Projet de réponse d'urgence au choléra

Document of The World Bank Report No: 89201-HT IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H639-0-HT) ON A GRANT IN THE AMOUNT OF SDR 9.9 MILLION (US$15 MILLION EQUIVALENT) TO THE REPUBLIC OF HAITI FOR A CHOLERA EMERGENCY RESPONSE PROJECT September 17, 2014 Health, Nutrition and Population Global Practice Haiti Country Management Unit Latin America and the Caribbean Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized CURRENCY EQUIVALENTS (Exchange Rate Effective: September 17, 2014) Currency Unit = Haitian Gourdes $1.00 = US$0.02 US$1.00 = $44.45 FISCAL YEAR October 1 – September 30 ABBREVIATIONS AND ACRONYMS CBR Cost-Benefit Ratio CDC Center for Disease Control CFR Case Fatality Rate CRD Center of Research and Development ( Centre de Recherche et de Développement ) DALY Disability-Adjusted Life Years Lost DELR Direction of Epidemiology, Laboratory and Research ( Direction d’Epidémiologie, de Laboratoire et de Recherc he ) DINEPA National Direction of Water and Sanitation ( Direction National de l’Eau et de l’ Assainissement ) FAES Economic and Social Assistance Funds ( Fond s d’Assistance Economique et Sociale ) FY Fiscal Year GDP Gross Domestic Product GOH Government of Haiti ICR Implementation Completion and Results Report IDA International Development Association IDB Inter-American Development Bank IFR Interim Financial Report ISR Implementation Status and Results Report LNSP National Laboratory of Public Health ( Laboratoire National de Santé Publique ) M&E Monitoring and Evaluation MSPP Ministry of Public Health and Population ( Ministère de la Santé Publique et de la Population ) NGOs Non-Governmental Organizations ORS Oral Rehydration Salt PAHO Pan-American Health Organization PDO Project Development Objectives PRUC Cholera Emergency Response Project ( Project de Réponse D’Urgence Au Choléra ) TEPAC Technicians on water and sanitation UNICEF United Nations Children's Fund UPMC U niversity of Pittsburgh Medical Center WHO World Health Organization Vice President: Jorge Familiar Special Envoy for Haiti: Mary Barton-Dock Practice Manager: Enis Bar ış Project Team Leader: Eleonora Cavagnero ICR Team Leader: Claudia Macías ICR Primary Author: Claudia Macías and Voahirana Rajoela ii HAITI Cholera Emergency Response Project CONTENTS Data Sheet A. Basic Information.......................................................................................................... iv B. Key Dates ...................................................................................................................... iv C. Ratings Summary .......................................................................................................... iv D. Sector and Theme Codes................................................................................................ v E. Bank Staff ....................................................................................................................... v F. Results Framework Analysis .......................................................................................... v G. Ratings of Project Performance in ISRs ....................................................................... ix H. Restructuring ................................................................................................................. ix I. Disbursement Profile ..................................................................................................... ix 1. Project Context, Development Objectives and Design ............................................ 1 2. Key Factors Affecting Implementation and Outcomes ........................................... 4 3. Assessment of Outcomes ....................................................................................... 12 4. Assessment of Risk to Development Outcome ...................................................... 17 5. Assessment of Bank and Borrower Performance .................................................. 18 6. Lessons Learned..................................................................................................... 20 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners........ 21 Annex 1. Project Costs and Financing .............................................................................. 22 Annex 2. Outputs by Component...................................................................................... 23 Annex 3. Economic and Financial Analysis ..................................................................... 25 Annex 4. Bank Lending and Implementation Support/Supervision Processes................. 32 Annex 5. Beneficiary Survey Results ............................................................................... 34 Annex 6. Stakeholder Workshop Report and Results....................................................... 35 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ......................... 36 Comments from Recipient ................................................................................................ 45 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ........................... 48 Annex 9. List of Supporting Documents .......................................................................... 49 Annex 10. Project contribution to the reduction of cholera incidence and mortality ....... 51 Annex 11. MAP IBRD 33471R ....................................................................................... 53 iii Data Sheet A. Basic Information Country: Haiti Project Name: Cholera Emergency Response Project Project ID: P120110 L/C/TF Number(s): IDA-H6390 ICR Date: 09/04/2014 ICR Type: Core ICR Lending Instrument: ERL Recipient: HAITI Original Total Commitment: XDR 9.90M Disbursed Amount: XDR 9.23M Revised Amount: XDR 9.90M Environmental Category: B Implementing Agenc y : Economic and Social Assistance Funds ( Fond s d’Assistance Economique et Sociale -- FAES) Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 11/19/2010 Effectiveness: 04/20/2011 02/07/2011 Appraisal: 12/03/2010 Restructuring(s): 06/04/2013 12/27/2013 Approval: 01/18/2011 Mid-term Review: Closing: 06/30/2013 12/31/2013 03/30/2014 C. Ratings Summary C.1 Performance Rating by I mplementation Completion and Results Report (ICR) Outcomes: Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Moderately Satisfactory Overall Bank Performance: Moderately Satisfactory Overall Borrower Performance: Moderately Satisfactory iv C.3 Quality at Entry and Implementation Performance Indicators Implementation Performance Indicators QAG Assessments (if any) Rating Potential Problem Project at any time (Yes/No): Yes Quality at Entry (QEA): None Problem Project at any time (Yes/No): No Quality of Supervision (QSA): None DO rating before Closing/Inactive status: Moderately Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health 73 73 Public administration- Health 27 27 Theme Code (as % of total Bank financing) Health system performance 13 13 Other communicable diseases 87 87 E. Bank Staff Positions At ICR At Approval Vice President: Jorge Familiar Pamela Cox Country Director: Mary Barton-Dock Alexandre V. Abrantes Practice Manager: Enis Bar ı ş Joana Godinho Project Team Leader: Eleonora Del Valle Cavagnero Maryanne Sharp ICR Team Leader: Claudia Macias ICR Primary Author: Voahirana H. Rajoela F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective of the Project is to improve the health and hygiene practices in order to reduce the spread of cholera and strengthen the Recipient’s institutional capacity to respond to outbreaks. Revised Project Development Objectives (PDO) (as approved by original approving authority) The PDO remained unchanged during the Project life. v (a) PDO Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : Percentage of population in Project intervention areas who know A) the cholera early warning symptoms and B) prevention steps. Value (quantitative or qualitative) Rapid Survey to be done TBD by Department A): 69 B): 18 A): 82 B): 14 Date achieved 22-Dec-2010 30-June- 2013 30-June-2013 30-June-2013 Comments (incl. % achievement) Partially achieved. Baseline data was available for four Departments in Sept. 2011 and for three Departments in Aug. 2012. Final baseline, defined as Department average, was available in June 2013 - A) 64, B) 13. See section 2.3 for explanation. Indicator 2 : Percentage of population in Project intervention areas with access to improved water sources. Value quantitative or Qualitative) Rapid Survey to be done TBD by Department 78 79 Date achieved 22-Dec-2010 30-June-2013 30-June-2013 30-June-2013 Comments (incl. % achievement) Achieved. Baseline data was available for four Departments in Sept. 2011 and for three Departments in Aug. 2012. Final baseline, defined as Department average, was available in June 2013. See section 2.3 for explanation. Indicator 3 : Increased institutional capacity as measured by achievement of at least four out of five of Component 2 indicators on an annual basis. Value quantitative or Qualitative) N/A Four out of five Component 2 indicators achieved Four out of five Component 2 indicators achieved Date achieved 22-Dec-2010 30-June-2013 30-June-2013 Comments (incl. % achievement) Achieved. Source of data: Project Reports. See section 3.2 for further details. vi (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : Number of communities that have received targeted health education and/or prevention activities. Value quantitative or Qualitative) 0 2,214 4,447 Date achieved 22- Dec- 2010 30-June-2013 30-June-2013 Comments (incl. % achievement) Surpassed. "Localities" were used instead of communities, given the Haitian context. Source of data: Project Reports. Indicator 2 : Number of health centers and posts, treatment and chlorination centers and units, and oral rehydration posts supported with supplies. Value (quantitative or qualitative) 0 223 256 Date achieved 22- Dec- 2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Surpassed. Source of data: Project Reports. Indicator 3 : Number of people receiving water treatment products and soap. Value quantitative or Qualitative) 0 178,400 856,688 Date achieved 22- Dec- 2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Surpassed. Source of data: Project Reports. Indicator 4 : Number of personnel and community workers trained. Value quantitative or Qualitative) 0 2,633 5,571 Date achieved 22- Dec-2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Surpassed. Source of data: Project Reports. vii Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 5 : Departmental Cholera Management Plan developed (by MSPP and DINEPA) for at least five departments. Value quantitative or Qualitative) N/A 5 6 Date achieved 22-Dec-2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Surpassed. Source of data: Project Reports. Indicator 6 : Establishment and functioning of one national and five regional Cholera and Emergency Response Units. Value quantitative or Qualitative) N/A 6 7 Date achieved 22-Dec-2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Surpassed. This indicator reflects the number of coordinators recruited; one national cholera focal point and 6 departmental cholera coordinators. Source of data: Project Reports. Indicator 7 : Quarterly project progress reports submitted to the Cholera Coordination Committee and to the Bank. Value quantitative or Qualitative) N/A Reports submitted Reports submitted Date achieved 22-Dec-2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Achieved. Quarterly service providers (NGOs, MSPP and DINEPA) progress reports were considered as Project progress reports. At least, 10 quarterly Project progress reports should have been submitted during the Project implementation period. Indicator 8 : Good quality quarterly Interim Financial Report ( IFRs ) are submitted to the Bank in a timely manner. Value quantitative or Qualitative) N/A IFR submitted IFR submitted Date achieved 22-Dec-2010 30-June- 2013 30-June-2013 Comments (incl. % achievement) Not achieved. From Effectiveness to Project closing date, 10 IFRs should have been submitted. At the end of the Project, 8 IFRs were submitted. viii G. Ratings of Project Performance in ISRs No. Date ISR Archived Development Objective (DO) Implementation Progress (IP) Actual Disbursements (USD millions) 1 02/23/2011 Satisfactory Satisfactory 0.00 2 08/09/2011 Satisfactory Satisfactory 3.00 3 03/28/2012 Moderately Satisfactory Moderately Satisfactory 6.63 4 11/09/2012 Moderately Satisfactory Moderately Satisfactory 9.91 5 05/29/2013 Moderately Satisfactory Moderately Satisfactory 13.10 6 12/27/2013 Moderately Satisfactory Moderately Satisfactory 14.27 H. Restructuring Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring Amount Disbursed at Restructuring in USD millions Reason for Restructuring & Key Changes Made DO IP 06/04/2013 MS MS 13.10 Six-month extension of closing date to allow implementation of remaining activities. 12/27/2013 MS MS 14.27 Three-month extension of closing date to allow finalization of remaining activities. I. Disbursement Profile ix 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. At the time of appraisal Haiti remained the poorest country in the Latin America and the Caribbean region and one of the poorest in the world , with a GDP per capita of US$673. Half of its 10 million population lived in absolute poverty (less than US$1 per day); and four-fifths lived on less than US$2 per day. Multidimensional poverty was far-reaching as evidenced by poor social indicators such as literacy, life expectancy, infant and maternal mortality. Haiti ranked 148 out of 179 in the United Nations Human Development Index in 2008. 1 2. Haiti was strongly impacted by the January 12, 2010 earthquake that struck its capital and nearby towns. The earthquake was the largest urban disaster in recorded history. It killed over 220,000 people, injured another 300,000, and displaced approximately 1.5 million, and is estimated to have wiped out a decade in poverty gains. Housing, infrastructure, public buildings, and businesses sustained enormous damage. The March 2010 Post-Disaster Needs Assessment evaluated damages and losses at US$7.9 billion or 120 percent of GDP, and reconstruction needs at US$11.3 billion. On November 5, 2010, hurricane Thomas hit Haiti causing heavy flooding, landslides, infrastructure destruction and the loss of crops in west of the city, which worsened the already precarious living conditions. 3. Ten months after the devastating earthquake, a severe outbreak of cholera was confirmed in Haiti. Between October and December 2010, 2,481 deaths and 60,644 hospitalizations from cholera were confirmed nationwide . It was the first time cholera - a diarrheal disease associated with the consumption of food and water contaminated by feces infected with the bacterium vibrio cholerae - had been identified in the country in at least 100 years. 2 Within a month of the initial report, cholera had spread to all regions of Haiti and the Dominican Republic, with which Haiti shares the island of Hispaniola. The in-hospital case fatality rate 3 in Haiti was estimated at 3.2 percent and the cholera specific mortality rate at 14.16 per 100,000 inhabitants. All ten of Haiti’s departments had confirmed cases of cholera. Living conditions, particularly those in the camps and in slum communities, made the country extremely vulnerable to the spread of cholera: (i) more than 30 percent of the population lacked access to potable water; (ii) more than 80 percent had no access to latrines; 4 and (iii) limited health knowledge and often low access to health care had worsened the situation. The already fragile public health system was further weakened by the earthquake making it more challenging to treat patients with health providers who lacked experience in managing cholera cases. These conditions posed the risk of significant mortality and cholera becoming endemic. 1 Human Development Report, United Nations Development Program, 2009. 2 Katherine E. Bliss and Matt Fisher. Water and Sanitation in the Time of Cholera. Center for Strategic and International Studies, September 2013. 3 [(Number of deaths/number of cases) x 100] 4 World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Joint Monitoring Program, 2012. 1 4. The Government of Haiti (GOH), in partnership with a number of agencies, created an Emergency Cholera Coordination Committee at the central level and corresponding committees at the departmental and commune levels to confront the situation . In addition, an Inter-Cluster coordination system was put in place (Health, Water Sanitation and Hygiene, Camp Coordination and Camp management and Logistics Clusters) to ensure a coordinated and rapid response on the ground. Moreover, the Government prepared a National Strategy for the Response to the Cholera Epidemic, including the health and water and sanitation response through the Cholera Inter-Sector Response Strategy estimated at US$164 million. The latter aimed at reducing avoidable mortality and morbidity by limiting the impact of the cholera outbreak. Improving awareness and hygiene practices were key to control and reduce cholera in Haiti. 5. As part of Haiti’s call to the international community for support, the GOH requested the World Bank’s assistance for its emergency response to the cholera epidemic. In just a few months, after the confirmation of the outbreak, the World Bank responded in record time by making a US$15 million equivalent grant available through a fast track Cholera Emergency Response Project aimed at supporting the GOH’s response to the outbreak and strengthening its capacity to manage this type of epidemics. This Project was the first World Bank operation in the health sector in over a decade. At the time, the World Bank was already supporting the GOH’s cholera prevention efforts through its Global Facility for Disaster Reduction and Recovery with a US$200,000 grant to assist the awareness raising and prevention program led by the Ministry of Public Health and Population ( Ministère de la Santé Publique et de la Population - MSPP). Since the start of the cholera outbreak, the World Bank was also helping the Directorate of Civil Protection to coordinate, together with MSPP, the response of the Government and its partners. 6. The Project was fully consistent with the World Bank Group’s Country Assistance Strategy FY09-12 (Report No. 48284-HT) discussed by the Executive Directors on June 2, 2009 and the 2012 Interim Strategy Note. The principal objectives of these were to invest in human capital and reduce vulnerability. Indeed, the four pillars laid out in the Interim Strategy Note are: (i) reducing vulnerability and increasing resilience; (ii) sustainable reconstruction in housing and electricity; (iii) building human capital; and (iv) revitalizing the economy through agriculture, community-driven development and private sector development. The pillars have a cross-cutting theme of strengthening governance and capacity. 1.2 Original PDO and Key Indicators (as approved) 7. The PDO was to improve the health and hygiene practices in order to reduce the spread of cholera and strengthen the institutional capacity to respond to outbreaks. Progress on achievement of the objectives of the Project was to be measured through three outcome indicators and eight intermediate result indicators. The Project’s outcome indicators were: (i) Percentage of population in Project intervention areas who know the cholera early warning symptoms and prevention steps; (ii) Percentage of population in Project intervention areas with access to improved water sources; and (iii) Increased institutional capacity as measured by achievement of at least four out of five of Component 2 indicators on an annual basis. 2 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification. 8. The development objective was not revised. Although the formal restructuring processes did not include changes in the Results Framework, clarifications on Project’s outcome indicators No. 1 and No. 2, and changes to their respective baselines and targets were agreed during Project implementation as documented in the Project’s supervision documents. Such implementation changes have been explained under Section 2.3. 1.4 Main Beneficiaries 9. The Project direct beneficiaries included over three million people in 4,447 localities across seven Departments that received treatment, education, and training on proper hygiene and water treatment for the prevention of cholera. 5 The Project targeted populations affected by the cholera epidemic and vulnerable groups living in camps (homeless people from the earthquake that struck Haiti in January 2010). It targeted seven of the 10 departments in Haiti (Artibonite, Centre, Ouest - in selected parts of Port Au Prince, Sud-Est, Nippes, Sud, Grand- Anse). The seven departments of the Project represent 73 percent of the total population with an estimated number of 7.4 million inhabitants. 6 The Project provided oral rehydration salt (ORS) to 121,895 people and water treatment products and soap to 850,000 people. The Project’s health and hygiene and promotion campaigns reached around 80 percent of the population in 4,447 localities. Over 5,500 community health and hygiene agents traveled to over 1,600 communities across the seven Departments, including the most remote areas. At the time of Project preparation, other World Bank partners were actively responding to emergency needs, including awareness-raising activities and distribution of chlorine tablets in the Nord and Ouest departments. 1.5 Original Components 10. The Project consisted of the following two components (see Annex 2). 11. Component 1: Support to the Government’s Response to Cholera at the Decentralized Level (appraisal: US$11.0 million; actual: US$11.0 million). The objective of this component was to carry out a program of activities for immediate response to cholera, as outlined in the National Strategy for the Response to the Cholera Epidemic. This component sought to respond to the needs at the departmental level through support to all service providers, whether public, mixed or private, undertaking interventions at all levels of the cholera response. This component included two sub-components: (i) Sub-component 1.1: Support to a Multi- sectoral Approach to Public Primary Health Care; and (ii) Sub-component 1.2: Support to the Health, Water and Sanitations Response of Non-Public Providers. 12. Component 2: Emergency Response Capacity Building (appraisal: US$4.0 million; actual: US$3.9 million). This component financed activities to support the successful implementation of Component 1 and to ensure that MSPP and National Directorate of Potable 5 See Table 3.1: Population at departmental level and in localities of intervention. 6 Haitian Institute of Statistics and Informatics, Population estimate in 2012. 3 water and sanitation ( Direction Nationale de l’Eau Potable et de l’Assainissement – DINEPA) were prepared to tackle cholera and other possible water-borne diseases. As such, this component supported a number of emergency response capacity building activities for MSPP and DINEPA as well as overall Project management and supervision through two sub- components: (i) Sub-component 2.1: Strengthening Government’s capacity to manage and respond to outbreaks; and (ii) Sub-component 2.2: Carrying out a program of activities to support the management of Project, including monitoring, supervision and audits. 1.6 Revised Components 13. The Project’s components were not revised during implementation. 1.7 Other significant changes 14. The Project had two level II restructurings. The first restructuring, approved on June 4, 2013, extended the Project closing date from June 30, 2013 to December 31, 2013 to allow the GOH sufficient time to implement the remaining activities such as the rehabilitation of rooms for infectious and diarrheal diseases treatment; the installation of incinerators for proper waste management; and additional support for epidemiological surveillance. 15. The second restructuring , approved on December 27, 2013, extended the closing date for the second time from December 31, 2013 to March 30, 2014 to ensure the completion of Project activities, specifically the construction of three ecological sanitary blocks and the delivery of one ambulance-boat. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 16. Project preparation and design were appropriately responsive to help the GOH respond quickly and effectively to damage caused by the cholera outbreak . The Project’s activities responded to the needs of the country and supported the Government’s National Response Strategy to the Cholera Epidemic. Despite the difficult conditions and because of an adequate commitment from the Government’s and the World Bank’s team, Project preparation was expeditious - about three months. 7 The preparation of the Project benefited from broad consultations with sector stakeholders such as MSPP, United Nations agencies, and selected implementing partners. 8 The GOH requested that the operation be financed from its International Development Association (IDA) allocation on grant terms. An alternative instrument was not considered given the crisis nature of the situation and the fact that the Project met the criteria defined under emergency operations. Funds were programmed based on the rapidly evolving situation and guided by the Government’s assessment of gaps and pressing needs. 7 The Concept Note review meeting was held in November 19, 2010, just a month after the cholera epidemic was declared, and the Project became effective on February 7, 2011. 8 Since then, the World Bank has built a strong partnership with key development partners in Haiti’s health, social protection, and water and sanitation sectors, including the US Government Center for Disease Control (CDC) and United States Agency for International Development (USAID), the Pan-American Health Organization (PAHO), the IDB, and Médecin Sans Frontiére (MSF). 4 17. Project design incorporated lessons learned from previous operations in Haiti, the World Bank experience with emergency response operations and international good practices to cholera response . The most relevant were: (i) Since cholera has a "fecal-oral" transmission and 88 percent of cases of diarrhea worldwide are attributable to unsafe water, insufficient hygiene, and inadequate sanitation, 9 a multisectoral approach based on prevention, preparedness and response, along with an efficient surveillance system, is key to mitigating cholera outbreaks, controlling cholera in endemic areas and reducing deaths. (ii) Projects with simple project objectives and design are easier to manage in emergency operations. Complex multi-sector operations are difficult to implement in low capacity environments. (iii) Close coordination with government agencies and stakeholders is essential to manage well intentioned, yet often disparate efforts of these groups. (iv) Linking emergency operations with previous and future technical assistance is essential to increase, inter alia , their sustainability. (v) Capacity building activities are crucial to foster government’s emergency response to manage and respond to outbreaks. 18. Given the high cholera case fatality rate, the Project focused mainly on emergency response by improving: (i) the population’s access to ORS and health care services; (ii) the use of safe water sources; (iii) the hygiene practices, such as hand washing and removal of excreta and awareness of the early symptoms of the disease; (iv) epidemiological surveillance; and (v) coordination between DINEPA and MSPP to effectively coordinate the response. 19. A number of risks included in the risk matrix did materialize during Project implementation, while others that were omitted proved to be relevant later. Among the risks that materialized was the Government’s limited capacity to respond rapidly. As a result, initial roll-out of emergency activities was implemented by three Non-Governmental Organizations (NGO) - Partners in Health/Zanmi Lasante, World Vision, and Save the Children, in Port Au Prince, Artibonite, Centre, and Sud Est Departments. The contracting of these NGOs to work at the community level was essential to the behavior change objectives and the expected uptake of prevention and treatment interventions. As the capacity of the Government was strengthened, departmental health authorities also contributed to the large-scale prevention and treatment efforts in these departments, while also expanding activities to include Grand Anse, Nippes, and Sud Departments. The severity of some risks was underestimated during preparation. For instance, although baseline data for two out of three outcome indicators were not available during preparation, the risk matrix did not include possible problems associated with this lack of information. 9 http://www.cdc.gov/healthywater/global/diarrhea-burden.html. 5 2.2 Implementation 20. Overall implementation was moderately satisfactory throughout Project life. Implementation progress was originally slow due to delays in the completion of preparatory activities with the Economic and Social Assistance Funds ( Fonds d’Assistance Economique et Sociale – FAES), NGO service providers, and DINEPA. Intensive World Bank supervision and increased monitoring, coordination, and communication with all involved institutions helped to promote implementation progress. Difficult access to localities due to their remoteness and the lack of roads posed a considerable challenge for the implementation of Project activities. High rotation of staff (five different General Directors in FAES during Project implementation) and heavy administrative procedures at the management level of FAES delayed the implementation of Project activities. The regular update and submission of procurement plans helped to improve implementation of activities and disbursement rates, although extension of the closing date twice was needed to allow full completion of programmed activities. Despite the delays, most of planned activities were finalized. The fiduciary procedures of the GOH and the World Bank followed regular (non-emergency) processes, particularly on procurement and thus lacked the flexibility needed in emergency situations. 21. The Project was implemented by FAES, in close coordination with other development partners and NGOs at a decentralized level. At the time of preparation, FAES was considered the best agency for assuming overall Project coordination given its experience with Bank-financed projects. In addition, the Project was conceived to be managed by FAES on behalf of and in close partnership with MSPP and DINEPA. However, MSPP started activities at a later stage due to the fact that, at the time of Project preparation, its efforts were not only focused on the cholera epidemic but on the remaining work from the January 2010 earthquake. This fact made difficult the relationship between the MSPP and FAES and thus the implementation of Project activities. It was not until the end of the first year of the Project that FAES was able to benefit from the collaboration of MSPP officials for the recruitment of institutional and community staff. Partners included mainly US Government Center for Disease Control (CDC), the Pan-American Health Organization (PAHO), United Nations Children's Fund (UNICEF), the Inter-American Development Bank (IDB), and Doctors without Frontiers ( Médecins Sans Frontières ) among others. As mentioned before, the initial phase of Project implementation was carried out by three NGOs hired to this end, which gave time for the Departmental health authorities to develop clear and prioritized plans on how to fight cholera at their level. 22. Project implementation at the community level was successful despite operational challenges. Community health and hygiene agents, including those working in very remote areas, were able to: (i) disseminate messages on proper hygiene and water treatment for cholera prevention; (ii) teach people to identify the cholera early symptoms; (iii) demonstrate the use of first-line cholera treatment products, such as ORS ; and (iv) distribute water treatment products like chlorine tablets. However, the delivery of services at the community level was negatively affected by several factors, namely: (i) limited availability of skilled community agents given the large amount of them required (more than 2,000); (ii) quality and duration of the training; (iii) difficulties in the coordination between FAES and MSPP - FAES was responsible for hiring the community health and hygiene agents and purchasing necessary goods, while MSPP was responsible for making sure that the plans and activities were executed timely and properly; and 6 (iv) difficulties in the communication between the central and decentralized levels (messages usually took a long time to descend from higher to lower levels and vice versa). 23. Frequent World Bank supervision and interaction with Project partners and stakeholders proved crucial for implementation progress . Problems encountered in Project implementation were addressed during regular implementation support meetings and bi-monthly supervision missions. Despite significant difficulties, the Project executed nearly US$14.9 million (99.6 percent of total grant amount), and achieved concrete and important results. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 24. The M&E framework was well fitted to measure the achievement of Project outcomes and was aligned with the GOH strategic priorities. The M&E framework included the following: (i) rapid baseline and ex-post surveys to be conducted (with representativeness at the departmental level) during Project implementation; (ii) routine data collection at the community level and monitored at the departmental level; and (iii) standard quarterly and annual reports. Due to the emergency nature of the operation, some definitions were delayed to Project implementation. Detailed monitoring and evaluation arrangements were outlined in the Project monitoring and evaluation Manual (December 2012), including roles and responsibilities, monitoring and supervision steps, timing and tools. Overall, the M&E framework allowed for the existing systems to be utilized and strengthened, however, it was much more difficult to implement than initially expected. 25. The M&E system was not sufficiently used as a management tool or to inform decision-making because reliable data to define baseline and ex-post target for two of the three PDO indicators was obtained at a very late stage of implementation. A two-phase rapid survey was planned for establishing baseline and ex-post for PDO indicator No. 1 (percentage of population in Project intervention areas who know cholera early warning symptoms and prevention steps), and for PDO indicator No. 2 (percentage of population in Project intervention areas with access to improved water sources). The first phase data was collected in four Departments before planning and implementation of activities by NGOs service providers (in June 2011), 10 and the second phase before those by MSPP and DINEPA (in March 2012). 11 The baseline for the Project intervention by Department was first reflected in the Aide Memoire of August 2012 (18 months after Project effectiveness). Agreement was reached with FAES to set the ex-post target at five percent increase from baseline. 26. Although the survey design and sampling methodology were agreed with FAES and the World Bank, surveys had to be harmonized after the first report was available in June 2013. The sampling methodology adopted for the baseline survey was intended to provide sufficient information on the first two Project outcome indicators in terms of the robustness of the estimates both at an aggregate level, as well dis-aggregated by each Department of intervention. In addition, proposed sampling took into account the possibility to assess the impact of the Project through comparison with non-targeted departments. However, 10 The NGOs Partners in Health/Zanmi Lasante, Save the Children and World Vision collected the data in the departments of Centre, Artibonite, Ouest and Sud-est. 11 The Center of Research and Development ( Centre de Recherche et de Développement -- CRD ) collected data in Nippes, Sud and Grand Anse. 7 oversampling and weighting problems with phase 2 Departments raised concerns regarding comparison across Departments and between baseline and ex-post data. Appropriate corrections were made to both baseline and ex-post data for phase 2 Departments. Consequently, although original baseline and ex-post target for PDO indicator No. 1 and PDO indicator No. 2 were to be determined by Department, it was later decided to define them as an average of the seven Departments covered by the Project (Harmonization Report 2013). This change was not made through a formal Project restructuring. 27. In addition to adjustments in the baseline and ex-post target of the above mentioned PDO indicators, clarifications on how to measure them were also made during supervision. “Percentage of population in Project intervention areas who know the cholera early warning symptoms and prevention steps” would mean observing and reporting diarrhea with rice water color and vomiting (as symptoms), and adopting and reporting four out of six means of prevention (as prevention steps). “Percentage of population in Project intervention areas with access to improved water sources” would mean regular access to clean chlorinated water. These clarifications and changes were documented through Aide Memoires (August 29 to September 9, 2011 and August 21 to 30, 2012), an Implementation Status and Results Report (ISR sequence 3). Table 1: Project Outcome Indicators – baselines and ex-posts Project Development Outcome Indicators Action taken during implementation Baseline (Original) Baseline (Defined during implementation) Cumulative Target Value (Original) Cumulative Target Value (Defined during implementation) Project Development Objective: To improve the health and hygiene practices in order to reduce the spread of cholera and strengthen the institutional capacity to respond to outbreaks . 1. Percentage of population in Project intervention areas who know A) the cholera early warning symptoms and B) prevention steps. Baseline and target established; Definition of indicator clarified Rapid Survey to be done 1 A: 64% 2 B: 13% 2 TBD by dept 1 A: 69% 2 B: 18% 2 2. Percentage of population in Project intervention areas with access to improved water sources. Baseline and target established; Definition of indicator clarified Rapid Survey to be done 1 78% 2 TBD by dept 1 78% 2 8 Project Development Outcome Indicators Action taken during implementation Baseline (Original) Baseline (Defined during implementation) Cumulative Target Value (Original) Cumulative Target Value (Defined during implementation) 3. Increased institutional capacity as measured by achievement of at least four out of five of Component 2 indicators on an annual basis. N/A N/A Four out of five indicators achieved Source: 1 Emergency Project Paper Results Framework, 2010; 2 Center of Research for Development harmonization report (average of seven departments covered by the Project), 2013. 28. Information for the intermediate outcome indicators was collected through the Project reports to allow the monitoring of the implementation progress in a quarterly basis . Baseline and ex-post target, set in December 2010 remained the same for five of the eight intermediate outcome indicators. Intermediate outcome indicator No. 2 (number of health centers and posts, treatment and chlorination centers and units, and oral rehydration posts supported with supplies) and No. 4 (number of personnel and community workers trained (by type of training)) and No. 6 (establishment and functioning of one national and five regional cholera and Emergency Response Units) were subject to some changes. In 2013, the cholera response strategy was changed by the MSPP. The new strategy no longer involved the use of permanent stand-alone cholera rehydration posts but rather the integration of the cholera treatment into the existing health system. Consequently, the target for these indicators was revised according to the implementation plan submitted by the Government and agreed with the World Bank team. 29. The Project’s activities contributed to achieving Project’s intermediate results effectively and in turn these contributed to the desired outcomes . Reducing the spread of cholera involves improved health and hygiene practices. This was a result of the implementation of community and sensitization and case management activities, carried out by the NGOs service providers and the decentralized departments of the MSPP under Component 1. The intermediate indicators of this component measured progress towards the Project’s first sub-objective, whereas the strengthening of institutional capacity was a result of the implementation of activities under Component 2. The latter was directly related to the strengthening of DINEPA , Direction of Epidemiology, Laboratory and Research ( Direction d’Epidémiologie, de Laboratoire et de Recherche - DELR), National Laboratory of Public Health ( Laboratoire National de Santé Publique - LNSP) and FAES. The intermediate indicators of Component 2 measured effectively progress towards the second sub-objective. 9 2.4 Safeguard and Fiduciary Compliance 30. Environmental Safeguard . The Project was classified as category B and triggered the Environmental Safeguard (OP 4.01) as a result of the increase of health care waste production due to the implementation of Component 1 and the inclusion of minor works. Component 1 included the implementation of activities such as management of healthcare waste within and from healthcare facilities, worker health and safety, and the inclusion of minor works. About 250 health facilities benefited from technical and financial support for waste management and environmental protection, including the installation of 12 incinerators acquired by the MSPP, out of which four were financed by the Project, the emptying of four septic tanks, and the construction of three ecological sanitary blocks. Over 50 latrines and seven water pumps in Truitier, an endemic area in Port Au Prince, were rehabilitated and are in use and managed by local community organizations. The Project contributed to the upgrade of the national Standards for Biomedical Waste Management and the Hygiene Promotion Plan. It also provided financial, technical and training support to NGO service providers and MSPP at all levels. The Environmental Unit of FAES followed an action plan including supervision and data collection in all Project sites. Despite these achievements, the implementation was hindered by frequent delays in the procurement of necessary safeguard equipment and in the disbursing of FAES funds for the recruitment of community agents. This is the reason for the Moderately Satisfactory rating in the last Project ISR. 31. Procurement . The procurement arrangements were performed Moderately Satisfactory in accordance with the last ISR. FAES internal procedures experienced some delays in the implementation of the plan. Nevertheless, most of the planned activities were completed. Despite the fact that FAES had previous experience with World Bank procurement rules, this was only limited to the procurement of works and the Project implied the procurement of medicines and medical equipment, among others. The procurement of these goods posed challenges to FAES team since it required getting to know a new market, the creation of a whole new database of suppliers, and acquiring specific technical skills. Throughout the implementation of the Project, FAES counted on the support of the National Laboratory for the development of technical specifications of medical supplies and equipment. In addition, FAES found innovative ways to overcome procurement bottlenecks. For example, FAES team worked jointly with different bidders in the design of a new ambulance prototype boat that was required but did not exist in the country. On the other hand, there were lessons learned for improving procurement processes. For instance, the experience with the recruitment of service providers in charge of collecting the baseline data showed that there was a need to strengthen the procurement process through allowing sufficient time to collect expressions of interest, the use of a wider range of publishing tools (internet, etc.) and awareness of potential applicants to recruit high-quality firms to carry out accurate, exhaustive, and timely community surveys and data analysis. For three months (from May to July 2012), the Project benefited from the daily support of procurement specialists which resulted in a timely review of procurement activities. Overall, the close relationship between the FAES and World Bank procurement team allowed procurement bottlenecks to be overcome. 10 32. Financial Management arrangements in terms of accounting, budgeting, fund flow, internal control, external audit and financial reporting were performed Moderately Unsatisfactory in accordance with the last ISR . Significant shortcomings existed. Main issues encountered were that FAES, the Project Implementing Agency, was unable to provide current disbursement rates and accurately projections. There was a high financial management staff turnover in FAES and weaknesses in the withdrawal application submission throughout implementation. Delays in submitting withdrawal requests and/or supporting documents were in part due to problems encountered by FAES in accessing the World Bank´s client connection system. Despite support from the World Bank’s supervision team, withdrawal applications took a long time to be submitted and were often incomplete, delaying disbursements and implementation of Project activities. In addition, a qualified opinion was issued in the audit report covering fiscal year ending on September 30, 2012 and an ineligible expenditure was identified (absence of supporting documentation related to salary paid to the health department) although this issue was resolved later on. Weaknesses existed but did not prevent the managing and monitoring of information required for Project implementation. Due diligence was taken by FAES with the recruitment of a consultant who helped to find out the missing supporting documentation that was verified by the auditors during the audit ending on September 30, 2012. At the time of preparation of this ICR, the audit report covering the period October 1 st , 2012 to September 30, 2013 was overdue. The final audit covering the period October 1st, 2013 to July 30, 2014 is expected to be submitted to the World Bank no later than November 30, 2014. 2.5 Post-completion Operation/Next Phase 33. The GOH continues to prioritize the fight against cholera. Interventions to achieve this goal are included in the Operational Plan 2013-2015 of the MSPP, which emanates from the National Plan for the Elimination of Cholera 2013-2022. The ultimate goal of the Plan is to eliminate cholera from the island of Hispaniola through technical and financial support from the international community and binational coordination. 12 34. The World Bank remains strongly engaged in the fight against cholera in Haiti. In fiscal year 2013, the World Bank