IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA IDA-H2330 TF TF-58241) ON A CREDIT IN THE AMOUNT OF SDR 2.

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank Report No: ICR IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA IDA-H2330 TF TF-58241) ON A CREDIT IN THE AMOUNT OF SDR 2.8 MILLION (US$4.0 MILLION EQUIVALENT) AND A GRANT IN THE AMOUNT OF SDR 2.8 MILLION (US$4.0 MILLION EQUIVALENT) TO THE REPUBLIC OF MOLDOVA FOR A AVIAN INLFUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (AIHP) PROJECT AS PART OF THE GLOBAL PROGRAM FOR AVIAN INFLUENZA (GPAI) November 11, 2011 Ukraine, Belarus and Moldova Country Unit Sustainable Development Department Europe and Central Asia Region

2 CURRENCY EQUIVALENTS (Exchange Rate Effective November 1, 2011) Currency Units = MDL, USD MDL 1.00 = US$ US$1.00 = FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS AI APL CAPMU CDC EC ECA EU FAO FM GDP GPAI HPAI H1N1 KAP IDA ICU ISR IT MAFI MDL MOH OECD PHRD POM QAG QER RCVD RISP SANCO SARS S I L SOPs Avian Influenza Adaptable Program Loan Consolidated Agricultural Project Management Unit Center for Disease Control European Commission Europe & Central Asia Region European Union Food and Agriculture Organization Financial Management Gross Domestic Product Global Program for Avian Influenza and Human Pandemic Preparedness and Response Highly Pathogenic Avian Influenza (H5N1) Influenza A Virus Knowledge-Attitudes-Practices International Development Association Intensive Care Unit Implementation Status and Results Information Technologies Ministry of Agriculture and Food Industry Moldovan Leu Ministry of Health Organization for Economic Cooperation and Development Policy & Human Resources Development Project Operations Manual Quality Assurance Group Quality Enhancement Review Republican Center of Veterinary Diagnosis Rural Investment and Services Project European Commission Health & Consumer Protection Directorate-General Severe Acute Respiratory Syndrome Standard Investment Loan Standard Operating Procedures ii

3 TACIS UNDP UNICEF USAID WHO Technical Assistance for Commonwealth of Independent States United Nations Development Program United Nations Children s Fund United States Agency for International Development World Health Organization Vice President: Philippe H. Le Houerou Country Director: Martin Raiser Sector Manager: Dina Umali-Deininger Project Team Leader: Anatol Gobjila ICR Team Leader: Anatol Gobjila ICR Primary Author: Daniel P. Gerber iii

4 MOLDOVA Avian Influenza Control and Human Pandemic Preparedness and Response (AIHP) Project as Part of the Global Program for Avian Influenza (GPAI) CONTENTS Data Sheet A. Basic Information... v B. Key Dates... v C. Ratings Summary... vi D. Sector and Theme Codes... vi E. Bank Staff... vii F. Results Framework Analysis... vii 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 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 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 MAP iv

5 MOLDOVA Avian Influenza Control and Human Pandemic Preparedness and Response (AIHP) Project as Part of the Global Program for Avian Influenza (GPAI) A. Basic Information DATA SHEET Country: Moldova Project Name: Avian Influenza Control & Human Pandemic Preparedness & Response Project Project ID: P L/C/TF Number(s): IDA-41880,IDA- H2330,TF-56630,TF ICR Date: 11/14/2011 ICR Type: Core ICR Lending Instrument: ERL Borrower: REPUBLIC OF MOLDOVA Original Total Commitment: XDR 5.60M Disbursed Amount: XDR 5.60M Revised Amount: XDR 5.60M Environmental Category: B Implementing Agencies: Ministry of Agriculture & Food Industry Ministry of Health Co-financiers and Other External Partners: United Nations Development Programme (UNDP) US Agency for International Development (USAID) World Health Organization (WHO) Government of Japan European Commission (EC) United Nations International Children s Education Fund (UNICEF) B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 03/23/2006 Effectiveness: 09/12/ /12/2006 Appraisal: 04/19/2006 Restructuring(s): 04/20/ /08/ /30/2011 Approval: 06/09/2006 Mid-term Review: 05/01/ /15/2008 Closing: 12/31/ /15/2011 v

6 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Satisfactory Moderate Satisfactory Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Satisfactory Overall Bank Overall Borrower Satisfactory Performance: Performance: Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation Performance Potential Problem Project at any time (Yes/No): Yes Problem Project at any time No (Yes/No): DO rating before Closing/Inactive status: D. Sector and Theme Codes Satisfactory Indicators Sector Code (as % of total Bank financing) QAG Assessments (if any) Quality at Entry (QEA): Quality of Supervision (QSA): Original None None Rating Agricultural extension and research Animal production 3 3 General public administration sector Health Other social services 3 3 Actual Theme Code (as % of total Bank financing) Health system performance Other communicable diseases Participation and civic engagement Pollution management and environmental health Rural services and infrastructure vi

7 E. Bank Staff Positions At ICR At Approval Vice President: Philippe H. Le Houerou Shigeo Katsu Country Director: Martin Raiser Paul G. Bermingham Sector Manager: Dina Umali-Deininger Benoit Paul Blarel Project Team Leader: Anatol Gobjila Anatol Gobjila ICR Team Leader: ICR Primary Author: Anatol Gobjila Daniel P. Gerber F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The overall objective of the Project is to minimize the threat posed to humans by Highly Pathogenic Avian Influenza (HPAI) and other infectious diseases that originate in animals. Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s) Indicator Indicator 1 : Value quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) vii Formally Revised Target Values Actual Value Achieved at Completion or Target Years A Moldovan Government laboratory identifies the presence of HPAI in case of an outbreak of HPAI among poultry. Within 48 hours of sample collection, Capacity for Zero diagnosis capacity. with 95% diagnosis exists. confidence. Date achieved 05/03/ /31/ /12/2010 Comments (incl. % Diagnosis capacity and speed tested as part of simulations achievement) The Government culls birds at the infection point and establishes a protection zone, Indicator 2 : with participation of local governments and the population in case of an outbreak of HPAI among poultry. Three comprehensive simulations were A real or simulated Value One national simulation successfully carried outbreak is fully quantitative or exercise has been completed out by Moldovan contained within 72 Qualitative) revealing partial readiness. authorities to test hours. preparedness and response capacity. Date achieved 05/03/ /31/ /01/2010 Comments (incl. % Substantially achieved.

8 achievement) Indicator 3 : Value quantitative or Qualitative) The Government compensates small farmers for culled birds in case of an outbreak of HPAI among poultry. Functionality of the compensation system Farmers are was fully tested No compensation compensated within during all three mechanism in place. 10 days after simulation exercises containment. and farmers can be compensated within 10 days. Date achieved 05/30/ /31/ /01/2010 Comments (incl. % achievement) Achieved. Indicator 4 : A Moldovan Government laboratory identifies the presence of HPAI in case of an outbreak of HPAI among people. Within 48 hours of Value Within 48 hours of sample collection quantitative or Zero capacity. sample collection with 95% Qualitative) with 95% confidence. confidence. Date achieved 05/30/ /31/ /01/2010 Comments (incl. % achievement) Achieved. Indicator 5 : Patients are transported safely and hospitalized in protected rooms in case of pandemic of HPAI among people. Value quantitative or Qualitative) Zero capacity. 100% of projected capacity for transportation and hospitalization is in place. 100% of projected capacity for transportation and hospitalization is in place. Date achieved 05/30/ /31/ /01/2010 Comments (incl. % Performance tested during H1N1 influenza outbreak. Achieved. achievement) Indicator 6 : Patient receives treatment appropriate to HPAI infection in case of pandemic of HPAI among people. 100% of projected 100% of projected Value capacity for care capacity for care and quantitative or Limited capacity. and medicated medicated treatment Qualitative) treatment is in place. is in place. Date achieved 05/30/ /31/ /01/2010 Comments (incl. % achievement) The events related to the H1N1 pandemic indicate that the project contributed to enhanced preparedness for patient treatment. viii

9 (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) ix Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : Health facilities constructed, renovated and/or equipped. Value (quantitative or Qualitative) Date achieved 05/30/ /31/ /01/2010 Comments Fully met. Construction and refurbishment of two facilities was fully completed. Both (incl. % facilities are now operational. achievement) Indicator 2 : Health personnel receiving training. Value (quantitative Nobody trained or Qualitative) Date achieved 05/30/ /31/ /01/2010 Comments (incl. % 500 key staff in both ministries trained. achievement) Indicator 3 : Detailed and operational response plan delivered, simulation exercises conducted. Value (quantitative or Qualitative) Zero plans, 1 simulation. 3 simulation exercises. 3 full simulation exercises on animal health response undertaken. Two full table-top exercises on human health response have taken place. Date achieved 05/30/ /31/ /01/2010 Comments All-together 5 simulation exercises undertaken, fully met - health system response (incl. % tested with H1N1 outbreak. achievement) A compensation fund with total funding of at least US$1.5 million (coverage of 3.5% of Indicator 4 : the poultry on household farms) is established, has legal status, and is functional to pay out legitimate claims. Value (quantitative or Qualitative) No fund exists. A fully functional and adequately funded compensation mechanism is in place. A fully functional and adequately funded compensation mechanism is in place. Date achieved 05/30/ /31/ /01/2010 Comments (incl. % The compensation fund mechanism has been tested as part of the simulation exercises. achievement) Indicator 5 : National public awareness and information campaign is conducted.

10 Value (quantitative or Qualitative) 15% of the activities under a communication plan have been delivered. Continuous. x A very effective awareness and communications program was implemented for three years by UNICEF. Date achieved 05/30/ /31/ /01/2010 Comments (incl. % achievement) Awareness and communications activities were implemented through respective component activities. Fully delivered with raised awareness for communication by all government stakeholders. Equipment for testing animals for HPAI delivered and personnel trained. Personnel Indicator 6 : have used laboratory equipment and results have been validated by an independent laboratory. Value (quantitative or Qualitative) None delivered or trained. Surveillance and diagnosis capacity fully in place. Equipment was delivered and installed in three refurbished laboratories. Personnel trained by foreign specialists and laboratories are now fully functional. Date achieved 05/30/ /31/ /01/2010 Comments Capacity building and training for laboratory continues as part of ongoing EU (incl. % engagement. achievement) Protective clothing, medicines, testing materials, etc., are delivered. Personnel are Indicator 7 : trained in the use of protective clothing, etc. Simulation exercises are successful. Value (quantitative or Qualitative) Limited delivery and training. All containment systems operational. All containment systems are operational. Equipment and materials have been procured and training on their use delivered. Response capacity was tested successfully in a series of simulation exercises. Date achieved 05/30/ /31/ /01/2009 Comments (incl. % Substantially delivered and achieved. achievement) Equipment for testing people for HPAI delivered and personnel trained. Personnel have Indicator 8 : used laboratory equipment and results have been validated by an independent laboratory. Value None delivered, no staff Diagnosis capacity Diagnosis capacity

11 (quantitative or Qualitative) trained. fully in place. fully in place. Laboratory personnel received training and the laboratories are fully functional. Date achieved 05/30/ /31/ /01/2009 Comments (incl. % achievement) Indicator 9 : Value (quantitative or Qualitative) Rechecking of samples at London WHO reference lab has shown 98% accuracy of tests. Substantially achieved. Equipment for the isolation intensive care room delivered to and installed in Toma Ciorba Hospital, Personnel trained. No equipment delivered, no staff trained. All systems for care and treatment are operational. xi All systems for care and treatment are operational. The ICU was commissioned and is now functional. Training of staff completed. Date achieved 05/30/ /31/ /01/2009 Comments (incl. % Capacity building and training for hospitals continues. achievement) G. Ratings of Project Performance in ISRs No. Date ISR Actual Disbursements DO IP Archived (USD millions) 1 12/11/2006 Satisfactory Satisfactory /20/2007 Satisfactory Satisfactory /06/2008 Satisfactory Moderately Satisfactory /23/2008 Satisfactory Moderately Satisfactory /04/2009 Satisfactory Satisfactory /30/2009 Satisfactory Satisfactory /15/2010 Satisfactory Satisfactory /04/2011 Satisfactory Satisfactory 7.23 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in USD millions 04/20/2010 N S S /08/2011 N S S 7.43 Reason for Restructuring & Key Changes Made Reallocation of resources for compensation fund towards further investments in animal and human health in line with PDO Reallocation of resources from the compensation fund category towards further investments in

12 Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in USD millions Reason for Restructuring & Key Changes Made animal and human health in line with PDO. 03/30/2011 S S 7.91 Closing date extension. I. Disbursement Profile xii

13 1. Project Context, Development Objectives and Design This was one of a series of projects prepared under the GPAI to improve country readiness for a possible AI pandemic in Moldova. 1.1 Context at Appraisal At the time of project preparation, Moldova remained one of the poorest countries in ECA with over half of its population living in rural areas. Agriculture played an important role in Moldova s economy with over four-fifths of its territory designated as agricultural land. In 2005, the sector contributed about a third of the GDP and employed some 40 percent of the population of 4.3 million people. The sector declined markedly following the loss of Soviet markets and the breakdown of the agricultural input supply system. Most rural households own small numbers of livestock held under relatively poor husbandry practices that provide immediate cash for pressing needs as well as animal protein. Moldova had no recorded outbreaks of HPAI (H5N1). However, cases of AI were reported in neighboring Romania and Ukraine, and risks were estimated to be elevated for most of Southeastern Europe. The risk of an H5N1 outbreak among poultry in Moldova was expected from contact of domestic birds with migrating waterfowl and/or the growing cross-border trade. The poultry sector in Moldova represented about 80 percent of all livestock at roughly 18 million heads, with significant seasonal variations. Poultry meat was a nutrition staple in rural areas where poverty incidence was high. Fourteen million birds were held by households (backyard poultry) and small commercial farmers characterized by unsafe bio-management practices, such as maintenance of multiple species in confined space and free-range roaming. The country s commercial poultry industry was dominated by 5 large commercial producers who maintained adequate bio-safety standards. The national veterinary system had undergone reforms with the aim of eventually reaching the animal health and food safety requirements for export of livestock and meat and dairy products to the EU. The adoption of a new Veterinary Law promoting private sector provision of veterinary services was going to move 2,500 veterinarians in public service to private practice. The new law mandated the National Agency for Sanitary Veterinary Service and Safety of Animal Origin Products to administer the public system, including the RCVD and its two satellite laboratories. EC funds had helped with rehabilitation of infrastructure and provision of equipment to establish minimal capacity at the RCVD. Nevertheless, assessment by the World Bank found that laboratory testing capacity and training in disease control and field services remained weak relative to European standards. The Ministry of Health was responsible for health care planning and regulation. However, most health care providers had been decentralized and made directly accountable to their rayon (local) administration. Each rayon health authority was led by a chief doctor, and was composed of primary and secondary providers. The public health system had been slowly improving, and financing of health care had increased to reach 4.7 percent of GDP in 2005, however per capita spending of US$25 remained very low. The Government had been focused on retraining 1

14 primary care doctors and equipment in health centers and had achieved good geographical coverage of primary care. As in the animal health sector, few resources had been invested in healthcare technology and most equipment and facilities were in urgent need of upgrading and replacement. The Government of Moldova had organized emergency teams, at both the local and national levels, to respond to possible outbreaks of Avian Influenza. Importantly, the Government of Moldova designed and enacted a National Contingency Plan for Avian Influenza, a National Preparedness Plan for Human Influenza Pandemic and a Republican Action Program on Avian Flu Prophylaxis on the Territory of Moldova that were in line with recommendations of the World Organization for Animal Health, FAO, and the WHO. Nevertheless, the Bank recommended further strengthening of the plans. The EU TACIS Program in Moldova provided support for such strengthening on the animal health side, within a dedicated activity under its Project for the Development of Animal Health and Food Safety Systems for the Control of Major Epizooties. It was also determined that Moldova met the eligibility criteria for financing under the GPAI as a country at risk with no outbreak, with Government commitment and appropriate plans for early detection and rapid response, including appropriate implementation and monitoring arrangements that international agencies and the donor community, including the Bank, could support. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The overall objective of the Project was to minimize the threat posed to humans by Highly Pathogenic Avian Influenza and other infectious diseases that originate in animals. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification The PDO was not revised, and the changes in reallocation of funds between the various activities that were made did not affect the PDO or its outcomes. 1.4 Main Beneficiaries The primary but indirect Project beneficiaries were farmers, poultry holders and citizens of Moldova. Project resources were intended primarily to help build institutional capacity to identify, manage and mitigate avian influenza outbreaks and pandemic situations, and support farmers whose poultry has been affected. The primary beneficiary institutions in the animal health sector were: the Ministry of Agriculture and Food Industry, the National Agency for Sanitary Veterinary Services and Safety of Animal Origin Products, and the Republican Center of Veterinary Diagnosis and its two satellite laboratories. The assistance consisted of TA, formulation of procedures and processes (including SOPs for each institution), staff training, and substantial rehabilitation and modernization of facilities, including equipment, consumable, vehicles, etc. 2

15 In the human health sector, the Ministry of Health had the primary coordination responsibility and was the primary beneficiary institution. However Moldova has a decentralized health care system whereby healthcare staff is subordinated to the rayon administration which benefited from connection and training as part of the installation of an IT based health information system. Each rayon health authority, led by a chief doctor, is composed of primary and secondary providers. Support consisted of training, the development of an effective patient and disease registry (IT health information system) with computer access at municipal level to monitor the evolution of any epidemic outbreak, rehabilitation and modernization of hospital and laboratory buildings, introduction of SOPs, enhancement of medicine reserves and support to measures aimed at limiting contagion in the case of outbreak. 1.5 Original Components (as approved) Component 1: Animal Health (US$3.6 million, of which US$2.85 million IDA). The component did not include activities related to backyard poultry restructuring, due to lack of identified funding. The Government expressed interest in implementing such activities if additional funding were to become available. Sub-component 1.A: Animal disease surveillance & diagnostics. The sub-component was to strengthen the RCVD and its two regional satellite laboratories. The key investments were to focus on essential equipment for testing for the presence o f HPAI in animals, for consumables and reagents. Technical assistance focused on building human resources in the use of database programs and in the analysis of data to support decisions on prevention and control of animal diseases. To develop an efficient disease information system, the sub-component aimed to support training on collection and analysis of epidemiological data and on risk assessments. Project was to support technical assistance to build institutional capacity for serology and virology tests for the disease. These technical assistance and training activities were to be financed largely with proceeds of the Japanese PHRD Grant (US$250,000). Sub-component 1.B: Animal HPAI control and outbreak containment. This sub-component aimed to support actions to contain any outbreak of HPAI, starting with culling of infected and at-risk poultry and then moving to disposal of their carcasses in a bio-secure and environmentally acceptable manner. Moreover, the sub-component promoted bio-security at commercial poultry farms and investments in control of movement of birds and products that may have been infected. The sub-component was to train and equip staff and external workers, and deliver personal protective clothing. In addition, it was to support technical assistance to review, assess, and if necessary recommend improvements in the Government s contingency plans for HPAI preparedness and response. Sub-component l.c: Compensation Fund. The purpose of the Fund was to encourage farmers to report possible outbreaks of Avian Influenza. In the absence of a Fund, experience shows that households will not report sick poultry because of the potential loss from culling. There are further reasons not to report: small farmers don t want to cause their neighbors to lose poultry to culling and want to avoid damaging the commercial reputation of their town and of their poultry industry. The activities of the Public Awareness and Information component did help address farmers concerns in those aspects. To respond quickly, the Fund should have had enough cash available to reimburse a substantial part of the production cost of several isolated outbreaks of AI. 3

16 To dissuade smuggling of poultry from areas not affected by HPAI, the Compensation Fund was set to refund only 75% of the assessed market value, as recommended by FAO at the time. The Bank suggested that MAFI the Compensation Fund, with assistance from CAPMU. Under the proposed arrangement, a local Extraordinary Anti-Epidemic Commission, organized by the Ministry s State Veterinary Inspectorate, was to value the loss of culled birds at each farm, sign a declaration of loss, and issue a receipt to the farmer. The CAPMU was to validate declarations of losses and pay Primarias (local mayoralties), who would in turn settle with farmers. Detailed operational and financial management arrangements for operating the Compensation Fund were prescribed in the POM. Component 2: Human Health (US$3.7 million, of which US$2.95 million IDA). The stock of medical equipment and facilities has deteriorated over past decades because of lack of spending on rehabilitation and investment. The focus of the component was therefore on procurement and training in use of key equipment and selective rehabilitation of hospital and laboratory facilities. Sub-component 2.A: Human health capacity building. The sub-component set out to bring technical assistance and train government staff in epidemiology at the national and rayon level. It also focused on procuring epidemiological surveillance software and train staff in its use. Importantly, it supported training in crisis preparedness and management. Moreover, it supported assessment & planning, and training in information and telecom systems. Finally, the subcomponent supported reviews and updates of the regulatory systems and development of guides for use of personal preparedness equipment. Training and capacity building activities were financed through the proceeds of the Japanese PHRD Grant (US$100,000). Sub-component 2.B: Human HPAI testing. The Ministry of Health did not have the technical capacity to test for the presence of HPAI in humans. Therefore, this sub-component financed key testing equipment for the National Laboratory for Viral Respiratory Diseases, which is the only viral laboratory in Moldova. The lab s personnel had a good quality professional background and were expected to learn to use new equipment quickly. Sub-component 2.C: Human health system response. When preventive health measures fail, patients are to be hospitalized in isolation rooms. The sub-component procured equipment for the intensive care unit(s) of designated hospitals. Furthermore, the sub-component purchased WHO accredited influenza kits (including vaccines) and purchased antiviral drugs such as Oseltamvir (Tamiflu) to boost national stockpiles. Component 3: Public Information and Awareness. (US$1.30 of which US$0.45 IDA). Institutional capacity building and training needs were to be covered from the Japanese PHRD Grant (US$150,000).The component was set to implement a three-stage strategic communication plan: i) A pre-epidemic campaign to promote health and safe behaviors to reduce risks to children, families, households and communities; and to promote responsible media reporting to avoid panic and misinformation. ii) An intensive communication campaign during the pandemic alert, to begin immediately if and when human transmission is confirmed. iii) Post epidemic communication support to promote recovery. 4

17 Component 4: Implementation support and monitoring & evaluation. (US$0.55 million, fully financed by IDA). This component set out to provide technical and financial support for project management, implementation, and monitoring and evaluation. In order to increase Government ownership and ensure sustainability after the closing date o f the Project, measures were to be taken to build capacity of the Implementation Agencies to implement the proposed Project. Therefore, the component provided support for strengthening implementation and monitoring capacity of MAFI and MOH by financing technical assistance, including auditing services, and incremental operating costs and monitoring and evaluation activities. In addition, this component funded training in project monitoring and evaluation at all administrative levels, and development of an action plan for monitoring & evaluations. It conducted baseline studies, ongoing participatory monitoring and evaluations, and a final project evaluation. Project evaluation included both quantitative and qualitative aspects and was conducted on a yearly basis. Specific surveys were conducted to obtain data for this purpose. Almost US$1.50 million were kept unallocated in light of the uncertainty of outbreaks and the difficulties that may have arisen during the implementation of the Project. This is particularly true for rehabilitation of older facilities that are often accompanied with cost overruns due to unknowns. 1.6 Revised Components The Components have substantially remained as designed under the Project. 1.7 Other significant changes The Project components were substantially implemented as designed. However, Project restructuring reallocated the proceeds earmarked for the compensation fund and the unallocated resources towards other activities in human and animal health in line with the overall Project objectives. As a project expected to address a potential emergency, the closing date had been very ambitiously defined as December 31, This date was extended twice and the Project effectively closed May 15, 2011, 16.5 months after the original date. Component 1: Animal health In order to get a better handle of the overall poultry stock and improve the geographical disease tracking, the Project had envisaged a poultry registration system. Later during Project implementation however, the conclusion was reached that it would be more effective, and ultimately also more in line with EU requirements, to add a separate module in the current livestock registration system to include poultry. It is worthwhile noting that poultry in the EU or OECD countries is not registered at the level of the individual animal but at the level of the agricultural household as a poultry holder. As with most other AI projects in the region, in Moldova too, the resources allocated to the compensation fund were reallocated towards further equipping laboratories and health and veterinary facilities with logistical equipment to transport animals, samples and patients suspected of infection as well as upgrading waste management technologies including incinerators and proper safe waste containers and disposal procedures. 5

18 Component 2: Human health In addition to the usual strengthening of laboratory and hospital capacities, the human health component in Moldova also served as the primary vehicle to help improve the country s health information system, linking up primary health care facilities and primary care providers at district level and the Central Epidemiological Services. The ready availability of consolidated disease data provides the basis to improve the degree of responsiveness by which the health sector overall can track the evolution not only of epidemic outbreaks, but also all disease trends affecting the population throughout the country. This is a crucial element in improving health care services and targeting of public health resources and improving responsiveness to emerging epidemic threats. Component 3: Public Information and Awareness the Public Information and Awareness activities were to a large part were sourced out to UNICEF. Such a partnership proved to be very effective in a number of AI projects in ECA. The focus has been to inform the public, reaching its various segments, about the threats posed by HPAI to human and animal health, and how to mitigate these threats. In addition, a significant focus was placed on training the media and government officials on managing information dissemination to the public in an effective and transparent way, without creating a sense of fear and panic that could further aggravate an epidemic or pandemic situation. Component 4: Implementation Support and Monitoring &Evaluation the management of the Project had been entrusted to an experienced PMU with an established track record and experience in coordinating management of Bank projects and with proven fiduciary capacities. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry The design of the Project was based on the approach developed as part of the Bank s GPAI in ECA which focused on strengthening veterinary services and improving their capacity to handle epizootic outbreaks, and on enhancing human health services in handling pandemic outbreaks. The GPAI and the subordinated operations were primarily viewed as emergency interventions to mitigate the risks presented by the outbreak of a virus that could jump across species and become a highly contagious human pathogen. Since the design of the Project was heavily influenced by the GPAI design and intent, and given the urgency, only limited background analysis was undertaken before project preparation. However, the Bank had substantial experience in both sectors from previous operations which safeguarded against design flaws. Proper consideration was given to ongoing donor programs and the overall Country Assistance Strategy, including ongoing and future projects in the respective subsectors. Even more importantly, key aspects of the Project were designed in direct collaboration with other development partners such as the WHO in the case of the Human Health Component, and UNDP/UNICEF in the case of public awareness and communication activities. The project preparation team had reviewed the Vietnam Avian Influenza Emergency Recovery Project and the Avian Influenza Control and Human Preparedness Project in the Kyrgyz Republic. The Vietnam experience showed that the capacity to contain an outbreak was crucial, 6

19 however, in part due to the different way in which poultry is held by households in Moldova, no human victims had ever been recorded. Experience gained in the development of HIV/AIDS awareness were integrated in the project design as well to create messages of broad public appeal that are easily absorbed by the population. The initiation of emergency teams with help from the WHO before the Project had started clearly demonstrated the government s commitment to addressing the risks posed by a potential AI epidemic/pandemic. Overall the project design was well suited and adequately integrated ongoing donor support to address Moldova s needs in handling a pandemic outbreak. In the aftermath of the AI scare, the actual outbreaks remained largely contained with no recorded loss of human life in ECA. Nonetheless, the projects were prepared as a stepping stone to help ready client governments in managing epidemics or future pandemics. As such, and demonstrated in the fairly limited impact of the H1N1 crisis that emerged in , the strengthening of diagnostic and emergency treatment capacity combined with effective public awareness and communication activities were extremely effective interventions. The hybrid design of the Project, as an emergency capacity building intervention, while simultaneously building a development platform for further improvements in both sectors was and remains highly relevant. 2.2 Implementation The primary challenge for this Project was to coordinate the efforts of multiple beneficiary institutions across various sectors, as well as coordinating multiple donor support. Decisions as to which facilities would be prioritized for rehabilitation support took some time, consequently works contracts could only be issued relatively late in the Project which led to delays. Agreements had to be reached to define the role of the WHO, UNICEF and the EC (under its food security program) in supporting the Government in preparing for the possible emerging pandemic. While this coordination and reaching of agreement between these actors led to a slow start, integration of the activities provided an opportunity to take advantage of each donor s strength and integrating expertise into a forum beyond national boundaries. A good example of this is the link-up with the WHO flu network that was greatly facilitated with WHO s involvement. The selection of CAPMU, a well-established and experienced unit, as the project coordination body made the launching of activities relatively painless and quick. The Project became effective in about 3 months of Bank approval, and by the first supervision mission, several procurement packages were already prepared for the acquisition of vaccines and contracting of key TA assignments. However, in spite of this early progress, disbursement was slow initially and could only accelerate once all the institutional modalities and decisions as to which facilities and laboratories in both animal and human health sector were agreed. The Project did not undergo a QER review before appraisal because it was processed as an Emergency Recovery Loan in response to the risks posed by a potentially emerging pandemic. Also, the Project was not subject to a QAG review. At Mid-term Review, the Project had accumulated significant delays due to difficulties with procurement of technically challenging 7

20 goods and works, but the component and activities remained relevant and no substantial changes were introduced to the project design. The Project underwent two closing date extensions amounting to 16.5 months. The extensions had resulted in full completion of original activities, as well as significant scaling up in priority areas identified by the animal and human health authorities. The first extension of one year was primarily due to the delays at the beginning of the Project to agree on the facilities that would benefit from rehabilitation works, as well as the implementation of scaled-up activities for supporting the strengthening of the RCVD with proceeds reallocated from the Compensation Fund. The second extension was essentially a technicality to allow a supplier that went through a force-majeure to deliver goods within the Project confines. Component 1: Animal health The component was largely implemented as designed however with the reallocation of the Compensation Fund, substantially higher investments were made in the development of laboratory capacities and effective collection and transportation of test samples. This equipment was procured not only for AI cases but also for other zoonoses. This applies to all laboratory facilities supported by the Project: RCVD, and two regional laboratories in the North and in the South in the towns of Drochia and Cahul respectively. The latter were substantially reconstructed to become regional centers for diagnostics viral, bacterial and microbiological diagnoses. The concentration of the laboratories in two major regional centers helped with specialization and allowed for economies of scale by downgrading the many small district laboratories to the status of sample collection facilities from which samples are sent to the newly refurbished facilities for testing in an uncontaminated environment, with adequate equipment and qualified staffing. The overall impression of the facilities visited displayed staff professionalism, systematic application of testing procedures, record keeping, and a solid knowledge base for the veterinarians in the region. Extensive training for staff in and outside the country helped in ensuring that the laboratories are not only equipped to internationally accepted standards, but that staff too understood and performed in line with their important mandate to ensure the early detection of any epizootic outbreak. The volumes of sampling, critical to justify the economic reasoning for these investments, seemed adequate and were showing the typical peaks and troughs of seasonality of infectious diseases. The RCVD laboratory also benefited from extensive investment support and technical assistance. Here, the Project co-financed previous investments by the EC, and led to the existence of a state-of-the-art facility that is currently providing a large spectrum of testing for animals and products of animal origin. Component 2: Human health The component was largely implemented as designed. Refurbishment works of a laboratory and hospital facilities turned out to be substantially more onerous that originally intended. The primary reason lies with the substantially higher needs to effectively complete the refurbishment of the Toma Ciorba Republican hospital for infectious diseases in Chisinau, including the construction of an elevator to move beds and patients from one floor to another, the construction of isolation rooms with adequate filtering, as well as the introduction of modern medical waste management practices. The works were complemented with adequate training of hospital and laboratory staff and a revision of the SOPs to ensure adequate measures to prevent cross contamination and containment of infection factors. Laboratory capacity was strengthened with equipment and training with sampling accuracies of retested samples at the London WHO Reference Laboratory at 98%. The upgraded laboratory facility is in stark contrast to the previously very limited and scarcely equipped spaces, offering 8

21 an environment where actual testing can be undertaken within the standards required for limiting cross contamination and safe handling of highly pathogenic samples. Three ambulances to complement the depleted existing fleet and several smaller vehicles for the effective transport of samples from rural areas were also purchased. Finally as reflected above, substantial efforts and resources went into the development of an effective medical information system equipping district primary health care facilities with IT equipment and training of staff. Component 3: Public Information and Awareness the Public Information and Awareness activities were largely contracted out to UNICEF. This partnership proved very effective. UNICEF implemented a three-year public communication program that was complex in content and extensive in reach. The campaign achieved a significant increase in levels of knowledge and awareness about risks associated with AI, other influenzas, as well as other communicable diseases. It contributed to increased levels of understanding amongst media and government officials on crisis communication. Last but not least, the Project s communication activities have been crucial in reaching the public during the H1N1 pandemic with timely and focused messages on the risks and adequate response behavior in avoiding infection and/or treatment options for infected patients. The positive effects of the Project s activities under the component have been document in regular KAP surveys. Component 4: Implementation Support and Monitoring &Evaluation as already reflect above, the management of the Project had been entrusted to an experienced unit. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E design: The Monitoring Evaluation framework was largely output driven focusing on the establishment of a number of capacities which in the future would avert or help avert and handle epidemic/pandemic situations. M&E implementation and utilization: The indicators do capture a series of steps and activities that serve as the basis and range to which good management of any possible outbreak could be measured. The measurement of the completion of outputs, in absence of a pandemic, give a good indication of the capacity improvements resulting from the Project and were regularly updated by CAPMU and in the ISR reports. The M&E indicators were not substantially changed and correspond with each other in the legal agreement, PAD and the ISR reports. While the M&E was heavily biased towards outputs, the approach in this case was sensible since the activities did very closely relate to the eventual outcomes, even if the outcome, especially the capacity for containment of outbreaks has not and cannot effectively be tested beyond simulations that were successfully performed at various stages of implementation. However, the proper diagnosis of the H1N1 virus and the effective response to the outbreak might certainly be a good indication of the human health system s improved capacity to react to an emerging crisis. 9

22 2.4 Safeguard and Fiduciary Compliance For the rehabilitation of the veterinary laboratories typical environmental impact assessments were undertaken and subsequent visits by safeguard specialists have not brought to light any issues related to the construction processes, handling of construction waste, or the handling of laboratory waste material that is now being systematically incinerated. There were no issues with land acquisition or resettlement under this Project in line with expectations at preparation. The Project s fiduciary aspects were implemented through an entity that has gained experience over the years with the implementation of several World Bank financed projects of varied complexity. Audits were on time and without, or only moderate qualifications related to internal controls. Overall, reviews of procurement and financial management by fiduciary team members have generally rated internal financial management, contract handling procedures and processes, as well as reporting as satisfactory. 2.5 Post-completion Operation/Next Phase Investments in both animal and human health sectors supported by the Project will have long lasting positive impacts. While some of the investments in vehicles and ambulances might only have a limited time horizon before needing replacement, and require a minimum of operating budgets, their net benefits are far broader than just in mitigating the impact of a possible AI pandemic. The health information system that has been designed and is being implemented nationwide will greatly help in monitoring epidemic outbreaks and reduce response times in identifying crucial concentration and focusing of resources where they are the most effective. While the resources in the human health sector are tight, they are adequate to maintain and operate the equipment that had been acquired under the Project, as evidenced by budget allocations for 2011 and 2012 for the operation of the hospital and laboratory facilities in question. Sustainability aspects are helped by the fact that the Project supported improvements in equipment/facilities for laboratory testing and hospitalization were versatile, and the latter are used in non-epidemic/pandemic settings for current public health needs related to testing, intensive care and ambulatory treatment of various infectious and respiratory conditions. In this sense, these facilities do not represent expensive upkeep items, that are conserved and set aside for emergencies, but are useful assets that provide the efficacy and economic efficiency necessary to incentivize the allocation of proper state funding for current operation. Further, personnel that had been trained to operate these equipment/facilities also make vocal advocates for ensuring adequate funding of consumables and maintenance. On animal health, as discussed above, the Project served as catalyst to help push through reforms to render the veterinary service more effective and more efficient by concentrating primary laboratory work to two regional facilities instead of a dispersed system of tiny poorly equipped and poorly staffed laboratories at district. In addition, the central veterinary laboratory in Chisinau is expected to play a prominent role as reference laboratory also in the context of improved food safety. In this context, a new Bank project is expected to assist Moldova to improve its sanitary and phytosanitary structure to come into line with EU requirements, not only for internal food safety but also to improve access to market with exports. 10

23 Laboratories to date remain fully state funded. The funding is provided based on yearly strategic plans approved by the State Veterinary Department of MAFI for risk-based epizootic surveillance and monitoring. This is in line with recommendations and approaches in the EU. In 2011 and 2012, the laboratories received sufficient funding for their operations, and levels of funding are expected to stay satisfactory in the future due to the growing role that these facilities will play in the country s food safety system and in the facilitation of exports of Moldovan produce of animal origin (including poultry products) to EU markets. As such facilitation functions evolve, there will be additional income streams emerging from chargeable services to support the operation and maintenance of the laboratory facilities, and further increase the sustainability of the investments that were made under the Project. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Over the past decade there have been a number of flu related emergencies that have had the potential to reach pandemic levels affecting tens of millions people. These emergencies have thus been monitored by scientists at the WHO and the CDC, starting with SARs in South Asia in 1998 which led to the culling of 10 of thousands of pigs in South Asia. That was followed by Avian Influenza in 2005, and more recently H1N1 was identified as having the potential to evolve into a dangerous pathogen that could kill tens of millions of people. Luckily none of the worst case scenarios imagined had become a reality and each of these potential pandemics has remained a largely localized phenomenon without a severe worldwide impact. Even if cases of infection were found in many places of the world, the virus never managed to reach the threshold of pandemic levels. Given the background of the GPAI, this Project like most of the projects prepared in the ECA region to minimize the risks posed by AI did not emerge from a carefully crafted national strategy but was designed in response to a potential crisis. In Moldova the Project was a hybrid that immediately dealt with short term investments in basic capacity building to ensure adequate public awareness, proper equipping of emergency response teams and acquiring adequate stocks of vaccines and a compensation mechanism that would facilitate reporting of outbreaks by farmers to limit contagion in case of an outbreak. Longer term capacity focused on rehabilitation and modernization of laboratory and hospital facilities including sample collection, transport and testing with improved capacity to deal with the contaminated. In this Project in particular, the investments under AI were linked into the broader reform agenda in both the animal and human health sectors that would provide benefits well beyond the narrow aims of the PDO. The investments supported under the Project provide for a platform for future improvements and modernization of both sectors not only in addressing emergencies, but also of longer term capacity and modernization, and sustainability. 11