement staff in World (P127319) as an immediate and Social (to cover both Bank Procurement measure Welfare HSSP and this procedures within the (b) Recruitment of a procurement (MoHSW) Project) 1 MoHSW Procurement Unit specialist experienced in World through the HSSP to carry of procurement Bank procurement to be Coordination Unit activities of the Project responsible for this Project within the Ministry’s Procurement Unit Inadequate procurement Given the emergency nature of the Procurement Unit To be taken capacity of in the MoHSW Project, the implementation team of the MoHSW into account in 2. to handle the emergency (the MoHSW) will contract UN the Investment nature of the Ebola crisis agencies for the implementation of Plan some parts of the Project Lack of sustainability within For sustainability reasons, the WB/MoHSW Immediately the Ministry Procurement current Procurement Officers in the and during the Unit to be able carry out Procurement Unit would be life of the procurement using World provided handholding training and Project 4 Bank Procedures TA will be provided by the Bank and where possible, be supported for short term training by GIMPA in Ghana Implementation Arrangements 20. Procurement Plan: The recipient has prepared an initial procurement plan for Project implementation which provides the basis for the procurement methods. It will also be available in the projects’ database and in the Bank's external website. The procurement plan will indicate those contracts which are subject to prior review. All other contracts will be subject to post review. The Procurement Plan will be updated in agreement with the Bank Team monthly during the first six months of implementation or as required to reflect the actual Project implementation in response to the emergency structure of the Project. 21. Frequency of Procurement Supervision: In addition to the prior review supervision to be carried out from Bank offices, two supervision missions (field visits) will be conducted each year, to carry out post-review of procurement actions. 22. Publication of Awards and Debriefing: The results of the bidding process for all ICB/LIB, Direct contracts and also for consultant contracts shall be published in the UNDB online in line with relevant paragraphs of the World Bank's Procurement and Consultant Guidelines. In addition, all NCB contracts shall be published in the national press. Publication of all other procurement activities, including debriefing and review shall be subject to the relevant stipulations in the Liberian Public Procurement and Concessions Act of 2005 amended and restated in September 2010. 23. Fraud and Corruption: All procurement entities as well as bidders and service providers (i.e., suppliers, contractors, and consultants) shall observe the highest standard of 66 ethics during the procurement and execution of contracts financed under the Project in accordance with paragraphs 1.16 and 1.17 (Fraud and Corruption) of the Procurement Guidelines and paragraph 1.23 and 1.24 (Fraud and Corruption) of the Consultants Guidelines, and “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants”, dated October 15, 2006 and revised in January 2011, in addition to the relevant Articles of the Liberia Public Procurement and Concessions Act. Table 11: Procurement and Selection Review Thresholds for Liberia Expenditure Contract Value Procurement Method Contract Subject to Prior Category (Threshold) US$ Review 1. Works ≥2,000,000 ICB All 1,000,000 - NCB First contract 2,000,000 <100,000 - Shopping Post Review 1,000,000 No threshold Direct contracting All contracts above US$100,000 each 2. Goods and ≥1,000,000 ICB All Non-Consulting Services 500,000 -1,000,000 NCB The First contract <500,000 Shopping Post review No threshold Direct contracting All contracts above US$100,000 each and all contracts with UN agencies will be prior reviewed; 3. Consultants Firms ≥500,000 QCBS; QBS; LCS; FBS All contracts <500,000 CQS Post review Individuals ≥100,000 EOI All contracts <100,000 comparison of 3 CVs Post review (Selection Firms No threshold Single Source All contracts above US$100,000 & Individuals each and all contracts with UN agencies will be prior reviewed All Term of reference regardless of the value of the contract are subject to prior review C. Procurement Arrangements for Sierra Leone 24. National Competitive Bidding (NCB) procedures to be followed shall be those set forth in the Recipient’s Public Procurement Act (“the Act”), provided, however, that said procedures shall be subject to the provisions of Section I and paragraphs 3.3 and 3.4, respectively, of the Procurement Guidelines, and subject to the following additional procedures (i.e. exceptions to the Act): (a) Bidding documents acceptable to the Association shall be used; (b) Eligibility to participate in a procurement process and to be awarded an Association- financed contract shall be as defined under Section I of the Procurement Guidelines. Accordingly, no bidder or potential bidder shall be declared ineligible for contracts financed by the Association for reasons other than those provided in Section I of the 67 Procurement Guidelines. Foreign bidders shall be allowed to participate in NCB procedures, and foreign bidders shall not be obligated to partner with local bidders in order to participate in a procurement process; (c) Bidding shall not be restricted to pre-registered firms, and foreign bidders shall not be required to be registered with local authorities as a prerequisite for submitting bids; (d) No margins of preference of any sort (e.g., on the basis of bidder nationality, origin of goods, services or labor, and/or preferential programs) shall be applied in the bid evaluation; (e) Joint venture or consortium partners shall be jointly and severally liable for their obligations. Bidders shall be given at least thirty (30) days from the date of publication of the invitation to bid or the date of availability of the bidding documents, whichever is later, to prepare and submit bids. Bids shall be submitted in a single envelope; (f) An extension of bid validity, if justified by exceptional circumstances, may be requested in writing from all bidders before the original bid validity expiration date, provided that such extension shall cover only the minimum period required to complete the evaluation and award a contract, but not to exceed thirty (30) days. No further extensions shall be requested without the prior written concurrence of the Association; (g) All bids (or the sole bid if only one bid is received) shall not be rejected, the procurement process shall not be cancelled, and new bids shall not be solicited without the Association’s prior written concurrence; (h) Qualification criteria shall be applied on a pass or fail basis; (i) Bidders shall be given at least twenty-eight (28) days from the receipt of notification of award to submit performance securities; (j) In accordance with the Procurement Guidelines, each bidding document and contract shall include provisions stating the Association's policy to sanction firms or individuals found to have engaged in fraud and corruption as set forth in the Procurement Guidelines; and (k) In accordance with the Procurement Guidelines, each bidding document and contract shall include provisions stating the Association's policy with respect to inspection and audit of accounts, records and other documents relating to the submission of bids and contract performance. 25. A General Procurement Notice (GPN) will be prepared and published in United Nations Development Business (UNDB) online, on the Bank’s external website and in at least one national newspaper after the Project is approved by the Bank Board, and/or before Project effectiveness. Specific Procurement Notices for all goods and works to be procured under International Competitive Bidding (ICB) and Requests for Expressions of Interest (REOIs) for all consulting services to cost the equivalent of US$300,000 and above would also be published in the United Nations Development Business (UNDB) online, Bank’s external website and the national press. For works and goods using NCB procedures, the Specific Procurement Notice (SPN) will only be published nationally. 68 Procurement Methods 26. Procurement of Works: Works contracts for incinerator units and rehabilitation of labs to be financed by IDA under this Project will be procured using shopping post review procedures based on a model request for quotations satisfactory to the Bank. 27. Procurement of Goods and Non-Consulting Services: Goods and non-consulting services to be procured for the Project activities include: PPEs, medicines and IPC/medical supplies; equipment required for surveillance, contact tracing, and laboratories; ambulance, vehicles; electric generators, water pumps; mobile laboratories and materials for training on social mobilization. 28. The procurement will be done using the Bank’s Standard Bidding Documents (SBDs) for all procurement under International Competitive Bidding (ICB). Bidding documents to be used under NCB procedures shall be acceptable to the Bank. 29. Selection of Consultants: The Project will finance consultancy services such as technical assistance, trainers, surveys, audits, supervision and Project implementation services, etc. Consultancy firms will be selected using the following methods: (a) Quality-and Cost-based Selection (QCBS); (b) Quality Based Selection (QBS); (c) Fixed Budget Selection (FBS); (d) Least Cost Selection (LCS) and (e) Selection based on Consultants’ Qualifications (CQS). Selection of Individual Consultants (ICs) would be followed for assignments which meet the requirements of paragraphs 5.1 to 5.5 of the Consultant Guidelines. Single Source Selection (SSS) of Consultants would be followed for assignments which meet the requirements of paragraphs 3.8 to 3.11 of the Consultant Guidelines for firms; UN agencies may be hired on sole- source basis following paragraph 3.15 of the Consultant Guidelines. Selection of individuals under paragraph 5.6 of the Guidelines will require the World Bank’s prior review if the contract is above US$ 100,000 equivalent. Short lists of consultants for services estimated to cost less than US$100,000 equivalent per contract may be composed entirely of national consultants. However, if foreign firms have expressed interest, they would not be excluded from consideration. 30. Training, Workshops, Study Tours, and Conferences: Training workshops (including training material and support), conference attendance and study tours, will be carried out based on approved quarterly training and allied activities plan. A detailed training and workshops’ plan giving nature of training/workshop, number of trainees/participants, duration, staff months, timing and estimated cost will be submitted to IDA for review and approval prior to initiating the process. The selection methods will derive from the activity requirement, schedule and circumstance. After the training, the beneficiaries will be requested to submit a brief report indicating what skill have been acquired and how these skills will contribute to enhance their performance and contribute to the attainment of the Project objective. 31. Operational Costs: Operational costs financed by the Project would be incremental expenses, including office supplies, vehicles operation and maintenance, maintenance of equipment, communication costs, rental expenses, utilities expenses, consumables, transport and accommodation, per diem, supervision costs, and salaries of locally contracted support staff. 69 Such services’ needs will be procure using the procurement procedures specified in the Project Implementation Manual (PIM) accepted and approved by the Bank. Assessment of the agencies’ (IPAU) capacity to implement procurement under the Project 32. The Integrated Project Administration Unit (IPAU) will be responsible for coordinating procurement under the Project. An assessment of the procurement capacity of IPAU concluded that the Procurement Unit has staff that are experienced in handling procurement under the World Bank procedures and based on the Sierra Leone Public Procurement Act. 33. The Project procurement risk, prior to mitigation measures is High. The risk is reduced to a residual rating of “Substantial” in view of the mitigation measures in place in Table 12 below. Table 12: Procurement risks and proposed mitigation measures No Key Risks Risk Mitigation Actions By Whom By When 1. Weak capacity at the Given the emergency of the IPAU/EOC/MoHSN/WB To take into IPAU on Procurement Project and the weak capacity account in of Health sector Goods (in technical and procurement and Commodities procurement) of IPAU on planning procurement of critical health sector goods, IPAU should contract UN agencies for the implementation of part of the Project Implementation Arrangements 34. Procurement Plan: The recipient has prepared an initial procurement plan for Project implementation which provides the basis for the procurement methods. It will also be available in the projects database and in the Bank's external website. The procurement plan will indicate those contracts which are subject to prior review. All other contracts will be subject to post review. The procurement plan will be updated monthly for the first six months of implementation, or as required, to reflect the actual Project implementation in response to the Ebola epidemic. All procurement activities will be carried out in accordance with approved original or updated procurement plans. 35. Frequency of Procurement Supervision: In addition to the prior review supervision to be carried out from Bank offices, two supervision missions (field visits) will be conducted each year, during other project supervisions, to carry out post-review of procurement actions. The procurement post-reviews will be done annually and will cover the management of procurement including staffing, filing, record keeping and contract management. The post reviews will be carried out on a sample basis and the sample size will depend on the Project procurement risk at the time of the review. In addition, post reviews of training activities (Workshops, Conferences, and Study Tours) will be conducted from time to time to review the selection of institutions/ facilitators/ course contents of training, and justifications thereof, and costs incurred. 70 36. Publication of Awards and Debriefing: The results of the bidding process for all ICB/LIB, Direct contracts and also for consultant contracts shall be published in the UNDB online in line with relevant paragraphs of the World Bank's Procurement and Consultant Guidelines. In addition, all NCB contracts shall be published in the national Press. Publication of all other procurement activities, including debriefing and review shall be subject to the relevant stipulates in the Liberian Public Procurement and Concessions Law. 37. Fraud and Corruption: All procurement entities as well as bidders and service providers (i.e., suppliers, contractors, and consultants) shall observe the highest standard of ethics during the procurement and execution of contracts financed under the Project in accordance with paragraphs 1.16 and 1.17 (Fraud and Corruption) of the Procurement Guidelines and paragraph 1.23 and 1.24 (Fraud and Corruption) of the Consultants Guidelines, and “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants”, dated October 15, 2006 and revised in January 2011, in addition to the relevant Articles of the Sierra Leone Public Procurement Act 2004. Table 13: Procurement and Selection Review Thresholds for Sierra Leone Expenditure Contract Value Contract Subject to Prior Category (Threshold) US$ Procurement Method Review 1. Works ≥2,000,000 ICB All 1,000,000 - 2,000,000 NCB First contract <100,000 - 1,000,000 Shopping Post Review All contracts above US$100,000 No threshold Direct contracting each 2. Goods and Non-Consulting Services ≥1,000,000 ICB All 500,000 -1,000,000 NCB The First contract <500,000 Shopping Post review All contracts above US$100,000 each and all contracts with UN No threshold Direct contracting agencies will be prior reviewed 3. Consultants Firms ≥500,000 QCBS; QBS; LCS; FBS All contracts <500,000 CQS Post review Individuals ≥100,000 EOI All contracts <100,000 comparison of 3 CVs Post review (Selection Firms No threshold Single Source All contracts above US$100,000 & Individuals each and all contracts with UN agencies will be prior reviewed All Term of reference regardless of the value of the contract are subject to prior review 71 D. Procurement Arrangements for Guinea Applicable procurement policies and procedures 38. General: A Country Procurement Assessment Review, carried out in Guinea in February 2002 flagged the main issues such as the lack of capacity regarding the recipient's staff, the absence of standard bidding documents at the national level, the insufficient capacity of local contractors for contracts subject to ICB, and corruption. Recommendations were made to address these issues. The Bank, through an IDF (TF 55853) signed in November 2005, provided support on the public procurement reform. The main objectives were to: i) enhance transparency of the procurement system, ii) put in place the new institutional framework (public procurement directorate controlling procurement transactions, public procurement regulatory body including an appeal committee for complaints, iii) update the procurement code, iv) design standard bidding documents. On March 2009, the legal framework was revisited and the new Procurement Law and the new Procurement Code were adopted and approved respectively on October 11, 2012 and December 03, 2012. The national procurement system is still governed by the Act L/97/016/AN passed on June 03, 1997 and its implementing regulations for six months after the publication of the new texts on the Official News. The new Public Procurement Code’s implementation texts were approved by the Government on July 22, 2014. 39. Procurement Documents: Procurement would be carried out using the Bank’s Standard Bidding Documents (SBD) for all International Competitive Bidding (ICB) for goods and works and for Standard Request for Proposal (RFP) for the selection of consultants through competitive procedures. The Recipient will develop standard documents based on the Bank’s SBDs for National Competitive Bidding (NCB) for goods and works and the Bank’s RFP for the selection of consultants through methods other than Quality and Cost Based Selection (QCBS), with modifications that will be submitted to IDA for prior approval. 40. The different procurement methods or consultant selection methods, the need for pre- qualification, estimated costs, prior review requirements, and time frame are agreed between the Recipient and the Bank in the Procurement Plan. The Procurement Plan will be updated on a monthly basis, at least during the first six months of implementation to reflect the rapidly changing needs of the country or as required to reflect the actual Project implementation needs and improvements in institutional capacity. 41. Advertising procedures: General Procurement Notice, Specific Procurement Notices, Requests for Expression of Interest and results of the evaluation and contracts award should be published in accordance with advertising provisions in the following the Bank Procurement and Consultant Guidelines. The borrower will keep a list of received responses from potential bidders interested in the contracts. 42. For ICB and request for proposals that involve international consultants, the contract awards shall be published in the United Nations Development Business (UNDB) online within two weeks of receiving IDA’s "no objection" to the recommendation of contract award. For Goods, the information to publish shall specify: (a) name of each bidder who submitted a bid; (b) bid prices as read out at bid opening; (c) name and evaluated prices of each bid that was 72 evaluated; (d) name of bidders whose bids were rejected and the reasons for their rejection; and (e) name of the winning bidder, and the price it offered, as well as the duration and summary scope of the contract awarded. For Consultants, the following information must be published: (a) names of all consultants who submitted proposals; (b) technical points assigned to each consultant; (c) evaluated prices of each consultant; (d) final point ranking of the consultants; and (e) name of the winning consultant and the price, duration, and summary scope of the contract. The same information will be sent to all consultants who submitted proposals. The other contracts should be published in national gazette periodically (at least, quarterly) and in the format of a summarized table covering the previous period with the following information: (a) name of the consultant to whom the contract was awarded; (b) the price; (c) duration; and (d) scope of the contract. Procurement methods 43. Procurement of Works. Contracts of works estimated to cost US$5,000,000 equivalent or more per contract shall be procured through ICB. Contracts estimated to cost less than US$5,000,000 equivalent may be procured through NCB. Contract estimated to cost less than US$ 500,000 equivalent per contract may be procured through shopping procedures. For shopping, contracts will be awarded following evaluation of bids received in writing on the basis of written solicitation issued to several qualified suppliers (at least three). The award would be made to the supplier with the lowest price, only after comparing a minimum of three quotations open at the same time, provided he has the experience and resources to execute the contract successfully. For shopping, the Project procurement officer will keep a register of suppliers updated at least every six month. 44. Procurement of Goods and Non-Consulting Services. Contracts of goods and non- consulting services estimated to cost at least US$500,000 per contract and would be procured through ICB. Contracts estimated to cost less than US$500,000 equivalent may be procured through NCB. Goods estimated to cost less than US$300,000 equivalent per contract may be procured through shopping procedures. For shopping, the condition of contract award shall be the same process as described above for procurement of works. 45. The following provisions shall apply to the procurement of goods, works and non- consulting services under NCB procedures: (a) Bidding documents acceptable to the Association shall be used. (b) Eligibility to participate in a procurement process and to be awarded an Association- financed contract shall be as defined under Section I of the Procurement Guidelines; accordingly, no bidder or potential bidder shall be declared ineligible for contracts financed by the Association for reasons other than those provided in Section I of the Procurement Guidelines. Foreign bidders shall be allowed to participate in NCB procedures, and foreign bidders shall not be obligated to partner with local bidders in order to participate in a procurement process. (c) Bidding shall not be restricted to pre-registered firms, and foreign bidders shall not be required to be registered with local authorities as a prerequisite for submitting bids. 73 (d) No margins of preference of any sort (e.g., on the basis of bidder nationality, origin of goods, services or labor, and/or preferential programs) shall be applied in the bid evaluation. (e) Joint venture or consortium partners shall be jointly and severally liable for their obligations. Bidders shall be given at least thirty (30) days from the date of publication of the invitation to bid or the date of availability of the bidding documents, whichever is later, to prepare and submit bids. Bids shall be submitted in a single envelope. (f) An extension of bid validity, if justified by exceptional circumstances, may be requested in writing from all bidders before the original bid validity expiration date, provided that such extension shall cover only the minimum period required to complete the evaluation and award a contract, but not to exceed thirty (30) days. No further extensions shall be requested without the Association’s prior written concurrence. (g) All bids (or the sole bid if only one bid is received) shall not be rejected, the procurement process shall not be cancelled, and new bids shall not be solicited without the Association’s prior written concurrence. (h) Qualification criteria shall be applied on a pass or fail basis. (i) Bidders shall be given at least twenty-eight (28) days from the receipt of notification of award to submit performance securities. (j) In accordance with the Procurement Guidelines, each bidding document and contract shall include provisions stating the Association's policy to sanction firms or individuals found to have engaged in fraud and corruption as set forth in the Procurement Guidelines. (k) In accordance with the Procurement Guidelines, each bidding document and contract shall include provisions stating the Association's policy with respect to inspection and audit of accounts, records and other documents relating to the submission of bids and contract performance. 46. Selection of Consultants. Consultant firms will be selected through the following methods: (a) Quality-and Cost-Based Selection QCBS; (b) Quality Based Selection (QBS); (c) Fixed Budget Selection (FBS); (d) Least Cost Selection (LCS) for standard tasks such as financial and technical audits and (e) selection based on the Consultant’s Qualification (CQS) for contracts which amounts are less than US$300,000 per contract. Single Source Selection, with prior agreement of IDA, for services in accordance with the paragraphs 3.8 to 3.11 of Consultant Guidelines. Selection of UN agencies in accordance with paragraph 3.15 of Consultant Guidelines; Individual Consultant (IC) will be hired in accordance with paragraph 5.1 to 5.5 of Bank Guidelines. Short lists of consultants for services estimated to cost less than US$100,000 per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines, if a sufficient number of qualified firms are available. However, if foreign firms express interest, they would not be excluded from consideration. Assessment of the capacity of the agencies to implement procurement 47. In Guinea the Bank conducted an assessment of the procurement capacity of the Ministry of Health during the Project preparation on August 2014 in accordance with Bank’s procurement Risk Assessment and Management System. The assessment reviewed the organizational structure for implementing the Project taking into account the emergency context, a number of 74 actors and stakeholders. The assessment identified a number of critical areas which have potential risk. 48. The potential risks identified are: (i) a large number of actors; (ii) the need to put in place a rapid and efficient mechanism for the Project implementation; and (iii) the need to put in place, by the Ministry of Health, a small fiduciary team which comprises one Procurement officer who is familiar with Bank procurement procedures. 49. Based on the assessment of the system in place, the Overall Project risk for procurement is high. It may be lowered to Substantial once the mitigations measures are implemented. Detailed procurement risk mitigation measures are presented as follow. 50. Mitigation measures: In order for these bodies to implement Bank funded activities in accordance with the Bank guidelines on procurement, the assessment mission recommended the followings: (i) putting in place, by the Ministry of Health, a small fiduciary team which comprises one Procurement officer who is familiar with Bank procurement procedures; and (ii) putting in place a good filing system. 51. Frequency of procurement reviews and supervision: Bank’s prior and post reviews will be carried out on the basis of thresholds indicated in the following table. IDA will conduct six-monthly supervision missions and annual Post Procurement Reviews (PPR), with a ratio of post review at least one to five contracts. IDA may also conduct an Independent Procurement Review at any time until two years after the closing date of the Project. 52. Country Overall Procurement Risk Assessment: High X Average Low Recommended Action Due Date Appoint by the Ministry of Health one procurement specialist on Terms of Before effectiveness Reference acceptable to IDA. Table 14: Procurement and Selection Review Thresholds Expenditure Contract Value Procurement Contract Subject to Category (Threshold) US$ Method Prior Review 1. Works ≥5,000,000 ICB All <5,000,000 NCB First contract < 500,000 Shopping Post review All contracts above US$100,000 >100,000 Direct contracting each 2. Goods and Non-Consulting Services ≥500,000 ICB All 75 <500,000 NCB The First contract < 300,000 Shopping Post review All contracts above US$100,000 each and all contracts with UN > 100, 000 Direct contracting agencies will be prior reviewed; 3. Consultants Firms ≥ 300,000 QCBS; QBS; LCS; FBS All contracts < 300,000 QCBS; QBS; LCS; FBS, The first contract < 300,000 CQS Post review Individuals ≥100,000 EOI All contracts <100,000 comparison of 3 CVs The first contract All contracts above US$100,000 each and all contracts with UN No threshold Single Source agencies will be prior (Selection Firms & Individuals All Term of reference regardless of the value of the contract are subject to prior review 53. Procurement Plan. The recipient has prepared an initial procurement plan for Project implementation. For each contract, the procurement plan defines the appropriate procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, the prior review requirements, and the time frame. The procurement plan will be updated monthly during the first six months of implementation to reflect the rapidly changing needs of the country, or as required, to reflect the actual Project implementation needs and capacity improvements. All procurement activities will be carried out in accordance with approved original or updated procurement plans. All procurement plans should be published on Bank website according to the Guidelines. 76 Annex 10: The Economic Impact of the Ebola outbreak in Guinea, Liberia and Sierra Leone 24 (as of August 27, 2014) 1. Key Messages • The economic impact of Ebola is likely to be significant for the economies of Guinea, Sierra Leone and Liberia, with current estimates for 2014 showing a halving of GDP growth in Liberia and Guinea with an impact of more than 3 percentage points for Sierra Leone. There is also a significant negative impact on fiscal balances ranging from US$80 million to US$120 million. 25 These estimates are based on optimistic scenarios of epidemiological containment within the next 6-9 months.26 • The ongoing crisis has substantial impact on the daily lives of millions of people through the tragedy of human loss; the closure of borders and markets; the interruption of agricultural cycles; the restriction on the movement of people; the suspension of regional and international flights; and the delay in public and private investments. The main first-round economic effects have been on agriculture and services, which together accounts for more than half of the total shock to economic activities across the three countries. • The severity of the longer-term impact will depend on the ability of the authorities to curb the epidemic and most importantly, restore confidence so that key global supply chains are not severed. Otherwise, the overall economic impact may be much more severe as the countries become more isolated; with new effects on economic activity from the cessation of large- scale mining and the interruption of international trade. • Assuming containment of the epidemic by end-2014, the post-crisis recovery across these three countries could be accelerated by consistent and credible health responses with the support of international partners. This could reduce the fear factor that is driving many economic decisions, local and international. Table 15: Projected Impact of the Ebola Outbreak, 2014 Country Estimates of GDP Impact Estimates of Fiscal Impact Initial GDP Revised GDP Absolute Change Change in Deficit as a Growth Growth in Deficit (US$ share of initial Projection (June projection million)1 Revenue (%) 2014) Guinea 4.5 2.4 -120.0 5.6 Liberia 5.9 2.5 -92.8 18.6 Sierra Leone 11.3 8.0 -79.0 13.6 Source: World Bank/IMF Staff Estimates Note: Figures do not include any donor response 24 Estimates of the economic impact of the crisis are based on estimated 2014 shares of the key economic sectors combined with estimated sector-specific growth rates, based on the impact seen so far of the various manifestations of the crisis on levels of economic activity. Work on the likely poverty effects remains underway. Importantly, these estimates assume no major disruptions in international supply chains, for example the cutting off of countries from international shipping, which would greatly exacerbate the effects. 25 These estimates do not account for any increases in grants that may result from the responses by international donors. 26 WHO and CDC. 77 Guinea 2. Impact on Economic Activity • Guinea was the first country to be affected by the Ebola virus, but swift action by international agencies (MSF and WHO), and by the national authorities, have succeeded in mitigating the impact. The Ebola virus has nevertheless had a significant negative impact on the Guinean economy. Economic growth for 2014 initially projected at 4.5 percent has now been revised downwards to 2.4 percent. The partial containment of the outbreak in the southeast part of the country, due to vigilance by the authorities and MSF, has helped prevent further spread of the disease and mitigate some of the shocks. Table 16: Guinea – Estimated GDP Impact of Ebola Initial Revised Projection Projection (Jan. 2014) Real GDP Growth Contribution to 4.5 2.4 growth shock (%) Agriculture 20.3 5.7 3.3 Forestry 0.0 3.5 3.5 Mining 3.8 -3.0 -3.4 Manufacturing 2.5 6.5 5.6 Services 73.5 6.7 3.8 Source: World Bank/IMF Staff Estimates. • The major impact of Ebola has been on the agriculture and services sectors. Projected agricultural growth in 2014 has fallen from 5.7 percent to 3.3 percent, while projected growth in the services sector has fallen from 6.7 to 3.8 percent. Agriculture in the affected areas has been hit particularly hard as there has been an exodus of people from farming areas in these zones, although the impact on food supply has not yet been discernible owing to cultivation lags. Declines in cross-border commerce, especially to Senegal and Liberia, have also impeded the flow of food items. So far there has not been any impact on prices (as of June CPI), although there is some exchange rate depreciation which can be expected to have an impact on prices, which the Bank is monitoring closely. Decrease in international travel to Guinea has also affected the economy, as projects involving expatriate workers or business travelers have been scaled down. Hotel occupancy rates in Conakry have averaged less than 40 percent in the first half of 2014 compared with an average of 80 percent occupancy before the crisis. • The mining sector has been only partially affected by Ebola, since the key mines are not located in Ebola-affected areas, with the exception of iron ore. Here the impact so far has not been felt on the production side, where production was already forecast to contract, before the Ebola outbreak. Current projected output contraction is 3.4 percent, only slightly more than the last pre-Ebola forecast of 3.0 percent. However, the worsening performance of the services sector is in part related to uncertainty in the mining sector, where several mining companies, including Vale and Rio Tinto, have evacuated many foreign workers. 78 3. Fiscal Impact • The fiscal impact of the Ebola outbreak is estimated at US$120 million, of which US$50 million are attributed to revenue shortfalls and US$70 million to increased spending for the Ebola program (Table 17). Slowing economic activity has lowered tax revenues. Lower revenues from VAT and tax on expatriates’ salaries have led to revenue shortfalls, and the government has adopted a US$70 million response plan to fund logistics, health centers, purchase of food and equipment, and salaries. Table 17: Guinea – Estimated Fiscal Impact of Ebola (US$ million) Initial Projection Revised Projection Difference Total Revenues and grants 1,701 1,650 -51 Tax revenue 1,306 1,261 -51 Non-Tax 1 1 0 Grants 388 388 0 Expenditure 3,010 3,080 70 Current Expenditure 1,976 2,116 70 Of which for health 0 50 50 emergency Capital Expenditure 964 964 0 Overall Balance -1,309 -1,430 120 Overall Balance (% of -4.0 -5.2 -1.2 GDP) Source: World Bank/IMF Staff Estimates. • If the Ebola outbreak spreads no further, Guinea’s outlook remains positive, but there is considerable downside risk of Ebola affecting Guinea’s mining sector. If Ebola reaches the mining areas, it could lead to a dramatic departure of business and FDI from Guinea, at a time when the country greatly needs the international support. An additional danger is that negative perceptions associated with Ebola linger even after the situation on the ground has improved. Liberia 4. Impact on Economic Activity • Of the three countries, economic activities in Liberia have been most substantially curtailed by the ongoing Ebola crisis. Since the first case of the Ebola virus was reported in March 2014, the virus has spread quickly along the North Western side of the country including the capital city Monrovia to cover parts of the country where most of the economic activities currently take place, including agriculture, mining and commerce. There is already disruption of production processes across several sectors, caused by not only by illness and death but by fear associated with the outbreak. In Liberia, mining, agriculture and services comprise approximately 13 percent, 25 percent and 50 percent of GDP, respectively. 79 Disruption across these sectors has reduced projected 2014 GDP growth by almost half, relative to the initial projection (see table 18 below). Table 18: Liberia – Estimated GDP impact of Ebola Initial Revised Projection Projection (June 2014) Real GDP Growth Contribution to 5.9 2.5 growth shock (%) Agriculture 18.0 3.5 1.3 Forestry -0.1 2.0 2.0 Mining 27.3 4.4 -1.3 Manufacturing 4.6 9.6 5.0 Services 50.2 8.1 4.0 Source: World Bank/IMF Staff Estimates. • In agriculture the regular planting and harvesting cycles have been interrupted and farmers are having difficulty accessing inputs and marketing production due to the closure of borders and markets. Both commercial and domestic agriculture have been affected. Commercial palm oil and rubber production have slowed in and Lofa County, considered the “breadbasket” of Liberia, borders Guinea and was first to be affected by the outbreak. • Production in the mining sectors is expected to contract. The closure of the China Union iron ore mine, the on-going evacuation of management and expatriate staff (including by the largest mining company, Arcellor Mittal) will lead to a decline in production relative to the original forecast. It is important to note that the mining sector has been the impetus for overall strong growth over the last three years. With the crisis, Liberia’s mining sector is likely to contract by more than 1 percent compared with an expected growth rate of 4.4 percent before Ebola. • The impact on Liberia’s nascent manufacturing sector is also significant. It is assumed that the impact on the manufacturing sector would be through the fall-off in demand for manufactured products dues to lower economic activity in key demand sectors such as hotels and restaurants (beverages, etc.) as well as construction (paints, cements, etc.). Manufacturing growth is projected to fall by half. • Liberia has a large services sector, accounting for more than 50 percent of GDP. This sector has been hardest hit by the Ebola crisis. Markets in both rural and urban centers have been closed and informal cross-border trading has been brought to a virtual standstill by the closure of borders with Guinea, Sierra Leone and Côte d’Ivoire. Construction, which was booming (as indicated by a 50 percent increase in cement sales in the first half of 2014), is now likely to slow considerably. With the suspension of regional and international flights, hotel occupancy rates in Liberia have fallen dramatically, in some cases to as low as five percent. Overall, services growth could be cut by more than half, from 8.1 to 4.0 percent. 80 5. Fiscal Impact • The fiscal impact of the Ebola crisis is also expected to be substantial for Liberia. Fiscal revenues have started to fall, reflecting the lower economic activity as well as lower tax compliance. Data from the Liberian Ministry of Finance shows a sharp drop in revenue collection for the latter part of July and it is estimated that more than US$10 million in revenues have already been lost since the outbreak. It is projected that tax revenues for the 2014/15 fiscal year, originally projected at US$399 million, could be lower by about US$40 million, or about 10 percent (see Table 19 below). Increased expenditure, directed mainly to the health sector (approximately US$20 million) , but also to address social protection needs related to the loss of livelihoods (about US$47 million), is substantial, and accommodated in part through some shifting from capital to recurrent spending. Increased spending in the face of the falling revenues and flat external grants will increase the FY2014/15 projected fiscal deficit from 7 percent to 11.8 percent of GDP, implying financing needs of about US$93 million. Table 19: Liberia – Estimated Fiscal Impact of Ebola (US$ million) Initial Revised Difference Projection Projection Total Revenues and grants 558.9 513.2 -45.7 Tax revenue 399.0 361.4 -37.6 Non-Tax 100.3 92.2 -8.1 Grants 59.6 59.6 0.0 Expenditure 717.6 764.7 47.1 Current Expenditure 441.9 509.1 67.2 Of which for health 0.0 20.0 20.0 emergency Capital Expenditure 275.6 255.6 -20.0 Overall Balance -158.7 -251.5 92.8 Overall Balance (% of GDP) -7.1 -11.8 4.7 Source: IMF/World Bank Staff 6. Impact on Food Prices and Inflation • The impact of the Ebola crisis on inflation and food prices in particular is expected to occur mainly through the disruption of agricultural production and trade. Food prices can be expected to rise, particularly for rice, which is the staple food crop produced and consumed in Liberia, with significant cross-border trade including Côte d’Ivoire, which will be disrupted by current border closures. Domestic food price inflation, which had slowed from an average of 12 percent in the first half of 2013 to about 5 percent for the first half of 2014, is likely to increase sharply reflecting reduced food availability and this may be reflected in the September CPI data which the Bank is monitoring closely. Overall inflation rose to 11 percent for the first half of 2014 up from 8 percent at the end of 2013. 81 7. Impact on External Balances • Lower exports, higher food imports, and reduced international travel and cross-border commerce will place a strain on the balance of payments. Liberia’s projected exports for 2014 are down from a previous estimate of US$560 million to US$467 million, nearly 4 percentage points of GDP less than the original projection, due to slowdown in iron ore, rubber and palm oil production. There has also been a sharp decrease in international travel to Liberia as several major airlines have suspended flights, leading to lower revenues and financial inflows, and many projects involving expatriate workers or business travelers have been scaled down. Cross border trade between Liberia, Sierra Leone, Guinea and Côte d’Ivoire is substantial and a source of livelihoods for many itinerant traders. The closure of Liberia’s borders with Sierra Leone, Guinea and Côte d’Ivoire is thus likely to result in further economic hardship for a segment of the population that is already poor. • Medium-term growth prospects will also be adversely affected by the outbreak. Medium-term growth will be driven by the potential for private-sector investors to mothball new investments, particularly in mining and construction. Furthermore, public investment is already being constrained by the need to shift capital spending to immediate recurrent spending categories in health and social protection, to respond to the crisis. Sierra Leone 8. Impact on Economic Activity • The outbreak of the Ebola virus in rural Sierra Leone in May 2014 began and intensified in two districts: Kenema and Kailahun, which border Guinea and Liberia. With Kailahun considered the breadbasket of Sierra Leone for both food and cash crop production, the immediate effects beyond loss of life were reduced productivity for those fortunate enough to have survived and the need to care for the afflicted and attendant loss of household income. With 89 percent of households engaged in agriculture in Kailahun (and 81 percent in Kenema), the immediate effects on economic activity are projected to be through reduced agricultural output. Since May, the Ebola Virus Disease has spread to all but one of the 13 districts, and to the capital Freetown. • With this geographic spread, the effects on economic activity have become more pronounced given their extension to various indirect transmission channels. For example, as government has taken action to halt the spread of the virus by restricting internal travel, the transport sector has been adversely affected. This has also reduced the availability of goods, including agricultural produce internally. Spillover effects to the services sector have operated mainly in two dimensions, first through outright bans on public markets, second through reduced demand from the formal economy due to reductions in household income or precautionary saving. • The trends in economic activity may be proxied by a number of available indicators. There has been a collapse in hotel occupancy rates, from an average of 50 percent prior to May, to less than 10 percent in July-August. Similarly, tourist arrivals are down 21 percent through 82 July, compared to the same period a year ago. Both cement imports/sales and petroleum sales have also fallen in July and August. School closures have been instituted in a number of districts as well. These proxies have been used to revise sector growth rates in order to simulate the overall effect on economic activity under different scenarios. These simulations suggest that economic activity in 2014 could be lower by between 3 and 5 percentage points, but the best current estimate is for a reduction of 3.3 percent relative to the initial forecast of 11.3 percent (Table 20). Table 20: Sierra Leone – Estimated GDP Impact of Ebola Initial Revised Projection Projection (June 2014) Real GDP Contribution 11.3 8.0 Growth to growth shock (%) Agriculture 27.8 4.8 2.6 Industry 54.5 24.9 18.4 of which (39.6) (27.3) (21.8) Mining Services 17.7 7.7 5.7 Source: World Bank/IMF Staff Estimates. • A government ban on and closure of all bars, night clubs and restaurants has already had a visible effect on demand for manufactured drinks (both alcoholic and non-alcoholic). The sole brewery has scaled back operations and threatened closure, in which event an estimated 24,000 jobs stand to be lost; 600 farm households who supply sorghum to the brewery would also lose their main livelihoods. The company has suspended planned investments for 2014. 9. Fiscal Impact • Government is revising its 2014 fiscal plan to take account of the higher expenditure needs of the crisis and the expected revenue losses due to lower economic activity. Preliminary indications are for an Ebola-related revenue loss of US$46 million combining with revenue underperformance of US$11 million prior to the Ebola outbreak for a total loss of US$57 million. 27 On the expenditure side the government has drawn up an Ebola response plan which foresees increased recurrent spending of some US$38 million, of which US$26 million is for health, financed in part by cuts to capital spending (Table 21). Combining these, the overall budget deficit rises by some US$79 million equivalent. The scope for increasing the fiscal deficit would appear to be limited to increases in external financing, as the domestic financial sector is presently under severe stress. 27 Over the first half year government revenue was lower than planned/forecast but this was largely unrelated to the crisis caused by the Ebola virus and reflected a continued structural decline in non-mineral tax revenues and a fall in iron ore royalty receipts due to falling international prices. 83 Table 21: Sierra Leone – fiscal operations (US$ million) Original Revised Difference Projection Projection Total Revenue 745 688 -57 and Grants Tax revenue 530 478 -53 Non-Tax 50 44 -6 revenue Grants 164 166 2 Expenditure 938 960 22 Current 567 604 38 Expenditure Of which for health 0 26 26 emergency Capital 371 355 -16 Expenditure Overall Balance -193 -272 -79 (% of GDP) -4.2 -6.0 -1.8 Source: World Bank/IMF Staff Estimates. 10. Impact on External Sector • The effects of the crisis on the external sector will be to increase the balance of payments financing gap. This will be mainly through reduced export earnings from the mining sector and increased food imports, but the more pronounced effect will be on the currency which has already weakened in recent weeks. Moreover there is also potential for a slowing or reversal of the recent sizable inflows of net FDI. 11. Impact on Inflation and Food Prices • Food price increases have already emerged due to the current restrictions on the movement of persons and the suspension of operations of weekly community markets in rural areas. There are shortages of basic food stuffs in urban areas. Some initial signs of such changes also appear in the Sierra Leone CPI data for June, which show a pick-up in the food price component to 7 percent over the previous 12 months, from 6.3 percent a month earlier. This rose in July to 7.6 percent, but the increase cannot be entirely attributed to Ebola related events as it also coincided with Ramadan, a period normally associated with rising food prices. Next Steps • As the epidemic is still unfolding and as yet there are no clear signals, particularly in the cases of Liberia and Sierra Leone, that the cumulative rate of infection is abating, the Bank 84 will continue to monitor the impact of Ebola on economic developments in the three countries. More particularly, the Bank will:  Continue to monitor key economic data on prices, including the prices of food staples, tax revenues, and trade flows. This will give us further insights into how the economy is responding to the crisis over time;  Broaden the scope of the initial, preliminary work to employ, where possible, more sophisticated models to estimate the full impact of the outbreak by better establishing the linkages between sectors and multiplier effects; and  Launch a program to collect data that will facilitate assessment of the impact at the household level so that the extent of the impact on poverty may be better understood. 85 Annex 11: Environment and Social Action Plan 1. Environment Safeguards Category and Key Safeguards Policies 1. Given the scope of Project intervention, which is not expected to have any sensitive, diverse or irreversibly adverse environment or social footprints on the ground, the Project has been assigned environmental category B. The proposed Project activities are not judged to have significant environment and social impacts. The Project triggers policy on Environmental Assessment (OP4.01) due to potential environmental health impacts and risks associated emergency assistance works to help combat the EVD within the three hardest hit Countries within the West African Country. An ESSAF (Environment and Social Screening and Assessment Framework) will be prepared prior to beginning of sub-project works to screen potential environmental/social impacts and risk and provide appropriate mitigation measures. 2. Natural Habitat or Forestry policy are not triggered as the Project activities will not involve either converting or degrading critical or sensitive natural habitats. All Project activities will be subjected to a screening checklist that will identify any potential natural area for further assessment. Also the proposed emergency Project to combat the spread of the EVD is not expected to involve the use of pesticide; therefore the Policy on Pest Management (OP4.09) is not triggered. 3. The policy on Indigenous People is not triggered as the Project areas are not known to have presence of indigenous people. Similarly the Project activities will not involve any involuntary land displacement or involuntary land acquisition. Therefore, the policy on Involuntary Resettlement (OP4.12) is not triggered. 2. Site and Project characteristics with respect to Environment and Social Risks 4. This Project will take place in Guinea, Liberia and Sierra Leone (three of the Mano River Union-MRU States), hardest hit by EVD within the West African Region to support the Governments to control the EVD outbreak and mitigate the social shock, especially the food crisis among the quarantined population. Most reported cases in the three hardest hit countries are within rural areas which are not easily accessible and also within densely populated cities. The health systems within these areas are weak, overburdened with low clinical staff support. 5. It is known that Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals. In the three affected countries, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest. Ebola is known to spread in the community through human-to-human transmission, with infection resulting from direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola Therefore, both the external environment and human behavior can influence in the spread of disease. Given the emergency nature of the proposed Project, during implementation an Infection 86 Prevention and Management plan will prepared to be integrated into the Project planning, which will be integrated with an Environmental Management Plan to ensure that the spread and recurrence of the disease could be minimized. 6. An emergency response to the crisis has been launched at both national and regional levels. Governments of Guinea, Liberia and Sierra Leone, with the technical support of WHO has developed an EVD Outbreak Response Plan in West Africa and have put in place an inter- ministerial task force to develop and operationalize the response plans. At the regional level, WHO is setting up an Ebola response center in Conakry involving other international agencies, such as US CDC, Institute Pasteur, MSF, UN agencies, and WAHO. The Center will serve as the main sub-regional operations hub to strengthen coordination and ensure resource use optimization across all outbreak control activities in the countries. A “cordon sanitaire,” (geographically representing a triangular area where Guinea, Liberia and Sierra Leone meet, separated only by porous borders and where 70 percent of the cases known at that time had been found has been isolated to that effect) has been agreed upon and implemented by the three MRU Head of States to curb further spread of the EVD from cross border movements. 7. The three components proposed under the emergency Project are not expected to have significant environmental footprints. The Project has been assigned an environment category B given the anticipated environmental and social risks and impacts resulting from the proposed interventions which are minor and can be easily localized, and measures to mitigate the impacts are already standard practice among the non-public sector service providers. 8. Component 1 on support to the EVD Outbreak Response Plans will finance the gaps for the three countries and development partners to implement outbreak response plan for Guinea, Liberia and Sierra Leone respectively. The plan will include coordination, finance and logistics; improving epidemiology and laboratory for early detection, reporting and referral through surveillance and investigation; case management and infection prevention and control; as well as social mobilization/public information to create public awareness. Most of the activities on the ground are not expected to involve large scale construction or involuntary displacement of people. However, environment and social impacts and risks resulting from infection control interventions; construction of temporary ETCs, as well as use and disposal of chemicals and management of healthcare waste within and from healthcare facilities are not ruled out. 10. Component 2 of the Project which involves financing Health workers will include support to enhance the field presence of health care workers, salary top-ups; laboratory diagnosis facilities and logistic support such as protective gears and insurance benefits. The environment and social impacts of such interventions is expected to be moderate. 11. Component 3 of the proposed emergency Project involves addressing food and nutrition crisis especially to people within the quarantined population of the MRU region. This would involve providing food and possibly portable water and sanitary facilities to the quarantined population in the MRU Region that crosses borders between Guinea, Liberia and Sierra Leone. 12. The Project would target quarantined and Ebola-affected households. This may include a particular focus on vulnerable population, such as under-five children, pregnant and lactating 87 women; and emergency school feeding. The distribution of food to affected and dispersed population, which would include internationally specialized food and be done through the existing infrastructure of World Food Program, will not involve building either major roads or food storage facilities. Therefore, it is expected that environment and social footprints of such interventions would not be significant. 3. Management of Key Environment and Social Issues 13. Healthcare Waste Management: The management of healthcare waste (medical waste, excreta and body secretions/fluids) could be a significant issue at the primary healthcare level and from the ETCs for EVD, particularly in terms of final disposal. Transmission of the EVD requires direct contact through broken skin or mucous membranes with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of an infected person. Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an EVD patient’s infectious fluids such as soiled clothing, bed linen, or used needles. Improper management of such healthcare waste especially at the community/household level by family members caring for EVD patients and handling/burial of dead family members from the disease have in many ways fueled the epidemic. 14. The Project will support the updating of existing national guidelines on Healthcare Waste Management in Guinea, Sierra Leone and Liberia in line with WHO standards, along with training for health care workers to manage medical waste following these guidelines. This will be supplemented through purchase of equipment for the proper handling, the disposal of medical waste in participating facilities, and the appropriate handling/burial of Ebola case fatalities. It will also enhance and sustain the ongoing public awareness education programs in the three countries as of the EVD Outbreak Response Plan to directly confront this behavior. Additionally laws have been enacted within Sierra Leone to deter family members from hiding EVD patients in their homes and not bringing them to appropriate treatment centers. Procedures along with an Environmental Management Plan (EMP) to carefully manage healthcare waste in healthcare facilities (especially in ETCs) will be included in the ESSAF, consulted on and disclosed prior to the beginning of Project activities. 15. Worker Health and Safety: Health-care workers have been exposed to the virus while caring for EVD patients. This happens because they may not have been wearing personal protection equipment or were not properly applying approved infection prevention and control measures when caring for the patients. The ongoing health-care provider’s education about proper infection control measures at all levels of the health system – hospitals, clinics, and health posts – in the three countries will be enhanced and sustained under the Project to mitigate this potential impact. Development of National guidelines on Infection Control will also be supported within the three beneficiary countries as a mitigation measure. 16. In addition to standard hand hygiene techniques, the Project will support the provision of appropriate personal protection equipment (PPE) will be mandated for all healthcare workers when providing care to EVD patients, and (ii) all areas in clinics will need to be cleaned and disinfected frequently, especially those that are in close proximity to an EVD patient. The PPE would include: gloves, an impermeable gown, boots/closed shoes with overshoes, a mask, and 88 eye protection for splashes (goggles or face shields). Infection Prevention and Control remains an important element of Project planning and response, along with the World Health Organization. The infection prevention plan will significantly contribute to minimizing the adverse environment and social impacts. 4. Safeguard instruments/Implementation Arrangements: 17. While the environmental risks and impacts associated with the proposed emergency interventions are not expected to be significant, there would be need to systematically assess and analyze these interventions, including institutional capacity to minimize any residual environment and social impacts to the surrounding environment and people in the three most affected countries, i.e. Guinea, Liberia and Sierra Leone. In particular the following specific actions are proposed prior to beginning of Project works: a. Identify Environmental Focal point in each of the affected countries, working collaboratively with the Ministry of Health, Ministry of Environment and Ministry of Social works; b. Prepare a terms of reference to develop an Environmental and Social Screening Assessment Framework (ESSAF), including procedures to identify critical environment and social risks and prepare specific mitigation and monitoring plans; and c. The ESSAF to include procedures for assessment of E&S risks, coordination of environmental risks mapping and planning across various implementing agencies, identifying critical risks; monitoring and supervision of all environment mitigation measures. 18. The ESSAF will include mapping environment, health and safety risks associated with geographical locations, as well as recommend measures to protect community and vulnerable biological environment from future contamination or destruction due to disposal of waste food; chemicals; medical waste or debris from temporary displacement. 5. Institutional Capacity Assessment: Sierra Leone 19. At the National level, an Ebola Emergency Operation Center (EOC) co-chaired by the Minister of Health and Sanitation (MoHS) and WHO Representative, and other participated by other Ministries and partners has been formed. The EOC will make project-related decisions (e.g., investment plan for Component 1) and provide oversight of the Project progress. The MoHS will lead the implementation of Component 1 with technical support from WHO. The MoHS will also contract out part of the work to technical agencies (e.g., WHO, UNICEF, UNFPA) to ensure the rapid delivery of services. The MoHS has been engaged in various Bank investments and as such, it has Project coordinating units which are very familiar with Bank Safeguard policies and procedures. The Sierra Leone Environmental Protection Agency has national environmental legislative requirements and screening procedures which are consistent with those of the E&S policy requirements of the Bank. Additionally the National Commission for Social Action (NaCSA) which will play a key role in the implementation of Component 2 of this Project has experience of Bank Safeguard requirements from the management of the 89 ongoing Bank Social Protection investments in the country. Liberia 20. Several taskforce units have been set up at the National level to help coordinate the Ebola emergency response Plan. However, at the Project level the National Technical Team (NTT) will make project-related decisions (e.g., investment plan for Component 1) and provide oversight of the project progress. The MoHSW will lead the implementation of Components 1 and 2 and contract out part of the work to technical agencies. The MoHSW has experience of Bank E&S requirements and due diligence procedures through years of overseeing many bank financed projects in the Country. Additionally, the Liberia Environmental Protection Agency has environmental legislative requirements and screening procedures which are consistent with those of the E&S policy requirements of the Bank. Guinea 21. The Inter Ministerial Committee headed by the Minister of Health was established on April 5, 2014 to oversee the implementation of the Emergency Ebola Action Plan. However, at the Project level, the National Health Crisis Committee will make Project decisions (e.g., on the investment plans for Component 1) and provide oversight of the Project progress. Implementation of Component 1 will be led by the MoH and part of the work will be contracted to relevant technical agencies (e.g., WHO, UNICEF). The MoH has experience of Bank E&S requirements and due diligence procedures through years of overseeing many bank financed projects in the Country. Additionally, the Guinea Environmental Protection Agency has environmental legislative requirements and screening procedures which are consistent with those of the E&S policy requirements of the Bank. 6. Consultations and Disclosure 22. The key stakeholders include individuals suffering from EVD, affected communities, healthcare workers, the donor community, the implementing Ministries and related government agencies specially set up to help implement the joint EVD Outbreak Response Plan within the three hardest hit countries. The draft ESSAF (including the updated Healthcare Waste management Plan) that will be prepared during implementation will be publicly consulted and disclosed in-country (and globally through the World Bank InfoShop) in a form and language appropriate for public comprehension and consulted on prior to its finalization. All comments provided during these consultations will be recorded, and included in the final ESSAF and any subsequent safeguard instruments which will be developed as required. Communication and dissemination campaigns form an integral part of activities promoted under this Project. Once final, the main elements of the ESSAF and any subsequent safeguard instruments will be disclosed in a form appropriate to public comprehension and in all healthcare facilities. 90