Document of The World Bank FOR OFFICIAL USE ONLY Report No: 75310-YE RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF YEMEN SCHISTOSOMIASIS CONTROL PROJECT GRANT H542-RY APPROVED DECEMBER 17, 2009 TO THE REPUBLIC OF YEMEN March 14, 2013 Human Development Group Middle East and North Africa This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ABBREVIATIONS AND ACRONYMS DA Designated Account IDA International Development Association ITIFA Independent Technical and Financial Internal Audit NTD Neglected Tropical Diseases PAU Project Administration Unit PDO Project Development Objective STHs Soil Transmitted Helminthes WHO World Health Organization Regional Vice President: Inger Andersen Country Director: Hartwig Schafer Sector Manager: Enis Barış Task Team Leader: Alaa Mahmoud Hamed Abdel-Hamid 2 REPUBLIC OF YEMEN CONTENTS Page A. SUMMARY ......................................................................................................................................... 4 B. PROJECT STATUS............................................................................................................................ 4 C. PROPOSED CHANGES .................................................................................................................... 4 ANNEX 1: RESULTS FRAMEWORK AND MONITORING................................................................ 6 ANNEX 2: TEMPLATE FOR TREATMENT OF NTDs SOE................................................11 3 Yemen Schistosomiasis Control Project RESTRUCTURING PAPER A. SUMMARY 1. This Restructuring Paper seeks your approval to introduce changes to the Yemen Schistosomiasis Control Project (IDA Grant H542, P113102) and any accompanying amendments to the project’s legal documents. The following changes are proposed to be addressed under this Level II restructuring: (i) retroactively amend the IDA’s financing percentage from 85% to 100% for Category 1(a) “Goods for Drugs;� (ii) scale down the scope of component one and two and include a new component for results-based financing of deworming and control of other neglected tropical diseases (NTDs); (iii) revise the Results Framework; and (iv) reallocate Grant proceeds, including adding an additional disbursement category. The project development objective (PDO) is to decrease the prevalence and intensity of infection of both urinary and intestinal schistosomiasis among school- aged children by 2015 in endemic regions in Yemen. This PDO will remain unchanged and is expected to be achieved by the Closing Date of June 30, 2016. The proposed date for the retroactive financing change will be the date of effectiveness of the project (August 3, 2010). There is no change in the procurement arrangements of the project. 2. There will be no change in the results indicators for Components 1 and 2. The results matrix is mainly focused on Component 1, and Component 2 comprises activities that support the implementation of Component 1. The reduction in Component 1 will not affect the scope of activities and its results as the reduction in scope resulted from savings from the reduction in prices in the procurement of drugs and the operational costs of the drug distribution campaigns. In addition, the reduction in Component 2 has resulted from savings in support of those activities that are jointly funded with the current Health and Population Project. The project has already achieved its end of project target related to the number of people reached with treatment by its second year of implementation; thus, this reduction will not affect the targets set for the project. 3. With implementation capacity developed and experience gained through implementation, the Government has requested inclusion of a results-based financing mechanism under the project. The new component, Output-Based Deworming and Control of Other Neglected Tropical Diseases (NTDs), will support routine preventive chemotherapy that will be disbursed based on outputs rather than inputs, an option discussed during preparation1 yet discarded as risky because of fiscal constraints and deficit risks at that time. This new component is one of the complementary interventions2 that will pilot test the introduction of routine deworming as part of a school health program as a prelude to a subsequent school based routine praziquantel (prophylactic chemotherapy) administration in non-endemic areas. This campaign-based preventive chemotherapy in the schools will enhance the sustainability of disease control activities through a comprehensive approach to control of parasitic and neglected tropical diseases, in line with WHO recommendations.3 The activities proposed under the new component are consistent with the PDO as they support the current comprehensive treatment standard which calls for treatment of schistosomiasis in conjunction with treatment for the other NTDs. Eventually, in the long run, it is expected that this campaign-based preventive chemotherapy approach will be progressively discontinued as transmission of schistosomiasis is successfully contained, and routine chemotherapy will be the only intervention remaining in place for individual cases in need of treatment. This approach will include, on a pilot basis, support to the control of other NTDs, including trachoma, consistent with other health 1 SCP PAD Page 11, para 37, Alternatives considered and reasons for rejection 2 SCP PAD Page 22, para 74, 75, 75, Complementary Interventions 3 SCP PAD Page 17, para 63, 64, 65, Sustainability 4 interventions and programs in Yemen.4 This approach, if successful, could possibly be expanded with subsequent additional financing for the project to support a broader and sustainable program of control of NTDs in Yemen. B. PROJECT STATUS 4. The project was signed on January 6, 2010 and became effective on August 3, 2010. The Closing Date is June 30, 2016. To date, the project has disbursed SDR 6.6 million (US$10.1 million equivalent) out of the total grant amount of SDR 15.8 million (US$25.0 million), representing 42% of total project funds. The project is currently rated satisfactory for progress towards achievement of the project development objective (PDO) and moderately satisfactory for implementation progress. The project’s audit reports have been received and there are no overdue audit reports. In terms of achievement of the PDO, the project has achieved remarkable coverage results across three rounds of treatment during its first year campaign against schistosomiasis, treating 6 million people (children and adults) in high- and meso-endemic areas, and treating 85% of targeted school-age children, exceeding both the project targets of 75% coverage, respectively. C. PROPOSED CHANGES  Results/indicators Three Intermediate Results Indicators will be added for Component 3: Output-Based Deworming and Control of Other Neglected Tropical Diseases. The indicators will read as follows ((Annex 1)  Program coverage - Targeted enrolled school age children in non-endemic Schisto districts for Soil Transmitted Helminths (STHs)  Persons treated for Trachoma by tetracycline or Azithromycin  Persons benefiting from surgery for Trachoma  Components Component 1: The scope of Component 1will be scaled down significantly and the allocation will be reduced by US$4.0 million equivalent (from 22.65 to 18.65 million). Component 2: The scope of Component 2 will also be scaled down and the allocation will be reduced by US$1.0 million equivalent (from 2.35 to 1.35 million). A new project component will be added, as follows: Component 3: Output-Based Deworming and Control of Other Neglected Tropical Diseases (US$5.00 million) This component will support the establishment of a school-based deworming program for the treatment of soil transmitted helminthes in non-schistosomiasis endemic areas, as well as extending support to other neglected tropical diseases such as onchocerciasis, trachoma, or other Neglected Tropical Diseases (NTDs) of public health importance. 4 SCP PAD Page 13, para 44, Integrated control of neglected tropical diseases 5 • Financing Project Costs (US$m) Components/Activities Current Proposed Component 1- Preventive Chemotherapy for Schistosomiasis 22.65 18.65 Control Component 2- Independent Monitoring, Audit and Project 2.35 1.35 Administration Component 3- Outputs-Based Deworming and Control of Other 0.00 5.00 Neglected Tropical Diseases (NTDs)  Disbursement arrangements: The disbursement letter will be amended to add a new type of supporting documentation under Section III Reporting on use of financing proceeds. For all expenditures related to Disbursement Category 7 “Treatments of NTDs,� the required supporting documentation for each request for reimbursement and for each reporting eligible expenditure paid from the Designated Account will be a Statement of Expenditures in the form attached (Annex 2), certified by the Independent Technical and Financial Internal Audit (ITIFA) and/or individual financial auditors.  Reallocation: 1. A new disbursement category of results-based financing for treatment of NTDs will be introduced, in the amount of SDR 3.2 million (US$4.8 million equivalent). The allocation for the new category will be reallocated from the current grant allocation as indicated below in Schedule 1 of Reallocation of Grant Proceeds. The new category will be financed by IDA at 100%. 2. Drugs are currently financed by IDA at 85%, with the Government financing the remaining15%. Procurement of drugs is being carried out through a contract with the World Health Organization (WHO). The Government of Yemen is facing budget constraints affecting its ability to contribute their share of 15% financing. It was agreed with the Government to change retroactively IDA’s financing percentage from 85% to 100% for Category 1(a) “Goods of Drugs.� The date for the retroactive financing change will be the date of effectiveness of the Project (August 3, 2010). 6 Schedule 1- Reallocation of Grant Proceeds Amount of the Grant Percentage of Category of Expenditure Allocated (expressed in Expenditures to be SDR) Financed (inclusive of Taxes) Current Revised Current Revised Current Revised Goods for: Goods for: (a) Drugs (a) Drugs 5,980,000 5,980,000 85 100 (1) (b) Laboratory (b) Laboratory 510,000 300,000 100 100 equipment and equipment and other goods other goods Amount Amount payable payable (2) Refund of Refund of 880,000 140,000 pursuant to pursuant to preparation preparation Section 2.07 Section advance advance of the 2.07 of the General General Conditions Conditions (3) Consultants’ Consultants’ 1,580,000 1,000,000 100 100 services, training services, training and workshops and workshops (4) Campaign costs Campaign costs 6,300,000 4,950,000 100 100 (5) Incremental Incremental 410,000 230,000 100 100 Operating Cost Operating Cost (6) Unallocated Unallocated 140,000 - - - (7) Treatment of NTDs - 3,200,000 - 100 Total Amount 15,800,000 15,800,000  Financial Management (FM): The FM arrangements will remain the responsibility of the PAU through the retention of the staff, maintaining adequate internal control procedures based on an acceptable FM Manual, maintaining acceptable accounting system, and maintaining the required quarterly financial reports, annual audited financial statements, and ITIFA. For the new Disbursement Category 7 (Treatment of NTDs), the PAU will transfer funds from the DA to a separate sub-account to be used as an advance to pay for the costs associated with the treatment of NTDs. The reporting of these expenditures will be done as per the method described in the disbursement section above which will be through statement of expenditures certified by the ITIFA or an Independent Auditor, reporting the number of people treated multiplied by the agreed upon unit cost per person per type of treatment. 7 ANNEX 1: Results Framework and Monitoring Project Development Objective (PDO): The project objective is to decrease the prevalence and intensity of infection of both urinary and intestinal Schistosomiasis among school-aged children by 2015 in endemic regions in Yemen. Revised Project Development Objective: No Change D=Drop Cumulative Target Values** ped C=Cont Responsibility Core PDO Level Results Unit of Data Source/ inue Baseline Frequency for Data Indicators* N= New Measure FY11 FY13 FY14 FY16 Methodology FY15 FY17 Collection R=Revised Indicator One: Percentage 19.40% <20% <10% Baseline-MTR- Prevalence of infection end of project Epidemiological Consulting firm C study reports surveys in selected sentinel sites Indicator Two: Number 6.87 100 <50 Baseline-MTR- Urinary schistosomiasis: eggs/10 ml eggs/ml end of project Epidemiological Consulting firm intensity of infection C study reports surveys in selected sentinel sites Indicator Three: Number 14.00 Baseline-MTR- Intestinal schistosomiasis: <100 epg <100 epg end of project Epidemiological Consulting firm intensity of infection C study reports surveys in selected sentinel sites Indicator Four: Direct project Number 0.00 3,000,000 6,000,000 Baseline, MTR, NSCP Performance NSCP beneficiaries X C end of project data (of which female) Percentage 0.00% 50% 50% INTERMEDIATE RESULTS Intermediate Result (Component One): Geographical and Program Coverage of large –scale distribution of praziquantel Revised Intermediate Result (Component One): Intermediate Result C Percentage 0.00 60% 70% 80% 90% 90% 90% After each large-scale Evaluation NSCP and indicator One: drug distribution. Surveys Consulting Firm Geographical coverage Intervention MTR Report End of Project evaluation report Intermediate Result Percentage 0.00 60% 60% 70% 70% 75% 75% After each large-scale NSCP NSCP and indicator Two: C drug distribution. Performance Consulting firm Program coverage - Intervention data Targeted enrolled and MTR Report Evaluation non-enrolled school-age surveys children End of Project evaluation report School census Percentage 0.00 80% 80% 80% 80% 80% 80% After each large-scale NSCP NSCP and Intermediate Result C drug distribution Performance Consulting firm indicator Three: .Intervention data Program coverage - MTR Report Evaluation Targeted enrolled school surveys age children End of Project evaluation report School census Percentage 0.00 55% 60% 65% 65% 70% 70% After each large-scale NSCP After each large- Intermediate Result C drug distribution. Performance scale drug dist. indicator four : Intervention data Intervention Program coverage - MTR Report Evaluation Targeted non-enrolled surveys school-age children End of Project evaluation report School census 9 INTERMEDIATE RESULTS (Component): Availability Of Drugs Revised Intermediate Result (Component): Intermediate Result C Yes/No Yes Yes Yes Yes Yes Yes Yes indicator Seven : Drug Availability - Timely Information to WHO Intermediate Result C Yes/No Yes Yes Yes Yes Yes Yes Yes indicator Eight: Drugs Availability - At Governorate Level Intermediate Result Number 10,000 15,000 20,000 indicator Nine : Health C personnel receiving training (number Revised Intermediate Result (Component Three): Intermediate Result N Percentage 0.00 80% 80% 80% After each drug dist. Evaluation School Records indicator Ten: Intervention surveys and Consulting Program coverage - firm End of Project evaluation School Health Targeted enrolled school report Program Data age children in non- endemic Schistosomiasis districts for STHs Intermediate Result N Percentage 0.00 75% 75% 75% After each survey. Evaluation Trachoma indicator Eleven: Intervention surveys Program and Persons treated for Consulting firm End of Project evaluation Trachoma Trachoma by tetracycline report Program Data or Azithromycin Intermediate Result N Percentage 0.00 75% 75% 75% After each survey. Evaluation Trachoma Intervention surveys Program and indicator Twelve: Consulting firm Persons benefited from End of Project evaluation Trachoma surgery for Trachoma report Program Data *Please indicate whether the indicator is a Core Sector Indicator (see further http://coreindicators) **Target values should be entered for the years data will be available, not necessarily annually 10 ANNEX 2: Template for Treatment of NTDs SOE THE WORLD BANK APPLICATION FOR WITHDRAWAL STATEMENT OF EXPENSES (SOE) Payments made during the reporting period from to Number of treatments Unit Cost per Total cost of NO. Category of Financing % of Financing Governorate Period Area Treatment Type during the period treatment treatment Notes : (1) Supporting documents for items listed above are retained at the Ministry of Health and available for World Bank inspection and audit. (2) We confirm that above payments are eligible, do not relate to any debarred Firms and do not exceed respective Contract amounts. 11