The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Project Information Document (PID) Appraisal Stage | Date Prepared/Updated: 13-Jun-2019 | Report No: PIDA26738 Apr 11, 2019 Page 1 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Project Data Country Project ID Project Name Parent Project ID (if any) Africa P167817 Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) AFRICA 29-Apr-2019 16-Jul-2019 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Republic of Chad, Republic ECCAS Secretariat, of Angola, Central African Ministry of Health and Republic, Democratic Population, Ministry of Republic of Congo, ECCAS, Health, Ministry of Health Republic of Congo and Population, Ministry of Health, Ministry of Health Proposed Development Objective(s) The project development objectives are: (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the participating countries; and (ii) in the event of an eligible crisis or emergency, to provide immediate and effective response to said eligible crisis or emergency. Components Component 1: Strengthening surveillance and laboratory capacity to rapidly detect outbreaks Component 2: Strengthening emergency planning and management capacity to rapidly respond to outbreaks Component 3: Public health workforce development Component 4: Institutional capacity building, project management, coordination and advocacy OPS_TABLE_FCC The processing of this project is applying the policy requirements exceptions for situations of urgent need of assistance or capacity constraints that are outlined in OP 10.00, paragraph 12. Yes PROJECT FINANCING DATA (US$, Millions) SUMMARY -NewFin1 Total Project Cost 280.00 June 3, 2019 Page 2 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Total Financing 280.00 of which IBRD/IDA 280.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 60.00 International Development Association (IDA) 220.00 IDA Credit 90.00 IDA Grant 130.00 Environmental and Social Risk Classification Moderate Decision The review did authorize the team to appraise and negotiate Other Decision (as needed) B. Introduction and Context June 3, 2019 Page 3 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Regional and Country Context 1. The Ebola Virus Disease (EVD) epidemic in West Africa in 2014-2015, multiple outbreaks 2016-20191, and the ongoing EVD outbreak in North Kivu, Democratic Republic of Congo (DRC) highlight both the threat of epidemic prone diseases in the Africa region and the importance of strong disease surveillance and response systems and inter-country collaboration to minimize economic costs and the loss of human lives in an outbreak. The Regional Disease Surveillance Systems Enhancement Program (REDISSE) was designed to assist countries in West Africa to prevent, detect and respond to disease threats both individually and through regional collaboration and collective action. 2. The Program now covers 11 West African countries. The extension of the REDISSE program approach to the countries of Central Africa is both logical and urgent for the following reasons: (i) the countries of West and Central Africa are geographically proximate and epidemiologically similar, with hotspots for the emergence of epidemic prone diseases; (ii) health systems in both sub-regions have comparable weaknesses and will benefit from similar interventions; (iii) the trade and cultural connections among the countries of West and Central Africa increase the risk of cross border disease transmission; and, (iv) high and urgent demand from the Central African governments for financial support for disease surveillance and response and an interest in working across borders consistent with the REDISSE program approach. 3. The REDISSE Program is multi-sectoral and aims to strengthen national and regional capacity to address disease threats at the human, animal and environmental interface which is the source of most known epidemic-prone and novel pathogens. The countries in the Central African region are at very high-risk2 for infectious disease outbreaks, particularly those of animal origin (zoonotic diseases). Models have shown that countries in Central Africa, and especially DRC, contain geographic areas where animal populations maintain infection with the Ebola virus3. The drivers of the countries of Central Africa are at particularly high risk of disease outbreaks from known pathogens and a potential source of novel infections. Emerging and re-emerging infectious diseases4 in the sub-region can be partly attributed to land use, deforestation and encroachment on previously remote rainforest habitats where humans may be exposed to new pathogens and wildlife reservoirs of diseases such as EVD5. 4. The REDISSE program aims to address the gaps and weaknesses in disease surveillance, preparedness and response systems across all participating countries and support country-led efforts to increase the resilience of the animal and human health systems of countries in the sub-region to better prevent and control infectious disease outbreaks The REDISSE Program was designed as an interdependent Series of Projects (iSOP) to allow the program to expand as a function of both need and demand. At present there are 11 West African countries participating in three effective projects under the REDISSE program6. 5. The regional benefits and positive externalities of effective disease surveillance and response are substantial. Collective action and cross-border collaboration are essential elements of the REDISSE program which (i) supports countries’ efforts to harmonize policies and procedures; (ii) empowers countries to engage in joint planning, implementation and evaluation of program activities across borders at regional, national and district levels, and; (iii) promotes resource sharing of high-cost specialized assets such as reference laboratories and specialized training and research institutions. 6. The surveillance and response capacity of the regional systems depends on open collaboration and the combined strength of individual national systems from central to community-level. The REDISSE program proposes to strengthen the full “value-chain� of disease surveillance and response community through district, province/state, national and regional levels. June 3, 2019 Page 4 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) 7. The present project, REDISSE 4: Central Africa (R4-CA), is the next step in the geographic expansion of the REDISSE Program. It presents the challenge of applying the REDISSE model in a sub-region with some challenges specific to the sub-region: (i) a high proportion of countries classified as fragile, conflict or violence prone (FCV) with significant institutional and human capitol constraints; (ii) high risk of transmission of diseases from animals to humans (zoonoses) associated with rapid changes in land use and high mammal biodiversity in the world’s second largest rainforest; and (iii) the relative weakness of regional coordinating institutions vis a vis West Africa. 8. These challenges demand some experimentation and innovation in the application of the REDISSE model, however the core structure of the new project, including the technical components and results framework, remains the same. The preparation of R4-CA is based on the experience and lessons learned during the preparation and early implementation of the first three projects in the series. Details on lessons learned and reflected in the project design are given under section F of this document. 9. R4-CA will contribute to regional and global health security by assisting countries in Central Africa to (i) meet obligations under the International Health Regulations (IHR 2005) through implementation of the Integrated Disease Surveillance and Response strategy (IDSR); and, comply with the World Organization for Animal Health (OIE) international standards. The project is also in line with the Global Health Security Agenda (GHSA) objectives and is structured to contribute to four of the key action packages defined in the GHSA strategy: (i) surveillance and reporting; (ii) laboratory capacity; (iii) health workforce; and, (iv) epidemic preparedness and response. 10. R4-CA will involve five countries: R4-CA will support five countries in Central Africa (Angola, the Central African Republic (CAR), Chad, the Republic of Congo (RoC) and the Democratic Republic of Congo (DRC)) to establish and maintain a coordinated approach to detecting and swiftly responding to disease outbreaks and public health threats of regional and international consequence. These countries belong to the Economic Community of Central African States (ECCAS), a sub-region of Africa with a total population of more than 192 million people. Involvement of these countries in the project was based, above all, on the expressed interest of the national governments in participating in the project. Epidemiologic considerations and the needs and assets of the project countries were also considered. The REDISSE Program is equipped to expand to include other ECCAS member countries when demand and resources become available. 11. The proposed operation will play a critical role in protecting the human capital of participating countries. Human capital—the knowledge, skills, and health that people accumulate over their lives that enables them to realize their potential as productive members of society—is one of the first things to suffer when there is an outbreak of disease. The World Bank’s Human Capital Index measures the productivity of the next generation of workers relative to the 1There were significant outbreaks of Lassa fever, Rift Valley fever, Yellow fever, dengue hemorrhagic fever, Marburg virus disease (MVD), meningitis, monkeypox, cholera and plague in Africa between 2016 -2019. 2 Allen et al., 2017 “Global Hotspots and Correlates of Emerging Zoonotic Diseases.� 10.1038/s41467-017-00923-8 3 A new model created at Oxford University shows areas where the Ebola virus is most likely prevalent in animal populations. These areas may be at risk for outbreaks of Ebola due to animal-human transmission. Viewed October 11, 2018 - https://www.siitube.com/articles/ethiopia-at- risk-of-animal-to-human-transmission-of-ebola-oxford-study_745.html 4 Richardson et al., 2016 “Drivers for Emerging Issues in Animal and Plant Health.� 10.2903/j.efsa. 2016.s0512 5 Daszak P. 2000. Emerging Infectious Diseases of Wildlife - Threats to Biodiversity and Human ealth. Science 287:443–449. doi: 10.1126/science.287.5452.443. 6REDISSE 1 was approved in June 2016 and includes Guinea, Sierra Leone and Senegal; REDISSE 2 was approved in March 2017 and includes Guinea Bissau, Liberia, Nigeria and Togo; REDISSE 3 was approved in May 2018 and includes Benin, Mali, Mauritania and Niger. June 3, 2019 Page 5 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) benchmark of complete education and full health. The 2014 EVD outbreak in West Africa brought both the health and education system in Guinea, Liberia and Sierra Leone to a halt7 and there was a disproportionate loss of human lives among health care workers from which the countries have yet to recover. This project will play a critical role in protecting the human capital of these 5 project countries by enhancing health security and reducing the risk of future loss of lives and disruption of essential services such as education, social protection and health. 12. Of the five (5) project countries, three (3) are already part of the Human Capital Project (Angola, Chad, and RoC). R4-CA will help participating countries integrate national and cross-border health security actions into their national human capital plans. 13. The World Bank Group (WBG) is also investing in a new Regional Integration (RI) operation to strengthen disease surveillance and response on the African continent. This is being done through the African Center for Diseases Control (ACDC) Project. The ACDC project will complement and enhance other IDA-financed regional integration initiatives8, including the REDISSE Program. Whilst the REDISSE projects focus on strengthening the diseases surveillance and response systems at the sub-regional (ECCAS, ECOWAS), national and sub-national levels, the ACDC project focuses on strengthening of the institutional architecture and capacity of a new Africa-wide public health entity. 14. The Africa CDC has a continental scope and a three-tiered administrative structure. The first tier is the Africa CDC Secretariat, which is based at the African Union headquarters in Addis Ababa, Ethiopia. The second tier consists of five regional collaborating centers (RCCs) based in Egypt, Gabon, Kenya, Nigeria, and Zambia. The third tier comprises the National Public Health Institutes (NPHIs) and Centers of Excellence based in the African Union’s 55-member countries. ACDC will focus on the upper tiers of the architecture, strengthening HQ and RCCs to fulfill their mandate while building public health Assets for the region as a whole, while REDISSE will support the bottom tier, strengthening NPHI and promoting a culture of regional coordination. 7Schools were closed on average for 33 consecutive weeks. 8The ACDCP may also complement the East Africa Public Health Laboratories Network (EAPHLN), the Southern Africa Tuberculosis Health Systems Strengthening Project (SATBHSS) and the Regional Integrated Surveillance and Laboratory Networks (RISLNET) platform. June 3, 2019 Page 6 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) June 3, 2019 Page 7 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Sectoral and Institutional Context Human Health 15. Most of the countries in the ECCAS region are hotspots for epidemic-prone infectious diseases. In this region, emerging and re-emerging diseases at the interface of human-animal-ecosystems occur with increased frequency. These add to the ongoing burden of neglected and endemic human and animal diseases, including zoonoses. The Ebola virus disease (EVD), one of the deadliest viral diseases, was discovered in 1976 when there was an outbreak of fatal hemorrhagic fever in the present-day Democratic Republic of Congo (DRC)9. Recent Ebola virus outbreaks in DRC in May (EVD9) and August (EVD10) 2018 had the potential to become regional epidemics through cross-border transmission. 16. EVD9 was rapidly controlled by the DRC government with support from development partners, including the World Bank. EVD10 and the efforts to contain and end the epidemic began in August 2018 and are still ongoing. It is now ranked as the second deadliest EVD outbreak after the West Africa epidemic. The outbreak is occurring in an area where conflict and violence are hampering public health efforts to end it. This illustrates the complex operational environment and challenges in the region and underlines the urgent need for this project. The response activities underway to address the emergency need to be complemented and followed by purposeful investment in technical and human capacity for prevention and preparedness. 17. Of 1,307 epidemic events in 72 countries between 2011 and 2017 for which data was available, 105 (8 percent) were within the eleven ECCAS countries. R4-CA countries accounted for 65.7 percent of the events in the ECCAS sub- region. 18. Over the past three and half decades, at least 30 new infectious pathogens have emerged worldwide.10,11;12 More than 70 percent of emerging infectious diseases that affect humans have their origins in wildlife. Infectious disease outbreaks can have a devastating impact on the social and economic situation of countries, particularly in FCV settings. The pandemic of H1N1; epidemics of SARS, H5N1 and Middle East Respiratory Syndrome Coronavirus (MERS-CoV); and recent outbreaks of EVD are reminders of persistent risk of infectious, zoonotic diseases and the economic losses they cause13. The World Bank estimates that the cost of the 2014-2015 EVD outbreak in West Africa was US$2.8 billion14. However, a recent study estimated the comprehensive economic and social burden from the 2014 EVD outbreak in West Africa to be US$53.19 billion (in 2014 US dollars)15. This includes US$18.8 billion estimated to be the cost of the deaths from non-Ebola causes. Additionally, a recent analysis by the World Bank shows that a severe pandemic such as the 1918 Spanish Flu could cost approximately US$3 trillion globally16, an estimate comparable to the impact of the 2008 global financial crisis. 19. In June 2007, the World Health Organization (WHO) via the International Health Regulation (IHR 2005) mandated governments to develop, strengthen and maintain the core capacities of national public health systems to detect, assess, notify, and respond promptly and effectively to health risks and public health emergencies of international concern (PHEICs)17. In the WHO Africa Region (WHO/AFRO), the Integrated Disease Surveillance and Response (IDSR) strategy serves as a framework to fulfil this mandate. However, to date, IDSR has not been fully implemented in most countries in the region18 and health systems remain limited for systematic collection, analysis, confirmation, and interpretation of disease surveillance data, in addition to insufficient capacity for preparedness and rapid response. 20. Country capacity to implement IHR 2005 is measured and monitored by the WHO using the Joint External Evaluation (JEE) Tool. The JEE is a data gathering instrument designed to evaluate a country’s capacities for health June 3, 2019 Page 8 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) security, including all IHR and GHSA-relevant capacities across all relevant sectors at a national level. The tool has 19 technical areas arranged according to the IHR and GHSA mandates to prevent, detect and respond to disease threats. JEEs have been conducted in four of the five project countries in the ECCAS region19 (CAR, Chad, DRC and ROC). The assessments revealed some common and key weaknesses in health systems for infectious disease surveillance, epidemic preparedness and response, including:  Limited availability of laboratory infrastructure for timely and quality diagnosis of epidemic-prone diseases;  Lack of interoperability of different information systems that hampers analysis and use of information for decision making and disease mitigation measures;  Inadequate infection prevention and control standards, infrastructure and practices;  Weak and inefficient management of the supply chain system;  Significant gaps in regional level surge capacity for outbreak response, stockpiling of essential goods, information sharing and collaboration;  Lack at each level of the health pyramid of a fit-for-purpose health workforce for disease surveillance, preparedness and response;  Community level surveillance and response structures either do not exist or need significant improvement; and  Lack of capacity for self-assessment. Animal Health 21. Within the animal sector, there is a high incidence and prevalence of infectious communicable diseases, both zoonotic and non-zoonotic. This situation impacts animal and human health, food safety, trade, and economic and rural development. Improvement of animal health requires increased and sustained investments in national veterinary services to meet international standards of quality defined by the World Organization for Animal Health (OIE) Code. 9 World Health Organization. Ebola haemorrhagic fever in Zaire, 1976. Report of an International Commission. Bulletin of the World Health Organization. 1978;56(2):271-293 10 . Nicholas Israel Nii-Trebi, 2017. Emerging and Neglected Infectious Diseases: Insights, Advances, and Challenges. Biomed Res Int. 2017; doi: 10.1155/2017/5245021 [Last accessed on 2018 July 09] (Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5327784/) 11 .Shuvankar Mukherjee. 2017. Emerging Infectious Diseases: Epidemiological Perspective. Indian J Dermatol. 2017 Sep-Oct; 62(5): 459–467. doi: 10.4103/ijd.IJD_379_17 [Last accessed on 2018 July 09] (Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5618832/) 12Jonathan Runstadler, 2018. Influenza’s wild origins in the animals around us. [Internet]. Available from: https://theconversation.com/influenzas-wild-origins-in-the-animals-around-us-91058. 13 World Bank, 2012 – People Pathogens and our Planet. Volume 2 – economic analysis 14 2014-2015 West Africa Ebola Crisis: Impact Update. Accessed October 30, 2018. http://www.worldbank.org/en/topic/macroeconomics/publication/2014-2015-west-africa-ebola-crisis-impact-update 15 Caroline Huber, Lyn Finelli, Warren Stevens; The Economic and Social Burden of the 2014 Ebola Outbreak in West Africa, The Journal of Infectious Diseases, , jiy213, https://doi.org/10.1093/infdis/jiy213. Accessed October 30, 2018. https://academic.oup.com/jid/advance- article/doi/10.1093/infdis/jiy213/5129071?rss=1 16 Burns et al. (2008) Evaluating the economic consequences of avian influenza (http://siteresources.worldbank.org/EXTAVIANFLU/Resources/EvaluatingAHIeconomics_2008.pdf). 17 International Health Regulation (IHR 2005) is a legally binding document set forth by the WHO that mandates country governments to develop, strengthen and maintain the core capacities of national public health systems to detect, assess, notify, and respond promptly and effectively to health risks and public health emergencies of international concern (PHEICs) World Health Organization (2008) 18 Report to the Director-General of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation. World Health Organization (2014) 19 Angola has planned to carry out its JEE later in 2019 June 3, 2019 Page 9 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Insufficient government funding and limited interest from donors to support veterinary services have not allowed significant progress to date in addressing systemic issues. 22. Movement of live animals is a major risk factor for the spread of livestock diseases and zoonotic infections. The frequent cross-border animal movement and livestock trade between countries in the region further increase the risk of the occurrence and spread of disease. Disease outbreaks in animals may threaten human health directly through infection or indirectly through loss of livelihood, increased poverty and food insecurity. In most of the countries in the sub-region, animal disease surveillance and animal health care delivery systems are inadequate, and there is no regional strategy for prevention and control of significant animal diseases20 such as the outbreak of highly pathogenic avian influenza A (H5N8) in DRC between October 2016 and July 2018. 23. The OIE Performance of Veterinary Services (PVS) Pathway is a global program for sustainable improvement of a country's veterinary services and the OIE PVS Pathway evaluation tool is, more or less, the animal health equivalent to the JEE tool. OIE has evaluated the performance of veterinary services in only two of the five R4-CA countries (Angola and CAR) since 2010. Although these countries have epidemiological surveillance systems for animal health in place, their use is hampered by a shortage of human resources, a weak information system and a lack of financial resources for implementation. 24. Regional leadership for animal health and veterinary services has historically been weak in the Central Africa sub-region. To help address this, during the fifteenth ordinary session of the ECCAS Conference of Heads of State and Governments held in N'Djamena on May 25, 2015, it was agreed that Chad would host a specialized technical center for animal health for Central Africa. The Regional Animal Health Center for Central Africa (Centre regional de santé animale pour l’Afrique centrale, CRSA-AC) became operational in N’Djamena on January 24, 2019. The Center will contribute to the improvement of border movements of animals, the circulation of veterinary medicines and animal products in the sub-region and reduce the risks of the emergence of trans-boundary animal diseases (TADs) and zoonoses. The Center will be supported by governments in the Sub-region and partners, including the OIE. R4-CA will assist the Center to develop the “One Health� (OH) agenda in the sub-region and develop the Integrated Regional Coordination Mechanisms (IRCM) for the control of trans-boundary animal diseases. Anti-Microbial Resistance (AMR) 25. There is increasing concern over the threat to human and animal health from antimicrobial resistance (AMR).21 Sub-Saharan African countries, including the REDISSE countries, not only lack systems to collect and analyze data on AMR, but also lack the resources and capacity22 to prevent and adequately treat infectious diseases. Furthermore, weak laboratory infrastructure and lack of trained laboratory and clinical personnel are factors that impact negatively on 20 Awa, D. N; Achukwi M. D. 2009. Review of livestock pathology in the central African region: epidemiological considerations and control strategies. In : L. SEINY-BOUKAR, P. BOUMARD (éditeurs scientifiques), 2010. Actes du colloque « Savanes africaines en développement : innover pour durer », 20-23 avril 2009, Garoua, Cameroun. Prasac, N'Djaména, Tchad ; Cirad, Montpellier, France, cédérom. [Available from: https://www.researchgate.net/publication/43076207_Review_of_livestock_pathology_in_the_central_African_region_epidemiological_consid erations_and_control_strategies] 21 Adeyi, Olusoji O. ; Baris, Enis; Jonas, Olga B.; Irwin, Alec; Berthe, Franck Cesar Jean; Le Gall, Francois G.; Marquez, Patricio V.; Nikolic, Irina Aleksandra; Plante, Caroline Aurelie; Schneidman, Miriam; Shriber, Donald Edward; Thiebaud, Alessia. 2017. final report. Washington, D.C.: World Bank Group, http://documents.worldbank.org/curated/en/323311493396993758/final-report. 22Dar OA, Hasan R, Schlundt J, Harbarth S, Caleo G, Littmann J et al. Exploring the evidence base for national and regional policy interventions to combat resistance. Lancet. 2016; 387:285–95 June 3, 2019 Page 10 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) surveillance in lower-middle income countries (LMICs). These countries are highly vulnerable23 to AMR, not only because of the high level of drug resistance to commonly prescribed antibiotics on the African continent24, but also because of the high prevalence of counterfeit and substandard antimicrobials and diagnostics which result in inadequate treatment and contribute to the further development of AMR. 26. Since countries that fail to prevent, detect, inform, react or control sanitary issues such as infectious diseases or AMR place other countries at risk, it is essential to take a regional approach to address these challenges. Within the Central African region, the extent of the AMR problem is not well known because surveillance of drug resistance is not carried out in most countries. AMR disproportionately affects the health and wellbeing of people in LMICs and threatens to undermine several of the public health and development gains made in the 20th Century such as available treatment of TB, Malaria and HIV and AIDs. One Health (OH) approach 27. The OH approach recognizes the connectedness of human, animal and environmental health and the need to address challenges in a collaborative, multi-sectoral and trans-disciplinary approach. Within the ECCAS region, there is a lack of multi-sectoral coordination to support implementation of such an approach. According to JEEs carried out in Chad and the CAR in August 2017 and January 2019 respectively, it was found that a lack of standard operating procedures hampers the functioning of the national One Health focal point in Chad (the national focal point for CAR had not yet been officially nominated) and limits implementation of the IHR 2005 and, by implication, the PVS Pathway. 28. The situation in other countries of the region is not very different. It is important, therefore, to strengthen the PVS Pathway and epidemiological surveillance network for animal health, to improve analytical capacity and exchange of information. The establishment of standard operating procedures clarifying the coordination mechanisms between sectors should improve the reporting procedures to WHO and OIE. 29. Given the trans-boundary nature of infectious diseases and the fact that a significant number of these pathogens can be transmitted between animals and humans (more than 70 percent of 1,450 known infectious diseases in humans are of animal origin), there is a critical need for coordination and exchange of knowledge and information between sectors involved with animal and human health at both national and regional levels. The response to the highly pathogenic avian influenza virus H5N1 crisis since 2005 contributed to enhancing cooperation between the human and veterinary health sectors in many countries in the region and lessons learned from successful regional programs for the control of selected priority diseases have demonstrated the efficiency of such coordination. Despite such evidence, in the absence of an ongoing high-profile crisis, routine collaboration has failed to take hold and there is still a need for a dedicated program incentivizing such a joint approach to break down the silos that hamper effective coordination. 30. The project will promote the OH approach to combat epidemics and major endemic diseases., OH is a collaborative approach that recognizes the linkages between human, animal and environmental health and the fact that stressors in any one of these domains impacts the others and increases the likelihood of deadly outbreaks. One Health focuses on training veterinarians, nurses and hospital workers on infection control measures, investing in health and 23Leopold SJ, van Leth F, Tarekegn H, Schultsz C. Antimicrobial drug resistance among clinically relevant bacterial isolates in sub-Saharan Africa: a systematic review. J Antimicrob Chemother. 2014;69(9):2337–53. 24 Tadesse BT, Ashley EA, Ongarello S, et al. Antimicrobial resistance in Africa: A systematic review. BMC Infect Dis. 2017; 17:616.https://doi.org/10.1186/s12879- 017-2713-1, (Accessed 2nd March 2019 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594539/) June 3, 2019 Page 11 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) animal information and surveillance systems, stimulating cross-border emergency preparedness exercises, equipping laboratories and supporting development of multi-sectorial standard operation procedures to combat zoonotic disease outbreaks. C. Relevance to Higher Level Objectives 31. The project is aligned with the World Bank Group Strategy for Africa (Resilience to shocks and climate change impacts), and the Africa Regional Integration and Cooperation Assistance Strategy for the period FY18-FY2325. More specifically, alignment is with Africa’s Regional Integration (RI) strategic priority 4, to “promote collective action to address risks of regional economic contagion, fragility, epidemic, and climate “hot spots��. This strategic priority rests on three arguments: (i) some of Africa’s development challenges and potential risks do not stop at national borders and require collective effort on the part of multiple countries; (ii) ensuring effective collective action requires clear understanding of the advantages and disadvantages of addressing these risks, including possible asymmetry of benefits for the parties involved and ensuring strong regional platforms that bring together key stakeholders; and (iii) over time, it will be important to make such collective actions /efforts more sustainable from a financing and institutional point of view and less reliant on development financing. 32. This project is aligned with the Pillar 2 of the Africa Strategy on Human Capital and the broader corporate engagement through the Human Capital Project launched by the Bank. This project will assist the governments to tackle some of the worst diseases which are both barriers and threats to human capital development, thereby increasing life expectancy and survival rates of adults. This strategic priority responds to sub-regional, regional or global risks that could impact the continent and compromise the development gains made so far. 33. The project is in line with the World Bank Group (WBG) mission to end extreme poverty and boost shared prosperity. R4-CA is also aligned with the Country Partnership Framework (CPF) of Chad. The CPFs of the other four project countries are presently being elaborated. 34. The R4-CA project is well aligned with the Africa Center for Disease Control (ACDC) project, which is supported by the Africa Center for Disease Control, a specialized technical institution of the African Union charged with the responsibility to promote the prevention and control of diseases in Africa. Its mission is to strengthen Africa’s public health institutions’ capacities, capabilities and partnerships to detect and respond quickly and effectively to disease threats and outbreaks based on science, policy, and data-driven interventions and programs. I. PROJECT DESCRIPTION C. Proposed Development Objective(s) Development Objective(s) (From PAD) The project development objectives are: (i) to strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in the participating countries; and (ii) to provide, in the event of an eligible crisis or emergency, immediate and effective response to said eligible crisis or emergency. 25Supporting Africa’s Transformation: Regional Integration and Cooperation Assistance Strategy for the Period FY18-FY23 dated December 15, 2017 (page 37) June 3, 2019 Page 12 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Key Results The following key indicators will be used to track progress towards the PDOs: a. Laboratory testing capacity for detection of priority diseases: (number of countries that achieve a Joint External Evaluation (JEE) score of 3 or higher out of 5); b. Progress in establishing indicator and event-based surveillance systems: (number of countries that achieve a JEE score of 3 or higher out of 5); c. Availability of human resources to implement IHR core capacity requirements: (number of countries that achieve a JEE score of 3 or higher out of 5). d. National multisectoral Multi-hazard emergency preparedness measures including emergency response plans are developed, implemented, and tested (national capacity scores) (No of countries that achieve a JEE score of 4 or higher) e. Progress on cross-border collaboration and exchange of information across countries (Number of countries that achieve a score of 4 or higher) f. Coordinated Surveillance Systems in place in animal and human health sectors for zoonotic diseases/pathogens identified as joint priorities: (number of countries that achieve a JEE score of 3 or higher). D. Project Description 35. The project will contribute to: (i) ensure more efficient collaboration and synergies between human and animal epidemiological surveillance and response networks at country and regional levels via the One Health platform; (ii) facilitate country and regional compliance with international standards for veterinary services, with a particular focus on early detection and rapid response capacity, as adopted by the OIE members states in the Terrestrial Animal Health Code, and use the findings and recommendations from the OIE PVS Evaluation Tool; (iii) develop national and regional capacity to fully implement IHR 2005 through the IDSR strategy, which calls for the continuous monitoring of mortality and morbidity, to identify and respond to threats before they can develop into large scale or trans-boundary epidemics. 36. Project Financing: The project financing in the amount of US$280 million is considered the fourth Investment Project Financing of the iSOP approach of the REDISSE Program. The REDISSE Program will eventually engage and support all 11 ECCAS member states26 in an effective and sustainable regional surveillance network in Central Africa. Project financing will be mobilized via contributions from individual country allocation of IDA and IBRD funds and a regional integration matching fund mechanism. . 26 This will depend on what other partners are already doing in Angola, Chad, Central African Republic, and the Democratic Republic of Congo. June 3, 2019 Page 13 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) . Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Assessment of Environmental and Social Risks and Impacts The project is likely to result in a range of impacts associated with the civil works and transport. This will include environmental impacts associated with any rehabilitation activities such as air and noise emissions, impacts on water quality and disposal and management of waste (including chemicals and medical waste). Impacts to biodiversity and living natural resources are not anticipated. Impacts to people are also anticipated again associated with civil works including to community health and safety as a result of traffic movements and the presence of workers (GBV, SEA and disease transmission). In addition, the working conditions of those employed to undertake rehabilitation activities will need to be managed in order to protect the workforce and meet GIIP in relation to occupational health and safety. Land acquisition is not anticipated as all civil works are planned to be on existing government land, but if the project has land acquisition leading to economic and/or physical displacement, a RPF or RAP will be prepared, consulted upon, cleared by the Bank and disclosed. All 5 countries are home to IP/SSAHUTLC who will need to be considered during project implementation in particular in relation to public health campaigns. Stakeholder Engagement will need to be undertaken both at the national level in relation to the overall program and the local level in relation to civil works and to ensure that public health campaigns are appropriately designed and implemented. Note: To view the Environmental and Social Risks and Impacts, please refer to the Appraisal Stage ESRS Document. . June 3, 2019 Page 14 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) E. Implementation Institutional and Implementation Arrangements 37. The R4-CA Project will be implemented at both regional and national levels with steering committees at each level. At the regional level, REDISSE considered other alternative Regional PIUs including (i) using the Organization for Coordination of the fight against Endemics in Central Africa (OCEAC) which was created in 1963 and serves as a specialized institution of the Central African Economic and Monetary Community (CEMAC), which does not cover all the ECCAS countries; (ii) the West African Health Organization (WAHO) but dropped since WAHO does not have the legal standing to directly intervene in Central Africa; (iii) the Africa CDC project (ACDC), but dropped based on: a) its limited health expertise, and b) the RCC-Gabon is yet to be functional. REDISSE 4 was left with the General Secretariat of ECCAS. R4-CA will therefore be implemented by the General Secretariat of ECCAS whose objective is supporting the facilitation of the Member States’ policies and programs to best contribute to the overall objectives of ECCAS – achieving regional integration and poverty alleviation through harmonious cooperation. 38. While existing REDISSE projects are managed by the West African Health Organization (WAHO), there is no equivalent institution in Central Africa. R4-CA will be managed by the health division within the ECCAS Secretariat. The project coordination unit in the health division will be guided by the decisions of the REDISSE Regional Steering Committee27 (RSC) comprised of representatives from the concerned ministries of the participating countries, under the political leadership of ECCAS. In the most recent past, the ECCAS Secretariat has received funding from the Bank’s Trust funds to manage some Bank funded projects. These projects include (i) an agriculture project (P121913) with a grant of US$3,900,000 from 2011-2016 and (ii) a disaster risk management (DRM) project (P166648) with a grant of US$1,265,000 until 2020, when the project ends. 39. At the national level in all the countries, the project will be implemented through the same project implementation units (PIU) in the ministries of health as for ongoing projects in the health sector, supported by the ECCAS General Secretariat. The PIU will be adapted to work across sectors to improve efficiency and alignment in the implementation of project interventions. The project complements but does not duplicate ongoing and new portfolio projects in all five participating countries. Given the multi-sectoral nature of the proposed activities, PIUs will be further strengthened when necessary, enabling resource sharing and more effective, efficient and timely management of implementation of all the projects in the sector. A national steering committee supported by a technical committee will be put in place to oversee yearly planning and monitoring of the project. The technical committee will be made up of representatives of the concerned departments from the Ministries that are involved in the project. The PIUs will coordinate implementation of the various project components by the sectoral ministries and NGOs and will be responsible for monitoring the use of funds by other implementing ministries and partners. . CONTACT POINT World Bank Enias Baganizi 27 Members of the RSC will include representatives of the ministries from the five countries involved in the project and will meet twice a year. June 3, 2019 Page 15 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Senior Health Specialist Andy Chi Tembon Senior Health Specialist Borrower/Client/Recipient Republic of Chad Dr Issa Doubragne Ministry of Economy and Development Planning contact@mepd.gouv.td Republic of Angola Ciel da Conceicao de Aguiar Cristovao Director General cielcristovao@minfin.gov.ao Central African Republic H.E. Félix Moloua Minister of Economy, Planning and Cooperation moloua57@gmail.com Democratic Republic of Congo Honore Tshiyoyo Project Coordinator minister.finance@gouv.cd ECCAS Son Excellence Ahmad Allam-Mi Secretary General secretariat@ceeac-eccas.org Republic of Congo S.E.M. Ingrid Olga Ghislaine EBOUKA-BABACKAS Minister of Planning, Statistics and Regional Integration Min.gov@yahoo.fr Implementing Agencies ECCAS Secretariat Andres Edu Mba Mokuy Deputy Secretary General clmokuy@yahoo.fr June 3, 2019 Page 16 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Dr Peggy CONJUGO Chef de Service Sante pegconj@gmail.com Ministry of Health and Population Emeriand Kibangou DEP emriand.kibangou@gmail.com S.E.M. Jacqueline Lydia Mikolo Minister of Health and Population Jl@govt.org Ministry of Health Dr Garba Tchang Salomon Coordonnateur Ddu PRSSMI/FBP garbasalomon@gmail.com Ministry of Health and Population S.E.M. Pierre SOME Minister of Health and Population psomep@gmail.com Dandy Marius Directeur de Cabinet dandymarius@gmail.com Adolphe Kossi-mazouka Coordonnateur Adjoint kosmazad@yahoo.fr Leon Koyadondri Coordonateur Adjoint kdonrileon@gmail.com Ministry of Health Dr Oly Ilunga Minister of Health ministre@sante.gouv.cd June 3, 2019 Page 17 of 18 The World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) Phase IV (P167817) Ministry of Health Antonio Zacarias Costa Director of Cabinet ngaveia felix@gmail.com FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Enias Baganizi Task Team Leader(s): Andy Chi Tembon Approved By Environmental and Social Standards Advisor: Practice Manager/Manager: Country Director: Vijay Pillai 13-Jun-2019 June 3, 2019 Page 18 of 18