IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H2030 TF TF TF-91995) ON A GRANT

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H2030 TF TF TF-91995) ON A GRANT IN THE AMOUNT OF SDR 2.8 MILLION (US$ 4.0 MILLION EQUIVALENT) TO THE KYRGYZ REPUBLIC FOR A Report No: ICR1767 AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE PROJECT Sustainable Development Department Central Asia Country Unit Europe and Central Asia Region June 27, 2012

2 CURRENCY EQUIVALENTS (Exchange Rate Effective December 31, 2011) Currency Unit = Kyrgyz Som (KGS) 1.00 = US$ US$ 1.00 = KGS FISCAL YEAR: January 01 December 31 ABBREVIATIONS AND ACRONYMS AI Avian Influenza IHR International Health Regulations ADB Asian Development Bank ILI Influenza-like illness AHIF Avian and Human Influenza Facility KAP Knowledge, Attitude and Practices Assessment APL Adaptable Program Loan LVPRI Livestock, Veterinary and Pasture Research Institute ASEAN Association of Southeast Asian Nations MAP Multi-country APL ASSP Agricultural Services Support Project MAWRPI Ministry of Agriculture, Water Resources and Processing Industry CC Component Coordinator MES Ministry of Emergency Situations CDC US Centers for Disease MOH Ministry of Health Control and Prevention DIVA Differentiation of infected M&E Monitoring and Evaluation from vaccinated animals EC European Commission NADIS National Animal Disease Information System ERA Emergency Recovery NAPA National advance purchase agreements Assistance ERL Emergency Recovery Loan NGO Non Governmental Organization EU European Union NSC National Steering Committee EWS Early Warning System NVL National Virology Laboratory FMD Food and Mouth Disease OFFLU OIE/FAO Avian Flu Network FMR Financial Monitoring Report OIE World Organization for Animal Health GDP Gross Domestic Product PCR Polymerase Chain Reaction GPAI Global Program for Avian PMR Project Management Report Influenza and Human Pandemic Preparedness and Response HPAI Highly pathogenic avian POM Project Operational Manual influenza H5N1 Influenza A virus PP Procurement Plan H1N1 Subtype of influenza A virus RAS Rural Advisory Services IATA International Air Transport Agency RCVD Republican Center for veterinary Diagnostics IDA International Development Association REAAC Republican Emergency Antiepidemic and Antiepizootic Commission IFAD International Fund for Agricultural Development RMIS Republican Medical Information System

3 SAEPF State Agency for TOT Training of Trainers Environmental Protection and Forestry SARS Severe Acute Respiratory UNDP United Nations Development Program Syndrome SES Sanitary Epidemiological VS Veterinary Services Station SOE Statement of Expenditures WHO World Health Organization SVD State Veterinary Department WP Work Program TCP Technical Cooperation WTO World Trade Organization Program TF Trust Fund Vice President: Country Director: Sector Manager: Project Team Leader: ICR Team Leader: Philippe Le Houerou Saroj Kumar Jha Dina Umali-Deininger Brian Bedard Sandra Broka

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5 Kyrgyz Republic Avian Influenza Control and Human Pandemic Preparedness and Response Project CONTENTS Data Sheet A. Basic Information... i B. Key Dates... i C. Ratings Summary... i D. Sector and Theme Codes... ii E. Bank Staff... iii F. Results Framework Analysis... iii G. Ratings of Project Performance in ISRs... xi H. Restructuring (if any)... xi I. Disbursement Profile... xii 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 (relating to design, implementation and outcome issues) Lessons Learned Comments 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 (if any) Annex 7. Summary of Borrower s ICR and/or Comments on Draft ICR Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Annex 9. List of Supporting Documents ANNEX 10. Map IBRD

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7 A. Basic Information Country: Kyrgyz Republic Project Name: Project ID: P L/C/TF Number(s): ICR Date: 06/26/2012 ICR Type: Core ICR Avian Influenza Control & Human Pandemic Preparedness & Response Project IDA-H2030,TF-56157,TF ,TF Lending Instrument: ERL Borrower: KYRGYZ REPUBLIC Original Total Commitment: Revised Amount: USD 3.43M Environmental Category: B USD 4.00M Disbursed Amount: USD 3.76M Implementing Agencies: Ministry of Health (MOH) Ministry of Agriculture, Water Resources and Processing Industry (MAWRPI) Cofinanciers and Other External Partners: Government of Japan - PHRD European Commission Avian and Human Influenza Facility Multi-Donor Trust Fund - Avian and Human Influenza Facility B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 12/19/2005 Effectiveness: 07/10/ /10/2006 Appraisal: 11/30/2005 Restructuring(s): 05/09/ /23/2010 Approval: 02/09/2006 Mid-term Review: 07/15/ /15/2008 Closing: 12/30/ /31/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Satisfactory Moderate Moderately Satisfactory Satisfactory i

8 C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Moderately Satisfactory Quality of Supervision: Moderately Satisfactory Implementing Agency/Agencies: Satisfactory Overall Bank Performance: Moderately Satisfactory Overall Borrower Performance: Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Performance any) Potential Problem Project at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: No No Satisfactory Quality at Entry (QEA): None Quality of Supervision (QSA): 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 8 8 Theme Code (as % of total Bank financing) Health system performance Other communicable diseases Participation and civic engagement Rural services and infrastructure Social safety nets ii

9 E. Bank Staff Positions At ICR At Approval Vice President: Philippe H. Le Houerou Shigeo Katsu Country Director: Saroj Kumar Jha Dennis N. de Tray Sector Manager: Dina Umali-Deininger Juergen Voegele Project Team Leader: Brian G. Bedard Gotz A. Schreiber ICR Team Leader: Sandra Broka ICR Primary Author: Sandra Broka Caroline Plante Nedim Jaganjac Amy Evans F. Results Framework Analysis Project Development Objective (from Project Appraisal Document): The overall objective of the Project is to minimize the threat in the Kyrgyz Republic posed to humans and to the poultry industry by Highly Pathogenic Avian Influenza (HPAI) infection and to prepare for, control, and respond to an influenza pandemic. 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, limiting the regional spread of HPAI, and enhancing economic and social prospects at the national, regional, and global levels. Revised Project Development Objective (as approved by original approving authority): The overall objective of the project is to minimize the threat in the Kyrgyz Republic posed by the Highly Pathogenic Avian Influenza (HPAI) infection as well as other poultry and livestock diseases and to prepare for the control and response to animal influenza pandemic and other zoonotic or infectious disease emergencies in humans. (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 National integrated preparedness, control and response plans prepared and accepted by WHO, OIE and FAO. National Target values for Preparedness, control preparedness, control this PDO-level and response plans N/A and response plans indicator were conform to intl. conform to not formally requirements. iii

10 requirements of revised. WHO, OIE and FAO. Operational plans further developed at local level and tested through simulation exercises. Control strategies prepared for 4 additional priority diseases. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Achieved. Although no HPAI case was detected in the country, documentation and interviews showed that a clear vision of early detection and response mechanisms had been established through the set of activities conducted during project implementation. Indicator 2 : Contained and diminishing pattern of HPAI in poultry. Government capacity for surveillance, monitoring & Value quantitative or Qualitative) N/A Government capacity for surveillance, monitoring and containment of HPAI infection of animal improved. Target values for this PDO-level indicator were not formally revised. containment of HPAI infection of animals improved. VS capacity to conduct passive & active surveillance to monitor HPAI and be prepared to implement containment & and eradication measures established. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Achieved. The high level of preparedness achieved should ensure proper reaction to an AI outbreak. Project extension included other diseases and led to successful design of brucellosis control, further implemented through AISP project in a pilot oblast. (b) Intermediate Outcome Indicator(s) Indicator Indicator 1 : Value (quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) National AI Strategy developed and adopted by government. N/A Government capacity for containment and control of HPAI outbreak improved. Formally Revised Target Values N/A Actual Value Achieved at Completion or Target Years Government capacity for containment and control of HPAI outbreak improved. VS capacity to control HPAI possible due to appropriate planning, monitoring, preparing and diagnostic capacities. Date achieved 12/31/ /31/ /31/ /10/2012 iv

11 Comments (incl. % achievement) Indicator 2 : Value (quantitative or Qualitative) Indicators 1 and 2 were combined for monitoring purposes. Achieved. The HPAI preparedness and control strategy was widely shared among stakeholders and awareness raised through trainings and communication activities. Outbreak Containment Plan conforms with the guidelines of FAO/OIE and GPAI. N/A Government capacity for containment and control of HPAI outbreak improved. N/A Government capacity for containment and control of HPAI outbreak improved. Existence of outbreak containment plans in line with international best practices. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicators 1 and 2 were combined for monitoring purposes. Achieved. HPAI emergency plans were developed, further adapted to fit local operational needs and tested through simulation exercises. Indicator 3 : Assessment of the Veterinary Services completed. Value (quantitative or Qualitative) N/A Assessment completed. N/A Assessment completed. Performance of VS evaluated, gap analysis, strategic plan and legislation missions completed. Strategic plan for reform ratified by Government. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator monitored sporadically, not in every ISR. Achieved. The country underwent all key steps of the OIE PVS-Pathway (framework developed by the World Organization for Animal Health to support the strengthening of VS). Indicator 4 : Laboratory equipment and materials are procured, distributed and installed. Value (quantitative or Qualitative) N/A High level of awareness of HPAI within the country. N/A LVPRI and RCVD facilities upgraded to BSL level 2 and equipped with modern diagnostic devices and staff trained for appropriate use; two regional Vet Labs also renovated and equipped. Date achieved 12/31/ /30/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 4, 5, 6 and 7. Achieved. The main central veterinary diagnostic establishments are equipped and staffed with competent people. Successful blind tests confirmed the competency acquired. Indicator 5 : Staff is trained in surveillance and diagnostic methods. Value (quantitative or Qualitative) N/A Sufficient core staff trained. N/A 100% State veterinary staff trained as well as key private v

12 practitioners, poultry producers and stakeholders. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator 6 : Value (quantitative or Qualitative) Indicator was not monitored separately, but combined with indicators 4, 5, 6 and 7. Achieved. Trainings in all provinces were delivered in close cooperation with the STOP-AI program and reached VS, local administration and poultry farm staff. Reporting and reaction time for suspected cases of AI is reduced to the minimally acceptable levels. N/A Reporting time acceptably rapid. N/A Awareness of reporting requirements and response mechanisms. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 4, 5, 6 and 7. Achieved. Awareness of all relevant groups on HPAI, capacity to diagnose HPAI and existence of emergency plans should allow VS to react in a timely manner. Indicator 7 : 75% average monitoring coverage in at risk areas. Value (quantitative or Qualitative) N/A 75% average monitoring coverage for poultry flocks in at-risk areas. N/A 100% of risk areas regularly monitored for HPAI. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 4, 5, 6 and 7. Achieved. The VS conducts regular monitoring in at-risk flocks (3,915 blood serum, 600 pathological materials, 9,000 other tests on AI and other poultry diseases done). Indicator 8 : Data collection and reporting including outbreak reporting, annual prevalence data. Value (quantitative or Qualitative) N/A N/A N/A Indicator was not monitored. Date achieved 12/31/ /31/ /31/ /10/2012 Comments The indicator was not monitored during the project (incl. % Indicator introduced during May 2010 restructuring. achievement) Indicator 9 : Emergency supplies procured and available at strategic locations in the field. Value (quantitative or Qualitative) N/A Emergency supplies in place. N/A Emergency supplies made available in strategic locations (SVD, LVPRI and RCVD). Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % Indicator was not monitored separately, but combined with indicators 9, 10 and 11. achievement) Indicator 10 : If appropriate, ring vaccination around infected areas completed. Value Not applicable (no (quantitative N/A Done if applicable. N/A HPAI outbreaks). or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 vi

13 Comments (incl. % Indicator was not measured, as ring vaccinations were not required due to no AI outbreak. achievement) Indicator 11 : Culling, disposal and disinfection activities completed as needed. Value Not applicable (no (quantitative N/A Done if applicable. N/A HPAI outbreaks). or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments Indicator was not measured, as culling, disposal and disinfection activities were not required to (incl. % be performed. achievement) Indicator 12 : Compensation provided to poultry owners rapidly and in a monitorable way. Value (quantitative or Qualitative) N/A Done if applicable. N/A Not applicable (no HPAI outbreaks). Date achieved 12/31/ /31/ /31/ /10/2012 Indicator not monitored. Comments Partially achieved. No compensations were provided as there were no outbreaks. (incl. % Compensation mechanisms were tested in the pilot brucellosis control program. The legal achievement) basis for compensation was drafted. Indicator 13 : Increased number of animals vaccinated. Value (quantitative or Qualitative) N/A N/A N/A Indicator was not monitored. Date achieved 12/31/ /31/ /31/ /10/2012 Comments Indicator was not monitored. (incl. % Introduced during May 2010 restructuring. achievement) Indicator 14 : Increased number of private veterinarians delivering vaccinations on a fee basis. Value (quantitative or Qualitative) N/A N/A N/A Indicator was not monitored. Date achieved 12/31/ /31/ /31/ /10/2012 Comments Indicator was not monitored. (incl. % Introduced during May 2010 restructuring. achievement) Inter-institutional/multi-sectoral coordination arrangements: legal, regulatory and institutional, Indicator 15 : in place. Value (quantitative or Qualitative) N/A National multisectoral coordination body established for control of pandemic. N/A National multi-sectoral coordination body established for control of pandemic. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 15, 16 and 17. Achieved. Merger of the HIV National CCM with other outbreak control Committee proved impractical. A separate Committee was established and works effectively. Indicator 16 : Command and control structure for program finance/management defined and in place. Value N/A Command and control Command and control vii

14 (quantitative or Qualitative) structure for program defined and adopted. structure for program defined and adopted. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 15, 16 and 17. Achieved. Command and control committee management and financing mechanisms were established early in the project. However, plans and mechanisms need to be updated. Indicator 17 : Health laws, regulations and other legal provisions revised and/or promulgated. Value (quantitative or Qualitative) N/A Compliance with IHR achieved but legislation was not changed. N/A Compliance with IHR achieved but legislation was not changed. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 15, 16 and 17. Partially Achieved. Although Kyrgyz complied with IHR regulatory framework, legislation was not formally changed to allow full compliance with IHR. Indicator 18 : National health surveillance for influenza virus developed at national level. Value (quantitative or Qualitative) In place National surveillance for influenza existed even before the project but was enhanced during the project. N/A National surveillance for influenza existed even before the project but was enhanced during the project. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 18, 19, 20 and 21. Achieved. Some influenza surveillance existed at the national level before the project but needed enhancement. The project activities contributed to surveillance improvement. Indicator 19 : Number of at risk regions in the country that have implemented a system for influenza virus surveillance and control. Value (quantitative In place In place. N/A Enhanced. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator 20 : Value (quantitative or Qualitative) Indicator was not monitored separately, but combined with indicators 18, 19, 20 and 21. Achieved. The project activities contributed to surveillance and control improvements. Number of health personnel trained in influenza virus surveillance and control. Practically 99% of Practically 99% of SES SES field N/A N/A field epidemiologists epidemiologists were trained. trained. Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 18, 19, 20 and 21. Achieved. Numerous trainings and internal processes were adopted to ensure capacity in influenza surveillance. Indicator 21 : Percentage of national and local agencies submitting regular weekly and monthly reports on the influenza pandemic. Value (quantitative In place. Enhanced. N/A Enhanced. viii

15 or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 18, 19, 20 and 21. Achieved. Country reported on weekly/monthly influenza statistics. Delays in the reporting process were reduced by using IT, but further improvements are required. Indicator 22 : 'Social distancing measures', such as quarantine, bans on mass gatherings, and travel restrictions, developed and backed up by communication strategy. Value (quantitative N/A In place. N/A In place. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 22, 23, 24 and 25. Achieved. It is important to highlight that, following WHO recommendations, travel restrictions were not imposed. Indicator 23 : Strategy to access pandemic vaccines developed. Value (quantitative N/A Completed. N/A Completed. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments Indicator was not monitored separately, but combined with indicators 22, 23, 24 and 25. (incl. % Achieved. Sufficient quantities of quality vaccines were timely obtained. achievement) Indicator 24 : Strategy to access anti-virals for national use (e.g., stockpiling) developed. Value (quantitative N/A Completed. N/A Completed. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 22, 23, 24 and 25. Achieved. Sufficient quantity of anti-virals was stockpiled. Indicator 25 : Contingency plans for maintenance of essential services within the health and outside the health system developed. Value (quantitative N/A Completed. N/A Completed. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 22, 23, 24 and 25. Achieved. Plans were developed early in the project. Indicator 26 : National communication strategy for pandemic influenza established and materials and messages prepared. Value (quantitative N/A Completed. N/A Completed. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % achievement) Indicator was not monitored separately, but combined with indicators 26, 27 and 28. Achieved. Effective communication strategy was implemented resulting in compliance with required measures and behavior change to prevent spreading of pandemic influenza. ix

16 Indicator 27 : Public information campaign launched in at-risk areas. Value (quantitative N/A Completed. N/A Completed. or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments Indicator was not monitored separately, but combined with indicators 26, 27 and 28. (incl. % Achieved. National level campaign was successfully completed. achievement) Indicator 28 : Evidence of high level of awareness by target groups following dissemination of messages. Value (quantitative or Qualitative) N/A Completed. N/A A KAP survey in 2010 showed that 88% of respondents were aware of the message. Date achieved 12/31/ /31/ /31/ /10/2012 Comments Indicator was not monitored separately, but combined with indicators 26, 27 and 28. (incl. % Achieved. achievement) Indicator 29 : Program reports, financial monitoring, procurement and disbursement reports, audits, management and financial reports prepared and submitted periodically. Value (quantitative N/A N/A N/A N/A or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % Indicator was dropped starting ISR2 and not monitored. achievement) Indicator 30 : Baseline developed for monitoring and evaluating Project impact six months after Grant effectiveness. Value (quantitative N/A N/A N/A N/A or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % Indicator was dropped starting ISR2 and not monitored. achievement) Indicator 31 : Methodology defined and monitoring and evaluation periodically undertaken. Value (quantitative N/A N/A N/A N/A or Qualitative) Date achieved 12/31/ /31/ /31/ /10/2012 Comments (incl. % Indicator was dropped starting ISR2 and not monitored. achievement) x

17 G. Ratings of Project Performance in ISRs No. Date ISR Actual Disbursements DO IP Archived (USD millions) 1 07/11/2006 Satisfactory Satisfactory /12/2006 Satisfactory Satisfactory /25/2007 Moderately Satisfactory Satisfactory /30/2008 Satisfactory Satisfactory /26/2009 Satisfactory Satisfactory /28/2010 Satisfactory Satisfactory /18/2011 Satisfactory Satisfactory /29/2011 Satisfactory Satisfactory /27/2011 Satisfactory Satisfactory 3.66 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change [check box] ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in US$m Reason for Restructuring & Key Changes Made 05/09/2010 Y S S 2.87 Although the project had contributed to a reduced risk for AI, there were other pressing animal and human health concerns that could be integrated with the on-going AI activities, and minor adjustments in the capacity building interventions under the project would also allow addressing these serious problems. The PDO was revised to include, in addition to AI, other poultry and livestock diseases, and to respond to other zoonotic infectious disease emergencies in humans. Reference to other zoonoses was introduced in Components 1, 2, 3 and 5, and three new intermediate results indicators were added. Extension of the project s closing date from 12/31/2010 until 12/31/2011 to allow for completion xi

18 11/23/2010 N S S of the project activities, which were delayed by a protracted process to complete the earlier project restructuring compounded by some disruption of project activities due to civil unrest in If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO Targets Against Formally Revised PDO Targets Overall (weighted) rating Satisfactory Satisfactory Satisfactory I. Disbursement Profile xii

19 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal: 1. In 2005 the highly pathogenic avian influenza (HPAI) H5N1 virus emerged as a global threat. On January 12, 2006 the Bank's Board endorsed the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) as a horizontal adaptable program 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. This was one of the Bank s contributions to a broad international response, which was launched at the ministerial conference in Beijing, China, in January 2006 with pledges of US$1.9 billion from 35 donors. Throughout 2006, the virus was spreading rapidly, and by the end of the year, 55 countries in Asia, Europe, Africa and the Middle East had reported HPAI cases in poultry or wild birds, including Azerbaijan, Croatia, Greece, Kazakhstan, Romania, Russia, Turkey and Ukraine in the ECA region. 2. HPAI outbreaks had been confirmed in the countries neighboring the Kyrgyz Republic. Situated on major migratory bird flyways and with outbreaks reported in neighboring countries (in particular, China, Kazakhstan and Russia), the Kyrgyz Republic clearly faced both public health and economic risks. The public health and especially veterinary services systems had limited diagnostic and surveillance capacity to address the HPAI threat, and public awareness capacity was weak. Biosecurity at the commercial poultry farms was reasonably good, but the large free-ranging segment of the poultry population lacked biosecurity and was vulnerable to HPAI infection (more than 80% of Kyrgyz households have some poultry). 3. Government s commitment to dealing with AI was high. A joint Bank/WHO/CDC appraisal mission in December 2005 addressed the readiness of the Kyrgyz Republic to proceed with a program of support under GPAI and concluded that the Kyrgyz Republic meets the eligibility criteria for countries at risk in GPAI category (iii) 1. The government s commitment was provided in the form of a formal request for the project (received on November 28, 2005), and a draft national plan on response to an avian influenza pandemic, which was prepared by the Government prior to the appraisal mission. 4. The project required a multi-pronged approach. The relatively poor status of the national human and veterinary health-care systems, outdated equipment and lack of test kits at the laboratories, limited scale of disease surveillance and control, lack of tradition for communication strategies, and the overall unpreparedness for disease emergency situations were placing the country at high risk. The project, therefore, required resolution of a whole set of issues concurrently, to strengthen the country s ability to respond to HPAI crisis. The responsibility for the project implementation was shared between the Ministry of Health (MOH) and the Ministry of Agriculture, Water Resources and Processing Industry (MAWRPI). 5. Rationale for the Bank involvement. HPAI control programs require a multi-disciplinary approach to integrate technical, social, economic, political, policy and regulatory issues in addressing a complex problem, and the World Bank served as an integrator in successfully addressing this problem. In addition, with its experience to assisting many countries under the GPAI umbrella, the Bank was able 1 Country Eligibility Criteria under GPAI category (iii) states: Countries at risk, with no outbreaks or at an early stage of an outbreak, will need to demonstrate governmental commitment to addressing the situation and have in place an appropriate plan for early detection and rapid response, including implementation and monitoring arrangements that the international agencies and donor community, including the Bank, could support. 1

20 to share valuable lessons learned from other countries that faced similar threats. The Bank also helped to mobilize funds under its other projects, as well as co-financing from other donors towards achieving the project objectives. Thus, in addition to the IDA grant of US$4 million, the Government of Japan supported the program with a PHRD Grant in the amount of US$1 million, and the grants totaling US$1.15 million were provided from the AHIF (including US$0.352 million from the multi-donor window and US$0.798 million from the EU window). 6. In addition, two IDA-financed projects: the Agricultural Support Services Project (ASSP) and Agricultural Investment and Services Project (AISP) were deployed in support of furthering the AI project goals. Following a restructuring, US$1.13 million were allocated under ASSP to rehabilitate buildings of four veterinary laboratories and to procure urgently needed equipment for them, as well as to construct a number of Bekkari holes for safe carcass disposal. AISP allocated US$1.6 million, which were supported by financing from an EU Trust Fund in the amount of EUR6.7 million, from IFAD in the amount of US$1.6 million, and from SDC US$0.2 million. The funding is being used for the following purposes: legal framework development (e.g., the veterinary law), further support to the SVD on the national disease control strategy development, staff training and equipment upgrades and a twinning program with the Swiss Federal Veterinary Office, training and start-up grants for private veterinary service development, and animal vaccination program 1.2 Original Project Development Objectives (PDO) and Key Indicators: 7. The program development objective of the GPAI is to minimize the threat posed to humans by highly-pathogenic avian influenza (HPAI) infection and other zoonoses and to prepare for, control, and respond to influenza pandemics and other infectious disease emergencies in humans. This project also contributed towards achievement of this umbrella PDO. 8. This PDO was adapted to the conditions in country, thus the Project Development Objective was to minimize the threat posed to humans and to the poultry industry by HPAI infection and to prepare for, control, and respond to influenza pandemics. To achieve this, three areas were to be supported: (i) prevention, (ii) preparedness and planning, and (iii) response and containment. Achieving these goals was to contribute to diminishing the burden of disease and loss of productivity, limiting the regional spread of HPAI, and enhancing economic and social prospects at the national, regional, and global levels. 9. The key project outcome indicators were: Evidence of improved effectiveness of participating animal and public health services in responding to the risk of an HPAI outbreak and/or pandemic: (i) (ii) National integrated preparedness, control and response plans prepared and accepted by WHO, OIE and FAO. Contained and diminishing pattern of HPAI infection in poultry. 1.3 Revised PDO and Key Indicators, and reasons/justification: 10. The original PDO has been revised as follows: The overall objective of the project is to minimize the threat in the Kyrgyz Republic posed by HPAI infection as well as other poultry and livestock diseases and to prepare for the control and response to an influenza pandemic and other zoonotic or infectious disease emergencies in humans. 2

21 11. ISR5 (June 2009) provides the rationale for revision: in consultations with the Deputy Prime Minister s Office and Ministry of Health, the project team was urged to consider the possibility of providing support for other pressing animal and human health concerns that could be integrated with the ongoing Avian Influenza (AI) including brucellosis, anthrax, rabies, TB, echinococcosis and others. The government wanted to use the funds allocated under the compensation funds to address such other issues, especially, since there was no AI outbreak and the threat had diminished. The project team reviewed this proposal and agreed that the project inputs should be considered in the broader context of animal disease control and especially as it relates to zoonotic diseases. It was agreed the restructuring of the project would be required to allow addressing these broader concerns but without compromising the basic integrity of the AI related project objectives. On the Bank s side it was agreed that minor adjustments in the capacity building interventions under the project including technical assistance related to epidemiology, support for the national animal disease surveillance system, and public awareness would similarly address these serious problems. It would allow for continuing to develop capacity to prevent AI in the short term, while working towards establishment of a more sustainable system for eradicating zoonoses in the longer term. 12. Although the revised PDO went beyond the GPAI original objectives, the restructured PDO provided an opportunity for better addressing the human/animal/environmental interface and, therefore, offered a more comprehensive approach to strengthen control of HPAI and other zoonoses including animal specific diseases. In addition, this approach in fact piloted the comprehensive one Health approach which was adopted by all stakeholders. 13. The key project outcome indicators were not revised. The expanded PDO was accommodated by adding three new intermediate results indicators (for Components 1.B and 1.C). 1.4 Main Beneficiaries (original and revised): 14. Although the PAD does not make a specific reference to the Main Beneficiaries of the project, the PDO implies that the entire human population and poultry industry of the country would benefit from the increased preparedness of the country and the reduced risk and impact of a pandemic. In particular it was important for rural households, 80% of which have some poultry, much of which is managed with the help of children. The bulk of backyard poultry production is consumed within the household and represents an important component of the diet, and some of it is sold. Market sales are done by women, thus backyard poultry assets and income are essentially women s assets and income. 15. With the expansion of the PDO and addition of other zoonotic diseases, the project beneficiaries, in addition to the human population and poultry industry also included the livestock sector of the country. In addition, as originally intended, a range of institutions have benefitted from the project activities, including the MOH, MAWRPI, Republican Central Veterinary Laboratory, State Veterinary Department, Sanitary-Epidemiological Service, health care providers. 1.5 Original Components (as approved): 16. The project had 5 components: (i) Animal Health; (ii) Human Health; (iii) Public Awareness and Information; (iv) Implementation Support and Monitoring and Evaluation; and (v) Emergency Imports. 17. Component 1: Animal Health. This component aimed to support national prevention and control strategies to cover the country s needs in the short, medium or long term, by supporting activities for: (i) enhancing HPAI prevention and preparedness capability, (ii) strengthening of veterinary services, 3

22 disease surveillance, diagnostic capacity and applied research, and (iii) strengthening HPAI control programs and outbreak containment plans, and improving bio-security in poultry production and trade. This component aimed also to provide resources for a Compensation Fund to compensate poultry owners for the loss of assets caused by mandatory destruction (culling) of their poultry. 18. Component 2: Human Health. This component targeted the reduction of the impact of a pandemic influenza virus through: (i) year-round surveillance; (ii) effective and accurate methods of diagnosis; (iii) social distance interventions; (iv) vaccines (once they become available); (v) anti-viral drugs; and (vi) strengthened medical services. It aimed to support activities for: (i) enhancing public health program planning and coordination, (ii) strengthening of the national public health surveillance system, and (iii) strengthening health system response capacity. 19. Component 3: Public Awareness and Information. This component was designed to promote awareness and improved coordination of the execution of the national action plan for avian influenza control. It included information and communication activities to increase the attention and commitment of government, the private sector and civil society organizations and raise awareness, knowledge and understanding among the general population about the risk and potential impact of a pandemic. It aimed also to support the Republican Emergency Antiepidemic and Antiepizootic Commission in its roles of triggering emergency responses by the Ministry of Agriculture, Water Resources and Processing Industry and the Ministry of Health, monitoring the actions taken by them, coordinating public statements to the media, and executing project evaluation activities. 20. Component 4: Implementation Support and Monitoring and Evaluation. This component aimed to support costs associated with project management and coordination and monitoring and evaluation. 21. Component 5: Emergency Imports. In case of a declared influenza pandemic, this component was to finance emergency imports identified as necessary under a well-defined preparedness and response program to be prepared as part of project implementation. These imports are likely to include: (i) pharmaceuticals and vaccines, (ii) medical and veterinary supplies and equipment, (iii) communication equipment, supplies and information campaigns, (iv) food and water containers, and (v) protective gear and clothing. 1.6 Revised Components: 22. During the restructuring of May 9, 2010, the components were slightly revised and now read as follows (the changes are in italic and underlined): 23. Component 1: Animal Health supported national prevention and control strategies to cover the country s needs in the short, medium or long term. Activities supported for: (i) enhancing prevention of HPAI and other zoonoses, and preparedness capability, (ii) strengthening of veterinary services, disease surveillance, diagnostic capacity and applied research, and (iii) strengthening HPAI and other zoonoses control programs and outbreak containment plans, and improving bio-security in poultry production and trade. It provided resources for a Compensation Fund to compensate owners of poultry and other domestic animals for the loss of assets caused by mandatory culling. 24. Component 2: Human Health targeted the reduction of the impact of the virus of a pandemic influenza and other zoonoses through: (i) year-round surveillance; (ii) effective and accurate methods of diagnosis; (iii) social distance interventions; (iv) vaccines; (v) anti-viral drugs; and (vi) strengthened medical services. It supported activities for: (i) enhancing public health program planning and 4

23 coordination, (ii) strengthening of the national public health surveillance system, and (iii) strengthening health system response capacity. 25. Component 3: Public Awareness and Information was designed to promote awareness and improved coordination of the execution of the national action plan for control of Avian Influenza and other zonoses. Information and communication activities to increase the attention and commitment of government, the private sector and civil society organizations and raise awareness, knowledge and understanding among the general population about the risk and potential impact of a pandemic. It supported the Country Multi-Sectoral Coordination Committee on Socially Significant and Dangerous Diseases in its roles of triggering emergency responses by the MAWRPI and MOH, monitoring the actions taken by them, coordinating public statements to the media, and executing project evaluation activities. 26. Component 4: Implementation Support and Monitoring and Evaluation. The component description remained unchanged. 27. Component 5: Emergency Imports. In case of a declared pandemic of influenza or any other zoonoses, this component will finance emergency imports identified as necessary under a well-defined preparedness and response program to be prepared as part of project implementation. These imports are likely to include: (i) pharmaceuticals and vaccines, (ii) medical and veterinary supplies and equipment, (iii) communication equipment, supplies and information campaigns, and (iv) protective gear and clothing. 1.7 Other significant changes: 28. Closing Date extension: The Closing Date was extended once, from December 30, 2010 to December 31, 2011 in order to allow the remaining activities to be completed. 29. Re-allocation of funds: followed the government s request expressed at the projects mid-term to include other zoonoses in the project, which would allow for more efficient use of the project funds in the absence of an AI outbreak. The project achievements as of that date, in particular, in legal and institutional framework development, institutional capacity building and awareness raising mechanism development allowed for serving a bigger purpose such as addressing the other priority zoonoses with little adjustments required. This approach was fully supported by the Bank s team, in particular given the importance of livestock (sheep and cattle) for rural livelihoods. A reallocation of the Grant proceeds was carried out to accommodate the expansion of scope of the project, in order to address other prevailing veterinary emergency issues in the country while maintaining the original focus on avian influenza preparedness. Some funds from the categories Eligible imported goods and commodities, Compensation Fund, Unallocated and Operating costs were redirected to increase the Civil Works (from SDR 56,000 to SDR 100,000) and Goods (from SDR 804,000 to SDR 1,630,000) Categories. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design, and Quality at Entry: 30. The project supported the implementation of two national-level policy documents: the National Poverty Reduction Strategy (NPRS) and the Bank s Country Assistance Strategy (CAS) approved by the Bank s Board in May The NPRS emphasized the importance of placing greater 5

24 attention on public health and combating communicable diseases and on public awareness campaigns concerning key health issues. One of the 16 specific key poverty indicators for monitoring progress towards the NPRS goal was a reduction in mortality from infectious diseases. The CAS noted the critical need for effective provision of health care services and for continued efforts to promote agricultural development as a key driver of growth and poverty alleviation. The project was to support both of these objectives: by improving the country s capacity to deal with the threat of serious communicable disease for humans, and by putting in place institutional capability to prevent massive loss of poultry due to avian influenza or at least minimize its impact on the agricultural economy and the rural poor in particular. 31. The Project s design followed the GPAI framework, which indicated that an appropriate balance between short and long-term actions needed to be taken. This guidance was appropriate for the project, as the project had to address a complex issue with a diversified set of measures. The immediate objective in the short-term was to reduce the risk to humans by preventing further spread of HPAI and enhancing detection, containment and treatment. The long-term strategy was to minimize the global threat and risk of HPAI in humans and domestic poultry, through progressive control and eradication of HPAI. 32. The Project was prepared and processed as an emergency investment operation using procedures under OP8.50 Emergency Recovery Loan. The preparation of the project was thus very fast. The Concept Note meeting of December 19, 2005 was also used as the Decision meeting, and issued the authorization to Negotiate. The Negotiations took place less than a month later, on January 11, The project was approved by the Bank s Board of Directors on February 9, 2006 and became effective on July 10, 2006 (effectiveness delay resulted from in-country processing). The project was the second to be processed under the GPAI (which meant that there was more sharing of knowledge during the implementation than learning from other operations during the preparation), and the last to be approved by the Board (all subsequent AI projects were approved by RVPs in accordance with horizontal APL procedures). 33. In a context of an emergency, the lack of data and information resulted in the project being partly built on assumptions. Although outcomes were eventually attained, the Project was ambitious in a context of weak institutions and infrastructures as developing strong policies, legal framework, and human capacity building are lengthy processes, thus required an extension of the closing date, albeit only for one year. This project was also the first ever of this scale involving the Veterinary Services in the country, thus little knowledge was available at the project outset. Although Veterinary Services made a great leap forward during the project, the project duration and budget were too limited to allow for development of a sustainable veterinary services system. It was fortunate that another World Bankfinanced project (AISP) was launched in 2008 and strongly linked with this project s development objectives to ensure continuity and/or complementarities of activities. It should also be noted that some indicators, in particular those built on an assumption of an AI outbreak, later appeared not to be relevant. 34. Eligibility for EMP deferral. As an emergency operation, the project was eligible for a delay in completion and disclosure of the Environmental Management Plan (EMP) to after appraisal. The RVP agreed that completion of the EMP could be delayed, and would be disbursement condition components 1 and 2 (animal health and human health) of the project. The EMP was completed and disclosed prior to Effectiveness. 6

25 2.2 Implementation: 35. Expansion of the PDO scope to include other zoonoses and increase the efficiency of the use of project funds. The country did not experience an AI outbreak. Therefore, the mid-term review of the project activities established that although the improved preparedness with Project support has contributed to a reduced risk for Avian Influenza in the Kyrgyz Republic, there were other pressing animal and human health concerns that could be integrated with the ongoing avian influenza activities, including brucellosis, anthrax, rabies, tuberculosis, echinococcosis and others. In addition, the government was interested in the efficient use of the project funds, in particular, the allocations for compensation funds and the emergency supplies, in the absence of an AI outbreak. Technically, the expansion of the PDO scope did not require major changes. Minor adjustments in the capacity building interventions under the project including technical assistance related to epidemiology, support for the national animal disease surveillance system, and public awareness helped to address these serious problems while continuing to develop capacity to prevent Avian Influenza in the short terms, and leading to a more sustainable and systematic way for eradicating zoonoses in the future. This project, in fact, piloted a comprehensive one Health approach. 36. Focus of the project activities on AI remained highly relevant throughout the project implementation period (and continues to be today, as the Kyrgyz Republic continues to consider itself a high risk country, in particular due to its proximity to countries with occurrences of AI outbreaks). The changes in the project involved a revision to the Project s Development Objectives and project components to allow the project to encompass some of these pressing issues, yet to preserve the integrity of the original Project design related to Avian Influenza. The initial Development Objectives and project components continued to be relevant and fully in line with the main objective of the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI), even though the international attention to the risk of a pandemic influenza originating from H5N started diminishing during Expanding the scope of the Project Development Objectives, however, allowed the Project to have a wider impact on animal health issues and to incorporate other disease priorities while maintaining the original project design. 37. Implementation proceeded swiftly, although the Project started with some delay (5 months after approval), due to a late ratification of the Project documents. The emergency aspects were dealt with as a priority such as provision of equipments and consumables for SVD and SES, including laboratory, and protective gear and sampling kits for SAEPF, and were subsequently followed by midto long term actions (strategic plan, legislation development, diseases diagnostic and control programs, among others). At the project mid-term it was determined that the progress had been satisfactory. It was also decided that the project should be restructured based on the urgent need voiced by the Government to address other zoonotic disease risks of concern which were posing a risk to people and animals. The second restructuring in the second half of 2010 allowed for completion of the project activities which were disrupted and delayed due to a civil unrest, which took place in the country in Spring and Summer of The Government was highly engaged all throughout the Project implementation: both MAWRPI and MOH early appointed Component Coordinators with responsibility for project activities under their respective ministries. Effective coordination between MAWRPI and MoH was established, with good cooperation experience between the Sanitary and Epidemiological Surveillance Service and Veterinary Service. Inter-agency coordination was especially good during the functioning of an AI project inter-agency secretariat ( ). After 2008, coordination between MAWRPI and MoH was maintained to develop infectious disease communications materials. 7

26 39. The Project was managed in close cooperation with other partners, in particular the OIE, the European Union and the USAID funded STOP AI program and Bank-financed AISP project. The EU Food Security Program provided assistance for the institutional review and reform of the SVD s regional structures, together with the OIE, which provided a number of recommendations to strengthen VS in line with international standards. The STOP AI program provided many trainings supported by both the Project and AISP. The AISP supported twinning programs with parallel financing from the SDC and further work on the legislation. The initial one health work started under the AI project and the AISP served as a model for other countries during the follow-on Central Asia One Health Project. FAO activities were also monitored to avoid duplication and ensure consistency of activities. WHO recruited an international expert to help with in-country project implementation and facilitate incorporation of the fast changing global guidance to measures to treat and control HPAI and pandemic influenza. 40. Disbursement of the Compensation Fund allocation experienced delays due to absence of AI in the country. The Project was designed to primarily address an emergency situation as the country was at a very high risk of HPAI occurrence, and unprepared for the prevention and control of the disease, therefore, provision of resources for a Compensation Fund under the Component 1 (Animal Health), and Component 5 (Emergency Import) aimed at responding to exceptional situations. It was indeed impossible to predict to which extent the disease would affect the country, and the allocation for such expenses was fully justified. As in other AI projects, Kyrgyzstan allocated funds for compensation, but did not need to use them due the absence of AI in the country (a positive development). They instead piloted a compensation scheme in the frame of the brucellosis control program implemented after project restructuring. However, towards the end of the project the counterparts ran out of time to reallocate and disburse all funds prior to project closing. The remaining portion of the IDA grant (US$240,000) was returned to the World Bank. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization: 41. Design. The original results framework was very long and complex, and was set up in the PAD and ISRs. While there were only two outcome indicators, 31 intermediary results indicators were initially established in the PAD. After the first supervision mission, the intermediary results indicators were revised to drop three (related to project management) and combine most of the remaining original 28 indicators into eight in the ISR. In addition, the indicators were slightly modified during the project implementation on several instances. During the restructuring of May 2010, three new indicators were introduced under Component 1, to capture the broadened PDO, which also covered other zoonoses, in addition to AI. Overall, the M&E system and the list of key indicators (original and revised) covered the PDO adequately both in quantitative and qualitative terms. However, while these changing indicators were consistently moving towards the achievement of the PDO (and consistent with other HPAI projects), the changes to the indicators were not formally recorded through a restructuring process (except for the three indicators pertaining to other zoonoses, which were introduced during the May 2010 restructuring). 42. Implementation and Utilization. Monitoring of the indicators was spotty, and not done correctly and systematically. For instance, the three indicators introduced during the May 2010 restructuring were not tracked at all. The APIU monitoring specialist found the monitoring indicators to be vague and unclear, thus the PIU was not sure what and how to monitor and measure. Two issues need to mentioned: (i) the fact that the data for M&E were collected by the component coordinators from the MOH and Min Ag (SVD) and other involved parties, which may have made the coordination efforts of M&E even more difficult; (ii) in retrospect, the combining of the indicators starting from ISR 2 may have lead to more uncertainty on the APIU side as to what and how to monitor. It may have been easier to track the large number of more specific indicators designed at the preparation stage. However, it 8

27 should also be mentioned that given the extremely short preparation time of the project, the team may have felt that not all indicators are relevant, thus the revision done in ISR2 was, to some extent, warranted. 2.4 Safeguard and Fiduciary Compliance: 43. Overall safeguards compliance in the project was satisfactory. The EMP identified the moderate adverse environmental effects of the Animal and Human Health Components. For the Animal component, the EMP addressed zoonotic disease containment and waste management as they pertain to disposal of special waste, emissions and materials at laboratories, and training for veterinary services workers to include procedures for safe handling of AI materials, safe culling of infected and at-risk poultry and disposal of carcasses. For the Human Health component, the EMP focused on equipment, refurbishing and training for reference and regional diagnostic laboratories to include key environmental issues in zoonotic disease containment and waste management. The EMP provided mitigation plans and monitoring plans to ensure appropriate attention to environmental issues, and tracking progress or problems in their management. 44. The project activities were carried out in accordance with the EMP. No AI outbreaks were detected in the country during the implementation period. Preparatory activities to deal with an outbreak have been carried out. These include construction of 27 Bekkari holes for disposal of carcasses, training for government and private vets in proper disposal procedures, study and monitoring of migratory waterfowl, upgrading of facilities for biological agents, and provision of equipment (vehicles, PPEs, laboratory equipment) that would be used in case of an outbreak. In addition, the Republican Center for Veterinary Diagnostics (RCVD) and laboratories in Osh city and Kochkorka village were fully reequipped and staff trained to enhance their ability to cope with an AI outbreak. For human health interventions, the National Virology Laboratory (NVL) has been renovated, PPEs provided for public health outlets, and training delivered on republican, regional and rayon levels throughout the republic. 45. As part of the 2010 restructuring, the SVD made specific requests for support to upgrade the existing vaccine storage facilities adjacent to the SVD headquarters to provide sufficient cold storage capacity for the national vaccination program. The project team agreed with this proposal and requested detailed cost estimates for these additional civil works. Although the storage would provide for HPAI vaccine if deemed necessary, it was recognized that this facility would be used primarily for other animal vaccines such as anthrax, rabies, brucellosis and, as such, could only be accommodated through a restructured project. Minor environmental disturbances were expected to occur during upgrading of the vaccine storage facilities in Bishkek. The original ISDS was updated to reflect this new activity. The project s Environmental Management Plan (EMP) was also updated to include the Annex on the monitoring and mitigation measures for minor renovation works. Both the revised ISDS and EMP were disclosed in Infoshop; the updated EMP was also disclosed in country. 46. Financial Management. Financial Management arrangements of the project, including budgeting and planning, internal controls, accounting and reporting, funds flow, staffing and external audit were assessed as satisfactory throughout the project life. The project was in compliance with financial covenants of the Financing Agreement, including timely submission of the Interim Unaudited Financial Reports (IFRs) and annual audited financial statements. Final audit report is expected on time, i. e. by June 30, Procurement. The procurement performance under the project was mixed, with majority of contracts awarded according to the agreed procurement schedule and provisions, while a few packages suffered slight delays due to low capacity of the implementing agency at the beginning of the project. As 9

28 recommended by the World Bank, the implementing agency hired the qualified local procurement specialists with experience in international/national procurement. This action strengthened the implementing agency's procurement capacity and significantly improved the procurement performance of the project. The format of the Procurement Plan used for the project was very good and all necessary information easily found (planned vs. actual dates and amounts, name of contractors etc.). Several Bank s supervision missions reported that the procurement processing under the project and filing system were found to be adequate and the missions did not note any major issues. According to the Bank requirements, the contracts that were not subject to the Bank prior review had to be subject to expost review on a sample basis. By the project completion, four procurement ex-post reviews were conducted for the project. The recommendations provided by the previous ex-post review missions were properly implemented before the next ex-post review mission. Lack of adequate physical inspection under the project may be considered as lesson learned. The project was included in the Kyrgyzstan Country Portfolio Fiduciary Review; and as a part of this exercise, the goods delivered under the following three contracts were inspected by a qualified specialists during the period of end September and early October No major procurement issues were identified. The review mission rated the procurement performance for the project as satisfactory. 2.5 Post-completion Operation/Next Phase: 48. This project was processed under OP 8.50 as an emergency operation and as such at the design stage there was no specific consideration to achieve sustainability. However, by broadening the PDO to include other zoonoses and animal diseases, the project introduced sustainability aspect in this operation and ensured that activities will continue to address global pandemic threat as well as countries ability to detect, contain and treat infections in humans and animals. The initial one health work started under the projects and the AISP served as a model for other countries during the follow-on Central Asia One Health Project, which continued to create sustainable environment to control zoonoses and animal health diseases and also enhance detection, treatment and containment of zoonoses in humans. In addition, the sustainability of the project activities will be further strengthened though a new AISP II currently under preparation with funding from IFAD, which will have activities contributing towards sustainability of the project activities. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation: 49. Project objectives, design, and implementation remain highly relevant to Kyrgyzstan today. Although the country did not experience an AI outbreak, they remain highly relevant to Kyrgyzstan s neighbors and the rest of the world. HPAI is still present endemically in some countries, in particular in South and South East Asia and the pandemic threat remains. The risk of pandemic and other zoonoses that originate in livestock or wildlife and can affect humans is growing globally and especially in developing countries. Another influenza pandemic that will be more severe than the one in is expected to occur one day. Capacity to detect HPAI rapidly was the first and foremost justified objective of this project. Still other endemic zoonotic diseases of public health or economic importance, such as brucellosis, anthrax, rabies, TB, echinococcosis and others continue to burden many poor people in Kyrgyzstan. The revision of the PDO to include other zoonotic diseases was therefore relevant, and easily built on activities conducted on HPAI. 50. In coherence with GPAI guidelines, the Project was also aiming at ensuring reasonable impacts through the development of institutional and technical capacity, improved governance and communication. Although the project was prepared as an emergency project, it has been recognized that 10

29 many of the systemic reforms anticipated under the GPAI would require more long term commitments to ensure sustainability. To this end the project worked closely with the EU and the OIE to develop legal reforms and prepare the groundwork for more long term interventions under parallel and anticipated follow-on projects. As an example, the integration of the project objectives and continuation of activities to strengthen veterinary services through the AISP which was approved in April 2008 and running up to June 2013, are key ensure sustainability of the initial project impacts. The initial one health work started under the AI project and the AISP served as a model for other countries during the follow-on Central Asia One Health Project. 51. In addition, the successful restructuring introduced further sustainability of this operation and ensured that activities would continue to address the global pandemic threat as well as the country s ability to detect, contain and treat infections in humans and animals. In this way the Bank-financed project, in cooperation with the USAID and EU projects, provided the groundwork for building a more comprehensive and systemic approach for the control of zoonoses and supported through the parallel and followed-on AISP, the Central Asia One Health Project and a new AISP II currently under preparation with funding from IFAD and which has activities continuing on this basis. 3.2 Achievement of Project Development Objectives: 52. The main elements of the original PDO were to: (i) minimize the threat in the Kyrgyz Republic posed to humans and to the poultry industry by Highly Pathogenic Avian Influenza (HPAI) infection and (ii) to prepare for, control, and respond to an influenza pandemic. The main elements of the revised PDO were to: (i) minimize the threat in the Kyrgyz Republic posed by the Highly Pathogenic Avian Influenza (HPAI) infection as well as other poultry and livestock diseases and (ii) to prepare for the control and response to an influenza pandemic and other zoonotic or infectious disease emergencies in humans. 53. The primary Project outputs were: (i) support to the veterinary sector, (ii) support to the human health sector, and (iii) strategic communication. The first restructuring that was endorsed in May 2010 did not change significantly those primary outputs. Only minor adjustments of activities such as capacity building interventions and upgrading of cold storage facilities for Veterinary Services were added to address the broader scope of the Project targeting zoonotic diseases in general. 54. After restructuring (paragraph 53), the PDO was broadened from solely the HPAI threat, to include minimizing the threats, control and response to other zoonoses. To accommodate the broadened PDO, both the indicators and activities under Components 1 and 3 were modified, while Component 2 remained largely the same. The ICR considers the achievement of PDO in two stages: before restructuring and after restructuring. As to the PDO itself, both the original and revised PDO had two parts. However, the discussion on outcomes below reflects on all component activities together, as they all contributed towards achieving of both parts of the PDO. 55. The causal linkages between outputs /outcomes to the original PDO can be summarized as follows: 11

30 Original outputs (i) Veterinary sector support for HPAI control (ii) Human health sector support focused on pandemic influenza. (iii) Strategic communication. Intermediate PDO Outcomes (i) Field and laboratory detection and response capacity for HPAI in birds. (ii) Detection of HPAI in humans and response capacity of health services (iii) Awareness of all sectors of the society (State services, producers, small holders and consumers). Original PDO elements (i) HPAI threat to human and the poultry industry minimized. (ii) Readiness for potential human pandemic. 56. The causal linkages between outputs /outcomes to the revised PDO can be summarized as follows: Revised outputs (i) Veterinary sector support for poultry and livestock diseases control (ii) Human health sector support for pandemic and other infectious diseases. (iii) Strategic communication. Intermediate PDO Outcomes (i) Surveillance and control strategies, including field surveillance, and lab diagnostic developed for 6 major diseases. (ii) Detection, containment and treatment (iii) Awareness and behavior change Original PDO elements (i) HPAI threat to humans and poultry and livestock diseases minimized. (ii) Preparedness for potential human pandemic and other zoonotic or infectious disease emergencies. 57. Overall, significant outcomes have been achieved under the project, towards achievement of the revised PDO: (i) groundwork was set for development of control strategies of six major diseases: brucellosis, anthrax, rabies, tuberculosis, FMD, echinococcosis and PPR, enabling the work to be continued under AISP; (ii) as a result of equipment, procedure and staff upgrades under the project, the Republican Central Veterinary Laboratory (RCVL) achieved 100% success in diagnosing HPAI samples through a blind test organized by an OIE/FAO Reference laboratory, and continues to act as a national reference laboratory for animal health and coordinates the work for avian influenza and other diseases. The Central Virology Laboratory in SES received refurbishment, equipment, procedure and staff training upgrades to enhance testing and isolation of virus. The development of local regulations for transportation of specimens allowed to achieve 100% accuracy in the samples sent by the Kyrgyz laboratory, which allowed the Kyrgyz laboratory to achieve accreditation from WHO for virus detection; (iii) SVD was reorganized in line with the national veterinary strategy assisted by the project, and the completed OIE assessment ascertained an improved capacity for containment and control of HPAI outbreaks in poultry; (iv) a successful sheep brucellosis control program was piloted for further scale-up under AISP: brucellosis-related abortions were reported to have been reduced by 75% in sheep in the project area, and a following the pilot, a total of nine million of sheep have already been vaccinated; and (v) the comprehensive public awareness and communication campaign (training, methodical information in 80,00 copies, 423 public media broadcasts) resulted in increased awareness of population of the 12

31 diseases transmitted from animals to humans 88% of respondents in a Knowledge, Attitudes and Practices (KAP) survey confirmed that they are aware of the AI and other zoonotic disease risks. Component 1: Animal Health 58. Output: Before restructuring: The RCVL (Republican Central Veterinary Laboratory) and LVPRI (Livestock, Veterinary and Pasture Research Institute) underwent important renovation works and were equipped with modern devices, including ELISA and PCR, allowing for achieving of BSL level 2; all veterinarians were trained to detect and react in the face of HPAI suspicion including through field simulation exercises; active surveillance on wild and domestic birds in strategic areas was done annually, including two in-depth studies; contingency plans for HPAI were upgraded and adapted to regions; office equipments and protective clothing were provided where needed, at central and field levels; some 27 Bekkari holes (to dispose of dead animals) were renovated or constructed; Veterinary Services were evaluated through the OIE PVS Pathway (performance of Veterinary Services) and received support to develop a modern legal framework. 59. After restructuring: the project contributed to development of strategies for the control of 6 major diseases and provided additional training to VS including laboratory staff; the national animal information system database was further developed to include brucellosis control; the veterinary vaccine warehouse was renovated with cold storage capacity; compensation mechanisms were tested in pilot regions for brucellosis control by compensating owners of livestock infected with brucellosis in 8 pilot rayons in two oblasts. 60. Outcomes: Before restructuring: Through the assistance from the project in the form of capacity building, technical assistance, key equipment and refurbishment of premises, the VS were enabled to conduct reliable HPAI diagnosis, through appropriate field detection, sampling, shipping and laboratory diagnosis; VS identified their level of compliance with international standards, developed a 5 year strategic plan, and drafted new legal basis; as ascertained by OIE assessment, the VS were ready to react in a coordinated manner and promptly to an HPAI outbreak, while ensuring safety of people in contact with the materials at risk; the effectiveness of wild bird and domestic birds surveillance was improved through regular surveys and sampling for laboratory diagnosis, and provided assurance about absence of disease; poultry farms introduced stringent biosecurity measures through the communications plan and training of veterinarians and staff, and construction of Bekkari holes. 61. After restructuring: initial steps of brucellosis control of were implemented successfully in the pilot regions, with the abortions from brucellosis reduced by 75%; efficacy of vaccines and drugs was increased through better storage conditions (the refurbished cold storage); groundwork was provided for the further development of the six other zoonoses control programs under AISP; laboratory diagnostic capacity was further improved by access to ELISA technique, in particular for rabies and brucellosis diagnosis; national disease information system was developed, and piloted for brucellosis control program (in particular, the compensation fund and the vaccinations). Component 2: Human Health 62. No significant differences were observed in the achievement of both Outputs and Outcomes before and after the restructuring of May

32 63. Output: Ministry of Health and its affiliated institutions established outbreak command and control mechanism for HPAI and other zoonoses; Hospital for infectious diseases established three isolation rooms, but then changed policy from isolation to intensive care treatment following new global policy recommendations; hospital staff were trained in treatment guidelines; virology laboratory received equipment and training and became accredited by WHO for virus detection; priority target groups were vaccinated annually with varied coverage levels, but it is estimated that high coverage was reached at most priority target groups; sufficient quantity of drugs were obtained and stored at central level for case of outbreak and pandemic. 64. Outcomes: Public health program planning and coordination was enhanced by setting up the National Epidemic Committee, with clear lines or responsibilities and well equipped to manage outbreaks; capacity in the human health sector was improved, which can be used during HPAI and other zoonoses outbreaks: better laboratory equipment and staff skills for virus detection, surveillance, containment and control, including compliance with IHR; appropriate equipment purchased for isolation rooms/intensive care for enhanced treatment at intensive care with modern technology; these achievements also provide feedback to animal sector through strengthened coordination and command mechanism at a central level that is now able to take the lead in containment and crisis management in case of pandemic among humans. It also set the groundwork for the close coordination between the animal and human health sectors, which was further carried forward under the Central Asia One Health project. Component 3: Public Awareness and Information 65. Output: Before restructuring: This component provided MoH, MAWRPI, REAAC, RAS and APIU with technical assistance, training and goods for support of awareness and public relations on HPAI through development of a communications strategy, production and dissemination of targeted AI information materials, training courses on informational methodologies and effective coordination and collaboration between stakeholders 2. An express poll of public awareness of AI risk, which was carried out in October 2006, revealed a high general awareness of AI risks, but little understanding of disease transmission and prevention measures. These findings were used to design the communications messages. Different messages were targeted for specific audiences, e.g., public health workers, veterinarians, farmers, traders, school children. For instance, the communications strategy included leaflets for farmers on AI prepared by the Rural Advisory Services (RAS), an extension service. Overall: (i) a modular training program for government ministry and agency officials, journalists, etc., was developed and implemented through workshops on HPAI surveillance, control and monitoring; as well as crisis communication and relations with mass media (the latter with 750 participants). Materials on external communication were disseminated in the workshops, including: methodical guidelines, booklets, leaflets on AI prevention (more than 80,000 copies distributed). In all, 423 information broadcasts were carried out. 66. After restructuring: A mid-term impact evaluation of the communications strategy was carried out as a Knowledge, Attitudes and Practices (KAP) assessment. Based on the KAP survey, the communications plan was revised and further developed with inputs from the Turkey AI counterpart project team, providing a good example of South-South learning and sharing of experience. 2 An express poll of public awareness of AI risk was carried out in October 2006, with the objectives to i) provide policy makers and major institutions involved in preventing and combating AI with a general picture on public awareness of the phenomena; ii) define which sources of information are most trusted and effective; and iii) identify which channels of information could be used for transferring information in pre-pandemic and pandemic times. 14

33 Implementation of the communications plan for the priority animal diseases, which was designed under the project is continuing under AISP. 67. Outcomes: Before restructuring: The outputs from the communications component were a key element in the improved public and professional preparedness achieved under the project for AI. For example, findings from the 2006 rapid KAP survey helped to shape the content and identification of target audiences for subsequent interventions under the project regarding design of public communications messages, training materials for public health and veterinary workers and media outreach. A well working communication methodology was implemented, which after the restructuring was replicated for awareness outreach for the other priority zoonoses. 68. After restructuring: Professional and public awareness and response capacity was greatly improved for the six other priority diseases that were addressed by the project after restructuring (same communications channels/methods were used for the other diseases learning from the very positive AI communication experience). Comprehensive coverage of zoonotic diseases-related issues was achieved through setting up of an inter-agency working group with a mandate of covering the broader range of zoonotic diseases than solely AI. Effectiveness of the communications strategy was improved by its tailoring to address the most important animal diseases in different parts of the country, for example, to focus on anthrax in Osh oblast. Achievement of the Final (post-restructuring) PDO 69. HPAI did not occur in the country, but the threat of this and other six priority zoonoses has been diminished by overall better preparedness and response capacity: good planning and coordination, better and earlier diagnosis capability, and much-improved public awareness raised through a country-wide communication campaign. Overall, the project interventions have, without any doubt, helped to achieve the PDO and key outcomes. 3.3 Efficiency: 70. The economic analysis relates the project costs to the project benefits which are characterized as the economic value of the stream of losses avoided in human health and the poultry industry from project activities. The benefits are expressed as the expected value of the economic loss avoided from one outbreak occurrence in a period of 15 years ( ) for With-Project and Without Project scenarios. 71. Human health benefits expressed in terms of loss avoidance include: (i) the economic value of hospitalization costs averted, (ii) the economic value of income loss avoidance from days lost due to illness, and (iii) lifetime income loss avoidance from fatal HPAI cases. Poultry industry benefits are also expressed in terms of loss avoidance and include: (i) the economic value of poultry meat production loss avoided, (ii) the economic value of egg production loss avoidance plus the avoidance of the loss of the economic value of the layer at the end of her productive life, and (iii) the costs of government eradication and poultry replacement programs. The number of human and poultry affected in an outbreak of HPAI (Gross Attack Rates) and death rate estimates were difficult to estimate and it is difficult to get practitioners to provide estimates as they do not have good statistical data and information to base their estimates on. Nevertheless, the estimates and sensitivity analysis provided robust results. 15

34 72. The base case scenario results are robust with a 34% ERR, Benefit-Cost ratio of 2.9 and a NPV of US$8.4 million. The ERR is robust even under sensitivity analysis parameters that severely restrict the benefit streams. Also, allowing only 75% of the benefits to be claimed by the Project because of the other AI and AI related projects in Kyrgyzstan, the results remain robust with a 26% ERR, Benefit-Cost ratio of 2.2 and a NPV of US$4.7 million. The economic analysis results confirm that the project was worth undertaking from an economic standpoint and a good investment for the people of Kyrgyzstan. The Parameters used in the analysis, especially the estimates of Gross Attack Rates and death rates for both human health and poultry, are very conservative leading to lower, but still highly satisfactory rates of returns to the project. Furthermore, there is no question as to the overall benefits from HPAI projects of this kind in terms of the decrease in human suffering and deaths which alone could be said to justify such projects. 73. In the terms of the amendment to the PDO, which introduced the coverage of livestock diseases under the project, it is difficult to describe the results in quantitative terms, in particular because the work on brucellosis vaccinations, etc., was done under AISP. However, qualitatively, the project set the foundations and systems in place, to enable to AISP to move forward with the works. In particular: (i) the laboratory equipment and staff skill upgrade facilitated lab-related work on other zoonoses, not just AI; (ii) the compensation fund mechanism set under the project was allowed to identify a mechanism to pay to farmers participating in the pilot brucellosis program; and (iii) the public awareness mechanism set up for the AI project facilitated outreach on other zoonoses. 3.4 Justification of Overall Outcome Rating: Rating: Satisfactory. 74. The project followed a template under GPAI guidance and PAD for Bank projects in a number of countries to address the threat of HPAI. The project was relevant: for the Kyrgyz Republic, given the significant HPAI threat, yet the limited capacity of the country to respond to and control the threat. When the HPAI outbreak did not occur, flexibility was shown by restructuring the project to broaden the project s focus on six other zoonoses. This, objectives and design maintained their relevance throughout the project. As concluded in Section 3.2, the project successfully achieved its revised PDO: including setting the groundwork for development of control strategies of six major diseases, enabling the work to be continued under AISP; strengthening the zoonotic disease testing, detection and control capacity in the country through equipment, procedure and staff upgrades under the project, to allow two key laboratories for human and animal health to achieve international recognition; a successful livestock brucellosis control program was piloted for further scale-up under AISP, significantly (up to 75%) reducing brucellosis-related abortions; and the comprehensive public awareness and communication campaign (training, methodical information in 80,00 copies, 423 public media broadcasts) resulted in increased awareness of population of the diseases transmitted from animals to humans 88% of respondents in a KAP survey confirmed that they are aware of the AI and other zoonotic disease risks. 75. The project was efficient, as the economic analysis above shows. However, the comparison of the economic analysis in the PAD and in the ICR is difficult, since the PAD one is based on an assumption of an HPAI outbreak, whereas in the reality there was no outbreak of HPAI in the Kyrgyz Republic. Thus, the number of human and poultry affected in an outbreak of HPAI and death rate estimates were difficult to estimate, and practitioners find it difficult to provide estimates as they do not have good statistical data and information on which to base their estimates. Nevertheless, the estimates and sensitivity analysis provided robust results, and the project was considered to make economically justified investments. In addition, consideration of qualitative benefits leads to the conclusion that the project s investments were justified and that it will have long-term economic benefits. 16

35 3.5 Overarching Themes, Other Outcomes and Impacts: (a) Poverty Impacts, Gender Aspects, and Social Development 76. Poverty-related impacts of the project. Despite the reduction in poverty in recent years, poverty in the Kyrgyz Republic remains prevalent, particularly in rural areas where up to 60% of households live in poverty, including 19% in extreme poverty. As the crisis was rising in the neighboring countries, unmanaged communication increased fear among rural households and resulted in spontaneous killing and destruction of poultry in many instances, depriving those households of valuable source of food proteins. It was the coordinated communication efforts provided under the project and confidence gained in State services that helped the situation return to normality and stop the loss of backyard poultry. In addition, by including other animal diseases such as brucellosis into the project design, PDO relevance for poverty alleviation became even stronger as those diseases are mostly affecting small farmers and affecting women more than men. (b) Institutional Change/Strengthening: 77. The Government s engagement during the project was strong, although the frequent changes in the Ministers and the Chief Veterinary Officer (five CVOs were in the office during the project implementation) resulted in the need to sell the message of the project repeatedly. Nevertheless, it was successfully done by the project team on both sides, as the Government s commitment at the project closing was very strong. The request for a Veterinary Services evaluation, which was followed by an indepth gap analysis and strategic plan under the OIE auspices, as well as support missions to legislation modernization testify of the government s willingness to tackle deficiencies in the animal health sector. The Project team supported this approach and worked in close cooperation with the OIE and the EU. These steps were critical to set up the basis for longer term reforms that the currently on-going AISP project continues to support. This was necessary not only to sustain achievements of the project but also to lay the foundations for well organized, equipped, and competent Veterinary Services. 78. The Government of Kyrgyz Republic was also the initiator of the expansion of the PDO scope to address other diseases, primarily brucellosis and has continued to be strongly supportive of the One Health approach aiming at addressing health issues at the animal/human/environment interface, taking the lead in the region in promoting this approach and further developing programs, now through AISP and building on the Central Asian Regional One Health project (March Sept 2011) studies. (c) Other Unintended Outcomes and Impacts: 79. Development of a Strategic Plan for strengthening the Veterinary Services towards achieving international standards. The ultimate goal was to ensure the VS s capacity to detect, prevent, control and eradicate diseases, including zoonotic ones. The process of prioritizing animal diseases prompted SVD to request OIE/PVS engagement, which led to the strategic plan being developed with EU support. This work and other efforts started under the AI project are being further supported through the Bank-financed Agricultural Investment and Services Project (AISP), representing useful transition of resources and capacities from one project to another 80. A number of positive and unexpected impacts on the veterinary services have been observed. Increased prestige, profile and motivation of the Veterinary Services was a very positive (and unplanned) outcome, reflecting the benefit of dedicated resources and attention (this was the first externally financed project that targeted the veterinary sector). Student enrollment in the veterinary 17

36 faculty from Naryn oblast (the pilot oblast for brucellosis control), where the veterinary profession was previously disregarded, increased to the level that they make between 25% and 30% of new veterinary students. Also in Naryn oblast, the number of private veterinarians increased by 150% (from 60 to 150) since the beginning of the AIHP project, reflecting the benefit of better availability of veterinary supplies and better defined working relationships between private and public vets. 81. Addressing other zoonoses will have a positive impact on trade in Kyrgyz meat products. Some of Kyrgyz Republic s large neighbours have formed a Customs Union, which the country also plans to join. Improving the zoonoses situation in the country will provide an opportunity for the Kyrgyz producers to meet the increasing quality requirements and to supply meat products to the other members of the Customs Union and beyond. 82. Another important aspect to note is that none of the Central Asian countries have legislation enabling them to comply with international health regulations, especially for sending virus for typization to reference laboratories outside former Soviet Union. However, despite this legislation, Kyrgyz managed to establish working relations with several reference laboratories outside the country and send specimens for confirmation and typization. The legal framework is trying to catch up with these developments. The existing legislation is still under revision, but it is unlikely that it will be changed without sustained efforts. 3.6 Summary of Findings of Beneficiary Surveys: 83. Two beneficiary surveys were carried out during the project implementation, a baseline survey in 2006, and a survey in 2010 to assess the public awareness on HPAI among the country s population. The objectives of the baseline 2006 rapid survey were to (i) provide policy makers and major institutions involved in preventing and combating AI with a general picture on public awareness of the phenomena; (ii) define which sources of information are most trusted and effective; and (iii) identify which channels of information could be used for transferring information in pre pandemic and pandemic times. The questionnaire topics were awareness about AI; specific knowledge; sources or information; level of trust of the sources of information; and what sources of information were considered most effective. The key findings were as follow: (a) a majority (+90%) of the population was aware of AI, but detailed knowledge about AI and modes of transmission were lacking; (b) majority of people (87% of adults) would report sick birds and possible cases of AI to veterinarians, health workers and sanitary & epidemiological services, trust of which was rather high; (c) universally across the country, clusters and across the sampling categories, people get most information on zoonotic diseases from mass media as the most reliable and quickest source of information, including television was acknowledged as the most popular source, with radio is the second most important; and (iv) gender may have had an effect on which channels of information are more effective. For instance, people who get information from RAS workers are more likely to be men, while people who get information from NGO s are more likely to be women. 84. The second public awareness survey ("Control of Avian Influenza and pandemic preparedness and as well as public awareness of outbreaks of other zoonotic diseases in the Kyrgyz Republic ) was carried out in 2010 with some 1,200 subjects throughout all 7 provinces of Kyrgyzstan. The survey assessed the level of awareness about zoonotic diseases, social, cultural habits and hygiene associated with animal care, public awareness about safety precautions and response to the pandemic, as well as identification of the most effective channels of information dissemination. The following key findings of the 2010 survey were noteworthy: (a) farmers and traders are well aware about main zoonotic diseases, as 88% of respondents knew that animals can be a source of zoonotic diseases, among them 86% of women farmers; (b) people knew that there was a risk of human infection with zoonotic diseases - 18

37 67.4% respondents were sure that there was a high risk of infection of human with zoonotic diseases; (c) sellers of livestock and poultry products followed the hygiene rules, and understood that meat of a sick animal could cause zoonotic diseases - 44% of sellers noted that they wash hands several times a day, including 28% washed hands after serving of the each customer; (d) the level of preparedness of the population for zoonotic diseases was rather low, mostly due to the lack of awareness about the symptoms of the disease and the main actions need to be taken and required to undertake in cases of zoonotic diseases (respondents awareness of the symptoms varied between 56% and 86%, depending on the disease); and (e) the main channels through which farmers and traders receive information on zoonotic diseases, was television (32%), followed by neighbors (18%) and relatives (16%). 4. Assessment of Risk to Development Outcome Rating: Moderate 85. Risks to development outcomes vary across all components. Overall, the risk is assessed as moderate mostly due to the consideration of political volatility in the country, which may lead to instability in the institutional arrangements, attrition of skills, as well as wavering government and budgetary support to the project outcomes. At this time, the risks are low as described, the institutional set-up has been finalized and is functioning well, and the government is very supportive of the project s causes and outcomes. However, in the longer term, the uncertainty increases. One mitigating factor is the continuation of the project activities under AISP, and, in the future under an IFAD-financed project 3, with a focus on the priority zoonoses, which may further help to improve the sustainability of the systems set up under the project, thus mitigating the political instability risks. 86. In terms of Animal Health component outcome, the risk is moderate: the instability of the State Veterinary Services institutions (5 Chief Veterinary Officer appointed during the Project implementation period, and regular change of staff whose capabilities not always matched the job requirements) and uncertainty about reform decisions, may undermine the longer term impact of Project activities. However, this risk is mitigated by the fact that AISP (April June 2013) has been developed in close coordination with the Project team and will ensure a continuity of activities and build upon achievements to further strengthen the Veterinary Services. The same team is also supporting the development of the IFAD-financed project referred to in the previous paragraph. 87. In terms of Human Health component outcome, the risk is also moderate. While the systems have been set up under the project and are functioning well, further maintenance needs to be ensured, to ensure that the efficient operation of systems is ensured. For example, pandemic plans should be updated on regular basis. 88. For the Public Awareness and Information Component, the risk to development outcomes is moderate, mostly due to the uncertainly related to the need for recurrent cost support for continuation of these activities. Effectiveness of the efforts was measured in a baseline 2006 express survey "Public awareness on AI" and compared to a 2010 survey on AI awareness and other zoonotic diseases. The results from the 2010 survey showed that 88% of respondents were aware of avian influenza and other 3 An IFAD-financed project in the total amount of US$20 million is currently under preparation, with an expected start date of April, The project, for the purposes of this ICR, will focus on furthering work on two animal-health-related aspects: (i) designing the specific arrangements for the implementation of the six national priority disease strategies, and (ii) strengthening the private veterinary services in the Kyrgyz Republic. It will also further build the linkages between the pasture committees and animal health services, in particular to ensure appropriate vaccinations of the animals. 19

38 zoonotic diseases risks. At the same time, these efforts need to be kept up. For instance, the pandemic was very mild and had negative effect for awareness, so media efforts should be maintained. 5. Assessment of Bank and Borrower Performance (relating to design, implementation and outcome issues) 5.1 Bank (a) Bank Performance in Ensuring Quality at Entry: Rating: Satisfactory 89. The Bank s team built a solid case during the project preparation (although partly relying on assumptions) to allow for quick preparation and approval of the project by the Bank s Board. To ensure the full scope of the necessary expertise, the preparation mission of December 2005 was multi-sector agency mission, comprising the World Bank, World Health Organization (WHO) and the US Center for Disease Control (CDC). The Project Concept Note review meeting took place on December 19, 2005, with Appraisal in December 2005, Negotiations on January 11, 2006, and Board presentation on February 9, The successful collaboration between the ECSSD and ECCHD should also be noted the project had two Task Team Leaders, one from each sector, however, the team was able to deliver on a very tight schedule. 90. The project was relevant: situated on major migratory bird flyways and with outbreaks reported in neighboring countries (in particular, China, Kazakhstan and Russia), the Kyrgyz Republic clearly faced both a public health and an economic risk. At the same time, the public health and especially veterinary services systems had limited diagnostic and surveillance capacity to address the HPAI threat, and public awareness capacity was weak. (b) Quality of Supervision: Rating: Moderately Satisfactory 91. Overall, the project activities were implemented well, in full and on time, and achieved sustainable results. During the project implementation period, implementation support missions took place at regular intervals, about two times a year. At the same time, post-mission Aide Memoires and Management Letters were not sent in a timely manner, and the ISRs were not submitted regularly. Based on the terms of reference and statement of mission objectives, specialists from both Sustainable Development (SD) and Human Development (HD) Departments were present on missions. 92. In addition, weaknesses were identified in the project s M&E system implementation, as a number of indicators were not tracked/reported on throughout the project implementation period, and, for instance, the indicators introduced during the May 2010 were not reflected in the project s internal reporting system, not tracked. (c) Justification of Rating for Overall Bank Performance: Rating: Moderately Satisfactory 20

39 93. The rating reflects Satisfactory rating for the Quality at Entry and Moderately Satisfactory for the Quality of Supervision. 5.2 Borrower Performance (a) Government Performance: Rating: Moderately Satisfactory 94. The government was committed during the project preparation and implementation, and, in particular during the second half of the project, considered the project to be highly beneficial to the country. The proposed rating is slightly downgraded due to the frequent changes of the top key staff in the government and veterinary services, which created the need to re-establish the right footing for the project implementation several times. These frequent changes in the top officials also caused some delay in the creation of a Secretariat at the Republican Emergency Antiepidemic and Antiepizootic Commission (REAAC). However, once established the Secretariat was recognized to be pro-active in the implementation of the communications strategy. A subsequent decision of the government to transfer the Secretariat under the umbrella of the MAWRPI resulted in a lower authority and activity and ultimately its disbandment. However, the expansion of the project focus to deal with endemic priority zoonotic diseases and the overall awareness created around disease prevention and control, nurtured a growing interest. This was confirmed by a request sent by the Vice Prime Minister to the World Bank on October 2011 to pursue financing of activities in the domain of zoonotic diseases, the importance of which has been underlined through this project and the regional ECA-One Health project. An additional identified issue is the weaknesses in the M&E systems, which were functioning under both ministries. (b) Implementing Agency or Agencies Performance: Rating: Satisfactory 95. The PIU showed effectiveness and responsiveness during the entire project implementation period. This was emphasized several times in different Aide-Memoires. Staff was recruited according to the specific identified needs, which allowed for adaptation to institutional changes and addition of activities of AISP. The project was implemented smoothly, and achieved its objectives. Procurement and financial management for the project were performed well. Together with the Component Coordinators (CC) appointed in the MOH and MAWRPI and other players, the APIU ensured a good level of coordination and monitoring of activities of all components of the project. 96. One identified weakness has been the M&E system for the project. An M&E specialist for both AISP and AI projects was hired by the APIU late Unfortunately, the monitoring indicators were found to be vague and unclear to the APIU staff, who did not know what and how to monitor and measure. As a result, the PIU staff mostly focused on preparation of quarterly reports for the Ministry of Finance and for the parliament, which contained the results of the physical activities carried out under the project: what was procured, what training were done, how many people participated, etc. Information to the Bank was provided mostly during the missions and at ad hoc requests. (c) Justification of Rating for Overall Borrower Performance: Rating: Satisfactory 21

40 97. The rating is based on the Moderately Satisfactory rating for Government Performance and the Satisfactory rating for the performance of the Implementing Agencies. 6. Lessons Learned. 98. A global template and coordination with specialized agencies can enable rapid, good project design. The GPAI was in place and was used as the basis for the preparation of this project. The existence of a sound, global plan ensures that an effective project can be formulated rapidly. WHO and CDC gave technical assurance for project implementation by working together with the World Bank s implementing partners and agencies. This lesson would be applicable to a wide range of projects, not just those in the health sector. 99. Putting project activities in longer-term perspective may help improve the project s sustainability. While the initial aim of the project was to address a possible emergency situation and ensure Avian Influenza preparedness and response capacity in the country, the restructuring allowed for a broader and more comprehensive approach to addressing important animal and human health threats. This longer-term vision opened the opportunities for progressive improvements and establishment of sustainable systems, as well as starting the dialogue with other donors and programs on the support to this project s objectives (it was evidenced by the additional operations and financing that IDA, EU, IFAD and SDC contributed to further the goals of this project). In addition, broadening of the PDO beyond HPAI paved the way to addressing zoonoses in more comprehensive way and contributed to development of integrated control of animal diseases and zoonoses which later resulted in one health approach and a Regional One Health Project in Central Asia In the context of weak governance and institutions, where the capacity building may take a longer and concerted effort, it is important to have step-by-step approach, to ensure higher effectiveness and chances of sustainability of achievements. The project started off by building the legal framework and institutional capacity for addressing possible Avian Influenza emergencies. However, minor subsequent adjustments then allowed the project to easily initiate work on other priority zoonoses, which allowed for a complex approach to addressing major animal and human health threats. Further work, building on the achievements of this project, is implemented by AISP, with animal vaccinations and other more practical applications of the AI project results Timely assessment, to the extent possible, of the occurrence of a possible health threat emergency will allow for more effective utilization of the project funds. Under this project, the decision to expand the PDO was taken 18 months before the project closing. Although it may have become clear earlier in the project implementation that the compensation fund allocation would not be used to a full extent, the decision to reallocate the funds for other activities was not made until it was too close to the project closing date. Due to the shortage of time before the project closing, it was not possible to reallocate and disburse the funds prior to project closing. This portion of the IDA grant (US$240,000) was returned to the World Bank. On a more general scale, if the future projects involving compensation funds focused on establishing the compensation fund (legal, administrative, financing options, piloting, and related communications) rather than financing compensations per se, it would allow avoiding such situations altogether In addition to the long-term investments supported by the project, it is necessary to ensure financing for additional operating costs in the future (for laboratory consumables, vaccines, drugs, etc.) to guarantee operation of the equipment and systems. In absence of an operational budget the sustainability of the financed equipment is significantly diminished. It is necessary to agree on a budget allocation from the government for these purposes, or find an alternative source of financing. 22

41 103. The number of indicators should be manageable, clear and measurable. A large number of indicators was an issue with many AI projects given the complexity of issues these projects were covering and the speed with which these projects were prepared. This project had original 31 indicators, which were then combined and/or dropped to streamline the M&E system. However, this lead to a lot of confusion on the PIU side, as well as deficiencies in the M&E system and poor monitoring of results on the Bank s side. Therefore, it is suggested to design a sound M&E system, to avoid the need for (sometimes several) revisions of the indicators, causing possible confusion. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: 104. Comments were received from the Ministry of Agriculture and Melioration (MOAM), which also consolidated the comments provided by the State Veterinary Department, Kyrgyz Scientific Research Veterinary Institute, Republican Center of Veterinary Diagnostics, and Department of Disease Prevention and Expertise. Overall, the comments were supportive of the ICR conclusions, and no significant issues were raised. The MOAM comments stressed that: (i) the general preparedness and response to control avian influenza, animal diseases and zoonotics were strengthened as a result of the project by setting up effective response measures at the national and local levels including all key parties responsible for agriculture, public health etc.; (ii) the logistic, training and human capacity of the state institutions and laboratories involved into the project implementation was also strengthened; (ii) the awareness of danger and threat caused by the avian influenza and other animal diseases among population, state and private organizations was significantly increased; and (iv) an effective and reliable compensation system was piloted. The comments also noted as a very important project result the integration of avian influenza and other priority animal disease, including zoonotic disease, control. The project s impact on animal health resulted in reducing the level of human virus diseases that allows for increasing cost effectiveness and minimizing the real threat to both animal and human health. More detailed comments and the Borrower s ICR are attached in Annex 7. (b) Cofinanciers: 105. Comments were received from the Delegation of the European Union to the Kyrgyz Republic. The comments were addressed in the text of the ICR and in the separate communication sent to the EU Delegation. See Annex 8 for details. (c) Other partners and stakeholders (e.g. NGOs/private sector/civil society): Not Applicable. 23

42 ANNEXES Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Components Appraisal Estimate (USD millions) Actual/Latest Estimate (USD millions) Percentage of Appraisal Animal Health Human Health Public Awareness and Information Implementation Support and Monitoring & Evaluation Physical Contingencies Total Baseline Cost Price Contingencies Total Project Costs Front-end fee PPF Front-end fee IBRD Total Financing Required (b) Financing Source of Funds Appraisal Estimate (USD millions) Actual/Latest Estimate (USD millions) Percentage of Appraisal Borrower IDA Grant JAPAN: Ministry of Finance - PHRD Grants AHI Facility Grants (EC and 9 other donors) ,060 Total This amount includes ASSP co-financing to the project in the amount of US$ 1 million. However, after this project was approved, the financial management for the two projects was carried out separately. Therefore, the Actual represents only the direct co-financing of the Borrower, PHRD grant and the AHI Facility grants. US$1.13 million under the ASSP, were used to rehabilitate buildings of four veterinary laboratories and to procure urgently needed equipment for them, as well as to construct a number of Bekkari holes for safe carcass disposal. 5 Does not include the US$1.13 million spent under ASSP. 6 Does not include the estimated allocation of US$1 million under ASSP. 24

43 Annex 2. Outputs by Component Component 1: Animal Health Achievements under this component are rated Satisfactory. The Animal Health 5 subcomponents were: (A) enhancing HPAI prevention and preparedness capability, (B) strengthening disease surveillance, diagnostic capacity and applied research, (C) strengthening HPAI control and outbreak containment capacity, (D) improving bio-security in poultry production and (E) compensation fund. Details of output per sub-component are provided below: A) Enhancing HPAI prevention and preparedness capability A1- Strengthening the National Policy and Regulatory Environment Comprehensive National Action Plan for Avian Influenza was updated and adapted at regional level to include operational components. The plans are available at the lowest administrative level. The Project supported and endorsed the Government s request to the World Animal Health Organization (OIE) to conduct an independent evaluation of VS using the Performance of Veterinary Services (PVS) Tool; the project collaborated with the EU s Food Security Program (EUFSP) to use the PVS report as the basis for developing a 5-year strategic plan and related investments to improve VS quality according to OIE international standards. Certain key elements of the strategic plan were further supported by the Project and helped inform the preparation of the AISP which now includes important components related to VS upgrading. Missions were conducted to support the development of a new Veterinary Law, in order to modernize the legal framework in accordance with international standards and engaged reforms, such as the privatization of veterinary practice, and compensation principles. Various versions of the law were developed that were not found fully adequate. Longer term support will be needed to help the VS come up with a sound primary legislation. Secondary pieces of legislation (6) were also developed that will be ready for adoption once the Veterinary Law will have been approved. A legal framework was developed with the support of international and local experts; as the enforcement of compensation principles is linked to the overall Veterinary Law which still needs further work before being presented for adoption, compensation legal basis is still pending. However, Government endorsed a pilot compensation program to work out the implementation arrangements and determine any shortcomings prior to final ratification and scaling up country-wide. A2 Updating essential information on Migratory Birds The strategic situation of Kyrgyz Republic for migratory birds claimed for enhanced knowledge and surveillance. Two studies were conducted, at the start and at the end of the Project. They focused on wild bird resting sites, species, census, and risks to the poultry holdings. No suspicion of HPAI was found in wild birds. Strengthened surveillance including sampling for laboratory diagnosis was held in poultry flocks in areas of higher risk of contact and infection. All tests came out negative. 25

44 The State Agency on Environment and Forestry awareness was strengthened, in particular its rangers which are best placed to detect any unusual wild bird mortality. (B) Strengthening disease surveillance, diagnostic capacity and applied research B1 Strengthening veterinary and related services As mentioned above, the Project worked closely with the EU Team to identify the major gaps in VS and develop a strategic plan to strengthen these services. Specific activities were conducted in a coordinated way with the concurrent AISP project to ensure complementary actions. This included provision of training and technical assistance in the field of disease surveillance, control strategies, data management, awareness raising ; as well as necessary equipments (IT, protective equipments, adapted vehicles such as refrigerated vehicles for vaccine transportation, laboratory diagnostic equipments) and key infrastructures (laboratory renovation works, and after restructuring, storage facilities of the SVD headquarters to provide sufficient cold storage capacity for the national vaccination programs). A training plan for SVD staff was developed, and all relevant field and headquarters staff, from public and private sectors, received in-depth training on HPAI, including communication guidance. Those trainings were done in close partnership with other programs such as USAID funded STOP AI. The Project also supported participation in FAO trainings on epidemiology. Epidemiological studies and recommendations for surveillance programs and provision of essential hardware at the SVD were financed as part of the national disease information system. IT specialists designed the system and its various modules and staff was trained for its use. After restructuring, the scope of the system was broadened beyond HPAI surveillance to include other zoonotic and transboundary diseases. The system was tested along with the implementation of the pilot brucellosis control program in 2 regions. B2 Strengthening diagnostic capacity Important repair works were done in the Republican Centre for Veterinary Diagnostics (RCVD) which was raised to a BSL level 2 and was equipped with ELISA and Polymerase Chain Reaction (PCR) devices; other 2 regional laboratories in Osh and Kochkor had facilities renovated and essential equipment, consumables and reagents procured for AI basic diagnosis. Staff received in-country training, with Project as well as FAO support and for some lead specialists in foreign Reference laboratories (RCVD 100% success in diagnosing HPAI samples through a blind test organized by an OIE/FAO Reference Laboratory proved its acquired capacity to diagnose Avian Influenza in a reliable manner). This laboratory continues to act as a national reference laboratory for animal health and coordinates the work of other VS regional laboratories for Avian Influenza and other diseases. As expected, infrastructure and equipment upgrading were great value not only for HPAI diagnosis, but also for all other major diseases. The expansion of the scope of activities after the Project restructuring and the ongoing supported activities through the AISP readily benefited from these investments: diagnostic capacities for rabies, foot and mouth disease, Brucellosis, echinococcosis, anthrax and PPR have been evaluated and will be further supported through AISP. B3 Community-based animal disease surveillance and early warning The Project coordinated with the STOP AI program re train-the-trainers activities and field trainings, as well as AISP to deliver trainings to private practitioners. It included additional materials related to other diseases of concern for which the project had been restructured. B4 - Strengthening Applied Veterinary Research Capacity 26

45 The Livestock, Veterinary and Pasture Research Institute (LVPRI) underwent important repairing works, and some essential equipment, consumables and reagents were provided. This Institute is now capable to develop applied research activities. Training of staff was supported through both the Project and the AISP, in-country and in foreign Reference laboratory to perform advanced diagnostic tests. (C) Strengthening HPAI control and outbreak containment capacity C1 Targeting virus eradication at the source In addition to the development of HPAI emergency plan, field and table-top simulation exercises were conducted involving all keys actors (State and private veterinarians, central and local key administrations, as well as poultry plant employees), allowing to test the plan and learn lessons from those exercises. After restructuring, Project resources were mobilized to help control brucellosis in addition to HPAI and supported the national disease control program. Rapid effects were observed in the pilot area where brucellosis related abortions were reported to have been reduced by 75% in sheep. These excellent results will help further justify the scaling up of the control program. C2 Human safety: training for field staff, farm and lab workers Training and provision of protective equipments (for labs and field staff) aimed at preventing contamination of people in the event of HPAI outbreaks in birds. Training materials and communication tools also included basic principles of personal hygiene, food preparation and preventative measures that would help to prevent infection from some of the other diseases of concern such as anthrax and brucellosis. (D) Improving bio-security in poultry production Trainings addressed biosecurity and biosafety together with the communication strategy. As outlined above, this was done in cooperation with the STOP AI program. Poultry farms were targeted in the communication plan and veterinarians, as well as poultry farm employees were involved in trainings. Bio-security in commercial farms has been increased and all staff sensitized about risks. Smallholders awareness was also raised and few suspicions were reported to the VS, which eventually proved not to be HPAI. Disposal facilities were constructed (27 Bekkari holes) with the primary aim to collect carcasses of birds in the event of an outbreak, as planned in the procedures. Still, it was acknowledged that burying or burning carcasses on the spot would be more suitable than transporting them with the risk of spreading the virus. Regardless of their use in an HPAI event, those Bekkari holes have a public sanitary role and now serve for the disposal of other dead animals, preventing stray animals from scavenging carcasses. (E) Compensation fund In the absence of HPAI cases, compensation mechanism was piloted by compensating owners of livestock infected with brucellosis in 8 rayons of Chui and Osh Oblasts. Component 2: Human Health Achievements under this component are rated Satisfactory. The 3 sub-components of Human Health were: (A) enhancing public health program planning and coordination, (B) strengthening of the public health surveillance, system, and (C) strengthening health system response capacity. 27

46 Details of output per sub-component are provided below: (A) Enhancing Public Health Program Planning and Coordination Establishment of outbreak/pandemic national coordination body was initially done through attempts to establish a National Coordination Committee, composition and functions of which changed several times in the attempt to strengthen its functions and include multisectoral approach and response to manage pandemic situation. The existing Country Coordination Mechanism for HIV/AIDS was merged with the National Epidemic Committee but this merger did not function well in practice as it was too big. Finally, two separate Committees were established with clear mandates and functions. The National Epidemic Committee, with clear lines of responsibilities and well equipped to manage outbreaks, was established. National Pandemic Preparedness Plan was prepared in 2005 and regular revisions have been done on regular basis since. (B) Strengthening of National Public Health Surveillance Systems B1 Improvement of health information and telecommunications systems System of surveillance of influenza-like illnesses is inherited from soviet style network of reporting, with epidemiologists based in regional and central sanitary epidemiological units. The existing surveillance system, which is based on wide spread network of epidemiological stations, despite some delays in reporting, provides relatively good information on increased number of ILIs and its geographical spread. The Kyrgyz Republic developed its own software based on CDC recommendation to upgrade reporting system and gain crucial time and accuracy. Project contributed by providing hardware to enable installation and operationalization of the software which is among the first ones of such kind in Central Asia. Although it was envisaged that this system will be upgraded, in addition to providing hardware for health information system, lack of clear definition of how and what needs to be done to improve the software prevented concrete action to upgrade the existing procedures and software. It should be noted that such situation is not unusual as expertise in this field is not readily available, and has only been developed in recent years following intense efforts piloted in several countries in the region. Opportunities to improve this reporting would be: in further strengthening of the existing health information system, and introduction of this module into health information system at all levels of care. B2 - Improvement of laboratory networks The Central Virology Laboratory in SES was partly renovated and equipment and training were provided under the project to enhance testing and isolation of virus. Close collaboration was established with the Center for Disease Control and Prevention in Atlanta Georgia, WHO and other bilateral organizations in Europe. These efforts resulted in accreditation of this laboratory by WHO. During pandemic of , specimens were sent to reference laboratories for confirmation and typization. Kyrgyz Republic is the only country in Central Asia that managed to ensure transport of virus to WHO reference laboratory despite unfavorable legislation. The main focus for compliance with IHR was on approving the procedures for reporting and for sending specimens to one of WHO reference laboratories for testing. Although all countries in the region have signed IHR, several NIS countries still have legislation mostly related to defense - that bans transport of any contagious specimens to WHO reference laboratory for typization and confirmation. However, 28

47 despite this legislation and honoring IHR obligations in global fight against pandemic flu specimens were sent for testing to accredited reference laboratories. WHO-funded Global Shipment Program and support from CDC were used to transport the virus. Several staff were trained and certified in IATA procedures with support of Stop-AI project funded by USAID. Development of local regulations and guidelines for transport of specimens is essential to achieve a high level of accuracy in testing as poor transport and storage of specimens can damage biological material resulting in high number of false negative results. So far all tests were 100% accurate and therefore the Kyrgyz laboratory gained accreditation from WHO. B3 Training Training in surveillance and containment included activities aimed at enhancing the theoretical and practical knowledge and skills of sanitary and epidemiological staff. At an early stage of the project, several joint human and animal teams for outbreak containment exercises were conducted. Only later WHO and OCHRA recommended to separate table-top and field exercises for human and animal outbreaks following the logic that up to Level 3 of epidemic it is really animal disease and only at Level 4 and higher this becomes human health outbreak with little or no efforts needed from veterinary side. Although the Kyrgyz Republic has inherited strong network of sanitary and epidemiological system, inadequate funding and lack of modernization of those services is preventing full utilization of such network and timely detection and better control of outbreaks. Attempts of SES team to enhance surveillance and reporting especially using modern technology and information system should be further strengthened and supported. (C) Strengthening Health System Response Capacity C1 - Social distancing measures Activates related to social distancing measures were mostly addressed under the Communications component and under Development of the National Pandemic Preparedness Plan activity. Health education and health promotion were among the key activates that improved compliance with social distancing measures and significantly advanced the general awareness of population for protection against flu. C2 - Vaccination for priority target groups Priority target groups for vaccination with seasonal flu were identified already at the beginning of the project. Priority target groups for vaccination followed WHO guidelines and recommendations. The main reason for vaccination with seasonal flu was to prevent genetic re-assortment of avian and seasonal flu in the same person which could result in development of strain that is transmissible human to human. The annual vaccination coverage varied but it is estimated that high coverage was reached at most priority target groups, with only exception of small farmers and poultry workers in remote areas. C3 - Drug therapy Some 1500 doses of Tamiflu were purchased under the project and stockpiled in the main hospital for infectious diseases. During the H1N1virus pandemic, the stock was depleted. Tamiflu became widely available in pharmacies throughout the country and strategic reserve of this drug is no longer stockpiled. C4 Medical services As per WHO recommendations, three isolation rooms were rehabilitated and adopted in the Clinic for Infectious Disease in Bishkek. However, since AI patients, as well as other severe pandemic flu cases need intensive care instead of isolation rooms, practical use of these isolation rooms is limited. All equipment was, therefore, transferred to intensive care. At the same time, much attention was paid to strengthen intra-hospital infection control for the isolation rooms rather than for intensive care facilities. 29

48 Despite the fact that project followed guidelines from WHO, in practice these guidelines proved unusable and example of transferring equipment from isolation rooms to intensive care presents a good example of adaptation to what is practical. It should also be mentioned that the country participated in a GDLN session organized by the World Bank that focused on clinical preparedness case treatment. Further several seminars were organized to enhance clinical skills of infectious disease specialists and specialists of intensive care for treatment of AI patients. Component 3: Public Awareness and Information Component Achievements under this component are rated Satisfactory. The Component had two sub-components: (a) capacity building; and (b) information and communication services. (A) Capacity Building There were no specific separate capacity building activities, capacity was built as part of the development of communication systems and materials. This component was designed to promote awareness and improved coordination of the execution of the contingency plans and the National AI strategy. Support was provided for information and communication activities to increase the attention and commitment of government, 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. Main activities included: a) development of a detailed Communication Action Plan; b) preparation and deployment of basic pre-pandemic communication materials; c) development and testing of messages and materials to be used in the event of a pandemic or emerging infectious disease outbreak; d) training of veterinary staff and health workers in implementing their responsibilities under the Communication Action Plan; e) measures to support effective coordination and collaboration among stakeholders; and f) in the event of a pandemic, funding for the immediate implementation of relevant parts of the Communication Action Plan. (B) Information and Communication Services B1 Communication preparedness A Communication Strategy was developed in 2006 with the help of an international consultant, approved by the World Bank and adopted for implementation. Rapid research was conducted on Public Awareness of AI. A modular training program was developed and implemented through workshops on HPAI surveillance, control and monitoring; for journalists on AI awareness; and for journalists and opinion leaders from relevant ministries and agencies on crisis communication and relations with mass media (the latter with 750 participants). Materials on external communication were disseminated in the workshops, including: methodical guidelines, booklets, leaflets on AI prevention (more than 80,000 copies distributed). In all, 423 information broadcasts were carried out including 80 TV spots, 43 publications by information agencies, 262 radio broadcasts and 98 newspaper articles. Two Open Days for the Kyrgyz mass media journalists were held in the State Veterinary Department and State Agency on Environmental Protection and Forestry, covering the activities carried out in these agencies to control and prevent AI and pandemic. 30

49 The Communication Strategy on AI and other zoonotic diseases was revised and refined in May 2009 with the help of a Turkish communications specialist. In 2010, three types of booklets and billboards, and five types of posters on zoonotic diseases, personal hygiene and quarantine regulations were prepared in Russian and Kyrgyz. 45 thousand copies of the posters and 120 thousand copies of booklets were transferred to SVD and DSSES for dissemination to farmers and health care facilities. Other outputs included: - Films and spots translated and broadcast on National TV. - Research on population s awareness of the diseases transmitted from animals to human. The results revealed that 88% of respondents are aware of AI and other zoonotic diseases risks. The outcomes of research were used for information and educational campaign on zoonotic diseases in Two dozen publications were issued ( Agrovesti, MSN, Vecherny Bishkek, Bazar Tamyry newspapers) and internet resources were dedicated to AI issues. From the beginning of the project the overall level of awareness and community preparedness for avian influenza increased with risk reduced. With restructuring, the project became engaged with other disease priorities. Communication activities developed under the AI project continue to be implemented by the APIU under the AISP. B2 Collaboration with stakeholders The major stakeholders include various ministries/departments (Economy and Finance, Agriculture, Health, Education, Transport and Communications, Veterinary Services, laboratories), NGOs, civil society, veterinarians and farmer involvement at the grass root level). In 2006, an inter-agency Secretariat on coordination, monitoring and evaluation of the National HPAI Response Plan was established under the Republican Emergency Anti-epidemic and Anti-epizootic Commission. Because of the Project restructuring, in early 2009 the coordination Secretariat was disbanded 7. From that point on, coordination efforts for AI and other zoonotic diseases were managed by MAWRPI, primarily through a working group comprising SVD and MoH. Through the work of the Secretariat up to 2010, analysis of health and veterinary legislation was provided with respect to prevention of especially dangerous infections including AI, and amendments were introduced into a number of normative documents. A plan for interaction between the public, private, international structures and civil society was prepared to ensure preparedness and operative response in case of occurrence and spread of AI. 7 When after the project restructuring the project started focusing on other zoonoses, the Government made a decision to disband the Secretariat, which was focusing solely on AI. An inter-agency working group was set up to continue the work on AI and other zoonoses, but with much less authority and visibility. In general, the focus then shifted more to AISP, which concentrated on brucellosis, anthrax and other zoonoses. 31