Document of The World Bank Report No: ICR00003330 FINAL, December 23 IMPLEMENTATION COMPLETION AND RESULTS REPORT ON THE VIETNAM AVIAN AND HUMAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS PROJECT FINANCING IDA CREDIT (4273) IN THE AMOUNT OF SDR 13.5 MILLION (US$ 20 MILLION EQUIVALENT) (March 13, 2007) IDA CREDIT (4992) IN THE AMOUNT OF SDR 6.2 MILLION (US$ 10 MILLION EQUIVALENT) (October 21, 2011) AHI FACILITY GRANT (TF057747) IN THE AMOUNT OF US$ 10 MILLION (April 12, 2007) PHRD GRANT (TF057848) IN THE AMOUNT OF US$ 5 MILLION (April 12, 2007) AHI FACILITY GRANT (TF099841) IN THE AMOUNT OF US$ 13 MILLION (October 21, 2011) TO THE SOCIALIST REPUBLIC OF VIETNAM UNDER THE FRAMEWORK OF THE GLOBAL PROGRAM FOR AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (GPAI) December 23, 2014 Health, Nutrition and Population Global Practice Vietnam Country Unit East Asia and Pacific Region i CURRENCY EQUIVALENTS Exchange Rate Effective December 1, 2014 Currency Unit=Vietnamese Dong (VND) VND 21,397.5 = US$ 1.00 US$ 1.46355 = SDR 1.00 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AHI Avian and Human Influenza AHIF Avian and Human Influenza Facility (World Bank-administered trust funds) AI Avian Influenza AIEPED Integrated National Operational Program on Avian Influenza, Pandemic Preparedness, and Emerging Infectious Diseases, 2011-2015 (Blue Book) BCC Behavior Change Communication CAHW Community Animal Health Worker CDC US Centers for Disease Control and Prevention DAH Department of Animal Health DARD Department of Agriculture and Rural Development DLP Department of Livestock Production DVO District Veterinary Officer DPMC District Preventive Medicine Center EC European Commission EID Emerging Infectious Disease FAO Food and Agriculture Organization (UN agency) FET Field-based epidemiology training GPAI Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response HPAI Highly Pathogenic Avian Influenza (including H5N1) ICR Implementation completion and results report ILI Influenza-like illness ISR Implementation Status Report KAP Knowledge, attitudes and practices (survey) LIFSAP Livestock Competitiveness and Food Safety Project (in Vietnam) MARD Ministry of Agriculture and Rural Development M&E Monitoring and Evaluation MOH Ministry of Health OIE World Organization for Animal Health OPI National Integrated Operational Program for Avian and Human Influenza, 2006- 2010 (Green Book) PCU Project Coordination Unit PDO Project Development Objective PHRD Policy and Human Resources Development Trust Fund (administered by the World Bank) PPE Personal protective equipment PPCU Provincial Project Coordination Unit PVS Performance of Veterinary Services (assessment) ii RRT Rapid Response Team (for response to outbreaks) SARS Severe acute respiratory syndrome (disease of animal origin) UNSIC UN System Influenza Coordination VAHIP Vietnam Avian and Human Influenza Control and Preparedness Project WHO World Health Organization (UN agency) Vice President: Axel van Trotsenburg Country Director: Victoria Kwakwa HNP GP Practice Manager: Toomas Palu Project Team Leader: Anh Thuy Nguyen ICR Team Leader: Olga B. Jonas iii VIETNAM AVIAN AND HUMAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS PROJECT TABLE OF CONTENTS Data Sheet A. Basic Information ................................................................................................................... vi B. Key Dates ............................................................................................................................. vi C. Ratings Summary ................................................................................................................... vi D. Sector and Theme Codes....................................................................................................... vii E. Bank Staff ............................................................................................................................ vii F. Results Framework Analysis ................................................................................................ viii G. Ratings of Project Performance in ISRs ................................................................................ xi H. Restructuring .......................................................................................................................... xi I. Disbursement Profile and Actual Disbursements from All Financing Sources ..................... xii J. Financing Instrument and Project Components .................................................................... xii 1. Project Context, Development Objectives and Design .............................................................1 2. Key Factors Affecting Implementation and Outcomes ............................................................4 3. Assessment of Outcomes ........................................................................................................10 4. Assessment of Risk to Development Outcome .......................................................................22 5. Assessment of World Bank and Borrower Performance ........................................................24 6. Lessons Learned......................................................................................................................26 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners.........................28 Annex 1. Project Costs and Financing ........................................................................................30 Annex 2. Outputs by Component................................................................................................31 Annex 3. Economic and Financial Analysis ...............................................................................43 Annex 4. Bank Lending and Implementation Support/Supervision Processes...........................47 Annex 5. Comments on Draft ICR and Recommendations from Borrower’s ICR ....................49 Annex 6. Comments of Cofinanciers and Other Partners/Stakeholders .....................................58 Annex 7. List of Supporting Documents ....................................................................................59 Annex 8. List of Persons Met .....................................................................................................61 Annex 8. List of Persons Met .....................................................................................................61 Map .............................................................................................................................63 Text Boxes, Tables, and Figures Box 1. The single most important area for productive investment ...................................19 Table 1. KAP survey results (% of target groups) ...............................................................17 Table 2. District-level preventive and curative capacities performance targets were exceeded .................................................................................................................18 Table 3. Project outcomes: nearly all targets surpassed or met ...........................................21 iv Table A3.1. Poultry destroyed by avian influenza, 2003-14 .....................................................44 Table A3.2. Overview of the economic costs influenced by stronger public health systems (national benefits only).............................................................................45 Figure 1. Project resources by component ..............................................................................4 Figure 2. Dramatic decline in number of poultry destroyed by AI and by AI disease control ....................................................................................................................12 Figure 3. Human deaths due to H5N1 avian flu declined dramatically in VAHIP provinces and in Vietnam ......................................................................................12 Figure 4. An example of market upgrading under VAHIP: poultry are off the ground and regular cleaning is possible .............................................................................14 Figure 5. Evidence of high risk awareness in paintings by children .....................................17 Figure A2.1. The eleven VAHIP provinces (map) .....................................................................31 Figure A2.2. Little or no biosecurity before improvement of markets .......................................32 Figure A2.3. Examples of improved markets .............................................................................33 Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health .....37 Figure A2.5. District Preventive Health Center managers and staff, along with provincial officials, and the VAHIP PCU, discuss improvements in local-level public health capacity. ......................................................................................................41 Figure A3.1. The poorest households suffer larger income declines than wealthier households with a ban on backyard poultry sales ..................................................46 Figure A5.1. Science of delivery under VAHIP ........................................................................51 v A. Basic Information VN-Avian & Human Influenza Country: Vietnam Project Name: Control &Prep IDA-42730, IDA-49920, TF- Project ID: P101608 L/C/TF Number(s): 57747, TF-57848, TF-99841 ICR Date: 12/08/2014 ICR Type: Core ICR Lending Instrument: ERL Borrower: Original Total Commitment: XDR 13.50M Disbursed Amount: XDR 18.55M Revised Amount: XDR 19.26M Environmental Category: B Implementing Agencies: Ministry of Health Ministry of Agriculture and Rural Development Cofinanciers and Other External Partners: US -- Centers for Disease Control and Prevention (CDC) US Agency for International Development (USAID) Japanese PHRD Grant European Community - AHIF Food and Agriculture Organization (FAO) WHO World Organisation for Animal Health (OIE) B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 10/03/2006 Effectiveness: 08/23/2007 08/23/2007 07/19/2010 Appraisal: 12/22/2006 Restructuring(s): 06/14/2011 06/29/2011 Approval: 03/13/2007 Mid-term Review: 08/15/2008 11/21/2008 Closing: 12/31/2010 06/30/2014 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Highly Satisfactory Risk to Development Outcome: Moderate Bank Performance: Satisfactory Borrower Performance: Satisfactory vi C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Rating Performance any) Potential Problem Project No NA None at any time (Yes/No): Problem Project at any time No NA None (Yes/No): Moderately DO rating before Closing: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) General agriculture, fishing and forestry sector 21 21 General public administration sector 50 50 Health 21 21 Other social services 7 7 Solid waste management 1 1 Theme Code (as % of total Bank financing) Health system performance 13 20 Natural disaster management 24 20 Other communicable diseases 25 30 Other social protection and risk management 13 10 Rural services and infrastructure 25 20 E. Bank Staff Positions At ICR At Approval Vice President: Axel van Trotsenburg James W. Adams Country Director: Victoria Kwakwa Klaus Rohland Practice Manager/Manager: Toomas Palu Hoonae Kim Project Team Leader: Anh Thuy Nguyen Samuel S. Lieberman, Binh Thang Cao, Lingzhi Xu ICR Team Leader: Olga B. Jonas vii ICR Primary Author: Olga B. Jonas F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The project development objective of VAHIP was "to assist the government to increase the effectiveness of public services in reducing the health risk to poultry and to humans from avian influenza in selected provinces, through measures to control the disease at source in domestic poultry, to detect early and respond to human cases of infections, and to prepare for the medical consequences of a potential human pandemic." Revised Project Development Objectives (as approved by original approving authority) The Project Development Objective was not revised. Most indicator targets were initially set for the end of the VAHIP-1 period (2007-10) and, after additional financing was approved in 2011, targets were set for the VAHIP-2 period (2011-14). (a) PDO Indicator(s) Actual Value Formally Original Target Achieved at Indicator Baseline Value Revised Values Completion or Target Values Target Years Increase in number of annual suspected highly pathogenic avian influenza (HPAI) cases Indicator 1 : in poultry reported and fully investigated per project province. All 39 of 39 reports 10 case reports per 275 case reports Value 0 of suspected HPAI province per year (11 provinces) investigated. Date achieved 02/15/2007 12/31/2010 06/30/2014 06/30/2014 Objective fully achieved in substance. Target of 275 HPAI reports could not be met because of lower disease prevalence than planned. Performance of reporting system Comments from village to district level very strong: 11,313 reports of suspected poultry disease reached provincial level in 2014, and 24,000 reports in 2013. For both veterinary and health sector, reduce reporting time of new outbreaks and return Indicator 2 : of laboratory confirmation to the affected commune. 4 (veterinary) 8.7 (veterinary) 4 (veterinary) 2.4 (veterinary) Values 4 (human 10 (human health) 4 (human health) 3.4 (human health) health) Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014 Targets surpassed. This is an important and substantial achievement in reporting Comments performance to laboratories and from laboratories to affected communes. Significant progress was achieved already by 2010, when the times reached 2.9 days Reduced fatality rate of human H5N1 cases compared to 2004/05 in the 11 project Indicator 3 : provinces 45% 35% 35% NA Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014 The indicator was not valid for periods with very low number of cases. In 2014 there Comments was 1 case, which was fatal. The calculated value of 100% is mathematically correct viii but does not measure progress on PDO. See text on human health PDO achievements. (b) Intermediate Outcome Indicator(s) Actual Value Formally Original Target Achieved at Indicator Baseline Value Revised Target Values Completion or Values Target Years Intermediate Result A1: Veterinary services on disease diagnostic and surveillance Indicator 1 : strengthened - Number of laboratories working at ISO 17025 standards for AI testing. Value 0 6 8 8 Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014 Comments Target surpassed, as the ambitious goal was fully met in 2013, ahead of schedule. Intermediate Result A2.1: Percentage of poultry traders applying good biosecurity Indicator 2 : practices at Ha Vy market. Value 25% 80% 100% 100% Date achieved 06/30/2006 06/30/2010 06/30/2014 06/30/2014 Target fully met. This was an ambitious target, in view of increasing market trade Comments volume. Indicator modified in 2012 to measure behaviors (rather than virus prevalence). Intermediate Result A2.2: Percentage of upgraded markets and slaughterhouses Indicator 3 : applying practice according to project guidelines. Value 11% 100% 100% Date achieved 06/30/2007 06/30/2010 06/30/2014 Target fully met. There was steady increase from the baseline of only 11 percent in Comments 2006, with progress above interim targets set during implementation. By the end of the project, the target was met in 76 upgraded markets and slaughterhouses. Intermediate Result A3: Percentage of positive samples for H5N1 virus at markets and Indicator 4 : slaughterhouses. 35 out of 52 commercial farms Value NA less than 2% 7.66% demonstrated disease-free Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014 Indicator for VAHIP-2 focused on markets (rather than farms, for which VAHIP-1 Comments target was exceeded). Ambitious target partly met; disease-prevalence outcome was beyond the control of the project. Improved surveillance yielded key information. Intermediate Result A5: Number of days that suspect outbreaks are completely Indicator 5 : contained (quarantine and culling). NB: In VAHIP-1, this indicator was no. of rapid response teams performing effectively; target was surpassed by 2011. Value 4 days 2 days less than 1 day Date achieved 06/30/2010 06/30/2014 06/30/2014 Target surpassed for this key system performance indicator. Improvements in Comments performance also exceeded interim targets, reaching 1.1 days already in 2013. Intermediate Result B1: Percentage of reports that are accurately completed and sent on Indicator 6 : time to the Provincial Preventive Health Centers Value 58% 84% 90% 98.6% Date achieved 06/30/2007 06/30/2010 06/30/2014 06/30/2014 Comments Target surpassed. Indicator reached 95.4% in 2013 and nearly 100% in 2014. ix Actual Value Formally Original Target Achieved at Indicator Baseline Value Revised Target Values Completion or Values Target Years Substantial improvement in system performance. Intermediate Result B1: Percentage of reports that are accurately completed and Indicator 7 : received at the District Preventive Health Centers Value 82% 90% 97.7% Date achieved 06/30/2010 06/30/2014 06/30/2014 Target surpassed. Indicator of important aspect of system performance reached 94.8% Comments in 2013. Indicator used in VAHIP-2 period. Intermediate Result B2: Percentage of project provinces developed the Pandemic Indicator 8 : preparedness plan (based on the MOH guideline). 100% (plans 100% (plans Value 0% 100% improved) improved) Date achieved 02/15/2007 06/30/2010 06/30/2014 06/30/2014 Target fully met in 2010, an important achievement in preparedness of 44 provincial Comments hospitals. Plans then improved and simulated in exercises. Intermediate Result B2: Percentage of district hospitals developed the pandemic Indicator 9 : preparedness plan Value N/A 100% 100% Date achieved 06/30/2010 06/30/2010 06/30/2014 Target fully met, improving preparedness during VAHIP-2 period in 124 district Comments hospitals. Indicator reached 85.4% in 2012. Intermediate Result B3: Percentage of target population that can accurately identify and Indicator 10 : have practiced at least one key preventive behavior (divided by the target groups) Curative: 40% Curative: 60% Curative: 86.2% Curative HCW: 91% Preventive: 40% Preventive: 60% Preventive: 88% Value Preventive HCW: 100% General population: General General population: General population: 56.4% population: 60% 40% 98.8% Date achieved 06/30/2008 06/30/2010 06/30/2014 06/30/2014 Targets surpassed for all three groups. Indicator values for knowledge and attitudes (not Comments shown here) increased as well. Increased/sustained risk awareness despite plummeting international attention. Intermediate Result B4.1: Number of DPMCs in 11 provinces fully equipped and have Indicator 11 : adequate capacity to implement their responsibilities and functions in compliance with MOH decisions on Preventive Medicine. Value 0 16 79 87 Date achieved 02/15/2007 06/30/2010 06/30/2014 06/30/2014 Target surpassed, by a substantial margin. Already in 2010, the achievement was 28 Comments DPMCs, significantly above the interim target of 16. Intermediate Result B4.2: Number of multisectoral simulation exercises conducted and Indicator 12 : reviewed at district levels in the project provinces Value 0 17 30 68 Date achieved 06/30/2007 06/30/2010 06/30/2014 06/30/2014 Target surpassed. Achievement more than double the plan. Interim targets surpassed Comments every year as well. x Actual Value Formally Original Target Achieved at Indicator Baseline Value Revised Target Values Completion or Values Target Years Intermediate Result B4: Number of health staff have been trained and/or capacity built Indicator 13 : by the project (cumulative). Value 11,005 Target value not set 21,905 69,012 Date achieved 06/30/2006 06/30/2010 06/30/2014 06/30/2014 Target surpassed. VAHIP achieved more than three times the level of training than Comments initially envisaged. This impacted especially district and local-level veterinary and human public health systems. Indicator 14 : VAHIP-1 indicator A4.1. Number of small scale poultry farm models demonstrated. Value 0 25 80 Date achieved 02/15/2007 06/30/2010 12/31/2010 Comments Target surpassed. 80 demonstration sites provided training to 1,760 small farmers. G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 07/21/2007 Satisfactory Satisfactory 0.00 2 09/16/2008 Satisfactory Moderately Unsatisfactory 1.45 3 02/19/2009 Satisfactory Moderately Satisfactory 2.36 4 04/12/2010 Satisfactory Moderately Satisfactory 6.90 5 03/21/2011 Satisfactory Moderately Satisfactory 16.70 6 03/11/2012 Satisfactory Satisfactory 20.72 7 03/31/2013 Satisfactory Moderately Satisfactory 21.96 8 10/23/2013 Satisfactory Moderately Satisfactory 23.50 9 06/20/2014 Moderately Satisfactory Moderately Satisfactory 26.39 H. Restructuring ISR Ratings at Amount Board Restructuring Restructuring Disbursed at Reason for Restructuring & Key Approved PDO Date(s) Restructuring Changes Made Change DO IP in USD millions Reallocation among disbursement 07/19/2010 N S MS 8.75 categories; extend closing dates of VAHIP-1 to 6/30/2011. Extend closing date of VAHIP-1 06/14/2011 S MS 18.62 to 12/31/2011. 06/29/2011 S MS 18.62 Revise indicators. xi I. Disbursement Profile and Actual Disbursements from All Financing Sources *: Due to the exchange rate differences between SDR and USD, the actual amounts will differ from original and revised amounts. ** Under IDA Credit no. 4492 US$ 1.0 million is undisbursed, and under IDA Credit no. 42730 XDR 0.6 million was cancelled. J. Financing Instrument and Project Components The World Bank, other donors, and technical agencies supported the implementation of the government’s plan. World Bank provided financing in the form of: IDA credits for Emergency Response Lending (ERL), a cofinancing Japanese Policy and Human Resource Development (PHRD) grant, and two cofinancing grants from the multidonor Avian and Human Influenza Facility (AHIF), which received funds from the European Commission, Australia, and eight other donors. World Bank ERL financing was part of an adaptable program loan (APL) entitled the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI). Project components mirrored the government’s plan, namely: (A) animal health, (B) human public health, and (C) coordination, monitoring and evaluation, and project management, with close coordination between the animal health and human health components. xii 1. Project Context, Development Objectives and Design 1.1 Global and Country Contexts at Appraisal 1. In December 2003, Vietnam reported its first cases of Highly Pathogenic Avian Influenza (HPAI) H5N1. Within four months the disease was detected in 57 of 64 provinces. Some 44 million poultry—17 percent of the nation’s stock—had been culled to prevent further outbreaks or had died from the disease. This was a severe cost to farmers and to the economy more broadly. The economic toll was some 0.5 percent of Vietnam’s GDP, or US$250 million. Animal health and disease surveillance systems were rapidly overwhelmed. Moreover, as 15 human deaths were recorded in 2004, there was increasing evidence that the H5N1 avian influenza virus could infect humans. This and the possibility that the virus could become capable of efficient human-to-human transmission, raised the prospect that an influenza pandemic would result. 2. By 2005 the H5N1 avian flu virus emerged as a global threat. 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 loan (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.1 The GPAI was based on guidance from the World Organization for Animal Health (OIE), the World Health Organization (WHO), and the Food and Agriculture Organization (FAO). Their inputs were coordinated by the Senior United Nations System Influenza Coordinator (UNSIC), appointed by the UN Secretary General. The GPAI was one of the World Bank’s contributions to a broad international initiative, which was launched at the UN General Assembly in 2005. This initiative mobilized US$3.9 billion from 35 donors at a series of five ministerial conferences, starting in Beijing, China, in January 2006 and concluding in Hanoi, Vietnam in April 2010. 3. 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 of H5N1 avian flu in poultry or wild birds, including in Vietnam and all neighboring and other South East Asian countries (Cambodia, China, Lao PDR, Myanmar, and Thailand). 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. The 2003 outbreak of the severe acute respiratory syndrome (SARS) served as a recent reminder. It had been quickly contained after 8,000 cases of human infection, of which 800 were fatal, but its economic costs were very high ($54 billion).2 4. The first World Bank-financed avian flu response project, the Vietnam Avian Influenza Emergency Recovery Project (AIERP), was approved in August 2004 as an emergency operation with US$5 million IDA financing. The project thus pre-dated the GPAI. It was fully 1 This amount was subsequently increased to US$1 billion in June 2009; see Extension of the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) and Increase of the GPAI Ceiling to $1 billion in Response to Influenza A(H1N1) Pandemic , R2009-0111, May 11, 2009. 2 Estimating the Global Economic Costs of SARS by Jong-Wha Lee and Warwick J. McKibbin in Learning from SARS: Preparing for the Next Disease Outbreak -- Workshop Summary, Institute of Medicine, Washington, DC, 2004, available at www.ncbi.nlm.nih.gov/books/NBK92473/. 1 implemented in less than three years in 10 provinces badly hit by the virus. The project enhanced national disease surveillance and diagnostic capacity, strengthened mechanisms in the poultry sector to contain serious outbreaks, and raised public awareness of risks and how to mitigate them. The AIERP provided a platform for action, which the government used to articulate and lead a concerted response from donors, international technical agencies, and civil society.3 The AIERP was a catalyst for the approach adopted in developing the GPAI in 2005, when the global threat from the H5N1 avian flu virus became apparent. 5. The Vietnam Avian and Human Influenza Control and Preparedness Project (VAHIP) was developed to follow the AIERP, which closed on June 30, 2007. VAHIP built on the AIERP platform and aimed to consolidate the gains made against avian influenza. VAHIP was financed by an IDA Credit (SDR 13.5 million, US$20 million equivalent), an Avian and Human Influenza Facility (AHIF) Grant (US$10 million), a Japan PHRD Grant (US$5 million), and the Government of Vietnam (US$3 million). The Project became effective on August 23, 2007. The original closing date was December 31, 2010. This was extended twice, initially to June 30, 2011 and then to December 31, 2011. 1.2 Original Project Development Objectives (PDO) and Key Indicators: Project Development Objective 6. The project development objective (PDO) was “to assist the government to increase the effectiveness of public services in reducing the health risk to poultry and to humans from avian influenza in selected provinces, through measures to control the disease at source in domestic poultry, to detect early and respond to human cases of infections, and to prepare for the medical consequences of a potential human pandemic.” The project was implemented in eleven provinces. 7. The PDO was and remains in line with Vietnam government’s plans for the medium and long-term control of avian influenza and other zoonotic disease threats, as set out in: (i) the National Integrated Operational Program for Avian and Human Influenza, 2006-2010 (OPI, called the “Green Book”) and (ii) the Integrated National Operational Program on Avian Influenza, Pandemic Preparedness, and Emerging Infectious Diseases, 2011-2015 (AIEPED, called the “Blue Book”). The PDO was fully consistent with the GPAI, which, like the OPI and the AIEPED, was based on the expert advice of the World Health Organization (WHO), the World Organization for Animal Health (OIE), Food and Agricultural Organization (FAO), US Centers for Disease and Prevention (US CDC), and other international agencies. 8. There were three key outcome indicators, aligned with the core aims of infectious disease control and prevention: i. Increase in number of suspected HPAI cases in poultry that are reported and fully investigated, per province. ii. For both veterinary and human health sectors, reduced reporting time of new outbreaks and reduced time to return of laboratory confirmation to the affected commune. 3 Vietnam Avian Influenza Emergency Recovery Project, Implementation Completion and Results Report, December 19, 2007 (Report No. ICR0000664). 2 iii.Reduce fatality rate of human H5N1 cases compared to 2004-5 in the 11 project provinces. The third indicator became irrelevant because the number of cases of H5N1 infection in humans declined dramatically throughout the project period compared to 2004-5; the problematic nature of this indicator confirms one of the lessons from the review of avian influenza projects by the Independent Evaluation Group (IEG).4 1.3 Revised PDO 9. The PDO was not revised, but indicators and targets were adapted when additional financing was provided in 2011 to extend project activities because implementation of the original project (VAHIP-1) was successful. The second phase (VAHIP-2) had a closing date of June 30, 2014. The additional financing was from an IDA Credit (SDR 6.2 million, US$10 million equivalent) approved on June 30, 2011, an AHIF Grant (US$13 million) endorsed by the AHIF Advisory Board on May 31, 2011, and the Government of Vietnam (US$2 million). 1.4 Main Beneficiaries 10. The main direct beneficiaries were in the 11 project provinces. Because the disease threat does not respect borders, the rest of the country, the region, and the global community benefited as well. Within the provinces, beneficiaries included the poultry sector, including households that keep poultry, who comprise a majority of households in rural areas. Other beneficiaries were persons in contact with poultry who would be exposed to disease risks, (e.g., children, workers engaged in slaughtering, processing and marketing poultry, consumers shopping at poultry markets, and cooks). Prevention of disease in poultry would also tend to increase the availability and affordability of protein (meat, eggs) and thus improve nutrition. Prevention of a severe influenza pandemic and other infectious disease outbreaks benefited the entire country by mitigating negative impacts on health, economic activity, and incomes. There were also cross- border benefits because by controlling disease outbreaks promptly and effectively, Vietnam was far less likely to export the disease. 11. The main intermediate beneficiaries of the Project were the animal health services in the Ministry of Agriculture and Rural Development (MARD) and the Ministry of Health (MOH), including the provincial and district-level departments and staff of these ministries whose capacities to perform their various functions in infectious disease prevention and control were strengthened. Staff from these two ministries received a range of training, building stronger capacity at central, provincial and local levels for project management as well as in technical competencies. 1.5 Original Components (as approved): 12. World Bank financing 5 for the Project’s three components mirrored the government’s plans, namely: (A) animal health, (B) human health surveillance and response, and (C) 4 World Bank Independent Evaluation Group (2014). Responding to Global Public Bads: Learning from Evaluation of the World Bank Experience with Avian Influenza, 2006-2013. 5 “World Bank financing” refers to financing for the Project from the International Development Association (IDA), Japanese PHRD and the AHIF. PHRD and AHIF are World Bank-administered trust fund arrangements. The 3 coordination, monitoring and evaluation, and project management, with close coordination between the animal health and human health components. 1.6 Revised components 13. Components were not revised during the project life, and there were no other significant changes in design, scope and scale, and implementation arrangements. Financing was reallocated among activities as warranted, and several indicators were adapted in 2011 to better support implementation during VAHIP-2. Such flexibility was foreseen at appraisal since need for responsiveness to an unpredictable disease risks would require adapted response approaches; other projects in the GPAI had this design characteristic as well. 14. Figure 1 shows the evolution of project activities. Initially animal health services received relatively more support, but after 2011 the vast majority of project financing went to build human public health capacities overseen by the Ministry of Health. Close collaboration between the two sectors was maintained in the entire 2007-14 project period, thanks to adequate provisions for integration and coordination. Overall, 34 percent of the funding was for the animal health sector, 51 percent was for the human health sector, and 15 percent was for project management and coordination across sectors and levels of government. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design, and Quality at Entry 15. The key factors were Vietnam’s leading position in avian influenza control gained from experience in controlling the disastrous avian influenza outbreaks in 2003-4; the existence of a global framework and external political and financial support; a robust country-led program with strong government commitment; coordinated engagement of all partners; emphasis on good communications; support from senior World Bank management; and a strong World Bank team responsible for support to preparation and appraisal of the operation. Vietnam’s leadership on European Commission was the leading contributor to AHIF, which also received funds from Australia and eight other donors. 4 these aspects substantially influenced the design of the GPAI, which then informed the preparation of avian and human influenza preparedness and response projects in some 60 countries in all regions. 16. Multisectoral framework and support to country and global objectives. The challenge posed by the H5N1 avian flu and pandemic threats necessitated a coordinated multisectoral response. Government plans (the OPI and the AIEPED) set out how multiple sectors and actors would have to work together and in line with the technical guidance from WHO, FAO, OIE, and others. The World Bank team provided substantial technical assistance to the preparation of both OPI and AIEPED to bridge actions across sectors. VAHIP supported this collaboration by providing adequate resources. The design of VAHIP built also on relevant World Bank operational experience, including in emergency responses to disasters, the global program to address HIV/AIDS, the AIERP, and other responses to outbreaks of animal-borne diseases. The rationale for World Bank involvement was strong not only because of the multisectoral and global character of the response, but also from the perspective of the country assistance strategy, which supports risk mitigation so as to sustain the country’s high economic growth and development achievements. Disease outbreaks, like avian and pandemic influenza, threatened to undermine progress in this regard. 17. Country-led project preparation and the World Bank’s rapid response. As the AIERP neared its June 30, 2007 closing date, the government quickly prepared the follow-on plan, which was informed by implementation experience and the international consensus on avian influenza control reflected in the GPAI. The VAHIP was prepared and appraised quickly. The World Bank used both its policy on Rapid Response to Crises and Emergencies (OP 8.00) and an Adaptable Program Loan (APL) framework to provide financing. 18. Project design. In addition to being based on guidance from the international technical agencies, the Project aligned to the OPI. The Project monitoring and evaluation (M&E) framework dovetailed with OPI and thus the government’s monitoring and reporting system. The design built upon the implementation experience during the AIERP, on the World Bank’s operational experience in the country, on analytical work done by the Bank and partners on the role of compensation in animal disease control globally;6 and on the Bank’s in-country working relationships with UN agencies and other partners. Intersectoral coordination mechanisms were a key part of the design, not an afterthought. Coordination also benefited from assistance provided by UNSIC. Such emphasis on systematic coordination was appropriate given the complex multisectoral challenge and numerous partners involved. 19. Crucial role of communications. The veterinary and human public health components each included a broad range of communications activities, since control of contagion would critically depend on the risk awareness and behaviors of farmers, poultry consumers, poultry traders, government workers, and others. Knowledge, Attitude and Practices (KAP) surveys gauged the impact of extensive awareness-raising campaigns. 6 World Bank (2006). Enhancing Control of Highly Pathogenic Avian Influenza in Developing Countries through Compensation: Issues and Good Practice. 5 20. Risk assessment. The major risks identified at appraisal included political commitment, slow disbursement and procurement, weak provincial-level capacity for project implementation (especially in financial management), inadequate coordination between the two ministries concerned, resistance to innovation in MOH, inadequate farm-level surveillance, and increased virus circulation. These risks were relevant to an evolving disease threat in an environment of uneven capacity. The mitigation measures were appropriate and proved effective. 2.2 Implementation 21. Consistently strong implementation, contributing to country-wide results. VAHIP was the follow-on project, in 11 provinces, to a major national emergency response that galvanized the government and communities. The high cost of inaction in avian flu control – the heavy toll in the 2004 avian flu outbreaks and associated human infections – was clear to all stakeholders. The OPI provided a robust and transparent framework for action, coordination, and knowledge exchange between VAHIP and non-VAHIP provinces. VAHIP introduced some innovations (for instance in market biosecurity), which were adopted by other provinces. Implementation started shortly after the effectiveness date and was completed by the VAHIP-2 closing date, without extensions. There were, however, delays, especially during the early phases in the project, and procurement and other processing were initially slow (this was not a project-specific problem, but is common to other projects in the country). Such delays were reflected in conservative ratings on implementation progress so as to provide incentive to rapid implementation in the face of the potentially high costs that would arise if the ambitious and comprehensive OPI program was not rapidly implemented. However, when the project ended, the overall implementation record was, in retrospect, commendable and achieved highly effective results in an efficient way (see Section 3. below). Disbursement rates largely mirrored the overall commendable implementation progress. 22. Intersectoral coordination. MARD implemented Component A and MOH implemented Component B. An intersectoral committee, chaired by the Prime Minister and receiving support from UNSIC, provided oversight. Thanks to adequate resources for coordination, strong leadership from the government, as well as a systematic coordination structure based on the OPI, there was sharing of information and joint action when warranted. Overall coordination in the 11 VAHIP provinces was assured by MARD during VAHIP-1 and then by MOH during VAHIP-2. 23. Response to the 2009 H1N1 flu pandemic. VAHIP contributed to responding to this challenge thanks to the concerted efforts to increase preparedness, which was an important part of the project from its beginning. Though VAHIP preparedness activities were motivated by the threat of H5N1 avian flu and the severe pandemic that could develop from this particular virus strain, they were also directly relevant to the response to the 2009 H1N1 influenza pandemic. The rise in illness in the population put some pressure on health care system, but this was only temporary as the 2009 H1N1flu pandemic had a short duration and low severity. Preparedness of health facilities and public health systems was nevertheless tested, with good results. 24. Impact of change in the external environment. International attention to the risk of a pandemic diminished over the project period, with a marked decline since 2009, when the H1N1 flu pandemic proved to be much less severe than feared. External financing assistance to developing countries, including Vietnam, declined rapidly in tandem, despite the continuing 6 disease control challenges. Reduced attention and financing have had the unfortunate result of decreasing external and internal political support for an important risk-reducing multisectoral activity, where preventative investments continue to fall well short of levels of investments warranted by the magnitude of the risk. Moreover, a substantial part of the costs of avian flu has fallen on poor farmers, and reduced international attention only leads to poor farmers bearing an even greater share of these costs. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 25. M&E. The results framework served implementation well overall. Values were regularly reported, though sometimes with delay, and regular M&E reports were thorough and used in adapting project activities. Several indicators were adapted during implementation to better guide monitoring of progress. Thus, to monitor progress toward the objective of “surveillance activities show improved disease status along the poultry marketing chain”, the initial VAHIP-1 indicator was “number of commercial farms in which freedom from infection was demonstrated.” By the original target date in 2010, 52 farms were inspected and 23 of them obtained disease-free certification. Based on epidemiological work, monitoring markets became a higher priority (though monitoring of farms continued), so a new indicator was substituted starting in 2011: “percentage of positive samples for H5N1 virus at markets and slaughterhouses.” Both the initial and the latter indicators were, however, challenging, since diseases outcomes were beyond the control of the project. Their use was nevertheless important and appropriate, since it served to focus attention to the critical issues of surveillance for disease in the poultry supply chain. Another modification concerned indicators to track preparation of pandemic response plans in provinces and districts. Although plans were prepared by 2010 (the end of VAHIP-1), fully meeting targets, some of the plans were subsequently assessed as unsatisfactory by the government. Thus, the targets for preparation of these plans in 100 percent of provinces and districts were maintained for the end of VAHIP-2. The targets were again met, but all the plans at the end of VAHIP-2 were of higher quality than at the end of VAHIP-1. 26. Data for a few indicators proved difficult to collect, and the selection and definition of some of these indicators proved problematic. For instance, the selection of one of the key indicators – the case fatality ratio (CFR) – did not anticipate that a dramatic drop in human cases would eliminate the information content of this indicator. Final outcome indicators for infectious diseases are inherently problematic because of influences beyond the control of physicians or veterinarians, especially when these diseases are new in the animal or human population. Moreover, the target value for the CFR was unrealistically too low, well below that warranted by the inherent virulence of the H5N1 avian flu virus and the values registered in all other countries. The indicators tracking performance of government capacities were, however, useful in gauging progress. Utilization of the system-performance indicators in this project is evidence that further supports the recommendations of the review of avian flu operations by IEG (2014) that greater reliance on intermediate indicators of system performance is warranted in disease control and prevention programs.7 7 For disease control and prevention projects, final outcomes are driven by multiple unpredictable factors, making attribution especially challenging. Intermediate indicators are warranted to guide implementation and to assess results. See: World Bank Independent Evaluation Group (2014). Responding to Global Public Bads: Learning from Evaluation of the World Bank Experience with Avian Influenza, 2006-2013. 7 2.4 Safeguard and Fiduciary Compliance 27. The safeguards triggered were for the environment, involuntary resettlement, and for ethnic groups. Compliance was satisfactory overall. Notably, toward the end of the project monitoring reports revealed that waste water management and treatment in the large Ha Vy poultry wholesale market, which was reconstructed under VAHIP, resulted in concentrations of pollutants in the water that were above the set norms. 28. Environmental safeguards. The project was designated as a category B based on the environmental impacts of project activities. There was environmental monitoring on the compliance during the operation of the culling/disposal site and live bird markets, and on small civil works to rehabilitate and upgrade isolation units and intensive care units. The Operational Policy and Bank Procedure (OP/BP) 4.01 on Environmental Assessment was triggered, and consequently an Environmental Management Plan (EMP) was developed to address the potential impacts in accordance with OP/BP 4.01 and national regulations. The PCUs in MARD and MOH assigned responsibility for environmental safeguard work under their respective components to dedicated staff. Reports on EMP implementation were periodically submitted for review to the World Bank. The requirements specified in the EMP were taken into account and adequately implemented. 29. A major investment under VAHIP was the reconstruction and improved biosecurity at the Ha Vy wholesale market near Hanoi where about 1 million poultry are traded annually. There had been no biosecurity before VAHIP (see Annex 2 photos), with solid and liquid wastes posing risks to humans and the environment. Under VAHIP, reconstruction and other measures to improve biosecurity reduced these risks. At the appraisal, major upgrade of the solid and waste water treatment facilities at the market was not foreseen and included for IDA financial support. Therefore, during implementation when the need arose it was agreed that the government’s counterpart funds would finance part of the civil works including the solid waste and wastewater treatment systems. Monitoring of the environmental standards at the market after the Government-financed works were implemented showed that the solid waste and wastewater treatment systems were not designed adequately and environmental pollution by poultry waste remained. The PCUs proactively carried out remedial actions. Addressing this problem proved challenging and time-consuming, largely because of the need for full cooperation among the authorities involved (i.e., the central government, the PCU, the Thuong Tin district government, the Thang Loi Commune government, and Market Management). By the end of the project, management issues were resolved: the waste treatment system was rehabilitated, and solid waste was collected and treated properly. The design for the rehabilitation of the wastewater treatment system of the live bird market was reviewed by the World Bank and found to be satisfactory. The rehabilitation of the wastewater treatment system was in the 3rd quarter of 2014, after the project closing date using the counterpart funds. The output of the wastewater treatment system improved marketly but still not fully meeting national standards. A larger septic tank is required and this is planned to be installed in 2015. The challenge of a high and growing volume of poultry trade in this major market will continue; thus continuing monitoring of the performance of the wastewater and other systems will be required, to rapidly detect and remedy any adverse impacts on nearby communities and the environment. This experience yielded a lesson for similar future projects (see para. 80). The overall environmental performance of the project was therefore moderately satisfactory. 8 30. Financial management: compliance with policies and procedures. The financial management function of the Project was in compliance with the Bank’s financial management policies and procedures. Performance was moderately satisfactory, despite the complicated and decentralized financial management modalities, which were designed to support the decentralized project implementation arrangements. Project implementation was managed by PCUs in MOH and MARD, and in provincial implementing agencies (Provincial Departments of Health/Preventive Health Centers and Animal Health Departments). The PCUs in MOH and in MARD served as focal points for Project budget approval, financial reporting, and audit. All other financial management areas (such as planning and budgeting, contract and expenditures management, expenditures approval, and accounting records maintenance) were decentralized to 11 provinces with 2 implementing agencies in each (one for the human health component and one for the agriculture component). The PCUs managed the Project designated accounts opened at commercial banks, separately for the health and agriculture components. In the provinces, each provincial PCU (PPCU) also opened a bank account in local currency to receive the Project funds transferred by PCUs based on the approved annual operational plan. PPCU reports on expenditures were submitted monthly. The PCU in MOH submitted quarterly interim financial reports to the World Bank. Financial audit by an independent firm was conducted annually and was unqualified; and all but one audit reports were submitted to the Bank on time before end of June of the following year in full compliance with the Financing Agreement. 31. Procurement. Procurement activities have been carried out in accordance with the respective procurement procedures stated in the Financing Agreement and elaborated in the agreed Procurement Plans. Where appropriate, the government’s cost norms were used to economize on project resources. After initial delays, procurement performance improved over time and was successful overall. This was achieved largely thanks to the shifting of the design for the animal health component from one that was centralized (and relying on a relatively large number of international and national consultants) in the initial project period, to managing more activities at the provincial level. This shift was implemented after the midterm review mission. Key factors behind the satisfactory procurement performance were the commitment and efforts of staff of all PCUs and PPCUs. Given the emergency and decentralized nature of the project, the decentralization of procurement functions from PCUs to PPCUs was a good approach and a lesson to be applied for similar future projects. 32. Disbursement. Performance in terms of the disbursement rate was satisfactory overall. Disbursements lagged somewhat during the initial VAHIP-1 period but then accelerated to above projected levels after 2010. There were no major issues. 2.5 Post-completion Operation/Next Phase 33. With contributions from VAHIP and other projects, the Vietnamese authorities have improved the performance of core animal health and human health capacities and coordination between the two systems (see outcomes in Section 3 below). The achievements are substantial, but there are two concerns. First, in some areas capacity is still incomplete and fragile. At the same time, risks of zoonotic disease outbreaks are still high; for avian flu, such risks are amplified by the high volumes of trade in live bird markets. Second, adequate operations and maintenance budgets will be needed for the veterinary and human public health systems to perform in addressing antimicrobial resistance and other One Health challenges; in the near term, 9 this is particularly relevant for the laboratories and for the equipment in preventive health care centers. The ongoing USAID-supported projects addressing emerging infectious diseases and health security and the IDA-financed Livestock Competitiveness and Food Safety project are providing some relevant support in this regard. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 34. The Project objectives were clear, relevant, and important to Vietnam’s economy, public health, and poverty-reduction goals. Though designed as a second emergency operation after the devastating 2003-4 avian flu outbreaks and in the context of a global emergency response, VAHIP combined continuation of the emergency response with extensive strengthening of the veterinary and public health systems by building medium- and long-term capacity. Collaboration between veterinary and human public health services was deliberately planned and supported, and this delivered excellent results. Such collaboration will remain critical for prevention and control of zoonotic diseases. The capacities created by VAHIP are dual-purpose, relevant not only to a particular strain of avian flu, but to control of other disease outbreaks as well. The public health system can react better to an introduction of Ebola or the Middle East Respiratory Syndrome (MERS) into Vietnam, for example, thanks to the preparedness and other improvements in public health systems that were made in response to the avian flu threat. These investments supported preparedness at the national, provincial and district levels to respond to disease outbreak emergencies. Since such outbreaks will continue to occur, the project was and will remain highly relevant. Veterinary and public health systems need capacity to respond to outbreaks promptly and effectively, to ensure that contagion does not spread and that substantial (potentially catastrophic) human and economic costs are prevented. 35. The risk to economies and public health of outbreaks of zoonotic and other infectious diseases persists and represents a substantial contingent liability on Vietnam’s economy and the government’s budget. In the future the government will need to resource and coordinate the veterinary and human public health services to continue to respond rapidly to outbreaks in poultry (of H5N1 and other types of avian flu such as H7N9), in other livestock, and in wildlife and to monitor for signs of transmission of zoonotic pathogens (including antimicrobial resistance) to the human population. The project’s substantial achievements are a valuable precedent on which the government and its partners can build. 36. Serious new infectious diseases of humans have been emerging steadily over the past 30 years, and this trend is set to continue; notably, 75 percent of the diseases are now zoonotic, since they originate in animals. Recent examples include Ebola, Middle East Respiratory Syndrome (MERS), several kinds of avian flu (including H7N9, which caused $15 billion of damage in China in 2013-14 and infected over 400 humans), and SARS. Though the SARS outbreak caused 800 deaths in 2003, it also caused $54 billion of economic damage, showing that the human health toll is far from the only cost of such disease outbreaks. The Ebola epidemic, too, is having a still-worsening impact on the economies and communities in West Africa; it may yet spread to other regions. The capacities built under VAHIP provide solid foundations from which to tackle such disease threats. Improved animal and human disease 10 surveillance systems developed for influenza will allow earlier and more effective detection and control of outbreaks. 37. Pandemics are infrequent, but the risk is high because of their impact. Capacity for early detection and control of zoonotic pathogens at their animal source therefore remains an important goal, with very large benefits because early control will stop exponential escalation of contagion in the country and across borders. This goal is embodied in the International Health Regulations (IHR 2005), which Vietnam and all other members of WHO have adopted. Early detection and prompt effective control reduce risks at the interfaces between animal, human, and the environmental health – if prompt action does not occur, contagion and associated costs can grow exponentially and become major crises. Vietnamese authorities have recognized that One Health approaches are required to reduce these risks: robust veterinary and human public health systems, with enabled communication and collaboration at the interface between them. Vietnam has been an international leader in adopting One Health approaches, which were incorporated in the OPI and the AIEPED. 38. Pandemic preparedness remains relevant to Vietnam as well. A pandemic will occur in the future; it is not a matter of “if” but “when”. A pandemic is all the more likely because prevention of pandemics through control of pathogens at their animal source is currently hindered by pervasive weaknesses of veterinary and human public health systems in most developing countries. By tackling a threat that does not recognize borders, the project’s objectives thus remain highly relevant not only to Vietnam, but also from regional and global perspectives. Reduction of pandemic risk is a valuable global public good. 3.2 Achievement of Project Development Objectives 11 39. The Project achieved its ambitious objectives. It built essential veterinary and human public health capacities in 11 provinces, and performance of these capacities improved based on M & E reports. These capacities are required for prevention and control of zoonotic diseases and those for preparedness to respond to a pandemic or similar public health emergency. By rapidly and effectively responding to investigate and control outbreaks and other actions, these capacities already contributed to dramatic and sustained declines in disease prevalence. While VAHIP supported implementation of the OPI and the AIEPED in 11 provinces, outcomes in these provinces depended on similar efforts in other provinces. All activities were completed by the Project closing date, which was not extended. In June 2014, the national and provincial project teams came together with their partners in Danang for a final project review, to take stock of the achievements as of the end of June 2014. 40. Attribution of outcomes. The main final outcomes already observed were a dramatic reduction in disease prevalence in poultry (Figure 2) and a large reduction in human fatalities from H5N1 avian flu infection (Figure 3). These trends are equally evident in the 11 project provinces and in the country as a whole. Attribution of these successful final outcomes is at best possible to OPI and AIEPED, since these programs comprised a coherent set of activities that complemented and reinforced each other in tackling a problem that does not respect administrative borders. The substantial strengthening of capacity in veterinary and human public health that was achieved is a precondition for sustaining such outcomes in years to come. 41. A second attribution issue arises from the inherent uncertainty about the spread and evolution of a HPAI virus like H5N1. It may be that the virus could have reduced its spread in Vietnam even if the farmers, poultry workers, the authorities, and the partners had done nothing. Such a scenario contrasts with the experience in more than a dozen developing countries struggling with the H5N1 virus becoming enzootic and even causing repeated human cases. This is still occurring in countries neighboring Vietnam and elsewhere. Based on evidence about the characteristics of the virus, such a dramatic decrease is highly unlikely without disease control 12 measures, however, especially since the flu virus is always bringing new surprises, according to virologists. Most important, however, the downside risk of not preventing and not controlling zoonotic outbreaks at their animal source whenever they occur is very large considering the exponential progression of contagion and infection risks to humans, even in the absence of pandemics. Reducing the circulation of H5N1 avian flu and similar pathogens has been (and will continue to be) inexpensive insurance. 42. Risks to both poultry and humans. The zoonotic nature of H5N1 avian flu means that the risk to poultry cannot be neatly separated from the risk to people, especially in communities where people keep poultry and other livestock un or near their dwelling, so that humans have frequent exposure to the avian flu virus and other zoonotic pathogens but public health standards are low. Moreover, when the flu virus originating in diseased poultry starts a pandemic, people will be rapidly exposed to pervasive health risks as well as to other shocks. Integration of planned activities across the animal health-human health interface was a key guiding principle of the Vietnam government’s plans and the GPAI. Close intersectoral coordination of implementation and integrated monitoring led to integrated decision-making on reprogramming. This and the inherent connectedness between the risks to poultry and to people should be kept in mind in interpreting the presentation of the outcomes below. 43. The impressive achievements of the project are evident in the results obtained toward the project’s sub-objectives. Five sub-objectives were mainly for animal health, namely: strengthening of veterinary services, enhanced disease control, disease surveillance and epidemiologic investigation, preparing for poultry sector restructuring, and emergency outbreak containment. Four sub-objectives concerned mainly human health: disease surveillance, curative care, behavior change and risk communication, and the local-level preventive medicine system. The project devoted deliberate attention and substantial resources to coordination among these sub-objectives and to monitoring of progress. The achievements are described below. 44. Strengthening of Veterinary Services. The two major aims were strengthening of veterinary laboratories and strengthening of disease reporting, which covered 144 districts and 13 2,686 communes and entailed monthly meetings community animal health workers (CAHWs). Results were substantial and often exceeded project targets. Whereas not a single veterinary laboratory met international standards in 2006, there were eight such laboratories by the end of the project, a major accomplishment that was, moreover, achieved ahead of schedule. There is now every reason to have full confidence in laboratory test results because tests are being conducted using testing systems that have been independently accredited. OIE has now accorded Vietnam its highest rating for the laboratory component of the Performance of Veterinary Services assessment. Surveillance has improved so that by the end of the project all participating districts and communes were able to produce reports, with over 97 percent of them providing full information and using the recommended template. The first PDO indicator, on reporting and investigation of outbreaks, had high target values to signal the importance of this veterinary service function (e.g., the target was that 275 case reports of HPAI be fully investigated in the first 5 months of 2014). Since there were 39 reports of HPAI in this period, this high target value was not met, although the veterinary authorities did prepare capacity to act effectively in case there had been more HPAI outbreaks. This improved capacity of the veterinary services was evident in more rapid response times when HPAI outbreaks did occur (see para. 50). 45. Enhanced Disease Control. The major activities were improvement of the large Ha Vy live poultry wholesale market near Hanoi (which handles about 1 million poultry annually), upgrading 42 other markets and 34 slaughterhouses in the 11 project provinces, and construction of a culling site for holding, humane destruction, and disposal of poultry in the northern border province of Lang Son to deal with seized poultry smuggled from China. Disease control was enhanced by use of surveillance data. These data included percentage of poultry traders applying good biosecurity practices at Ha Vy market and percentage of upgraded markets and slaughterhouses applying practices according to project guidelines. 46. A range of biosecurity improvements have been implemented at Ha Vy market. Among these, three specific practices were indicators of the improvements associated with the reconstruction of the market: (i) keeping poultry for sale on the flooring, (ii) regular cleaning of selling points, and (iii) cleaning of transport equipment/vehicles before going out of the market. Starting from a baseline of 25 percent in 2006, all three indicators reached 100 percent by the end of the project, after uneven progress during the period as traders were not Figure 4. An example of market upgrading: poultry are readily adopting biosecurity practices off the ground and regular cleaning is possible (more examples are in Annex 2) because of their cost. Achieving behavioral change among poultry traders was a major challenge, a task made more complicated by the increased number of poultry sold through the market and the need for payment for cleaning and other services which was resisted by the traders. Hence, while the target for this indicator was met, it is likely that this will not be maintained on all occasions, given the huge number of traders involved. Targets for upgraded markets 14 and slaughterhouses to apply practices according to project guidelines were met as well, reaching 100% by the end of the project; moreover, accomplishments for each year were consistently ahead of targets. 47. Disease Surveillance and Epidemiologic Investigation. Monthly H5N1 avian flu virus surveillance activities at Ha Vy market, Lang Son culling site, as well as in 55 other markets and 11 slaughterhouses, were successfully carried out, and 285 outbreaks were investigated. Provincial and district veterinary staff were trained on outbreak investigation and mapping. The percentage of positive samples for H5N1 virus at markets and slaughterhouses, with a target of less than 2% throughout the duration of VAHIP-2, was selected as an overall measure of improvements in disease control and prevention both in markets and at the farm level within project provinces. While the indicator was above 2% in 2012-14, this is also a reflection of the quality of surveillance rather than increased disease prevalence. (Without regular robust surveillance, disease would not have been detected, which could be misinterpreted as absence of disease.) A higher prevalence of infection is expected in poultry during the first half of the year, which coincides with the high-risk Tet Festival period and the cooler winter months, and this contributes to the high value of 7.7% of samples positive for H5N1 in markets and slaughter houses for the first half of 2014 (in the same period, the value was 0% in Ha Vy market). Markets have been modified to markedly reduce the likelihood of becoming persistently infected. But if infected poultry are brought in to markets and tested, the improvements in market hygiene will not be apparent from the surveillance results. 48. Surveillance has provided extremely valuable information about the continuing circulation of avian flu viruses including genetic data and confirmed the importance of measures in markets to prevent the virus from spreading and persisting. In 2014, only 11 of the 197 positive samples were from the Northern provinces, demonstrating that different risk factors are present in different parts of the country. This experience confirms IEG findings on the difficulty with using data on disease or infection status as an indicator, given the confounding factors along the production and market chains that influence the end result. 49. Preparing for Poultry Sector Restructuring. Studies and training (see Annex 3 for details) contributed to the capacity of the government and communities to better manage risks associated with poultry production and marketing, whose rapid growth is driven by increasing incomes. In 22 districts, 1,760 households received training on biosecure poultry production; these households then became trainers for others in their communities. 50. Emergency Outbreak Containment. Preparedness was substantially increased thanks to simulation exercises, training courses on rapid outbreak response, study tours, a communication program in 367 primary schools involving more than 500,000 students (who in turn communicated on preparedness to their parents), and equipment and supplies for emergency response in project provinces. The key indicator chosen was the number of days it took for suspect outbreaks to be completely contained (quarantine and culling) with a 2-day target. Responses have progressively become very rapid, with complete containment achieved in less than 1.5 days. By the end of the project in 2014, it was even possible to do it in less than a day. This highly satisfactory performance of a key component of the disease control system warrants particular recognition. It resulted from the training provided in outbreak response, simulation exercises, rapid availability of the test results from accredited laboratories, changes to protocols 15 which allowed culling on suspicion, and the excellent leadership of the animal health teams at the provincial level. 51. Disease Surveillance. VAHIP introduced innovations to the country’s surveillance system for infectious diseases in humans: shift to considering the village health workers as the first source of data at the lowest level; private sector, press, and media as an additional data sources interacting with the district, provincial and national levels; and in line with the One Health approach, integration of the veterinary centers at all levels, interacting with the Regional Animal Health Offices (RAHOs), the Pasteur Institutes and NIHE for the confirmation of AI cases. At the same time, a commune-based online reporting system for infectious diseases was installed, based on upgrading of existing software developed earlier by the Preventive Health System Support Project financed by the Asian Development Bank. This was accompanied by training of several thousand health workers (see Annex 3 for detail). Indicators of timeliness and completeness of reporting show that the surveillance system is performing well, and performance targets were exceeded by the end of the project. Extension to other provinces of this type of surveillance system with online reporting is underway, since compatibility among reporting systems within the country is important. Figure 5. Evidence of high risk awareness in paintings by 52. Curative Care. Provincial children hospitals improved their capacities to (more examples from school-based contests are in Annex 2) deal with human cases of H5N1 avian flu and similar acute infections that may require isolation and intensive care. The hospital segment of the pandemic simulation exercise was successfully developed. For details of the equipment and training provided, see Annex 3. The two indicators measured development of the pandemic preparedness plan by provincial and district hospitals, an essential and highly valuable step in building preparedness. By the end of the project, targets were exceeded for the 44 provincial hospitals and 124 district hospitals in the VAHIP provinces: 100% of all these hospitals have developed their preparedness plans for an influenza pandemic. 53. Behavior Change and Risk Communication. VAHIP included communication activities for both health workers and for the general population. Another important target group were ethnic minority groups. The coverage and the volume of the communication materials produced were enormous: 16 20,532 health staff were trained on behavior change communications (BCC) skills, 264,000 posters were disseminated; and 4.2 million leaflets were produced. The range of strategies was broad and included several types of competitions, which attracted a very large number of participants. For example, in the provinces of Long An and Tay Ninh, a poster-making contest among schoolchildren received a total of 18,000 entries (sample entries are in Figure 5 and Annex 2). An essay-writing contest among adults in Thai Binh attracted hundreds of entries. The instruments for communications were written (leaflets, handbooks, etc.), verbal (radio and loudspeaker broadcasts; group discussions, etc.) and visual communication (billboards; calendars; educational film, etc). Person-to-person communication was used extensively to relay messages about influenza prevention and control, especially during home visits in communities with ethnic minority groups. 54. Risk communication entailed development of both writing and oral skills, with 65 and 49 trainees respectively. The project also provided communication equipment, most of it for mass communication. Notably, the training material on risk communication developed by VAHIP was recently reviewed and approved by the MOH and recommended for use by academic institutions and projects conducting training on risk communication. This is the first material on risk communication to be approved and endorsed for use by the MOH. 55. To evaluate impacts, Knowledge, Attitudes and Practices (KAP) surveys were conducted among health workers and the general population four times: in 2008 and 2011 for the Phase 1 provinces, and in 2012 and 2014 for the Phase 2 provinces. The results are in Table 1. The surveys revealed increases in both knowledge and attitudes and in behaviors that are indicated to prevent infection. The proportion of respondents at the end of the project with such knowledge and behaviors was above the 60 percent targets set for each of the sub-groups (curative health workers, preventive health workers, and general public). The target for health workers was, however, set too low given their Table 1. KAP survey results on correct knowledge, attitude and practice initial relatively toward at least one key preventive behavior (% of target groups) high level of Target Aspect PHASE 1 PHASE 2 knowledge and Group Assessed 2008 2011 % Relative 2012 Target 2014 %Relative protective behavior. Difference 2014 Difference The general Curative Knowledge/ 87.5 93.1 6.4 92.4 60 100.0 8.2 health staff Attitudes population had the Practice 91.0 97.2 6.8 74.0 60 86.2 16.5 largest Preventive Knowledge/ 74.0 86.5 16.9 84.4 60 96.1 13.9 improvements in health staff Attitudes knowledge and Practice 100.0 100.0 0.0 82.0 60 88.0 7.3 General Knowledge/ 20.8 54.5 162.0 50.0 60 80.0 60.0 behaviors after the population Attitudes communication and Practice 56.4 98.4 74.5 34.0 60 98.8 190.6 training interventions. 56. Strengthening Preventive Medicine System at Local Level. The training of district level health staff on communicable diseases, information technology, communications skills, use of equipment that was provided under the project (see Annex 3), and the conduct of multisectoral simulation exercises yielded impressive results. The number of District Preventive Medicine 17 Centers (DPMC) that are fully equipped and have capacity to implement their responsibilities and functions increased dramatically, from just 28 in 2010 to 87 in 2014, above the end-of- project target of 79. Simulation exercises to build preparedness for outbreak response and training on planning responses benefited more than 10,000 district-level staff, a significant achievement in fostering risk awareness and building response capacity at the local level. Post- graduate training for 90 district-level staff is important in strengthening technical skills at that level and was an opportunity that is seldom available to staff working at the local levels. 57. Most of the equipment provided has multiple uses since the objective was to strengthen the district preventive medicine system, rather than to limit equipment to that used for the management of influenza and similar diseases. The equipment included items which are needed for other purposes within the core public health functions like reproductive health. A narrow focus on infectious diseases, or even just influenza, would not have been as effective in building the capacity of the district preventive medicine system. 58. Multisectoral coordination was a strong feature of the strengthening of the preventive medicine system (Table 2). The most important activity was conduct of 68 major simulation exercises involving 15,146 participants, which is highly valuable in building preparedness. In addition, the project also conducted 24 internal and 3 external experience-sharing activities where 590 PPCU and district level staff involved in the project visited other provinces in order to observe their activities and share their experiences with the various project Table 2. District-level preventive and curative capacities performance targets were exceeded components. Local coordination became INDICATOR ACTUAL TARGET % DIFFERENCE more effective thanks to the project 2014 2014 organizing 1,179 workshops involving Percentage of districts which implemented the revised policy for preventive medicine 80 75 6.7 29,518 participants. Finally, as part of the Number of PPMCs in 11 project provinces fully project each of the 11 project provinces equipped and have adequate capacity to fully implement their responsibilities and functions in 87 79 10.1 compliance with the MOH decision prepared operational guidelines on multisectoral coordination. This deliberate Number of multisectoral simulation exercises conducted and reviewed at district levels in the 68 37 83.8 and intense effort at building links to project provinces veterinary services and other sectors, Number of health staff who have been trained 69012 21905 215.1 reinforced through multisectoral simulations of responses to emergencies, is a good practice example. 3.3 Effectiveness and Efficiency 59. The project was exceptionally effective because it produced large economic and health benefits at a very modest cost. This achievement is all the more notable because it occurred despite the challenges of an inherently complex and largely unpredictable zoonotic disease threat. The project tackled an emergency (since major renewed outbreaks were possible) and, at the same time, made lasting systemic improvements to animal and human public health systems in 11 provinces. Both of these actions are highly productive investments and an excellent value for money. The project was highly efficient at the conceptual level, since it tackled a potentially major threat to human health (widespread infections with H5N1 avian influenza or even emergence of an influenza pandemic) by reducing contagion at its animal source. Infectious disease control is far less costly when done early and at the source, because contagion and costs of containing it can grow exponentially. Containing contagion in poultry is possible at a fraction 18 of the cost of containing it once it spreads in the human population. The deliberate One Health approach was thus the most efficient choice. Moreover, it was also humane, since human cases did not serve as sentinels of a poultry disease, as was seen in other countries. The project also used efficient implementation methods, to lower costs and to generate additional productive outputs with the savings. 60. VAHIP investments (and similar investments in other provinces under the OPI and AIEPED plans) produced high economic benefits, far above the cost of the investments, and will continue to do so if the public health capacities created under OPI and AIEPED are maintained. The analysis in Annex 3 finds that annual spending $77 million on building and operating veterinary and human public health systems8 would yield an expected annual benefit of $105 million (assuming that future prevented outbreaks and reduced pandemic impacts are just one tenth of the high-impact outbreaks in 2004). The calculation conservatively assumed that a severe flu pandemic occurs seldom: once in a hundred years. Therefore the annual risk (expected value of costs) is just 1 percent of the impact of the event once it happens. Clearly, when economic benefits exceed costs every year (and do so by a wide margin), these public investments should have been made, were highly effective, and significantly increase the total economic resources of the country for years to come. 61. The economic rate of return on the investments is very high and such high net benefits would by themselves more than justify a highly satisfactory rating for overall outcome. Annex 3 presents the calculations, which assumed that disease risk was not reduced in the first 5 years of the project, so there were only investment costs in that period. Benefits were thus assumed to start only in year 6. With these conservative assumptions, the rate of return on the OPI and AIEPED investments in disease control and prevention is 29 percent annually in real terms. If the disease risk is reduced by 20 percent from the 2004 value (instead of by only 10 percent), the expected rate of return is 129 percent annually in real terms. These highly positive rates of return reflect the very large economic benefit to the country, and are well above the returns on other public investments. Additional benefits accrued to the rest of the world, from a reduction in pandemic risk. While these benefits are certain, their valuation is not possible because the shares of Vietnam in the global avian flu “virus load” before and after VAHIP are unknown. National benefits alone, however, more than justified the investments. These high rates of return are consistent with global experience and with the findings of a recent Lancet commission on health, headed by Harvard University professor Lawrence Summers (Box 1). When an outbreak occurs, costs can escalate very rapidly so having robust public health systems to prevent preventing the escalation because they are prepared pays off very well.9 8 This is equivalent to the average annual amount spent during the OPI and AIEPED periods. 9 Most countries neglect public health systems and do not make investments in preparedness. Experts advised Guinea, Liberia, and Sierra Leone to invest $26 million in disease detection and disease outbreak control preparedness, during an assessment of preparedness in 2007. These investments were not made, and public health systems for disease outbreak control remained weak. The Ebola outbreak in West Africa could have been stopped in March 2014 for less than $200 million. In August, this estimate was $1 billion. At the end of October 2014, the estimate of cost to stop the outbreak was $4 billion (and rising). In addition, the people of Guinea, Liberia, and Sierra Leone are hard-hit by disease, food insecurity, loss of jobs, and other disruptions, while their and neighboring economies suffer. This is a recent stark example of the high costs of weak health sector policies, which are too common. Unlike Vietnam under VAHIP, most developing countries neglect public health systems for disease outbreak control. 19 Box 1. The single most important area for productive investment Harvard University professor and former US Treasury Secretary Lawrence Summers said that, because pandemic risk is high: "[veterinary and human public health systems are] probably the single most important area for productive investment on behalf of mankind." Source: Video of high-level panel on health, World Bank, April 11, 2014, www.worldbank.org/pandemics 62. Efficiency was evident throughout implementation, to an impressive degree. The project adopted approaches that generated outputs in a low-cost way. Communications activities mobilized tens of thousands of communicators at very low cost. For example, in school-based activities teachers, at minimal additional cost, helped organize a contest for school children, to paint scenes about avian flu control. The children produced remarkably well-informed images, showing emotional grasp of the complexities of a zoonotic disease. The children and their 18,000 evocative images conveyed the messages at low cost and far beyond the classroom, to the families and communities. VAHIP implementation staff also adopted inventive low-cost solutions that mobilized resources from local and provincial governments, as well as from organizations and communities. Another cost-efficient approach was to adopt government cost norms for many activities (rather than higher norms, like those used by some donors), which was an important efficiency measure, given the numerous programs of training, workshops, and consultations among provinces. Another illustrative instance was decision to not pay for new customized software, but rather to generate savings by adapting surveillance software from an Asian Development Bank-financed project. This lowered costs overall, without reducing effectiveness and timely availability of the resulting “hybrid” system. 3.4 Justification of Overall Outcome Rating Rating: Highly Satisfactory 63. The Project was and remains highly relevant. It more than achieved the project development objective of strengthening public health capacity to respond to H5N1 flu outbreaks, preparing for pandemic influenza and other infectious disease outbreaks, and more generally building systems for disease prevention and control, especially at district level. The outcome stands out as unambiguously highly satisfactory within the country and project parameters: extraordinarily high economic and health benefits were generated by modest investments in successful emergency operations and in building (and testing) core public health systems. While modest, the investments were challenging technically and managerially – and these challenges were met in a way that has been, and can continue to serve as, an example to follow in other countries. The outcomes in building public health systems are also well above the results achieved by most other developing countries, where public health systems are weak and chronically neglected. The Chairman of the Lancet Commission on Health stressed that this is the area for the most productive investments on behalf of mankind; VAHIP was unambiguously such an investment that should be replicated widely. 20 64. The project was aligned to the government’s plan and country systems. The development outcomes were substantial as reflected not only in the very high economic returns but also in the high achievement rates for the outcome indicators measuring public health system performance. Targets for many indicators of system performance were surpassed (Table 3). The systemic capacity improvements were not only done in a relatively brief span of time, but they are also a much too rare instance of proactive investment in public health systems where the expected economic returns and impact on population health status are higher than for other public investments. Table 3. Project outcomes: nearly all targets surpassed or met Indicators of Other intermediate performance of Project key outcome indicators Share of all project Number of indicators that: veterinary and indicators (e.g., training, risk indicators human public awareness) health systems Surpassed target 1 9 2 71% Fully achieved target 1 1 1 18% Partly achieved target 1 6% Target not applicable 1 6% 65. Vietnam showed consistency over a decade in investing in disease prevention, which is grossly neglected in most countries. Unlike the vast majority of developing countries, under VAHIP Vietnam succeeded in implementing a health sector policy that is superior to, and far less costly than, coping with the aftermath of lack of prevention. It is a tribute to the commitment and sound policy-making of the Vietnam government that the investments in public health systems were pursued despite growing apathy and neglect among the international community. Moreover, the overall rating of highly satisfactory is justified by: effective and increasingly swift responses to outbreaks in poultry, strong improvement in surveillance and reporting of diseases (including fast turn-around times), upgrading of a large number of preventive health care centers at local level to meet standards, decision to use project flexibility to expand the use of highly productive simulation exercises, success of the information and education campaigns, adequate and timely compensation for culled poultry, a range of biosecurity measures, and exemplary leadership in sharing knowledge on One Health approaches and avian flu control globally. Finally, the highly satisfactory overall outcome rating is justified by the remarkable results in diagnostics capacity and management; these results were recognized by the international certification of 8 laboratories within a short time span. This is a world-class achievement that very favorably contrasts with the mismanagement of biosecure laboratories in many other countries. Finally, the project had no shortcomings. 3.5 Overarching Themes, Other Outcomes and Impacts 66. Poverty impact and gender aspect. H5N1 influenza outbreaks initially affect the poultry population. But, if not contained, they could directly and indirectly affect the majority of the human population of the country since nearly all rural households and some periurban households raise poultry. Among the poor, poultry often live in or very close to the family dwelling. Poultry is often traded in live-bird markets by women, and raised by women and 21 children (who may thus be most exposed to the virus both in poultry and in poultry droppings); children tend to suffer the most if the availability of affordable protein declines when large numbers of poultry die due to disease. Repeated large outbreaks of avian influenza in Vietnam would thus have devastating impacts on the poor (see Annex 3 for results of a study of distributional impact). Since small disease outbreaks were promptly controlled and large outbreaks did not occur at all (in part thanks to control of small outbreaks), the poor benefited. The Project contributed as well to prevention of pandemic influenza (to an unknowable extent) and to preparedness. A pandemic would hit the poor the hardest, in Vietnam and elsewhere. Preparedness to mitigate the impact of this potentially catastrophic shock thus has an important pro-poor bias; this benefit will be realized when a pandemic occurs. 67. Social development. Without the Project, the spread of H5N1 flu would have been more likely. A severe pandemic could have occurred instead of, or in addition to, the 2009 H1N1 pandemic. In those events, the entire population of Vietnam would have been affected, possibly with severe economic and social disruptions and increases in poverty, as mentioned above. The project created capacity that will help prevent such potentially devastating impacts on the entire society. The pandemic response plans and use of simulation exercises under VAHIP are important in this regard. Plans will need to be periodically exercised through simulations and updated as warranted for the expected benefits (mitigation of pandemic impact on society and the economy) to materialize. 68. Institutional change/strengthening. The Project contributed substantially to strengthening animal health and public health systems and, notably, to collaboration between them. There was significant progress, notably, at the provincial and district levels and in skill- acquisition by a large number of local-level staff. Collaboration between human and animal public health services was largely successful, which augurs well for future joint work. Such collaboration is critical in detecting, reporting, investigating, diagnosing and effectively controlling zoonotic diseases which are, and will remain, a significant threat in Vietnam and in neighboring countries. Strengthening of the laboratories and improved management has achieved capacity that meets rigorous international standards. 69. Other unintended outcomes and impacts (positive and negative). The focus was on influenza in poultry and humans. However, the systemic improvements can and should be deployed against other threats. Antimicrobial resistance is already a significant problem; better surveillance (using the systems improved under VAHIP) in both livestock and humans is already an urgent need. Pandemic plans, stocks of PPEs, training on infection control, and the many outbreak response simulation exercises that were carried out put Vietnam in a stronger position to effectively deal with any imported Ebola cases. Strengthening of preparedness through planning and simulations will continue to be highly productive, considering the low cost. 4. Assessment of Risk to Development Outcome Rating: Moderate 70. The improvement in performance of veterinary and human public health systems in the 11 VAHIP provinces has been dramatic. Now these systems, and those built in the rest of the country thanks to the OPI and AIEPED, will need to keep pace with Vietnam’s rapidly growing economy and popular aspirations for better health. If the performance of the systems worsens (or 22 does not improve sufficiently), the country will be vulnerable to reversal of its development gains and possibly devastating spread of disease. Such adverse shocks can undo years of development progress; public health systems are required to deliver the core public service of protecting the population and the economy from such shocks. The government will require financial and technical assistance for further development of capacity in disease control and prevention (including not just avian flu, but also other zoonotic diseases, antimicrobial resistance, and other One Health challenges). It will also need to give a high priority to the operations and maintenance of the systems that have been built and improved. 71. It will be difficult to meet the twin challenges of operating the systems already built (and preventing their erosion) and further increasing veterinary and human public health capacities. The ongoing AIPED (2011-15) addresses One Health issues, such as influenza and other zoonotic diseases and food safety. Since 2003, Vietnam has mobilized considerable internal resources and also received external support from donors that was often above the envelopes normally available for Vietnam. The significant decline of attention and financing since 2009 has created a sustainability issue. The government has a contingency in its budget for responding to disasters. The two ministries’ regular operating and investment budgets (financed by domestic and donor funds) will have to make adequate allocations for sustained strengthening and operations of core animal and human public health functions. Ensuring adequate budgets to sustain and further increase performance standards should remain a priority because of the large positive economic and health impacts of these expenditures. 72. There are two major risks to the sustainability of the public health systems and the services they need to deliver to sustainably improve health and economic growth. First, external assistance has declined and is highly uncertain since strengthening of animal health systems is not a priority for donor financing. Human public health systems are a low priority in donors’ health sector programs (relative to curative health care). Neither WHO nor OIE have resources for adequate technical assistance that is needed to carry out authoritative assessments of core public health capacities for outbreak disease control and prevention, subsequent prioritization of investments, and definition of other measures to help countries achieve veterinary and human public health systems that meet international standards. Second, domestic resources for the operations and maintenance of the public health system capacities may be difficult to mobilize as well, if Vietnam follows the pattern common in many countries of low health sector interest in prevention of disease outbreaks, such that funding for prevention usually only materializes sporadically, after devastating disease outbreaks that occur precisely because of the weak public health systems. 73. The rating on Risks to Development Outcome suggested by the above could be “Substantial.” The rating is, however, “Moderate”, for three reasons. First, there is evident commitment to ensuring operations of high-maintenance capacities like the laboratories, district preventive health care centers, and surveillance systems. Second, Vietnam has established a remarkably successful public health system strengthening record, using an approach which has already served as an example to other countries dealing with zoonotic disease threats. Finally, Vietnam has a strong record of making sound economic development choices and implementing policies that benefit the country. Robust veterinary and human public health systems are unambiguously among policies that are good for economic growth, as well as for health security. 23 5. Assessment of World Bank and Borrower Performance 5.1 Bank (a) Ensuring Quality at Entry Rating: Satisfactory 74. The Project was prepared rapidly as an emergency operation by the Vietnam government with support from a strong team from the World Bank, comprising diverse specialists, operation officers, and an advisor—all with technical skills necessary to guide project design. World Bank team benefited from collaboration with FAO, WHO, US CDC, UNSIC and other experts who were actively engaged in the response to the H5N1 flu threat. World Bank support to the government in preparing the government’s plans (the OPI and AIEPED) was effective and appreciated by counterparts. The project, in turn, aligned very well with these plans. World Bank support to project preparation was also informed by the GPAI, which embodied international best practice and was, in fact, substantially based on Vietnam’s successful experience in the initial phases of controlling the disease in 2003-2006. The internalization of this experience by the project team, and incorporation of such best practice into the VAHIP ensured that quality at entry was highly satisfactory. The mitigation plan for addressing critical risks was sound and relevant. The rating would be Highly Satisfactory if it were not for the sharp reduction of the World Bank’s support to the global program during the VAHIP-2 period. From 2010 when the Human Development Network (HDN) took over responsibility for the global program (including operations ongoing in 30 countries at the time), engagement of the Bank in the global program declined sharply and thus made inadequate contributions for global risk communications, global coordination, and advocacy for preparedness and prevention. 10 Since Vietnam was contributing to an important global public good (as well as generating national benefits), this gap in World Bank support sent unfortunate signals about a dramatic decline in interest of the global community in pandemic risk reduction. (b) Quality of Supervision: Rating: Satisfactory 75. The task team was multisectoral and provided effective and well-coordinated implementation support, with relentless follow-up on the details of implementation of the numerous and diverse activities in 11 provinces. The decentralized structure of the project required engagement with counterparts who were not familiar with implementing World Bank- financed projects. It is a testament to the commitment and inventiveness of the World Bank’s multisectoral team that ambitious targets were achieved and many were exceeded, despite the complex multisectoral challenges and decentralized implementation. Environmental issues were resolved satisfactorily thanks to the team’s support. Since most of the supervision activities were conducted from the World Bank’s country office, a continuous and intensive effort was possible, with implementation assistance to the provincial levels. The financial management and procurement teams were continuously engaged in supporting project activities. Likewise, the social and environmental safeguards specialists assisted with achieving compliance and participated in reviews. All activities financed by the World Bank were completed successfully without the project being extended. In their comments, government counterparts specifically appreciated Bank flexibility during implementation and the contributions of the Hanoi office- based team (Annex 5). The strong performance of the task team in providing implementation 10 World Bank, Independent Evaluation Group (2014). 24 support was all the more commendable in view of the World Bank’s weak institutional incentives for effective operational work that spans multiple sectors. (c) Justification of Rating for Overall Bank Performance: Rating: Satisfactory 76. Strong World Bank performance during the preparation phase (which entailed support to formulation of the OPI and then the AIEPED, preparation of a robust multisectoral framework, alignment to a global program, coordination with partners around a country-owned plan, and an emergency response with rapid processing) was followed by the team’s relentless attention to the details of implementation in two major sectors and consistently high and successful coordination effort in the supervision phase. This exemplary performance offset the gaps in advocacy and other institutional support and warrants an overall Bank performance rating of Satisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Satisfactory 77. The project achieved or surpassed all relevant outcome targets. Equally important, nearly all interim targets were met during implementation and many were exceeded. The veterinary and human public health systems at provincial and district levels significantly improved their capacity to perform and deliver core public health services to the country, including for: surveillance through support to CAHWs, biosecurity, communications on animal diseases to health care workers, farmers, traders, and others, rapid response to infectious disease outbreaks, hospital care for the treatment of highly pathogenic diseases, and speed and accuracy of laboratory testing. The government formulated plans for pandemic response in the health sector, in other sectors, and across ministries and levels of government; these plans were tested in numerous simulations, which is a significant result. Vietnam made a timely and substantial contribution by showing global leadership in the adoption of One Health approaches in controlling zoonotic diseases at their animal source. The government mobilized to effectively share its knowledge with the international community on the occasion of the international ministerial conference on animal and pandemic influenza in Hanoi in 2010. This contribution was beyond that envisaged in the OPI and AIEPED (or the VAHIP) and added substantial value to global efforts against the pandemic threat. Commitment to building public health systems is extremely difficult to sustain, as shown by the common neglect of these systems in most developing countries. This neglect is highly costly, as evidenced by the ongoing Ebola crisis (and similar crises to come). The government’s sustained commitment to prevention over a decade is by itself sufficient grounds for a satisfactory rating. (b) Implementing Agency or Agencies Performance Rating: Satisfactory 78. As noted above, VAHIP was developed and implemented by MARD, MOH, and other departments of the government and implemented in a decentralized way. The difficulties created by a complex project with decentralized implementation were effectively addressed and overcome thanks to exceptional commitment to improving veterinary and human public health capacities and openness to innovation. For instance in financial management, VAHIP yielded valuable lessons for similar future projects. There was strong and highly beneficial engagement from the People’s Committees, which contributed critical support (for instance for whole -of- society multisectoral simulation exercises) and also provided tangible assets such as buildings at the provincial and district levels. VAHIP achievements were facilitated by their commitment and 25 implementation competence. Moreover, implementing agencies made adjustments flexibly, supported deliberate and successful coordination across sectors at central, provincial and district levels, and exploited opportunities for additional efficiencies, to stretch the limited resources available to produce additional results. When the monitoring of environmental impacts showed problems, the PCU and relevant government departments sought to remedy problems proactively. (c) Justification of Rating for Borrower Performance Rating: Satisfactory 79. VAHIP achieved excellent results as a multisectoral project because of strong government leadership and commitment from the two ministries responsible for implementation. It was implemented in a significantly decentralized way. The difficulties created by a complex multisectoral project with decentralized implementation in 11 provinces were effectively addressed during implementation and overcome thanks to exceptional commitment to improving veterinary and human public health capacities and openness to innovation. Building the veterinary and human public health capacity that is required for ensuring high economic and health benefits within Vietnam and going beyond the project to contribute knowledge to the global community more than offsets the record in the ISRs of moderately satisfactory ratings of implementation progress during much of the project period. Altogether, a satisfactory rating is therefore amply justified. 6. Lessons Learned 80. The following lessons can help inform future programs that build veterinary and human public health systems for prevention and control of diseases.  An emergency is an opportunity to reduce risks over the medium term. This will help prevent future costly emergencies. VAHIP was launched in the wake of a major disaster caused by the 2003-04 avian flu outbreaks and in the context of an unprecedented global emergency response to a pandemic threat. Vietnam successfully seized the political support and resources that were mobilized to implement its comprehensive and integrated veterinary and human public health plans at national, provincial, and district levels. Impressive progress was made in building a wide range of capacities, such as the outstanding improvement in animal health laboratories. There is no doubt that thanks to the government’s and donors’ attention to development imperatives (a functioning public health system is essential to reduce risks to development), performance of the systems needed to prevent and control zoonotic diseases and similar public health threats has improved, which will bring large benefits for years to come. Investments in capacity to tackle zoonotic diseases at their source, including continuing training on biosecurity, strengthening livestock and wildlife surveillance, communications, and rapid response teams, will substantially lower the costs of future emergencies and save human lives.  One Health approaches are effective in disease control and prevention. This recognition grew out of implementation of VAHIP and the concerted coordination between MARD and MOH in dealing with a dangerous zoonotic pathogen. In view of the benefits of a multisectoral approach to disease control and prevention in Vietnam, the government hosted a week-long workshop on One Health approaches for participants from 25 countries ahead of the Hanoi Ministerial Conference on Animal and Pandemic Influenza in April 2010, 26 providing valuable guidance on implementation of One Health approaches to Ministerial delegations responsible for animal and human public health in 71 countries.  One Health approaches are feasible when there is good leadership. Overcoming barriers between the veterinary and human public health services was challenging. It was possible thanks to deliberate institutionalization (signing an interministerial circular and a memorandum of understanding and setting up coordination mechanisms and operational guidelines at all levels). This enabled joint planning and evaluation of results as well as sharing of information and other resources and conduct of joint activities, where warranted. The impetus of an emergency situation and interest from senior leaders, technical teams, agencies, and partner countries help facilitate coordination as well.  Behavior change takes time and resources. Poultry market traders only started adopting safe behaviors when they understood and accepted the rationale. Working with traders to solve management problems of the large Ha Vy market was essential and lasted longer than initially planned.  Upstream attention to environmental impacts helps prevent problems. Technical review of the design of environmental protection works (such as solid waste and wastewater treatment systems) should be included from the beginning of project implementation.  Transition from emergency response to systemic improvements is important. Transition to medium-term system strengthening was envisaged in the OPI and the AIPED and was successful. This is a solid basis to sustain progress, which will help Vietnam reduce threats from infectious diseases and similar conditions, such as antimicrobial resistance. Notably, chronic under-resourcing of veterinary services has not yet been fully overcome and further substantial investments are warranted. The approach of early disease control at the animal source is a precedent for public health system capacity-building for prevention of other zoonotic diseases and similar conditions.  Successful market upgrades. Lessons from slaughterhouse and market upgrades under VAHIP will be useful in further efforts to reduce disease transmission in similar facilities in the rest of the country.  M&E indicators. Final outcome indicators (such as disease prevalence and the case fatality ratio) are by themselves not sufficient to evaluate progress and thus may be misleading. They need to be complemented by measures of system performance for functions that are required for disease control and prevention. VAHIP chose useful indicators of “intermediate” outcomes. Looking ahead, independent assessments of veterinary and human public health systems according to the methodology and benchmarks established by WHO and OIE can serve as robust measures of performance, on which the government and its partners can rely.  Technical definitions are critical for M&E. A key lesson was that what constitutes “suspect cases” of H5N1 avian flu disease in poultry needs to be unambiguously defined for all types of enterprises and flock sizes. When some communes, districts and provinces use different definitions, it is exceedingly difficult to aggregate outcomes, compare among locations, and devise appropriate responses.  Use of consultants. External expertise was essential for the highly technical task of improving laboratories and their management. Laboratory quality management expertise from the Australian Animal Health Laboratory had highly satisfactory results. In other areas, 27 too, technical consultants provided good value, especially when they were able to regularly provide inputs to project management.  Decentralized implementation. This was both necessary (because disease control and prevention activities occur in numerous districts and villages) and challenging (because local capacity was uneven and alignment with national policies and programs was required). Successful implementation required investment in decentralized functions for implementation and in coordination. These were resources well-spent. Provinces and districts identified their own needs, procurement plans, and training plans. This improved implementation performance and reduced demands on the central project management units.  Financial management with decentralized activities. Important lessons were learned. First, decentralization of activities to provinces and districts helped to increase their capacity in Project management and also their ownership of implementation of Project activities. The human resource capacity built up by the Project at the decentralized levels will be available after Project closing and is a very good resource for the Government to implement similar activities. Second, close interaction of the PCUs with PPCUs and supervision of the PPCUs by the PCUs (especially the MARD PCU), enhanced the quality of the financial reporting function at the local level, reduced mistakes, and reduced errors in use of funds. Third, comingling of funds from IDA, AHIF, and PHRD was efficient and reduced transactions costs for the government. Although donors often apply separate cost norms and financial management procedures, in this Project all the funds were pooled as one source and treated equally.  Engaging stakeholders beyond MOH and MARD. The provincial political authorities (People’s Committees), were formally involved in VAHIP. Their contributions to multisectoral simulation exercises were indispensable and highly successful; they also provided other substantial assistance, such as funds, land and buildings. Mobilization of organizations of students, youth, women, farmers and ethnic minorities was part of the IEC outreach. This helped create pools of community-based educators that could convey knowledge to their friends and neighbors about avian flu risks and behaviors to reduce them. School-based IEC proved very successful, with children becoming knowledgeable about poultry disease and pandemic risk and about ways to prevent infection.  Training health workers on communications, especially risk communications. This helped extend messages to communities and improved infection control in health care facilities. There is opportunity to substantially increase the reach of this training by involving more health workers. Moreover, such training needs to be periodically repeated.  Rule to balance expenditures on training and equipment in health care centers. The use of the 30-70 rule (30% training, 70% equipment) proved helpful in guiding decisions at the district level. The rule aims to avoid waste entailed in unused or abused equipment.  Quality of supervision and implementation support. Substantial implementation support was instrumental to the success of this technically complex, emergency, and multisectoral operation. Government comments highlighted this aspect as well. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 28 81. Comments and suggestions made by the PCUs of MARD and MOH are presented in Annex 5, together with corresponding responses, and alongside recommendations from the government’s ICR for reducing avian influenza and other zoonotic disease risks in the future. (b) Partners 82. The Implementation Completion and Results (ICR) mission benefited from discussions with WHO, FAO, USAID, US CDC and the European Commission about their views of the implementation and outcomes of VAHIP. 83. FAO and WHO had been actively engaged in the response to avian influenza but their activities have declined when funding ended. Based on the experience and outcomes of VAHIP, FAO considered that collaboration on animal health with WHO and with MOH will essential in the future. Since the European Commission’s (EC) response to avian flu response was managed from Brussels, the EC delegation in Vietnam was not directly involved in supporting VAHIP, though their overall impression is that it had been a valuable initiative. USAID’s ongoing projects related to zoonotic risks have been greatly reduced from previous levels and are now the only major externally-funded activities addressing these issues. 29 Annex 1. Project Costs and Financing (a) Project Cost at Appraisal by Component (in US$ million equivalent) VAHIP-1 VAHIP-2 Total Components 2007-10 2011-14 2007-14 A. Animal Health 17.2 4.31 21.51 B. Human Health 16.0 16.28 32.28 C. OPI Integration & Coordination, 4.8 4.41 9.21 Results M&E, and Project Management Total Project Costs 38.00 25.00 63.00 Total Financing Required 38.00 25.00 63.00 (b) Financing Appraisal Actual/Latest Percentage Type of Source of Funds Estimate Estimate of Financing (US$ million) (US$ million) Appraisal IDA credit 30.00 30.00 100 AHI Facility grant 23.00 23.00 100 PHRD trust fund grant 5.00 5.00 100 Government budget 5.00 5.00 100 Total 63.00 63.00 100 30 Annex 2. Outputs by Component 84. This section is based on the government’s project completion report, presentations at the final VAHIP workshop, and the World Bank’s Implementation Status Reports. To achieve the objective of the project, VAHIP had to deliver inputs and intermediate outputs in 11 project provinces (Figure A2.1), which can be categorized into four major areas, namely: a. Civil works (e.g., upgrading of waste treatment systems, Figure A2.1. The eleven VAHIP provinces improvement of Ha Vy Market near Hanoi, improvement of other smaller markets and slaughter houses, and upgrading of isolation wards of provincial hospitals); b. Tools and technology (computer hardware and software; upgrading of veterinary laboratories to meet ISO standards; laboratory, hospital and communication equipment for provincial and district hospitals, provincial and district preventive medicine centers, and some of the provincial IEC centers); c. Capacities (technical support, training of veterinary laboratory staff, animal and human health workers in quality management, surveillance, prevention, control, detection and management of infectious diseases, behavior change and risk communication; training of specific sub-groups of the general population on prevention and control of avian influenza and other infectious diseases, on behavior change, and risk communication; and 31 d. Approach (One Health, strengthening the sub-national level with focus on districts and communes). These inputs resulted in outputs, which in turn contributed to the project’s outcomes. The major outputs produced by each project sub-component are presented in the following sections. 85. Sub-component A1: Strengthening of Veterinary Services. Among the outputs were: - Supply of laboratory equipment required to perform testing for avian influenza viruses, including appropriate real time polymerase chain reaction equipment; - Calibration of major equipment; training in calibration for minor equipment (pipettes, etc.) for national, regional and some provincial laboratories, including certification of trainees; - Organization of proficiency testing for nine veterinary laboratories with the national Center for Veterinary Diagnosis (NCDM) providing the samples for testing. NCDM is also applying for accreditation for this purpose; - Installation of a novel waste-handling system at the laboratory in Vinh; - Regular meetings of staff in the laboratory network to discuss important issues in common and to share experiences on quality management; - Establishment of a Quality management and Safety Board in each laboratory and conduct of regular (quarterly) meetings of the Board; - Employment of contract staff in laboratories to ensure sufficient trained manpower was available to perform all testing; and - Testing of more than 200,000 samples. 86. Another important activity was improving disease reporting, which covered 144 districts and 2,686 communes. It involved monthly meetings with community animal health workers (CAHWs). All participating districts and communes were able to produce reports, with over 97% of them providing full information, using the recommended template. 87. Sub-component A2: Enhanced Disease Control. There were three main civil works and infrastructure improvement activities under this subcomponent. Examples are shown in Figures A2.2 and A2.3). First, a major activity was the improvement of the Ha Vy wholesale poultry market near Hanoi. The outputs included: - Planning and construction of the market; - Liaison with traders to implement behavioral changes; - Provision of equipment and materials to improve the hygiene and biosecurity of the market; - Provision of technical advice on upgrading the market and market management; and - Installation of waste treatment facilities. Second, upgrading of 42 other markets and 34 slaughterhouses, thanks to the following: - Support of minor capital works including waste handling; - Assistance in market design and management; - Provision of equipment for cleaning and disinfection; - Training of market stall holders on biosecurity and hygiene; and - Employment of market managers. Third, a culling site for holding, humane destruction, and disposal of poultry was constructed in the northern border province of Lang Son to deal with seized poultry smuggled from China. 32 Figure A2.2. Little or no biosecurity before improvement of markets Ha Tinh and Dong Thap markets before VAHIP Ha Vy market before VAHIP 88. Sub-component A3: Disease Surveillance and Epidemiologic Investigation. The major outputs were: - Monthly (A)H5N1 virus surveillance at Ha Vy market, Lang Son culling site as well as in 55 other markets and 11 slaughterhouses; - 285 outbreaks investigated; and - Training on outbreak investigation, disease reporting, and mapping. Figure A2.3. Examples of improved markets 33 New biosecure features in Dong Thap market. Poultry are off the Separate space for slaughtering poultry at Dong Thap market. Daily ground, and surfaces can be cleaned and disinfected more easily. cleaning and disinfection are now possible. About 1 million live poultry are traded annually in Ha Vy market. Poultry for resale leaves Ha Vy market in a cage perched on a small motorcycle. Market biosecurity prevents spread of disease to customers, traders, and farmers. Washing trucks as they leave Ha Vy market prevents spread of World Bank expert Binh Thang Cao talks about market biosecurity disease to the communities and farms where they go next to collect as VAHIP ends in June 2014. Ha Vy market upgrades are a poultry. substantial achievement, but more effort is needed to protect animal and human health. 34 89. Sub-component A4: Preparing for Poultry Sector Restructuring. Activities were conducted only during Phase 1 of VAHIP and had the following among the outputs: - Training, including: o Master of Science training for 3 DLP officials in the UK and Australia; o Development of biosecurity standards and methods for examining and assessing poultry farms and conducting training courses in this area for 49 officials from the livestock sector; o 3 training courses for 132 DLP officers on spatial planning and risk assessment; o Study tour to South Korea for 16 officers of DLP and DARDs of 11 project provinces to learn about biosafe poultry production; - Support to 40 small farms in 4 selected provinces for upgrading biosecurity; - Baseline surveys in 4 provinces participating in poultry sector restructuring to support the development of spatial planning and risk assessment profiles; and - Training courses for about 1,760 farm households from 44 communes or 22 districts on biosecure poultry production; these trained households then became the key poultry producers and information disseminators in their communes. 90. Sub-component A5: Emergency Outbreak Containment. This sub-component had among its major outputs the following: - Simulation exercises in all project provinces - Training courses on rapid outbreak response - 11 study tours - Communication program in 367 primary schools involving more than 500,000 students - Equipment and supplies for emergency response 91. Sub-component B1: Disease Surveillance. Two innovations were introduced to the country’s surveillance system for infectious diseases. a. A new model for a communicable disease surveillance system, which modified the existing system as follows: - Community village health workers are considered as the first source of data; - The private sector is an additional data source, transmitting data to the Commune Health Centers; - The press and the media are additional information sources, interacting with the district, provincial and national levels; and - In line with the One Health approach, the veterinary centers at all levels are integrated in the infectious disease surveillance system, interacting basically with the Regional Animal Health Offices (RAHOs), the Pasteur Institutes and NIHE for the confirmation of AI cases. b. Installation of a commune-based online reporting system for infectious diseases. This online reporting system installed by VAHIP is an upgrading of existing software developed earlier by the Preventive Health System Support Project of the Asian Development Bank (ADB). The lowest level of online data transmission in the ADB software is the district. VAHIP modified the software to enable data entry at and transmission from the CHC level. In 35 addition to the software, other outputs under sub-component B1 include several training activities aimed at strengthening the surveillance system like for example, the training of: - 4432 health staff on the new model for the infectious disease surveillance system - 1570 CHC staff on software application - 103 staff who were sent for the FETP; and - 67 staff who were sent for overseas training in 6 countries. 92. In addition, vehicles, supplies, and equipment to strengthen the capacity of the district rapid response teams were also provided. These included, among others, the following: - 874 computers - 38 vehicles for outbreak investigation and 301 motorbikes - 339 specimen collection kits - 655 special clothing and 14,619 PPEs. 93. Sub-component B2: Curative Care. The outputs included the following: a. Upgrading of the 12 isolation wards of the provincial hospitals in 11 project provinces; b. Vehicles and medical equipment for provincial and district hospitals, including: - 30 ambulances - 27 ventilators - 112 monitors - 28 mobile x-rays - 360 terifusion syringe pumps and infusion pumps; c. Training of health workers on various aspects related to the use of the equipment provided, diagnosis and treatment of infectious diseases, infection control in hospitals, and the development of hospital pandemic prepared plans. These include, among others: - 542 staff trained on the use and maintenance of hospital equipment - 912 staff trained on infection control in hospitals - 227 staff trained on the development of the district hospital preparedness plan for AI - 47 staff sent for overseas training d. Development of guidelines on the following areas: - Use of sterilized chemicals in health care facilities - Infection control in health care facilities - Development of the hospital preparedness plan for AI at the district level In addition to the above, 4,500 copies of the training material on diagnosis and treatment of respiratory patients were reproduced and distributed to health workers. A hospital scenario for the simulation exercise was also developed. 94. Sub-component B3: Behavior change and risk communication. This subcomponent differed somewhat from communications components of other health projects because health workers as well as the general population were targeted. Another important target group were ethnic minority groups. 36 95. The coverage of this sub-component and the volume of the communication materials produced were enormous: 20,532 health staff were trained on BCC skills, 264,000 posters were disseminated; and 4.2 million leaflets were produced. The range of strategies was broad and included several types of competitions, which attracted a very large number of participants. For example, in the provinces of Long An and Tay Ninh, a poster-making contest among schoolchildren received a total of 18,000 entries (Figure A2.4). An essay-writing contest among adults that was conducted in Thai Binh attracted hundreds of entries. 96. Outputs included all types of communication -- written (leaflets, handbooks, etc.), verbal (radio and loudspeaker broadcasts; group discussions, etc.) and visual (billboards; calendars; educational film, etc.). Person-to-person communication was used extensively in relaying messages about influenza prevention and control, especially among ethnic minority groups where home visits were frequently done. Risk communication was just newly introduced in Vietnam. Training in this area included the development of writing and oral skills, of 65 and 49 trainees, respectively. The project also provided communication equipment, most of it for mass communication (for example amplifiers, microphones) and 546 units of other communications equipment. Outputs included: - Training of trainers on Behavior Change Communications (BCC) - Communication skills for ethnic minority groups - BCC monitoring in the community - Handbook on Communication for Influenza Prevention in the Community - Risk communication on emerging infectious diseases prevention 97. Notably, the training materials on risk communication developed by VAHIP were recently reviewed and approved by the MOH, which recommended them for use by academic institutions and others conducting training on risk communication. This is the first material on risk communication to be approved and endorsed for use by the MOH. To evaluate the effects of the various communication activities conducted by VAHIP, Knowledge, Attitudes and Practices (KAP) surveys were done among health workers and the general population four times: in 2008 and 2011 for the Phase 1 provinces, and in 2012 and 2014 for the Phase 2 provinces. 37 Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 1 of 3) 38 Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 2 of 3) 39 Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 3 of 3) 40 98. Sub-component B4: Strengthening Preventive Medicine System at Local Level. The major outputs included training of health staff in districts, equipment for the DPMCs, and the conduct of multisectoral simulation exercises. Simulations of outbreak response and training on planning responses benefited more than 10,000 district-level staff, a significant achievement. Several thousand district-level health staff were trained in other areas as well, including: - Newly emerging communicable diseases (7,865 trainees) - Basic information technology (1,128 trainees) - Communication skills (4,233 trainees) Post-graduate training had 90 district-level trainees, who strengthened their technical skills. It was for them also a learning opportunity that is seldom available to local-level staff. 99. Most of the equipment provided by VAHIP was under sub-component B4. Since the objective was strengthening of the whole district preventive health system, the range of equipment was wide, as needed for core public health functions like reproductive health, which are all in the domain of the district preventive health. Equipment included, for example: - 74 level 2 biosafety cabinets - 60 ultralow temperature fridges Figure A2.5. District Preventive Health Center managers - 64 urine biochemical analyzers and staff, along with provincial officials, and the VAHIP PCU, discuss improvements in local-level public health - 52 portable ultrasound capacity. They plan for maintenance of equipment and for - 38 mobile x-ray systems further collaboration with veterinary services (June 2014). - 526 chemical sprayers with shoulder straps - 62 spectroscopy for water analysis - 261 loudspeakers, amplifiers and cassette players - 87 digital cameras 100. Multisectoral coordination included conduct of 68 major simulation exercises involving 41 15,146 participants. In addition, the project also conducted 24 internal and 3 external experience- sharing activities where 590 PPCU and district level staff involved in the project visited other provinces in order to observe their activities and share their experiences with the various project components. Local coordination became more effective thanks to the project organizing 1,179 workshops involving 29,518 participants. Each of the 11 project provinces prepared operational guidelines on multisectoral coordination. 42 Annex 3. Economic and Financial Analysis 101. The economic risks posed by H5N1 avian influenza, a poultry disease caused by a zoonotic (animal-origin) pathogen, fall into five main categories: i. direct costs to the poultry sector of the disease in poultry and associated disease control measures in case of disease outbreaks; ii. indirect effects of losses to producers, processors, and traders as consumers reduce demand for poultry and poultry products, leading to disruptions and even collapse of markets for poultry and poultry products; iii. losses to other sectors of the economy of the country and even the region more broadly in sectors where perceptions of infection risks are important, such as the tourism sector; iv. in case of human infections (which have been sporadic and rare to date), human health costs, including costs of health care for patients and loss of income because of illness and death; and v. the risk of an influenza pandemic, which all countries face and which is a top global catastrophic risk; this risk derives from a small (but non-zero) probability of occurrence in any year and a potentially large impact on public health, economies, communities, and national security. 102. Global Public Good. Prevention and control of avian and human influenza deliver an important global public good to all countries because they reduce the risk of pandemic influenza. Awareness of pandemic threat was the main driver of global efforts in 2005-13 to prevent spread of H5N1 avian flu in poultry. The global community realized that the uncontrolled multiplication of H5N1 avian flu viruses in poultry represented an unacceptably high risk, and that controlling the virus at its animal source was a feasible, effective, and least-cost means to reduce this risk. If action was not taken in Vietnam to limit the contagion in poultry, the risk to the world’s population and the economies of all countries would remain high. Since H5N1 avian flu in poultry has spread across national borders (it spread to 61 countries in Asia, Europe, and Africa by 2007), controlling spread in Vietnam also contributed to the global public good of reduced poultry disease risks in neighboring countries and beyond. 103. A traditional “with and without project” type of cost-benefit analysis offers at best partial insights. The large global benefit – that a severe influenza pandemic has not emerged to date – cannot be attributed only to any one country’s or region’s success in controlling the virus. But if the circulation of the virus had not been reduced in Vietnam and in the VAHIP provinces, the probability of emergence of a devastating pandemic would be greater than without the achievements of Vietnam and other countries. 104. VAHIP and Vietnam’s country-wide program can be economically more than justified solely on the basis of delay or prevention of a pandemic. A severe influenza pandemic would give rise to costs equivalent to 4.8% of global GDP (World Bank, 2008). This cost would be $3.7 trillion (based on 2013 GDP) globally. Optimistically assuming that the probability of pandemic onset in any year is just 1%, the economic cost of an influenza pandemic to the world has an expected annual value of $37 billion. By controlling the disease, Vietnam’s program contributed 43 to reducing this substantial global risk. Benefits from avian flu control to the poultry sector and the rural economy are not needed to justify the investments in veterinary and human public health systems because even a small reduction in pandemic risk (for instance, from $37 billion to $33 billion) is much higher than the global costs of investments in all developing countries for disease control and prevention.11 105. Vietnam’s plan for avian flu control and pandemic flu preparedness and prevention in 2006-15 (the Green Book and the Blue Book) was costed at Table A3.1. Poultry destroyed by avian influenza, 2003-14 $634 million or an average of Year Whole VAHIP Whole VAHIP $63 million per year. VAHIP country provinces country provinces (number) (2003-4=100) (2007-14) contribution was $23 million, or an average of 12/2003-04 43,900,000 11,284,418 100.0 100.0 $3 million per year. Since 2005 4,457,790 1,259,083 10.2 11.2 disease spreads across 2006 - - 0.0 0.0 administrative boundaries and 2007 236,582 65,860 0.5 0.6 international borders, outcomes 2008 106,058 24,667 0.2 0.2 in VAHIP provinces depended 2009 112,847 22,664 0.3 0.2 also on successful 2010 75,769 48,752 0.2 0.4 implementation in the rest of 2011 151,356 19,163 0.3 0.2 the country -- and in 2012 616,109 151,162 1.4 1.3 neighboring countries. It is therefore more meaningful to 2013 79,522 49,478 0.2 0.4 assess the benefits of the 01-06/2014 211,573 102,691 0.5 0.9 national effort than to attempt Total 49,947,606 13,027,938 isolating the expected benefits Sub-total stemming from VAHIP alone. in 2007-14 1,589,816 484,437 3.6 4.3 106. Measures to prepare for a pandemic and to improve surveillance in both animals and humans will have been a sound investment even if a human pandemic strain of H5N1 influenza virus does not emerge. It could have emerged and imposed high costs. There are other benefits as well. Table 1 shows the dramatic decline in the last 10 years of poultry deaths from H5N1 avian flu outbreaks; some 50 million poultry died or were destroyed in disease-control efforts. During the VAHIP period (2007-14) contagion among poultry was much more limited, and 1.6 million poultry died or were destroyed. The reduction in outbreaks could have been due to chance, but in the absence of VAHIP and similar efforts in the rest of the country, the risk of disease spread would have been too high. VAHIP provinces accounted for about 30 percent of the losses. Table 3.2 shows the benefits to Vietnam. There are benefits from reduced poultry deaths, benefits from reduced human medical costs for patients (not calculated since they are relatively small and would not affect the totals), and benefits from pandemic preparedness (calculated as a reduction of pandemic risk in Vietnam). Reduced pandemic risk in Vietnam is an outcome that is not due 11 Annual spending of $3.4 billion on veterinary and human public health systems would be sufficient to bring these systems in 139 developing countries to the international standard of performance. Current spending on these systems in all developing countries is less than $500 million annually. World Bank (2012) People Pathogens and Our Planet, The Economics of One Health. Inadequate systems allow contagion to spread and in the absence of early control, inflict exponentially rising costs, as shown most recently in the Ebola epidemic. 44 to the changed probability of a pandemic (this is the same for all countries) but rather results from the comprehensive and thorough pandemic planning and numerous simulation exercises carried out under VAHIP (and similar projects in other provinces). If these pandemic preparedness activities reduce the chaos, delays, lack of coordination, and poor communications that inevitably derail disaster responses in the absence of planning, then Vietnam’s pandemic costs could fall by 10 percent. If such a pandemic started in 2015, it would cost the Vietnamese economy $9 billion (equivalent to 4.8% of GDP). But thanks to preparedness under VAHIP and other projects, the costs would be $8 billion, or a saving of $1 billion. On an expected value basis, assuming that the probability of pandemic onset is 1 percent in any year, the annual benefit to Vietnam from pandemic preparedness through simulation exercises of pandemic response plans is $10 million since pandemic risk is reduced from $91 million per year to $82 million per year. This is far more than the expenditures on pandemic plans and simulation exercises, confirming that the benefits on this component exceed the costs by far. Table A3. 2. Overview of the economic costs influenced by stronger public health systems (national benefits only) (1) (2) (3)= (4) (5) (6) (7) (8)= (2)+ (2)/(1) 0.1*(5) +(7) GDP ($b) Costs of Cost as % Sever e Pandemic risk, Number of Medical costs, Total costs outbreaks of GDP pandemic annual, $m 12 human treatment of ($m) ($ m) potential cases human cases cost ($b) ($ m) 2004 49.4 247 0.50% 2.4 24 29 n.a. 250 (actual) (actual) (actual) (estimated) (estimated) (actual) 2013 171.4 0.49 0.00% 8.2 82 2 n.a. 83 (actual) (actual) (actual) (estimated) (estimated) Benefit of (1) an averted outbreak in poultry as severe as the one in 2004 and (2) an averted severe pandemic: 2015 189 945 0.50% 9.1 91 - - 107. The benefits of control of avian flu in poultry to the poultry sector and the related economic activities are substantial as well (Table A3.2). Improved veterinary and human public health system and pandemic preparedness that includes simulation exercises will enable a faster and more effective control of disease outbreaks and response to a pandemic. The economic benefits of performing public health systems are large. These systems deliver a highly valuable public good, which is worth at least $105 million annually (in 2015 terms) to Vietnam. 108. This $105 million value was calculated as follows. If another outbreak like the one in 2004 occurred in 2015, it would cost Vietnam’s economy $945 million. If such an outbreak is prevented, the $945 million is the benefit of prevention. A much more conservative approach is to assume that only 10 percent of this amount will actually be prevented by the public health systems. Thus the benefit of prevention is $95 million for an outbreak in 2015. Similarly, the value of pandemic risk ($91 million in 2015, based on 1 percent probability of onset) is reduced only by $10 million (and not the entire $91 million) in the calculations. On this basis and assuming that government expenditures continue at a real level equivalent to $77 million per year (same as in the AIEPED), the expected rate of return on the investments in veterinary and human public health is 29 percent annually. If averted losses in the poultry sector were 20 12 Annual expected value of pandemic influenza impact on the economy in Vietnam, probability 1% per year of a severe flu pandemic, for example. The same result obtains for a moderate pandemic, with a probability of onset of 2% in any one year. 45 percent (instead of 10 percent) of the 2004 value of losses of the outbreak, the internal rate of return would be 129%. This scenario would be equivalent to prevention of a large outbreak of an animal disease like that in 2003-4 once every five years. 109. Poverty impacts. The costs of avian influenza differ for different social groups, such as poor rural households or small commercial poultry producers. The proportion of poultry production undertaken by backyard and small commercial systems is much higher at lower levels of per capita income. In Vietnam, where the bulk of poultry production is still by backyard producers, the impact has fallen mostly on individual rural households, and has only partly been offset by government compensation Figure A3.1. The poorest households suffer larger income declines than to farmers. Survey data show wealthier households with a ban on backyard poultry sales that the poorest quintile of households relies more than 3 times as much on poultry income than does the richest quintile, so there are also adverse distributional effects. Research has shown that income from poultry is much more equally distributed than overall income. Reductions in poultry income due to avian flu or to avian flu control strategies will thus tend to worsen income distribution in Vietnam. Since diseases outbreaks have declined dramatically since 2004, major negative impacts on the poor and rural income distribution have been prevented (Figure A3.1). Source: FAO case study in Vietnam 110. Mitigation of global pandemic risk. Vietnam’s effective and prompt control of H5N1 flu outbreaks in poultry and strengthened human health systems to detect and appropriately handle any human H5N1 flu cases helped mitigate the pandemic flu risk globally. However, the global pandemic risk may still be rising, notwithstanding the reduction due to the successful H5N1 flu control in Vietnam. The probability of emergence of a pandemic virus depends on the virus load in the environment; this would increase with greater unchecked spread of avian flu in poultry, including in poultry in Vietnam. This contribution of OPI and AIEPED to the global effort to prevent a severe influenza pandemic was very important, but it is impossible to quantify. 46 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Anh Thuy Nguyen Operations Officer EASHD Binh Thang Cao Sr. Agricultural Specialist EASRD Jan Hinrichs Agriculture Economist FAO Les D. Sims Animal Disease Management Specialist FAO Mai Thi Nguyen Senior Operations Officer EASHD Nguyen Chien Thang Senior Procurement Specialist EASRD Quynh Xuan Thi Phan Financial Officer EASFM Samuel S. Lieberman HD Sector Coordinator EASHD TTL Severin Kodderitzsch Practice Manager GFADR TTL Thu Thi Le Nguyen Operations Analyst EASRD Supervision/ICR Anatol Gobjila Senior Operations Officer GFADR Anh Thuy Nguyen Operations Officer GHNDR TTL Binh Thang Cao Senior Agricultural Specialist EASVS TTL Hai Yen Tran Program Assistant EACVF Hoi-Chan Nguyen Senior Counsel LEGES Huy Toan Ngo E T Consultant EASVS - HIS Huy Toan Ngo Environment EASVS Jan Hinrichs Agriculture Economist FAO Jennifer K. Thomson Chief Financial Management Specialist OPSOR Lan Thi Thu Nguyen Natural Resources Economist GENDR Les D. Sims Animal Disease Management Specialist FAO Lingzhi Xu Senior Operations Officers GHNDR Ly Thi Dieu Vu Consultant GSURR Mai Thi Nguyen Senior Operations Officer GHNDR Mai Thi Phuong Tran Financial Management Specialist GGODR Maya Razat Program Assistant GSPDR Minh Thi Hoang Trinh Program Assistant AFCNG Nga Quynh Nguyen Program Assistant GHNDR Nga Quynh Nguyen Program Assistant GHNDR Nghi Quy Nguyen Social Development Specialist GSURR Nguyen Chien Thang Senior Procurement Specialist EASRP-HIS Nguyen Hoang Nguyen Procurement Specialist GSURR Nguyen Hoang Nguyen Procurement Specialist EASR2 Quynh Xuan Thi Phan Financial Officer GEFOB Samuel S. Lieberman Lead Economist EASHD - HIS TTL Severin L. Kodderitzsch Practice Manager GFADR Shiyong Wang Senior Health Specialist GHNDR 47 Responsibility/ Names Title Unit Specialty Thang Chien Nguyen Senior Procurement Specialist EAPPR Thao Thi Phuong Nguyen Program Assistant EACVF Thu Thi Le Nguyen Operations Analyst GENDR Thuy Cam Duong Environmental Specialist GENDR Tuan Anh Le Social Development Specialist GSURR Olga Jonas Economic Adviser GHNDR ICR TTL Laurent Msellati Practice Manager GFADR ICR adviser Piers Merrick Senior Operations Officer MNADE ICR adviser (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) USD Thousands Stage of Project Cycle No. of Staff Weeks Travel Consultant Costs Lending FY07 72.37 47.42 253.56 FY08 35.15 8.40 0.00 Total: 107.52 55.82 253.56 Supervision/ICR FY09 38.12 18.59 7.75 FY10 35.08 7.52 0.00 FY11 31.41 6.25 0.00 FY12 14.10 3.23 0.00 FY13 18.84 6.44 16.58 FY14 19.10 19.34 0.41 Total: 156.65 61.37 24.74 48 Annex 5. Comments on Draft ICR and Recommendations from Borrower’s ICR 111. The government’s ICR, VAHIP Consolidated Project Completion Report for the Animal and Human Health Components from the Ministry of Health and the Ministry of Agriculture and Rural Development (Ophelia M. Mendoza and Les D. Sims, consultants, October 2014), was submitted to the World Bank. It is a thorough and well-argued analysis of project outputs, implementation experience, and achievements. Rather than present a summary of the government’s entire ICR (which would duplicate much of the main text of this report), the following sections present: (i) comments from the government on the World Bank’s draft ICR report, (ii) graph on the science of delivery under VAHIP, and (ii) additional recommendations for future approaches to zoonotic disease prevention and control from the government’s ICR report. Comments from the government on the draft ICR 112. The Ministry of Health and the Ministry of Agriculture and Rural Development reviewed the draft of this ICR report in November 2014 and kindly provided corrections and suggestions, which have been reflected in the main text. The comments from the Ministry of Health were: The VAHIP was successfully implemented. The results of the project have contributed to strengthening the capacity of the health system backup from the central to local levels in the prevention of infectious diseases. There are many factors contributing to the success of the project, including the World Bank. The role of the World Bank is not only in the preparation of the project, to find funding for the project, but also in the process of project implementation, specifically as follows: - World Bank has played a very active role in the process of project implementation. The regulations and agreements between the World Bank and the investors (General Department of Preventive Medicine, Ministry of Health) in the project framework were fully implemented. The documents and management records of projects submitted to the World Bank were answered in a timely manner. - In addition to the mission in accordance with the project framework, the World Bank has actively coordinated regularly with PCUs and PPCUs to find the solutions to the difficulties encountered during the project implementation. - The flexibility of the World Bank, especially in terms of making changes in budgetary allocation, made it easy for the project to transfer unused funds for certain items and transfer it to other activities, which can benefit from additional financial resources. This flexibility made it possible for the project to exceed the targets for a number of important activities like the number of simulation exercises conducted, the number of participants trained, as well as the number of districts and communes covered under the Additional Financing phase. These facilitating factors which made it easier for the project implementation. - There are however factors which slowed some activities of the project such as very low cost norms often discouraged participation especially in training activities which required participants to travel from their districts/communes to the training venue. 49 - Because the project must operate within the legal frameworks of the World Bank and Vietnam governments, sometimes have trouble finding a solution to satisfy both the legal frameworks. This is an issue that needs to be scrutinized for the project in the future to have a project manual easy to implement and effective in accordance with the requirements of the World Bank and the Government of Vietnam. The World Bank’s draft implementation completion and results report on VAHIP fully reflects the activities and outcomes of the project. The lessons learned and recommendations are accurate. We completely agree with the content of the report and sincerely thank the valuable contribution of the World Bank on the success of the project. The following feedback was provided by the Ministry of Agriculture and Rural Development (edited for clarity, with comments added): - We agree with almost the content mentioned in the draft ICR report, except for analysis of objective and result indicators because there are some gaps compared with the government’s M&E reports provided. [Comment: the indicators in this ICR are based on the government’s ICR and the set of indicators monitored in ISRs, whereas the project’s excellent M&E reports are more extensive and detailed. The government’s ICR provided a valuable discussion of the challenges of monitoring progress in control of poultry disease in large geographic areas with high-volume poultry production and trade; the program was inherently complex both technically and operationally, which was appropriately reflected in the M&E reports.] - A project design shortcoming was the capital distribution. A small capital amount was distributed among 11 provinces and their 144 districts to undertake many diverse activities, and this slowed progress especially at the beginning. The lesson from this experience was taken on board in developing LIFSAP project in which the capital is focused and invested in a certain number of provinces. As a result, much progress can already be seen in the LIFSAP project implementation. [Comment: this is a good recommendation to consider in other decentralized programs where there may be risks of spreading effort too thinly.] - Reimbursement mechanism posed several difficulties. The ceiling of the special account was too small to distribute funds to 12 project implementation units, causing difficulty in disbursement, especially in the final stages of the project. The threshold for direct payment was too high. Exchange rate for refunds of advances from the provinces to the special account was not specified in the legal agreement or the project implementation manual, and this complicated processing of disbursement. [Comment: these are valuable observations to consider in the design of disbursement arrangements in similar future projects.] - World Bank support to project management and coordination: with authority to make decisions devolved to the office in Hanoi, the World Bank’s experts have been active and in very close touch with issues relating the project management and coordination. The World Bank team members have dealt with the issues promptly and efficiently, therefore, it helps push the project progress. However, we recommend that after a mission, the management letter and aide-memoire should be agreed by the two parties in order to ensure higher accuracy and unanimous understanding between the parties. Thanks for your cooperation. [Comment: thank you very much for this comment. A shared view of project challenges and solutions is very important, but so is clarity about disagreements and problems. Errors 50 should, of course, be minimized as much as possible, and the World Bank team has truly appreciated the corrections and discussions of differing assessments.] Figure A5.1. Science of delivery under VAHIP Source: Government of Vietnam ICR, p. 29 INPUT OUTPUT OUTCOME IMPACT SMALL CIVIL WORKS SMALL CIVIL WORKS • Upgradiing of provincial • 12 Isolation Wards of 11 SMALL CIVIL WORKS hospital Isolation Wards provincial hospitals • Capacity of 11 provincial upgraded hospitals for infection control improved TOOLS AND TECHNOLOGY TOOLS AND TECHNOLOGY TOOLS AND CAPACITIES • Rapid and effective • Computer hardware and • Online reporting system for • Completeness and control of AI and EIDs software infectious diseases installed timeliness of reporting of • Laboratory, hospital and infectious diseases at all communication • Provincial and district levels improved • Coordinated hospitals and preventive equipments for district medicine centers provided • Increased access to and institutionalized multi- and provincial hospitals and preventive medicine with hospital, laboratory and use of upgraded sectoral response to AI equipments for diagnosis departments communication equipments and case management of and EIDs at all levels infectious and other CAPACITIES CAPACITIES • HWs trained on management diseases and conditions • Decreased morbidity • Technical support especially at district level • Training of HWs on and planning; surveillance • Human resources and mortality due to AI prevention, surveillance, software application; disease strengthened and capable and EIDs control and surveillance, prevention, of effective and rapid management of control and management; detection and response to infectious diseases; and on BCC and risk AI and EIDs management and communication • Heightened community planning • Sub-groups of the population awareness on prevention • Training on BCC and risk trained on prevention and and control of AI and EIDs control of AI and EIDs APPROACH communication for HWs • Stakeholders adopt and and subgroups of APPROACH implement a multi-sectoral population • MARD and MOH approach in policy and collaboration practice in relation to APPROACH pandemic preparedness • One Health institutionalized at all levels • Multi-sectoral RRTs formed and response to AI and • Strengthening oF EIDS District Health System and activated Recommendations for next steps after VAHIP (from Part 3 of the government’s ICR) 1. RECOMMENDATIONS ON TACKLING NEWLY-EMERGED ZOONOTIC AVIAN INFLUENZA VIRUSES 113. VAHIP ends at a time when external events are creating additional pressures on the poultry sector and new challenges from emerging zoonotic diseases are arising. It is evident that while many of the gains from VAHIP will be sustained, much still needs to be done to ensure that livestock reared in Vietnam do not pose a risk to human health locally and globally. 114. In the past 12 months, four new strains of avian influenza virus have caused human disease in the broader region, including viruses of the H5N6, H7N9, H10N8 and H6N1 subtypes. Most of these have been linked to live poultry markets. New strains of H5N1 virus continue to emerge and spread in the region with one particular clade of H5N1 virus now spread across Vietnam from north to south and into Cambodia over the past 2 years (Clade 2.3.2.1c). This has complicated control programs, especially in the south where vaccination was targeted at Clade 1 viruses that have been endemic to this area since 2003-4. In addition, H5N8 viruses have emerged in China and spread to South Korea and Japan. As of yet there have been no known 51 human infections but infection has been reported in dogs with access to infected poultry and experimentally infection of mammals with an earlier strain of this virus has been reported. 115. Of these viruses, the H7N9 virus has been the most significant causing losses to the poultry sector in China of more than US$15 billion. This virus first emerged as a problem in March 2013 in Shanghai but has also caused major losses in eastern and southeastern provinces, especially Zhejiang and Guangdong. H7N9 spreads more efficiently from poultry to humans than the H5N1 subtype, with almost 10 times more human cases reported for H7N9 in just over 12 months than for H5N1 in the period from 2003 to 2014. Of the more than 400 cases of human infection with H7N9 in China, approximately one third of cases have been fatal. 116. Some improvements had been made to live poultry markets in China prior to the emergence of this virus, but these upgrades were not sufficient to prevent the virus from becoming established in markets. This virus has resulted in temporary and, in some cases, permanent closures of live poultry markets. The trend in China at present is to shift away from live poultry sales in major urban centers because of the emergence of H7N9 virus. 117. While the H5N1 virus can be silent in ducks and may be present in markets without any apparent increase in mortality, when it gets in to susceptible chickens it causes severe disease. This is not the case with H7N9, which only produces sub-clinical infection. Unless active surveillance programs are in place, H7N9 will not be detected in poultry. In China the first indication of infection with this particular virus was the detection of human cases, although a related virus was detected in 2010. 118. H7N9 has been a tipping point for live poultry markets in China and if (when) this virus gets to Vietnam it will probably result in similar effects unless markets are being managed or are capable of being managed in a manner that prevents this virus from becoming established in markets. Detection of this virus, especially if associated with fatal or severe human cases, will almost certainly accelerate the shift from sale of live poultry in markets to centralized slaughter, unless the markets are extremely well managed with excellent hygiene and strict controls on sources of poultry. If cases of severe or fatal disease are associated with any particular market in Vietnam there will be calls, on public health grounds, for a temporary closure of that market. The current national contingency plan for H7N9 includes temporary market closures as one of the measures to be taken. 119. VAHIP has been instrumental in reducing the risks associated with live poultry trade in some markets and many of the small markets improved by VAHIP would pose a very low risk of remaining infected with H7N9 virus if it were to gain entry to Vietnam. Nevertheless in some of the existing larger markets where only minor changes have been made, the markets are still at risk of becoming and remaining infected if this virus does get to Vietnam. If this occurs it will be necessary to undertake radical changes to the way some existing markets are managed, including reconstruction, if they get infected. Ha Vy market has many of the changes in place that will help it to cope if this virus emerges but will still require extreme care and diligence to implement all of the required biosafety measures if it is to remain a viable part of the live poultry trade. Much will depend on the capacity of the market management team to control entry of poultry (preventing birds of unknown origin from entering) and to continue implementing measures that break any cycles of transmission if the virus became established in the market. 52 120. A shift away from live poultry sales especially in major urban centers should be implemented over time. In addition, no new live poultry markets should be built (except to replace existing facilities). However, until such time as this switch occurs it is important for live poultry markets to operate and to be able to operate in a manner that reduces the public health risk to traders. This will include measures such as regular market rest days and regular cleaning. 121. Despite the best efforts of veterinary services to prevent viral incursions, new strains of zoonotic avian influenza virus will be detected in Vietnam. Lao PDR has just detected H5N6 virus and this virus has now been detected in Vietnam across a number of provinces in north and central Vietnam. H7N9 virus has been detected in Guangxi province adjacent to Vietnam, and it is only a matter of time before viruses of this subtype are detected in Vietnam based on the past history of viral incursions. 2. RECOMMENDATIONS ON REDUCING RISKS FROM OTHER PATHOGENS 122. As the global population increases it is almost inevitable that other new agents will emerge from animal populations to infect humans that either have pandemic potential or cause a pandemic. One recent example is the emergence of a novel (MERS) coronavirus with likely links to viruses found in camels and bats. Many of the elements that have been developed under VAHIP will be very helpful in tackling these diseases and should be built on. Experiences from elsewhere in the region should also be examined for relevance to parts of Vietnam. The Healthy Livestock, Healthy Village, Better Life program that formed part of the World Bank avian influenza project in Cambodia demonstrated that local actions at the village level can be taken to strengthen biosecurity and disease control measures while at the same time improving profitability from poultry production. The levels of poverty in villages in Cambodia are greater than those in Vietnam but elements of this program may be adaptable to parts of Vietnam. This has been proposed in AIPED. 123. One of the key lessons to be taken from this program is that the activities were not just directed against one disease and villages played an active role in disease control and prevention. 124. Much still needs to be done to ensure livestock production and marketing in Vietnam is undertaken in a manner that does not pose a threat to public health and the environment. Development and modernization of poultry markets and the shift to centralized slaughter will not occur evenly (it is evident already that certain central slaughter facilities are operating well round Ho Chi Minh City but others are struggling to gain traction in the market. Market shocks as a result of emergence of new diseases remain a constant threat to all parties, even to those who already have biosecure systems of production and marketing in place, based on the experiences from China. A One Health/Ecohealth approach is needed to these issues in which the factors that lead to disease emergence are considered, understood and addressed instead of focusing only on the immediate issues of emergency control of outbreaks when they occur. 3. RECOMMENDATIONS TO REDUCE RISKS FROM H5N1 AVIAN INFLUENZA 125. As expected when VAHIP was first developed, the H5N1 virus has not been eliminated from Vietnam. However, a new equilibrium has been established. The virus continues to circulate causing occasional disease outbreaks but nothing like those seen in 2003-04 when 53 H5N1 viruses first emerged as a serious problem. Most outbreaks of disease are localized and confined to a relatively small number of farms/households and affect terrestrial poultry such as chickens or quail, and occasionally ducks and wild birds (swifts). Many farms have remained free from infection for a number of years but the risk of infection has not gone away. Any problems in implementation of farm biosecurity systems could result in viral incursion. VAHIP has helped to reduce one problem which is persistence of virus in live poultry markets. The measures that are being implemented in VAHIP markets are capable of breaking infection chains. In addition VAHIP has demonstrated that it is possible to maintain disease free farms despite the persistence of the virus in other parts of the poultry production and marketing system. 126. When cases of disease are recognized in poultry they are generally handled rapidly and efficiently resulting in culling of diseased flocks but this does not address the root of the problem. These include the persistence of virus in some duck populations and poorly controlled movement of poultry including (in the past) considerable smuggling of poultry across international borders. VAHIP has also demonstrated the risk posed by smuggled spent hens based on the positive tests for H5N1 virus in the past. 127. If progress is to be made towards eradication of H5N1 virus these issues need to be addressed. Already we are seeing some improvement in traceability of poultry and controls on sources in Ha Vy market. This trend needs to continue with continual improvement of the process. Grazing ducks especially those transported over long distances pose a particular hazard but it has not yet been possible to prevent infection in all flocks of these ducks using existing vaccines. Until such time as better duck vaccines are available it will be difficult to make much progress in shifting from the current equilibrium. Nevertheless there are ways to protect other types of poultry by reducing their contact with ducks and ways to achieve this should be assessed, including improvements in farm and village biosecurity measures. 128. Livestock production still offers a powerful means of poverty reduction for the rural poor but the challenges associated with small scale production are increasing as markets consolidate and requirements for traceability and residue control increase. Ways need to be found to ensure that poultry can still play a vital role in addressing poverty. In many rural areas small scale poultry production is a crucial source of income and food security. 129. A two to three tier livestock sector is developing with the production systems depending on both the type of farm and the market chain. Larger scale farms are likely to dominate the market for major cities although opportunities remain for some niche products. This top tier of producers will adapt to market demands and will likely have the funds needed to ensure they supply an H5N1 virus- free product. The second tier comprises smaller commercial farms that do not have the same financial resources to invest in biosecurity measures. They are at risk of being excluded from major markets unless they can demonstrate that their birds remain free from infection. The third sector is the small scale village producer with some excess birds for sale on occasions. They can probably retain local sales but will struggle to gain market share in major urban centers. 4. RECOMMENDATIONS ON BUILDING RESILIENCE 54 130. When a new disease emerges one of the first questions is: from which species is the agent derived? Despite moves to try to minimize the use of labels such as ‘bird flu’, when a new disease emerges and there is evidence that the agent may be derived from poultry, then some product avoidance will occur. If the agent is found in poultry, all parts of the poultry sector will be affected, as was the case with H7N9 in China. The H7N9 virus has largely been transmitted from poultry to humans in live poultry markets. Consumption of poultry has been demonstrated not to be a risk factor for human cases. Yet there has been avoidance of all poultry products. The only way to build resilience into the livestock sector is to be prepared for the emergence of new diseases, including design of appropriate messages for communication. VAHIP has helped to do this. 5. RECOMMENDATIONS ON DISEASE SURVEILLANCE & REPORTING SYSTEM 131. The following would help the sustainability and utility of the disease surveillance system:  Expansion of the software application for the online reporting system to non-VAHIP communes, districts and provinces. This is essential for the proper pilot-testing of the online system and its eventual nationwide adoption.  Implementation of data quality control mechanisms to ensure accuracy and reliability of the data. While the computer software can be programmed to incorporate built-in checks for certain elements of accuracy and reliability, the greatest responsibility for data accuracy and reliability still lies with the health worker who needs to be trained to ensure these aspects of data quality at the point of data collection, long before the data is entered into the computer.  Further software enhancements should include functions like the incorporation of population data to enable the computation of rates at lower levels, and the construction of an EPI CURVE which is a basic tool used by epidemiologists for outbreak investigation.  Training of provincial, district and commune level staff on data analysis and utilization to convert them from mere data providers to data users. Right now, the district and commune level staff are merely transmit data to higher levels once it is collected. Providing them with the skills to analyze and use the data they have collected will make them realize the importance of maintaining data quality and will improve management of health programs at lower levels, through effective use of health information.  Conduct of a systematic and thorough assessment of the feasibility and resource implications of the new disease surveillance model suggested by VAHIP. The new model emphasizes the use of village health workers and the private health sector as data sources at the peripheral level, and formally includes the animal health sector in the infectious disease surveillance system. This has implications for data flow and data quality which need to be studied thoroughly before the new model can be considered for adoption.  Strengthening the linkage between the national database for emerging infectious diseases (EIDs) and regional and global databases, to share information with, and learn from experiences in, other countries. 6. RECOMMENDATIONS ON MOH-MARD COLLABORATION 55 132. VAHIP has been instrumental in activating and institutionalizing the MOH-MARD collaboration and a lot of benefits have been achieved through this collaboration. As such, it is important for it not only to be sustained but also to be expanded. For instance:  Replicate process of MOH-MARD collaboration other provinces, prioritizing border provinces with Cambodia where AI continues to spread, and hence risks to enter Vietnam in the future.  Continue to develop and conduct short joint training programs for MOH and MARD staff at province, district and commune levels. This will further strengthen the linkage between staff of both ministries. Examples of areas where joint training can be conducted are applied basic epidemiology for human and animal health workers; social determinants of health and their role in One Health; integrated methods of joint human and animal disease surveillance; and health promotion and communication within the One Health framework.  Use the process of MOH-MARD collaboration followed by VAHIP as model for other collaborations needed to enhance MOH functions, for instance with Ministry of Education and Training for school health; with MOLISA for occupational health or gender-related programs; and with Ministry of Transportation and the Police for vehicular accidents. 7. RECOMMENDATIONS ON STRENGTHENING THE DISTRICT HEALTH SYSTEM 133. Substantial resources from the human health component of VAHIP were spent to strengthen the district health system. However, the activities undertaken and the outputs and outcomes derived were merely the initial seeds of a robust district health system. Many more measures are needed, including:  Ensure quality control in laboratories conducting new tests/procedures as a result of VAHIP – provided equipment. A system of monitoring and supervision of district laboratories by the provincial laboratories may be needed in relation to this.  Develop concrete guidance and norms for future inputs to strengthen district laboratories. This is important to ensure procurement of appropriate equipment and other resources, which donors may finance so as to build on the VAHIP achievements and further strengthen the district preventive medicine system.  Develop policies for the optimum use of equipment in district laboratories and hospitals  Develop policies to minimize the brain-drain of trained district staff to higher levels and to other institutions like the NGOs. 8. RECOMMENDATIONS ON THE COMMUNICATION PRODUCTS OF VAHIP 134. VAHIP produced useful and interesting communication products like the paintings of the school children or the essays for essay-writing contests. They can be effective health promotion materials for the continuing prevention activities for AI and other EIDs. The children’s paintings can be used as design for health promotion messages on greeting cards, bags, t-shirts, stationeries, notebook covers, etc. The designs can be used on posters for schools to teach children about influenza prevention and control. Publication of the winning essays in local newspapers can sustain people’s interest and remind readers about continuing threat of AI and other EIDs. Materials used in the large number of simulation exercises could be assembled into a 56 compendium of exercises, to serve as reference material for future trainings and simulation exercises. 9. OPTIONS FOR FUTURE LIVESTOCK PROJECT WITH ONE HEALTH APPROACH 135. It is worth considering a project combining elements of LIFSAP and VAHIP that targets only a small number of predominantly rural provinces in which the whole livestock sector is examined and strengthened. This could include activities for village based producers, small scale commercial producers and large scale producers, aimed at improving all three as well as activities downstream (markets and slaughterhouses) and upstream (feed supply and breeding farms). It can involve all types of livestock, not just poultry and build on the experiences from the two projects. A project of this nature would provide marked economic benefits to the provinces and reduce the public health and environmental effects of livestock production. It could focus on provinces that have performed well in either VAHIP or LIFSAP (they have the experience to make a project work) and would allow the gains made so far from these two projects to be consolidated. A One Health approach would be adopted and the project would have a 5 year time frame to allow for appropriate investments. A project of this nature would undertake work that allows the following:  Understand all aspects of the livestock production and market chains  Identification of points in production and market chains for interventions that are expected to make a difference to productivity, profitability, animal health and welfare and public health  Further strengthening of veterinary and animal production services within the target provinces using a strong preventive focus  Ensuring better traceability of livestock and livestock products in the province  Control and prevention of major livestock and zoonotic diseases through better animal management and vaccination and smart use of antimicrobial compounds  Building resilience for livestock producers in the face of flooding and droughts and disruptions to markets  Defining the major constraints to production in each system (including diseases)  Prevention of chemical residues  Prevention of environmental degradation as a result of livestock production  Implementing rational livestock development plans covering each production type  Building community resilience to major hazards (for example: floods, fire, and disease outbreaks) and related market shocks  Improving markets so that they don’t pose a risk to the public or traders  Ensuring adequate food resources for livestock  Build on the gains made in and positive experiences from LIFSAP and VAHIP  Focus on a small number of provinces and doing a thorough job is almost certainly better than doing a more superficial approach in multiple provinces.  The model developed could then be used for other provinces in the future provided the process is well documented and key lessons are learned. 57 Annex 6. Comments of Cofinanciers and Other Partners/Stakeholders All comments from partners are presented and addressed in Section 7 of the main text. 58 Annex 7. List of Supporting Documents VAHIP Consolidated Project Completion Report for the Animal and Human Health Components. October 2014. Ministry of Health and the Ministry of Agriculture and Rural Development (Ophelia M. Mendoza and Les D. Sims, consultants). Program Framework Document for Proposed Loans/Credits/Grants in the Amount of US$500 million Equivalent for a Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response, Report No. 34388, World Bank, December 5, 2005. Animal and Pandemic Influenza – A Framework for Sustaining Momentum, Fifth Global Progress Report, United Nations and the World Bank, July 2010 (http://un-influenza.org). Integrated National Plan for Avian Influenza Control and Human Pandemic Influenza Preparedness and Response, January 2006 (Red Book). National Integrated Operational Program for Avian and Human Influenza (OPI), 2006-2010. Ministry of Agriculture and Rural Development and Ministry of Health, Government of Vietnam, May 2006 (Green Book). Integrated National Operational Program on Avian Influenza, Pandemic Preparedness, and Emerging Infectious Diseases (AIPED), 2011-2015 - Strengthening responses and improving prevention through a One Health approach. Ministry of Agriculture and Rural Development and Ministry of Health, Government of Vietnam, October 2011 (Blue Book). Five-Year Health Development Plan: 2010 – 2015, Ministry of Health, Government of Vietnam. Vietnam National Strategic Framework for Avian and Human Influenza Communications: 2008-2010 ASEAN Medium-Term Plan on Emerging Infectious Diseases (2012-2015). Asia Hanoi Declaration at the International Ministerial Conference: ”Animal and Pandemic Influenza: The Way Forward” (IMCAPI 2010) Pacific Strategy for Emerging Diseases (WHO SEARO and WPRO - 2005; 2010). European Union (2010), Outcome and Impact Assessment of the Global Response to the Avian Influenza Crisis, 2005-2010. Keogh-Brown, M, Wren-Lewis, S, Edmunds, WJ, Beutels, P and Smith, RD (2009), The Possible Macroeconomic Impact on the UK of an Influenza Pandemic, University of Oxford, Department of Economics Discussion Paper 431. World Bank (2008), Evaluating the Economic Consequences of Avian Influenza, by Andrew Burns, Dominique van der Mensbrugghe, and Hans Timmer, available at www.worldbank.org/pandemics. World Bank (2012). People, Pathogens and Our Planet, Volume 2, The Economics of One Health. 59 World Bank (2014). Independent Evaluation Group (IEG) Responding to Global Public Bads: Learning from Evaluation of the World Bank Experience with Avian Influenza, 2006- 2013. World Bank (2012). Connecting Sectors and Systems for Health Results. Public Health Policy Note. The Lancet Commission on Investing in Health (2013). Global Health 2035: a World Converging Within a Generation. Jonas, O. (2013) Pandemic Risk. World Development Report 2014 background paper, World Bank. Available at www.worldbank.org/pandemics. Lee, Jong-Wha and McKibbin, Warwick J. (2004). Estimating the Global Economic Costs of SARS in Learning from SARS: Preparing for the Next Disease Outbreak -- Workshop Summary, Institute of Medicine, Washington, DC, 2004, available at www.ncbi.nlm.nih.gov/books/NBK92473/. 60 Annex 8. List of Persons Met Ministry of Health - Project Coordination Unit (PCU) Dr. Vu Sinh Nam Director Mr. Vu Van Quy Coordinator Mr. Nguyen Manh Hung Planning consultant Mrs. Tran Minh Thu Technical consultant on B4.2 Mrs. Tran Thi Kim Ngan M&E consultant Mr. Nguyen Minh Thang Procurement consultant Mr. Du Quang Thanh Communication consultant Mrs. Nguyen Hong Trang Curative Care consultant Ms. Ophelia Mendoza International Consultant on Final Evaluation Ministry of Agriculture and Rural Development - PCU Mr. Pham Viet Anh Director Mrs. Lam Anh Hung Deputy Director Mrs. Pham Bich Ngoc Chief Accountant Mrs. Lai Thi Kim Lan Coordinator Mrs. Le Minh Tam Lab consultant Mr. Le Van Kiem M&E consultant Mrs. Cao Phuong Anh Planning officer World Health Organization Dr.Kasai Chief Representative Dr. Nguyen Thi Phuc Acting Team Leader Food and Agriculture Organization (of the United Nations) Dr. Jongha Bae - Chief Representative Dr. Scott Newman Mrs. Nguyen Thi Phuong Oanh Operations Officer Mr. Nguyen Song Ha Assistant to Representative Ms. Markaday Priya Operations Officer Ms. Astrid Tripodi Operations Officer European Commission Ms. Tran Thuy Duong Poverty Reduction Program Officer US Centers for Disease Control and Prevention (CDC - Vietnam) Mr. David B. Nelson Deputy Director Chief, Influenza and Animal-Human Health Interface Mr. James C. Kile Program 61 USAID Mrs. Laurel Fain Director, Office of Health Mrs. Kim Thuy Oanh Infectious Disease Specialist Mrs. Huong Infectious Disease Specialist Department of Animal Health Mrs. Nguyen Thu Thuy Deputy Director General Mr. Nguyen Ngoc Tien Epidemiology Specialist General Department of Preventive Medicine Dr. Tran Dac Phu Director General Regional Animal Health Office No. 6 (RAHO6) Mr. Binh Director General Mrs. Thai Thi Thuy Phuong Vice Director Dr. Ngo Thanh Long Director of Animal Health Diagnostic Center Mr. Phuong Deputy Director of Animal health Diagnostic Center Mr. Phuong Epidemiology Department Ho Chi Minh City Public Health Institute Dr. Le Vinh Deputy Director Mrs. Kim Anh Deputy Director of Training Center Ho Chi Minh City Pasteur Institute Dr. Cao Thi Bao Van Deputy Director Dong Thap Province People's Committee and PPCU Mr. Phu Deputy Head of PPC's Cabinet Mr. Truong Tan Buu Director of PPCU, Deputy Director of DOH Mr. Vo Be Hien Head of sub-department of Animal Health Mr. Tran Van Hai Planning Officer 62 Map 63