Document of

The World Bank

Report No: NCO00001902

NOTE ON CANCELLED OPERATION

ON A

LOAN

IN THE AMOUNT OF US$491 MILLION

TO THE

UNITED MEXICAN STATES

FOR AN

INFLUENZA PREVENTION AND CONTROL PROJECT

November 22, 2011

Human Development Sector Management Unit

Mexico and Colombia Country Management Unit

Latin America and the Caribbean Region

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CURRENCY EQUIVALENTS

(Exchange Rate Effective June 1, 2011)

Currency Unit = MXN

1 MXN = US$0.086

US$ 1.00 = MXN 11.668

FISCAL YEAR

January 1 – December 31

ABBREVIATIONS AND ACRONYMS

ACC Applicable anticorruption clauses

AHIF Avian and Human Influenza Facility Grant for the Influenza A/H1N1

Prevention

AIDS Acquired Immune Deficiency Syndrome

BIRMEX Laboratories of Biologics and Reagents of Mexico- Laboratorios de

Biológicos y Reactivos de México

BP Bank Procedure

CENAVECE National Center for Epidemiological Surveillance and Disease Control -

Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades

CENSIA National Center for Child and Adolescent Health - Centro Nacional para la

Salud de la Infancia y la Adolescencia

CNPHI Canadian Network for Public Health Intelligence

CPS Country Partnership Strategy

DGAE Adjunct Directorate of Epidemiology - Dirección General Adjunta de

Epidemiología

DGAPP Adjunct Directorate of Preventative Programs - Dirección General Adjunta de

Programas Preventivos

FY

GAC

GDP

GoM

GPAI

HDI

HIV

OP

PDO

RPMs

SARS

SHCP

SINAVE

SISVEFLU

SPSH

SS

UPPH

Fiscal Year

Governance and Anti-corruption

Gross Domestic Product

Government of Mexico

Global Program for Avian and Human Influenza Preparedness

Human Development Index

Human Immunodeficiency Virus

Operational Policy

Project Development Objective

Regional Procurement Managers

Severe Acute Respiratory Syndrome

Federal Secretariat of Finance - Secretaría de Hacienda y Crédito Público

National System for Epidemiological Surveillance - Sistema Nacional de

Vigilancia Epidemiológica

Epidemiological Surveillance System for Influenza-Sistema de Vigilancia

Epidemiológica de Influenza

Social Protection System in Health-Sistema de Protección Social en Salud,

SPSS

Federal Secretariat of Health - Secretaría de Salud

Under-Secretariat for Prevention and Promotion in Health- Subsecretaría de

Prevención y Promoción

ii

Vice President: Pamela Cox

Country Director: Gloria Grandolini

Sector Manager: Joana Godinho

Project Team Leader: Christoph Kurowski

NCO Team Leader: Claudia Macias

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UNITED MEXICAN STATES

Influenza Prevention and Control Project

CONTENTS

Data Sheet

A. Basic Information ................................................................................. Error! Bookmark not defined. B. Key Dates .............................................................................................. Error! Bookmark not defined.

C. Ratings Summary ................................................................................. Error! Bookmark not defined. D. Sector and Theme Codes ....................................................................... Error! Bookmark not defined. E. Bank Staff .............................................................................................. Error! Bookmark not defined.

F. Ratings of Project Performance in ISRs (if available).......................... Error! Bookmark not defined.

1. Context, Project Development Objectives, and Design ...................................................................... 1

2. Post-Approval Experience and Reasons for Cancellation ................................................................... 8 3. Assessment of Bank Performance ..................................................................................................... 12 4. Assessment of Borrower Performance .............................................................................................. 14

5. Lessons Learned ................................................................................................................................ 15

Annex 1. Bank Lending and Implementation Support/Supervision Processes ......................................... 17 Annex 2. List of Supporting Documents .................................................................................................. 19 MAP IBRD 33447R .................................................................................................................................. 20

1

1. Context, Project Development Objectives, and Design

1. Country Background. As Mexico neared the end of the annual influenza season in early

2009, health officials had noticed an unusual increase in patients presenting flu-like symptoms.

Testing revealed that a new strain of influenza A/H1N1 was responsible for the infections. By

mid-June, the spread of A/H1N1 around the world had led the WHO to declare a Phase 6

Pandemic Alert, which according to that agency was an indication that “a global pandemic is

underway” and that “actions should shift from preparedness to response”. By the time the

negotiations of a proposed loan in the amount of US$491 million to the United Mexican States

(the Borrower) in support of the Influenza Prevention and Control Project (the Project) were

being concluded in September 2009, there had been more than 52,000 laboratorial-confirmed

cases causing the death of more than 350 people in Mexico. Health care providers had reported

more than 175,000 clinical cases, according to which the Bank estimated that the total number of

infections exceeded 347,000.

2. At the same time, in 2009, Mexico was expected to experience its sharpest economic

contraction since the 1994-95 peso crisis: the Secretaría de Hacienda y Crédito Público (SHCP,

the Ministry of Finance and Public Credit) had in August projected that GDP would decline 6.8

percent, a sharp drop from the moderate growth of the previous four years. The cause of this

contraction was the global financial crisis that had precipitated a sharp drop in the demand for

Mexico’s exports. In addition, the global financial crisis had affected Mexico’s economy

through lower oil prices, capital flight (and consequent credit contraction) and a decline in

remittances (with resultant reduction in consumer demand). The economic contraction had

contributed to a large projected budget deficit for 2009, at the time projected to reach 2.1 percent

of GDP that circumscribed the Government’s ability to direct resources toward its response to

the A/H1N1 influenza outbreak that was affecting its population.

3. Reciprocally, the A/H1N1 epidemic was further weakening fiscal and macroeconomic

prospects. Direct public expenditures on the response to the first wave of A/H1N1 were

estimated by the Government to have exceeded US$600 million, and the macroeconomic impact

of the epidemic was estimated by the Government and the Bank to range from 0.3 to 0.8 percent

of GDP. The A/H1N1 epidemic was affecting the economy through lost revenues due to reduced

demand from social distancing, particularly in the retail sector, as well as through a severe drop

in tourism revenue. Further, the economic downturn was expected to result in an increase in

poverty, thereby creating conditions that could facilitate the spread of the A/H1N1 virus.

4. Adding to the Government’s concerns was the fact that epidemiologists, based on the

patterns of past influenza pandemics, expected that a second wave of A/H1N1 would affect

Mexico during the winter, and that by then the virus could have mutated into a more virulent

strain.

5. At the same time, the A/H1N1 epidemic and the economic contraction threatened human

development and specifically health outcomes in Mexico, many of which were already

incommensurate with the country’s income level. While Mexico’s overall Human Development

Index (HDI) was close to that of countries with similar levels of GDP per capita, some outcomes

were closer to those much poorer countries. Infant mortality, at 28 per 1000 live births, was

2

above the expected level for a country with Mexico’s per capita GDP. Further, human

development outcomes varied widely across Mexico’s federal entities (31 states and the Federal

District). For purposes of illustration, Mexico’s HDI ranked 52nd

among countries in the world,

while that of the State of Chiapas, would, if it were a country, result in a rank of 107th

in the

world.

6. Sector Background. Mexico’s health system was not ideally positioned to confront the

twin challenges of the epidemic and the recession. The Government was spending about 2.9

percent of GDP in health, well below the regional average of 3.6 percent for countries in the

Latin American and Caribbean region. Partly as a consequence of this, more than half of all

health expenditures were out-of-pocket. Social health insurance programs and national health

services operate in parallel with decentralized state-level health service provision; this

fragmentation was problematic because it constrained effective planning and sector-wide

coordination.

7. Conceived at the outset of the current administration, the Government’s National

Epidemiological Surveillance System (SINAVE) Plan 2007-2012 and its National Health Sector

Program 2007-2012, together focused, inter alia, on improving the epidemiological surveillance

and strengthening the response capacity of health services. The Government’s five-year plan for

SINAVE and the health sector emphasized the need for strengthening preparedness for disease

epidemics. The Bank was already supporting several pillars of the Government’s National

Health Sector Program through several ongoing and proposed operations (see Rationale for Bank

Involvement, below), but not directly in the area of health surveillance. The proposed Project

would complement and expand upon the Bank’s support to Mexico’s health sector, by supporting

the country in addressing the A/H1N1 epidemic and, in parallel, improving health surveillance.

8. Rationale for Bank Involvement. The rationale for the Bank’s involvement was strong.

At the Bank and IMF Spring Meetings in April 2009, Mexico’s Minister of Finance and Public

Credit and the Bank’s President agreed upon a package of assistance to help close the gap

between the costs of controlling the first wave of influenza A/H1N1, improving detection,

expanding its response capacity and the budget resources available that included the

reprogramming of an ongoing operation, preparing a new loan to support the Government’s

efforts, and securing grant funding under the Avian and Human Influenza Facility (AHIF). The

Bank responded initially by reprogramming US$25.7 million from the then ongoing Third Basic

Health Care Project to reimburse expenditures on laboratory equipment, laboratory supplies,

anti-viral medicines and medical supplies.1 Assistance under the AHIF was to support state

health systems in promoting preventive behaviors. The Project was expected to supplement

these resources.

1 In April 2009, the Bank agreed to restructure Third Basic Health Care Project, Project ID P066321 to allow the

then remaining loan funds (approximately US$25 million remaining in the Designated Account) as an immediate

financial assistance to purchase vaccines, pharmaceuticals and medical equipment and supplies. The second order

project restructuring was agreed and the Federal Ministry of Health presented the respective procurement plan that

would require higher management approval since the procurement involved retroactive financing of goods

purchased under direct contracting. In the end, the Bank did not approve procurement by direct contracting, and the

Bank worked with the Federal Ministry of Health to identify expenditures under the Project that would be eligible

for financing under the Loan, which had been fully disbursed by its Closing Date. Assistance under the emergency

restructuring of this project was also not utilized for the A/H1N1 response.

3

9. At the same time, the Bank had a long history of providing assistance to Mexico’s health

sector. Starting with the First Basic Health Care Project in the late 1980s, the Bank had

supported expanding the reach and improving the quality of health services, ensuring the

financial sustainability of social health insurance programs, expanding non-contributory health

insurance coverage of the poor, and developing institutional capacity in the health sector.

Following the implementation of three successive health projects, the Bank was, at the time,

working with the Government on the preparation of a project in support of the Government’s

non-contributory health insurance program, Seguro Popular, that provides universal health

coverage to Mexico’s population. The Bank had also engaged in extensive analytical work and

advisory services on health care issues in tandem with implementation support and project

preparation.

10. The Bank also had extensive experience in supporting Governments throughout the world

in preparing for and responding to influenza epidemics, in controlling infectious disease, and in

strengthening national epidemiological surveillance systems. This experience included that

acquired through the Global Program on Avian Influenza, the response to the SARS epidemic

and HIV/AIDS, especially in Latin America, and strengthening national epidemiological

surveillance systems also in Latin America.

11. The flexible design of the World Bank Group’s Country Partnership Strategy (CPS)

2008-2013 discussed by the Bank’s Board on April 8, 2008 facilitated a timely and effective

response to Mexico’s changing development needs in the face of the deteriorating global

financial and economic environment. The Project was consistent with the objectives and

principles of engagement of the CPS that included flexibility, fast response and selectivity in

addressing developing challenges. The Project, processed as an emergency response in

accordance with OP/BP 8.00, demonstrated the Bank’s flexibility and fast response capacity to

Mexico’s changing financing and development needs, and was closely aligned with two of the

development challenges identified in the CPS, namely sustainable growth through investment in

human capital and strengthening institutions.

12. The Project was consistent with OP/BP 8.00 since it would provide resources that the

Government needed to preserve human capital, restore economic activity, and prepare and

mitigate the effects of potential future health emergencies. By strengthening the Government’s

ability to monitor and control influenza epidemics, the Project was expected to support these

eligible objectives defined in OP 8.00. Alternative sources of financing had been considered,

including from the Bank’s Global Program for Avian and Human Influenza Preparedness

(GPAI), but given the magnitude of the resources that Mexico would require, the Bank opted for

preparing a stand-alone project that would be considered directly by its Board of Directors.

13. Development Objectives. The development objective of the Project was to strengthen the

capacity of the Mexican health system to monitor the spread of influenza viruses and to control

epidemic waves. The capacity to monitor the spread of influenza viruses rested on the

robustness of the SINAVE, the improvement of which entailed developing SINAVE’s

information technology system, upgrading Mexico’s national reference laboratory, training staff,

and strengthening data analysis, research and evidence-based public health decision making.

4

The capacity to control influenza epidemic waves depended on the infrastructure to effectively

distribute medicines, vaccines and medical supplies and the strategic reserves thereof.

Project Components. The Project comprised two components, as described below.

14. Component I: Strengthening the capacity to monitor the spread of influenza viruses

(US$64 million). The objective of this first component was to strengthen the capacity of the

Mexican health system to monitor influenza activity. The Project was expected to accomplish

this by: (a) strengthening the management and technical quality of the SINAVE through

developing SINAVE’s information technology system and upgrading the Borrower’s national

reference laboratory for epidemiological surveillance, including construction and equipping; (b)

ensuring the quality, relevance and timeliness of epidemiologic information through

organizational reforms in the Secretaría de Salud (the Borrower’s Federal Secretariat of Health,

SS) including the establishment of a central analysis unit and mobile units, setting up

epidemiological research programs to assess the relevance and deepen the understanding of

information collected, and certifying SINAVE according to international standards; and (c)

improving SINAVE’s human resource capacity through training its staff in new processes,

management schemes and bio-security in laboratories, applying new information technologies

and platforms, carrying out knowledge events promoting a culture of analysis, research and

dissemination of information for policy-making.

15. Component II: Strengthening the capacity to control epidemic waves of influenza

viruses (US$426 million). The objective of this second component was to strengthen the

capacity of the Mexican health system to control influenza epidemic waves. The Project

expected to accomplish this by strengthening the infrastructure to effectively distribute

medicines, vaccines and medical supplies, replenishing and expanding the country’s strategic

reserves thereof. In particular, the Government planned to vaccinate more than 20 million

Mexicans against A/H1N1 in the winter of 2009, as soon as the vaccine became available. The

proposed loan would reimburse the Government for the expenditures it had incurred during the

first wave of influenza A/H1N1 for the purchase of medicines, vaccines and medical supplies on

or after April 23, 2009, once it met the eligibility criteria under each of the Project components.

16. Costs and Funding. The Project cost by Component is presented in the Table below.

Project Cost by Component Local US$ million Loan US$ million Total US$ million

I. Strengthening the capacity to

detect an influenza outbreak

63.700 0.3 64.000

II. Strengthening the capacity

to respond to an epidemic

36.775 389.000 425.775

Total Baseline Cost 100.475 389.300 489.775

Front-end Fee 1.225 1.225

Total Loan amount 491.000

Price Contingencies 11.000 36.000 47.000

Interest during Construction 0.800 - 0.800

Total Financing Required 112.275 426.525 538.800

5

17. Implementation Arrangements. The Project would have been coordinated and

implemented using organizational structures and staff of the Federal Secretariat of Health (SS),

specifically through organizational units under the Under-Secretariat for Prevention and

Promotion in Health (UPPH), including the National Center for Epidemiological Surveillance

and Disease Control (CENAVECE), the National Center for Child and Adolescent Health

(CENSIA) and the Directorate of Operations. Within CENAVECE, the Adjunct Directorate for

Epidemiology (DGAE) and the Adjunct Directorate for Preventive Programs (DGAPP) would

have had important roles. The DGAE would have served as the Project Coordination Unit and

have led the implementation of the Project’s Component I. In close collaboration with DGAE,

DGAPP and CENSIA would have led the implementation of the Project’s Component II.

Although not formally incorporated as an implementing agency under the Project, BIRMEX, a

financially autonomous public limited company registered in Mexico, was the only agency

responsible for purchasing and delivering A/H1N1 vaccines, which were at the time in limited

supply, for the Government.2

18. The Directorate of Operations was to have supported DGAE, DGAPP and CENSIA in all

fiduciary tasks, including preparing and updating the Project’s Operational Manual and

procurement plans, carrying out the procurement of goods, works and services, preparing ex-post

procurement reviews, non-audited Interim Financial Reports, Project Financial Statements and

Statements of Expenditures, Records and Summary Sheets and preparing for Project audits. On

fiduciary matters, all units and in particular the Directorate of Operations would have been

supported by Nacional Financiera, a public financial agent with ample experience in supporting

the implementation of Bank-financed projects.

19. The Project was to have been implemented at the national level, including the central

acquisition of all works, goods and services. Yet, the impact of the Project was to depend on

complementary activities carried out by federal entities. For this, DGAE was to ensure that

project activities were incorporated into Cooperation Agreements that were routinely entered

into by the Federal Secretariat of Health with each of the federal entities. These Cooperation

Agreements were to include, inter alia, the federal entities’ obligations to carry out

complementary activities, for the distribution of medicines and vaccines and to comply with the

Project’s safeguard requirements.

20. Eligible expenditures financed by the Federal Secretariat of Health with resources from

the National Budget were to be reimbursed by the Bank on the basis of supporting documents.

Eligible expenditures paid by the Government between April 23, 2009 (the date the new

influenza strain had been identified) and the date of loan signing could have been reimbursed up

to an amount not exceeding 40 percent of the loan amount.

21. Risk Analysis. The Emergency Project Paper, in its section on Project Risks and

Mitigating Measures, identified four key risks (although it provided no risk ratings), and

corresponding mitigating measures, as follows:

2 The contracts with BIRMEX provided the Government not only with access to large amounts of influenza vaccines

despite the global shortage, but also provided these vaccines at prices below those offered by competitors and the

Pan American Health Organization

6

i. Mexico could face challenges in preparing for a second wave of the A/H1N1 influenza

epidemic in particular, its response capacity could be insufficient to control a second

wave. Global production of the A/H1N1 vaccine (when it was developed) was expected

to be insufficient to meet global demand in the short-term, the national vaccination

program might not have the capacity to vaccinate large groups of the population, and

Mexico’s stock of anti-viral drugs would likely be insufficient to respond to a second

wave with an attack rate of more than one percent. The Government was taking steps to

mitigate this risk, including: the strategic reserve of vaccines was being stocked to

inoculate more than 20 million people; Mexico in partnership with a leading

pharmaceutical company was developing domestic vaccine production capacity that

would start in the Spring of 2011 and through that partnership, had preferential access to

20 million doses of an A/H1N1 vaccine as soon as they became available; and the

Government with financing under the Loan would invest heavily in strengthening the

country’s cold chain as the most likely bottleneck for further scaling up of its vaccination

program (that in any given year had the capacity to vaccinate close to 20 million against

seasonal influenza).

ii. The A/H1N1 vaccine that was being developed could be expected to cause adverse health

events more frequently and of more severe nature than anticipated and tolerable. This

risk for a new vaccine was considered to be higher than that of a well-established vaccine

since it would only have been tested in clinical trials with some of the potential target

population. The risk of intolerable side effects would be mitigated by close monitoring

of adverse health event and changes to vaccination protocols, if necessary. Mexico was

considered to have a comprehensive system for the surveillance of vaccine associated

events, and staff of health facilities participating in vaccination campaigns had been

trained to notify adverse events and investigate causalities.

iii. Implementation capacity constraints could hamper the timely execution of Project

activities and investment in information technology might not be sustainable. This

encompassed three main risks that had been foreseen: that human resource capacity at

the UPPH were already taxed with responding to the epidemic, and would likely have

limited time and resources to manage the Project, that large investments in information

technology required corresponding investments in maintenance capacity and also that

these information technology investments would call for a challenging cultural shift

toward real-time analysis and effective dissemination of epidemiological intelligence.

These risks were considered to be mitigated by the planned upgrading and staffing of the

DGAE into a General Directorate, the hiring of fiduciary specialists into the Directorate

of Operations together with possible support from other units, the probable out-sourcing

of information technology support services, including the possibility of leasing rather

than purchasing hardware, and significant training of SINAVE staff to support the

cultural change.

iv. Reductions in fiscal space expected as a consequence of the economic crisis could reduce

the Government’s budget for the Project’s activities. The severe economic downturn was

expected to produce a sharp contraction in fiscal space and force difficult trade-offs. The

Government had taken steps to mitigate this risk: the President publicly committed

7

himself to some of the Project’s objectives and intervened personally to reduce planned

budget cuts to the Federal Secretariat of Health’s’ budget, the Federal Secretariat of

Finance (SHCP) and the Federal Secretariat of Health had begun talks about additional

budgetary allocations for A/H1N1 preparedness and response in 2009, and the

Government considered drawing resources from the Trust Fund for Catastrophic Health

Expenditures.

22. In addition, the Project’s financial management residual risk was considered to be

Modest, with the only financial management risk rated Substantial being that related to Entity

risk; while the Federal Secretariat of Health had implemented several Bank-financed projects,

the Project’s Project Coordination Unit had not. The Project’s Procurement risk was considered

to be Substantial, based mostly on the risk posed by the lack of experience of staff in the

Directorate of Operations in carrying out procurement processes in accordance with Bank

Guidelines, compounded by the emergency nature of the Project.

23. Quality at Entry. The Project responded to the high-level request by the Government

and the agreement at the highest level in the Bank to support Mexico in addressing the A/H1N1

influenza epidemic (see Rationale for Bank Involvement). This high-level agreement put

pressure on both the Government and the Bank’s teams to deliver the agreed assistance in view

of the visibility it had generated. The request came less than one and a half months from the

outset of the new strain of the influenza in Mexico. Project preparation benefitted from an in-

depth knowledge of Mexico’s health sector developed over the course of over twenty years of

financial and technical support and a strong policy dialogue with Government authorities on

sector-related strategy and issues. As a result of this, the activities to be supported under the

Project would have been reinforced by related Bank operations, ongoing and under preparation.

They would not be carried out in a vacuum, but rather as part of a comprehensive plan to

strengthen the capacity of Mexico’s heath system to respond to the immediate A/H1N1 challenge

that the system faced, and in the process to leave in place a stronger capacity of monitoring and

controlling epidemic waves. The Project was also prepared within a package of emergency

support that included in addition the restructuring of an ongoing project3 and the securing of

grant funding under the Avian and Human Influenza Facility.

24. The Project was prepared expeditiously—in less than two months--under OP/BP 8.00 and

included emergency recovery and activities aimed at preparedness and mitigation, through

improved surveillance. Loan negotiations began in July 2009, but continued on until October

2009. This delay in concluding negotiations reflected the lengthy discussions between the SHCP

and the Federal Secretariat of Health regarding the amount of resources the latter could absorb

and its need for additional budgetary allocations in order to implement the Project, especially

since external financing is normally not incremental to an executing agency’s budget in Mexico.

Before loan negotiations, the Bank had anticipated that the non-incremental financing and high

transaction costs (i.e., complying with Bank fiduciary and other requirements) could lead to

incentive issues with the Federal Secretariat of Health and had already explored the possibilities

for providing assistance through alternative lending instruments, under the then recently Board-

approved changes to the Avian and Human Influenza Facility (AHIF) financing facility,

including the Development Policy Lending with Catastrophe Deferred Drawdown Option (CAT

3 Third Basic Health Care Project, Project ID No. P066321

8

DDO). However, after considerable internal discussion, the team was advised to follow a

Specific Investment Loan option, in accordance with OP/BP 8.00, and agreed to include

financing of additional staff within the Federal Secretariat of Health to coordinate activities and

ensure compliance with the Bank’s fiduciary requirements, which the Federal Secretariat of

Health accepted in end-2009.

25. The Catastrophe Deferred Draw Down option was not considered because financing

available through this scheme was more in the realm of longer term recovery and reconstruction

needs, whereas the Project was designed to cover a shorter term emergency program for

containing the epidemic (with some longer term surveillance activities) and not for economic

recovery.

2. Post-Approval Experience and Reasons for Cancellation

26. The US$491 million Loan for the Project was approved by the Bank’s Board on

November 24, 2009 and signed on November 30, 2009. After three extensions of the original

February 26, 2010 effectiveness deadline, the Loan lapsed without becoming effective on

February 28, 2011.4 The factors that, combined, and to a greater or lesser extent led to this

outcome included: (i) the lack of incentive for Federal Secretariat of Health to utilize the loan in

view of its lack of incremental financing, (ii) problems in utilizing retroactive finance according

to Bank policies, (iii) a lack of consensus for moving forward with a loan restructuring, and (iv)

a milder than expected course of the A/H1N1 epidemic that translated into reduced budgetary

allocations to the Federal Secretariat of Health. Despite the problems with the Bank’s loan, the

Federal Secretariat of Health made in the period following approval until now significant

progress towards the Project’s objectives, with continued technical and advisory support from

the Bank.

27. Lack of Incentive to Utilize the Loan. Mexico’s budget reality is such that external

finance is generally not incremental to the executing agencies. Therefore, the proceeds of the

Bank’s loan were to accrue to the country’s budget through SHCP that had pre-financed

expenditures for the purchase of the anti-virals and vaccines, and for the expenditures that

Federal Secretariat of Health incurred and would incur for the implementation of activities under

Component I under its normal budget allocation. However, the external financing had important

implications to the Federal Secretariat of Health in terms of its need to comply with the Project’s

fiduciary requirements even though the financing associated with the Project would produce no

incrementality to its budget. Although an important counter-balance to this was the technical

implementation support that the Federal Secretariat of Health was to receive from the Bank

under the Project, overall there was little incentive of the Federal Secretariat of Health to

implement the Project with Bank financing. Negotiations were affected by the lengthy

discussions between SHCP and Federal Secretariat of Health as to the overall project cost, with

Federal Secretariat of Health requesting that at least some of the external finance be provided in

the form of incremental finance to the agency. For the same reason, this lack of incentive to the

SS later affected the decision to move ahead with a loan restructuring.

4 The three extensions were as follows: a six-month extension until August 31, 2010, followed by a three-month

extension until November 30, 2010, followed by a final three-month extension until February 28, 2011.

9

28. Problems in Utilizing Retroactive Finance. In line with OP/BP 8.00, the Loan had

provisions to reimburse the Government for up to US$196.4 million (or 40 percent of the loan

amount) for eligible expenditures incurred since the outbreak of the new A/H1N1 influenza virus

on April 23, 2009 under expedited Bank procurement procedures. Nevertheless, despite the

emergency, the Government was not able to obtain retroactive financing of the goods

(particularly vaccines and anti-viral medicines) that were procured and delivered prior to the

signing of the Loan Agreement. Loan signing only took place about seven months after the

outbreak of A/H1N1, and by the time the Government had incurred already a significant amount

of retroactive expenditures. The considerable delays towards effectiveness, caused mostly by the

need for internal clearances described below, only made the problems in utilizing retroactive

finance more important in the final outcome.

29. The Task Team requested internal clearances for the direct contracting for the purchase

of the anti-virals and the A/H1N1 influenza and seasonal influenza vaccines in the amount of

approximately US$150 million. The direct contracting for the purchase of anti-virals was

authorized but would have required a restructuring to include the supplier, BIRMEX, a

financially autonomous public limited company in Mexico as an implementing agency under the

Project (and not contracted as an independent provider). Authorization for retroactively

reimbursing amounts for both purchases was subject to the retrofitting of each of the contracts

with primary suppliers with anticorruption clauses as required by the Bank’s anticorruption

guidelines. However, in accordance with Mexico’s legal framework, it was not possible for the

Government to retrofit vaccine and anti-viral medicine contracts to comply with the Bank’s

guidelines. While the Government of Mexico during negotiations had in general concurred to

retrofit the contract with suppliers of anti-viral medicines and A/H1N1 vaccines, upon

consultation with the Federal Secretariat of Health’s Legal Department, the Government

concluded that Bank conditions for retroactive financing could not be reconciled with federal

legislation and regulation. More specifically, any amendment of closed contracts to introduce

additional language (including language consistent with the anti-corruption guidelines) would be

inconsistent with internal regulations.

30. Possible Project Restructuring. With this constraint in utilizing retroactive financing

(that represented such a large amount of the Loan), the Government and the Bank began

discussing the possibility of a project restructuring that would include additional activities aimed

at strengthening Mexico’s efforts to monitor the spread of influenza viruses and controlling

epidemic waves, consistent with the Project’s Development Objectives (PDO). The Bank began

preparing a Level One Restructuring that would respond to the Government’s request to expand

the scope of the Project to capture epidemic response outcomes. The PDOs, as approved focused

the Project merely on capacity. The proposed Restructuring would expand the scope of the

Project’s second objective to respond, not only control, epidemic waves, by introducing a third

project component that would entail: (a) an expansion of the scope of the Project’s Indigenous

People Plan to ensure that indigenous people benefitted from the response; (b) the introduction of

the national Commission of Social Protection in Health as one of the Project’s implementing

agencies; (c) the adoption of the premium of the Popular Health Insurance as a new category of

eligible expenditures to finance the delivery of services during the epidemic (with expenditures

incurred between April 23, 2009 and loan signing to be considered as retroactive finance, subject

10

to the cap of 40 percent of the loan amount); and (d) adjustments to the financial management

and disbursement arrangements to reflect the new arrangements for this new component.

31. As background, the response to the epidemic had been financed by and large through the

Social Protection System in Health (SPSH). From January to October 2009, the SPSH provided

41.5 million consultations for its beneficiaries, 25.9 percent more than were registered in the

same period of the previous year, while affiliating 4.2 million new beneficiaries. Service

delivery, through the use of mobile health units and the establishment of temporary clinics, was

complemented by communications campaigns promoting the use of health services by

individuals with influenza symptoms but discouraging the use of health services for non-urgent

matters. Given the increase in health service delivery and the effect of communication

campaigns during the peak of the epidemic, the Government estimates that at least 30 percent of

consultations provided to beneficiaries of the SPSH’s Popular Health Insurance during 2009 and

the first half of 2010 were related to influenza5. As part of the proposed Restructuring, the

Project’s results and monitoring framework, its institutional arrangements, the Environmental

Action Plan and the Indigenous Peoples Plan would be adjusted to conform to a restructured

project. The proposal for a Project Restructuring never moved forward, in part due to the lack of

incentive to the Federal Secretariat of Health, even though both the Federal Secretariat of

Finance and the Federal Secretariat of Health recognized that it would address the disbursement

issues that had thus far affected the Project and Loan.

32. Milder than expected A/H1N1 Epidemic. The Mexican Congress did not authorize the

proposed 2010 budget for vaccines and medicines, thereby declining to maintain funding that

had become available during the course of the epidemic in 2009. Then, by mid-July 2010,

having caused more than 72,500 laboratory-confirmed infections and the death of more than

1,300 people in Mexico, infection trends of the A/H1N1 virus were confirmed to be on a decline,

which in turn led the SHCP to allocate a significantly smaller budget for project activities to be

carried out in 2010. In August of the same year, the World Health Organization reviewed global

A/H1N1 epidemic trends calling for a shift in focus towards “post-pandemic period” strategies.

The nature of the Project, given this turn-around in the epidemic, shifted from one of emergency

response to one of only strengthening longer-term capacity and ability to respond to future

emergencies. Although the Federal Secretariat of Health remained fully committed to the

Project’s objectives, especially to its Component I that aimed to strengthen Mexico’s

epidemiological surveillance capacity (with or without restructuring), and to a proposed Project

Restructuring, it required incremental budgetary resources from the Bank’s Loan to produce the

expected outcomes. Given the nature of external financing in Mexico, however, the Bank’s

disbursements would not be incremental to the Federal Secretariat of Health’s budget, and the SS

would have to implement the Project with a significantly reduced budget allocation.

33. Progress Towards Project Objectives. Despite the absence of disbursements from the

Bank’s Loan, the Federal Secretariat of Health made significant progress towards the PDOs, as

5 The Popular Health Insurance is a key pillar of Mexico’s Social Protection System in Health serving people

without contributory social security. The Bank is financing the Popular Health Insurance under the Project in

Support to the Social Protection System in Health Loan (Loan 7860-ME)

11

measured by the Project’s Outcome Indicators and Intermediate Outcome Indicators, through

December 31, 2010.6 These results were as follows:

34. The SINAVE performance index7 and the SISVEFLU index8 were indicators selected to

measure progress towards the first PDO, that is: strengthen the capacity of the Mexican health

system to monitor the spread of influenza viruses. The SINAVE performance index improved

from a baseline of 79.8 in December 2008 to 81.5 in December 2010 (against a target of 83.0 by

December 2011). Similarly, the SISVEFLU index improved from a baseline of 49.0 in

December 2008 to 61.0 in December 2010 (against a target of 65.0 by December 2011). These

improvements were made possible through progress towards the achievement of intermediate

outcomes under the Project, including:

Establishment of a central Epidemiological Analysis Unit, improving the quality of

epidemiological information produced by the SINAVE. This Unit developed a number

of knowledge products for policy decision-making including the analysis of case studies

of the first A/H1N1 epidemic wave;

Carrying out an evaluation of the SINAVE information technology platform.

Findings of this evaluation, together with lessons learned from an analysis of the

implementation of the Canadian epidemiological surveillance system guided the

development of a plan to upgrade the SINAVE platform;

Strengthening the capacity of sentinel health facilities and administrative health units

through the provision of equipment and training of staff. By December 31, 2010, 47

percent of state jurisdiction epidemiological offices were fully equipped and connected to

the new information technology platform (against a baseline of zero and a target of 80

percent by June 30, 2012), and 31 percent of sentinel health facilities had their staff

trained in the use of the new information technology platform (against a baseline of zero

and a target of 80 percent by June 30, 2012).

35. Progress towards the Project’s second PDO, that is, to strengthen the capacity of the

Mexican health system to control epidemic waves of influenza, was to be measured by two

6 In part, this is because Bank financing and disbursements in Mexico are not incremental to the implementing

agency. The Federal Secretariat of Health had budgetary allocations approved by SHCP, and would implement the

Project using those allocations. Bank disbursements were to reimburse the Treasury for previously-allocated

amounts. 7 The SINAVE index comprises measures for three of it four sub-systems, including nine different elements, as

follows: (1) the system for the weekly notification of reportable diseases; (2) the sentinel health facility surveillance

system; (3) the surveillance system for acute flaccid paralysis; (4) the surveillance system for acute febrile illness;

(5) the surveillance system for HIV/AIDS; (6) the surveillance system for diabetes; (7) the surveillance system for

neural tube defects; (8) the registry system for malignant neoplasms, and (9) the surveillance system for addictions.

Examples of indicators for these elements include: the percentage of medical centers reporting cases in a timely

manner, the number of consecutive weeks of reporting, the number of notified cases of specific diseases among

children, the percentage of samples drawn according to standards and percentage of probable cases tested in a timely

manner. Data for these indicators is provided by health facilities, sentinel sites and laboratories across the country

and consolidated by the SINAVE at the federal level. 8 The SISVEFLU index comprises measures for the timeliness and quality of sample processing, and the use and the

representativeness of generated information. Specific measures include: timely notification of probable cases,

timely investigation of cases, adequacy of sample collection, timeliness of shipment of samples, concordance of

samples, compliance with case identification goals and follow-up of diagnosed and notified cases. Data for this

index is provided by the national laboratory network and consolidated annually by the federal “Caminando a la

Excelencia” program.

12

outcome indicators: (1) percentage of population vaccinated against influenza A/H1N1, and (2)

number of antiviral treatments stockpiles. The Project was able to exceed the targets for both of

these indicators. By December 2010, 24 percent of the population had been vaccinated against

A/H1N1 (against a baseline of zero and a target of 15 percent by June 30, 2012), and the

Government purchased more than 2.150 million treatments of antiviral medicines to replenish

and expand the country’s strategic reserves (against a baseline stockpile of 1.2 million in October

2009 and a target of 2.150 million by June 30, 2012). This was possible, in part, through efforts

to update equipment necessary for the correct functioning of the cold chain for the proper

distribution of vaccines.

36. The Government, however, postponed the construction of Mexico’s national reference

laboratory, instead allocating limited resources to activities that had an immediate impact on the

control of the A/H1N1 epidemic.

3. Assessment of Bank Performance

Rating: Moderately Satisfactory

37. The Bank’s Performance is rated Moderately Satisfactory. The Project was prepared

expeditiously, within the framework of emergency assistance, in accordance with OP/BP 8.00,

that included the Project, a first order restructuring of the now completed Third Basic Health

Care Project, and a grant, approved by the Avian and Human Influenza Facility that would

ensure the successful production and dissemination of messages on influenza-related behavior

change. The Bank’s team was country-based, very experienced, and had a thorough knowledge

of Mexico’s health sector and a very active and productive engagement and policy dialogue with

sector authorities developed over years of preparation and supervision of new and ongoing

operations, as well as through an active program of non-lending, analytical and advisory

services. It brought this experience and dialogue, together with the Bank’s broader lessons of

experience with emergency responses in health to bear in assisting the Government first in

putting its emergency response in place, and, concurrently, in delivering and integrated package

of assistance, consistent with the CPS and with the Bank’s then ongoing assistance program in

health. The Project’s focus not only on emergency finance of needed inputs, but also on

preparedness and mitigation of future health emergencies through strengthening Mexico’s

epidemiological surveillance capacity was commendable. Realizing that the incentive issues

surrounding non-incremental finance could come to affect the negotiation and implementation of

the Project, the team actively explored the use of alternative instruments that would get around

possible problems.

38. The Bank’s team was persistent in trying to help the Government in getting the Loan

effective and disbursing, and worked closely with the SS through continuous dialogue to support

the activities the agency was carrying out. Despite repeated efforts to find a solution to the

impasse with regard to the financing of retroactive expenditures for vaccines and anti-virals, it

became clear in November 2009 that this would not be possible. The Bank then opted for

working with the Government to prepare a first order Project Restructuring that would allow the

Loan to finance Mexico’s emergency response efforts in an alternative manner. However, with

the A/H1N1 epidemic no longer on the radar screen, and consequently reduced budgetary

13

allocations to the Federal Secretariat of Health (and the non-incremental nature of Bank finance

to executing agencies in Mexico) the processing of the by then fully developed Restructuring

proposal never moved forward.

Bank performance in providing technical assistance during the epidemic outbreak

39. The Bank carried out an assessment of the performance of the Mexican epidemiological

surveillance system (SINAVE), identifying areas in which the Canadian Network for Public

Health Intelligence (CNPHI) could serve as a model to help improve SINAVE’s performance,

and to develop a strategy for developing or adapting technology. The Bank also supported the

GoM through a US$1.7 million Avian and Human Influenza (AHIF) grant, in the development of

a national education communication campaign for influenza prevention and comprehensive risk

communication strategies at the local level. The Bank supported a number of decisions and

actions taken by the GoM that contributed effectively to contain the epidemic.

Bank performance on project processing

40. The Project was processed expeditiously - in less than two months- under OP/BP 8.00.

The Project was consistent with the policy, but emergency purchases under the Project were

treated by the Bank as regular purchases typical of SIL operations. The loan provided for

retroactive financing, up to 40% for goods that had been procured under the Borrower’s

emergency procurement procedures. However, Bank policy on Fraud and Corruption requires

that bidders, suppliers and contractors under Bank-financed contracts include the applicable

anticorruption clauses (ACC). This required the Government to retrofit contracts that had been

executed months earlier, many of them just a few days after the epidemic outbreak started. As

this contravened Mexican legislation, the Government was not able to do so because it

contravened Mexican legislation and internal regulations.

41. As mandated by the Bank procedural guidelines for rapid response to crisis and

emergencies, in emergency situations, procurement actions need to be facilitated through higher

levels of delegation to the Borrower and, within the Bank, through the delegation by RPMs

(Regional Procurement Managers) of higher levels of approval authority to Bank Procurement

Specialists on task teams to allow for the use of direct contracting, shopping, and simpler

procurement methods for the delivery of urgently needed services and goods. However, in the

case of this Project, the procurement delegation prerogative was not in effect due to the loan

amount and the contracts amount that needed to be cleared to allow the Government to access to

retroactive financing.

42. Since the emergency started in April 2009, the Bank had anticipated that the non-

incremental financing and high transaction costs (i.e., complying with Bank fiduciary and other

requirements) could lead to incentive issues with the Federal Secretariat of Health and explored

the possibilities for providing assistance through alternative lending instruments, under the then

recently Board-approved changes to the Avian and Human Influenza Facility (AHIF) financing

facility, including the Development Policy Lending with Catastrophe Deferred Drawdown

Option (CAT DDO). However, after considerable internal discussion, the team was advised to

follow a Specific Investment Loan option, in accordance with OP/BP 8.00. Finally, despite the

14

fact that the Project was prepared in less than two months, the lengthy negotiations (3 months)

affected project processing. The considerable delays towards effectiveness, caused mostly by the

need for internal procurement clearances, made retroactive finance impossible. It also made the

Government to lose interest in the loan.

4. Assessment of Borrower Performance Rating: Moderately Satisfactory

43. The Borrower’s Performance is rated Moderately Satisfactory. The Government’s

response to the A/H1N1 outbreak was swift, as was its request to the Bank for assistance. The

SHCP allocated resources needed to pre-finance needed medicines and vaccines, when they

became available, using their internal procurement procedures, and established arrangements for

purchase of vaccines, which in any event were streamlined given proprietary rights and the

global shortage of A/H1N1 vaccines at the time. The highest level of Government intervened

initially to preclude budget cuts to the Federal Secretariat of Health, despite a severe economic

downturn that had reduced the Government’s fiscal space. This support for sustained budget

allocations fell somewhat, however, once the epidemic lost steam. The Federal Secretariat of

Health, as the main implementing agency, carried out the Project within its allocated budget. In

so doing, it remained fully committed to the Project’s objectives. When it became clear that it

would not be possible to utilize loan resources, either as originally approved or as it could have

been restructured neither the Federal Secretariat of Finance nor the Federal Secretariat of Health

wanted to request the Loan’s cancellation, and the Loan was left to lapse.

Government performance during the epidemic outbreak

44. A number of decisions and actions taken by the GoM contributed to attenuate the

magnitude and the rate of disease spread. Such actions allowed saving valuable time to

understand the virulence and transmission features of the virus and to distribute medical

countermeasures in health care facilities. Although quick and effective action was taken, Mexico

needed to strengthen the epidemiologic surveillance system, including the public health

laboratories and information tools. The project was envisaged as a means to achieving this. Since

the approval of the Project in November, 2009, progress towards achieving project objectives

was considerable. The GoM implemented a number of actions which have strengthened its

capacity to monitor effectively, distribute vaccines, medicines and medical supplies as well as

expanding the country’s strategic reserves of these medical supplies.

Government performance in project processing

45. The Project was affected by the enduring discussions between the Ministry of Finance

(SHCP) and the Federal Ministry of Health throughout the whole project preparation and

processing. Despite the enthusiasm regarding the Project Development Objectives, and

especially to its Component I, there were doubts on the part of the Federal Secretariat of Health

with regard to committing to a Bank loan in the absence of confirmation of additional budgetary

allocations for the Federal Secretariat of Health. The lack of clarity around this issue resulted in

lengthy loan negotiations, which lasted from July to October 2009. During this period, the

discussions were mainly centered on the amount of resources that the Federal Secretariat of

15

Health could absorb and its need for additional budgetary allocations to implement the project.

The discussions were further complicated in November 2009, shortly after the project was

approved, when it became clear that that financing of retroactive expenditures for vaccines and

anti-virals would not be possible. In January 2010 when the Mexican Congress refused to

maintain funding for vaccines and medicines that had become available during the course of the

epidemic in 2009, the Government interest in the project decreased significantly. This complex

process explains the three project effectiveness extensions. Finally, following the decline in

infection rates confirmed in mid-July 2010, the Government allowed the third deadline to lapse

on February 28, 2011.

46. The Government was not willing to proceed with the proposed restructuring, although it

could have provided a straightforward manner of disbursing retroactive finance against an easy

to disburse category of expenditures: eligible federal social contributions to the premium of the

Popular Health Insurance to cover the costs of medical services provided during the influenza

epidemic. While there may not have been any incentive for the Federal Secretariat of Health in

the restructuring, it would have provided an alternative for disbursement to the Government that

was most definitely within its program of emergency response to the A/H1N1 epidemic. But, a

restructuring along these lines would have required bringing another implementing agency on

board, and, by that time the epidemic had subsided and, more importantly, the Bank’s then

recently approved loan for the Project in Support of the Social Protection System in Health

(Loan 7860-ME) had become effective and begun disbursing, thereby providing finance for the

premiums of the Popular Health Insurance (Seguro Popular).

5. Lessons Learned

47. The Project, its design and implementation experience offer a couple of lessons that are

relevant to the design of Bank-financed emergency operations, especially those related to

epidemics.

48. Non-incremental financing incentives. In Mexico, external financing is generally not

incremental for sector agencies. This has important implications for executing agencies and their

willingness to comply with the often-extensive requirements of Bank-financed projects.

Although the strong technical implementation support that those agencies receive under Bank-

financed projects is welcome, the Bank should reassess the value added of a non-additional loan

in middle income countries such as Mexico, which nevertheless comes with Bank fiduciary and

safeguard requirements on the sectors.

49. GAC policy and its application under emergency situations. Although GAC measures

aim to limit exposure to fraud and corruption risks and manage reputational risks of the Bank and

the Borrower, these limit the flexibility of quickly prepared and disbursed operations. There is

room for improvement in the way the Bank engages with countries on GAC issues in general,

but particularly in emergency situations.

50. Consistency of emergency policies (OP/BP 8.00) with other fiduciary policies. Even

though OP/BP 8.0 operational guiding principles have been developed bearing in mind the need

to respond with speed, simplicity and flexibility in emergency situations, the policy is not fully

16

aligned with other fiduciary policies and guidelines, such as GAC and procurement. Therefore,

policies may benefit from reassessment in terms of their compatibility; and task teams will

benefit from more explicit guidance on the application of emergency policies, especially when

dealing with health emergencies.

51. Efficacy of the emergency instrument in health emergencies. In public health

emergencies it is difficult to predict the course of the emergency or the damage caused in terms

of human lives and health. Other instruments, such as a DPL or a CAT-DDO, may provide a

better option for responding to client needs in view of the fiduciary requirements related to the

emergency purchases.

52. Different Nature of Emergencies requires different responses. The Bank supports

different borrowers in responding to very different types of emergencies under OP/BP 8.00. The

unique element of this Project was the lack of information of the A/H1N1 Influenza, followed by

the lack of predictability of the eventual outcome of the epidemic. As compared to emergencies

relating to natural disasters that typically consist of more predictable and quantifiable damages

and losses, the emergency supported by the Project was a dynamic one. There was an outbreak of

a previously unknown virus that spread rapidly, and the World Health Organization had declared

a Phase 6 Pandemic Alert, indicating that a global pandemic was underway. Expectations were

that Mexico would experience a second wave of A/H1N1 in the winter, and that by then the virus

would have mutated into a more virulent strain.

53. Implications for the Bank in responding to public health emergencies. There are a

number of aspects that the Bank needs to consider when responding to public health

emergencies. First, the preparation of pandemic-related operations requires even greater urgency

in response, since the emergency is ongoing and possibly expanding exponentially. Second, the

preparation of these operations faces much greater uncertainty than that of other emergency

responses. Finally, since there is greater uncertainty of the emergency’s outcome, the Project

and the achievement of its PDOs face greater risks, especially those related to the longer-term

preparedness and mitigation. In the case of this Project, when the infection trends of the

A/H1N1 Influenza were, thankfully, confirmed to be on a decline, activities for improved

epidemiological surveillance continued, but with less budgetary support. The difficulty in

finding an easy solution also would seem to imply that these operations pose a higher

reputational risk to the Bank.

17

ANNEXES

Annex 1. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/Specialty

Lending (from Task Team in Emergency Project Paper Data Sheet)

Christoph Kurowski Senior Health Specialist LCSHD Task Team Leader

Claudia Macias

Senior Operations Officer LCSHH NCO Task Team Leader

Maria E. Castro-Munoz

Senior Social Development

SpecialistConsultant

LCSSO

Marta Elena Molares-

Halberg,

Lead Counsel LEGLA

Francis V. Fragano

Senior Environmental

Specialist

LCSDE

Manuel Antonio Vargas

Madrigal

Senior Financial

Management Specialist

LCSFM

Dmitri Gourfinkel,

Financial Management

Analyst

LCSFM

Snezana B. Mitrovic, Lead Procurement Specialist LCSPT

Jose M. Martinez

Senior Procurement

Specialist

LCSPT

Jean-Jacques Verdeaux

Senior Procurement

Specialist

LCSPT

Tomas Socias

Senior Procurement

Specialist

LCSPT

Gabriel Penaloza Procurement Analyst LCSPT

Silvia Moran-Porche Procurement Assistant LCSPT

Judith Marcano Williams Program Assistant LCSHD

Manuela Villar Uribe Consultant LCSHD

Christina Novinskey Consultant LCSHD

Dorothy Kronick Consultant LCSHD

Abelardo Octavio Cerecedo Consultant LCSHD

18

(c) Staff Time and Cost (from SAP) [all fields are pre-populated by the system]

Stage of Project Cycle

Staff Time and Cost (Bank Budget Only)

No. of staff weeks US$ thousands

(incl. travel and consultants costs)

and consultants) Lending (by FY)

FY09 5.38 15,419.82

FY10 31.21 103,834.75

TOTAL 36.59 119,254.57

Supervision/NCO (by FY)

FY10 16.54 84,629.92

FY11 23.32 68,004.19

TOTAL 39.86 152,634.11

Supervision (from Task Team Members in all archived ISRs, if available)

Christoph Kurowski Senior Health Specialist LCSHD Task Team Leader

Claudia Macias Senior Operations Officer LCSHH NCO Task Team Leader

Snezana B. Mitrovic Lead Procurement Specialist LCSPT

Tomas Socias

Senior Procurement

Specialist

LCSPT

Jean-Jacques Verdeaux

Senior Procurement

Specialist

LCSPT

Gabriel Penaloza Procurement Analyst LCSPT

Silvia Moran-Porche Procurement Assistant LCSPT

Dmitri Gourfinkel

Financial Management

Analyst

LCSFM

Manuela Villar Uribe Consultant LCSHD

Ietza Bojorquez Consultant LCSHD

Marcos Gonzalez-Marron Consultant LCSHD

Suzana Nagele de Campos

Abbott

Consultant ECSHD

Maria E. Castro-Munoz Consultant LCSSO

19

Annex 2. List of Supporting Documents

1. Project Concept Note, June 17,2009]

2. Emergency Project Paper, Report No. 49367-MX, November 4, 2009

3. Implementation Status Reports, Numbers 1-3

4. OPCS Case Recommendation and Review Report

20

MAP IBRD 33447R