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FOR OFFICIAL USE ONLY Report No: PAD3217

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT APPRAISAL DOCUMENT

ON A PROPOSED CREDIT

IN THE AMOUNT OF SDR 65.8 MILLION (US$90.0 MILLION EQUIVALENT)

TO THE REPUBLIC OF ZAMBIA

A PROPOSED CREDIT

IN THE AMOUNT OF SDR 54.9 MILLION (US$75.0 MILLION EQUIVALENT)

AND A PROPOSED GRANT

IN THE AMOUNT OF SDR 54.9 MILLION

(US$75.0 MILLION EQUIVALENT) TO THE FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

AND

A PROPOSED GRANT

IN THE AMOUNT OF SDR 7.4 MILLION

(US$10.0 MILLION EQUIVALENT) TO THE AFRICAN UNION

FOR THE

AFRICA CENTRES FOR DISEASE CONTROL AND PREVENTION REGIONAL INVESTMENT

FINANCING PROJECT

NOVEMBER 15, 2019 Health, Nutrition and Population Global Practice Africa Region

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

CURRENCY EQUIVALENTS

(Exchange Rate Effective Nov 11, 2019)

Currency Unit = Special Drawing Rights (SDR)

SDR 1.00 = US$1.37

US$1.00 = SDR 0.73

FISCAL YEAR

January 1 - December 31

Regional Vice President: Hafez M. H. Ghanem

Country Director: Deborah L. Wetzel

Regional Director: Dena Ringold

Practice Manager: Ernest E. Massiah

Task Team Leaders: Patricia Geli, Musonda Rosemary Sunkutu, Roman Tesfaye

ABBREVIATIONS AND ACRONYMS

ACDCP Africa CDC Regional Investment Financing Project

AF Additional Financing

Africa CDC Africa Centres for Disease Control and Prevention

AMR Anti-microbial Resistance

AMRSNET Africa Centers for Disease Control and Prevention Antimicrobial Resistance Surveillance Networks

ANISE The African Network for Influenza Surveillance and Epidemiology

AU African Union

AUC African Union Commission

BSL Bio-safety Level

CAR Central African Republic

CDC Centers for Disease Control and Prevention

CERC Contingent Emergency Response Component

CPF Country Partnership Framework

CSC Country Steering Committee

DRC Democratic Republic of Congo

EA-RCC Eastern Africa Regional Collaborating Center

EAPHLN East Africa Public Health Laboratories Project

EBS Event-based Surveillance

ECCAS Economic Community of Central African States

ECDC European Union CDC

ECHO Extension for Community Health Outcomes

ECOWAS Economic Community of West African States

ECSA-HC Eastern, Central and Southern Africa Health Community

EPHI Ethiopian Public Health Institute

EQA External Quality Assessment

EQA PT External Quality Assessment Proficiency Testing

ESIA Environmental and Social Impact Assessment

ESMF Environmental and Social Management Framework

EU European Union

EVD Ebola Virus Disease

FCV Fragile, Conflict-affected, and Vulnerable

FETP Field Epidemiology Training Program

FM Financial Management

GBV Gender-based Violence

GDD Global Disease Detection Program

GMU Grants Management Unit

GRM Grievance Redress Mechanism

GRS Grievance Redress Service

IBRD International Bank for Reconstruction and Development

ICT Information, Communication and Technology

IDA International Development Association

IDSR Integrated Disease Surveillance and Response

IEG International Evaluation Group

IFMIS Integrated Financial Management Information System

IFR Interim Financial Report

IHR International Health Regulations

IPR Independent Procurement Review

IPF Investment Project Financing

IT Information Technology

KPI Key Performance Indicator

MoH Ministry of Health

MoU Memorandum of Understanding

NHPI National Public Health Institution

OIE World Organization for Animal Health

PBA Performance-based Allocation

PCD Partnership and Cooperation Directorate

PFM Public Financial Management

PHEIC Public Health Event of International Concern

PHEOC Public Health Emergency Operations Center

PIM Project Implementation Manual

PIU Project Implementation Unit

PPSD Project Procurement Strategy for Development

PSU Procurement and Supplies Unit

PTSC Project Technical Steering Committee

PTSD Procurement, Travel and Store Division

RCC Regional Collaborating Center

REDISSE Regional Disease Surveillance Systems Enhancement

RHB Regional Health Bureaus

RISLNET Regional Integrated Surveillance and Laboratory Network

SA-RCC Southern Africa Regional Collaborating Center

SADC Southern Africa Development Community

SATBHSS Southern African Tuberculosis and Health Systems Support

SDR Special Drawing Rights

SLIPTA Stepwise Laboratory Quality Improvement Process Towards Accreditation

SNNP Southern Nations, Nationalities, and Peoples

SoE Statement of Expenditure

SoP Series of Projects

TB Tuberculosis

UN United Nations

UNDP United Nations Development Program

US CDC United States Centers for Disease Control and Prevention

WAHO West African Health Organization

WHO World Health Organization

WHO AFRO World Health Organization Regional Office for Africa

ZNPHI Zambia National Public Health Institute

The World Bank Africa CDC Regional Investment Financing Project (P167916)

TABLE OF CONTENTS

DATASHEET ........................................................................................................................... 1

I. STRATEGIC CONTEXT ...................................................................................................... 7

A. Continental Context .......................................................................................................................... 7

B. Sectoral and Institutional Context .................................................................................................... 8

II. PROJECT DESCRIPTION .................................................................................................. 25

A. Project Development Objective ..................................................................................................... 25

B. Project Components ....................................................................................................................... 26

C. Project Beneficiaries ....................................................................................................................... 35

D. Results Chain .................................................................................................................................. 36

E. Rationale for World Bank Involvement and the Role of Partners .................................................. 37

F. Lessons Learned and Reflected in the Project Design .................................................................... 39

III. IMPLEMENTATION ARRANGEMENTS ............................................................................ 42

A. Institutional and Implementation Arrangements .......................................................................... 42

B. Results Monitoring and Evaluation Arrangements......................................................................... 45

C. Sustainability ................................................................................................................................... 45

IV. PROJECT APPRAISAL SUMMARY ................................................................................... 48

A. Economic and Financial Analysis ............................................................................................... 48

B. Technical Analysis....................................................................................................................... 49

C. Safeguards .................................................................................................................................. 54

V. KEY RISKS ..................................................................................................................... 58

VI. RESULTS FRAMEWORK AND MONITORING ................................................................... 62

ANNEX I: IMPLEMENTATION ARRANGEMENTS ..................................................................... 74

ANNEX II: ECONOMIC AND FINANCIAL ANALYSIS ................................................................. 93

ANNEX III: ALIGNMENT WITH OTHER WORLD BANK PROJECTS AND OTHER PARTNER PROJECTS ............................................................................................................................ 98

ANNEX IV: ENHANCED PROJECT ACCOUNTABILITY FRAMEWORK ....................................... 100

ANNEX V: CLIMATE VULNERABILITIES, MITIGATIONS SOLUTIONS AND ADAPTATION MEASURES ........................................................................................................................ 102

ANNEX VI: REGIONAL DISEASE SURVEILLANCE AND RESPONSE NETWORKS IN AFRICA ....... 104


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DATASHEET

BASIC INFORMATION BASIC_INFO_TABLE

Country(ies) Project Name

Africa, Ethiopia, Zambia

Africa CDC Regional Investment Financing Project

Project ID Financing Instrument Environmental Assessment Category

P167916 Investment Project Financing

A-Full Assessment

Financing & Implementation Modalities

[ ] 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)

Expected Approval Date Expected Closing Date

10-Dec-2019 31-Dec-2025

Bank/IFC Collaboration

No

Proposed Development Objective(s)

The Project Development Objective is to support Africa CDC to strengthen continental and regional infectious disease detection and response systems.


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Components

Component Name Cost (US$, millions)

Governance, Advocacy, and Operational Frameworks 2.14

Public Health Assets 210.80

Human Resources Development 23.52

Project Management 13.54

Contingent Emergency Response Component (CERC) 0.00

Organizations

Borrower: Federal Democratic Republic of Ethiopia

African Union Republic of Zambia

Implementing Agency: Zambia Ministry of Health Ethiopia Ministry of Health Africa Centres for Disease Control and Prevention

PROJECT FINANCING DATA (US$, Millions)

SUMMARY-NewFin1

Total Project Cost 250.00

Total Financing 250.00

of which IBRD/IDA 250.00

Financing Gap 0.00

DETAILS-NewFinEnh1

World Bank Group Financing

International Development Association (IDA) 250.00

IDA Credit 165.00

IDA Grant 85.00


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IDA Resources (in US$, Millions)

Credit Amount Grant Amount Guarantee Amount Total Amount

Ethiopia 75.00 75.00 0.00 150.00

National PBA 25.00 25.00 0.00 50.00

Regional 50.00 50.00 0.00 100.00

Zambia 90.00 0.00 0.00 90.00

National PBA 30.00 0.00 0.00 30.00

Regional 60.00 0.00 0.00 60.00

Africa 0.00 10.00 0.00 10.00

Regional 0.00 10.00 0.00 10.00

Total 165.00 85.00 0.00 250.00

Expected Disbursements (in US$, Millions)

WB Fiscal Year 2020 2021 2022 2023 2024 2025 2026

Annual 4.52 27.35 41.31 50.10 54.96 52.81 18.95

Cumulative 4.52 31.87 73.18 123.28 178.24 231.05 250.00

INSTITUTIONAL DATA Practice Area (Lead) Contributing Practice Areas

Health, Nutrition & Population

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

No

b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or No


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men's empowerment

c. Include Indicators in results framework to monitor outcomes from actions identified in (b) No

SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT)

Risk Category Rating

1. Political and Governance ⚫ High

2. Macroeconomic ⚫ High

3. Sector Strategies and Policies ⚫ Moderate

4. Technical Design of Project or Program ⚫ Moderate

5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial

6. Fiduciary ⚫ High

7. Environment and Social ⚫ High

8. Stakeholders ⚫ Moderate

9. Other

10. Overall ⚫ High

COMPLIANCE

Policy Does the project depart from the CPF in content or in other significant respects?

[ ] Yes [✓] No

Does the project require any waivers of Bank policies?

[ ] Yes [✓] No

Safeguard Policies Triggered by the Project Yes No

Environmental Assessment OP/BP 4.01 ✔

Performance Standards for Private Sector Activities OP/BP 4.03 ✔

Natural Habitats OP/BP 4.04 ✔


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Forests OP/BP 4.36 ✔

Pest Management OP 4.09 ✔

Physical Cultural Resources OP/BP 4.11 ✔

Indigenous Peoples OP/BP 4.10 ✔

Involuntary Resettlement OP/BP 4.12 ✔

Safety of Dams OP/BP 4.37 ✔

Projects on International Waterways OP/BP 7.50 ✔

Projects in Disputed Areas OP/BP 7.60 ✔

Legal Covenants

Sections and Description Ethiopia and Zambia: Schedule 2, Section 1, A 2. The Recipient shall, by no later than three (3) months after the Effective Date, establish and thereafter, maintain at all times during the implementation of the Project, a Country Steering Committee with terms of reference, functions, composition and resources satisfactory to the Association, to be responsible for reviewing and approving annual work plans, reviewing implementation progress, provision of technical guidance and support to implementing agencies, and information dissemination at the national level.

Sections and Description Zambia: Schedule 2, Section I, 3, (b), (i). By no later than one (1) month after the Effective Date, recruit a finance officer, a procurement officer, an internal auditor, an environmental safeguards specialist, a public health/social safeguards specialist, an infectious disease specialist, and an IT specialist for the PIU.

Sections and Description Zambia: Schedule 2, Section I, 3, (b), (ii). By no later than one (1) year after the Effective Date, recruit a monitoring and evaluation specialist for the PIU.

Sections and Description Ethiopia: Schedule 2, Section 1, A 3, (c), (i). By no later than one (1) month after the Effective Date, recruit a finance officer, a procurement officer, and an environmental and social safeguards officer for the Grants Management Unit.

Sections and Description Ethiopia: Schedule 2, Section 1, A 3, (c), (ii). By no later than one (1) year after the Effective Date, recruit a monitoring and evaluation specialist for the Grants Management Unit.

Sections and Description Africa CDC and Ethiopia: Section I.D (2) of Schedule 2. Develop and adopt a Joint Action Plan for the operationalization of the Africa CDC-Ethiopia MOU within 1 year of effectiveness of both Financing Agreements.


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Sections and Description Ethiopia: Section I.C (2.b) of Schedule 2. Prepare, approve and disclose the Updated Safeguard Instruments prior to tendering or commencement of civil works for the BSL-3 Lab.

Sections and Description Zambia: Section I.C (2.b) of Schedule 2. Prepare, approve and disclose the Updated Safeguard Instruments prior to tendering or commencement of civil works for the BSL-3 Lab.

Sections and Description Africa CDC: Section I.A (2) of Schedule 2. Assign a finance officer and procurement officer for the PIU within 1 month of the Effective Date; Recruit a finance officer and a procurement officer for PIU within 3 months of the Effective Date; Recruit an M&E Specialist within 1 year of the Effective Date.

Conditions

Type Description

Effectiveness Ethiopia and AU: Section. 5.01(a). Entry into an MOU between Ethiopia and Africa CDC Type Description

Effectiveness AU, Ethiopia and Zambia: Section 5.01(b). Adoption of a Project Implementation Manual Type Description

Effectiveness AU and Zambia: Section 5.01(c). Recruitment of a project coordinator for the PIU Type Description

Effectiveness Africa CDC: Section 5.01(d). Recruitment of a director, or putting into place of appropriate

alternative staffing arrangements, for the SA-RCC Type Description

Effectiveness Ethiopia: Section 5.01(c). Recruitment of a Project coordinator for the Grants Management

Unit


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I. STRATEGIC CONTEXT

A. Continental Context

1. Over the last decade, the prevalence of communicable diseases has continued to decline across much of the world, but in Africa the probability of a pandemic has risen from 3-10 percent to 26-65 percent, and this risk is expected to continue increasing unless immediate action is taken.1 Across the continent, a combination of weak national health systems, high population growth rates, conflict and state fragility, rapid urbanization, the large-scale movement of people, goods, and livestock across borders, the adverse effects of climate change, and the dense proximity of animals and humans is driving the emergence and re-emergence of infectious diseases. While economic growth and ongoing donor engagement have supported significant improvements in many key health indicators, rates of communicable disease morbidity and mortality remain stubbornly high, and the rising risk of pandemics threatens hard-won gains in social and economic development throughout the region.

2. Africa’s population is growing at an extremely rapid pace, and due to rural-urban migration the urban population is growing faster than the continental average. Over 60 percent of Africa’s population is below the age of 25, and the continent’s total population is increasing by about 30 million people each year. The United Nations (UN) projects that the African population will reach 1.68 billion by the end of the next decade, an increase of 500 million people between 2016 and 2030. About 40 percent of the total population currently lives in urban areas, and the urban population is projected to hit 50 percent of the continental population, or 800 million people, by 2030. Much of Africa’s rapid urbanization is unplanned, and according to UN-Habitat about 56 percent of the urban population (about 190 million people) lived in slums in 2014. Inadequate sanitary facilities and limited health services in these areas magnify the epidemiological risks posed by population growth and urbanization. Meanwhile, rural population growth is pushing human settlements further into wilderness areas, and rising demand for meat and dairy products is driving an increase in livestock populations. The resulting intensification of contact between humans and both wild and domestic animals is heightening the risk posed by zoonotic diseases.

3. Continental integration efforts have gained momentum in recent years, generating a wide and expanding range of economic opportunities. The centerpiece of the African Union’s (AU) Agenda 2063 is an effort to accelerate sustainable economic growth and poverty reduction by leveraging economic integration to overcome the small market size of many member states. In 2017, the AU agreed that institutional reforms to facilitate collective action by African countries were urgently needed to address the complex challenges facing the continent. At the January 2018 AU Summit, the assembled heads of state agreed to move forward on major regional integration priorities, including the creation of an African continental free-trade area, a single African air-transportation market, and laws allowing the free movement of persons across borders. The continental free-trade agreement would create a single market of about 1.2 billion people with a combined GDP of over US$2 trillion. The “open skies” air-transportation agreement would significantly increase demand for passenger and cargo services and expand the supply of air-transportation services to remote and sparsely populated areas. The laws authorizing the free flow

1 McGeer, Allison 2008, “Planning for pandemic influenza” Power point presentation at Roche Conference on The Next Pandemic: Are you legally prepared”? April 23, 2008.


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of persons between African countries would also formalize the already large and growing movements of people across the continent’s porous borders. 4. However, as geographic barriers continue to disappear, local health risks become global threats. The 2014-2015 West Africa Ebola Virus Disease (EVD) outbreak infected more than 28,000 people and killed an estimated 11,000. Despite its relatively difficult transmission mechanism, EVD devastated national health systems, disrupted regional economies, inflicted lasting reputational damage that continues to discourage travel and investment, and revealed systemic vulnerabilities in Africa’s infrastructure that a more contagious pathogen might one day exploit. In 2018, the ninth and tenth EVD outbreaks occurred in the Democratic Republic of Congo (DRC), and efforts to contain the tenth outbreak are still ongoing. In addition, of the 69 countries with endemic cholera worldwide, 42 are in Sub-Saharan Africa. With an estimated 1.7 million cholera cases and 66,000 deaths per year, the region accounts for most of the global cholera burden, including 57 percent of cases and 64 percent of deaths in endemic countries. A WHO study found that between January and August 2016, 18 Sub-Saharan African countries reported cholera outbreaks. In 2017, cholera outbreaks were recorded in Angola, Central African Republic (CAR), DRC, Ethiopia, Kenya, Malawi, Somalia, South Sudan, Tanzania, and Zambia. Meanwhile the rising incidence of noncommunicable diseases, the increasing frequency of vehicular injuries, persistently high maternal mortality rates, and threats posed by environmental toxins complicate the regional disease landscape.

5. These trends are projected to continue for the foreseeable future, and if they are left unaddressed, the probability of another major continent-wide epidemic will increase significantly. Because a communicable disease threat anywhere in Africa is a threat everywhere, a coordinated continental approach that fully leverages existing resources is vital to safeguard public health and stem the rising risk posed by pandemics. As the international experience has consistently demonstrated, investing in disease-surveillance and rapid-response systems is far less costly, in terms of both lives and money, than ad hoc efforts to combat outbreaks that are already underway. As Africa becomes increasingly populous and interconnected, meeting its multidimensional health challenges will require a regional institution capable of monitoring disease risks, analyzing threats, and mounting a swift and calculated response anywhere on the continent.

B. Sectoral and Institutional Context Sectoral context

6. Infectious diseases remain the leading cause of death in Africa, and three macro-level trends are expected to increase the global threat posed by emerging and re-emerging infectious diseases. In recent decades, much of the global burden of disease has gradually shifted from infectious to noncommunicable diseases, but Africa continues to face extremely high rates of infectious disease morbidity and mortality. While high-income countries have reduced their aggregate mortality rate from communicable diseases to just 7 percent, in Africa communicable diseases continue to cause a full 55 percent of all deaths. Worldwide, non-communicable diseases represent the five leading causes of death, but infectious diseases and vaccine-preventable diseases continue to dominate mortality in Africa. Moreover, three trends are intensifying the risk of infectious disease pandemics, both in Africa and around the world. 7. First, increasingly dense interactions between humans and animals magnify the risk of zoonotic diseases. An estimated 60 percent of all human diseases, and 75 percent of emerging infectious diseases, are zoonotic. A recent study (International Livestock Research Institute, 2012) estimated that 56 zoonoses were responsible for 2.7 million human deaths and around 2.5 billion


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cases of human illness each year worldwide; of the 28 countries with the highest burden of endemic zoonoses, 23 are in Africa. A growing recognition of the close connectivity between human, animal, and environmental health has led to the development of holistic strategies for combatting zoonotic diseases, including the “One Health” approach. Combatting zoonoses is an especially critical priority in Africa, as the continent’s livestock sector has the potential to deliver agricultural-led growth and socioeconomic transformation. The Africa Centers for Disease Control and Prevention (CDC) strategic objective of strengthening existing disease-surveillance systems and building integrated disease surveillance and response (IDSR) mechanisms linking the livestock, agricultural, and environmental sectors under the One Health approach is expected to boost livestock production and improve livestock value chains.

8. Second, climate change continues to influence infectious-disease transmission patterns and expand their geographic range, especially for vector- and water-borne diseases. African countries face regular outbreaks of cholera, dysentery, malaria, hemorrhagic fevers (e.g., EVD, Rift Valley fever, Crimean-Congo fever, Lassa fever, and yellow fever), and meningococcal meningitis outbreaks are endemic in the so-called “meningitis belt.” The WHO estimates that climate change will increase the incidence of diarrheal disease by 10 percent over the baseline scenario by 2030, with especially negative implications for the health of young children. Furthermore, the size of the population that is at risk for malaria will increase by 3 to 5 percent, reflecting millions of additional people exposed to malaria each year.

9. Third, evidence of increasing anti-microbial resistance (AMR) to the most commonly used antibiotics threatens to reverse hard-won gains in controlling common infectious diseases, especially among infants and children. In addition to their death toll, antimicrobial-resistant infections impose a significant financial cost on patients, healthcare systems, and society. This challenge is particularly severe in Africa, where the burden of infectious diseases is greatest and where patients with resistant infections are less likely to have access to, or be able to afford, expensive second-line treatments.

10. To effectively control infectious disease, national health sectors across Africa require significant investment in physical and human resources, institutional capacity, and critical infrastructure. Recent outbreaks of EVD in DRC, Lassa fever in Nigeria, and bubonic and pneumonic plague in Madagascar all confirm the critical importance of strengthening regional disease-surveillance, preparedness and response systems. The limited capacity of national health systems, especially in areas such as research, surveillance, information management, early detection, and rapid response to outbreaks, greatly increases the risks posed by communicable disease. Public health spending remains low in Africa, with very few countries exceeding the Abuja target of allocating 15 percent of total government expenditures to the health sector. Evidence from joint external evaluations in several countries, as well as country-led self-assessments, reveal critical weaknesses in African health systems, including the limited availability of diagnostic laboratory infrastructure, the lack of efficient disease-surveillance and information systems, inadequate infectious-disease prevention and control standards, inefficient supply-chain management, insufficient surge capacity to respond to outbreaks, and a shortage of critical workforce skills.

11. In the wake of the 2014-2015 West Africa EVD outbreak, regional disease surveillance, preparedness, and response activities have expanded, but their scope remains limited. In 2014, the Africa Catalytic Growth Fund provided a US$10 million grant to the West African Health Organization (WAHO) to support the West Africa Regional Disease Surveillance (WARDS) Project, which is designed to strengthen regional disease surveillance and response systems among


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Economic Community of West African States (ECOWAS) member states. Meanwhile, the East Africa Public Health Laboratory Networking Project2 (EAPHLN), which was approved under the regional-integration financing window in 2010, has helped Kenya, Tanzania, and Uganda establish a network of efficient, high-quality, accessible public health laboratories for the diagnosis and surveillance of tuberculosis and other communicable diseases. In 2016, an additional financing (AF) grant in the amount of US$50 million was approved to extend the laboratory network to Rwanda.

12. During and in the aftermath of the West Africa EVD outbreak, national authorities called on the World Bank and other development partners to play a much more prominent role in disease surveillance and response. The World Bank responded by launching the 2015 Ebola Emergency Response Project3 (EERP) with an initial financing envelope of US$105 million equivalent, which was increased by a US$285 million equivalent AF in the same year. The objective of the EERP was to strengthen controls on EVD outbreaks and accelerate the recovery of essential health services in Guinea, Liberia, and Sierra Leone.

13. In addition to financing immediate crisis response, the World Bank initiated advisory services and analytics (ASA) projects and new grant and lending operations to hedge against future public health threats arising from EVD and other epidemic-prone and emerging pathogens. The World Bank’s intensified focus on disease risks at the regional and global levels has produced new tools, such as the Pandemic Emergency Financing Facility, and enabled the adaptation and routine integration of existing tools, such as the Contingent Emergency Response Component (CERC), into IDA operations. The World Bank was also mandated by its Board of Directors to assist 25 countries in developing multi-sector pandemic emergency plans. Twenty-one of these countries are in the Africa region. The World Bank is carrying out this mandate through pipeline projects and new country-specific operations implemented with support from a Japan International Cooperation Agency-financed trust fund for universal health coverage.

14. In the years since the West Africa EVD outbreak, the World Bank has significantly scaled up its support for regional disease-surveillance systems. To build institutional capacity to detect and contain disease threats, the World Bank is compiling a portfolio of purpose-built regional operations that complement ongoing and planned efforts to strengthen regional and national health systems, as well as disease-control projects with compatible objectives. The World Bank’s current financing commitments for disease surveillance and epidemic control amount to US$1.3 billion, and World Bank-supported projects are being implemented in 20 countries across Sub-Saharan Africa. 15. In 2016, the World Bank launched the West Africa Regional Disease Surveillance Systems Enhancement (REDISSE) Program4, which consists of three interdependent series of projects (SoPs). Current financing for REDISSE totals US$390.8 million equivalent, and the program is coordinated by WAHO across 11 West African countries5. A recently approved fourth SoP6 expanded REDISSE coverage to Central Africa. Africa CDC Regional Investment Financing Project (ACDCP) is fully aligned with REDISSE activities.

2 P111556. 3 P152359. 4 P154807, P159040, and P161163. 5 REDISSE 1: Guinée, Sierra Leone, Sénégal; REDISSE 2: Guinea Bissau, Liberia, Nigeria, Togo; REDISSE 3: Benin, Mali, Mauritania, Niger. 6 P167817.


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16. The World Bank also launched the Southern African Tuberculosis and Health Systems Support (SATBHSS) Project7 in 2016. The SATBHSS Project is designed to improve the coverage and quality of tuberculosis (TB) control and occupational lung disease services while building regional capacity to manage the burden of TB and occupational diseases. SATBHSS is coordinated by the New Partnership for Africa’s Development Agency and the Eastern, Central, and Southern Africa Health Community (ECSA-HC), which provide technical support to the project countries.

17. The establishment of the Africa CDC represents a unique opportunity to link regional disease surveillance and response projects into an integrated system. When the projects described above were designed and approved, Africa lacked a supranational public health security institution with a continental mandate. Comprehensive regional integration will fully leverage the existing capacity of African health institutions while maximizing the impact of investments by international development partners, both in the health sector and beyond.

Institutional Context

18. In January 2017, the Africa CDC was formally established as a specialized technical institution of the AU tasked with supporting all African countries in improving disease surveillance, prevention, and emergency response. The Africa CDC’s mandate includes addressing disease outbreaks, manmade and natural disasters, and public health events of regional and international concern. The institution’s longer-term objective is to build the capacity of national health systems to reduce the disease burden on the continent. The Africa CDC is a specialized technical institution of the AU that serves as a platform for member states to share knowledge, exchange lessons learned, build capacity, and provide technical assistance to each other. This African-owned institution is guided by principles of leadership, credibility, ownership, delegated authority, timely dissemination of information, transparency, accountability, and value addition. 19. The Africa CDC was established following the 2013 Abuja AU Summit, which charged the African Union Commission (AUC) with developing plans for a new regional disease surveillance and response institution in line with the goals of Agenda 2063. The summit established an ambitious long-term vision for the continent’s health sector, stating that “By 2063, every citizen will have full access to affordable and quality health care services, universal access to sexual and reproductive health and rights information, and these services will be available to all women, including young women. Africa will be rid of all the neglected tropical diseases and all communicable and infectious diseases, such as EVD, will be brought under control.” The AU subsequently developed the 2016-2030 Africa Health Strategy, which outlined the Africa CDC’s critical role in disease prevention, surveillance, and emergency preparedness and response. 20. As an African-owned institution, the Africa CDC brings tremendous franchise value to support and coordinate public health activities on the continent in collaboration with existing international public health institutions. The Africa CDC is African-owned, African-led, African-managed, and staffed with the full authority of all AU member states. Its mandate is to develop continent-wide disease prevention and control policies and interventions and to establish consistent surveillance, detection, and reporting methods across Africa. The Africa CDC has the capacity to confer with heads of state and to engage directly across ministries of finance, health, defense, justice, trade, agriculture, and the environment. It has the authority to leverage its stature as a specialized technical institution of the AU to mandate financial contributions from AU member

7 P155658.


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states and to advocate for member States to harmonize laws and policy approaches across sectors that impact health. The Africa CDC also has direct access to the AU Peace and Security Council’s existing infrastructure and mechanisms for deploying supplies and personnel, which will be critical to ensure an expeditious response during an outbreak.

21. To accomplish its strategic objectives, the Africa CDC has adopted a three-tier administrative structure at the continental, regional, and national levels. The Africa CDC’s strategic objectives include: (i) establishing early warning and response platforms to identify health risks and address emergencies; (ii) assisting member states in obtaining the skills and capabilities required to comply with the 2005 International Health Regulations (IHR); (iii) supporting national and regional hazard-mapping exercises and risk assessments; (iv) directly supporting member states in addressing international public health emergencies; (v) promoting public health and disease prevention by strengthening national health systems; (vi) establishing partnerships and encouraging member states to collaboratively address emerging and endemic diseases and organize joint responses to public health emergencies; (vii) harmonizing regional disease-control and prevention policies and aligning the surveillance systems of member states; (viii) supporting institutional building among member states through field-based epidemiological and laboratory training programs; and (ix) developing continent-wide policies and interventions focused on disease prevention and control. The Africa CDC’s three-tiered structure includes the Africa CDC Secretariat, a continental institution headquartered in Addis Ababa, five Regional Collaborating Centers (RCCs) in strategic locations across Africa, and National Public Health Institutions (NHPIs) in all 55 AU member states (Figure 1 and Box 1).

Figure 1: The Institutional Structure of the Africa CDC


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22. At the continental level, the Africa CDC’s organizational structure is designed around the institution’s four initial strategic pillars, and it will adapt over time to reflect shifts in strategic priorities across functions and disease areas. In the first two years since its inception, the Africa CDC has focused on two strategic pillars, disease surveillance and outbreak response. Over the next few years, the Africa CDC will expand its operations under the other two pillars—laboratory systems and public health research and institutions—by building out laboratory infrastructure, expanding information systems, strengthening epidemic preparedness, and increasing public health research capacity, while continuing to strengthen its disease surveillance and response functions. The Africa CDC’s long-term strategy envisions its progressive expansion across infectious disease categories and other public health verticals over the next 10-15 years. The Africa CDC will also expand its activities around noncommunicable diseases; environmental health; reproductive, maternal, newborn, and child Health; injuries; and mental health, and it will begin providing routine healthcare services. The Africa CDC’s organizational structure will change over time its evolving strategic priorities (Chart 1), including activities supported by the proposed ACDCP. A key design principle of the ACDCP is to gradually expand interventions to build capacity around the four key

Box 1. The Three-Tiered Administrative Structure of the Africa CDC

The Africa CDC has a continental scope and a three-tiered administrative structure. The first tier is the Africa CDC Secretariat, which is based at the AU headquarters in Addis Ababa, Ethiopia. The Secretariat provides strategic direction and promotes high-quality public health practices among member states through capacity-building efforts focused on continuous quality improvement in the delivery of public health services and the robust prevention of public health emergencies and threats. In the event of a public health emergency on the continent with cross-border or regional implications, the Africa CDC is mandated to deploy responders, in consultation with affected member states, and to support member states in delivering an effective response. The Africa CDC will take the appropriate steps to notify the AUC Chairperson and, where applicable, the Governing Board, relevant member states, and relevant stakeholders of its activities simultaneously. Per a framework agreement, the Africa CDC is collaborating with the World Health Organization (WHO) on emergency investigation and response. The WHO is leading and coordinating international efforts in these areas, and it will continue to support national and regional health institutions by promulgating norms and standards pertaining to epidemic preparedness and response. The second tier consists of five RCCs based in Egypt, Gabon, Kenya, Nigeria, and Zambia. In line with the strategic objectives outlined by the AU’s Africa CDC Framework of Operations and Governance of the RCCs guidance note, the RCCs will build effective and efficient systems for disease surveillance, expand laboratory facilities and networks, develop and improve information systems, strengthen emergency preparedness and response mechanisms, and support public health research among member states in their respective regions. The third tier comprises the NPHIs and Centers of Excellence based in the AU’s 55 member states. Building strong health systems in Africa requires robust national public health institutions that can implement existing WHO frameworks for integrated disease surveillance and the 2005 IHR. Because existing NPHIs vary widely in their scope of work and structure, a degree of flexibility is required within the frameworks that govern the establishment and functioning of these institutions. RISLNET will harness the public health assets that exist in each African region to support the RCCs. The purpose of the network is to improve surveillance and control of high-priority endemic or neglected conditions by fully leveraging the capacity of existing public, private, and nonprofit laboratory networks. The Centers of Excellence will identify specific activities and objectives for RISLNET on an ongoing basis.


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strategic pillars and prioritize support to RCCs and NPHIs based on existing needs, ownership, and political commitment.

23. At the regional institutional level, the Africa CDC has begun signing agreements with the countries that will host the RCCs and is preparing to launch the initial phase of Regional Integrated Surveillance and Laboratory Network (RISLNET). The host-country agreements for Gabon and Zambia were signed on the margins of the 34th General Assembly of the AU in February 2019. A similar agreement with Kenya for the Eastern Africa Regional Collaborating Center (EA-RCC) is expected to be signed in December 2019; an agreement with WAHO for the Western Africa RCC will be signed by the end of the calendar year; and an agreement with Egypt for the Northern Africa RCC is at an advanced stage in the negotiation process. To assure that a coherent network links the RCCs, NPHIs, and Centers of Excellence, and to more efficiently harness and integrate the continent’s existing public health assets, the Africa CDC will launch RISLNET in each of the five RCC regions. 24. At the national level, the Africa CDC has committed to the establishment and strengthening of NPHIs. The Africa CDC has developed a framework for collaboration and coordination between the Africa CDC Secretariat and the NPHIs, as well as a model framework for laws and regulations pertaining to infectious-disease management and response. The Africa CDC is currently developing a scorecard for tracking AMR progress and a framework for One Health activities for NPHIs. To date, the Africa CDC has engaged with Kenya, Madagascar, South Sudan, and Somalia to assist in establishing their NPHIs. Ultimately, the NPHIs in each region will be anchored by their respective RCC. Close collaboration between the RCCs and national stakeholders will help to drive the development of regionally appropriate plans for AMR, pandemic preparedness, and

Figure 2: The Institutional Structure of the Africa CDC


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rapid response. RISLNET is being rolled out in a phased sequence, with the Central Africa region serving as a pilot following a successful inaugural meeting held in Libreville, Gabon in February 2019. 25. The Africa CDC is still at an early stage in its development, and its most pressing challenge will be to establish itself as an effective regional institution. To fulfill its mandate, the Africa CDC must rapidly expand its administrative and technical capabilities by hiring staff, obtaining technical assistance, and building out its physical and organizational infrastructure. The AU and its member states have demonstrated a clear commitment to the success of the Africa CDC. However, maintaining regional institutions is challenging and the Africa CDC will build on the global experience for developing similar institutions. 26. The global experience of the existing CDCs indicates that building a competent and credible CDC takes time and that a new institution should initially focus on the most urgent public health issues within the scope of its mandate (Box 2). Building on these experiences, the Africa CDC will leverage its efforts to establish and integrate RISLNET around AMR. The lack of continent-wide AMR surveillance data, especially for pathogens that require complex testing methods, inhibits a thorough understanding of the full extent of AMR and its impact in Africa. Although gains have been made in collecting AMR data related to TB and malaria, several challenges remain, including inadequate demand by clinicians for diagnostic testing; deficiencies in laboratory infrastructure; limited resources to continuously collect, transport, and test specimens for AMR; the absence of standardized protocols and quality-assurance criteria; and weak collaboration between the human and animal health sectors. The Africa CDC Antimicrobial Resistance Surveillance Networks (AMRSNET) will serve as the primary coordinator for AMR surveillance and control on the African continent, complementing existing activities by the WHO, national health ministries, the AU Inter-African Bureau for Animal Resources and Pan African Veterinary Vaccine Centre of AU, and non-governmental organizations working on AMR. Following the One Health model, AMRSNET will incorporate ministries of agriculture, veterinary health organizations, and networks working on animal and environmental health. The RCCs will convene these diverse partners to facilitate data and specimen sharing and disseminate findings. Because it derives its institutional authority from the AU, the Africa CDC will be uniquely positioned to promote continent-wide policy and advocate across all sectors of government and society based on the work of the WHO, the UN Food and Agriculture Organization, the World Organization for Animal Health (OIE), non-governmental organizations, and other AMRSNET partners.


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27. During its first year of operation, the Africa CDC has already registered several notable achievements.8 The Africa CDC has responded to multiple disease outbreaks, including the EVD

8 Based on a report that evaluated the accomplishments of Africa CDC since its inception during a meeting that departments convened in Tanzania from March 25-26, 2019 by the Commissioner for Social Affairs, Director of Africa CDC,

Box 2. Building on the Global Experience of the CDCs and Similar Institutions

The international experience shows that developing a continental public health institution typically takes over two decades, as the establishment of a central office must be accompanied by the gradual expansion of a surveillance system that reaches the periphery of its geographic range. The center and periphery must be linked by clear communication lines and supported by a high-quality laboratory system, a public health emergency team with adequate equipment, and numerous other offices and functions. For the Africa CDC, the task is complicated by the absence of national public health institutions in several AU member states and the nascent stage of their development in others. The European Union CDC (ECDC): Among the various CDCs, the ECDC’s political background is most similar to that of the Africa CDC. During the 1980s and 1990s, European Union (EU) member states established networks to monitor and control several specific infectious diseases under an initiative funded by the European Commission’s Directorate-General for Health. These networks were loosely organized; some did not include all EU member states, and others included non-EU countries. Economic integration played a major role in driving the establishment of a common EU disease surveillance and control mechanism, as the free movement of goods and people within the EU required harmonizing infectious-disease standards across member states. The 2003 SARS outbreak accelerated progress in developing a regional approach to disease surveillance and control, as it became evident that the EU member states had reacted to this outbreak in very different ways regarding travel advice, border controls, import restrictions, etc. The decision to establish the ECDC was taken in 2004, and the ECDC officially became active in May 2005. US CDC: The US CDC started in 1942 as the Program for Malaria Control in War Areas, and it initially focused on military training camps in the southern United States, where malaria was endemic at the time. After the end of the Second World War, the program expanded its remit into other tropical diseases, and in 1946 it became the Communicable Disease Center. In 1947, the center took over the plague laboratory from the Public Health Service; in 1957 it absorbed the national sexually transmitted infection (STI) program; and in 1960 it integrated the national TB program. During the 1960s, the center expanded its work on noncommunicable diseases, and it was renamed the Center for Disease Control in 1970. China CDC: The China CDC was founded in 1998, but the 2003 SARS outbreak in China dramatically increased its size and institutional profile. Its remit spans the full range of public health issues, but infectious-disease surveillance and prevention remain its most important focus areas. Pasteur Institutes: Many of the Pasteur Institutes founded in former French colonies served as public health institutes. The first was established in Saigon (now Ho Chi Minh City, Vietnam) in 1891 and the second in Africa Tunis (now Tunis, Tunisia) in 1893. Ethiopia established the Imperial Medical Research Institute, Africa’s oldest national public health institute, in 1940. In 1951, a bilateral agreement with France created the Pasteur Institute of Ethiopia (Institut Pasteur d’Ethiopie), which subsequently evolved into the Ethiopian Public Health Institute (EPHI). The EPHI will serve as an Africa CDC center of excellence.

The Swedish Public Health Agency: Sweden established the National Bacteriological Laboratory in 1907. It developed into a surveillance institute and became the Swedish Institute for Infectious Disease Control in 1993. In 2014, it was renamed the National Public Health Agency, and its mandate was expanded.


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outbreak in the DRC. The Africa CDC has deployed 65 responders to the EVD-affected areas and is supporting laboratory testing and the training of healthcare workers. Other achievements include establishing and operationalizing RISLNET in central Africa, acquiring the Journal of Public Health in Africa, hosting two International Conferences on (Re-)Emerging Infectious Diseases in Addis Ababa, and creating a scholarship program. These achievements are remarkable given that the Africa CDC has filled less than one-third of the 65 regular staff positions that the AU will finance. While the recruitment process for the initial 30 staff is ongoing, external secondments are supplying additional technical expertise. 28. The AUC is contributing to the financial sustainability of the Africa CDC and its associated institutions and systems. All 55 AU member states contribute financially to the AUC, which has committed 0.5 percent of the AU’s annual operational budget, or US$1.75 million, to the Africa CDC. In the last two years, the actual budget allocated by the AU to the Africa CDC exceeded US$17 million, surpassing the amount committed at the Africa CDC’s inception by an order of magnitude and underscoring the commitment of all 55 member states. The Africa CDC’s institutional relationship with the AUC and the AU member states will reinforce local ownership of the activities initiated under the proposed ACDCP and help ensure its long-term sustainability. ACDCP features designed to ensure long-term sustainability are presented in Section III-C (Institutional Arrangements) of the project appraisal document (PAD). The ACDCP builds on the successful implementation of the EAPHLN Project over the past eight years, which provided a detailed review of recurrent costs for laboratories, staff, and operations and maintenance (Box 3).

Director for Social affairs, and representatives of AUC.


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Box 3: Operational Sustainability of BSL-3 Laboratories Public health laboratories are crucial components of disease surveillance and response systems, as outbreaks cannot be effectively contained if they are not detected promptly. Lack of adequate laboratory capacity, particularly for epidemic-potential diseases is a major challenge across Africa. In many countries, the lack of adequate BSL-2 and BSL-3 laboratories means that samples are handled with limited biosafety and biosecurity measures in place, posing a risk to technical workers and communities. The establishment of BSL-3 regional facilities as part of the Africa CDC laboratory network will facilitate the timely detection of outbreaks and help protect the biosafety of workers. The high-containment factor of BSL-3 laboratories entails special management challenges and affects how these facilities are planned, constructed, and operated. A ten-year review of Management Principles for Building and Operating Biocontainment Facilities (2013) highlighted three factors in the planning and design stages that are critical for successful BSL-3 laboratory projects: (i) risk assessment, (ii) facility maintenance, and (iii) the construction budget. The ACDCP also builds on the wealth of experience accumulated through the EAPHLN in increasing the efficiency of capital and current expenditures on BSL-3 laboratories. Combined, these lessons and experiences will help the ACDCP mitigate the risk that facilities may fail to meet certification and safety requirements, exceed their capital budget, experience operating cost overruns, or suffer implementation delays. While the availability of data for comparable facilities in other countries in Sub-Saharan Africa has enabled the Africa CDC and the host countries of Ethiopia and Zambia to estimate laboratory operational costs, detailed models that include specific equipment, procedures, policies, and accounting variables are needed to predict these costs precisely. Based on a recent EPHI analysis, US$55 million will be needed to cover the cost of designing, constructing, equipping, and operationalizing a BSL-3 laboratory suite that meets international standards. This estimate includes the establishment of a proficiency testing system and panel production center, a laboratory-equipment maintenance center, a biobank center, and a central warehouse. In addition, the life-cycle cost analysis for operating the entire national research laboratory complex at full capacity for 20 years is estimated at US$30 million, reflecting an annual operating cost of US$1.3-1.8 million. The costs of supplying laboratory reagents and other consumables and upgrading or replacing high-tech equipment account for a combined 82 percent of the total annual operating cost of the national research laboratory complex. These estimates will enable Ethiopia and Zambia to accurately plan and budget for these facilities. The experience of the ECDC and other institutions highlights the importance of “institutionalizing” public health assets to foster long-term sustainability, and an assessment tool for measuring progress on the institutionalization of NPHIs will be developed under Component 1.1. Because human lives, research programs, and institutional reputations all depend on the proper functioning of BSL-3 facilities, a high-level commitment to support operating costs is critical. The Africa CDC will work with the Ethiopian and Zambian health ministries to build political consensus around the importance of investing in the operations of BSL-3 laboratories. Additionally, the ACDCP will explore opportunities to maximize finance for development and mobilize private resources to enhance laboratory sustainability through programs such as managed equipment services.

Effective skills training and robust employment incentives are crucial to the sustainability of BSL-3 laboratory operations. The Africa CDC will establish an Africa CDC Fellowship Program (supported under Component 3.1) and, through trainings and training-of-trainer programs, build continent-wide indigenous capacity for laboratory and equipment maintenance. Long-term capacity-building will reduce reliance on foreign laboratory workers, lowering operating costs and improving sustainability.


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29. As part of its start-up phase, and in line with its focus on the strategic pillars of disease surveillance and outbreak response, an increasing share of the Africa CDC’s work will concentrate on clinical and public health laboratories with quality-assurance programs and international accreditation. Only a small proportion of clinical laboratories in Africa are certified as compliant with international standards for quality assurance. As referral and specialized testing centers, public health laboratories play an essential role in generating high-quality data about priority health issues, including AMR, as well as conducting isolation and susceptibility testing, which involves verifying procedures and results from clinical diagnostic laboratories. To perform these roles, public health laboratories must participate in external quality-assurance programs and strive to achieve international accreditation. The Africa CDC is collaborating with member states to: (i) assess the adherence of public health laboratories to international standards; (ii) designate supranational reference laboratories for AMR; (iii) provide specialty testing, training, and capacity-building among national laboratories; and (iv) develop a plan for implementing tools like the Africa CDC’s AMR scorecard to strengthen disease surveillance (Box 4).

C. Relevance to Higher-Level Objectives

30. The ACDCP is in line with the World Bank’s twin goals of eliminating extreme poverty and boosting shared prosperity, which can be affected by health crises and epidemics. The ACDCP also supports the World Bank’s objectives for crisis-risk management by strengthening regional preparedness.9 The ACDCP is consistent with the Regional Integration and Cooperation Assistance Strategy for Africa for FY18-23, which highlights the need for collective action on critical transnational priorities, including disease surveillance, prevention, and control. The strategy

9 World Bank. 2018. Global Crisis Risk Platform (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/762621532535411008/Global-Crisis-Risk-Platform

Box 4. The Role of Laboratories in Pandemic Preparedness Infectious-disease outbreaks, including the recent West Africa EVD outbreak and the ongoing DRC EVD outbreak, highlight the importance of swift detection to rapid response. As laboratory services play an important role in all aspects of disease detection, including for disease monitoring, notification, and response, an effective laboratory network is essential to implement IHR and strengthen pandemic preparedness. The laboratory component of the Africa CDC’s RISLNET composes three levels: A. National sentinel laboratories, most of which are hospital-based, work closely with local and national public health laboratories to recognize and rule out potential biological threat agents and other emerging risks to public health. Sentinel laboratories are an integral part of RISLNET, as the system relies heavily on their ability to identify potential threats. These laboratories also provide surge capacity and can detect infections at the district and community level. B. National reference laboratories, which have specialized testing capabilities (e.g., BSL-2 facilities, strain characterization), provide test development and agent-specific expertise that can be leveraged when needed by the network. These laboratories work with hospitals and first responders to maintain competency in clinical specimen collection, packaging, and shipment. C. Specialized reference laboratories provide testing for high-priority threat agents in a variety of matrices. In addition to their testing function, these laboratories also conduct outreach to national sentinel laboratories, first responders and other member states. Specialized laboratories provide a high level of analysis, and they help maintain the quality of the laboratory system by developing standard methods and providing proficiency testing and exercises.

http://documents.worldbank.org/curated/en/762621532535411008/Global-Crisis-Risk-Platform


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emphasizes the importance of supporting communities affected by forced displacement, such as the large refugee populations residing in Ethiopia and Zambia. The ACDCP is consistent with the strategy’s “theory of change,” which emphasizes the need for regional projects to sustain a robust commitment to the regional integration agenda, and it will enhance cross-border collaboration on disease surveillance and response, exploit economies of scale, and strengthen solidarity among African states. The ACDCP supports institution-building at the Africa CDC Secretariat to ensure that the organization executes its continental mandate and supports Ethiopia and Zambia in developing the functions necessary to implement their respective regional and national project components.

31. The ACDCP is aligned with the World Bank’s Country Partnership Frameworks (CPFs) for Ethiopia10 and Zambia.11 Improving the quality, equity, and utilization of health services is Focus Area 2.2 of the Ethiopia CPF. The project fills critical gaps in the World Bank’s support to the Ethiopian health sector, as the current portfolio does not explicitly include disease surveillance and response. The ACDCP is also aligned with three objectives of the Zambia CPF: (i) improving rural health outcomes; (ii) strengthening the ability of vulnerable communities to manage the effects of climate change; and (iii) integrating Zambia into the broader region. 32. The ACDCP meets the five criteria for utilizing IDA regional funds:

a. Regional projects must involve three or more countries, all of which need to participate for the project’s objectives to be achievable. The ACDCP is designed as an SoP. Its first phase will be implemented by Ethiopia, Zambia, and the Africa CDC, which is an AU institution. The Africa CDC is a flagship institutional initiative supported by the AUC, to which all 55 AU member states contribute financially. The Africa CDC will undertake interventions across all 55 AU member states, and support for additional RCCs and NPHIs will be prioritized based on existing needs, ownership, and political commitment. The ACDCP’s support for the Africa CDC will generate substantial benefits beyond Ethiopia and Zambia, and the project will have a positive impact on numerous fragile, conflict-affected, and vulnerable (FCV) countries, which are especially vulnerable to disease risks.

b. Regional projects must have benefits, either economic or social, which spill over country

boundaries. The ACDCP’s benefits transcend national boundaries. The project will strengthen disease surveillance and response systems in Ethiopia and Zambia, as well as the broader Horn of Africa and Southern Africa subregions. Effective disease surveillance and response mechanisms are a regional public good and stemming the spread of epidemics will have highly positive social and economic spillover effects on countries across Africa.

i. All of Ethiopia’s neighboring fragile states are highly susceptible to outbreaks at

subnational levels. Strengthening core pandemic preparedness and response capacities in Ethiopia will help protect neighboring countries with weaker health systems, and a significant share of the proposed project investment will focus on areas along the borders with neighboring fragile states. Direct benefits of ACDCP investments in Ethiopia will be measured in Djibouti, Eritrea, Somalia, South Sudan, and Sudan.

10 Report Number: 119576. 11 Report Number: 128467.


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ii. Zambia shares overland borders with eight countries, which heightens the risk of imported diseases. Six of these countries are part of the Africa CDC’s Southern Africa Regional Collaborating Centre (SA-RCC).12 ACDCP investments in Zambia will benefit the entire Southern Africa region, including multiple non-SA-RCC countries. The SA-RCC has launched a solidarity program to support the ongoing EVD outbreak response in the DRC, and its activities include case-based learning, collaborative problem-solving, technical advice, resource mobilization, and the sharing of best practices. Direct benefits of ACDCP investments in Zambia will be measured for Malawi, Mozambique, Zimbabwe initially and then in the rest of the SA-RCC countries plus DRC and Tanzania after the mid-term review.

iii. ACDCP activities targeting border areas will also benefit large refugee populations

in both Ethiopia and Zambia. Moreover, the sample-testing protocols and supportive networks developed by the project will enable health authorities in all 55 AU member states to benefit from the laboratories and other public health assets created in Ethiopia and Zambia.

c. Regional projects must provide clear evidence of country or regional ownership and

demonstrate commitment of the majority of participating countries. The ACDCP is supporting the Africa CDC, an Africa-owned and Africa-led specialized agency established by the AU Heads of State to combat priority health risks across the continent. A successful Africa CDC would empower the 55 member states to strengthen outbreak detection, prevention, and response. In addition to the AU, the financial and institutional commitments of the Governments of Ethiopia and Zambia as Phase 1 countries demonstrate their shared sense of ownership over the project. The ACDCP has been incorporated into the national health-sector strategies of both Ethiopia and Zambia, and it is a key component of the AU’s continental public-health agenda.

d. Regional projects must provide a platform for a high level of policy harmonization between

countries. The ACDCP provides a platform for policy harmonization among all 55 AU member states. During the first phase, which includes the rollout of RISLNET in three regions of Africa—East, South, and West–countries will begin aligning their regulatory frameworks for managing disease samples, and this process will progressively expand to encompass a wider array of countries and policy areas. The Africa CDC also has direct access to the AU, a continental forum for cross-country collaboration, which will facilitate the development of a harmonized approach to disease control and prevention.

e. Regional projects must be part of a well-developed and broadly supported regional strategy. The ACDCP directly contributes to the AU’s continental health strategy, which enjoys a broad stakeholder consensus, and it is aligned with the objectives and priorities of various multilateral health and development institutions. The ACDCP is fully consistent with the World Bank’s “Supporting Africa’s Transformation: Regional Integration and Cooperation Assistance Strategy” for FY18-23 and with the World Bank Group’s IDA 18 commitments13

12 SA-RCC member states comprise Angola, Botswana, eSwatini, Lesotho, Malawi, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe. Zambia’s non-SA-RCC neighbors are the DRC and Tanzania. 13 Completion of preparedness plans and development of governance framework as indicated by: (i) pandemic preparedness plan is endorsed by WHO, CDC, OIE and other similar technical agencies, and/or adoption by national authorities and/or (ii) the completion of a National Action Plan for Health Security.


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for pandemic preparedness (Box 5). The ACDCP is also aligned with the international standards and guidelines of the WHO, OIE, and UN Food and Agriculture Organization.

Box 5. The ACDCP is Aligned with World Bank’s IDA 18 and Corporate Commitments

The ACDCP is fully consistent with the World Bank Group’s IDA 18 commitments. Currently, 29 African countries have delivered on their IDA commitments. The ACDCP will help the remaining countries meet their commitments by providing institutional support, offering policy guidance, and facilitating the exchange of knowledge and best practices to strengthen pandemic preparedness through its support for disease surveillance and detection, human-resource management, and response mobilization. Furthermore, the Africa CDC’s focus on continental preparedness, detection and response capacity, advocacy, and adaptation to climate-change-related health risks will contribute to the health and productivity of workers in Africa in line with Africa’s Human Capital Plan.

The 29 African Countries Receiving IDA Support for Pandemic Preparedness

Total IDA Countries

Pandemic Preparedness

Plan Completed

Countries

39 29

Burundi, Comoros, Eritrea, Kenya, Mozambique, Rwanda, Somalia, Tanzania, Uganda, Zambia, Zimbabwe, Chad, Ethiopia, Guinea, Nigeria, Sudan, Benin, Burkina Faso, Cameroon, Cote d’Ivoire, Ghana, Liberia, Mauritania, Senegal, Sierra Leone, DRC, Lesotho, Niger, South Sudan

FCV states: There is a significant overlap between outbreak vulnerability and fragility, conflict, and violence in Sub-Saharan Africa, which includes both a majority of FCV-affected states and 22 of the world’s 25 most outbreak-vulnerable countries. Fragile states typically spend less on health as a percentage of their GDP (6.98 percent vs. a global average of 9.94 percent), and they often have weak institutions and weak health systems and are less able to prevent, detect, and respond to outbreaks. Additional challenges such as mass displacement, food insecurity, and the interruption of essential services further elevate the risk of outbreaks in FCV countries. The ACDCP’s first phase will strengthen the public health capacities of the Africa CDC, Ethiopia, and Zambia, which will benefit communities in neighboring countries, many of which are affected by FCV. Strengthening continental public health institutions such as the Africa CDC will improve infectious-disease detection and control across the region, with direct benefits for the almost 1 million registered refugees in Ethiopia, the third-largest refugee population in Africa (UNHCR, 2019). Gender: The ACDCP promotes gender equity in the health sector by increasing opportunities for epidemiology skills training and career progression for women. The inclusion of gender-specific targets for training will promote gender equality in the healthcare workforce, enable women to play a more active role in improving health outcomes, and encourage equitable development by maximizing women’s economic empowerment. The ACDCP will adopt gender-sensitized training in applied epidemiology and employ gender-based violence (GBV) mitigation measures to address gendered vulnerabilities around outbreaks, particularly in fragile areas. Climate change: Climate change is both an acute threat to global development and a risk multiplier for disease outbreaks.

The ACDCP is expected to generate significant climate co-benefits by promoting adaptation to the infectious-disease

threats posed by climate change and through the climate-change mitigation activities incorporated into the project.

Further details on climate-change mitigation and adaptation measures and the climate co-benefits generated by the

project are presented in Section IV.

Citizen engagement: The ACDCP will ensure citizen engagement and representation by communities in line with the World Bank’s Strategic Framework for Mainstreaming Citizen Engagement in World Bank Group Operations. Maximizing Finance for Development: Reflecting lessons from other regional projects, the ACDCP recognizes the need to promote partnerships with the private sector to address weaknesses in public health systems and leverage complementary benefits. The Africa CDC Foundation, which will be launched in early 2020, will actively engage with the private and philanthropic sectors to forge partnerships and that support the activities of the Africa CDC.

http://consultations.worldbank.org/data/hub/files/consultation-template/engaging-citizens-improved-resultsopenconsultationtemplate/materials/finalstrategicframeworkforce.pdf


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The SoP Instrument 33. The SoP instrument was selected for the ACDCP due to its continental scope and programmatic approach; the SoP will enable the phased incorporation of countries into the project and allow lessons learned to inform subsequent phases. The ACDCP’s scope is initially regional and ultimately continental. The project’s first phase (SoP1) will prioritize RCCs and NPHIs based on their role as regional Centers of Excellence within the Africa CDC framework, as well as existing needs, ownership, and political commitment. SoP1 will entail institutional support to the Africa CDC Secretariat and the Governments of Ethiopia and Zambia, all of which have demonstrated robust ownership of the project and a credible commitment to its successful implementation.

34. Ethiopia has a comparative advantage in supporting several of the Africa CDC’s continental functions. The country is strategically located and hosts the continent’s oldest and most well-established NPHI. The project will leverage this advantage by implementing activities in Ethiopia that will have a major regional impact, including: (a) the establishment of a regional reference laboratory and a centralized event-based network for surveilling priority pathogens across the continent; (b) the piloting and rollout of the AMR scorecard; and (c) the implementation of a system to collate national surveillance data and ensure that selected countries are connected to the platform. Ethiopia’s proximity to multiple fragile states and status as a major land and air transportation hub greatly increases its vulnerabilities to epidemics, and limited disease-detection functions in Ethiopia expose Africa and the world to the potential undetected spread of diseases. In addition, Ethiopia currently hosts almost 1 million registered refugees14 from neighboring fragile states, the third-largest refugee population in Africa. Most refugees are located in underdeveloped areas with limited health services and depend heavily on humanitarian assistance. All of Ethiopia’s neighboring fragile states are highly susceptible to disease outbreaks at the subnational level. Strengthening core pandemic preparedness and response capacities in Ethiopia will help protect neighboring countries with weak health systems and limited epidemic response capacity, and a significant share of the project’s investment will focus on areas near the country’s borders with fragile states.

35. Consistent with the operational model of the Africa CDC, the Zambian Government took a bold policy decision in February 2015 to establish the Zambia National Public Health Institute (ZNPHI) as a specialized public health authority and technical arm of the Ministry of Health (MoH). Additionally, the 10 SA-RCC member states elected Zambia to serve as the regional host country. Under the host-country agreement signed in February 2019, the Zambian Government will provide office space, interim management, and technical and support staff. A budget line to finance the SA-RCC’s operational costs has been embedded in Zambia’s annual national budget. SA-RCC member states vary in terms of their available infrastructure and health systems, and the region’s overall diagnostic capacity and ability to efficiently and effectively respond to public health emergencies are inadequate. Although some diagnostic facilities are present in South Africa, most are not readily accessible to other countries in the region due to a combination of national priorities, high costs, and logistical barriers. The proposed investments in Zambia will provide critical public health assets and strengthen the healthcare systems that serve Southern Africa’s 174 million people, with spillover benefits across the African continent.

14 Global Trends: Forced Displacement in 2018, UNHCR (2019).


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36. SoP1 supports the rollout of RISLNET in Eastern, Southern, and Western Africa, which will help link existing institutions and pool the capabilities of national health authorities. Depending on the outcomes of SoP1 and subject to financial sustainability considerations, future SoPs may expand RISLNET into a continental platform and close gaps in pandemic preparedness. RISLNET’s rollout will prioritize fragile situations, especially in countries adjacent to Ethiopia. Countries that have experienced violent conflict, political instability, large-scale population displacement, natural disasters, or other destructive and destabilizing events face an especially high risk for epidemics. Epidemics that occur in fragile situations are especially difficult to address, and the capacity of local health sectors is often very limited, leading to the rapid spread of disease. The ACDCP will provide technical assistance to establish and strengthen NPHIs and develop comprehensive preparedness plans.

37. Ongoing dialogue with the other prospective RCC host countries—Egypt, Gabon, Kenya, and Nigeria—will ascertain their commitment and readiness for inclusion in subsequent SoPs, and the status of this dialogue will be discussed as part of the mid-term review. The criteria for moving forward with subsequent SoPs include the host-country governments’ signature of the RCC hosting agreements combined with the successful rollout of RISLNET. For RISLNET to be functional: (a) at least one of the core laboratory networks or surveillance networks must be in operation; (b) a legal instrument (e.g., statute) that guides the operationalization of the network must be approved by all relevant member states; (c) joint activities must be implemented under different core sets of networks, including the provision of training, supplies, equipment, and quality-control verification; and (d) a robust information-sharing platform must be established to serve as the foundation for the network.

Complementarity of the ACDCP with Other Regional Operations

38. The ACDCP will complement and enhance other IDA-financed regional integration initiatives, including REDISSE, EAPHLN, and SATBHSS via the RISLNET platform. While these projects focus on strengthening diseases surveillance and response systems at the national and sub-regional levels, the ACDCP focuses on building the institutional capacity of an Africa-wide public health institution, as well as the public health assets of the RCC host countries. While the existing regional projects strengthen sub-regional surveillance and laboratory networks, the ACDCP supports the integration of these sub-regional surveillance networks into RISLNET. Through RISLNET, the Africa CDC will be able to leverage sub-regional laboratories to support the 55 AU countries, including those that are not covered by active regional programs. The ACDCP will work closely with complementary regional projects such as REDISSE to align SoP implementation, harmonize health policies across the continent, and improve the efficiency of disease-surveillance networks. The establishment and expansion of additional RCCs under subsequent SoP phases will enable the Africa CDC to provide implementation support to ongoing and future regional projects.

39. The ACDCP will engage with other regional project focal persons and will work closely at the country, regional, and continental levels to maximize synergies. For example, REDISSE 2 took the newly minted Africa CDC structure into account, and the Nigeria CDC, which is hosting the West Africa RCC, was targeted for capacity-building to enable it to carry out its national and regional roles. Finally, the newly proposed REDISSE 4 will develop a subcontracting relationship between its implementing agency—the Economic Community of Central African States (ECCAS)—and the Central Africa RCC to pave the way for the Africa CDC’s expansion in Central Africa. All countries in REDISSE 1-4 are working to strengthen their NPHIs, which compose the third tier of the Africa CDC


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structure. The ACDCP will link the REDISSE, EAPHNL, and SATBHSS projects’ support for regional disease surveillance and laboratory systems into an expanding network of networks (Table 1).

40. To minimize the risk of duplication of activities, and to facilitate collaboration and knowledge transfer between projects, the ACDCP will invite the regional coordinators of these projects to the Africa CDC’s annual meetings. The ACDCP incorporates the experiences and lessons learned during the preparation and implementation of the regional projects. These lessons and experiences are detailed in the section on lessons learned.

Table 1. Regional Organizations and Projects

II. PROJECT DESCRIPTION

A. Project Development Objective

41. The Project Development Objective is to support Africa CDC to strengthen continental and regional infectious disease detection and response systems.


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PDO Indicators

Early detection and timely reporting of outbreaks

• Countries that have achieved the required timeliness15 of reporting for immediately reportable16 diseases under IDSR. (Percentage)

• Samples from suspected outbreaks of immediately reportable diseases that are confirmed within the stipulated WHO standard time at reference laboratories supported by the project. (Percentage)

Rapid response to infectious disease outbreaks

• Countries responding within 48 hours to confirmed outbreaks of immediately reportable diseases. (Percentage)

Laboratory quality

• Bio-safety Level (BSL)-2 and BSL-3 laboratories supported by the project that have been awarded a Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) rating of two stars or higher under the regional World Health Organization Regional Office for Africa (WHO AFRO) stepwise accreditation program. (Number) (for Ethiopia and Zambia)

Regional and continental indicators

• Africa CDC standard manuals, procedures, guidelines developed (Yes/No) o For NPHI management and operations (Yes/No) o For epidemic preparedness and response (Yes/No)

• Regions with functional RISLNETs. (Number)

• At least one yearly outreach event conducted to link implementing partners of existing regional disease surveillance and response projects in a systematic way. (Number)

• The information technology systems developed by the Africa CDC, EPHI, and ZNPHI have been connected. (Yes/No)

B. Project Components

42. The project will support the development of vital institutional capacities to execute measurable functions at the Africa CDC headquarters in Addis Ababa, the SA-RCC in Lusaka, and the Ethiopian and Zambian health authorities. The actions supported by the ACDCP are organized under five strategic components: (i) governance, advocacy, and operational frameworks; (ii) public health assets; (iii) human resource development; (iv) project management support; and (v) a CERC for Ethiopia and Zambia. Under each strategic component, complementary actions by the three implementing bodies—the Africa CDC17 and the Ethiopian and Zambian Governments—will establish the physical infrastructure, organizational framework, and technical capabilities necessary for the Africa CDC to execute its core functions and lay the groundwork for its progressive expansion into a continental health institution. In line with the Africa CDC’s operational model, the EPHI and ZNPHI will be the Africa CDC’s operational agencies at the country level, and their regional reference laboratories, emergency-response centers, data-management centers, and surveillance systems

15 All immediately reportable diseases must be reported to the regional level (Africa CDC and WHO country office) within 24 hours. 16 As defined by the IDSR system. For Ethiopia: Acute Flaccid Paralysis /Polio, anthrax, avian human influenza, cholera, guinea worm, measles, neonatal tetanus, pandemic influenza A, rabies, smallpox, SARS, VHF, yellow fever Zambia: Acute Flaccid Paralysis/Polio, Viral Haemorrhagic fever, anthrax, cholera, influenza due to a new subtype, maternal death, measles, meningococcal meningitis, plague, SARS, typhoid fever, yellow fever; any Public Health Event of International Concern (PHEIC). 17 The Africa CDC Secretariat, the SA-RCC and other RCCs.


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will serve as centers of excellence for piloting regional disease-control mechanisms, including the One Health approach (Box 6), before scaling them up in neighboring countries. The project components described below are designed to leverage network effects and exploit economies of scale to enhance the efficiency of scarce public health resources, overcome national-level functional constraints, and maximize the positive spillovers produced by integrated transnational disease surveillance and emergency-response systems.

Component 1: Governance, Advocacy, and Operational Frameworks (US$2.14 million equivalent)

43. The proposed project will support the development of consistent guidelines and standards for coordination between the Africa CDC Secretariat and the NHPIs across the continent, including provisions for sharing public health assets, transferring specimens, and sharing data on disease surveillance and outbreaks. The ACDCP will also ensure that the relevant institutional arrangements facilitate efficient coordination between the EPHI, the Africa CDC, the SA-RCC, and the ZNPHI, and it will create a framework for operationalizing the RCC and RISLNET. The specific activities to be financed under each sub-component are described below.

Subcomponent 1.1: Africa CDC (US$1.50 million)

44. This subcomponent will finance technical assistance for the Africa CDC Secretariat and the SA-RCC. The technical assistance provided by the ACDCP will support the Africa CDC in: (i)

Box 6. Piloting the Innovative “One Health” Approach

The One Health approach will be piloted at the regional laboratories supported by the ACDCP in Zambia. To achieve its goal of ensuring a healthy and prosperous nation, the Zambian Government has adopted a holistic “health in all policies” approach that requires all public institutions to regard health and wellbeing as a key element of policy development. Meanwhile, the Ministry of Health has adopted the One Health approach to address emerging and re-emerging zoonotic infections in Zambia. To address emerging and re-emerging infectious diseases in Sub-Saharan Africa, the Ministry of Health through the ZNPHI has called for the development of innovative measures to ensure early detection, monitoring, and identification of pathogens. A high-level Steering Committee has been formed comprising representatives at the director level or equivalent from various government institutions and nongovernmental partners. The working group will facilitate joint research, coordination, and resource mobilization, as well as the production of scientific evidence to inform policy and programs on public health matters, particularly with regard to zoonotic infections. To strengthen the implementation of the 2005 IHR, the working group will embrace the “One Health” approach and address all IHR core capacities and technical areas related to national public health security. A memorandum of understanding that stipulates the roles and responsibilities of all parties is under review by the Ministry of Justice. The ACDCP will support improvements in animal health by establishing an animal-health laboratory and sentinel surveillance sites for selected animal diseases, including zoonotic diseases. The project will also support the procurement of reagents for diagnosing selected animal diseases and build the capacity of animal-health experts. To address the challenge of AMR, the Ministry of Health’s “One Health” approach includes the implementation of the National Action Plan for Antimicrobial Resistance. The AMR governance structure includes a multisectoral Steering Committee and a high-level multisectoral Coordinating Committee. The project will also facilitate the rollout of the AMR scorecard developed at continental level by the Africa CDC, which includes addressing AMR in the animal health sector.


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developing consistent frameworks, standards, protocols, procedures, and guidelines for establishing NPHIs (“standardized frameworks”); (ii) conducting country assessments and evaluations on NPHI establishment and performance; (iii) developing protocols to facilitate and support the regional use of laboratories and other public health assets (“supportive protocols”), both across the continent and in Ethiopia and Zambia as part of RISLNET; (iv) adapting Africa CDC protocols, frameworks, standards and guidelines for RCCs and promote their adoption at the national level; (v) strengthening Africa CDC’s Advisory and Technical Council and technical working groups; (vi) convening an Africa CDC annual conference and other project-related conferences and workshops; (vii) developing and disseminating multi-sectoral preparedness and response plans; and (viii) supporting the development of frameworks, standards, procedures and guidelines to facilitate effective coordination and collaboration between the SA-RCC, ZNPHI, and Southern Africa Development Community (SADC).

Subcomponent 1.2: Ethiopia (US$0.29 million)

45. This subcomponent will finance the adaptation, adoption and operationalization of the standardized frameworks and supportive protocols in Ethiopia.

Subcomponent 1.3: Zambia (US$0.35 million)

46. This subcomponent will finance: (i) the adaptation, adoption, and operationalization of the standardized frameworks and supportive protocols in Zambia; and (ii) the development of an institutional framework, operational guidelines, and protocols for operationalizing the SA-RCC Host Country Agreement.

Component 2: Public Health Assets (US$210.80 million equivalent)

47. The proposed project will support the establishment of a small number of fit-for-purpose laboratories, transnational surveillance networks, emergency-response mechanisms, and other health assets designed to manage disease risks on a regional or continental scale.


48. The subcomponent will support the creation and integration of regional surveillance networks via the Africa CDC and its RCCs to roll out RISLNET in new areas. RISLNET will leverage existing regional public health assets—including the surveillance and laboratory networks operated by public agencies, private organizations, foundations, and universities—to create an integrated electronic network of regional surveillance platforms. The proposed project will finance: (i) the development of a unified information technology (IT) platform and infrastructure for connecting RCCs and NPHIs; (ii) technical workshops on selected public health challenges; (iii) transportation and processing of samples for testing at Africa CDC-affiliated laboratories in Ethiopia and Zambia;18

18The Africa CDC-affiliated network of laboratories need comply with WHO Guidance on regulations for the transport of infectious substances will be applicable for transportation of infectious substances to and from the laboratories to be financed by the project / the protocol for transportation of infectious substances. A protocol for transportation of infectious substances, which is based on WHO guideline, has been included in the environmental and social safeguards instruments prepared for the Ethiopia and Zambia components of the Program. Transportation of infectious materials to and from these labs should comply with the requirements of the above-mentioned protocol. Africa CDC secretariat should make sure that infectious substances transportation to and from the labs in Ethiopia/Zambia constructed under the project Africa CDC-affiliated network of laboratories will comply with the WHO Guidance on regulations for the transport of infectious substances /the protocol for transportation of infectious substances. Storage and handling of chemicals to be procured by Africa CDC secretariat should comply with the requirements set out in safeguards instruments which have been prepared for the Ethiopia and Zambia components of the project.


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(iv) the procurement of reagents and specialized materials for sample testing; and (v) technical assistance for the operationalization of RISLNET bureaus in Eastern, Southern, and Western Africa. 49. The subcomponent will provide technical assistance for the piloting and rollout of the Africa CDC AMR scorecard in Ethiopia.

50. The subcomponent will also support the Africa CDC in developing innovative information-sharing systems and establishing itself as a trusted source for health information. The Africa CDC has begun implementing the Extension for Community Health Outcomes (ECHO) platform in the Central Africa RCC and SA-RCC. The platform uses videoconferencing and structured case presentations to develop virtual communities of practice. This subcomponent will finance: (i) the design and development of an electronic information platform and database for disease intelligence; (ii) the implementation of an electronic distribution list to rapidly disseminate guidance to public health officials and healthcare providers on emerging threats; (iii) the development and distribution of a periodic report that provides a detailed analysis of disease trends; and (iv) the development of multimedia information products designed to increase public awareness of disease risks and recommended health practices.


51. This subcomponent will enable the EPHI to serve as a center of excellence for disease detection and response in East Africa and to host one of the regional reference laboratories for the East Africa RISLNET. It will finance, inter alia: (i) the design, construction, equipping, furnishing and setup of a BSL-3 national reference laboratory, including the establishment of a proficiency testing system and panel production center, a laboratory equipment maintenance center, a biobank center, and a central warehouse; (ii) the construction and equipping of selected reference BSL-2 laboratories at selected locations along Ethiopia’s borders; and (iii) the equipping of selected BSL-2 regional reference laboratories. 52. With support from the ACDCP, the EPHI will become a center of excellence in AMR prevention, preparedness and detection in East Africa. This subcomponent will finance: (i) the development and dissemination of AMR tools and policies; (ii) the expansion of the Africa CDC AMR scorecard pilot in Ethiopia; and (iii) capacity building for the Ethiopian and Eastern African AMR network.

53. The EPHI data-management center will serve as a regional and national hub for data-sharing, disease surveillance and reporting, integrated data analysis, evidence translation, and database development. This subcomponent will finance: (i) the implementation of an IT needs assessment for EPHI’s data-management center; (ii) the design, installation, and operationalization of a new communications platform, including the procurement and development of the related software and hardware; and (iii) the recruitment and training of EPHI IT staff.

54. The EPHI will serve as a center of excellence for emergency response operations. The ACDCP will finance: (i) the development, adaptation, and dissemination of guidelines for strengthening surveillance systems, including at points of entry; (ii) the provision of training in disease surveillance; (iii) the expansion of selected international travelers’ vaccination centers, screening points, and airport isolation sites; (iv) the equipping and networking of national and subnational public health emergency operations centers (PHEOCs); and (v) the creation of a national


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and regional platform for sharing experiences on disease surveillance and public health emergency response coordination.

55. The standardized frameworks will provide a basis to guide the use of the laboratories and public health assets financed under Subcomponent 2.2.19 The Africa CDC and EPHI are in the process of negotiating a memorandum of understanding (MoU) that will form the basis for more detailed arrangements for sharing public health assets and other areas of collaboration under the project. The MoU will be a condition of effectiveness for both the Africa CDC and Ethiopia financing agreements. The parties will develop a Joint Action Plan (JAP) within a year of project effectiveness to ensure the operationalization of the MoU. The JAP will outline issues pertaining to cost-sharing arrangements and issues of sustainability. It should also cover the requirements related to the RISLNET Agreement. Completion of the JAP in form and substance acceptable to the World Bank will be a dated covenant in both these financing agreements.


56. Strengthening Zambia’s national public health laboratory system and associated information networks will improve the ability of the ZNPHI and SA-RCC to effectively detect and rapidly respond to disease outbreaks. Zambia’s national public health laboratory system has significant weaknesses in terms of disease surveillance, detection, and response capabilities, which negatively affects its ability to host the SA-RCC. Within Zambia, environmental, climatic, geographic, cultural, and socioeconomic factors contribute to the persistence of epidemic-prone areas.

57. The proposed project will enable the ZNPHI and SA-RCC to serve as a center of excellence for Southern Africa in multiple areas. These include disease-surveillance systems, epidemic preparedness and response, laboratory systems and networks, information-management systems, health and medical research, and public health security workforce development. This subcomponent will finance: (i) the design, construction, equipping, furnishing, and outfitting of a BSL-3 national reference laboratory, including an animal laboratory, establishment of a proficiency testing system and panel production center, a biomedical equipment maintenance center, a biobank center, and warehouse; (ii) the establishment of a PHEOC; (iii) the establishment of an Information, Communication and Technology (ICT) center (including hardware and software) data management, communication and security systems; and (iv) the design and construction of offices and training facilities for ZNPHI and the SA-RCC.

58. The ACDCP includes five additional activities related to Zambia and the SA-RCC. The project will support: (i) the strengthening of disease prevention and control capabilities for Zambia, the SA-RCC member states and other countries; (ii) expansion of sentinel surveillance sites for AMR and human and animal diseases; (iii) implementing a pilot of the Africa CDC AMR scorecard in Zambia; (iv) the creation of public health research and information systems; and (v) the operationalization of a RISLNET for the SA-RCC in line with the SA-RCC Host Country Agreement. The Southern Africa RISLNET Statute will form the basis for the more detailed arrangements for sharing public health assets and other areas of collaboration under the ACDCP. The statute will be finalized during project implementation.

Component 3: Human Resources Development (US$23.52 million equivalent)

19 EPHI’s laboratory will be one of the reference laboratories for the Eastern Africa RISLNET/RCC. There will also be other reference laboratories in Kenya, Uganda, which have been supported by the East Africa Laboratory Network Project.


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59. The subcomponent will support the development of a diverse and skilled cadre of public health workers to fulfill the Africa CDC’s complex mandate and to ensure that the public health assets described above are fully utilized. The Africa CDC will build human resource surge capacity at the national, regional, and continental levels by working with RCCs and NPHI partners to create a pool of trained African professionals able to respond rapidly and effectively to infectious disease outbreaks and other public health emergencies. Training programs will build on existing courses in member states to increase the number of highly skilled technical experts operating in key areas.


60. The proposed project will coordinate and support the Africa CDC’s human resource development at the continental level. It will ensure that emergency, surveillance and response mechanisms function effectively; the BSL-3 and BSL-2 laboratories and their bio-bank and panel production centers are fully utilized; data and knowledge are managed properly; research collaboration with national, Africa CDC, and international partners is productive; and critical information on disease threats and best practices for managing public health priorities are widely disseminated. This subcomponent will finance activities in three key areas: (a) the establishment of partnership agreements with health education institutions to support the development and implementation of public health training programs; (b) technical assistance for establishing and operationalizing an Africa CDC fellowship program to build critical skills among entry-level, mid-career, and senior technical staff at the Africa CDC Secretariat and in RCCs; and (c) development and delivery of training to NPHI staff.


61. The ACDCP will assist the EPHI in creating highly skilled workers to operationalize the regional- and national-level assets and systems supported by the ACDCP. Ethiopia has participated in emergency management situations in various African countries, but the health authorities will require a combination of hiring and training to effectively address national and regional disease risks, fully utilize new and existing health assets, and successfully implement Ethiopia’s project components. This subcomponent will finance the training of key personnel in critical skills related to laboratory systems (including occupational health and safety, and environmental and social safeguards), disease surveillance, outbreak investigations, emergency responses, data management, and risk communication.


62. The ACDCP will assist the ZNPHI in developing a diverse and skilled cadre of public health and livestock sector workers in line with the One Health approach to fulfill Zambia’s domestic and regional mandates and to ensure that the public health assets created under subcomponent 2.3 are functional and fully utilized. This subcomponent will finance technical assistance at the national and regional levels to support: (i) the building of public health human resource surge capacity at the national and regional levels; (ii) the preparation of a comprehensive human-resource needs assessment for disease surveillance and response activities in Zambia; and (iii) the development and delivery of training in critical skills related to laboratory systems, including occupational health and safety standards and environmental and social safeguards, as well as disease surveillance, outbreak investigations, emergency response, data management, and risk communication; and (iv) the


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salaries and retention of seven core professional staff within the ZNPHI covering its strategic pillars20 during the transitional period (2019-2021) to ensure programmatic continuity until the ZNPHI becomes an autonomous institution.21

Component 4: Project Management (US$13.54 million equivalent) 63. Implementing the ACDCP will require administrative and human resources that exceed the current capacity of the implementing institutions.


64. This subcomponent will finance: (i) support for procurement, financial management, environmental and social safeguards, monitoring and evaluation, and reporting; (ii) recruitment and training of project implementation unit (PIU) staff and technical consultants; and (iii) operating costs.

Subcomponent 4.2: Ethiopia (US$4.60 million) 65. This subcomponent will finance: (i) support for procurement, financial management, environmental and social safeguards, monitoring and evaluation, and reporting; (ii) recruitment and training of Grants Management Unit (GMU) and EPHI staff and technical consultants; and (iii) operating costs.

Subcomponent 4.3: Zambia (US$7.24 million) 66. This subcomponent will finance: (i) support for procurement, financial management, environmental and social safeguards, monitoring and evaluation, and reporting; (ii) recruitment and training of PIU staff and technical consultants; and (iii) operating costs.

Component 5: The Contingent Emergency Response Component (CERC) 67. There is a moderate-to-high probability that, during the implementation of ACDCP SoP1, Ethiopia and/or Zambia may experience an epidemic or outbreak of public health importance or other health emergency with the potential to cause major adverse economic and/or social impacts. In anticipation of such an event, this component will improve Ethiopia and Zambia’s response capacity in the event of an emergency, following the procedures described in World Bank Policy on Investment project financing (IPF) paragraph 12 (Rapid Response to Crisis and Emergencies). This CERC will enable Ethiopia and Zambia to request and access rapid World Bank support for mitigation, response, and recovery in the affected area or areas. The CERC will serve as a first-line financing option for emergency response. Unused IDA funding will be allocated to this subcomponent in the event of an emergency. These measures will ensure the swift mobilization and deployment of resources in response to major infectious disease outbreaks, thereby limiting the financial and operational burden on local health systems.

20 These include surveillance and disease intelligence, emergency preparedness and response, laboratory systems and network, information systems, public health research, and workforce development. 21 This will occur through the passage of the ZNPHI Act and the Treasury’s authorization to finance the ZNPHI as an autonomous institution.


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68. Ethiopia and Zambia will each prepare a CERC Operations Manual as part of the Project Implementation Manual (PIM) as a condition of disbursement of the funds allocated to the CERC. Triggers for CERC activation will be clearly outlined in the PIM and its annexes. Disbursements will be made against an approved list of goods, works, and services required to support crisis mitigation, response, and recovery.

Subcomponent 5.1: Ethiopia (US$0 million) 69. Immediate support will be provided, as needed, in response to an eligible crisis or emergency.

Subcomponent 5.2: Zambia (US$0 million) 70. Immediate support will be provided, as needed, in response to an eligible crisis or emergency. Project Financing

71. IPF is the lending instrument for the proposed ACDCP. The IPF would include country and regional IDA credits and grants with a combined value equivalent to US$240 million equivalent to finance activities managed by Ethiopia and Zambia, as well as an IDA regional grant equivalent to US$10 million to finance activities managed by the Africa CDC (Table 2). The total IDA grant and credit allocation would be equivalent to US$250 million for Phase 1 of the project. ACDCP SoP1 is expected to continue for six years (calendar years 2020-2025). A detailed budget allocation by project component is presented in Tables 3 and 4.

Table 2: Funding Allocation under ACDCP SoP1

Country/Regional Institution

Country IDA Regional IDA Total

Africa CDC 10 10

Ethiopia 50 100 150

Zambia 30 60 90

Phase 1 total 80 170 250


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Table 3: Budget Allocation by Project Component (US$)

Project Components

Project Cost (US$)

Africa CDC Ethiopia Zambia22

Component 1: Governance, Advocacy, and Operational Frameworks23

2,140,000 1,500,000 290,000 350,000

Component 2: Public Health Assets

210,800,000 Disease surveillance and intelligence

- 1,760,000 2,070,000

Emergency preparedness and response

90,000 7,300,000 1,990,000

Laboratory systems and networks

- 105,920,000 63,840,000

Information systems

3,000,000 17,540,000 2,515,000

Support for the operationalization of RCCs and RISLNET

2,900,000 - 1,875,000

Subtotal: 5,990,000 132,520,000 72,290,000

Component 3: Human Resources Development

23,520,000 810,000 12,590,000 10,120,000

Component 4: Project Management

13,540,000 1,700,000 4,600,000 7,240,000

Component 5: CERC

0.00 0.00 0.00

Total 250,000,000

10,000,000 150,000,000 90,000,000

22 Activities under Component 2 to operationalize RCC and RISLNET are critical to ensure successful functioning of the SA-RCC under the support to Zambia. 23 There are activities under Component 1 that are critical to the operationalization of activities under Component 2 such as emergency preparedness and response.


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Table 4: Budget Allocation by Project Component by Recipient (%)

Project Components

Project Cost (%)

Africa CDC Ethiopia Zambia

Component 1: Governance, Advocacy, and Operational Frameworks

0.9%

15.0% 0.2% 0.4%


84.3%

Disease surveillance and intelligence

1.2% 2.3%

Emergency preparedness and response

0.9% 4.9% 2.2%

Laboratory systems and networks

- 70.6% 70.9%

Information systems 30.0% 11.7% 2.8%

Support for the operationalization of RCCs and RISLNET

29.0% - 2.1%


9.4%

8.1% 8.4% 11.2%

Component 4: Project Management

5.4%

17.0% 3.0% 8.1%

Total (%) 100 100% 100% 100%

C. Project Beneficiaries

72. The ACDCP will benefit nations and communities across Africa, especially poor households, communities bordering fragile states, refugees, and other populations that are at high risk of epidemic disease. Key beneficiaries include populations in Ethiopia (106 million) and Zambia (18 million), as well as communities in countries bordering Ethiopia, and the project will directly benefit the nine countries covered by the SA-RCC: Angola (30 million), Botswana (2 million), eSwatini (1.5 million), Lesotho (2.3 million), Malawi (19 million), Mozambique (30 million), Namibia (2.5 million), South Africa (57 million), and Zimbabwe (17 million). Based on risk assessments, other non-SA-RCC countries may be considered as beneficiaries under the SA-RCC. More effective public health sectors among Africa CDC member states will contribute to the wellbeing of populations across the region. In addition to the overall social and economic benefits of improved health indicators and lower mortality rates, the project will increase productivity in the rural sector by reducing animal deaths, increasing animal fertility, and boosting the marginal output of animal products. Finally, the ACDCP


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will strengthen domestic, regional, and continental institutions and build the capacity of their staff, reinforcing the framework for an integrated Africa.

D. Results Chain

73. Critical interventions are needed to reduce morbidity and mortality rates from existing and emerging infectious diseases across Africa. The Africa CDC’s development of standardized multi-tier manuals, procedures, guidelines, and agreements for the use of BSL-3 reference laboratories and their adaptation by the AU’s 55 member states will improve disease surveillance and emergency response across the continent. Furthermore, the establishment of RISLNET in RCCs and the operationalization of the SA-RCC will increase cross-border collaborations and investigations. The construction and upgrading of reference laboratories and the operationalization of event-based surveillance (EBS), PHEOCs, and IT/data-management centers will improve active and routine surveillance, testing, and operations systems. Other interventions will ensure that the number of African professionals and semi-professionals trained in critical skills involved in disease detection and response steadily increases. Together, these activities will improve the detection of infectious disease outbreaks, strengthen response systems, improve laboratory quality, and promote information sharing (Figure 3).

Figure 3: Results Chain


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E. Rationale for World Bank Involvement and the Role of Partners

74. The World Bank is among the few global institutions capable of mobilizing the necessary resources, co-convening the wide range of stakeholders, and coordinating the extensive and sophisticated activities necessary to implement such a challenging project. With its multi-sectoral breadth of experience and projects the World Bank can draw on other complementary initiatives such as its EAPHLN, REDISSE program, Pandemic Emergency Financing program, Africa Higher Education Centers of Excellence Program and the Global Financing Facility. The World Bank will draw on its regional experience in other sectors to ensure the project is implemented efficiently and transparently, and it will leverage its strong working relationships with the Ethiopian and Zambian Governments, the SADC, and the SA-RCC member states to sustain the political will required to further develop a new continental organization.

75. As a specialized agency of the AU, the Africa CDC has the authority to leverage its stature to mandate financial contributions from member states and to influence member states to enact laws and harmonize approaches across sectors that impact health. Over the two years since the official launch of the Africa CDC, the initial allocation that was recommended from the AU’s annual operational budget has grown from US$1.75 million to US$17.35 million in 2019—underscoring the robust commitment of all AU 55 member states. The Africa CDC has established bilateral partnerships with several countries that have resulted in the following joint engagements and commitments: China (official commitment to construct the US$80 million Africa CDC headquarters in Addis Ababa and secondment of two technical advisors from the China CDC); Japan (approximately US$1.5 million contribution to the Africa CDC to strengthen health systems and implement the 2005 IHR at the member-state level); Kuwait (US$3 million provided to the Africa CDC for public health workforce development in ten member states and for the renovation of Secretariat offices); the United States (over US$10 million provided in in-kind contributions to the Africa CDC, including ten African epidemiologists, three permanent US government advisors, US$3 million for a public health emergency operations center, and US$600,000 for a regional information-exchange platform); and Kenya (voluntary contribution of US$1 million to support the Africa CDC). 76. The Africa CDC is also mobilizing financial support and contributions from development partners around the world. Key partner contributions include in-kind support in the form of staff secondments based on Africa CDC needs (USAID); staffing support to the Africa CDC (Bill and Melinda Gates Foundation); in-kind contributions and seconded staff (Public Health England); in-kind contributions and the secondment of two staff (RESOLVE To Save Life). Other international partner organizations include the African Development Bank, WHO Afro, the International Association of National Public Institutes, the Coalition for Epidemic Preparedness Initiative, the Japan International Cooperation Agency, UNAIDS, the Institute for Health Metrics and Evaluation, and the University of Washington Seattle. The Africa CDC’s innovative approach to creating south-south exchanges and integrating Africa’s universities and academic institutions in the Africa CDC ecosystem through the RISLNET framework will be crucial to institutional sustainability and ownership by member states (Box 7). In partnership with the AU and World Economic Forum, the Africa CDC launched the establishment of the Africa Public Health Foundation (APHF) in September 2019. The foundation will facilitate public-private cooperation in support of the Africa CDC’s mission to strengthen health and economic security.


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77. Ethiopia’s development partners are working to improve the capacity and quality of its healthcare systems. Key initiatives by development partners include support for laboratories (United States Centers for Disease Control and Prevention (US CDC), US President’s Emergency Plan for AIDS Relief, US CDC-Global Health Platform, Global Health Security Agenda, Global Fund, USAID/Challenge TB, USAID/PMI, African Society for Laboratory Medicine, Clinton Health Access Initiative, Defense Threat Reduction Agency); malaria control (Global Fund, Bill and Melinda Gates Foundation); biosafety and biosecurity, sentinel site surveillance, zoonotic diseases (DTRA); public health emergency management (WHO, US CDC, UNICEF, UN Population Fund, Public Health England, GAVI, SDG Pooled Funding Contributors, Bill and Melinda Gates Foundation); AMR (US CDC-Global Health Platform (Global Health Security Agenda), Ohio State University, American Society for Microbiology); health-system resilience and emergency-response capacity (DFID, KOICA); data management (University of Washington Institute for Health Metrics and Evaluation); guinea worm disease eradication (the Carter Center); risk communication (Johns Hopkins Center for Communication Programs); emergency response (the water, sanitation and hygiene cluster, the nutrition cluster, and the health cluster, including members such as Médécins sans Frontières, Save the Children, etc.); logistics and supply-chain management (USAID); and sexual and reproductive health (UNFPA). 78. International partners also support multiple aspects of Zambia’s health sector. Key areas include health promotion, risk communication, and water, sanitation and hygiene (UNICEF), policy

Box 7: Institutional Sustainability and the Role of Partnerships

Before the creation of the Africa CDC, no financing mechanisms or adequate incentive structures were in place to motivate governments in high-risk countries to invest in epidemic preparedness, particularly when those investments would compete with more visible priorities such as building physical infrastructure. Consequently, many countries remain underprepared to deal with the threat of disease outbreaks. As a specialized agency of the AU, the Africa CDC has the authority to leverage its stature to mandate financial contributions from member states and to influence member states to enact laws and harmonize approaches across sectors that impact health. Over the two years since the official launch of the Africa CDC, the initial allocation that was recommended from the AU’s annual operational budget has grown from US$1.75 million to US$17.35 million in 2019, underscoring the commitment of the 55 AU member states. Recent estimates by the International Working Group on Financing Preparedness highlights the relatively low cost of upgrading national epidemic preparedness systems, as reaching an adequate level of preparedness requires an investment of just US$0.50-US$1.50 per person per year. The Africa CDC is uses advocates to further increase contributions from member states by emphasizing that investments in preparedness are cost-effective and affordable. The AU provides room to channel additional supplementary resources to the Africa CDC if its budget utilization rate is high. In addition, the Africa CDC Board recently approved the establishment of the Africa CDC Public Private Philanthropic Strategy to optimize engagement with the public and private sectors. The Africa Public Health Foundation, which was launched in September 2019, is expected to raise US$1 billion over the next 10 years to support sustainable development initiatives. It expects to raise an additional US$200 million for a commercial healthcare fund to accelerate innovations in healthcare. The Africa CDC will be reaching out to partners as it evolves and will organize periodic meetings to share progress and lessons learned. Finally, the Africa CDC, through regional economic organizations, including the SADC, is working to fully leverage existing regional health programs and collaborative forums to strengthen coordination between the NPHIs and RCCs.


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guidance (SADC), AMR (ReACT-Africa), human resource development (Japan International Cooperation Agency, China CDC, World Bank), international health regulation (WHO, DFID), technical assistance (Africa CDC), public health emergency management and incident management systems (US CDC). External entities will further support analytical work relevant to the Africa CDC and its operations.

F. Lessons Learned and Reflected in the Project Design 79. The Africa Regional Integration and Cooperation Assistance Strategy identifies generic lessons from the international experience with regional integration projects. These were addressed during project preparation by developing a “project readiness filter” in collaboration with the three implementing agencies; using an SoP approach with three clients who have demonstrated strong project ownership and commitment; balancing infrastructure financing with disease surveillance, prevention, and control; harmonizing policy, regulatory, and institutional arrangements; including political-economy experts and monitoring and evaluation specialists in the design phase; and effectively collaborating with animal health and human health experts and agencies from all sectors. The ACDCP is also informed by lessons learned from two recent IEG reviews and multiple individual projects. The former includes “Two to Tango: An Evaluation of the World Bank Group Support to Fostering Regional Integration” (IEG, 2019) and “World Bank Group Support to Health Services: Achievements and Challenges” (IEG, 2018). The latter includes relevant lessons from REDISSE 1 and 2, EAPHLN, and SATBHSS. 80. Implementation arrangements must be carefully assigned based on comparative advantages. Defining the role of regional institutions and strengthening their institutional capacity can facilitate the implementation and management of regional activities. The ACDCP includes clear implementation arrangements that precisely define the roles of the Africa CDC, the SA-RCCs, national institutions, and partner organizations. 81. Working with a regional institution is vital to the success of regional projects. This institution should have the ability to: (a) convene stakeholders backed by an agreed mandate; (b) manage regional resources through sub-contracting or direct management; and (c) directly access policymakers and inform the policy process. Although it is a new institution, the Africa CDC is backed by a mandate encompassing all 55 AU member states. 82. External financing for preparedness activities should support multi-country regional initiatives and resource-sharing to ensure positive spillover effects and efficiency gains.24 The ACDCP will facilitate cross-border knowledge exchange and continental resource-sharing to leverage efficiency gains and advance global public goods. The ACDCP has developed draft MoUs between the Africa CDC and the executing entity in Ethiopia that defines the framework for cooperation to ensure that positive spillover effects are created and can be measured through the efficient exchange of information. Results indicators are designed to track benefits accruing to countries not included in ACDCP SoP1.

24 International Working Group: From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level (2017).


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83. Stakeholder coordination and regional collaboration must be strengthened through both formal and informal approaches. Stakeholder ownership, coordination, and collaboration presents a significant challenge. The ACDCP will utilize both formal agreements (e.g., MoUs) and informal approaches (e.g., knowledge exchange, simulation exercises) to strengthen collaboration. The Africa CDC will also convene periodic meetings and annual conferences at which representatives from member states, multi-sectoral stakeholders including representatives from the livestock sector, and global partners will review recent progress and offer input on plans and priorities. 84. Investments in institutional capacity at the regional level must be complemented by investments at the national level. Lessons from REDISSE highlight the importance of developing a robust regional management implementation unit through recruitment and capacity-building, as such a unit greatly strengthened WAHO. The ACDCP will build strong management and implementation units at each level through staff recruitment and the contracting of technical assistance specialists, coupled with ongoing training and oversight. Additionally, the ACDCP will leverage existing PIUs/GMUs in participating health ministries and recruit additional staff to strengthen regional institutional capacity. 85. Addressing challenges in cross-sectoral collaboration are crucial to the success of the One Health approach. Lessons from REDISSE illustrate that the One Health approach dramatically increases project complexity, and aligning priorities across different sectors can be challenging. In some cases, institutions may seek funding for activities that do not contribute to the project objective. Meanwhile, a tendency to focus on the human health sector may divert attention from the animal health and environmental health components of the One Health approach. The ACDCP will seek to inculcate a sense of common cause and benefit by encouraging the active participation of all three sectors and by including representatives from the animal health and environmental sectors in the steering committee that reviews the Africa CDC’s annual workplan and budget, which will promote coordination both at the strategic level and in implementation. 86. Preestablished contracts with institutions or vendors improve the speed of financing response during emergencies. Lessons from previous CERC activations for outbreak response highlight the procedural constraints involved in signing contracts during an emergency. Signing ex ante MoUs between the Africa CDC, national governments, and third-party implementing agencies can improve the speed and efficiency of emergency response. The Africa CDC has already signed an MoU with the WHO that outlines its responsibilities in emergency investigation and response efforts, as well as routine tasks.

87. Experiences with CERC activation in Nigeria and the DRC highlight that many outbreaks can be effectively managed through project components, and it is not necessary to activate the CERC for every outbreak. Although the ACDCP includes a CERC, the ACDCP components encompass core public health capacities, which will enable the project to finance some or all of the activities in the response plan without the need for CERC activation.


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Gender Considerations 88. In line with the World Bank’s 2016-2023 gender strategy and the AU Strategy on Gender, gender considerations are an integral aspect of the ACDCP. Recent health emergencies in Sub-Saharan Africa demonstrate how women can be disproportionately affected by outbreaks, both directly and indirectly. The disruption of health systems due to emergency response has an adverse impact on general access to primary healthcare, including sexual and reproductive health, maternity, and child health services. Meanwhile, women represent majority of both frontline health personnel and household caregivers, which puts them at an elevated risk of exposure to disease transmission. All workshops organized by the Africa CDC will include gender-sensitivity exercises such as gender sensitization for contact tracing, emergency management, and risk communication. In addition, ACDPC results indicators will be disaggregated by gender.

89. Reports and lessons learned from other regional disease-surveillance projects (e.g., WARDS)25 highlight that women in Sub-Saharan Africa are underrepresented in science, technology, engineering, and mathematics professions26 and have little or no access to training in field epidemiology. To mitigate gender inequity in access to training, the ACDCP’s results framework will monitor gender-disaggregated training indicators and assign targets for women’s participation and training in applied epidemiology. This focus on gender parity will help the ACDCP to leverage investment in women as a means of strengthening continental capacity for disease surveillance and response to health emergencies. Furthermore, the inclusion of gender-specific targets for training would yield triple dividends encompassing gender (by improving gender equality), health (by increasing human resources in the health sector to achieve UHC 2030), and development (by maximizing women’s economic empowerment).

90. Additionally, the ACDCP will strive to enhance women’s voice and agency by promoting women’s leadership and training and by addressing GBV-related risks. GBV risks are closely linked to conflict, and they increase further during public health emergencies, as the ensuing population displacement can put women and children in an especially vulnerable position. Although the GBV risk assessment for the ACDCP has been rated low, the project will mitigate GBV risks through training on GBV prevention and by ensuring grievance redress mechanisms (GRMs) include procedures to address GBV cases.

25 At the close of the West Africa Regional Disease Surveillance WARDS project in 2017, an Implementation Completion and Results Report (ICR) found a gender disparity in access to the training opportunities provided under the project. 26 Global gender gap is at 47 percent, with 30 percent of male students graduating from Science Technology Engineering Mathematics subjects, in contrast to only 16 percent of female students (2016 Global Gender Gap Report, World Economic Forum).


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III. IMPLEMENTATION ARRANGEMENTS

A. Institutional and Implementation Arrangements

91. The ACDCP is continental in scope. The Africa CDC will benefit all 55 AU member states by providing training, legal, and administrative support to facilitate a harmonized and cooperative approach to disease surveillance and response across countries. In addition to the CERCs for Ethiopia and Zambia, the Africa CDC will provide project-funded emergency assistance during disease outbreaks by facilitating the shipment of samples to project-supported laboratories in Ethiopia. The RCCs will build effective and efficient systems for disease surveillance, expand laboratory facilities and networks, develop and improve information systems, strengthen emergency preparedness and response mechanisms, and support public health research among member states in their respective regions. The NPHIs will serve as dedicated national-level institutions for coordinating public health interventions. The project will be implemented by three entities: (i) the Africa CDC; (ii) the Ethiopian MoH; and (iii) the Zambia MoH. Facilities in Ethiopia and Zambia will provide services and capacity-building programs for officials, NPHI staff and other public health professionals from selected AU member states through the project-supported centers of excellence.

92. The ACDCP leverages multiple existing institutional arrangements and coordination platforms, including the Africa CDC, SA-RCC, the Ethiopia MoH, the EPHI, the Zambia MoH, and the ZNPHI. The EPHI and ZNPHI will put in place country steering committees (CSC) for multisector participation and collaboration at the country level. The Africa CDC is a specialized technical institution of the AU that will be responsible for the overall coordination of the ACDCP through the Project Technical Steering Committee (PTSC) that will be established (Figure 4). The PTSC will engage with PIUs from other World Bank-funded projects to coordinate implementation.

Figure 4. ACDCP Institutional Arrangements


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The Project Technical Steering Committee (PTSC)

93. Project oversight will be provided by a PTSC that includes the directors of the Africa CDC, EPHI, and ZNPHI. The PTSC will also invite experts and specialists to participate in its activities on an ad hoc basis. The PTSC will meet at least twice per year to finalize annual workplans, review implementation progress, provide technical guidance to the implementing agencies, and share information among relevant stakeholders. Representatives from the agriculture and livestock sectors as well as other regional projects such as EAPHLN, SATBHSS and REDISSE will participate in the annual meetings to ensure coordination and harmonization among the various regional projects on surveillance and laboratory networks on the continent. The Africa CDC will serve as the PTSC secretariat; it will schedule meetings, receive and consolidate advance reports from the implementing agencies, and prepare a semiannual summary report to be disseminated upon authorization by the PTSC. The steering committee’s activities will be guided by terms of reference that clearly define its functions, responsibilities, and role in the ongoing collaboration between the Africa CDC, SA-RCC, EPHI, and ZNPHI from both countries.

Country Steering Committees (CSC)

94. CSCs will be established to oversee the Ethiopia and Zambia project subcomponents. The CSCs will include representatives identified by each country based on country preferences. Each CSC is expected to comprise representatives from the ministries of health, agriculture/livestock, and finance, as well as academia and civil society. The CSCs will monitor the functions of the implementing agencies at the country level, review annual workplans and implementation progress, provide technical guidance and support to the relevant health ministries and NPHIs, and share information among project stakeholders.

Africa CDC

95. The Africa CDC will be the key implementing agency for project Subcomponents 1.1, 2.1, 3.1, and 4.1. The Director of the Africa CDC will be responsible for the execution and management of activities supported under those project subcomponents. The AU Service Division’s Directorate of Finance and Accounting will be responsible for the overall fiduciary management of project funds, including payment authorizations and internal control mechanisms, and will provide quarterly financial reports to the Africa CDC. The PIU based at the Africa CDC will be responsible for the day-to-day management of these project subcomponents, as well as the preparation of annual operational, procurement, and financial plans, the drafting of contract documents, and the preparation of consolidated implementation reports. The PIU will also follow up with the AU Service Division on payments and other operational transactions. The Africa CDC will hire consultants for the PIU, including an accountant and procurement officer, and it may also outsource activities to third parties or implementing partners through contract agreements acceptable to the World Bank. A project coordinator will be hired before project effectiveness. Based on the hosting agreement, the Government of Zambia has seconded staff to the SA-RCC, including the ZNPHI Director, who is currently the acting Director for the SA-RCC. The Africa CDC is in the final stages of recruiting or seconding a director for the SA-RCC, or putting in place an appropriate alternative staffing


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arrangement, as a condition of effectiveness. The Africa CDC may also hire additional technical consultants to support its own operations as needed.

Ethiopia

96. The Ethiopia MoH will be the implementing agency for project Subcomponents 1.2, 2.2, 3.2, 4.2, and 5.1. The State Minister for Programs will be responsible for the execution of project activities. The GMU of the Ethiopia MoH’s Partnership and Cooperation Directorate (PCD) will be responsible for the day-to-day management of activities supported under these subcomponents, as well as the preparation of a consolidated annual workplan and a consolidated activity and financial report for the above-mentioned project components. The PCD already manages and coordinates several donor-funded projects in the health sector, including the Sustainable Development Goal Program for Results (P123531). In addition, technical directorates at the Ethiopia MoH, the regional health bureaus, and other key agencies will be involved in project activities based on their functional capacities and institutional mandates. The GMU will recruit additional staff to implement the project subcomponents, including: a project coordinator (before project effectiveness); an environmental/social safeguards specialist, a financial officer a procurement officer (by no later than one month after project effectiveness), and a monitoring and evaluation officer (by no later than one year of project effectiveness), to strengthen the GMU. The GMU may also recruit specialized technical staff as needed, and some activities may be outsourced to third parties through contract agreements acceptable to the World Bank.

97. The EPHI will serve as the key technical entity for these subcomponents. It will both support the PCD and directly implement certain technical activities and procurement of laboratory equipment and ICT systems. The EPHI will report directly to the State Minister, and it will share the project’s technical and financial updates with the PCD-GMU and Office of the State Minister of Programs. If necessary, the EPHI will also reinforce the GMU with additional staff, including accountants and procurement officers, to manage project activities under its purview (see Annex I). The Ethiopia MoH will also deploy the staff needed for proper implementation of the environmental and social management plan as specified in the project’s Environmental and Social Impact Assessment (ESIA).

Zambia

98. The Zambia MoH will be the implementing agency for project Subcomponents 1.3, 2.3, 3.3, 4.3. and 5.2 during the transition period until the ZNPHI is established as an autonomous legal entity separate from the Zambia MoH. The Permanent Secretary for Administration and the Permanent Secretary for Technical Services will be responsible for managing project activities in line with their respective administrative mandates. The Zambia MoH will establish a PIU that will be responsible for: (i) the day-to-day management and execution of activities supported under these project subcomponents; (ii) the preparation of annual activity and procurement plans; (iii) the drafting of contract documents; and (iv) the preparation of a consolidated report on the implementation of the project components. The PIU will also closely follow up with the Directorate of Finance and Procurement Unit. The Zambia MoH will recruit additional staff for the PIU to implement the project subcomponents, including: a project coordinator (before project


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effectiveness); an environmental safeguards specialist, a financial officer, a procurement officer, an internal auditor (by no later than one month of project effectiveness), a public health/social safeguards specialist, monitoring and evaluation officer, and an IT Specialist (by no later than one year of project effectiveness). The PIU may also recruit specialized technical staff as needed, and some activities may be outsourced to third parties through contract agreements acceptable to the World Bank.

99. Furthermore, the various Zambia MoH technical directorates and other sector ministries will be involved in project activities based on their functional capacities and institutional mandates. Zambia is currently in the process of passing the ZNPHI Act to establish the ZNPHI as a statutory board. Once the ZNPHI Act has been passed and the establishment of the ZNPHI as an autonomous legal entity is attained, the overall responsibility for project execution, coordination, and management will be transferred to the ZNPHI, subject to a satisfactory fiduciary assessment of the ZNPHI and any required project restructuring.

100. The Ethiopian and Zambian health ministries will develop CERC Operations Manuals as an annex to their respective PIMs. Ethiopia’s Program State Minster and Zambia’s Permanent Secretary for Administration and Permanent Secretary for Technical Services will be responsible for submitting the CERC Operations Manuals to the World Bank.

B. Results Monitoring and Evaluation Arrangements

101. The ACDCP’s results framework includes both intermediate and final outcome indicators. Each implementing agency is assigned at least one intermediate outcome indicator, reflecting the recommendations of the 2013 IEG report on managing epidemics described above. The monitoring and evaluation system has been specifically designed to track incremental improvements in biosecurity, surveillance, diagnosis, and outbreak response, and regular reports on intermediate outcomes will help improve the efficiency of project implementation. Outcome indicators are detailed in Section VI.

102. PIUs and GMU within each of the three implementing entities will be responsible for: (i) collecting and compiling all data relating to their specific suite of indicators; (ii) evaluating results; (iii) providing the relevant performance information to the PSC; and (iv) reporting results to the World Bank immediately prior to each semiannual supervision mission. Each PIU and GMU will perform its functions in accordance with the methodology prescribed in its respective project implementation manual, and each appoint a project-funded monitoring and evaluation technical expert. During the project’s first two years, each PIU and GMU’s self-assessed results will be reviewed annually by an independent, external monitoring and evaluation expert, who will validate the quality of the data and verify the findings of the self-assessments. From year three onward, external evaluations are expected to be undertaken every two years.

C. Sustainability 103. The Africa CDC Project includes key features designed to ensure its long-term sustainability:


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(i) The Africa CDC is a flagship institutional initiative established by the AUC, to which all 55 AU member states contribute financially. During the two years since the official launch of the Africa CDC, the initial allocation that was recommended from the AU’s annual operational budget has grown from US$1.75 million (0.5 percent of the AU budget) in 2017 to US$17.35 million in 2019—highlighting the commitment of all 55 member states. The Africa CDC’s institutional relationship with the AUC and the AU member states will reinforce local ownership of the activities initiated under the ACDCP and help ensure its long-term sustainability.

(ii) The Governments of Ethiopia and Zambia and the agencies directly responsible for implementing project Subcomponents 1.2, 2.2, 3.2, 4.2, and 5.1 and 1.3, 2.3, 3.3, 4.3, and 5.2, respectively, have expressed credible commitments to the effective implementation and continued funding of the Africa CDC’s activities, which will help ensure the sustainability of the gains achieved through the ACDCP.

(iii) Upon closure of the ACDCP, these governments will bear lead responsibility for addressing financing gaps, but external funding can be catalytic. Ethiopia has already proven its ability to sustain its NPHI, which was established in 1940. In response to the recent scaling back of bilateral financing for epidemic preparedness and response activities, the Government has significantly increased the budget allocation to the EPHI, which rose nearly fourfold over the past 10 years in nominal terms from a base of Ethiopian birr 30,044,507. To account for the additional financial requirements that come with operating a BSL-3 lab, the EPHI, in consultation with the Ministry of Finance, has undertaken a preliminary assessment and analysis of the costs related to construction, equipping and furnishing, and sustainable operation of a new national reference laboratory complex with a BSL3 suite that meets international standards, including the establishment of a proficiency-testing system and panel production, a laboratory-equipment maintenance center, a biobank center, and a central warehouse. In addition, the lifecycle cost for operating the complex at full capacity for 20 years was estimated and discussed with the Ministry of Finance during project preparation and negotiations.

(iv) During implementation, the EPHI and ZNPHI will finalize 20-year lifecycle plans, which will be used as the basis for determining future financing needs. Based on these projections, partner governments and potential donors will be engaged to ensure adequate funds remain available after project closure.

(v) In Zambia, the annual national budget to support the operations of the ZNPHI and Zambia’s obligations to the SA-RCC under the Host Country Agreement has increased more than threefold in nominal terms since its inception in fiscal year 2017—demonstrating the government’s commitment to fulfilling its role in the project. This budget line will be retained and ring-fenced to support operational costs as well as ZNPHI staff emoluments. Resources will also be leveraged from other line ministries and stakeholders included as part of the One Health approach to enable cost-sharing in the operations of the BSL-3 laboratory and other project-supported facilities. Furthermore, the ZNPHI Bill provides for the establishment of a dedicated Emergency Fund to enable the mobilization of additional resources. Zambia will sign MoUs and other agreements with SA-RCC member states and the Africa CDC to enable access to the laboratory and other infrastructure investments under the ACDCP. The agreements will include cost-sharing through contributions for laboratory reagents and consumables, the attachment of staff on a rotation basis, and the provision of expert services,


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inter alia. Other strategies for ensuring the long-term sustainability of operations will include establishing a strong Research Grants and Contracts Unit to compete for and attract funding, building research and development capacity, promoting public-private partnerships in research, training and academic development, and providing specialized analytical and consultancy services in areas such as environmental and chemical analysis, water-quality monitoring, and pathology services, among others.

(vi) The ACDCP will provide a complete suite of interventions and health assets, including technical support, to build the disease-surveillance and response functions of Africa CDC, Ethiopia, Zambia, and the SA-RCC. Building local capacity will be vital for implementing authorities to sustain the operations after the ACDCP closes.

(vii) The ACDCP will support governmental and community efforts to adapt to the effects of climate change, and especially its impact on zoonotic and vector-borne diseases, as detailed in Annex VI.

(viii) Three subcomponents include a comprehensive human resource needs assessment designed to inform staff recruitment and training. The ACDCP’s human resource requirements include a wide range of both technical and administrative professionals, as well as semi-professional community-based implementers. The ACDCP will ensure that all key positions including the seven key staff at the ZNPHI are filled, that all personnel have been adequately trained, and that any issues involving staff retention or program participation incentives have been addressed. As the cadre of qualified staff recruited and trained through the ACDCP will be vital to the sustainability of its operations, the ACDCP will seek to identify and address the incentives and drivers for retaining staff. In particular, the ACDCP will: (a) aim to implement activities that improve staff motivation and retention through operational research to understand staff incentives, the provision of training and mentorship, and the development of vertical career progression paths; and (b) ensure that the Government of Zambia, based on the commitment made through a letter to the World Bank, takes over the salaries/emoluments of the seven core staff to be supported under the project by putting in place a staffing and salary/emolument structure supported by a legal framework with a clear staff-retention scheme, career progression, and continuous staff development over a transition period of three years from project effectiveness.

104. The international experience shows that an unanticipated reduction in international support can undermine the sustainability of regional health programs. IEG (2013) records the World Bank’s experience with avian influenza outbreaks in the early 2000s. Under the Global Program on Avian Influenza Control and Human Pandemic Preparedness and Response, the World Bank financed 83 operations across 63 countries that addressed avian influenza, zoonotic diseases, or pandemic preparedness or response. However, by 2013, international support for these priorities had largely ceased, as attention shifted elsewhere. This experience highlights the risks posed by changing donor priorities, but also underscores the extent to which a highly effective project can lessen the perceived urgency of donor action, undermining sustainability. To address these challenges, the ACDCP’s donor outreach focuses on its permanent role in disease prevention, rather that presenting itself as a remedy to a specific public health emergency. During implementation, the ACDCP will work proactively with government and international partners to secure a diverse range of long-term financing, which will mitigate the risks posed by competing donor priorities and national budget constraints.


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105. Finally, the ACDCP will publicize its positive impact on public health and economic productivity through regular reports to member governments and international partners, as well as general publications. By demonstrating the substantial value that the Africa CDC generates for its member states and highlighting its ongoing contributions to the objectives of international partners and other stakeholders, the ACDCP will make a powerful case for continued political, financial, and technical support.

IV. PROJECT APPRAISAL SUMMARY

A. Economic and Financial Analysis

106. Annex II provides a detailed economic and financial analysis of the ACDCP. There is a strong economic case for investing in a continent-wide disease surveillance and response systems, as preventing and controlling disease outbreaks yields large and lasting economic benefits. Disease outbreaks can cause severe short-term economic shocks by rapidly eroding consumer and business confidence, causing a sharp decline in aggregate demand; they can disrupt logistics networks, causing unpredictable fluctuations in trade volumes; and they can reduce aggregate supply though labor absenteeism and the suspension of business activities. Over the medium term, the adverse reputational effects of disease outbreaks can discourage investment and suppress economic activity across entire regions—including in countries with no reported cases of the disease. Finally, disease outbreaks can inflict lasting damage on stocks of both human and physical capital, reducing economic productivity and slowing long-term growth.27

107. The ACDCP will enhance the capacity of AU member states to rapidly detect and respond to national and international public health threats. Over time, the ACDCP will significantly reduce the burden of infectious diseases, particularly among poor and vulnerable populations, and decrease the risk of future outbreaks. These impacts will improve economic security among AU member states, enhancing their growth and development prospects. In addition, the ACDCP will enable Ethiopia and Zambia to help improve global health security.

108. The rationale for a publicly provided regional approach to disease surveillance and response network in Africa has five dimensions. First, the enormous burden imposed by infectious diseases in Africa is a unique regional challenge that requires a continent-spanning solution. Endemic infectious diseases impose severe social and economic costs that spill across national borders, and epidemics, such as the recent West Africa EVD outbreak, have caused considerable economic damage in countries with no reported cases. Second, the porous borders between African countries and the continent’s increasingly dense physical and economic integration intensify the risk of pandemics, and this risk cannot be effectively mitigated at the national level. Because a disease threat anywhere is a threat everywhere, coordinated action to reduce disease risks is vital to regional and global health security. Third, disease-surveillance systems are a global public good, as protection from disease outbreaks is both nonrival and nonexcludable. Consequently, even efficient markets

27 Human Development Report, Sustaining Human Progress: Reducing Vulnerabilities and Building Resilience, United Nations Development Program (UNDP), 2014.


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will provide a suboptimal supply of disease surveillance and response capacity. Fourth, the high unit costs, large sunk costs, and massive economies of scale involved in disease surveillance magnify the benefits of cross-country collaboration. Sophisticated health infrastructure and facilities, such as BSL-3 reference laboratories, specialized research institutions, and advanced training institutes, require large upfront investment outlays and must consistently operate at close to full capacity in order to be cost effective. For developing countries, collaboration is vital to overcome individual financial constraints and realize economies of scale in population coverage. Fifth, a continental institution is necessary to harmonize administrative and policy changes at the national level, consolidate lessons learned from the international experience, and disseminate best practices.

109. The value added by World Bank support reflects its regional perspective, extensive network of stakeholder relationships, vast institutional experience, and core mandate. The proposed project fits squarely into the World Bank’s Regional Framework for Communicable Disease Control and Preparedness Program and is closely aligned with its global mission to end extreme poverty and promote shared prosperity. Annex II presents a detailed assessment of the rationale for public-sector financing and the value added by the World Bank.

B. Technical Analysis

110. The ACDCP’s design incorporates best practices with respect to governance and accountability, technical standards for health infrastructure, civil works, and procurement of goods and services. The relative newness of the concept and institutions will necessitate significant ACDCP investment in strengthening Africa CDC staff recruitment, training, evaluation, and mentorship systems; procedures for strategic planning, budgeting, procurement, administration, monitoring and evaluation, internal controls, risk mitigation, and transparency; IT infrastructure (including both hardware and software), essential support services from external consultants to conduct evaluations and provide technical assistance.

Financial Management

111. Financial management (FM) assessments were carried out by the World Bank to evaluate the adequacy of FM arrangements to support project implementation. The objective of the assessments was to review whether: (a) the budgeted expenditures are realistic, prepared with due regard to relevant policies, and executed in an orderly and predictable manner; (b) reasonable records are maintained and financial reports produced and disseminated for decision-making, management, and reporting; (c) adequate funds are available to finance the Project; (d) there are reasonable controls over Project funds; and (e) independent and competent audit arrangements are in place.

112. Based on the ACDCP’s design, implementations arrangements, and assessment of the main entities and sub-implementers, the fiduciary risk is considered Substantial. Key risk factors relate to: (i) multiple implementing entities at the federal and regional levels in Ethiopia, some with capacity gaps, and high rates of staff turnover; (ii) complex FM arrangements, including monitoring and reporting given the number of entities involved, with subsequent risk of delays in implementation, reporting, and disbursements; (iii) the transfer of funds to sub-implementers, some of which have


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weak internal controls; (iv) the use of parallel systems (Ethiopia) or manual procedures (Zambia) for preparing financial reports, which may affect their quality and timeliness; (v) weaknesses in internal audit functions, including lack of familiarity with World Bank requirements; (vi) delays in processing transactions/payments by the AU; and (vii) internal control weaknesses related to fixed-asset and inventory management at the EPHI and inadequate resources to follow up on outstanding audit queries in Zambia.

113. The ACDCP contains several measures designed to mitigate fiduciary risks. These include: (i) a clear definition of staffing needs in different entities to strengthen their capacity; (ii) the establishment of coordination mechanisms among different entities, including deadlines and requirements for budget preparation, transfers of funds, and reporting; (iii) reforms to strengthen fixed-asset and inventory management at EPHI; (iv) the use of separate bank accounts, accounting records, and reporting requirements for EPHI and Regional Health Bureaus (RHBs); (v) revision of roles and responsibilities within the Ethiopia MoH (grant finance and GMU) regarding the preparation and submission of interim financial reports (IFRs); and (vi) definition of clear working relationships between the proposed FM staff at the Africa CDC Secretariat and the AU Finance Unit. For Zambia: (i) training in World Bank FM and disbursements procedures to the seconded senior accountant, other seconded staff, and the internal auditor throughout the life of the project; and (ii) arrangements to maintain comprehensive records for contract management.

114. Subject to the successful completion of the agreed action plan, the proposed FM arrangements can be considered acceptable to the World Bank. 115. The World Bank has provided up to US$2 million in optional retroactive financing to reimburse the Africa CDC for any necessary preparatory work undertaken prior to effectiveness. The Zambia MoH has requested and obtained a project preparation advance in the amount of US$2,081,958 to finance the following activities: (a) the preparation of detailed engineering designs, architectural drawings, and bidding documents for the construction of a BSL-3 laboratory, office complex, and auxiliary structures, and for updating the relevant safeguards instruments; (b) the provision of technical advisory services to validate the design with respect to infectious-disease controls, environmental safeguards, social and occupational safety safeguards, as well as the quality of civil and structural engineering, refrigeration and air-conditioning engineering, and electromechanical engineering; (c) the provision of support for project preparation and management, including the provision of training in procurement, FM, auditing, and monitoring and evaluation to core MoH staff; (d) stakeholder consultations on project activities; (e) the preparation of the PIM and Contingency Emergency Response Manual; and (f) support for the ZNPHI’s retention of critical human resources related to the ZNPHI’s strategic pillars, including surveillance and disease intelligence, emergency preparedness and response, laboratory systems and networking, information systems, public health research, and workforce development.

Procurement

116. ACDCP procurement will be carried out in accordance with the World Bank’s Procurement Regulations for IPF borrowers (Borrowers Regulations, July 2016 revised November 2017 and August 2018); the “Guidelines on Preventing and Combating Fraud and Corruption in Projects


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Financed by IBRD Loans and IDA Credits and Grants,” revised July 1, 2016; and the provisions stipulated in the Financing Agreements. Procurement under the project will be carried out according to the arrangements described in Annex I.

117. Implementing agencies:

a. AUC procurement will be coordinated by a PIU that will be established under the Africa CDC. A procurement officer will be hired for the PIU to support and coordinate procurement activities. The PIU will use the AUC’s Procurement, Travel and Store Division (PTSD), including its existing decision-making structure for processing procurement.

b. Ethiopia’s procurement implementation will be undertaken by two agencies: (i) the Ethiopia MoH; and (ii) the EPHI. The Ethiopia MoH will be responsible for works procurement of the BSL-3 laboratory and BSL-2 regional laboratories. The EPHI will be responsible for all laboratory equipment procurement, as well as for the planned supply and installation of IT systems.

c. Zambia procurement implementation will initially be carried out by Procurement and Supplies Unit (PSU) within the Zambia MoH and later by ZNPHI once established as an independent legal entity. Currently, ZNPHI is a directorate of Zambia MoH but will become a legal entity following enactment of the ZNPHI Act. PSU of Zambia MoH and later ZNPHI shall be responsible for all procurement.

118. Procurement risk assessment:

a. AUC:

i. Main risks identified include: (a) procurement process and decision-making delays because the Africa CDC is a specialized agency; and (b) extra workload that would be imposed on an already overextended procurement team working in PTSD.

ii. To mitigate these risks, the following actions are recommended: (a) hire and assign an experienced procurement expert at the PIU to coordinate and support procurement activities of this project with PTSD; and (b) sensitize the procurement decisionmakers about the project’s needs and tight implementation schedule.

b. Ethiopia: A procurement risk assessment was carried out at both the Ethiopia MoH and EPHI for the Ethiopia subcomponents.

i. Main risks identified include: (a) lack of prior experience implementing procurement under the World Bank-financed projects at EPHI; (b) slow procurement processing and decision making with potential implementation delays; (c) new Procurement Endorsing Committee members that do not have procurement experience with potential to block procurement processes and decisions; (d) limited technical capacity at Ethiopia MoH to lead, manage, prepare and evaluate technical aspects of BSL-3 laboratory; (e) limited technical capacity at Ethiopia MoH to handle technical aspects of ICT design, supply and installation contract; and (f) poor contract management system with potential time and cost overrun and poor quality deliverable.


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ii. To mitigate the identified risks, the following actions are recommended: (a) hire procurement experts with experience in World Bank-financed projects at both the Ethiopia MoH and EPHI; (b) develop, implement, and monitor an accountability framework with defined business standards for staff involved in procurement and contract management, including internal approvals; (c) provide procurement training to new endorsing committee members and to those that require such training; (d) hire a technical expert with experience in the field of laboratory design and implementation; (e) hire an IT specialist with experience managing the implementation of complex management information systems; (f) create an appropriate contract management plan, develop key performance indicators (KPIs) and hire adequate staff to administer and monitor contract implementation; and (g) Ethiopia MoH to assign site contract management engineers at each construction site.

c. Zambia: Procurement staff selected to work in the ZNPHI will be drawn from the Zambia MoH and will report to the Zambia MoH Head of Procurement. Some staff members have previously worked on World Bank-funded projects in areas such as FM and procurement. After the ZNPHI becomes an autonomous legal entity, a procurement assessment will be conducted to guide capacity-building activities and ensure efficient procurement under the project.

i. The Procurement Risk Assessment identified the following risks: (a) inadequate preparation of terms of reference for consulting assignments; (b) slow procurement processing and decision-making with potential implementation delays attributable to in-house Zambia MoH and external delays by the Office of the Attorney General in the Ministry of Justice in reviewing and clearing draft contracts; (c) challenges in choosing the right market approach for complex procurements; (d) unrealistic procurement planning; (f) inadequate contract-management systems, which could lead to time and cost overruns and poor-quality deliverables; (g) poor recordkeeping; and (h) residual risk of the project covering seven ZNPHI staff salaries.

ii. To mitigate the identified risks, the following actions are recommended: (a) the PIU and the World Bank to extensively review and approve terms of reference; (b) develop, implement and monitor an accountability framework with defined business standards for staff involved in procurement and contract management, including internal approvals, with this accountability framework to be part of the PIM procurement process; (c) provide procurement trainings to new members of the PIU using sample contract procurement management tools with implementation milestones; (d) create appropriate contract-management plans, develop KPIs, and ensure monitoring of contract implementation, assign suitably qualified and experienced site contract management engineers/architects at each construction site; (e) ensure that all procurements undertaken under the project have systematic and complete record keeping arrangement and carry out procurement post reviews (audits) and/or independent procurement reviews (IPRs) as part of compliance checks and monitoring by the World Bank; and (f) ensure a


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plan is in place to have the Zambian Government gradually assume responsibility for the staff salaries covered by the project.

119. With the procurement risk rated Substantial for Zambia and High for Ethiopia and the AUC, the overall ACDCP procurement risk rating is High. Once the mitigation actions described above have been implemented, the residual risk rating will be Moderate.

Climate Screening and Climate Co-Benefits

120. Climate change is a growing problem for Sub-Saharan Africa, which is increasing the frequency and severity of extreme weather events and acting as a risk multiplier for epidemics that can undermine decades of developmental gains. Environmental factors, extreme weather events, and anthropogenic changes all increase the risk of outbreaks. Changes in the epidemiology of infectious diseases associated with climate variability in Africa over the last 40 years highlight the growing evidence of the impact of climate change on infectious-disease transmission patterns, vector capacity, reproduction, and geographic range. For example, according to the WHO, the risk of malaria and other mosquito-borne disease outbreaks increases by approximately fivefold in the year following an El Niño event. Similarly, climate change could increase the burden of diarrhea by up to 10 percent by 2030 in some regions and indirectly increase rates of severe stunting by damaging agricultural output. EVD is just one of many infectious pathogens28 that are projected to become more frequent as climate change progresses. Climate change also influences human health indirectly by pushing populations into poverty, migration, and conflict, which further increase the risk of outbreaks. Both Eastern Africa and Southern Africa are climate-sensitive geographic regions as well as hotspots for emerging infections, and 88 percent of Sub-Saharan African countries are at significant risk of adverse health impacts due to their climate sensitivity and limited ability to adapt to climate shocks. 121. This project has been screened for climate change, and vulnerabilities have been identified. The overall assessment of potential risks in the Summary Climate and Disaster Risk Screening Report is assessed as “Low Risk.” The project is categorized as “slightly exposed” to all hazards, including extreme temperatures, precipitation and flooding, drought, sea-level rise, storm surge, and strong winds. 122. The climate co-benefits generated by the ACDCP are expected to be significant due to the impact of climate change on infectious disease threats and the climate mitigation activities incorporated in the project. The ACDCP will strengthen climate-resilient health systems in Africa by enabling the Africa CDC to improve continental capacity to detect and respond to infectious diseases, which are a climate-related threat. Under Subcomponent 1.1, measures to build the Africa CDC’s institutional capacity, establish harmonized guidelines, and create multi-hazard and multi-sectoral response plans will support a more effective emergency response to climate-associated infectious diseases. The ACDCP’s emphasis on the One Health approach will explicitly link human, animal, and

28 Climate plays a central role in the transmission of zoonotic and vector-borne diseases such as Lassa fever, Rift Valley fever, Dengue fever, Chikungunya, yellow fever, malaria, and Zika virus, among others. Severe weather events are also closely associated with outbreaks of enteric infections such as cholera.


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environmental health, while the Africa CDC’s stature as a specialized AU agency will enable it to convene actors and stakeholders from multiple sectors to align climate-change adaptation measures with the management of climate-related disease risks. ACDCP investments will contribute to sustainable, effective, and efficient regional collaboration to mitigate public health risks and counter the adverse economic consequences associated with infectious diseases, while also improving the continuity of care following a disaster. Under Component 2, the ACDCP leverages climate co-benefits through both adaptation and mitigation measures. Building and enhancing public health assets will directly strengthen the capacity of the Africa CDC and the Governments of Ethiopia and Zambia in critical areas such as disease surveillance, laboratory analysis, and emergency management. ACDCP activities include the establishment of data management systems and early warning systems to monitor changes in climate and infectious disease patterns, the creation and strengthening of laboratory facilities, and the integration of regional disease-surveillance networks to enable the swift detection of climate-sensitive outbreaks and facilitate a timely emergency response to climate-related events. Under Component 3, the ACDCP will invest in training public health professionals to build the capacity of laboratory diagnostics, early warning systems, and emergency response mechanisms, which will further mitigate climate-related disease risks. The inclusion of CERC under Component 5 will provide access to contingent emergency financing in response to extreme weather events and climate-related threats, including epidemics. 123. The ACDCP’s implementation incorporates measures to mitigate its climate impact by reducing emissions from waste and water treatment, increasing energy efficiency, and reducing greenhouse gas emissions. Under Component 2, laboratories constructed, renovated, or outfitted will be upgraded with climate-smart infrastructure, such as solar panels, low-energy lighting, energy-efficient heating, ventilation, and air conditioning, modern autoclaves, efficient water-treatment systems, etc. The project will also procure and install energy-efficient equipment where available.

C. Safeguards

(i) Environmental Safeguards

124. This project component has been classified as Category A. The project triggers safeguard policies for environmental assessments (OP/BP 4.01) and physical and cultural resources (OP/BP 4.11). The project will have highly positive environmental impacts by improving disease surveillance, monitoring, and containment. However, it also entails considerable environmental risks due to the inherently dangerous nature of the pathogens, reagents, and other materials used in or produced by the operations of project-supported laboratories. The construction of the laboratories will also pose both environmental and social risks. However, all risks associated with the laboratories are manageable and site-specific. 125. The environmental and social risks associated with this project are high due to the dangerous nature of the pathogens tested in project-supported laboratories and the toxic biproducts that may be produced by their construction and operation. The project will finance the construction of two BSL-3 laboratories, one in Ethiopia and one in Zambia; the construction, equipping and furnishing of 15 BSL-2 laboratories along Ethiopia’s borders; the equipping and furnishing eight BSL-2 district laboratories already constructed by the Global Fund in Ethiopia which


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will be located on existing compounds. These laboratories will test infectious agents from both livestock and human samples, which can generate biological waste, chemical waste, and other hazardous biproducts. Laboratory-associated infections due to inadequate adherence to occupational health and safety standards have been known to cause illness and death among laboratory workers. In addition, environmentally sound laboratory construction will require adequate provisions for solid-waste management and wastewater treatment. Environmental issues associated with the construction of the BSL-3 and BSL-2 laboratories are manageable and site-specific, as they are related to solid and liquid construction waste management, the sourcing of materials, and the siting of solid-waste and wastewater treatment facilities.

126. Safeguards will also be necessary to protect the occupational health and safety of workers and the surrounding community during both the construction and operational phases, and the anticipated influx of contractual workers from outside the community must be properly managed. Physical risks to workers involved in the construction of the proposed BSL-3 laboratories will be mitigated by strict adherence to international best practices for construction-site safety. Key risks include electrical, fire, and explosion hazards, as well as physical hazards such as slip-and-fall accidents, ladder accidents, power-tool accidents, motor-vehicle accidents, excessive noise, physical strain, heat or cold stress, sunburn, dust, and dangerous particulates. The influx of labor associated with contractual workers brought in from outside the community needs to be well managed. The NPHIs in Ethiopia and Zambia will apply international best practices to the construction of the laboratories and other facilities, such as relevant US Occupational Safety and Health Administration guidelines. Because BSL-3 laboratories will process dangerous biological materials, which have the potential to cause serious or potentially lethal harm to personnel and to the community, effective administrative and engineering controls will be put in place. The BSL-3 laboratories being financed under the project will be designed and operated according to strict international standards, thereby minimizing any potential threat to human health. The incidence of laboratory-acquired infections in US CDC laboratories has been extremely low since the US CDC first issued laboratories guidelines in 1974. Additional guidelines, standards, practices and procedures have been established by the US CDC, the US National Institutes of Health (NIH), the WHO, and the proper use of BSL-3 safety equipment and facility safety barriers, greatly reduces the risk of infections and diseases to site workers, visitors, and the community. Infection-control and waste-management plans have been developed for both Ethiopia and Zambia to ensure that appropriate occupational health and safety measures will be implemented, with adequate engineering and administrative controls, improvements in functional capacities, and close monitoring of potential environmental and social risks. 127. ESIAs for the two BSL-3 laboratories have been prepared by the PIUs in Ethiopia and Zambia. The ESIAs set forth design and operation specifications, maintenance and repair procedures, waste-management approaches, and effluent and emission standards. The ESIAs clearly indicate potential impacts and mitigation measures, as well as institutional arrangements for managing environmental safety risks and include specific environmental impact and safety guidelines for construction contractors. The ESIA for Ethiopia’s BSL-3 laboratory, which includes an ESMP, will be updated, along with the ICWMP, to reflect the relevant design details before the tendering or commencement of civil works. These works include the installation of a new incinerator at EPHI, the decommissioning of retired incinerators, updates to the design of the wastewater treatment system


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to be constructed at EPHI, and an assessment of the capacity of existing wastewater treatment plants to handle incineration residues and wastewater sludge. Similarly, Zambia will update the ESIA, which also includes an ESMP, along with the ICWMP, before the commencement of civil works to assess the due diligence of the Zambia Medicines Regulatory Authority’s incinerators, the final disposal sites for sludge from onsite wastewater treatment plant, and the fly-ash produced by the incinerators. The ESIAs were publicly disclosed on July 3, 2019 (Ethiopia) and August 2, 2019 (Zambia).

128. In addition, an Environmental and Social Management Framework (ESMF) has been prepared for the 15 BSL-2 laboratories to be constructed in Ethiopia. The ESMF comprehensively addresses rules for the safe handling, storage, and use of hazardous materials, and it includes techniques for preventing, minimizing, and controlling environmental impacts during the construction phase. Training programs supported by the ACDCP will prepare laboratory workers to recognize and respond to hazards once the laboratories are operational. Grievance-redress mechanisms and chance-find procedures have also been built into the safeguard instruments. These documents were developed in consultation with a wide range of stakeholders and were publicly disclosed on July 3, 2019.

129. The Africa CDC will ensure that the project-financed transportation of infectious substances to and from the project-constructed laboratories in Ethiopia and Zambia, and from other countries per the MoU and RISLNET agreements, will comply with the WHO guidance on regulations for the transport of infectious substances. Once the samples are in Ethiopia or Zambia, the respective country will assume responsibility for them, and the national environmental and social safeguards instruments will be applicable. Similarly, the procurement and transportation of chemicals and reagents to be procured by the Africa CDC will be handled in accordance with the applicable WHO guidelines and regulations and with due regard to appropriate health, safety, social, and environmental standards and practices. Once the chemicals and reagents are in Ethiopia or Zambia, the respective country will assume responsibility for them, and the national safeguards instruments for the storage and handling of such materials will be applicable.

(ii) Social Safeguards Ethiopia

130. Social risks are rated Moderate. The project is not expected to lead to any land acquisition or physical displacement, and hence the involuntary resettlement policy OP4.12 was not triggered. All ACDCP activities are site-specific and will occur within existing limits of the respective health facility compound. As ACDCP activities do not require additional land, no negative impacts on livelihoods, restriction on access, or disturbances that may lead to resettlement or physical relocation are anticipated. To preclude any other social impacts of the project and address environment impacts and risks, the client has prepared an ESIA, which includes an ESMP, for the BSL-3 laboratory, as well as an ESMF for the BSL-2 laboratories. These documents adequately address all potential social risks, including community health and safety issues and avoidance of child labor and GBV.


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131. As the site of the ACDCP’s only major construction project, the BSL-3 laboratory, will be in Addis Ababa, GBV-related risks are assessed as not substantial. Nevertheless, contractors will be required to adopt mitigation measures in their code of conduct, including a zero-tolerance policy for sexual harassment, and to hold periodic training of workers on preventing and responding to GBV. The project’s ESMFs also address the health and safety of workers and the community, including specialists that will be involved in the implementation of the project.

132. Planned construction activities may result in the establishment of worker camps by contractors engaged to undertake works. Potential risks and measures to prevent the labor influx from negatively affecting the local community will be explicitly articulated in the ESMF, the contractors’ codes of conduct, and contract conditions. Adherence will be closely monitored and reported on by the supervising engineer.

133. The ACDCP will establish and strengthen the GRM. The mechanism provides guidance on the process of complaint resolution for both contractors and affected communities. The GRM will assist in ensuring quick resolution of disputes before they can escalate to unmanageable levels and avert the risk of work stoppages which could negatively impact attainment of project timelines. The GRM mechanism will also have a procedure to address GBV cases. Responsible persons for the GRM will be adequately resourced and trained on how to manage GBV-related issues confidentially and in line with a survivor-centered approach in cooperation with the Bureau of Women, Children, and Youth Affairs.

Zambia

134. Social risks are rated as Moderate. Potential risks will be limited and site-specific. The risk of land acquisition and economic displacement is not anticipated and therefore the policy on involuntary resettlement has not been triggered. Planned construction activities will be undertaken within institutional premises that have been secured by ZNPHI, and documentation of land transfers have been confirmed. To mitigate potential social risks that may arise during project implementation, an ESIA, which includes an ESMP, has been prepared with measures to address social risks associated with construction. Procedures for managing project-related and worker grievances have been drafted. The GBV risk assessment for the project has been rated minimal, but contractors will be required to adopt mitigation measures in their codes of conduct and hold periodic workers trainings on GBV prevention and response.

(iii) Grievance-Redress Mechanisms 135. Communities and individuals who believe that they are adversely affected by a World Bank-supported project may submit complaints to existing project-level grievance redress mechanisms or the World Bank’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 World Bank’s independent Inspection Panel which determines whether harm occurred, or could occur, as a result of World Bank 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 World Bank Management


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has been given an opportunity to respond. For information on how to submit complaints to the World Bank’s corporate 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.

V. KEY RISKS

136. The overall project risk rating is High. Risks in four of the nine categories are rated High. These include political and governance risks, macroeconomic risks, fiduciary risks, and environment and social risks. Institutional capacity for implementation and sustainability risk is rated substantial. Risks related to sector strategies and policies, technical design and stakeholder risks are all rated Moderate. ACDCP is a bold, complex, and expansive initiative involving a wide range of stakeholders in a diverse region marked by high poverty rates and limited public-sector capacity. While a considerable degree of risk is inherent in a project of this scale, scope, and ambition, important mitigation measures have been integrated into its design. Political and Governance Risks: High

137. The ACDCP will involve multiple institutions in two national governments, and its activities will directly or indirectly impact countries across Africa. Ethiopia is surrounded by seven neighboring countries, many of which are fragile states, while the SA-RCC includes Angola, Botswana, eSwatini, Lesotho, Malawi, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe. The involvement of a wide range of countries increases political and governance risks, especially those related to the harmonization of legislative and institutional arrangements for disease surveillance and response. While the AU and the Governments of Zambia and Ethiopia have demonstrated a strong sense of ownership over the project and a credible commitment to its success, coordinating the activities of multiple countries to advance the project’s development objectives will be an ongoing challenge.

Macroeconomic Risks: High

138. The ACDCP will require a long-term financial commitment from the Governments of Ethiopia and Zambia, as well as the AU. The project’s ongoing fixed and operational costs are expected to be substantial and will likely rise over time as human and livestock populations continue to increase. There is a high risk that adverse economic conditions and/or fiscal constraints may prompt governments to reduce funding for the program. Any such disruption in funding would adversely impact service quality, leading to an increased threat of disease outbreaks in both humans and livestock. This risk is partially mitigated by the broadly favorable medium-term economic outlooks for both Ethiopia and Zambia.

139. Ethiopia’s GDP growth rate has averaged about 10 percent over the last decade. The country’s robust expansion has been underpinned by public investment and productivity gains, but


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in recent years droughts and weak export prices for agricultural commodities have slowed growth and given rise to external imbalances (IMF, 2018). The Government has adopted a responsible borrowing strategy, rising imports have reduced the current-account deficit, and foreign direct investment is increasing rapidly.

140. Ethiopia’s economic prospects for the medium term are expected to remain positive and stable. Annual real GDP growth is projected at about 8 percent, as sound fiscal policies contribute to moderate deficits and monetary policy remains prudent. Foreign direct investment is expected to boost manufacturing and exports. However, the economy will remain vulnerable due to the risk of exchange-rate overvaluation, limited progress in structural adjustment, the persistently weak performance of the tradeable sector, and the country’s vulnerability to terms-of-trade shocks (World Bank 2018).

141. Zambia’s GDP growth rate slowed from 3.8 percent in 2016 to 3.4 percent in 2017 despite high copper prices, an expansive monetary policy, and a strong agricultural season. Large public expenditure arrears accumulated in 2016 and heavy domestic borrowing constrained leading to the private sector and slowed growth. The public debt stock has risen sharply in recent years, and debt service is crowding out other public expenditures and diminishing foreign-exchange reserves (World Bank, 2018). In October 2017, the IMF reclassified Zambia as being at high risk of debt distress, which is expected to put upward pressure on lending rates.

142. The World Bank has revised Zambia’s 2019 GDP growth forecast down to 3.6 percent, reflecting weaker-than-expected growth in 2017, a poor harvest, and intensifying macroeconomic headwinds. Three assumptions underpin the medium-term outlook: (i) poor rainfall will adversely affect the 2019 agricultural season; (ii) the Government will implement its planned fiscal consolidation, as well as measures to increase foreign-exchange reserves, improve debt management, and ensure the financial and operational sustainability of the public electricity utility; and (iii) the Government will implement its economic recovery program (Zambia Plus). Three major external risks threaten the medium-term outlook: (i) falling copper prices; (ii) rising oil prices; and (iii) tightening global financing conditions.

Institutional Capacity for Implementation and Sustainability Risks: Substantial 143. Implementation arrangements are complex, and institutional capacity is variable. Several key agencies have little experience implementing complex projects involving large amounts of money, significant infrastructure construction, multiple simultaneous tasks, and continuous multi-stakeholder coordination. In Ethiopia, the EPHI’s limited capacity will require the GMU of the Ethiopia MoH to undertake project works and manage other project inputs, with EHPI providing support and technical assistance. This arrangement could delay project implementation, but there is no viable alternative at this stage. Previous World Bank-funded projects in Zambia have been delayed due to capacity constraints, and the ACDCP will ensure project readiness at the effectiveness date by utilizing the Project Readiness Filter, which is expected to significantly reduce startup delays. Potential readiness issues in Zambia will not impact Ethiopia’s effectiveness date. Complex administrative procedures within the AU may slow implementation, and the project team will work closely with AU counterparts to ensure that funds are disbursed on time. Instances for poor


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performance by any of the three implementing entities could negatively impact the project’s overall effectiveness. To mitigate this risk, the three implementing agencies will jointly establish a project steering committee through which the directors of each agency will support one another and provide technical guidance.

144. The scale of the surveillance and response network established by the project poses risks to its sustainability, especially after World Bank funding ceases. The success of the ACDCP will hinge on the creation of a network of highly trained healthcare workers to conduct laboratory tests, investigate disease outbreaks, monitor and analyze data, and improve operational capacity at the facility level. The ongoing fixed and variable funding requirements after the project closes are significant and will likely increase over time. When attempting to access regional and national funding for ongoing operations, the surveillance and response program may face challenges from competing projects. Some existing laboratories currently lack adequate operational funding, which limits their ability to undertake sample testing, highlighting the seriousness of financial sustainability risks.

Fiduciary Risks: High 145. The Zambian Ethiopian health ministries will be responsible for managing considerable project resources. Both institutions have prior experience implementing externally funded national health projects, and both have demonstrated a clear commitment to this project, but their administrative capacity is limited. Moreover, the project’s scale, geographic scope, and multi-sectoral nature will exacerbate fiduciary risks.

146. Fiduciary risk is affected by different factors. These include (i) multiple implementing entities at the federal and regional level in Ethiopia (for certain activities), some with capacity gaps and high rates of staff turnover; (ii) complex FM arrangements, including monitoring and reporting given the number of entities involved, and transfer of funds to sub-implementers, which would delay implementation, reporting and disbursements; (iii) the use of parallel systems (Ethiopia) or manual procedures (Zambia) for preparing financial reports, (iv) weaknesses in internal audit function; and (v) delays in processing transactions/payments by the AUC. As noted above, a temporary moratorium has been imposed on the hiring of AUC staff pending the completion of a review of AUC’s hiring practices, and the Africa CDC may need to request an exception. Ethiopia MoH has experience implementing large-scale procurements under World Bank-financed projects, but the EPHI’s relative inexperience could slow procurement processes and delay the implementation of activities for which the EPHI is responsible.

147. To mitigate fiduciary risks, all implementing entities will reinforce their PIUs or GMU with experienced finance and procurement officers or establish a PIU with an adequate complement of qualified staff. In addition, some specialized procurement activities may be outsourced to third parties through appropriate contracting agreement acceptable to the World Bank. Specific coordination mechanisms for the operation of financial management arrangements are being defined, including the use of separate bank accounts for EPHI and RHBs and clear working relationships between the proposed FM staff at the Africa CDC Secretariat and the AUC Finance Unit.


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To permanently strengthen governmental capacity for project implementation, various training and fellowship programs are incorporated into the project components.

Environmental and Social Risks: High 148. Environmental safeguards. The BSL-3 laboratories supported by the ACDCP will be designed and operated based on international good practices, which will minimize risks to human health and environmental quality. The laboratories will adhere to the guidelines, standards, practices and procedures established by the CDC, the US National Institutes of Health, and the WHO. In addition, various safeguards will mitigate the environmental and social risks associated with this project, including the preparation of (i) ESIAs and infection control and waste-management plans for the BSL-3 laboratories in Ethiopia and Zambia; (ii) an ESMF for the 15 new BSL-2 laboratories expected to be constructed and equipped and eight existing BSL-2 laboratories expected to be equipped during year three of the project; and (iii) a protocol included in the ESMF for environmental and social auditing of equipment procurement for the 15 new BSL-2 laboratories expected to be constructed.

149. Social safeguards. The project’s safeguards assessment will need to ensure that the proposed laboratory sites do not negatively impact local populations. All project activities are site specific, will occur on existing structures, and do not require land, and therefore no negative impacts on livelihoods or restriction of access and disturbances that may lead to resettlement or physical relocation. Therefore, OP4.12 has not been triggered for this project. However, to preclude any other social or environment impacts, the clients have prepared ESIAs, which include ESMPs, for the BSL-3 in Ethiopia and Zambia and an ESMF for the BSL-2 laboratories in Ethiopia. The social protection team has reviewed both documents to ensure that all potential social risks, including community health and safety issues and the avoidance of child labor and GBV, are adequately covered. These two documents were disclosed before appraisal.

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VI. RESULTS FRAMEWORK AND MONITORING

Results Framework COUNTRY: Africa

Africa CDC Regional Investment Financing Project

Project Development Objectives(s)

The Project Development Objective is to support Africa CDC to strengthen continental and regional infectious disease detection and response systems.

Project Development Objective Indicators

RESULT_FRAME_T BL_ PD O

Indicator Name DLI Baseline End Target

1. Early detection and timely reporting of outbreaks (surveillance)

Countries that have achieved the required timeliness of reporting for immediately reportable diseases under IDSR. (Percentage)

0.00 100.00

Samples from suspected outbreaks of immediately reportable diseases that are confirmed within the stipulated WHO standard time at reference laboratories supported by the project (Percentage)

0.00 80.00

2. Rapid response to infectious disease outbreaks (response)

Countries responding within 48 hours to confirmed outbreaks of immediately reportable diseases (Percentage)

0.00 100.00

3. Laboratory quality

BSL-2 and BSL-3 laboratories supported by the project that have been awarded a SLIPTA rating of two stars or higher under the

0.00 25.00


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RESULT_FRAME_T BL_ PD O


regional WHO AFRO stepwise accreditation program (Number)

Ethiopia (Number) 0.00 24.00

Zambia (Number) 0.00 1.00

4. Regional and continental indicators

Africa CDC standard manuals, procedures, guidelines developed (Yes/No)

No Yes

For NPHI management and operations (Yes/No) No Yes

For epidemic preparedness and response (Yes/No) No Yes

Regions with functional RISLNETs (Number) 1.00 4.00

At least one yearly outreach event conducted to link implementing partners of existing regional disease surveillance and response projects in a systematic way (Number)

0.00 6.00

The information technology systems developed by the Africa CDC, EPHI, and ZNPHI have been connected (Yes/No)

No Yes

PDO Table SPACE

Intermediate Results Indicators by Components

RESULT_FRAME_T BL_ IO


Component 1: Governance, Advocacy, and Operational Framework

Zambia: Selected policy reform notes are developed to propose revisions to legislation, procedures, and regulations as a first step to harmonize legal frameworks among SA-RCC countries (Yes/No)

No Yes


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Africa CDC: the SA-RCC is operational (Yes/No) No Yes

MOU signed between Ethiopia and Africa CDC to facilitate cooperation/collaboration and to establish arrangements to ensure the shared use of the Ethiopia’s public health assets (Yes/No)

No Yes

Zambia: Country Hosting agreement for the SA-RCC implemented (Yes/No) No Yes


Ethiopia: Laboratories constructed and equipped as per standards (BSL-2 and BSL-3) (Number) 0.00 24.00

National Reference Laboratory BSL-3 (Number) 0.00 1.00

Regional Reference laboratories (Number) 0.00 23.00

Zambia: Laboratories constructed, upgraded as per standards (BSL-3) (Number)

0.00 1.00

Regional reference laboratory (Number) 0.00 1.00

NPHI’s system for PHEOCs is operational based on standards (both national and regional) (Yes/No) No Yes

Ethiopia (Yes/No) No Yes

Zambia (Yes/No) No Yes

NPHI system for Communication and Technology (ICT)/Data Management Center is operational (Yes/No) No Yes



Ethiopia: AMR scorecard rolled out in all 11 regions in Ethiopia (Number) 0.00 11.00

Zambia: AMR scorecard implemented in 10 provinces in Zambia (Number)

0.00 10.00


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NPHI system for EBS is operational according to Standard Operating Procedures (Yes/No)

No Yes



Annual operating costs for BSL-3 laboratories have been confirmed and set aside in the annual budget (Yes/No)

No Yes



Citizens and/or communities involved in planning/implementation/evaluation of development programs (Yes/No)

No Yes




Ethiopia: Professional/semi-professional personnel trained through the Project in critical skills such as disease surveillance, outbreak investigations and response, M&E, risk communication, auditing (Number)

0.00 800.00

Of which female (Percentage) 0.00 30.00

Zambia: Professional/semi-professional personnel trained under the Project in critical skills including disease surveillance, outbreak investigations and response, M&E, risk communication, auditing (Number)

0.00 500.00


Africa CDC - Number of personnel trained in Field Epidemiology Training Program (FETP) (Number)

0.00 200.00



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IO Table SPACE

UL Table SPACE

Monitoring & Evaluation Plan: PDO Indicators

Indicator Name Definition/Description Frequency Datasource Methodology for Data Collection

Responsibility for Data Collection

Countries that have achieved the required timeliness of reporting for immediately reportable diseases under IDSR.

Ethiopia and Zambia reach 85% of the required timeliness.

Bi-annually

Project reports

Review of project reports/administer a structured questionnaire to PIUs and NPHIs of countries

EPHI, ZNPHI, RCC, Africa CDC.

Samples from suspected outbreaks of immediately reportable diseases that are confirmed within the stipulated WHO standard time at reference laboratories supported by the project

Numerator: Number of suspected outbreaks of immediately reportable diseases with samples tested at reference laboratories Denominator: Total number of suspected outbreaks of immediately reportable diseases which require laboratory confirmation

Bi-annually

Project reports

Review of project reports/administer a structured questionnaire to PIUs and NPHIs of countries covered by the Project.

EPHI, ZNPHI, RCC, Africa CDC

Countries responding within 48 hours to confirmed outbreaks of immediately reportable diseases

Numerator: Number of countries which responded to outbreaks of immediately reportable diseases within 48 hrs

Annually

Project reports

Review of Annual Project Reports/Administer a structured questionnaire to PIUs of countries



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Denominator: Total number of countries

BSL-2 and BSL-3 laboratories supported by the project that have been awarded a SLIPTA rating of two stars or higher under the regional WHO AFRO stepwise accreditation program

Number of laboratories in Ethiopia and Zambia that have been awarded a SLIPTA rating of two stars or above under the regional WHO AFRO step-wise accreditation program

Annually

Annual project reports

Review of Annual Project Reports/Administer a structured questionnaire to PIUs of countries of the regions covered by the project


Ethiopia

Zambia

Africa CDC standard manuals, procedures, guidelines developed

Annually

Annual project reports

Review of Annual Project Reports/Administer a structured questionnaire to PIUs of countries of the regions covered by the project

Africa CDC, RCC

For NPHI management and operations

For epidemic preparedness and response

Regions with functional RISLNETs Number of RCCs with RISLNETs established and functioning

annually

Annual progress reports

Review of annual project reports/administer a structured questionnaire to PIUs

Selected countries, EPHI, ZNPHI, RCC, Africa CDC


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of countries of the regions covered by the project.

At least one yearly outreach event conducted to link implementing partners of existing regional disease surveillance and response projects in a systematic way

The information technology systems developed by the Africa CDC, EPHI, and ZNPHI have been connected

ME PDO Table SPACE

Monitoring & Evaluation Plan: Intermediate Results Indicators

Indicator Name Definition/Description Frequency Datasource Methodology for Data Collection

Responsibility for Data Collection

Zambia: Selected policy reform notes are developed to propose revisions to legislation, procedures, and regulations as a first step to harmonize legal frameworks among SA-RCC countries

Policy reform notes are developed to propose revisions to legislation, procedures, and regulations as a first step to harmonize legal frameworks among SA-RCC countries.

First year

Policy reform notes.

Review of policy reform reports/administer a structured questionnaire to PIUs and NPHIs of countries of the regions covered by the project

ZNPHI, Africa CDC, RCC

Africa CDC: the SA-RCC is operational

The SA-RCC adopts Africa CDC’s protocols and guidelines and implements the institutional framework, operational guidelines and protocols developed during the project to operationalize

Implementation progress quarterly

Project reports

Review of Project reports/administer a structured questionnaire to PIUs and NPHIs of countries of the regions covered by the project

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the RCC Host Country Agreement.

MOU signed between Ethiopia and Africa CDC to facilitate cooperation/collaboration and to establish arrangements to ensure the shared use of the Ethiopia’s public health assets

MOU signed between the Africa CDC and EPHI regarding the use of the BSL3 reference laboratory.

effectiveness condition

project reports, supervision reports

Review of Project Reports/Administer a structured questionnaire to PIUs and NPHIs of countries of the regions covered by the project

Africa CDC, RCC

Zambia: Country Hosting agreement for the SA-RCC implemented

The Country Hosting agreement is signed for the SA-RCC

Project reports, supervision reports


Africa CDC, RCC

Ethiopia: Laboratories constructed and equipped as per standards (BSL-2 and BSL-3)

Number of laboratories constructed and/or upgraded as per standards.

Annually

Project reports/supervision missions


Africa CDC

National Reference Laboratory BSL-3 Number of BSL3 laboratories constructed.

Annually

Project reports/Supervision missions

Review of Project Reports/Administer a structured questionnaire to PIUs and NPHIs of countries of the regions covered

PIU (EPHI)


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by the project

Regional Reference laboratories

Number of regional reference laboratories (BSL2) constructed and/ or upgraded.

Annually

Project reports; supervision mission

Review of Project Reports/ Administer a structured questionnaire to PIUs and NPHIs of countries of the regions covered by the project

PIU (EPHI)

Zambia: Laboratories constructed, upgraded as per standards (BSL-3)

Number of laboratories constructed and/or upgraded as per standards.

Annually

Project reports; supervision missions


PIU (ZNPHI)

Regional reference laboratory Number of BSL3 laboratories constructed.

Annually

Project reports; supervision missions

Review of Project Reports/ Administer a structured questionnaire to PIUs and NPHIs of countries of the regions covered by the project

PIU (ZNPHI)

NPHI’s system for PHEOCs is operational based on standards (both national and regional)

bi-annually

Project reports, supervision missions

Review of Project Reports/Administer a structured questionnaire to PIUs


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and NPHIs of countries of the regions covered by the project

Ethiopia

Zambia

NPHI system for Communication and Technology (ICT)/Data Management Center is operational

bi-annually

Project reports, supervision reports


Ethiopia PIU (EPHI)

Zambia PIU (ZNPHI)

Ethiopia: AMR scorecard rolled out in all 11 regions in Ethiopia

Zambia: AMR scorecard implemented in 10 provinces in Zambia

NPHI system for EBS is operational according to Standard Operating Procedures

bi-annually

Project reports



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Ethiopia

Zambia

Annual operating costs for BSL-3 laboratories have been confirmed and set aside in the annual budget

Ethiopia

Government annual budget

MOF

Zambia

Government annual budget

MOF

Citizens and/or communities involved in planning/implementation/evaluation of development programs

Ethiopia

Zambia

Ethiopia: Professional/semi-professional personnel trained through the Project in critical skills such as disease surveillance, outbreak investigations and response, M&E, risk communication, auditing

Number of professional/semi-professional personnel trained in critical skills including disease surveillance, outbreak investigations and response, M&E, risk communication, and auditing.

Bi-annually

Project reports


PIU (EPHI)

Of which female Numerator: Number of personnel trained are

Bi-annually

Project report

PIU (EPHI)


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female, Denominator: Total number of personnel trained

Zambia: Professional/semi-professional personnel trained under the Project in critical skills including disease surveillance, outbreak investigations and response, M&E, risk communication, auditing

Number of professional/semi-professional personnel trained in critical skills including disease surveillance, outbreak investigations and response, M&E, risk and communication.

Bi-annually

Project reports


PIU (ZNPHI)

Of which female

Numerator: Number of personnel trained are female, Denominator: Total number of personnel trained

Bi-annually

Project reports

PIU (ZNPHI)

Africa CDC - Number of personnel trained in Field Epidemiology Training Program (FETP)

Number of personnel that completed FETP.

Bi-annually

Project reports


PIU (Africa CDC)

Of which female

Numerator: Number of personnel trained are female, Denominator: Total number of personnel trained

Bi-annually

Project reports

PIU (Africa CDC)

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ANNEX I: IMPLEMENTATION ARRANGEMENTS

150. The Africa CDC Financing Agreement between IDA and the AU will be signed by the chairperson of the AUC. 151. During project preparation, FM assessments were carried out by the World Bank to evaluate the adequacy of FM arrangements to support project implementation. The objective of the assessments was to review whether: (a) the budgeted expenditures are realistic, prepared with due regard to relevant policies, and executed in an orderly and predictable manner; (b) reasonable records are maintained and financial reports produced and disseminated for decision-making, management, and reporting; (c) adequate funds are available to finance the Project; (d) there are reasonable controls over Project funds; and (e) independent and competent audit arrangements are in place.29

The assessments build significantly on the World Bank’s knowledge of country FM systems, as well as experience and performance of the entities that are involved in other World Bank-financed operations.

152. Based on the implementation arrangements defined for the project, the assessment scope included the following entities:

• Regional Coordination: The AU and the Africa CDC Secretariat.

• Ethiopia: The Ethiopia MoH, the EPHI, and the regional health bureaus of Oromia and the Southern Nations, Nationalities, and Peoples (SNNP) regions, which would be involved in capacity building and training activities.30

• Zambia: The Zambia MoH that would initially undertake responsibility for project implementation in Zambia. The ZNPHI is currently a directorate under the MoH, but once it is established as an autonomous government entity it will assume overall responsibility for project execution, coordination, and management, subject to a satisfactory fiduciary assessment of ZNPHI together with a detailed transition plan.

153. Fiduciary risk is considered HIGH due to the following risk factors:

(i) The presence of multiple implementing entities at the federal and subnational levels in Ethiopia, some with capacity gaps, and high staff-turnover;

(ii) A lack of experience with World Bank-financed projects among some of the implementing agencies. (iii) The complexity of coordinating FM functions and monitoring and reporting on project activities

due to the number of entities involved, which creates risks of delays in implementation, reporting, and disbursements.

(iv) The financing of laboratory construction and high-value procurement via large transfers to sub-implementers, some of which have internal control weaknesses;

(v) The parallel recording of project transactions in national Integrated Financial Management Information System (IFMIS) databases in Zambia and Ethiopia and the preparation of project financial reports (IFRs and annual financial statements) via other systems, such as Peachtree in

29 FM assessments were carried out in compliance with IPF World Bank Policy and related Directives and Guidance Notes, including World Bank Directive: Financial Management Manual for World Bank Investment Project Financing Operations issued February 4, 2015 and effective from March 1, 2010; and the World Bank Guidance: Financial Management in World Bank Investment Project Financing Operations Issued and Effective February 24, 2015. 30 The Ethiopian Pharmaceutical Supply Agency was also assessed; but it was decided that they would not participate in project implementation.

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Ethiopia or manual procedures in Zambia, which could lead to the duplication of efforts and may affect the timeliness and reliability of financial information if adequate controls are not in place.

(vi) The overall weakness of internal audit functions, as internal audit units are understaffed and unfamiliar with World Bank requirements;

(vii) Internal control weaknesses related to fixed-asset and inventory management at EPHI; and (viii) Potential delays in processing transactions and payments by the AU.

154. To address the challenges described above, the following mitigating measures have been discussed:

• Confirm staffing needs in different entities (PIUs) to build FM capacity, with financing provided under the project or seconded/designated by the Government;

• Discuss and agree on coordination mechanisms among different entities and set clear deadlines and requirements for budget preparation, transfer of funds, and reporting, together with regular supervision arrangements by the lead implementing entity;

• Agree with the EPHI on specific measures to strengthen the management of fixed assets and inventories;

• Confirm the requirement of separate bank accounts and accounting records for the EPHI and RHBs, together with reporting requirements;

• Review the roles and responsibilities within the Ethiopia MoH for grant finance and GMU involved in the preparation and submission of IFRs;

• Define clear working relationships between the proposed FM staff at the Africa CDC Secretariat’s PIU and the AU’s Finance Unit; and

• Agree on the assignation of responsibilities for maintaining comprehensive records for contract management within the Zambia MoH, including contract dates and amounts contracted, paid and outstanding.

155. If the proposed mitigation measures are successfully implemented, the proposed FM arrangements can be considered acceptable to the World Bank.

SUMMARY OF FINANCIAL MANAGEMENT ARRANGEMENTS31

156. Country Public Financial Management (PFM) Systems. Most countries are gradually and consistently working on to strengthen their PFM systems, and the World Bank has been supporting those efforts through various interventions. Consistent with current portfolio practices, project implementation in each country and the Africa CDC will follow the relevant national or organizational PFM regulations, systems for budgeting, accounting, and banking arrangements, as they apply to different types of entities. This framework will be supplemented where needed to ensure project needs are met and risks are adequately addressed, especially in terms of internal controls, financial reporting, and auditing. The following sections describe specific arrangements in different countries. 157. As part of the governance and anti-corruption arrangements, the project’s FM systems will include internal controls and audits to prevent and detect fraud and corruption. Each of the components’ budgets and audited financial statements will be posted on the each implementing agencies website, contributing to transparency and accountability. Each implementing agency will establish mechanisms to receive and redress complaints, including systems to record all complaints received, the official to whom they were directed, and the outcome. The project will comply with the

31 Detailed FM assessment reports for each of the entities are available in project files.

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World Bank’s Anticorruption Guidelines, which were promulgated in 2006 and revised in 2011 and 2016.

ORGANIZATION AND STAFFING

158. AU. The Africa CDC is a specialized technical institution of the AUC. The AU will be responsible for project FM and procurement arrangements. AU service division/the Directorate of Planning, Budgeting, Finance and Accounting will be responsible for the overall fiduciary management of the project funds including the internal control system. To that end, specific technical, and fiduciary specialists would be hired to manage the day-to-day coordination of project activities. Until finance staff hiring is complete (three months after effectiveness), the AU will assign a FM expert (within one month of effectiveness). 159. Ethiopia: Within the Ethiopia MoH, project activities will be coordinated by the PCD and the GMU which is accountable to the PCD will handle the day to day management of this project. A team will be established under the Ethiopia MoH-GMU to ensure effective coordination of the ACDCP activities including procurement and FM and ensure adherence of all World Bank implementation and reporting guidelines. For FM purposes, the MoH and EPHI will hire at least two and three finance staff, respectively. Finance staff will be assigned at the regional health bureaus. 160. As per the project’s design, the EPHI, as well as the RHBs of Amhara, the SNNP, Tigray and Oromia will be responsible for specific activities. Hence, project funds will flow to these entities. The EPHI, as sub-recipient, shall be financed through an agreement that stipulates agreed deliverables with associated indicators and targets. For Project purposes, the EPHI will reinforce its GMU with a financial and procurement specialist. 161. Zambia. Within the Zambia MoH, the Director of Finance will assume overall responsibility for project FM functions. Additionally, the PIU to be established within the Zambia MoH to support day-to-day implementation will include an accountant dedicated to the project, who would interact with the Finance Directorate. The ZNPHI currently has a senior accountant and an internal auditor seconded by the Government. These two staff report administratively to ZNPHI’s Director, but functionally report to Zambia MoH’s Director of Finance and Principal Internal Auditor, respectively. Overall, Project will benefit from Zambia MoH’s existing arrangements, including staff and systems that have been put into place under the Zambia Health Services Improvement Project and SATBHSS projects. Additionally, all accounting and internal audit staff involved in project implementation will be trained in World Bank FM and disbursements procedures continuously throughout the life of the project.

PLANNING AND BUDGETING

162. Country and/or institutional budgetary requirements and regulation in terms of budget formulation, execution and monitoring will be followed in each of the three participating countries. 163. AU. Overall, the AU follows a well-established budget preparation process and calendar, although some communication gaps are noted in notifying approved budget to the finance team. The planning and budgeting process is coordinated by the Internal Programme and Budget Committee that scrutinizes, consolidates, and compiles the budget estimates and submits to the AUC chairperson for presentation to the Permanent Representative Committee for subsequent approval by the Assembly. The financial resources from development partners are declared and included as part of the Commission’s budget. Budget control and monitoring is overall considered adequate and is supported by SAP system. Transaction are subject to SAP built-in controls, and “real time” data is

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available to follow up on the project funds and activity. Budget variance analysis is made on IFRs of the World Bank-financed project.

164. Ethiopia. As the lead implementing entity, the Ethiopia MoH will be responsible for preparing and consolidating the annual budget of the project in consultation with EPHI and RHBs. The Ethiopia MoH will follow the government’s budget procedure and calendar to have the annual budget approved and proclaimed under the Ministry. Within Ethiopia MoH, there is a clear and well-established budget preparation and review process through the Policy, Plan, Monitoring and Evaluation Directorate. The budget approved by the Minister is finally sent to the Ministry of Finance to be proclaimed at the parliament. A Budget Control and Follow-up Case Team is established under the Finance and Procurement Directorate, and it is responsible for budget monitoring, which is overall strong, and supported by country IFMIS. Monthly budget monitoring report are produced and circulated to the relevant directorates. In addition, for a World Bank-financed project, budget variance analysis is provided in quarterly IFRs. EPHI’s budget is closely monitored by its management. Quarterly reviews are conducted, and review reports approved by the Director General are sent to the parliament and Ministry of Finance. For low utilizations, an “Accelerated Plan” is prepared by the relevant departments and monitored by senior management. 165. The RHBs of Oromia and the SNNP. For donor funded projects, an annual activity is prepared by the woreda and technical experts based on the budget ceiling received from the Federal level, which is then reviewed and agreed with all stakeholders. The approved budget will only be submitted to Bureau of Finance and Economic Cooperation. Budget monitoring is supported by the IBEX software report. 166. Zambia. The Zambia MoH will prepare its annual budget based on the procurement and work plans, which are to be submitted to the World Bank at least two months before the beginning of the project’s fiscal year. The budget will follow national procedures, as well as the budgeting guidelines in the FM Manual. The budget should be approved before the beginning of financial year. During the financial year, the budget will be monitored on a semi-annual basis using IFRs. The IFRs will compare the budget and actual expenditure and significant variances will need to be explained.

ACCOUNTING SYSTEMS, POLICIES AND PROCEDURES

167. AU. The AU uses SAP to process and record financial transactions. It has adequate internal IT support system and uses the organization’s Financial Rules and Regulations, approved by the Head of States. It maintains it accounts on a double entry accrual basis of accounting following International Public Sector Accounting Standards. SAP is also used to record and report on the project financial transactions. Chart of accounts allows reporting of World Bank-financed transactions (especially income and expenditures by activities/components). However, the current system does not provide a separate trial balance for a specific project. To address this issue, the procurement of a grant management module is under way. AU is testing the implementation of a planning tool, which is expected to be completed by beginning 2020. The Financial Rules and Regulations codify key procedures and regulations in budgeting, payment, accounting, reporting, auditing, etc, and it is complemented by a detailed procedures manual. The Financial Rules and Regulations are being revised. In terms of staffing, the External Resources Management Division provides overall guidance on FM issues. There are qualified staff in this unit. 168. Ethiopia. The Ethiopia MoH applies the modified cash basis of accounting and the government’s accounting manual. IFMIS is used for financial accounting and reporting. In addition, donor financed projects use Peachtree accounting software. The program will have a detailed FM

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manual, as part of the project implementation manual, which will reflect the FM arrangements, internal control procedures, fund flows and reporting aspects of the program. For donor funded projects, both Peachtree and IFMIS are used simultaneously. However, reports are not produced from IFMIS as it requires customization to cater for grant projects. The Peachtree accounting software is not operating in a multi-user mode and thus two or more users could not work at the same time and in the same file. This affects timeliness and quality as recorded transactions are not independently checked. For the purpose of this project, the government’s chart of account will be customized for recording transactions on Peachtree, if required. The government accounting manual is used for managing financial transactions by EPHI. Starting from Ethiopia FY2011 (2018/19), IFMIS is being implemented. In previous years, IBEX was used to record the regular government budget financial transactions whereas Peachtree was used for grant-financed projects. Training on IFMIS has been provided to all finance staff. However, financial report has not been produced so far.

169. RHBs of Oromia and SNNP uses Peachtree accounting software for donor-funded projects at the regional level, whereas manual accounting is used at the zonal and woreda levels. 170. Accounting centers for program funds are Ethiopia MoH, EPHI, RHBs of Amhara, SNNP, Oromia, and Tigray regions. All these entities will maintain accounting books and records and prepare financial reports in line with the system to be outlined in the FM Manual. Each implementing agency is responsible for maintaining the project’s records and documents of the project transactions which will be made available to the World Bank’s regular supervision missions and to the external auditors. Arrangements for consolidation of the program financial information are discussed under Financial Reporting below. In terms of staffing, the Grant Finance Case Team (GFT) is staffed with 16 accountants and two cashiers. Due to high staff turnover in the GFT and GMU, it is agreed that staff will be hired to handle the FM of the program. 171. Zambia. The project will use the government’s IFMIS to prepare Project accounts. The Project will use cash basis accounting, in line with International Public Sector Accounting Standards. The project will develop a FM procedures manual as part of the PIM by effectiveness that will document the accounting policies and procedures to be used for the project. All accounting staff will be trained in the World Bank’s FM and disbursement procedures during project implementation. IFRs will be prepared manually based on the information extracted from the country IFMIS. Thus, it will be critical that the PIM includes necessary internal controls to ensure timeliness and reliability of project financial information.

INTERNAL CONTROLS AND INTERNAL AUDIT

172. Internal controls comprise the whole system of control, financial or otherwise, established by management. The purpose of internal controls is to: (a) carry out project activities in an orderly and efficient manner; (b) ensure adherence to policies and procedures; (c) ensure maintenance of complete and accurate accounting records; and (d) safeguard the project’s assets. 173. AU. SAP is used for processing payments and provides adequate security to various users in terms of data entry, verification and approvals. Duties are adequately segregated. The authorized signatories approve payments and related documents before payments are processed. Transactions to be processed are checked by Finance for availability of budget, relevance, fund availability and compliance to rules, regulations and agreements. Overall, AUC’s internal control system over payments is strong and there is a comprehensive process in place. However, the process involves several individuals and unless the respective officers and officials sign-off timely, payments can be delayed. In addition, if requests are rejected at any stage, reworking the process on the system may

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also be time taking. To avoid potential delays, the FM expert expected to be hired at the Africa CDC secretariat PIU need to closely work with the AUC counterparts and regularly follow-up transaction and payments processing to alleviate the challenge. Monthly bank reconciliations are prepared, and counter checked. Fixed assets register is maintained on SAP and can easily be identified. 174. Internal audit. AU has an internal audit Directorate reporting directly to the Chairperson. It has an Internal Audit Charter approved/ adopted in July 2012. The Permanent Representative Committee Sub-Committee on Audit Matters follows up on all internal and external audit matters including investigations, and the Internal Audit Progress Committee follows up on implementation of audit recommendations. Despite its constraint in staffing, the Directorate performs internal audit on program funds in the commission on a risk-based approach. 175. Ethiopia. The functions of preparing, certifying, approval of payments; ordering, receiving and accounting for purchases are clearly segregated. In the Ethiopia MoH, there are six signatories who sign based on threshold limits set (Directors and Ministers authorize the upper limit, >ETB 500,000), and proper fixed asset register is maintained on IFMIS. However, the document review in EPHI noted that the budget expert does not often certify but this is done by the personnel verifying the request, the fixed asset register is not maintained, and the inventory management has significant shortcomings. Bank reconciliation is done monthly and since the start of IFMIS implementation, this has further improved. RHBs prepare monthly bank reconciliation, but there is gap in maintaining project specific fixed asset register. 176. Internal Audit. There is an internal audit unit in the Ethiopia MoH, though this is understaffed (Structure 15, actual 6). Staff turnover is high mainly due to salary and benefit issues, and training provided to internal auditors is inadequate. An annual report is produced and submitted to the Minister, and major issues raised are presented in the quarterly Joint Steering Committee meeting. EPHI has an internal audit department with eight staff. However, they do not audit the Grant Projects due to work overload. However, the internal audit department is being reorganized in to a Directorate to increase its capacity. Internal audit units in RHBs are understaffed, and therefore the scope of work is limited. 177. Zambia. The Project will process transactions using the rules and regulations specified under the Public Finance Management Act 2018. While the current accounting regulations are adequate to assure a strong control environment, there is lack of compliance and enforcement. To mitigate these risks, the FM procedure manual will be prepared as part of the PIM to strengthen control measures under the project. Additionally, the PIM will include explicit requirements and responsibilities to maintain up to date records for contract management, which should be periodically reconciled with accounting records. 178. Internal Audit: Zambia MoH is serviced by the Internal Audit Unit with positions filled up to provincial level only. At the district level, there are no internal auditors. Therefore, internal audit verification at the district level are done by the provincial and Zambia MoH-HQ based internal auditors. The internal audit functions have also shifted from pre-auditing as it used to be in the past to post audit. The post audits are done on all transactions and on a risk basis at the ministry HQ. The internal auditing function is weak and will need to be strengthened through training of the Internal Audit Unit and the Audit Committee to give them the capacity to follow up and resolve both internal and external auditing issues, and this training is being carried out under the Zambia Health Services Improvement project.

FINANCIAL REPORTING

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179. Each implementing agency will prepare semi-annual or quarterly IFRs and annual project financial statements. IFRs will be submitted to the World Bank within 45 days after the end of the period. In the case of AU and Ethiopia MoH, IFRs will be prepared on a quarterly basis, as these will be used for disbursement purposes. The financial reports will be designed to provide quality and timely information to the project management. Specific formats and content were agreed during appraisal taking into account the final arrangement between Ethiopia MoH and sub-implementers in Ethiopia. IFRs are expected to include as a minimum: (i) a statement of sources and uses of funds for the reporting and cumulative period (from project inception) reconciled to opening and closing bank balances; (ii) a statement of uses of funds (expenditure) by project component/ subcomponent comparing actual expenditure against the budget, with explanations for significant variances for both the period and cumulative period. Specific reporting practices are further explained below. 180. AU. AU will prepare quarterly IFRs in relation to Components 1.1, 2.1, 3.1 and 4 of project implementation. AU has experience in preparing and submitting timely and good quality IFRs. 181. Ethiopia. The Ethiopia MoH will prepare a quarterly consolidated IFRs collecting the quarterly IFRs of EPHI, and the RHBs of Amhara, SNNP, Oromia, and Tigray region. Ethiopia MoH also has experience with World Bank reporting requirements, but IFRs are submitted with delay. The accounting recording and report generation is made at the GFCT whereas report compilation and submission to the World Bank is done by the GMU. There seems to be duplication of efforts at the two units which may contribute to the delay in submission of reports. In compliance with the Federal Republic of Ethiopia’s financial rules and regulations as well as IDA requirements, Ethiopia MoH will produce annual financial statements similar to the contents of the quarterly IFRs with some modifications deemed necessary. These financial statements will be submitted for external audit at the end of each year. 182. Zambia. Zambia MoH will be required to produce semi-annual IFRs to manage and monitor the use of project funds. The formats and contents of the IFRs are to be discussed and agreed with Zambia MoH, together with the internal controls and mechanism followed for the preparation. Zambia MoH will also prepare the Project’s annual accounts/financial statements within three months after the end of the accounting year in accordance with accounting standards acceptable to the World Bank. The financial statements will be required to be submitted to the World Bank within six months after the end of the fiscal year.

EXTERNAL AUDIT

183. Under World Bank policy, implementing entities are required to submit annual project financial statements audited in accordance with international standards of auditing by an acceptable external auditor and following terms of reference approved by the World Bank. The auditor will also provide a management letter, which will inter alia outline deficiencies or weakness in systems and controls, recommendations for their improvement, and report on compliance with key financial covenants.

Table 5: Auditing Schedule

Country Implementing entity

Audit Type Auditor Due Date

Regional AU Project financial statements Management Letter

Auditor acceptable to the World Bank

Six months after the end of each fiscal year

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Ethiopia MoH Project financial statements (covering Ethiopia MoH, EPHI, and the four RHBs) Management Letter

Office of the Auditor General or by an auditor nominated by Auditor General acceptable to the World Bank

Six months after the end of each fiscal year

Zambia MoH Project financial statements Management Letter

Office of the Auditor General

Six months after the end of each fiscal year.

184. Disclosure of Audit Report: In accordance with the World Bank’s policies, the recipient is required to disclose the audited financial statements in a manner acceptable to the World Bank; following the World Bank’s formal receipt of these statements from the borrower, the World Bank makes them available to the public in accordance with The World Bank Policy on Access to Information.

FUNDS FLOW AND DISBURSEMENT ARRANGEMENTS 185. Disbursement arrangements will follow World Bank’s disbursement guidelines and general practice and procedures applicable in each country, with which most implementing entities are familiar. Accordingly, the following disbursement methods may be used to withdraw funds from the IDA credits/grants: (a) advance; (b) reimbursement; (c) direct payment; and (d) special commitment. Under the advance method, a designated account in US dollars will be opened in an acceptable financial institution and it will be used exclusively for deposits and withdrawals of designated account proceeds for eligible expenditures. Funds deposited into the designated account as advances would follow World Bank’s disbursement policies and procedures, to be described in the Financing Agreement and in the Disbursement and Financial Instructions Letter. Following the current practices advances made to the designated account would be documented through the use of Statement of Expenditures (SoEs) or IFRs, and supporting documents defined in the disbursement letter (Table 6 and Figure 5).

Table 6: Funds Flow and Disbursement Arrangements

Country Imp. Entity

Designated Account (US$)

Other project bank accounts

Supporting documents (to be further detailed in Disbursement Letter)

Regional AU Designated Account in US$ at commercial bank acceptable to World Bank

Local-currency bank account (commercial bank)

Quarterly IFRs Six-month cash forecast

Ethiopia

MoH

Designated Account – US$ (National Bank of Ethiopia)

Local-currency (birr) account

Quarterly IFRs Six-month cash forecast

EPHI Designated local-currency (birr) account

Quarterly reports to be submitted to Ethiopia MoH

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RHBs Designated local-currency (birr) accounts

Quarterly reports to be submitted to Ethiopia MoH

Zambia

MoH

Designated Account – US$ (Bank of Zambia)

Local-currency bank account (Bank of Zambia)

SoE

186. The project will follow the Ethiopian government’s Channel 2 fund-flow mechanism. The Ethiopia MoH will open a designated US$ bank account at National Bank of Ethiopia into which project funds will be disbursed by the World Bank. In addition, a separate Birr account will be opened by Ethiopia MoH. The EPHI, RHBs of Amhara, SNNP, Oromia, and Tigray regions will each open project designated local currency bank accounts into which Ethiopia MoH will transfer funds for project implementation. Necessary fund flow arrangements will be made and approved by the World Bank, for PSA or any other Agency if its involvement is required during implementation. 187. The specific mechanism and requirements for the transfer of funds from the Ethiopia MoH to sub-implementers, including, periodicity, supporting documents and reporting arrangements will be detailed in the PIM. Funds transferred to sub-implementers pending to be documented should be reflected as advances in Ethiopia MoH’s consolidated IFRs. 188. The Zambia MoH will open a designated account denominated in U.S. dollars and a project account denominated in local currency, both at the Bank of Zambia. The signatories to these accounts should be in line with the FM Manual and they should be submitted to the World Bank between the signing of the project and its effectiveness. Withdrawal applications should be prepared within one month after project effectiveness.

Figure 5: Funds-Flow Diagram

AUC Ethiopia MoH Zambia MoH

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STRENGTHS AND WEAKNESSES

(i) AU – Overall, the internal control system over payments is strong with adequate segregation of

duties mainly in the approving and authorizing procedures. However, the payment process requires the involvement of several individuals within the finance division (finance officers, certifying officer, authorizing officer, releasing officer, treasury (where cheques are prepared)), which may cause delays in payments, thus affecting implementation. The FM expert expected to be hired at the Africa CDC PIU need to work closely with the AU counterparts.

(ii) Ethiopia MoH – the internal control system follows the usual government system and this is found to be strong with adequate segregation of duties. However, there seems to be some level of duplication between the GFCT and the GMU, as further explained above, which would delay submission of reports. The roles and responsibilities of these units need to be clearly defined to address the concern.

(iii) Zambia MoH - The main strength identified is that the project will use the existing FM

arrangements at Zambia MoH including staff, financial regulations and procedures. The main capacity constraints in the Zambia MoH are that the project module of IFMIS is dysfunctional and the internal audit unit lacks adequate resources to carry out their work effectively.

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FINANCIAL MANAGEMENT ACTION PLAN Action Due Date Responsible Status

Ge

ne

ral

Asp

ect

s

1. Prepare FM manual to be part of the PIM By effectiveness MoH in Ethiopia MoH in Zambia CDC/AUC

2. Design and deliver a training for FM staff, and internal audit units covering standard World Bank requirements and Project specific FM requirements.

Within three months after effectiveness

World Bank FM team

Eth

iop

ia/A

fric

a C

DC

/AU

C

Budget 3. Set-up timetable for budget preparation and consultation for each implementing entity.

Beginning of implementation

Ethiopia MoH

Accounting 4. Agree on the accounting software to be used at all implementing entities. 5. Recruit FM specialists at Ethiopia MoH, EPHI, and AU 6. Acquire server that enables multi-user mode for Peachtree software

By appraisal One month after effectiveness, for Ethiopia, three months after effectiveness for AU Six months after effectiveness

Ethiopia MoH EPHI, RHBs, AUC EPHI AUC Ethiopia MoH Ethiopia MoH

Completed Peachtree for Ethiopia and SAP for AU Agreed for both. AU agreed to assign staff within one month of effectiveness until hiring is finalized Completed

Flow of funds 7. Agree on the specific arrangements and requirements for the transfer of funds from the Ethiopia MoH to sub-implementers.

By Appraisal World Bank-Ethiopia MoH-EPHI--RHBs

Agreed

Internal control and Internal audit 8. Maintain Contract Registry for high-value contracts. 9. Ensure vacant positions are filled in the internal audit units of implementers. 10. Fixed asset register should be maintained at EPHI. Necessary store control mechanisms should be in place. RHBs should keep project specific fixed asset register. 11. Discuss and agree on the mechanism to address delays in processing transactions/payments at AUC

During implementation Six months after effectiveness During Negotiations By appraisal

Ethiopia MoH, EPHI Ethiopia MoH, EPHI, AU, RHBs EPHI, RHBs AUC

Completed for EPHI, RHBs during implementation as deemed necessary Completed

Financial reporting 12. Clarify roles and responsibilities at the MoH for report preparation and compilation (for grant finance and GMU) 13. Agree format and content of the IFR

By Appraisal During negotiations

Ethiopia MoH World Bank, Ethiopia MoH, AUC

Completed Completed

External audit 14. External auditors to be recruited

Within 3 months of effectiveness

MoH -AUC

Zam

bia

Financial reporting 15.Review and agree on the specific mechanisms for the preparation and periodicity of IFRs

By negotiations

MoH, AU, World Bank

Completed

Internal control 16.Define the role and responsibility, and details for maintaining up to date records for contract management

During implementation

MoH

Flow of funds 17. Review and confirm the funds flow arrangements for the financing of activities in SARCC member states.

During implementation

MoH/World Bank

IMPLEMENTATION SUPPORT AND SUPERVISION PLAN

189. The World Bank’s FM team will provide implementation support over the project’s lifetime. The project will be supervised on a risk-based approach. Supervision will cover but not be limited to the review of audit reports and IFRs and advice to the task team on all FM issues. Based on the current assessed risks, and on a preliminary basis, the project will be supervised at least twice a year and may be adjusted as needed.

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Table 7. Implementation Support Plan

FM activity Frequency

Desk reviews IFR review Semi-annual/Quarterly.

Audit report review of the program Annually. Review of other relevant information such as interim internal control systems reports

Continuous as they become available.

On-site visits

Review of overall operation of the FM system Semi-annually (implementation support mission)

Monitoring of actions taken on issues highlighted in audit reports, auditors’ management letters, internal audit, and other reports

As needed, but at least during each implementation support mission.

Transaction reviews (if needed). As needed. Institutional-building support

FM training sessions by World Bank FM team. Following the project transition and thereafter as needed.

PROCUREMENT ARRANGEMENTS

190. Compliance with World Bank Group Regulations and Guidelines: Procurement under the project will be carried out in accordance with the World Bank Procurement Regulations for IPF borrowers (Borrowers Regulations), July 2016, revised November 2017 and August 2018; the Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants, revised July 1, 2016; and the provisions stipulated in the Financing Agreement.

191. The World Bank’s Standard Procurement Documents: The standard procurement documents for the World Bank shall be used for all contracts subject to international competitive procurement.

192. Procurement Plan: The Procurement Plan, as agreed between the World Bank and the Borrower, will specify procurement methods and their applicable thresholds, as well as activities that will be subject to the World Bank’s prior and post review. The Implementing Agencies shall submit the Procurement Plan through STEP, and it will be disclosed by the World Bank to the public - on the World Bank website - when the Plan is approved by the World Bank. The Procurement Plan will be revised as needed throughout the project duration to reflect the actual project implementation needs and improvements in institutional capacity.

193. Procurement Implementation Monitoring using STEP: Through mandatory use of STEP by the Borrower, the World Bank will be able to monitor all procurement transactions.

194. Use of IT advancements: Zambia launched an electronic government procurement system on July 8, 2016. The system was piloted on government-financed projects in eight procuring entities. The World Bank supported the Government under the just completed Public Financial Management Reform project to develop and partially roll out the system. Once the system has been assessed by the World Bank and found acceptable, the World Bank may agree to its use under the project subject to putting in place the necessary IT environment, connectivity, and staff training.

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195. Main procurement activities:

a. AUC: Procurement activities will involve goods procurement for: (i) Supply and installation of Africa CDC’s Health Information Exchange Platform; (ii) Provision of consultancy services for mapping of public health assets, technical secretariat for project ECHO, workshops, and workforce development; (iii) supply of reagents for reference laboratories to support cross country specimen testing; and (iv) various individual consultants and institutional building activities.

b. Ethiopia: The project will involve procurement of works, goods, and consultancy services. The project will finance the cost for: (i) BSL-3 laboratory involving both works, and supply and installation of laboratory equipment; (ii) consultancy services for BSL-3 laboratory functional requirement and bidding document preparation, design review, supervision and advisory; (iii) construction of 15 BSL-2 level regional laboratories; (iv) supply of laboratory equipment for 21 regional laboratories; (v) construction and installation of External Quality Assessment Proficiency Testing (EQA PT) Panel Production, Bio-bank and Central Warehouse complex; (vi) supply and installation of national ICT for laboratory management information system and for National Laboratories Networking System; (vi) furniture and IT equipment; and (vii) various institutional building activities, etc.

c. Zambia: The project will involve procurement of works, goods, and consultancy services. The project will finance the cost for: (i) BSL-3 laboratory involving both works, and supply and installation of laboratory equipment; (ii) Provision of consultancy services for Architectural design and supervision for the tender for construction of the four story ZNPHI/RCC Laboratory & Office complex; (iii) supply of laboratory equipment; (iv) Supply of furniture and IT equipment; and (vii) various institutional building activities, etc.

196. Procurement Strategy: MoH, EPHI and ZNPHI have prepared their Project Procurement Strategy for Development (PPSD) for the Ethiopian and Zambian finance ministries, and the AU has prepared the PPSD for AUC. Issues in the PPSD will be considered as a basis to determine market approaches for key procurements, particularly those relating to the BSL-3 laboratories and equipment.

197. The Ethiopia PPSD identified major procurable items under the project and proposed packaging, market approach, and methods in line with identified risks and market conditions. The main critical activity for the Ethiopia component is establishment of BSL-3 laboratory. The PPSD recommended Design and Build contract for construction as well as supply and installation of in-situ safety and laboratory facilities. But for supply of laboratory equipment for BSL-3 laboratory, it recommended separate procurement. The main risk for BSL-3 implementation is identified to be technical capacity of the client which need to be addressed through hire of qualified technical specialist.

Institutional arrangement for procurement:

198. Zambia: procurement implementation will be undertaken by ZNPHI once established. Currently it is a department of MoH. ZNPHI will become a legal entity once Parliament approval is obtained. Until then procurement shall be carried out by the PSU within the MoH. The Permanent Secretary heads the MoH in Lusaka Province and procurement is conducted through a unit headed by the Head of the PSU. The PSU is adequately staffed with professionally qualified personnel. The staff has adequate experience to carry out large and complex procurement for projects on competitive bidding basis. However, due to movement of officers by Public Service Commission by means of transfers there will be need to build capacity of some officers who may have just moved to the ministry procurement unit. Capacity needs to be built in contract Management and relevant aspects of the new global advancements in procurement carried in the Borrowers Regulations.

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199. Ethiopia: procurement implementation will be undertaken by two agencies: (i) Ethiopia MoH; and (ii) EPHI. The Ethiopia MoH will be responsible for works procurement of BSL-3 and BSL-2 laboratories. The EPHI will be responsible for procurement of all laboratory equipment as well as for planned Supply and Installation of IT systems. Two key directorates will play a procurement role in the Ethiopia MoH, namely; (i) Ethiopia MoH’s Finance, Procurement and Property Administration that is responsible for procurement processes and (ii) Public Health Infrastructure Directorate that provides technical input and support for all works procurements and manages contract implementation of works contracts. Staffed with adequate number of engineers, the Infrastructure Directorates annually involves in procurement of works of more than US$50 million. Given the available capacity and experience the Ethiopia MoH will be responsible for all works procurement and contract management of works contracts under the project. The MoH shall assign site contract management engineers for each contract site who will coordinate support and assistance from RHBs. Similarly, under EPHI, the finance, Procurement and Property Administration Directorate will be responsible for procurement implementation. A Procurement Case team under the Directorate is responsible for collecting the annual procurement needs, processing tenders and facilitating bid evaluations, following up of goods in transit and certifying payments and maintaining procurement records.

200. In AUC procurement will be coordinated by the PIU to be established and dedicated to coordination, monitoring and reporting against implementation activities at Secretariat and Regional Collaborating Centre level. A procurement Expert will be hired for the unit to support procurement activities. The Unit will use the PTSD for processing procurement activities including the decision-making structure. The AU’s corporate procurement function is centered at PTSD that has also experience in implementing World Bank-financed procurement activities.

Procurement risk assessment, Identified Risk and Risk Mitigation Measures

201. Zambia: Procurement risk assessment was carried out of the MoH. The ZNPHI, being currently a department of MoH, will become a legal entity once Parliament approval is obtained. Staff earmarked to work in the ZNPHI will be drawn from the MoH. The staff include some who have previously worked on World Bank funded projects in different areas such as FM and procurement. The Procurement Risk Assessment identified the following Risks:

i. (a) Inadequate preparation of “Terms of Reference” for consulting Assignments; (b) Slow procurement processing and decision making with potential implementation delays attributable to in-house MoH; (c) Challenges to adequately chose the right “Market Approach” for complex procurements; (d) Unrealistic Procurement Planning; (f) Inadequate contract management systems with the potential to lead to time and cost overrun and poor-quality deliverables; (g) Poor Record Keeping; and (h) residual risk of the project covering seven ZNPHI staff salaries

ii. To mitigate the aforementioned identified risks the following action points are recommended: (a) Terms of reference must be extensively reviewed and approved by the PIU and the World Bank; (b) develop, implement and monitor an accountability framework with defined business standards for staff involved in procurement and contract management including internal approvals [this accountability framework should be part of the PIM procurement section]; (c) provide procurement trainings to new members of the PIU using sample contract procurement management tools with implementation milestones; (d) create appropriate contract management plan, develop Key Performance Indicators (KPIs) and ensure monitoring of contract implementation, assign suitably qualified and experienced site contract management engineers/architects at each construction site; (e) ensure that all procurements

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undertaken under the project have systematic and complete record keeping arrangement and carry out procurement Post Reviews (audits) and/or IPRs as part of compliance checks and monitoring by the World Bank; and (f) ensure a plan is in place to have the Government of the Republic of Zambia assume the responsibility on a gradual basis of the staff salaries covered on the project.

iii. Contract Management Issues: For all large and complex contracts on this project to be defined as being above the prior review threshold, contract management plan must be prepared for each contract. The MoH will need to appoint a contract manager in line with the World Bank’s procurement Framework and provisions of the PPA Act The contract management plans need to be prepared for each high value and high risk contract to indicate and manage anticipated risk mitigation measures, indicate the need to take preemptive steps as opposed to adversarial steps to resolve disputes and above all avoid the blame culture by instead making timely decision with sufficient and timely notices and making decisions based on the contract provisions to carryout remedies. This is important because of predominance of failed contracts in the Zambian market and noted payment delays by clients, which leads to unethical conduct and governance problems in contracts.

202. Based on the above procurement risks, the overall procurement risk rate of the project is Substantial.

203. Ethiopia: The risk assessment was carried out at both Ethiopia MoH and EPHI. Main risks identified include:

i. (a) lack of prior experience in implementing procurement under the World Bank-financed projects; (b) slow procurement processing and decision making with potential implementation delays; (c) new Procurement Endorsing Committee members that do not have procurement experience with potential to block procurement processes and decisions; (d) limited technical capacity at Ethiopia MoH to lead, manage, prepare and evaluate technical aspects of BSL-3 laboratory; (e) limited technical capacity at Ethiopia MoH and EPHI to handle technical aspects of ICT design, supply and installation contract; and (f) poor contract management system with potential time and cost overrun and poor quality deliverable.

ii. To mitigate the identified risks, following are recommended action points: (a) hire Procurement Experts with experience in World Bank-financed projects both at Ethiopia MoH and EPHI; (b) develop, implement and monitor an accountability framework with defined business standards for staff involved in procurement and contract management including internal approvals [this accountability framework should be part of the PIM procurement section]; (c) provide procurement trainings to new members of Endorsing Committee members and to those that require such training; (d) hire technical Expert with experience in the field of laboratory design and implementation; (e) hire an IT specialist with experience in managing implementation of complex information system development and implementation; (f) create appropriate contract management plan, develop KPIs and hire adequate staff for administration and monitoring of contract implementation; and (g) Ethiopia MoH to assign site contract management engineers at each construction site.

204. Risk assessment carried out at AUC identified the following risks: (a) procurement process and decision-making delays because the Africa CDC Institution is a separate quasi-independent entity; and (b) extra workload that would be involved to already overstretched procurement team working in PTSD. To mitigate these risks the following actions are recommended: (a) hire and assign experienced procurement Expert at the PIU to coordinate and support procurement activities with PTSD; and (b) sensitize the procurement decision makers about the project needs and tight implementation schedule.

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205. Based on the identified procurement risks for the project procurement in Ethiopia and by the AUC, the overall procurement risk rating is High.

206. Based on the procurement risk rating for Ethiopia, Zambia and AU, the risk rating for the project is HIGH. Once the procurement mitigation actions have been implemented, the residual risk will allow the project procurement risk to be revised to Moderate Risk.

207. Selection methods: The table below describes the various procurement methods and thresholds to b e applied for procurement activities.

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Table 8. Risk Based Thresholds for Procurement Approaches and Methods (US$, thousands, as of June 2016) and prior review thresholds

Method Market Approach Procurement method

threshold (US$)

Prior review threshold

(US$)

Works (including turnkey, supply & installation of plant and equipment)

Request for Bid (RFB)

Open National Ethiopia < 7,000,000

≥ 5,000,000 Zambia <10,000,000

Open International Ethiopia ≥ 7,000,000

Zambia ≥ 10,000,000

Request for Proposal (RFP) Open International Ethiopia

≥ 7,000,000

≥ 5,000,000 Zambia

≥ 10,000,000

Goods, information technology, and non-consulting services

Request for Bid (RFB)


≥ 1,500,000 Zambia < 2,000,000


Zambia ≥ 2,000,000

Request for Proposal (RFP)


≥ 1,500,000 Zambia ≥ 2,000,000


Zambia ≥ 2,000,000

Request for Quotation Limited National < 100,000 NA

Arrangement through UN Agencies

As per Paragraphs 6.47 and 6.48 of Procurement Regulations for IPF Borrowers

Consulting services

QCBS National < 200,000

≥ 500,000 International ≥ 200,000

LCS National < 200,000 ≥ 500,000

CQS National ≤ 100,000

≥ 500,000 International ≤ 200,000

Individual Consultant (IC)

Open / Limited / International / National

NA ≥200,000

Direct NA ≥100,000

Arrangement through UN Agencies

As per Paragraphs 7.27 and 7.28 of Procurement Regulations for IPF Borrowers

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Table 9. Selection Methods and Thresholds for AUC Component

Category Prior Review (US$,

millions)

Open International

Open AUC Competition

RFQ Short List of National

Consultants

Works

≥ 5.0 ≥ 7.0 < 7.0 ≤ 0.2 NA

Goods, IT and non-Consulting Services

≥ 1.5 ≥ 1.0 < 1.0 ≤ 0.1 NA

Consultants (Firms)

≥ 0.5 NA NA NA NA

Individual Consultants

≥ 0.2 NA NA NA NA

208. National Procurement Arrangements: when approaching the national market the country’s own procurement procedures may be used. When the Borrower uses its own national open competitive procurement procedures as set forth in:

a. Ethiopia: in Public Procurement and Property Administration Proclamation No. 649/2009, it shall be subject to the provisions of paragraphs 5.3 and 5.4 of the Procurement Regulations while other procedures shall be subject to paragraphs 5.3 and 5.5 of the Procurement Regulations. The national standard bidding documents will be modified to reflect the requirements included in these provisions.

b. Zambia: in The Zambia - Public Procurement Act, 2008, and as amended in January 2011 and its accompanying Procurement Regulations, of 2013.

209. The AU Component shall use the provisions of AUC’s own procurement procedures when approaching the national market as agreed in the Procurement Plan. The World Bank has reviewed the Procurement Manual of the AUC for procurement of goods and services and has found them acceptable in terms of consistency with the World Bank’s procurement principles. Hence, open competitive bids approaching the continental and regional market shall follow the procedure set forth in Section 4.4.1 of the Procurement Manual issued by the AUC, provided that such procedure shall be subject to the above requirements as provided for in paragraph 5.4 of the Borrowers Regulations.

210. When the Borrowers use national procurement arrangements other than open competitive bidding (e.g., restricted competitive bidding, requests for quotations, shopping, or direct contracting), the Borrowers must ensure that such arrangements meet the requirements set forth in paragraph 5.5 of the Borrowers Regulations.

Implementation Support and Post-Review:

211. The World Bank will prior review contracts based on risk and complexity of activity which will be indicated in the Procurement Plan. The a priori review contracts will be updated in the Procurement Plan annually or as necessary during implementation, based on the procurement capacity assessment during implementation support missions. i. The World Bank will carry out regular procurement supervision missions on annual basis and carry

out procurement post review and/or IPRs on annual basis. Contracts not subject to prior review

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will be subject to post review by the World Bank as per procedures set forth in Annex II – “Procurement Oversight” of the Borrowers Regulations. The sample contracts for the procurement post reviews and IPRs will be risk-based. The percentage for sample audits based on the contract risk rating will be as follows: high risk 20 percent; substantial risk 15 percent; moderate risk 10 percent and low risk 5 percent.

ii. Using STEP, comprehensive information of all contracts for goods, non-consultancy services and consultants’ services awarded under the sub-component, for all contracts subjected to the World Bank’s prior-review as well as post-review, will be available automatically, including but not limited to: (a) brief description of the contract; (b) estimated cost; (c) procurement method; (d) timelines of the bidding process; (e) number of participated bidders; (f) names and reasons of rejected bidders; (g) date of contract award; (h) name of awarded supplier, contractor or consultant; (i) final contract value; and (j) contractual implementation period, and so on.

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ANNEX II: ECONOMIC AND FINANCIAL ANALYSIS

212. The following economic analysis is divided into four sections. The first presents the economic rationale for the ACDCP as a continental project. The second describes the critical links between livestock and human health. The third profiles the major infectious disease groups in Ethiopia and Zambia. The fourth projects the ACDCP’s economic impact against a baseline scenario. The analysis presented in these four sections underscores the unique challenges facing the African health sector and underscores the vital importance of establishing regional and continental institutions to provide effective disease surveillance, detection, and response. The results of the economic analysis also reveal that the benefits of the proposed project would far outweigh its cost.

The Rationale for a Continental Project

213. The rationale for publicly financed continental and regional institutions dedicated to disease surveillance and response has five components, the first of which is the overwhelming economic burden that infectious diseases impose on the African continent. Communicable diseases constrain regional and national economic and social development, decrease productivity, undermine human capital formation, and deter foreign investment. The scale of the economic losses resulting from communicable diseases is staggering. Economic losses inflicted by the 2014-16 EVD outbreak were estimated at a total of US$2.8 billion for Guinea, Liberia, and Sierra Leone and US$3.6 billion for the West Africa region, and in 2017-18 a relatively limited cholera outbreak killed over 6,000 people in Africa. The HIV/AIDS pandemic in the 1980s and 1990s claimed an estimated 35 million lives and reduced Africa’s GDP growth rate by 2-4 percent per year. Although malaria incidence has roughly halved since 2000, malaria remains a leading cause of under-five mortality and significantly inhibits economic growth across much of the continent. Overall, pandemics are projected to incur annual economic losses equal to 1.5 to 2 percent of GDP in countries covered by the ACDCP.

214. Second, Africa’s porous and often unpatrolled borders demand a transnational approach to disease surveillance and response. The large-scale migration of human populations, especially in FCV states, entails major disease risks that cannot be effectively managed at the national level. Even routine commerce and travel across borders poses disease risks that exceed the monitoring and response functions of national authorities. Managing the threat of zoonotic diseases emerging from wild animal populations and itinerant livestock herds requires a regional or even continental scope, as well as a strategic approach that emphasizes close collaboration between the human and animal health sectors. Because few African countries have the resources necessary to establish adequate health controls, both for humans and livestock, along their national borders, a coordinated, externally financed, and internationally supported regional approach is essential to control the spread of disease.

215. Third, infectious-disease surveillance and response mechanisms are a global public good. Controlling the spread of infectious diseases generates benefits that are nonrival and nonexcludable. Effective disease-surveillance and response systems generate positive externalities across national borders, and even countries with highly effective health systems cannot fully mitigate threats that emerge in countries with weaker systems. As the costs and benefits of disease surveillance, detection, and response cannot be internalized by any individual government, they must be funded collectively through international institutions.

216. Fourth, sharing resources is vital to the efficiency of health spending. Sophisticated and costly facilities such as the BSL-3 reference laboratories supported by this project via the RCCs are vital to control communicable disease, but they are only cost-effective if they can continuously operate at

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close to their full capacity. Sharing these facilities and other assets among multiple countries can greatly increase their efficiency and make critical services available to smaller countries where standalone facilities and assets would not be viable. Meanwhile, transnational disease surveillance and management systems offer opportunities to eliminate parallel administrative structures, yielding additional cost savings.

217. Fifth, a continental institution can harmonize administrative and policy changes at the national level, consolidate lessons learned from the international experience, and disseminate best practices. The ACDCP will coordinate an initially regional and ultimately continental effort to align key provisions of the legal, regulatory, and policy frameworks of AU member states to enable them to collaborate more effectively on transnational health challenges. In addition, the Africa CDC, the RCCs, and the Centers of Excellence supported by the project will serve as repositories of regional knowledge on disease surveillance and response, and lessons learned from the experience of Ethiopia, Zambia, and other countries involved in the project’s early stages will inform the design of subsequent interventions.

218. The ACDCP has all the hallmarks of an effective project at the continental, regional, and national levels. It enjoys strong support among national governments, implementing agencies, and international partners. The AU has demonstrated robust ownership over the project and committed substantial financial resources to ensure its success.

The Links between Livestock and Human Health

219. Most emerging and epidemic-prone diseases originate from either wild or domesticated animals. Africa’s livestock populations are increasing, and human settlements continue to encroach on wild areas, intensifying the risks posed by zoonotic diseases. In addition, animal health is critical to food security and livelihoods, particularly among Africa’s vast rural population. The OIE estimates that about 10 percent of animal production is lost through diseases in countries with poor veterinary services. Effective disease surveillance could help reduce these losses on a highly cost-efficient manner. By taking a holistic approach to human and animal health, the ACDCP will both mitigate the threat of zoonotic diseases and improve productivity in the livestock sector, with highly positive implications for poor households and rural communities.

220. Across Africa, animal husbandry plays a vital role in food security and livelihoods, particularly among poor households. For example, rural areas are home to about 80 percent of Ethiopia’s 106 million people. Livestock production is a main source of livelihoods of about 80 percent of the rural population and contributes 19 percent to Ethiopia’s GDP. The number of cattle doubled between 1960 and 2010 to about 52 million, and livestock production is growing by about 2.5 percent per year.32 However, diseases, parasites, and inadequate nutrition significantly diminish marginal productivity in Ethiopia’s livestock subsector. Boosting productivity by alleviating the livestock disease burden could rapidly increase income levels among the rural population, which includes a large share of the country’s poorest households. Similarly, about two-thirds of Zambia’s population lives in rural areas, and the rural poverty rate is estimated to be above 70 percent. Nearly half of the country’s rural households’ own livestock, and approximately 300,000 rural households own cattle. As in Ethiopia, smallholder livestock production in Zambia is characterized by low productivity, reflecting poor animal nutrition and heavy losses due to animal diseases. While the Zambian Government has recognized the considerable economic potential of the livestock subsector, livestock diseases continue to constrain production, with negative implications for food security and rural livelihoods.

32 Gates Foundation, 2017. “Ethiopia Livestock Sector Analysis.”

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221. Human exposure to zoonotic diseases is a key determinant of pandemic risk. An estimated 75 percent of human disease pathogens originated from animals.33 Key zoonotic diseases include multiple flu virus strains, bubonic plague, tuberculosis, severe acute respiratory syndrome, Middle East respiratory syndrome, rabies, and AIDS. The rapid growth of livestock herds contributes to pandemic risk by intensifying contact between humans and animals. The threat of zoonotic epidemics is most acute in developing countries, which are experiencing the fastest growth in livestock populations and where both veterinary services and human disease-monitoring and response systems are weakest.

222. Inadequate veterinary services and poor zoonotic disease surveillance can cause a critical delay in responding to disease outbreaks. When initial human infections go undetected by health authorities, containing an epidemic becomes far more difficult, and the losses it inflicts increase exponentially (Figure 6).

Figure 6: Illustrative relationship between the time of detection of an emerging zoonotic disease and total cost of outbreak

223. The AIDS pandemic offers a clear example of this problem, as a failure to correctly identify and effectively contain the virus after the first human infections enabled its worldwide spread. Weak zoonotic disease surveillance in a single country poses a significant risk, and this risk is magnified in regions where multiple neighboring countries all have limited surveillance capacities and where domestic and wild animal populations regularly traverse national borders.

Major Infectious Disease Groups in Ethiopia and Zambia

224. Ethiopia and Zambia have both made remarkable progress in reducing the lethality of major infectious diseases, but population growth is contributing to persistently high absolute levels of morbidity and mortality. In Ethiopia, the total number of deaths from diarrheal diseases fell by 30 percent between 2000 and 2016, while the number of deaths from diarrhea per million people dropped from 1,200 to just 565. However, the total number of diarrhea cases increased by 33 percent over the period, and the number of cases per million people fell only slightly. Respiratory infections and other vector-borne diseases present similar patterns, with total cases increasing by 24 and 62 percent, respectively, even as the number of per capita cases declined, and mortality rates from both groups plunged. The exception is malaria, which was the only vector-borne disease to have experienced a sharp decline in both relative and absolute morbidity and mortality, as the total number

33 Jonas, Olga B. 2013. “Pandemic Risk.” Background Paper, World Development Report. World Bank, Washington DC

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of cases fell by 81 percent between 2000 and 2016, while the number of deaths dropped by 91 percent. Similar trends are evident in Zambia, where the total number of diarrhea cases increased by 17 percent over the period, respiratory infections by 17 percent, and other vector-borne diseases by 63 percent, yet mortality rates for all three disease groups fell in both relative and absolute terms. As in Ethiopia, the total number of malaria cases fell, albeit by just 14 percent, while the total number of deaths from malaria dropped by 44 percent.34

225. These figures enable the construction of a baseline health scenario against which the impact of the ACDCP can be projected. The broad decline in the numbers of cases and deaths per million people across all major infectious disease groups is expected to continue under the baseline scenario. However, the ACDCP is expected to substantially accelerate this decline, resulting in far lower morbidity and mortality rates by the end of the projection period in 2040. These projections are described in detail in the following section.

Economic Assessment of the Proposed Intervention

226. Three variables are used to assess the economic impact of the ACDCP. The first is the projected number of infant and maternal lives saved over a period of 20 years. The second is the ACDCP’s projected capital and operating costs over the same period. The third is the projected change in per capita GDP in Ethiopia and Zambia over the period. The Lives Saved Tool (LiST)35 estimates the number of children under five and their mothers whose lives would be saved by the ACDCP based on historical mortality data for the target countries. A population model (Spectrum) is used to project national population growth, and these estimates are combined with LiST to calculate the number of deaths within the target group that would occur with and without the ACDCP. The analysis projects the ACDCP’s on the preventive interventions, vaccinations, and curative interventions implemented by the Ethiopian and Zambian health ministries. The model does not account for the possibility of an exotic epidemic during the projection period, as this risk cannot be reliably quantified. However, it may reasonably be assumed that the presence of the Africa CDC would reduce the probability of new epidemics and mitigate the impact of any that occurred, as identifying and responding to disease outbreaks are among its core functions.

227. Ethiopia and Zambia present similar patterns of infant and maternal mortality. The three leading causes of neonatal deaths in both countries are asphyxia, premature birth, and sepsis, and the leading causes of post-neonatal deaths are pneumonia and diarrhea. The neonatal mortality profiles of the two countries are very similar, but Zambia has significantly higher rates of post-neonatal mortality from malaria and AIDS, while Ethiopia has higher rates of post-neonatal morality from measles. The causes of maternal mortality in both countries are also comparable. However, Ethiopia has slightly higher mortality rates from each direct cause (ante-, intra-, or postpartum hemorrhage, hypertensive disorders, sepsis, abortion, and embolism), while Zambia has higher mortality rates from all indirect causes.

228. The LiST analysis projects that interventions supported by the ACDCP will save a total of 132,999 infant and maternal lives in Ethiopia and another 61,688 in Zambia between 2020 and 2040. At a rate of 3 percent per year, this translates to 5.8 million time-discounted life years saved in Ethiopia

34 Institute for Health Metrics and Evaluation (IHME), 2016. “GBD Results Tool.” Seattle, WA: IHME, University of Washington. http://GHDX.health data.org/gbd-2016 (Accessed March 6, 2019). Other vector-borne diseases include African trypanosomiasis, Chagas disease, schistosomiasis, leishmaniasis, lymphatic filariasis, onchocerciasis, dengue fever, and yellow fever. Population statistics are from the Spectrum model. 35 Developed by Avenir Health with support from the Bill and Melinda Gates Foundation; Johns Hopkins Bloomberg School of Public Health; the Pan-American Health Organization; UNAIDS; UNICEF; USAID; and WHO.

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and 2.7 million saved in Zambia.36 The estimated input costs used in this analysis include: (i) total project costs; (ii) operational and maintenance costs for two BSL-3 laboratories for 15 years; (iii) operational and maintenance costs for the supported regional laboratories for 20 years; (iv) operational and maintenance costs for one mobile laboratory for 20 years; (v) disease-surveillance and response costs in Ethiopia and Zambia, including vaccinations and treatments for 20 years; (vi) operational costs for the EPHI and ZNPHI for 20 years; and (vii) compensation to livestock owners for the compulsory slaughter of infected animals.

229. The “three times per capita GDP” model was used to assess the cost-effectiveness of the interventions supported by the ACDCP. Under this model, interventions are deemed cost-effective if their per capita cost is less than three times the average per capita GDP of the target countries. The projection’s 20-year horizon includes an estimated project-implementation period of six years. The combined time discounted cost (for Ethiopia and Zambia) is estimated to be US$190 per life saved whereas the per capita GDP for Ethiopia and Zambia is US$1,900 and US$4,024 per annum, respectively. It is concluded that the project and proposed interventions are highly cost effective based on the evaluated benefits. The evaluation of the project also included an assessment of the project's rate of return using the same costs and benefits as were used to determine the three times per capita GDP methodology described here. The resulting rate of return was 33 percent which was calculated using the modified internal rate of return methodology. The results of both these analyses are consistent with economic analyses undertaken by others in similar environments.37

230. Numerous additional benefits generated by the ACDCP are not captured by this analysis. Due to its relatively narrow parameters, the analysis does not include: (i) the impact of ACDCP-supported interventions outside of Ethiopia and Zambia; (ii) the reduction in the probability of a regional or continental pandemic due to improved disease-monitoring and response capabilities; (iii) the benefits from early disease detection in border areas of Ethiopia’s and Zambia’s neighboring countries resulting from disease screening by project supported regional laboratories; (iv) the productivity gains generated by additional working days that would otherwise have been lost to illness; (v) the value of the time-discounted life years saved among beneficiaries who are not mothers or infants; (vi) the productivity and equity gains from improved income and food security in the rural sector; (vii) the possibility of expanded access to export markets for animal products due to improvements in sanitary conditions; and (viii) the efficiency gains in health-sector personnel and asset management generated by improving the flow of information between institutions and disseminating best practices.

36 Ethiopia’s population is projected to increase by 46 percent over the next 20 years, from about 110 million in 2020 to 161 million in 2040. Meanwhile, Zambia’s population is expected to increase by 73 percent, from about 18.6 million in 2020 to 32.2 million in 2040. 37 (a) Olga B. Jonas, Pandemic Risk, background paper, World Development Report, 2014. (b) Operational Framework for Strengthening Human, Animal, and Environmental Public Health Systems at their Interface, World Bank Group, 2018. (c) People, Pathogens and Our Planet, Volume 2- The Economics of One Health, The World Bank 2012. (d) Thresholds for the cost-effectiveness of interventions: Alternative Approaches. WHO, February 2015.

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ANNEX III: ALIGNMENT WITH OTHER WORLD BANK PROJECTS AND OTHER PARTNER PROJECTS

Project Africa CDC Regional Investment Financing Project

EAPHLN SATBHSS REDISSE 1, 2, 3 West Africa REDISSE 4 – Central Africa

Fin

anci

ng

by

cou

ntr

y/in

stit

uti

on

Tentative financing: Africa CDC: US$10 million Ethiopia: US$150 million Zambia: US$90 million

ORIGINAL FUNDING Total US$78.33 million Kenya (US$23.5 million); Tanzania (US$15.05 million); Uganda (US$10. 1 million); Rwanda (US$15.01 million); Burundi (US$15.01 million) ADDITIONAL FINANCING Total funding – US$50.3 million Kenya (US$10.1 million); Tanzania (US$15.05 million); Uganda (US$15.05 million); Burundi (US$10.01 million)

US$122 Million Lesotho (US$15 million); Malawi (US$17 million); Mozambique (US$45 millions); Zambia (US$45 million)

REDISSE 1 (US$114 million)

• WAHO US$24.06 million; Guinea: US$30.00 million; Sierra Leone: US$30.00 million; Senegal: US$30.00 million

• Additional financing of US$10.5 million for WAHO in pipeline

REDISSE 2 (US$147 million

• Guinea Bissau: US$21 million; Liberia: US$15 million; Nigeria:US$90 million; Togo: US$21 million

REDISSE 3 US$120 million

• Benin: US$30 million; Mali: US$30 million; Mauritania: US$20 million; Niger: US$40 million

REDISSE 4: DRC (US$150 million) Chad (US$30 million) CAR (US$15 million) Republic of Congo (US$15 million) Angola (US$60 million) ECCAS (US$10 million)

Pro

ject

D

eve

lop

me

nt

Ob

ject

ive To strengthen Africa

CDC to improve inter-regional networks for timely infectious disease detection and response.

To establish a network of efficient, high quality, accessible public health laboratories for the diagnosis and surveillance of TB and other communicable diseases.

(i) improve coverage and quality of key TB control and occupational lung disease services in targeted geographic areas of the participating countries; (ii) strengthen regional capacity to manage the burden of TB and occupational diseases.

(i) to address systemic weaknesses within the animal and human health systems that hinder effective cross sectoral and cross border collaboration for disease surveillance and response, and; (ii) in the event of an eligible emergency, to provide immediate and effective response to said eligible emergency

(i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the participating countries and; (ii) to provide, in the event of an eligible crisis or emergency, immediate and effective response to said eligible crisis or emergency

Pro

ject

Im

ple

men

tati

on

:

Re

gio

nal

act

ivit

ies Continental

activities: Africa CDC Secretariat

Regional Implementing agency is ECSA–HC

ECSA–HC was selected competitively to serve as the Regional Coordinating Organization ECSA-HC will facilitate the establishment of a Regional Advisory Committee and serve as its secretariat by the time the project becomes effective.

WAHO is implementing agency.

ECCAS

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Pro

ject

Co

mp

on

en

ts • Governance,

Advocacy, and Operational Frameworks

• Public Health Assets

• Human Resource Development

• Project management

• CERC

Regional Diagnostic and Surveillance Capacity 1.1: Diagnostic Services for Vulnerable Populations in Cross Border Areas 1.2: Reference and Specialized Services and Drug Resistance Monitoring 1.3: Disease Surveillance and Preparedness 1.4. Support for Pathology services 1.5. Surveillance of Antimicrobial resistance 2. Joint Training and Capacity Building 3. Joint Operational Research, Knowledge Sharing/Regional Coordination, and Program Management 3.1: Joint Operational Research 3.2: Knowledge Sharing & Regional Coordination 3.3: Program Management

Innovative Prevention, Detection, and Treatment of TB 1.1: Enhancing case detection and treatment success 1.2: Rolling out a standardized package of occupational health services and mining safety standards across the four countries 2: Regional Capacity for Disease Surveillance, Diagnostics, and Management of TB and Occupational Lung Diseases 2.1: Improving quality and availability of human resources in the targeted areas 2.2: Strengthening diagnostic capacity and disease surveillance 2.3: Strengthening mine health regulation 3: Regional Learning and Innovation, and Project Management 3.1: Operational research and knowledge sharing 3.2: Centers of excellence in TB and occupational lung disease control 3.3: Regional coordination, policy advocacy, and harmonization 3.4: Project management

Surveillance and Information Systems 1.1: Support coordinated community–level surveillance systems and processes across animal and human health 1.2: Develop capacity for interoperable surveillance and reporting systems 1.3: Establish an early warning system for infectious disease trend prediction Strengthening of Laboratory Capacity 2.1: Review, upgrade, and network laboratories 2.2: Improve data management and specimen management systems 2.3: Enhance regional reference laboratory systems Preparedness and Emergency Response 3.1: Enhance cross–sectoral coordination and collaboration for preparedness and response 3.2: Strengthen capacity for emergency response 3.3: Contingency emergency response component Human Resource Management for Effective disease control and epidemic preparedness 4.1: Healthcare workforce mapping, planning, and recruitment 4.2: Enhance health workforce training, motivation, and retention Institutional capacity building, project management, coordination, and advocacy 5.1: Project coordination, fiduciary management, monitoring and evaluation, data generation, and knowledge management 5.2: Institutional support, capacity building, advocacy, and communication

Strengthening surveillance and laboratory capacity to rapidly detect outbreaks 1.1: National and sub-national surveillance system 1.2: Health information and reporting systems 1.3: Laboratory diagnosis capacity 1.4: Supply chain management systems Strengthening emergency planning and management capacity to rapidly respond to outbreaks 2.1: Emergency management systems 2.2: Medical countermeasures 2.3: Non-pharmaceutical interventions 2.4: Research and evaluation 2.5: Contingent emergency response Public health workforce development 3.1: Public health staffing 3.2: Enhance public health workforce training 3.3: Regulations Institutional Capacity Building, Project Management, Coordination and Advocacy 4.1: Project coordination, fiduciary management, monitoring and evaluation, data generation, and knowledge management 4.2: Institutional support, capacity building, advocacy, and communication at regional level.

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ANNEX IV: ENHANCED PROJECT ACCOUNTABILITY FRAMEWORK 231. An enhanced accountability framework has been put in place for this project to provide increased assurance that funds are used for the intended purposes with economy and efficiency and attain value for money. The objectives of a strengthened accountability framework include:

i. Development and implementation of a robust improvement in accountability for the use

of project funds to attain expected outcomes for the various programs; ii. Provision of guidelines on minimum requirements to be complied with regarding

workshops, training, and related activities. Specific accountability framework for training, workshops, study tours, etc.

232. An enhanced accountability framework for the purposes of training, workshops, study tours, etc. as follows:

i. At the beginning of each fiscal year, a separate training summary plan shall be developed and shared with the TTL for review as part of the annual work plan.

ii. Local and international training, would require prior clearance from the World Bank’s TTL before being undertaken. The request for clearance should, at a minimum, include the following: - A demonstrated linkage between the rationale for the workshop/training/etc. and the Development Objective of the project shall be established; - Annual Work Program (AWP) to which the activity falls shall be identified; - The number of trainees, their function and mode of selection will be defined (number of times during the past 18 months that listed trainees had benefitted from training); - Number of years before retirement from service of each of the proposed trainees; - The process used for selection of training provider, and if foreign training, rationale for not proposing local training, to be provided; - Training prospectus and reference to the beneficial outcome of the training to be provided; - Detailed costing of the event: if local training/workshop/sensitization, the following additional information would need to be provided: i) venue for the event, ii) how venue was or is proposed to be selected, iii) venue rental, refreshments/lunches, per diem, transport cost (air or land travel cost per trainee); - No residential local training program will be allowed where the venue of the training is in the locality of the trainees; the preferred choice of locality should be the location of most officials to be trained.

233. Only based on these above submissions and the TTL’s prior clearance will expenses be committed and become eligible for financing under the project.

234. Each PIU will ensure a formal process of accountability is instituted on training expenditures which will include:

i. Submission of training report by the trainee;

ii. Certificate of attendance from the training institution; iii. Relevant travel certifications such as air tickets, boarding passes for air travel, hotel bills

etc.;

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iv. Consistent with the Government’s cashless policy, air tickets shall be procured directly from the airline through electronic payment or check (no cash payments shall be allowed); and

v. Similar practice shall also be applied in the payment to vendors and tuition fee to training providers.

235. Reduced amount of DSA (Daily Subsistence Allowance) will be paid where training/workshop organizers provide meals and accommodation. Cash advance granted to Project staff must be retired by concerned staff within the timeline specified in the PIM before new advance is granted. Where retirement of an advance is past due, an automatic payroll deduction of the unretired amount should be affected. To keep track of cash advances disbursed, an Advances Register shall be maintained as a control measure.

236. The Project Internal Auditor shall include in their work program periodic random audits of travel advances and withdrawal thereof, as well as a review of the training/workshop conducted. A report of this review shall be provided to the PIU as well as the World Bank TTL.

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ANNEX V: CLIMATE VULNERABILITIES, MITIGATIONS SOLUTIONS AND ADAPTATION MEASURES

237. Climate change is growing problem for Sub-Saharan Africa, where it is contributing to the increasing frequency and severity of extreme weather events including drought, flooding, heatwaves and windstorms. The unpredictability of extreme events is compounded by the problem of shifting baselines, as seasonal norms are changing. Seasons starting at different times and in different locations, leading to important effects on human systems and societies.

238. These climatic changes affect human health through direct physical effects such as heat as well as drowning and injuries from flooding events. There is also an impact on infectious disease transmission patterns and geographic range, especially for vector- and water-borne diseases. Climate change also influence human health indirectly by pushing populations into poverty, stimulating migration and conflict.

239. Looking specifically at infections disease given the objectives of this project is it useful to stress that the infectious disease mediated impacts of climate change. WHO estimates that by 2030 there will be 10 percent more diarrheal disease than there would have been with no climate change and that it will primarily affect the health of young children. A number of outbreaks across the continent are caused by diseased linked to climate change, these include cholera, dysentery, malaria, hemorrhagic Fevers (e.g., EVD, Rift Valley fever, Crimean-Congo fever, Lassa fever, and Yellow fever), and meningococcal meningitis outbreaks endemic to countries along the “meningitis belt.” Furthermore, the population at risk for malaria will increase by 3 to 5 percent, which means that millions of additional people would probably become infected with malaria each year. This project intends to address these climate related vulnerabilities through the following activities, providing both mitigation and adaptation measures.

240. This project has been screened for climate change and the following vulnerabilities were identified through the process. The overall assessment of potential risks in the Summary Climate and Disaster Risk Screening Report is assessed as “Low Risk.” All hazards including extreme temperature, precipitation and flooding, drought, sea level rise, storm surge and strong winds were categorized as “slightly exposed.” This exposure risk is assessed at this level for both the current and future timescales. Although this project was categorized as low risk, there are a number of mitigation and adaptation measures that will be implemented to reduce the impact of the project’s activities on the environment and reduce greenhouse gasses and to ensure the project provides appropriate adaptation measures for climate-associated infectious diseases.

241. The project will support the continent in adapting to many of the potential effects of climate change and climate variability on vector-borne disease. These adaptation measures will provide important benefits for countries where humans live in close contact with livestock and other animals that are part of many vector-borne disease transmission life cycles. Under Component 1, the main objective is to strengthen human and institutional capacities to improve emergency response capacity to respond effectively to infectious disease outbreaks, particularly those associated with climate change. This will ensure a harmonized approach to the development of standardized guidelines, protocols and multi-sectoral preparedness plans to identify gaps in the detection and response to climate-associated infectious diseases.

242. Component 2 will have adaptation and mitigation measures. Disease surveillance systems are central activities in this component to prevent, prepare and respond to climate-induced vector-borne diseases in Africa. This will include strengthening early detection mechanisms and data

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management systems for changes in climatic conditions and to monitor changes in infectious disease patterns, including endemic (i.e., malaria) vector-borne diseases and those that have epidemic/ pandemic potential with a shift in climate (i.e., EVD). This will ensure climate resilience by increasing the functionality of these systems to model future climate scenarios. Furthermore, this project under Component 2 will also implement climate mitigation measures through the following activities. The laboratory buildings and equipment that will be supported by this project will adopt energy efficiency measures was well as other features to encourage the reduction of greenhouse gas emissions. Laboratories are known to be energy intensive due to the enormous amount of energy and ventilation that is required to allow a typical laboratory to be operational. However, in recent years there have been a number of measures put in place to ensure improved energy-efficiency. This project will ensure that the laboratories built, renovated and fitted out will include a number of policies and features of a “Smart Laboratory,” using best practices without sacrificing occupant safety. These features have been known to reduce energy use by 30-50 percent. This will include: (i) Ventilation: ensuring recirculation of air where feasible; variable air volume features and

digital controls that will be integrated with advanced air quality and occupancy sensors (ii) Temperature/Humidity control: Automatic temperature setback throughout the office areas

and storeroom at night (iii) Lighting/Electricity: use of movement sensors for lighting; LED light bulbs; ensure that there

is an end of the day walk through to switch off all unnecessary electrical items (iv) Building: energy-efficient construction material, windows and roof; installation of non-wax

flooring (reduces use of chemicals to clean); use of carpet tiles from sustainable sources (v) Water: Use of chiller baths instead of continuous water flow; energy-efficient and low water

consumption toilets and urinals; installation of automatic shut off valves in all sinks (vi) Waste: a hazardous and overall waste reduction plan will be put in place that will ensure

appropriate disposal of wastes; plan to share surplus of chemicals with other labs; and substitute hazardous chemicals with non-hazardous chemicals whenever possible; reduce the use of paper by ensuring default on printers are double-sided, recycle used paper, and ensure non-paper electronic systems; use of environmentally friendly chemicals for all cleaning needs

(vii) Laboratory Material: policy in place to reduce unnecessary tests through monitoring, which will help reduce the use of serum-separation tubes and other plastics where feasible, reuse specimen collections bags and urine collection bottles

(viii) Equipment: equipment purchased will be of low-energy consumption (ix) Staff: policies will be put in place to reduce staff gasoline consumption such as encouraging

and rewarding use of walking, cycling, low-carbon public transport, carpooling and motorcycles usage; improvement in technology (wifi access, teleconference set-up, etc.) to avoid unnecessary meetings outside of the laboratory

243. Under Component 3, public health professionals will participate in training programs to increase their knowledge and capacities to be able to respond rapidly and effectively to infectious disease outbreaks and other public health emergencies. This will include the development of course modules in partnership with African Universities and Africa CDC that integrate effective response to climate-induced emergencies and simulation exercises to test health services/laboratories and other emergency operations for climate-induced disasters.

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ANNEX VI: REGIONAL DISEASE SURVEILLANCE AND RESPONSE NETWORKS IN AFRICA

East African Integrated Disease Surveillance Network (EAIDSNet)

• Formed in 2001, the East African Integrated Disease Surveillance Network (EAIDSNet) is a regional collaborative initiative of the national ministries of the East Africa Community (EAC) Partner States responsible for human and animal health in collaboration with the national health research and academic institutions. For more information, visit www.eac.int/eaidsnet

• Enabled early detection and averted outbreaks of Ebola, Rift Valley Fever, Marburg etc.

The Southern African Centre for Infectious Disease Surveillance (SACIDS)

• Formed in 2009, SACIDS is a consortium of academic and research institutions with a One Health focus. SACIDS bridges the ministries of human health, livestock and wildlife in SADC countries and brings together infectious disease researchers from these sectors. At national level, each participating institution forms a National Centre for Infectious Disease Surveillance. At regional level, Sokoine University of Agriculture, Tanzania, serves as a formal institutional base for the network.

REDISSE West Africa REDISSE is a World Bank-funded regional project that aims to (i) to address systemic weaknesses within the animal and human health systems that hinder effective cross sectoral and cross border collaboration for disease surveillance and response, and; (ii) in the event of an eligible emergency, to provide immediate and effective response to said eligible emergency. REDISSE has five components including Component 1 (Surveillance and Information Systems) and Component 2 (Strengthening of laboratory network Capacity) in West Africa region.

• Guinea, Senegal, Sierra Leone, Guinea-Bissau, Nigeria, Liberia, Togo, Mali, Mauritania, Benin, Niger, and ECOWAS region (WAHO serves as the regional implementation unit).

EAPHLN EAPHLN is a World Bank project that aims to establish a network of efficient, high quality, accessible public health laboratories for the diagnosis and surveillance of tuberculosis and other communicable diseases.

• Kenya; Tanzania; Uganda; Rwanda; Burundi

Regional Sahel Pastoralism Support Project (PRAPS)

PRAPS is a World Bank-funded project that strengthens regional disease surveillance network for priority animal diseases. The Project Development Objective (PDO) of PRAPS is to “improve access to essential productive assets, services, and markets for pastoralists and agro-pastoralists in selected trans-border areas and transhumance axes across six Sahel countries, and strengthen country capacity to respond promptly and effectively to pastoral crises or emergencies.”

MenAfriNet Funded by Bill & Melinda Gates Foundation and CDC Foundation, MenAfriNet is a regional surveillance network to collect and analyze high quality case-based meningitis surveillance data from representative sites across the meningitis belt of Africa.

The African Network for Influenza Surveillance and Epidemiology (ANISE)

ANISE is a network of laboratorians, epidemiologists, public health officials, clinicians, veterinarians, researchers and policy-makers who work together to strengthen the capacity for surveillance and research related to influenza and other respiratory viruses in Africa. ANISE was founded in 2009 and currently has more than 260 members from more than 30 countries working on improving detection, case management, control and prevention of influenza and other respiratory viruses in Africa.

Network of African Noncommunicable Diseases Interventions (NANDI)

The Network of African Noncommunicable Diseases Interventions (NANDI) was established in 2001 by the WHO. NANDI focusses on creation of three training centers (Guinea, Angola, and Tanzania) and training for Cervical cancer diagnosis and treatment across Sub-Saharan Africa; as well as for the surveillance of non-communicable diseases.

Child Health and Mortality Prevalence Surveillance (CHAMPS)

Funded by Bill & Melinda Gates Foundation, CHAMPS seeks to identify definitive causes of and prevent child deaths through community engagement, diagnostic and laboratory innovations, surveillance network advances, policy-to-action activities and rapid, open access to data. CHAMPS collects and shares data from a network of sites in Sub-Saharan and South Asia. CHAMP sites in Africa include: Harar and Kersa (Ethiopia), Kisumu (Kenya), Bamako (Mali), Manhica (Mozambique), Makeni (Sierra Leone), Soweto (South Africa).

Network of African Noncommunicable Diseases Interventions (NANDI)

The Network of African Noncommunicable Diseases Interventions (NANDI) was established in 2001 by the WHO. NANDI focusses on creation of three training centers (Guinea, Angola, and Tanzania) and training for Cervical cancer diagnosis and treatment across Sub-Saharan Africa; as well as for the surveillance of non-communicable diseases.

African Rotavirus Surveillance Network

African Rotavirus Surveillance Network, which was established in four countries in 2006 and had expanded to 29 countries by 2016, collected surveillance data on rotavirus from sentinel sites.

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African Cholera Surveillance Network (Africhol)

The African Cholera Surveillance Network was launched in 2009 as a consortium of organizations with expertise in cholera prevention and control and is managed and technically supported by the Agence de Médecine Préventive. Africhol, established in 2009 by Bill & Melinda Gates, aims to determine the incidence of cholera in sub-Saharan African through the creation of a surveillance network. Data gathered from the project serves to inform decisions on optimal interventions for cholera prevention and control, including vaccination and improved water and sanitation.

Global Disease Detection Program (GDD) by WHO (Regional center part of global network)

Funded by CDC and WHO, GDD is a program for developing and strengthening global public health capacity to rapidly identify and contain disease threats from around the world. The program comprises both field-based and CDC-headquarters components. CDC currently operates 7 GDD Regional Centers, of which Kenya and Egypt are in Africa region. These centers work with the host country and the region to develop core capacities in the following areas: emerging infectious disease detection and response; training in field epidemiology and laboratory methods; pandemic influenza preparedness and response; zoonotic disease research and containment at the human-animal interface; health communication and information technology; and laboratory systems and biosafety. The GDD Center in Kenya is co-located with the Kenya Medical Research Institute in Nairobi and works in partnership with regional and international organizations dedicated to protecting the public’s health.