Document of The World Bank · 2017. 2. 13. · document of the world bank report no: icr2457...

Document of

The World Bank

Report No: ICR2457

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-37510 IDA-37511 IDA-45230 IDA-48580)

ON A

CREDIT

IN THE AMOUNT OF SDR 124.86 MILLION (US$ {190.4} MILLION EQUIVALENT)

TO THE

FEDERAL REPUBLIC OF NIGERIA

FOR A

PARTNERSHIP FOR POLIO ERADICATION PROJECT

December 5, 2012

HEALTH, NUTRITION AND POPULATION UNIT AFCW2 AFRICA REGION

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CURRENCY EQUIVALENTS

(Exchange Rate Effective 05/15/12)

Currency Unit = Naira (N) N 1.00 = US$ [0.006] US$ 1.00 = N [157]

FISCAL YEAR

ABBREVIATIONS AND ACRONYMS AFP Acute Flaccid Paralysis BMGF Bill and Melinda Gates Foundation CAS Country Assistance Strategy CDC Centers for Disease Control and Prevention CI Confidence Interval CSM Cerebro-Spinal Meningitis DHS Demographic and Health Survey DO Development Outcome DSNO Disease Surveillance and Notification Officer EIM Enhanced Independent Monitoring EPI Expanded Program on Immunization ERC Expert Review Committee FA Financial Agreement FM Financial Management FMOH Federal Ministry of Health GIS Geographical Information System GON Government of Nigeria GPEI Global Polio Eradication Initiative ICC Inter-Agency Coordinating Committee IDA International Development Association IEC Information, Education and Communication IP Implementation Progress IPDs Immunization Plus Days ISR Implementation Status and Results IWCS Intensified Ward Communication Strategy LGAs Local Government Areas MCH Maternal and Child Health MDGs Millennium Development Goals MTR Mid-Term Review NIDs National Immunization Days NNT Neonatal Tetanus NPI National Program on Immunization OIC Officer In Charge

OPV Oral Polio Vaccine PAD Project Appraisal Document PDO Project Development Objectives PEI Polio Eradication Initiative PHC Primary Health Care PHSS Public Health Service and Solutions RI Routine Immunization SIA Supplementary Immunization Activities SNID Sub-National Immunization Days UNF UN Foundation UNICEF United Nations Children’s Fund VCM Volunteer Community Mobilizers WHO World Health Organization

Vice President: Makhtar Diop

Country Director: Marie Francoise Marie-Nelly

Sector Manager: Trina Haque

Project Team Leader: Dinesh Nair

ICR Team Leader: Shunsuke Mabuchi

NIGERIA Partnership for Polio Eradication Project

CONTENTS

Data Sheet

A. Basic Information

B. Key Dates

C. Ratings Summary

D. Sector and Theme Codes

E. Bank Staff

F. Results Framework Analysis

G. Ratings of Project Performance in ISRs

H. Restructuring

I. Disbursement Graph

1. Project Context, Development Objectives and Design ........................................................... 1 2. Key Factors Affecting Implementation and Outcomes ........................................................... 5 3. Assessment of Outcomes ...................................................................................................... 13 4. Assessment of Risk to Development Outcome ..................................................................... 27 5. Assessment of Bank and Borrower Performance .................................................................. 29 6. Lessons Learned .................................................................................................................... 32 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ....................... 33 Annex 1. Project Costs and Financing ...................................................................................... 34 Annex 2. Outputs by Component .............................................................................................. 35 Annex 3. Economic and Financial Analysis ............................................................................. 36 Annex 4. Bank Lending and Implementation Support/Supervision Processes ......................... 37 Annex 5. Beneficiary Survey Results ....................................................................................... 38 Annex 6. Stakeholder Workshop Report and Results ............................................................... 38 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ................................. 39 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ................................... 49 Annex 9. List of Supporting Documents................................................................................... 54

MAP

A. Basic Information

Country: Nigeria Project Name: Partnership for Polio

Eradication Project

Project ID: P080295 L/C/TF Number(s):

IDA-37510,IDA-

37511,IDA-

45230,IDA-48580

ICR Date: 12/17/2012 ICR Type: Core ICR

Lending Instrument: SIL Borrower: GOVERNMENT OF

NIGERIA

Original Total

Commitment: XDR 20.90M Disbursed Amount: XDR 123.21M

Revised Amount: XDR 124.78M

Environmental Category: C

Implementing Agencies:

NPHCDA

Cofinanciers and Other External Partners: JICA World Health Organization (WHO) US -- Centers for Disease Control and Prevention (CDC) UNICEF Bill and Melinda Gates Foundation

The Rotary Foundation

B. Key Dates

Process Date Process Original Date Revised / Actual

Date(s)

Concept Review: 10/03/2002 Effectiveness: 08/06/2003 08/06/2003

Appraisal: 01/20/2003 Restructuring(s):

Approval: 04/29/2003 Mid-term Review:

Closing: 10/31/2005 04/30/2012

C. Ratings Summary

C.1 Performance Rating by ICR

Outcomes: Satisfactory

Risk to Development Outcome: Moderate

Bank Performance: Satisfactory

Borrower Performance: Satisfactory

C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)

Bank Ratings Borrower Ratings

Quality at Entry: Satisfactory Government: Moderately Satisfactory

Quality of Supervision: Satisfactory Implementing Agency/Agencies:

Satisfactory

Overall Bank Performance:

Satisfactory Overall Borrower Performance:

Satisfactory

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): Yes

Quality of

Supervision (QSA): Satisfactory

DO rating before

Closing/Inactive status: Satisfactory

D. Sector and Theme Codes

Original Actual

Sector Code (as % of total Bank financing)

Health 100 100

Theme Code (as % of total Bank financing)

Child health 67 67

Health system performance 33 33

E. Bank Staff

Positions At ICR At Approval

Vice President: Makhtar Diop Callisto E. Madavo

Country Director: Marie Francoise Marie-Nelly Mark D. Tomlinson

Sector Manager: Trina S. Haque Laura Frigenti

Project Team Leader: Dinesh M. Nair Cornelis P. Kostermans

ICR Team Leader: Shunsuke Mabuchi

ICR Primary Author: Shunsuke Mabuchi

F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document) Financial Agreement (FA): Assist the Borrower in its efforts to eradicate Poliomyelitis through the provision of oral polio vaccine.

Project Appraisal Document (PAD): Assist the Government of Nigeria achieve its goal of interrupting transmission of wild poliovirus by the end of 2003 and sustain these efforts throughout the period 2003-05, through effective oral polio vaccine (OPV) coverage of the target population. Revised Project Development Objectives (as approved by original approving authority)

None (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 : Effective OPV coverage of the target population

Value quantitative or Qualitative)

44% (Range: 37%--59%) in northern endemic states During March 2002--February 2003 (CDC, 2003).

Coverage for OPV is at least 80% in each endemic State (FA)

Eight states average: 89% Kano: 91% Jigawa: 93% Sokoto: 84% Zamfara: 84% Katsina: 88% Kaduna: 88% Bauchi: 91% Niger: 95% (Independent performance audit, Oct/Nov, 2012)

Date achieved 02/28/2003 10/31/2005 11/18/2012

Comments (incl. % achievement)

Achieved: Independent performance audit in October/ November 2012 contracted by the World Bank concluded that the target was surpassed. This audit used WHO's standard cluster survey method to assess immunization coverage (WHO, 2001).

(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 : Timely delivery of OPV for use in FGN polio eradication program

Value (quantitative or Qualitative)

Erratic vaccine arrival. Stock-outs of all routine vaccines in early 2003.

The polio vaccines will arrive at least 5 weeks before the SIAs in the national store.

"At least 5 weeks" was deleted from the target.

No single incident occurred where late arrival of OPV caused delay in the schedule of an immunization

campaign during the 9 years of project period. No vaccine stock-outs at the federal level since the beginning of the project.

Date achieved 02/28/2003 10/31/2005 04/30/2012 04/30/2012


Achieved: "5 weeks" target was arbitrary and was outside the control of GON and UNICEF. The project in Pakistan also dropped the timeline for the same reason (Pakistan ICR, 2008).

Indicator 2 : Cold Chain system established and operational


Not effective

Established and operational: 75% of state stores have sufficient capacity for routine immunization (RI) and penta immunization. 90% of LGAs have adequate capacity to accommodate RI and new/underutilized vaccines.

Date achieved 02/28/2003 04/30/2012


Cold Chain Capacity Assessment (2012) concluded that all the state stores except Delta and Ondo and all the LGAs in the reviewed 4 states are ready for new vaccine introductions.

Indicator 3 : Social mobilization program implemented


Not implemented

Implemented: Awareness of polio is highest among other vaccine preventable diseases at 75% in 18 states in 2010, 50 percent increase from 2007 (KAP survey, 2010).

Date achieved 02/28/2003 04/30/2012


1,827 trained volunteer community mobilizers (VCM) and 184 ward supervisors are in place to conduct community sensitization in endemic states. Support from traditional and religious leaders have been organized to mobilize community.

Indicator 4 : Targeted capacity building program implemented

Value Not started Implemented: e.g.,

(quantitative or Qualitative)

70% of vaccination teams met all the criteria for good performance (e.g., follow micro-plan, enter every household).

Date achieved 02/28/2003 04/30/2012


Target achieved: All LGA PHC coordinators, local immunization officers, health educators, ward focal persons, supervisors and vaccination teams were trained before campaigns.

Indicator 5 : Surveillance program implemented (e.g., # cases per 100K, stool sample collection)


• AFP detection rate at least 2 cases per 100,000 • Adequate stool specimen more than 80%

• AFP detection rate at least 7-8 cases per 100,000 • Adequate stool specimen more than 93% • Percentage of meeting the two targets increased from 75% in 2007 to 88% in 2012.

Date achieved 10/31/2005 04/30/2012


Achieved: The two national polio laboratories reduced the time between date of onset of an AFP to final results from 32 days in 2008 to 12 days in 2009. Ibadan lab was provisionally accredited in July 2012.

Indicator 6 : Bank participation in the ICC assessing outputs and DO


Full participation Full participation (100%) in ICC and ERC.

Date achieved 10/31/2005 04/30/2012


Achieved: e.g., The Bank promoted the IPD approach to incentivize communities to take vaccination, which contributed to the 75% reduction of polio cases in 2007 and the broad distribution of Vitamin A with OPVs (162.4 million doses from 2006-11).

Indicator 7 : WHO performance audit of inputs, outputs, DO triggers for buy-down


Implemented Implemented

Date achieved 10/31/2005 04/30/2012


First performance audit was implemented in October 2010, deferred due to additional financings and extensions of the project. Second performance audit was carried out in October and November 2012.

G. Ratings of Project Performance in ISRs

No. Date ISR Archived

DO IP Actual

Disbursements (USD millions)

1 06/10/2003 Satisfactory Satisfactory 0.00




5 09/13/2004 Unsatisfactory Satisfactory 28.70




9 04/18/2006 Satisfactory Moderately Satisfactory 51.46





14 01/10/2009 Moderately Satisfactory Moderately

Unsatisfactory 79.04

15 06/30/2009 Moderately Satisfactory Moderately Satisfactory 79.04

16 12/16/2009 Moderately Satisfactory Satisfactory 114.50

17 06/18/2010 Moderately Satisfactory Satisfactory 128.04





H. Restructuring (if any) Not Applicable

I. Disbursement Profile

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1. Project Context, Development Objectives and Design (this section is descriptive, taken from other documents, e.g., PAD/ISR, not evaluative)

1.1 Context at Appraisal (brief summary of country and sector background, rationale for Bank assistance)

1. Polio as a crippling infectious disease: Poliomyelitis is a highly infectious disease

caused by a virus. It invades the nervous system and can cause irreversible paralysis in a matter of hours. It can strike at any age, but it mainly affects children under five years old.

2. Polio is spread through person-to-person contact. When a child is infected with wild

poliovirus, the virus enters the body through the mouth and multiplies in the intestine. It is then shed into the environment through the feces where it can spread rapidly through a community, especially in situations of poor hygiene and sanitation. If a sufficient number of children are fully immunized against polio, the virus is unable to find susceptible children to infect, and dies out. Young children who are not yet toilet-trained are a ready source of transmission, regardless of their environment.

3. Polio can be spread when food or drink is contaminated by feces. There is also

evidence that flies can passively transfer poliovirus from feces to food. Most people infected with the poliovirus have no signs of illness and are never aware they have been infected. These symptomless people carry the virus in their intestines and can “silently” spread the infection to thousands of others before the first case of polio paralysis emerges (GPEI, 2010).

4. Vaccination for immunity: There is no cure for polio, but polio is preventable

through inexpensive vaccines. Three doses of Oral Polio Vaccines (OPV) in the first year of life can prevent all three different types of poliovirus in more than 95% of recipients. Also, when 80-86% of people are vaccinated in a community, it is difficult for poliovirus to gain a foothold in the community. This provides community protection – herd immunity from poliovirus (The College of Physicians of Philadelphia, 2012).

5. Global initiative to eradicate polio: In 1988, the World Health Assembly launched

the Global Polio Eradication Initiative (GPEI) with the goal of eradicating polio by the end of 2003. At that time, polio was endemic in 125 countries (PAD, 2003). Only seven countries in the world remained polio-endemic at the end of 2002, with 99 percent of all global cases found in India, Nigeria and Pakistan. Nigeria was the major reservoir of polio virus in Africa and the second largest reservoir of wild polio virus after India (PAD, 2003). Achieving polio eradication therefore depended crucially on progress in Nigeria.

6. Polio eradication program in Nigeria: Prior to the Nigeria Partnership for Polio

Eradication Project there was already a national program in place, led by the National

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Program on Immunization (NPI), a para-statal of the Federal Ministry of Health (FMOH) that was responsible for both routine immunization and for immunization campaigns. In 2002, the recorded 202 polio cases were concentrated in 14 states with 177 of 774 Local Government Areas (LGAs) remaining high risk. These areas were targeted for intense social mobilization and supplementary immunization activities (SIAs).

7. International polio eradication experts were of the opinion that the global polio

eradication effort was in its final stage (PAD, 2003), with the GPEI setting the goal of eradicating the disease by 2005. It was however acknowledged that this would pose a formidable challenge since the final push for full eradication would require reaching every single child with polio vaccine even in the most difficult areas.

8. Based on the recommendations of the Expert Review Committee (ERC), the

Government of Nigeria (GON) along with its partners prepared a plan to strengthen the national eradication effort and attain polio free status for Nigeria by the end of 2003. The additional cost of vaccine was estimated at US$38 million and the Bank was requested to contribute to this overall plan with a credit of US$28.70 million (PAD, 2003).

1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved)

9. This project was a part of the country’s program to eradicate polio, and was

responsible for the uninterrupted and timely supply of OPV to campaign site. The PDO as stated in the Financing Agreement (Development Credit Agreement - FA), was to: “Assist the Borrower in its efforts to eradicate Poliomyelitis through the

provision of oral polio vaccine”.

10. In the PAD, the PDO was to: “Assist the GON achieve its goal of interrupting

transmission of wild polio virus by the end of 2003 and sustain these efforts

throughout the period 2003-05, through effective OPV coverage of the target

population.” While the PAD cites the timelines for the country’s polio eradication program in its PDO, the FA does not mention the timelines, since they were GON’s goal but not the project’s.

11. Given that the project’s responsibility is the stable supply of OPV, both the original

PAD and the FA state that the project's success would be measured by the following key indicators and targets:

• Coverage of supplemental vaccination activities. Target: Coverage for OPV is at least 80% in each endemic state – PDO indicator.

• Timely arrival at national level of OPV procured through UNICEF. Target: Vaccines arrive at least five weeks before the SIAs in the national store in Abuja – Intermediate results indicator.

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1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification

12. In the project paper for the third additional financing in 2010, the PDO and the FA

were aligned, and the timelines in the PDO for interrupting transmission of polio virus (“by the end of 2003”) and subsequent sustained efforts (“throughout the period 2003-05”) were dropped.

13. The indicator: “Timely arrival at national level of OPV procured through UNICEF”

was retained as an intermediate results indicator, but was removed from the assessment for the buy-down of the IDA credit. First, the target of “at least five weeks before the SIAs” was arbitrary and did not have any scientific rationale. Second, the independent performance audit in 2010 concluded that the indicator did not measure GON’s performance. Vaccine arrival was found to be dependent on a number of factors outside the control of the GON and UNICEF who is the agent for vaccine procurement (PHSS, 2011), including delays due to: i) constrained global supply of OPV; ii) change in type of vaccine to be used at short notice due to the changing epidemiology of virus; and iii) coordinating OPV with very limited number of producers. Also, there was not a single occasion for nine years during the life of the project when late arrival of OPV interfered with the implementation of an immunization campaign (PHSS, 2011). For the same reason, the Second Partnership for Polio Eradication Project in Pakistan (2006-2008) dropped the same arbitrary 5-week target for the timely arrival of OPV in 2007 (Pakistan ICR, 2008).

1.4 Main Beneficiaries and Benefits

(original and revised, briefly describe the "primary target group" identified in the PAD

and as captured in the PDO, as well as any other individuals and organizations expected

to benefit from the project)

14. The project targeted all children in Nigeria up to the age of five. Vaccine-preventable diseases, and polio in particular disproportionately affects poor families and immunization coverage is lower in poor and socially disadvantaged groups (PAD, 2003).

15. The benefits go far beyond the national target group since it will affect other countries

and benefit both the present and future generations. In addition, adults indirectly benefit from the project as they also have a risk of being infected by polioviruses.

1.5 Original Components (as approved)

16. The PAD listed three components that were fully integrated into the government’s

polio eradication program (Table 1). The project covered Component 1, with US$28.70 million IDA credit. Other components were led by the government with support from WHO and UNICEF, given their comparative advantages and experiences in operational support for polio eradication (Table 1).

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Table 1: Program components and responsibilities

Component

Contents Finance (USD)

Responsibilities

1 Timely provision of adequate supplies of OPV for eradication campaigns

38.20 million

Financed by IDA (US$28.70 million). OPV procurement by UNICEF. Distribution by NPI.

2 Supplemental operations comprising three areas: cold chain, social mobilization, and training.

53.80 million

Supported by WHO and UNICEF, through large contributions from donors and the GON.

3 Support for epidemiological and laboratory surveillance

65.10 million

Surveillance conducted by WHO. Progress assessed by Expert Review Committee (ERC).

Source: PAD, 2003 1.6 Revised Components

N/A 1.7 Other significant changes

(in design, scope and scale, implementation arrangements and schedule, and funding

allocations)

17. The Project was amended three times in response to the government’s requests for

additional financing (Table 2). The total cost increased from US$28.7 million to US$190.4 million. The closing dates were also amended from October 31, 2005 to April 29, 2012.

Table 2: Amendments for the Additional Financing

Additional Financing

Date of Amendment

Reasons

1

US$ 51.7 million

May 10, 2005

Because of the increase in polio cases in 2003-04, several extra SIAs needed to be organized to intensify campaigns, as recommended by the ERC. Additional operational costs were supported by WHO, UNICEF and partners. The GON mobilized US$ 4.5 million from JICA for OPV, leaving a shortfall of US$ 51.7 million.

2

US$50 million

September 8, 2008

Widespread fears that the OPV contained anti-fertility agents and HIV led to rejections of campaigns and a large spurt in polio cases. This required a scale up of project activities including an innovative OPV delivery mechanism, Immunization Plus Days (IPDs), that combined other immunizations and goods delivery. The GON was unable to cover the additional financing needs, or to obtain additional funds from other agencies in good time. This required the Bank to cover 59% and 64.2% of the 2008-09 overall cost of OPVs.

3

US$ 60

March

ERC recommended the scheduling of two full National Immunization Days (NIDs) and four Sub-National Immunization

Scope of the

project

5

million 17, 2011

Days (SNIDs) for 20 high risk states, and to include polio immunization in the semi-annual Maternal and Child Health (MCH) days for 2011. This required US$60 million for a year. Use of GON or other donor funds were not viable due to urgency.

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry (including whether lessons of earlier operations were taken into account, risks and their

mitigations identified, and adequacy of participatory processes, as applicable) 18. Simple, performance-based and harmonized design: The design benefited from the

following: i) it was simple to implement for GON and the Bank and allowed GON to concentrate on technical and programmatic issues; ii) it was results-based; iii) it had a robust M&E framework that used independent means for verifying data. The ERC ensured that all available data was carefully considered and used; and iv) it was a part of the GON’s broader polio eradication program and harmonized with the operational support provided by other donors such as WHO and UNICEF.

19. Innovative financing mechanism: According to the WHO, the largest threat to the

global initiative to eradicate polio was the funding gap for activities from 2003 to 2005. This was highlighted at the end of 2002 when the shortage of global resource commitments scaled back a number of activities in 2003. In response, during project preparation, the Bank explored a partnership with the Bill and Melinda Gates Foundation (BMGF), Rotary International and the UN Foundation (UNF). Under this partnership, the Bank provides IDA credit to the country while BMGF, Rotary and the UNF finance a Trust Fund in the Bank which is used to “buy-down” the credit upon successful achievement of project targets. This was an innovative solution to the funding challenges (Table 3). The joint supervision mission by partners concluded that the buy-down “allowed OPV to be purchased for campaigns in a timely manner” throughout the project, while “other polio-affected countries have faced difficulty in securing funds for OPV in a timely manner and had to postpone or cancel campaigns” (AM, April 2010).

Table 3: Funding challenges and solutions provided by the buy-down

Funding challenges Solution provided by the buy-down GON/ Polio eradication is a global public good

that benefits other countries; as such, GON has less interest in borrowing money for polio at the expense of other more pressing issues.

Buy-down can turn the credit into a grant, conditional on results. This motivated the government to borrow funds for polio eradication and enabled the Bank to fill the financing gap for the global public good.

World Bank

Aimed to finance the global public good as a “financier of last resort”.

BMGF and

• Aimed to finance results rather than traditional inputs.

• Buy-down enabled financing for the achievement of results.

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other donors

• Had budget constraints and wanted to leverage their funds and maximize their impact.

• Buy-down enabled financing of a much larger order than the grant value by leveraging the discount factor of IDA’s long-term loan.1

20. Rapid response to the funding gap: The project and its innovative financing

mechanism were thoroughly discussed internally as well as with the concerned partners. Despite the new approach, the project team went from concept review to Board approval in less than seven months and to Effectiveness within eight months. This fast-track processing enabled the government to fill the immediate vaccine gap in 2003-05 (Interview, NPHCDA).

21. Optimistic View of Polio Eradication: At entry, global experts on polio believed that

Nigeria was in the final stage of polio eradication. This was reflected to the optimistic timelines in the GON’s goal of eradicating polio cited in the PDO in the PAD (i.e., interrupting transmission of wild polio virus by the end of 2003 and sustain these efforts throughout the period 2003-05). As mentioned in section 1.2, the project did not use the timelines in the PDO for the legal agreement (i.e., FA).

22. The optimism in the country’s goal was based on the evident success of polio

eradication in other countries. In addition, there were epidemiological, programmatic, political and cultural concerns that were impossible to anticipate at the time. For example: i) OPV would be less efficacious because of competition from other entero-viruses; ii) rumors would spread that OPV was a “plot” to control Muslim populations; and iii) approaches to service delivery that had worked well elsewhere (including in other parts of Nigeria) would be more difficult in the northern states.

23. Appropriate risk identification and response: A number of other risks were rightly

identified during preparation. The country responded to the issues in NIDs proactively and improved routine immunization throughout the implementation phase of the project (Table 4). Security risk remains a challenge, but insecure states maintain above average performance among endemic states.

Table 4: Identified risks in PAD 2003 that affected the project implementation

Risk identified (PAD 2003)

Risk mitigation measure (PAD 2003)

Retrospective Comments at ICR

The accelerated strategy of 2 NIDs and 3 SNIDs each year will not raise polio immunization coverage in all hard

Active involvement of local, religious and traditional leaders has been sought to increase acceptance of vaccination by the

• Active involvement of religious and traditional leaders contributed to dramatic reduction of cases in 2009-10.

• The quality of campaigns in hard to reach pockets has been addressed by developing household-based micro-plans for planning

1 By committing the buy-down grant upfront donors can finance the larger amount of credit because the net present value of the long-term credit is much smaller than its face value.

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to reach pockets sufficiently.

population. and monitoring and improving team selection and composition, etc. (See 2.5 for details).

Weaknesses of the routine immunization (RI) services may hamper polio eradication efforts.

RI is receiving more attention from GON. Several external partners, amongst them the Bank, will address the strengthening of RI through other support.

RI improved significantly – BCG from 23% in 2003 to 76.41% in 2010, measles from 25.3% in 2003 to 63.55% in 2010, DPT3 from 24.8% in 2003 to 67.73% in 2010 (NICS, 2003, 2010). However, further strengthening of RI would be needed especially in the northern region.

Political instability may hamper the eradication campaigns

NPI seeks the full involvement of traditional and local leaders in the eradication campaigns. So far, it has been successful in doing so.

• Involvement of local leaders contributed significantly to the stability and improvement of campaigns especially after 2009.

• Recent instability due to terrorist attacks was unexpected and uncontrollable through the project. However, insecure states (i.e., Borno, Yobe) are performing above average among northern states (See 4. for details).

2.2 Implementation (including any project changes/restructuring, mid-term review, Project at Risk status, and actions

taken, as applicable) Summary

• The project experienced some unexpected challenges that were not directly controllable by the project such as: (i) widespread rejection of campaigns in 2003-05 by the northern states based on malicious and un-founded rumors, which reversed previous gains and momentum; (ii) the election and leadership change in 2008 and 2011; and (iii) deteriorating security in the northern states. However, the country responded to these challenges proactively and appropriately, and demonstrated significant progress each time performance ratings deteriorated.

24. During the nine years of implementation, the project experienced ratings below

“Satisfactory” (i.e., project at risk) several times:

• September 2004 (Development Outcome (DO): Unsatisfactory);

• April 2006 (Implementation Progress (IP): Moderately Satisfactory);

• January 2009-June 2010 (DO and IP: Moderately Satisfactory). 25. The project was not restructured as the strategic focus of the project remained

appropriate, but GON and the partners responded proactively to the rises in polio cases. The main supervisory mechanism was the ERC, given that the project was a part of the country’s polio eradication program, and that the ERC had global expertise in polio eradication (See section 2.3 for details). The Bank’s supervision missions supplemented the ERC. A Mid-Term Review (MTR) was also not conducted as the ERC played a role of reviewing the program’s progress every 4-6 months.

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26. The “Unsatisfactory” result in 2004 was because the polio campaigns were not carried out in the most needed northern states. This was caused by the rejection of immunization activities by the political and religious leaders and communities of the northern states in 2003-05 amid widespread fears that the OPV contained anti-fertility agents and even the AIDS virus (PAD, 2005). This originated from “the alleged malpractices where US-based Pfizer tested meningitis vaccine in Kano state in the north and eleven children died and many others suffered injuries” (Frishman, 2009). The doubt extended to the OPVs and combined with political and religious tensions between north and south and Christian and Muslim communities. Supreme Council for Sharia in Nigeria asserted that the polio eradication initiative was “part of a plot by western governments to reduce Muslim populations” (Yahya, 2007).

27. In response, the GON launched aggressive communication activities. This included

the testing of the vaccines by local scientists from Kano state both in-country and at internationally reputed laboratories and several high level meetings with the state Governors and local religious leaders by a representative of the UN Secretary General. As a result, in August 2004, immunization activities were reinstated in Kano state. Furthermore, in April 2006 the GON introduced an innovative immunization plus days (IPDs) approach that included: (i) fixed post immunization; (ii) inclusion of vitamin A and injectable antigens such as measles and DPT that parents appreciated more; and (iii) the use of trained health workers rather than volunteers. This increased the OPV coverage and reduced the polio cases significantly from 1,122 in 2006 to 285 in 2007 (ISR, January 2007).

28. The “Moderately Satisfactory” rating for IP in 2006 was related to poor reporting

from the NPI. This will be further discussed in detail in section 2.4 below. 29. The main reason of the consistent “Moderately Satisfactory” ratings from January

2009 to June 2010 was deteriorated campaign performance due to new leadership issues in NPI. All of the six endemic northern states had more than 10% of under-five children who had never received OPV (16th ERC, 2008). As a consequence, Nigeria experienced an upsurge in polio cases from 285 cases in 2007 to 798 cases in 2008. The ERC stressed the importance of improving state ownership and accountability and community leaders’ engagement.

30. The GON and partners responded vigorously to the recommendation. As summarized

in Table 5, their efforts were translated into operations such as Task Forces at state and LGA levels and active monitoring by traditional and religious leaders.

Table 5: Initiatives to revitalize the momentum to eradicate polio (2009-2010)

Levels Initiatives Description National Abuja

Commitment (February 2, 2009)

All the state Governors, the President and Bill Gates signed the Abuja Commitment that defines their accountability in polio eradication including:

• Quarterly review with all LGA chairmen by the Governor

• More allocation of resources (staff and finance)

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• Quarterly reporting of polio activity status to the President

State and LGA

State and LGA immunization task forces

• State Governor and LGA chairmen organized the task forces at state and LGA levels to track standard indicators regularly.

• As of March 2010, nearly half of the states had functioning PEI coordination committees.

Community

Engagement with traditional and religious leaders

• Northern Traditional Leaders Forum and Committee on Primary Health Care Delivery convened and chaired by traditional leaders.

• Traditional leaders committed to monitor polio eradication activities and to ensure that Ward and village heads play a supervisory role in IPDs in high risk LGAs.

Source: Abuja Commitment, 2009; 18th ERC, 2009; 19th ERC, 2010

31. These efforts led to a significant reduction of polio incidents to 21 cases in 2010; and

DO and IP ratings were upgraded to “Satisfactory” since 2010. This was due to the “increased IPD coverage and reduction in ‘zero-dose’ children in the high-risk states” (19th ERC). For example, in 2009, for the first time in the history of the program, the proportion of 'zero-dose' children in nearly all states fell to below 20% (17th ERC).

32. The polio increased to 62 cases in 2011, due to: (i) national election in 2011 distracted political and local leadership from focusing on polio eradication; (ii) a deadly car bomb attack on the UN House in Abuja struck a terrible blow to the UN family (UNICEF, WHO); and (iii) increasing insecurity particularly in a few northern states (Kano, Borno) complicated the campaign operations (GPEI, 2011). However, the impact of the election, leadership changes and the UN bomb attack on the incidence of polio was much smaller than the election in 2007-08 where polio cases increased from 285 to 798 – this was partly due to the strengthened system for polio campaigns throughout 2009-10. The government reacted to this increase proactively and intensified the activities focusing on areas where polio cases concentrate – this is further discussed in section 3.2 and 4.

2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization

33. Results framework mainly tracked the two key indicators: 1) OPV coverage (PDO

indicator – target: at least 80% in endemic states); and 2) timely arrival of OPV at national store (intermediate indicator). Other intermediate indicators such as: 3) cold chain established and operational; 4) social mobilization program implemented; 5) targeted capacity building implemented; and 6) surveillance program implemented have also been tracked. This results framework and the M&E system had several strengths, which have rarely been seen within the health system of Nigeria:

• Design: It focused on a few indicators of compelling importance. It also relied on independently verifiable data, and had independent evaluation system in place – e.g., independent performance audit for buy-down, Enhanced Independent Monitoring (EIM) and Lot Quality Assurance Sampling (LQAS);

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• Implementation: There was a continuous flow of data for monitoring – e.g., weekly polio cases update using surveillance system, EIM for all states and LQAS for high risk LGAs to review the OPV coverage in each campaign, and other operational data such as staff performance, taskforce meetings carried out, and micro-plan completed and used;

• Utilization: Regular rigorous performance monitoring mechanisms ensured the use of data for decision making at each level – For example, ERC that consists of global experts of polio meet every 4-6 months with all stakeholders including senior federal and state staff, traditional and religious leaders and development partners. During the 2-day ERC meeting, all the outcomes and operational data are reviewed and discussed. The meeting ends with very specific policy recommendations from the ERC based on the data discussed, and the implementation of the recommendations are reviewed in the next ERC meeting. This enables the evidence-based policy decisions. Similar rigorous performance review mechanism is in place with monthly Presidential Task Force, and state and LGA taskforces for each campaign.

34. Some indicators, such as those for the cold chain, social mobilization, and capacity

building were defined vaguely. However, measurable indicators and independent data became available for them – e.g., percentage of the vaccination teams that meet all the predefined responsibilities (e.g., systematically conduct house-house activities; correctly record reasons and conduct revisits), availability (%) of cold chain storage. Also, indicators for surveillance (i.e., annualized non-polio AFP rate and percentage stool adequacy for surveillance) were very clearly defined. These indicators were monitored regularly and reported in every ERC. Formal assessments and surveys had also been carried out to verify the progress of the intermediate indicators – e.g., KAP survey (2008, 2010) for social mobilization, cold chain assessment (2012) and joint vaccine security mission (2003, 2010) and wastage report (2011) for cold chain.

2.4 Safeguard and Fiduciary Compliance (focusing on issues and their resolution, as applicable) 35. Environment: The environmental screening category for the project was C as it was

determined to have no significant negative environmental impact. OPV is supplied in small plastic vials which are disposed in accordance to the WHO guidelines.

36. Social: No social safeguards were triggered by the project. The project was pro-poor

as its focus has been immunizing unreached children in the northern states, where poverty and poor health status concentrate. In Nigeria during March 2002 to February 2003, OPV coverage in the northern states was 44% (median, with range: 37%-59%), while the coverage in the southern states were 86% (median, with range: 83%-95%) (CDC, 2003). The project removed this wide regional and income disparity in OPV coverage, and achieved average 89% OPV coverage in northern states where income poverty was concentrated – this is further discussed in section 3.3 and Table 9.

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37. Financial Management: A joint WHO-UNICEF mission on vaccine security in 2003

suggested that audit teams from EC and the World Bank had noted serious flaws with NPI’s financial reporting (World Bank, 2008b). To keep the project operationally simple, in this project, IDA funds were directly transferred to UNICEF, based on the withdrawal application provided by the GON. UNICEF maintained a separate ledger account for credit transactions with the Bank and provided updated funds utilization reports detailing purchase orders that were fully executed and delivered.

38. Independent audit and the review by the Bank’s Financial Management (FM)

specialist in the 1st quarter of 2006 provided “Unsatisfactory” rating and revealed the following:

• Submission of ICC reports and payment account delayed for 3 years and 8 months, and the submitted report was draft and unsigned;

• ICC finance committee reports had gap of about US$1.4 million between receipts and partners’ contribution in operating cost (not the IDA-financed component);

• Utilization reports and vaccine arrival reports were not submitted on a quarterly basis.

39. The independent audit recommended regular supervision by an FM specialist and the

team. In response, a supervision mission was conducted by the new Task Team Leader (TTL) in February 2006, and agreement was reached with the new NPI CEO on the frequency of reporting (AM, 2006). Also, a new supervision plan was put in place, defining the responsibilities of the TTL and Nigeria-based specialists in ensuring the timely receipt of the reports (Supervision Plan, 2006). Following these actions, there had been no major delays or flaws in reporting until project closure.

40. At the closure of the project in April 30, 2012, the UNICEF utilization report showed an unutilized balance of US$7.5 million. However, UNICEF, based on their agreement with the GON went ahead to further utilize this amount for further procurement of vaccines, even though by the World Bank’s policies and procedures that would not be classified as eligible. This was due to the different understanding of the definition of the eligible expenditure between the FA between GON and the Bank (i.e., only supplies delivered by April 30 is eligible) and UNICEF’s legal agreement with GON (i.e., commitments made by April 30 is also eligible). The Bank’s management has proposed a solution which allows the GON to use its own expenditures incurred in support of the Polio Program in Nigeria to substitute for these ineligible expenditures (the expenditures incurred after April 30 2012).

41. These issues did not create any disruptions on the project results such as timely OPV

supply and OPV coverage. 42. Procurement: Procurement of the vaccines was done through UNICEF on behalf of

the GON, and the NPI/NPHCDA was responsible for the distribution of the vaccines in the country. This arrangement was based on the challenges that the country faced in direct procurement by the government.

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• Due to delayed partial release of funds in 2001 and non-release of funds in 2002 and 2003 by the Ministry of Finance, all routine vaccines became out of stock, and no basic EPI vaccines except for OPV had entered the country since Q3 of 2001 (World Bank, 2008b).

• The country paid higher prices than those obtained by UNICEF who usually obtains the lowest price due to its procurement volumes and relationship with multiple manufacturers (Table 6) (World Bank, 2008b).

• With non-release of funds by the Ministry of Finance for two years, the country risked losing credibility with manufacturers, which can lead to fewer bidders for tenders. Also, it was likely that the manufacturers began to add risk factor charges. Further, the stopped order from Nigeria due to the non-release of funds could encourage more manufacturers to exit from the market, leading to even more serious global vaccine scarcity and further increase in price.

Table 6: UNICEF’s average 2003 prices compared to prices offered to Nigeria in its 2002 tender

Product Latest Nigeria tender price 2002 (US$/dose)

UNICEF world average price 2003 (UD$/dose)

Overpayment by GON compared to UNICEF

BCG 20d 0.135 0.063 +116% DPT 20d 0.180 0.085 +112% Measles 10d 0.220 0.131 +67% TT 20d 0.140 0.040 +248%

Source: World Bank, 2008b

43. With the approval of the Bank project, the government shifted to UNICEF

procurement in late 2003, and committed to the timely release of funds. As a consequence, the procurement improved remarkably with no stock-out reported at the national level since the last quarter of 2003 (World Bank, 2008b). As further discussed in section 3.2, there was no single disruption of SIA due to the delayed OPV arrival for nine years of the entire project period.

2.5 Post-completion Operation/Next Phase (including transition arrangement to post-completion operation of investments financed by

present operation, Operation & Maintenance arrangements, sustaining reforms and institutional

capacity, and next phase/follow-up operation, if applicable) 44. As the final efforts to eradicate polio, GON and development partners have been

increasing commitments and intensifying activities (See section 3.2 for details).

45. GON increased its commitment to eradicate polio: GON has demonstrated commitment to the polio eradication at the highest level by the establishment of a Presidential Task Force and Accountability Framework with oversight by the President. The commitment increased with the 2012 Polio Eradication Initiative (PEI) Emergency Plan and the agenda for the Presidential Task Force that includes monthly meetings to review the progress. The government committed US$30 million each

13

year for polio immunization for the next two years, allocated US$50 million for polio and routine immunization to NPHCDA in early 2012, and transferred part of the finance to WHO for their operational cost. It has rarely been seen in Africa that a country pays a development partner for their staff cost.

46. Partners are also intensifying the support: A repeater project (P130865, US$95

million) was approved by the World Bank Board on July 10th, 2012, which will provide OPVs for the next two years through the same mechanism as this project. Furthermore, BMGF plans to strengthen the performance management on polio eradication in the five endemic states, and is preparing a project to improve routine immunization with the Dangote Group and the Governor of Kano state that recorded 2nd largest number of cases this year. Bilateral agencies such as JICA and KfW are also preparing to finance intensified SIA operations.

3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation (to current country and global priorities, and Bank assistance strategy) Rating: High Summary

• The project was highly relevant as it aligned with global, national and the World Bank’s priorities, and the project approach appropriately responded to the urgent OPV procurement needs.

• Project implementation was also highly relevant as it forged strong partnerships between the government and partners, as well as with states and local leaders probably for the first time at this scale in the health sector in Nigeria. Use of UNICEF in procurement also transformed procurement capacity and efficiency.

Relevance of Objectives: High 47. As a global public good: Polio eradication is a global public good because of its

epidemic potential across countries. Polio remains a lethal and maiming disease that is entirely preventable. Nigeria is one of three remaining countries where polio remains endemic, and poliovirus has spread into West Africa from the country, causing outbreaks in previously polio-free areas (GPEI website). The project fully supported this important goal.

48. As a part of the national program: As above mentioned, the project was fully

integrated into the national polio eradication program and provided important financial and technical support for OPV supply. Polio eradication is one of the six pillars of the country’s “Saving One Million Lives” initiative, a countrywide initiative that aims to address issues of fragmentation of programs and efforts, suboptimal coordination and lack of focus on results, and most importantly to save lives through effective health interventions.

14

49. As a priority aligned to the Country Partnership Strategy (CPS) objective of the Bank: The operation was also aligned with regional strategic priorities and in line with the CPS objective of assisting Nigeria to reduce poverty through improvements in health status and higher productivity levels. It also supported the Bank’ s commitment to the Millennium Development Goals (MDGs) by improving access to quality health services, vaccination coverage and maternal care services (PAD, 2003).

Relevance of Design: Substantial 50. Relevant project approach: As discussed in sections 2.1, 2.3 and 2.4, three elements

of design were innovative and highly relevant in the Nigerian context: (i) The performance-based buy-down arrangement that filled the financing gap that

other countries experienced without the buy-down arrangement, and provided a strong incentive for the country to achieve the agreed result;

(ii) Simple design with clear demarcation with other partners and robust M&E framework and performance review system that allowed the availability of reliable data collected and utilized at every campaign; and

(iii)Utilizing UNICEF procurement that eliminated vaccine stock-outs and achieved low cost and uninterrupted procurement of OPV for the entire project period.

Relevance of Implementation: High 51. Strong partnership with GON and partners: As a part of the country’s program to

eradicate polio, the project was implemented in very close collaboration with the GON and development partners. The Bank financed the OPV through UNICEF, UNICEF ensured the purchase and on-time delivery of OPV to the national store, and NPI/ NPHCDA with support from UNICEF ensured the on-time arrival of the OPV from the national store to the campaign sites. WHO and UNICEF supported supplementary activities such as cold chain, capacity building and monitoring of vaccination team, social mobilization and surveillance. BMGF provided GIS for micro-planning and monitoring, and financed the trust fund for the buy-down with Rotary, CDC and UNF. Roles were clearly defined while information was widely shared through well structured meetings (e.g., ICC an ERC at the policy level, and technical group meetings by activity and state and LGA). This allowed the highly efficient operations with least transaction cost.

52. Relevant procurement implementation: As discussed in section 2.4, despite the

constrained OPV market and changing polio epidemiology that required the complicated forecasting of different types of OPVs, UNICEF managed to procure sufficient number of OPVs on time for every campaign. Before the UNICEF procurement, Nigeria struggled with forecasting and data management. The country was able to submit only one annual report to WHO on immunization coverage in 1999-2005, despite the annual requirement (World Bank, 2008b). By UNICEF, the vaccine forecasting had been done two quarters in advance (World Bank, 2008b).

53. Strong result-focused partnership with states and local leaders: The health

systems in Nigeria is fragmented with the federal government only responsible for

15

tertiary care while state governments manage secondary, and LGAs manage primary care. In practice there are many overlaps in roles and responsibilities, with state controlling the funds release and major human resources functions (Oxford Policy Management, 2011). Limited roles of the federal government in primary care generally make the country programs inefficient and difficult to implement.

54. In contrast, in polio, under the Abuja Commitment (Table 5 for details) signed by the

President, state Governors and Bill Gates, accountability of the state Governors and LGA Chairmen and data reporting and performance review mechanisms were clearly defined, implemented and monitored (e.g., meeting of state/LGA taskforces and meeting of Governor and LGA Chairmen were monitored in every campaign). This result-focused data review and accountable partnership between federal government, state and LGAs would be the first successful model at this scale in Nigeria. This model is quoted by a joint partner review mission by World Bank, Global Fund, DFID, USAID, CHAI, etc. as a good example to follow for the country’s “Saving One Million Lives” initiative (Joint Partners Review Mission, 2012).

55. Furthermore, GON also established effective collaboration with traditional and

religious leaders in the northern states. They committed to monitor polio eradication activities, ensure that Ward and village heads play a sufficient supervisory role in each campaign, and contribute to the selection of competent vaccinators in high risk LGAs. This was the first effective involvement of local leaders in primary health care delivery at this scale in Nigeria, and contributed to the rapid reduction of polio cases in 2009 and 2010, as well as current increase in OPV coverage in smaller hot spots (e.g., high-risk/endemic LGAs).

3.2 Achievement of Project Development Objectives (Efficacy) (including brief discussion of causal linkages between outputs and outcomes, with details on

outputs in Annex 2) Rating: High Summary

• The project increased the OPV coverage in the northern endemic states (PDO indicator) from 44% in 2002-2003 to 89% and achieved the target of more than 80% coverage in the northern endemic states.

• It also improved vaccine procurement significantly from stock-outs of all routine vaccines in 2003 to no stock-outs at the central level, and ensured that all the OPVs arrived without delays in every campaign during nine years of project period.

• Moreover, the functional systems and tools developed through the project for the immunization campaigns were remarkable and something that the country had never achieved at this scale given its fragmented health systems.

16

PDO Indicator: Effective OPV Coverage in children under 5 years of age (Target: at least 80% in all endemic States) - Achieved 56. The PDO indicator, i.e., “OPV coverage at least 80% in endemic states” was

surpassed in the independent performance audits carried out by the Bank in four northern states in October 2010, and in eight northern states in October and November 2012 (Figure 1). In the audit in 2012, average OPV coverage reached at 89%. This is a remarkable improvement given the baseline OPV coverage of 44% (median, with range: 37%-59%) in 12 endemic northern states (CDC, 2003). The audit rated this improvement “Very impressive” (PHSS, 2011), and concluded that buy-down should be triggered.

Figure 1: Effective OPV coverage (%) in selected northern high risk states (October, 2010, October/November 2012), based on independent performance audit

83%

76%

89%94%

91%

84%88%

93%

84% 84%

91%95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Borno Kano Zamfara Katsina Jigawa Sokoto Kaduna Bauchi Niger

2010 Oct

2012

Oct/Nov

Source: PHSS, 2011 and 2012; CDC, 2003

Key Intermediate Indicator: Timely delivery of OPV - Achieved 57. Timely delivery of OPV for use in FGN polio eradication program was an

intermediate indicator, but also defined as an indicator that measures the project’s success in the PAD and FA, along with OPV coverage. The project had achieved this indicator for the entire period of the project:

• Despite the current global polio vaccine production constraints, for nine years of the entire project period, there was no single incidence that polio campaign was postponed because of the delay in OPV arrival.

• Independent audit concluded that robust vaccine procurement was in place and that NPHCDA had a strong system to clear vaccine shipments as soon as they arrived at the airport and transport them to states within 48 to 72 hours (PHSS, 2011).

Target 80%

Baseline in 2002-03 44% (range 37-59%)

Achieved average 89%

17

• Before the project, government’s direct procurement led to the stock-outs of all routine vaccines in 2003. This threatened the supply of OPV. The project procured the OPV through UNICEF, which immediately eliminated the stock-outs of routine vaccines at the central level since the last quarter of 2003 (World Bank, 2008b).

Other Intermediate Indicators: Cold chain, social mobilization, capacity building, surveillance 58. In addition to the achievement of the PDO indicator and the key intermediate

indicator on OPV delivery, as summarized in Table 7, there has been a remarkable strengthening of the system for polio immunization over the project period. Moreover, as highlighted in Table 5 and section 3.1 above, probably for the first time in Nigeria at this scale, the project has built a result-focused accountable relationship between federal, state and LGA levels, as well as the effective partnership with traditional and religious leaders. Micro-plans that capture all households were also developed for the first time and provided a basis for data-based immunization and monitoring in endemic states. These achievements stand out, given the difficulty in building a functional service delivery mechanism under the fragmented health system in Nigeria.

Table 7: Output indicators and summary achievements

Output indicators

Summary achievements

Cold Chain system established and operational.

Established and operational

• Large number (about 1,000 per year) of cold chain equipment (i.e., freezers and fridges) were installed in 2006-2008 to support RI and campaigns (UNICEF record).

• As a result, 75% of state-level stores have sufficient capacity for Routine Immunization (RI) and penta immunization (after planned repair). Further, 90% (after planned repair) of LGAs in 20 states have adequate physical capacity to accommodate RI and new/underutilized vaccines (Cold Chain Capacity Assessment – draft, 2012).

• The draft assessment concluded that all the state stores except Delta and Ondo and all the LGAs in the reviewed 4 states are ready for new vaccine introductions (Cold Chain Capacity Assessment – draft, 2012).

Social mobilization program implemented.

Implemented • Awareness of diseases that affect children is highest in polio at 75% in 18

states in 2010, a 50 % increase from 2007 (KAP survey, 2010). This is significant given three of the five most recognized diseases (i.e., measles, malaria and diarrhea) reduced or did not improve their recognition (KAP survey, 2010).

• 1,827 trained volunteer community mobilizers (VCM) and 184 ward supervisors are in place to conduct community sensitization in seven high-risk states (24th ERC, 2012).

• Organized support from traditional and religious leaders has been available – e.g., Emirs have signed a pact with the Sultan to fix vaccinator selection/accountability problems in the worst wards (24th ERC, 2012).

Targeted capacity

Implemented • Average 72% of vaccination teams meet all the criteria for good performance

18

building program implemented.

(e.g., follow micro-plan, enter every household) in 2012 (WHO data).

• All LGA PHC coordinators and local immunization officers were trained in micro-planning, training, and vaccination team selection.

• Health educators at LGAs were trained to engage with traditional leaders and implement social mobilization – 88% of the entire teams evaluated to have sufficient inter-personal communication skills in 2012 (WHO data).

• Health facility staff were trained as ward focal persons and supervisors for (i) micro-planning at ward level and (ii) supervision of vaccinators.

• Team members of 63 LGAs, 1,577 VCMs and 167 Ward Supervisors were trained on community involvement approach in 2012 (ongoing).

Surveillance program implemented

Implemented and achieved the targets

• Acute Flaccid Paralysis (AFP) detection rate has been meeting the target of at least 2 cases per 100,000 (with average 7-8 cases) in all regions.

• The adequate stool specimen target of more than 80% has been attained in all states (e.g., average 93% in 2010 and 2011).

• Percentage of LGAs meeting the above two targets increased from 75% in 2007 to 88% in 2012 (WHO data).

• The two national polio laboratories reduced the median time between date of onset of an AFP to final results from 32 days in 2008 to 12 days in 2009 (WHO data). Ibadan is provisionally accredited in July 2012 (24th ERC, 2012).

Program goal/Sector indicator: Interruption of polio 59. The ultimate goal of the country’s program was the eradication of poliovirus and the

project assisted the country by ensuring uninterrupted timely OPV supply to the campaigns. PAD and FA was clear that the project's success will be measured by the achievement of the targets for OPV coverage and timely OPV delivery (PAD 2003, FA 2003).

60. The project did not use the number of polio cases as a project indicator, because: (i) it is beyond the scope of the project; and (ii) the epidemiology of polio is complex and dynamic and cannot model. Although the project met its targets as a part of the country program, the country has not achieved its ultimate program goal yet.

61. However, clear progress had been made during the project period. Figure 2 shows

that all the momentum was lost with the unexpected widespread rumor about negative side-effects of OPVs and the subsequent rejection of polio campaigns by the northern states in 2003-05. In contrast, the reduction of cases after 2006 has been remarkable.

19

Figure 2: Past trend of total confirmed polio cases in Nigeria (2002-2011)

202

355

782830

1122

285

798

388

2162

0

200

400

600

800

1000

1200

02 03 04 05 06 07 08 09 10 2011

Source: WHO statistics

62. This progress was also reflected in the number of states that became free from polio.

Figure 3 shows that the polio-free states increased from 13 states in 2002-09 to 27 states (75% of entire country) in 2010-12 (Figure 3). Polio had been contained in limited number of northern states. In 2012, just three states (Kaduna, Kano, Katsina) have 60% of all polio cases (WHO data). Likewise, the number of LGAs within states with polio cases decreased from 243 LGAs in 2009 to 55 LGAs in 2012 (Figure 4).

63. The fact that the OPV3 coverage in northern states increased from 44% in 2003 (CDC, 2003) to 89% in 2012 (PHSS, 2012) also suggests that the reduction of cases after 2006 was backed by robust systems improvements and improved OPV coverage.

Figure 3: Number of polio-free states in Nigeria

21

13

5

15

18

13

109

28 28

25

0

5

10

15

20

25

30

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: WHO data

Project period

Long unexpected rejection of SIAs and non-compliance

Significant reductions with system strengthening

Avg 13

States

Avg 27

States

20

64. The comparison of the polio trends with other endemic countries in Table 8 explains the complex and dynamic nature of the polio eradication. The dynamic trend in Nigeria looks similar to the trend in India that declared polio-free status earlier this year. In India, just a few years before the polio-free status there were 741 cases of polio and interruption of transmission looked unlikely. In contrast, Pakistan and Afghanistan have not eradicated polio even after the 10 years of low polio incidence. This is possibly due to insecurity that allows pockets of wild polio virus to persist. Moreover, cases in Pakistan increased recently, making it the country with the most polio cases in 2010-11.

Table 8: Comparison of polio endemic countries (2002-2011)

Year 2002 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 2011

Nigeria 202 355 782 830 1123 285 798 388 21 62

India 1600 225 134 66 676 874 559 741 42 1

Pakistan 90 103 53 28 40 32 117 89 144 192

Afghanistan 10 8 4 9 31 17 31 38 24 76

Source: WHO statistics

65. Nigeria is treating the setback experienced in 2011 (GPEI, 2011) and polio cases

increased to 108 cases as at November 30, 2012. However, the progress made through the project contained polio. The number of LGAs that have polio cases dramatically decreased from 243 LGAs in 2009 to 55 LGAs in 2012 (Figure 4). Given these achievements during the project, the remaining challenge will be to achieve immunity coverage (at least 80%) in the smaller hot spots (e.g., LGAs) where polio cases concentrate. Main issues in these hot spots include: (i) lack of data that covers all the households; (ii) insufficient rigor/motivation of vaccination teams in vaccinating all children they are responsible to vaccinate; and (iii) non-compliance of mothers in vaccinations influenced by persistent rumors and scare mongering.

Figure 4: Number of LGAs with polio cases

153

244

223234

163

243

199

22

4255

0

50

100

150

200

250

300

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: WHO data

21

66. The country has set appropriate approaches to these issues. Most importantly, it focuses its vaccination and monitoring efforts on the limited number of specific hot spots of polio. For these areas, it has developed new micro-plans that record all the households to avoid missing any children. This is integrated into GIS for more effective planning and monitoring. It has also promoted rigorous selection of the vaccination team, with help from the traditional and religious leaders who know all the community members. Team composition has been changed to have more teams in the endemic areas. Further, to make the vaccination team, ward leaders and LGA chairmen accountable for results, the country has put in place LQAS, a rigorous survey to assess the OPV coverage, in all the high-risk/endemic LGAs. The movements of the vaccination teams are also monitored in real time through the GPS and teams that have not visited communities or miss households are to be identified immediately. For non-compliance, UNICEF deployed 1,827 trained volunteer community mobilizers (VCM) who are rooted in communities and speak the local language. Support by traditional and religious leaders who have a strong influence on local communities has also been organized through regular monitoring mechanisms.

67. As a result of these effective and intensified approaches, 53% of highest risk/endemic

LGAs achieved over 80% OPV coverage in October 2012. This was a rapid increase from 16% in February 2012 (Figure 5). This improvement in immunization coverage in smaller hot spots of polio is ongoing, and shows encouraging progress. If this positive trend continues, the impact on polio cases should become evident in the coming year.

Figure 5: Percentage of high risk LGAs that achieved >80% OPV coverage

13%

23%

16%

24%

35%37%

53%

0%

10%

20%

30%

40%

50%

60%

2010

(Avg)

2011

(Avg)

Feb-12 Mar-12 May-12 Jul-12 Oct-12

Source: WHO data

154 140 82 86 108 145 134 Number of LGAs sampled

22

3.3 Efficiency (Net Present Value/Economic Rate of Return, cost effectiveness, e.g., unit rate norms, least cost,

and comparisons; and Financial Rate of Return) Rating: Substantial Summary

• The economic benefits and pro-poor nature of the benefits suggest the high rate of return of the polio eradication initiative, even with conservative scenarios.

• The project established efficient and effective operations with focused, data-driven and accountable approaches and lowest vaccine and supervision costs.

68. High Economic Return and Equity: An economic analysis estimated that the incremental net benefits of the GPEI between 1988 and 2035 assuming that the polio will be eradicated in 2015 are US$40 billion (Tebbens et al, 2010). Sensitivity analysis suggested that the net benefits remains positive over a wide range of assumptions, and that including additional externalities such as mortality reduction with Vitamin A supplements together with OPVs increases the net benefit to US$59-130 billion (Tebbens et al, 2010). Given that the difference in the incremental net benefits between the 2012 eradication scenario and 2015 eradication scenario is about US$2 billion (Tebbens et al, 2010), further delays in eradication will only marginally reduce the estimated net benefits. As discussed in section 3.5 below, under the IPD strategy, Nigeria has been distributing on average 27 million doses of Vitamin A every year since 2006 focusing on the northern states. This should have contributed significantly the external benefit and equity impact of the PEI in the country.

69. Furthermore, as discussed in section 2.4, the polio campaign itself was pro-poor. In

2002-2003, OPV coverage in the northern states was 44% (median, with range: 37%-59%), while the coverage in the southern states were 86% (median, with range: 83%-95%) (CDC, 2003). The project removed this wide regional and income disparity in OPV coverage and achieved average 89% OPV coverage in northern states where income poverty was concentrated. Table 9 that compares income, education and other key health indicators between the north and south indicates that the achievement in equity in the OPV coverage through the project is remarkable.

Table 9: Comparison of Northern and Southern states

Indicators North South Inequality ratio* 1. People in lowest income quintile (%) 33.4% 5.2% 6.4

2. Female who completed primary education (%) 7.9% 14.3% 1.8

3. Births assisted by skilled health worker (%) 23% 71.7% 3.1

4. Children 12-23 months fully vaccinated (%) 13.3% 40.7% 3.1

5. OPV coverage per campaign (%) 89% n/a Less than 1.1** * Calculated by North/South for indicator 1, and South/North for indicator 2, 3, 4, 5. ** 1.1 assuming that southern states attained 100% OPV coverage (Improvement from 2.0 in 2002-03). Source: NDHS 2008, PHSS2012

23

70. Efficient Operation: The project established least cost and effective operations.

• Least cost OPV: Procurement through UNICEF ensured the least cost of OPV due to large volume of purchase and greater competition among manufacturers (World Bank, 2008b), while ensuring uninterrupted timely delivery of OPV to campaign site during the entire project period (See table 6).

• Low cost Bank supervision: Simple design and focused target (e.g., with single PDO indicator) of the project allowed the very low staff cost including preparation and supervision (Total US$263,090 for six years – US$43,848 per year).

• Focused operations: Very focused intensive operations in endemic states and recently on limited high-risk/endemic LGAs in these states allowed the highest return on investment.

• Data-driven operations: As discussed in section 2.3, country’s operations were fully guided by reliable data (e.g., LQAS, household micro-planning and GIS) that are collected and used in every campaign (i.e., nine times a year in endemic states).

• Accountable partnership: As discussed in section 3.1, the country established an accountable and collaborative relationship between federal, state and LGAs as well as with local leaders. Further, the demarcation with other development partners was very clear, which minimized the transaction cost.

3.4 Justification of Overall Outcome Rating (combining relevance, achievement of PDOs, and efficiency) Rating: Satisfactory Relevance Achievement of PDO (Efficacy) Efficiency

High High Substantial Overall Outcome Rating: Satisfactory

• Relevance – High: As discussed in section 3.1, project objective, design and implementation were highly relevant, with many innovative and effective approaches (e.g., buy-down, utilization of UNICEF, partnership with state and local leaders).

• Efficacy – High: The project overcame the widespread rejection of polio campaigns and achieved the PDO indicator of 80% OPV coverage (with average 89%) at endemic states. It also achieved the timely arrival of vaccines for campaigns for the entire nine years. Furthermore, it established robust systems for polio immunization of a quality and scale that the country had never experienced.

• Efficiency – Substantial: Project efficiency was substantial, with high economic benefits and equity and least cost operations with focused, data-driven and accountable approaches.

• The country has not yet achieved its broader goal of polio eradication, but the impact of recent focused efforts in high-risk LGAs suggest that the country is making good progress toward the goal.

24

3.5 Overarching Themes, Other Outcomes and Impacts (if any, where not previously covered or to amplify discussion above)

Summary

• The project raised awareness of polio from 50% to 75% and removed the inequality in the OPV coverage between the north and south.

• It also distributed 162.4 million doses of life-saving Vitamin A in 2006-2011 focusing on the children in the northern states – This should have protected millions of children from Vitamin A deficiency-led diseases.

• The project has established valuable systems and tools that can serve routine immunizations (RIs) and other health services – many of them such as micro-plans, cold chain and surveillance have been fully used for RIs or other services.

(a) Poverty Impacts, Gender Aspects, and Social Development

71. Project reduced the inequality in OPV coverage and raised awareness on polio:

As noted in Section 1.4, 2.4 and 3.3, SIAs targeted poor, remote and underprivileged communities whose immunization coverage tends to be lowest while their vulnerability to polio is high due to unsanitary and crowded living conditions. The fact that the project raised the OPV coverage in the northern states from 44% to 89% which is the same level as the coverage in the southern states is remarkable from equity perspective (See Table 9). The social mobilization and communication strategy also raised awareness of polio across the country. Polio becomes the most salient disease mentioned that affects children under five years, with 75% awareness in 2010 up from 50% in 2007 (KAP Study, 2010).

72. Project provided life-saving vitamin A and other health interventions with OPV:

Furthermore, through the IPD strategy that provides other health interventions with the OPV vaccination, the campaign approach brought significant additional health benefits to the under-five children. Most remarkably, since the start of the IPD in 2006 until 2011, 162.4 million doses of vitamin A had been provided to the under-five children focusing on northern states (on average 27 million doses per year) (WHO data). Vitamin A deficiencies can lead to blindness, weaken immune system of the children and make them vulnerable to common diseases such as measles, malaria, diarrhea and acute respiratory tract infections. One high-dose vitamin A capsule can provide a child sufficient vitamin A for six months, and this alone can reduce under-five child mortality by about 24% in populations at risk of vitamin A deficiency (Vitamin angels, 2012). 31.3% of children under-five year old in the sampled northern states (i.e., Kaduna, Kebbi, Kano, and Borno) were vitamin A deficient (Maziya-Dixon et al, 2006). A simple estimate assuming the above prevalence of vitamin A deficiency, efficacy of the vitamin A treatment and necessary frequency suggest that the IPD should have protected about 1-2 millions of children from the vitamin A deficiency-caused diseases.

73. Furthermore, the vitamin A distribution contributed to equity. 123 million doses

(76%) had been provided in the northern states, and the ratio of the total Vitamin A distribution to the estimated population of under-five children was 9.1 in the northern

25

states compared to 3.6 in the southern states (WHO data). This suggests that the IPD approach added significant pro-poor impact on the target population. In addition to the Vitamin A distribution, soaps (52 million), insecticide-treated bed nets (ITNs) for malaria prevention (3 million), albendazoles (0.5 million) and oral rehydration salt (ORS) (0.1 million) was provided with the OPVs (WHO data).

(b) Institutional Change/Strengthening (particularly with reference to impacts on longer-term capacity and institutional development)

74. The project has established systems and tools that can also serve RIs and other health

services (Table 7). Many of them such as micro-plans, cold chain and most notably surveillance have already been used for RIs or other services (Table 10).

Table 10: Major system strengthening through the project and its utilization

Established systems

Institutional strengthening through the project (Examples)

Utilization of the strengthened system in RI or health services

Collabora-tion with State/LGA/ local authority

• Governor’s quarterly review with all LGA chairmen.

• Task Forces at state and LGA levels to track standard in every campaign.

• Accountability framework defines and monitors deliverables of State/LGA/Ward.

• The same state, LGA and ward teams are used for other campaigns such as measles, meningitis and yellow fever.

Micro-plans • Household-based micro-plans are ready for 96% of prioritized LGAs (24th ERC, 2012).

• Geographical Information System (GIS) has been introduced to map households for planning/monitoring.

• New micro-plans will be used in the upcoming measles and yellow fever campaigns (GON, 2012b; 2012c).

Cold chain • 75% of state and 90% of LGA storages have sufficient equipment for RI and campaigns.

• The installed equipment has been fully utilized for RI and other campaigns for measles, meningitis and yellow fever.

Trained personnel

• All LGA PHC coordinators and local immunization officers were trained for micro-planning, training, etc.

• Health educators were trained for engagement with traditional leaders.

• Health facility staff were trained as supervisor of vaccinators.

• Same health workers have been used for other campaigns as well as for RI, which built broader immunization capacities.

Social mobilize-tion

• 1,827 trained VCM and 184 ward supervisors were deployed in seven endemic states.

• Traditional leaders monitor Ward and village level immunizations and engage with non-compliance households.

• Approaches for polio are fully utilized for measles and yellow fever vaccination campaigns (GON, 2012b; 2012c).

Survei-llance

• Each LGA has at least one Disease Surveillance and Notification Officer (DSNO) for initial investigation.

• DSNOs and facilitators have already been fully utilized for the surveillance of other

26

• WHO employs an LGA facilitator per LGA and cluster level consultants to support DSNOs in AFP surveillance.

diseases such as measles, neo-natal tetanus, yellow fever, meningitis (See below).

75. The use of institutional arrangements established under the project is remarkable in

surveillance where the surveillance structure, human resources and laboratory developed through polio program have been fully utilized to detect and control other diseases. Examples include the following:

• Measles: Nigeria used the existing AFP surveillance structure and started measles case based surveillance in 2006. All Disease Surveillance Notification Officers (DSNOs) were trained on measles case based surveillance. Measles performance indicators show progressive improvement over the years. In Figure 6, both rate of reporting of suspected measles and non-measles febrile rash illness rate increased over time. Also, the percentage of districts investigating measles increased dramatically. These data suggest that the rate of reporting of suspected measles went up because of the improved reporting, rather than of the increase in measles cases. Further, regular surveillance has helped in guiding the program to target high risk age groups in follow-up measles campaigns (WHO data).

Figure6: Improvements of measles surveillance

Source: WHO

• Neonatal tetanus (NNT): The polio surveillance structure was also used to start surveillance for NNT in 2006, and this has been fully functional since 2007. Geographical distribution has been established throughout the country. This information has been used to determine the priority states and LGAs in NNT elimination interventions. Three Southern States (Abia, Rivers and Ogun) were targeted for mass TT campaign in 2009 and 2010 (WHO data).

Rate per 1,000 popula-tion

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• Yellow fever: Nigeria started case and laboratory based surveillance for yellow fever in 2009 using the polio structure. In 2010, 552 suspected cases were investigated from 190 LGAs. In 2011, 360 cases were investigated from 128 LGAs. Percentage of cases that had blood samples collected achieved 98%.

• Cerebro-spinal meningitis (CSM): In 2009, Nigeria experienced a large epidemic of meningitis. The existing surveillance structure was used to detect and report cases. More than 56,000 CSM cases have been reported with 2,477 deaths. With focused effort using the surveillance data, the burden of meningitis fell to 1,120 CSM cases and 61 deaths in 2011.

(c) Other Unintended Outcomes and Impacts (positive or negative)

76. The polio activities carries opportunity costs for health systems delivering other

health services. 2 weeks prior to and a week after each NID and SID, core part of the health systems at LGAs such as PHC coordinators, local immunization officers and health educators, as well as health facility staff such as OICs and skilled health workers are engaged in the campaigns.

77. In 2012, two NIDs and two MCH weeks across the country, and five SIDs in the northern endemic states were implemented in a year. This means nine campaigns a year in the northern states, and each campaign uses about 3 weeks of the health staff’s time at the LGA and health facility levels.

78. However, outpatient visits to public PHC facilities in Nigeria is typically less than 2

visits per day even when the health center has more than 10 staff2. This serious underutilization of health workers could absorb the intensified activities in polio campaigns. Rigorous study would be needed to understand the real opportunity costs of the polio campaigns in the Nigerian context.

3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops (optional for Core ICR, required for ILI, details in annexes) Not applicable.

4. Assessment of Risk to Development Outcome Rating: Moderate 79. As discussed in section 3.2, the project achieved the 89% OPV coverage in endemic

states and contained poliovirus into limited number and area of hot spots (e.g., LGAs). The country has started intensifying the efforts to increase the OPV coverage in these high-risk/endemic LGAs, which already started show encouraging results (Figure 5).

2 This has been particularly well documented in Nasarawa, Ondo, and Adamawa states where the Nigeria State Health Investment Project has been pilot-tested.

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Therefore, the risk that development outcomes (i.e., immunity OPV coverage – more than 80%) will not be maintained is Moderate.

80. Table 11 summarize the major risks for the country to further increase the OPV

coverage in the remaining high-risk/endemic LGAs and to achieve its ultimate goal of polio eradication. They include: 1) deteriorating security; 2) performance of vaccination teams in smaller spots of high-risk areas (e.g., LGAs); and 3) persistent rumors/scare mongering. As discussed in section 3.2 and in Table 11, the country has been intensifying the appropriate approaches for 2) and 3).

81. Most challenging risk would be 1) deteriorating security. This causes multiple

challenges in campaign operations including campaign delays, inability to mobilize international staff, low staff retention and long travelling time (Table 11). NPHCDA plans to have an in-depth analysis of nature and impact of insecurity on the program, while strengthening the involvement of local leaders and community members. So far, the OPV coverage in the high risk LGAs in two especially insecure states (Borno and Yobe) have been above the average of endemic states (LQAS).

Table 11: Current Risks to polio eradication and GON’s risk mitigating activities

Key risks Rating Reasons Risk Mitigating Activities 1) Deteriorating security in the northern states can make polio campaigns difficult and less effective

Significant

• Threat of the terrorist group Boko Haram is increasing.

• Deteriorating security in northern states is leading to:

- Delays in campaigns; - No international staff

(WHO) deployed; - Low retention of

national staff; - Much longer travelling

hours for vaccinators (with security checks).

• NPHCDA plans to have an in-depth analysis of nature and true impact of insecurity on program performance and develop a plan for implementation in insecure areas (24th ERC).

• Strengthen the involvement of local traditional and religious leaders in team selection and monitoring of campaigns (24th ERC).

• Utilize the local community members for vaccination and social mobilization teams.

• So far, the OPV coverage in the high risk LGAs in two states with serious security risks (i.e., Borno and Yobe) have been above the average of endemic states (LQAS).

2) Vaccination teams with insufficient performance exist in smaller spots of high-risk areas (e.g., LGAs)

Moderate

• “Children absent” (71%) and “has not visited” (6%) accounted for 77% of the reasons of having missed children, which suggests persistent vaccinator performance issues combined with heightened security

• Doubled the number of teams in the high risk areas by restructuring the team composition (23rd ERC).

• Local traditional and religious leaders strengthened engagement in team selection and monitoring of team performance (24th ERC).

• Strengthen planning and monitoring in the high-risk LGAs by utilizing household-based micro-plans and

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issues (24th ERC, 2012).

introducing the live monitoring of team’s movement through GPS.

• Develop emergency operations centres in endemic states to strengthen the performance management at state, LGA and vaccination team levels.

3) Persistent rumors/scare mongering can lead to non-compliance of the mothers

Moderate

• “Non-compliance (NC)” accounted for 23% of the reasons of having missed children (24th ERC, 2012).

• NC spread across 8 states, and detailed research required to understand NC due to ‘no reason given’ and ‘child absent’ as the main reason for missed children. (UNICEF, 2012)

• Deployed 1,827 trained VCMs and 184 ward supervisors who speak local language (24th ERC).

• Recruiting 158 LGA and 40 additional State social mobilization consultants (24th ERC).

• Introduce analysis of coverage data, tally sheet, VCM household data, and identified chronically missed children after each campaign (UNICEF, 2012)

• Introduced quarterly feedback from Northern Traditional Leaders Committee to maintain their participation & support.

5. Assessment of Bank and Borrower Performance (relating to design, implementation and outcome issues)

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry (i.e., performance through lending phase)

Rating: Satisfactory 82. As discussed in section 2.1 and 3.1, the project introduced a number of innovative

and effective approaches such as the performance-based buy-down, simple OPV financing integrated into the GON’s program, single sourcing of UNICEF for procurement. These approaches filled the OPV financing gap, enabled the focused implementation on the OPV supplies and eliminated the devastating stock-outs of routine vaccines. Furthermore, despite the introduction of these new approaches, the project processed from concept review to Effectiveness in eight months. The innovative solutions to the financing gap and rapid response made the Bank’s performance at entry “Satisfactory”.

(b) Quality of Supervision (including of fiduciary and safeguards policies)

Rating: Satisfactory Summary

• Despite the initial supervision and reporting issues, Bank’s supervision has been highly effective in making sure that the country has sufficient OPVs to carry out accelerated SIAs throughout the nine years of the project period.

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• The Bank participated in ERC as a “leading voice” and contributed to innovate the campaign approach with IPD, which enabled the 75% reduction of polio cases and distribution of 162.4 million doses of life-saving vitamin A. The government and partners also highly appreciated the clear communication and reliable delivery of committed outputs.

83. Responsive support to assure continuous OPV supplies for campaigns: There

were four occasions where the shortage of OPVs were expected due to delays in polio eradication and intensified SIAs (2003, 2005, 2008 and 2011). Each time the Bank responded rapidly to fill the gaps through the project and additional financing. This was very responsive and relevant support to the government. During the interview, the NPHCDA and partners (e.g., WHO, UNICEF) highly valued the Bank’s clear and reliable communications and on-time delivery of committed outputs.

84. Insufficient supervision at the early stage: Only one formal supervision mission

was carried out from March 2004 to January 2006. ISRs during the period (May, December 2004, and June, December 2005) did not describe progress and issues sufficiently, except for the ISR in September 2004 when the project was rated “Unsatisfactory”. This coincides with the period when IP rating deteriorated due to poor reporting (See section 2.4 for details). However, in response to this, changes were made; and the frequency of supervision missions, quality of ISR, and reporting by the GON/UNICEF improved significantly, with the change of TTL. These issues at the early stage did not affect the campaign operations and sufficient OPVs had been delivered to campaign sites without delays.

85. Contributions to innovate campaign operations: As explained in section 2.3, the

main supervisory mechanism was the ERC given its supervisory role and expertise in the GON’s polio eradication program. Bank fully participated in the ERC meetings. The Bank’s contributions in ERC was appreciated as a “leading voice” (Interview, WHO). For example, the Bank promoted the IPD approach3 to incentivize the communities to take vaccination and provide other essential health intervention using polio mechanism. This contributed to the 75% reduction of the polio incidence in 2007 (ISR, January 2007), and enabled the distribution of 162.4 million doses of vitamin A in 2006-2011, which could have protected millions of children from vitamin A deficiency-led diseases.

86. Least cost supervision: As discussed in section 3.3, simple design, focused

implementation and use of ERC as the main supervisory mechanism enabled the Bank to achieve the PDO with the very low staff cost including preparation and supervision (Total US$263,090 for six years – US$43,848 per year).

3 An innovative approach that entails (a) introduction of fixed posts during which children were physically seen and vaccinated (b) inclusion of injectable antigens such as Measles and DPT that parents appreciated more and (c) the use of trained health workers during IPDs rather than volunteers who were used during house-to-house campaigns.

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(c) Justification of Rating for Overall Bank Performance

Rating: Satisfactory

• The Bank made it possible for the country to have sufficient amount of OPVs without any stock-outs or delays for every polio immunization campaign for the entire project period. , by developing innovative project design and providing flexible financing. Given that there were large finance gap and stock-outs of all routine vaccines, this was remarkable achievements.

• Despite the initial supervision and reporting issues, the Bank’s supervision has been highly effective in ensuring the stable OPV supply and promoting innovative approaches (e.g., IPD) while maintaining the least cost operations and supervision.

5.2 Borrower Performance (a) Government Performance

Rating: Moderately Satisfactory

87. High level political commitment: Remarkable political commitment and ownership by the GON had been demonstrated and translated into operations and finance during the project. For example, Abuja Commitment signed in 2009 between the President, all state Governors and Bill Gates defined their responsibilities in polio eradication (Table 5) and developed an accountable collaboration between the federal and state levels. This is probably the first functional accountable partnership between the federal and state levels in the health sector at this scale. Since then, the Presidential Task Force, Governors’ Task Forces and LGA Task Forces had been operational to track the achievement against targets for each level at every campaign. As discussed in section 2.5, GON has also been financing a significant portion of the operations cost for SIAs and RIs including staff cost for WHO, and the entire OPV cost for RIs.

88. Political challenges faced and overcome: Despite the highest level of GON’s

commitment, as discussed in 2.2, the project also faced challenges such as unexpected rejection of OPV due to unfounded rumor that it anti-fertility agents and HIV (2003-2006), leadership issues in NPI (2008) and distraction by the national elections (2007, 2011). Although GON reacted to these challenges proactively and achieved remarkable reductions of polio cases, these challenges during the project make the rating “Moderately Satisfactory”.

(b) Implementing Agency or Agencies Performance

Rating: Satisfactory 89. Achievement of PDO with system strengthening: As discussed in sections 3.2 and

3.5, NPHCDA as a main implementer mobilized local resources, forged effective partnership with states and achieved the PDO indicator (OPV coverage at least 80% in endemic states). It also ensured the rapid delivery of OPVs from the central store to the campaign site, which led to the on-time arrival of the OPVs in every campaign for

32

nine years. Furthermore, it established robust systems and tools (Table 7 and 10) that enabled the significant reduction of polio cases and helped the current intensive efforts to stop polio transmission in smaller hot spots (e.g., LGAs). These are satisfactory achievements given the limited capacity of the country’s health systems.

90. Rapid responses to emerging challenges: Each time polio cases increased, the

NPI/NPHCDA implemented ERC’s recommendations and contained or reduced the cases in a year (e.g., 2004-05, 2006-07, and 2008-09/10).

91. Intensified efforts to stop the transmission in hot spots: With 89% OPV coverage

in endemic states achieved and polio cases contained into limited smaller hotspots, the NPHCDA started intensifying the efforts to stop the transmissions in these smaller hot spots. Intermediate results show the rapid increase of the high-risk/worst performing LGAs achieving over 80% OPV coverage (Figure 5). This suggests that the appropriate final efforts have been made under the leadership of the NPHCDA.

(c) Justification of Rating for Overall Borrower Performance

Rating: Satisfactory 92. As discussed above, GON’s strong commitment, rapid responses to crises,

achievement of the PDO indicator and the establishment of robust systems and tools to eradicate polio have been remarkable. Robust approaches to address remaining operational challenges have been taken with promising progresses.

6. Lessons Learned (both project-specific and of wide general application)

93. Buy-down is an innovative financing solution to global issues, but performance-based

buy-down requires careful management to appropriately incentivize borrowers for

results. In global issues such as polio, the government has difficulty in receiving credit at the expense of other in-country priorities. Buy-down solved this financing challenge by turning the credit into grant upon the achievement of agreed targets, and by enabling donors to increase the value of the grant through the discounting effect of long-term lending. However, managing the performance-based element was not easy, as a large amount of money is at stake. The Bank needs to be a proactive mediator between the government and buy-down donors on buy-down conditions to motivate the government to achieve the targets while making firm and realistic decisions on the enforcement of the conditions.

94. Careful attention needs to be given on indicators, targets and timeframes. Targets and timeframes need to be realistic and evidence-based while they should be able to motivate stakeholders. The country’s timeframes for the polio eradication, although they were the best knowledge of experts and based on experiences of other countries, were overly optimistic given the challenging health systems and socio-economic situation of Nigeria. Also, the five-week target for the timely delivery of the OPV

33

(key intermediate indicator) was arbitrary and not supported by the evidence. Later it was dropped based on the evidence that the target will neither controllable by the GON nor necessary for carrying out IPDs on time. Strict reality check with analysis of data needs to be done in setting targets and timelines.

95. Health systems approach is essential even for a vertical program, and strengthening

service delivery systems for the project can have positive impacts for the delivery of

other health services. The project showed that defining accountability at every level of the government, as well as developing effective partnerships with traditional and religious leaders are crucial to make the program successful even when the program targets only one disease. It also indicated that many of the systems and tools built through the polio program are applicable for RIs and other health services. Careful planning to build a health system and tools through campaigns and utilizing them for RIs needs to happen from both campaign side and RI sides.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: N/A (b) Cofinanciers: N/A (c) Other partners and stakeholders: N/A (e.g. NGOs/private sector/civil society)

34

Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent)

Components Appraisal

Estimate (USD millions)

Additional Financing

(USD millions)

Actual/Latest Estimate (USD

millions)

Percentage of Appraisal

Timely provision of adequate supplies of OPV for eradication campaigns

28.70 161.70 190.40 15.07%

Total Baseline Cost 28.70 161.70 190.40 15.07%

Physical Contingencies

0.00

0.00

0.00

Price Contingencies

0.00

0.00

0.00

Total Project Costs 0.00 0.00

Front-end fee PPF 0.00 0.00 .00

Front-end fee IBRD 0.00 0.00 .00

Total Financing Required 0.00 0.00

(b) Financing

Source of Funds Type of

Cofinancing

Appraisal Estimate

(USD millions)

Actual/Latest Estimate

(USD millions)

Percentage of Appraisal

Borrower 128.40 0.00 .00

International Development Association (IDA)

28.70 190.40 15.07%

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Annex 2. Outputs by Component Component PDO output

indicators Summary achievements

1. Timely provision of OPV for eradication campaigns

OPV timely delivered

Achieved • Robust vaccine procurement was in place, and in all instances

reviewed during 2009-10 shipment of vaccines occurred before each SIA. There was no disruption of SIA observed during the period of study (PHSS, 2011).

• Independent performance audit in 2010 suggested that the indicator did not measure GON performance, as vaccine arrival was outside of the control of GON and UNICEF (PHSS, 2011). The global market for OPV was severely constrained and the “5 weeks” was arbitrary timeline. What mattered was that all campaigns took place on schedule, which had been achieved at every campaign during the 9 years of entire project period. The same arbitrary timeline was also dropped for the same reason in the polio eradication project in Pakistan (Pakistan ICR, 2008).

2. Supple-mental operations comprising three areas: cold chain, social mobilization and training

Cold Chain system established and operational.

Established and operational • Large number (about 1,000 per year) of cold chain equipment

(i.e., freezers and fridges) were installed in 2006-2008 to support RI and campaigns (UNICEF record).

• As a result, 75% of state-level stores have sufficient capacity for Routine Immunization (RI) and penta immunization (after planned repair). Further, 90% (after planned repair) of LGAs in 20 states have adequate physical capacity to accommodate RI and new/underutilized vaccines (Cold Chain Capacity Assessment – draft, 2012). The draft assessment concluded that all the state stores except Delta and Ondo and all the LGAs in the reviewed 4 states are ready for new vaccine introductions (Cold Chain Capacity Assessment – draft, 2012).

Social mobilization program implemented.

Implemented • Awareness of diseases that affect children is highest in polio

at 75% in 18 states in 2010, a 50 % increase from 2007 (KAP survey, 2010). This is significant given three of the five most recognized diseases (i.e., measles, malaria and diarrhea) reduced or did not improve their recognition (KAP survey, 2010).

• 1,827 trained volunteer community mobilizers (VCM) and 184 ward supervisors are in place to conduct community sensitization in seven high-risk states (24th ERC, 2012).

• Organized support from traditional and religious leaders has been available – e.g., Emirs have signed a pact with the Sultan to fix vaccinator selection/accountability problems in the worst wards (24th ERC, 2012).

Targeted Implemented

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capacity building program implemented.

• Average 72% of vaccination teams meet all the criteria for good performance (e.g., follow micro-plan, enter every household) in 2012 (WHO data).

• All LGA PHC coordinators and local immunization officers were trained in micro-planning, training, and vaccination team selection.

• Health educators at LGAs were trained to engage with traditional leaders and implement social mobilization – 88% of the entire teams evaluated to have sufficient inter-personal communication skills in 2012 (WHO data).

• Health facility staff were trained as ward focal persons and supervisors for (i) micro-planning at ward level and (ii) supervision of vaccinators.

• Team members of 63 LGAs, 1,577 VCMs and 167 Ward Supervisors were trained on community involvement approach in 2012 (ongoing).

3. Support for epidemio-logical and laboratory surveillance

Surveillance program implemented

Implemented and achieved the targets

• Acute Flaccid Paralysis (AFP) detection rate has been meeting the target of at least 2 cases per 100,000 (with average 7-8 cases) in all regions.

• The adequate stool specimen target of more than 80% has been attained in all states (e.g., average 93% in 2010 and 2011).

• Percentage of LGAs meeting the above two targets increased from 75% in 2007 to 88% in 2012 (WHO data).

• The two national polio laboratories reduced the median time between date of onset of an AFP to final results from 32 days in 2008 to 12 days in 2009 (WHO data). Ibadan is provisionally accredited in July 2012 (24th ERC, 2012).

Annex 3. Economic and Financial Analysis (including assumptions in the analysis)

Not applicable.

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Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members

Names Title Unit Responsibility/

Specialty

Lending

Supervision/ICR

Janet Omobolanle Adebo Team Assistant AFCW2

Adewunmi Cosmas Ameer Adekoya

Financial Management Specialist AFTMW

Akinrinmola Oyenuga Akinyele

Sr Financial Management Specialist AFTMW

Bayo Awosemusi Lead Procurement Specialist AFTPW

Boubou Cisse Senior Human Development Economist

AFTEW

Therese M. Diomi Temporary AFTSP

Abiodun Elufioye Program Assistant AFCW2

Ramesh Govindaraj Lead Health Specialist SASHN TTL

Benjamin P. Loevinsohn Lead Public Health Specialist AFTHW

Ngozi Blessing Obi Malife Program Assistant EASER

Ayodeji Oluwole Odutolu Senior Health Specialist AFTHW

Anne U. Okigbo Senior Operations Officer AFTHE TTL

Adenike Sherifat Oyeyiola Sr Financial Management Specialist AFTFM

Cornelis P. Kostermans Lead Public Health Specialist SASHN TTL

Eva Jarawan Lead Health Specialist EASHH TTL

Dinesh Nair Sr Health Specialist AFTHW TTL

Shunsuke Mabuchi Health Specialist AFTHW

(b) Staff Time and Cost

Stage of Project Cycle

Staff Time and Cost (Bank Budget Only)

No. of staff weeks USD Thousands (including travel and consultant costs)

Lending

FY03 17 76.82

FY04 0.00

FY05 0.00

FY06 0.00

FY07 0.00

FY08 0.00

Total: 17 76.82

Supervision/ICR

FY03 0.00

FY04 4 23.35

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FY05 20 69.80

FY06 21 83.37

FY07 12 36.86

FY08 8 49.71

Total: 65 263.09

Annex 5. Beneficiary Survey Results (if any) Not applicable.

Annex 6. Stakeholder Workshop Report and Results (if any)

Not applicable.

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Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR

Federal Ministry of Health

National Primary Health Care Development Agency Nigeria *****

Nigeria: Partnership for Polio Eradication Project

Implementation Completion Report Introduction and Background Polio Eradication is a global public good because of its epidemic potential and its devastating impact especially on children age 0 – 59 months. Polio remains a lethal and maiming disease that is entirely preventable. Nigeria has made real progress in the last few years in Polio Eradication and may interrupt the transmission in the next few years. The World Bank has been a major financier of Nigeria’s Polio Eradication efforts especially in the procurement of Oral Polio Vaccine (OPV). There is strong evidence of Government ownership of Polio Eradication Initiative (PEI). OPV stock-out at this time would result in a substantial increase in the number of cases of polio in Nigeria and regionally. It is therefore in the interest of the international community to continue to ensure that adequate OPV financing – as well as technical assistance – is available as a public god to countries which are still polio endemic. The World Bank support for Polio Eradication Initiative in Nigeria commenced since 2003. WHO and UNICEF are the lead technical Partners for Polio Eradication globally and in Nigeria. Through them, other donors provide grant funds for operations, surveillance activities and vaccine procurement. In 2003, the World Bank in collaboration with other partners such as Bill and Melinda Gates Foundation, United Nations Foundation (UNF) with funding from Centre for Disease Control and Prevention (CDC) financed the polio eradication program for procurement of OPV to bridge the vaccine funding gap. This was through an innovative financing mechanism of International Development Association (IDA) Buy-down project with an initial buy-down grant of US$ 28.7 million (Project ID P080295) for procurement of oral polio vaccine (OPV), followed by additional financing as shown in the Table 1 below. After successful completion of the initiation project (US$ 28.7 million) and two (20 subsequent additional financing of (US$ 51.7 million and US$ 50 million), a performance audit was commissioned by IDA in October 20120 to evaluate if the triggers were met (timely arrival of OPV and immunization coverage) the buy down trigger was met. Other International donors such as Government of Japan, European Union, KfW, Rotary International, CIDA, the Bill and Melinda Gates Foundation and the US Centers for

40

Disease Control (CDC) among others, either directly or through UNICEF and WHO also finance OPV and other areas such as Operations, Logistics, Social Mobilization, Surveillance. On March 17, 2011 an Additional Financing of SDR 39 million (US$ 60 million equivalent) was granted. The additional financing which supported procurement of oral polio vaccine was Category C project with non fiduciary issues and was consistently rated as satisfactory. The third additional financing which is the US$ 60 million closed in April 2012. To help ensure the timely availability of funding for the uninterrupted supply of Oral Polio Vaccine (OPV) in 2011, the project accommodated up to 20% retroactive financing. Project Information

• Project Objective The objective was to assist Nigeria’s effort to eradicate polio through supply of the oral polio vaccine (OPV), for the country’s Supplemental Immunization Activities (SIAs), initially during 2003. Due to continued persistence of the polio virus additional financing in 2005, 2008 and 2011 respectively have been provided in an effort to completely eradicate polio in Nigeria.

• Key Performance Indicators Key indicators to measure project performance were the following: i. Timely arrival of the Oral Polio Vaccine (OPV) at the National Strategic Cold

Store of NPHCDA, Abuja: (target of at least five weeks before each round of the SIAs)

ii. SIA coverage in the targeted population (under five years old children) in each of the endemic states (target 80%).

• Total Cost of the Project Find below the trend in the disbursement history of World Bank Buy Down credit from 2003 to 2011.

Table 1: Overview of World Bank Buy Down Credit P080295

(original credit, #37510)

P080295 (1st additional credit, #37511)

P080295 (2nd additional credit, #45280)

P)80295 (3rd additional credit, #48580)

Board approval March 2003 March 2005 September 2008

February 2011

Effectiveness date (original)

May 2003 December 2006 December 2008 April 2011

Closing date October 2005 December 2006 April 2012 April 2012

Total Grant (millions)

$190.4

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Achievements of Development Objective The project purpose was to assist Government of Nigeria in eradicating poliomyelitis. The objective was to finance and provide oral polio vaccine (OPV), needed during 2003 to 2012 and monitor its effective use in the country’s Supplemental Immunization Activities (SIAs), due to the efforts made by the country. The Nigerian Polio Eradication Initiative made significant progress in reduction of WPV cases in 2010; the number of WPV cases was reduced by 94.9% compared to 2009. The table shows different types of polio cases reported 2009 and 2010 for the same period (January – September) Table 2: Trend in WPV cases during the period January – September 2009 and January – September 2010

Serotype 2009 (Jan – Sept) 2010 (Jan – Sept) % Decrease

W1 74 5 93.2

W3 306 4 98.6

cVDPV 150 18 88.0

Total 530 27 94.9

Source: Performance Audit Report by Public Health Service and Solution.

• Key Performance Indicators 1. Timely Arrival of Vaccines (OPV for SIAs)

Vaccines to arrive at least 3 weeks before the Supplemental Immunization Activities (SIAs) to the National Strategic Cold Store in Abuja. Tool UNICEF/NPHCDA vaccine arrival report.

2. SIA Coverage Immunization coverage of SIA (immunization coverage of OPV is at least 80 percent in each endemic state). Tool: cluster sample survey as per WHO methodology.

Assessment of key performance indicators

1. Timely Arrival of OPV for SIAs UNICEF undertakes the procurement and supply of OPV through its international procurement division based on Copenhagen as agreed under project. So far World Bank has disbursed the total sum of $190.4M for procurement of OPV using IDA funds disbursement mechanism. All the vaccines procured by UNICEF were delivered to the National Strategic Cold Store prior to the planned SIAs. The 5 weeks timeline is not relevant to evaluate the performance of GoN as it is outside the Government and UNICEF’s control.

2. Coverage According the 2010 and 2012 Performance Audit report the aggregated OPV coverage in all high risk states exceeded the 80% target. The same report

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observed that given the very low level of coverage at inception of the programme in all the high risk States, particularly Kano State, the epicenter of WPV in Nigeria, challenges outside direct implementation such as non compliance, difficult terrain, political instability, poor commitment at various levels, the improvement made both in immunization performance and WPV transmission was very impressive.

Government Performance during Project Preparation and Implementation

• Government has supported the programme in the area of storage, distribution, setting up Logistics Working Group made of Partners, ensuring adequate forecasting of the vaccines, planning delivery dates with UNICEF, training of programme officers on vaccine handling, distribution of vaccines to state and follow up to LGAs, monitoring and reduction of vaccine wastage.

World Bank Performance This project (partnership for polio eradication initiative) was to support the country on the Polio Eradication Initiative. The Bank responded in a timely manner based on vaccine needs in the country as recommended by the various expert committees (ERC, GPEI, ICC) on the needs for the programme. The World Bank provided additional funding from inception of the credit in 2003, with 1st, 2nd and 3rd additional financing to date. It is worthy to note that the Bank officials have often facilitated in the development of the project and processes leading to the board approvals for the project and drafting of financial agreement with the government of Nigeria. Current Plans and Activities on Future Operation of the Project

(i) Financial Commitment Commitment of Mr. P President through a pledge of US$ 30 million annually for two years (2012 – 2013), and the pledge for 2012 has been redeemed. (ii) Setting up of a Presidential Task Force To spearhead the final push to polio eradication a Presidential Task Force on Polio Eradication was officially inaugurated on 1st March 2012. This task force has the objective of providing leadership support for Nigeria’s efforts to accelerate the interruption of poliovirus transmission by the end of 2012. The Task Force is chaired by the Minister of State for Health and its membership is drawn from the National Assembly (Chairman Senate Committee on Health, Chairman House Committee on Health), the Nigeria Governors Forum, the National Primary Health Care Development Agency, the Federal Ministry of Health, Polio high risk and polio-free states, Northern Traditional Leaders Committee on Primary Health Care, Nigeria Inter-Faith Group and Global Polio Eradication Initiative (GPEI) Partners. (iii) Development of the newly revised 2012 Emergency Plan:

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This plan includes clarification of the levels of responsibility of stakeholders at all levels, restructuring and revising work load and remunerations and introducing improved supervision. The accountability framework further holds the local government administration accountable to the president for the performance in polio eradication. Highlight of the Emergency Plan includes the following:

• Much closer involvement of His Excellency the President of the Federal Republic of Nigeria through the recently established Presidential Task Force on Polio Eradication.

• Closer linkages between the Presidential Task Force and State Task Forces.

• Introduction of national PEI Accountability Framework with well defined indicators for use at all levels.

• Optimization of new technologies including GIS/GPS, SMS…etc.

• Systematic introduction of revisit strategy; Short Interval Additional Dose strategy in areas that have been consistently missed or where access may be a problem due to insecurity.

• Surge of technical capacity from Government and partners in the highest risk areas.

• The preparation of a detailed plan for improving team performance.

• The preparation of a detailed plan for improving team performance. Innovations: New technologies such as the use of geographic information system/global positioning system (GIS/GPS) to locate all villages and hamlets is rapidly being expanded and short message service and toll free lines for reporting and communication are being added. The plan also includes new micro-planning guidelines which will use the GIS technology. A new training package is being developed for these new technologies as well as for training in interpersonal communication. Finally, a tool to investigate reasons for children being missed is already in use and is regularly being improved.

(iv) Financial Resources Requirement (FRR): The IDA financing will provide for adequate oral polio vaccine procurement for the programme (2013 -2014). Other potential financiers of vaccine requirement over and above what is financed through this credit are BMGF, Rotary International, CDC, United States Agency for International Development (USAID), Department for International Development (DFID), Kreditanstalt fur Wiederaufbau (KfW), the Government of Japan, UNICEF and WHO. Summary of Financial Resource Requirement for 2012 – 2013 in Nigeria is as tabulated below:

Total requirement 414,756,787

Total confirmed funding 189.127,862

Total Tentative funding 136,428,270

Funding gap (exclusive of tentative funding) 225,628,925

Funding gap (inclusive of tentative funding) 89,200,655

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The above financial requirement is for the basic assumption given below:

Basic assumptions

2012 2013 2012 – 2013

Remark

No of NIPDs 2 2 4 Scope of NIPDs: all 36 states plus FCT

No of SIPDs 5 4 9 Scope for SIPDs: 11 HR states

Wastage rate 1.1 1

Target population per NIPDs

58,638,535 60,514,969 Based on highest immunized as recorded in tally summary data in 2012.

Target population per SIPDs

24,773,167 25,565,909 Population growth rate of 3.2% applied for 2013 projection

Ex. Rate

155

(v) Abuja Commitment The Nigeria Governors Forum, a very strong political body in Nigeria, has recently endorsed its commitment to polio eradication though their participation in the ‘Nigeria Immunization leadership Challenge fund which jointly with Bill and Melinda Gates Foundation (BMGF) provides a bonus of US$ 500,000 to states which can document adequate immunization coverage. (vi) Public Private Partnership (PPP) There has been intense lobbying of private sector through influencial personality in Nigeria for their involvement of private sector in the eradication of polio in Nigeria. To this end, a unit in the office of the Executive Director/CEO NPHCDA known as the Public Private Partnership is saddled with the responsibilities of interfering with influential personality in Nigeria has been set up. The first interaction between the NPHCDA and influential personality in Nigeria took place in Lagos in July 2012, those in attendance were the Honourable Minister of state for Health, the Executive Director/CEO NPHCDA, and business moguls like Aliko Dangote led the cream influential personalities in Nigeria. There was a strong commitment from the Private Sector after that meeting for collaboration with the private sector for polio eradication in Nigeria. Current Status of Other Key Project Components Cold Chain System The cold chain, logistics system and the quality vaccine are among the backbone of the immunization program. According to the National Immunization policy, cold

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chain equipment for the immunization programme shall include cold rooms, cold vans, deep freezers, icepack freezers, ice-lined refrigerators, solar refrigerators, cold boxes, vaccine carriers, ice packs, thermometers, generator sets and voltage stabilizers. All cold chain equipment shall comply with the WHO/UNICEF Product Quality & Safety (PQS) requirements and be environmental-friendly (CFC-free). The cold chain system in Nigeria is based on a ‘push-pull’ system of vaccine distribution with four levels of distribution structures at National (with zonal stores as extended storage at national level), State, Local Government (LGA) and health facility levels. National, zonal and state levels are equipped with cold rooms due to the large volumes of vaccines they handle at any given time. LGA levels are mainly equipped with refrigerators and freezers. The policy also provides for minimum requirements of at least 2 solar refrigerators per LGA store and 1 solar refrigerator per ward at health facility, in recognition of the problems of electric power supply nationally and improving access to vaccines at health facilities . Health facilities primarily operate on fast cold chain (cold boxes, vaccine carriers) for service delivery either at the fixed facilities/posts or during outreach services for both routine and SIAs including polio SIAs (IPDs). The entire cold chain and logistics system benefits both routine immunization (RI) and polio SIAs (IPDs) as well as other SIAs, towards ensuring adequate storage of vaccines at the right temperature to ensure potency. Fast cold chain is also important in the surveillance system for reverse cold chain that ensures quality of stool specimen for AFP case investigations. Although the cold chain system at national, zonal and State levels is adequate for current RI needs, including penta introduction (except for the state store of Delta and Ondo), some LGAs/wards and their facilities require more fast cold chain, especially vaccine carriers, for polio SIAs. This challenge is currently being addressed by Government and partners including UNICEF and WHO with procurement of additional vaccine carriers that will benefit both RI and SIAs. For RI, especially in the light of introduction of new vaccines, the challenges go beyond the fast cold chain. In a recent (June 2012) cold chain assessment conducted in 20 States (in North West Zone – Kano, Kebbi and Sokoto, in North-East Zone – Taraba, Yobe and Borno, in North-Central Zone - Nasarawa, Niger, Kogi and Benue, in South-West Zone - Oyo, Ogun, Osun and Ondo, in South-South Zone - Cross River, Delta and Bayelsa, and in South-East Zone - Abia, Imo and Ebonyi States). Only 1199 (23%) of total wards (5199) in 20 states, have a solar refrigerator in at least one HF. Among those wards, only 609 have functional solar refrigerator (SR). 90% of the LGA stores have adequate capacity for RI including new vaccine (Pentavalent vaccine – “Penta”). 11 of 20 states have adequate operational capacity to accommodate all new vaccines in view now and for the future (Penta, Pneumo and Rota). While the capacity of three state stores (Yobe, Ogun and Oyo) can be improved by repairing the non-functional cold rooms, five state stores (Bayelsa, Nasarawa, Ondo, Delta and Kano) will require additional cold rooms. The storage volume of Abia state store can be improved by providing additional refrigerators.

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The assessment also identified additional cold chain equipment to be provided and installed to be ready for new planned vaccine introduction (6 cold rooms, 55 solar refrigerators at LGA level and 4000 solar refrigerators at ward level) to comply with national policy. This requirement is based on assumption that all the non-functional equipment (about 2000 units (39%) of total PIS listed/PQS qualified equipment) is repaired. It also identified which cold chain equipment is faulty that could be repaired or which ones need to be replaced among other findings and recommendations. It was also noted that a large proportion of domestic equipment is being used for immunization program (27% of electrical equipment and 4% share in solar refrigerators). These units are required to be replaced with qualified units progressively. Cold chain revamping took place between 2011 and 2012 were a total of 13 cold rooms were supplied and installed across the geopolitical zones and the National Strategic Cold Store, 5 trucks were supplied across the country to assist in vaccine distribution and 206 solar refrigerators supplied to states and installed in health facilities at ward level for proper storage of vaccines. Surveillance Effective surveillance requires a sensitive system to detect the presence of microbes within the environment, intermediary hosts, and clinical cases. As eradication progresses, the sensitivity of detection systems is steadily enhanced to detect all existing foci. Surveillance has played a major/vital role in polio eradication in Nigeria. Acute Flaccid paralysis (AFP) surveillance is the gold standard for surveillance in the polio eradication initiative. Polio eradication relies on acute flaccid paralysis (AFP) surveillance to identify and confirm poliomyelitis cases by viral isolation. Surveillance performance is monitored using WHO targets for case detection and adequate stool specimen collection. NPAFP detection rates meeting the target of at least two cases per 100,000 were achieved in all states during January 2010--June 2011.The national NPAFP detection rate among children aged <15 years was 7.8 per 100,000 during 2010 and an annualized 7.7 per 100,000 during January – June 2011. The adequate stool specimen target of ≥80% was attained in all states during January 2010--June 2011. Among AFP cases reported nationally, adequate stool specimens were collected from 5,560 (93%) of 6,000 cases during 2010 and 2,788 (93%) of 2,998 cases during January--June 2011. The proportion of districts, or local government areas (LGAs), in the 12 high-risk states meeting both surveillance targets decreased from 89% (254 of 286) in 2009 to 83% (236 of 286) in 2010, to 75% (215 of 286, provisional data) during January--June 2011; many LGAs not meeting both indicators in the high-risk states are contiguous. To supplement laboratory testing of specimens obtained through AFP surveillance, environmental testing of sewage samples for poliovirus began in Kano state in July 2011.

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Trend from 2003 to date cases of WPV POLIO EPIDEMIC TREND IN NIGERIA

YEAR WPV CASES

2003 355

2004 792

2005 830

2006 1122

2007 286

2008 796

2009 388

2010 21

2011 62

Surveillance and laboratory have undergone various transformations particularly in the area of AFP surveillance, and have added positive values in the PEI programme in Nigeria. There are two (2) National Polio Laboratories in the country namely, Ibadan and Maiduguri respectively. Both had always met the WHO annual accreditation. Over the time samples have been received by the Ibadan Lab in 2011 in which over 8122 samples were collected and in 2012 over 1530 samples were collected. Maiduguri Lab received over 4077 samples in 2011 and 713 were received in 2012. AFP SURVEILLANCE PERFORMANCE NPAFP NPAFP NPAFP NPAFP Rate Rate Rate Rate % Two % Two % Two % Two Adequate Adequate Adequate Adequate Specimens Specimens Specimens Specimens % LGAs % LGAs % LGAs % LGAs meeting both meeting both meeting both meeting both target target target target indicators indicators indicators indicators NPAFP NPAFP NPAFP NPAFP Rate Rate Rate Rate % Two % Two % Two % Two Adequate Adequate Adequate Adequate Specimens Specimens Specimens Specimens % LGAs % LGAs % LGAs % LGAs meeting both meeting both meeting both meeting both target indicators target indicators target indicators target indicators NPAFP NPAFP NPAFP NPAFP Rate Rate Rate Rate % Two Adequate % Two Adequate % Two Adequate % Two Adequate Specimens Specimens Specimens Specimens % LGAs meeting % LGAs meeting % LGAs meeting % LGAs meeting both target both target both target both target indicators indicators indicators indicators NC NC NC NC 9999 93939393 92929292 9999 93939393 95959595 8888 93939393 91919191NE NE NE NE 9999 95959595 98989898 9 92929292 94949494 9999 93939393 95959595NW NW NW NW 9999 90909090 92929292 9999 90909090 90909090 7777 87878787 89898989SE SE SE SE 6666 93939393 81818181 9999 96969696 92929292 9999 98989898 91919191SS SS SS SS 7777 95959595 84848484 8888 96969696 87878787 7777 97979797 86868686SW SW SW SW 5555 93939393 84848484 6666 94949494 88888888 5555 95959595 82828282National National National National 7777 97979797 88888888 8888 97979797 91919191 7777 94949494 89898989

Zone Zone Zone Zone Jan - Aug 2009 Jan - Aug 2009 Jan - Aug 2009 Jan - Aug 2009 Jan - Aug 2010 Jan - Aug 2010 Jan - Aug 2010 Jan - Aug 2010 Jan Jan Jan Jan – Aug 2011 Aug 2011 Aug 2011 Aug 2011

Major actions taken are: Increase frequency of visits of major Hospitals, Revision of Reporting Sites with additional sites, Inclusion of additional informants into the surveillance network, Line-list and strengthening Surveillance within Nomadic camps (2011 – 6% of polio cases were in Nomads and 2012 – 10% ), Rapid surveillance Assessments (RSA) and action plans, Increased supervision to DSNOs activities, Environmental surveillance in Kano and scaled up to Sokoto state, Sero-surveillance survey study conducted in Kano State with

48

revealing results, Collection of samples from contacts of inadequate AFP cases and the introduction of the Reverse cold chain project. In line with Mr. President’s commitment to polio eradication in Nigeria there are some major achievements on surveillance;

– Increase in frequency of sample collection in sites in Kano and scale up of Environmental Surveillance (ES) to Sokoto State in May 2011.

– Quarterly implementation of 2011 Rapid Surveillance Assessment (RSA) recommendations. April, July, Oct, 2011

– National surveillance training for clinicians and nurse May – Sept 2011 – Rapid surveillance reviews in response to any ‘orphan’ virus. Ongoing

Enhanced surveillance sensitivity in identified areas with surveillance gaps through Designation of assistant DSNOs in persistently underperforming LGAs, Deployment of more community informants in all high risk LGAs and Intensified

weekly supervisory visits to underperforming LGAs, Ensuring full functioning of secondary and tertiary hospitals in the surveillance network, Improve guided supportive supervision and monitoring of the States towards attaining and maintaining AFP surveillance indicators and strengthening case detection and active case search (ACS) in high risk States particularly the less endemic states. Lessons Learnt:

o Procurement and supply of additional OPV used in campaigns through this channel has assisted immensely in achieving our objectives, especially of ensuring uninterrupted supply of vaccine (OPV) for planned SIAs.

o This project has benefited children below the age of five in Nigeria although it has not been possible to interrupt transmission of polio in the country.

o This source of funding is not only efficient but paramount in achieving polio eradication in Nigeria.

o Intensive monitoring through deployment of monitors and participation of partners in IPDs improved the quality of implementation process.

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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders (A) WHO Introduction and Back Ground Nigeria has registered considerable progress in Polio Eradication since the inception of the programme in 1996. Between 2006 and 2012, the annual incidence of polio cases declined by over 90%. Endemic transmission remains limited to only a small geographical area in northern Nigeria i.e. over 91% of the 774 Local Government Areas in Nigeria have not had a case of indigenous wild poliovirus for at least 12 months. As a result of improving quality of polio eradication campaigns, population immunity has continued to increase in most parts of the country. Genetic sequencing has also demonstrated increasing restriction of the genetic biodiversity of the remaining chains of poliovirus transmission. The last remaining chains of endemic poliovirus transmission occur in areas that continue to have sub-optimal quality of both immunization campaigns as well as low routine immunization coverage. The factors that have contributed to the persistent transmission include insufficient local leadership and accountability by community leaders, health workers and volunteers involved in immunization activities. Insecurity in several areas in northern Nigeria has also resulted in immunization activities not be effectively implemented. These challenges are being effectively addressed by the Presidential Task Force on Polio Eradication that is working effectively with the Nigeria's Governors' Forum and the Northern Nigeria Traditional Leaders Committee on Primary Health Care. The first project was approved in April 2003 and covered vaccine procurement for the period April 2003 to October 2005. The initial funding was for USD 28.70m. Because of increase in polio cases in the period 2003-2004 due to the unfortunate controversy over safety of the vaccine, increased number of campaigns were required. The project was amended in May 2005 to provide an additional USD 51.7m. Intensified campaigns were still required beyond 2008 and the project was further amended to provide an additional USD 50 m in September 2008 and then again in March 2011 to provide a further USD 60m. The additional funding obtained and the vaccines procured contributed very significantly to the tremendous progress that Nigeria achieved in reducing the incidence and geographical spread of poliovirus over the period 2006-2012. This also contributed to also reducing international spread of poliovirus from Nigeria to other countries in the African Region and beyond. Achievement of Development Objectives The project development objective was to assist the Government of Nigeria to achieve the goal of interrupting transmission of wild poliovirus through effective use of oral polio vaccine and adequate coverage of the target population.

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With the support provided by the project, Nigeria was able to mount immunization campaigns of increasing quality that reached and covered target age children that were hitherto not immunized and were susceptible to infection with poliovirus. All the indicators, agreed upon to measure attainment of the project development objectives were achieved. Assessment of Key Performance Indicators Two main key indicators were used to measure project performance. 1. Timely arrival of Oral Polio Vaccine (OPV) at the National Strategic Cold Store in Abuja. Target at least five weeks before each round. During the project period the target was revised and the "five weeks before each round" was deleted. During the 9 year period of the project, all OPV was delivered in time for all planned campaigns to be implemented as planned without any postponement. 2. SIA coverage in the target under 5 year old population. Target was at least 80% in the endemic states. This indicator was measured by an Independent performance audit that used WHO's standard cluster survey methodology. The immunization coverage in the 8 highest risk endemic states increased from an average of 44% in March 2003 to 89% in Oct/Nov 2012. Supplemental project indicators demonstrated strengthening of the national cold chain system, improvements in social mobilization activities, effective capacity building at the LGA, health facility and community level, strengthened surveillance systems as well as effective Government-partner coordination through a national Immunization Inter-Agency Coordination Committee (ICC) Lessons Learned 1. The design of indicators for projects should be done to ensure that factors' extraneous to the concerned parties are excluded. Timely arrival of OPV was subject to factors such as availability on the global market that were not within the influence of main stake-holders in the project. 2. The project design and implementation process fostered closer partnership between the Government of Nigeria and all partners of the polio eradication effort. 3. This project contributed substantially to strengthening of the overall health systems through capacity building of health workers, improved cold chain capacity, strengthened disease surveillance systems and stronger linkages between the formal health sector and the community leadership.

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(B) UNICEF Nigeria Partnership for Polio Eradication Project

(IDA 48580)

Implementation Completion Report

The Government of Nigeria, working with its development partners including UNICEF and the International Development Association (IDA) has designed and is implementing the Partnership for Polio Project to maintain effective Oral Polio Vaccine (OPV) coverage of the target population critical for interrupting Polio transmission and eradication, Government's Partnership for Polio Eradication Project. The project uses the IDA buy-down financing mechanism established with the support of Bill and Melinda Gates Foundation (BMGF), Rotary International and Centres for Disease Prevention and Control (CDC). From past experience, other potential financiers of OPV procurement for Polio Eradication through UNICEF over and above what is financed through the World Bank Buy-Down include Government of Japan, BMGF, CDC, Kreditanstalt fur Wiederaufbau (KfW), and the use of UNICEF Regular Resources. From 2003 to date, the Government has received IDA credits 37510-NG, 37511-NG, 45230-NG pursuant to initial credit and additional credit agreements of 2003, 2005 and 2008 respectively towards the cost of the OPV Supplies for Polio Eradication Supplemental Immunization Activities (SIAs) called Immunization Plus Days IPDs) in Nigeria. The current IDA credit 48580-NG SIGNED May 2011 but with some retro-active financing from 2010 is yet to be closed, while processes to access the new board approved IDA of $95M that will support OPV procurement for polio SIAs through 2014 are ongoing. UNICEF’s Supply Division is mandated to establish a Global Centre for Children’s Supplies and pursues its mandate by, among other things, providing the services of purchasing and/or stocking, set packing and dispatching supplies, equipment, and other materials in support of UNICEF’s programme activities. Hence UNICEF, through procurement services agreements signed with the Government, has been charged with the responsibility of procuring all the OPV for Polio Eradication SIAs (and indeed other vaccines for immunization) in Nigeria through funds of transferred directly through UNICEF Supply Division. Quantities and costs have been based on type of OPV recommended for specific rounds of Supplemental Immunization Activities (SIAs), called Immunization Plus Days (IPDs) in Nigeria, depending on prevailing epidemiological trend and the prevailing unit costs at the time of ordering. Two key Performance Indicators were specified to trigger the Buy-Down for the initial and two additional financing are:

1. Timely arrival of Oral Polio Vaccines (OPV) for SIAs (Target: procured OPV must be delivered to the National Strategic Store at least 5 weeks before the start of planned SIA)

2. SIA coverage - Immunization coverage of SIA (Target: immunization coverage of OPV is at least 80 percent in each endemic state)

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Achievement: The first performance indicator is the one that is directly related to UNICEF support to the Buy-Down. Despite challenges in global availability and deliverability, UNICEF made all reasonable efforts to ensure that quantities and dates for deliveries reflect the Supplemental Immunization Activities or Immunization Plus Days (SIA or IPDs) schedule as proposed by the Polio Eradication Programme in Nigeria. No round of SIAs was delayed, postponed or rescheduled due to the late arrival of vaccines at the National level for onward distribution to the lower level (States and LGAs). The coverage indicator has also been met and verified along with first indicator by an independent performance audit at the end of 2010. UNICEF-related supporting activities: UNICEF and other polio partners also support Government of Nigeria in the strengthening of systems that ensure vaccine potency for immunization activities including polio SIAs. The cold chain, logistics system and ensuring the quality vaccine are among the backbone of the immunization program. The national cold chain policy provides for minimum requirements of at least 2 solar refrigerators per LGA and 1 solar refrigerator per ward at health facility level. In recognition of the problems of electric power supply nationally. Health facilities operate on fast cold chain (cold boxes, vaccine carriers) for service delivery either at the fixed facilities/posts or during outreach services for both routine and SIAs including polio SIAs (IPDs). The entire cold chain and logistics system benefits both routine immunization (RI) and polio SIAs (IPDs) as well as other SIAs, towards ensuring adequate storage of vaccines at the right temperature to ensure potency. Fast cold chain is also important in the surveillance system for reverse cold chain that ensures quality of stool specimen for AFP case investigations. Although the cold chain system at national, zonal and State levels may be adequate, many LGAs/wards and their facilities require more fast cold chain, especially vaccine carriers, for polio SIAs. This challenge is currently been addressed by Government and partners including UNICEF and WHO with procurement of additional vaccine carriers that will benefit both RI and SIAs. UNICEF, among other partners, supports Government in the following areas among others:

• Adequate forecasting of the quantities and type of vaccine required based on prevailing epidemiology

• Support to State level forecast of OPV required and vaccine distribution plan per round of SIA as well as collation of OPV utilization report from the States through consultants deployed to all 36 States and the Federal Capital Territory (FCT)

• Supporting the national government in submission of OPV vaccine arrival reports (VAR) and to UNICEF Supply Division

• Capacity building in supply chain management with emphasis on effective vaccine management, including supply of cold chain equipment and cold chain logistics (CCL) system strengthening

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• Programme communication and social mobilization for demand creation

• Monitoring of the program activities for assurance quality

• Specifically, in respect of the World Bank Buy Down, sharing of fund utilization report with the national Government (NPHCDA) with which UNICEF signed an MoU for the OPV procurement at the country level.

Challenges:

• Delays in accessing the Buy-Down after Board approval, including delays in

Governments processing of application documents for the Buy-Down.

• Difficulties with coverage targets and population issues which continue to be a

sensitive challenge in Nigeria with the tendency to rely on ‘previous consumption

method’ in forecasting vaccine requirement for subsequent rounds of polio SIAs

(this often tends to affect forecasting accuracy).

• Shortage of bivalent (bOPV) in the global vaccine market.

• Limited number of WHO-prequalified manufactures/suppliers of OPV types

• Different interpretation of the closing date of the project between the MoU signed

by UNICEF with Government of Nigeria (NPHCDA) and the legal agreement

between the Government of Nigeria and the World Bank.

Lessons learned:

• Procuring vaccines through UNICEF has contributed to sustainable supply of

affordable vaccines for polio eradication in Nigeria and has been rated

satisfactory by the performance audit.

• Need for increased number of WHO pre-qualified manufacturers/suppliers to

ensure a larger stockpile of OPV at the beginning of each year.

• Need for polio partners and donors to continue to support cold chain (fast and

slow) and system strengthening to ensure potency of vaccines

• The factors that affect the time of vaccine arrival are diverse and often beyond the

control of UNICEF (ranging need to respond to sudden change in vaccine forecast

due to changing epidemiology and ERC recommendations to delays in providing

funds to UNICEF), hence the inadequacy of the performance indicator on vaccine

arrival and its removal as a performance indicator in the new buy-down currently

being processed.

• The introduction of new OPV technology (monovalent and bivalent OPV) in

Nigeria contributed to the reduction in polio cases recorded in 2010

• Heightened insecurity in a number of Northern States since 2011 political election

continues to contribute to increase in number of polio cases in these northern

Nigeria.

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Annex 9. List of Supporting Documents World Bank

• 2003 Original Project Appraisal Document (PAD)

• 2005 Supplemental Credit Document for 1st Additional Financing

• 2008 Project Appraisal Document for 2nd Additional Financing

• 2008b Study on Comparative Efficiencies in Vaccine Procurement Mechanisms

• 2008 Implementation Completion and Results Report on for a Second Partnership for Polio Eradication Project

• 2010 Project Paper for 3rd Additional Financing

• Bank Implementation Status Results (ISRs): 1-21

• Aide Memoires (AMs)

• 2006 Audit Report for ICC

• 2006 Report from FM Specialist

• 2006 Supervision plan

• 2011 Performance Audit Final Report, PHSS

• 2012 Kosterman et al. Future World Bank Support for Polio Eradication. ERC

• ERC Recommendations: 8-24

• 23rd ERC Presentations

• 24th ERC Presentations Government of Nigeria

• 2009 Abuja Commitment

• 2010 KAP Survey Report

• 2010 Report on Nigeria 2010 National Immunization Coverage Survey (NICS)

• 2010 Report on the Vaccine Security Mission

• 2011 Nigeria Vaccine Wastage Report

• 2012 Nigeria Cold Chain Capacity Assessment in 20 States

• 2012b Introduction Plan for Yellow Fever Preventive Campaigns in Nigeria

• 2012c National Plan for Measles Follow up Campaign 2013 CDC

• 2003 Progress Toward Poliomyelitis Eradication --- Nigeria, January 2002--March 2003

• 2004 Progress Toward Poliomyelitis Eradication --- Nigeria, January 2003--March 2004

UNICEF

• 2012 Evidence Based Communication to Support Polio Eradication in Nigeria WHO

• 2001 Description and comparison of the methods of cluster sampling and lot quality assurance sampling to assess immunization coverage.

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• WPV trend (2000 – 2012)

• LQAS data (November 2009 – July 2012)

• AFP surveillance data (2007 – 2012)

• Team performance data (2009 – 2012)

• IPD goods distributed with OPV (2009 – 2012)

• 2011 AFP Surveillance feedback, Jan – Dec 2011, Nigeria

• 2011 Review of the AFP Surveillance System in Kano, Jigawa, Kebbi, Plateau, Borno, Zamfara, Yobe states

• 2012 Discordance of LQAS and EIM, February 2012 GPEI (Global Polio Eradication Initiative)

• 2011 Chapter 3. Off-Track: Nigeria, Pakistan, Afghanistan. Annual Report.

• 2010 Polio and Prevention. (http://www.polioeradication.org/Polioandprevention.aspx)

Others

• 2012 The College of Physicians of Philadelphia. The History of Vaccines. (http://www.historyofvaccines.org/content/articles/why-vaccinate)

• 2012 Joint Partners Review Mission. Aide Memoire, Saving One Million Lives Joint Partners Review Mission, October 16-24, 2012.

• 2012 Vitamin Angels. (http://www.vitaminangels.org/why-vitamin)

• 2011 Tebbens, Duintjer et al. Economic analysis of the global polio eradication initiative. Vaccine 29 (2011) 334–343.

• 2011 Oxford Policy Management. Political Economy and Institutional Assessment for Results Based Financing for Health. October 2011.

• 2009 Frishman, Alan. Major reason for Nigerian boycott of polio vaccine. Health Affairs. Vol. 28. No.6. 1860-1861.

• 2007 Yahya, Maryam. Polio vaccine – “No thank you!” barriers to polio eradication in northern Nigeria. Oxford University Press.

• 2006 Busie B. Maziya-Dixon, Isaac O. Akinyele, Rasaki A. Sanusi, Tunde E. Oguntona, Sagary K. Nokoe, and Ellen W. Harris. Vitamin A Deficiency Is Prevalent in Children Less Than 5 y of Age in Nigeria. The Journal of Nutrition. May, 2006. 2255-2261.

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MAP

Polio cases as of September 25, 2012

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