IMPLEMENTATION COMPLETION AND RESULTS REPORT (Loan/Credit No. IBRD-48220) ON A LOAN IN THE AMOUNT OF 27.3 MILLION (US$34.4 MILLION EQUIVALENT) TO THE

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (Loan/Credit No. IBRD-48220) Sustainable Development Department Turkey Country Unit Europe and Central Asia Region ON A LOAN IN THE AMOUNT OF 27.3 MILLION (US$34.4 MILLION EQUIVALENT) TO THE REPUBLIC OF TURKEY FOR AN AVIAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (AIHP) PROJECT July 27, 2012 Report No: ICR2366

2 A/H1N1 A/H5N1 Influenza virus A swine flu, strain associated with 2009 human flu pandemic Influenza virus A bird flu, highly pathogenic strain of global concern CURRENCY EQUIVALENTS (Exchange Rate Effective May 17, 2012) Currency Unit = New Turkish Lira, YTL US$ 1.00 = 1.8 YTL GOVERNMENT FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS ISN ISR ii Interim Strategy Note Implementation Status and Result Reports AH Animal Health M&E Monitoring and Evaluation AIHP Avian Influenza and Human Pandemic Preparedness and Response MARA Ministry of Agriculture and Rural Affairs, changed in Ministry of Food, Agriculture, and Livestock (MFAL) AI Avian Influenza MFAL Ministry of Food, Agriculture, and Livestock AIWG Avian Influenza Working Group MoH Ministry of Health ARD Agriculture and Rural Development (a World Bank Department) MTR Mid-Term Review BSL Biosafety Level NPIAP National Pandemic Influenza Action Plan CAS Country Assistance Strategy NPV Net Present Value CCHF Crimean Congo Hemorrhagic NZDC National Zoonotic Disease Committee Fever CDC US Center for Disease Control OIE World Organization for Animal Health CEU Central Execution Unit PAD Project Appraisal Document EA Environmental Assessment PDO Project Development Objectives EMP Environmental Management PPE Personal Protective Equipment Plan ERR Economic Rate of Return PT Project Team EU European Union PVS Performance of Veterinary Services FAO Food and Agriculture Organization RT-PCR Real-Time Reverse Transcriptase Polymerase Chain Reaction FM Financial Management SCWG Strategic Communications Working Group GDPC /GDFC UNDP United Nations Development Programme General Directorate for Protection and Control of the Ministry of Agriculture, later changed in General Directorate for Food and Control GoT Government of Turkey UNICEF United Nations International Children s Fund GPAI Global Program for Avian Influenza USAID United States Development Assistance Agency HD Human Development (a World USDA United States Department of Agriculture Bank Department) HPAI Highly Pathogenic Avian Influenza VS Veterinary Services

3 ICR IDF Implementation Completion and Result Report Institutional Development Fund WHO World Health Organization Vice President: Country Director: Sector Manager: Project Team Leader: ICR Main Author: Philippe H. Le Houerou Martin Raiser Dina Umali-Deininger Brian Bedard Maurizio Guadagni iii

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5 Turkey Avian Influenza Control and Human Pandemic Preparedness and Response Project Data Sheet CONTENTS A. Basic Information... v B. Key Dates... v C. Ratings Summary... v D. Sector and Theme Codes... vi E. Bank Staff... vi F. Results Framework Analysis... vii G. Ratings of Project Performance in ISRs... xv H. Restructuring (if any)... xvi I. Disbursement Profile... xvi 1. Project Context, Development Objectives and Design Key Factors Affecting Implementation and Outcomes Assessment of Outcomes Assessment of Risk to Development Outcome Assessment of Bank and Borrower Performance Lessons Learned on Issues Raised by Borrower/Implementing Agencies/Partners Annex 1. Project Costs and Financing Annex 2. Outputs by Component Annex 3. Economic and Financial Analysis Annex 4. Bank Lending and Implementation Support/Supervision Processes Annex 5. Beneficiary Survey Results Annex 6. Stakeholder Workshop Report and Results Annex 7. Summary of Borrower's ICR and/or on Draft ICR Annex 8. of Cofinanciers and Other Partners/Stakeholders Annex 9. List of Supporting Documents Table 1. Confirmed Human Cases of HPAI reported to WHO, Table 2. Project size relative to population and poultry stocks (2006), selected countries Table 3. Turkey - Human Zoonoses Cases during (OIE) Table 4. Yearly AIHP Project Expenditures (current 000 US$) Table 5. Economic Returns and Sensitivity Analysis Figure 1. Turkey Evolution of HPAI outbreaks in poultry iv

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7 A. Basic Information Country: Turkey Project Name: Avian Influenza & Human Pandemic Preparedness & Response APL 2 Project Project ID: P L/C/TF Number(s): IBRD-48220,TF ICR Date: 07/30/2012 ICR Type: Core ICR Lending Instrument: ERL Borrower: REPUBLIC OF TURKEY Original Total Commitment: USD 34.40M Disbursed Amount: USD 31.39M Revised Amount: USD 28.78M Environmental Category: B Implementing Agencies: Ministry of Health Ministry of Agriculture Cofinanciers and Other External Partners: EUROPEAN UNION US Agency for International Development (USAID) B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 12/15/2005 Effectiveness: 09/11/ /11/2006 Appraisal: 12/16/2005 Restructuring(s): Approval: 04/24/2006 Mid-term Review: 10/15/ /17/2008 Closing: 11/30/ /31/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Satisfactory Moderate Satisfactory Satisfactory v

8 C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Highly Satisfactory Government: Satisfactory Quality of Supervision: Moderately Satisfactory Implementing Agency/Agencies: Satisfactory Overall Bank Performance: Satisfactory Overall Borrower Performance: Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project Yes at any time (Yes/No): Problem Project at any time (Yes/No): No DO rating before Closing/Inactive status: Satisfactory Quality at Entry (QEA): Quality of Supervision (QSA): None None Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Agricultural extension and research Animal production General public administration sector Health Other social services 2 2 Theme Code (as % of total Bank financing) Health system performance Other communicable diseases Participation and civic engagement Pollution management and environmental health Rural services and infrastructure E. Bank Staff Positions At ICR At Approval Vice President: Philippe H. Le Houerou Shigeo Katsu Country Director: Martin Raiser Andrew N. Vorkink Sector Manager: Dina Umali-Deininger Laura Tuck Project Team Leader: Brian G. Bedard Mark R. Lundell vi

9 ICR Team Leader: ICR Primary Author: Brian G. Bedard Maurizio Guadagni F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The proposed project aims to minimize the threat in Turkey posed to humans by the highly pathogenic avian influenza infection and other zoonoses in domestic poultry and prepare for the control and response to an influenza pandemic and other infectious disease emergencies in humans. To achieve this, three areas will be supported: (i) prevention, (ii) preparedness and planning and (iii) response and containment. Achieving these goals will contribute to diminishing the burden of disease and loss of productivity in Turkey, limiting the regional spread of AI, and enhancing economic and social prospects at the national, regional, and global levels. Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s) Indicator Indicator 1 : Value quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Evidence of improved effectiveness of participating animal and public health services in limiting the spread of an HPAI outbreak and consequent pandemic in Turkey. 21 human cases, out of Contain spread which 12 confirmed by and number of WHO, including 4 human cases fatalities, in early 2006 No new human cases after 2006 Date achieved 04/15/ /15/ /15/2012 Unclear wording, suitable for an outcome rather than an indicator. The indicator used during supervision to evaluate this outcome was the number of human (incl. % cases. If we use this indicator, it was achieved since no new human cases were reported after Evidence of widespread adoption of recommended practices for the prevention Indicator 2 : and control of HPAI among poultry producers, distributors, and retail vendors. Value quantitative or Qualitative) 202 outbreaks Contain spread and number of cases 17 outbreaks in 2007 and 7 outbreaks in 2008 Date achieved 04/15/ /15/ /15/2012 Unclear wording and typo at page 42 of PAD. The indicator used during supervision to evaluate this outcome was the number of animal outbreaks. There (incl. % were 17 animal outbreaks in 2007 and 7 in No new animal outbreaks after Achieved Indicator 3 : Improving trend in poll of experts designed to gauge HPAI readiness in Turkey vii

10 Value quantitative or Qualitative) number of experts trained number of experts trained viii number of experts trained Date achieved 04/15/ /15/ /15/2012 (incl. % Unclear wording of the indicator. The number of experts trained on HPAI issues increased significantly. See Iintermediate indicators 10, 14, and 19, all achieved and one exceeded Inter-institutional and multi-sector coordination arrangements in place, National Indicator 4 : Zoonotic Disease Committee fully operational and National contingency plans established and functional. Value quantitative or Qualitative) MARA and MoH HPAI contingency plans; NPIAP and Crisis Centers exist HPAI contingency plans and NPIAP tested and implemented; National Zoonotic Disease Committee established and functional HPAI contingency plans and NPIAP tested and implemented; National Zoonotic Disease Committee established and functional Date achieved 04/15/ /15/ /15/2012 (incl. % The evaluating team merged 3 similar intermediate indicators as an outcome indicator (15,16,17). These indicators assess the level of multi-sector coordination. A satisfactory level of coordination was achieved. (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : Detailed assessment of the Animal Health Department of the GDPC; Selfassessment of the VS executed OIE-PVS and PVS Value (quantitative or Qualitative) No assessment 100% complete Gap-Analysis performed by MFAL (ex MARA) with OIE support Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved. OIE PVS assessment and Gap Analysis completed Indicator 2 : Linking of Veterinary Control Research Institutes to the World Animal Health Information System (WAHIS) maintained by the GDPC The Laboratories have an internal Value information (quantitative Not linked 100% complete management or Qualitative) system in place ; MFAL uses

11 WAHIS to report sanitary information collected through their national database ("TURKVET"), including laboratory results, to the OIE Date achieved 04/15/ /15/ /15/2012 (incl. % Indicator 3 : Value (quantitative or Qualitative) Partly achieved and partly not feasible. Laboratories report timely to MFAL diagnostic results. ("TURKVET") was improved with the addition of poultry diseases monitoring and management. A direct link between WAHIS is however not feasible BSL-3 attained in two reference laboratories and other regional laboratories upgraded to reach 75% coverage of at-threat areas Bornova and Pendik at BSL-2; 6 other labs have limited coverage BSL-3 attained; other labs cover 75% coverage of at-threat areas 3 laboratories were upgraded to BSL-3 level and the 5 others to BSL-2 Diagnostic capacity (in terms of volume an quality) much higher than at the start of the project Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved. Buildings and equipments are modern and staff is trained. Labs results are being confirmed by international reference labs. Still activity under BSL-3 level is very limited. Indicator 4 : 100% monitoring of poultry breeding stock farms Value (quantitative or Qualitative) 50% monitoring 100% monitoring All poultry breeding flocks subject to regular official monitoring for AI, among other pathogens Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Indicator 5 : Emergency supplies procured and available at strategic locations in the field All provinces provided with Supplies for 2,946 Value sufficient personal staff and 982 (quantitative Limited protective teams procured or Qualitative) equipments and deployed important stocks still available and ix

12 ready for use if need be. Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Indicator 6 : 15 mobile incineration units deployed and accessible by areas at risk Value (quantitative or Qualitative) 0 mobile incinerators deployed 15 mobile incinerators deployed x 8 larger capacity mobile incinerators positioned in the 8 Vet Research Institutes incinerators tested during simulation exercises Date achieved 04/15/ /15/ /15/2012 Achieved. The number of incinerators purchased is lower than initially planned (incl. % but they have a higher capacity, which was deemed more useful and efficient. Certification of readiness rating obtained from FAO/OIE (following readiness Indicator 7 : review) Value (quantitative or Qualitative) Unknown 100% of staff and teams certified In the PVS evaluation, OIE ranked "early detection and emergency response" competency at level 4 (max being 5) which shows a high level of performance achieved by the VS Date achieved 04/15/ /15/ /15/2012 Achieved. Neither OIE nor FAO formal certification system for readiness exist. Still, readiness is regarded as achieved through the set of measures applied and (incl. % supported by the project, and identified during the PVS evaluation mission of June Indicator 8 : Significant reduction in unconfined backyard poultry farming Value (quantitative or Qualitative) 30 million poultry farmed in unconfined circumstances: high risk share to be determined % reduction to be determined No permanent change in backyard practices Date achieved 04/15/ /15/ /15/2012 (incl. % Not achievable. Socio-economic studies and pilot programs to enhance biosafety in backyard farming systems were conducted through the project and concluded that full confinement was not achievable as a permanent measure. Indicator 9 : Compensation Fund established with clear operating modalities Value Compensation Fund Compensation Compensation Fund

13 (quantitative or Qualitative) being planned Fund fully functional functional, with clear procedures and mechanisms in place 100% of poultry culled compensated Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Indicator 10 : Number of people trained on animal health issues Value (quantitative or Qualitative) No baseline available No original target available 324 vets (4 per province) were trained as trainers for surveillance and outbreak management 42 vets on epidemiological principles 33 staff trained to capture wild birds 50 lab specialists trained on laboratory techniques Date achieved 04/15/ /15/ /15/2012 (incl. % Though no original target was set, and important number of animal health workers was trained, significantly contributing to achieve project objectives. It can be considered achieved Indicator 11 : Increased surveillance and outbreak investigation capacity Value (quantitative or Qualitative) N/A 100% of provinces with laboratory capacity for containment and control of HPAI outbreak improved 100% of provinces with laboratory capacity for containment and control of HPAI outbreak improved Date achieved 04/15/ /15/ /15/2012 Achieved. All 81 provinces of the country have the capacity to collect samples (incl. % and safely send them to the central laboratories for testing. Number of Public Health Laboratories available for routine influenza diagnosis Indicator 12 : and typing, rehabilitated and equipped, with improved biomedical waste management systems qualifying as National Influenza Center Value (quantitative or Qualitative) Two public health laboratories are 1 Laboratory capable of capable of carrying out 100 tests/day carrying out 300 tests/day Two public health laboratories are capable of carrying out 300 tests/day xi

14 Date achieved 04/15/ /15/ /15/2012 Achieved. Two public laboratories have the capacity to diagnose and type influenza with adequate biosecurity measures and qualified staff. The results of (incl. % their Influenza tests are regularly reconfirmed by International Reference Laboratories. Number of provincial public health directorates with a computerized information Indicator 13 : and telecommunications systems in place and operational Value (quantitative or Qualitative) 25% 100% xii All of the 81 provincial health directorates are computerized and operational Date achieved 04/15/ /15/ /15/2012 Achieved. All 81 provinces of the country are part of a computerized information (incl. % network. Indicator 14 : Number of health personnel trained in influenza virus surveillance and control Value (quantitative or Qualitative) 4,000 5,000 (including re-training) 30 central trainerof-trainers and 5,000 health personnel from all 81 provinces were trained. In addition the 4,000 previously trained personnel were retrained Date achieved 04/15/ /15/ /15/2012 (incl. % Exceeded Indicator 15 : Number of sentinel site provinces complying with bi-weekly (winter) and monthly (summer) reporting on influenza occurrence Value (quantitative or Qualitative) All 81 provinces have sentinel sites and reports on a monthly and biweekly manner. Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Indicator 16 : % of positive tests confirmed by reference laboratory Value 100%. The tests (quantitative 100% 100% were true positive. or Qualitative) Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved

15 Indicator 17 : Evidence of improved bio-safety in National Influenza Centers Value No known cases of No known cases of No known cases of AI in (quantitative AI in laboratory AI in laboratory laboratory workers or Qualitative) workers workers Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Biweekly report from National Influenza Center through MoH to provincial Indicator 18 : health departments on compiled results of national surveillance (Influenza-Like- Illnesses and confirmed cases) introduced as feedback mechanism Value (quantitative or Qualitative) Only positive results xiii All results All results are being reported in MoH biweekly reports. Date achieved 03/15/ /15/ /15/2012 (incl. % Achieved Number of professionals and support personnel trained for active surveillance, Indicator 19 : case finding, and proper diagnosis, treatment and care to contain outbreaks and reduce occurrence and case fatality during both pre-epidemic and pan-endemic phases Value (quantitative or Qualitative) Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved. 250 health workers including Doctors and para-medical staff they received training specifically on treatment and medical management in addition to training on outbreak control. Indicator 20 : Cumulative incidence rate Value (quantitative or Qualitative) 0.3% 0.0% 0.0% Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved. No known cases of AI during the project life-cycle. Similar to the main outcome indictor. Indicator 21 : % change in the AI case fatality Value 0% case fatality (quantitative 19% fatality rate 0% case fatality rate or Qualitative) Date achieved 04/15/ /15/ /15/2012 Since there were no other human cases after 2006, this indicator could not be (incl. % tested. Indicator 22 : Capacity to store vaccines and drugs safely increased Value Several small vaccine A large and Large and efficient

16 (quantitative or Qualitative) storage facilities spread around Ankara efficient facility facility recently built, but there was no time yet to make it operational Date achieved 04/15/ /15/ /15/2012 Achieved. A large and efficient vaccine warehouse facility was recently built in (incl. % Ankara to allow storing large quantities of vaccines Political and civic leadership organized around a national strategic risk Indicator 23 : communication plans Value (quantitative or Qualitative) No coordinated plan 100% complete A strategic communication plan has been developed and tested during simulation exercises Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Indicator 24 : Research based risk communication strategies and products, responding to the need of priority audiences, are developed Risk Value communication (quantitative 50% 100% complete products have been or Qualitative) developed Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved. Several communication products tailored for various audiences were developed Indicator 25 : Consistent awareness raising and behavioral change interventions made with population at risk Value Communication (quantitative or Qualitative) 50% 100% complete products were not broadcasted Date achieved 04/15/ /15/ /15/2012 Not Achieved. Communication products were not broadcasted because concern (incl. % about the pandemic had faded Indicator 26 : Consistent awareness raising and behavioral change interventions made with population at risk Value (quantitative or Qualitative) 50% 100% complete Not monitored Date achieved 04/15/ /15/ /15/2012 (incl. % The change in reported hygiene and sanitation behaviors was not monitored xiv

17 Indicator 27 : Ministry of Health Information Communication Center (SABIM) operational Value (quantitative or Qualitative) 50% 100% complete SAMIB Hotline function Date achieved 04/15/ /15/ /15/2012 Achieved. The SABIM Crisis Management Communications Hotline (184) is (incl. % function Program progress reports, financial monitoring, procurement and disbursement Indicator 28 : reports, audits, management and financial reports prepared and submitted periodically Value (quantitative or Qualitative) 0 All report completed on time Satisfactory reports were provided with minimal delays Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved Indicator 29 : Methodology defined and monitoring and evaluation periodically undertaken M&E reports Value All report provided regularly (quantitative 0 completed on time with minimal or Qualitative) delays Date achieved 04/15/ /15/ /15/2012 (incl. % Achieved G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 08/17/2006 Satisfactory Satisfactory /06/2007 Moderately Satisfactory Moderately Satisfactory /11/2008 Moderately Satisfactory Moderately Satisfactory /17/2008 Satisfactory Satisfactory /26/2009 Satisfactory Satisfactory /07/2009 Satisfactory Satisfactory /20/2010 Satisfactory Moderately Satisfactory /15/2011 Satisfactory Moderately Satisfactory /29/2011 Satisfactory Moderately Satisfactory /27/2011 Satisfactory Moderately Satisfactory xv

18 H. Restructuring (if any) Not Applicable I. Disbursement Profile xvi

19 1.1 Context at Appraisal 1. Project Context, Development Objectives and Design 1. Animal outbreaks of the Highly Pathogenic Avian Influenza (referred to as HPAI, which is the strain H5N1), began in late 2003 and spread in several East Asian countries in The virus reached Western Europe at the end of 2005, with Turkey being among the first countries struck in the region. Nearly 600 sporadic cases of human infection with HPAI virus had been reported by 15 countries in Asia, Africa, the Pacific, Europe and the Near East with major economic and health repercussions. The peak of outbreaks in Turkey and neighboring countries (Azerbaijan, Egypt, Iraq, and Romania) was in early Among the neighboring countries, only in Egypt the disease became endemic, with human cases even in the first few months of 2012, as visible from the table below. Table 1. Confirmed Human Cases of HPAI reported to WHO, COUNTRY First 100 days of 2012 TOTAL Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Azerbaijan Egypt Iraq Turkey Other countries (mostly in Asia) WORLD The first animal case of HPAI in Turkey was diagnosed in October 2005 in backyard poultry. From January to March 2006, the disease was detected in 58 out of 81 Turkey s provinces with more than 230 cases confirmed in backyard flocks and wild birds. This resulted in the culling of over 2.5 million birds and the implementation of poultry movement restrictions inside and outside the country. The map below illustrates outbreaks detected in poultry and wild birds between December 2005 and March 2006 and reported to the World Organization for Animal Health (OIE). 3. The outbreaks in poultry were followed by infection in humans. In contrast to the previously reported cases of H5N1 in southern and eastern Asia, human cases in Turkey were concentrated in small geographic areas during a short period. As of January 20, 2006, 21 human cases of the H5N1 virus in humans tested positive even though only 12 were confirmed by the World Health Organization (WHO). Four infected persons died as a result. The majority of patients were younger than 15 years old. These cases were the first occurrence of death in humans from H5N1 strain outside of Asia but due to early case 1 Adapted from the World Health Organization (WHO) 1

20 detection and effective treatment, the case fatality rate in Turkey was lower. 4. The above described situation and high media attention on the risk of a pandemic created panic among the population which resulted in a total stop of poultry products consumption, further affecting the poultry industry economy. Within two weeks of the outbreak, the consumption of poultry in Turkey had dropped substantially and retail poultry prices had fallen by 30 percent. As a result, the poultry and egg sector incurred losses of roughly US$0.9 million daily during October 2005-March 2006 (prior to the outbreak the GDP of the poultry and egg sector ranged US$ billion annually) This prompted the international community to take emergency measures to prevent and combat the disease. The World Bank adopted a Global Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) plan in December This plan provided the rationale for implementation of rapid and coordinated action and guidance for Bank s support to vulnerable countries. 6. The seasonal migration of birds contributes to the transmission of new strains to different geographical regions. Turkey, like most countries in the area, is located on the migration routes of many migratory birds including water fowl. Thus the chance of a future outbreak of a strain of the H5N1 virus in Turkey is a real possibility. 7. Issues in the Animal Health system at appraisal: The incursion of the H5N1 virus in the country was not detected soon enough by the Veterinary Services (VS) to contain and eradicate it, and this led to a rapid and extensive spread of the disease among backyard poultry in the country; The situation became difficult to control for the VS, as equipment (personal protective equipment, disinfection devices and products, etc.) was far insufficient and teams were not prepared enough to organize actions on the field in an effective and coordinated manner; Capacity for culling and disposal of animals was not adequate in terms of technique and equipment; Compensation was provided to farmers by the State and was important to ensure transparency but mechanisms and procedures had to be better defined and streamlined; and Veterinary laboratories were quickly overwhelmed by the number of samples submitted and did not have the appropriate capacity and materials to provide timely and fully reliable results. As a consequence, 30% of some regional labs results were found to be cross-contaminated. 8. Issues in the Public Health system at appraisal: A National Pandemic Influenza Action Plan (NPIAP) was already in place at project appraisal, constituting a comprehensive scope. However, the emphasis on inter-sector cooperation and collaboration was not sufficient; Although the existing surveillance system had proven to function properly, the laboratories in Istanbul and Ankara were not able to cope with the increased demand when the pandemic struck. As a consequence of the weak diagnostic capacity (particularly in terms of specimen handling), 9 out of 21 cases (43%) of human HPAI were not confirmed by WHO; Upgrading the vaccine/drug storage warehouse was crucial for storage of vaccines and other influenza related medications; and Existing health system response capacity needed strengthening of non-pharmaceutical containment measures such as social distancing measures and protective actions of health care workers. The contingency plans on how to maintain essential services in case of a pandemic were not in place. 2 Source: Turkish Poultry Meat Producers & Breeders Association 2

21 1.2 Original Project Development Objectives (PDO) and Key Indicators 9. The proposed project aims to minimize the threat in Turkey posed to humans by the highly pathogenic avian influenza infection and other zoonoses in domestic poultry and prepare for the control and response to an influenza pandemic and other infectious disease emergencies in humans. To achieve this, three areas will be supported: (i) prevention, (ii) preparedness and planning and (iii) response and containment. Achieving these goals will contribute to diminishing the burden of disease and loss of productivity in Turkey, limiting the regional spread of AI, and enhancing economic and social prospects at the national, regional, and global levels. 10. The above PDO can be separated in two coordinated dimensions: (i) on the animal side to minimize the threat in Turkey posed to humans by the highly pathogenic avian influenza infection and other zoonoses in domestic poultry, and (ii) on the human side prepare for the control and response to an influenza pandemic and other infectious disease emergencies in humans. Thus, while the animal side of the PDO was limited to poultry diseases, the human side was broader and included other infectious diseases. 11. The key project outcome indicators were: Evidence of improved effectiveness of participating animal and public health services in limiting the spread of an HPAI outbreak and consequent pandemic in Turkey. The indicator used to evaluate this outcome was the number of human cases; Evidence of widespread adoption of recommended practices for the prevention and control of HPAI among poultry producers, distributors, and retail vendors. The indicator used to monitor this outcome was the number of animal outbreaks; and Improving trend in poll of experts designed to gauge HPAI readiness in Turkey. The indicator used to evaluate this outcome was the number of people trained on HPAI or zoonotic disease issues. 12. Given the relevance of inter-sector coordination, the ICR team also examined how the project promoted inter-institutional and multi-sector coordination, particularly the functioning of the National Zoonotic Disease Committee and the establishment and use of the National Contingency Plans. 1.3 Revised PDO and Key Indicators, and reasons/justification 13. A proposal to modify the PDO was discussed during the mid-term review mission to expand the scope of the whole project to priority zoonotic diseases control. This change was not supported by the Government of Turkey (GoT) and no further proposal was made during the last phase of project implementation. 14. Neither PDO nor key indicators were modified during project implementation. 1.4 Main Beneficiaries 15. The main beneficiaries of the actions supported by the project were not specifically spelled out in the Project Appraisal Document (PAD). They were: Overall population of Turkey. The threat posed to humans in Turkey by HPAI infection affected the whole population of the country. Also other countries in the region and the rest of the world benefitted from the reduced likelihood of pandemic; The poultry industry is also benefitting from the minimization of the HPAI threat. Rapid eradication of poultry outbreaks in 2007 and 2008 shortened the duration of the export ban. Appropriate communication quickly restored confidence of the population in the safety of poultry 3

22 products and boosted consumption within a few months after the first outbreak, thereby limiting the crisis impact on producers and the food industry as a whole; Small farmers also benefitted from the coordinated actions supported by the project. Thanks to a rapid control of outbreaks in 2007 and 2008, the number of small culled birds was significantly reduced and farmers were compensated for their loss; and Institutional beneficiaries were the VS of the Ministry of Agriculture (Ministry of Agriculture and Rural Affairs(MARA) which became Ministry of Food, Agriculture, and Livestock in 2011 (MFAL), its staff and its laboratory, surveillance and inspection services, and the Ministry of Health (MoH), its staff, its laboratory and epidemiological surveillance units, and the department of communicable diseases. 1.5 Original Components 16. The three project components were in line with the Global Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI): Component 1: Animal Health (US$30.86 million). This component targeted the prevention, control and total eradication of HPAI through three subcomponents: (i) national policy framework and development of a national strategy; (ii) strengthening disease surveillance and diagnostic capacity; and (iii) outbreak containment plan; Component 2: Human Health (US$20.84 million). This component targeted the reduction of the impact of a pandemic influenza virus through: (i) enhancing public health program planning and coordination; (ii) strengthening the national public health surveillance system; and (iii) strengthening health system response capacity. The project aimed to help the MoH to build its institutional capacity to implement the recently prepared NPIAP in coordination with the MFAL; and Component 3: Public Awareness and Coordination Support (US$ 2.78 million). This component supported information and communication activities to increase the attention and commitment of government, the private sector, and civil society organizations and to raise awareness, knowledge and understanding among the general population about the risk and potential impact of the pandemic. It also aimed to support the National Zoonotic Disease in its roles of triggering emergency responses by the MARA and MoH, monitoring the actions taken by them, coordinating public statements to the media, and executing project evaluation activities. 1.6 Revised Components 17. The components were not revised. 1.7 Other significant changes 18. The project was extended once from November 30, 2010 to December 31, Five funds reallocation proceeds were issued during the project life. Main changes include the reallocation in October 2010 of an important share of funds from Compensation Fund (Euro 2,350,000) and Poultry Restructuring Sub-Project (Euro 900,000) to Goods and Works in order to complete the upgrading of Biosafety Level 3 (BSL-3) Laboratory under the Animal Health Component. This was a consequence of the fact that by 2010 the Compensation Fund had fulfilled its function, while it became clear that significant Poultry Restructuring was not achievable without an emergency situation. In November 2011, funds from Goods, Consultant s Services and Training and Incremental Operating Costs were reallocated to Works in order to finance the construction of a larger vaccine storage 4

23 warehouse under the Human Health component. This reallocation increased works from Euro 2,500,000 to 6,100, According to the PAD, implementation of the Animal Health component was the responsibility of the Central Executing Unit (CEU) of the Agricultural Reform Implementation Project. However, shortly after starting, it was agreed to change such implementation arrangement: the project implementation responsibility switched from the CEU to MARA s General Directorate for Protection and Control (GDPC) in charge of the management and supervision of VS. Additional staff was hired to ensure compliance with financial and procurement management. This structure was maintained during the whole project. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 21. The project was triggered by the critical situation faced by Turkey s poultry sector and the global concern over the potential pandemic. The detection of HPAI virus in poultry as from October 2005 in Turkey spurred a rapid response from the World Bank and other international organizations in support of the government to control the animal outbreaks and to avoid further spread among animals and the population. This situation took a crisis dimension when human cases were detected in early 2006 and four deaths linked to HPAI virus were confirmed. 22. A project developed in 2004 that had been implemented in Vietnam for about one year provided a few insights, preliminary recommendations and lessons learned. These recommendations, including a two-pronged (animal and human) approach and a coordinated management structure empowered with cross-sector responsibilities were incorporated into this project s preparation. The project was prepared within the framework of the GPAI and under the provisions of the World Bank emergency policy guidelines (OP/BP 8.50). Project design was built on the World Bank experience gained in HPAI prevention and control in other countries, as well as international guidelines and reports from WHO, OIE, and Food and Agriculture Organization (FAO). These stressed the need to use a systemic and coordinated approach in addressing zoonotic diseases based on short, mid and long term actions. 23. The project was prepared in a short time and under difficult emergency circumstances. This timely delivery was crucial given the emergency nature of the project. 24. A lesson from the experience of other HPAI operations was the importance of inter-agency coordination to reduce the risk of leaving important issues uncovered or overlapping. Indeed several international agencies acted in a coordinated manner to support the effort of the Government. The main international agencies were: the European Union (EU), which already had significant experience on animal health, livestock issues, and food safety in Turkey because of pre-accession negotiations and geographical proximity; the WHO had a role in assessing the threat for a human pandemic; the United Nations International Children s Fund (UNICEF) was very active in the communication campaign since humans cases where concentrated among young people; the United States Development Assistance Agency (USAID), which also channeled support from the US Center for Disease Control (CDC) and the US Department of Agriculture (USDA) had a role because of its training expertise and available facilities in the region; the OIE was offering support to its Members to strengthen their VS performance and quality; and FAO had had a long term dialogue on animal health and in particular in terms of transboundary animal diseases. The emergency situation created the conditions for an interagency coordination which has been considered effective. Although the project was officially co-financed by USAID and EU 5

24 parallel financing, coordination in both design and implementation was carried out also with other agencies, such as UNICEF and FAO. Indeed the project was presented as a good example of inter-agency coordination at a conference in Vietnam in April At the outset, the Government s commitment to fight against HPAI was strong, as evidenced by, inter alia, the established NPIAP, the expenditures incurred in compensating winter 2006 culling, and the absence of animal to human transmissions in subsequent outbreaks. 2.2 Implementation (including any project changes/restructuring, mid-term review, Project at Risk status, and actions taken, as applicable): 26. Given its cross-cutting approach, the project was complex to manage and coordinate. Still all three project components were implemented, even if with some delays, as reflected by the marginally satisfactory ratings in some Implementation Status and Result Reports (ISRs). This was in part consequence of diminishing attention to the risk of a pandemic influenza. The Loan disbursed around 86% of the allocated funds. This should not be assessed as a low disbursement. In fact, only a small share of funds allocated for the compensation fund was used for this purpose (US$0.26 million out of the US$5 million initially allocated). This was a positive outcome the rapid diseases containment but it resulted in the perception of slow disbursements The project has never been considered a problem project and the actions taken during supervision were adequate to guarantee good support to implementation. In October 2008 the Bank conducted a Midterm Review (MTR). 28. Unlike many other HPAI projects, this project was not restructured to address other non poultry zoonotic diseases. The PDO was worded in a way that the human health component could cover also other infectious diseases in addition to HPAI, while the animal health component was limited to poultry diseases. The government decided to keep this focus on poultry diseases when the MTR proposed the expansion also of the animal health component scope. This was a missed opportunity given the relevance of zoonotic diseases in Turkey (see Table 3, page 25). The inclusion of other zoonotic diseases in addition to HPAI would have helped the project to spur a longer-term institutional and technical capacity building effort beyond merely single disease focused operation. Since the original PDO was broader for human health, the MoH did start to address other pressing issues like Crimean Congo Hemorrhagic Fever 5 and brucellosis in cooperation with the Ministry of Agriculture. Still the project did contribute to open a constructive dialogue with the Government on food safety and the One Health initiative which address the disease risks at the human-animal-environmental interface and diseases, the so-called zoonotic diseases which people contract from animals. 29. Implementation arrangements. The Ministry of Agriculture implemented the Animal Health and Awareness Components, and MoH implemented the Human Health component. Project activities were implemented by the relevant directorates and departments in each ministry, with support of dedicated 3 The title of the conference was TOWARDS ONE HEALTH: NEW APPROACHES TO MANAGING ZOONOTIC DISEASES 4 Setting aside adequate funds for a rapid response to a HPAI outbreak, including compensation fund, was the appropriate approach, but such contingent funds are not distinguished in Bank systems from other undisbursed balances, giving rise to possible misinterpretations about project performance. 5 Turkey has experienced an expanding outbreak of CCHF with increasing numbers of notified cases and associated fatalities (2002: 17/0; 2003: 133/6; 2004: 249/13; 2005: 266/13; 2006: 438/27; 2007: 713/33; 2008: 1315/63; 2009: 1300/62). Source : Eurosurveillance, 6

25 consultants for Procurement, Financial Management, and Monitoring and Evaluation who were part of the Project Management Support Unit. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 30. M&E Design: A separate M&E process was established for the human health component and the animal health and communication components. A single M&E unit under project management servicing all components may have strengthened coordination. Organization and responsibilities of the bodies in charge of monitoring and evaluation were clearly defined in the PAD. 31. The PAD included an excessively long results framework, and many of the 41 indicators appeared later not to be properly worded, repeated, or not relevant enough to track progress in achieving the outcomes and eventually reaching the PDO. The results framework remained focused mainly on input and output indicators, with few outcomes reported. An excellent quality baseline socio-economic survey had been carried out and was used to design poultry restructuring activities. 32. M&E Implementation and Utilization: Regular semi-annual and annual reporting by the implementing agencies was carried out according to provisions of the PAD. Monitoring of the restructuring of the poultry sector was crucial to scale down the initial overambitious objective of reducing the practice of backyard poultry rising, which seems to have resulted from panic during the 2006 crisis. In light of the post emergency situation, a restructuring of the poultry sector without an emergency risk situation may not even be necessary. 2.4 Safeguard and Fiduciary Compliance 33. Environmental Safeguards. As an emergency operation, the project was eligible for a delay in completion and disclosure of the Environmental Management Plan (EMP) after appraisal. An acceptable EMP was completed and disclosed prior to Effectiveness. The EMP addressed zoonotic disease containment and waste management as pertained to disposal of special waste, emissions and materials from laboratories, and training for VS workers, to include procedures for safe handling of Avian Influenza (AI) materials, safe culling of infected and at-risk poultry and disposal of carcasses and infected materials, and construction waste management. 34. The project was implemented in compliance with the EMP. Veterinarians were trained on appropriate culling and disposal techniques and disposal of used Personal Protective Equipment (PPEs). These techniques were reinforced during the simulation exercises. The laboratories that were upgraded under the project received training on good standard operating procedures, including waste management practices, biosafety, and liquid waste decontamination systems. The contract for the mobile incinerators similarly provided also for training in safe and effective operations of the equipment. For the human health component, the EU provided lab safety and waste management training for the laboratories that were upgraded to BSL-3 6. Training courses and simulation exercises have incorporated environmental safeguards issues effectively. The other main environmental safeguards issue for the project was associated with the construction and operation of the Vaccine and Drug Storage Warehouse under the 6 BSL-3 is suitable for work with infectious agents which may cause serious or potentially lethal diseases as a result of exposure by the inhalation route or direct contact. There are some highly technological barriers required at BSL-3, characterized by having a double-door entry, and particular attention is given to air movement in these labs. Air moves from areas of lesser contamination to areas of higher contamination, such as from the corridor into the laboratory. Air movement is also single pass; exhaust air is not re-circulated to other rooms. All work that may create aerosols or splatter is done inside a biological safety cabinet. Wall, ceiling and floor penetrations are sealed to keep aerosols in and to keep gaseous decontaminants in. Further detail on biosafety levels is available at 7

26 Human Health component. The construction was carried out in conformity with the project EMP and Turkish regulations governing construction waste management. Operation of the Warehouse had not yet begun at the time of drafting of this Implementation Completion Report (ICR). 35. Financial Management (FM). Both implementing entities maintained moderately satisfactory to satisfactory FM arrangements over the life of the project as documented in the FM supervision reports prepared by Bank FM specialists. The audit reports for the project were received on time and had unqualified (clean) audit opinions. The project had two special accounts, one for the MoH and one for the Ministry of Agriculture. Both Ministries had FM arrangements separate from each other and consolidated reporting was not required. Audit reports were also separately prepared and submitted for each implementing Ministry. 36. In the MoH, each general directorate was responsible for incurring project expenditures. The Project Management Support Unit had an oversight role and was also responsible for gathering all relevant data and supporting documentation from the general directorates to produce quarterly financial monitoring reports and the annual financial statements. The Project Unit in the Ministry of Agriculture was responsible for making project payments as well as maintaining project accounting. MARA has consistently maintained the services of a very experienced financial management staff. The staff turnover in MOH, however, was high, leading to delays in recording project transactions at times. In general though MOH FM staffs were also experienced and the delays in project recording were dealt with promptly. 37. The animal health component included the compensation payments to farmers in case of an HPAI outbreak. Specific control and documentation procedures were developed to put an effective and efficient system in place both with respect to FM arrangements and to urgent intervention activities. The Provincial Directorates have opened bank accounts to be used for AIHP payments in case of an outbreak. MARA issued a circular detailing the procedures and distributed it to the stakeholders. These procedures were put into application during the winter of In accordance with the agreement, the Treasury Controllers have conducted an Operational Review of the compensation payments. The report covered compensation payments made as of September 22, There were no other compensation payments after that date. There were several minor observations and recommendations made by the operational review team relating to the compensation payment process. The major observation was that even though the main objective of compensation payments was to register payments in cash at the time of the culling, it was not possible to actually execute that during an outbreak. The compensation payments were made to the farmers after the culling process via bank transfers. A second important observation of the operational review team related to the lack of publicity campaigns by the provincial and regional MARA directorates. The regional and provincial offices were required to inform poultry producers on methods of compensation payments, and start and end dates of payments by using written and visual media. Instead the poultry producers were only contacted through the local municipal offices (mukhtars). 39. Procurement. Procurement compliance has been satisfactory throughout the project. Procurement activities under the project were carried out in compliance with the Bank s procurement policy and procedural requirements. Procurement arrangements defined in the original Loan Agreement and PAD were not revised. Because of the emergency nature of the project, shopping procedures with a threshold up to US$2 million were allowed for a certain number of emergency contracts. Since this threshold is higher than standard operations, such shopping procedures were subject to World Bank's prior review. There were no fraud or corruption issues observed or suspected during implementation. 8

27 40. The procurement arrangements were followed by two separate relevant specialists under MoH and MARA. The procurement capacity of both specialists was adequate and both performed well through the implementation of the project. 41. The project was regularly supervised by the Bank s procurement specialist. Given the emergency nature of the project, there were some planning issues concerning procurement activities. Additionally, significant delays were observed until the initiation of the construction works of the vaccine warehouse as a result of design delays. Close follow-up and assistance from the Bank team were provided to help addressing these issues. 2.5 Post-completion Operation/Next Phase 42. Coordination mechanisms established between the Ministries of Agriculture and Health have become a strength in the management of other zoonotic diseases such as Crimean Congo Hemorrhagic Fever (CCHF), rabies and brucellosis. Further development of zoonotic diseases control programs has been viewed as essential by the government and is underway with the support of the World Bank Institutional Development Fund (IDF) One Health approved in December 2010: this IDF is built on achievements of the HPAI project and is aimed at further expanding areas of expertise and cooperation between these ministries. 43. The Turkish VS are engaged in a long term upgrading process. Increased capacity gained in terms of organization, management, coordination, communication and competency with the support of the project are expected to have long lasting effect. This belief is underpinned by the commitment of the government in the livestock sector coupled with significant levels of co-financing to achieve the control of priority diseases in the frame of EU accession. A possible collaboration between the EU and the World Bank in the area of food safety is also under review. 44. Looking forward, there is a risk that the very success government has had to date in controlling and containing AI might make it more difficult in the long term to commit the resources required to maintain a high level of alertness. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 45. The project objective was in line with the GPAI. It was particularly relevant for Turkey which had to face a surge of HPAI outbreaks among animals and the advent of human cases. Given the incidence and impact of H5N1 in Asian countries and the likelihood that it would eventually spread to West Asia of which Turkey was the one of the first countries to be affected it was important for the Bank to assist Turkey in minimizing HPAI risks. Even after the outbreaks went under control and the global pressure slowed down on H5N1 virus, this objective continues to be highly relevant, in particular when seen with a broader perspective encompassing all zoonotic diseases which still have to be controlled or eradicated in Turkey, like CCHF, rabies, brucellosis and tuberculosis. 46. The project s overall design was conducive to achieve the stated development objective, which remained relevant during the project, and even after project closing. Effective interagency cooperation and implementation arrangements have led to rapid progress in achieving the outcomes. This project is exemplary in showing how the government together with more than six international agencies coordinated activities in a context of crisis. Activities were customized to fit the country needs in a flexible and complementary manner, and implemented jointly or in parallel by various agencies. No important topic was left uncovered while overlapping was minimal. 9

28 47. The project design was robust and incorporated and consolidated the skills and resources of two line Ministries. Project implementation, even if longer than initially expected, was conducive to achieving the project objectives. Except for the extension of closing date, the project design did not need to be changed to maintain its relevance. 3.2 Achievement of Project Development Objectives 48. The project significantly contributed to achieve the stated PDO of minimizing the threat posed to humans by HPAI and Turkey is now more prepared to face similar threats. The constructive coordination among several agencies, mentioned in other parts of this report, makes it challenging to attribute the overall achievement to a single agency or project. The economic analysis assumed that the project s contribution to achieving the PDO was at 85% The capacity of Turkey to contain HPAI outbreaks increased significantly from 2006 to This is clearly visible in the evolution of outbreaks (see maps below). In 2007 and 2008, 17 outbreaks (geographically grouped) and 7 outbreaks (isolated without epidemiological link) were respectively reported. No more outbreaks occurred since then. Compared to the 2005/2006 situation, this illustrates the great progress made in 2 years: from extensive spread in 2006 to reduced spread in and finally full containment (absence of spread) after this. Few thousands poultry were culled in 2007 and 2008 in contrast with the 2.5 million in 2005/2006. Figure 1. Turkey Evolution of HPAI outbreaks in poultry 8 December 2005 March 2006: 202 outbreaks February-April 2007: 17 outbreaks January-March 2008: 7 outbreaks 7 This share was estimated on the basis of the financial contribution of the project (including various financiers) versus the total estimated expenditure to achieve that objective. 8 Only domestic outbreaks, all resolved. Source: OIE 10