Document of The World Bank Report No: ICR00002781 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H3610 TF-56832 TF-58146) ON GRANTS: IDA-H361-KH IN THE AMOUNT OF SDR 3.8 MILLION (US$ 6 MILLION EQUIVALENT) (March 24, 2008) PHRD-TF056832 IN THE AMOUNT OF US$ 3 MILLION (May 8, 2008) AHI FACILITY-TF058146 IN THE AMOUNT OF US$ 2 MILLION (May 8, 2008) TO THE KINGDOM OF CAMBODIA FOR A AVIAN AND HUMAN INFLUENZA CONTROL AND PREPAREDNESS EMERGENCY PROJECT UNDER THE FRAMEWORK OF THE GLOBAL PROGRAM FOR AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (GPAI) October 27, 2014 Agriculture Global Practice East Asia and Pacific Region CAMBODIA – GOVERNMENT FISCAL YEAR January 1 – December 31 CURRENCY EQUIVALENTS (Exchange Rate Effective as of August 15, 2014) Currency Unit = Cambodian Riel (KHR) 1 Cambodian Riel = US$0.00025 US$1.00 = SDR0.65 ABBREVIATIONS AND ACRONYMS AHI Avian and Human Influenza AHICPEP Avian and Human Influenza Control and Preparedness Emergency Project AHIF Avian and Human Influenza Facility AI Avian Influenza AIDS Acquired Immuno-Deficiency Syndrome APL Adaptable Program Loan ARI Acute Respiratory Infection CAMEWAR Cambodia Early Warning System CBDRM Community Based Disaster Risk Reduction Programs DAHP Department of Animal Health and Production DM Disaster Management EMIS Emergency Management Information System EMP Environmental Management Plan EU European Union FAO Food and Agriculture Organization FM Financial Management GDP Gross Domestic Product GGF Good Governance Framework GPAI Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response HSSP2 Second Health Sector Support Program HIV Human Immuno-Deficiency Virus HPAI Highly Pathogenic Avian Influenza H5N1 One Strain of the HPAI virus IA/IAs Implementing Agency/Implementing Agencies IBRD International Bank for Reconstruction and Development IDA International Development Association IEC Information, Education and Communication IFR Interim Financial Report IHR International Health Regulation ILI Influenza-Like Illness IP Indigenous People IPA International Procurement Agent IPAPs Indigenous People’s Activities Plans IPC The Pasteur Institute IPPF Indigenous People’s Planning Framework KAP Knowledge, Attitude and Practice KI Key Informants KPI Key Performance Indicators MAFF Ministry of Agriculture, Forestry and Fisheries MEF Ministry of Economy and Finance MERS Middle East Respiratory Syndrome M&E Monitoring and Evaluation MIS Management Information System MOH Ministry of Health NAMRU-2 United States Naval Medical Research Unit NCDM National Committee for Disaster Management NGO Non-Government Organization NaVRI National Veterinary Research Institute OIE Animal Health World Organization PCN Project Concept Note PDO Project Development Objective PDR People’s Democratic Republic PHRD Policy and Human Resources Development PI Pandemic Influenza PIP Project Implementation Plan PPE Personal Protection Equipment PPRRP Pandemic Preparedness, Response and Recovery Program RC Rapid Containment RGC Royal Government of Cambodia RRT Rapid Response Team SARS Severe Acute Respiratory Syndrome UN United Nations UNDP United Nations Development Program UNICEF United Nations International Children’ Education Fund VAHW Village Animal Health Workers VFL Views from the Frontline VHV Village Health Volunteers WHO World Health Organization Vice President: Axel Van Trotsenburg, EAPVP Country Director: Ulrich Zachau, EACTF Country Manager: Alassane Sow, EACSF Global Practice Senior Director: Juergen Voegele, GFADR Global Practice Director: Ethel Sennhauser, GFADR Practice Manager: Nathan M. Belete, GFADR Project Team Leader: Mudita Chamroeun, GFADR ICR Team Leader: Mudita Chamroeun, GFADR ICR Primary Author: Les Sims, FAO Consultant KINGDOM OF CAMBODIA AVIAN AND HUMAN INFLUENZA CONTROL AND PREPAREDNESS EMERGENCY PROJECT TABLE OF CONTENTS Data Sheet A. Basic Information .......................................................................................................... i B. Key Dates …….............................................................................................................. i C. Ratings Summary.......................................................................................................... ii D. Sector and Theme Codes ............................................................................................... ii E. Bank Staff ……. .......................................................................................................... iii F. Results Framework Analysis ......................................................................................... iii G. Ratings of Project Performance in ISRs ....................................................................... viii H. Restructuring ……………………………………………………………………………..viii I. Disbursement Graph …. .…….. ..................................................................................... ix Project: 1. Project Context, Development Objectives and Design ...................................................... 1 2. Key Factors Affecting Implementation and Outcomes ...................................................... 5 3. Assessment of Outcomes .............................................................................................. 14 4. Assessment of Risk to Development Outcome ............................................................... 24 5. Assessment of Bank and Borrower Performance ............................................................ 25 6. Lessons Learned .......................................................................................................... 27 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ..................... 29 Annexes: Annex 1. Project Costs and Financing ............................................................................... 31 Annex 2. Outputs by Component ...................................................................................... 32 Annex 3. Economic and Financial Analysis ....................................................................... 40 Annex 4. Bank Lending and Implementation Support/Supervision Processes....................... 43 Annex 5. Beneficiary Survey Results ................................................................................ 45 Annex 6. Stakeholder Workshop Report and Results.......................................................... 47 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR .............................. 51 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ................................ 53 Annex 9. Compensation and Vaccination .......................................................................... 55 Annex 10. List of Supporting Documents .......................................................................... 57 Map - IBRD 41262 .......................................................................................................... 59 A. Basic Information Avian and Human Influenza Control and Country: Cambodia Project Name: Preparedness Emergency Project IDA-H3610,TF- Project ID: P100084 L/C/TF Number(s): 56832,TF-58146 ICR Date: 10/27/2014 ICR Type: Core ICR ROYAL KINGDOM Lending Instrument: ERL Borrower: OF CAMBODIA IDA XDR 3.80M IDA: XDR 3.78M Original Total PHRD: USD 3.00M Disbursed Amount: PHRD: USD 3.00M Commitment: AHIF: USD 2.00M AHIF: USD 2.00M IDA: XDR 3.80M Revised Amount: PHRD: USD 3.00M AHIF: USD 2.00M Environmental Category: B Implementing Agencies: Ministry of Economy and Finance Ministry of Agriculture Forestry and Fisheries (MAFF) Ministry of Health (MOH) National Committee for Disaster Management (NCDM) Cofinanciers and Other External Partners: United Nations International Childrens' Education Fund (UNICEF) European Community - AHIF United Nations Development Programme (UNDP) World Health Organization (WHO) Government of Japan Policy and Human Resource Development (PHRD) Food and Agriculture Organization (FAO) Animal Health World Organization (OIE) US Naval Medical Research Unit II Pasteur Institute B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 04/28/2006 Effectiveness: 08/06/2008 08/06/2008 04/27/2011 05/11/2006 12/28/2011 Appraisal: Restructuring(s): 09/11/2007 10/18/2012 06/26/2013 Approval: 03/24/2008 Mid-term Review: 02/14/2011 02/14/2011 Closing: 12/31/2011 04/30/2014 i C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: Overall Bank Overall Borrower Moderately Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Rating Performance any) Potential Problem Project Yes Quality at Entry (QEA): None at any time (Yes/No): Problem Project at any Quality of Supervision No None time (Yes/No): (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Agricultural extension and research 26 26 Animal production 4 4 Central government administration 49 49 Health 8 8 Sub-national government administration 13 13 Theme Code (as % of total Bank financing) Natural disaster management 33 33 Other communicable diseases 34 34 Rural services and infrastructure 33 33 ii E. Bank Staff Positions At ICR At Approval Vice President: Axel van Trotsenburg James W. Adams Country Director: Ulrich Zachau Ian C. Porter Country Manager: Alassane Sow Nisha Agrawal Global Practice Senior Director: Juergen Voegele Global Practice Director: Ethel Sennhauser Christian Delvoie Practice Manager: Nathan M. Belete Rahul Raturi Project Team Leader: Mudita Chamroeun Alan L. Piazza ICR Team Leader: Mudita Chamroeun ICR Primary Author: Les Sims F. Results Framework Analysis 1. Project Development Objectives Financing Agreements. The original project development objective (PDO) was to assist the Recipient in implementing its Comprehensive Avian and Human Influenza (AHI) National plan, specifically, to minimize the threat posed to humans and to the poultry industry by AHI infection, and to prepare for, contain and respond if necessary to human pandemics. This is the PDO in all the legal agreements (IDA, AHIF and PHRD Grants), which was the one adopted during project implementation and, consequently, it is the PDO used for assessment of project impacts and results. Technical Annex PDO. The Technical Annex has a slightly different version of the PDO, not materially divergent but broader and more ambitious. It was the following: “Project's overall development objective is to support the implementation of the Cambodia Comprehensive AHI National Plan contributing to minimize the threat posed to humans and the poultry sector by AHI infection in Cambodia, and to prepare for, control, and respond if necessary to a human influenza pandemic. More specifically, the Project was expected to provide direct support to the implementation of the National Comprehensive AHI Plan to produce the following outcomes: (a) contain the spread of the disease, thus reducing losses in the livelihoods of commercial and backyard poultry growers and damages to the poultry industry and diminishing the viral load in the environment; (b) prevent or limit human morbidity and mortality by stemming opportunities for human infection, and strengthening curative care capacity; and (c) prevent or curtail macroeconomic disruption and losses by reducing the probability of a human pandemic and improving emergency preparedness and response.” Revised Project Development Objectives The PDO was not revised. Changes were made to outcome indicators as described in Section 1.3. iii (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Number of villages adopting two or more disease preventive measures Indicator 1: recommended under the "Healthy Livestock, Healthy Village, Better Life" scheme. Value quantitative or 0 0 30 30 Qualitative) Date achieved 10/15/2012 10/15/2012 10/18/2012 04/30/2014 Fully Achieved. Indicator added as result of restructuring approved on October Comments 18, 2012. In all of the 30 villages more than two measures are being (incl. % implemented. Villagers are continuing improved poultry and livestock achievement) production with improved biosecurity. Indicator 2: No cases of H5N1 HPAI in periurban commercial poultry flocks once control and preventive measures are implemented Value Limited number of cases quantitative or prior to project 0 Not applicable Qualitative) commencement Date achieved 08/05/2008 08/05/2008 10/18/2012 10/18/2012 Indicator dropped. Although control and preventive measures were Comments implemented in these farms no cases of H5N1 HPAI were reported after project (incl. % commencement and the indicator was dropped through formal restructuring on achievement) 18 October 2012. Evidence of improved effectiveness of participating animal and human health Indicator 3: services in responding to the risk of avian influenza in poultry and a human pandemic of influenza Value Low effectiveness of quantitative or response preparation for High efficiency High efficiency Qualitative) identified risks Date achieved 08/05/2008 06/30/2011 04/30/2014 Achieved. High efficiency measured by the speed and quality of response to Comments reported outbreaks in poultry and humans by both animal and human health (incl. % response teams with data supporting this improvement from intermediate achievement) indicators. (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years a.1. Number of new VAHWs trained using the revised curriculum and Indicator 1: percentage of these providing disease reports at commune meetings. iv Value (quantitative 0 2100 2122 or Qualitative) Date achieved 08/05/2008 08/05/2008 04/30/2014 Achieved (102% of the target value). Refresher courses provided to existing Comments VAHWs on AHI. New training materials and kits with basic equipment for (incl. % VAHWs provided to all those trained and certified. About 83% of trainees are achievement) providing disease reports regularly. a.2. Number of reports of suspected HPAI from VAHWs including percentage of Indicator 2: suspect cases investigated, percentage of investigated cases from which samples were collected and percentage of cases test for AI and Newcastle disease Value (quantitative Low level reporting 200 180 or Qualitative) Date achieved 08/05/2008 08/05/2008 04/30/2014 Comments Partially achieved. All suspect cases investigated in 24 hours and tested. A (incl. % fourfold increase in the number of suspect cases reported compared to 2009 (180 achievement) in 2013, 141 in 2012, 54 in 2011, 48 in 2010 and 42 in 2009). a.2.(i). Percentage of suspect cases investigated and time from report to Indicator 3: investigation. Value Low number of (quantitative investigation with 90% 90% or Qualitative) longer period Date achieved 08/05/2008 08/03/2012 04/30/2014 Comments (incl. % 439 (96%) out of 465 suspected HPAI cases were investigated within 24 hours. achievement) Indicator 4: a.2.(ii) Percentage of investigated cases from which samples were collected. Value Low number of sample (quantitative 80% 82% collected or Qualitative) Date achieved 08/05/2008 08/03/2012 04/30/2014 Comments (incl. % 142 (82%) cases typical of AI had samples collected out of 174 investigated. achievement) a.2.(iii) Percentage of cases from which testing for Avian Influenza and Indicator 5: Newcastle Disease are done. Value Low testing on both (quantitative 100% 100% diseases. or Qualitative) Date achieved 08/05/2008 08/03/2012 04/30/2014 Comments (incl. % All samples collected were transported and tested in NaVRI. achievement) a.3. Targets for training in emergency vaccination met and government advised Indicator 6: of finding v Value 100% of target (quantitative 0 125 (125 district vets) or Qualitative) Date achieved 08/05/2008 08/05/2008 04/30/2014 Comments Achieved. An additional 90 vets were trained under Healthy Livestock Healthy (incl. % Village, Better Life program, thus exceeding the target. achievement) a.4. Percentage of farms or markets on which recommended risk mitigation Indicator 7: measures to prevent AI are fully implemented Value Limited number of farms (quantitative provided 70% 85% or Qualitative) recommendations Date achieved 08/05/2008 06/30/2011 04/30/2014 Comments Achieved (target exceeded). 85% of farms provided with recommendations had (incl. % adopted the measures. 648 farmers and 211 traders trained in basic bio-security achievement) measures. Biosecurity booklets printed and disseminated. Indicator 8: b.1. Percentage of provincial and district Rapid Response Teams trained. Value (quantitative 20% 80% 100% or Qualitative) Date achieved 08/05/2008 06/30/2011 09/07/2011 Comments Exceeded. Refresher training courses also provided to all members of the Rapid (incl. % Response Teams. achievement) b.2. Percentage of Village Health Volunteers trained in Avian Influenza Indicator 9: monitoring, reporting and control measures. Value (quantitative 10% 70% 100% or Qualitative) Date achieved 08/05/2008 06/30/2011 08/03/2012 Comments This indicator was deemed to have been met because the target had been reached (incl. % prior to the start of project implementation. It was shifted to HSSP2 when the achievement) formal restructuring was conducted. b.3. (In case of outbreaks) Percentage of warning signals detection of clusters of Indicator 10: patients with clinical symptoms of influenza, closely related in time and place followed by field investigation within 24 hours. Value (quantitative No outbreak 70% 100% or Qualitative) Date achieved 08/05/2008 06/30/2011 09/07/2011 Achieved. RRT respond to all within 24 hour. People in same household & Comments village with H5N1 case were followed up. Timely sharing of information through (incl. % IHR mechanism. Most outbreak detection were made from clinical cases and achievement) some from sentinel surveillance. Indicator 11: b.4. Percentage of sentinel sites that generate ILI surveillance reports on time. vi Value (quantitative 30% 70% 100% or Qualitative) Date achieved 08/05/2008 06/30/2011 04/30/2014 Comments Exceeded. No. of ILI sites increased 6 to10. Severe Acute Respiratory Infection (incl. % detection 4 sites operated to get accurate data for seasonal influenza & new PI achievement) strains. b.5. Percentage of targeted hospital staff trained for infection control and case Indicator 12: management. Value (quantitative 20% 80% 80% or Qualitative) Date achieved 08/05/2008 06/30/2011 04/30/2014 Achieved target. 465 hospital staff/clinicians trained. 170 staff refreshed. Comments Antiviral drugs now available at Sub/National hospitals & use encouraged on (incl. % suspects cases before lab result. This has contributed to fall in case fatality ratio achievement) in 2014. b.6. (In case of outbreaks) Percentage of suspected patients treated according to Indicator 13: infection control and case management guidelines. Value (quantitative No outbreak 70% 100% 100% or Qualitative) Date achieved 08/05/2008 06/30/2011 09/07/2011 09/07/2011 Comments Achieved. Both original and revised targets (target was revised to 100% in May (incl. % 2011). achievement) Indicator 14: b.7. Pandemic preparedness plan developed and desk-top exercise implemented. Value Not developed or Plan developed Plan developed and (quantitative implemented and implemented implemented or Qualitative) Date achieved 08/05/2008 06/30/2011 04/30/2014 Comments Achieved. MoH finalized Pandemic Preparedness Plan, Rapid Containment (incl. % Plan, and Risk Communication Plan in June 2013. achievement) c.1. NCDM’s TOR modified to include inter-ministerial Cooperation for Indicator 15: Pandemic Preparedness Value (quantitative Not yet modified TOR Modified TOR Modified or Qualitative) Date achieved 08/05/2008 06/30/2009 04/30/2014 Comments Achieved (in Year 5 instead of Year 1 of the project). DM Law was passed (incl. % through the Council of Ministers in 2013 and currently under final review at achievement) NCDM for re-submission and enactment by the RGC. Indicator 16: c.2. PPRRP prepared and tested. Value Developed and Developed and (quantitative Not yet prepared or tested Tested Tested or Qualitative) vii Date achieved 08/05/2008 08/03/2010 04/30/2014 Achieved. PPRRP developed and tested in targeted in nine high risk provinces: Comments Kampot, Kampong Cham, Mondulkiri, Prey Veng, Banteay Meanchay, Takeo, (incl. % Preah Sihanouk, Kampong Thom and Pursat (six in Year 4 instead of Year 2 of achievement) the project). c.3. NCDM emergency MIS and M&E systems designed, developed and Indicator 17: established. Value Designed, Designed, Not yet designed, (quantitative developed and developed and developed, or established or Qualitative) established established Date achieved 08/05/2008 08/03/2010 04/30/2014 Comments Achieved. Emergency MIS and M&E systems designed, developed and (incl. % established (in Year 3 instead of Year 1 of the project). achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 01/16/2009 Satisfactory Satisfactory 0.63 2 06/30/2009 Satisfactory Satisfactory 0.71 3 01/27/2010 Moderately Satisfactory Moderately Satisfactory 0.89 4 11/11/2010 Moderately Satisfactory Moderately Satisfactory 2.36 5 12/11/2011 Moderately Satisfactory Satisfactory 3.57 6 11/30/2012 Moderately Satisfactory Satisfactory 4.67 7 06/26/2013 Moderately Satisfactory Satisfactory 5.33 8 01/27/2014 Moderately Satisfactory Satisfactory 5.71 9 04/24/2014 Satisfactory Satisfactory 5.71 H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions Reallocation PHRD Grant 04/27/2011 N MS MS 2.73 TF056832 Extension closing date and 12/28/2011 N MS S 3.76 reallocation for IDA, AHIF and PHRD viii Amendment to Supplemental Letter No. 2 of Revised Indicators; reallocation for IDA, AHIF and PHRD; and the 10/18/2012 N MS S 4.67 transfer of the Component B to the Bank-assisted HSPP2 Project; and changed percentage of the three sources of funds. Extension closing date and 06/26/2013 N MS S 5.33 reallocation for IDA, AHIF and PHRD I. Disbursement Profile ix 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. In 2003-04, highly pathogenic avian influenza (HPAI) viruses of the H5N1 subtype 1 which had been present and evolving in China since 1996 emerged as a regional concern when 7 Asian countries reported outbreaks of the disease (Thailand, Cambodia, Vietnam Indonesia, Japan, Lao PDR and the Republic of Korea). These viruses emerged as a greater global threat in 2005 as they moved from Asia into Europe and on to West Africa and parts of North Eastern Africa. On January 12, 2006, the World Bank’s Board endorsed the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) as a horizontal adaptable program (APL) to provide up to US$500 million of immediate emergency assistance to countries seeking support to address this threat to public health and economies of all countries. Throughout 2006, the virus was spreading rapidly, with additional countries reporting cases of HPAI; by the end of the year, 55 countries in Asia, Europe, Africa and the Middle East had reported cases in poultry or wild birds, including all the countries neighboring Cambodia (Lao PDR, Thailand, and Vietnam). The international community was concerned that the response should be prompt and effective so as to prevent a potentially catastrophic impact on public health and economies similar to that produced by the 2003 outbreak of the severe acute respiratory syndrome (SARS). SARS was contained and caused fewer than 800 fatalities, but its economic costs were very high (US$54 billion). 2. The Royal Kingdom of Cambodia had much to lose from avian influenza. At the time of the initial outbreaks it was a poor country undergoing rapid development with a poultry population of approximately 17 million chickens and 7 million ducks, all susceptible to infection. Cambodia had achieved political and macroeconomic stability and, since 1993, had been experiencing rapid economic growth. Nevertheless, Cambodia's economy remained vulnerable and economic growth had not translated into widespread poverty reduction. With a GDP per capita of US$390 (in 2005) and social indicators showing limited progress since the 1960s, Cambodia was (and remains) one of the poorest countries in the world. About 35% of the population remained below the national poverty line, with about 15% living in extreme poverty. Poverty in Cambodia was overwhelmingly located outside Phnom Penh, with poverty incidence of more than 50% in the worst affected areas. 3. Cambodia was one of the first countries in Southeast Asia to experience AHI infection. The first case of H5N1 HPAI in Cambodia was reported in December 2003, and the first wave of the outbreak during January to May 2004 had a severe impact on smallholder farmers who raise the majority of the country's poultry under subsistence conditions and on small-scale commercial poultry farms. HPAI cases emerged again in late 2004 and early 2005, and four human cases (all of which were fatal) were reported in 2005. There were a few confirmed outbreaks among chicken, ducks and fighting cocks in 2006, and these cases were quickly contained (about 2500 birds were killed by disease or culling during the February 2006 outbreak); however, two additional human deaths were confirmed in 2006. In 2007, another human death was confirmed. The repeated outbreaks and associated loss of human life and livelihoods highlighted the country's 1 Avian influenza viruses are divided into highly pathogenic and low pathogenicity strains based on their virulence. These viruses are divided into subtypes such as H5N1, H9N2 etc. 1 inadequate disease surveillance system, the limited capacity to control the disease, and the persistence of infection in the region. 4. Cambodia is situated between two large poultry producing countries (Thailand and Vietnam) which experienced far greater outbreaks of avian and human influenza (AHI) 2 in poultry and humans. As a result, the region was identified as a potential flashpoint for the possible emergence of a human pandemic strain of influenza. It was therefore necessary to mount a response against this virus across the sub-region. 5. At the time the project was prepared the Government of Cambodia had developed an integrated AHI control and human pandemic preparedness and response plan. It was working closely with the international community to build its capacity for disease surveillance, disease control and prevention, outbreak investigation, and emergency response but much more work was needed to control the disease. This plan was developed with the support of, and in line with, the strategies and plans developed by the lead international agencies on AHI including United Nations Development Program (UNDP), World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE). 1.2 Original Project Development Objectives (PDO) and Key Indicators 6. There were two different versions of the Project Development Objective. The PDO in the legal agreements (IDA, AHIF and PHRD) was to assist the Recipient in implementing its Comprehensive Avian and Human Influenza (AHI) Plan, specifically, to minimize the threat posed to humans and to the poultry industry by AHI infection, and to prepare for, control, and if necessary respond to human influenza pandemics. This was the PDO adopted consistently during the entire implementation period (as appears in all ISRs) and the one used in this ICR for final assessment of project’s results (see paragraph 65). 7. The other version in the original Technical Annex was: “Consistent with the GPAI, the Project's overall development objective is to support the implementation of the Cambodia Comprehensive AHI National Plan contributing to minimize the threat posed to humans and the poultry sector by AHI infection in Cambodia, and to prepare for, control, and respond if necessary to a human influenza pandemic. More specifically, the Project is expected to provide direct support to the implementation of the National Comprehensive AHI Plan to produce the following outcomes: (a) contain the spread of the disease, thus reducing losses in the livelihoods of commercial and backyard poultry growers and damages to the poultry industry and diminishing the viral load in the environment; (b) prevent or limit human morbidity and mortality by stemming opportunities for human infection, and strengthening curative care capacity; and (c) prevent or curtail macroeconomic disruption and losses by reducing the probability of a human pandemic and improving emergency preparedness and response.” Since the early stages of implementation, this version of the PDO was considered excessively complex and ambitious, as well as largely infeasible given the expected implementation period, and the resources available. 2 The term AHI is used to describe infection with and disease caused by avian influenza viruses in both poultry and humans which when this project was developed focused on influenza viruses of the H5N1 subtype. The term Influenza A(H5N1) is the standard term to describe this virus in humans and is used in this document to describe cases of infection in humans with this virus. 2 1.3 Revised PDO and Key Indicators, and reasons/justification 8. The PDO was not revised. 9. A problem of attribution arose with the first outcome indicator. No new cases of H5N1 avian influenza were reported from commercial farms (which had been one of the main sites of disease in 2004) throughout the life of the project meaning it could not be used as an indicator for success of interventions. When H5N1 HPAI first occurred in Cambodia, periurban commercial farms were among the premises affected. It was expected that, as a result of project activities, these farms would modify practices so as to become and remain disease-free. However, since the project commenced all reported cases of H5N1 HPAI were from rural areas and primarily from backyard poultry, not the targeted periurban commercial farms. As a result it was necessary to replace this indicator through formal restructuring in October 2012 with another that measured the number of villages implementing measures recommended by the project to reduce the risk of avian influenza. These measures were developed under the “Healthy Livestock Healthy Village Better Life” program which was introduced successfully to 30 villages. The new PDO indicator is the number of villages adopting two or more disease preventive measures recommended under the Healthy Livestock, Healthy Village, Better Life scheme. Baseline data were collected for this indicator during the initial selection of villages participating in the scheme, and it was found that none of the villages were implementing two or more of the measures recommended at that time 1.4 Main Beneficiaries 10. The main direct beneficiaries were poultry and livestock keepers across Cambodia, who comprise a majority of households in rural areas. This included rural women who are primarily involved in rearing household chickens and also preparing food for their families. Other beneficiaries were village animal health workers who received training that enhanced their capacity to provide animal health services at the village level, and persons in contact with poultry who would be exposed to disease risks, especially children. Prevention of disease in poultry and other livestock increases the availability and affordability of protein (meat, eggs) and thus improves nutrition, and access to cash from sales of poultry for school fees and other household expenses. The Project also benefited the general population by supporting government’s efforts to investigate outbreaks and limit spread of influenza A(H5N1), the 2009 pandemic H1N1 influenza virus and other infectious diseases such as cholera whenever they occurred. 11. Other beneficiaries of the Project were: i) the animal health services in the Department of Animal Health and Production (DAHP) within the Ministry of Agriculture Forestry and Fisheries (MAFF) along with provincial and district counterparts; ii) human health services in the Ministry of Health (MOH); and, iii) staff in the National Committee for Disaster Management. Their capacities to perform their various functions in pandemic preparedness and infectious disease prevention and control were strengthened. Staff from these three agencies also received training from the Project’s procurement and financial management (FM) consultants; the three agencies thus also benefited from stronger capacity in these areas. 12. The global community benefited from the work of rapid response teams in detecting possible onward transmission of the virus in communities once zoonotic cases were identified therefore undertaking measures aimed at preventing emergence of a pandemic agent. The information on viruses from surveillance studies was crucial for pre-pandemic vaccine strain selection by WHO which is a global public good. 3 1.5 Original Components 13. World Bank Financing for the Project’s three components aligned with those of the national comprehensive avian influenza plan. The supported activities were in line with recommendations made by the leading international technical agencies (FAO, OIE and WHO) and the World Bank’s GPAI. 14. Animal health - Component A (IDA=US$4.56 million; AHIF=US$1.51 million; Total=6.07 million) focused on controlling the disease at source in poultry through strengthening of veterinary services from the central to village level. The component was directed at improving prevention, recognition, reporting and responding to avian influenza and other emergency animal diseases. Support was given in the form of training and training resources for village animal health worker (VAHWs), through assistance in drafting appropriate animal health laws and training in emergency responses, including vaccination. Resources needed to implement emergency responses were provided. High risk practices in farms and markets that facilitate persistence and transmission of virus were identified and appropriate measures to reduce these risks were implemented. Existing animal health Information Education and Communication (IEC) programs were strengthened. 15. Human health - Component B (IDA=US$0.55 million; AHIF=US$0.18 million; PHRD=US$1.92 million; Total=US$ 2.65 million) focused on rapid identification and effective management of human cases. Support included: a) training and provision of resources for health care workers, health care providers, Village Health volunteer (VHV) and provincial Rapid Response Teams to facilitate surveillance, investigation and rapid response to cases. b) Procurement and distribution of appropriate medicines, medical equipment and Personal Protection Equipment (PPE) to support case management and infection control in referral hospitals. c) Laboratory capacity strengthening through a national laboratory strategy and continuous education and refresher training for laboratory staff and provision of appropriate materials for specimen collection and transport inside Cambodia and internationally to WHO reference laboratories and d) development of pandemic preparedness plans for the health sector. 16. Interministerial Coordination for Pandemic Preparedness, Project coordination and Management – Component C (IDA=US$0.77 million; AHIF=US$0.30 million; PHRD=US$1.08 million; Total= US$2.15 million) focused on quickly and efficiently mobilizing a coordinated multisectoral and society-wide response to an influenza pandemic. It also aimed to improve the effectiveness of Cambodia’s response to floods, droughts, and other natural disasters. Activities included: a) modifying the National Committee for Disaster Management’s (NCDM) Terms of Reference to enhance inter-ministerial cooperation for pandemic influenza preparedness, b) preparing and testing a Pandemic Preparedness, Response, and Recovery Program (PPRRP), c) designing, developing and establishing an emergency MIS system and an M&E system (for the overall national PPRRP) for NDCM and d) integrating pandemic preparedness, response and recovery activities into the ongoing Community Based Disaster Risk Reduction Programs (CBDRM). 1.6 Revised Components 17. Components were not revised during the project life but changes were made to implementation arrangements for the human health component and an additional program was added to animal health subcomponent A3. From January 2012, all AHICPEP activities related to component B (except for the consultancy services contract with the WHO and the national consultant on financial management) were transferred under an existing project supporting the human health 4 sector entitled the Second Health Sector Support Program (HSSP2) Pooled Fund through formal restructuring, on October 18, 2012. HSSP2 Pooled Fund finances activities on communicable diseases, including H5N1 and other emerging diseases, in the areas of capacity and quality improvement, behavior change and communication, and operating costs. The remaining budget under Component B (MOH) was reallocated to support the activities in Components A and C (MAFF and NCDM). This was done to reduce fragmentation of World Bank financing to the human health sector and as part of a sustainable exit strategy. 18. The Healthy Livestock, Healthy Village, Better Life program was introduced under the Animal Health component. In 2011, when there was an increase in human cases it was evident that different approaches to prevention of avian influenza were required in Cambodia to those used in the past. By 2011, the project had undertaken a number of studies to assess the range of available control and preventive measures. Many of the human Influenza A(H5N1) cases occurred in households where dead and sick poultry were prepared for food, despite considerable efforts to raise awareness of the risks associated with this practice. It was also recognized that, although compensation for culling of poultry is a preferred method for assisting in disease control, this measure was unlikely to be introduced by the government due to unfavorable experiences with compensation programs in the past. Therefore, alternative methods were needed to ensure better reporting. The Healthy Livestock, Healthy Village, Better Life program was the method chosen. It was introduced initially to 15 villages and extended to a further 15 villages once the gains from the first villages were assessed. The program used participatory methods in each village to assess disease risks and to work out appropriate disease control measures for poultry and other livestock that could be implemented by villagers. Training in disease prevention and control was provided much of which was based on measures implemented in an earlier EU-funded Smallholder Livestock Production Program (2005-2010). A number of low cost measures were implemented in these villages including: construction and use of cages for housing young chicks so as to increase chick survival; vaccination of poultry against Newcastle disease another major cause of losses of poultry; regular village cleaning days; improved household biosecurity especially targeted at traders who could no longer enter premises; systems for reporting of disease to VAHW, Village Heads or Village Health Volunteers; and, systems for quarantine of poultry in all households in villages by confining scavenging poultry and providing them with feed for a few weeks once any household experienced increased mortality in poultry. 19. There were no other significant changes in design, scope and scale. Financing was reallocated among activities when other partners provided support to activities previously identified for Project financing and when activities included in the National Plan required additional support (such as production of IEC material). 1.7 Other significant changes 20. The project closing date was extended twice (on December 28, 2011 and on June 26, 2013) to ensure the PDO was achieved and to enhance the chances of sustainable outcomes from the project. The total cumulative extension of the closing date was 28 months. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 21. The key factors in designing an appropriate project were the existence of a global framework and a country-led program, strong government commitment, coordinated engagement of all partners, and the strength of the World Bank team responsible for support to preparation and for appraisal of the 5 operation. Issues arose during the first appraisal that delayed implementation (discussed in detail below). 22. GPAI framework adapted to country circumstances. The challenge posed by the H5N1 avian influenza and pandemic threats necessitated a coordinated multisectoral response. The GPAI framework set out how multiple sectors and actors would have to work together and provided a template for the design of country responses, based on guidance from WHO, FAO, UNDP and OIE. The design built on the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) framework and relevant World Bank operational experience, including in emergency responses to disasters in Cambodia, the global program to address HIV/AIDS, the Vietnam Avian Influenza Emergency Project, and other responses to outbreaks of animal-borne diseases. Cambodia’s Comprehensive National Plan on Avian and Human Influenza was prepared in 2005 in response to outbreaks of avian influenza H5N1 in poultry and sporadic human infections in all neighboring countries. The National Plan served as a core foundation of the project. It comprised a multisectoral program including actions on animal health, human health, communications, and pandemic preparedness. It laid out measures and activities, participation from all key partners, indicative financial resource availability, and financing gaps. UNSIC, FAO, WHO, OIE, UNDP, the World Bank, and others assisted the government in improving the National Plan, its funding, and ensuring that the National Plan would strengthen country systems for infectious disease detection, diagnosis, prevention and control, both in animals and in human populations. Such strengthened systems would then be better able to respond to any other disease outbreaks in the future. The Bank had considerable experience in Cambodia, including experiences in the development and implementation of several recent operations in the country (including emergency operations). The rationale for World Bank involvement was strong from the perspective of the country assistance strategy. 23. Delayed preparation. After the World Bank’s Board endorsed the GPAI in January 2006, the Project was prepared and appraised on an emergency basis in early 2006 (January to May) in accordance with Bank Policy OP 8.00-Rapid Response to Crisis and Emergency situations. The original project design followed the traditional approach of relying on Borrower’s specialized agencies to coordinate and implement the project activities. A Bank mission carried out the first appraisal in accordance with this approach in May 2006. However, in view of major issues identified at that time in the World Bank’s portfolio of operations in Cambodia, the World Bank had substantial concerns about local capacity to manage the program efficiently and transparently. As a result, the World Bank strongly advised the project should be implemented through UNDP, FAO and WHO, as executing agencies acting on behalf of the RGC. Under this approach, these UN agencies would have been responsible for the procurement and financial management (although following Bank’s policies and procedures), as well as being in charge of actual implementation of activities. In accordance with this decision, the project design was adjusted and the task team engaged in intensive discussions with all parties involved to find a practical way to implement the project under this mechanism. 24. The Technical Annex was revised accordingly and legal agreements were drafted to be negotiated with RGC, UNDP, WHO and FAO at the same time. However, after prolonged discussions between the World Bank, UNDP, FAO and WHO, a general consensus emerged indicating that implementing the project through these UN System institutions was not feasible. The main reason was that the involved UN agencies felt that their own policies would conflict with Bank policies for procurement and financial management. These intensive discussions resulted in more than a year delay in project negotiation and approval. By mid-2007, an agreement was reached between the Bank and these UN agencies in relation to their participation as executing agencies of the project. Consequently, it was agreed that the Cambodian government would assume full 6 responsibility for the implementation of the project (following the original approach) with the technical support of the specialized agencies of the UN system (under technical assistance contracts to be signed with the RGC and financed by the project). 25. As a result, the project had to be reappraised in September 2007. In order to reinforce the implementation arrangements, it was agreed between the Bank and the RGC that an international procurement agent (already in the process of being hired to assist with other Bank operations in the country at the time) was also going to provide support to substantial procurement activities under this project. In December 2007, an Independent Procurement Agent (IPA) was recruited by the Government to carry out procurement under all Bank-financed projects in Cambodia, following instances of fraud and corruption identified in other projects in the portfolio. After a difficult start- up phase, which resulted in the recruitment of a new IPA firm in 2009, the coordination between the IPA and the implementing agencies improved. 26. The decision in favor of government implementation was ultimately justified by the good performance of the local implementing agencies (IAs). Furthermore, the proposal of involving specialized UN Agencies in project implementation through contract services provided to the Cambodian government for specialized technical expertise also proved successful. Unfortunately, after this second appraisal, a lengthy discussion over the TOR for the UN agencies led to more delays in processing, allowing the Board approval to take place only in March 2008 and effectiveness in August 2008. Under these circumstances, UNDP decided not to participate as a provider of technical assistance. Even though the operation was prepared following emergency procedures, this chain of events resulted in a total lapse from Project Concept Note (PCN) to Board approval of about 23 months and PCN to effectiveness of about 28 months. 27. Project design. The Project design was closely fitted to Cambodia’s National Plan with each element in the plan included as a subcomponent. IDA, AHIF, and PHRD provided flexible financing for filling gaps in the country’s response to the disease and throughout the course of its implementation. The design built on the World Bank’s operational experience in Cambodia, support from technical experts in avian influenza in the region and working relationships with UN agencies and other partners in the country. The design of the National Plan and the Project provided for intersectoral coordination mechanisms, and this emphasis on coordination was appropriate in view of the complex multisectoral challenge and numerous partners involved in supporting the National Plan. There was an intensive and deliberate effort to coordinate the actions to be included under this emergency operation with other activities supported at the same time by international organizations, bilateral donors, international and local NGOs, private sector and the Cambodian government. In general, the project design and complexity was consistent with the implementing capacity of the local agencies and with the perceived levels of risk. 28. PDO and results indicators. The PDO was relevant, appropriate and consistent with the GPAI program objective. It was assumed throughout project design (and subsequently through implementation) that minimizing the threat posed to humans and to the poultry industry by AHI infection in Cambodia was a long term goal, consistent with the objective of the 2005 FAO/OIE strategy document on which the GPAI was based, and also consistent with the field situation in Cambodia. The measure for the second PDO-level indicator related to improved effectiveness of animal and human health services was qualitative rather than quantitative. However, it was supported by evidence from the intermediate results indicators. Improving effectiveness of veterinary and human health services in responding to cases of avian influenza was a very important objective of this project and it was therefore appropriate for this to be included as an objective indicator. 7 29. Influenza A(H5N1) was entrenched in the lower Mekong area. When the project was designed it was recognized that eradication of H5N1 avian influenza from Cambodia was not feasible during the life of the project (unlike the situation in many other countries supported under GPAI). Instead the project aimed to construct the necessary platform on which to build long term successful control and preventive programs for avian influenza. Achievements under key performance indicators (KPIs) demonstrate this has been done and the goals set have been met or exceeded. 30. Critical importance of a response tackling the root cause of outbreaks as well as emergency preparedness. During project preparation, it was apparent from international disease control strategies and the experiences from other countries where the virus was entrenched (as was the case in Cambodia) that a focus on emergency responses (case detection and culling), while important, did not address the root causes of the problem. It was therefore necessary to build measures into the project that helped prevent the disease at source in poultry. This approach was also adopted in neighboring Vietnam. This approach goes beyond that usually applied in emergencies, but is now well established as the appropriate response to disease outbreaks of this kind. By the time the project was designed, Cambodia had been dealing with H5N1 HPAI for over 3 years and it was evident that emergency responses alone were not sufficient to prevent additional cases from occurring. 31. Risk assessment. The major risks identified at appraisal included political commitment, institutional and technical authority and capacity, the possible ineffectiveness of intervention activities in containing the spread of avian influenza, financial management capacity, and the lack of a compensation system for farmers for their culled infected birds. These risks were relevant, reflecting an evolving disease threat in an environment of limited institutional capacity. The mitigation measures were appropriate, although the factors that resulted in endemic infection in countries such as Cambodia with influenza A(H5N1) virus relate to the structure of the poultry sector and the structural weaknesses in veterinary services and these factors could not be and were not expected to be overcome during an emergency project. 32. Compensation for culled poultry. Compensation is recognized as an important element of disease control programs in which culling of animals occurs following detection of disease. The Cambodian National Plan when drafted in 2005-06 included the following on compensation: “The Government is currently considering the development of a compensation policy for farmers whose poultry are culled. Depending on the outcome of these discussions, the government may seek donor support for a compensation fund.” International agencies and relevant government departments repeatedly but unsuccessfully requested introduction of a compensation policy both before and after this statement. The lack of acceptance by RGC was due to a number of concerns at high level in government, including earlier experiences from compensations in different programs (especially, gun surrender mechanisms). Consequently, a small contingency fund was included in the project for payment for birds taken for diagnostic and investigation purposes but, given government policy it was not possible to incorporate provisions for a formal compensation scheme. 33. Vaccination. Mass vaccination was not included formally in this project as a tool for protection of poultry against H5N1 avian influenza (see discussion note in Appendix 9 of the Technical Annex). Instead the project was designed to test and develop capacity to implement emergency vaccination in the face of outbreaks of H5N1 HPAI in case it was needed. 8 2.2 Implementation 34. Strong support from the National government. The initial launch of the project involved some 600 people and the meeting was addressed by the Prime Minister. This provided a very clear demonstration of the Government's strong ownership of the project, including the three IAs, and the commitment of the Government to achieving the PDO. This support was maintained throughout the implementation of the project. 35. Activities completed despite delayed start up. Although implementation of the project was delayed, this did not affect overall implementation. The delays were due largely to a lack of familiarity with Bank procedures by staff in the IAs and legal complications in signing contracts between the Government of Cambodia and the UN agencies, FAO and WHO. A particular issue related to the detailed Terms of Reference, scope of work and staff to be provided by these agencies. Nevertheless, despite the delays in signing these contracts, within 12 months the project had purchased and distributed 110 motorcycles to district offices to allow for better case investigations and VAHW training courses were being conducted with revised training material. This demonstrated that the IA was prepared to take matters forward without waiting for formal support from the international agencies. All planned activities within the control of the project were completed by the time the project ended in April 2014, including some additional activities that were initiated based on findings from the project and the increase in human cases in 2011. During the delay, support by other donors on avian influenza meant that other activities related to AI control and prevention continued while the project became fully operational, demonstrating the importance of donor coordination. 36. Flexibility during implementation and response to resolve problems. The Project demonstrated considerable flexibility to ensure that the project met its objective. In 2011 when the number of cases of influenza A(H5N1) in humans increased dramatically, and it was evident that existing mechanisms to promote disease reporting in animals were not working as well as expected, the “Healthy Livestock, Healthy Village, Better Life” program was developed and adopted. This program came about because of recognition of the need for a novel, holistic approach to this disease that helped overcome the twin barriers to reporting - poverty and absence of compensation for culled poultry 3. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 37. The National Plan did not have an accompanying M&E framework. M&E indicators were developed during project design to provide clear indicators of progress towards the PDO and for the National Comprehensive AHI plan. It included a mix of outcome and output indicators. NCDM was responsible for coordinating and managing the M&E process and worked with the other IAs to ensure that there was appropriate understanding of the indicators and systems in place to record progress. Appointment of M&E consultants was delayed and the framework and systems for collecting relevant data were not introduced until 2010. Outcome indicators were designed to measure improvements in the response to avian influenza and the avian influenza situation. 3 See paragraph 32. Multiple requests were made to the Ministry of Economy and Finance to reconsider the position on compensation and allow it to be paid for poultry culled as part of disease control programs. The number of poultry being destroyed annually was very low. Agreement was reached with MEF in the final year of the project and MAFF is now in the process of developing appropriate plans. The absence of compensation placed staff from MAFF in a very difficult and at times dangerous position when conducting field work because of protests from local villagers when attempts were made to cull poultry. 9 38. It was expected that cases would continue to occur in rural areas, that more reports would be received of suspect cases as the VAHW network and links with District Veterinary Services were enhanced, and that the response to reported cases would improve as the project progressed. 39. The M&E system was fully established and used by NCDM, MOH and MAFF. Staff from the three IAs were trained to operate the system online. The project not only built the capacity of national project staff but also provincial staff on project M&E and the Emergency Management Information system (EMIS). NCDM organized four training sessions at four provinces (Kampong Cham, Takeo, Battambang and Kratie) which covered almost all the relevant provincial line department staff MAFF, MOH and PCDM of 23 provinces. 40. Adjustments to indicators. During the preparation of this ICR, questions were asked as to whether the PDO remained relevant or whether it should have been modified during the course of the project. This issue was considered during each supervision mission. As the main objective was support to the Cambodian National Avian Influenza Plan and this was being substantially achieved there did not and does not appear to be any justification for a change. The measures being implemented will minimize the threat posed to humans and to the poultry from AHI infection. The fact that there have been new cases of infection with H5N1 influenza virus in humans and poultry during the course of the program does not detract from the work that has been done to strengthen animal health and human health services that will reduce this risk over time 4. 41. The lessons learned from a number of GPAI projects released in 2014 5 pointed out that evaluation of avian influenza projects is inherently difficult due to the complex results chain, the difficulty in observing outcomes, the lack of a credible counterfactual, and challenges in determining attribution. This was also an issue during design of monitoring and evaluation systems for this project. The goal during design was to find a small number of suitable outcome indicators that overcame these challenges without overburdening the IAs. 42. Two outcome indicators were defined to assess progress towards the PDO. The first aimed to provide a measure of avian influenza control in the animal health sector, which, in turn, would provide information on the reduction of risk to humans through reduced viral load. This indicator – “No new cases of avian influenza in periurban commercial poultry farms” - was expected to measure successes in controlling and preventing this disease through introduction of enhanced biosecurity and other measures based on advice from the project. Given the small number of farms of this type in Cambodia compared to the millions of backyard flocks this was expected to be achieved during the life of the project. As discussed previously this indicator was dropped because no cases of disease were reported in these farms during the life of the project. 43. The second indicator assessed the improved performance of animal health and human health services, which was the major area for investment by the project. This was a broad indicator that looked for evidence of improved effectiveness of participating animal and human health services in responding to the risk of avian influenza in poultry and a human pandemic of influenza. This indicator was supported by the intermediate indicators such as the number of case reports and the time to response following reports. Additional intermediate indicators were added during formal 4 It is, perhaps, time for a revised National Plan that recognizes the extended period required to prevent all avian and human cases and the possibility that this virus will not be eliminated. 5 https://ieg.worldbankgroup.org/Data/reports/avian_flu1.pdf 10 restructuring on October 18 2012 to further demonstrate achievements in support of this objective. It was also possible to use qualitative data that strongly suggested improved effectiveness to support the case. 44. Total case numbers in poultry or humans were not used as outcome indicators because there was no prospect of disease elimination during the course of the project. Given this situation there was always the possibility of an increase (or decrease) in case numbers for reasons outside the control of the project and issues with attribution of successes and apparent “failures”. In fact, an increase did happen when the number of human cases increased in 2011 (8 cases) and again in 2013 (26 cases). There was a fall in case numbers in 2012 (3 cases). The average number of human cases per annum from 2010 to 2014 currently stands at just over 9. Variations have been seen in other countries, year on year, especially in Egypt where, for example, case numbers increased from 8 in 2008 to 39 in 2009, with no known reason for the variation. Nevertheless, the increase in cases was a factor in rating the achievement of the PDO as Moderately Satisfactory during support missions from 2011 onwards until the final review. 45. Despite not being used as outcome indicators, total case numbers in both humans and poultry were still measured and used to help guide the project. Following the increase in human cases in 2011 the project undertook a detailed stock take to identify areas where additional measures could be introduced so as to reduce the risk of disease in poultry and humans. It was from this review that the “Healthy Livestock, Healthy Village, Better Life” program was introduced. It represented a major achievement for the project for control and prevention of avian influenza. 46. The new outcome indicator based on achievements in villages implementing the Healthy Livestock, Healthy Village, Better Life program and the original second indicator continued to provide evidence supporting achievement of the PDO. 47. The evidence for increased effectiveness includes the improvements in response time to outbreaks, the full investigation of all outbreaks by rapid response teams (some of which is documented in formal publications 6) and the increase in the number of reported cases from VAHW. The new indicator provides a direct measure of the outcomes from project interventions at the village level. 2.4 Safeguard and Fiduciary Compliance 48. The project has been very successful in social safeguards preparation and implementation and the final overall rating of the social safeguards performance was ‘Satisfactory’. This “Satisfactory” rating was supported by the following activities during the project preparation and implementation. 49. Social Safeguards Instruments: The project was implemented in areas with substantial ethnic diversity and indigenous people are often among the poorer and more vulnerable sections of the population when facing AHI. The project triggered the Bank’s OP 4.10 on Indigenous People (IP) and an Indigenous People’s Planning Framework (IPPF) was developed in May, 2008. The framework was used to ensure that the communities of indigenous people could benefit from the project implementation by receiving information in local languages and in culturally appropriate and accessible ways. Based on the policies and procedures set out in the IPPF, both MAFF and MoH prepared Indigenous People’s Activities Plans (IPAPs) on an annual basis. The objective of 6 Chea N et al (2014) Two clustered cases of confirmed influenza A(H5N1) virus infection, Cambodia, 2011.Euro Surveill.19(25) 11 these IPAPs was to provide detailed sets of actions to meet the objective of the IPPF, which is to enable indigenous communities to better address both the animal and human health risks of AHI through the development and implementation of an indigenous people focused communication strategy. Progress in IPPF/ IPAP implementation was incorporated in the progress reports prepared by MAFF, MoH and NCDM prepared throughout the life of the project. 50. Social Safeguards Implementation: During project implementation, steps have been taken so that a wide range of the Cambodian population, including poor and indigenous people, benefit from the project. As a result, quite a number of IP were involved in project activities. For example, of the 3230 people who attended the VAHW refresher training organized by MAFF, 155 of them were representatives from communities of IP; 59 people from indigenous communities received training as new VAHW; 1212 IP participated in VAHW’s monthly meetings organized by MAFF. Some women from IP groups also joined the training. The trained VAHWs shared knowledge on AHI with their communities in local language and in culturally appropriate manners. Field visits to IP’s communities confirmed that knowledge on AHI was gained by local IP communities through the project implementation and human behavior was also changing. Due to the nature of the project, the project has no negative impacts to IP’s communities. 51. In summary, the project was designed to ensure that IP received equal social and economic benefits that are culturally appropriate and gender inclusive and this goal has been successfully achieved during the project implementation. 52. Environmental issues. Culling and disposal of poultry was undertaken based on standards developed by FAO and implemented by MAFF with the small number of carcasses of culled poultry burned and/or buried. Samples were transported to laboratories in purpose built bio-safe containers. Hospital waste management was handled in accordance with standard MoH procedures for infectious waste. 53. Disbursement rate. The Project’s disbursement rate increased favorably from 2010 at an average 22% per year until 2012 once all consultants were on board. One of the key reasons for slow disbursement at the start was the delay in signing the contracts with FAO and WHO which in turn delayed implementation of a number of other activities. The IA’s overcame these problems resulting in 99% disbursement by the end of the project. The diagram below illustrates Project’s annual disbursements by the three sources of funds: 2014 2013 Total (US$) 2012 TF 56832 2011 TF 58146 2010 IDA H3610 2009 2008 Year $(500,000) $- $1,500,000 $500,000 $1,000,000 $2,500,000 $2,000,000 $3,000,000 54. Due to a low disbursement at the outset, the Project was able to disburse only around 60% of the entire allocated fund by the original closing date (31 December 2011). After the first extension, the Project’s disbursement was still quite strong at 20% in 2012 and 15% in 2013. There was a 12 negative disbursement for IDA fund in 2014. This was due to refund from FAO for unused balance of US$58,000. 55. Financial management. The financial management performance rating of the Project was moderately satisfactory throughout the project implementation. Audit opinion on the audited annual financial statements was unqualified; however, the submission was late for the last two audit reports. The audited financial statement for FY2013 has been overdue for more than three months by the time of writing. MEF has discussed with the auditor to consolidate the final audit for FY2014 with the 2013 financial statement. Given that there are a few adjustments to be made related to classification of NCDM’s expenses for drivers and support staff, the final audit report for FY13 and FY14 are expected to be submitted by 31 October 2014. An exceptional two month grace period was granted to the government for proceeding with such adjustments. The quarterly IFR submission of MOH was generally on time with a few exceptions where the submission was less than a month late. For MAFF and NCDM, the IFRs were generally submitted late by less than a month. 56. During the implementation support missions, a number of shortfalls in controls were identified and mitigating measures were provided to the project to rectify the problems. . 57. Procurement. Procurement under the Project was carried out by the international procurement agents engaged by the Ministry of Economy and Finance (MEF), except for procurement packages procured through Direct Contracting, procurement from United Nations Agencies, and Single- Source and Sole-Source Selection methods, Selection of individual consultants (regardless of value), hiring of NGOs, procurement of goods estimated to cost less than $50,000 per contract, and procurement of works estimated to cost less than $100,000 per contract, which were carried out by the project IAs (NCDM, MOH, and MAFF). Despite significant procurement delay, particularly the hiring of UN Agencies (FAO and WHO) as consultants, at the project start up, all procurement activities were successfully completed during the project extension without non- compliance to the Bank’s procurement guidelines. 2.5 Post-completion Operation/Next Phase 58. Outcomes are sustainable. One of the strengths of the project is that many of the measures introduced are durable and will be sustained once the project ends. The training materials introduced under Component A will be valuable resources for future training of animal health workers and farmers. The newly trained VAHWs will provide support for many years to come and were provided with training on control, treatment and prevention a range of diseases, not just avian influenza, so is broadly applicable. Links between VAHW and district staff have been strengthened and this will ensure continued reporting of disease outbreaks. It is expected that meetings will continue between district staff and VAHW because both now recognize the value of these meetings. 59. Training in hospitals in infection control procedures is relevant for any infectious disease and the recent emergence of MERS and H7N9 avian influenza demonstrate that novel pathogens with the potential to spread in health care settings continue to emerge posing a potential global threat. The shift of Component B to HSSP2 ensured that it was sustainable because of the on-going availability of funds for activities undertaken in this project. 60. Rapid response teams continue to operate whenever disease outbreaks occur to ensure that these are fully investigated. Epidemiologists trained under the program will continue to use their skills in disease investigations and reporting will continue to be in compliance with the International 13 Health Regulations. Improved laboratory capacity offers hope for expansion of diagnostic tests for other influenza viruses and other agents. 61. Villages that have adopted the measures under the Healthy Livestock, Healthy Village, Better Life program have already recognized the benefits that arise from the program and are self-funding inputs such as wire mesh for poultry cages and vaccines for poultry. They have already seen how the program increases their income through increased poultry survival and this converts to improved supplementary income, especially for women. The program will be expanded by the government and is also expected to form part of additional financing under the World Bank LASED project. The program has also been identified as a potential means of improving income of villagers to pay for health equity funds – a form of health insurance for poor families. 62. Pandemic preparedness plans also assist with other disasters such as floods or typhoons. Animal health and disaster management legislation, once promulgated, will provide a framework for disease control programs in animals including better controls on animal movement. The disaster management legislation will result in greater coordination in the event of a serious emergency which crosses over various ministries. These not only include severe disease pandemics but also other major disasters such as floods, drought and cyclones. NCDM has demonstrated that it can play a coordinating role as it has done with this project. 63. Social development. The project created capacity that will help prevent potentially devastating impacts on the entire society. Strengthening of veterinary services has to continue as many of the gaps identified in the OIE Gap Analysis remain. The passage of animal health laws will provide a foundation for better disease control but must be backed by appropriate enforcement capacity (appropriately trained staff and political will to enforce legislation). Cross border movement of animals including poultry remains poorly controlled. It is expected that a project managed through FAO on cross border trade between Vietnam and Cambodia will help to provide improvements in this area. 64. Surveillance programs are expensive but need to be maintained to ensure that viruses circulating in poultry (and other livestock) are fully characterized. Supports from other donors, including the EU, are expected to continue for this purpose. If Influenza A(H7N9) finds its way to Cambodia, some of the measures to improve biosecurity in markets and farms from this project will help to minimize its impact. Information gained from the project can be used to help plan for closure and/or reconstruction of these markets and shifts towards central slaughtering of poultry, which should be considered as a possible means of supply of poultry carcasses to retail outlets in country. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 65. The project objectives were and remain highly relevant. They are in line with the National Plan and international strategies for control and prevention of H5N1 HPAI. When the national strategy was being developed in 2005 the objective was to minimize the risk of avian influenza. Much has been learned about places where H5N1 virus is entrenched (see FAO 2011 7 ) including reinforcement of the message that, in these places, emergency responses to the disease alone do 7 FAO (2011) Approaches to controlling, preventing and eliminating H5N1 Highly Pathogenic Avian Influenza in endemic countries Available at http://www.fao.org/docrep/014/i2150e/i2150e00.htm 14 not address the underlying reasons that permit disease outbreaks to occur in the first place. A combination of strengthened emergency response and longer term measures is needed and has been applied through the project in Cambodia. To make progress towards disease control, veterinary services have to be strengthened and changes are needed in the ways poultry are produced and sold that reduce the risk of disease transmission, as described above. The project introduced measures to help achieve these goals. These included enhancements to farm and household biosecurity and marked improvements in the training and knowledge of VAHWs. 66. Strengthening of veterinary services was required and formed a cornerstone of the project. Countries with low national veterinary and human public health capacities are the weak links in the global system that should deliver pandemic prevention. Most of the activities under Component A were designed to strengthen veterinary services especially at the local field level. A review of Cambodian veterinary services was conducted by the OIE under its Performance Vision Strategy program in 2007 and was followed by a gap analysis in 2011. These reviews found that most areas of Cambodia’s veterinary services were at a very low level of development and did not meet international standards. The gap analysis recommended strengthening of these services. The risks and costs associated with this problem have been well described elsewhere (Jonas 2014)8. Therefore investment in veterinary services was essential. 67. Investment was also needed in human health services and pandemic preparedness. This was required especially in the areas of early recognition and response to cases of avian influenza and in preparedness for an influenza pandemic. This remains relevant given the risk of emergence of a novel pandemic agent appears to have increased based on the new or re-emerging pathogens that have been reported in 2013 and 2014, including the Middle East Respiratory Syndrome (MERS), Influenza A(H7N9) in China and Ebola virus disease in West Africa. These diseases all provide reminders of the ever present risks of an emerging pandemic agent and it is now accepted that it is not a matter of if but when a pandemic agent will emerge. In addition, Cambodia is in an area recognized as being at high risk for avian influenza. H5N1 avian influenza viruses have persisted in the Lower Mekong area for over 10 years since they were first recognized in this area in 2003. The high level of risk is evident from the 56 cases of this disease in humans and multiple outbreaks in poultry in Cambodia throughout this period. 68. The project design was appropriate as it provided support for implementation of measures aimed at strengthening veterinary and human health services and the lead agency on national disaster management as well as the coordination between the three departments. 69. The project was designed in a way that allowed it to respond appropriately to the increase in cases in 2011. In 2011 when eight human cases of Influenza A(H5N1) were detected, all fatal, it was evident that disease was continuing to occur in poultry without being reported, and messages regarding consumption of sick and dead poultry were not being heeded. This problem had been confirmed by knowledge, attitudes and practices (KAP) surveys conducted before and during this project. The Healthy Livestock, Healthy Village, Better Life program implemented as a result of this review helped to overcome the problem of consumption of dead poultry through better education and improved poultry survival. A new KAP survey was undertaken to understand better 8 Jonas O (2014) Pandemic Risk World Development Report Background Paper Available at http://siteresources.worldbank.org/EXTNWDR2013/Resources/8258024-1352909193861/8936935-1356011448215/8986901- 1380568255405/WDR14_bp_Pandemic_Risk_Jonas.pdf 15 the reasons for consumption of sick and dead poultry and new IEC material was produced and distributed based on the findings of the KAP survey. 70. Project implementation through the three IAs supported by WHO and FAO provided an excellent balance with the technical agencies able to provide appropriate training and support to government. 71. Overall the relevance of the objectives, design and implementation were and remained high throughout the life of the project. The project was also in line with CAS given the costs to poor households associated with this disease and the potential to reduce poverty in rural communities through improved disease control for both animals and humans. It does not depart from the CAS in content, but as an emergency operation prepared in response to an unforeseen event, the project covered other significant aspects described in the project Technical Annex. 3.2 Achievement of Project Development Objectives 72. In this section achievements under each part of the PDO are discussed. The main component of the PDO was to assist the implementation of Cambodia’s Comprehensive AHI National Plan and was substantially achieved 73. The targets for the outcome indicators for the PDO were met and demonstrate that appropriate disease preventative measures were implemented at village level and the effects of enhanced capacity of veterinary and human health services in responding to outbreaks of the disease. However these indicators only partially reflect the scope of the benefits and importance of building a stronger platform in the form of enhanced veterinary and human health services, enhanced pandemic preparedness and greater resilience in villages for disease control and prevention. The additional measures and achievements are described in more detail below and in Annex 2. 74. Tackling risks in both poultry and humans by building capacity. The Cambodian comprehensive plan and the second part of the PDO aimed to minimize the threat posed to humans and to the poultry industry by AHI infection in Cambodia. Prevention of avian influenza in humans requires prevention of infection at source in poultry. To achieve this, the major focus of the work under the animal health component was to improve the quality of VAHW so as to increase reports of disease with signs suggestive of HPAI in village poultry 9. Enhancement of veterinary services was largely (but not only) achieved by training of VAW. As most livestock in Cambodia are kept by smallholders at village level the only effective way to provide services to this sector is via a network of well-trained VAHW. Targets set for training were exceeded. 75. The number of reports from VAHW increased more than fourfold from levels in 2009 to those in 2013 and the first quarter of 2014 (Fig 1). This represents a major achievement. Because of these reports, four outbreaks of influenza A(H5N1) were identified in poultry without accompanying human cases in 2014. Actions were taken to prevent the disease from spreading in poultry in these cases, therefore reducing the risk of human exposure and cases. 9 Most of these outbreaks are due to diseases other than avian influenza because the signs of disease are very similar but it is essential to get reports of these outbreaks 16 180 160 140 120 100 80 60 40 20 0 2009 2010 2011 2012 2013 2014 (Q1) Figure 1 Increase in reports of suspect cases of avian influenza by VAHW from 2009 to 2014 76. Other evidence of improved effectiveness of participating animal and human health services in responding to the risk of avian influenza include improved speed of response time to suspected and confirmed outbreaks in poultry and humans as defined in the intermediate indicators. These gains are attributable to training and provision of resources by the project and, as a result, all cases of influenza A(H5N1) were responded to within 24 hours by animal health and human health staff 77. The effects of the project on the poultry industry could not be measured due to the absence of case reports from the industrial sector throughout the duration of the project. Nevertheless it appears that the economic effects of this disease on poultry producers both commercial and village level, were not as severe as expected, when the project was developed. 78. Compensation, alternatives to compensation and effects on disease reporting. As discussed previously, compensation for culled poultry was not included in the project. The need for compensation was repeatedly stressed throughout the project by IAs and during supervision missions. The issue was also examined in an FAO consultancy study conducted in 2011. In the last year of the project approval in-principle was provided for compensation to be paid, although, by the closing date of the project, details of the scheme had not been finalized. Nevertheless, the pressure from the project was a major factor in getting agreement on the need for a well-managed compensation system. This outcome forms part of the platform that the project has built for further gains in disease control. Alternatives to compensation were also implemented in the Healthy Livestock, Healthy Village Better Life program. More information on the issue of compensation and its relevance to the project is provided in Annex 9. 79. Similarly, mass vaccination of village level poultry was not incorporated in the project largely because it was not deemed to be cost effective based on experiences from Vietnam and Egypt. Issues relevant to vaccination are also discussed in Annex 9. 80. On the human health side, rapid response teams from the human health sector ensured that there was no onward human to human transmission of avian influenza virus. This is also a crucial element of pandemic prevention. As an example, detailed information was obtained on the 17 investigations into the three human cases in 2013 in Takeo province and the excellent follow up work conducted by the rapid response team in ensuring no transmission of the virus had occurred. Briefly, blood samples were collected from household members (two samples taken two weeks apart), they were observed for two weeks and, if any symptoms develop, nasopharyngeal swabs were collected and anti-viral treatment commenced. Others in the village either exposed to the patient or to dead poultry were also observed for two weeks and if any becomes symptomatic, they are also tested and treated with antiviral medication. This work ensures that if transmission of an influenza virus between humans occurs it is detected early providing an opportunity to limit the extent of transmission. So far, no evidence of human to human transmission has been detected in Cambodia. This is a vital part of pandemic prevention and is effective provided a high percentage of primary “poultry to human” cases are detected. 81. Outcome of prevention efforts. Despite this clear success in supporting the comprehensive plan, the H5N1 avian influenza virus has not been eradicated from Cambodia. Cambodia accounted for two thirds of the world’s human H5N1 cases in 2013 and overall 30% of reported global cases from 2011 to June 2014. The project design recognized from the outset that the H5N1 avian influenza virus would not be eradicated from Cambodia during the life of the project. This is because poultry disease reporting is still imperfect, messages about not preparing sick or dead poultry for consumption are not being followed by a small but significant proportion of households, and possible human H5N1 cases are not always being identified at the local level quickly enough to save lives, largely because these cases are being treated first by private sector health care workers and the early signs of this disease in humans mimic other common diseases. 82. Reconciling the objective of case minimization with an increase in human cases from 2011 onwards. In places such as Cambodia, minimizing (making as small as feasible) the threat of avian influenza to poultry and humans depends on changing three factors, all of which will take many years to implement fully. The changes required are: (a) Modifying poultry production and marketing systems - The project was able to make changes to production systems through implementation of improved biosecurity in farms and villages where the project was implemented. However, these changes are incremental and it was not going to be possible to restructure the current production systems practiced by 1.9 million smallholder and village producers during the life of the project. (b) Changing behavior of rural residents so that they no longer prepare sick and dead poultry for food or handle sick and dead birds and report disease. Some behavioral changes were obtained in villages where measures were implemented but it was never going to be possible to overcome all rural poverty, the key driver of this action. (c) Enhancing capacity of veterinary services and responding to outbreaks. Considerable enhancement of veterinary services was achieved including training of VAHW. It was measured through the second outcome PDO supported by other information including the increase in the number of reports of disease suspicious of avian influenza. The strengthening of veterinary services in accordance with international standards is also a major undertaking and would require many years to achieve. 83. The project was undertaking the necessary capacity building and implementation of novel programs to minimize the effect of this disease in the long term (consistent with the FAO/OIE strategy. These improvements were measured by the outcome and output indicators. They will contribute to long term minimization of infection in poultry and humans but fluctuations in case numbers can occur until these are more widely adopted. 18 84. Progress in the areas of human health and pandemic preparedness/prevention (once human cases occur) are less constrained by structural problems in the poultry industry as the work performed by human rapid response teams and by treatment teams in hospitals, supported by the project, has demonstrated. 85. Increased human cases but reduced human case fatality rate. Despite the increase in human cases there was also a marked reduction in case fatality ratio for humans. This fell from 19 of 21 cases (90.5 percent fatality) between 2005 and 2012 to 18 of 35 (51.4 percent) in 2013-14. This was below the overall global average for case fatality ratio of 59%. One possible reason for the increase in case detection is that cases that would not have been diagnosed in earlier years, because of limited testing, were being identified. This almost certainly played some role because, as a result of the project, testing was extended to a larger number of laboratories. Some 70 tests per week are conducted for influenza A(H5N1) as part of active surveillance programs. Several cases in 2014 were detected through a recently established program designed specifically to test febrile patients and one was found through contact tracing (3 of 9 cases). These would not have been detected prior to introduction of these systems in the years when H5N1 HPAI first occurred in Cambodia. 86. Improved case detection almost certainly contributed to lowering of the case fatality ratio. Earlier treatment was made possible by providing antiviral drugs to provincial locations and allowing clinicians to treat on the basis of suspicion when clinical signs and history provided evidence of a possible case. The exact extent of the improvement due to better access to diagnostic tests and antiviral drugs cannot be determined (as some of this may be due to identification of some milder cases that would not have been detected in the past). Nevertheless earlier detection of cases and treatment in accordance with agreed protocols is the first step towards early treatment with antiviral drugs, which is known to improve treatment outcomes. 87. Meeting international obligations in health reporting Cambodia has demonstrated remarkable transparency in reporting all cases of influenza A(H5N1) in humans and poultry. All cases are reported officially to WHO and OIE as soon as they are identified, in line with international obligations. These reports are available to the general public. This demonstrates the strong commitment by the Government of Cambodia to transparency in disease reporting and provides an excellent model for other countries. Transparency and timely reporting continued even when the number of cases increased. The project provided support for case detection and encouraged the rapid reporting of cases. 88. Surveillance studies and case investigations in poultry and humans allowed viruses to be fully characterized. A key element of the project was the improved surveillance that resulted in detection and characterization of new strains of influenza A (H5N1) viruses and the detection of avian influenza viruses in live poultry markets. This information is vital for understanding the evolution of these viruses and determining their origins and is used globally for pandemic preparedness (WHO 2014 10). This work also allowed the viruses from poultry and humans to be compared in studies aimed at understanding the increase in human cases in 2013 (Rith et al 2014 11). This particular study using data collected from activities supported by the project also demonstrated the value of follow up investigations by rapid response teams once human cases were identified. Some of the viruses isolated in early 2014 had molecular changes suggesting they 10 WHO (2014) http://www.who.int/influenza/vaccines/virus/characteristics_virus_vaccines/en/ 11 Rith et al 2014 J. Virol published ahead of print http://www.ncbi.nlm.nih.gov/pubmed/25210193 19 might be transmitted more easily between people but the follow up work done by rapid response teams demonstrated no sustained human-to-human transmission. 89. The other objective of the Cambodian AHI plan forming part of the PDO was to prepare for contain, and respond to human pandemics. Pandemic preparedness activities were conducted by all three IAs with the major work conducted by NCDM working with provinces to introduce them to the whole of society approach that is needed in the event of a serious pandemic. The activities undertaken by the rapid response teams were also important in pandemic prevention. Although there was an influenza pandemic in 2009 it was relatively mild and did not result in the social disruption that would occur in the event of a more severe disease. 90. Attribution of outcomes. By the time this project was implemented few other resources were being provided to support the control and prevention of avian influenza in Cambodia under the National Plan although other projects supporting livestock production funded by the EU were still in place. Some of the activities from the EU project supporting small scale livestock production were adopted in this project including some of the biosecurity measures in villages. The project was the main provider of support for the implementation of National plan, providing over 50% of the donor funding. This included over 85% of the funding for strengthening of veterinary services. 91. Without the inputs in training and the regular meetings held between VAHW and District staff, supported by the project, improvements in reporting of suspect cases of avian influenza in poultry would not have been achieved and RRT would not have been able to undertake their vital work in monitoring contacts of cases. Epidemiological training programs for the human health sector would not have occurred and surveillance studies that determined the extent of infection in markets would not have been conducted. Pandemic preparedness activities would not have been conducted. 92. The number of villages that have adopted two or more disease prevention measures recommended by the project has reached the end-of-project target of 30 villages, representing over 1440 households. The gains obtained in these villages were entirely attributable to the introduction of the Healthy Livestock Healthy Village Better Life program that was developed and funded by the project and would not have occurred without the project 3.3 Efficiency 93. As an avian influenza pandemic did not emerge it is not possible to determine precisely the effectiveness of the investment in pandemic responses. Nevertheless it is possible to demonstrate that only minor improvements in pandemic preparedness and response would provide a return on the investment. 94. Even if preparedness activities from the project resulted in only a 1.2% reduction in costs when a severe pandemic occurs, it will have been an effective investment (total budget for NCDM for Component C – $2.15 million). 95. In addition, the investments in the Health sector would be recovered if early identification and treatment of cases (key elements of this project managed by the Ministry of Health) reduced hospitalization rates in a severe pandemic by only 2% (8400/420,000), and if survival of patients infected with the virus increased by 1.3% (819/63,000) as a result of investments in enhanced treatment protocols and isolation facilities in hospitals then the investments in to the Health Sector (Component B – total investment $2.65 million). 20 96. The direct losses from avian influenza to the poultry sector were much lower than anticipated when the project was designed. However, much of the investment in this project under Component A was directed at strengthening of veterinary services, especially at the village level through training of VAHW in disease recognition, prevention and treatment. The multiplier effect of this training is enormous as VAHW provide private sector animal health services to the villages they serve. This includes provision of vaccination and treatments for diseases of all farm animals. 97. If, across the country, VAHW trained in the project prevent losses from vaccine preventable diseases through vaccination of poultry pigs and cattle the overall benefit in one year would be approximately one third of the investment in the Agriculture sector across the life of the project ($6.07 million) per annum. See Annex 3 for basis of calculations. 98. A benefit-cost analysis focusing on prevention of emergence of an avian influenza pandemic prevention is not possible because it is not possible to quantify the extent to which the measures implemented reduced the likelihood of emergence of a pandemic strain of virus. These activities are a form of insurance and part of a global public good. The low cost of this activity is dwarfed by the estimated cost of a severe global influenza pandemic that could be averted by the actions of these teams ($3 trillion). 99. Similarly, it is not possible to estimate the extent to which actions by animal health services prevented emergence of a pandemic strain of virus. Nevertheless it has been suggested that even if one in five mild pandemics were to be averted a return on investment of about 14% would be achieved from investments in veterinary services (World Bank 2012) 12. 100. Every household that adopts the Healthy Livestock, Healthy Village, Better Life program activities for poultry rearing is likely to have a net gain of more than $80 per annum from increased survival of poultry (based on a flock size of 10 hens) due to a doubling in the number of chicks that survive. A return on investment of approximately 100% was recorded covering the cost of feed and vaccines for those who adopted the measures (a formal economic assessment of the program was conducted by FAO). So far, the overall gains to the country from this program are modest because it has only been applied to 30 villages but there is considerable potential for major gains once the program is expanded. 3.4 Justification of Overall Outcome Rating 101. Rating: Moderately Satisfactory 102. Project indicators met or exceeded. The Project was effective in supporting the implementation of the National Plan for responding to H5N1 influenza, preparing for pandemic influenza and other infectious disease outbreaks, and building capacity in disease surveillance, prevention and control, especially strengthening of veterinary services. It met, or largely met, all of the indicators set for the project. The project was closely aligned to the National Plan and the capacity of existing government and private sector services. The development outcomes were substantial as reflected in the achievements for the outcome indicators that were supported by data from intermediate indicators. 12 World Bank (2012). People, Pathogens and Our Planet, Volume 2: The Economics of One Health 21 103. The increase in reported human cases does not reflect a problem with project implementation but rather it resulted from a combination of events including improvements in surveillance systems that can be attributed to gains from the project. Some of the changes may be due to changes in the virus that are outside the control of the project and some of the increase is probably due to an expansion of the range of the virus in poultry across the country. This is best explained by movement of silently infected ducks that escape detection, which is based on reporting of clinical disease. The increase in cases in Cambodia in 2013 now appears to be atypical and in line with similar variations seen in Egypt in 2009. Although increases in human cases were not reported elsewhere in 2013 it is not possible to perform direct comparisons between different countries because of the marked differences in the poultry rearing and marketing systems, levels of poverty, quality of veterinary and animal health services and availability of resources to implement certain control and preventive measures. 104. The overall rating would have been considered satisfactory based on substantial achievement of the PDO, high relevance of the project due to the on-going challenges presented by AHI and the substantial efficiency brought about as a result of investments in VAHW, human health services and pandemic preparedness. However the increase in human cases from 2011 onwards (and more evident in 2013-2014) suggested the objectives, as stated, were not fully met and there is more ground to be covered to decrease the level of risk for the population. This factor resulted in a rating of moderately satisfactory, which was consistent with the PDO ratings assigned in the ISRs for about four years. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 105. The AHI project was enriched after the updating of the design by adding “Healthy Livestock, Healthy Village, Better Life’ scheme in June 2012. There was no new outbreak in those villages. Farmers in the villages feel comfortable to deal with household poultry and they know how to manage it safely and economically. The case study shows the farmers have alternative safer source of income. An Impact Study was performed by FAO in 15 villages at the beginning of 2013 13. The study shows that the “Healthy Livestock, Healthy Village, Better Life’ scheme is economically sound and socially functional in the target villages. As noted above, the official record of H5N1 human cases showed that the women and girls appear to be at a slightly greater risk than the men. Based on case documentation, the reason why more females were affected is that they are the ones primarily involved in household backyard chicken raising and prepare food for their families (including, in some cases preparing and cooking dead chickens). It is therefore very important that they are encouraged to continue to participate in project activities. (b) Institutional Change/Strengthening 106. The PHRD Grant was fully blended with the IDA grant for the AHICPEP project and therefore contributes to all aspects of the project. The Grant provided assistance to the three Implementing Agencies (MAFF, MOH and NCDM) to deal with avian and human influenza issues covering the animal health system, human health system and inter-ministerial cooperation for pandemic preparedness. The main institutional change was a greater awareness of the threat posed by avian influenza and response to this disease. Key institutional impacts on MAFF included greater 13 Hinrichs J (2013) Report on Healthy Livestock Healthy Village Better life program 22 involvement in disease control at village level, enhanced surveillance information that was used in post graduate training, and experience in managing a World Bank funded project. NCDM developed greater capacity in coordination and management of disease outbreaks. MOH had major institutional strengthening through training of epidemiologists, formation of rapid response teams and greater collaboration with MAFF and NCDM. Both WHO and FAO fulfilled their contractual obligations and were instrumental in developing appropriate training materials and courses and drafting of legislation. Closer links were established between the implementing agencies and the technical agencies, and between WHO and FAO. Involving the agencies provided access to other programs such as the global framework for transboundary animal diseases that provides support for cross border initiatives. (c) Other Unintended Outcomes and Impacts (positive or negative) 107. During the period of the project, it is noted that there are unintended outcomes and impacts. They include the following: • Trained VAHW are providing support to village livestock producers helping to prevent treat and control other diseases of livestock and as noted in the economic assessment, this provides a greater economic return than the gains from control of avian influenza for the agricultural sector. • New hopes of multi-sectoral coordination: the role of NCDM in coordination for implementing the project made an example of multi-sectoral coordination. The lessons can be replicated for any multi-sectoral programs of the RGC and is a positive impact • At the community level cooperation between VAHW and Village Health volunteers increased. • Some farmers reacted negatively when staff came to cull poultry. This would have occurred with or without the project but it provided a further catalyst for consideration of introduction of a compensation scheme for culled poultry. • Some households in villages outside of Healthy Livestock villages have adopted the improved methods used to rear their poultry such as rearing poultry in cages without direct inputs from the project demonstrating that they recognize the benefits of the methods used in these villages. • Communities have become aware of the dangers posed by poultry traders in transmission of disease. This has resulted in behavioral changes that prevent traders from entering households. Instead poultry are brought to the traders outside the premises. • H5N1 has been recognized in the Cambodia Country Report: Views from the Frontline (VFL) 2013 draft report has been developed and waiting for a national consultation. It is posted in Cambodian national DRR Google Portal as a result; all the DRR agencies in Cambodia and Southeast Asia were updated about it. It is also shared to the Global Platform for Disaster Reduction (GPDRR) conference held at Geneva on 19-23 May 2013. The situation of H5N1 has been communicated to many countries and readers. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 108. A formal beneficiary survey was not conducted. The KAP survey conducted from December 2012 and February 2013 was used to determine whether the project contributed to an increase in the knowledge base and behavioral change that leads to a reduction of risk for the transmission of avian influenza from poultry to poultry, as well as from poultry to humans. Results from 612 respondents interviews of villagers (most of respondents had minimal education, limited financial means, living in rural areas and raising poultry in small backyard for self-consumption) showed that, the villagers had a clear understanding AI, and understood that AI can spread from poultry to 23 poultry and poultry to humans. About half of them knew the specific symptoms that would manifest in a human case of AI. An area of great concern is that, large number of the respondents would allow poultry to have access to their homes Another area of concern is the general lack of hygiene in relation to both the cleaning of hands as well as of the utensils used in the slaughter and preparation of poultry – only about half of the villages clean the utensils used for cooking. Another problematic situation is they did not separate cooked and raw food during the cooking process. This is potentially a cause for concern (although more of a concern for other diseases leading to food borne illness rather than influenza). Another clear finding of the report, in spite of the high level of awareness to an increase in the knowledge base and behavioral change towards AHI, was that a significant number of people continued to consume sick and dead poultry. 4. Assessment of Risk to Development Outcome 109. Rating: Significant 110. Many of the gains from the project are expected to be sustainable as described earlier. However the risks to development outcomes remain significant. 111. H5N1 HPAI remains entrenched in the region and the virus continues to evolve. The two most recent cases of infection in humans have been shown to be due to a different strain of H5N1 virus - one that had been circulating in southern Vietnam for 12 months before crossing to Cambodia. There is no indication that this particular strain is more severe in humans or more likely to convert to a human pandemic strain but it is probably more pathogenic in ducks than the existing strain, causing additional losses for the agricultural sector. It demonstrates that, as these viruses evolve, it is possible for new strains to find their way to Cambodia. Other new strains have emerged in China on a regular basis, many of which then find their way into Vietnam. Others have been transported over relatively long distances by migratory birds such as the H5N8 virus that appeared in South Korea in early 2014. A novel H5N6 virus has also recently been detected in Lao PDR and Vietnam and is closely related to a strain of virus detected in various parts of China. These viruses are all derived from the original strains of H5N1 virus first detected in 1996 in China. It is possible that one of these novel strains will be or become more readily transmissible to humans as has been seen with the recently emerged H7N9 virus. This H7N9 virus is also a concern because it does not produce any clinical signs in infected poultry removing one of the clues of its presence in poultry. If this particular virus infected smallholder poultry flocks in Cambodia even contact with apparently healthy chickens could pose a public health risk. 112. Capacity gaps in veterinary services have been reduced by the project but there remains much work to do to ensure that veterinary services reach appropriate international standards. This will require long term support from both the government and donors. Investments in veterinary services are regarded as a global public good and the payoff from this investment can be very high in terms of zoonotic and potentially pandemic diseases averted. Much more needs to be invested in veterinary services to bring them up to international standards. 113. Vehicles supplied by the project have a limited lifespan especially those in mountainous provinces. Many of these vehicles will provide benefits well beyond the life of the project but unless additional funds can be found to replace vehicles over time the links between district staff and VAHW and the capacity to respond to disease outbreaks will gradually diminish due to reduced mobility. If vehicles are returned to the government pool after the project this could also affect response to outbreaks unless priority is given to this activity. 24 114. Surveillance for avian influenza and other emerging diseases remains an important and expensive activity. The project has demonstrated the importance of information generated from surveillance systems and funds are required from government or donors to continue well targeted surveillance. Unless a reliable source of funds is found there is a risk that the required surveillance testing especially in the veterinary area will diminish. This is expected to be less of an issue for the human health side which in general is better resourced. Surveillance testing also requires well equipped laboratories with appropriate resources for quality management programs. The EU is expected to provide resources in this vital area as part of their on-going support for MAFF. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry 115. Rating: Moderately Satisfactory 116. The project design was relevant and consistent with broader GPAI goals and objectives and the Cambodian Integrated National plan. The implementation and fiduciary arrangements were sound and appropriate to the existing institutional capacity and political economy in Cambodia. 117. The Project was prepared by the Cambodian government with support from a strong team from the World Bank, comprising avian influenza specialists, operation officers, and a consultant with over 20 years of experience in animal health in Cambodia. The process benefited from collaboration with FAO, WHO, and UNDP. Alignment of the Project with the National Plan was a strong feature of the design. World Bank support to project preparation was based on the GPAI. The mitigation plan for addressing critical risks was sound and relevant. 118. However, there were some shortcomings affecting Quality at Entry. The main one was the excessive delay in preparation and approval of the operation, in spite of being prepared as an emergency project under OP 8.00. These delays were exclusively due to decisions taken by the Bank at that time and resulted in postponement of the start of implementation of activities that were critical under the threat of a potentially dangerous epidemic. In addition, the definition of more appropriate outcome level indicators (measurable and closely related to the PDOs), could have facilitated the quantification of the final results of the project. (b) Quality of Supervision 119. Rating: Satisfactory 120. Eight supervision missions were conducted and these provided strong guidance to the project on areas of focus. Action plans were developed for implementation after each mission and agreed with the implementing agency. The Project task team provided substantial implementation support, with relentless follow-up on the details of implementation and ensuring that the results framework informed adjustments by the implementing agencies and partners in activities in the plan. The team effectively mobilized specialized expertise when needed. Since a poultry-disease program was technically complex and donors had little experience in the animal health sector, the task team mobilized relevant technical expertise from FAO. The task team demonstrated a high degree of flexibility as reflected in the four project restructurings. The mission reports were comprehensive, detailed, substantive, with clear guidance on follow-up, and highly appreciated by 25 both the government and partners. The World Bank’s relationship with the partners and other donors was strong, resulting in coordinated financing of activities. 121. The financial management and procurement teams participated in every review; the social safeguards specialist participated in reviews in the Project’s initial phase. (c) Justification of Rating for Overall Bank Performance 122. Rating: Moderately Satisfactory 123. After delays in the preparation phase occurred, there was a strong World Bank performance during implementation and consistently high and successful coordination effort in the supervision phase. The Bank performance rating is based on the progress of the overall project implementation, outcomes and impacts and disbursement of virtually all funds by project. In reference to the overall analysis of the progress of the project (physical/quantitative and qualitative), outcome achievements, fund disbursement; it can be concluded that the performance of the bank is moderately satisfactory. 5.2 Borrower Performance (a) Government Performance 124. Rating: Satisfactory 125. The RGC remained engaged throughout the project and provided support for the technical agencies. Representatives of Ministry of Economy and Finance were present at all wrap up meetings for support missions and were prepared to assist in overcoming problems such as payment arrangements for petrol for district staff for motorbikes supplied by the project. 126. The government and IAs demonstrated their initiative in introducing “the Healthy Livestock, Healthy Village, Better Life” program vides information on poultry mortalities in the pilot villages to village health volunteers 127. Close links were established between NCDM and upper levels of government. Although the two legislative packages are still to be ratified they have been considered by government committees prior to the general election in September. Legislative programs were delayed during and after the election (not just affecting legislation for this project). A commitment from government to introduction of compensation was obtained during the life of the project. Counterpart funds in the form of salaries were provided for staff in IAs working on the project throughout the life of the project. Government supported each of the restructures including the two project extensions. . (b) Implementing Agency or Agencies Performance 128. Rating: Satisfactory 129. The implementing agencies completed all of the activities in the project, completed work schedules set following each support mission and a very high proportion of funds were disbursed. Coordination between the implementing agencies improved throughout the project. The implementing agencies demonstrated their initiative when there were delays in signing contracts with FAO and WHO by continuing work on project activities related to work to be conducted by the two technical agencies. They also built on the long term relationships with these agencies. In 26 the case of MAFF this included training of VAHW with modified training materials. MOH continued to deploy rapid response teams for outbreaks. 130. The IAs demonstrated flexibility in responding to crises. MoH followed up on a possible cluster of human cases and also conducted investigations into the possible reasons for the increase in cases in 2011 and 2013. MAFF implemented the Healthy Livestock Program and undertook additional publicity in response to increased human cases. NCDM undertook a new KAP survey to assist in understanding the reasons for the increase in cases. The IAs were responsive to all proposals following Bank support missions. 131. The IAs spent considerable time developing the M&E system and in training of staff at central and provincial level on the importance and use of the system. (c) Justification of Rating for Overall Borrower Performance 132. Rating: Satisfactory 133. The project has been very successful in achieving its PDO of supporting the implementation of Cambodia’s Comprehensive Avian and Human Influenza National Plan. Overall the rating is based on satisfactory performance of Government and of the three implementing agencies. 6. Lessons Learned 134. Indicators based on the number of cases of disease are influenced by factors outside the control of the project and are unreliable. A number of GPAI projects, including AHICPEP, have used outcome indicators based on apparent improvements in disease situation. Superficially it makes sense to use these as an ultimate measure of effectiveness. However, as was demonstrated in Cambodia, the number of cases can be affected by factors outside the control of the project. In fact, sometimes an increase in cases could reflect improvements as a result of project activities because of improved reporting or diagnostic testing. For example the extent to which the increased number of cases of influenza A(H5N1) in humans from 2011 onwards was the result of better reporting and testing or due to a genuine increase in the number of cases of disease is still not clear. 135. There is also an issue with attribution when dealing with changes in the number of cases. For example, one of the initial key indicators in this project (the number of cases of avian influenza in peri-urban commercial poultry) had to be dropped because no new cases were detected in this sector during the course of the project. This was coincidental and not attributable to gains from project activities. 136. Reasonable compensation should be offered to farmers whose poultry are culled for disease control purposes. Staff from MAFF involved in the culling of poultry in the event of outbreaks were sometimes unable to do their job properly because of resistance from angry villagers who would not allow them to cull potentially infected poultry. This problem will be alleviated once they can pay appropriate compensation. Steps have been taken during the project to ensure this can occur in the future. 137. Much has been done but much more needs to be achieved to control H5N1 HPAI in poultry. A common theme identified during the preparation of this report is that although the project has met its objectives more still needs to be done to fully contain and eventually eliminate influenza 27 A(H5N1). Additional funds from government and donors are required to continue this work and fill remaining gaps. Long term investments are required. 138. Poverty continues to play a major role in influencing disease control and prevention. KAP surveys before and during the project repeatedly identified poverty as a driver of certain behaviors such as preparation of sick and dead poultry for food, and non-reporting of disease. The Healthy Livestock, Healthy Village, Better Life program recognized that improving poultry survivability and productivity removes one reason for these practices. If more poultry survive there is no incentive to dress and cook a dead chicken (there are plenty of other healthy birds) and there is more likely to be early reporting of mortality. Any measures that help to reduce poverty will assist in preventing zoonotic influenza A(H5N1). However it will be many years before the necessary behavioral changes will be made by all who keep poultry and rural poverty will continue to hamper efforts to change this behavior 139. Procurement and financial management arrangements for the engagement of the UN agencies in an emergency disease response project should be clearly established at the corporate level in advance. This was a key reason for the delay between initial designs to approval. It needs to be fully understood, so that it does not happen in future emergency projects. With the emergence of Ebola virus disease in West Africa and the need for inter-agency partnerships there are likely to be some lessons of relevance from this project in this area otherwise it might result in delays in approving of new emergency projects. 140. Reasons for the delay in signing contracts between the government and the UN agencies need to be understood to avoid a repeat in the future. It took almost 18 months to finalize contract arrangements between the UN agencies, FAO and WHO, and the Government of Cambodia. Most of this related to legal procurement issues that should be anticipated in any new projects in which these agencies are involved. As many of the activities in the project depended on the work done by the agencies, such as training needs analysis by FAO (which delayed finalization of the new training material for VAHW), this affected project implementation. The Bank legal procurement team should examine these issues in detail and prepare appropriate advice. 141. The health status of poultry is threatened by the poor controls on poultry movements. One of the crucial issues that remains to be addressed in Cambodia but for which some background work has been conducted (such as improved legislation and training in biosecurity for villages) is the weak control over poultry movements. Until such time as there is better control of movement of poultry within Cambodia and across borders disease outbreaks will recur. Limited controls on movement of other types of livestock also threaten the health status of livestock in the country. 142. H7N9 represents a genuine zoonotic threat and low level human pandemic threat. Influenza A(H7N9) emerged in China in March 2013 and so far has not been found in poultry in any other country. Experiences with H5N1 virus suggest that it is only a matter of time before this virus spreads to neighboring countries. Work done in the project to enhance biosecurity in farms and at markets will reduce the likelihood of this virus becoming established in these places. Nevertheless it is evident from the studies done on existing markets during this project that if H7N9 virus were to become established in these markets, human cases would be expected to and this would be followed by temporary market closures. The effects on smallholders would be high as the price of poultry would fall causing severe economic hardship (the outbreak in China has already cost more than US 16 billion in losses to the poultry sector based on an assessment by the USDA Foreign 28 Agricultural Service 14). As this virus does not cause disease in poultry, infection in birds will only be detected if appropriate systems are in place to check for infection through active surveillance. 143. Additional investments are needed in the livestock sector. The livestock sector in Cambodia is still relatively inefficient and under-developed and there is considerable scope for programs and or projects to assist in its development building on work from this project and others including support from the EU. Poor control and prevention of livestock diseases is one of the constraints. This includes diseases of cattle such as foot-and-mouth disease and haemorrhagic septicaemia and diseases of pigs such as porcine respiratory and reproductive syndrome, which has been a major cause of losses in Asia in the past 10 years. . 144. Avian influenza provides a strong incentive for investment in the health sector but administrative costs can be reduced if activities are incorporated into existing programs. Cambodia already had a project in place to strengthen health services (HSSP2) and the decision made in 2010 to incorporate the influenza project into this project was done to reduce duplication. While this can potentially result in a loss of focus on avian influenza the benefits in terms of sustainability and coordination outweigh this concern. In the case of veterinary services or NCDM there was no equivalent project in place. 145. On-going funding for pandemic preparedness is required. Pandemic preparedness is a form of insurance. It is only when a crisis occurs that the adequacy of coverage/preparedness becomes apparent. However insurance is also something that is allowed to lapse when risks are seen as remote. Some excellent first steps towards pandemic preparedness have been made but these need to be consolidated. The cost to the Cambodian economy of a severe human pandemic would be in the billions of dollars. Pandemic preparedness cannot prevent all of these losses but they can help to improve resilience of businesses and the community and reduce the losses incurred, include loss of life. The recent (2014) Ebola virus disease outbreak in West Africa demonstrates the importance of having systems in place to manage both the medical and non-medical consequences of a severe disease and the devastating impact on the economies of affected countries when they are not. 146. Detailed case investigations and monitoring provide opportunities to reduce the probability of emergence of a pandemic agent. The work undertaken by officers in Health Departments following detection of human cases provided the best possible chance of detecting any evidence of human to human transmission of the virus therefore allowing measures to be implemented to prevent its spread. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 147. The Government provided Recipient’s completion report (June 2014), end project evaluation report (May 2013), and direct input during the preparation of the ICR, and as well as provided written comments on the dart report. A summary of the comments is incorporated in the final ICR and a summary of Recipient’ completion report is in Annex 7. 14 See USDA GAIN report, http://gain.fas.usda.gov/Recent%20GAIN%20Publications/Poultry%20and%20Products%20Semi- annual_Beijing_China%20-%20Peoples%20Republic%20of_3-3-2014.pdf 29 (b) Co-financiers 148. The European Union and the Embassy of Japan provided direct input during the meeting conducted for the preparation of the ICR mission in May-June 2014. (c) Other partners and stakeholders 149. The FAO and WHO provided direct input during the preparation of the ICR, and as well as provided written comments on the draft report. 30 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) 15 Component A 5.80 5.90 102% Component B 3.50 2.64 75% Component C 1.70 2.21 130% Total Baseline Cost 11.00 10.75 98% Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs 11.00 10.75 Front-end fee PPF 0.00 0.00 .00 Front-end fee IBRD 0.00 0.00 .00 Total Financing Required 11.00 10.75 (b) Financing Actual/Latest Appraisal Type of Estimate Percentage of Source of Funds Estimate Cofinancing (USD Appraisal (USD millions) millions) 16 Avian and Human Influenza Facility 2.00 2.00 100.00 Borrower 0.00 0.00 0.00 IDA Grant 6.00 5.75 96.00 JAPAN: Ministry of Finance - PHRD 3.00 3.00 100.00 Grants 15 Based on information from the client connection on 13 May 2014. 16 Based on information from the Client Connection on 13 May 2014. 31 Annex 2. Outputs by Component 150. Component A -- Animal Health Systems (total cost of about US$6.07 million). The Animal Health Component was divided into six subcomponents and these were further broken down into specific activities. The overall objective of the animal health component was to minimize the levels of infection with H5N1 HPAI viruses in Cambodia. A1. Strengthening veterinary services 151. Veterinary services from the central to village level were strengthened at all levels. This sub- component enhanced the capacity to prevent, recognize and respond to avian influenza and other emergency animal diseases through improved training and training resources for village animal health worker (VAHWs), enhanced reporting by VAHWs and development of appropriate animal health laws. Under this subcomponent the outputs resulted in better and earlier recognition of cases of avian influenza, better information on diseases that assists in devising control and preventive strategies and also helped to reduce the impact of other animal diseases. 152. Improving veterinary legislation. The Project supported the production of new veterinary legislation for disease control and prevention. This was required to clarify the duties obligations and responsibilities of the official veterinary services and farmers in disease control and prevention. The legislation was finalized and presented to the Council of Ministers. Once passed it will provide much needed support for veterinary services in controlling avian influenza and other important diseases of livestock. 153. Strengthening the training system for VAHW. The Project supported improvements to training materials and methods of training for VAHW. The existing training methods and materials were reviewed and new updated training manuals and materials were produced in Khmer that provide information on the recognition, control, prevention and treatment of a range of important diseases of livestock and poultry. 32 154. Training of trainers. The Project supported 169 selected government staff from across the country to become trainers of VAHW. They were provided with new training materials including manuals for trainees and trainers and equipment required to allow these trainers to deliver courses, including projectors and computers, was purchased. A further 174 staff were trained to provide refresher training on avian influenza to VAHW. 155. During the project, 2122 new VAHW were trained (including 161 females and 59 indigenous persons). An additional 3230 village animal health worker (including 242 females and 155 indigenous persons) were provided with refresher training on avian influenza using newly developed and improved training materials. Furthermore, monthly meetings organized by district veterinary staff were attended by over 41,500 VAHW. These meetings provided additional opportunities for training and exchange/reporting of information on disease occurrence and disease control and prevention. The flow on effects of this training to other diseases is an additional and important benefit of the project. 156. Training of VAHW. The Project supported this vital activity resulting in refresher training of 3230 VAHW on avian influenza and full training of 2122 new VAHW. Special effort had been made to include the IP in the project development, for example, 3,230 people attended the VAHW refreshers course training organized by MAFF, and 155 of them are representatives from IP’s communities. Some 59 people from indigenous communities received training for new VAHW while 1,212 IP participated in VAHW’s monthly meeting. Of 1,255 female VAHWs in the country, 403 received training from the project, and constitute 7.5% of those who received training under the project. 157. The newly trained VAHW were provided with a basic instrument kit and attended monthly meetings with district staff to provide feedback on disease outbreaks and to gain further understanding of new or re-emerging diseases that could affect local livestock producers. Overall a total of 41,000 interactions between animal health workers and district staff occurred at monthly meetings supported by the project. By providing a well-trained cadre of VAHW, village level producers have access to basic animal health services and state veterinary services gain access to disease intelligence at the community level. VAHW see the benefit of these regular meetings and based on information gathered during the review they will continue to attend after the project is completed. 158. Support for District Veterinary Staff. The project supported the link between District Veterinary Staff and VAHW by providing them with resources to travel to villages including the supply of 210 motor cycles and fuel. 159. Strengthening the Department of Animal Health and Production (DAHP). The project provided support to DAHP through provision of computers, contract staff to ensure recording of surveillance information and vehicles therefore facilitating field investigations and interactions with provincial and district staff. 160. Strengthening capacity of Provincial and Municipal Offices. The project provided vehicles to allow these staff to conduct field visits including disease investigations. LCD projectors were also provided to each office. 161. Strengthening Laboratory Capacity. Other donors had already provided considerable support for veterinary laboratories in Cambodia. However there was still a need for new basic laboratory facilities at the National Veterinary Research Institute (NaVRI) and at provincial level. The project provided funds to fill this gap and construct these facilities. 33 A2. HPAI Investigation and Response 162. This subcomponent focused on improving the response to outbreaks of disease in particular H5N1 HPAI. 163. Rapid response to disease outbreaks. Resources provided by the project allowed investigation of every case with a high suspicion of being caused by H5N1 HPAI virus in poultry. In addition whenever cases were detected in humans follow up testing of poultry was also conducted. 164. Trials on emergency vaccination. The option of using vaccination to control and prevent outbreaks of H5N1 HPAI, as used in other countries, has not yet been adopted in Cambodia. Nevertheless it is still important to have the capacity to implement emergency vaccination in the event of an uncontrolled outbreak of avian influenza or other diseases. This must be conducted in a manner that does not result in transmission of disease by vaccinators. Training was provided to 41 district and provincial coordinators and additional training in vaccination was provided to animal health workers. This provided a platform on which to build emergency and other vaccination programs. 165. Support for emergency responses. The project facilitated the response to disease outbreaks by providing emergency supplies and vehicles. Without these it would not be possible to respond to new disease outbreaks. 166. Enhanced regional coordination. The employment of four regional coordinators under the project improved interactions between the central and provincial level. It also provided improved feedback on measures being implemented to control disease. The coordinators were also heavily involved in supporting the Healthy Livestock Healthy Village Better Life program. 167. Support for additional surveillance. Additional surveillance activities were supported by the project that allowed detection of H5N1 HPAI virus in markets. This demonstrated the on-going threat to public health and allowed viruses to be fully characterized Information from active surveillance programs was published in scientific journals by members of the Cambodian government team. The work helped to unravel the genetics of viruses in Cambodia which is crucial for helping to understand the epidemiology of the disease 17. A3. Reducing risk in production and marketing systems 168. As expected the threat from avian influenza in the region did not diminish significantly during the life of the project. In fact from 2011 onwards there was an upsurge in human cases requiring an urgent re-assessment on control and prevention of this disease. 169. Study on risks and risk reduction in production and marketing systems. The project supported studies on risks and risk reduction in market chains and also examined whether there were 17 The work allowed study of the evolution of viruses from 2004 through to 2013 (Clade 1 to Clade 1.1 including emergence of distinct Cambodian lineages) and the emergence of a novel reassortant virus that occurred about the time of the increase in cases in 2013, although the overall significance of this change remains unclear. It also allowed the identification in 2014 of a Clade 2.3.2.1c virus in two human cases similar to that already found in southern Vietnam. 34 practical ways to implement vaccination for smallholder flocks, especially duck flocks, in Cambodia (with limited scope found for application). The results from the study provided information on the risks in market chains that will be used in the future to restructure poultry markets. 170. Appropriate measures were introduced to reduce high risk practices in production and in marketing that facilitate persistence and transmission of virus. This resulted in the Healthy Livestock, Healthy Village, Better Life Program in 2011. 171. Healthy Livestock Healthy Village Better Life. 172. A range of options was explored to assist in improving control and prevention through AHICPEP and the project assisted the Government of Cambodia to implement the novel “Healthy Livestock, Healthy Village, Better Life” program. This program: • reduces the risk of avian influenza • allows villages to play an active role in disease control and prevention • prevents other animal diseases, • improves public health, • increases productivity, profitability and resilience of villagers • provides the capacity to improve nutrition and wellbeing by providing cash and high quality protein for woman and children through improved survivability of poultry. 173. If an outbreak of disease in poultry caused by H5N1 avian influenza virus were to occur, it provides opportunities to increase the likelihood of early appropriate treatment of any sick children exposed to diseased poultry through the increased awareness of village heads, VAHW and village health volunteers (VHV) and the whole community. 174. This program aims to improve disease prevention in individual communities, which is always preferable to trying to stop the disease once it occurs and becomes widespread. It has been introduced to 30 selected villages in three provinces. It has strong support from government at all levels and the communities that have been involved. It has doubled the number of chickens reared as a result of increased chick survival with a return on investment of over 100% reported in one economic assessment by an FAO consultant. 175. The introduction of the program resulted in communities working together to control and prevent disease rather than relying on single measures applied haphazardly by individuals. When disease outbreaks occur, the community introduces control measures to prevent the disease from spreading within the community through the use of simple, easily affordable, quarantine measures. None of these villages has experienced an outbreak of H5N1 HPAI since the program commenced but other diseases have occurred in and around the villages and were contained or prevented from gaining entry. 176. The program provided greater resilience to those involved. In 2013 major flooding in Battambang province inundated crops resulting in no income from this source for several months for many rural residents. However, in a village implementing the Health Livestock Healthy Village Better Life program residents still had a source of income from the extra chickens they had reared as a result of the Healthy Livestock Healthy Village Better Life program. 177. This is the first effective ‘One Health’ program in the region for avian influenza, developed in line with the recommendations from the Inter-ministerial Conference on Avian and Pandemic 35 Influenza in Hanoi in 2009, which called for multi-sector, multi-disciplinary, and community- based actions when addressing disease threats that arise at the animal-human-environment interface. 178. Although this program has only been implemented in 30 villages it provides very strong evidence for the benefits of this approach and it will be expanded. Villages that have adopted the measures can be used as models and mentors for other villages wanting to apply the measures. Funding has already been obtained from the Government of Cambodia to support the scheme after the project is closed. Construction of cages for housing chickens in Healthy Villages 179. Preparation of materials to support improvements in farm and market biosecurity. Three separate manuals were produced and used to train farmers and market traders in ways to reduce the risk from avian influenza. A4. Information, Education and Communication (IEC) 180. When the project commenced other projects were supporting avian influenza IEC activities. As these other projects were completed and the need for more publicity on avian influenza became apparent with the increase in human cases in 2011 additional funds were used in this area. Activities conducted included production of posters caps and T-shirts with appropriate messages related to avian influenza control and prevention. A number of publicity events, including village marches, were held to raise awareness of avian influenza. 36 A5. Enhancing pandemic preparedness for animal health staff 181. Staff from MAFF attended all relevant meetings on pandemic preparedness. They also gained greater familiarity with the operations of NCDM and developed a close working relationship with this center. Component B Human Health 182. The support from this project resulted in major achievements in a number of areas. These include: (a) Applied Epidemiology Training (AET) which has produced a cadre of members of rapid response teams well trained in disease investigation. The skills of these trainees will continue to build as they conduct more case investigations and this represents an investment that will provide long term returns; (b) ongoing strengthening of the national surveillance systems and response activities to outbreaks including technical assistance, information technology support for surveillance, funding of MOH’s RRT for emergency outbreak responses, training and feedback sessions by RRT for improving outbreak responses, and RRT workshop in four provinces. The RRT are still being funded by government to continue their important work; (c) development of case management guidelines, curriculum and training materials and training clinical staff from sentinel hospitals, and conduct of refresher training for clinicians in the four affected provinces; (d) strengthening laboratory capacity for conducting microbiological tests and laboratory information system through a web-based link to the national laboratory, and particularly for H5N1 in the areas of sample collection, storage and transportation, and development of National Laboratory Policy and Strategy; (e) development of a Pandemic Preparedness Plan, Rapid Containment Plan, and Risk Communication Plan for the Health Sector (MOH will revise this plan to be a “Public Health Emergency Preparedness Plan” to cover broader emerging diseases); and (f) development of the policy and strategy for infection control and waste management. 183. B1 Education for health workers. The project supported the distribution of IEC materials. Much of the work in education of village health workers had been completed before the project commenced. Training for village health workers in aspects of avian influenza was included under the Healthy Livestock Healthy Village Better Life program. Village Health workers in these villages became key focal points for villagers in the event of poultry deaths. The Applied Epidemiology training program provided by WHO resulted in a major improvement in the skills in disease investigation of the participants, and form part of rapid response teams. 184. B2 Surveillance, Investigation and Response. The project provided funds for field staff to undertake case and outbreak investigations. This included the crucial activities of the rapid response teams that investigated all human cases and assessed whether onward transmission had occurred. These teams responded within 24 hours to all cases. 185. Data collection and analysis was enhanced through standardization of reporting and analysis of surveillance data in the National level disease information system referred to as Cambodia Early Warning System (CAM EWAR). There has been improvement in ILI surveillance in the public health system attributable in part to the support of the project. Three of the nine human cases in 2014 were detected either as a result of investigations of a rapid response team (one case) or through a specific active surveillance program (the febrile illness study conducted by the Health Department in conjunction with United States Naval Medical Research Unit (NAMRU-2) (two cases). Without these programs these cases would likely have gone undiagnosed, demonstrating the importance of active surveillance in case detection. ILI surveillance reports were delivered on time. The number of ILI sites increased from 60 to 10. 37 186. B3 Case Management and infection control. The project supported activities in hospitals at provincial level to allow for assessment and management of cases before referral to one of 5 national hospitals designated to handle avian influenza cases. This included the purchase of supplies, ambulances and equipment such as PPE at 5 hospitals. Training was also provided in infection control and waste management. Availability of antiviral medications at lower level hospitals now allows for earlier treatment on the basis of exposure history and clinical signs, before laboratory confirmation is obtained. This is also believed to have played some role in the reduction in fatal cases in 2013. 100% of staff targeted on infection control and case management was trained. All suspected cases were treated in accordance with infection control and case management guidelines demonstrating the effectiveness of the training. 187. B4 Laboratory support. The project supported strengthening of human health laboratories and the development of the national laboratory policy and strategy. This contributed to the increase in the number of laboratories performing testing for avian influenza which may have played a role in the increase in the number of cases detected. 188. B5 Pandemic preparedness planning. The pandemic preparedness plan was produced and was tested in desk top exercises. It was tested in the 2009 influenza pandemic and also with outbreaks of other diseases including cholera. 189. B6. Rapid containment plans. The rapid containment plan was developed. Component C Inter-Ministerial Cooperation for Pandemic Preparedness and Project Coordination 190. The Inter-Ministerial Cooperation for Pandemic Preparedness and Project Coordination achieved its component objectives. All activities planned have been completed. The Disaster Management Law has been drafted but has not been ratified due to factors beyond the control of the project. Pandemic Preparedness, Response and Recovery Program (PPRRP) have achieved most of its targets. The existing NCDM Emergency MIS (EMIS) and project monitoring and evaluation (M&E) systems and its framework, tools and software have been used by IAs. A KAP survey was conducted, the report finalized and findings used in developing new IEC materials. The end-of-the project evaluation was conducted by an international consultant and the report has been finalized. Project Management and Inter-Ministerial Coordination has functioned properly and effectively, including support for the overall implementation arrangements for the project as a whole, covering project coordination, ensuring linkages across relevant agencies and with international partners, and for guiding and monitoring project implementation at the central level. 191. C1 NCDM Capacity Building NCDM Secretariat. The project supported the establishment of a full time NCDM secretariat to support integration of actions in the event of an influenza pandemic and to support actions in the event of other disasters. 192. Draft Disaster Management Law. The project funded the drafting of the Disaster Management (DM) Law. This has been reviewed and edited in the Inter-Ministerial Meeting at the Council of Ministers and re-submitted following the July 2013 national elections but it is still not ratified. The final draft is ready to be re-submitted to the Council of Ministers for approval. Eleven consultative meeting/workshops on the draft law were organized at national and sub-national levels with government officials, NGOs and development partners. Ten training sessions on disaster management concepts and AHI have been organized and completed in nine provinces (one training session in each province) and one at the national level. 38 193. C2 Pandemic preparedness, response and recovery program (PPRRP). The PPRRP was fully developed and tested in nine provinces. Line ministries staff were trained on influenza pandemics. PPRRP workshops were organized for 63 media officers from 22 state and private radios, TV stations and newspapers to enable them to effectively relay and transmit AHI messages and issues to the public. PPRRP workshops were also organized for sub-national staff, including the PPRRP formulation in nine provinces. 194. C3 NCDM Emergency Management Information System and M&E system. The project funded the development of the NCDM Emergency Management IS (EMIS) and M&E systems and its framework, tools and software have been developed and used by NCDM, MOH and MAFF. Moreover, the project also trained media officers from state and private institutions to enable them to effectively relay and transmit AHI messages and issues to the public through their media channels. The EMIS was developed in consultation with stakeholders. Training and refresher training on EMIS was conducted for NCDM national and provincial staff to improve capacity on EMIS software and the effective collecting and management of emergency data. The M&E system is now fully established and effectively used by NCDM, MOH and MAFF during the project period. The project not only built the capacity of national project staff but also provincial staff on monitoring and evaluation and the EMIS. Four training sessions were also organized in regional centers which were attended by provincial line department staff from MAFF, MOH and PCDM. It is expected the government will continue to use the emergency MIS (EMIS) and M&E systems after project completion. 195. C4 Pandemic preparedness activities have been incorporated into the existing Community Based Disaster Risk Reduction Programs (CBDRM). Stakeholder consultations on pandemic preparedness integration into CBDRM were organized in 23 provinces and the commune emergency management system was also established in all communes/sangkats in the country. Seven Training of Trainer (ToT) sessions were conducted in six districts of the three high risk provinces for focal persons on the integration of AHI into the CBDRM Program. This was complemented by actual planning exercises to enable participants to immediately apply what they have learned. Public awareness campaigns on AHI were organized in cooperation with MAFF in Phnom Penh and Siem Reap, and Preah Sihanouk. The IEC materials were produced in consultation with MOH and MAFF and distributed to communities to improve their awareness on pandemic preparedness. The project also organized seven review workshops in six districts of the three high risk provinces to review DRR plans. 39 Annex 3. Economic and Financial Analysis 196. Undertaking economic analysis of a project of this type is problematic. The major reason for conducting the project is to control avian influenza so as to reduce the likelihood of emergence of an agent that produces a severe global pandemic. The global costs associated with a severe influenza pandemic in terms of lost GDP are estimated at $3 trillion but it is not possible to quantify the extent to which this risk has been reduced as a result of project activities. The activities of rapid response teams in monitoring for human to human transmission of avian influenza virus following zoonotic human cases is a form of insurance but no sustained transmission was detected. 197. As an avian influenza pandemic did not emerge it is not possible to determine precisely the effectiveness of the investment in pandemic responses. Nevertheless it is possible to demonstrate that only minor improvements in pandemic preparedness and response would provide a return on the investment. 198. According to the original project Technical Annex the direct costs of a severe human influenza pandemic to Cambodia were estimated to be $195 million. . An early response to a severe pandemic, coordinated by NCDM, resulting in uptake of non-therapeutic measures such as social distancing by communities, could reduce this cost significantly. The total budget for activities under pandemic preparedness represent only 1.1% of the estimated cost of a severe pandemic to Cambodia suggesting that there would be a significant return on the investment if a severe pandemic were to occur. 199. In addition, the investments in the Health sector would be recovered if early identification and treatment of cases (key elements of this project managed by the Ministry of Health) reduced hospitalization rates in a severe pandemic by only 2% (8400/420,000), and if survival of patients infected with the virus increased by 1.3% (819/63,000) as a result of investments in enhanced treatment protocols and isolation facilities in hospitals then the investments in to the Health Sector (Component B – total investment $2.65 million). 200. The overall cost to the community from avian influenza in poultry has not been as large as anticipated in the initial economic assessment which, in part, may reflect improved control of the disease as a result of project activities. This assessment assumed a loss of 17.5% of the poultry in Cambodia (approximately 5 million head) but this scenario was derived from experiences in Vietnam in 2004 when wide area culling was used in an effort to control the disease. This method of control has since been abandoned in countries where the virus is endemic because of the severe costs to the community and the fact that it did not eliminate the virus. 201. Instead, most outbreaks in Cambodia only affect a small number of individual flocks or villages with culling restricted to the affected flock or village. The total cost of poultry deaths in the initial assessment, assuming 17.5% death rate and an average value per head of $1.5 was estimated at $7,612,500. It was assumed in the original benefit cost ratio that these losses would no longer occur once the project was fully implemented resulting in savings of this amount. 202. Avian influenza has caused multiple outbreaks of disease over the life of the project but most of these have been localized and overall resulted in the death and destruction of fewer than 30, 000 poultry in the past 5 years. For example, in 2013, based on official reports to OIE, some 14900 head of poultry died or were destroyed in 7 outbreaks. Even assuming that only 20% of cases are reported the total cost to the Cambodian economy is still relatively low (c. 150,000 head of poultry x $4.50 (the value of meat poultry at market) at approximately $675,000 for the life of the project, 40 although individual farmers and villagers still suffered severe losses when all of their poultry died. As discussed above it is also not possible to determine the extent to which the measures implemented reduced the number of cases in poultry. However focusing only on avian influenza understates the economic benefits of this project. 203. One of the key elements of the project was the training of village animal health workers in the control and prevention of animal diseases. These workers provide services to local villages on a fee for service basis and have been trained in application and benefits of vaccination of livestock including poultry. A number of vaccine preventable diseases are endemic to Cambodia including foot-and-mouth disease, blackleg, hemorrhagic septicemia, hog cholera, fowl cholera, duck virus enteritis and Newcastle disease. Rabies is also endemic in the canine population. 204. Having access to trained VAHW provides farmers with access to basic preventive services. It is estimated that if each of the VAHWs involved with the project (either through initial training, refresher training or VAHW meetings with District staff) undertook full vaccination of 2000 chickens annually for Newcastle disease in his/her village then this could result in savings of approximately $1.25 million per annum even if Newcastle disease (prior to vaccination) only occurred in the village once every 10 years. Number of villages with trained VAHW 5000 Poultry vaccinated per village per annum 2000 Villages affected per annum (without vaccination) 500 Total birds vaccinated per annum 10,000,000 Cost of vaccination (10 cents per bird) $1,000,000 Value per meat bird at market (from Hinrichs) $4.50 Mortality rate in unvaccinated birds 50% Bird losses prevented per annum 500,000 Total for bird losses prevented $2.25 million Total savings per annum $1.25 million 205. For pigs, preventing animals from dying from vaccine-preventable diseases such as hog cholera would result in annual savings of $450,000, based on a conservative value of $100 per head. This would require full vaccination of only 100 pigs by each trained VAHW, per annum assuming 20% of villages are exposed to this disease every year. Number of villages with trained VAHW 5000 Pigs vaccinated per village per annum 100 Villages affected per annum (without vaccination) 500 Total pigs vaccinated per annum 500,000 Cost of vaccination ($0.1 per pig) $50,000 Average value per pig $100 Mortality rate in unvaccinated pigs 10% Pig losses prevented per annum 5000 Total for pig losses prevented $500,000 Total savings per annum $450,000 206. For cattle and buffalo preventing 2% cattle dying from vaccine preventable disease vaccine each year from vaccine preventable diseases per village served by village animal health workers trained 41 by the project represents a saving of some $1.2 million per annum, based on a conservative value of $500 per head 18. Number of villages with trained VAHW 5000 Cattle vaccinated per village per annum 50 Villages affected per annum (without vaccination) 500 Total cattle vaccinated per annum 250,000 Cost of vaccination ($0.2 per animal) $50,000 Value per animal $500 Mortality rate in unvaccinated cattle (estimate) 10% Cattle losses prevented per annum 5000 Total for cattle losses prevented $1,250,000 Total savings per annum $1.2 million 207. If these modest gains are achieved as a result of training of VAHW, the overall benefit in one year would be approximately one third of the project investment in animal health ($6.07 million). 18 A review of the costs and benefits of vaccination against haemorrhagic septicaemia in Cambodia has been published recently – see Kawasaki M, Young JR, Suon S, Bush RD, Windsor PA (2013). The Socio-economic Impacts of Clinically Diagnosed Haemorrhagic Septicaemia on Smallholder Large Ruminant Farmers in Cambodia. Transbound Emerg Dis. 2013 Oct 8. This paper suggests losses to households can be more than $900 as a result of this disease. A more conservative figure has been used in the calculations above 42 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Evelyn Bautista-Laguidao Senior Executive Assistant CROVP Alan L. Piazza Senior Economist EASSD TTL (2008 Board) Hope Phillips Volker Senior Operations Officer EASHD Co-TTL (2007) Piers Merrick Senior Operations Officer MNA TTL (2007, Guzman Garcia-Rivero Operations Adviser EASRD Preparation) Mudita Chamroeun Senior Rural Development Specialist GFADR Task Team Steven Schonberger Practice Manager Officer EASRD Laurent Msellati Practice Manager GFADR Murray Mclean Consultant, Veterinary EASRD Animal Health Project Cost/Economic Surajit Goswami Consultant, Economist EASRD Analysis Ethel Joyce Yu Program Assistant CSODR Supervision/ICR Alan Piazza Senior Economist SDV TTL Mudita Chamroeun Senior Rural Development Specialist GFADR TTL (2010) Guzman P. Garcia-Rivero Consultant GFADR Maria Theresa G. Senior Operations GFADR Quinones Officer ICR primary author, FAOCP/G Leslie David Sims Consultant and Animal Health FADR Specialist Task Team Leader for Laura Rose Senior Economist GHNDR the Cambodia’s HSSP2 Task Team Leader for Timothy A. Johnston Sector Leader ECCU4 the Cambodia’s HSSP2 Ahsan Ali Lead Procurement Specialist GGODR Nina Bhatt Senior Social Development Specialist GSURR Satoshi Ishihra Senior Social Development Specialist GSURR 43 Financial Management Seida Heng Consultant GFMDR Specialist Financial Management Reaksmey Keo Sok Financial Management Specialist GGODR Specialist Amara Khiev Operations Assistant EACSF Bunlong Leng Environmental Specialist GENDR Nareth Ly Operations Officer GHNDR Teri Nachazel Program Assistant MNCA4 Narya Ou Program Assistant EACSF Sreng Sok Procurement Specialist GGODR Communications and Saroeun Bou Communications Officer EAPEC IEC Jun Zeng Social Development Specialist GSURR Social Safeguards Implementation Sarin Khim Consultant GFADR Support Samnang Hir Consultant GEDDR Infrastructure Hafiz Khairul Consultant GFADR M&E Consultant (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY06 37.65 289.64 FY07 16.53 105.44 FY08 21.60 150.44 Total: 545.52 Supervision/ICR FY06 0.00 FY07 0.00 FY08 0.8 4.02 FY09 16.98 65.03 FY10 14.07 69.54 FY11 12.76 62.61 FY12 16.19 57.27 FY13 15.55 41.31 FY14 14.17 53.99 FY15 0.00 4.80 Total: 357.57 44 Annex 5. Beneficiary Survey Results 208. No beneficiary survey was carried out as part of the ICR preparation, however, the project used information from the KAP survey undertaken in 2012-2013, The KAP data collected was wide ranging and clearly structured with 612 respondents being interviewed from five different provinces from throughout Cambodia. Most all of the respondents who were questioned had minimal education and were of limited financial means. They were villagers living in rural areas in Cambodia, whose relationship with poultry mostly consists of small backyard concerns for self- consumption. Only 13 percent of the respondents were small commercial poultry farmers. Most of the poultry raised and slaughtered does chicken (81 percent), with duck comprise most all of the remainder at 17 percent. 209. The villagers had a clear understanding of AI, and understood that AI can spread from poultry to poultry and sometimes from poultry to humans, and more specifically, 86 percent of the respondents realized that AI is primarily spread via sick and weakened poultry. And yet, only about half of the villagers knew of the specific symptoms that would manifest in a human case of AI. An area of great concern is that a surprisingly large number of the respondents – 75 percent – would allow poultry to have access to their homes. The chickens could wander as they wished and were usually only confined at night. The fact that only 68 percent of the households would actually separate and isolate poultry that are demonstrating symptoms of disease could easily become a gateway for the spread of AI. 210. Another area of concern is the general lack of hygiene in relation to both the cleaning of hands as well as of the utensils used in the slaughter and preparation of poultry – only about half of the villages clean the utensils used for cooking. Another problematic situation is in relation to the 67 percent of respondents who stated that they did not separate cooked and raw food during the cooking process. This is potentially a cause for concern. Clearly, there are several areas of respondent behavior and habitual daily practice that are disturbing, and where a supportive educational initiative could be helpful. 211. Another clear finding of the report, in spite of the high level of awareness of the implications of AI which owed to AHICPEP’s activities to contribute to an increase in the knowledge base and behavioral change towards AHI, was that a significant number of people continued to consume sick and dead poultry, who allowed their poultry to wander freely in their homes, and who continued to engage with poor standards of hygiene in relation to the slaughtering and preparation of the poultry as food. There was also a clear exaggeration and reluctance to report sick/dead birds or possible AI cases to the authorities. Perhaps the actual impacts of the AI outbreaks, which have resulted in relatively minimal loss of life, have led to relaxed attitudes in relation to the disease. As with traffic accidents, it always happens to someone else. 212. In conclusion the data obtained from the village KI concerning the AHI KAP had been presented. A focus was initially placed on accumulating some general information about the KI, then the interview process was aimed at ascertaining what was generally known about AI by the KI. The last phase, where the interviewing the KI took place, was to seek out information in relation to both the preparedness and responses to Avian Influenza. 213. A group of 82 KI respondents was identified and interviewed. An average of three KI candidates from each village was interviewed with the KAP survey protocol. The vast majority had heard of AI and a still significant number (80 percent) thought that there was the potential for a serious outbreak of Avian Influenza. There was less stated knowledge about the specific symptoms of 45 what comprised a typical contraction of AI. About half of the KI respondents expressed that fever and flu would present as likely symptoms. 214. The KI were then asked to respond to the following question: “If you were asked to prepare a plan to deal with these problems, what would be the important actions you would suggest?” This question leads to some interesting and helpful responses. The majority (with 83 percent) made the suggestion that an Avian and Human Influenza campaign should be set up in order to effectively deal with a real or perceived outbreak of AI. Such an educational campaign was thought to be useful in bringing a practical awareness of how to combat and respond to an outbreak of AI. And finally, half of the KI respondents thought that an organized sanitation awareness campaign was needed to help prevent, or at least to lessen the impact of an Influenza outbreak in Cambodia. 215. The questioning of the KI focused on the training for the prevention, surveillance, and the reporting. A highly significant number – 91 percent – stated that they had received some kind of training in relation to AI in Cambodia. Half of this number was later visited by health authorities as a follow up measure. As can be seen, Cambodia has made clear headway in an organized way to prepare for a possible AI outbreak owing to AHICPEP being able to build capacity to prepare for, control and respond to AI. However, there is doubt about the ability to sustain an effort towards preparing for a possible AI outbreak, particularly post AHICPEP. 46 Annex 6. Stakeholder Workshop Report and Results 216. The end-of-the project evaluation has been conducted by an external international consultant, including stakeholder workshop in May 2013 and the workshop reports/results/comments have been incorporated under “End project evaluation report”. However, the project has been decided to extend for another ten months from June 30, 2013 to April 30, 2014, and the final Recipient’s completion report has been submitted to the World Bank in June 2014. Even this is not an intensive learning ICR, an implementation completion and results mission in May-June, 2014 conducted with an intensive discussion, meetings and field visit to meet with the beneficiaries, villagers and affected people. A wrap-up meeting was held at different level, and stakeholders as well as a comprehensive wrap-up was held at NCDM on June 11, 2014, to discuss the main outcomes of the DPO with broad representation from Government’s agencies as well as other donors and stakeholders. 217. List of Attendees and Persons Met in Cambodia: N Name Position Institution o. 1 H.E. Dr. Nhim Vanda 1st Vice President of NCDM and PD NCDM 2 H.E. Hang Samoeun Vice President of NCDM NCDM 3 H.E. Prof. Eng Huot Secretary of State and Program Director MOH 4 H.E. Orm Kimsear Secretary of State MAFF 5 H.E. Ponn Narith Secretary General NCDM 6 H.E. Lam Heng Hout Deputy Secretary General and Deputy PD NCDM 7 H.E. Kim Vothana Deputy Secretary General and PM NCDM 8 H.E. Keo Vy Supporting Staff NCDM 9 H.E. Nith Hel Advisor NCDM 10 H.E. Seak Vichet Advisor NCDM 11 H.E. Bun Vandy Assistant, 1st Vice President of NCDM NCDM 12 Mr. Khun Sokha Director of Training NCDM 13 Mr. Ou Chandy Deputy Director General NCDM 14 Mr. Phlang Pouleu Rath Technical Officer NCDM 15 Mr. Peou Sopheap Chief of Finance NCDM 16 Mr. Phay Sopheap Procurement Officer NCDM 17 Ms. Suy Rina Accountant Officer NCDM 18 Mr. Ku Bunnavuth NTC NCDM 19 Mr. Phoeun Sophak CBDRM Consultant NCDM 20 Mr. Chhea Layhy NTC NCDM 21 Mr. Mao Saohorn Technical Officer NCDM 22 Mr. Thin Phirun Assistant to 2nd V2 NCDM 23 Mr. Houn Sin Admin Assistant NCDM 24 Mr. Chhuon Samrith Director of Department of Cooperation and Debt MEF Management, General department of Budget, Ministry of economy and finance 25 Mr. Tauch Chankresna Deputy Director, Department of Cooperation and MEF Debt Management, General Department of Budget 26 Mr. Houl Bonnaroth Chief, Office of Multilateral Cooperation 2 MEF (OMC2), Department of Cooperation and Debt Management, General Department of Budget 27 Mr. Im Soeun Project Officer MEF 28 Ms. Thin Saro Deputy Chief MEF 47 29 Dr. Sorn San Project Director DAHP/MAFF 30 Dr. Than Sovyra Project Manager DAHP/MAFF 31 Ms. Heng Morany Accountant Officer DAHP/MAFF 32 Mr. Song Kim Chhuon M&E Consultant DAHP/MAFF 33 Ms. Phauk Khun Financial Officer DAHP/MAFF 34 Mr. Chan Sovan TCC, DAHP DAHP/MAFF 35 Dr. Ly Sovann Deputy Director of Communicable Disease Control CDC/MOH Department 36 Dr. Chan Vuthy Vice Chief of DSB CDC/MOH 37 Dr. Khuon Vibol Planning Officer HSSP2/MOH 38 Mr. Kong Taing Eng Finance Officer HSSP2/MOHFM EF 39 Dr. Kak Seila Hospital Director, Isolation Room in Battambang Battambang province 40 Mr. Pen Setha NaVRI Lab Manager Battambang province 41 Mr. Meng Sothy Deputy Director, Provincial Department of Agr Takeo 42 Mr. Sor Daro Vice Chief of Provincial DAHP Takeo 43 Mr. Chan Chorn Vice Chief Takeo 44 Mr. Kan Ra Director of Multi-Sectors, Sala Khet Takeo 45 Mr. Hem Salot Director of Provincial Health Department Takeo 46 Mr. Tom Kimly Chief of Provincial Health Development Takeo 47 Mr. Ith Eng Sror RRT, OD Prykabas, Takeo 48 Mr. Leng Pharak RRT, H.C. Kransla Takeo 49 Mr. Kang It Districk Coordinator Tram Kak District Takeo 50 15 IP, Souy indigenous Kor Dauntie Village, Trapaing Chor Commune, O'Ral Kampong Speu People (Elderly, adult and District children) 51 Mr. Georges Dehoux Attaché/Cooperation Section EU Delegation of the European Union in the Kingdom of Cambodia 52 Dr. Dirk L. Van Aken Livestock Sector Expert, EU/NIRAS EU 53 Mr. Naoki MITORI 1st Secretary/Head of Economy and Economic Embassy of Cooperation Japan 54 Ms. Nina Brandstrup Representative, FAO FAO 55 Mr. Lotfi Allal ECTAD Team Leader FAO 56 Dr. Dong-il Ahn Representative, WHO WHO 57 Dr. Reiko Tsuyuoka Emerging Diseases Surveillance and Response/Team WHO Leader 58 Mr. Alassane Sow Country Manager WB 59 Ms. Mudita Chamroeum Task Team Leader/Senior Rural Development WB Specialist 60 Ms. Laura Rose Senior Health Economist/Task Team Leader, HSSP2 WB 61 Maria Theresa G. Quinones Senior Operations Officer WB 62 Mr. Les Sims ICR Author/Animal Health Specialist, Consultant WB/FAO 63 Mr. Jun Zeng Social Development/Social Safeguard Specialist WB (EASCS) 64 Mr. Reaksmey Keo Sok Financial Management Specialist WB 65 Ms. Nareth Ly Operations Officer WB 66 Mr. Saroeun Bou Communications Officer WB 67 Mr. Sreng Sok Procurement Specialist WB 68 Mr. Bunlong Leng Environmental Specialist, Consultant WB 69 Mr. Samnang Hir Infrastructure Specialist, Consultant WB 48 70 Mr. Khairul Hafiz M&E Consultant, Consultant WB 71 Mr. Khim Sarin Implementation Support Specialist WB 72 Ms. Narya Ou Program Assistant WB 218. A presentation was made on preliminary findings of the ICR mission. In general, there was agreement on the analysis and the ratings. Several points were raised and finalized and documented in the Aide Memoire of the Implementation Completion and Results Mission Report, as well as in the management letter dated June 24, 2014 to the government counterparts, which also form as a basis for this final write up of the ICR. In addition, the mission team also receive a final recipient’s completion report (RCP) on June 11, 2014. 219. The agreed next step and recommendations formed at the Wrap-Up: a) Although the project has been completed a number of actions recommendations for further activities to consolidate gains from the project. This provides a summary of the actions recommended throughout this document to ensure that the gains from the project are sustained and the final administrative steps are completed. b) The project has been successful and, as demonstrated by the high level of achievement of the PDO and the intermediate results indicators, the Implementation Agencies have done an excellent job of project implementation. The Bank team would nevertheless like to highlight the following key points for consideration by the government and the international community: • Continuing Disease Threat. Cambodia accounted for two thirds of the world’s human H5N1 cases in 2013. While the project design recognized from the outset that the H5N1 avian influenza virus would not be eradicated in Cambodia, the project has made some significant contributions in addressing the risks and in preparing for a major pandemic. This is because poultry disease reporting is still imperfect, messages about not preparing sick or dead poultry for consumption are not being followed by a proportion of households, and possible human H5N1 cases are not always being identified at the local level quickly enough to save lives, largely because these cases are being treated first by private sector health care workers. However, the following challenges continue to exist: (i) poultry disease reporting is still imperfect; (ii) messages about not consuming sick or dead poultry are not being heeded by all; and (iii) possible human H5N1 cases are not always being identified at the local level quickly enough to save lives. Furthermore, the avian influenza (H7N9) virus in China has the potential to spread through the region, representing another public health and pandemic risk. These challenges require the continuing implementation of activities supported under the project. It shows that the work being done by NCDM on pandemic preparedness is still required and should be extended. • Innovative and Alternative Solutions. The project has supported innovative solutions to these problems such as the highly successful Healthy Livestock, Healthy Village, Better Life pilot (which was not in the original project design). It is an excellent example of a community-based One Health program. In addition, the government now seems to be ready to reconsider its position on incentives to offset poultry owners’ losses on the culling of H5N1 contact poultry. The possibility of vaccination against H5N1 in the Healthy Livestock, Healthy Village, Better Life program should also be re-assessed by the government for possible implementation. 49 c) The Implementing Agencies advised the mission that they strongly believe that the project’s activities need to be pursued and the achievements consolidated. They have highlighted the facts that: (a) the avian influenza continues to threaten Cambodia and other countries in the region, and (b) the project has developed a highly promising and successful solution to this ongoing threat. In this context, the mission was informed that the Government has provided some US$700,000 in funding for support for the Agriculture sector, the Health sector will continue to receive funds from government and through HSSP2 and NCDM is expected to receive support from the Asian Development Bank. 50 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR 220. Avian and Human Influenza Control and Preparedness Emergency Project (AHICPEP) was implemented in Cambodia with funding support from Multi Donor Trust Fund, contributed by IDA, PHRD and AHIF in an overall objective of assisting the Royal Government of Cambodia in implementing its comprehensive Avian and Human Influenza (AHI) National Plan, specifically, to minimize the threat posed to humans and to the poultry industry by AHI infection, and to prepare for, control, and respond if necessary to human influenza pandemics in the country. The project had three components: Component A carried out through Ministry of Agriculture, Forestry and Fishery (MAFF) called "Animal Health Systems", Component B carried out through Ministry of Health (MOH) called "Human Health Systems", and Component C carried out through National Committee for Disaster Management (NCDM) called "Inter-Ministerial Cooperation for Pandemic Preparedness and Project Coordination". 221. The independent end-project evaluation team and the World Bank missions evidenced the project activities consistent with the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI). The AHICPEP was successful in many ways with overall ‘Satisfactory’ implementation rating but the H5N1 threats persist in Cambodia. The National Comprehensive Pandemic Preparedness and Emergency Response Plan remains priority for the RGC due to the prevailing threats of H5N1 and potential threats from H7N9. 222. Multi-sectoral project like AHICPEP requires strong inter-ministerial coordination. NCDM have made a good example of inter-ministerial coordination. Such successful coordination experience is very valuable for the Cambodian Government to replicate in its multi-sectoral programs. In order to enhance the supports and make the system effective, there is a need to have adequate legal supports. In this regard, MAFF finalized the Animal Health and Production Law and submitted to the Council of Ministers for enactment process. NCDM also reviewing the comment from Council of Ministers on the draft Disaster Management (DM) Law and will finalize it to facilitate inter- ministerial coordination, pandemic preparedness and emergency response activities; and MOH should have the Communicable Diseases Control policy to increase the capacity of infection control, communicable diseases and case management efficiently, enhance the lab capacity to better address the H5N1 and also potential risks of H7N9. 223. In order to enhance public awareness on pandemic outbreak, respective project authorities conducted awareness campaigns through mass media – Radio, TV, and newspapers, especially before the key social events like Chines New Year, Khmer New year, and Pchhum Ben (Ancestors’ day) Ceremony. To further reach out the information at the grass root community people, community forum events were organized with IEC materials, video clip, songs, comedy, painting/arts and debating among university and school students from number of villages and communes of different parts of the country, engaging all possible public media focusing on how to deal with sick and dead poultry, consequences of eating sick or dead poultry, etc. The Comprehensive Pandemic Preparedness and Emergency Response Plan at sub-national level developed incorporating the provincial line sectors investing the lessons learned from the respective provinces. The contribution of the Rapid Response Team (RRT) made significant positive impacts in pandemic risk reduction and response efforts at sub-national level. 224. The progress of the activities, effectiveness of the system and efficiency of the team members found relatively weak in the health systems at sub-national and local levels. NCDM needs to keep supporting the strategic approaches for PPRRP engaging stakeholders and private sectors at respective areas and add mock-drills with simulation exercises at all higher risk provinces. 51 225. In Cambodia, bird-flu outbreaks occur mainly from villages. So, the project engaged and intervened to improve the capacity of Village Surveillance Team, VAHW, VHSG, Village Chief and Deputy Village Chief, Commune Council Members, HC staffs in investigation, reporting and supporting in overall needs for the villagers so they know how to address the outbreak. There is a strong request from the provincial levels to create an Emergency Fund with supporting guidelines at sub-national levels to support emergency planning and implementation, as there is no available budget to support during the emergency. It is important to continue the capacity improvement of the RHs, HCs, and representatives from Villages; and private hospitals/ clinics to ensure available services on AHI if any outbreak. 226. The “Healthy Livestock, Healthy Village and Better Life program” implemented in 30 high risk villages under this project, has been recognized as an innovative and proven profitable scheme for Cambodian villages on global “one health” approach. The scheme contributed in village households’ poverty reduction as well as social safety net against disease outbreak. 227. The IP villagers are considered more vulnerable to AHI and other communicable diseases due to low capacity, language limitations, less communication with the on-going developments. In order to improve their capacity and ensure access to proper information on AHI, a gender balanced IPs team with at least six persons along with VAHW, VHSG, Village Chief, Deputy Village Chief, CRC Volunteers from each village as the focal points were empowered to carry out the support services for the respective IP villages on AHI issues. The IP culture and gender sensitive refresher courses needs to continue at least two times a year to sustain the community capacity, to enhance coordination, and to make more effective in disease investigation and reporting from the villages, in case of any outbreak. 228. The Prime Minister of Cambodia, Somdech Hun Sen expressed during the closing ceremony of an agricultural conference on 28 March, 2014 that even the government has done a lot in past few years, the country needed to prepare more measures to curb the spreading of H5N1 strain of avian influenza, which broke out the worst last year and this year. Experts say most communicable diseases are preventable. The concerned actors along with the development partners need to analyze the root cause of the AHI in Cambodia and set up a funding flow system to sustain a collaborative effort with multiple disciplines – working locally, nationally, regionally and globally to attain the best condition for human and animal health and the environment. 229. Overall, AHICPEP has played a vital role during 2008-2014 in establishing a strong platform in Cambodia on which longer term successful control and preventive programs for avian influenza can be fostered. Cambodian people are grateful to the World Bank, Japan government, European Union and other AHI funding countries who not only contributed in this life saving project by funding but also supported by regular implementation and supervision missions, led by the Task Team Leader, Ms. Mudita Chamroeun (Senior Rural Development Specialist, GFADR). 52 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders 230. The draft ICR mission Aide Memoire has been discussed with the other development partners and stakeholders at the May 29 to June 11, 2014 mission and the draft ICR have been sent out for comments to EU, Japanese Embassy, WHO and FAO and their comments have been incorporated in the final version. 231. FAO: The report gives a balanced assessment of the successes, challenges and recommendation of the project. 232. WHO: All comments from WHO partner are presented and addressed in page vii under comments of indicator 14.b.7, and para. 179. 233. European Union (EU): The EU commented that the report appropriately reflects the need for a pragmatic approach to emergency animal disease control initiatives and put into perspective the difficulties encountered when donor funds need to be translated into emergency operations, with 23 months delay before the programme became operational. It clearly explains that the high ambition of ‘eradication’ of H5N1 from Cambodia was not feasible during the life of the project and the need for revised National Plans in view of the reality that the virus will not be eliminated. 234. Though the project is classified as emergency disease control, the activities implemented are rather those of a project on institutional strengthening. This indeed reflects the reality of Cambodia and the need for Programme Based approaches. The emphasis on the need to strengthen veterinary services is highly relevant. 235. It is acknowledged that poverty remains the main driver for persistence of AHI. It is also known from other countries that money is the main driver for successful animal disease control programmes. 236. Related to the previous comment, village initiatives showed that even small changes in ‘wealth creation’ can have a positive impact on disease control. 237. Improved knowledge on diseases leads to increased reporting, which may give an impression of increased disease incidence. To measure progress of initiatives on disease control it is important to carefully choose a combination of indicators (as has been done in this WB project) and to properly explain to non-technical higher government officials, that increased level of reporting is a necessary first step to successful disease control. Special reference is made to the indicator on improved performance of animal health and human health services, measuring the number of cases reported and time to respond. 238. The project supported multisectoral and interministerial cooperation. At the time of implementation, RGC started working with DPs towards Program Based Approaches. It would be useful to know if any dialogues on this subject were conducted within the framework of this project. 239. The report depicts the AHICPEP project very much as a standalone project. 240. It would be useful to describe briefly how the project has made use of national initiatives that had started before the WB intervention and how the project used and expanded on experiences gained by previous initiatives. Reference should be made, among others, to activities implemented by FAO (e.g. the EU-funded Smallholder Livestock Production Program (2005-2010), from which 53 VAHW training materials and initiatives such as village biosecurity have been used as basis for developing activities in the AHICPEP). 241. The AHICPEP emphasized on the animal health and veterinary services aspects of AHI control. AHI control is a transboundary issue which requires regional coordination between countries. The report does not make reference to the FAO/OIE Global Framework for the progressive control of Transboundary Animal Diseases (GF-TADs), which is the facilitating mechanism that endeavors to empower regional alliances in the fight against transboundary animal diseases (TADs), to provide for capacity building and to assist in establishing programs for the specific control of TADs based on regional priorities. Any coordination made with GF-TADs, by the project or by DAHP, should be mentioned. 242. The report highlights that surveillance for AI and other emerging diseases remains an important and expensive activity, and the need for sustained funding. It would be useful to include in the report any information from exercises in resource mapping by the respective ministries. The Livestock Component of the EU-funded Program 'Promotion of inclusive and sustainable growth in the Agricultural Sector: Fisheries and Livestock', would provide support for surveillance activities in the provinces, collection and shipment of samples, and emergency animal disease control. 243. The report emphasizes the need for logistic support to animal disease control. 244. There are clear details on the number of motorbikes that were procured, but numbers of vehicles are not mentioned. 245. On the other hand, the report highlights that vehicles provided for the project have been extremely valuable in getting district, provincial and national staff to the field and that the project provides a strong justification for ensuring all districts have access to a vehicle and petrol for case investigations and follow up meetings with VAHW. 246. Noted risks to sustainability are limited lifespan of vehicles and the need government funds for petrol and vehicle maintenance and eventually vehicle replacement. 247. If details could be provided on experiences in logistics management and estimated requirements in the WB project, these could serve as valuable lessons learned for future initiatives. Sustainability of this logistics aspect is also related to Government commitment to AHI/TADs control; e.g. according to the DAHP, the vehicles supplied to DAHP under this WB project are supposed to be transferred to MAFF for ‘general’ purposes. 248. The report mentions the successful establishment of an M&E system used by NCDM, MOH and MAFF. It would be useful if this could be shared with DPs. 249. The report states that for DAHP no initiatives are in place that could provide support to AI control under a wider context of strengthening the veterinary services. EU has provided past and present EU support to veterinary services. " 54 Annex 9. Compensation and Vaccination 250. During the review of the project these two issues were raised because they are used in other countries to assist in control of the disease in poultry. The fact that they are not used may provide some explanation for the increase in cases seen in Cambodia but not elsewhere. These issues are discussed below. 251. There is no doubt that the payment of cash compensation during the course of the project would have facilitated activities in the field when avian cases were detected and animals had to culled. Most also hold the view that availability of compensation would have increased reporting and therefore may have reduced the number of human cases if more people had reported poultry deaths. However, we cannot quantify the extent to which this would have occurred and a number of factors influence decisions to report. 252. Experiences from a number of other countries where generous compensation was available demonstrate that disease reports do not always occur despite the availability of compensation (as was seen with outbreaks of H5N1 HPAI in Hong Kong SAR, China in 2002 and Japan in 2004). It is pertinent that the knowledge, attitudes and practices survey conducted in 2013 in Cambodia found that only 8% of respondents who said they would not report dead birds to authorities saw lack of compensation as the reason for not reporting. 253. Availability of compensation would not have resulted in disease elimination largely because much of the infection in ducks is silent and cannot be detected without regular testing of all duck flocks. Farmers do not know that their ducks are infected unless they are tested regularly (which is not feasible at present in Cambodia) or, for some reason, the infected ducks develop disease. Despite the availability of compensation, stamping out of infection has not proven to be effective in disease elimination in Vietnam or China where H5N1 viruses have persisted in poultry. 254. In addition, compensation is also not necessary for an increase in disease reports. As reported elsewhere in this review a four-fold increase in reports of cases with signs suggestive of avian influenza has been achieved during this project through training of and reports by VAHW, despite the absence of compensation. 255. The absence of a compensation policy has been suggested as one of the reasons for the difference in the number of cases when comparing Cambodia and Vietnam but there are other factors that also influence this including, greater levels of poverty in Cambodia; the different structure of the poultry sector (more intensive production and therefore improved biosecurity in Vietnam); use of vaccination; and, possibly even human genetic factors that could play a role in susceptibility (not yet proven). Each country has a different risk profile for avian influenza and comparisons between countries should be performed with caution. 256. In 2011 when the increase in human cases occurred and agreement on compensation had still not been obtained, alternatives to increase reporting had to be found. This was another catalyst for the Healthy Livestock, Healthy Village, Better Life program and it has proved to be successful in encouraging reporting of deaths in poultry. 257. This program increases the number of chicks surviving, increasing income and therefore reducing the need to prepare dead birds for food. It allows owners to dispose of and/or sent away dead birds for testing. 55 258. The training that formed part of the program resulted in better reporting of poultry mortality to village officials and also in actions taken collectively by villagers to control any outbreaks before they could spread in the village. This was done by encouraging early reporting of disease to village animal health workers, village heads and/or village health volunteers followed by restricting movement of all poultry within the village for several weeks, especially in and around the site of the initial outbreak. This was achieved by keeping all birds in cages or under upturned baskets and provision of feed so that birds did not have to scavenge. Early action to isolate sick birds reduces the need for culling in the event of an outbreak. 259. Vaccination. Vaccination has not been used in Cambodia for protection of poultry against H5N1 avian influenza. A discussion note on vaccination was included in the project Technical Annex (Appendix 9). Throughout the project, options for use of vaccination was considered by the implementing agencies, during support missions and by FAO as part of their assessment of options for disease control, conducted as part of their technical activities in support of the project. 260. Training has been provided in emergency vaccination in case it is needed but routine mass vaccination is too expensive and is no longer favored as an approach for village level producers in countries where it has been used in the past. 261. Well managed vaccination can help to prevent this disease but formal national programs on mass vaccination of village level poultry have been abandoned by both Vietnam 19 and Indonesia because it is both costly and inefficient as a long term measure. This is largely because of the high rate of turnover of poultry that prevents development of solid flock immunity. Vaccination also requires appropriate supply chains for the particular vaccine and these are not in place in Cambodia. 262. For individual villagers who might want to purchase and use vaccination the cost would outweigh the benefits unless they experience disease outbreaks due to avian influenza every few years. Duck farmers see no reason to vaccinate against a disease that does not normally kill their birds. 263. Vaccination is also complicated by the emergence of new strains of H5N1 virus that have been present in southern Vietnam for several years and were recently found in human cases in Cambodia. This could require the formulation of a special vaccine for the lower Mekong area. 264. The option of vaccination could still be considered if the number of human cases increased dramatically and other measures were not able to prevent the transmission of the virus from poultry to humans but is not now seen as a viable option in a resource poor country without considerable donor support. 56 Annex 10. List of Supporting Documents 1. AHICPEP Technical Annex Report No. T7674, February 27, 2008 2. AHICPEP Recipient’s Project Completion Report (PCR), May 2014 3. AHICPEP KAP Survey Report/NCDM, May 2013 4. Bio-Security Program on Technology Development for Commercial Poultry Farm/MAFF, December 2011 5. Guideline for Bio-Security Program on Technology Development for Commercial Poultry Farm/MAFF, December 2011 6. AHICPEP Project Financial Management Manual, Version v1.7 – Sept. 4, 2009 7. AHICPEP Implementation Status Results Reports Seq. No. 1-9, Management Letter and Aide Memoires, World Bank. 8. Financing Agreement Avian and Human Influenza Control and Preparedness Emergency Project (IDA Grant H361-KH) between Kingdom of Cambodia and International Development Association, May 08, 2008. 9. Financing Agreement Avian and Human Influenza Control and Preparedness Emergency Project (IDA Grant H361-KH) between Kingdom of Cambodia and International Development Association: Amendments, December 28, 2011, and June 27, 2013. 10. Grant Agreement Co-Financing Avian and Human Influenza Control and Preparedness Emergency Project, AHI Facility Grant No. TF058146 between Kingdom of Cambodia and International Development Association, May 08, 2008. 11. Grant Agreement Co-Financing Avian and Human Influenza Control and Preparedness Emergency Project, AHI Facility Grant No. TF058146 between Kingdom of Cambodia and International Development Association: Amendments, July 31, 2009; June 30, 2011; September 6, 2011; December 28, 2011 and June 27, 2013. 12. Grant Agreement Co-Financing Avian and Human Influenza Control and Preparedness Emergency Project, PHRD Grant No. TF056831 between Kingdom of Cambodia and International Development Association, May 08, 2008. 13. Grant Agreement Co-Financing Avian and Human Influenza Control and Preparedness Emergency Project, PHRD Grant No. TF056831 between Kingdom of Cambodia and International Development Association: Amendments, December 28, 2011, and June 27, 2013. 14. IEG (2014), Responding to Global Public Bads. Learning from evaluation of the World Bank experience with avian influenza 2006-13. 15. FAO (2011), Approaches to controlling, preventing and eliminating H5N1 Highly Pathogenic Avian Influenza in endemic countries. 16. Hinrichs J (2013) Report on Healthy Livestock Healthy Village Better Life program 57 17. Jonas O (2014), Pandemic Risk World Development Report Background Paper. 18. Kawasaki M, Young JR, Suon S, Bush RD, Windsor PA (2013). A review of the costs and benefits of vaccination against haemorrhagic septicaemia in Cambodia. The Socio-economic Impacts of Clinically Diagnosed Haemorrhagic Septicaemia on Smallholder Large Ruminant Farmers in Cambodia. Transbound Emerg Dis. 2013 Oct 8. 19. Rith et al (2014) J. Virol published ahead of print, http://www.ncbi.nlm.nih.gov/pubmed/2521019 3 20. World Bank (2012). People, Pathogens and Our Planet, Volume 2: The Economics of One Health 21. WHO (2014) Antigenic and genetic characteristics of zoonotic influenza viruses and development of candidate vaccine viruses for pandemic preparedness. 22. USDA GAIN Report, Number 14012, March 3, 2014. 58 59