i

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No: 69664-NG

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR 61.3 MILLION

(US$95 MILLION EQUIVALENT)

TO THE

FEDERAL REPUBLIC OF NIGERIA

FOR A

POLIO ERADICATION SUPPORT PROJECT

June 13, 2012

This document has a restricted distribution and may be used by recipients only in the

performance of their official duties. Its contents may not otherwise be disclosed without World

Bank authorization.

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CURRENCY EQUIVALENTS

(Exchange Rate Effective April 30, 2012)

Currency Unit = Naira

US$1 = Naira 156.9

US1$ = SDR 0.645

FISCAL YEAR

January 1 – December 31

ABBREVIATIONS AND ACRONYMS

AFP Acute Flaccid Paralysis

ALGON

Bank-UN FMFA

BCG

BMGF

CAS

CDC

Association of Local Governments of Nigeria

World Bank United Nations Financial Management Framework Agreement

Bacillus Calmette-Guérin

Bill and Melinda Gates Foundation

Country Assistance Strategy

Centers for Disease Control, Atlanta USA

CEO/ED

CHEW

cMYP

DALY

DFID

DHS

DPT

DSNO

EIM

EPI

ERC

Chief Executive Officer/Executive Director

Community Health Extension Workers

Comprehensive Medium Term Expenditure Framework for Immunization

Disability Adjusted Life Years

Department for International Development

Demographic and Health Survey

Diphtheria, Polio, Tetanus

Disease Surveillance and Notification Officer

Enhanced Independent Monitoring

Expanded Program of Immunization

Expert Review Committee

FGN Federal Government of the Republic of Nigeria

FM Financial management

FMOF

FMOH

ICC

IDA

IMB

IPV

GAVI

GIS

GPEI

GPEP

GPS

KfW

Federal Ministry of Finance

Federal Ministry of Health

Interagency Coordination Committee

International Development Association

Independent Monitoring Board

Injectible Polio Vaccine

Global Alliance for Vaccines and Immunization

Geographic Information System

Global Polio Eradication Initiative

Global Program to Eradicate Poliomyelitis

Global Positioning System

Kreditanstalt fur Wiederaufbau

LID Local Immunization Days

iii

LGA

LQAS

Local Government Agency

Lot Quality Assurance Sampling

MDG

MNCH

Millennium Development Goals

Maternal, Neonatal and Child Health

MOU Memorandum of Understanding

NIPD

NGO

NPHCDA

National Immunization Plus Days

Non Government Organizations

National Primary Health Care Development Agency

OPV

PDO

Oral Polio Vaccine

Project Development Objectives

PETF

PEI

PTFoPE

RI

SIA

SDR

Polio Eradication Trust Funds

Polio Eradication Initiative

Presidential Task Force on Polio Eradication

Routine Immunization

Supplementary Immunization Activity

Special Drawing Rights

SIPD Sub-national Immunization Plus Days

SIL Specific Investment Loan

STF/SIACC

UN

UNICEF

State Task Force/State Interagency Coordination Committee

United Nations

United Nation Children‟s Fund

UNF

VDPV

WHO

United Nations Fund

Vaccine Derived Polio Virus

World Health Organization

WPV Wild Polio Virus

Regional Vice President: Makhtar Diop

Country Director: Marie Francoise Marie-Nelly

Sector Director: Ritva Reinikka

Sector Manager: Jean- Jacques de St. Antoine

Task Team Leader: Dinesh Nair

iv

NIGERIA

Polio Eradication Support Project

TABLE OF CONTENTS

Page

I. STRATEGIC CONTEXT .................................................................................................1

A. Country Context ............................................................................................................ 1

B. Sectoral and Institutional Context ................................................................................. 2

C. Higher Level Objectives to which the Project Contributes ............................................ 6

II. PROJECT DEVELOPMENT OBJECTIVES ................................................................6

A. Project Development Objective .................................................................................... 6

B. Project beneficiaries ..................................................................................................... 7

C. PDO Level Results Indicators ...................................................................................... 7

III. PROJECT DESCRIPTION ..............................................................................................7

A. Project Components ....................................................................................................... 9

B. Lending Instrument ....................................................................................................... 9

C. Project Cost and Financing .......................................................................................... 9

D. Lessons Learned and Reflected in the Project Design .................................................. 9

IV. IMPLEMENTATION .....................................................................................................10

A. Institutional and Implementation Arrangements ........................................................ 10

B. Results Monitoring and Evaluation ............................................................................ 10

C. Sustainability .............................................................................................................. 11

V. KEY RISKS AND MITIGATION MEASURES ..........................................................12

A. Risk Ratings Summary Table ..................................................................................... 12

B. Overall Risk Rating Explanation ................................................................................ 12

VI. APPRAISAL SUMMARY ..............................................................................................12

A. Economic and Financial Analyses .............................................................................. 12

B. Technical analysis ...................................................................................................... 13

C. Financial Management ............................................................................................... 15

D. Procurement ................................................................................................................ 16

E. Social (including Safeguards) ..................................................................................... 16

v

F. Environment (including Safeguards) .......................................................................... 17

Annex 1: Results Framework and Monitoring .........................................................................17

Annex 2: Detailed Project Description .......................................................................................20

Annex 3: Implementation Arrangements ..................................................................................29

Annex 4: Operational Risk Assessment Framework (ORAF) .................................................36

Annex 5: Implementation Support Plan ....................................................................................38

Annex 6: Economic and Financial Analysis ..............................................................................39

vi

.

PAD DATA SHEET

Nigeria

Polio Eradication Support (P130865)

PROJECT APPRAISAL DOCUMENT .

AFRICA

AFTHE

.

Basic Information

Date: 13-June-2012 Sectors: Health (100%)

Country Director: Marie Francoise Marie-Nelly Themes: Child health (100%)

Sector Manager/Director: Jean J. De St Antoine/Ritva S.

Reinikka

Project ID: P130865 EA Category: C - Not Required

Lending Instrument: Specific Investment Loan Team Leader(s): Dinesh M. Nair

Joint IFC: No .

Borrower: Federal Ministry of Finance

Responsible Agency: National Primary Health Care Development Agency

Contact: Dr Mohammed Ado Title: Executive Director

Telephone No.: (234-9) 314-2925 Email: info@nphcda.gov.ng .

Project Implementation Period: Start Date: 10-Jul-2012 End Date: 31-Dec-2014

Expected Effectiveness Date: 01-Oct-2012

Expected Closing Date: 31-Jul-2015 .

Project Financing Data(US$M)

[ ] Loan [ ] Grant Term: Standard IDA terms with a “buy-down” provision by which third - party funded trust funds will cover

the service and commitment fees and purchase the credit at its net value if the project meets an agreed trigger.

[ X ] Credit [ ] Guarantee

For Loans/Credits/Others

Total Project Cost (US$M): 95.00

Total Bank Financing (US$M): 95.00 .

Financing Source Amount(US$M)

BORROWER/RECIPIENT 0.00

International Development Association (IDA) 95.00

Total 95.00 .

Expected Disbursements (in USD Million)

Fiscal Year 2013 2014 2015 2016

Annual 20.00 45.00 30.00 0

Cumulative 20.00 65.00 95.00 95

vii

.

Project Development Objective(s)

To assist the Government of Nigeria, as part of a global polio eradication effort, to achieve and sustain at least 80% coverage with oral polio vaccine

immunization in every state in the country. .

Components

Component Name Cost (USD Millions)

Supply of oral polio vaccine to national strategic cold stores 95.00 .

Compliance

Policy

Does the project depart from the CAS in content or in other significant respects? Yes [ ] No [ X ] .

Does the project require any waivers of Bank policies? Yes [ X] No [ ]

Have these been approved by Bank management? Yes [X] No [ ]

Is approval for any policy waiver sought from the Board? Yes [ ] No [X]

Does the project meet the Regional criteria for readiness for implementation? Yes [X] No [ ] .

Safeguard Policies Triggered by the Project Yes No

Environmental Assessment OP/BP 4.01 X

Natural Habitats OP/BP 4.04 X

Forests OP/BP 4.36 X

Pest Management OP 4.09 X

Physical Cultural Resources OP/BP 4.11 X

Indigenous Peoples OP/BP 4.10 X

Involuntary Resettlement OP/BP 4.12 X

Safety of Dams OP/BP 4.37 X

Projects on International Waterways OP/BP 7.50 X

Projects in Disputed Areas OP/BP 7.60 X

.

Legal Covenants

Name Recurrent Due Date Frequency

Institutional Arrangements (Section I.A, Schedule 2 of

Financing Agreement)

X

Description of Covenant

Obligation to maintain, throughout the implementation of the Project, the National Primary Health Care Development Agency, an inter-agency coordination

committee, and an expert review committee, with functions, staff and resources satisfactory to the Bank

Name Recurrent Due Date Frequency

UNICEF financial management arrangements (Section II.B.2,

Schedule 2)

X semester

Description of Covenant

The Recipient shall, in accordance with the terms of the UNICEF Procurement Agreement: (i) require UNICEF to maintain a separate ledger account in

which all receipts and expenditures financed under the Project will be recorded; (ii) require UNICEF to prepare and furnish to the Recipient as soon as available, but in any case not later than 60 days after the end of each quarter, “utilization” reports prepared in accordance with the provisions of the UNICEF

viii

Procurement Agreement; and (iii) as soon as possible after their receipt from UNICEF, furnish copies of the said reports to the Association.

Name Recurrent Due Date Frequency

Audit-on-request provision (Section II.B.4, Schedule 2) X As indicated in the

Association‟s audit request

Description of Covenant

The Recipient shall, upon the Association‟ request, have the Financial Statements for the Project audited in accordance with the provisions of Section 4.09 (b)

of the General Conditions. Such audit of the Financial Statements shall cover the period indicated in the Association‟s request. The audited Financial

Statements for such period shall be furnished to the Association not later than the date indicated in the Association‟s request

Name Recurrent Due Date Frequency

Retroactive financing (Section IV.B.1, Schedule 2) Upon effectiveness

Description of Covenant

No withdrawal shall be made for payments made prior to the date of the Financing Agreement, except that withdrawals up to an aggregate amount not to exceed the equivalent of SDR 12.26 million may be made for payments prior to this date but on or after May 1, 2012, for Eligible Expenditures.

Name Recurrent Due Date Frequency

Provisions for buy-down of Credit principal and commitment

and service charges from the Polio Buy-Down Trust Funds (Sections 2.08 and 2.09), model form of Assignment and

Release Agreement (Schedule 4), and definitions of

capitalized terms (Appendix)

X Semi-annual payments of

principal and charges according to the payment

schedule in the Financing

Agreement

Description of Covenant

The Association shall: (a) as administrator of the Global Program to Eradicate Poliomyelitis Trust Funds (“GPEP Trust Funds”) and on behalf of the

Recipient, pay the Commitment Charge and the Service Charge, as they fall due under this Agreement, until the earlier of: (i) the date of the Assignment and Release Agreement; or (ii) the Buy-Down Completion Date; and (b) following the Assignment Trigger: (i) acting in its own capacity, assign its rights, title

and interest in the debt payable by the Recipient under this Agreement to the Association as administrator of the GPEP Trust Funds in return for receipt of the

Repayment Amount; and (ii) as administrator of the GPEP Trust Funds, release and discharge the Recipient from its payment obligations arising in relation to the debt due under this Agreement, and cancel such indebtedness, by concluding an Assignment and Release Agreement with the Recipient and the

Association in its own capacity.

Notwithstanding the above provisions, in the event that there are insufficient funds in the GPEP Trust Funds to pay: (a) the Commitment Charge and the

Service Charge as they fall due under this Agreement; or (b) the Repayment Amount due under this Agreement, the payments of the Commitment Charge and

Service Charge or the Repayment Amount pursuant to Section 2.08 of this Agreement shall be limited to the amount of funds available in the GPEP Trust Funds for such purpose, and the assignment and release of the Recipient‟s debt under the Assignment and Release Agreement shall be limited to such amount.

Name Recurrent Due Date Frequency

Execution of UNICEF Procurement Agreement Effectiveness condition

Description of Covenant

The Additional Condition of Effectiveness is that the UNICEF Procurement Agreement has been executed and delivered, under terms and conditions satisfactory to the Association in accordance with Section III of Schedule 2 to the Financing Agreement, and all conditions precedent to its effectiveness

(other than the effectiveness of the Financing Agreement) have been fulfilled. .

Team Composition

Bank Staff

Name Title Specialization Unit

Luis M. Schwarz Senior Finance Officer Fiduciary and disbursement aspects CTRLA

Bayo Awosemusi Lead Procurement Specialist Procurement aspects AFTPC

Frederick Yankey Sr Financial Management

Specialist

Financial Management aspects AFTFM

Manush Hristov Senior Counsel Legal aspects LEGAF

Joseph Ese Akpokodje Senior Environmental Institutions Safeguard aspects AFTEN

ix

Specialist

Dinesh M. Nair Senior Health Specialist Team Leader AFTHE

Abimbola Ogunseitan E T Consultant Procurement aspects AFTPC

Adewunmi Cosmas Ameer

Adekoya

Financial Management Specialist Financial Management aspects AFTFM

Ogo-Oluwa Oluwatoyin Jagha Monitoring & Evaluation

Specialist

M&E aspects AFTDE

Shunsuke Mabuchi Health Specialist Management and technical aspects AFTHE

Ugonne Margaret Eze Team Assistant Administration AFCW2

Non Bank Staff

Name Title Office Phone City

Birte Sorensen Consultant .

1

NIGERIA

Polio Eradication Support Project

PROJECT APPRAISAL DOCUMENT

I. STRATEGIC CONTEXT

1. With 62 confirmed cases of polio in 2011, Nigeria is one of only three countries1 globally

and the only country in Africa where polio remains endemic (the fourth country, India, had its

last case in January 2011). Polio eradication in Nigeria is therefore a global public health

priority and has serious implications for its neighbors. Almost all polio cases in other parts of

Africa, and some in Asia, have been linked genetically to a strain of the virus originating in

Nigeria.

2. The previous project, Partnership for Polio Eradication, in the amount of SDR 20.9 million

(US$ 28.70 million equivalent) was approved on April 29, 2003 and became effective on August

6, 2003. The Project was amended on May 10, 2005 to incorporate an Additional Financing of

SDR 33.4 million (US$ 51.7 million), again on September 8, 2008 with a second Additional

Financing of SDR 31.8 million (US$50 million) and on March 17, 2011 with a third Additional

Financing of SDR 39 million (US$ 60 million equivalent). The project which supported

procurement of oral polio vaccine was a Category C project with no fiduciary issues and was

consistently rated as satisfactory. Similarly this project, aims to provide predictable financing for

oral polio vaccine over the next three years and prevent any gap in vaccine supply that could

interrupt the polio eradication effort. To help ensure the timely availability of funding for the

uninterrupted supply of Oral Polio Vaccine (OPV), the project will include up to 20% retroactive

financing.

3. There is a strong rationale for the project: 1) Polio eradication is a global public good

because of its epidemic potential but also because of its devastating impact both on children and

adults. Polio remains a lethal and maiming disease that is entirely preventable. 2) Nigeria has

made real progress in the last few years in Polio eradication and may interrupt the transmission

in the next few years. The Bank has been a major financier of Nigeria‟s Polio efforts and the

major financier of OPV so there is an interest in ensuring that polio eradication in Nigeria is

achieved. 3) There is strong evidence of Government ownership of polio eradication. 4) 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

good to countries which still have endemic polio.

A. COUNTRY CONTEXT

4. Nigeria fares poorly on key health indicators. Comparing the data from 2003 and 2008

Demographic and Health Surveys it is evident that Nigeria has made limited progress in

1 The other two countries are Afghanistan and Pakistan.

2

delivering critical health services and that it is unlikely to meet the health related targets for the

Millennium Development Goals (MDG) especially for MDG4 (for which the target value is an

under five mortality rate of 67), as shown in Table 1.

Table 1: Trends in health indicators in Nigeria

Indicator (%) 2003

2008

Antenatal Care Coverage 60.1 58

< 5y child mortality per 1,000 live births 187 157

% children age 12 – 23 months received all basic immunizations

(BCG, measles, and 3 doses each of DPT and polio)

13 23

% children age 12 – 23 months received no immunizations 27 29

DPT3 Coverage 20.1 35.4

Measles Coverage 31.4 41.4

Source: DHS

5. There are regional differences in achievements of key health indicators. While the

southern states fare better than the national average the northern states fall substantially behind

on a number of indicators. Likewise for polio eradication, the northern states remain with

endemic polio while the rest of the country has been polio free for almost ten years.

Table 3: Regional disparities, indicator ranges – DHS 2008

Range in indicators Northern states Southern States National Average

Children 12- 23 months fully immunized (%) 6-26 36-43 23

Children under 5 who are stunted (%) 44-53 22-31 41

Delivery assisted by skilled provider (%) 10-43 36-82 39

Current Use of Any Modern

Methods of contraception (currently

married women 15-49 years) (%)

3-11 12-21 10

B. SECTORAL AND INSTITUTIONAL CONTEXT

6. Nigeria has made progress in eradicating Polio for many years. While the country had

more than 1,100 cases of polio in 2006, very intensive efforts resulted in a substantial reduction

in the number of cases between September 2009 (388 cases) and 2010 (21 cases). The

independent monitoring of OPV coverage has also demonstrated that it is on average 80%, even

in the endemic states. Suboptimal program implementation at the local level, massive staff

transfers and security issues in a few states during the national election year 2011, however,

resulted in an increase in the number of cases totaling 62 cases in eight endemic states by the end

of 2011. The transmission of all three types of polio virus was restricted to the northern states,

particularly Borno, Zamfara, Sokoto, Yobe, Kaduna, Bauchi, Jigawa, Katsina, Kano, Kebbi,

Niger, and Plateau.

3

Figure 1. Annual number of polio cases

7. As shown in Figure 1, during the March 2012 Expert Review Committee2 meeting, an

analysis of the 62 cases found in 2011 showed that 95% of all cases were found in eight key

states and 80% of all cases are in five states – Kano, Jigawa, Borno, Zamfara, Sokoto. 67% of

the cases were found in known high risk Local Government Agencies (LGA) and all cases in

other areas were genetically related to the cases in these high risk LGAs. 90% of all cases were

found in children under 5 years of age; out of these, 32% had received no dose of OPV

(compared with the national average of only 2% of children missed in 2011). The average polio

case can therefore be described as a young child who has received zero doses or is under-

immunized, and is from a high risk LGA in a high risk state.

8. Nigeria is one of the three remaining countries with endemic polio transmission. The

Independent Monitoring Board for the Global Polio Eradication Program note in its September

2011 report that: “Seven countries have persistent polio transmission. Three countries have

endemic transmission – Afghanistan, Nigeria and Pakistan. India has interrupted polio

transmission in 2011. Nigeria made strong progress in 2010, but has slipped backwards in 2011.

Afghanistan continues to make slow but steady progress. Pakistan‟s program is failing. Most

cases in Africa (apart from Angola and D. R. Congo) can genetically be traced back to Nigeria.”

Table 4: Polio Epidemic trends by country and year

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Nigeria 28 56 2023 355 782 830 1123 285 798 388 21 62

India 285 268 1600 225 134 66 676 874 559 741 42 1

Pakistan 199 119 90 103 53 28 40 32 117 89 144 192

Afghanistan 27 11 10 8 4 9 31 17 31 38 24 76

9. Nigeria‟s polio eradication effort includes: (i) routine immunization; and (ii) campaign

immunization. In single disease eradication efforts such as this, campaigns may be the most

effective way to reach vulnerable populations in the short term, while health systems are being

2 The ERC is a committee of international and national polio experts who meet regularly to assess the polio

eradication efforts and provide advice on frequency of immunization days, type of vaccine to be used and research

to be undertaken., 3 Surveillance systems were inadequate before 2003.

202

355

782 830

1123

285

798

388

21 62

0

200

400

600

800

1000

1200

2002 03 04 05 06 07 08 09 10 2011

4

strengthened to respond adequately in the longer term. Routine immunization covers children

under the age of five at health facilities and through outreach services. The targeted diseases

include tuberculosis, measles, diphtheria, tetanus, hepatitis B, yellow fever and polio. The

routine immunization is mainly funded by the government with some support provided by

Global Alliance for Vaccines and Immunization (GAVI) for cold chain equipment and

improvement. Campaign immunization supplements the routine polio immunization through: 1)

National Immunization Plus Days (NIPDs); 2) Sub-national Immunization Plus Days (SIPDs); 3)

Local Immunization Days (LIDs); 4) Mop-up activities; and 5) Maternal, Neonatal and Child

Health weeks. Short Interval Additional Doses are used in locations not adequately covered by

any of the above activities.

10. The supporting activities include: (i) OPV supply chain management; (ii) community

mobilization, communication and advocacy activities; and (iii) monitoring and evaluation. For

the immunization campaigns, OPV is procured and delivered by UNICEF to the country several

weeks in advance and placed in the National Primary Health Care Development Agency

(NPHCDA) cold stores in Abuja from where they are distributed directly to the campaign sites

with a buffer stock managed by the NPHCDA. As the vaccine is not stored in any intermediate

points, wastage and delays are minimized.

11. Community mobilization focuses on reaching children in high-risk states and hard to reach

areas through increasing human resources and eliminating barriers that lead to non-compliance.

Volunteer community mobilizers cover a large number of settlements in Kano, Kebbi, and

Sokoto in an attempt to identify, characterize and facilitate the vaccination of chronically missed

children4. Mass communication efforts include using celebrities and the private sector to convey

messages effectively. The Nigeria Governors Forum, a very strong political body in Nigeria, has

recently endorsed its commitment to polio eradication through their participation in the „Nigeria

Immunization 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.

12. OPV coverage is tracked through enhanced independent monitoring (EIM), cluster survey as

used in the independent performance audit and Lot Quality Assurance Sampling (LQAS). In

EIM, independent monitoring staff observes the immunization campaigns, and calculate the

polio immunization coverage as “the number of children vaccinated/ estimated catchment

population”. In the cluster survey, all wards in each high risk state will be listed and stratified

into high, medium and low transmission wards, and 30 clusters will be randomly selected from

each stratum proportionately to the number of wards in each stratum. Within the cluster, 7

households that have at least 1 child under the 5 years of age will be randomly selected. LQAS

tracks immunization coverage by carrying out a household survey and thoroughly investigating

children in randomly selected lots. EIM claims on average 36% more OPV coverage than the

LQAS. The government and WHO therefore plan to scale up the LQAS, while improving the

quality of the EIM.

4 The Game Changer [March 2012]: UNICEF Quarterly Newsletter on Polio Eradication Initiative in Nigeria.

5

13. Cases of acute flaccid paralysis (AFP) are identified by the local Disease Surveillance and

Notification Officer and confirmed by WHO staff. Stool samples are sent to one of the two

laboratories in the country for analysis within 2-3 days of notification. Laboratory staff

identifies the poliovirus and analyze the virus to determine its origin. WHO employs LGA

facilitators who support the state government on AFP surveillance. Community Health Extension

Workers at primary health care facilities and hospitals are the “focal persons” who coordinate

AFP surveillance activities. Environmental surveillance tests of the water in sewage/drainage

have been initiated in Kano and Sokoto and will be scaled up to other states. The AFP

surveillance system in Nigeria consistently surpasses WHO standards.

14. To spearhead the final push to 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.

15. The Federal Government of Nigeria (FGN) has furthermore prepared an Emergency Plan

for Polio Eradication. The main features of this emergency plan are: (i) direct engagement of

the President through a Presidential Task Force; (ii) the establishment of a National

Accountability Framework; and (iii) the preparation of a detailed plan for improving team

performance. 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. In addition, a large number

of additional staff is being placed in the High Risk Areas, and Intensified Ward Communication

Strategy and Village Community Mobilizers are being placed in high risk wards. A Short

Interval Additional Dose of OPV will also be introduced in selected locations where security or

other issues limit access during regular campaign days. 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.

16. While there is strong commitment at the federal level this is not always translated into action

on the ground. The NPHCDA has therefore started deploying most of their professional staff to

the field during the preparation for and implementation of the national and sub-national

immunization rounds in the high risk states.

6

17. A number of institutions are working closely with the FGN to intensify the efforts to

eradicate polio (e.g., WHO, UNICEF, Bill and Melinda Gates Foundation (BMGF), Centers for

Disease Control, USA (CDC)). The FGN also continues to closely follow the regular advice

provided by the Expert Review Committee (ERC) with regards to the type of vaccine to use,

frequency of immunization rounds, research to be conducted and strategies to be followed to

achieve program objectives.

18. In order for all of the efforts described above to succeed the Oral Polio Vaccine (OPV) must

be available, on time and of good quality. For the OPV financed by the World Bank, UNICEF

undertakes the procurement, supply and delivery to the end users. This system is well tested and

there have been no cases where immunization was interrupted due to non-availability of OPV.

19. The IDA financing will provide for 100% of the oral polio vaccine representing 45% of the

overall polio eradication cost in Nigeria over the project period. 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.

C. HIGHER LEVEL OBJECTIVES TO WHICH THE PROJECT CONTRIBUTES

20. This project will contribute to the achievement of Global Polio Eradication and thereby

contribute to preventing a debilitating disease from affecting all children in the future. The

eradication of polio will be a global public good, the benefits of which will accrue to wealthy and

poor countries in perpetuity. The operation is aligned with Regional strategic priorities and

adheres to the selectivity principle by supporting the three main pillars and key objectives of the

Nigeria Country Partnership Strategy (2010-2013): governance, maintaining non-oil growth and

promoting human development. The CPS further notes that the Bank will invest in improving

health related MDGs by creating improved access to quality health services, improved

vaccination coverage and improved maternal care services. In addition the Africa Strategy –

Africa’s Future and the World Bank’s Support to it – is founded on strengthening governance

and public sector capacity. A key pillar of the strategy is to reduce vulnerability by designing,

monitoring and evaluating safety-net and health systems reforms.

II. PROJECT DEVELOPMENT OBJECTIVES

A. PROJECT DEVELOPMENT OBJECTIVE

21. The development objective of the project is to assist the Government of Nigeria, as part of a

global polio eradication effort, to achieve and sustain at least 80% coverage with oral polio

vaccine immunization in every state in the country.

7

B. PROJECT BENEFICIARIES

22. The project beneficiaries will be all children in Nigeria, but with the current eradication

program focusing on the Northern states and the „difficult to reach‟ Local Government Agencies

(LGA), it is the children living in these areas who will disproportionately benefit from the

project. Ultimately, all children in the world will benefit once polio has been eradicated globally.

C. PDO LEVEL RESULTS INDICATORS

23. The immunization coverage of OPV is at least 80 percent in the country and in each endemic

state. The data for these indicators will be Enhanced Independent Monitoring (EIM) and cluster

sample survey as per the WHO standard methodology.

III. PROJECT DESCRIPTION

24. The project will provide funding for the procurement and supply of Oral Polio Vaccine for

the Nigeria polio eradication efforts. This is a follow on project to the Partnership for Polio

Eradication Project (P080295), which closed on April 30, 2012. The target of 80% for OPV

coverage was reached for the original and the first two additional credits of the previous project5.

The overall PDO achievement and implementation progress were rated as satisfactory, legal

covenants were complied with, and there are no outstanding audit, fiduciary, environmental or

social issues.

25. Compared to the previous project, which included additional donor- and counterpart-

financed polio eradication activities, this project is limited to the IDA financed part of the Polio

Eradication Program. In line with this, the project development objective has been modified to

address only the OPV coverage. The project complies with the requirements for a repeater

project i.e. (i) it is consistent with the current Country Assistance Strategy (CAS) objectives; (ii)

the previous project has demonstrated tangible results and was rated as satisfactory for the past

12 months; (iii) there are no unresolved fiduciary, environmental or safeguard issues; and (iv)

there is demonstrated client support for Bank participation in this further effort to eradicate polio.

26. As the epidemiology of polio is non-linear, multi-factorial and complex, it is not possible to

predict how long it will take to eradicate polio from Nigeria. The developments in Nigeria over

the last five years, the recent intensified efforts by the country and its partners, as well as the

recent success of eradication efforts in India, however, indicate that there is an opportunity that

transmission of polio could be interrupted within the next two years. A follow on project is

therefore justified to ensure that there is secured financing of OPV for this – possibly – final

effort to eradicate polio from Nigeria.

5 The verification of target completion for the third additional credit will be conducted in the summer of 2012; see

paragraph 29.

8

27. Using the same procurement arrangements that were applied in the original project, the OPV

to be financed by the credit will be procured and supplied by UNICEF, based on a procurement

agreement (MOU) between the Borrower and UNICEF. The Bank will disburse funds directly to

UNICEF, which in turn will purchase the required polio vaccine based on instructions from the

FGN. Globally, there are only a few producers of polio vaccine and as the epidemic is coming to

an end, these producers are increasingly reluctant to continue their production. It is, therefore,

essential that Nigeria is able to transfer funds to UNICEF in time to secure the required OPV for

Nigeria. Likewise, UNICEF must know that they have adequate funding for vaccine for them to

negotiate with the vaccine producers regarding both price and delivery schedules. Since UNICEF

took over responsibility for bringing the vaccine to the country in 2003, there have been no cases

of delayed delivery or vaccine stock-out.

28. The project is also expected to continue the use of the IDA buy-down financing mechanism,

which was established for the previous project with support from BMGF, Rotary International

and CDC.6 Under the previous project, the donors agreed to buy down the principal and any

accruing commitment and service charges of IDA credits in lieu of the Borrower (thereby turning

them into grants to the Borrower), contingent on an agreed trigger being met during

implementation. The buy-down trigger is that the coverage of the target population for oral polio

vaccines is at least 80% in each endemic state, as verified through an independent assessment

commission by IDA. Thus far, the triggers for the original and first additional credits have been

met and verified, and their buy-down has been successfully completed, which has resulted in

turning the credit into a grant to the borrower. The trigger for the second additional credit has

also been met and verified, and it will be purchased at the same discount rate, while the decision

regarding the third additional credit will be taken when the results of the August 2012

performance review become available.

29. As mentioned, the project will continue to make use of this IDA buy-down mechanism. The

indicator which will trigger the buy-down will remain the same i.e. that at the end of the project,

the immunization coverage of the target population for oral polio vaccine is at least 80 percent in

each endemic state. The performance on this trigger will be measured through an independent

performance audit undertaken by IDA and will thereby contribute with an independent measure

of the quality of the National polio eradication effort. In endemic states selected by the ERC,

OPV coverage is estimated using the WHO EPI cluster sampling method. The survey is

conducted within seven days of a NIPD, and OPV coverage determined by history and finger

mark.

30. However, due to the size of the repeater credit, and the amount required for the buy-down

i.e. approximately US$ 60 million at present estimates, the buy-down donors will not be in a

position to commit the entire buy-down amount at the time of Board presentation of the credit.

6 In July 2002, a partnership with the BMGF, and the United Nations Fund (UNF) was formed to "buy-down" the

cost of IDA credits for polio eradication activities in a group of countries identified by WHO, as the remaining

polio-endemic countries, including: Nigeria, Afghanistan, Pakistan and India. Rotary International and CDC are the

financiers of the UNF. Two Polio Eradication Trust Funds (PETFs), financed by BMGF and UNF and managed by

the World Bank were established. The PETFs pay all charges for the eligible credits during implementation and pay

off the net present value of their principal as soon as the projects are successfully completed. Thus the IDA credit

becomes a full grant to the Borrower (see the PAD for the previous Partnership for Polio Eradication Project for

more details).

9

An amendment to the trust fund agreements with the buy-down donors will therefore be prepared

stating that the replenishment will be in stages, with US$ 30 million expected to be committed at

the time of Board presentation, and the remainder by January 2013. In the unlikely event that any

of the donors fail to pledge or to pay the pledged buy-down funds, FGN as the Borrower will

remain liable to repay the Credit to IDA together with any accrued commitment and/or service

charges.

A. PROJECT COMPONENT

31. The project has only one component i.e. the supply of oral polio vaccine to national strategic

cold stores in Abuja. The credit will purchase approximately 655 million doses of OPV which,

over a two year period will be used to immunize children under the age of five all over Nigeria.

Since more immunization rounds will be conducted in the Northern states, the project will

primarily benefit the children residing in these states.

B. LENDING INSTRUMENT

32. The lending instrument is a Specific Investment Loan (SIL) to FGN. The Amount is US$ 95

million.

C. PROJECT COST AND FINANCING

Project Components Project cost US$ IBRD or IDA Financing % Financing

1.Provision of Oral Polio Vaccine

Total Baseline Costs

Physical contingencies

Price contingencies

95million 95 million 100%

Total Project Costs

Total Financing Required

95 million

95 million

95 million

33. The project will include a provision for retroactive financing, as per the conditions and

criteria set out in OP 6.00 of up to US$19 million, with a cutoff date of May 1st 2012 for vaccine

procurements using IDA approved procedures.

D. LESSONS LEARNED AND REFLECTED IN THE PROJECT DESIGN

34. A number of factors played a role in the reduction of polio in 2010: (i) substantial

involvement of the political and traditional leaders leading to consistent reduction in Wards

achieving < 90% coverage and the improvement in polio immunization status of children; (ii) the

Abuja commitment which included the formation of functioning Expanded Program of

Immunization/Polio Eradication Initiative coordination committees as well as formation of LGA

task forces for polio eradication; (iii) intensified communication activities; (iv) introduction of

mono- and bivalent OPV; and (v) improved focus on routine immunization coverage.

10

35. During 2011, the partial breakdown of LGA and Ward management structures due to

massive transfer of staff following the national elections and the heightened security risk in a

number of Northern states unfortunately led to an increase in the number of polio cases.

36. Regarding the supply of vaccines, experience shows that while vaccines were chronically

short in Nigeria until 2003, they have consistently been delivered on time after UNICEF took

over the supply through a procurement services agreement.

37. Lessons from the earlier credit include: (i) keeping the project simple and reducing the risk

by continuing the procurement of OPV through UNICEF has contributed to the continuous

supply of OPV and a satisfactory rating; (ii) the introduction of an element of performance based

financing with an independent assessment has provided useful focus on reaching specific

indicators as well as valuable information used to adjust the program focus.

IV. IMPLEMENTATION

A. INSTITUTIONAL AND IMPLEMENTATION ARRANGEMENTS

38. The institutional arrangements will remain the same as those under the previous Project.

While the project management falls under the National Primary Health Care Development

Agency (NPHCDA), it is being closely monitored by the Federal Ministry of Health, the

Minister of State for Health and the President. The Project will not require additional

implementation capacity beyond what was already available for the preceding project, namely

the use of existing public health infrastructures at Federal, State and LGA level with technical

support from the Expert Review Committee, WHO, UNICEF and CDC. In response to the

increase in cases seen in 2011, WHO has brought in more than 1700 additional staff to be placed

in the states and LGAs which continue to have active polio cases. The Project will be monitored

through the existing monitoring mechanisms and already functional surveillance systems as well

as the newly introduced accountability mechanism under the President‟s overview.

39. As described, the FGN has introduced a number of new and improved procedures to better

achieve the objectives of the project. In addition, the FGN has already provided US$50 million

in 2012 to pay for the increased intensity of the polio campaigns i.e. additional field teams,

increased remuneration in focus states, additional and better trained supervision and independent

monitoring staff and an expansion of the GIS mapping, and for routine immunization.

B. RESULTS MONITORING AND EVALUATION

40. The WHO surveillance system provides weekly information on polio cases, their typology

and distribution. Data from this system will feed into the results framework. The Project‟s

outcome measures e.g., “immunization coverage of OPV is at least 80 percent in each endemic

state” measures the quality of the OPV campaigns while the monitoring of the cases of Acute

Flaccid Paralysis measures the quality of surveillance. Furthermore the monitoring of the

Vaccine Vial Monitoring will measure the quality of the cold chain. No additional cost will be

needed for monitoring, while the independent evaluation of performance requires internal World

Bank funds for data collection by an independent agency.

11

C. SUSTAINABILITY

41. The project will last three years and is intended as a measure to secure OPV availability in

the short term. However, in line with WHO standards, it will be at least four more years – or

possibly longer – before Nigeria can be declared polio free. While this single focus eradication

effort does bring additional benefits such as improved coverage with vitamin A, improved

disease surveillance and laboratory capacity, it also taxes the general health system in that it

takes away staff for a considerable amount of time thereby preventing them from providing other

services and it results in overall program fatigue. While this project will ensure effective OPV

coverage of the target population in the short term i.e. until the end of 2014, it is proposed to

prepare a more comprehensive IDA credit in support of the overall maternal and child health

agenda including routine immunization targeting the Northern states.

42. The FGN has prepared a multi-year plan for immunization (including polio eradication) and

has to date been able to meet the costs either from its own funding or from partners. Once the last

case of polio is confirmed and three years of surveillance have passed with no new cases, the

cost of polio immunization will be limited to that conducted as part of routine immunization and

there will be a saving on the overall immunization budget of approximately US$100 million per

year.

43. Due to the documented high economic and public health benefit of global polio eradication,

substantial technical and financial support is provided by the international partners for the polio

eradication efforts in Nigeria. As mentioned, WHO brought in more than 1,700 additional

personnel to be placed at field level. Of these, 95% will be located at ward and LGA level and

their principal role will be to support LGA and ward teams to improve operational aspects,

particularly micro-planning, vaccination team selection, training and supervision as well as the

use of local data to fine-tune and improve local operational plans for immunization and

surveillance.

44. The current Emergency Plan for Polio Eradication is building substantial local government

and civil society support for implementation and accountability at state, LGA and community

level (see paragraph 65, 66 and Annex 2 and 3 for details). While the technical and community

interventions are currently focused on the polio eradication efforts, the capacity built will in the

long run substantially benefit both routine immunization efforts and general basic health service

provision.

12

V. KEY RISKS AND MITIGATION MEASURES

A. RISK RATINGS SUMMARY TABLE

Stakeholder Risk L

Implementing Agency Risk

- Capacity M

- Governance L

Project Risk

- Design L

- Social and Environmental L

- Program and Donor L

- Delivery Monitoring and Sustainability L

Overall Implementation Risk M

B. OVERALL RISK RATING EXPLANATION

45. The overall risk rating for the previous project was LOW due to the high government

ownership, and commitment to the polio eradication efforts; strong involvement of religious and

community leaders; proven capacity of the implementing agency; multi donor support and

involvement of the ERC. While this project has similar features, the recent security issues in the

target area cause concerns. Overall implementation risk has therefore been rated as

MODERATE.

VI. APPRAISAL SUMMARY

A. ECONOMIC AND FINANCIAL ANALYSES

46. Economic analysis: Persons affected by polio are disabled, and this bears substantial costs

on society connected with their treatment costs as well as their loss of productivity. Several prior

studies provide important economic support for polio eradication efforts. The economic benefit

per case prevented is substantial and includes the savings per Disability Adjusted Life Years

(DALY) as well as the avoided medical costs. Financing of polio eradication also has significant

and broad public health benefits over and above polio eradication. While approximately 55% of

the global annual polio eradication budget constitutes one-off costs associated with polio

supplementary immunization activities (e.g. purchase of polio vaccine, transport of vaccinators),

the remaining estimated 45% is allocated for training of health staff, local -level micro planning,

refurbishment of vaccine cold-chain systems, and the scaling up of technical capacity for

vaccine-preventable surveillance and monitoring networks. This proposed project would also add

value to existing processes by (i) channeling additional resources into cost effective intervention

(as the OPV is known as being an effective and inexpensive vaccine) to allow accelerated

progress against polio in Nigeria (resulting in more rapid human and economic development than

would have occurred without the project); and also (ii) reducing unit costs through bulk

13

purchasing (as there is also evidence from GAVI that some prices have been reduced through

bulk purchasing).

47. Financial Gap analysis: In March 2012, the ERC recommended to schedule two full

national immunization days and four sub-national immunization days for the high risk states in

addition to a number of mop-ups and local immunization days. It also supports the continuation

of polio immunization as part of the semi-annual Maternal Neonatal Child Health (MNCH)

weeks. This will require approximately 400 million doses of OPV at the cost of around US$ 45-

50 million for one year. The resources from this project, with a closing date of July 2015 are

therefore estimated to be financing the entire vaccine requirement for two years.

B. TECHNICAL ANALYSIS

48. For polio to occur in a population there needs to be an infecting organism, a susceptible

human population, and a cycle of transmission. If the vast majority of the population is immune

to a particular agent, the ability of that pathogen to infect another host is reduced, the cycle of

transmission is interrupted, and the pathogen cannot reproduce and dies out. This concept, called

community immunity or herd immunity is important to disease eradication because the reduction

in the number of susceptible individuals can eventually eliminate the pathogen. Because

poliovirus can only survive for a short time in the environment (a few weeks at room temperature

and a few months between 0–8°) the virus dies out without a human host.

49. Among those individuals who receive oral polio vaccine, only 95 percent will develop

immunity. That means 5 of every 100 given the vaccine will be susceptible to developing polio

even after OPV immunization. They will however be protected by the immunity of those around

them. It is estimated that 80-86 percent of individuals in a population must be immune to polio

for the susceptible individuals to be protected by herd immunity. Failure to reach these levels of

immunity results in the occurrence of polio cases in that community and also places other

communities at risk of importing polio.

50. While the FGN has followed the global guidelines for polio eradication it has realized that

the quality of its work has to date not been adequate to reach the goal. Consequently it has

prepared a 2012 Polio Eradication Emergency Plan to strengthen its efforts towards polio

eradication. The plan aims to achieve the interruption of poliovirus transmission by the end of

2012 and sets out the following objectives: (i) to implement the highest quality SIPDs, with

specific focus on high risk States and LGAs; (ii) to achieve the highest quality AFP surveillance

in all states before the end of 2012; and (iii) to increase the routine OPV3 coverage in the highest

risk LGAs to at least 50%.

51. In addition to these plans to strengthen program management, work is also being carried out

(with support from BMGF) to determine the most effective use of the different types of OPV and

to measure the immunity resulting from SIPDs.

52. The project does not require additional implementation capacity beyond what is already in

place for the previous Project, namely management by the National Primary Health Care

Development Agency, the use of existing public health structures at Federal, State and Local

14

Government levels with technical assistance from the Expert Review Committee, WHO, the

Centers for Disease Control and UNICEF. The project will be monitored through the existing

monitoring mechanisms and already functional surveillance systems as well as through regular,

joint donor supervision missions. With the buy-down arrangement for this credit, the FGN has a

strong incentive to meet the project objective as this will turn the credit into a grant to the

borrower.

53. Nigeria now clearly has the tools available including low cost vaccines. The reasons for

low uptake are known, the plans and tools for addressing these reasons are ready, and there is

strong political leadership and commitment. If the 2012 Emergency Plan is adequately followed

and implemented at all levels, Nigeria is in a position where polio eradication within a few years

is possible.

54. Justification for Government intervention: Vaccination, including polio vaccination,

creates positive externalities as an immunized child reduces the risk of spreading diseases to

others. However, since parents do not take into account these benefits when deciding whether to

vaccinate a child, the number of children immunized would be less than optimal without pro-

active Government intervention. Government intervention is also justified for equity concerns as

the poor and marginalized are the least likely to be immunized.

55. Justification for World Bank's support: Polio eradication is a global public good, the cost

of which should be subsidized to governments since the resources needed in the short term for

the final eradication of poliomyelitis are substantial and the countries where polio is still endemic

are poor and have large competing health priorities.

56. The Independent Monitoring Board of the Global Polio Eradication Initiative identifies weak

health systems as a key barrier to delivering on the timeline to global eradication and notes that

unless health care systems have also improved, gains in coverage levels from mass immunization

campaigns may not be sustained. The Bank‟s experience with the implementation of polio

eradication projects in Pakistan and Nigeria underscores the dependence on strong health

systems - particularly mechanisms for governance, accountability and reliable procurement and

supply chains. Evidence from Africa, South Asia and East Asia demonstrates the relationship

between vaccination coverage and access to maternal and neonatal care. These services thus

operate as complementary goods, indicating the potential for significant efficiency gains in

programs designed to support both.

57. This necessary concentration on polio activities does carry opportunity costs for health

systems delivering basic services. Repeated and intensive polio activities deplete human and

financial resources from routine vaccination or other health programs at multiple levels. It

follows that to intensify polio prevention and achieve eradication; an additional, time-limited

investment must be made specifically in these activities - including mechanisms to shield

program staff from any additional burden.

58. This project therefore is limited to a three year period to cover the acute need for secured

financing for polio vaccine. During this period follow-on larger, health systems strengthening

15

project will be prepared with a focus on maternal, neonatal and child health services in the

underperforming areas of the country.

C. FINANCIAL MANAGEMENT

59. As this is a repeater project, the financial management arrangements under this project will

remain the same as under the previous Partnership for Polio Eradication Project (P080295) and

its related additional financings. The funds for the procurement of OPV, which is the sole

component of this project, will be disbursed directly by the World Bank to UNICEF,

(Copenhagen, Denmark). The assessment of the financial management arrangement for the

project focused exclusively on the OPV expenditures financed by the Bank to obtain the

assurance that the Bank‟s fiduciary requirements are met, especially that funds will be used for

the purpose intended with due regard to economy and efficiency.

60. These procedures are consistent with the procedures agreed and documented in the original

PAD of the previous project and summarized below:

i) An agreement will be signed between the Federal Government of Nigeria and

UNICEF on a single source contract for the purchase of Oral Polio Vaccine

(OPV);

ii) The Agreement will be cleared with the World Bank Procurement unit, and its

signature will be specified as a condition of effectiveness of the project;

iii) The OPV will be procured in accordance with UNICEF‟s rules, regulations and

procedures;

iv) The credit proceeds will be disbursed by the Bank directly to UNICEF for the

purchase of the required OPV on the basis of instructions from the Government of

Nigeria;

v) UNICEF will maintain a separate ledger account in its books through which all

receipts and expenditures, for the purposes of providing these services

contemplated by the Agreement, will be recorded;

vi) UNICEF will report every semester to the FGN (with a copy to the Bank) on the

use of funds received: (a) balance at the beginning and end of the reporting

period; (b) the sales and purchase orders placed by UNICEF during the reporting

period; (c) the actual quantities of OPV delivered during the reporting period; and

(d) the expenditures from the OPV Procurement Account during the reporting

period.

61. The Borrower will not be directly involved in the management of the funds related to this

IDA credit. All financial management responsibilities are vested in UNICEF. The reports

submitted under vi) above will allow the project to meet the Bank‟s financial reporting

requirements, given that UNICEF financial regulations and procedures are accepted under the

Bank-UN Financial Management Framework Agreement (Bank – UN FMFA) which UNICEF

has signed. This project, as in the case of the previous project (P080295) and related additional

financings, will also not request for financial audits. The team has received an audit exemption

for this project from the Bank Financial Management Sector Board, with the understanding that

16

the IDA reserves the right in the Financing Agreement to request for such audit should any issue

come to its attention.

62. Since the funds will be managed by UNICEF, and its FM systems and financial regulations

are acceptable under the Bank-UN FMFA agreement, no formal assessment of UNICEF systems

was conducted, rather the assessment was limited to the existing arrangements that ensures that

the procured OPV vaccines are delivered to the Government and that the accompanying invoices

and delivery notes are consistent with the financial statements submitted by UNICEF. The

assessment therefore was limited to the review of the records presented by UNICEF to the

Government, including the delivery notes covering the vaccines and traced to the distributed

quantities by government and also the financial statements submitted by UNICEF.

63. The assessment found this system to be functioning well and no exceptions were noted,

which gives the assurance that the funds are used for the purposes of the project. This

arrangement therefore meets the Bank‟s FM requirement.

D. PROCUREMENT

64. The existing procurement and disbursement procedures applied under the current project,

which have been assessed to be satisfactory, will continue. UNICEF will undertake the

procurement and supply of OPV through its international procurement division, based in

Copenhagen as agreed under the previous Project. OPRC has given the Regional Procurement

Advisor authority to provide IDA “No Objection” to the draft procurement agreement (MOU)

between the FGN and UNICEF for the duration of the project. This is under process and is

expected to be signed by July 2012, and in any event prior to effectiveness of the project.

“Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD

Loans and IDA Credits and Grants” dated October 15, 2006 and revised in January 2011, as well

as “Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans

and IDA Credits and Grants by World Bank Borrowers” dates January 2011 will apply. Under

the MOU, UNICEF will buy the vaccines from the most advantageous source, while taking into

account its other obligations to respond to the global needs for OPV and its own institutional

requirements. With respect to disbursement arrangements, no changes to the existing

disbursement arrangements are foreseen for this operation.

E. SOCIAL (INCLUDING SAFEGUARDS)

65. The Project has a strong poverty focus since poor families, particularly poor children, are

the primary beneficiaries. Poor people living in unhygienic conditions are at greatest risk of

having polio. Besides, children in poor families tend to have the lowest immunization coverage.

The Project specifically aims to benefit vulnerable groups and previously neglected groups to

receive polio immunization. In high risk LGAs, the national program will deploy over thousand

volunteer community mobilizers to network and create a conducive environment towards

immunization in the community and keep a line list of all children under the age of five.

Likewise LGAs with the most nomads and known polio risk are being targeted, working with

veterinarians, leaders and local NGOs and using GPS to ensure that they are reached by

17

vaccination teams. The aim is to identify and characterize the chronically missed children and to

motivate their parents, thereby solving cases of non-compliance.

66. The program also builds awareness and political support of LGA Chairmen in collaboration

with Association of Local Governments of Nigeria (ALGON) by requiring their participation in

the supervision of SIA and RI. Further, to consolidate traditional leader‟s engagement – the

NPHCDA ensures active participation of traditional leaders in Task Forces at all levels and

traditional leaders head rapid response teams to deal with non-compliance in all high risk/

vulnerable LGAs. They are called to help vaccinators and social mobilization teams to convince

non-compliant households to accept OPV and thereby assist with addressing non-compliance in

all high risk and vulnerable LGAs. The government also plans to strengthen the engagement of

Faith-Based and Community-Based organizations in mobilizing communities. National advocacy

teams visit State Governors and other top government officials of the high risk states in ensure

complete political support. (See Annex 2, paragraph 23 and 27-30 for details).

F. ENVIRONMENT (INCLUDING SAFEGUARDS)

67. The Project is not envisaged to cause environmental risks and the environmental category

for the project is C, as for the previous Project. There is no construction financed under the

project.

18

Annex 1: Results Framework and Monitoring .

Country: Nigeria

Project Name: NG-Polio Eradication Support (FY13) (P130865) .

Results Framework .

Project Development Objectives .

PDO Statement

To assist the Government of Nigeria, as part of a global polio eradication effort, to achieve and sustain at least 80% coverage with oral polio vaccine

immunization in every state in the country. .

Project Development Objective Indicators

Target Values Data Source/

Responsibility

for

Indicator Name Core Unit of

Measure Baseline

YR1

YR3

Frequency

Methodology Data Collection

Immunization

coverage of

OPV in the

country

Percentage 91.80

7 80

80

Every

Immunization

round

EIM UNICEF,

NPHCDA

Immunization

coverage of

OPV in each

high risk state

Percentage

Kano 76

Zamfara 89

Katsina 94

Borno 82

(Oct,2010)8

80 80 2012,

2014

Cluster sample

survey

according to

WHO

approved

methodology

World Bank

/NPHCDA

executed

performance

audit/LQAS

7 This baseline value is a national average based on data collected during the campaigns and compares the number of children immunized to a population target,

while the indicator below uses cluster sampling, a much more robust methodology, but is limited to the high risk states. The 80% value is the internationally

recommended value for achieving herd immunity. 8 Baseline from 2010 Performance Audit (PA). Since more states are endemic- future performance audits /LQAS will include more states in the surveys.

19

Direct project

beneficiaries

of which

female9

(number)10

Number 0 X10

X10

Annual

WHO,

UNICEF

campaign

reports

UNICEF,

NPHCDA

Children

immunized

(number)10

Number 0 X

10 X10

Annual

WHO,

UNICEF

campaign

reports

UNICEF,

NPHCDA

.

Intermediate Results Indicators

Cumulative Target Values Data Source/

Responsibility

for

Indicator Name Core Unit of

Measure Baseline

YR1

YR3

Frequency

Methodology Data Collection

Percentage of

teams with

viable vaccine

according to the

Vaccine Vial

Monitor

Percentage 97 97 98 Every round

WHO

campaign

report

WHO

Percentage of

campaigns

where vaccines

are available on

time

Percentage 100 100 100 Every round

WHO/UNICE

F campaign

reports

UNICEF,

NPHCDA

.

9 As the national program does not disaggregate by gender, the proportion of female will be an estimated figure.

10 Core indicator - cumulative for the project period inclusive of NID and SIA. The NID target is to reach 80% of the children in the country between 0- 5years

which is about 32 million children in each round. The target for the SIAs will vary with the number of high risk states covered, as determined by the epidemic.

20

ANNEX 2: DETAILED PROJECT DESCRIPTION

Immunization

1. To be certified as polio free, a country or a region must document at least three years of zero

polio cases due to wild poliovirus; disease surveillance efforts must meet international standards

and each country must illustrate the capacity to detect, report and respond to “imported” polio

cases. Each country must then continue to maintain immunization levels through their routine

efforts until the world is declared polio free. Laboratory stocks must be contained and safe

management of the wild virus in inactivated polio vaccine (IPV) manufacturing sites must be

assured before the world can be certified polio-free.

2. For polio to occur in a population there needs to be an infecting organism, a susceptible

human population, and a cycle of transmission. Poliovirus is transmitted only through person-to-

person contact and the transmission cycle of polio is from one infected person to another person

susceptible to the disease. If the vast majority of the population is immune to a particular agent,

the ability of that pathogen to infect another host is reduced, the cycle of transmission is

interrupted, and the pathogen cannot reproduce and dies out. This concept, called community

immunity or herd immunity is important to disease eradication because if the number of

susceptible individuals can be reduced to a small number through vaccination, the pathogen itself

can also be eliminated. Because poliovirus can only survive for a short time in the environment

(a few weeks at room temperature, and a few months between 0–8°) without a human host the

virus dies out.

3. Herd immunity is an important supplement to vaccination. Among those individuals who

receive oral polio vaccine, only 95 percent will however develop immunity. That means 5 of

every 100 given the vaccine won‟t develop any immunity and will be susceptible to developing

polio. They will however be protected by the immunity of those around them. It is estimated that

80-86 percent of individuals in a population must be immune to polio for the susceptible

individuals to be protected by herd immunity. Failure to reach these levels of immunity results in

the occurrence of polio cases in that community and also places other communities at risk of

importing polio.

The Polio Eradication Program in Nigeria

4. Nigeria‟s polio immunization program consists of 1) routine immunization and 2) campaign

immunization. Routine immunization immunizes children under five with various vaccines at

health facilities and through outreach services. The targeted diseases include not only polio but

also tuberculosis, diphtheria, measles, hepatitis B, yellow fever, etc. The polio vaccine used for

the routine immunization is tOPV11

. The FGN fully funds their routine immunization program

while GAVI provides support for upgrading the cold chain. While immunization coverage is still

low, the government aims to increase the routine OPV3 coverage in the highest risk LGAs to at

11

Trivalent oral polio vaccine (tOPV) has advantages such as ease of administration and development of both

mucosal and humeral antibodies. It induces herd immunity, thereby preventing spread of wild virus in the

community. It finally protects against Vaccine Derived Polio.

21

least 50%, and plans to increase the number of village health workers significantly for wider

immunization coverage.

5. Overview: Campaign immunization supplements the routine immunization in four forms: 1)

National Immunization Plus Days (NIPDs); 2) Sub-national Immunization Plus Days (SIPDs); 3)

Local Immunization Days (LIDs); 4) Mop-up activities and 5) Maternal, Neonatal and Child

Health Weeks.

6. NIPDs aim to immunize all the children under-five in the country through house-to-house

visits. Usually bOPV12

is used for the NIPDs. In addition to providing OPV, additional health

interventions such as Vitamin A, malaria prevention and other services are provided. NIPDs are

held twice at the beginning of the year (e.g., in 2012, February and March-April).

7. SIPDs mainly aim to immunize the children in high-risk states and LGAs, using the

combination of bOPV and tOPV rounds. In 2012, the government plans to undertake five SIPDs

taking ERC advice on the geographical areas to be covered and the type of OPV to be used.

8. Other immunization activities, i.e., LIDs and Mop-ups focus on covering areas with low

immunization coverage and localities where cases of polio have been confirmed. LIDs are

planned in May and November 2012 and supported by UNICEF for outreach activities and

logistics, and Mop-up activities will follow ERC recommendations. In addition, CDC sends

selected STOP team, 11 short-term, highly qualified health professionals in the United States, for

three-month on non-salary basis to support routine and campaign immunizations and

surveillance.

9. The FGN runs semi-annual, nationwide Maternal, Neonatal and Child Health (MNCH)

weeks which include polio immunization in addition to other high impact services such as

Vitamin A supplementation, routine immunization and malaria prevention for mothers and

children.

Table 5: Main immunization approaches in Nigeria

Approaches Targets Description Frequency

Routine

immunization

All children

under-five

- Immunization at health facilities and

through outreach activities (once a week).

- Vaccines include polio (tOPV), BCG, Hep

B, measles, yellow fever, etc.

- Funded by the government

Daily and weekly basis

NIPDs All children

under-five

- House-to-house immunization targeting all

the under-five children in the country.

- Polio immunization (bOPV) plus other

services such as Vitamin A.

Twice a year at the

beginning of the year

(Feb and Mar) in 2012

SIPDs Children under-

five in high risk

states

- Usually targeting high risk or any states that

had confirmed cases of polio.

- ERC advises which states to target.

- Uses the combination of bOPV and tOPV.

Five times a year in 2012

12

Bivalent oral polio vaccine (bOPV) was found to induce a significantly higher immune response than the tOPV.

Though the tOPV targets all polio strains, bOPV targets types 1 and 3, which persist in polio-endemic countries such

as Nigeria. It allows children in polio hotspots to develop resistance quicker than tOPV.

22

LIDs Children that are

missed in

immunization

- Aims to reach all the children who are

missed.

- National council on health decides who to

target.

Based on epidemiology

Mop up

activities/Short

Interval Additional

Dose

Areas with cases

or suspected, or

not covered well

- House-to-house immunizations targeting

specific areas where: 1) polio cases have

been confirmed – or suspected; or 2) the

immunization activities didn‟t work well.

- ERC advised that the Mop-up strategy

should be reserved for areas that become

reinfected outside the key transmission

zones. It also advised that the role of Mop-

ups in the transmission zones should be

revisited based on the evolving

epidemiology.

Following ERC advise

MNCH weeks Children and

mothers

nationwide

Polio immunization, Vitamin A

supplementation, routine immunization and

malaria prevention for mothers and children.

Twice a year

Other supporting activities

10. OPV supply chain: OPV supply chain has two channels: 1) for vaccination campaigns,

which the World Bank is financing through this project, OPV is delivered to the country several

weeks before the campaign dates and distributed through the NPHCDA to the campaign sites

from the port, except for the buffer stocks that are managed by the NPHCDA; and 2) for routine

immunization, vaccines are delivered from the port to the National Strategic Cold Store and

NPHCDA distributes them to health facilities. As OPV for campaigns is not stored in any

intermediate points, wastage and delays are minimized in this process compared to the routine

immunization process.

11. Logistics structure for routine immunization: The logistics system for routine

immunization consists of five-levels (Figure 1): NSCS; zones (6); states (36); LGAs (774); and

health facilities providing immunization (22,876 facilities)13

.

12. Forecasting for routine immunization: The immunization program in Nigeria uses the

standard UNICEF Supply Division forecasting tool for estimating vaccine needs at the national

level, applying the target population method of forecasting (i.e., use last national census and

assumes the <1 year age group comprises of 4% of the total population. The program‟s target

coverage is 80% in the 2010 forecast). National forecasters and UNICEF apply GAVI

recommended global wastage rates to calculate wastage multipliers which is 1.33 for OPV.

Accuracy rate of the forecast has been low for the routine vaccines, and NPHCDA procured 46%

less OPVs than forecasted in 2009. It was partly because large quantities of tOPV from late

2008 campaigns were rolled over into the routine program for 2009.

13

NPHCDA/UNICEF. 2010. Report on the Vaccines Security Mission.

23

Figure 1: Vaccine logistics system in Nigeria

Source: NPHCDA/UNICEF. 2010. Report on the Vaccines Security Mission.

13. Supervision of routine immunization: Median monthly health facility wastage rate and

session-specific wastage rate for OPV for sampled health facilities14

were reported high at 19%

and 35% respectively15

. A Joint vaccine security mission conducted by NPHCDA and UNICEF

identified delays in decision-making for distribution from NPHCDA, insufficient supervision,

poor compliance to operational guidelines, lack of vaccine management practices, and poor

maintenance of refrigerated trucks and stand-by generators as the causes of this wastage.

14. To calculate the target population – and OPV doses required, UNICEF takes the greatest

number of children immunized from the past rounds and multiplies with a wastage factor of 1.1.

To this they add the cohort born in the previous year, i.e. 6.4 million children.

15. Community mobilization, communication and advocacy activities: Numerous

initiatives have been initiated by the government to raise individual and political awareness on

polio immunization, with support from development partners such as UNICEF and BMGF

(Figure 2). Community mobilization focuses on reaching children in high-risk states and hard to

reach areas through increasing human resources and eliminating barriers that lead to

noncompliance. For example, with the funding from BMGF and CDC and support from

UNICEF, volunteer community mobilizers are going to cover 557 settlements in Kano, 200 in

Kebbi, and 200 in Sokoto as the first phase of the program to identify, characterize and facilitate

the vaccination of chronically missed children16

. Mass communication leverages celebrities such

14

26-35 samples for the health facility wastage rate, and 24-30 samples for the session-specific wastage rate. From

January to June 2011 15

NPHCDA/UNICEF/WHO/CDC. 2011. Nigeria Vaccine Wastage Assessment – Draft Report. August. 16

UNICEF. 2012. The Game Changer. March.

NSCS

Zonal Cold Stores

SMT

State Cold Stores (SMT)

DVD-MT

LGAs (VM2)

VM1

Health Facilities (VM1)

Commodity Flow

Data Flow

24

as London Olympic stars and the private sector in Polio-Free Torch campaigns, journalist in

media awards, and a dedicated website to convey messages effectively to large population. In

addition, with a strong commitment from the President, the government and development

partners engage in high-level advocacy to the governors and religious and traditional leaders in

the high-risk northern states.

Figure 2: Overview of community mobilization, communication and advocacy activities

16. M&E: The progress of the program is monitored through enhanced independent

monitoring (EIM), cluster surveys as in the performance audit and Lot Quality Assurance

Sampling (LQAS). In EIM, independent monitoring staff trained by WHO cover all the area

where the campaign immunizations are implemented, and calculate the Polio immunization

coverage as “the number of children vaccinated/ estimated catchment population”. In contrast,

LQAS is a type of household survey. A WHO‟s research in high-risk states suggested that the

EIM claims on average 36% more OPV coverage than the coverage identified by the cluster

surveys. The government and WHO therefore plan to scale up the LQAS, to cover 161 LGA of

774 (20%) in 2012, while improving the quality of the EIM.

17. Performance audit: While EIM and LQAS will be used for program monitoring

purposes, project evaluation as well as performance on the buy-down trigger will be measured by

the performance audit conducted by the World Bank through an independent agency. In endemic

states selected by the ERC, OPV coverage is estimated using the WHO Expanded Program of

Immunization (EPI) cluster sampling method. The survey is conducted within seven days of a

NIPD, and OPV coverage determined by history and finger mark. In the performance audit

conducted in 2010 an average of 80% coverage was found to have been achieved in the endemic

states resulting in the buy-down of the credit.

18. Surveillance: Acute flaccid paralysis (AFP) surveillance is typically built around the

Disease Surveillance and Notification Officer (DSNO). Each LGA has at least one DSNO and

high-risk LGAs have an additional DSNO. DSNOs are employed by the Ministry of Local

Government and managed by Local Government Authorities. When children with AFP are

Polio

communication

activities

Community

mobilization

Mass

communication

Political

advocacy

• Intensified Ward Communication Strategy (IWCS)

• Volunteer community mobilizer network

• Interpersonal communication training

• Parents awareness campaigns

• Engagement of traditional and religious leaders

• Outreach to nomadic population

• Presidential Taskforce for Polio Eradication

• High Level Advocacy Team advocacy to high risk states

• Nigeria Immunization Challenge

• Northern Traditional Leaders Committee

• Polio-Free Torch Campaign

• Polio-Free Nigeria Media Awards

• Dedicated website for Polio Eradication Initiative

25

identified, they will be reported to DSNOs. Initial investigations are then conducted by the

DSNO within 48 hours of notification, with re-investigations of all cases being done by WHO

staff. After the investigations, their stool samples will be collected by DSNOs and transported to

one of the two laboratories in the country for analysis within 2-3 days of notification of the case.

Lab staff will isolate and identify poliovirus, and map the virus to determine the origin of the

virus strain. The DSNOs also engage in active case search that reviews patient registries with

the personnel at reporting sites to identify any possible missed AFP. In addition to the AFP

surveillance, environmental surveillance that tests the water in sewage/drainage has been

initiated by WHO in Kano and Sokoto, and will be scaled up to other states. 19. In addition to the government staff, WHO employs a “LGA facilitator” in each LGA and

"cluster level international consultants" responsible for 3-4 LGAs. They are responsible for

supporting the state government and DSNOs in implementing AFP surveillance. DSNOs do not

have a supervisory structure above the LGA level, aside from the state DSNO and the WHO

cluster consultant. In most cases, Community Health Extension Workers (CHEWs) at both

primary health care facilities and hospital are designated to be a “focal person” to coordinate

AFP surveillance activities and serve as the point of contact for the DSNO.

Table 7: Personnel involved in AFP surveillance in Kano State (Example)

Government staff WHO staff

Staff Number Staff Number

State State Epidemiologist

State DSNO

1

1

State Coordinator

Surv. Focal person

1

1

"Cluster"(not an

official admin-

istrative level)

Cluster or international consultant 14

LGA DSNO 60 LGA facilitator 44

Reporting site Focal persons 276

TOTAL 338 TOTAL 60

Source: Review of the AFP surveillance system in Kano state, Nigeria 24-27 May, 2011

2012 Polio Eradication Emergency Plan

20. Program goals and objectives: The government has prepared a “2012 Polio Eradication

Emergency Plan” to strengthen their efforts towards polio eradication. The plan aims to achieve

the interruption of poliovirus transmission by the end of 2012. To achieve this goal, the

government set the country‟s program objectives as: (a) to implement highest quality SIPDs,

with specific focus on high risk States and LGAs (b) to achieve highest quality AFP surveillance

quality in all states before end of 2012 and (c) to increase the routine OPV3 coverage in the

highest risk LGAs to at least 50% in all high risk LGAs.

26

21. Priority activities: The government‟s priority activities to achieve the above objectives

consist of four main areas of focus: (a) enhancing SIPD quality to reach all children, with

specific focus on the chronically missed children; (b) intensified advocacy, behavior change

communication and mobilization at all levels; (c) accelerating routine immunization delivery and

(d) enhancing surveillance for poliovirus detection (2012 Polio Eradication Emergency Plan).

Further, (e) accountability framework has been established to hold stakeholders responsible for

the implementation of these focus areas.

22. SIPD quality: To increase the coverage of the children, especially of those chronically

missed, the government engages in multiple activities. First, it works to improve micro-plans by

including all settlements and hamlets, using Geographic Information System (GIS). The data is

automatically uploaded through a GPS tracking device, which is used for evening review

meetings to ensure „real time‟ information for corrective action. Moreover, the government is

strengthening vaccinator teams especially in the high-risk areas with revised team selection

process, new and standardized vaccinator training, and required logistics including adequate

vaccines. It also addresses irrational team workloads, team shortages and remuneration issues by

restructuring team compositions, employing more teams and testing options tailored to different

contexts to inform new operational guidelines. The government is also working on improving the

independent monitoring and to identify quality gaps more reliably, as well as scaling up tools for

high-risk areas such as stock route maps for nomad populations and short-interval additional

dose strategy.

23. Advocacy, behavior change communication and mobilization: In order to secure

increased support from policy makers and opinion molders and enhance demand for vaccination,

the government is aiming to: 1) counter resistance/non-compliance, which was half of the cases

last year – over a thousand community mobilizers will be deployed to high-risk areas to engage

families, promote immunization and keep a line list of all children under the age of five; 2)

initiate an outreach campaign to map, engage and mobilize religious leaders (imams, madrassa

headmasters, etc.) in high risk areas.; 3) build awareness and political support of LGA Chairmen

in collaboration with Association of Local Governments of Nigeria (ALGON) – LGA Chairmen

are required to participate in supervision of SIAs and RI, and coordinate and attend daily review

meetings during implementation in addition to releasing funds for the activities; 4) strengthen the

engagement and involvement of Faith-Based and Community Based organizations in mobilizing

communities particularly in the highest risk areas; 5) conduct visits by national advocacy teams

to the high risk states for advocacy to State Governors, members of National and State

legislatures and other top government officers.

24. Routine immunization (RI) delivery: Government targets improving RI coverage in the

highest risk LGAs through: 1) evidence based micro-plans with rapid participatory review of

the critical barriers and uptake of routine immunization; 2) increase of human resources, logistics

including vaccines and cold chain; 3) stronger linkages with Traditional Birth Attendants in

mobilizing mothers and caretakers; 4) rounds of LIDs in LGAs with low RI coverage; 5)

initiation of outreach effort in 10-15 LGAs, focused in Kano and Jigawa, with persistent cVDPV

transmission; 6) tracking and immunization of newborn children through midwives services

scheme facilities; and 7) outreach sessions targeting nomadic and migratory populations.

27

25. Surveillance: To strengthen surveillance, the government plans to engage in: 1) priority

surveillance training for clinicians and nurses; 2) deployment of more community informants in

high risk LGAs; 3) strengthening of secondary and tertiary hospitals in the surveillance network;

4) advocacy to States to ensure provision of funds for surveillance; 5) rapid surveillance reviews

in response to any „orphan‟ virus; 6) monitoring of quarterly implementation of rapid

surveillance assessment recommendations; and 7) increased environmental surveillance in Kano

State and with expansion to Maiduguri and Sokoto.

26. Accountability framework: The government established the framework that clarifies

responsibilities and timelines of individuals at every level as a tool to hold everyone responsible

for delivering rapid improvement. The framework and national polio accountability report will

be monitored monthly by the Presidential Task Force on Polio Eradication (PTFoPE). The report

focuses on the high-risk LGAs, identifies the 3-4 most critical barriers and solutions to them, and

recommends rewards and sanctions.

27. Social inclusion and accountability: The government‟s program has a strong poverty

focus. Poor people living in unhygienic conditions are at greatest risk of having polio. Besides,

children in poor families tend to have the lowest immunization coverage. With support from

development partners such as UNICEF and CDC, the program will now target chronically

missed children and nomad population. For example, of eleven LGAs (25%) in Kano state with

state stock routes, none of the wards with nomads had been listed in the micro-plans. NPHCDA

and CDC are working together to develop a scalable solution to integrate the high-risk nomad

populations by: 1) targeting LGAs with the most nomads and known polio risk; 2) working with

the area‟s trusted and knowledgeable veterinarians; 3) carefully assigning the right people to the

local teams; 4) working directly with the Ardos (leaders) and local NGOs; 5) revising ward-level

micro-plans; and 6) verifying micro-plans and team performance using GPS.

28. With support from UNICEF, the NPHCDA is scaling up the use of Volunteer

Community Mobilizers to: 1) identify, characterize and facilitate the vaccination of chronically

missed children; 2) mobilize noncompliant parents through community friendly approaches and

resolve all cases of non-compliance; and 3) create a conducive environment in the community

through networking and partnership.

29. Further, to consolidate traditional leader‟s engagement – the NPHCDA now ensures

active participation of traditional leaders in Task Forces at all levels and traditional leaders head

rapid response teams to deal with non-compliance in all high risk/ vulnerable LGAs. Also, the

Jigawa State Government launched the Community Leaders Against Polio initiative through

which the governor of Jigawa called on all community leaders to help vaccinators and social

mobilization teams to convince non-compliant households to accept OPV and to support the

implementation and supervision of immunization campaigns and Immunization Plus Days.

30. For accountability, multiple layers of independent monitoring have been established. EIM

and LQAS will be used for program monitoring by independent monitors, and project evaluation

will be carried out through the independent performance audit administered by the World Bank.

Further, the government has finally strengthened the information sharing through

www.poliofreenigeria.com which provides updates on the latest social data related to polio and

the communication efforts carried out in the field. Stories from the field will be featured on the

28

site along with the difficulties faced in some high risk areas with non-compliance, missed

children and low demand for vaccination. The site will also feature a selection of communication

materials which can be used to motivate various stakeholders to support polio eradication efforts

as well as materials to promote OPV acceptance amongst caregivers.

29

ANNEX 3: IMPLEMENTATION ARRANGEMENTS

Project Institutional and Implementation Arrangements17

1. Federal Level. The project will be managed and implemented through the existing

government structure. Federal Ministry of Health as the overall health institution will provide

overall guidance and stewardship to the project. The Federal Ministry of Finance (FMOF) as the

borrowing agency will provide the financial guidance for the project. Since immunization is a

federal responsibility the main implementing agency is the National Primary Health Care

Development Agency which has a Department for Disease Control and Immunization which also

includes Polio Eradication. This department has till date demonstrated leadership and strong

commitment towards polio eradication.

2. Due to the upsurge in Polio cases during 2011 a Presidential Task Force on Polio

Eradication (PTFoPE) was officially inaugurated by His Excellency President Goodluck

Jonathan on 1st March 2012. This task force has the overall objective of providing leadership

support to Nigeria‟s efforts to accelerate interruption of poliovirus transmission by the end of

2012. The PTFoPE is chaired by the Honorable Minister of State for Health and has membership

drawn from the National Assembly (Chairman Senate Committee on Health, Chairman House

Committee on Health), National Primary Health Care Development Agency, Federal Ministry of

17

HiLAT: High Level Advocacy Team; ERC: Expert Review Committee; RI: Routine Immunization; WG Working

Group; NIFAA Nigerian Inter Faith Action Association; FOMWAN: Federation of Muslim Women‟s Association of

Nigeria

30

Health, Polio high risk and polio-free states, Northern Traditional Leaders Committee on

Primary Health Care, Nigeria Inter-Faith Group, Nigeria Governors Forum and GPEI Partners.

3. The PTFoPE is expected to meet monthly to review the progress in polio eradication with

specific attention being given to the status of implementation of the 2012 Polio Eradication

Initiative (PEI) emergency plan. Key areas to be reviewed during the monthly meetings of

PTFoPE include (a) reports on the Abuja Commitments; (b) Status of funding for priority PEI

activities including timing of fund release; (c) quality of PEI activities (SIPD, Surveillance, RI)

particularly in the highest risk areas; (d) actions undertaken to address sub-optimal program

performance; and (e) monthly reports on the national accountability framework from all 36

States and Federal Capital Territory.

4. State level. At the state level the project is managed by the State Ministry of Health/State

Primary Health Care Development Agency. The state technical teams are responsible for

implementation oversight, coordination and monitoring. A State Task Force/State Inter-

agency Coordination Committee (STF/SIACC) has been established under the auspices of the

Governor and include membership from State Ministries, Departments and Agencies including

Local Government, Health, Women‟s Affairs, Education, Local Government Commission,

National Orientation Agency; Civil Society including Traditional and Religious Leaders as well

as partners. The STF/SIACC is expected to meet at least once monthly to review the overall

status of Polio Eradication in the state with particular attention being given to the status of

implementation of the 2012 PEI Emergency Plan in the highest risk areas. Key areas to be

reviewed during the monthly meetings of STF/SIACC include (a) status of implementation of the

Abuja Commitments; (b) Status of funding for priority PEI activities including timing of funding

release; (c) quality of PEI activities (SIPD, Surveillance, RI) particularly in the highest risk

LGAs and wards; (d) actions undertaken to address sub-optimal program performance; and (e)

monthly reports on the national accountability framework from all LGAs in the state.

5. The STF/SIACC are expected to support the functioning of LGA Task Forces and

provide required technical and/or advocacy support to LGAs with persistent sub-optimal

performance. The State Task Forces are also expected to maintain a close functional relationship

with the PTFoPE. The State Technical Team serves as the secretariat of the STF/SIACC and is

responsible for preparing all the background documentation for the STF/SIACC.

6. The Local Government Agency Primary Health Care Department is responsible for

managing the local level activities such as local level planning, supervision of local staff and

overall implementation of the immunization activities. Ultimately, it is the capacity and

accountability of managers at this level across the country which determines the outcome

of the polio eradication efforts.

7. A Local Government Agency Task Force is expected to be chaired by the LGA

Chairman with members drawn from senior members of the Local Government Council,

councilors for health, District Head and members of the LGA Technical Team. The LGA Task

Force is responsible for ensuring that priority activities required to ensure high quality

implementation of PEI activities in the LGA are fully implemented as recommended. Specific

focus should be paid to the highest risk wards in the LGA.

31

8. LGA Task Forces are expected to provide regular feedback to State Task Forces.

Wherever required, the State Task Forces will organize capacity building for LGA Task Forces.

Supportive structures:

9. An Inter-Agency Coordination Committee (ICC) is chaired by the Honorable Minister

of Health and oversees all immunization activities in the country including polio eradication.

Membership of the ICC is from the Federal Ministry of Health, National Primary Health Care

Development Agency, National Agency for Food and Drug Administration and Control and

Partner Agencies (WHO, UNICEF, World Bank, BMGF, CDC) as well as the Association of

Local Government of Nigeria. The ICC plays a very important role in ensuring seamless

coordination of polio eradication activities with the broader immunization and Primary Health

Care agenda in Nigeria. The ICC is expected to meet at least once monthly.

10. Core Group and ICC Working Groups: The Core Group is chaired by the Chief

Executive Officer/Executive Director (CEO/ED) of NPHCDA with members from NPHCDA,

relevant ministries, international organizations, donors and civil society. Working groups are

established in the areas of operations, vaccines, logistics, monitoring and evaluation, routine

immunization and social mobilization to support the Core Group. Responsibilities of the Core

Group include:

Monitoring: the Core Group will ensure monitoring of implementation of the 2012 PEI

emergency plan as well as monthly monitoring of the new State and LGA Accountability

Framework;

Reporting: the Core Group will: (a) ensure the necessary reports, including a report on

the State and LGA Accountability Framework, are prepared for the Secretariat to transmit

to the Presidential Task Force in a timely fashion; (b) provide summary update from each

meeting to the Task Force Chairman;

Advisory: the Core Group will identify specific challenges to polio eradication and

recommend practical solutions to the Task Force;

Implementation: will facilitate the implementation and follow-up of the decisions of the

Task Force;

Feedback and Information sharing: the Core Group will ensure information sharing

mechanisms, including email lists to distribute pertinent and timely information about

polio eradication to the National Task Force and relevant partners.

32

National State LGA Ward

Chairman Pres. Task Force Chairman State Task Force Chairman LGA Task

Force LGAF

ED NPHCDA Comm. SMOH /ED SPHCDA DPHC WFP

Director, CHS, NPHCDA UNICEF SM consultant LGA consultant LGA Health

Educator

UNICEF Polio Comm. chief

WHO Communication

Officer

Director, DCI, NPHCDA State Epidemiologist DSNO Surveillance

Focal Person

WHO National Surve.

Officer WHO Surveillance Officer LGAF Field Monitors

Director, DCI, NPHCDA State M & E LIO WHO LGA

facilitator

WHO National Data

Manager WHO State Coordinator WHO LGA facilitator WFP

Director, DCI, NPHCDA State Cold Chain Off. LGA CCO LGA CCO

UNICEF EPI Manger UNICEF VSL consultant WHO LGA facilitator WFP

Director, DCI, NPHCDA WHO State Coordinator LIO LIO

WHO LGA

facilitator

WFP

State Health Educator

Director, DCI, NPHCDA WHO State Coordinator LGAF

SIO LIO

State Core Trainer LGA Core trainer

Tiers of Stakeholders responsible for accountability

Coordination

Communication

1

3

ResponsibleThematic AreaS/ No

Surveillance

State Health Educator LGA Health Educator LGAF

2

4Data

Management

Vaccine Supply

& Logistics 5

6WHO LGA facilitator

Operations

7Community

Mobilization

WHO EPI TL SIO

WFPChairman TWG (WHO)

8 Trainings

Director, CHS, NPHCDA UNICEF SM consultant

LGA Health Educator WFP

11. Expert Review Committee on Polio Eradication and Routine Immunization for

Nigeria comprises national and international experts on immunization and polio eradication. The

ERC meets six-monthly to review both immunization and polio eradication efforts and progress

and to provide detailed advice on how to improve program performance. The ERC especially

advises on the number and frequency of national and sub-national immunization rounds to be

performed during the following year.

12. The Independent Monitoring Board (IMB) for the Global Polio Eradication Initiative

comprises global experts from a variety of fields relevant to the work of the GPEI who assess

progress towards the attainment of a polio-free world on a quarterly basis. They were

established at the request of the Executive Board and the World Health Assembly. Reports from

the group's quarterly meetings go directly to the heads of the spearheading partner agencies - the

WHO, Rotary International, the CDC, UNICEF and BMGF and are public shortly afterwards.

13. The IMB convenes on a quarterly basis to independently evaluate progress towards each

of the major milestones of the Global Polio Eradication Initiative (GPEI) Strategic Plan 2010-

2012 as 'on track', 'at risk' or 'missed', on the basis of polio epidemiology, poliovirus virology,

standard performance indicators and other program data. Additionally, the IMB provides

assessments of the risks posed by existing funding gaps. If, during its deliberations, the IMB

conclude any of the milestones or process indicators to be 'at risk' or 'missed', the relevant

national authorities and/or implementing/donor partners are engaged to establish emergency

corrective action plans. At subsequent meetings, the IMB will then evaluate the quality,

implementation and impact of any such corrective action plans.

33

Financial Management

14. As this is a repeater project, the financial management arrangements under this project

will remain the same as under the previous Partnership for Polio Eradication Project (P080295)

and its related additional financings. The funds for the procurement of OPV, which is the sole

component of this project, will be disbursed directly by the World Bank to UNICEF,

(Copenhagen, Denmark). The assessment of the financial management arrangement for the

project focused exclusively on the OPV expenditures financed by the Bank to obtain the

assurance that the Bank‟s fiduciary requirements are met, especially that funds will be used for

the purpose intended with due regard to economy and efficiency.

These procedures are consistent with the procedures agreed and documented in the original PAD

of the previous project and summarized below:

vii) An agreement will be signed between the Federal Government of Nigeria and

UNICEF on a single source contract for the purchase of Oral Polio Vaccine

(OPV);

viii) The Agreement will be cleared with the World Bank Procurement unit, and its

signature will be specified as a condition of effectiveness of the project;

ix) The OPV will be procured in accordance with UNICEF‟s rules, regulations and

procedures;

x) The credit proceeds will be disbursed by the Bank directly to UNICEF for the

purchase of the required OPV on the basis of instructions from the Government of

Nigeria;

xi) UNICEF will maintain a separate ledger account in its books through which all

receipts and expenditures, for the purposes of providing these services

contemplated by the Agreement, will be recorded;

xii) UNICEF will report every semester to the FGN (with a copy to the Bank) on the

use of funds received: (a) balance at the beginning and end of the reporting

period; (b) the sales and purchase orders placed by UNICEF during the reporting

period; (c) the actual quantities of OPV delivered during the reporting period; and

(d) the expenditures from the OPV Procurement Account during the reporting

period.

15. The Borrower will not be directly involved in the management of the funds related to this

IDA credit. All financial management responsibilities are vested in UNICEF. The reports

submitted under vi) above will allow the project to meet the Bank‟s financial reporting

requirements, given that UNICEF financial regulations and procedures are accepted under the

Bank-UN Financial Management Framework Agreement (Bank – UN FMFA) which UNICEF

has signed. This project, as in the case of the previous project (P080295) and related additional

financings, will also not request for financial audits. The team has received an audit exemption

for this project from the Bank Financial Management Sector Board, with the understanding that

the IDA reserves the right in the Financing Agreement to request for such audit should any issue

come to its attention.

34

16. Since the funds will be managed by UNICEF, and its FM systems and financial

regulations are acceptable under the Bank-UN FMFA agreement, no formal assessment of

UNICEF systems was conducted, rather the assessment was limited to the existing arrangements

that ensures that the procured OPV vaccines are delivered to the Government and that the

accompanying invoices and delivery notes are consistent with the financial statements submitted

by UNICEF. The assessment therefore was limited to the review of the records presented by

UNICEF to the Government, including the delivery notes covering the vaccines and traced to the

distributed quantities by government and also the financial statements submitted by UNICEF.

17. The assessment found this system to be functioning well and no exceptions were noted,

which gives the assurance that the funds are used for the purposes of the project. This

arrangement therefore meets the Bank‟s FM requirement.

Procurement

18. The procurement risk for the project is rated low since the project does not require any

direct involvement of the Borrower in the management of the procurement process. UNICEF

will be responsible for the supply of vaccines and as such act as a supplier selected by the FGN

under IDA procurement guidelines. Therefore an assessment of the capacity of the NPHCDA to

conduct procurement under the project will not be required. OPV will be procured by UNICEF

in accordance with UNICEF's procurement rules, regulations and procedures and its financial

regulations and rules. The decision to allow the use of UNICEF as a supplier is based on the

following: (1) UNICEF's proven track record as a purchasing agent for OPV vaccines on behalf

of the governments using domestic and donor resources; (2) UNICEF's reliance on the WHO

prequalification process which is based on very rigorous prequalification criteria that provide

adequate quality control measures; and (3) The low capacity for vaccine procurement in

NPHCDA. The amount of vaccines needed will be regularly adjusted following the Expert

Review Committee advice.

19. The NPHCDA will be responsible for project execution. This agency was created in 1992

as a parastatal agency under the Federal Ministry of Health. Since then it has established

management structures countrywide. NPHCDA shall be responsible for the distribution and

administration of the vaccines in the country. UNICEF will submit a utilization report on a

quarterly basis to NPHCDA (copy to the Bank) on: (a) the unobligated balance in the OPV

Procurement Account; (b) the sales and purchase orders placed by UNICEF; (c) the actual

quantities of OPV delivered; (d) the expenditures from OPV procurement account during the

reporting period. The Agreement between UNICEF and the FGN, copy of which will be

available in the project file, sets out the terms and conditions under which UNICEF will supply

the OPV. The OPV will be delivered in accordance with the delivery schedule and consignees set

out in Annex 3 of said Agreement.

Social (including Safeguards)

20. The Project has a strong poverty focus since poor families, particularly poor children, are

the primary beneficiaries. Poor people living in unhygienic conditions are at greatest risk of

having polio. Besides, children in poor families tend to have the lowest immunization coverage.

The Project specifically aims to benefit vulnerable groups and previously neglected groups to

35

receive polio immunization. In high risk LGAs, the national program now engages volunteer

community mobilizers to network and create a conducive environment towards immunization in

the community. Likewise LGAs with the most nomads and known polio risk are being targeted,

working with veterinarians, leaders and local NGOs and using GPS to ensure that they are

reached by vaccination teams. The aim is to identify and characterize the chronically missed

children and to motivate their parents, thereby solving cases of non-compliance. Traditional and

religious leaders are engaged in task forces at all levels to help vaccinators and social

mobilization teams to convince non-compliant households to accept OPV and thereby assist with

addressing non-compliance in all high risk and vulnerable LGAs.

Environment (including Safeguards)

21. The Project is not envisaged to cause environmental risks and the environmental

category for the project is C, as for the previous Project. There is no construction financed under

the project.

36

ANNEX 4: OPERATIONAL RISK ASSESSMENT FRAMEWORK (ORAF)

NIGERIA

Polio Eradication Support Project

Stage: Board

Project Stakeholder Risks Rating LOW

Description : At this time when Nigeria is close to reaching

polio free status, the stakeholder risks are limited to mis-placed

optimism resulting in less than required efforts once the polio

cases have come down.

Risk Management: Government and civil society remain strongly committed to the polio

eradication goal. The Expert Review committee forms a credible oversight body monitoring

project implementation and providing guidance. The international community will continue

to strongly promote and support complete eradication in Nigeria

Resp: Client Stage: Implementation Due Date : Status:

In progress

Implementing Agency Risks (including fiduciary)

Capacity Rating: MODERATE

Description : While federal and state level implementation

capacity and motivation may be high, a number of LGAs may

fail to adequately implement the program

Risk Management: The strong involvement of religious and traditional leaders and the

strong presence of international agencies in country protect the program against any political

interference. The increased posting of international staff in the high risk states reduces the

risk that they do not adhere to program procedure and guidelines.

Resp: Client Stage: Implementation Due Date : Status:

In progress

Governance LOW

Description : A risk to the program is failure to deliver vaccine

on time and of good quality

Risk Management: Vaccine is purchased and delivered in country by UNICEF; through

international, bulk procurement they are well placed to ensure good quality.

Resp: Client, UNICEF Stage: Implementation Due Date : Status: In progress

Project Risks

Design Rating: LOW

Description : This is a follow on project with proven design.

The program is monitored regularly adjusted to ensure

problems are identified early and addressed.

Risk Management: This is a follow on project with proven design. The program is

constantly monitored by WHO, CDC, and ERC meets regularly to review program progress

and make updated recommendations on program improvements

Resp: Client, WHO,

CDC, ERC Stage: Implementation Due Date :

Status: In progress

37

Social & Environmental Rating: LOW

Description: Disposal of vaccine vials need to be done

carefully.

Risk Management: The vials are taken to the state by the State Technical Facilitator

(contracted and supervised by WHO) as part of the vaccine accountability monitoring. The

unopened vials (vials which have not been used and whose Vaccine Vial Monitor and

Expiry dates are still viable) are taken back into the cold storage at the State Cold Store. The

empty vials are boarded at the state level and incinerated.

Resp: Client Stage: Implementation Due Date : Status:

In progress

Program & Donor Rating: LOW

Description : (i) Harmonization of donor engagement is

important for maximum effectiveness.(ii) There are estimated

US$162 million funding gap for 2012 and 2013 for Polio

Eradication

Risk Management : (i) All partners follow the same guidelines and updated

recommendations from the ERC (ii) The funding gap will be covered with the IDA credit, the secured funding from KfW of US$20 million and a tentative commitment from the Government of Japan and CIDA. Specifically for OPV, the IDA credit secures funding up to and including 2014

Resp: Donors Stage: Implementation Due Date : Status:

In progress

Delivery Monitoring & Sustainability Rating: LOW

Description : State monitoring and surveillance systems need to

be strong to pick up epidemic trends.

Risk Management : The special surveillance and monitoring systems in place under this

program are well tested and are supervised by WHO; the recent introduction of GIS

mapping to identify communities missed by polio rounds has proven to be effective and is

now being expanded.

Resp: Client, WHO Stage: Implementation Due Date : Status:

In progress

Overall implementation risk rating Rating MODERATE

Description:

The overall risk rating for the previous project was LOW however the recent security issues in the target area cause concerns. Continued high commitment of

Government to the polio eradication efforts; strong involvement of religious and community leaders, use of local staff for project implementation and multi

donor support will ensure implementation remains strong despite security concerns.

38

ANNEX 5: IMPLEMENTATION SUPPORT PLAN

Strategy and Approach for Implementation Support

1. While the World Bank credit is limited to financing OPV the success of the project is dependent

on the quality of implementation of all components of the Nigeria Polio Eradication Program. The Bank

team will therefore take active part along with all other partners in the dialogue, joint reviews, quarterly

ICC meetings and 6 monthly ERC meetings.

Implementation Plan – Basic Timetable

Activity Frequency Skills required

Bank Budget

Resource

Estimate

(US$)

Partner Role

Program Review Six-monthly or

however frequent

ERC meetings take

place

Synchronized with

ERC meetings

Technical (Polio

Eradication, Public

Health, Social

Development)

10,000 Responsible for follow up

action to the review and

ERC recommendations

ICC meetings Quarterly Technical (Polio

Eradication and

Public Health)

Responsible for follow up

action to the review and

ERC recommendations

Joint Partner

Review Once in two years Technical (Polio

Eradication and

Public Health)

30,000 Responsible for follow up

action to the review and

ERC recommendations

World Bank Implementation Support - Skills Mix & Inputs

Skills Needed Planned Staff Weeks

(Annual)

Public Health 6

Social Development 1

Financial Management 1

Procurement 1

Trust Fund Management 1

39

ANNEX 6: ECONOMIC AND FINANCIAL ANALYSIS

1. Polio cases result in treatment costs and loss in productivity due to disability. Therefore

the economic benefit per prevented case of paralytic polio includes the savings per DALY for

each prevented case, as well as the avoided direct medical treatment costs. A study18 published

online in November 2010 in the leading medical journal Vaccine estimates the economic benefits

of the Global Polio Eradication Initiative (GPEI) at between US$40-50 billion based on activities

from 1988 through 2035 (assuming eradication of wild polioviruses in 2012 or shortly

thereafter). Estimating costs and cases from 1988-2035 based on actual and projected

expenditures, reported polio incidence and model projections, the study “Economic Analysis of

the GPEI” evaluated incremental cost-effectiveness ratios and net benefits estimates by

comparing the GPEI with routine vaccination only. The study further states that low-income

countries will benefit most accounting for approximately 85% of the net benefits. In total, more

than 8 million cases of paralytic polio in children will have been prevented, translating into real

savings from reduced treatment costs and gains in economic productivity. The study also

reported health benefits of 'add-on' interventions of the GPEI, such as the systematic

administration of Vitamin A and other life-saving interventions, which result in an additional

US$17-90 billion in benefits.

2. The analysis focuses on 104 mostly lower income countries that directly benefited from

the GPEI since 1988. It does not include the very substantial net benefits still accruing in the rest

of the world as a result of their national polio elimination efforts. In a study published in 2007 by

Drs. Thompson and Duintjer Tebbens, polio eradication was found to be a much better

investment than 'control' of polio in low income countries, both from a humanitarian and

economic perspective. The 2007 analysis estimated that if the goal of polio eradication efforts

were abandoned, the outcome would be worse. Either hundreds of thousands of children would

again be paralyzed by polio over the coming years, or a very high level of investment would

have to be maintained forever to keep the polio incidence at the current low levels, if the high

cost of cases was not to continue to occur forever.

The broader benefits of eradicating polio

3. Financing of polio eradication has significant and broad public health benefits over and

above polio eradication. While approximately 55% of the Global annual polio eradication budget

constitutes one-off costs associated with polio supplementary immunization activities (e.g.

purchase of polio vaccine, transport of vaccinators), the remaining estimated 45% is allocated for

training of health staff, local -level micro planning, refurbishment of vaccine cold-chain systems,

and the scaling up of technical capacity for vaccine-preventable surveillance and monitoring

networks.

4. These activities, along with the broader assets of the polio infrastructure (such as the

expertise of human resources) are being used in many countries to implement the Global

Immunization Vision and Strategy launched in 2006, which includes the introduction of new and

under-used vaccines. The implementation of the 'Reaching Every Ward' approach, based on the

18 Aylward RB, Acharya A, England S, Agocs M, Linkins J. Global health goals: Lessons from the worldwide effort to eradicate poliomyelitis. Lancet 2003;362(9387):909-14

40

polio eradication model for reaching entire populations with routine immunization services

through a ward-based approach, has resulted in significant gains in routine immunization levels.

Medium Term Expenditure Framework for Immunization

5. In Nigeria, financing of the health sector is done by the three tiers of government i.e.

federal, state and LGA. A number of development partners and a small proportion of the private

sector are more strategic in funding activities that move immunization in Nigeria. In late 2005,

WHO and UNICEF, together with GAVI Alliance partners, developed guidelines for developing

a comprehensive Multi-Year Plan (cMYP) for immunization to support countries in improving

their planning for immunization. This new approach aims to simplify and harmonize various

immunization planning activities at national level to avoid duplication of efforts and high

transaction costs and ensure alignment with national systems.

6. The cMYP for Nigeria covers the period 2011-2015. The total cost of the immunization

program for the period 2011 – 2015 is estimated at US$2.4 billion. Significant cost components

are routine vaccines and injection supplies which constitute 25% of the cost; supplemental

immunization activities make up 33% of the cost; and shared health system costs make up 15%

of the cost. The below table highlights the estimated immunization costs between 2011 and 2015.

Total Immunization budget

2011 2012 2013 2014 2015

US$ US$ US$ US$ US$

Vaccine Supply and Logistics $40,056,512 $82,252,667 $157,889,679 $256,930,487 $348,604,211

Service Delivery $53,823,970 $62,008,572 $70,529,312 $80,703,687 $92,480,454

Advocacy and Communication $5,008,176 $5,346,394 $5,283,805 $5,688,946 $6,455,653

Monitoring and Disease Surveillance $17,298,999 $19,289,423 $23,215,964 $26,721,972 $31,607,980

Programme Management $18,919,242 $21,282,702 $25,378,162 $30,096,709 $35,737,934

Supplemental Immunization Activities $210,959,269 $170,925,906 $176,745,091 $134,211,818 $106,494,321

Shared Health Systems Costs $61,227,775 $67,711,727 $75,059,589 $83,135,125 $92,301,903

$407,293,943 $428,817,392 $534,101,602 $617,488,744 $713,682,457

Routine Immunization $196,334,674 $257,891,486 $357,356,511 $483,276,926 $607,188,136

Supplemental Immunization Activities $210,959,269 $170,925,906 $176,745,091 $134,211,818 $106,494,321

7. The overall immunization program has an average funding gap of 21% for the period

2011-2015. Past trends indicate that the financing gap is being met through contributions from

government and partners. In addition, the Office of the Senior Special Assistant to the President

on the MDGs is a strong partner to the Immunization Program, in recognition that this

intervention will contribute directly to the attainment of MDG4 indicating that the FGN may

eventually finance any remaining gap in financing. In 2010, this office provided significant

funds for immunization; e.g. measles control efforts were funded to the tune of 2.2 Billion Naira,

polio eradication efforts supported with 2.7 Billion Naira, cold chain expansion supported with

1.035 Billion Naira and other immunization related activities received 3.6 Billion Naira.

41

8. Specifically for Polio Eradication the estimated funding gap for 2012 and 2013 was

calculated to be US$162 million. With the IDA credit, the secured funding from KfW of US$20

million and a tentative commitment from the Government of Japan and CIDA there is unlikely to

be a funding gap for the next few years. Specifically for OPV the IDA credit secures funding up

to and including 2014. It is anticipated that following the last case of polio in Nigeria, the

country will continue to use SIPDs and NIPDs for three additional years following which Nigeria

can look forward to integrating polio into routine immunisation. During the project the IDA team

will work with the FGN and partners to prepare expenditure and financing projection for final

polio eradication and surveillance until the time when polio immunization forms part of routine

immunization.

9. In the medium term, it is expected that the government immunization budget line will be

reclassified from a capital expenditure item to a recurrent expenditure item, which would further

increase the security of funds for immunization activities. Finally, the 10th European

Development Fund has approved 50 million Euros for RI strengthening in Nigeria.

10. At state level, each State has been supported to develop a State Strategic Health

Development plans akin to the National Plan. Functional state task forces on primary health care

and immunization exist in all states and have the important mandate to facilitate the release of

operational funds for immunization activities as outlined in their respective state plans.

Sustainability

11. FGN now finances the costs of routine immunization and the bulk of the operational cost

for polio eradication. FGN investments in routine vaccine procurement for 2011 were

approximately US$33 million and support for operational expenses for Polio was US$17 million.

The Federal Budget for health amounts to between 5.6% and 3.2% of the total FGN budget with

NPHCDA the agency for leading primary health care and immunization activities receiving 7.6%

of the health budget. The table below shows the trends for the years 2008-2012. The NPHCDA

budget has shown significant increases between 2010 and 2012 for both routine immunization

and operational expenses for the polio SIPDs and NIPDs (see table below).

Federal Health budget FEDERAL MOH : 2008-2010 ( million Naira)

BUDGET YEAR

2008 2009 2010

Health (Actual Release) 144,839 153,690 131,311

Health as a percentage of Total FGN Budget 5.6% 5.8% 3.2%

NPHCDA Budgets allocations and expenditures ( million Naira)

Total Allocation 11,737 15,469 7,717

Recurrent Allocation 1,700 1,702 1,286

Expenditures 704 1,684 1,286

42

Federal Immunization budget FEDERAL MOH : 2008-2012 ( million Naira)

BUDGET YEAR

2008 2009 2010 2011 2012

Health (Actual Release) 144,839 153,690 131,311 241,175 284,967

Health as a percentage of Total FGN

Budget 5.6% 5.8% 3.2% 5.1% 6.4%

NPHCDA Budgets allocations and expenditures ( million Naira)

Total Allocation 11,737 15,469 7,717 14,693 23,726

Recurrent Allocation 1,700 1,702 1,286 2,182 2,041

Expenditures 704 1,684 1,286 na

12. Nigeria‟s commitment to polio eradication remains strong and the NPHCDA is making a

major effort to translate this federal commitment into improved action on the ground. The

Emergency Plan for Polio Eradication adequately addresses this with mobilization of both local

government and civil society structures at state, LGA and community level. While such

structures will benefit the polio eradication efforts in the short term they will, in the long term,

benefit routine immunization as well as the provision of basic health services.

Chappal WaddiChappal Waddi(2,419 m )(2,419 m )

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NIGERIA

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other informationshown on this map do not imply, on the part of The World BankGroup, any judgment on the legal status of any territory, or anyendorsement or acceptance of such boundaries.

0 50 100 150

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IBRD 33458

SEPTEMBER 2004

N IGERIASELECTED CITIES AND TOWNS

STATE CAPITALS

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MAIN ROADS

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STATE BOUNDARIES

INTERNATIONAL BOUNDARIES