Document of The World Bank · CURRENCY EQUIVALENTS (Exchange Rate Effective 06/30/2008) Currency Unit = PKRs PKRs 1.00 = US$ 0.01 US$ 1.00 = 68.10 FISCAL YEAR July 1- June 30

Document of The World Bank

Report No: ICR0000985

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-41450 IDA-41451)

ON A

LOAN/CREDIT

IN THE AMOUNT OF SDR 32.9 MILLION (US$ 46.7 MILLION EQUIVALENT)

TO THE

ISLAMIC REPUBLIC OF PAKISTAN

FOR A

SECOND PARTNERSHIP FOR POLIO ERADICATION PROJECT

December 30, 2008

Human Development Sector UnitSouth Asia Region

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CURRENCY EQUIVALENTS

(Exchange Rate Effective 06/30/2008)

Currency Unit = PKRs PKRs 1.00 = US$ 0.01

US$ 1.00 = 68.10

FISCAL YEAR July 1- June 30

ABBREVIATIONS AND ACRONYMS

AFP Acute Flaccid Paralysis AJK Azad Jammu and Kashmir BMGF Bill & Melinda Gates Foundation CAS Country Assistance Strategy DO Development Objective EMRO Eastern Mediterranean Regional Office (WHO) EPI Expanded Program on Immunization FANA Federally Administered Northern Area FATA Federally Administered Tribal Areas GoP Government of Pakistan GPEI Global Polio Eradication Initiative IACC Inter-Agency Coordination Committee IBRD International Bank for Reconstruction and Development ICR Implementation Completion and Results Report IDA International Development Association IEG Independent Evaluation Group IMR Infant Mortality Rate ISR Implementation Status and Results Report JICA Japan International Cooperation Agency MDG Millennium Development Goal/s M & E Monitoring & Evaluation NID National Immunization Days NIH National Institute of Health NWFP North Western Frontier Province OPV Oral Polio Vaccine PAD Project Appraisal Document PDO Project Development Objective PEI Polio Eradication Initiative PKR Pakistani Rupee PPEP Partnership for Polio Eradication Project PPF Project Preparation Facility PRSP Poverty Reduction Strategy Paper PSES Pakistan Socio Economic Survey

QEA Quality at Entry QSA Quality at Supervision SASHD South Asia Human Development Division SIAs Supplementary Immunization Activities SNID Sub-National Immunization Days SPPEP Second Partnership for Polio Eradication Project TAG Technical Advisory Group UNF United Nations Foundation UNICEF United Nations Children’s Fund WHO World Health Organization WPV Wild Polio Virus

Vice President: Isabel M. Guerrero Country Director: Yusupha B. Crookes

Sector Manager: Julie McLaughlin Project Team Leader: Inaam Haq

ICR Team Leader: Preeti Kudesia

Pakistan Second Partnership for Polio Eradication

CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph

1. Project Context, Development Objectives and Design............................................... 12. Key Factors Affecting Implementation and Outcomes .............................................. 43. Assessment of Outcomes ............................................................................................ 94. Assessment of Risk to Development Outcome......................................................... 125. Assessment of Bank and Borrower Performance ..................................................... 136. Lessons Learned ....................................................................................................... 167. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 17Annex 1. Project Costs and Financing.......................................................................... 18Annex 2. Outputs by Component ................................................................................. 19Annex 3. Economic and Financial Analysis................................................................. 20Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 20Annex 5. Beneficiary Survey Results ........................................................................... 21Annex 6. Stakeholder Workshop Report and Results................................................... 21Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 22Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 27Annex 9. List of Supporting Documents ...................................................................... 32

MAP

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A. Basic Information Country: Pakistan Project Name:

Pakistan: Second Partnership for Polio Eradication Project

Project ID: P097402 L/C/TF Number(s): IDA-41450,IDA-41451ICR Date: 12/30/2008 ICR Type: Core ICR

Lending Instrument: SIL Borrower: ISLAMIC REPUBLIC OF PAKISTAN

Original Total Commitment:

XDR 32.9M Disbursed Amount: XDR 46.8M

Environmental Category: C Implementing Agencies: Expanded Program on Immunization, Ministry of Health Cofinanciers and Other External Partners: B. Key Dates

Process Date Process Original Date Revised / Actual Date(s)

Concept Review: 08/10/2005 Effectiveness: 03/08/2006 03/08/2006 Appraisal: 10/24/2005 Restructuring(s): Approval: 01/26/2006 Mid-term Review: Closing: 06/30/2008 06/30/2008 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory

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

Quality at Entry: Satisfactory Government: Satisfactory

Quality of Supervision: Moderately Satisfactory Implementing Agency/Agencies: Moderately Satisfactory

Overall Bank Performance: Moderately Satisfactory Overall Borrower

Performance: Moderately Satisfactory

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C.3 Quality at Entry and Implementation Performance Indicators Implementation

Performance Indicators QAG Assessments (if any) Rating

Potential Problem Project at any time (Yes/No):

No Quality at Entry (QEA):

None

Problem Project at any time (Yes/No):

No Quality of Supervision (QSA):

Satisfactory

DO rating before Closing/Inactive status:

Satisfactory

D. Sector and Theme Codes

Original Actual Sector Code (as % of total Bank financing) Health 100 100

Theme Code (Primary/Secondary) Child health Primary Primary Other communicable diseases Primary Primary E. Bank Staff

Positions At ICR At Approval Vice President: Isabel M. Guerrero Praful C. Patel Country Director: Yusupha B. Crookes John W. Wall Sector Manager: Julie McLaughlin Anabela Abreu Project Team Leader: Inaam Haq Inaam Haq ICR Team Leader: Preeti Kudesia ICR Primary Author: Preeti Kudesia F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective is to assist Pakistan's effort to eradicate polio through supply of the oral polio vaccine (OPV), for the country's supplementary immunization activities (SIAs) during 2006-07. This is an input into the Government of Pakistan#s (GoP's) program to eradicate Polio and is a follow-on project of the Partnership for Polio Eradication Project. Revised Project Development Objectives (as approved by original approving authority)

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(a) PDO Indicator(s)

Indicator Baseline Value

Original Target Values (from

approval documents)

Formally Revised Target Values

Actual Value Achieved at

Completion or Target Years

Indicator 1 : OPV immunization coverage in the targeted population in each of the four provinces

Value quantitative or Qualitative)

97%

Coverage of 85% achieved in the provinces in 2006 and 2007

For the target group (<5yrs) more than 85% coverage achieved in all four provinces in 2006, 2007 and 2008

Date achieved 08/30/2005 06/30/2008 06/30/2008

Comments (incl. % achievement)

Post campaign coverage independent survey of Jan 2008: Punjab: 99%, Sindh: 95%, NWFP/FATA: 97% and Balochistan: 94%; Post campaign coverage for 2006: Punjab: 98%, NWFP/FATA: 96.13%, Sindh: 96.63% and Balochistan: 95.88%;

Indicator 2 : Number of confirmed Polio Cases reported

Value quantitative or Qualitative)

28 0

2006: 40 cases 2007: 32 cases 2008 17 cases (until June 30, 2008)

Date achieved 12/31/2005 06/30/2008 06/30/2008 Comments (incl. % achievement)

After June 30, 2008 (project closing) the number of reported cases has increased substantially - 81 cases have been reported until October, 15 2008

(b) Intermediate Outcome Indicator(s)

Indicator Baseline Value

Original Target Values (from

approval documents)

Formally Revised

Target Values

Actual Value Achieved at

Completion or Target Years

Indicator 1 : Timely arrival of the OPV at the central stores of the EPI Supply of vaccine 5 weeks prior to SIA rounds in 2006 and 2007

Value (quantitative or Qualitative)

0% arrived in stipulated time; 70% arrival between 20-34 days

Arrival 5 weeks prior to each SIA

Arrival at district stores 5 days prior to each SIA, measured in at least one-third of districts

2007 (June 14 to Dec 31): 89.5% of 4 rounds 2008 (till June 30): 80% of one round

Date achieved 09/30/2006 06/13/2007 06/30/2008 06/30/2008 Comments (incl. % achievement)

2006: 0% of 8 rounds 2007 (till June 13): 20% of 5 rounds

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G. Ratings of Project Performance in ISRs

No. Date ISR Archived DO IP

Actual Disbursements (USD millions)

1 04/03/2006 Satisfactory Satisfactory 27.23 2 10/03/2006 Satisfactory Satisfactory 27.23 3 04/20/2007 Satisfactory Satisfactory 47.92 4 09/06/2007 Satisfactory Satisfactory 69.06 5 03/21/2008 Satisfactory Satisfactory 69.06 6 06/30/2008 Satisfactory Satisfactory 69.24

H. Restructuring (if any) Not Applicable

I. Disbursement Profile

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

1.1 Context at Appraisal Pakistan is committed, though not on track1, to achieving the health related Millennium Development Goals (MDG) with an infant mortality rate at 78 per 1,000 live births, under-five mortality rate at 94 per 1,000 live births, and maternal mortality ratio at 276 maternal deaths per 100,000 births2. The Country Assistance Strategy (CAS), April 2006 supports the country’s Poverty Reduction Strategy Paper (PRSP). For achieving health outcomes, the strategy is to continue and strengthen the shift from curative services to preventive and primary health care; and prioritize control of communicable diseases, reproductive health, child health and nutrition. A multivariate analysis using the Pakistan Socio Economic Survey (PSES) suggests that expanded immunization coverage linked with other services is associated with the largest potential decline in IMR3 . In 1988, the 41st World Health Assembly launched the Global Polio Eradication Initiative (GPEI) to eradicate polio by the end of the year 2003. GPEI is the largest public health initiative that has successfully supported elimination of polio from all but four countries4 in the world. Despite this progress, the situation remains fragile as between 2003-05, 25 previously polio-free countries were re-infected due to imports of the virus. Persistent pockets of polio transmission in northern India, northern Nigeria, and the border between Afghanistan and Pakistan are key epidemiological challenges. Polio virus transmission in endemic countries remains the last hurdle for a polio free world, as a single infected child can put the entire world’s children at risk. The Polio Eradication Initiative (PEI) started in Pakistan in 1994 with initiation of Supplemental Immunization Activities (SIA) as part of the routine Expanded Program on Immunization (EPI). In 1999, immunization activities were intensified with house-to-house immunization. Subsequently Sub-National Immunization Days (SNID) were introduced to target high risk districts and the areas bordering Afghanistan and Iran. The Government of Pakistan (GoP) financed National Immunization Days (NID) during 1994-96 primarily using its own resources. Subsequently, to further intensify efforts, assistance was secured from various global development partners. As the prospect of elimination5 of polio came closer, additional financing was needed to meet the enhanced vaccine requirements. IDA has supported Pakistan’s PEI since 2003. This was done through an innovative financing mechanism – the buy-down arrangement through the Partnership for Polio Eradication Project (PPEP) (2003-05) which included a supplementary credit similar to the project under review. Funds provided by partners, the Bill & Melinda Gates Foundation (BMGF) and United Nations Foundation (UNF) established the Polio Eradication Trust Fund (managed by the World Bank).

1 Draft Health Sector Review, September 2008 2 Pakistan Demographic and Health Survey, 2006-07 3 World Bank 2005 – South Asia Human Development Sector, Discussion Paper Series, Report No.8 4 Afghanistan, India, Nigeria and Pakistan 5 In the country context, the appropriate description is ‘elimination’, while ‘eradication’ is used in the global context.

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These funds were used to pay the service fees for the Credit during implementation and “buy-down” the net present value of the IDA Credit when the project was certified by competent technical authorities to have been successfully completed. Since the IDA buy-down mechanism converts the credit into a grant only upon satisfactory implementation, it encourages the government to focus on sound implementation and results. At the same time, the buy-down mechanism is preferred over a normal IDA credit as polio eradication is a responsibility of the global community and not just the last few polio-endemic countries. Also, the incentive for a single country to invest in elimination is limited. Through the partnership, the partners were also able to access rigor of the Bank’s project preparation and supervision in support of their efforts for polio eradication. Following successful completion of the first partnership project, there was a need to continue with the SIA’s for at least another three years. For this, stable and secure financing of oral polio vaccine (OPV), which comprised more than half of SIA expenditures was required for 2006-07, and thus the agreement for IDA to support this follow-on project.

1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The objective was to assist Pakistan's effort to eradicate polio through supply of the oral polio vaccine (OPV), for the country's supplementary immunization activities (SIAs) during 2006-07. The Second Partnership for Polio Eradication Project (SPPEP) was part of the WHO-led multi-country effort and would contribute to a global public good, i.e., the eradication of polio from the world. SPPEP was a follow-on project of the first Partnership for Polio Eradication Project. The key indicators to measure project performance were the following:

• Timely arrival of the OPV at the central stores of the Expanded Program on Immunization, Islamabad; (Target: at least five weeks before each of the SIAs);

• SIA coverage in the targeted population (under-five children) in each of the four provinces during 2006 and 2007 (Target 85%); and

• Number of confirmed cases reported (Target Zero Case). Achievement of the targets for the first two key indicators would be the trigger for the IDA buy-down.

1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification At the time of Additional Financing for the SPPEP (described in Section 1.7), which became effective on June 14, 2007, the PDO remained the same. However, there was a change in one of the key performance monitoring indicators. The first indicator – arrival of OPV at the central stores at least five weeks before each SIA – was revised to “timely arrival of OPV at the District stores five days before each SIA”. This revision was deemed necessary since the original indicator was difficult to achieve due to a global supply shortage of OPV and delayed supply of monovalent OPV due to the tight global supply situation, compounded by the fact that the change in type of vaccine to be used in some rounds was realized at short notice (due to the changing epidemiology). SPPEP was approved by the Board on January 26, 2006 and became effective on March 08, 2006. The first PPEP closed

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on June 30, 2006, and the same key indicators as the first project were retained for SPPEP. Subsequently, the third party performance audit (August 28 – September 5, 2006) for the first PPEP highlighted that this indicator was inappropriate (ambitious and unachievable) to assess GoP performance as OPV arrival was determined by the global supply situation which was beyond the control of GoP. Implementation of SPPEP during its first year also substantiated that the indicator was ambitious. Therefore, at the time of additional financing the Borrower and the Bank agreed to revise the indicator to one which was within the control of GoP and hence, realistic to measure its performance.

1.4 Main Beneficiaries, The beneficiaries of the project were all under-five children of Pakistan. The SIAs particularly targeted poor, remote and underprivileged communities, and children whose mothers were unable to take them to health facilities due to restricted female mobility, as these groups were more difficult to access through routine immunization. Children, who for different reasons, did not receive the immunization, would also potentially have benefitted from the herd immunity developed when immunization coverage of at least 80% was achieved. Additionally, the children being administered OPV as part of NIDs, also received Vitamin A, which besides reducing the incidence of Vitamin A deficiency-related blindness, also plays an important role in the reduction of infant mortality. Polio immunization with the objective of polio eradication is a global public good and therefore, the beneficiaries extend beyond the immediate target group to all children in the world and a polio-free future.

1.5 Original Components (as approved) The project had a single component, financing for the timely procurement and supply of OPV and its effective use during 2006- 07 SIAs. The project supported the PEI, by financing its first component (US$ 61.40 million). The three components of PEI are: (i) OPV procurement; (b) supplemental operations; and (iii) surveillance. Co-financiers funded the second and third components – supplemental operations (US$ 36.00 million) and surveillance (US$ 3 million), thereby amounting to a total support of US$ 100.40 million. The other two components of PEI were supported by UNICEF and WHO. The second component of supplemental activities included: (a) maintenance of the cold chain; (b) social mobilization; and (c) training. International and national contractual staff, with WHO and UNICEF oversight, supported the national units and field units/activities at the provincial and district levels and below. The third component of surveillance included laboratory and epidemiological surveillance, which is fully operational in Pakistan and is regularly reviewed by technical experts – the Technical Advisory Group (TAG) - a group of international and national experts.

1.6 Revised Components Not Applicable

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1.7 Other significant changes Additional Financing: The original credit for SPPEP of US$ 46.70 million was disbursed about ten months (July 2007) earlier than envisaged. Despite effective implementation of SIAs with high coverage of the targeted population in 2006, the number of polio cases had increased from 28 in 2005 to 40 in 2006. This increased number of polio cases was to some extent due to the resurgence of one of the three types of the polio virus. Wild Polio Virus (WPV) transmission continued in four geographical zones and extended up to Southern Afghanistan. However, despite the increased number of cases, there was epidemiological evidence that virus transmission had been restricted in the country and the opportunity for elimination in Pakistan remained strong. The TAG endorsed intensifying the SIAs besides improving their quality, increasing the number of SNIDs and case response campaigns, enhancing co-ordination with Afghanistan, and increasing the use of type-specific monovalent vaccine for specific rounds. The increased number of proposed rounds increased the potential vaccine requirement. Therefore, an additional Credit of US$ 21.14 million was proposed by GoP, approved by IDA on June 07, 2007 and became effective on June 14, 2007, in order to finance the procurement of additional OPV required for SIAs planned between August 2007 – January 2008. The PDO, project component and other aspects of the project remained the same. One key performance indicator was changed as described in Section1.3.

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry This project was the second partnership for polio eradication following a successful first, similar project (PPEP). The project was prepared prior to closure of the first project. At that time (Oct-Nov. 2005), the number of polio cases in Pakistan had declined significantly, and it was expected that the country was most likely to interrupt WPV transmission by the end of 2005, when the incidence fell to 28 cases.

Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Until 06/30/2008*

No. of cases

1147 341 558 199 119 90 103 53 28 40 32 17

* 81 cases had been reported until October 15 2008 As per WHO recommendations to certify the country as polio-free, it would require at least 12 months to demonstrate that interruption had occurred, and Pakistan would need to continue SIAs for at least three years following the last confirmed case to ensure total elimination. Until global eradication was achieved, SIAs with high coverage would be necessary to prevent reintroduction of the virus into Pakistan. Based on these facts, and recommendations of the TAG, GoP was fully committed to polio elimination, and had prepared a plan for supplementary immunization activities for 2006-08 as follows:

Year No. of NIDs No. of mop-ups/outbreak response rounds 2006 6 4 2007 4 2 2008 4 2

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In order to support this plan, GoP requested the Bank to support the first component of it’s PEI and address the critical financing gap by procuring requisite quantities of OPV utilizing the IDA buy-down mechanism, which had been piloted for the first project. Thus the project supported an effective program strategy that had been fully endorsed by international experts, utilizing a simple and clearly defined design that was working for the first project. Project design reflected lessons learned, and was to be implemented through the existing EPI program management structures rather than a separate project management unit. Though the IDA buy-down mechanism had not yet been triggered to draw-down the credit (subsequently attained) as the first project was ongoing, the program was reported to be achieving its objectives. The performance-based project design enabled the country’s PEI to focus on outcomes and results. A technically validated monitoring and evaluation system was in place to measure these results. The only weakness in the design was the choice of the indicator of timely arrival of the vaccine, which is described in Section 1.3. At project preparation, the primary risk assessed was the delay in achieving polio eradication both nationally and internationally, despite high coverage of SIAs. In hindsight, this risk has proved to be real. The program revised its strategy to include the use of monovalent OPV in response to the changing viral epidemiology. Prior to project appraisal and negotiations, Pakistan was affected by a devastating earthquake on Oct 08, 2005. Although it was envisaged that the risk of reestablishment of polio virus in the affected areas of Azad Jammu and Kashmir (AJK) and North Western Frontier Province (NWFP) was low, GoP started preemptive OPV immunization targeting all children in the tented villages and attending field hospitals, and through mobile teams in accessible areas.

2.2 Implementation Several factors contributed to implementation of the project, which was overall moderately successful. These include: (i) a consistent commitment of the government to polio elimination and establishment of a strong partnership with donors and technical experts; (ii) timely preparation (which ensured a smooth transition from the first to second project, thereby ensuring no interruption in OPV supplies for planned SIAs; (iii) utilizing the same design and financing mechanism as the first project; (iv) existence and effective use of a reliable monitoring and surveillance system enabling identification of high-risk areas and changing viral epidemiology; (v) a well functioning cold chain, social mobilization, and training which were critical factors enabling the project to achieve the high coverage rates of SIAs; and (vi) high quality technical oversight of the program by national and international experts coupled with an adequate response to surveillance data. During implementation, as described in Section 1.7, the project responded to the need for additional financing to enable procurement of OPV required for the period Aug 2007 – Jan 2008. GoP had explored alternate financing options, including from other development partners. However, it was determined that Bank financing and the leverage of IDA buy-down was the preferred option. Procurement of OPV, which constituted the single component of the project, was efficiently managed by adopting the same arrangement as used for the first project. UNICEF was the designated procurement agent for OPV. This was deemed necessary due to the very tight supply

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and demand situation of OPV required for the global eradication effort. OPV was procured and supplied to GoP under an agreement between GoP and UNICEF. UNICEF’s international procurement division, based in Copenhagen, undertook the procurement following UNICEF’s procurement procedures. The National Program Manger, EPI, was responsible for receiving the OPV at the National Institute of Health (NIH), Islamabad, and for its in-country storage, distribution, administration and use. UNICEF’s internal controls on use of funds, procurement and utilization of vaccine were considered adequate and it was agreed that the Bank would rely on these. Disbursements were made under a single blanket Withdrawal Application for the full amount of credit. Vaccine requirements were forecasted by the National Program Manger, EPI, with the technical support of WHO and UNICEF. This was based on the latest estimates of the population of children under five years of age and the number of rounds/doses to be given per child during the given year. These requirements were endorsed by the Inter-Agency Coordination Committee (IACC)6 and the TAG based on surveillance data.

2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E Design: The monitoring and surveillance system for the program, including for SIAs, was well established even prior to the first project. SPPEP made use of the same system, thereby ensuring utilization, and further strengthening of the existing capacity and sustainability. The M&E system included: (i) SIA coverage data; (ii) output monitoring of quality and coverage of SIA; (iii) SIA outcome monitoring through Acute Flaccid Paralysis (AFP) surveillance; (iv) periodic progress assessment reports of the TAG/independent coverage and quality evaluations; (v) Vaccine Arrival Reports (VAR) which, besides vaccine arrival time, also provided details of vaccine condition at arrival – right temperature, quantities and expiration dates; and (vi) WHO performance audit within three months of project closing which would report on timely vaccine procurement, vaccine use, and coverage of target population. The indicators utilized by the project, and the revision, have been described in Sections 1.2 and 1.3. The coverage indicator was retained at 85% though reported baseline average coverage was higher. This was because a minimum level of 85% is important for herd immunity. Since June 2008 the program has been utilizing finger marking checks rather than recall. This has indicated the potential for over-reporting of coverage rates based on recall alone. Based on these recent reports, WHO has recommended that, in the future, the coverage indicator should remain 85% as reported by finger marking. M&E Implementation:

(i) SIA coverage data was regularly reported by recording the number of children immunized during each round against the number in the target group. This target was calculated by applying growth rate projections to the 1998 population census figure.

6 Members of IACC – Ministry of Health, GoP, federal and provincial EPI program officers, UNICEF, WHO, World Bank, JICA, DFID, public health advisors – national and from EMRO.

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(ii) Output monitoring of quality and coverage was undertaken immediately after each SIA in all districts. This was done by district-level semi-independent teams consisting of national and district staff and WHO/UNICEF consultants. Output indicators of quality included information on percentage of missed/poorly covered areas, teams that had recorded unvaccinated children, teams with at least one female member, training attendance, and communication efforts including display of posters and announcements in mosques.

(iii) The AFP surveillance system in Pakistan has been fully operational and has achieved and maintained international standards for quality in key indicators since 2000. These indicators are: (a) non-polio AFP rate - at least one non-polio AFP case per 100,000 persons aged < 15 years7; and (b) completeness and timeliness of stool specimen collection – at least 80% of AFP cases with two adequate stool specimens collected from patients within 14 days of onset of paralysis. The surveillance system is supported by nearly 67 WHO Surveillance Officers throughout the country.

(iv) The TAG reviews (both by national and international professionals) the status of PEI. A review in early 2008 reported that despite security challenges significant efforts were being made by the program to address constraints and that its previous recommendations were being implemented. It also emphasized areas for follow-up and strengthening.

(v) A post-campaign independent assessment for the January 22- 24, 2008 NID was undertaken by the Health Services Academy, Islamabad. Campaign coverage was reported based on a randomized cluster survey in identified districts in all four provinces of the country, including a cluster from 12 towns of Karachi8. This survey also reported on the reasons for non-vaccination of children, the level of awareness of households, and how communities get their information.

(vi) The WHO/EMRO Audit Report was carried out between August 17-28, 2008, and its findings concluded that the targets for the project had been achieved. These findings would be used to trigger the IDA buy-down.

M&E Utilization: The program has effectively utilized data for planning SIAs, including vaccine requirements and geographical areas/population groups needing focused attention. The last supervision mission for the project in Feb-Mar 2008 reported that despite effective implementation of SIAs, polio virus transmission persisted in two zones of the country and also spread to some polio-free districts of NWFP and Sindh province in 2007. The increasing number of cases and persisting transmission was due to: resurgence of the P3 sub-type of the polio virus; inaccessibility to children due to the highly volatile and changing security situation in areas (mainly NWFP and parts of Balochistan) and federally administered tribal areas (FATA); gaps in

7 This is for non-endemic countries. The appropriate indicator for endemic countries is at least 2 non-polio AFP cases per 100,000 persons < 15 years of age.

8 The results of this assessment indicated that at the national level the vaccination coverage among children less than five years of age was 96%. Coverage at the provincial level ranged from 94% to 99%, with Balochistan showing the lowest , and Punjab the highest coverage.

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performance due to inadequate management and significant changes in health manpower in the provinces and many of the high risk districts; pockets of refusals; and continued low coverage with routine immunization in polio free areas. Based on these findings and in order to address persistent transmission of the polio virus, in March 2008, the Bank team recommended to the program that the current technical and implementation strategy needed to be reviewed. This is subsequently being addressed by the program.

2.4 Safeguard and Fiduciary Compliance Environment: The environmental screening category for the project was C as it was determined to have no significant negative environmental impact. OPV is supplied in small plastic vials which are disposed in accordance to the WHO guidelines9. Social: The safeguard policy regarding projects in disputed areas (OP/BP/GP 7.60) was triggered as the project credit supported SIAs in AJK, a disputed area between India and Pakistan since 194710. Financial Management: Based on the financing agreement, IDA funds were directly transferred to UNICEF, and hence GoP was not involved in the management and accounting of funds. UNICEF maintained a separate ledger account for credit transactions with the Bank and was meant to provide updated funds utilization reports detailing purchase orders that were fully executed and delivered. The current project, like other polio eradication projects, was granted an exemption from the audit requirement. In Feb-March 2008, the Bank team reported that UNICEF had abandoned the practice of mentioning the source of funding for each supply on respective purchase orders. It was recommended that this be maintained; and is being subsequently done. Submission of quarterly project reports (sources and use of funds) by the program to the Bank was delayed, as was the case during the first project also. However, this did not compromise monitoring by the Bank since UNICEF provided regular reports, providing similar information. In February 2008, the Bank team observed that the Bank financed activities as part of the overall UNICEF activities were subject to two types of audit. The first was an institution-wide internal audit, and the second, an external audit of annual financial statements carried out by a professional firm of accountants. Both these audits were necessary to provide adequate fiduciary assurance to the stakeholders that the funds were utilized for the purposes intended. UNICEF confirmed that none of these audit reports contained any audit observation with respect to the procurement done utilizing Bank funds.

Procurement: UNICEF was contracted by GoP on a single source basis for procurement of OPV; which was done using UNICEF’s own procedures. UNICEF procured and made available 509, 000,000 doses of OPV (both mono and tri-valent vaccines) utilizing US$ 67.84 million of IDA funds from both the original and supplementary credits until end June 2008. The amount of vaccines procured and delivered by UNICEF to EPI tally with vaccine amounts in EPI records.

9 Incineration of used vials and burial of residual waste. SIAs (with WHO oversight) ensure that every used OPV vial (matched with no. of OPV doses administered) is accounted for at the EPI center after returning from the field. Subsequently, the used vials are subjected to the standard agreed treatment. 10 By supporting the project, the Bank does not intend to prejudice the final determination of the parties’ claims on the disputed areas

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There were no procurement related issues except not meeting the original OPV supply indicator, the reasons for which are described in Sections 1.3.

2.5 Post-completion Operation/Next Phase Since polio virus transmission persists in Pakistan, GoP would need to continue to implement SIAs. The Global PEI is currently reviewing the situation and debating the optimal strategy to be implemented. The EPI program has prepared a three year (2008-2010) program strategy and financing plan, which envisages the country needing about US$ 193 million. This includes the cost of SIA operations, surveillance, OPV procurement, and technical assistance. The Ministry of Health, GoP, has requested the Bank in March 2008 (with a formal request on August 15, 2008) to explore options for a follow-on project using the IDA buy-down mechanism for procurement of OPV. A proposed next operation with about US$ 70 million for IDA buy-down is likely to be appraised in December 2008.

3. Assessment of Outcomes

3.1 Relevance of Objectives, Design and Implementation Rating: Satisfactory Polio eradication continues to remain a priority for the global community, and though significant strides have been made towards achieving this goal, the challenge remains. Pakistan is one of the four endemic countries for polio. The project objective remains highly relevant as the project supported the polio elimination program of the country by agreeing to finance the critical gap of OPV procurement. The Pakistan CAS of April 2006 and the Government’s PRSP and Medium Term Development Framework 2005-10 all highlight the importance of preventive care for communicable diseases, including immunization, and maternal and child health, especially for the poor. Global polio eradication will become a reality only when every endemic country eliminates the disease and virus transmission is interrupted. Till such time, the requirement for OPV and immunization needs will persist.

3.2 Achievement of Project Development Objectives Rating: Moderately Satisfactory Since 1994, when Pakistan started its polio elimination efforts, there has been a significant reduction in the number of polio cases. Although, during the project period, the number of cases reported has been increasing, there is epidemiological evidence that the program had managed to geographically restrict virus transmission: the number of districts reporting cases has reduced from 22 in 2006, 18 in 2007 to 16 in 2008 (January to June, 2008). Subsequently, the latter half of 2008 is seeing an increasing number of cases11. Currently there are 3 main transmission zones: Central NWFP (reporting 24 cases), Karachi towns (reporting 4 cases) and Central Pakistan (corridor extending from southern Punjab, Northern Sindh to North West Balochistan – reporting 12 cases). The remaining 41 cases have been reported from non transmission zones, but most of them can be linked to virus spread from the transmission zones. Federally

11 81( 59 P1, 22 P3) cases till October 15, 2008 – Punjab (22 P1; 0 P3), Sindh (16 P1, 0 P3), NWFP (9 P1, 15 P3), FATA (2 P1, 5 P3), Balochistan (7 P1, 0P3), Islamabad (3 P1, 2 P3)

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Administered Northern Area (FANA) and AJK continue to remain polio free since 1998 and 2000 respectively. Islamabad, which was polio free since 2003, had reported two cases in the first six months of June 2008. Thus, despite regular implementation of good quality SIAs, high (97%) coverage of the target population, and a well-functioning surveillance system, the project indicator of zero reported cases of polio cases was not met during the project period, and a further concern is the increasing numbers of reported cases during the last few months (after project completion). Recent (mid-2008) TAG meetings specially convened to review the polio situation in Sindh and NWFP concluded that the upsurge in cases was due to a confluence of factors which included: (i) persistent transmission of wild polioviruses in key reservoir areas; (ii) deterioration of security in the key reservoirs of NWFP and FATA resulting in a decrease in campaign quality and intensification of transmission in that area; (ii) large-scale population movements from security-compromised reservoir areas (e.g. NWFP & FATA) into previously polio-free areas; (iii) increase in population susceptibility in polio-free areas due to the recent reduction in the number of polio campaigns and the deterioration of an already weak routine immunization service delivery system in 2008 (due to vaccine stock outs among other factors); and (iv) suboptimal impact of monovalent OPV largely as the result of insufficient coverage in reservoir areas thereby allowing transmission of each serotype to persist and eventually spread. The project achieved its second key indicator: SIA coverage in the targeted population (under-five children) in each of the four provinces during 2006, 2007 and until June 30, 2008 (Target 85%) (Annex 2) The project contributed to the successful implementation of a total of 18 NIDs/SNIDs (Annex 2, Table 1) during the project period by financing 509million doses of OPV. Each round immunized about 30 million children in the target age group. As described in Section 1.3, the original indicator of timely arrival of the OPV at the central stores at least five weeks before each of the SIAs was revised in May 2007 to: “timely arrival of OPV at the District stores five days before each SIA”. This indicator was not fully met. From January 2006 – June 13, 2007 (measured against original indicator): none of the eight SIAs for 2006, and only 20% of the June 2007 SIAs met the target. During this period 69% of the total IDA Credit (US$47.92 of US$69.24) was utilized. From June 14, 2007 – June 30, 2008 (measured against the revised indicator): 89.5% of 4 SIAs for 2007; and 80% of one SIA for 2008 met the target. During this period remainder of the 31% of IDA Credit was utilized. All districts received OPV three-four days prior to each SIA. The WHO Performance Audit (August 2008) carried out a detailed analysis of vaccine arrival, logistics of distribution throughout the country for use in the SIAs. The audit concluded that despite a variable system of distribution for each province, it was highly commendable that so far no SIA12 was delayed, postponed or re-scheduled due to late arrival of vaccine at the district level for distribution to the team of vaccinators. This, according to the WHO Performance Audit, is an indication of the remarkable capacity that has been developed at the provincial level and below. The WHO audit

12 Since 1994, when NIDs were held for the first time, until August 2008, 83 SIAs have been held in Pakistan

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also noted that facilities for storage of vaccine at minus 20 degrees Centigrade were available only at the central and provincial stores, and divisional stores at Sindh. Therefore to maintain the integrity of the cold chain it was desirable that the vaccine arrived in the districts only about 2-3 days before the SIA. The audit recommended that the indicator dealing with timely arrival of vaccine at the district level should be arrival 3-5 days before the SIA instead of five days, measured in one third of randomly selected districts.

3.3 Efficiency The project objective supported elimination of poliomyelitis from Pakistan. Elimination of polio from the remaining four endemic countries, including Pakistan, is facing challenges with an increasing number of reported cases. Currently there is an ongoing debate regarding eradication versus effective control of poliomyelitis. Worldwide eradication of wild polioviruses is likely to yield substantial health and financial benefits. International research13suggests that the intensity of immunization (and concomitant increased costs) must be increased to achieve eradication, and that even small decreases in intensity could lead to large outbreaks. It has also been demonstrated that any circulation of wild polio virus will lead to outbreaks, even at a time when global population immunity is at its highest. In 2002-03, GPEI scaled back its immunization campaigns because of limited financial resources. Political challenges to vaccination in northern Nigeria and coverage gaps in India led to large outbreaks. These conditions led to exportation and a resurgence of wild polio virus cases in countries previously free of viral transmission and necessitated additional expenses exceeding $ 400 million during 2004-06 to again stop virus circulation in those countries. Therefore, one school of thought is that a wavering commitment to eradication would lead to a much larger number of cases and greater cumulative costs. On the other hand, the merit of strengthening routine immunization and its impact on polio elimination in the endemic countries is also being advocated. At the time of writing this report, the global discussion continues.

3.4 Justification of Overall Outcome Rating Rating: Moderately Satisfactory The development objective of the project was clearly defined and highly relevant to the continuing global goal of polio eradication. The project enabled (by financing the requisite doses of mono and trivalent OPV) the national program to plan and implement supplementary immunization activities, recommended by technical experts as the methodology for interrupting polio virus transmission in endemic countries. This component of the project was strongly supported by the high quality training, communication, monitoring and surveillance activities, which are an integral part of Pakistan’s PEI, and supported by WHO/UNICEF. Although, even the revised target of vaccine supply within the stipulated time prior to the SIAs was not met, no SIA was postponed and there was no shortage of OPV during the SIAs. Despite these efforts, an increasing number of polio cases have been reported, resulting in the global community debating the feasibility of polio eradication. Towards the close of the project (April-June 2008) the project supported the following: (i) a detailed review of reasons for delayed arrival of OPV; and (ii) a revised technical and implementation strategy to address the persisting transmission of the virus

13 Eradication versus control of poliomyelitis: an economic analysis, K.M.Thompson, R.J. Duintjer Tebbens, 2007

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in Pakistan. Based on the monitoring and surveillance data that was available, these reviews could have been done earlier, to substantially influence the 2008-10 program strategy.

3.5 Overarching Themes, Other Outcomes and Impacts (if any, where not previously covered or to amplify discussion above) (a) Poverty Impacts, Gender Aspects, and Social Development As noted in Section 1.4, SIAs targeted poor, remote and underprivileged communities whose immunization coverage tends to be lowest; and vulnerability to polio, the highest due to unsanitary and crowded living conditions. The social mobilization and communication strategy maintained the awareness and knowledge among the population through mass media and intensified inter-personal communication in high risk districts through District Social Mobilization Teams. However, recent reviews indicate that there continue to be pockets of refusal to accept the vaccine, and more work will need to be done to make them beneficiaries of the program. SIAs worked with the Lady Health Workers (the community outreach workers), teachers and other local functionaries, and emphasized inclusion of women in the vaccination teams, in order to address the stringent norms of seclusion and restriction of female mobility in parts of the country. (b) Institutional Change/Strengthening The PEI, and more specifically the SIAs, demanded an elaborate system of organizing large scale campaigns, and the program effectively responded to the same. Each NID round involved organizing about 80,000 teams, including 70,000 mobile teams, 9,000 fixed teams and 4,600 transit teams to cover about 30 million eligible children across the country. In addition, each campaign was supervised and monitored by about 800 campaign support persons, 15,000 area in-charges and 2,700 zonal supervisors. Over the years, the national program staff at various levels, including those working in vaccine stores, have acquired much experience and valuable skills in ensuring that the vaccine reaches the districts in time for the scheduled SIA. (c) Other Unintended Outcomes and Impacts (positive or negative) While about 15 days prior to each SIA, all program and non-program health functionaries at all levels are focused on the micro-planning, it is debatable and variable whether the SIAs negatively impacted routine immunization. During the time of the first and the current polio projects, the proportion of fully immunized children in Pakistan increased from 53% to 76%. It was reported that in provinces/districts with good management capacities, the SIAs, including the communication activities, were actually used to enhance the effectiveness of routine immunization. On the other hand, for those with low capacity, the SIAs tended to compromise routine activities. Coverage of routine immunization, particularly in high risk districts, has been reported to be of concern, and the revised implementation strategy of the program is planning to pay particular emphasis to this.

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

4. Assessment of Risk to Development Outcome Rating: Significant

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Pakistan continues to face the challenge of persisting and increasing polio virus transmission, although the government is committed to polio elimination and is fine-tuning its technical and implementation strategy in order to address the identified weaknesses. The key constraints/challenges to elimination in Pakistan have been described in earlier sections. EPI has prepared a plan for 2008-10 and projected the financial requirements for the same. The program would, through different strategies, specifically focus on the difficult to reach areas/populations, the changing epidemiology of the disease, and the volatile and unpredictable security situation. Social mobilization and community involvement has played an important role in the success of the program to date, and would have to be further strengthened to ensure full coverage and acceptance by certain groups. The institutional arrangements for program management are well established and sustainable. However, polio elimination in Pakistan will continue to be challenging, both in terms of mobilizing adequate resources and responding to the changing epidemiology. This is indicated by the upsurge of polio cases during 2008.

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

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Satisfactory This project was a follow-on project to the first Partnership for Polio Eradication Project, and was prepared while that project was being implemented, thereby ensuring no interruption to the planned immunization activities. The Bank responded to the projected need by GoP for continued financing for OPV for use in supplemental immunization activities during 2006-07. Since the financing mechanism of IDA buy-down seemed to be working well for the first project, and in Nigeria, it was agreed to adopt the same mechanism, with its clear advantages. Procurement arrangements, with UNICEF as the sole procurement agent, also remained the same as the first project. The project was appraised between October 18 – November 02, 2005 while ensuring that it did not disturb the ongoing earthquake relief operations. Despite sound preparation, the team however failed to adequately recognize the inappropriateness of the performance indicator of arrival of the vaccine at the central store five weeks prior to each SIA, which was used for the first project. The ICR for the first project and the WHO Performance Audit both highlighted this issue. However, these reports were not available at the time of project appraisal. As a result of this, the same indicator was also retained for this project and was revised only in the second year of its implementation. The issue of the project supporting routine immunization was discussed during preparation. It was determined that routine immunization was being supported by GAVI, WHO and UNICEF, and this was considered adequate. Therefore, the project did not support routine immunization. (b) Quality of Supervision Rating: Moderately Satisfactory Two formal supervision missions were carried out during the two and a half years life of the project. These missions included participation of fiduciary specialists. The mandated six-monthly supervision missions by the Bank were not deemed necessary by the task team as the project was reasonably simple, and the task team, including the team leader, was based in

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Islamabad; thereby saving on the much sought after supervision resources. Being in the field facilitated interaction and follow-up, by the team leader with client counterparts, on a routine basis. In addition, the team worked closely with counterparts - UNICEF (particularly focus on vaccine arrival and quarterly submission of project progress reports) and participation in SIAs (interaction with WHO/UNICEF teams; and was a member of the IACC). The IACC met every 3-6 months (more often, if required, as has been the case during 2008) and discussed policy and technical issues to provide guidance to the program. VARs, which record the quality of vaccine at arrival, were monitored by the task team. The first supervision mission, conducted about 11 months after project effectiveness, highlighted the challenge of the SIAs not being able to reach certain high risk groups – nomadic migrant populations, minorities and infants. Subsequently, plans were prepared and implemented by the program to address the same. The project did not have a formal mid-term review. The second supervision mission was conducted about four months prior to project closure on June 30, 2008. This mission highlighted several critical issues and recommended follow-up measures - plan to deal with the large-scale migration and its impact on polio transmission/resurgence, access to security compromised areas, and focused communication strategy. These are now being incorporated into the government’s project implementation plan for a proposed third follow-on project. It is likely that more frequent supervision missions could have highlighted the critical issues earlier. (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory Overall Bank performance was moderately satisfactory. The Bank responded promptly to the request of GoP for a second project, which became effective prior to closing of the first project, thereby ensuring no financing gap for OPV. The project design remained simple with a decision to continue using the IDA buy-down mechanism. However, this simplicity may have compromised the Bank’s leverage to provide inputs to the other two components of the PEI. Supervision of the project did not depend entirely on formal supervision missions, rather on routine follow-up with the program and technical partners. The indicator measuring vaccine arrival could have been revised earlier (soon after the ICR for the first project and WHO performance audits were available). Also, the important ground reality of appropriate vaccine storage facilities not being available at the district level (as analyzed by the recent WHO performance audit) could potentially have been identified much earlier in collaboration with the program. This weakness resulted in the project using an inappropriate indicator for half the project period, though it did not adversely affect project outcomes. Additionally, there was no social development specialist on the task team during supervision, who could have worked with the program, to address the critical issue of access to difficult to reach population groups.

5.2 Borrower Performance (a) Government Performance Rating: Satisfactory Government commitment at the highest level for polio elimination from the country is evident in the successful collaboration with donor partners for both the first and second projects. The commitment continues with the 2008-10 EPI plan towards polio elimination. Organizing SIAs across the country is an elaborate process requiring the support and engagement of not only health sector personnel, but several allied departments and donor partners at the provincial and

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district levels. Financing for human resources and recurrent costs, primarily from government sources, was estimated to be a substantial part of program costs. Government, political and religious functionaries have played a significant role in creating public awareness of the necessity of polio immunization and supporting the program to try and reach the more remote and difficult areas/populations. However, greater insight into the reasons for underperformance in some geographical areas has recently been determined to be due to frequent changes of key health personnel resulting in an inadequate understanding and commitment to the program. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory The EPI program management which is responsible for implementation of the PEI has been able to successfully plan and execute all planned SIA activities during the project period. This is reflected by the fact that all 18 SIAs during project period were carried out as planned, with about 97% coverage of the target population, with availability of adequate OPV at all vaccination sites. Despite this, challenges remain with a persisting viral transmission. A reflection of the continued commitment to polio elimination and a revised implementation strategy was the subject of a technical consultation14 held in Karachi at the request of GoP on June 24-25, 2008. This consultation highlighted both the achievements and challenges individually for the four provinces, thereby the future need for a more province-specific strategy for EPI. In June 2008, the TAG reported that the rapid institutionalization of the recommendation of campaign evaluation through independent monitoring of finger marking had been impressive and yielded positive results. The program could have more pro-actively highlighted to the Bank task team the ambitious nature of the performance indicator related to vaccine arrival in the country, including the inadequate vaccine storage facilities at district levels, which could potentially jeopardize the cold chain. There was also a weakness in regular reporting since the quarterly progress reports meant to be submitted to the Bank were delayed. In addition, the reported increase in population susceptibility in the polio-free area, which according to the experts has been due to a reduction in the number of polio campaigns in those areas, and the deterioration of an already weak routine immunization service delivery system in 2008 (due to vaccine stock outs among other factors), is an indication of program management weakness. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory Overall Borrower performance is rated moderately satisfactory. GoP remains fully committed to polio elimination, and the EPI has successfully implemented all planned SIAs, with timely supply of vaccines to the vaccinators, sound post-campaign assessments of coverage and quality,

14 The consultation included senior officials of health from the federal and provincial levels, nine members of the TAG, experts from WHO, UNICEF, World Bank, DFID, Rotary International and Japan International Cooperation Agency

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and a well performing surveillance system. The remaining challenge is to collect, analyze, and respond to disaggregated data for districts to be able to focus on the high risk areas/population groups, and measure effectiveness of specific strategies designed to target these groups.

6. Lessons Learned Important lessons have been learned from implementation of this project:

Simple design: The project had a simple design, procurement by UNICEF, and a straightforward objective of supporting one component of a larger effectively functioning national program. With a relatively simple project design and objectives, it was easier to measure success. This principle could be applied to projects across sectors and countries; however it does need to be acknowledged that development issues often do not have simple solutions, and hence the complexity of many Bank projects. Also, the simple design could have compromised the Bank’s role to have an effective dialogue for the entire EPI. IDA buy-down mechanism: The project successfully used the innovative IDA-buy down financing mechanism, which had been used for the first project and a similar project in Nigeria. Based on the Pakistan and Nigeria experience, the World Bank HNP Anchor is expanding the pilot program for using the buy-down financing mechanism. Potential health sector projects under preparation would be selected based on three minimum eligibility criteria: significant cross-border externalities, measurable outcomes, and meet standard Bank appraisal requirements. Currently, Botswana and Swaziland (middle-income countries) are exploring buy-downs for HIV-AIDS prevention projects supported by IBRD loans. Utilizing existing program management: The project was entirely implemented by the existing EPI management unit and hence sustainable after project completion. Awareness and ability to respond to changing environment: At project appraisal, the program was expecting that Pakistan would eradicate polio by the end of that year. This however did not happen, and polio transmission continues to pose a challenge. This is partly due to the complex viral epidemiology and emerging security concerns resulting in inaccessibility to certain geographical areas. However, it has been acknowledged that it is also due to weak implementation at the provincial/district levels in certain cases. For the next few years, the remaining polio endemic countries will need to be continuously responsive to the changing environment. Realistic indicators and close monitoring: Ensuring realistic indictors to measure project success is important. The OPV supply indicator as developed was ambitious, and when developed did not take into account the global OPV demand-supply situation. At the same time, an early recognition of the inappropriateness of an indicator and revising/changing it can be critical to project success. Polio eradication versus effective control and routine immunization: Any future Bank support for polio elimination from Pakistan and the other endemic countries would need to reach consensus on the ongoing global debate of the seemingly difficult challenge of polio eradication. At the same time, the merits of routine immunization strengthening (and the

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striking the right balance with polio immunization campaigns) would need to be addressed as a priority. Future Bank projects may also need to assess whether the simple provision of OPV for SIAs is sufficient, or supporting other elements of the program may provide greater leverage for effective policy dialogue and program implementation.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies – Borrower has reviewed the ICR with no additional comments. Borrower’s ICR inputs in Annex 7. (b) Co financiers; - No comments received. (c) Other partners and stakeholders (e.g. NGOs/private sector/civil society)- No comments received. Inputs from WHO and UNICEF in Annex 8.

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Annex 1. Project Costs and Financing

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

Components Appraisal Estimate (USD millions)

Actual/Latest Estimate (USD

millions)

Percentage of Appraisal

Procurement and supply of Oral Polio Vaccine and its effective use 46.70 67.84* 145%

Total Baseline Cost 0.00 67.84

Physical Contingencies 0.00

0.00

0.00

Price Contingencies 0.00

0.00

0.00

Total Project Costs 0.00 67.84 Front-end fee PUFF 0.00 0.00 0.00 Front-end fee BIRD 0.00 0.00 0.00

Total Financing Required 46.70 67.84 145%

(b) Financing15

Source of Funds Appraisal Estimate

(USD millions)

Actual/Latest Estimate

(USD millions)

Percentage of Appraisal

Borrower 1.90 1.90 100% International Development Association (IDA) 46.70 67.84* 145%

JAPAN: Japan International Cooperation Agency (JICA) 12.80 12.80 100%

* includes additional IDA credit

15 Financing for the entire program – Total USD 100.40 million at appraisal included (in USD million): Borrower 1.90, IDA 46.70; JICA 12.80; UNICEF 7.30 and WHO 31.70

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Annex 2. Outputs by Component

SIA coverage during project period from different sources of data collection Table 1: Reported SIA coverage by province

NIDs SNIDs Punjab NWFP/FATA Sindh Baluchistan2006 6 2 100.50% 98.13% 108.74% 100.50% 2007 4 5 99.34% 96.54% 114.27% 90.70% 2008 1 - 99.44% 91.35% 113.57% 93.52%

Table 2: Post campaign coverage of target groups by province

Province 2006 2008* Punjab 98 99%

NWFP/FATA 96.125 97% Sindh 96.625 95%

Baluchistan 95.875 94% *Independent survey Jan 2008

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Annex 3. Economic and Financial Analysis

Cost benefit analysis does not easily apply to disease eradication, especially disease elimination at the country level. Net present value/economic rate of return were not estimated at project appraisal, or for this report, since the benefit is largely a global public good.

Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/ Specialty

Lending Inaam Haq Senior Health Specialist SASHD Task Team Leader Amie E. Batson Senior Health Specialist SASHD Anwar Ali Bhatti Financial Analyst SACPK Asif Ali Senior Procurement Specialist SCARPS Furqan Ahmad Saleem Financial Management Specialist SARFM Amna W. Mir Program Assistant SASHD

Supervision Inaam Haq Senior Health Specialist SASHD Task Team Leader Asif Ali Senior Procurement Specialist SCARPS Amie E. Batson Senior Health Specialist HDNHE Anwar Ali Bhatti Financial Analyst SACPK Shahnaz Kazi Senior Economist SASHD Nasreen Shah Kazmi Team Assistant SASHD Amna W. Mir Program Assistant SASHD Furqan Ahmad Saleem Financial Management Specialist SARFM

Hasan Saqib Senior Financial Management Specialist SARFM

(b) Staff Time and Cost Staff Time and Cost (Bank Budget Only)

Stage of Project Cycle No. of staff weeks USD Thousands (including

travel and consultant costs) Lending

FY06 10 23.48 FY07 0.00 FY08 0.00

Total: 10 23.48 Supervision/ICR

FY06 1 1.14 FY07 6 8.87 FY08 10 20.91 FY09 1 0.00

Total: 18 30.92

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

Annex 6. Stakeholder Workshop Report and Results (if any) Not Applicable

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Annex 7. Summary of Borrower's ICR

Federal EPI Cell National Institute of Health

Islamabad *****

Pakistan: Second Partnership for Polio Eradication Project

(P097402 – Credit # 4145 and 4145-1-PAK)

Implementation Completion Report Introduction and Back ground Pakistan Polio Eradication Initiative had been a major national effort since 1994, and has been supported by several donors. WHO and UNICEF are the lead technical partners for polio eradication globally and in Pakistan. Through them, the donors are providing grant funds for the operations, surveillance and vaccine costs. During 2003-05 the World Bank in collaboration with other partners including Bill and Melinda Gates Foundation UN Foundation, CDC and Rotary International financed the polio eradication program for procurement of OPV to bridge the funding gap using an innovation financing mechanism of IDA Buy-down project with an assistance of US$ 42.69 million (ref IDA credit # 3167 and 3167-1) for procurement of oral polio vaccine (OPV). After successful completion of project and third party performance assessment IDA buy down was triggered and the credit amount was converted to ‘Grant’ for the Government of Pakistan. Persistent virus circulation in Pak-Afghan block compelled Global Polio Eradication Technical Advisory Committee to further intensify supplementary immunization activities for next two years. This required an estimated quantity of 461.28 million doses for 2006-07 with an estimated cost of US$61.4 million. The Bank was approached for continuation of IDA Buy down assistance to address the financial gap of approximately US$46.7 million. The project (P097402) was approved on 22 December 2005. The allocated funds were utilized by early 2007 and on the request of GoP an additional financing for the Project amounting US$21.14 million was approved on May 10, 2007 for the rest of 2007 and early 2008. Project information Following is the selected data pertaining to Second Pakistan Partnership for Polio Eradication Project: P097402 (original) ID P104900 (supplementary) Board Approval ( Original) January 26, 2006 May 10, 2007 Effectiveness date (Original) March 08, 2006 June 14, 2007 Closing date June 30, 2008 June 30, 2008

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Original Credit Amount US$ 46.700 million US$ 21.140 million TOTAL (a+b) US$ 67.840 million Amount disbursed US$ 67.840 million Key Performance Indicators The following two indicators and their means of verification were agreed to be used to measure project performance:

Indicator Means of verification 1 Timely arrival of OPV at the district stores 5 days

before each SIA (ID P104900)

WHO monitoring reports

2 SIA coverage of 80% achieved in the remaining endemic provinces during financing period.

Cluster Sampling Survey according to WHO approved Methodology.

Achievement of Development Objectives The project purpose was to assist GoP in eradicating poliomyelitis. The objective was to finance and provide oral polio vaccine (OPV), needed during 2006-08 and monitors its effective use in the country’s Supplementary Immunization Activities (SIAs). Pakistan has made significant efforts towards polio eradication. As a result, the numbers of confirmed polio cases decreased substantially from 104 in 2003 to only 32 in 2007 (an overall reduction of 69%). The number of confirmed polio cases decreased substantially in all the provinces during project implementation period. Although localized virus transmission persists in most of the provinces while no case reported from AJK and FANA since 2000. Technical advisory group reviewed the current situation and quite confident that Pakistan is likely to interrupt transmission of wild polio virus if all the recommendations are fully implemented. The project implementation was completed by the end of 1st quarter of 2008 with full disbursement and utilization of original and supplementary credit. The Project financed approximately 85% of OPV for polio eradication during 2006-2007 and first quarter of 2008 through the original and additional credit. On the request of the Government of Pakistan, the Bank is considering, “Polio Eradication 3rd Project through IDA Buy Down” to finance the procurement of additional OPV required during 2009-2011 During the project period 11 NIDs and 7 SNIDs (4 case responses/mop ups) were undertaken, administering about 590 million doses of OPV to the target children. The project through procurement and distribution of OPV through UNICEF contributed significantly to ensuring timely availability of vaccine for each round. Pakistan has successfully met the challenge of preparing, implementing, and evaluating multiple, nationwide immunization rounds while maintaining and improving quality of SIA with an average coverage of more than 95% during the project period. SIA monitoring has provided quick feedback to identify low-performing areas and rectify problems during the round under implementation or for more effective planning of the next round.

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AFP surveillance has remained sensitive and has improved overall in Pakistan. Surveillance quality is measured by two primary indicators: 1) the non polio AFP rate (at least one non polio AFP case per 100,000 persons aged <15 years) and 2) the completeness and timeliness of stool-specimen collection (at least 80% of AFP cases with two adequate stool specimens collected from patients within 14 days of paralysis onset). Both indicators were at target values or higher at the national and provincial levels. Overall AFP surveillance in Pakistan meets or exceeds WHO performance-indicator targets in most areas and is continuously reviewed to detect quality gaps and respond to them quickly. The social mobilization and communication strategy continue to maintain awareness and knowledge among the mass audiences through mass media, including newspapers, radio and television, and intensified inter personal communication in high risk districts through use of District Social Mobilization teams. Assessment of the Key Performance Indicators OPV Procurement: UNICEF was disbursed US$ 67,870,000 for procurement of OPV. UNICEF procured and made available to GOP about 401 million doses of OPV using IDA funds. Of the total amount disbursed to UNICEF, it is estimated that UNICEF has utilized US $ 67.87 million for supply of OPV. All the vaccine delivered by UNICEF was made available to the provincial and district offices prior to planned SIAs. Timely arrival of vaccine at the district stores: The revised target for this indicator was “timely arrival of OPV at the district stores five days before each of the supplementary immunization activities (SIAs)” and this indicator would be measured in at least one third of all districts (to be randomly selected) for each round. The timing of vaccine arrival in the central stores is a major determinant of the vaccine arriving in the districts, 5 days before the SIAs. The time of vaccine arrival in Central stores in relation to the SIAs, during the period January 2006 to January 2008, has been quite variable. The vaccine (for most SIAs there are 2-3 shipments) arrived from a minimum of 5 days to a maximum of 7 weeks before the SIA for which it was meant to be used. There are a variety of reasons for the late arrival of vaccine in Pakistan which were not under the control of the GOP. It was worth noting that even though in the instances where the vaccine arrived in Islamabad less than two weeks before the start of the campaigns (NIDs of 24-26 Jan 2006, NIDs of 4-6 April 2006, NIDs of 18-20 July 2006, NIDs of 12-14 September 2006, SNIDs of 27-29 March 2007, SNIDs of 22-24 May 2007 and SNIDs of 11-13 Dec 2007), it was able to reach 100% of the districts, 3-5 days before the campaign was to begin. Since 2007, the process of procurement of vaccine and its distribution in the country has become slightly more complex as more than one type of vaccine was being used in any given SIA and the frequency of SIAs in the country has increased. NO SIAs was either delayed, postponed or re-scheduled due to the late arrival of vaccine at the district level for distribution to the teams. SIAs Coverage: The quality of SIAs is regularly monitored through post campaign monitoring that some times involves external experts and even by independent firms/institutions to have

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Punjab 6983 6884 99 623 603 97Sindh 12436 11774 95 1156 1028 89NWFP/FATA 11232 10878 97 1333 1267 95Balochistan 7995 7554 94 844 782 93Total 38646 37090 96 3965 3680 93

<6 months vaccinated Percentages

Total number of children <5 years

checkedProvinces

Total number of children <5 years

vaccinated Percentages

Total number of <6 months checked

unbiased results. An independent assessment was also carried out for January 2008 NIDs using WHO standard 30 household cluster survey technique. Data was collected by independent monitors and the services of Health Services Academy were hired for the sampling technique, compilation, analysis and report writing. The Independent Post Campaign Coverage Assessment carried out for 24-26th January 2008 used randomized cluster sampling in 67 districts/towns of the four main provinces of the country. 2/3 of the districts were from the districts in known transmission zones and 1/3 from the non-transmission zones. The areas for assessment were randomly selected within each district. In each cluster selected, data was collected from 7 households having at least one child within the target age group for polio immunization (<5 years of age) through a house-to-house survey using a standardized checklist. The total number of clusters taken was 2070, with 450 from districts in Punjab, 720 from districts/towns in Sindh, 540 from districts in NWFP/FATA and 360 from districts in Balochistan. The results of this independent assessment showed that at the national level the vaccination coverage among children less than 5 years of age was 96%. The following table shows that coverage at the provincial level ranged from 94% to 99%, with Balochistan showing the lowest coverage and Punjab the highest. The coverage among infants less than 6 months was 93% ranged from 89% to 97%, with the lowest coverage from Sindh province followed by Balochistan (93%).

TTaabbllee sshhoowwiinngg NNaattiioonnaall && pprroovviinncciiaall ccoovveerraaggee ooff cchhiillddrreenn aasssseesssseedd ffoorr JJaannuuaarryy 0088 NNIIDDss

REPORT OF WHO/EMRO MISSION FOR CARRYING OUT A PERFORMANCE AUDIT OF THE SECOND PAKISTAN PARTNERSHIP FOR POLIO ERADICATION PROJECT; IDA BUY DOWN The performance audit of this project conducted by WHO/EMRO mission (17 - 28 August 2008) speaks that the coverage data for the SIAs conducted during the project period showed the coverage at the provincial level was above the target set for this indicator (85%) and the Mission was highly impressed by the mechanisms put in place by the Government of Pakistan at the federal level and by the provincial health departments at the provincial level to ensure that the vaccine reached the districts in time for distribution for the SIAs. No SIAs was either delayed, postponed or re-scheduled due to the late arrival of vaccine at the district level for distribution to the team of vaccinators even when the vaccine had arrived in Islamabad less than 2 weeks before the campaign.

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The report concludes with the remarks, “The Performance Audit of the Second Pakistan, Partnership of Polio Eradication Project has shown that the targets set in the Project Appraisal Document between the Government of Pakistan and World Bank/IDA have been achieved”. The assistance and support of the World Bank mission in Pakistan for facilitation and coordination between UNICEF and Ministry of Health in resolving financial disbursements and procurement related issues was extremely helpful in successful implementation of project. Lessons Learnt. Procurement and supply of additional OPV through this mechanism has assisted in getting close to our objectives. The project has benefited all children of Pakistan below the age of 5 years. This highly effective and efficient source of funding would help Pakistan achieve polio eradication thereby freeing its resources for other sectoral priorities. The two indicators attached to the evaluation of the project have been successfully achieved. The urgency to meet the two IDA Buy down indicators has kept other components of the whole polio eradication system on the go. The program strongly supports the observation of the WHO mission that considering varied geopolitical situation in the country the process indicator should be rephrased as arrival of vaccine at the districts from 3-5 days before the campaign rather than 5 days before the campaign.

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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders

(A) WHO.

Implementation Completion Report

Introduction and Back ground Pakistan has made tremendous progress in polio eradication since the launch of the program in 1994, the number of cases declined from more than 1000 a year to only 28 in 2005. Unfortunately, because of some operational issues and security problems the progress halted in the last three years and Pakistan remains one of only 4 remaining polio endemic countries. However, there is reduction in the biodiversity of polio viruses circulating in the country. The emergency consultation meeting held in Karachi in June, 2008 concluded that Pakistan is in a strong position to eradicate polio if the planned activities implemented correctly. The First Partnership approved in 2003 and covered the vaccine procurement for the period 2003-2005. The original project financing was for US $ 20 million. However, in view of the persistent low intensity transmission, intensification of the SIAs was recommended by the Technical Advisory Group. This required supplementary financing of US $ 21.51 million bringing the total financing for the project to US $ 41.51. The whole amount was written off as the performance audit done by WHO showed satisfactory performance. The Second Partnership approved in January 2006 and covered the vaccine required for January 2006- December 2007. US $ 46.7 million provided to the GoP through IDA Buy-Down in partnership with Bill & Melinda Gate Foundation. Supplementary IDA approved in June 2007 through which and additional US $21.14 provided to the GoP in partnership with CDC and UN Foundation. Measuring the performance: The performance is measured against only two objectively measurable indicators these are:

Indicator Means of verification 1 Timely arrival of OPV at the district stores 5 days

before each SIA (ID P104900)

WHO monitoring reports



Achievement of Development Objectives The project purpose was to assist GOP in eradicating poliomyelitis. The objective was to finance and provide oral polio vaccine (OPV), needed during 2006-07 and monitor its effective use in the country’s Supplementary Immunization Activities (SIAs).

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The project completely met the set objective of making oral polio vaccine available for all supplementary immunization activities during the project implementation period. The project implementation was completed by the end of 1st quarter of 2008 with full disbursement and utilization of original and supplementary credit. The Project financed approximately 85% of OPV for polio eradication during 2006-2007 through the original and additional credit. During the project period 11 rounds of National Immunization Days (NIDs), 5 sub national immunization days (SNIDs) and 4 case responses/mop ups were undertaken, administering about 550 million doses of OPV to the target children. The project through procurement and distribution of OPV through UNICEF contributed significantly to ensuring timely availability of vaccine for each round. Pakistan has successfully met the challenge of preparing, implementing, and evaluating multiple, nationwide immunization rounds while maintaining and improving quality of SIA with an average coverage of more than 95% during the project period. WHO and UNICEF jointly supported GOP to implement the project through:

1. Forecasting the type and quantity of vaccine required 2. Collection of OPV utilization report from the provinces. 3. Support the government in submission of quarterly OPV arrival and utilization report

to the WB 4. Monitoring and evaluation of the program activities and submission of

recommendations to the Government stakeholders 5. Hiring of independent consultants for assessment of the project implementation

against the agreed indicators.

Monitoring and Evaluation of the campaign activities plays a vital role in successful implementation. WHO, UNICEF and other partners extend financial assistance for hiring services of the qualified, skilled, experienced and committed professionals, who facilitate the District Health Management Teams for smooth implementation of campaigns to achieve the set targets. This activity has provided quick feedback to identify low-performing areas and rectify problems during the round under implementation or for more effective planning of the next round. AFP surveillance has remained sensitive and has improved overall in Pakistan. Surveillance Officers hired by WHO work in close collaboration with the District Surveillance Coordinators and District Superintendents Vaccination to achieve the set targets and improve the Surveillance quality which is measured by two primary indicators: 1) the non polio AFP rate (at least one non polio AFP case per 100,000 persons aged <15 years) and 2) the completeness and timeliness of stool-specimen collection (at least 80% of AFP cases with two adequate stool specimens collected from patients within 14 days of paralysis onset). Both indicators were at target values or higher at the national and provincial levels. Overall AFP surveillance in Pakistan meets or exceeds WHO performance-indicator targets in most areas and is continuously reviewed to detect quality gaps and respond to them quickly. The social mobilization and communication

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strategy continue to maintain awareness and knowledge among the mass audiences through mass media, including newspapers, radio and television, and intensified inter personal communication in high risk districts through use of District Social Mobilization teams. Assessment of the Key Performance Indicators WHO carried out and independent performance audit of the second Pakistan partnership for polio eradication project: IDA Buy Down for the period 17 -28 August which concluded that that the project met all the objective by timely providing the required amount of OPV for supplementary immunization activities. SIA Coverage of 80% achieved in the remaining endemic provinces in the financing period: The mission examined various sets of coverage data for the SIAs conducted during the project period which showed that the coverage at the provincial level was above the target set for this indicator (85%). Timely Arrival of OPV at the district store 5 days before each SIA: Regarding the second indicator, the Mission concluded that despite the occasions in which this indicator could not have been met this indicator was also achieved because no single planned activity postponed or cancelled due to late arrival of the vaccine and it was suggested that this indicator needs be revisited and vaccine arrival 3-5 days before the campaign should be used rather than at least 5 days. The key reasons behind successful implementation of the project are:

1. Simple design and objectively verifiable monitoring indicators. The project is dealing with only one component of polio eradication initiative which is vaccine procurement. The two indicators developed to monitor the performance are very SMART. There was no need to develop specific data collection instrument to report on the two indicators because the required data are routinely generated by the program.

2. Using UNICEF system for vaccine procurement 3. Presence of well structured polio eradication management system at the federal and

peripheral level with inbuilt monitoring mechanism 4. Strong partnership

Lessons learnt:

1. The program should be more flexible in estimating the vaccine requirement taking into consideration the rapidly changing economical and political situation of the country. A large stockpile should be considered to avoid as much as possible the need for supplementary projects.

2. Ensuring fast cold chain system is very necessary to maintain the vaccine efficacy in the presence of an average 6 hour a day load shedding. So regarding a minimum of 5 days as a cut off point for timely arrival of vaccine at district level may be too long and should be reduced to 3 days.

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(B) UNICEF.

Pakistan Second Partnership for Polio Eradication Project (ID P097402 & IDP104900)

Implementation Completion Report

In order to maintain the pace of successful implementation of Polio Eradication Project, the Ministry of Health, Government of Pakistan approached the Bank for financial assistance under the World Bank IDA Buy-Down Project to meet the shortfall of Oral Polio Vaccine (OPV) for supplementary Immunization Activities in 2003 (First Partnership). After successful completion of First Partnership, the Second Partnership was approved in January 2006 and covered the vaccine required for January 2006- December 2007. US $ 46.7 million provided to the GoP through IDA Buy-Down in partnership with Bill & Melinda Gate Foundation. Supplementary IDA approved in June 2007 through which and additional US $21.14 provided to the GoP in partnership with CDC and UN Foundation. The following two performance indicators were agreed and were monitored during the course of partnership:

Indicator Means of verification

1 Timely arrival of OPV at the district stores 5 days before each SIA (ID P104900) WHO monitoring reports



The objective of the project was to finance and ensure availability of OPV, needed during 2006-07 and monitor its effective use in the country’s Supplementary Immunization Activities (SIAs). UNICEF was mandated to procure and ensure timely availability of vaccine in the country. Despite short notices by the program for changes in type of OPV and / or increase in quantity, UNICEF Supply Division made all the efforts and successfully met the deadlines. The coordination and cooperation between country supply team and Ministry of Foreign Affairs in obtaining exemptions proved instrumental in ensuring timely availability at the facilities. The project completely met the set objective of making oral polio vaccine available for all supplementary immunization activities during the project implementation period. The project implementation was completed by the end of 1st quarter of 2008 with full disbursement and utilization of original and supplementary credit. The Project financed approximately 85% of OPV for polio eradication during 2006-2007 through the original and additional credit. WHO and UNICEF jointly supported GOP to implement the project through forecasting the type and quantity of vaccine required, collection of OPV utilization report from the provinces, support

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the government in submission of quarterly OPV arrival and utilization report to the WB, monitoring and evaluation of the program activities and submission of recommendations to the Government stakeholders and hiring of independent consultants for assessment of the project implementation against the agreed indicators.

WHO, UNICEF and other partners extend financial assistance for hiring services of the qualified, skilled, experienced and committed professionals, who facilitate the District Health Management Teams for smooth implementation of campaigns to achieve the set targets. This provided quick feedback to identify low-performing areas and rectify problems. WHO carried out and independent performance audit of the second Pakistan partnership for polio eradication project: IDA Buy Down for the period 17-28 August which concluded that that the project met all the objective by timely providing the required amount of OPV for supplementary immunization activities.

SIA Coverage of 80% achieved in the remaining endemic provinces in the financing period: The mission examined various sets of coverage data for the SIAs conducted during the project period which showed that the coverage at the provincial level was above the target set for this indicator (85%). Timely Arrival of OPV at the district store 5 days before each SIA: Regarding the second indicator, the Mission concluded that despite the occasions in which this indicator could not have been met this indicator was also achieved because no single planned activity postponed or cancelled due to late arrival of the vaccine.

The Project is dealing with only one component of polio eradication initiative which is vaccine procurement. The two indicators developed to monitor the performance are very SMART. Presence of a well structured polio eradication management system at the federal and peripheral level with inbuilt monitoring mechanism and strong partnership were the key success factors. Lessons learnt:

1. The program should be able to timely intimate on changing vaccine forecast, and the project should have enough flexibility in accommodating the changes that are purely based on virus epidemiology.

2. A large stockpile of all three types of vaccines should be considered by the program in the very beginning.

3. An improved capacity of vaccine management especially at districts and sub-district levels and a fast cold chain system would be an asset to maintain the vaccine efficacy in the presence power interruption for an average 10-12 hour a day.

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Annex 9. List of Supporting Documents

1. Country Assistance Strategy Progress Report for Islamic Republic of Pakistan: April 28, 2004

2. Country Assistance Strategy for the Islamic Republic of Pakistan for the period FY 06-09: April 4, 2006

3. International Development Association Project Paper for a proposed additional financing credit in the amount of SDR 14 million to the Islamic Republic of Pakistan for a second partnership for polio eradication project: May 10, 2007

4. Project Appraisal Document for the second partnership for polio eradication project: December 22, 2005

5. Financing Agreement between Islamic Republic of Pakistan and IDA for second partnership for polio eradication project: February 17, 2006

6. Project Implementation Plan of Pakistan: Polio eradication 2nd project through IDA buy down

7. Implementation completion and results report on a loan/credit of SDR 20.23 million to Pakistan for Partnership for polio eradication: January 25, 2007

8. Implementation Status and Results Report of June 30, 2008 for Pakistan, second partnership for polio eradication project

9. Management Letter and Aide Memoire of March 18, 2008 10. Management Letter and Aide Memoire of February 26, 2007 11. Polio Eradication Initiative Pakistan: WHO (2002-08) 12. WHO national surveillance bulletin: Issue 8 August 2008 13. WHO’s Post campaign independent coverage assessment report of January 2008 NIDs 14. Summary report: World Bank (IDA) Polio Eradication buy downs: January 24, 2008 15. Summary of IDA buy-downs 16. Report on expanded pilot for IDA credit buy-downs 17. Report of WHO/EMRO mission for carrying out a performance audit of the second

Pakistan Partnership for Polio Eradication Project: IDA buy down: August 17-28, 2008 18. Progress and Predicaments: Health Status in Pakistan: Draft Discussion: September 16,

2008 19. CR Report on the Emergency Technical Consultation on Polio Eradication in Pakistan:

June 24-25, 2008-10-14 20. Pakistan: Demography and Health Survey: 2006-07 21. Pakistan Social and Living Standards Measurement Survey (2005-06) 22. Pakistan Social and Living Standards Measurement Survey (2004-05) 23. Wild Poliovirus Weekly update: WHO: September 24, 2008 24. Eradication versus control for poliomyelitis: an economic analysis 25. IEG ICR review of the Pakistan-Partnership for Polio Eradication

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