Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD3174 INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT PAPER ON A PROPOSED THIRD ADDITIONAL GRANT IN THE AMOUNT OF SDR 142.9 MILLION (US$200 MILLION EQUIVALENT) TO THE UNITED NATIONS CHILDREN'S FUND AND THE WORLD HEALTH ORGANIZATION FOR THE YEMEN EMERGENCY HEALTH AND NUTRITION PROJECT APRIL 16, 2019 Health, Nutrition & Population Global Practice Middle East And North Africa Region This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s policy on Access to Information. CURRENCY EQUIVALENTS Exchange Rate Effective January 31, 2019 Currency Unit = Yemen Rials (YER) YER 249.90 = US$1 US$1 = SDR 0.71 FISCAL YEAR January 1 - December 31 Regional Vice President: Ferid Belhaj Country Director: Marina Wes Senior Global Practice Director: Timothy Grant Evans Practice Manager: Ernest E. Massiah Moustafa Mohamed ElSayed Mohamed Abdalla, Naif Task Team Leaders: Mohammed Abu-Lohom ABBREVIATIONS AND ACRONYMS AF Additional Financing APA Alternative Procurement Arrangement BCR Benefit Cost Ratio BEmONC Basic Emergency Obstetric and Neonatal Care CEmONC Emergency Obstetric and Neonatal Care CEN Country Engagement Note CERC Contingency Emergency Response Component CFSs Child Friendly Spaces CRW Crisis Response Window CTC/DTC Cholera/Diarrhea Treatment Center eDEWS Electronic disease early warning system DHO District Health Office DNA Dynamic Needs Assessment DTCs Diarrhea treatment centers EHNP Emergency Health and Nutrition Project ESMF Environmental and Social Management Framework FCV Fragility, Conflict and Violence GARWSP General Authority for Rural Water and Sanitation Project GDP Gross Domestic Product GHO Governorate Health Office GPS Global Positioning System GRM Grievance Redress Mechanism GRS Grievance Redress Service FM Financial Management HACT UN Harmonized Approach to Cash Transfers HCI Human Capital Index HCP Human Capital Project IDA International Development Association IDP Internally Displaced Person IFR Interim Unaudited Financial Reports INGOs International non-governmental organizations INSS Integrated Nutrition Surveillance System IPC Integrated Phase Classification JMP Joint Monitoring Programme for Water Supply, Sanitation and Hygiene KSA Kingdom of Saudi Arabia MAM Moderate Acute Malnutrition M&E Monitoring and Evaluation MNH Maternal and Newborn Health MWMP Medical Waste Management Plan MSP Minimum Service Package NGO Non-governmental Organization NNGO National Non-governmental Organization OCV Oral Cholera Vaccine OHS Occupational Health and Safety OP Operational Policy ORP Oral Rehydration Point PDO Project Development Objective PHC Primary Health Care PHCF Primary Health Care Facility PSS Psycho-social Support PPE Personal Protective Equipment SAM Severe Acute Malnutrition TOR Terms of Reference TPM Third Party Monitoring UAE United Arab Emirates UN United Nations UNICEF United Nations Children’s Fund USAID US Agency for International Development VSL Value of Statistical Life WASH Water, Sanitation and Hygiene WBG World Bank Group WFP World Food Programme WSS Water and Sanitation Services WHO World Health Organization WWTP Waste Water Treatment Plant Yemen, Republic of Emergency Health and Nutrition Project Third Additional Financing TABLE OF CONTENTS I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING ........................................ 7 II. DESCRIPTION OF ADDITIONAL FINANCING .................................................................... 13 III. KEY RISKS ..................................................................................................................... 21 IV. APPRAISAL SUMMARY .................................................................................................. 22 V. WORLD BANK GRIEVANCE REDRESS .............................................................................. 31 VI. SUMMARY TABLE OF CHANGES .................................................................................... 32 VII. DETAILED CHANGE(S) ................................................................................................... 32 VIII. RESULTS FRAMEWORK AND MONITORING ................................................................... 35 ANNEX 1: MENTAL HEALTH AND PSYCHO-SOCIAL SUPPORT SERVICES IN PRIMARY AND SECONDARY LEVELS OF CARE ............................................................................................... 51 ANNEX 2: REVISED COST TABLE............................................................................................ 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) BASIC INFORMATION – PARENT (Emergency Health and Nutrition Project - P161809) Country Product Line Team Leader(s) Yemen, Republic of IBRD/IDA Moustafa Mohamed ElSayed Mohamed Abdalla Project ID Financing Instrument Resp CC Req CC Practice Area (Lead) P161809 Investment Project GHN05 (9320) MNC03 (1491) Health, Nutrition & Financing Population Implementing Agency: United Nations Children's Fund, World Health Organization ADD_FIN_TBL1 Is this a regionally tagged project? Bank/IFC Collaboration No Original Environmental Approval Date Closing Date Current EA Category Assessment Category 17-Jan-2017 30-Jun-2020 Partial Assessment (B) Partial Assessment (B) Financing & Implementation Modalities Parent [ ] Multiphase Programmatic Approach [MPA] [✓] Contingent Emergency Response Component (CERC) [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Disbursement-Linked Indicators (DLIs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [✓] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [✓] Alternate Procurement Arrangements (APA) [ ] Hands-on, Enhanced Implementation Support (HEIS) Development Objective(s) April 16, 2019 Page 1 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) To contribute to the provision of basic health, essential nutrition, water and sanitation services for the benefit of the population of the Republic of Yemen. Ratings (from Parent ISR) RATING_DRAFT_ NO Implementation Latest ISR 06-Apr-2017 14-Oct-2017 19-Apr-2018 01-Nov-2018 31-Dec-2018 05-Mar-2019 Progress towards achievement of S S S S S S PDO Overall Implementation S S S S S S Progress (IP) Overall Safeguards S S S S S S Rating Overall Risk H H H H H H BASIC INFORMATION – ADDITIONAL FINANCING (Yemen Emergency Health and Nutrition Project Third Additional Financing - P167195) ADDFIN_TABLE Urgent Need or Capacity Project ID Project Name Additional Financing Type Constraints P167195 Yemen Emergency Health Restructuring, Scale Up Yes and Nutrition Project Third Additional Financing Financing instrument Product line Approval Date Investment Project IBRD/IDA 14-May-2019 Financing Projected Date of Full Bank/IFC Collaboration Disbursement 30-Oct-2022 No Is this a regionally tagged project? April 16, 2019 Page 2 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) No Financing & Implementation Modalities Child [ ] Series of Projects (SOP) [✓] Fragile State(s) [ ] Disbursement-Linked Indicators (DLIs) [ ] Small State(s) [ ] Financial Intermediaries (FI) [ ] Fragile within a Non-fragile Country [ ] Project-Based Guarantee [✓] Conflict [ ] Deferred Drawdown [✓] Responding to Natural or Man-made disaster [✓] Alternate Procurement Arrangements (APA) [ ] Hands-on, Enhanced Implementation Support (HEIS) [✓] Contingent Emergency Response Component (CERC) Disbursement Summary (from Parent ISR) Net Source of Funds Total Disbursed Remaining Balance Disbursed Commitments IBRD % IDA 483.00 413.05 76.89 84 % Grants % PROJECT FINANCING DATA – ADDITIONAL FINANCING (Yemen Emergency Health and Nutrition Project Third Additional Financing - P167195) PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFi n1 SUMMARY (Total Financing) Proposed Additional Total Proposed Current Financing Financing Financing Total Project Cost 483.00 200.00 683.00 Total Financing 483.00 200.00 683.00 of which IBRD/IDA 483.00 200.00 683.00 Financing Gap 0.00 0.00 0.00 April 16, 2019 Page 3 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) DETAILS - Additional Financing NewFinEnh1 World Bank Group Financing International Development Association (IDA) 200.00 IDA Grant 200.00 IDA Resources (in US$, Millions) Credit Amount Grant Amount Guarantee Amount Total Amount National PBA 0.00 200.00 0.00 200.00 Total 0.00 200.00 0.00 200.00 COMPLIANCE Policy Does the project depart from the CPF in content or in other significant respects? [ ] Yes [ ✔ ] No Does the project require any other Policy waiver(s)? [ ✔ ] Yes [ ] No Explanation Two policy waivers are sought under the proposed Additional Financing: (i) waiver of the application of the Bank's Anti-Corruption Guidelines, in favor of relying on the fraud and corruption procedures of UNICEF and WHO, as per the legal agreements; and (ii) waiver of any application of the IDA Commitment Charge to UNICEF and WHO during the life of the project. The financial impact of the latter is expected to be negligible. Has the waiver(s) been endorsed or approved by Bank Management? Approved by Management [ ] Endorsed by Management for Board Approval [✔] No [ ] Explanation The policy waiver memorandum was endorsed by management for Board approval. INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population April 16, 2019 Page 4 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Contributing Practice Areas Water Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks Gender Tag Does the project plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified through SCD and CPF Yes b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment Yes c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes PROJECT TEAM Bank Staff Name Role Specialization Unit Moustafa Mohamed Team Leader (ADM Public Health GHN05 ElSayed Mohamed Abdalla Responsible) Naif Mohammed Abu- Team Leader Water Resource Management GWA05 Lohom Procurement Specialist (ADM Jamal Abdulla Abdulaziz Procurement GGOPM Responsible) Financial Management Moad M. Alrubaidi Financial Management GGOMN Specialist (ADM Responsible) Amer Abdulwahab Ali Al- Environmental Specialist (ADM Environmental Safeguards GENME Ghorbany Responsible) Ibrahim Ismail Mohammed Social Specialist (ADM Social Safeguards GSU05 Basalamah Responsible) Amr Elshalakani Team Member Public Health GHN05 Andrianirina Michel Eric Team Member Disbursement WFACS April 16, 2019 Page 5 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Ranjeva Dambudzo Josephine Team Member Water and Sanitation GWA05 Muzenda Ebrahim Mohammed Team Member Communications MNAEC Yahya Al-Harazi Mariam William Guirguis Team Member Administrative Support GHN05 Mirna Ahmed Mehrez Ali Team Member Research GHN05 Hassanin Miyuki T. Parris Team Member Operations Support GHN05 Raghada Mohammed Team Member Administrative Support MNCEG Abdelhady Abdelhamied Saba Nabeel M Gheshan Counsel Legal Support LEGAM Extended Team Name Title Organization Location April 16, 2019 Page 6 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) I. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING A. Introduction 1. This Project Paper seeks the approval of the Executive Directors to provide a third additional grant in the amount of SDR 142.9 million (US$200 million equivalent) financed by the International Development Association (IDA) to the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in support of the Yemen Emergency Health and Nutrition Project (EHNP) (P161809) for the benefit of the Republic of Yemen. The proposed grant will help sustain and expand the delivery of integrated health, nutrition and water and sanitation services (WSS) in response to the persistent severe needs and continuous deterioration of the health, nutrition, and water and sanitation systems in Yemen. 2. The original project was approved by the World Bank Group’s (WBG) Board of Executive Directors on January 17, 2017 in the amount of SDR 147.8 million (US$200 million equivalent), including SDR 91.45 million (US$123.75 million equivalent) to UNICEF and SDR 56.35 million (US$76.25 million equivalent) to WHO). The first additional financing (AF1) in the amount of SDR 60.7 million (US$83 million equivalent), including SDR 45.3 million (US$62 million equivalent) to UNICEF and SDR 15.4 million (US$21 million equivalent) to WHO was approved by the Board on May 19, 2017. The AF1 mainly focused on the provision of an integrated nutrition package in response to the food insecurity and malnutrition crisis in the country. The second additional financing (AF2) in the amount of SDR 143.9 million (US$200 million equivalent), including SDR 93.5 million (US$130 million equivalent) to UNICEF and SDR 50.4 million (US$70 million equivalent) to WHO was approved by the Board on August 25, 2017 and incorporated an emergency health, water and sanitation interventions for the cholera outbreak. 3. The project is implemented by WHO and UNICEF together with local health and WSS authorities and institutions and has rapidly achieved significant implementation progress. To date, substantial results have been achieved through the EHNP. Nearly 15 million people have received health, nutrition and/or population services, including 3.7 million women and children receiving nutrition services and 6.9 million children immunized (of which about 5 million are under the age of five), over 3,550 health facilities have received operating costs, basic health and nutrition supplies, and/or equipment and furniture, nearly 15,000 health personnel have been trained, and 1.68 and 1.97 million people have gained access to safe water and sanitation, respectively. 4. The Project Development Objective (PDO) will remain unchanged. Several PDO-level and intermediate indicators’ targets are proposed to be revised to account for the proposed package of interventions. 5. This proposed third additional financing (AF3) is being processed under the paragraph 12 of the Bank Policy on Investment Project Financing (Projects in Situations of Urgent Need of Assistance and Capacity Constraints), given the ongoing violence and instability. It is also prepared in accordance with paragraph 3(b) of Operational Policy (OP) 2.30, Development Cooperation of Conflict: if there is no government in power, Bank assistance may be initiated by requests from the international community, as properly represented (e.g. by UN agencies), and subject in each case to the prior approval of the Executive Directors. 6. To ensure a sustained, comprehensive, appropriate and timely response in Yemen, an integrated and enhanced package of appropriate health, nutrition, water and sanitation interventions is deemed necessary. April 16, 2019 Page 7 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) These interventions will continue to be offered nationwide with a focus on the highly-affected areas using prioritization and needs assessment tools such as, but not limited to, Vulnerability Matrix, HeRAMS 2018, epidemiological tracking and surveillance system, all supported by the ongoing EHNP. Thus, prioritization will be based on an objective analysis that responds to the changing geographic needs of the population, arising from a protracted conflict situation. 7. For four years since the eruption of the conflict, Yemeni people have continued to suffer from the severe economic decline and the brunt of ongoing hostilities. In addition, changes in the frontlines and the collapsing essential public services have taken a massive toll on the Yemeni population, exacerbating chronic vulnerabilities. In the last four years, the ongoing conflict has killed or injured more than 50,000 people – mostly civilians (the Armed Conflict Location and Event Data Project - ACLED, 2018). Over two-thirds of the population (19.7 million) do not have access to health care, and well over half of the population (17.8 million people) require support to meet their basic water, sanitation and hygiene (WASH) needs, of which 12.6 million are in acute need. Twenty-nine percent of health facilities have been damaged by the ongoing violence, and 45 percent of health facilities are not functioning according to the latest Dynamic Needs Assessment (DNA, Phase III). On the other hand, the shock of displacement due to conflict in the last few years has hit the Yemeni population hard; 3.3 million have become Internally Displaced Persons (IDPs), among which 89 percent have been displaced for more than a year amid severe economic decline. The IDPs, dispersed across 21 governorates, are further pressuring the delivery of the basic services in an already impoverished country. 8. The proposed AF3 will sustain and complement the activities initiated under the parent project, expanding the delivery of an integrated package of health, nutrition and WSS services. The proposed AF3 aims to address the situation through an integrated three-pronged approach: (i) Response: to cater to the short-term needs of the affected population; (ii) Prevention: to address the demand and supply-side issues of nutrition and infection and transmission of diseases; and (iii) Institutional and capacity building: to support and develop local health, water and sanitation institutions to better prevent, detect and control future outbreaks and to respond to the needs of the population. B. Country Context 9. The ongoing conflict in Yemen remains unresolved. At present, the conflict is riddled with a cobweb of actors, regional powers, dynamics and armed groups on the ground and is deepening societal fragility and fault lines in Yemen. Many factors such as tribal, regional and sectarian divisions, long-standing grievances, elite capture of resources and corruption have been the major causes of fragility drivers operating across Yemen. Three conflicts have divided the torn country into many areas of territorial, political control and static frontlines; the national-level conflict, the Southern Secession conflict and violent extremists. Since the initial phases of the conflict, especially at the frontlines, the brunt of violence and suffering that the population has been experiencing have changed little. However, latest peace talks hosted by the UN shown a few positive signs. 10. Prior to the start of the conflict in 2014, Yemen was highly reliant on diminishing oil and gas resources for public revenue; their reserves represented 25 percent of Yemen’s GDP, nearly three quarters of government revenues, and 90 percent of the country’s exports. The gradual depletion in oil reserves before the onset of the conflict has resulted in steep decline of the oil revenues and raised the budget deficit to 10 percent of GDP. The economy of Yemen has been collapsing since the conflict erupted in 2015, and the real GDP has April 16, 2019 Page 8 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) contracted by 35 percent since late 2014. In addition, the public revenues have declined by about 50 percent in 2015 and by additional 20 percent in 2016 due to the fall in oil revenues (77 percent) and non-oil revenues (34 percent). 11. Additionally, the conflict affected the country’s trade balance, with an estimated drop by 51 percent and 54 percent in exports and imports, respectively, between 2014 and 2015 owing to the decrease of the foreign exchange reserves of the Central Bank of Yemen. The latter has become dysfunctional at the end of 2016 and unable to curb runaway inflation. The labor markets have been severely affected. Participation in the public sector has steeply declined; employment has decreased by 13 percent in Al-Hodeidah, Sana’a city and Aden, while for the private sector, enterprises have been operating with half of the capacity they had before the conflict. About 40 percent of the workforce was lost with reduced operating hours by almost half, and 74 percent of the firms have reported physical damage. C. Sectoral Context 12. Although the World Bank, through its partnership with UNICEF and WHO, has been supporting the health and WASH sectors with the largest funding for health in the region (US$483 million equivalent), the situation is still deteriorating due to the conflict and the immense needs of the population across the country. 13. The health care system continues to be a victim of Yemen's conflict where poverty, hunger and unsafe drinking water have taken their toll. The already dire humanitarian situation in Yemen has been exacerbated by successive outbreaks of diseases such as cholera (see Box 1) and diphtheria over the last year. The recent conflict in Al-Hodeidah has also added more strain on the population due to the seaport closure. Since the conflict escalation, the continuous shortages of staff and supplies, mainly fuel, have put further strains on facilities. Moreover, since 2015, more than 160 health centers and hospitals were caught in conflict situations. Box 1: Ongoing Cholera Epidemic in Yemen The first wave of the cholera epidemic started in October 2016 and spread rapidly to 135 districts by mid-December 2016. The cases were greatly reduced by March 2017, but the second wave of the epidemic began in April 2017, after the water and sanitation systems almost collapsed mainly in 15 main urban centers where the wastewater treatment plants were nonfunctioning. In addition, distribution of water by private tankers using unregulated sources and transportation mechanisms has been reported to be a major source of infection of drinking water. The EHNP contributed to the efforts on the ground by responding quickly with the activation of the Contingent Emergency Response component in May 2017 and the approval of the second AF in August 2017, which included water, sanitation and hygiene (WASH) subcomponent. The number of suspected cholera cases decreased in 2017, but then increased in the second half of 2018 with the second wave continuing in 2019. Between October 2016 and January 2019, a total of 1,455,585 suspected cholera cases was reported in Yemen as well as 2,906 related deaths, with a case fatality rate of 0.2%.1 14. Multiple disease outbreaks requiring emergency response - cholera, diphtheria, measles, dengue, scabies - often emerge in several and unpredictable locations. After the decline of cholera cases at the end of 2017, 1 WHO (2019). Cholera Situation in Yemen. http://applications.emro.who.int/docs/EMROPub_2019_EN_22332.pdf?ua=1 April 16, 2019 Page 9 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Yemen's shattered health system started to battle diphtheria, which was a challenge given the ongoing conflict and blockades creating daily threats to public health. Moreover, given the ongoing logistical difficulties, bringing the needed medical equipment and supplies with specialized medical staff into the needy areas in Yemen is difficult rendering all the humanitarian and health actors struggling. According to the analysis conducted by the Health Cluster consisting of various partners, the main causes of avoidable deaths in Yemen are communicable diseases, maternal, perinatal and nutritional conditions (together accounting for 50 percent of mortality) and non-communicable diseases (39 percent of mortality). 15. Failing to meet the MDG 1 of eradicating extreme poverty and hunger, food insecurity and malnutrition are two of the most serious health challenges in Yemen. Food supply chains have been affected by the conflict resulting in soaring food prices coupled with an already reduced purchasing power owing to the conflict’s economic impact. The latter has gradually devastated the livelihoods of Yemenis, which has made it more difficult for them to meet minimal food needs. Yemen is currently witnessing one of the world’s highest chronic malnutrition rates, with a child dying every 10 minutes from preventable causes. Some 1.7 million children are suffering from Moderate Acute Malnutrition (MAM) and nearly 357,000 children under 5 have Severe Acute Malnutrition (SAM), while Global Acute Malnutrition rates are as high as 28 percent in some locations – around twice the emergency threshold of 15 percent. 16. Furthermore, there has been an overall decline in access to improved sources of water from 66 percent to 55 percent between 1990 and 2010. In 1990, more than 96 percent of urban areas had access to improved water (84 percent piped and the remaining 12 percent other improved sources). This fell to 72 percent in 2010. Similarly, in rural areas, access to an improved source of water has declined from 59 percent to 47 percent over the same time period. In a nutshell, since 2015, access to improved water sources reduced by almost half, cost of water increased by 45 percent and purchasing power decreased. Yemen's water and sanitation infrastructure has suffered significant damage. According to the latest DNA, the costs for WSS over five years among the 16 cities included in the DNA vary between US$650 million and US$795 million, and between US$1 billion and US$1.2 billion for the corresponding governorates of these cities. It also shows that 21 percent of water and sanitation assets have been damaged, and less than 70 percent of water facilities in the assessed areas are functioning (44 percent fully and 24 percent partially). The infrastructure has been damaged, and there have been lack of energy (electricity and fuel), spare parts, operation and maintenance funds. In addition, civil servants have not been paid for over three years. This confluence of factors has undermined the water and sanitation systems in Yemen and contributed to the repeated waves of cholera outbreaks. Currently, only 22 percent of rural and 46 percent of urban populations are connected to partially functioning public water networks, whilst the lack of electricity or revenues creates significant reliance on humanitarian support. With reduced safe water access, communities resort to unsafe water sources, while only 24 percent of households treat water at home. 17. An increase in access to improved sanitation – though with a wide disparity between rural and urban areas – achieved over the years is being compromised. About 12 percent of the population in rural areas and 70 percent in urban areas had access to improved sanitation in 1990, which improved to 34 percent and 93 percent, respectively, in 2010. Access to improved facilities also increased mainly in urban areas. Open defecation was mostly prevalent in rural areas with 44 percent of the rural population practicing it in 1990. Although it declined over time, 22 percent still practiced it in rural areas in 2010. Since the conflict started, sanitation and wastewater treatment services have been overwhelmed. Open defecation or exposed sewage has been observed in 60 percent of cholera response observations. Significantly, districts in acute need of April 16, 2019 Page 10 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) sanitation increased over four-fold from 36 to 167 districts. 86 of those districts have the highest severity (6), where over 85 percent of households do not have access to safe sanitation. 18. Yemen was a fragile country before 2015 and will likely continue to be vulnerable to poverty, water scarcity, and natural disasters, all of which may be exacerbated by different factors, including the climate change, and may result in outbreaks and disease pattern changes in the future. These events may cause further strain in the struggling health system. D. Rationale for the Additional Financing 19. In 2018, the WBG launched the Human Capital Project (HCP). This makes the case for investing in people through country engagement and analytical work, while raising awareness of the costs of inaction and bolstering demand for interventions that will build human capital. The first pillar of the HCP is the Human Capital Index (HCI). The index measures the human capital of the next generation, defined as the amount of human capital that a child born today can expect to achieve in view of the risks of poor health and poor education currently prevailing in the country where that child lives. Using pre-conflict data, Yemen has ranked 143 out of 157 countries with an index score of 0.37, with girls scoring lower at 0.35. This means a child born in Yemen today will realize only 37 percent of his/her productivity potential. Sub-indicators show that 94 out of 100 children born in Yemen survive to age five, 78 percent of 15-year-olds will survive until age 60, and 46 out of 100 children are stunted. The results of the HCI highlight the importance and urgency to invest in health, education and in overall human development outcomes in the country.2 20. The EHNP continues to be the main pillar in the international support system that provides vulnerable Yemenis with basic health, nutrition, water and sanitation services. Under the deteriorating operational environment and amidst challenges, including the recent escalation of conflict in the governorate of Al- Hodeidah and moving frontlines, disease outbreaks, worsening economic context and difficulty in working with local authorities, the project has managed to disburse nearly 84 percent (US$413 million equivalent) to date and is showing remarkable progress and results. Positive outcomes include achieving full functionality at 51 percent of health facilities, reaching nearly 15 million people with health, nutrition and population services and 1.68 and 1.97 million people with access to improved water and sanitation sources, respectively. The end targets for several indicators have already been surpassed. 21. To date, substantial results could be attributed to the EHNP, namely; (i) 3,550 health facilities receiving operating costs, basic health kits, and/or equipment and furniture; (ii) nearly 15,000 health personnel trained; (iii) 3.7 million women and children receiving nutrition services; (iv) about 700,000 successfully treated from cholera which brought the case fatality rate down from 2.3 to 0.2 percent, and thus saving thousands of lives; (v) 6.9 million children immunized (of which 5 million are under the age of five); and (vi) 630,583 women received antenatal care while 182,904 births were attended by skilled health professionals. The project ratings for the progress towards achieving the PDO and implementation progress have been Satisfactory since the start of the project. 22. The project has also had strong results in contributing to the control of the cholera epidemic through WASH and community engagement interventions. About 251 primary health care facilities (PHCFs)3 and 106 2 The HCI for Yemen is primarily based on the pre-conflict 2014 data. The situation has significantly worsened since then. 3 Rehabilitation work is in progress at 315 PHCFs. April 16, 2019 Page 11 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) schools have been provided with WASH services, while 1.68 and 1.97 million people have been provided with access to improved water and sanitation services in urban and rural cholera affected areas. In addition, six million people received hygiene consumables. The project is also supporting public water supply systems in 15 cities by providing operational support to water and wastewater facilities. 23. The project has been ensuring complementarities and maximizing synergies with other IDA-financed projects. For instance, the Yemen Integrated Urban Services Emergency Project is assisting the EHNP- supported health facilities with the installation of the solar systems and thus moving towards with more sustainable and cost-effective energy solutions, which also complements WSS interventions under the EHNP in three major cities (Aden, Sana’a and Al-Hodeidah). The Emergency Crisis Response Project is providing cash assistance to the malnourished households identified through the EHNP, so they can afford transportation to the EHNP-supported facilities where they get treatment. Lastly, the Emergency Electricity Access Project provides solar systems to key WSS facilities in peri-urban and rural areas. 24. Other UN agencies, bilateral donors, international and local organizations are currently stepping up their support and ground presence in the country. WHO, UNICEF, United Nations Office for Project Services, the United Nations Office for the Coordination of Humanitarian Affairs, Médecins Sans Frontières (Doctors Without Borders), GIZ, the US Agency for International Development (USAID), and the International Committee for the Red Cross are among the leading organizations that provide mainly emergency, preventive and essential maternal and child health care services as well as WSS. Currently the Health Cluster in Yemen co-led by WHO consists of 6 UN agencies, 29 international non-governmental organizations (INGOs) and 35 national NGOs (NNGOs). IDA was among the largest donors to fund the Health Cluster’s work in 2018. As for the Nutrition Cluster, which is co-led by UNICEF, it has a total of 36 partners, of which 3 are UN partners and 17 national NGO, 15 international NGOs (INGOs) and the Ministry of Public Health and Population itself. The King Salman Humanitarian Aid and Relief Centre (KS Relief), United Arab Emirates and WB were among its major donors. The Yemen WASH cluster has 82 partners registered, of which 64 are active players. There are also additional 37 sub-implementing partners who do not directly report to, but coordinate with, the cluster. Of the 64 partners, 4 are UN agencies, 21 are INGOs and 39 are NNGOs. UNICEF as the WASH Cluster co-lead accounted for more than 82 percent of the total WASH cluster response achievements for supporting the water systems (operational and repairs / rehabilitation), 96 percent of the total cluster sanitation achievements, and 70 percent of the emergency water supply total achievements in 2018. 25. The model of implementing project activities through partnering with UN agencies spearheaded by the EHNP has become an exemplary model for other donors and development partners to follow. For example, UNICEF is being supported by the UK Department for International Development in a multisectoral approach to partially address cholera and malnutrition through community awareness interventions and bringing together health, nutrition, water and sanitation, child protection and social protection elements; the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE) are supporting the rollout of the minimum service package nationwide, the European Union through UNICEF is supporting the community health workers model in the country, and USAID is supporting reproductive, maternal and newborn health. WHO, on the other hand, is mainly supported by KSA, UAE, USAID, King Salman Humanitarian Aid and Relief Centre (KS Relief), and the Central Emergency Response Fund for public health and secondary care activities. In addition, the GAVI Vaccine Alliance, Japan, Qatar, Sweden, Kuwait, Canada, Germany, ECHO, and Italy are major contributors in the health sector in Yemen. April 16, 2019 Page 12 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) 26. Given the remarkable performance and momentum of the project, its full compliance with Financial Management (FM), audit and safeguards requirements, and its contribution to building resilience for individuals and the health and water/sanitation systems to prepare for future public health emergencies, the proposed AF3 will be an important next step in maintaining and expanding health, nutrition and WASH services to the Yemeni population whose needs are, and will continue to be, immense under the uncertain country situation. II. DESCRIPTION OF ADDITIONAL FINANCING 27. The proposed AF3 will maintain the overall design of the project, support the scale-up of the ongoing activities, and enable UNICEF and WHO to deliver the health, water and sanitation services through a network of local health and water and sanitation institutions and partners. The PDO will remain unchanged: to contribute to the provision of basic health, essential nutrition, water and sanitation services for the benefit of the population of the Republic of Yemen. Under Component 1, the ongoing activities will be maintained and expanded with a focus on the integrated package of nutrition and WSS interventions, cholera activities and essential health interventions that have been supported by the parent project. In addition, the AF3 will have an intensified focus on providing mental health and psycho-social support at the primary and secondary level, as well as expanding the support to the community health and nutrition program. The focus and activities under Component 2 will also remain unchanged. The closing date will be extended by two years to June 30, 2022 to ensure adequate time to complete all activities, especially those with a system perspective. Finally, target values for several existing PDO-level and intermediate results indicators are proposed to be revised to account for the expanded scope of services. WHO and UNICEF will remain the IDA grant recipients. The bilateral joint program agreement between UNICEF and the World Food Programme (WFP), which was initiated under the AF1, is expected to continue to undertake complementary nutrition activities, particularly with regard to prevention and management of MAM along with the provision of fortified nutritious supplements/food. 28. This proposed AF3, building on the lessons learned from the implementation of the original project and its two AFs, will follow a three-pronged approach that groups different project activities together and helps address: i) Response to the short-term needs for health, nutrition and WSS at the community, facility and hospital levels; ii) Prevention of acute and chronic malnutrition, disease outbreaks, e.g. cholera, diphtheria, Dengue fever, etc.; and iii) Institutional and capacity building: that will help ensure long-term development outcomes through relying on the local systems. Supporting the local health institutions and key water utilities and institutions will maintain the operational and technical capacity of the staff and therefore minimize future shocks to the health and water sectors. All activities supported by the EHNP will continue to be sustained by the proposed AF3 and are summarized in Table 1. Component 1: Improving Access to Health, Nutrition, Public Health Services and Water and Sanitation Services (US$190.0 million equivalent). 29. This component will support the coverage of the population of Yemen with health and nutrition services as outlined in the Minimum Services Package (MSP)4 and WSS services at both primary health care (PHC) level 4 The MSP was designed by WHO in collaboration with UNICEF and the Bank along with other partners and is supported through the EHNP. It includes the following categories of services: general services and trauma care; child care at all levels; nutrition; April 16, 2019 Page 13 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) and at referral secondary care centers, as well as capacity building of the health and water and sanitation systems. The services are offered through the integration of the PHC model with the referral services, thus ensuring a continuum of care for the population. The AF3 will help preserve and strengthen the health system through supporting, inter alia, financial management, supply chain management, and information management and leadership capacities of local institutions. 30. In addition, this component will prioritize the funding of psycho-social support at all levels of care and expand the community health program horizontally by covering more geographic regions and vertically through integrating more services into their domain. Funding for this component will cover the provision of operating costs, basic supplies (water and fuel), equipment, maintenance, medical and non-medical supplies, essential drugs, vaccines, micronutrients, fortified nutritious supplements, WASH consumables and kits, training, per diem and transportation allowances, and minor rehabilitation of existing facilities. Subcomponent 1.1: Strengthening the Integration of Primary Health Care Model (implemented by UNICEF - US$95.0 million equivalent) 31. This subcomponent will ensure continued delivery of: (i) key health and nutrition services at the PHC level through (a) integrated outreach (outreach and mobile teams for the population in remote areas and IDPs); (b) community-based interventions; and (c) PHC facilities; (ii) targeted food supplementation program, blanket supplementary feeding program, and distribution of nutritious supplements and fortified food; (iii) cholera preparedness and prevention activities such as, but not limited to, supporting the rapid response teams, and cholera case management; and (iv) facilitating community engagement and generating demand for health, nutrition and WSS services through community sensitization and promoting key healthy behaviors. 32. The subcomponent will aim to ensure the delivery of MSP services with a particular focus on integrating the maternal and newborn health (MNH), child nutrition, SAM children without complication, infant and young child feeding, micronutrients supplementation, integration of Early Childhood Development interventions with health and nutrition, prevention of chronic malnutrition through school health and outreach programs that promote healthy diet, integrated management of childhood illness, and routine delivery of selected public health programs and immunizations through different delivery models. 33. The proposed AF3 will also expand and integrate psycho-social support (PSS) and mental health services to children in need. Under the ongoing project, PSS has been offered through a network of health and social workers in child friendly spaces (CFSs) which are available within the primary health care facilities or in adjacent structures. Similarly, services offered at the secondary level facilities have included mental health. The proposed AF3 will help expand the coverage of PSS for improved access at the community level and integrate the PSS with mental health services at the hospital level where severe cases are referred for appropriate management (see Annex 1). Subcomponent 1.2: Supporting Health and Nutrition Services at the First Level Referral Centers (implemented by WHO - US$40.8 million equivalent) 34. This subcomponent will complement the PHC model and ensure the continuum of care at the referral communicable diseases; reproductive, maternal, and newborn health; non-communicable diseases; mental health; and environmental health in health facilities. April 16, 2019 Page 14 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) centers and hospitals by supporting: (i) management of SAM cases at in-patient Therapeutic Feeding Centers /Stabilization Centers for patients with complications or who failed home-based Outpatient Therapeutic Program; (ii) provision of Basic Emergency Obstetric and Neonatal Care (BEmONC) and Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) services in targeted referral centers; (iii) management of cholera cases through supporting the diarrhea treatment centers (DTCs) and oral rehydration points (ORPs); (iv) screening and case management of non-communicable diseases and its complications including diabetes, hypertensions, tumors, and mental health and psychosocial support; and (v) sustaining the national capacity of blood banks. Subcomponent 1.3: Sustaining the National Health System Preparedness and Public Health Programs (implemented by WHO - US$19.0 million equivalent) 35. This subcomponent will support nationwide public health programs and measures in the form of: (i) prevention to support nationwide public health campaigns, including vaccination and neglected tropical diseases, to prevent disease outbreaks; (ii) Integrated Nutrition Surveillance System (INSS), which is meant to provide ongoing nutrition, health, and food security information to inform decisions in a timely manner; (iii) system strengthening and resilience-building measures to s-upport the epidemiological and diagnostic laboratory capacity of the local institutions particularly the reference labs at the governorate level; and (iv) maintaining the electronic disease early warning system (eDEWS). In addition, this subcomponent will enhance the preparedness of the public health system to respond to disease outbreaks through supporting nationwide rapid response teams at the district and governorate levels, which will ensure immediate multi- sectoral coordination and response to outbreaks. Subcomponent 1.4: Improving Access to WSS and Strengthening Local Systems (US$35.2 million equivalent) Subcomponent 1.4(a): Improving Access to Safe Water and Sanitation at Households, Schools, Health Facilities, Public Markets and Other Communal Gathering Places (implemented by both UNICEF and WHO) 36. The proposed AF3 will aim to sustain the operationalization of water supply system and waste water treatment plants in major cities and expand the ongoing EHNP WSS interventions in urban and rural areas. WSS activities will be expanded to new areas in terms of restoration of services and basic rehabilitation of key WSS facilities. 37. Key short-term interventions will be maintained with a focus on the cholera preparedness and prevention approach. This will include: (i) bulk chlorination of water sources, piped network and private water trucks; (ii) distribution of consumable hygiene kits, chlorine tablets, jerry cans, cleaning, disinfection materials and storage; and (iii) awareness raising and communication for adoption of positive preventive hygiene practices. Moreover, this will also include quick-fix interventions to address the public health risks through quick impact projects. The medium-term interventions will include basic rehabilitation of key water and sanitation facilities in urban and rural areas. 38. WHO will be responsible for water supply activities to health facilities through the existing public water supply system and water quality testing. Provision of water trucking to health facilities is to be gradually replaced by a more sustainable and cost-effective approach. April 16, 2019 Page 15 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Subcomponent 1.4(b): Systems/Institutional Strengthening toward Further Prevention and Resilience Building (implemented by UNICEF) 39. Strengthening the local water institutions is key to ensure sustainability of water and sanitation and hygiene promotion service delivery and the operational capacity of WSS institutions. It will also support the prevention of and preparedness for future outbreaks. 40. (i) Supporting the operation and maintenance of WSS systems, including water supply system and waste water treatment plants (WWTPs), to provide access to sustainable services through: (a) expanding basic rehabilitation for selected water sewerage networks and WWTPs, both in rural and urban areas; (b) provision of necessary parts, supplies, essential fuel and other implementation expenses for system operations; and (c) supporting the regulator, National Water Resources Authority, local corporations, and water laboratories with instruments for monitoring groundwater abstraction and controlling the quality of source water. This also includes continuous capacity building of key staff and critical cadre of frontline volunteers for continuous hygiene promotion and social change discourse. 41. (ii) Enhancing water security by protecting water resources in selected urban and rural areas through the demarcation of well-fields and their catchment areas (hydrological basin mapping in some locations). The development of regulatory mechanisms will be explored to strengthen partnerships with private water providers for sustainable access to safe water and sanitation. 42. (iii) Improving local capacity at the institutional, community and household levels through water safety planning, including water quality testing and monitoring; and capacity building and training of water user associations to address public health outbreaks from the WSS perspective. Component 2: Project Support, Management, Evaluation and Administration (US$10.0 million equivalent). 43. The proposed AF3 will continue to support administration and monitoring and evaluation (M&E) activities to ensure smooth and satisfactory project implementation. The component will finance: (i) general management support for both WHO and UNICEF; (ii) hiring of Third-Party Monitoring (TPM) agents, with terms of reference satisfactory to IDA, that will complement the existing TPM arrangements for both agencies; and (iii) technical assistance.5 Component 3: Contingent Emergency Response (UNICEF and WHO - US$0) 44. Having been triggered twice since the start of the project (for famine risk and cholera outbreak), the zero- dollar Contingent Emergency Response Component (CERC) will continue to be in place to provide expedited response in case of emergency. There is a probability that an epidemic or outbreak of public health importance or other emergencies may occur, during the life of the project, causing major adverse economic and/or social impacts. An Emergency Response Operational Manual has been prepared and agreed upon by the IDA to be used if this component is triggered. 5 Technical assistance means the agencies’ advisory services other than consultants’ services on account of monitoring, evaluat ion and supervision of activities under components 1, 2 and 3, including direct staff time for the agencies’ staff assigned from time to time to perform needed services under the project. April 16, 2019 Page 16 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Table 1: Summary of Activities Supported by the EHNP Original Project AF1 (FY17) AF2 (FY18) Proposed AF3 (FY17) Basic health services such as maternal, child and newborn health and nutrition services provided through different modes of delivery through: PHCFs (provided with operating costs, supplies, medicines), outreach services (per diem payment to health workers) and community- based services (community health volunteers delivering nutrition services at the household level, PSS) Community-based Targeted Supplementary Feeding Programs, Blanket Supplementary Feeding Programs for all children and pregnant/lactating women, and fortified nutritious supplements and/or food for households with a malnourished child Subcomponent 1.1 Cholera case treatment centers, emergency (UNICEF) operating centers, community-level operational support to OCV campaigns Scale up community interventions, complement PSS with mental health services, and system strengthening measures. Referral centers and hospitals provided with operating costs, supplies, medicines, equipment, fuel, water to provide continuum of care. Management of SAM cases, BEmONC, CEmONC, non-communicable diseases Response and control of cholera at hospital Subcomponent 1.2 levels, DTCs and ORPs (WHO) Closer coordination between primary and secondary levels for mental health interventions Surveillance, public health campaigns (immunization, neglected tropical diseases, cholera management), specialized institutions such as blood banks Subcomponent 1.3 Integrated Nutrition Surveillance System (WHO) OCV campaigns, lab capacity, electronic disease early warning systems, rapid response teams (a) Rehabilitation of critical infrastructure, Provision of necessary parts, supplies, fuel and other implementation expenses for system operations; and piloting innovative techniques for remote areas. (UNICEF) Subcomponent 1.4 Water supply activities to health facilities (UNICEF and WHO) through the existing public water supply system (WHO) (b) improving local capacity at urban/rural areas, through water safety planning, water quality testing and monitoring; and, capacity April 16, 2019 Page 17 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) building and training of water user associations, enhancing water security by protecting water resources in urban and rural areas (UNICEF) Component 2 M&E, TPM, technical assistance, fiduciary and project management (UNICEF and WHO) Component 3 Expedited response in case of emergency (UNICEF and WHO) 45. Similar to the parent project, the proposed AF3 contributes to the WBG’s twin goals of ending extreme poverty and boosting shared prosperity in a sustainable manner through operationalizing the humanitarian- development nexus as it aims for social inclusion and achieving progress in non-monetary dimensions of welfare. It also supports the HCP for Yemen by working to increase child and adult survival rates and helping to reduce stunting rates. The proposed AF3 directly supports the implementation of the WBG’s expanded Middle East and North Africa Regional strategy (March 2019) which aims to support peace and stability through social and economic inclusion, particularly for the following: (i) renewal of the social contract by preserving inclusive service delivery resilience and improving emergency services to conflict-affected poor; and (ii) resilience to IDP/refugee shocks by strengthening existing public health service delivery mechanisms and improving health and nutrition service delivery to IDPs and local communities. 46. It also directly supports the objective of the Yemen Country Engagement Note (CEN) for FY17-18 (Report No. 106118-YE, discussed by the Board of Executive Directors on July 19, 2016) to provide emergency support to preserve local service delivery capacity to support conflict-affected families and communities. The AF3 is also well aligned with the CEN for FY20-21 (pending discussions by the Board of Executive Directors on May 14, 2019) and its primary objectives – (i) continued support for basic service delivery and institutional preservation; and (ii) extending support to livelihoods, human capital, and basic economic recovery – as it aims to continue the provision of needed health, nutrition, and water and sanitation services and build human capital. Finally, the AF3 enables the delivery of free critical health, nutrition and WSS services to vulnerable populations in an extremely fragile context, which directly contributes to the World Bank Health, Nutrition and Population and Water Global Practices’ goals of supporting progress towards universal health care and ensuring financial protection and service delivery and universal sustainable access to water and sanitation services. 47. To address access to and use of health, nutrition and WSS services and health education from a gender perspective, and to support the project initiatives that include mechanisms for reducing gender differences within varying sociocultural contexts, the project will include: (a) sex-disaggregated data and gender statistics/targets in the project’s results framework, hence ensuring availability of comparable, gender- disaggregated data as part of project monitoring and evaluation which will be important to maintain and enhance the gender lens within the operations; (b) community-based consultations that take into consideration the full and equal participation of women, men, girls and boys; (c) family planning, maternal and reproductive health services, along with basic gender-based awareness on domestic violence and childhood marriage (particularly affecting girls) at the community level, through community health program activities; (d) paying special attention to gender equality in implementation; and (e) improving access and utilization of key public services through creating greater awareness about these services among program patients, specifically women, and facilitating interface between community representatives and local service providers. The project is also aligned with the World Bank Gender Strategy and contributes to the first pillar – “improving gaps in human endowments” - through providing access to health and nutrition services, as well April 16, 2019 Page 18 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) as new knowledge and skills on maternal and child health and nutrition and sanitation and hygiene practices. 48. Table 2 below illustrates the proposed changes in the project’s results framework. The proposed changes are mainly for increased end targets. Table 2: Changes in the Results Framework Progress as Targets for the Revised Cumulative Targets Indicator 6 of October Parent Project with AF3 2018 People who have received essential 13,000,000 14,571,154 16,000,000 health, nutrition and population services7 People provided with access to 1,800,000 1,685,541 2,500,000 improved water sources in cholera affected areas People provided with access to 450,000 250,000 450,000 improved water sources in cholera affected areas - rural8 People provided with access to 1,350,000 1,435,541 2,050,000 improved water sources in cholera affected areas – urban Number of outreach rounds 3,000 4,505 12,000 conducted People who have received hygiene 4,500,000 5,018,000 6,000,000 consumables People vaccinated with oral cholera 10,000,000 725,000 9,000,000 vaccine9 People provided with access to 1,400,000 1,970,000 3,000,000 improved sanitation services in cholera affected areas People provided with access to 150,000 120,000 500,000 improved sanitation services in cholera affected areas - rural People provided with access to 1,250,000 1,850,000 2,500,000 improved sanitation services in cholera affected areas - urban Number of mobile team rounds 1,500 1,172 2,000 6 These targets are the latest ones, revised at the time of the AF2 approval. 7 The targets for the sub-indicators (female 55 percent and IDPs 10 percent) remain unchanged. 8 The target for this indicator is proposed to remain the same because the combination of recent assessments (Multi-Cluster Location Assessment (MCLA), WASH Household Assessment, Partner Assessments, MOWE data and KAP Surveys, etc.) indicated the need for more sanitation interventions than access to improved water sources in rural areas. 9 The target for this indicator is proposed to be reduced due to the decreasing cases of cholera; it may be further adjusted depending on the situation and the capacity built. April 16, 2019 Page 19 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Progress as Targets for the Revised Cumulative Targets Indicator of October Parent Project6 with AF3 2018 Health facilities provided with 800 3,550 3,800 equipment and medical/non-medical supplies (number) Women who have received basic 660,000 564,998 800,000 nutrition services (number) (This will be part of the CRI.10) Children immunized (number) (This 5,500,000 6,900,416 7,000,000 will be part of the CRI.) Pregnant women receiving antenatal 200,000 630,583 700,000 care during a visit to a health provider (number) Births (deliveries) attended by skilled 40,000 182,904 225,000 health personnel (number) (This will be part of the CRI.) New electronic disease early warning 1,200 1,982 2,000 system (eDEWS) data collection sites (number) Health personnel receiving training 7,500 14,826 15,000 (number) Local NGOs involved in service 15 28 30 provision (number) Beneficiaries satisfied with services 30% 70% 60% provided11 Children U5 who have received basic 1,050,000 3,190,766 4,000,000 nutrition services (number) (This will be part of the CRI.) People with suspected cholera, who 300,000 700,000 800,000 have received treatment 10 People who have received essential health, nutrition and population (HNP) services (a Corporate Results Indicator – CRI) was introduced in December 2018 in the results framework as part of the corporate exercise to ensure the inclusion of the CRI in all relevant operations. This change did not require restructuring. This indicator is limited in scope as it is the sum of the following three sub-indicators: “Number of children immunized”, “Number of women and children who have received basic nutrition services”, and “Number of deliveries attended by skilled health personnel”. Hence, the end target of this CRI in the results framework (12,025,000) is smaller than the end target of the first PDO indicator (16,000,000) which has the identical name and a wider scope. 11 The latest data shows 70 percent. An end target of 60 percent is proposed as the methodology of capturing satisfaction will be elaborated and future data may be modest. April 16, 2019 Page 20 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) III. KEY RISKS 49. The nature and level of risks as identified in the parent project remain valid and relevant for the proposed AF3. The overall risk rating is High. This rating stems from the exceptional context of the ongoing conflict and the deteriorating health, nutrition and WSS in the Republic of Yemen. The key risks that may affect the effective implementation of the project include: (i) political and governance; (ii) sector strategies and policies; (iii) macroeconomics; (iv) environmental; (v) technical design; (vi)institutional capacity for implementation and sustainability; (vii) fiduciary; (viii) stakeholders; and (ix) other risks, namely, the lack of official counterpart. The mitigation measures that were identified in the parent project remain valid. 50. Political and governance risks (high). The ongoing conflict in Yemen can negatively affect implementation and supervision, which could result in resource diversion of funds only benefiting population residing in areas linked to political interests. In addition, control of geographical areas by different political or armed factions could lead to interference and inadequate targeting of truly vulnerable people. This challenging environment also poses sector strategies/policies risks (high) with the presence of different health authorities in the country. Maintaining a strong focus on lower level collaboration with communities and primary health facilities and working with politically neutral implementing partners and with different levels of different authorities are key mitigation measures. 51. Macroeconomic risks (high). The economic impact of the crisis has been devastating for Yemen, aggravating an already weak pre-conflict economic performance. The government is unable to fund the operational costs of the health facilities, and there is a risk of salary payments to health personnel continuing to be sporadic or non-existent due to the shortage of public resources. While this project cannot mitigate risks associated with macroeconomics, the project does contribute to maintaining urgently needed public services and local capacities. 52. Environmental risks (high). Environmental risks and impacts that are envisaged under this additional financing would continue to be related to: medical waste management and disposal; impacts related to implementation of WSS interventions; and Occupational Health and Safety (OHS) aspects related to health and WSS interventions. The Environmental and Social Management Framework (ESMF) and the Medical Waste Management Plan (MWMP) haven already been prepared and in place to address any anticipated risks and impacts. Overall, the direct benefits and positive externalities of WSS and health interventions are very large compared to risks and impacts envisaged; nonetheless and considering the challenging environment in which the project is implemented in, the risk rating will be maintained as High. 53. Technical design and institutional capacity risks (substantial). The project builds on the success of the IDA-financed operations in partnership with UN organizations in Yemen and aims to expand currently offered services, which can pose significant risks with regard to the capacity of local service providers in the health and WSS sectors. Risks will be mitigated by the diversity of interventions and implementation modalities currently adopted by UNICEF and WHO through their network of service delivery providers; the strong focus on the communities and on the services that have proven effective will provide reasonable mitigation measures. The security challenge and frequent mobility of the population fleeing heavily conflict-affected areas may compromise the ability of UNICEF and WHO and their implementing partners to adequately identify eligible potential beneficiaries. This will be mitigated by the strong field presence and knowledge of the agencies and their implementation partners. In addition, the project will cover all governorates in Yemen on April 16, 2019 Page 21 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) a needs basis that will follow a transparent, evidence based and pre-agreed upon set of criteria outlined in the technical analysis section. 54. Fiduciary, stakeholder and other risks (high). Risks related to fiduciary, stakeholders, and the lack of official counterpart still remain. In an event of conflict escalation and resulting closure of UNICEF and/or WHO offices in Yemen would be mitigated by the local staff following the business continuity plan for project implementation as much as feasible. To minimize risks related to delivering goods to health facilities, communication and outreach activities are being conducted to inform the public of the EHNP’s support and increase visibility. With regard to procurement delays due to difficulties in importing and transporting goods following an outbreak or mass injuries, such risks will be mitigated by providing retroactive financing for advance planning, using UNICEF’s and WHO’s own available resources to access goods stored in Yemen or nearby countries and by providing implementation expenses for capacity building and operational support. Risks associated with lengthy procurement process will be mitigated by advance planning and delegating authority as needed to the regional procurement adviser. To strengthen fiduciary oversight, TPM is in place and includes fiduciary reviews. Given the limited local TPM capacity in the country, there is a likely risk of poor-quality monitoring or accessibility issues during the project implementation. Therefore, the EHNP is expanding the ongoing TPM arrangements to include more local agencies and thus diversifying the TPM arrangements. This is also complemented by the use of technology for better targeting, delivery of goods and services, and understanding of what is happening on the ground. IV. APPRAISAL SUMMARY A. Economic and Financial Analyses 55. The parent project was projected to have the following direct economic benefits: (i) maternal and child health and nutrition services would yield around US$88 million in lives saved; and (ii) saving lives by providing secondary care would yield US$170 million. Overall, the internal rate of return of 75 percent and a benefit- cost ratio (BCR) of 1.5 are expected. The proposed AF3 will both sustain and complement the activities initiated under the parent project by scaling up the delivery of an integrated package of health, nutrition and WSS services. This will be attained by supporting the ongoing activities with a focus on the integrated package of nutrition interventions, cholera activities and essential health interventions. Therefore, additional economic benefits are likely to occur because of the additional resources provided by the proposed AF3. 56. The additional financial benefits and costs are valuated from the societal perspective. Net benefits and costs are discounted over the expected life of the AF3 through the Discounted Cash Flow method at the social discount rate of 15 percent12 in real terms.13 The timeframe is based on a horizon of six years; the costing of the economic analysis starts in 2019 and ends in 2022, and the benefits flows will start approximately in 2019 and will last till 2022. An effectiveness rate is assumed for each intervention based on previous results of the parent project. 12 Reflecting devaluation that has led to a significant inflation of goods such as food and medicines and services such as health care and sanitation. 13 This is mainly to reflect the preference of the Yemeni population to receive the benefits of the reduced mortality and morbidity earlier than later (time preference) and to explain the increased ambiguity about receiving predicted benefits further into the future (risk premium). April 16, 2019 Page 22 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) 57. This cost-benefit analysis relies on the fact that responding to the persistent severe needs and continuous deterioration of the health, nutrition, water and sanitation systems in Yemen would lead to an improvement in the health outcomes of the EHNP-targeted Yemeni population. Benefits and costs are expressed in USD monetary terms in the analysis, and benefits are expressed on a common basis in terms of their net present value. 58. The AF3 is supporting the response to the critical food insecurity and malnutrition crisis and will ensure that the Yemeni population continues to have access to a package of critical nutrition services. Investment in nutrition, particularly during the first years of life, is one of the highest proven value-for-money development interventions.14 Addressing malnutrition is proven to generate economic benefits through different pathways which all lead to improved human capital, including an increase in future productivity and higher earnings through better cognitive skills, better schooling and higher wages. Moreover, malnutrition is one of the risk factors of chronic diseases and is usually closely linked to mortality. 59. Hodinot et al (2013), for instance, have estimated that each dollar invested in reducing stunting through nutrition interventions would yield US$13.4-US$28.6 in positive economic returns. Accordingly, and given the focus of this AF on nutrition, it alone would generate more than US$1 billion in economic returns and future productivity, considering the current context of the country and the varying implementation capacity across governorates. 60. With the effective coverage of the target population, the AF3 will support the provision of relevant maternal and childhood health services. Women and their children bear the biggest health burden in Yemen. The under-five child mortality (55.4 per 1000 live births) is among the highest in the Middle East and North Africa region while the maternal mortality rate is one of the highest in the world (385 per 100,000 live births) with only a 45 percent chance that her delivery will be attended by a skilled health professional. Providing free health care services is found to increase the health care utilization and reduce the child and maternal mortality rates in underdeveloped countries (Gulmezoglu, 2016; Figueirdo, 2018). 61. Given the success achieved so far through the project in increasing the utilization rates of the health care services (providing antenatal care to half a million women and immunization services to 6.5 million children), AF3 is expected to increase the health care coverage which will directly help avert the maternal and under five deaths in the country, which are preventable if services are provided at appropriate times. Thus, if the average under-5 mortality rate and Maternal Mortality Ratio are applied to this project’s target population, around 222,000 mortalities could be estimated. Applying a four-year societal perspective and assuming a modest effectiveness of 25 percent, the project would be expected to save 55,500 lives annually. With a conservative estimated value of statistical life (VSL)15 in Yemen at US$10,000 for each life‐year saved, this would yield an estimated annual economic benefit of US$345 million. 14 as concluded by Alderman et al (2016) and Hodinot et al (2013) who demonstrated that all targeted nutrition interventions have a Benefit Cost Ratio of well above 1.0. 15 Given the income elasticity (0.5‐0.9) of statistical value of life (VL = VLY * LY where VLY=Value of Life year and LY=Life expectancy in Years), Viscusi and Aldy (2003) April 16, 2019 Page 23 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) B. Technical Design: 62. The proposed AF3 would follow the same technical design and implementation arrangements as the parent project.16 The design builds on the important lessons learned from the EHNP and other IDA-financed projects in Yemen and from IDA engagements in emergency health and nutrition and WSS operations in other fragility, conflict and violence (FCV) countries. This accumulated experience builds on: (i) using a design that allows room for flexibility in response to the changing socio-political and sectoral challenges; (ii) working with UN partners in times of conflict to achieve optimal penetration of services to the citizens; (iii) using and strengthening the local technical and implementation capacity to preserve the future developmental prospects of Yemen; (iv) maintain the support to existing services which have shown success since the start of the project and expanding into other services which have been shown to be necessary for the needs of the population, e.g. psycho-social and mental health support and boosting the community health program; (v) building a knowledge platform and generating adequate evidence for informing the operational directions and supporting nationwide policy decisions; (vi) creating strong coordination platforms with other donors and international organizations; and (vii) heavily relying on the use of technology for service provision, supervision, monitoring and planning. 63. This AF3 will maintain implementation responsibility with UN agencies in an FCV context. This modality uses the strong stewardship and implementation oversight offered through the UN partners, while optimizing the use of available capacities at the decentralized levels, which in turn helps to preserve and maintain the capacities for developmental objectives. Both agencies will aim to: (i) train, equip and retain the existing, and new, human capacities working at the local levels; (ii) preserve the functionality of the existing facilities providing direct services to the population; and (iii) address urgent challenges that may threaten the overall long-term developmental potential of the country. Targeting: 64. The targeting will continue to be nationwide with a focus on the highly-affected areas using prioritization and needs assessment tools, e.g. Vulnerability Matrix developed by WHO, HeRAMS 2018, epidemiological tracking and surveillance system. The proposed nationwide interventions will be tailored according to: (i) the population’s needs based on objective assessments and reliable analyses; (ii) implementation capacity of the local health and water authorities; and (iii) the security and accessibility situations. Therefore, the targeting methodology for the interventions is reviewed periodically to ensure adequate responsiveness. C. Financial Management 65. The financial management (FM) arrangements under the proposed AF3 will be governed by the Financial 16UNICEF and WHO, the implementing agencies, are the key players of the Health, Nutrition and WASH Clusters of Partners in Yemen. They implement the EHNP and deliver essential services using their existing channels and network of providers, governorate health offices (GHOs), district health offices (DHOs) and international/local NGOs. UNICEF supports services at PHCFs and through outreach/mobile teams formed from PHCFs and uses GHOs/DHOs in their supervisory and monitoring roles. WHO works at the secondary level to provide operational and capacity support and oversees national targeted campaigns. April 16, 2019 Page 24 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Management Framework Agreement, consistent with the parent project. The nature and level of risks and mitigating measures as identified in the parent project remain valid and relevant for the proposed AF3. Mitigation measures are built into the project design and continue to be monitored and managed using a working risk matrix closely reviewed during implementation support missions. Both UNICEF and WHO have continued to update the risks, impact and mitigating measures. They use their own staff, consultants and third-party agencies to monitor implementation of the project. Additionally, significant progress has been made to leverage technology to enhance real-time and remote monitoring as summarized below: • Geo-tagging - Real time monitoring of physical implementation of WASH urban sub-projects. • Remote sensors - Real time monitoring of the fuel consumption of the main water pumps, which will be scaled up covering all main fuel storage tanks. • Real time end user monitoring of project implementation through two-way exchanges (SMS based) with health workers. • Remote sensors and Global Positioning System (GPS) – monitoring and tracking supplies, drugs and equipment. The Bank team along with WHO and UNICEF developed an implementation plan to use remote sensors to monitor goods. In January 2019, WHO successfully piloted a shipment tracking system monitoring the movement and temperature of goods using GPS connected to the Global System for Mobile network. The team is currently discussing the development of a monitoring tool which can be transferred to the authorities to enhance planning, transparency and accountability in delivery of goods. This will be developed in the context of building the local capacity of the supply chain management system, financial management, procurement, warehousing, stock management, distribution, to help local government authorities. 66. Financial management capacities and systems of implementing partners engaged by UNICEF and WHO are assessed to determine the risks and required risk assurance intervention including programmatic visits, spot checks and financial audits. A workflow process indicating the timing, accountability and verification of field monitoring visits and spot checks is developed to ensure that the planning and follow-up of assurance activities are done at the field office-level with appropriate oversight and support from the national office. Some of the partners have already been identified as high risk because of either weaker financial management systems or previous negative experiences and alternative implementation arrangements are established (i.e. working through other partners with strong capacities). UNICEF and WHO report to the IDA a summary of the financial management issues and actions taken as part of the progress reports, which are reviewed and monitored closely during implementation support missions. 67. The banking/liquidity crisis in Yemen continue to affect the program implementation and payments to implementing partners. However, UNICEF and WHO have been able to secure agreements with banks to avail or deliver local currency or USD as needed. UNICEF is using commercial banks as a third-party modality to pay the health workers directly. In locations with bank branches, health workers are requested to open bank accounts. For locations without bank branches, the agreement with the commercial bank provides for using exchange companies to deliver payments. UNICEF verifies the list of health workers to ensure payments are made only to health workers engaged in delivery of project activities. 68. Withdrawals from the AF3 will be made based on Interim Unaudited Financial Reports (IFRs). UNICEF and WHO will prepare and submit IFRs in accordance with the format and periodicity agreed with the World Bank. Disbursements and flow of funds under the parent project and AFs for both UNICEF and WHO have been April 16, 2019 Page 25 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) processed efficiently and in a timely manner. UNICEF and WHO will continue to maintain their FM systems and separate ledger accounts to record transactions of the project and prepare and submit to the Bank six- monthly IFRs showing receipts and expenditures. Overall, the FM and disbursement arrangements have worked well and remain adequate for the proposed AF3. Both UNICEF and WHO will continue with their independent monitoring systems through programmatic visits focusing on implementation issues and utilization of resources by national and local partners, as well as spot checks, and financial audits. A third- party monitoring agency will continue to verify implementation progress and carry out spot checks to assess partners’ FM and internal controls in line with the UN Harmonized Approach to Cash Transfers (HACT). The results of these assessments and TPM reports will be shared with the World Bank and contribute to the World Bank’s implementation support of the project. D. Procurement 69. The proposed AF3 does not introduce any major changes to the technical design or the implementation arrangements of the project, including the nature of procurement activities. The procurement arrangements of the proposed AF3 will thus be similar to those of the parent project and its AFs and Alternative Procurement Arrangements (APA) will be applied under the proposed AF3 as defined in the Financing Agreement. This is in line with the World Bank’s procurement framework (Section III.F), given that UNICEF and WHO procurement procedures were assessed and found acceptable to the World Bank. The proposed project is processed under the paragraph 12 of the Bank Policy on Investment Project Financing (Projects in Situations of Urgent Need of Assistance and Capacity Constraints), given the ongoing violence and instability. The proposed project is also prepared within the context of OP 2.30 (Development Cooperation and Conflict). Since there is no official government counterpart to sign the financing agreement, it is proposed that UNICEF and WHO be the grant recipients and implementing agencies for the proposed IDA grant. UNICEF and WHO will implement the AF3, given their solid experience and proven track record and satisfactory performance in implementing the ongoing parent project. This experience along with their capacity, field presence and social protection mandate, make UNICEF and WHO the most suitable partners for the World Bank to continue implementing the proposed AF3. Under the AF3, UNICEF and WHO will continue contracting several consultancy services, including TPM agencies as part of the monitoring activities to follow up on implementation and ensure that the agreed upon procedures are followed and to report on any deviations. 70. UNICEF and WHO will follow their own procurement rules and procedures; therefore, no contracts will be subject to prior or post review. The use of the World Bank’s Systematic Tracking of Exchanges in Procurement tool will not be required under this project. However, UNICEF and WHO are using their own tracking systems which generate procurement related reports on a regular basis. E. Social (including Safeguards) 71. The health activities under component 1 of the proposed AF3 will continue service delivery at the PHC level to provide the essential health and nutrition services to the population, the delivery of MSP with a particular focus on integrating the MNH, child nutrition, improve the access to psycho-social support (PSS) and mental health services within the primary health care facilities. In addition, WSS activities under subcomponent 1.4 will include the improvement of access to safe water and sanitation at households, schools and health facilities. It will include the rehabilitation and maintenance of existing water and sewerage facilities both in urban and rural areas. It will also include chlorination of water pipe network and the private water April 16, 2019 Page 26 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) tankers. Based on the proposed activities mentioned above, OP 4.12 will not be triggered since no land acquisition, loss of livelihood income or restriction to access parks and cultural sites is expected. The AF3 is not expected to have any negative impacts or issues related to gender-based violence or harm on individuals because the types of activities are meant to enhance and provide positive services with focus on integrating the maternal and newborn health. Additionally, the project will ensure continued health services delivery to vulnerable and most needed groups especially in rural and remote areas. 72. Grievance Redress Mechanism (GRM). Currently, both UNICEF and WHO are relaying on the call center of the TPM agency to receive calls, register and forward complaints to the authorized persons at UNICEF and WHO. In addition, other channels are adopted like WhatsApp, complaint boxes, and brochures which are distributed among targeted beneficiaries with contact information and details. All complaints are tracked, resolved and closed in a timely manner and the TPM conducts satisfaction survey at targeted locations during monitoring and reports the results. For the AF3, both implementing entities will enhance the communication and awareness campaign of the GRM at the central level and the targeted communities through different channels like NGOs, TV and Radio announcements and social media. F. Environment (including Safeguards) 73. According to the OP 4.01 on Environmental Assessment, this proposed AF3 is classified as Environmental Category B. Activities to be supported will scale up the ongoing interventions under the EHNP. 74. To ensure proper management of potential environmental impacts, the existing MWMP prepared for the parent project as well as the ESMF (disclosed on January 25, 2017 and October 2, 2017, respectively, on the World Bank’s external website) will continue to be implemented under the proposed AF3. 75. As per the ESMF, subprojects that are implemented under the project undergo initial screening for potential environmental and social impacts by each implementing organization, i.e. WHO and UNICEF. Based on the initial screening, proper risk level is assigned to the subproject considering its anticipated impacts, and subsequently proper safeguards instruments are prepared, if needed. The safeguards instrument is then submitted it to the IDA for revision and clearance. This includes subprojects involving supplying pumps and motors which require implementing OHS measures and might have potential environmental impacts. 76. The implementation of the MWMP will continue under this operation for ensuring proper management of medical waste that is generated under the project. Measures to be implemented include, but not limited to, supplying personal protective equipment (PPE), safety boxes and containers for fixed health facilities and for mobile outreach vaccination campaigns; training of health care providers on managing medical waste; and proper storage of vaccines to prevent generation of waste that would result from improper storage or expiration of vaccines. To that end, the project under the operation will continue providing refrigeration units – if needed - to some health care units as well as solar panels to secure continuous supply of energy to storage units. Measures for mitigating the risk of transferring infectious diseases to health care workers will be implementing include distributing proper PPEs, and training health care staff on infection control measures and medical waste management at health facilities. 77. As part of the MWMP, the implementing organizations will ensure that the ‘cycle’ of waste management is complete i.e. from segregation to safe disposal. To that end, proper measures will be implemented for April 16, 2019 Page 27 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) supporting proper segregation, collection, storage and transportation of waste for safe disposal e.g. incineration. 78. Institutional Arrangements. The project will use the existing institutional arrangement which includes two Environmental and Social Officers at the central level for supervising the implementation of safeguards’ measures and procedures which are provided under the project’s ESMF and MWMP. At the regional level and for the purpose of on-site management and monitoring of environmental and social safeguards aspects, five safeguard Focal Points are assigned under each implementing organization. The project will continue to use TPM agencies to enhance on-site monitoring and reporting. These arrangements have enhanced the performance and compliance of implementing agencies with safeguards guidelines and requirements and have strengthened the management of environmental safeguards aspects including occupational health and safety risks. To date, no significant impacts or risks are recorded or reported under the project. 79. Capacity Building. Training sessions and capacity building activities will continue to be conducted under this operation before major health activities such as vaccination campaigns or as part of the support provided to the health facilities. The training targets health care workers and managers and cover topics of medical waste management such as waste segregation, collection, transportation and final disposal as well as mitigating the risk of transferring infectious diseases. G. Climate Change Adaptation 80. Climate change threatens food security in Yemen. Average annual temperatures in the project area, already 1.4 ⁰C above pre-industrial levels, are projected to rise 3.3 ⁰C by 2060 and 5.7 ⁰C by 2100.17 Recently observed drought-induced crop failure has caused starvation among subsidence farmers, and deeper food insecurity for women and children in both rural and urban areas. Agricultural output, which is below levels achieved half a century ago, could fall further at a time when over 80 percent of cereal grains are imported but not distributed due to blockades (FAO 2018). Small-scale artisanal fisheries, another vital source of nutrition and income in vulnerable communities, are rapidly declining as fish stocks plummet from climate- induced ocean acidification, deoxygenation, and habitat destruction.18 As food supply drops, prices rise further impairing the ability of the poor to adapt. The UN calls “the devastating food insecurity” in Yemen the world’s worst humanitarian crisis since the institution was founded in 1945. 81. Rising temperatures will also exacerbate water scarcity and natural disaster risk. Yemen’s limited surface water supplies evaporate faster in hotter weather while ground aquifers, already among the most stressed in the world, struggle to replenish amidst arid conditions (World Resources Institute Aqueduct and World Bank 2018). Groundwater tables are declining between two and seven meters annually.19 Further depletion of water resources is expected to reduce agricultural output by 40 percent (World Bank 2010).20 When land, already severely degraded by conflict, refugees, and poverty, is exposed to higher temperatures and climate-induced variable precipitation, the results are catastrophic. Flood damages increase as there is 17 World Bank Climate Change Knowledge Portal based on a business-as-usual emissions scenario (RCP8.5). 18 A “dead zone” the size of Scotland completely devoid of oxygen and marine life was recently discovered off the coast of Yemen . As fish migrate to cooler waters, FAO data shows nearly 90 percent of fish stocks in the Gulf of Aden and the Southern Red Sea are depleted (fully exploited, over-exploited, or collapsed). 19 Yemen’s Individually Determined National Contribution to the UNFCCC Paris Agreement, p10. 20 World Bank (2010), “Yemen – Assessing the Impacts of Climate Change and Variability on the Water and Agricultural Sectors .” April 16, 2019 Page 28 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) no vegetation to absorb rainfall.21 Denuded biomass speeds the expansion of desertification. By 2050, water shortages are expected to reduce GDP in Middle East and North Africa countries by 6 to 14 percent (World Bank 2018).22 According to the Notre Dame Global Adaptation Index, which measures overall climate risk, Yemen is one of the most vulnerable and least ready countries in the world, ranking 167 out of 181 nations.23 82. Public health will suffer from climate change as well. Nutritional deficits stemming from climate-induced food insecurity are projected to dramatically increase childhood stunting within coming decades. Livelihood disruption from extreme weather will aggravate mental health problems. Mortality and morbidity from heat- related illnesses, such as skin cancer, heat stroke, and cardiovascular disease, are also forecasted to rise as heat waves move from a current baseline of less than 10 days per year to 30 days per year by 2030 and 150 days per year by 2100.24 Pre-mature deaths among the elderly could increase by 1,400 percent by the end of the century (WHO and the United Nations Framework Convention on Climate Change 2015). More frequent storms and flooding is expected to amplify the incidence of infectious disease such as cholera, diphtheria, and dengue, which spread along water and mosquito-borne vectors. The warmer and wetter conditions forecasted in Yemen as well as greater water salinity from sea level rise promote the growth of vibrio cholerae bacteria.25 Flash floods, moreover, could contaminate water supplies with fecal matter and expand existing cholera outbreaks. Experts also predict a rise in schistosomiasis, lymphatic filariasis, scabies, and malaria cases.26 Finally, more extreme weather coupled with water scarcity and higher temperatures will impair the ability of Yemen’s health system to respond to the challenges above. Essential medical supplies and personnel may be unavailable after natural disasters thus limiting treatment options for cholera, diphtheria, and dengue -- diseases that can be cured or prevented with antibiotics, freshwater (rehydration), vaccinations, and comfortable bedrest. 83. Negative climate impacts will disproportionately affect Yemen’s vulnerable populations. Low income groups lack the resources to withstand higher temperatures, sea level rise, erratic rainfall, and other natural disasters (Hallegatte, World Bank 2016), and poor Yemenis make up half of the country’s population.27 In 2016, Yemen’s GDP per capita was US$660.28. Hence, citizens not only lack sufficient financial wherewithal to cope with climate shocks, but research also demonstrates that the bottom 40 percent in MENA suffer the highest economic losses from extreme weather (Wooden, World Bank 2014). Climate-induced shocks, which reduce food security, water supply, and income levels, can be catastrophic for the vulnerable. In the short term, extreme weather contributes to injuries, household food insecurity, disease and disability, increased population displacement, and economic insecurity. In the medium term, Yemen’s economy is expected to contract up to 24 percent by 2050 due to climate change (Verner, World Bank 2013). 84. Yemen Country Engagement Note reinforces these findings. It underscores the nation’s vulnerability to climate change, lack of adaptive capacity, and recommends that operations incorporate disaster risk 21 In 2015 and 2018, Cyclones Chapala, Mekanu, and Luban struck Yemen, caused widespread flooding, killed dozens of people, and resulted in billions in property losses. These storms were caused in part by record-breaking sea surface temperatures. 22 World Bank (2018), “Beyond Scarcity: Water Security in the Middle East and North Africa.” 23 ND-GAIN Country Index, 2019. 24 World Bank (2014), “Turn Down the Heat: Confronting the New Climate Normal”, p159. 25 Lipp et al (2002), “Effects of Global Climate on Infection Disease: the Cholera Model,” Clinical Microbiology Reviews, pp757-770. 26 World Bank (2014), “Turn Down the Heat: Confronting the New Climate Normal”, p130, 169. 27 The latest poverty headcount ratio of 48.6% is from 2014. The percentage may be higher now after four years of conflict. April 16, 2019 Page 29 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) management into their design.28 85. The proposed operation alleviates climate-induced health impacts, food insecurity, and water scarcity by strengthening the provision of basic health, nutrition, and WASH services among affected populations. Climate change negatively impacts the health outcomes of Yemenis, especially for women and children living in poverty. Poor health and degraded WASH infrastructure weaken the country’s adaptive resilience and impair Yemen’s ability to cope with climatic shocks. 86. Components of EHNP AF3 explicitly foster climate adaptation through three pillars . The supported services not only treat and prevent malnutrition and diseases of today but build resilience for the future by increasing immunity (through immunization) so children can grow stronger and battle diseases better throughout life. Thus, the project helps beneficiaries and caregivers adapt to any change in morbidity patterns. • Food security and nutrition support. Climate-induced drought, extreme heat, desertification, and ocean acidification / deoxygenation are compromising Yemen’s agricultural and fisheries productivity. Furthermore, given Yemen’s high dependence on food imports, the country is exposed price swings and shortages stemming from external weather shocks (i.e., collapse of Russian wheat crop in 2010). o Subcomponent 1.1 (US$60 million / US$95 million), strengthening food security and balanced nutrition among vulnerable mothers and children, including IDPs, through the TFSP and BSFP; also generating capacity around and demand for nutrition services. Maternal and newborn nutritional health, including the treatment of malnutrition and community-based awareness campaigns and screening, is a strong focus of subcomponent 1.1. o Subcomponent 1.2 (US$15 million / US$40.8 million), supporting in-patient TFCs. o Subcomponent 1.3 (US$5 million / US$19 million), establishing an INSS, which is designed to foster food security through the timely disbursement of nutritional health information to national decision makers. • Disease surveillance and treatment (both communicable and non-communicable). Better monitoring reduces natural disaster risk while more accessible and affordable treatment improves national capacity to handle climate-health impacts. Moreover, involving local communities in health sector planning as well as disease surveillance and treatment builds resilient systems that not only yield sustainable, long-term outcomes but also enable on-the-ground stakeholders to address and manage future challenges, including those related to climate change. o Subcomponent 1.1 (US$10 million / US$95 million), dispatching mobile outreach teams to rural areas, facilitating local stakeholder engagement and community-based health interventions, investing in cholera prevention and treatment, and creating demand for health services. The subcomponent also focuses on psycho-social and mental health services for children in need. This is salient because climate change is extremely disruptive, and its associated stress (i.e., loss of livelihood, involuntary migration) damages mental health. o Subcomponent 1.2 (US$10 million / US$40.8 million), enabling non-communicable disease screening through a network of first-level referral centers and funding the operation of 28 World Bank (2016), “Yemen Country Engagement Note, FY17-FY18,” p9-10, 31, 32, 34, 54-56. Also in Box 6 “Cross cutting topics: climate, gender, youth, resilience” of the CEN for FY20-FY21, pending discussions by the Bank’s Board of Executive Directors on May 14, 2019. April 16, 2019 Page 30 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) nationwide blood banks. This latter activity is climate-smart because it increases adaptive capacity towards increasingly frequent extreme weather such as floods and cyclones, events that cause bodily harm and blood loss (i.e., collapsing buildings, sharp waterborne debris). o Subcomponent 1.3 (US$10 million / US$19 million), fostering preventative health activities to curb disease outbreaks, strengthening diagnostic capacity of laboratories at the governate level, and maintaining the electronic Disease Early Warning System (eDEWS). These measures allow Yemen to respond to climate-health shocks in an evidence-based, multi-sectoral manner. • Water and sanitation infrastructure improvement. Strengthening WASH services reduces water scarcity and promotes public health. Clean freshwater supplies and hygienic sanitation facilities contribute to the treatment and prevention of climate-exacerbated diseases such as cholera (curbing water contamination and hydrating patients), scabies (washing skin and laundering infected bedding/clothes in hot water), and dengue and diphtheria (drinking fluids to recover or to dissolve anti-biotics and reducing mosquito spawning grounds). o Subcomponent 1.1 (US$5 million / US$95 million), engaging the community and generating demand for water and sanitation services. o Subcomponent 1.4 (US$35.2 million / US$35.2 million), improving access to safe drinking water through bulk chlorination and community education and strengthening overall resilience among WASH systems by providing critical infrastructure maintenance and restoration, protecting water security through nature-based solutions in select rural and urban areas, and improving national, local, and household capacity to cope with waterborne disease outbreaks. V. WORLD BANK GRIEVANCE REDRESS 87. Communities and individuals who believe that they are adversely affected by a World Bank (WB) supported project may submit complaints to existing project-level grievance redress mechanisms or the WB’s Grievance Redress Service (GRS). The GRS ensures that complaints received are promptly reviewed in order to address project-related concerns. Project affected communities and individuals may submit their complaint to the WB’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of WB non-compliance with its policies and procedures. Complaints may be submitted at any time after concerns have been brought directly to the World Bank's attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate Grievance Redress Service (GRS), please visit http://www.worldbank.org/en/projects-operations/products-and-services/grievance-redress-service. For information on how to submit complaints to the World Bank Inspection Panel, please visit www.inspectionpanel.org April 16, 2019 Page 31 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) VI SUMMARY TABLE OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Implementing Agency ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔ VII DETAILED CHANGE(S) COMPONENTS Current Component Name Current Cost Action Proposed Component Proposed Cost (US$, (US$, millions) Name millions) Improving Access to Health, 460.57 Revised Improving Access to 650.57 Nutrition, and Public Health Health, Nutrition, Public Services Health, and Water and Sanitation Services Project Support, 22.43 Revised Project Support, 32.43 Management, Evaluation Management, and Administration Evaluation and April 16, 2019 Page 32 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Administration Contingent Emergency 0.00 Contingent Emergency 0.00 Response Response TOTAL 483.00 683.00 LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Current Proposed Proposed Deadline Closing(s) Closing for Withdrawal Applications IDA-D1630 Effective 31-Jan-2020 31-Jan-2020 30-Jun-2022 30-Oct-2022 IDA-D1640 Effective 31-Jan-2020 30-Jun-2020 30-Jun-2022 30-Oct-2022 IDA-D1950 Effective 31-Jan-2020 30-Jun-2020 30-Jun-2022 30-Oct-2022 IDA-D1960 Effective 31-Jan-2020 31-Jan-2020 30-Jun-2022 30-Oct-2022 IDA-D2310 Effective 30-Jun-2020 30-Jun-2020 30-Jun-2022 30-Oct-2022 IDA-D2320 Effective 30-Jun-2020 30-Jun-2020 30-Jun-2022 30-Oct-2022 Expected Disbursements (in US$) DISBURSTBL Fiscal Year Annual Cumulative 2017 79,900,000.00 79,900,000.00 2018 229,599,999.97 309,499,999.97 2019 173,500,000.03 483,000,000.00 2020 150,000,000.00 633,000,000.00 2021 50,000,000.00 683,000,000.00 2022 0.00 683,000,000.00 2023 0.00 683,000,000.00 SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Latest ISR Rating Current Rating Political and Governance ⚫ High ⚫ High Macroeconomic ⚫ High ⚫ High Sector Strategies and Policies ⚫ High ⚫ High April 16, 2019 Page 33 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Technical Design of Project or Program ⚫ Substantial ⚫ Substantial Institutional Capacity for Implementation and ⚫ Substantial ⚫ Substantial Sustainability Fiduciary ⚫ High ⚫ High Environment and Social ⚫ High ⚫ High Stakeholders ⚫ High ⚫ High Other ⚫ High ⚫ High Overall ⚫ High ⚫ High LEGAL COVENANTS2 LEGAL COVENANTS – Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Sections and Description OPS_LEGAL_CONVENANT_CHILD_NODATA No information available Conditions April 16, 2019 Page 34 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) VIII. RESULTS FRAMEWORK AND MONITORING Results Framework COUNTRY: Yemen, Republic of RESULT_NO_PDO Yemen Emergency Health and Nutrition Project Third Additional Financing Project Development Objective(s) To contribute to the provision of basic health, essential nutrition, water and sanitation services for the benefit of the population of the Republic of Yemen. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 To contribute to the provision of basic health and essential nutrition services for the Yemenis People who have received essential health, nutrition 0.00 10,000,000.00 15,000,000.00 15,300,000.00 15,600,000.00 16,000,000.00 16,000,000.00 and population services (Number) Rationale: The end target is revised: (1) because the target has been surpassed; and (2) reflecting the additional resources and the extended implementation period. As Action: This indicator has before, this indicator counts individuals who have benefited from one or more of the various health and nutrition services supported by the project (e.g. been Revised maternal and newborn health care, maternal and child nutrition including screening and treatment of malnutrition, screening and first referral level treatment of non-communicable diseases, psycho-social services, immunization and other child health services, treatment of diarrhea and so on.) People who have received essential health, nutrition and 0.00 50.00 55.00 55.00 55.00 55.00 55.00 population services (% female) (Percentage) April 16, 2019 Page 35 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Rationale: Action: This indicator Intermediate targets are added; the end target remains the same. has been Revised People who have received essential health, nutrition and 0.00 5.00 10.00 10.00 10.00 10.00 10.00 population services (% IDPs) (Percentage) Rationale: Action: This indicator Intermediate targets are added; the end target remains the same. has been Revised People who have received essential health, nutrition and 0.00 40.00 50.00 50.00 50.00 50.00 50.00 population services (% children under 5) (Percentage) Rationale: Action: This indicator Intermediate targets are added; the end target remains the same. has been Revised To contribute to the provision of water and sanitation services for the Yemeni population People provided with access to improved water 0.00 1,000,000.00 1,680,000.00 2,075,000.00 2,300,000.00 2,500,000.00 2,500,000.00 sources in cholera affected areas (Number) Rationale: Action: This indicator has The end target is revised, reflecting the additional resources and the extended implementation period. been Revised April 16, 2019 Page 36 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 People provided with access to improved water sources in cholera 0.00 150,000.00 250,000.00 350,000.00 400,000.00 450,000.00 450,000.00 affected areas - rural (Number) Rationale: Intermediate targets are added; the end target remains the same. The target for this indicator is proposed to remain the same because the combination of Action: This indicator recent assessments (Multi-Cluster Location Assessment (MCLA), WASH Household Assessment, Partner Assessments, MOWE data and KAP Surveys, etc.) has been Revised indicated the need for more sanitation interventions than access to improved water sources in rural areas. People provided with access to improved water sources in cholera 0.00 1,430,000.00 1,430,000.00 1,750,000.00 1,900,000.00 2,050,000.00 2,050,000.00 affected areas - urban (Number) Rationale: Action: This indicator The end target is revised, reflecting the additional resources and the extended implementation period. has been Revised PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Improving Access to Health, Nutrition, and Public Health Services Number of outreach rounds conducted (Number) 0.00 1,500.00 4,500.00 7,500.00 10,000.00 12,000.00 12,000.00 Action: This indicator has Rationale: been Revised April 16, 2019 Page 37 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 The end target is revised: (1) because the previous target has been surpassed; and (2) reflecting the additional resources and the extended implementation period. People who have received hygiene consumables 0.00 3,000,000.00 5,000,000.00 5,300,000.00 5,600,000.00 6,000,000.00 6,000,000.00 (Number) Rationale: Action: This indicator has The end target is revised: (1) because the initial target is nearly achieved; and (2) reflecting the additional resources and the extended implementation period. been Revised People vaccinated with oral cholera vaccine (Number) 0.00 300,000.00 750,000.00 5,000,000.00 8,000,000.00 9,000,000.00 9,000,000.00 Rationale: Action: This indicator has been Revised The target for this indicator is reduced due to the decreasing cases of cholera; it may be further adjusted depending on the situation and the capacity built. People provided with access to improved sanitation services in 0.00 1,000,000.00 2,000,000.00 2,250,000.00 2,680,000.00 3,000,000.00 3,000,000.00 cholera affected areas (Number) Rationale: Action: This indicator has The end target is revised: (1) because the initial target has been surpassed; and (2) reflecting the additional resources and the extended implementation period. been Revised People provided with access to improved sanitation services in 0.00 9,000.00 120,000.00 300,000.00 400,000.00 500,000.00 500,000.00 cholera affected areas - rural (Number) April 16, 2019 Page 38 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Rationale: Action: This indicator The end target is revised: (1) because the initial target has been achieved; and (2) reflecting the additional resources and the extended implementation period. has been Revised People provided with access to improved sanitation services in 0.00 800,000.00 1,850,000.00 2,100,000.00 2,400,000.00 2,500,000.00 2,500,000.00 cholera affected areas - urban (Number) Rationale: Action: This indicator The end target is revised: (1) because the initial target has been surpassed; and (2) reflecting the additional resources and the extended implementation period. has been Revised Number of mobile team 0.00 750.00 1,200.00 1,500.00 1,800.00 2,000.00 2,000.00 rounds (Number) Rationale: Action: This indicator has The end target is revised, reflecting the additional resources and the extended implementation period. been Revised Health facilities provided with equipment and 0.00 150.00 3,500.00 3,650.00 3,750.00 3,800.00 3,800.00 medical/non-medical supplies (Number) Rationale: Action: This indicator has The end target is revised: (1) because the previous target has been surpassed; and (2) reflecting the additional resources and the extended implementation been Revised period. For the remaining period, however, the efforts will be focused on maintaining the functionality of the facilities already being supported by the project. Children immunized 0.00 5,000,000.00 5,500,000.00 5,500,000.00 5,500,000.00 (number) (Number) Rationale: Action: This indicator has The data will be captured under the CRI (children immunized is one of the sub-indicators). been Marked for Deletion April 16, 2019 Page 39 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Pregnant women receiving antenatal care during a visit 0.00 100,000.00 630,000.00 650,000.00 680,000.00 700,000.00 700,000.00 to a health provider (Number) Rationale: Action: This indicator has The end target is revised: (1) because the initial target has been surpassed; and (2) reflecting the additional resources and the extended implementation period. been Revised Births (deliveries) attended by skilled health personnel 0.00 20,000.00 40,000.00 40,000.00 40,000.00 (number) (Number) Rationale: Action: This indicator has been Marked for Deletion The data will continue to be captured under the CRI (births attended by skilled health personnel is one of the sub-indicators). New electronic disease early warning system 0.00 300.00 1,982.00 2,000.00 2,000.00 2,000.00 2,000.00 (eDEWS) data collection sites (Number) Rationale: Action: This indicator has been Revised The end target is revised as the previous target has been surpassed. Health personnel receiving training (Number) 0.00 2,000.00 14,000.00 14,300.00 14,600.00 15,000.00 15,000.00 Rationale: Action: This indicator has been Revised The end target is revised as the previous target has been surpassed. The AF3 will focus on retraining rather than training more health workers. Number of community nutrition sites covered by a new Integrated Nutrition 0.00 40.00 90.00 500.00 900.00 1,100.00 1,100.00 Surveillance System (Number) April 16, 2019 Page 40 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Rationale: Action: This indicator has The end target remains the same; intermediate targets are entered. been Revised People who have received essential health, nutrition, 0.00 7,000,000.00 10,000,000.00 10,835,000.00 11,500,000.00 12,025,000.00 12,025,000.00 and population (HNP) services (CRI, Number) Rationale: Action: This indicator has This corporate results indicator (CRI) is introduced as per the corporate requirement. This indicator is limited in scope as it is the sum of the following three sub- indicators: (i) children immunized; (ii) deliveries attended by skilled health personnel; and (iii) women and children receiving nutrition services. Although the been Revised name of the indicator is identical to the first PDO indicator, this CRI will have smaller figures due to its narrow definition. Number of children immunized (CRI, 0.00 4,000,000.00 6,500,000.00 6,660,000.00 6,800,000.00 7,000,000.00 7,000,000.00 Number) Rationale: Action: This indicator The data have been captured as a stand-alone indicator, but with the AF3, as a sub-indicator of the CRI. The end target is revised as the previous target has has been Revised been surpassed. Number of women and children who have received basic nutrition 0.00 3,000,000.00 3,500,000.00 4,000,000.00 4,500,000.00 4,800,000.00 4,800,000.00 services (CRI, Number) Rationale: This indicator is the sum of the two indicators: "Women who have received basic nutrition services"; and "Children U5 who have received basic nutrition Action: This indicator services". The end target is revised as follows: for children=4,000,000 and for women=800,000. The end target is revised as the previous target has been has been Revised surpassed. Number of deliveries 0.00 100,000.00 150,000.00 175,000.00 200,000.00 225,000.00 225,000.00 attended by skilled April 16, 2019 Page 41 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 health personnel (CRI, Number) Rationale: Action: This indicator The data have been captured as a stand-alone indicator, but with the AF3, as a sub-indicator of the CRI. The end target is revised as the previous target has has been Revised been surpassed. Project Support, Management, Evaluation and Administration Local NGOs involved in service provision (number) 0.00 7.00 28.00 30.00 30.00 30.00 30.00 (Number) Rationale: Action: This indicator has The end target is revised because the initial target has been surpassed. been Revised Beneficiaries satisfied with services provided 0.00 20.00 60.00 60.00 60.00 60.00 60.00 (Percentage) Rationale: Action: This indicator has The latest data shows 70 percent, but an end target is 60 percent as the methodology of capturing satisfaction will be elaborated and future data may be been Revised modest. Contingent Emergency Response Children U5 who have received basic nutrition 0.00 2,000,000.00 3,000,000.00 3,400,000.00 3,800,000.00 4,000,000.00 4,000,000.00 services (Number) Rationale: Action: This indicator has The end target is revised reflecting the additional resources and the extended implementation period. been Revised April 16, 2019 Page 42 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Women who have received basic nutrition services 0.00 100,000.00 570,000.00 600,000.00 700,000.00 800,000.00 800,000.00 (Number) Rationale: Action: This indicator has The end target is revised reflecting the additional resources and the extended implementation period. been Revised People who have received cholera treatment 0.00 300,000.00 700,000.00 750,000.00 780,000.00 800,000.00 800,000.00 (Number) Rationale: Action: This indicator has The end target is revised reflecting the additional resources and the extended implementation period. been Revised IO Table SPACE Monitoring & Evaluation Plan: PDO Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection The indicator measures the actual utilization of the services. This would be Service reflected through the providers at Every 6 Aggregating reports People who have received essential number of the project different UNICEF and WHO months from service providers health, nutrition and population services beneficiaries, who have levels received services supported by the project, i.e. number of direct project beneficiaries. April 16, 2019 Page 43 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) Service provid Of the people who have People who have received essential Every 6 ers at Aggregating reports received services, the UNICEF and WHO health, nutrition and population months different from service providers percentage of female services (% female) levels beneficiaries is captured. Service provid Of the number of people People who have received essential Every 6 ers at Aggregating reports who received services, UNICEF and WHO health, nutrition and population months different from service providers percentage of IDPs is services (% IDPs) levels captured. Of the people who have Service People who have received essential received services, the Every 6 providers at Aggregating reports UNICEF and WHO health, nutrition and population percentage of children months different from service providers services (% children under 5) under the age of 5 is levels captured. “Improved water sources” includes piped household 1. UNICEF Each of the connections (house or yard field staff; 2. implementing agencies connections) and Implementing send their data to the community water points partners (local WASH focal point for Every 3 People provided with access to improved (public standpipes, corporations, each field staff at hub UNICEF months water sources in cholera affected areas boreholes, protected dug NGOs, Urban level. This staff then wells, and protected spring PMU and transmits this and rainwater collection). GARWSP); 3. information to the Cholera affected areas as TPM agency UNICEF HQ. defined by the eDews tracking system People provided with access to Same as the main indicator, Every 3 Same as the Same as the main UNICEF improved water sources in cholera in rural areas defined by months main indicator indicator affected areas - rural catchment areas People provided with access to Same as the main indicator, Every 3 Same as the Same as the main UNICEF improved water sources in cholera in 15 urban cities months main indicator indicator April 16, 2019 Page 44 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) affected areas - urban ME PDO Table SPACE Monitoring & Evaluation Plan: Intermediate Results Indicators Mapped Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection The project is expected to cover around 300 districts Every 6 GHOs and Aggregating reports across Yemen, with 5 UNICEF Number of outreach rounds conducted months DHOs from GHOs and DHOs outreach rounds or more each year, depending on the needs. 1. UNICEF Rapid Response Teams Hygiene consumables field staff; 2. distribute the refers to products that Implementing consumables at real people use on a recurring partners (local time based on a line-list Every 3 People who have received hygiene basis for hygiene purposes. corporations, of suspected cases UNICEF months consumables Products include soap, NGOs, Urban received from Ministry chlorine tablets, jerry cans PMU and of Health and WHO, for storing water and GARWSP); 3. based on updated others. TPM agency epidemiological data. As Number of people who campaigns People vaccinated with oral cholera WHO Campaign reporting WHO have received one or two are vaccine doses of cholera vaccine. conducted People provided with access to improved Improved sanitation Every 3 1. UNICEF This indicator is based UNICEF sanitation services in cholera affected facilities are those months field staff; 2. on the daily water areas designed to hygienically Implementing consumption for April 16, 2019 Page 45 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) separate excreta from partners (local households connected human contact (as per the corporations, to the water network in Joint Monitoring NGOs, Urban target cities. The outflow Programme for Water PMU and (sewage) per capita was Supply, Sanitation and General defined for each Hygiene - JMP - definition). Authority for household connection, Improved sanitation Rural Water based on 80% of the facilities are those and Sanitation volume of water designed to hygienically Project - supplied. This is used on separate excreta from GARWSP); 3. the design of sewerage human contact, and TPM agency system; however, the includes: flush/pour flush beneficiaries number is to piped sewer system, calculated on the septic tanks or pit latrines; number of the HHs ventilated improved pit connected to the latrines, composting toilets system/network. In rural or pit latrines with slabs. areas, the methodology will be different for each type of the sanitation facilities. For decentralized systems and its onsite treatment, the beneficiaries’ calculation is according to actual HHs connected to the decentralize system. For others, it will be per household having respective facility. April 16, 2019 Page 46 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) People provided with access to Same as the main indicator, Every 3 Same as the Same as the main UNICEF improved sanitation services in in rural areas as per water months main indicator indicator cholera affected areas - rural supply definition Same as People provided with access to Same as the main indicator, Same as the Same as the main the main UNICEF improved sanitation services in in urban areas as per main indicator indicator indicator cholera affected areas - urban sanitation definition The mobile teams are expected to cover the Every 6 NGOs, GHOs Aggregating reports areas where there is no UNICEF Number of mobile team rounds months and DHOs submitted fixed facility, twice a week across the project's life cycle. This indicator measures the operational capacity WHO and UNICEF sustained by the project. Every 6 GHOs and aggregate the Health facilities provided with equipment UNICEF and WHO This includes all primary months DHOs information sent by and medical/non-medical supplies and referral health care GHOs and DHOs. facilities supported by the project. Every 6 GHOs and UNICEF and WHO Children immunized (number) months DHOs reports This indicator measures the cumulative number of pregnant women receiving Every 6 GHOs and Aggregating information Pregnant women receiving antenatal care UNICEF and WHO at least one antenatal care months DHOs from GHOs and DHOs during a visit to a health provider visit to a health provider as a result of Bank-financed activities. Births (deliveries) attended by skilled Every 6 GHOs and UNICEF and WHO health personnel (number) months DHOs reports April 16, 2019 Page 47 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) WHO aggregates The number of eDEWS sites Every 6 GHOs and New electronic disease early warning information from GHOs WHO established throughout the months DHOs system (eDEWS) data collection sites and DHOs. country under the project. This indicator measures the cumulative number of WHO and UNICEF Every 6 GHOs and health personnel of aggregate reports from UNICEF and WHO Health personnel receiving training months DHOs different cadres receiving GHOs and DHOs. training through the project. The Integrated Nutrition Surveillance System Number of community nutrition sites The number of nutrition Every 6 GHOs and monitors and receives UNICEF and WHO covered by a new Integrated Nutrition sentinel sites established months DHOs information from the Surveillance System throughout the country. community nutrition sites. Service People who have received essential Every 6 providers at Aggregating reports WHO and UNICEF health, nutrition, and population (HNP) months different from service providers services levels Service Every 6 providers at Aggregating data from WHO and UNICEF Number of children immunized months different service providers levels Every 6 Service Aggregating data from Number of women and children who WHO and UNICEF months providers at service providers have received basic nutrition services different April 16, 2019 Page 48 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) levels Service Every 6 providers at Aggregating data from Number of deliveries attended by WHO and UNICEF months different service providers skilled health personnel levels This reflects the NGOs and Every 6 UNICEF monitors the Local NGOs involved in service provision CBOs taking part in UNICEF UNICEF months engagement with NGOs. (number) implementation of the project activities. Data are collected as part of third party This satisfaction survey is Every 6 monitoring activities, Beneficiaries satisfied with services TPM agency TPM agency part of the Third Party months visiting health facilities provided Monitoring activities. and interviewing patients. The cumulative number of children under the age of 5 Every 6 GHOs and Aggregating reports Children U5 who have received basic who have received any WHO and UNICEF months DHOs from GHOs and DHOs nutrition services basic nutrition service provided through the project. The cumulative number of women of child bearing age Every 6 GHOs and Aggregating reports Women who have received basic nutrition WHO and UNICEF who have received basic months DHOs from GHOs and DHOs services nutrition services through the project The cumulative number of Every 6 GHOs and Aggregating reports People who have received cholera WHO and UNICEF people with a suspected months DHOs from GHOs and DHOs treatment case of cholera who have April 16, 2019 Page 49 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) received treatment provided through the project. ME IO Table SPACE April 16, 2019 Page 50 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) ANNEX 1: MENTAL HEALTH AND PSYCHO-SOCIAL SUPPORT SERVICES IN PRIMARY AND SECONDARY LEVELS OF CARE 1. Living in a conflict setting can have a significant impact on the mental health and psycho-social well- being with short-term and long-term consequences for individuals, families and communities, especially children. Mental health and psycho-social problems in emergencies are highly interconnected. In conflict settings people can be affected in many ways and might require complementary types of services at household, community, and health facility levels. Almost four years have passed since the beginning of the escalated crisis, and the support to PPS and mental health services remains minimum while the needs of the Yemeni people continue to increase. 2. At the primary care level, the proposed AF3 will support improving access to PSS to children in need through a network of health and social workers in CFSs which are available within the primary health care facilities or in adjacent structures. PSS helps children and communities to recover from the worse impacts of conflict and diseases, retain or rebuild social structures, and build their resilience. Early and adequate psycho-social support can: 1) prevent distress and suffering developing into something more severe and long term; 2) help people cope better and resume their normal lives; and 3) meet community-identified needs. It is organized as a community-based initiative including a wide range of activities for different age groups of children, including drawing, clay, handicrafts, drama, singing, writing, storytelling, play, sports, as well as more structured life skills, and resilience building programs. 3. UNICEF will support the identification of vulnerable children by health workers during their contact through service delivery, and/or by community volunteers/facilitators in the CFSs. They are provided with basic PSS by the trained health workers. In addition, trained social workers will visit the CFS twice a week to provide a more advanced PSS, and to refer to a higher-level facility in case of need. One social worker will be attached to each health facility to receive identified children to assess their situation and develop individual intervention plans and refer them to other needed services including focused/structured PSS and other basic social services. Community based psycho-social support and CFSs could be prioritized and linked to health facilities that will be identified and supported by the project. 4. The proposed AF3 will also support mental health services at the hospital level to complement PSS services at primary care and community levels, which are also supported by other agencies. The AF3’s support will be based on the Inter-Agency Standing Committee (IASC) guidelines on Mental Health and Psycho-Social Support (MHPSS) in emergency settings. Following the guidelines, WHO will focus on the clinical services; hence, its support will be directed towards integrating the mental health care within the package of health services to be provided at the district, inter-district, and governorate hospitals. To do so, WHO will build the capacity of health workers at targeted hospitals by conducting a series of mental health training based on WHO Mental Health Gap Action Program (MHGAP). Additionally, WHO will extend its support to include five specialized mental health facilities in the country to ensure the availability of quality services at referral level. In general, support to the hospitals and the specialized facilities will comprise provision of medicines, medical supplies and equipment, provision of fuel and water, and contracting specialists when required, in addition to capacity building. April 16, 2019 Page 51 of 52 The World Bank Yemen Emergency Health and Nutrition Project Third Additional Financing (P167195) ANNEX 2: REVISED COST TABLE Revised component’s costs (US$ million) Proposed Revised total Costs under original Costs Costs Component Name costs costs project under AF1 under AF2 under AF3 (Parent + AFs) 191.00 (US$40 million Component 1: Improving Access to reallocated to 78.49 191.08 190.0 650.57 Health, Nutrition, and WSS services Component 3) Subcomponent 1.1: Strengthening the 118.54 (US$30 million Integration of Primary Health Care reallocated to 59.09 38.35 95.0 310.98 Model (UNICEF) Component 3) Subcomponent 1.2. Supporting 52.46 (US$8 million Health and Nutrition Services at the reallocated to 13.90 27.29 40.8 134.45 First Level Referral Centers (WHO) Component 3) Subcomponent 1.3. Sustaining the 20.00 (US$2 million National Health System Preparedness reallocated to 5.50 30.00 19.0 74.50 and Public Health Programs (WHO) Component 3) Subcomponent 1.4. Improving Access to WSS to Control and Prevent 0.00 0.00 95.44 35.2 130.64 Cholera and Strengthen Local Systems Component 2: Project Support, Management, Evaluation and 9.00 4.51 8.92 10.0 32.43 Administration UNICEF Indirect Cost 3.60 1.81 3.79 3.9 13.10 WHO Indirect Cost 2.22 1.00 1.95 1.9 7.07 TPM and Evaluation 1.50 0.35 0.68 2.5 4.98 Direct Costs 1.68 1.35 2.50 1.7 7.27 0.00 (US$40 million were later reallocated Component 3: Contingent Emergency to Component 3 from 0.00 0.00 0.00 (40.00) Response (UNICEF + WHO)29 Subcomponents 1.1 & 1.3) Total Financing 200.00 83.00 200.00 200.00 683.00 29 This component has been triggered by UNICEF (US$30 million) due to the unprecedented rates of malnutrition and imminent risk of famine and by WHO (US$10 million) for the cholera outbreak in 2017. April 16, 2019 Page 52 of 52