Document of

The World Bank

Report No: 25051-UNI

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR 20.90 MILLION

(US$28.70 MILLION EQUIVALENT)

TO THE

FEDERAL REPUBLIC OF NIGERIA

FOR A

PARTNERSHIP FOR POLIO ERADICATION PROJECT

March 27, 2003

AFTH3Africa Regional Office

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CURRENCY EQUIVALENTS

(Exchange Rate Effective November 1, 2002)

Currency Unit = NairaI Naira = US$128

US$1 = Naira 0.0078

FISCAL YEARJanuary I -- December 31

ABBREVIATIONS AND ACRONYMSAFP Acute flaccid paralysisCDC Centers for Disease Control and Prevention (USA)CIDA Canadian International Development AgencyDALY Disability-adjusted life yearsDFID Department for Intemational Development (UK)EPI Expanded Program for ImmunizationERC Expert Review CommitteeEU European UnionFGN Federal Government of NigeriaFMOH Federal Ministry of HealthGF Bill & Melinda Gates FoundationGPEI Global Polio Eradication InitiativeHSDP2 Second Health System Development ProjectICC Inter-Agency Coordinating CommitteeIDA International Development AgencyIPV Injectible Polio VaccineNGO Non-governmental organizationNID National Immunization DayNORAD Norwegian Agency for Development Co-operationNPI National Programme on Immunization (Nigeria)OPCS Operations Policy & Country ServicesOPV Oral Polio VaccinePETF Polio Eradication Trust FundRI Rotary InternationalRMC Resource Mobilization and CofinancingSIA Supplemental Imrnunization ActivitiesSNID Sub-national Immunization DayUNF United Nations FoundationUNICEF United Nations Childrens' FundUSAID United States' Agency for International DevelopmentWHO World Health Organization

Vice President: Callisto E. MadavoCountry Manager/Director: Mark Tomlinson

Sector Manager/Director: Laura FrigentiTask Team Leader/Task Manager: Kees Kosterrnans

NIGERIAPARTNERSHIP FOR POLIO ERADICATION PROJECT

CONTENTS

A. Project Development Objective Page

1. Project development objective 2

2. Key performance indicators 2

B. Strategic Context

1. Sector-related Country Assistance Strategy (CAS) goal supported by the project 22. Main sector issues and Government strategy 2

3. Sector issues to be addressed by the project and strategic choices 4

C. Project Description Summary

1. Project components 7

2. Key policy and institutional reforms supported by the project 8

3. Benefits and target population 9

4. Institutional and implementation arrangements 9

D. Project Rationale

1. Project alternatives considered and reasons for rejection 11

2. Major related projects financed by the Bank and/or other development agencies 12

3. Lessons learned and reflected in the project design 12

4. Indications of borrower commitment and ownership 13

5. Value added of Bank support in this project 13

E. Summary Project Analysis

1. Economic 142. Financial 15

3. Technical 15

4. Institutional 16

5. Environmental 17

6. Social 17

7. Safeguard Policies 19

F. Sustainability and Risks

1. Sustainability 19

2. Critical risks 19

3. Possible controversial aspects 20

G. Main Loan Conditions

1. Effectiveness Condition 212. Other 21

H. Readiness for Implementation 21

I. Compliance with Bank Policies 22

Annexes

Annex 1: Project Design Summary 23Annex 2: Detailed Project Description 25Annex 3: Estimated Project Costs 28Annex 4: Cost Benefit Analysis Summary, or Cost-Effectiveness Analysis Summary 29Annex 5: Financial Summary for Revenue-Earning Project Entities, or Financial Summary 35Annex 6: (A) Procurement Arrangements 36

(B) Financial Management and Disbursement Arrangements 38Annex 7: Project Processing Schedule 41Annex 8: Documents in the Project File 42Annex 9: Statement of Loans and Credits 44Annex 10: Country at a Glance 46Annex I 1: Summary of IDA Buy-Down Mechanism 48

MAP(S)iBRD,30707

NIGERIAPARTNERSHIP FOR POLIO ERADICATION PROJECT

Project Appraisal DocumentAfrica Regional Office

AFTH3

Date: March 27, 2003 Team Leader: Kees KostermnansSector Manager: Laura Frigenti Sector(s): Health (100%)Country Director: Mark D. Tomlinson Theme(s): Fighting communicable diseases (P), ChildProject ID: P080295 health (S), Health system perfornance (S)Lending Instrument: Specific Investment Loan (SIL)

.P1Poject Financing Data' 2 'IJ Loan [XI Credit [ Grant [] Guarantee E j Other:

For Loans/CreditslOthers:Amount (US$m): 28.7

Proposed Terms (IDA): Standard Credit with a special provision for third party funded Trust Fund to purchase thecredit at its present value once it has disbursed.Commitment fee: 0.00-0.50%

iFinrancing-P1an(US$m): -: Sou6rc.K.V' -LocaI§ ;Foreign 2> E Total'T

BORROWER 94.30 34.10 128.40IDA 0.00 28.70 28.70Total: 94.30 62.80 157.10

Borrower: GOVERNMENT OF NIGERIAThe Borrower's contribution is largely through the Inter-Agency Coordinating Committee (ICC).Responsible agency: FEDERAL MINISTRY OF HEALTHNational Programme on Immunization (NPI)Contact Person: Dr. (Mrs) A. Awosika, National Coordinator, Chief ExecutiveNational Programme on InnmunizationPlot 1266, Ammadu Bello Way,Area 11, Garki-Abuja, NigeriaTel: 234-09-3141285/9 Fax: 234-09-3141286 Email: npice@infoweb.abs.netor: npihq@infoweb.abs.net

Estimated Disbursements ( Bank FY/US$m):ex t l Yx -; . .| 2003 -- 1-r. t S 04 2 005...-. . ,-, ;5 _ ,__

Annual 7.50 13.30 7.90Cumulative 7.50 20.80 28.70

Project implementation period: 2003-2005Expected effectiveness date: 05/20/2003 Expected closing date: 10/31/2005

A. Project Development Objective

1. Project development objective: (see Annex 1)

This project is part of a multi-country program and will contribute to a global public good: theeradication of Poliomyelitis by 2005 as aimed for by the World Health Organization (WHO) through itsGlobal Polio Eradication Initiative (GPEI).

The purpose of this project is to assist the Government of Nigeria achieve its goal of interruptingtransmission of wild poliovirus by the end of 2003 and sustain these efforts throughout the period2003-05, through effective oral polio vaccine (OPV) coverage of the target population.

2. Key performance indicators: (see Annex 1)

The project's success will be measured by the following key indicators and targets:o Timely arrival at national level of OPV procured through UNICEF. Target: vaccines arrive at least 5

weeks before the Supplemental Immunization Activities (SIA) in the national strategic store inAbuja. Tool: UNICEF/NPI vaccine arrival report.

o Coverage of supplemental vaccination activities. Target: coverage for OPV is at least 80% in eachendemic State. Tool: cluster sample survey according to a WHO-approved methodology.

Results for these indicators will be decisive for the IDA buy-down (see section D.5).

Annex I provides a complete list of project indicators.

B. Strategic Content

1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1)Document number: IDA - R-2001-0081 (IFC-R-2001-01000) Date of latest CAS discussion: 06/14/2001

This operation is part of a global effort to eradicate poliomyelitis. Nigeria is one of the few remainingcountries in which the disease is still prevalent.

The proposed operation is consistent with the CAS objective of assisting Nigeria to reduce povertythrough improvements in health status and higher productivity levels. Poliomyelitis causes prematuredeath or lifelong disability that reduces capacity to benefit from education and employment opportunitiesand places a burden on the health care system. Reducing illness and death from polio is fully consistentwith the CAS objective of enhancing equity and accelerating human development of the poor. Thisdisease disproportionately affects the poor, especially their children, as immunization coverage is lowestamong the lowest socioeconomic strata, while the disease is easily transmitted in areas with poorsanitation.

2. Main sector issues and Government strategy:

When WHO started the polio-eradication carnpaign in 1988, the disease was endemic in 125 countriesworld-wide. By 2001, poliomyelitis was still prevalent in only ten countries in the world. Nigeria is oneof them.

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Distribution of endemic poliomyelitis in 1988, the year the World HealthAssembly voted to eradicate the disease, and at end-2001.

1988> 125 countries

200110 countries

Source WHO, 2002.

This situation may not be surprising. Nigeria's health outcomes in general are below the average for thecountry's level of development and income. Large inequalities in basic services coverage and in healthand nutrition outcomes exist between the poor and non-poor. Specifically, general vaccination coverageis low. Over the last decade Government's health services have been declining in quality.

The Federal Government of Nigeria (FGN) is addressing these issues by developing a Medium-TermPlan of Action (MTPA) for Health to provide a more effective framework for health sector investment.The objectives of the Plan include the following:

* Expand and strengthen primary health care services throughout the country;* Eradicate, eliminate and control childhood and other vaccine-preventable diseases through adequate

routine immunization activities;* Establish a National Center for Disease Control, Prevention and Eradication to integrate all disease

control efforts and health promotion activities;* Expand provision of family and reproductive health services with special emphasis on reducing STIs

and HIVIAIDS; and* Broaden financing options, including the establishment of a national health insurance scheme to

improve access to affordable care.

The Plan was developed through a broad-based consultative process initiated by the government to bringtogether key stakeholders.

The general health sector is supported by the Bank through a sector-wide project - the Second HealthSystems Development Project (HSDP2), which will be implemented in parallel to the proposed polioproject.

The national eradication program has been remarkably effective compared to other health programs,although new polio infections still occur. Thanks to the effort of the Government and various partner

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agencies, the incidence of poliomyelitis has declined dramatically over the last decade and with it therelative burden of disease. The eradication efforts are led by the National Programme on Immunization(NPI), a parastatal of the Federal Ministry of Health, which was established by Decree No. 12 in 1997.NPI is responsible for both routine immunization and SlAs, i.e. polio eradication campaigns orcampaigns during a meningitis outbreak.

Three strategies make up Nigeria's polio eradication program, namely:Conduct high quality supplemental immunization activities (SlAs),Improve routine immunization coverage for OPV to 80% in all States by 2005,Sustain certification standard Acute Flaccid Paralysis (AFP) surveillance.

Coordinated planning and implementation of the three strategies are outlined in a five-year plan andsubsequent annual plans. NPI's Plan for Polio Eradication establishes the goal for interruptingtransmission of the wild poliovirus in 2003. Effective management and coordination in the remaininghigh risk States is required to meet this goal.

3. Sector issues to be addressed by the project and strategic choices:

The global polio eradication effort is in its final stages. The final steps in the global Polio EradicationInitiative, however, pose the greatest challenge. The final eradication push requires reaching all childrenwith polio vaccine, even in the most difficult areas, including those affected by conflict. It requiresmaintaining high level political will and support.

Nigeria is one of the remaining priority countries identified by the GPEI that would require particularlyintense and sustained efforts to interrupt polio transmission. The other countries include India, Pakistan,Afghanistan, Niger, Democratic Republic of the Congo, Ethiopia, Angola, Egypt, Somalia and Sudan.Virologic and epidemiological data place Nigeria as the major reservoir of polio virus in Africa and thesecond major global reservoir of wild polio virus (after northern India). Achieving the global target ofpolio eradication by 2005 will depend crucially on progress in the 10 identified countries, and, in Africa,especially in Nigeria. Situated at the crossroads between West and Central Africa, and the commercialhub of both regions, Nigeria is of primary strategic importance for interrupting virus transmission.

Since 1995, when Ministers of Health in the Africa Region unanimously adopted a resolution urgingmember states to begin the implementation of polio eradication strategies, progress in Nigeria has beenencouraging. Through the adoption of eradication of polio by the Heads of State meeting in the AnnualSummit, July 1996, in Yaounde, high level of commitment for polio eradication in Nigeria was secured.

Since 1996 Nigeria has been conducting National Immunization Days (NIDs), through which all childrenunder five are targeted for immunization, through facility-based and house-to-house campaigns,accompanied by major publicity campaigns. In 1998, AFP Surveillance was introduced and rapidprogress has been made in strengthening surveillance capacity with support from WHO and the Centerfor Disease Control and Prevention (CDC), as well as from the work of two national laboratories. In200 1, surveillance targets were achieved for non-polio AFP rate of 1 case per 100,000 population under15 years of age and they are approaching the international standard for collection of adequate diagnosticspecimens from at least 80% of AFP cases within 48 hours of onset of paralysis. Internationalsurveillance standards were exceeded in 2002.

Poliovirus transmission is now known to be concentrated in 14 states. Out of 774 Local GovernmentAuthorities, approximately 177 are high risk due to known poliovirus circulation, borders with infecteddistricts, or characterized by civil strife or displaced populations. These areas are being targeted for

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intense social mobilization and supplementary immunization activities including holding Sub-nationalImmunization Days (SNIDs).

The following map shows the incidence of confirmed cases of Poliomyelitis in 2002.

Confirmed Wild Poliovirus Cases,Nigeria, 2002

Total Cases: 181Type 1: 155Type 3: 26

17 January 2003

Source WHO, 2002.

Surveillance data indicate that an intensification of the Polio Eradication Initiative is required to achievetimely eradication. As a result, the Government of Nigeria together with WHO, UNICEF and otherpartners of the Inter-agency Coordinating Committee (ICC) have established a plan to attain polio-freestatus. This plan is based on recommendations of an Expert Review Committee of recognized nationaland international experts. It involves conducting two rounds of NIDs and three rounds of SNIDs in 2003and the same in 2004 depending on the results of previous efforts. Two rounds of SNIDs are planned forthe first quarter of 2005. The cost of the vaccine alone for these scheduled rounds of NIDs/SNIDs inNigeria is around US$ 38 million.

An extra benefit of this project will be the distribution of vitamin A capsules to children 6-59 monthsduring NIDs in 2003 and 2004. These capsules are now routinely distributed with the OPV during thecampaigns, while in 1999 only 22% received vitamin A, according to UNICEF. It is estimated thatsupplementing at least 80 percent of children with two doses of vitamin A annually in countries, likeNigeria, where vitamin A deficiency is high, decreases child mortality by 23 percent, given its largeimpact on the case fatality rates of common infectious childhood diseases.

The whole world will benefit from the collective success of eradicating polio. However, this successdepends on the actions of individual countries. The national benefits of controlling the last few cases ofpolio are relatively small, particularly in comparison to other diseases which affect large numbers of the

- 5 -

population. As a result, the intemational community is being called upon to assist with this global publicgood.

Globally US$2.2 billion has been spent to date, with a further US$725 million required for the period2003-2005. Around US$425 million are in place in pledges and projection against this requirement,leaving a gap of around US$300 million to finish the job. Most of the money is needed to financenational and cross-border activities in the final few countries that were still polio-endemic at the end of2001.

Donors to the Global Polio Eradication Initiative, 1985-2001 (totalcontributions = US $ 1 870 million)

UNICEF WHO Regular Budget Australia

Belgium Aventis Pasteur/IFPMACanada Other

European Union U D

Netherlands

Germany X UN Foundation.

Denmark /

Bill and Melinda GatesFoundation :

Japan \ World Bank IDA Creditto Govt of India

Rotary /International United Kingdom

Source: WHO, 2002.

It is estimated that Nigeria faces an oral polio vaccine funding gap of approximately US$ 28.7 million forplanned supplementary polio activities during 2003 and 2004, and in the first quarter of 2005.

IDA will support the global and Nigeria's efforts for polio eradication in a partnership with the Bill &Melinda Gates Foundation (GF), Rotary International (RI) and United Nations Foundation (UNF) (seesection D.5 "Value added of Bank support" for details).

Strategic Choices

Eradication of poliomyelitis depends on successful implementation of vaccination camnpaigns, but also onthe establishment of high quality routine immunization services. It was decided that this project wouldkeep a narrow focus on short-term efforts for eradication. Strengthening routine immunization servicesis a longer-term goal which would be better addressed through wider sectoral support of the HSDP2.

A special IDA buy-down arrangement (see Section D.5) was made for this project, which is one of aseries of projects supporting polio eradication in various countries. One could argue that in this case,Nigeria and the other countries would only be eligible for a norrnal IDA Credit. However, there are goodarguments to consider grant funding for the effort:

- 6 -

o since the decision to eradicate Poliomyelitis was taken at a global level, it has become a globalresponsibility and not just the responsibility of the last remaining countnes. Moreover, as indicated

- above, the national benefits of eradicating the last few cases of poliomyelitis are relatively small.Therefore, extra donor support in the form of Grant funding is justified.

o The global eradication of an infectious disease is a global public good. Once a disease is eradicatedno one person's receipt of this protection will diminish the protection everyone else enjoys, andevery newborn entering the global community is also protected.

The IDA buy-down mechanism, which will turn the Credit effectively into a grant if the project isimplemented successfully, creates an extra incentive for all involved to focus on real results.

Under this project, the Bank chooses to finance the procurement of vaccines only. Other components ofNigeria's National Polio Eradication Program, such as program management, logistics, socialmobilization, Vitamin A capsule distribution, etc. will be financed by the FGN with contributions fromother donors. These donors have been involved in support for the program already for many years andintend to continue to do so, mostly through WHO and UNICEF. IDA will finance vaccine procurementbecause of the gap in financing for these goods, and because this activity can be monitored and measuredin a comparatively precise way. This monitoring is'particularly important for project evaluation becauseof the IDA buy-down arrangement (see Section D, para 5 and Annex 11).

C. Project Description Summary

1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed costbreakdown):

This project is part of a multi-country program that will contribute to a global public good: theeradication of Pohomyelitis by 2005 as aimed for by the WHO through its Global Polio EradicationInitiative (GPEI).

The purpose of this project is to assist the Government of Nigeria achieve its goal of interruptingtransmission of wild poliovirus by the end of 2003 and sustain these efforts throughout the period2003-05, through effective oral polio vaccine (OPV) coverage of the target population.

The first component, which is the only one financed by IDA, is the timely provision of adequate suppliesof OPV for eradication campaigns, immunizing all children under five years of age. Vaccines will beprocured through UNICEF for the supplementary immunization activities carried out during 2003 and2004 and first quarter of 2005. UNICEF is the established supplier for polio vaccine in Nigeria.

The second component, supplemental operations, comprises three main areas: cold chain, socialmobilization, and training. These are integral to the success of the program as the major operationalstrategy is to reach every child (0-59 months) through a house-to-house delivery of OPV. Specialattention is given to insure coverage of hard to reach and/or resistant populations.

During the planning and implementation process for SIAs transport of these vaccines through vaccinecarriers to the children is coordinated with the vaccination teams. Social mobilization and IEC withparents and communities occur at local, district, state and national levels. Effective media coverage invisual, audio, and print form to make the public aware of the program benefits and to motivate them toreceive the vaccination teams is also planned. Mobilization of community leaders, health staff, andvolunteers for planning and implementation of SIAs especially the hard to reach is ongoing. Trainingand advocacy with these groups in microplanning, supervision, administration of OPV, record keeping,

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and cold chain maintenance occurs prior to each round of immunization. WHO and UNICEF throughlarge contributions from a wide variety of bilateral and private donor agencies support the supplementaloperations.

The third component provides support for epidemiological and laboratory surveillance. An ExpertReview Committee of national and international experts meets periodically to assess progress. Itproduces an analysis of the situation of polio eradication in Nigeria and detailed recommendationsintended to provide strategic directions to the eradication activities in the coming period. These reportsare available for monitoring and evaluation purposes along with periodic assessments on the quality ofsupplemental operations.

Upon completion, the project will be evaluated by WHO, in coordination with the ICC, within threemonths of the project closing. WHO's performance audit will report on the program in general,including areas such as vaccine procurement, cold chain, surveillance, and social mobilization, withspecific emphasis on the timeliness of OPV procurement and vaccination coverage of the children in thetarget age group. Coverage will be measured using WHO's standard methodology for vaccinationcoverage surveys. WHO will submit this report to FGN with copies to the ICC and the World Bank. Itwill be reviewed by the Bank to trigger the IDA buy-down and used for its standard ImplementationCompletion Report.

A small amount of the Credit (US$50,000) will be set aside to provide financing for an extra independentaudit, in the unlikely event that such is deemed necessary.

F- i . * - ' :ndicative BanIt- % ofnf, 4, ;,'" {.,,-' Compoant, . osts, of . finardcing Bank-

,_*'-_,, _____!______';______i____-"-'__'_'_'_ '_'_____-__ ' ' (u w) Xotal (US$m) <financingOral Polio Vaccine Procurement 38.20 24.3 28.70 100.0Supplemental Operations 53.80 34.2 0.00 0.0Surveillance and M&E 65.10 41.4 0.00 0.0

Total Project Costs 157.10 100.0 28.70 100.0

Total Financing Required 157.10 100.0 28.70 100.0

2. Key policy and institutional reforms supported by the project:

The project is not seeking major policy and institutional reforms. Its focus is on providing financing forvaccines in an internationally supported global effort to eradicate polio. However, in Nigeria the projectmay indirectly support reforms related to the:

o integration between the polio eradication program and the routine irmmunization program;o strengthening and expansion of the coverage of the immunization program, particularly for

disadvantaged areas;o increase of budgetary allocations for proven cost-effective interventions in child health such as

immunization for vaccine-preventable diseases; ando promotion of public/private partnerships.

The above reforms will be promoted in collaboration with the IDA-supported HSDP2, which is a betterinstrument for this, given its sector-wide approach. The European Union (EU) is also supporting routineimmunization services.

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3. Benefits and target population:

This project would target all children up to the age of five. Vaccine-preventable diseases, and polio inparticular, disproportionately affect poor families, and coverage is lowest in poorer and sociallydisadvantaged groups. This project will provide the additional vaccine required for carrying out theNIDs and SNIDs which specifically target poor groups, in particular those in remote and underprivilegedcommunities. This project will help Nigeria eliminate polio as a public health problem. The preventionof disability would alleviate human suffering and decrease economic loss and social burden of thedisease.

The project is part of a global effort to eradicate poliomyelitis worldwide. Such eradication is a globalpublic good. Therefore the benefits of this project go far beyond the national target group. It will benefitthe present and all future world populations.

Supplemental immunization activities have been a drving force for entry of health programs intocommunities. Already southern areas of Nigeria are benefiting from the apparent interruption of wildvirus transmission as illustrated in the map in Section B.3.

The development of strategies and provision of adequate financial and human resources by governmentand partners has buttressed overall national commitment. Collaboration between NPIVthe FederalMinistry of Health and the States, and LGAs has helped generate political will and ownership at thecommunity level to deliver immunization services for all vaccine preventable diseases to all children.

Collaboration with traditional institutions and religious leaders as focal points for social mobilizationcommittees has increased community participation and reduced reported cases of rejections and/orrefusals to a limited number of households in northem areas. Implementation of a house-to-houseimmunization strategy enabled contact with some communities for the first time. Awareness of polioimmunization by caregivers has increased demand for other antigens.

Gains in polio eradication have also contributed to improvements in routine immunization services bystrengthening cold chain, logistics, transport, and training systems. APF surveillance exceedsinternationally accepted standards for detecting the circulation of the wild poliovirus and contributestoward the development of a national integrated surveillance system.

Lessons learned from partnership for resource mobilization and management, coordination of activitiesand monitoring and evaluation have been applied to other global initiatives like the Global Alliance forVaccines and Immunization and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

4. Institutional and implementation arrangements:

The project will be implemented and monitored through existing Government structures established byNPI and in coordination with the ICC.

The key implementation structures include the Health departments at national, State and LocalGovernment Authority levels. NPI has overall responsibility for the polio eradication program, includingpolicy making, planning at national level, storage and distribution of vaccines, procurement and supply ofcold chain equipment, financing of consumable materials, coordination of surveillance and monitoringand evaluation of the program, besides resource mobilization. Planning for implementation andoversight, coordination and monitoring is done by the State Health Commissioners while LocalAuthorities are responsible for micro-planning and implementation activities.

NPI coordinates the support and activities of partners through the ICC for immunization. The ICC was

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established in 1996. It is composed of the Federal Ministry of Health, NPI, and partner agencies such asCIDA, DFID, EU, Japan, RI, MSF, NORAD, the National Red Cross Society, UNICEF, USAID, andWHO among others. The Honorable Minister of State for Health who calls meetings on a monthly basischairs it.The ICC has emerged as a strong force in support of polio eradication. Serving as an advisory body tothe Federal Ministry of Health, it provides advice on effective planning and management, and advocatesfor resource mobilization and allocation for the national immunization program. Some of its functionsinclude:

o To foster solid partnerships by coordinating all inputs and resources available from inside andoutside the country in order to maximize resources for the good of the child.

o To support the national level reviews and endorse workplans such as the NID Plans of action, NPIannual plans, NPI five-year plans, etc as well as reports.

o To mobilize resources, both within the country and externally, for use in the program.O To facilitate transparency and accountability by reviewing use of funds and other resources, together

with the NPI at regular intervals. This process in turn motivates continued resource mobilization forimmunization activities.

o To advocate for both technical.and political support that helps to validate its authority on issuespertaining to immunization.

o To support and encourage as much information sharing and feedback, not only at national level, butalso by the implementing levels within the country and interested partners outside Nigeria.

o To provide moral, technical, political and other support that would encourage the immunization teamto continue producing good results and address other issues as they arise.

All partners are represented in the committees and participate in overall implementation. Six integratedzonal teams (NPI, WHO, UNICEF) were established and empowered to provide technical support toStates for both supplemental immunization and surveillance activities. In addition, the followingagencies participate actively in the following areas:WHO AFP surveillance and technical issues on all immunizations,UNICEF Procurement, supplies, social mobilization and routine immunization,USAID Social mobilization, finance and training,Rotary Advocacy and social mobilization at the grass roots level.

The ICC is composed of four sub-committees, each with their own respective leadership who meet on amonthly basis and report back. These sub-committees are for Technical, Social Mobilization, RoutineImmunization and Finance. The Technical Sub-committee is comprised of three working groups of itsown (Logistics, Routine Immunization, and Training). A Core Operational committee meets asfrequently as required to coordinate implementation of the Plan.

For SIAs, UNICEF is responsible for the procurement of OPV acting as a central procuring agent for theglobal polio program. The Borrower, through NPI, shall enter into agreement with UNICEF to procurethe vaccines. The vaccines shall be procured in accordance with UNICEF's rules, regulations andprocedures relating to procurement. Payments will be made directly to UNICEF. NPI shall beresponsible for the distribution and administration of the vaccines in the country.

This project has three components. The first component, which is financed by IDA, is executed under anagreement between the Borrower and UNICEF. The credit proceeds will be disbursed directly toUNICEF on a single source contract with them for the purchase of OPV, after due clearance with NPI.All expenses have been agreed beforehand (costs of vaccines, including freight, and UNICEF handlingfee). UNICEF will prepare and submit quarterly financial reports to the Borrower and IDA in an agreedformat. This will be used by IDA to monitor the outstanding balance as well as funds received and spent

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by UNICEF. It will also enable IDA to verify expenditures before any subsequent disbursement.Borrower will receive a copy of the reports prepared by UNICEF and will be able to confirm receipt ofthe quantities of goods indicated in these reports. The Borrower is not required to appoint an independentexternal auditor or to submit an audit report of the annual financial statements. The Borrower reservesthe right to appoint an independent auditor to audit the accounts and/or review the reports prepared byUNICEF prior to submission of the reports by UNICEF to the Bank. If project effectiveness is delayed,IDA may retroactively finance the SIA scheduled for financing under the project, if the procurementmethod complies with World Bank guidelines.

The remaining two components of the project are Supplemental Operations and Monitoring andEvaluation. These components are to be financed by the Borrower (NPI) with contributions fromPartners, which will be channeled through WHO and UNICEF. The funds will be managed by the ICCwhose Finance Committee will be primarily responsible for financial management and reporting. IDA'srequirements for annual financial statements and FMRs will be satisfied by ICC's normal annual reportsand periodic reports to be provided with respect to the rest of the Project, while IDA retains the right torequire an independent audit.

The arrangement of procurement through UNICEF was chosen given the expertise of the Agency. Thearrangement will be the same for the other countries in which the Partnership for Polio Eradication willprovide support.

In order to enable IDA, UNICEF and WHO to collaborate in the supervision, evaluation, and monitoringof the cold chain, social mobilization, training activities, and other aspects of performance under theeradication program, IDA, UNICEF and WHO will inform the other in advance of any supervisionmissions to be undertaken to Participating Countries, and provide to the other a report setting out themain findings or results of such mission.

During implementation of the Initiative in the Participating Countries, ICC will provide partners withmonthly financial report. The ICC has a functioning Financing Sub-committee that prepares budgets,financial statements of expenditures, reports and organizes audits for individual donor funds that arepooled with Government funds into a Joint Polio Fund.

The World Bank will become a member of the ICC.

D. Project Rationale

1. Project alternatives considered and reasons for rejection:

The project is part of the Partnership Investment Program for Polio, a joint initiative of the Bank withpolio partners GF, RI and UNF.

Careful consideration was given to financing various components of the Global Polio EradicationInitiative as part of this Partnership Program. These were rejected in favor of financing only OPVprocurement for the following reasons:

* other multilateral agencies are better positioned to finance components other than OPV, such asoperational costs and surveillance. For example, WHO annually receives large amounts for thesepurposes. UNICEF, the other main partner, also has a broader role of supporting logistics andoperations.

* Rotary International, one of the co-financiers of this project preferred this specific use of the funds;* simplicity of project design, which is especially important given the IDA buy-down mechanism; and* programmatic support to the immunization program, can be better provided through the Bank's longer

term broader support to the health sector.

We also considered procuring the vaccines through the Government. Given the fact that this project forNigeria is one in a series, and given the specific financing arrangements, however, it was decided that itwould be more prudent to organize procurement of the vaccines through UNICEF, an Agency withconsiderable expertise in the area.

2. Major related projects financed by the Bank and/or other development agencies (completed,ongoing and planned).

1 l l Latest SupervisionSector Issue Project (PSR) Ratings

.____ _____ ____ _____ _____ ____ _________ _____(Bank-financed projects only)Implementation Development

Bank-financed Progress (IP) Objective (DO)

Health Systems Health Systems Development S SProject II

Public health Imo Health and Population S UProjectEssential Drugs Project S UNational Population Project HU UHealth Systems Fund Project S SHIV/AIDS Response Project U U

Other development agenciesWHO, UNICEF, EU, USAID, CDC, Various projects supportingCIDA, Government of the Netherlands, various areas of the healthGovernment of Japan, NORAD, sectorUNFPA, DFID, Ireland Aid

IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory)

3. Lessons learned and reflected in the project design:

Important lessons learned from smallpox eradication are being applied to polio. First, program focus ison disease surveillance rather than on immunization coverage. Second, flexible control strategies aredriven by surveillance data. For example, Nigeria is employing NIDs flexibly, based on surveillance dataindicating where the main pockets of the disease are. A similar approach is planned for "mopping-up"the final cases, as eradication nears.

The project design also reflects the lessons from earlier IDA-supported HNP projects:o Keep the project design simple and well-defined. IDA support will focus on a single component of

the polio eradication program in Nigeria.o Use of a Project Coordination Unit may undermine the regular structures in the Ministry. The

project will only use regular structures and institutions already in place.o Establish good coordination with the other partners. The Country Office now has a qualified health

specialist who will be able to provide implementation support locally and participate in the ICCmeetings for overall program coordination.

o Establish effective supervision strategies. The monitoring and evaluation strategy for this project hasbeen designed early on and very precisely to ensure that measurable indicators are established andthat staff are trained in data collection procedures.

o Establish availability of counterpart funding to facilitate smooth implementation. WHO has adopted

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arrangements to make sure that counterpart funding will flow timely to the country from its RegionalOffice in Harare.

4. Indications of borrower commitment and ownership:

The polio eradication campaigns have brought a close cooperation between the Federal Government,State Governments and traditional leaders. On various occasions, top leadership has spoken about polioeradication. President Obasanjo travelled to Sierra Leone to launch last year's synchronized NIDs inWest Africa and signed the Lungi Declaration, pledging his commitment to polio eradication and healthsystems strengthening, hence demonstrating his personal commitment to the eradication effort. The FirstLady and the Ernir of Kano, in addition to many other leaders, have personally participated in thecampaigns. The FMOH-NPI has developed a 2000-2005 Strategic Plan for Polio Eradication andCertification.

The NPI took strong leadership in the fast preparation of this project.

5. Value added of Bank support in this project:

In response to the appeal from the Global Polio Eradication Technical Advisory Committee, the Bank hasdeveloped a new mechanism known as the Partnership Investment for Polio Eradication, to provide fundsto selected countries to intensify and accelerate their polio eradication programs. In July 2002, apartnership with the GF, RI and UNF was formed to "buy-down" the cost of IDA Credits to grant termsfor polio eradication activities in a group of countries identified by WHO, as the remainingpolio-endemic countries, including: Nigeria, Afghanistan, Pakistan and India. A Polio Eradication TrustFund (PETF), financed by GF and RI (through UNF) and managed by the World Bank was established.The PETF will pay all charges for the Credit during implementation and pay off the IDA debt as soon asthe projects are successfully completed. Thus the IDA Credit becomes a full Grant (see Annex 11 fordetails).

Through this mechanism, an IDA Credit would be provided to Nigeria for polio eradication, but uponsatisfactory completion of the project, contributions from the partners (GF, RI, UNF) would be utilized to"buy-down", or cover the charges and repayments on the IDA Credit. Thus Nigeria can access what is inessence "grant" funding for polio. Since the buy-down will be made at Net Present Value of the Credit,the arrangement also offers a very attractive way of financing for the GF and RI: they need only about athird of the funds they otherwise would need to finance the same goods or services. Given the largeglobal benefits that will result from polio eradication-benefits that far exceed national gains-there is astrong case for grants to support polio eradication.

Responding to its global responsibility, the Bank will pilot, through this project, a new approach toencourage urgent action on a global public good with significant externalities. This mechanism willpermit the Bank to engage public and private partners in a common global cause.

For Nigeria the polio eradication initiative has been a imajor national effort since 1996, and has receivedsubstantial assistance from many development partners. These partners are financing with grant fundsabout half of the estimated remaining vaccine, operational and surveillance costs of polio eradication.The program is financed mainly by donor support which is provided by-and-large on a short term basis.Although these funds have been forthcoming in the past, they sometimes arrive at the last minute. Banksupport provides some stability for an important component of the program, the procurement of vaccines,and it is hoped that Bank support will leverage funds from other development partners.

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E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8)

1. Economic (see Annex 4):o Cost benefit NPV=US$ million; ERR = % (see Annex 4)o Cost effectivenessO Other (specify)Justification: Using standard public finance criteria, public involvement in, and financingof, the campaign to eradicate polio is clearly justified. Control of an infectious disease is aclassic example of a public good for health. Global eradication is thus a clear global publicgood with high externalities.

Because of the diversity of the communities, government administrative levels and partnersthat have contributed to the implementation of GPEI, it is impossible to accurately quantifythe value of the financial and in-kind expenditures within a country. After quantifying thenumber of NIDs volunteer hours per country, wage rates from the year 2000 WorldDevelopment Indicators statistical database were applied to establish a monetary value forthe 'volunteer' effort. Based upon these calculations, world-wide polio endemic countrieswill have contributed at least US$ 2.35 billion in volunteer time alone for polio eradicationactivities between 1988 and 2005, according to a forthcoming WHO study. Thesecalculations do not account for the fact that volunteer time is taken away from other regularduties, nor do they reflect the substantial government resources used at the national, state,province, district and local community levels to pay for petrol, social mobilization, trainingand other costs. Many countries, including Nigeria, incurred substantial additionalopportunity costs by designating NIDs as national public holidays to facilitate the use ofgovernment personnel and other resources.

Between the launch of the GPEI in 1988 and its target date of 2005 for global certification,external sources will have provided at least US$ 2.75 billion to polio endemic countries tohelp cover the costs of implementing the necessary strategies. External financing has beenused for OPV and for NIDs operational costs (e.g. cold chain refurbishment, training, socialmobilization). The strengthening of surveillance has absorbed external resources forequipment (e.g. vehicles, computers), supplies, training, personnel and related costs. Someexternal resources have been needed for enabling factors, such as the certification andcontainment processes, advocacy and resource mobilization, documentation, meetings andadministration. A number of mechanisms have been used to channel these external resourcesto polio-endemic countries, the primary ones being multilateral funding through the WHO orUNICEF, and direct bilateral funding to recipient countries.

Normal cost-benefit analysis does not easily apply to disease eradication. While the costs oferadicating the last case of polio are very high in relation to the by then very low burden ofthe disease, the benefits of successful eradication are infinite. The disease will be extinctfrom the world forever, unless a man-made mistake or disaster causes it to re-emerge.However, ceasing immunization seems no longer a straightforward option. The recentincrease in terrorist threats has also had a big impact on the development of post-eradicationcertification strategies.

WHO estimates that even with improvements in routine immunization coverage, the burdenof disease due to polio would still be significant were eradication not to take place. Between2001 and 2040 there would be 10.6 million new cases of polio worldwide, representing the

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loss of 60 million disability-adjusted life years (DALYs) (discounted at 3%), nearly all ofwhich would occur in low-income developing countries. Eradication would result in a costsavings in all countries if polio vaccination were to stop in 2010 wherever OPV is currentlybeing used. Even in the 'worst case' scenario, in which OPV would be replaced with auniversal Injectible Polio Vacccine (IPV) strategy, the cost per DALY saved would be low,at approximately US$50 per discounted DALY saved in developing countrnes.

According to the World Health Assembly Resolution 41.28, which launched GPEI in 1988,eradication is to be pursued in ways that strengthen the delivery of primary health careservices in general and immunization in particular. Annex 4 provides an analysis of the polioeradication efforts and their impact on routine services in Southern Africa, which hasconditions similar to Nigeria.

2. Financial (see Annex 4 and Annex 5):NPV=US$ million; FRR = % (see Annex 4)Present efforts to eradicate polio world-wide are financially supported by a large group of bilateral andprivate donor agencies, mainly under the coordination of WHO and UNICEF. These agencies alsoprovide programmatic assistance in the implementation of the eradication efforts. The actual countrieswhere poliomyelitis is still endemic provide an estimated 50 percent of the financing of the efforts,mainly through human resources and recurrent costs.

The project supports the procurement of the polio vaccine. The amount of vaccine procured will dependon the needs identified by the polio surveillance. There remains a risk that eradication will be delayed,hence requiring additional funds in the future. In that case, extra funds would also be needed forprogram support. Commitment to eradication is high and continued future support from the globalcommunity is likely.

Fiscal Impact:

Financial sustainability is not an issue since the supplementary activities of the polio eradication programwill end with the disease.

Improved surveillance systems set up for poliomyelitis will need to be integrated in regular operations ofthe health sector, in terms of functioning and financing. There is anecdotal evidence of positive synergiesbetween the polio eradication program and health systems, but these have not been fully exploited.

3. Technical:

There are several reasons why polio can and should be eradicated. There is no animal reservoir tosustain the disease, the virus has a limited persistence in the environment, there is no long-term carrierstate, permanent immunity is provided following infection, and a safe, highly effective, and easilyadministered vaccine is available. Polio causes paralysis, most frequently in children, and between5-10% of cases die when the breathing muscles are paralyzed. Polio is incurable and its effects arelargely irreversible.

There has been a delay in meeting the global eradication target for the year 2000. This is not unlikesimilar experiences in the Americas (9 months late, 1991) or the Western Pacific Regions (2 years late,1997). Nigeria is still on target, however, to meet the revised timeframe by 2005, as indicated in theglobal strategic plan.

-15-

The eradication strategies are clearly proving to be successful. At this point in the initiative, the mostsignificant risks are: (1) weaknesses of the routine immunization services; (2) the possibilities thatpolitical support could decline; (3) decreasing funding from donor agencies, and (4) possible lack ofaccess to hard-to-reach pockets of the population to sufficiently increase effective immunizationcoverage.

In Nigeria, polio eradication efforts are proving successful. Not only has the number of cases in generalgradually decreased, but new cases also appear to be more concentrated in certain areas of the country.

4. Institutional:

4.1 Executing agencies:

The project will be implemented through the existing Federal, State and local structures implementingthe national polio eradication program. No new structures will be created.

NPI will be responsible for project execution. It is a relatively strong agency in the health sector. It wascreated only in 1997 as a parastatal of the FMOH. Since then it has established structures and a strongmanagement country-wide.

Other partners supporting the national polio program such as the EU, DFID and USAID have carried outinstitutional reviews of the federal and local structures involved. They support capacity building andoverall program strengthening activities. The Bank will work closely with the partners and will keepinformed of the relevant institutional issues.

Programmatic support is provided by UNICEF and WHO. The latter agency for example coordinates thesurveillance efforts and employs a large group of medical officers recruited from the Africa region forthe eradication program.

4.2 Project management:

No new management structures need to be created for the project.

4.3 Procurement issues:

UNICEF and the World Bank have agreed on the text for an Agreement for Procurement Servicesbetween the Govermment of the implementing country and UNICEF for the procurement of OPV. Thisagreement will serve for this project in Nigeria and similar projects in other countries benefitting fromthe Partnership for Polio Eradication. IDA has accepted that UNICEF uses its own procedures for theprocurement and delivery of the vaccines.

4.4 Financial management issues:

As this project does not require any direct involvement of the Borrower in the disbursement of IDAcredit, and IDA funds will be transferred to directly to UNICEF, there are no significant financialmanagement issues. Assurance that the Bank's fiduciary requirements are met, especially that funds areused for the purpose intended with due regard to economy and efficiency, will be obtained through themeasures discussed in Annex 6 and addressed in the OPV Agreement executed between the Borrowerand UNICEF. Upon receipt of a direct payment request from NPI, IDA funds will be transferred toUNICEF for the procurement of vaccines. UNICEF's regular financial management systems and auditingprocedures will be used for this project.

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Financial management procedures need to be further developed for the components that are not financedby IDA. Also the procedures need to be adhered to. The financial management system should be able tosupport ICC's management to ensure proper accountability in project implementation. It should becapable of producing timely, relevant and reliable financial information that will enable the managementof ICC to plan, monitor and appraise the overall progress towards the achievement of project objectives.NPI is taking steps to address the identified weaknesses.

A small amount of the Credit will be set aside to cover the cost of a possible independent extra audit, anevent which is deemed very unlikely.

5. Environmental: Environmental Category: C (Not Required)5.1 Summarize the steps undertaken for environmental assessment and EMP preparation (includingconsultation and disclosure) and the significant issues and their treatment emerging from this analysis.

The project will contribute in a significant way to the eradication of wild polio virus from theenvironment, leading to world-wide eradication of poliomyelitis. The project's methodology, stimulatingoral vaccination with the attenuated virus, has no significant negative environmental impact which wouldneed to be addressed in this project.

The project, which entails the procurement of oral polio vaccines, will need to dispose of the small plasticvials which contain the vaccine for up-to-ten children. This will be done in accordance with WHOguidelines for polio vaccination campaigns. These vials are not contaminated since they have not been inphysical contact with any patient. No sharps such as needles or vial cutters are involved in the oralvaccination methods. Therefore, the program has no infected medical waste.

Since the project will finance a specific activity of limited character under the present program of theMinistry of Health, which receives sector-wide support under the Health Systems Development II, it is notdeemed necessary that a new environmental assessment be carned out.

5.2 What are the main features of the EMP and are they adequate?

NA

5.3 For Category A and B projects, timeline and status of EA:Date of receipt of final draft:

NA

5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EAreport on the environmental impacts and proposed environment management plan? Descnbemechanisms of consultation that were used and which groups were consulted?

NA

5.5 What mechanisms have been established to monitor and evaluate the impact of the project on theenvironment? Do the indicators reflect the objectives and results of the EMP?

NA

6. Social:6.1 Summarize key social issues relevant to the project objectives, and specify the project's social

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development outcomes.

The project specifically aims to benefit vulnerable groups and previously neglected groups by providing

polio immunization. Poor families, particularly their children, would be the primary beneficiaries of the

project. Quantitative studies have found low utilization rates at public health facilities, which cater to the

poor. Qualitative assessments of other health projects indicate that lack of physical access to services is

a problem in some areas; a larger problem seems to be the poor quality of health services. While

wealthier groups can purchase health services from the private sector, the poor are unable to afford these

services and continue to rely on traditional practitioners. The project would address these issues by

developing specific strategies and by using polio surveillance data to reach the "hard-to-reach"

populations.

6.2 Participatory Approach: How are key stakeholders participating in the project?

The Polio Eradication Program has established a framework for broad, on-going participation largely

through the ICC. This mechanism includes representatives from: (i) key govermment

ministries/departments; (ii) multilateral agencies (UNICEF and WHO); (iii) bilateral agencies (CIDA,

NORAD, Governments of Japan, The Netherlands and Ireland, the EU, DFID, USAID, CDC); (iv)

NGOs; and (v) community mobilization and media experts. The ICC meets regularly to review needs

and strategies of the national polio eradication program, and assesses performance of supplementary

immunization activities.

For the last few years the program has achieved a coverage of around 90 percent in 80 percent of the 37

States in the country. This was done by placing high priority on mobilizing participation of the

beneficiaries as well as of the key stakeholders. Traditional and religious leaders have been sensitized

over the last two years and are very committed to the cause. Rejection of polio vaccination now concerns

only a very small percentage of the population.

6.3 How does the project involve consultations or collaboration with NGOs or other civil society

organizations?

The ongoing polio eradication program holds consultations with partner NGOs and community groups

which actively participate in social mobilization activities for NIDs. NGOs and community groups are

represented in the ICC mechanism described earlier, and they participate with government

representatives in joint training workshops for the micro-planning of polio activities. The national

Rotary and the Red Cross are especially active partners.

6.4 What institutional arrangements have been provided to ensure the project achieves its social

development outcomes?

The current institutional arrangements for the national polio program have been effective in increasing

the number of Nigerian children immunized against polio, and in reaching certification-level AFP

surveillance (one case of AFP per 100,000 population under 15) and approaching the international

standard for collection of adequate diagnostic specimens from at least 80% of AFP cases within 14 days

of onset of paralysis. This project will reinforce these arrangements to promote interaction and

coordination between the government departments, international agencies, NGOs and community groups

at the national, State and local levels.

6.5 How will the project monitor performance in terms of social development outcomes?

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Key project performance indicators on polio cases will measure the effectiveness of the project to reachthe "hard-to-reach" populations.

7. Safeguard Policies:7.1 Are any of the following safeguard policies triggered by the pro ect?

r- @> -3 -g;., Polic ;ZX 1.,. . .. i-4 *;i "I A, rd.bj'*; _

Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) (9Yes * No

Natural Habitats (OP 4.04, BP 4.04, GP 4.04) (9 Yes * No

Forestry (OP 4.36, GP 4.36) ()Yes * No

Pest Management (OP 4.09) (9 Yes * No

Cultural Property (OPN 11.03) ( Yes S NoIndigenous Peoples (OD 4.20) ( Yes * No

Involuntary Resettlement (OP/BP 4.12) ( Yes. * No

Safety of Dams (OP 4.37, BP 4.37) U Yes S NoProjects in International Waters (OP 7.50, BP 7.50, GP 7.50) ( Yes * NoProjects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60)* ( Yes * No

7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies.

N.A.

F. Sustainability and Risks

1. Sustainability:

Since the supplementary activities of the polio eradication program will end with the disease, eradicationefforts are ultimately sustainable. In addition, there is a high commitment from international agencies tosupport Nigeria in its Polio Eradication Program up to a successful completion, as part of the globaleffort.

The benefits of polio eradication are infinite since the disease will be extinct forever, unless a man-mademistake or disaster causes the disease to re-emerge.

2. Critical Risks (reflecting the failure of critical assumptions found in the fourth column of Annex 1):

There remains a risk that global eradication of polio will be delayed requiring additional funds in thefuture.

Risk Risk-Rating Risk,Mitigation.Measure'From Outputs to Objective1. Larger than expected funding gap. M Estimates were made on the basis ofThe present funding gap is based on international experience. Estimates were madetoday's estimates. These estimates, at the high end of possible scenarios.however, will need to be adapted in view Participation of the World Bank in the globalof recommendations of the Expert . eradication efforts makes new funds availableReview Panel. and may motivate others to contribute (more).2. There is a risk that the accelerated M Active involvement of local, religious andstrategy of 2 NIDs plus 3 SNIDs each traditional leaders has been sought to increaseyear will not raise polio immunization acceptance of vaccination by the population.

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coverage in all hard-to-reach pocketssufficiently to make Nigeria polio free by2005. This would delay global polioeradication.3. Weaknesses of the routine M Routine immunization is now receiving moreimmunization services may hamper polio attention from FGN. Several extemal partners,eradication efforts. amongst them the Bank, will address the

strengthening of routine immunization throughother support.

4. Political support for polio eradication N The international community will stronglycould decline. promote eradication in the last few remaining

countries.5. Political instability may hamper the N NPI seeks the full involvement of traditionaleradication campaigns. and local leaders in the eradication campaigns.

So far, it has been successful in doing so.6. "Grant" as provided under this project M Polio eradication is presented as a special casefor polio eradication may create a with large extemalities for the country, thusdisincentive for Government to finance justifying the special buy-down arrangement.the routine immunization from its ownfunds or non-grant funding.

From Components to OutputsGood cooperation amongst partners. N All partners meet in regular ICC meetings to

coordinate the efforts.Timely release of funds by the N Additional financial management staff is beingmultilateral partners. recruited by WHO. Assurance of good

performance has been sought from localRepresentatives of the Agencies.

Financial Management risk with regard H ICC needs to strengthen its internal controlto the components not financed by IDA arrangements. Additionally, Financial

Management Procedures need to be adhered to.

Overall Risk Rating N The ICC coordinating mechanism will continueto be used. It has proven to be successful inresolving a diverse range of issues related tothe implementation of the eradication efforts.

Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligible or Low Risk)

The risk of the overall Polio eradication program in Nigeria must be rated modest. However, for thisproject the risk seems low. So far, the program has been remarkably successful compared to other healthprograms.

3. Possible Controversial Aspects:

This Credit will bring the IDA resources for Nigeria somewhat above the level of the present low-casescenario of approximately US$ 200 Million. It seems justified that Nigeria receives the extra IDA funds

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and that this project does not impact the lending portfolio in the pipeline for this and next fiscal yearsince these funds will be used towards a program with large externalities: the global eradication ofpoliomyelitis.

The IDA buy-down mechanism may be controversial for the Bank and for the Borrower. Although itdoes not require any policy changes for the World Bank, a performance based IDA buy-down mechanismis new, when it is financed through GF and/or RI. Under the Development Credit Agreement for thisproject, Nigeria will receive a normal IDA Credit from the World Bank, with two special conditions.The Trust financed by GF and RI will pay for the service fee and commitment fee, if any, of the Creditand will buy-down the IDA debt incurred by Nigeria for this project upon its successful completion. Thefinal success of the project will be measured through a performance audit by WHO, supported by an ICCapproved team, in States that remain endemic by project completion. Within three months of projectclosing, WHO will submit this report to the FGN with copies to ICC and the World Bank. Theperformance audit by WHO does not preclude the Bank's own responsibilities for project supervision andevaluation. If the project is unsuccessful, the Borrower will be required to repay IDA as under any otherIDA Credit.

Special support for vertical programs like through this IDA buy-down arrangements for polio eradicationmay be perceived as disruptive to other broader or more urgent local priorities. It may also cause aproliferation of funding instruments for narrowly-defined programs, hampering the Bank's intention toprovide more sector-wide or budgetary support. In this case, such special support seems justified, sincethe GPEI already started in 1988 and is close to successful completion.

For some, it seems unjustified that a Government borrows for a disease which causes only a low burdenon its population. One must, however, consider that the low burden is a consequence of until heretosuccessful disease control and eradication efforts. Polio eradication is a priority for FMOH. There arealso important side-effects of the polio eradication campaign at national level which address localpriorities, such as the simultaneous distribution of Vitamin A (sharply reducing case fatality for commonchildhood infectious diseases), strengthening the cold chain which benefits the routine immunizationprogram, training of health workers, and disease surveillance, etc.

G. Main Loan Conditions

1. Effectiveness Condition

Legal Opinion

2. Other [classify according to covenant types used in the Legal Agreements.]

Conditions for World Bank Board Presentation:* The signing of the contract by Nigeria and UNICEF for procurement services under the project.* Agreement on survey methodology for measurement of vaccination coverage, satisfactory to WHO.

H. Readiness for Implementation

3 1. a) The engineering design documents for the first year's activities are complete and ready for thestart of project implementation.

3 1. b) Not applicable.

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2. The procurement documents for the first year's activities are complete and ready for the start ofproject implementation.

1 3. The Project Implementation Plan has been appraised and found to be realistic and of satisfactoryquality.

[]4. The following items are lacking and are discussed under loan conditions (Section G):

1. Compliance wi2h Bankt Policies

Z 1. This project complies with all applicable Bank policies.C] 2. The following exceptions to Bank policies are recommended for approval. The project complies

with all other applicable Bank policies.

Kees Kostermans Laura Frigenti Mark D. TomlinsonTeam Leader Sedor Wlanagar Country Director

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Annex 1: Project Design SummaryNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

:4; ,Key Pe ormrrance - Datt .Cllecti4n Sratey ;,.:Hierarchy,of.Ojectiyes .: . + . ! . Indicatrs,,.,i 1 lt rE - 5^ ,, ,,,;,,,, ,/, ^ ,;,,,,,v .Cntt' lnssdinatlors. ;

Sector-related CAS Goal: Sector Indicators: Sector/ country reports: (from Goal to Bank Mission)Poverty reduction and Demographic and Health Political stability.accelerated human Surveysdevelopment throughimproved health of poorchildren. Studies on inequalities in

healthGlobal Program Goal forthe Polio EradicationPolio eradicated world-wide In Nigeria: transmission of WHO-supported country Successful eradicationby 2005. wild polio virus interupted by specific evaluation reports. programs at global level.

end of calendar year 2003. GPEI reports. Continuing globalcommitment and support.

Project Development Outcome I Impact Project reports: (from Objective to Goal)Objective: Indicators:Effective OPV coverage of the OPV coverage in children Polio surveillance reports and Good cooperation betweentarget population. under 5 years of age is at least NID/SNID reports verified by Government and traditional

80% in all endemic States in independent monitors. leaders.2005.

Output from each Output Indicators: Project reports: (from Outputs to Objective)Component:1. OPV provided to the 1. Procurement of UNICEF UNICEF audit and financialNigeria Polio Eradication certified OPV timely delivered reports.program. for use in FGN polio

eradication program. FGN, UNICEF and WHO( Target: the polio vaccines monitonng reportswill arrive at least 5 weeksbefore the SIAs in the nationalstrategic store.)

2. Supplemental operations for 2.1 Cold Chain system Various Assessment reportspolio eradication. established and operational. provided to the ICC.

2.2 Social mobilizationprogram implemented. Semi-annual reports by Expert2 3 Targeted capacity Review Committeebuilding programimplemented.

3. M&E, supervision system 3.1 Bank participation in Annual cycle of supervision ICC partners continue to workestablished and operational. the ICC assessing outputs and with clear benchmarks. in good partnership.

D.O. Review of implementation,3.2 WHO performance progress, financial reports.audit of inputs, outputs, D.O.

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triggers for buy down Performance Audit preparedSurveillance program for ICC and sent throughimplemented (e.g # cases per WHO to WB for IDAIOOK, stool sample buy-down.collection).

Project Components I Inputs: (budget for each Project reports: (from Components toSub-components: component) Outputs)I. Procurement of OPV. USD 38.2 Million. FGN, UNICEF and WHO Good cooperation amongst the

IDA USD 28.7 Million monitoring reports partners.* Timeliness of Government'srequest for funds for theprocurement of the poliovaccines; target: Governmentwill send to the Bank a requestfor payment to UNICEF atleast 6 months before thescheduled SIA.

* Timeliness of disbursementof WB funds to UNICEF forOPV procurement; target: atleast 5 months before the SIA.

2. Supplemental operations FGN/ICC USD 53.8 Million3. Surveillance, Monitoring FGN/ICC USD USD 65.1and Evaluation Million

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Annex 2: Detailed Project DescriptionNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

This project is part of a multi-country program and will contribute to a global public good: theeradication of Poliomyelitis by 2005 as aimed for by WHO through its GPEI.

The purpose of this project is to assist the Government of Nigeria achieve its goal of interruptingtransmission of wild poliovirus by the end of 2003 and sustain these efforts throughout the period2003-05, through effective OPV coverage of the target population.

The proposed project has three components: (1) Procurement of OPV, (2) Supplemental Operations, and(3) Surveillance and Monitoring and Evaluation.

The project's success for the IDA buy-down will be measured by the following key indicators andtargets:* Timely arrival at national level of OPV procured through UNICEF. Target: vaccines arrive at least 5

weeks before the SIA in the national strategic store in Abuja. Tool: UNICEF/NPI vaccine arrivalreport.

* Coverage of supplemental vaccination activities. Target: coverage for OPV is at least 80% in eachendemic State. Tool: cluster sample survey according to a WHO-approved methodology.

While IDA would finance the procurement of OPV, Government with large contributions from a widevariety of bilateral and private donor agencies support the logistics and actual implementation of SIAs.They also support epidemiological and laboratory surveillance.

Distribution arrangements and storage of vaccines at national, State, and LGA levels are functional.During the planning and implementation process for SIAs transport of these vaccines through vaccinecarriers to the children is coordinated with the vaccination teams. Social mobilization and EEC withparents and communities occurs at local, district, state and national levels. Effective media coverage invisual, audio, and print form to make the public aware of the program benefits and to motivate them toreceive the vaccination teams is also planned. Mobilization of community leaders, health staff, andvolunteers for planning and implementation of SIAs especially the hard to reach is ongoing. Trainingand advocacy with these groups in micro'planning, supervision, administration of OPV, record keeping,and cold chain maintenance occurs prior to each round of immunization.

By Component:

Project Component 1 - US$38.20 million

The first component is the timely provision of adequate supplies of OPV for eradication campaigns,immunizing all children under five years of age. IDA will fund USD 28.7 M to this component only byfinancing the procurement of polio vaccines through UNICEF for the supplementary polio activitiescarried out during 2003 and 2004 and first quarter of 2005 (with financing required to be in place sixmonths before scheduled activities). UNICEF will supply polio vaccine to the country. The Agency isalready the established supplier for polio vaccine in Nigeria.

The component's success will be measured by the following indicators and targets:* Timeliness of Government's request for funds for procurement of the polio vaccines; target:

Government will send to the Bank a request for payment to UNICEF around 6 months before the

- 25 -

scheduled Supplemental Immunization Activity (SIA).o Timeliness of disbursement of WB funds to UNICEF for OPV procurement; target: at least 5 months

before the SIA.o Timeliness of procurement by UNICEF; target: the polio vaccines will arrive at least 5 weeks before

the SIAs in the national strategic store for vaccines.

Project Component 2 - US$53.80 million

Supplemental operations comprise three main areas: cold chain, social mobilization, and training. Theseare integral to the success of the program as the major operational strategy is to reach every child (0-59months) through a house-to-house delivery of OPV. Special attention is given to insure coverage of hardto reach and/or resistant populations.

Distribution arrangements and storage of vaccines at national, State, and LGA levels are functional.During the planning and implementation process for SIAs transport of these vaccines through vaccinecarriers to the children is coordinated with the vaccination teams. Social mobilization and EEC withparents and communities occurs at local, district, state and national levels. Effective media coverage invisual, audio, and pnnt form to make the public aware of the program benefits and to motivate them toreceive the vaccination teams is also planned. Mobilization of community leaders, health staff, andvolunteers for planning and implementation of SlAs especially the hard to reach is ongoing. Trainingand advocacy with these groups in microplanning, supervision, administration of OPV, record keeping,and cold chain maintenance occurs prior to each round of immunization.

WHO and UNICEF through large contributions from a wide variety of bilateral and private donoragencies support the supplemental operations. They also support epidemiological and laboratorysurveillance.

The success of this component will be measured by the following indicators and targets:o Timeliness of distribution of the polio vaccines; target: the vaccines will arrive at least 3 days before

the SIA at the Local Government Authority (LGA).o Loss of vaccines; target: loss of vaccine due to cold chain problems between port of entry and LGA

cold stores remains below 3 percent as measured by Vaccine Vial Monitor.a Timeliness of release of funds for SIA operations (training, social mobilization, transport); target:

funds arrive at least 3 weeks before each round.

Project Component 3 - US$ 65.10 millionMonitoring and Evaluation

This component has three sub-components: (a) surveillance, (b) regular program reviews by the expertcommittee and (c) a Performance Audit at the end of the project.

Regular disease surveillance will be carried out for AFP, through regular surveillance systems of MOHand special mobile teams for the polio eradication efforts. The surveillance subcomponent also includeslaboratory surveillance and equipment and supplies.

An Expert Review Committee of national and intemational experts meets periodically to assess progress.It produces an analysis of the situation of polio eradication in Nigeria and detailed recommendationsintended to provide strategic directions to the eradication activities in the coming period. These reportsare available for monitoring and evaluation purposes along with periodic assessments on the quality of

- 26 -

supplemental operations.

Upon completion, the project will be evaluated by WHO, supported by an ICC-approved team, withinthree months of the project closing. WHO's Performance Audit will report on the program in general,including areas such as vaccine procurement, cold chain, surveillance, and social mobilization, withspecific emphasis on the timeliness of OPV procurement and vaccination coverage of the children in thetarget age group. OPV vaccination coverage in endemic States will be measured using WHO's standardtechnical criteria for vaccination coverage surveys. WHO will submit this report to FGN with copies tothe ICC and the World Bank. It will be reviewed by the Bank to trigger the IDA buy-down and used forits standard Implementation Completion Report (see Annex 12 for further details).

The success of this component will be measured by the following indicators and targets:* Transmission of wild polio virus; target: transmission interrupted by the end of calendar year 2003* Maintaining certification-standard surveillance indicators; target: at least one case of acute flaccid

paralysis (AFP) per 100,000 population under 15, and adequate stools timely collected from 80% ofAFP cases.

ACTORS I i.F.gL '.W'.' u 3, or a-rot. O Vrarg iw5.',. '

Annual Receive Distributon trirution

NPI estOPV an of OPV to of OPVto(estimated comlt tate I AsIquantities) VAR

IDA l Transfer | 'N\'Association' cc of

Clearing Review of

UNICgEF Supply c and VAR andNigeria request ctransport measuensI

to Central taken ifI_________ Cold Store needed

UNICEF Supply est mat Procure not cc Payment of

Division OPV an sp

TIME BACK FROM NID: -6 mo -5 1/2 mo -5 mo -6 wks -5 wks -2 wks -3 days

Rolling evr3FREQUENCY: forecast 6 every 3

Mo. m

DURATION: weeks 1 2

- - Action flow

Consultation processcc Copies of document to be communicated

-27-

Annex 3: Estimated Project CostsNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

- ~~~Local "~''ForeigT tal5n-;J'PrdjecfC6st By Component . 'US $'mf|o n US $million -. US $ntio

Vaccine procurement 0.00 38.20 38.20Supplemental Operations 53.80 0.00 53.80Surveillance and M&E 40.50 24.60 65.10Total Baseline Cost 94.30 62.80 157.10

Physical Contingencies 0.00 0.00 0.00Price Contingencies 0.00 0.00 0.00

Total Project Costs 94.30 62.80 157.10Total Financing Required 94.30 62.80 157.10

~~ '*'~ - . ~~ K. ~~. Lociil Foreign T -Total~

;i.- vPre*t CostBy Category. US $rilji i n US $millio US i

Goods 0.00 38.20 38.20Works 0.00 0.00 0.00Services 92.80 20.60 113.40Training 1.50 4.00 5.50

Total Project Costs' 94.30 62.80 157.10Total Financing Required 94.30 62.80 157.10

Identifiable taxes and duties are 0 (US$m) and the total project cost, net of taxes, is 157.1 (US$m) Therefore, the project cost shanng ratio is 18 27%of total project cost net of taxes.

- 28 -

Annex 4: Cost Benefit Analysis SummaryNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

GLOBAL HEALTH STRATEGIES

VERSUS LOCAL PRIMARY HEALTH

CARE PRIORITIES - A CASE STUDY

OF NATIONAL IMMUNISATION

DAYS IN SOUTHERN AFRICA

B Schreuder, C Kostermans

Bulding on the successftul eradicabon of smallpox, the WorldHealth Organisation, together with other agencies, is nowmoving quickly to the eradication of poliomyelftis, onginallyaimed for the year 2000. Plans for the subsequent globaleradication of measles are in an advanced stage Eradicahonof both polio and measles incorporate as a fundamentalstrategy high routine coverage, surveillance and specialnational immunisation days (NlDs), which are supplemen-tary to routine vaccination services.

There has been a lively debate on whether poor countries,with many health problems that could be controlled, shoulddivert their hmited resources for a global goal of eradicationthat may have low pnonty for their children. Frrm a cost-effectiveness perspective, NiDs are fully justifiable. However,,field observations in sub-saharan Africa show that NiDsdivert resources and, to a certain extent, attention from thedevelopment of comprehensive pnmary health care (PHC).The routine immunisation coverage rates dropped on averagesmce the introduction of NIDs in 1996, which is contrary towhat was observed in the westem Pahfic and other regions.

The additional investment to be made when moving fromdisease control to eradication may exceed the financialcapacity of an individual country. Since the industnalisedcountries benefit most from eradication, they should takeresponsibility for covering the needs of those countries thatcannot afford the investment. The WHO's frequent argumentthat NiDs are promotive to PHC is not confirmed in thesouthern African region The authors think that the Wl{Oshould, therefore, focus its attention on diminishing thenegative side-effects of NIDs and on getting the positive side-effects incorporated in the integrated health services in asustainable way.

5 Af, Mad 1 200). 91. 249 254

R-,li rh,lpea,l hi/ltiaie, Am#1sr.d,a

s Schreudea. MD, l'1

WoIl.f Banik

C KvskennAS, ML). Mi'lli

-29- < > it

In disease control one can distinguish between effective their view strengthening routine immunisation services is morecontrol, elimination, global eradication, and extinction. All sustainable.require deliberate efforts. 'Ihis article attempts to bring both parties together by

Effective control is the reduction of disease incidence, considering points of mutual agreement It has been writtenprevalence, morbidity or mortality to a locally acceptable level, from personal pardctpation m the first rounds of NIDs as wellwhile elimination of disease or infection is the reduction to zero as participation in the southern African sub-regional plannungof the incidence in a defined geographical area Both control and evaluationt meetings of national Expanded Programme forand elimination require continued control measures. Imrnmunisation (EPI) managers, organised by the WHO/Africa

Global eradication is the reducbon to zero of the worldwide Regional Office (AFR0). Costs and operahtonal aspects of NIDsincidence of infection caused by a specific agent, intervention in southem Africa are also analysed in this study. Finally, themeasures are no loner needed. Extinction occurs when the study includes replies of subscribers to the Afro-Net discussionspecific agent no longer exists in nature or the laboratory I group on NlDs Replies were to the following questions:

From an economic point of view, elimination is generally (t) What are tie direct costs (both human and monetary)'considered to be less cost-effective than disease control, since (u) Can an individual country afford not to participate tn athe cost per case controlled usually follows the law of global itubative? (hw4 How does an mdividual poor cottntrydiminishing retums. Eradication is especialy attractive, since benefit from NIDs? ( (v) What are the negative effects of NIDsany specific intervention can be stopped after global on sustainability of PHC? (v) Can these effects be ninimised?certification that transmission of infection has ceased.

Building on the successful eradication of smallpox in 1979, THE DILEMMAS OF ERADICATIONthe World Health Organisation (WHO), United Nations In their article entitled 'Ethical dilemmas in current planningChildren's Fund (UNICEF) and other agencies are now moving for polio eradication', Taylor et at.' looked at the dilemunas ofquickly towards the eradicatirm of polinmyelitis, which they polio eradication at global level The authors expressed theirhorpe to achieve by the year 2000. Plans for the global concern at the intensification of worldwide eradication efforts,;eradication of measles are in an advanced stage. in particular the organisation of NiDs The authors also raised a

The eradication programmes for polio and measles questions regarding the balance between global goals and localiincorporate the following three fundamental strategies: high prorities and the resultng ethical implicatons.routine coverage, supplemental vacdnation (national Probably the most important question raised by the authorsimmunisation days (NIDs)) and active surveillance In is whether poor countries, with many controllable healthparheular the NIDs have occasioned lively debate, with problems, should divert their limited resources towards aproponents and opponents sometimes taking dogmatic global goal that has low prionty for their children.positions. Unfortunately the authors do not provide a clear-cut answer tot

In the southern African sub-region, the strategy for polio is this question. This article attempts to provide such an answer *'to have 2 annual NlDs I month apart in the cold season, for southern Afnca. S

continuing for up to 3 years. The target group for vaccination isall children below the age of 5 years, regardless of their What are the costs of NMDs?vaccination status. With regard to measles, countries have done A cost study of NIDs in the southem African WI 10 sub-regidAcampaigns among children aged between 9 months and 14 showed that the average direct ost per vaccinated child of twoyears. Malawi implemented its campaign in September 1998 rounds of polio vaccine was around US$0.92. This included tlnand Swaziland and South Africa did mathematical modelling cost of vaccines, training, logistics, and social mobilisation. ,to show when the follow-up campaigns must be held Vaccines, at 48% of the total, constituted the major cost The

On the one hand, proponents of NIDs claim that eradicaton cost of a single measles vaccination dunng a campaign, givencannot be achieved through routine services alone They with a disposable syringe that is properly destroyed, is alsodemonstrate the enormous savings that can be achieved after close to US$I Some savings can be made by giving measleseradication, owing to the highly favourable cost-effectiveness and polio vaccines at the same time, but the different(C/E) ratios. operabtonal strategies for polio and nmeasles eradication may -

On the other hand, opponents claim that the almost military not always allow for this.vertical approach of NTDs competes with and negatively affects The total costs of MDs in the sub-region have beencomprehensive primary health care (PHC) development. Some calculated For polio we assumed the maximum scenario ofalso fear that eradication strategies are becoming the public three annual campaigns of two rounds for all children agedhealth strategies for the coming century. diverting funds and under 5 years For measles we assumed three campaigns ar,attention from the continuous care of vulnerable individuals. In initial campaign for all chilcireni aged between 9 months and:

- 30 -

March 2001, Vol. 91, No. 3 SAMJ

years and two campaigns (for children in the same age group) recruit basic health workers from the pooxl of available staff orat 4-year intervals thereafter A 5% additional cost for trainees, NIDs have not substantially affected the normal dailyintensifying epidemiological surveillance is included in the executon of other PHC services The bme spent by district,calculations Table I shows that the total cost is around USS 114 prnvincial, and central staff is, however, much moremillion substantial. District staff are diverted for I -2 months to plan,

in both 1996 and 1997 expenditure on NIDs to the region was mobilise, support, train, organise logistics. and evaluate amostly provided by external funds The exception was South campaign At provincial level this time may easily double, andAfnca, which paid the full amount with intemal funds at central level It may requwre up to half of the total available

Social costs paid by the community to participate in NlDs are time of the natronal EPI manager and histafer staffnot included in the above calculabons. A costing study in Cnwquently, central and prvundal staff can pay mudi leMalawi' calculated that a mother spends 3 hours and 20 attention to routine services.minutes to bong her child to one round of NIDs Taking a rural What are the side-effects of NIDs?salary as USS0 5 per day, the mother's tme for two rounds ofpolio adds approximately $0.4 to the direct costs. The hudden Eradiction strategies cannot be seen in isolabon - bothcost of salaries and operaionral costs of health care facilities, posbtive and negabtve side-effects have been extensivelyalways covered by internal funds, were also excluded from our documented The proponents of eradication frequently claimcalculations that experience in the Amencas has shown that vaccination

campaigns can have a positive impact on the development of

Can countries afford to pay for NIDs? PHC and that social mobilisaton reduced distrust betweenSociety has to balance expenditure on NIDs with expenditure health services staff and communities anid fostered a newon other pressing needs In South Afnca, NIDs annually awareitess of health and prevention Iconsumne less than 1/1 01I0 of the total recurrent budget for The p olio eradication initiative has had a positive impact onhealth In contrast, a poor country such as Mozambique with the quality of epidemiological surveillance systems in mostan internal health budget of roughy US$30 million per annum countries in the southem Afncan sub-region By improving(US$1 7 per capita), would have to spend US$3 mullion (or surveiDance of suspected polio (acute flaccid paralysis (AFP)),109/) of its annual health budget on one national polio attention was focused on the importance of disease surveillance

'campaign With all the goodwil in the world, there is probably systems, which were stmngthened accordingly It is not clearerno country that can suddenly uicrease its health budget by whether this improvement will be sustainable once the extra

(10Y%. Extemal financial support in the form of loan, credit, or resources put in for polio surveillance are withdrawn Not only'grant is therefore indispensable In practice, such support has did the sensitivity of the reporting of cases of suspected poliobeen forthcoming (AFP) inLrease, but It also contributed to the qtality of the

,'~, Affordab,iity ofuturnan resources ts a putentialiy more information system and called attention to the importance of-Affordabilltys of human resources is a potentially more eieilgclsrelac ssc hl ti o e la,i

;serious issue Vaccination teams usually consist of two to four epidemiological surveillance as such While It is not yet cleat it,eieople, at least onie of them a professional. In practice, health is hoped that the impact of NlDs will go further than that off,workers are withidrawn from their normal duties for between 2 the polo intiatve alone, and that improvements to

surveillance will be made in sustainable waysSdays and 2 weeks As no country has found it difficult to

i WL5at5mtespf tatal direct costs (n mist5tiw US$3 eftD In UseSouth Afddcanbsuten ar ,d1 . ,

Fln, M. 5; 5ePoptulation' a;.'1," ,l, lt4i I5'A,' 'Wi71O'. ;tr 'Ir (mIlion) v' 9O yessais' 4 PoIo .",¢ , 0- 4yeasPo,o 5 y Meas;eas Total .

1&7~~'~ 6m 44.7. y 8.97 .-... ~"1520a " 21 4' 179 109 419, . . .5" 2.64 ,q .154 191" ''$' t8 5 '' '6 .6,31 46.9 922

i iujue , 15.8 18.5 "'; -' ' 847 44.' i223 Mm20

i thAf0ca irp ' , . 37B6.' , j !S.,s';) I4.5,~ .j '~ .i 15. jLi.88 , 5. ' ' 38.6 | , .'' ' ' 24.34"8 ~ ''' ;4022 'r i,;,; ', 2l rilande, , , 1 , F09 1.92 '''049 i 4159 068 117' z

11.5 19.2 6 40 ~~~~4~. '9.0 14

Stai t 94z | ., S 177 / .46,37 43.6 ' e 68.35 - 11471'

Pa*x5x t,,s 1 W Wo r id Oe-etopese 1993. i,

-31

The NiDs for measles have drawn attention to the need to Opponents of NIDs do not always make the necessaryimpmve injection safety Many countries have introduced auto- distinction between the global goal of eradicabon and the goaldestruct synnges and needles dunng campaigns Countries of providing daily care to the individual through PHCalso had to recognise the need to set up a waste disposal Opponents frequently miscooceive NiDs as bemg ansystem, including collection in boxes and proper incinerabon altemative way to improve rouhne coverage figures, and thenTo date, auto-destruct syringes and needles have mostly been reject NlDs on grunds of inefficiency.used only dunng the NIDs, and not for routine vaccinations orcurative services. Also, it is stil not clear if the impact of NIiis National perspective versus global responsibilitieson-inection safety will be sustainable On the negative side, the Eradication of a disease is the ultimate goal m terms ofposihve impact of campaigns on the coverage rates of routine sustainable impact on that disease There is no doubt that theimmunisations in the western Pacific, as descnbed by Aylward current global strategLes for the eradication of both polio andrt al1' could not be confirmed in the southem African region nmeasles can pass the cost-effectiveness (C/E) test with honourOn the contrary, the coverage rates of the most important (see Fig. 2) If the world does not embark on eradication ofanhgens have, on average, declined since the introduction of polio and measles, it wvill face a gradually increasing level ofthe NIDs in 1996 (Fig 1) costs per disability-adjusted life-year (DALY) gained The C/E

ratios for control will, in the final phase, reach unacceptably-ecO- BCG high levels Against this, C/E rahos for eradication strategies

ess.l DP-TXPV3 become, within the rather short time of less titan 10 years of0% >_concluding the investment, more favourable than those for

75X=.' control alone.'

65i Fig 2 depicts the cost-effectiveness ratos of contrul andr-. eradication strategies for both polio and measles.

91 92 93 94 95 aS _7 go__

Fig I Aiera8 e cooracgrates af threc antigens in 9 coutitries of tite 70 -- M_. M_rfsouuliern African block rwotine imminisaltin programmes nrm997 -4 r-1997) 5 -1

Many countries in sub-Saharan Afnca claim that campaigns I

are temporarily disruptive A South Afncan sttidy claimed thatcampaigns divert attention from the development tif routine 3 -services Barron' suggested that mass campaigns are oniv 20acceptable as a catalvst to build PHC services and mobilise _ - 0 -s Ov -iscommunity awareness of health issues He concludes that sincethis usually does not happen. campaigns have a negatve °4impact on routine services 2000 2010 2S20 20S0

Personal observations in the field and reactions sent bv Fig. 2. Cost-effectwrncss ratios for global polio and iireasiese-mail confirm the competihve and disruptve effect of NIDS eradicatioti and onitrei in a tnir perspectiveon building sustainable P1iC services So far nobody insouthern Afnca has argued that NIDs support PIiC Contrary The average annual costs per DALY gained by controlto claims in othet parts of the world, NIDs have to some extent strategies wll gradually nse as a result of the increasingdisrupted the development of integrated PHC structire in the number of children to be vaccinated and the declirnig numbersouthern African region. This is mainly at management level, of DALYs gained because of the ever-lower traitsmission ratewhere time spent organising NIl)s competes with tinie spent uf the disease The costs per vaccinated chuld in the controlon routine tasks Participation in NlDs is also usually paid for strategy will vary greatly by contuient, but for reasons ofand this may crests envy In those who are excluded, causing simplicity we applied an amount of US$S as the average costtensions among the staff NlDs may also undermine confidence per vacciated cild in the control scenaro for both diseasesin pnmary level care As we heard one mother say 'If we come Costs assume l(PYo vaccination coverageto the facility because we are following the Road-to-I sealth The average aniual costs per DALY gained in an eradicationchart, why do we suddenly need extra vaccinahons? strategy are based ont the total costs of the eradication strategySomething must be wrong with the maternal and child health divided by the number of DALYs gained smce the start of theservices in the health centre.' eradication Total costs of polio eradication are estimated at

- 32 -March 2W1M Vol 91. No. 3 SAMI

USS] billion, and that tor measles at US$3 7 billioi (UNICEF, greater resources should be prepared to assist, for exanmple by1997) The average annual costs are the result of the division of providing vaccLnes or covering recurrent coststhe total costs by the number of years since the start of One ran queshon whether NlDs are an absolute requirementeradication A 3% annual discointing has been applied to for eradicating polio In fact, NIDs have never been undertakenconrect for utility in the future un the USA and Canada. Other countres with high rouhne

It is assumed that for both polio and measles, all routine coverage rates and a reliable surveillance system in placevaccinations will be suspended 3 years after global certificatio (in{duding South Africa) decided niot to complete the hill set ofof a world free of polio or measles Population proje,thioiis and 4 years of two rounds of NIDs, relying rather on theirexpected numbers of DALYs gained are projections of the surveillance system as a prerequisite for the 'Free of polio'tiends presented iLi the Global Burden of Diseases senes ' certification

Bart et al! " demonstrated that enormous savings, particularly However, the current coverage rates of the routine EPIIn the industrialised world, would be made after the global services in some countnes in the southern Afncan sub-regioncertificaton of a world free of polio The future savings niade (lTable 11) do not provide a solid basis for achieving the targetby investing now in eradication efforts are substantial These for global eradication of polio in a reasonable time penod

tsavings should be used to support the further development of Considenng that upgrading the routine EPI services implies ag;integraled PHC. and to compensate for the disruption to these major effort, in the short term It is much mnore cost-effective to

services that NlDs are currently provoking organise NIDs The impact of NIDs on disease transmission is

Initatives for global eradicaton of disease are comparable to probably greatest in those countnes where rouhne coverage is,2other global agreeXments between countries on issues such as lowest. As a result of their weak infrastructure, these areItiuman rights and the banning of land mines and nuclear probably the very countnes that will experience mostweapons Given its great impact. such an agreement should be disruption from *NIDs To minuuse the negahve side-effects inp red with the greatest possible care and only endorsed if these ciiuntnes, NlDs must be planned very carefully and wellhe expected contnbution of each individual country is defined in advance Instead of persisting in pointng iut the posihve

detail impact NIDs have on P-IC, the WliO would dii better to pay52he eradicahon of polio was enclorsed bv a 1988 glubal more attention to the negative side-effects of NlDs If PHC hasi The eradication of polio was endorsed by a 1988 global to be strengthened, there are more appropnate ways of doing

lution of all member states of the WHO, and wasonfirmed at the World Summit for Childreni n 1990. On both

9asions the endorsement of polio eradicahon was based . , , ,-

«lely on technical feasibility and expected future benefits Table n gCo,era8 e ramt ) Io routrne *C aabon sire iorplications of NlUs on health systems and PHC were not polio LIrd dosel and'me&sles i:acin.aton nM., .'- ..

rensidered ', ; Pio. Ntaais'',

ince eradication is a global initiative, commitments should A36ota , , ' . r i

-shared according to capacity between the 'haves' and 'have- : nu .,. ,, d

As long as there Ls no consensus regarding their tal - 13 87 -i

irtance, eradicahon initiatives may not receve the qu1az,r,bie 61 '- ' ' . -2

Issary broad support and funding If the initiative is not a'inita 65 5-bitised bv donors it becomes an empty statement, and the South Afra' ' "3 1

a-n ots can onivadopt a pisture of passive resistance ,SsaziL[ind ' 'i 473 -'4$K,' .,

M a nonetarv point of view the industrialised woirld Z _:Sits iost fom rapid eradicahtin I lowever the benefits in ' - C ', e. F,a .

ase reduction are greater in developing countres where the WtO 0% .Cdenec of new cases of both polio and measles is higher -

lylor et al: raise the question uf whether poor countnesmany health problems should divert their limited The creation of vertical NTlDs structure should not be bluntly

e tov.ards a global goal that has low pnonty for their rejected it serves a completely different objectve to that ofchildrenl By definition, global eradication mnitiatives need individual care provided by the integrated routine scrvices

:ippport of all countnes of the world, iion-participaton uf a Periodic cainpaigiis carI never replace the continuous care of.eculintry could leopardise the entire exencise PHC

0 individual couiitir refuses toi implement eradication The disctission shouild, therefore, not be about whethertenions it would not be Lunethical to exercise some vaccinations should be administered through routine services

re (n that country If that coiuntry, however, suffers from or through NlDIs Society needs integrated PHC, and it needst,.ints i implementaton, then coiimitted countries witl NIDs on a temporary basis to eradiLdte disease efficiently

- 33 -

Eradication initiatives could contnbute to sustauiabledevelnpmenl of the health infrastructure by improvingepidemiological surveillance systems. This will not only bebeneficial to the health infrastructure as a whole, but will alsoprevent too many vaccinations being administered, apossi'bidity in unreliable sturveiflance systems Investing msurveillance will quickly pay off

Since the Alma Ata conference in 1979, disctissions on theextent to which target-driven programnies affect sustaunablePHC have been polarised. The himited health budget has to bedivided between both eradication programmes and PHC. andin that respect they are competbve. Dunng the past 20 yearstarget-driven vertical programmes have been separate trmand have cumpeted with integrated PHC Each systemcontributes in its own way towards improving health. Bothsystems have a vertical target dimensioni and a horizontalindividual care dimensucm. The vertical dimension is strongerin target-dnven programmes, the horizontal is stronger inPEIC Vertical programmes may have a special place in certainphases of the fight againist diseases, namely in the begmning tostart up a programme and at the end to finish the job. To date,the world is still divided into honzontalists and verticalists.Both groups would do better to sit down together and weavethe honzontal and vertical fibres into a sustainable web

'The views expressed in this artcle are those of the authorsand shotild not be attnbuted to their respective orgarusahons.

We thank the following people for providing ideas andcomiiients on this article Julie Ctiff (Universidade EudardoMondlane, Maputo), Febalty Cutts (London School of Hygiene and'ftopical Medicine), llilbrand Haak (Consultant for HealthDevelopment, Leiden), Robin Biellik (WHO, Harare). Lucy Gdlson(Centre for Health Policy, University of the Witwatersrand,Johannesburg).

(.Wln VA. ii WUly 19M2 Uyl CE Ct,,i rr r.hyl C Ethii dA.i in n pnnin.g i o.r dlvi,, A.

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W nEVt tnn / rh/ cC 199Jllt y LnL. I p1 AU 71.G* Qkinx I)--- - Inn ty Vl I IDnI t-.d

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lltImt,VIWO 01- MM 74f1E X14;5

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-34-*A .,..-L VVII 31..1 eli 5. 3 CAiji

Annex 5: Financial SummaryNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

Years ending 2005

Total FY 1 FY 2 FY 3FinancingRequiredInvestment 7.5 M 13.3 M 7.9 MCosts(vaccines)

-35 -

Annex 6(A): Procurement Arrangements

NIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

Procurement

1. The procurement system in Nigeria is in the process of being reformed at all levels. Thegovernment procurement reform program was fashioned in line with the recommendations of the year 2000Nigeria Country Procurement Assessment Report (CPAR). All the three tiers of governments are operatingunder the Financial Regulations (FR), which are essentially an internal set of rules for economic controls.The CPAR identified major weaknesses in the procurement polices and practices in Nigeria and madeappropriate short-, medium- and long-term recommendations. Based on the short-term recommendations ofthe 2000 Nigeria CPAR, the procurement procedures section of the Financial Regulation at the federalgovernment level, was revised on June 27, 2001, to ensure clarity and transparency by incorporatingdetails of the various procurement methods and their applications for goods, works and services amongothers. For now, this revision applies only for federal projects as the states are yet to adopt these changes.However, it is envisaged that the states and local governments will adopt the revised Financial Regulation.To make this possible, FGN is making arrangements to disseminate the findings and recommendations ofthe CPAR at State and LGAs Levels. The ineffective Federal and Departmental Tender Boards have beenabolished while the Ministerial Tender Boards have been strengthened with powers to approve contractawards. Also a Procurement Reform Implementation Unit (PRIU) and a Steering Committee that wouldinitiate and supervise initial implementation of reforms have been established at the federal governmentlevel. The reforms have five main features:

o Enactment of a new procurement law based on the UNCITRAL model law.o Establishment of a public procurement oversight body, the Public Procurement Commission (PCC),

independent of the Tender boards with responsibility for the efficiency and effectiveness of theprocurement function across the public sector

o Revision of key areas of the Financial Regulations to make them more transparent.O Deep restructuring of Tender Boards and approval procedures for contracts. Specifically, abolish

Federal Tender Board and Departmental Tender Boards and strengthening Ministerial Tender Boardsby vesting them with powers to approve contract awards.

o Building procurement capacity in the public sector through a restoration of professionalism inprocurement and intensive training of procurement staff.

Until government takes major steps to reform the procurement policies and practices in the country(presumable the reform process will reach an advanced stage by FY04), procurement risk for doingbusiness in Nigeria are assessed as high. However, the procurement risk for the proposed project is ratedlow since the project does not require any direct involvement of the Borrower in the management of theprocurement process. This is because UNICEF will use its procurement procedures to procure thevaccines.

2. All goods financed under the IDA credit will be procured in accordance with UNICEF'sprocurement rules, regulations and procedures and its financial regulations and rules. The decision toallow the use of UNICEF's procedures is based on the following: (1) UNICEF's proven track record as apurchasing agent for OPV vaccines on behalf of the governments using public funds and donor resources;(2) UNICEF's reliance on WHO prequalification process which is based on very rigorous prequalificationcriteria that provide adequate quality control measures.

3. Since UNICEF will be responsible for the procurement of the vaccines using its own procurementprocedures, and in accordance with OPCPR's instructions on vaccines procurement issued in October 17,2002, an assessment of the capacity of the National Program for Immunization -NPI- (Project

- 36 -

Implementing Agency) to conduct procurement under the project will not be required.

4. The amount of vaccine needed depends on the needs identified, and regularly adjusted, by theExpert Review Committee based on surveillance results If on the basis of these results, not all projectfunds are needed for procurement of polio vaccines for SIAs during year 2003 through first quarter of year2005, IDA funding will be reprogrammed for the procurement of OPV needed for SIAs in the second halfof year 2005 and year 2006. If the IDA funds are not exhausted by the end of 2006 and SIAs are nolonger needed, the remaining funds will be used for procurement of polio vaccines for routineimmunization program; in which case, confirmation of the Expert Review Committee shall be required.

5. The NPI will be responsible for project execution. It is a relatively strong agency in the healthsector. It was created only in 1997 as a parastatal of the Federal Ministry of Health. Since then it hasestablished structures and a strong management countrywide. NPI shall be responsible for the distributionand administration of the vaccines in the country. UNICEF will submit an utilization report on a quarterlybasis to NPI (copy to the Bank) on (a) the unobligated balance in the OPV Procurement Account, (b) thesales and purchase orders placed by UNICEF, (c) the actual quantities of OPV delivered, (d) theexpenditures from OPV procurement account during the reporting period. The Agreement betweenUNICEF and the FGN, copy of which is available in the project file, sets out the terms and conditionsunder which UNICEF will procure the OPV. The OPV will be delivered in accordance with the deliveryschedule and consignees set out in Annex 3 of said Agreement.

6. A small amount of the Credit will be set aside to procure an independent audit if IDA would so requirefor parts of the project not financed by IDA. Consultant for assignment of a standard routine nature such asaudits, may be selected on the basis of Least-Cost method in accordance with provisions of paragraph 3.6of the Guidelines: Selection and Employment of Consultants by World Bank Borrowers dated January1997, revised September 1997 and January 1999.

Procurement methods (Table A)

Table A: Project Costs by Procurement Arrangements(US$ million equivalent)

I_' 9 ,g; I' r',Procuee i , M -ethd

ExpenditureCategory, -: I- 1 , N t_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N C ,.3 O th e r . . . o a C s

1. Works 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

2. Goods 0.00 0.00 38.20 0.00 38.20(0.00) (0.00) (28.65) (0.00) (28.65)

3. Services 0.00 0.00 0.05 58.77 58.82(0.00) (0.00) (0.05) (0.00) (0.05)

4. Miscellaneous 0.00 0.00 0.00 60.08 60.08(0.00) (0.00) (0.00) (0.00) (0.00)

Total 0.00 0.00 38.25 118.85 157.10(0.00) (0.00) (28.70) (0.00) (28.70)

Figures in parenthesis are the amounts to be financed by the IDA Credit All costs include contingencies.

v Other procurement method: Sole Source for goods, Least Cost for audit services.

Non Bank Financed: Operational costs, including distribution of OPV. Epidemiologic surveillance. Laboratorysurveillance.

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Annex 6(B) Financial Management and Disbursement ArrangementsNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

Financial Management

1. Summary of the Financial Management Assessment

Overview of Implementation ArrangementsI. IDA has entered into a partnership with UNICEF and funding agencies such as the GatesFoundation and Rotary International to support this project. The project has three components. The firstcomponent, which is financed by IDA, supports the purchase of oral polio vaccine (OPV). Although IDAfinancial resources will be provided to the Nigeria Government, third party funding will "buy down" theservice charge and repayments by financing the net present value of the IDA credits. This, in effect,means grant funding for the program. The IDA credit will finance a single contract for the supply ofvaccines. An Agreement will be signed between the Nigeria government and UNICEF for procurementservices following the arrangements below:

a. Oral Polio Vaccine (OPV) will be procured in accordance with UNICEF's rules, regulations, andprocedures. These arrangements will be cleared by the procurement unit of the Bank,b. The Government of Nigeria will deliver a blanket withdrawal application to the Bank,authorizing the Bank to make direct payment to UNICEF of all amounts requested by UNICEF underthis Agreement through an initial, and subsequent quarterly, withdrawal applications;c. UJNICEF will maintain a separate ledger account, through which all of UNICEF's receipts andexpenditures for the purposes of providing the services contemplated by this Agreement will berecorded; andd. UNICEF will report quarterly to the Nigeria Government (with copy to the Bank) on the use offunds received: (a) balance at the beginning and end of the reporting period; (b) the sales andpurchase orders placed by UNICEF during the reporting period; (c) the actual quantities of OPVdelivered during the reporting period; and (d) the expenditures from the OPV Procurement Accountduring the reporting period.

(The implementation arrangements described above are based on the proposed agreement betweenUNICEF and the borrowers, a copy of which is available in the project file.)

2. The remaining two components of the project are Supplemental Operations and Monitoring andEvaluation. These components are to be financed by the Borrower (NPI) through contributions fromPartners, which will be largely channeled through WHO and UNICEF. The funds will be managed bythe Inter-Agency Coordinating Committee (ICC) whose Finance Committee will be primarily responsiblefor financial management and reporting.

Financial Management Arrangements

3. The Borrower is not directly involved in the management of funds relating to IDA-financedcomponent. This will be the responsibilities of UNICEF under the aforementioned Agreement. Thecredit proceeds will be disbursed by the Bank directly to UNICEF on a single source contract withUNICEF for the purchase of OPV. The quantities will be agreed in advance and the price is relativelystable. The assurance that the Bank's fiduciary requirements are met, especially that funds are used forthe purpose intended with due regard to economy and efficiency, is obtained through the following mainmeasures:

UNICEF's procedures for the procurement of OPV will be agreed on with the Bank;All expenses will be on items agreed beforehand (costs of vaccines, including freight, andUNICEF handling fee);The quarterly financial report will allow close monitoring of the outstanding balance as well as

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funds received and spent by UNICEF. The Bank will be in a position to verify expendituresbefore any subsequent disbursement;

* The Nigeria Government will receive a copy of the reports prepared by UNICEF and will be ableto confirm receipt of the quantities of goods indicated in these reports.

IDA's annual financial statements and FMRs requirements will be satisfied by the reports to be providedby UNICEF for Part A of the Project and ICC's normal annual reports and periodic reports to be providedwith respect to the rest of the Project.

4. Given that under IDA-financed component of the project, i.e. procurement of OPV, funds will bedisbursed directly by the World Bank to UNICEF, Copenhagen, Denmark, an assessment of the financialmanagement arrangement for the project focused exclusively on the non-Bank financed components ofthe project - Supplemental Operations and Monitoring and Evaluation. These components are to befinanced by the Borrower (NPI) through contributions from Partners, which will be channeled throughWHO and UNICEF. The funds will be managed by the ICC, whose Finance Committee will be pnmarilyresponsible for financial management and reporting.

5. The review of the audited financial statements and domestic reports of ICC revealed that theinternal control arrangement is weak. The Memorandum of Understanding between ICC and thecontributing agencies on one hand and NPI and funding agencies on the other hand has not been fullyadhered to. The completeness and accuracy of payments made could not be substantiated. These impliesthat there is a high risk of misuse of project funds which may negatively affect the realization of projectobjectives.

6. The overall conclusion of the assessment is that there is a need to strengthen the internal controlsof the ICC. Financial Management Procedures need to be further developed for the components of theproject that are not financed by IDA. Also, the procedures need to be adhered to. The financialmanagement system should be able to support ICC's management to ensure proper financialaccountability in the project implementation. It should also be capable of producing timely, relevant andreliable financial information that will enable the management of ICC to plan, monitor and appraise theoverall progress towards the achievement of project objectives. NPI is currently taking steps to addressthe weaknesses identified.

B. Risk Analysis:

7. Inherent Risks: The Country Financial Accountability Assessment (CFAA) conducted in CY2000 revealed that the systems for planning, budgeting, monitoring and controlling public resources inNigeria have deteriorated to a level that they do not provide any reasonable assurance that funds are usedfor the purpose intended. The Assessment rated risk of waste, diversion and misuse of funds as highuntil such a time as its recommendations have been implemented. There is, therefore, a need for a reviewof the extent to which the Assessment's recommendations have been implemented to determine thecurrent level of risk.

8. Control Risks: Based on the conclusion of the FM assessment for the agency responsible forimplementing the non-Bank components, there appears to be a high risk to the use of non-Bank funds.This has implication for the overall success of the project. The overall project risk from a financialmanagement point of view is considered high.

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2. Audit Arrangements

The borrower is not required to appoint an independent extemal auditor for the purpose of the project.For the procurement of OPV, financed by IDA, the financial statements of UNICEF will be relied on.For the other non-Bank financed component, the audited financial statements prepared annually by theimplementing Agency, ICC will be relied on. A copy of this audited financial statement and themanagement letter which is made available to all members of ICC will also be made available to IDA.However, IDA would reserve the right to ask for an independent audit of the project financial statements,if deemed necessary. A small amount of the Credit has been set aside for this.

3. Disbursement Arrangements

The credit proceeds will be disbursed by IDA directly to UNICEF on a single source contract withUNICEF for the purchase of OPV.

Allocation of credit proceeds (Table C)

Table C: Allocation of Credit Proceeds

'xpanhdituier'C`tegory;., I - mount in 1Usmiflioi:. f ;- iancin g PercbntageMedical goods 28.65 100Audit services 0.05 100

0.00

Total Project Costs 28.70

Total 28.70

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Annex 7: Project Processing ScheduleNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

Project Schedule PianActuaTime taken to prepare the project (months)

First Bank mission (Identification) 10/08/2002 10/08/2002

Appraisal mission departure 01/20/2003 01/20/2003

Negotiations 02/11/2003 02/24/2003

Planned Date of Effectiveness 05/15/2003

Prepared by:NPI, WHO, UNICEF and World Bank.

Preparation assistance:The Project was prepared in very good collaboration with government counterparts and developmentpartners in Nigeria.The Government counterpart team was made up of staff of the NPI, led by Dr. A. Awosika.

WHO and UNICEF have very actively participated in the project's design and preparation. Dr. JohnFitzsimmons, WHO, Technical Officer Polio Eradication and EPI, was a full member of the projectpreparation team. Headquarter, regional and local staff of WHO and UNICEF participated actively in theproject preparation missions.

Given the multi-country character of this undertaking - similar projects are envisioned in around 7 othercountries -- many central and regional departments in the World Bank have been involved. Amie Batson(Sr. Health Specialist) led discussions on the IDA buy-down arrangements with the GF and RI and ledthe discussions on the procurement arrangements with UNICEF, in cooperation with various departmentsin OPCS, RMC and LEGVP. Given the novelty of the financing mechanism, the burden on AFTQK andthe Nigerian Country Team leadership was unusually high for project preparation.

The Peer reviewers were: Mariam Claeson (Lead Public Health Specialist) and Jules Pieters (WHO).

Bank staff who worked on the project included:Name Speciality

Kees Kostermans Lead Public Health Specialist, Team leaderRashmi Sharma Operations OfficerAnne Okigbo Sr. Operations OfficerYolanda Tayler Sr. Procurement SpecialistEdward Olowo-Okere Sr. Financial Management SpecialistAdenike Mustafa Financial Management SpecialistBayo Awosemusi Sr. Procurement SpecialistKaren Hudes Sr. CounselNellie Sew Kwan Kan Program AssistantAbiodun Elufioye Program Assistant

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Annex 8: Documents in the Project File'

NIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

A. Project Implementation Plan

Project Implementation Plan, January 24, 2003.

B. Bank Staff Assessments

Aide memoire of Project Identification and Appraisal Mission.

C. Other

Strategic Plan for the Eradication of Poliomyelitis and Certification, 2000-2005, Federal Ministry ofHealth, National Programme on Inmmunization (NPI), Nigeria.

National Programme on Immunization, Brief on Routine Immunization 2002, Brief on RoutineImmunization, September 2002.

National Programme on Immunization, Decree No. 12, 1997.

Strategic Plan for the Eradication of Poliomyelitis and Certification, 2000-2005, Federal Ministry ofHealth, National Programme on Immunization (NPI), Nigeria.

Guidelines and Terms of Reference for the Interagency Co-ordinating Committee (ICC) for theStrengthening of Immunization Services in Nigeria.

Minutes of the Inter-Agency Coordinating Committee (ICC) Meeting held at the Honourable Minister ofState for Health's Conference Room, Federal Secretariat, Abuja, on Thursday, June 13th, 2002.

EPI Policy and Strategic Approaches in the Americas. A joint statement by ICC Member Agencies.Expanded Program on Immunization.

Joint AFRO/HQ Country visit, Nigeria, 29-30 November 2002

WHO PEI Social Mobilization Review Report, August 2002, By Dr. Nosa Owens-lbie, NSMO and Mr.Jones Mpakateni, TOSM.

Poliomyelitis Eradication by the year 2000 and strategies for imporving control and surveillance of otherpreventable diseases in the South-East Asia Region, A joint Statement by United Nations Children'sFund, Rotary Integration, The Centers for Disease Control and Prevention (USA), The Task Force forChild Survival and Development and World Health Organization, South-East Asia Region. World HealthDay, April 7, 1995.

Agreement between Melinda and Bill Gates Foundation and the World Bank, June 6, 2002.

Notes for Record of Meeting between the World Bank Mission, NPI and the Director, MultilateralInstitutions Department, Federal Ministry Finance on Wednesday, October 16, 2002.Expert Review Committee on Polio Eradication in Nigeria. Report of the meeting, 16-19 September2002, Final Draft September 20, 2002.

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Minutes of HNP Sector Board Meeting, December 5, 2002.

Agreement for Procurement Services between The Government of Nigeria by and through the Ministry ofHealth and UNICEF, The United Nations Children's Fund for the Procurement of Oral Polio Vaccine aspart of the Government's Campaign to eradicate Poliomyelitis.

Agreement Letter to UNICEF from World Bank on the Purchase of OPVs that UNICEF will sign withbuying countries, December 12, 2002.

Polio Eradication Program IDA Buy-down Mechanism, World Bank, Gates, Rotary/UNF PolioCollaboration, Technical Briefing to World Bank Board by Human Development Network and ResourceMobilization Department, December 17, 2002.

Minutes of Negotiations and Negotiated version of DCA.

Exchange of letters between World Bank and WHO on WHO's role in Project evaluation, dated March2003.*Including electronic files

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Annex 9: Statement of Loans and Credits

NIGERIA: PARTNERSHIP FOR POUO ERADICATION PROJECT1 1-Mar-2003

Difference between expectedand actual

Original Amount in US$ Millions disbursements

Project ID FY Purpose IBRD IDA Cancel Undisb Ong Fmm RevdP071494 2003 Unversna Basic Education Project 000 101 00 000 10078 000 000

P074963 2003 Lagos Urban Transport Pro)ect 0 00 100 00 0 00 100 46 4 46 0 00

P072018 2002 Nigeria Transrrission Development Project 0 00 100.00 0 00 105 92 18 74 0 25

P070291 2002 HIV/ADS Response Project 0 00 90 30 0 00 94 42 17 33 0 00

P070290 2002 Health Systems 0.00 127.01 0.00 134 92 20 62 0 00

P069901 2002 CornunltyBased UrbanDeveloppment 000 110.00 0.00 11651 1699 000

P070293 2001 NG PRIVATIZATION SUPPORT PROJECT 000 114.29 000 11624 24 13 000

P069086 2001 Comnunity Based Poverty Reducton 0.00 60 00 0 00 58 09 12 21 6 21

P066571 2000 SECOND PRIMARY EDUCATION PROJECT 0 00 55 00 0.00 47 51 4742 2 39

P065301 2000 ECON.MGMT CAP BLDG. 0 00 20 00 0 00 10.28 2 05 0 00

P064008 2000 SMALLTOWNS WATER 0 00 500 000 378 -1 11 000

Total: 0.00 882 60 0 00 888 89 162 84 8 86

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NIGERIASTATEMENT OF IFC's

Held and Disbursed PortfolioJun 30 - 2002

In Millions US Dollars

Committed DisbursedIFC IFC

FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic

1998 AEF Ansbby 0.10 0 00 0.00 0.00 0.10 0.00 0.00 0.001996/98 AEF Bailey Bridg 0.32 0 00 0.00 0.00 0.32 0 00 0.00 0 001996 AEF Courdeau 0.07 0 00 0.00 0.00 0.07 0.00 0.00 0.001997 AEF Ekesons 0.10 0.00 0.00 0 00 0.10 0.00 0.00 0.001999 AEF Global Fabri 0.32 0.00 0.00 - 0.00 0 32 0.00 0.00 0.001999 AEF Hercules 1 30 0.00 0.00 0.00 1.30 0 00 0.00 0.001999 AEF Hygeia 0.29 0.19 0.00 0.00 0.29 0.19 0.00 0 001996 AEF Mid-East 000 0.00 0 12 0.00 0.00 0.00 0.12 0 001997 AEF Moorhouse 1.07 0.00 0.00 0.00 1.07 0.00 0.00 0.002000 AEF Oha Motors 0.84 0.00 0.00 0.00 0.84 0.00 0.00 0 001997 AEF Radmed 0.25 0.00 0.00 0.00 0.25 0.00 0.00 0.002001 AEF SafetyCenter 0.50 0.00 0.00 0 00 0.00 0.00 0.00 0.001997 AEF Telipoint 0 08 0.00 0.00 0.00 0.08 0.00 0.00 0.001995 AEF Vinfesen 1.00 0.00 0 00 0.00 1.00 0.00 0 00 0.001994 Abuja Intl 1.75 0.71 0.00 0.00 1.75 0.71 0.00 0.001964/66/89 Arewa Textiles 0.00 0.12 0.00 0.00 0 00 0.12 0.00 0.002000 CAPE FUND 0.00 7.50 0.00 0.00 0.00 3.75 0.00 0.002000 Citibank (Nig) 39.20 0.00 0.00 0.00 9.20 0.00 0.00 0.002001 Delta Contractor 15.00 0.00 0.00 0 00 0.00 0.00 0.00 0.002000 Diamond Bank 0 00 0.00 18.00 0.00 0.00 0.00 18.00 0.002000 FSB 4.50 0.00 18.00 0.00 0.00 0.00 18.00 0.001992 FSDH 0.00 0.86 0.00 0.00 0 00 0.86 0.00 0.002000 GTB 20.00 0.00 0.00 0.00 5.00 0.00 0.00 0 002000 IBTC 20.00 0.00 0.00 0.00 20.00 0.00 0.00 0.001981/85/88 Ikeja Hotel 0.00 0.25 0.00 0.00 0.00 0.25 0.00 0.001993 Tourist Co Nir 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.002001 UBA 30.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Total Portfolio: 136.69 9 63 36.12 0.00 41.69 5.88 36.12 0.00

Approvals Pending Commitment

FY Approval Company Loan Equity Quasi Partic

2000 AEF SafetyCenter 0.00 0 00 0.08 0.002002 MTNN 75.00 0.00 25.00 0.002002 NTEF- SCB 20.00 0.00 0.00 0.002001 FCMB 10.00 0.00 0.00 0.002001 Novotel Hotel 2.50 1.50 0.00 0.002001 Citibank/lFC JV 30.00 0.00 0.00 0.002002 NTEF - ANZ 10.00 0.00 0 00 0 00

Total Pending Commitment: 147.50 1.50 25.08 0.00

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Annex 10: Country at a Glance

NIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECTSub-

POVERTY and SOCIAL Saharan Low-Nigeria Africa Income Development diamond'

2001Population, mid-year (millions) 129 9 674 2,511 Life expectancyGNI per capita (Atlas method, US$) 290 470 430GNI (Attas method, US$ bilitons) 37 1 317 1,069

Average annual growth, 199541

Populabon (%) 2 6 2 5 19Labor force () 2 7 2 6 2.3 GNI Gross

per pnmaryMost recent estimate (latest year available, 199541) capita . enrollment

Poverty (% of population below national poverty line)Urban population (% of total population) 45 32 31Life expectancy at birth (years) 47 47 59Infant mortality (per 1,000 live births) 84 91 76Child malnutntion (% of children under 5) 27 . , Access to improved water sourceAccess to an Improved water source (% of population) 57 55 76Illiteracy (% of population age 15+) 35 37 37Gross pnmary enrollment (% ofschool-age populaton) 82 78 96 Nigena

Male 89 85 103 - Low-income groupFemale 74 72 88

KEY ECONOMIC RATIOS and LONG-TERM TRENDS

1981 1991 2000 2001Economic ratlos'

GDP (US$ billions) 599 27 3 41 1 41 2Gross domestic Investment/GDP 23 4 22 7 27.6 TradeExports of goods and services/GDP 22.5 37 2 52 3 48.3Gross domestc savings/GDP 19 2 29 3 34 0 26.9Gross national savings/GDP 16.1 20.5 27.6 23.6

Current account balance/GDP -10 1 -3.6 4 8 0 0 Domestic IvsmInterest payments/GDP 1 1 7 5 50 savingsnvesmentTotal debt/GDP 191 122.8 83.1 779 svnTotal debt service/exports 9.1 23.4 15 5 20.4Present value of debt/GDP . 66.2Present value of debt/exports 125.4

Indebtedness1981-91 199141 2000 2001 200145

(average annual growth)GDP 3.3 2.4 38 39 34 4NgenaGDP per capita 0 3 -0.3 1 3 1 5 1.2 -- Low-income groupExports of goods and services 3.1 3 7 -1.6 5.6 2.8

STRUCTURE of the ECONOMY1981 1991 2000 2001 Growth of Investment and GDP (%)

(% of GDP) rsoAgriculture 26 9 30 4 29.5Industry 37 6 45 6 46.0 40

Manufacturing 9 2 5.9 4.1 20

Services 35 5 24 0 24 5 .

Private consumption 67 9 58 5 45.5 47.9 -20 57 98 95 o0 01

General government consumpbon 12 9 12 2 20.5 25.2 - GD0 -G DPImports of goods and services 26.6 31 3 41.1 49.0

1981-91 199141 2000 2001 Growth of exports and Imports (%)(average annual growth)Agnculture 4 6 38 5.2 5.1 30

Industry 0.9 0 9 6 7 1 4 I:Manutfactunng 1 6 1.2 4.9 4.2 1

Services 51 2 6 -0 3 51 o '1

Private consumption -2.5 9.1 -17.9 0.6 'o IGeneral govemment consumption -3 2 10 7 86 2 14.7 .15

Gross domestic investment -3 8 8 2 39 7 18.5 - Expors ImportsImports of goods and servces -12.2 6.1 16.0 18.9 -

Note 2001 data are prelimrnary estimates*The diamonds show four key indicators in the country (in bold) compared with its income-group average If data are mrsing, the diamond will be incomplete

-46 -

Nigeria

PRICES and GOVERNMENT FINANCE1981 1991 2000 2001 Inflation (%)

Domestic prices(% change) soConsumer prices 20.8 13.0 6.9 18.9 soImplicit GDP deflator 16.2 20.2 25.4 6.0 405

Government finance 20

(% of GDP, includes current grants) oCurrent revenue .. 17.7 46.1 47.5 -20 96 97 ea 09 coo O

Current budget balance 6.2 0.7 24.0 19.8 - GDP deflator --C PtOverall surplus/deficit .. .. 2.4 -3.0

TRADE1981 1991 2000 2001 Export and Import levels (USS mill.)

(US$ millions)Total exports (fob) 17,718 12,127 20,441 18,700 25.000

Fuel 17,162 11,665 19,550 17,621Liquified natural gas .. .. 623 735Manufactures 85 30 45

Total imports (cf) 22,013 8,736 13.718 15,544 lFood 3,604 760 1.761 2,044Fuel and energy 301 44 178 197 so1i_Capital goods .

99 96 97 98 99 50 91Export price index (1995=100) 219 117 160 146Import price index (1995=100) 66 86 95 99 * Exports trnwortsTerms of trade (1995=100) 332 136 169 147

BALANCE of PAYMENTS1981 1991 2000 2001 Curent account balance to GDP (%)

(US$ millions) Exports of goods and services 18,511 12,324 21,409 19,694 20

Imports of goods and services 21,839 10,376 16,813 18,327Resource balance -3,327 1,948 4,596 1.367 is -

Net income -2,147 -2,978 -4.343 -3,155

Net current transfers .. 50 1.724 1,803 - 9 5Current account balance -6,042 -980 1,977 15 -10 9 97 IF

Financing items (net) -158 1,267 1,982 1,008Changes In net reserves 6,200 -287 -34959 -1.023 -20 -

Memo:Reserves including gold (USS millions) 3,923 4,150 9.400 10,423Conversion rate (DEC, locallUSS) 0.8 12.0 101.7 111.6

EXTERNAL DEBT and RESOURCE FLOWS1981 1991 2000 2001

(USS mllilons) Compoaltlon of 2001 debt (USS mill.)Total debt outstanding and disbursed 11,421 33.528 34,134 32,130

IBRD 562 3,297 1.625 1,337 G: 1,440 A 1,337

IDA 37 . 59 644 621 G: 621

Total debt service 1,789 2.945 3,362 4,082 F: 5,879

IBRD 72 582 376 285IDA 1 1 9 13 0;. D 8a373

Composition of net resource flowsOfricial grants ..Official creditors 87 43Private creditors 1.715 -120Foreign direct investment .. 588 1.374 1,800Portfolio equity 0 0 0 0 E: 14,480

World Bank programCommitments 388 566 140 305 A - BRD E -BilateralDisbursements 74 255 86 27 B -IDA D -Other mulUtiateral F -PrivatePrincipal repayments 29 276 277 215 C -tMF G -Short-termNetflows 45 -21 -191 -188Interest payments 44 308 108 83Net transfers 2 -329 -299 -271

ueveiopment Economics Yil ilUz

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Additional Annex i 1: Summary of IDA Buy-Down MechanismNIGERIA: PARTNERSHIP FOR POLIO ERADICATION PROJECT

Introduction

This annex describes the arrangements for the implementation of the IDA buy-down mechanismfor polio eradication projects, which aims to convert the terms of a normal IDA development credit togrant terms through provision of additional extemal donor resources under clearly defined performancecriteria. In the context of the Nigeria polio eradication project, the first operation utilizing thismechanism, resources for the buy-down will become available as a result of an agreement between IDAand GF. RI has indicated that it will finance the same mechanism for other polio eradication projects,through UNF. The buy-down mechanism complies with IDA's existing financial policies.

The Partnership

The World Bank's Health, Nutrition & Population sector Anchor explored the possibility ofpartnering with GF to assist polio eradication by providing countries with IDA financial resources butwithout IDA repayment obligations. GF agreed to provide funds to an IDA-administered trust fund, thePETF that will buy down the debt incurred by recipient countries for successful implementation of polioeradication projects. In addition to making commitment and service charge payments to IDA on behalfof the recipients during project implementation, the PETF will, upon successful project implementation,buy down the net present value of the principal amount of the development credit.

The Mechanism

IDA is extending a development credit to Nigeria. The Development Credit Agreement willinclude two special provisions:

1. The PETF will pay the applicable service charges and commitment charges, if any, and2. The PETF will buy down the principal amount of the credit upon successful completion of theproject, as determined by a WHO Performance Audit.

The buy-down will be funded by contributions to the PETF from GF. The buy-down mechanismoperates in three stages-credit signing, project implementation, and project completion. These stagesare described below.

At Credit Signing

IDA and PETF determine the discount rate (the prevailing SDR-basket Commercial InterestReference Rates (CIRR) on the date of credit signing) and the foreign exchange rate (SDR:USD) that willbe used to calculate the estimated net present value at final buy-down. The PETF sets aside funds thatare denominated in USD and invested pending disbursement. The set-aside amount equals IDAcommitment and service charge payments over the projected implementation period and the estimatedamount needed to buy down the principal of the credit at the end of the implementation period. IDAhedges the foreign exchange risk under its existing currency rebalancing mechanism.

During Project Implementation

Under the project, IDA, acting on a request from the recipient country, disburses funds to

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UNICEF, the agency responsible for procuring the polio vaccine. UNICEF in turn supplies the vaccinesto the recipient government.

The PETF pays the commitment and service charges on the disbursed amounts during theimplementation of the project.

If the implementation period is substantially longer than initially projected, funds required to payservice charges could exceed the funds set aside. However, the investmnent income on the set-asidebuy-down amount would provide a cushion against this risk. If the implementation period exceeds fiveyears, the responsibility for servicing the credit will revert to the recipient country unless the GF grantsan extension.

At Project Completion

Upon completion of the project, WHO conducts a Performance Audit to determine if the IDAfunds achieved their intended results. The performance audit measures the results for two indicators:

1. Timely arrival of OPV in the country at central level, and2. Vaccination coverage for OPV during the vaccination campaigns.

If the WHO performance audit evaluates the project as satisfactory, the IDA buy-down will betriggered. The PETF will then pay off the IDA credit at the net present value of the credit based on thedefined foreign exchange and discount rates to buy down the principal of this credit (RepaymentAmount). IDA will in turn cancel this credit and release the recipient from any future liability. If thecredit is not fully disbursed, the final Repayment Amount will be calculated on a pro-rata basis. If theWHO performance audit evaluates the project as unsatisfactory, the recipient will remain obligated topay back IDA on the terms of the credit.

The following figure describes the time line of events.

Figure 1: Timeline of Events under IDA Buy-down Mechanism.

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Timeline

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,c ) |:'Project C ompletion

Contracts-Establish NPV*

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4 t_/ [ PETFMakes fInterim Paymeni'ts,,|

CreditSigning Project Implementation Project Completion

*NPV-Net Present Value

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