PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE. REPORT NO.: AB2342 Avian and Human Influenza Control and Preparedness Emergency Project Region

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE REPORT NO.: AB2342 Avian and Human Influenza Control and Preparedness Emergency Project Region EAST ASIA AND PACIFIC Sector Health (50%); Animal Production (50%) Project ID P Borrower(s) ROYAL GOVERNMENT OF CAMBODIA Implementing Agencies Ministry of Agriculture, Forestry and Fisheries #200 Norodom Boulevard, Sangkat Tonle Basak, Khan Chamkarmorn Phnom Penh, Cambodia Ministry of Health No Kampuchea Krom Boulevard Phnom Penh, Cambodia National Committee for Disaster Management #274 Monivong Boulevard Phnom Penh, Cambodia Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared January 25, 2008 Date of Appraisal May 16, 2006 Authorization Date of Board Approval March 27, Country and Sector Background Introduction The continuing outbreaks of highly pathogenic avian influenza (HPAI) in recent years have caused substantial damage to the poultry industry in several regions of the world, resulted in some loss of human life, and raised concerns about a possible human pandemic. 1 Large scale 1 Avian influenza, or bird flu, is a contagious disease of animals caused by viruses that normally infect only birds and, less commonly, pigs. Avian influenza viruses are highly species-specific, but have, on rare occasions, crossed the species barrier to infect humans. In domestic poultry, infection with avian influenza viruses causes two main forms of disease, distinguished by low and high extremes of virulence. The low pathogenic form commonly causes only mild symptoms and may easily go undetected. The highly pathogenic avian influenza (HPAI) form spreads

2 outbreaks began in 2003 in several Southeast Asian countries, and HPAI has now reached Europe, the Middle East, and West Africa. More than 150 million birds have died from the disease or been killed as part of the effort to contain HPAI. Economic losses to the Asian poultry sector alone are estimated at around US$10 billion. Much of these losses have been suffered by millions of poor farm households who depend upon poultry for home consumption and some cash income. There have been 317 laboratory-confirmed human cases of infection with HPAI (hereafter, Avian and Human Influenza, or AHI) since 2003, and 191 of these died. Nearly all of the confirmed cases are known to have had contact with birds, and so far AHI does not transmit easily from human-to-human. However, the virus is evolving and it is believed that it may acquire the characteristics which would enable efficient human-to-human transmission. 2 Each additional human case gives the virus an opportunity to improve its transmissibility in humans, and thus develop into a pandemic strain. The recent spread of the virus to poultry and wild birds in new areas further broadens opportunities for human cases to occur. While neither the timing nor the severity of the next pandemic can be predicted, the probability that a pandemic will occur has increased. If the virus achieves high transmissibility between humans and is highly pathogenic, then a severe human pandemic could result with very large losses of human life and enormous economic disruptions and losses on a global scale. The global response to the threat of AHI in humans and domestic poultry comprises three key strategies: (i) progressively controlling and eradicating the spread of the disease in animals, thus lowering the animal-origin virus load in the environment and reducing the risks of human infection, (ii) preventing and limiting the spread of the disease among humans, thereby reducing the opportunity for the virus to improve its human transmissibility, and (iii) in the event of a pandemic, helping affected populations cope with its effects. AHI prevention and control involves many players in the areas of health, agriculture, natural disaster response, finance and planning, and a multi-sectoral approach is therefore essential. It is also recognized that individual countries are central to a coordinated and effective global response. Country strategies should be developed in accordance with country-specific needs and circumstances, and the strategies should be owned by the individual governments facing the threat of AHI. Regional Dimension In East Asia and the Pacific, cases of AHI have occurred in a number of countries, including Cambodia, China, Lao People s Democratic Republic (PDR), Indonesia, Japan, Korea, Malaysia, very rapidly through poultry flocks, causes disease affecting multiple internal organs, and has a mortality that can approach 100%, often within 48 hours. H5N1 is one strain of the HPAI virus. 2 The virus can improve its transmissibility among humans via two principal mechanisms. The first is reassortment in which genetic material is exchanged between human and avian viruses during co-infection of a human or pig. Reassortment could result in a fully transmissible pandemic virus, announced by a sudden surge of cases with explosive spread. The second mechanism is a more gradual process of adaptive mutation, whereby the capability of the virus to bind to human cells increases during subsequent infections of humans. Adaptive mutation, expressed initially as small clusters of human cases with some evidence of human-to-human transmission, would probably give the world some time to take defensive action. 2

3 Myanmar, Thailand, and Vietnam. Responses to the outbreaks in domestic and wild fowl have included screening, surveillance, precautions at the borders, movement control inside the country, culling programs, and control of wildlife reservoirs. The World Organization for Animal Health (OIE) reports that, for 2004, over 60 million birds were destroyed, and approximately 131 million vaccinated. This response was the result of over 800 outbreaks, with over 22 million cases (this number includes the number of fowl which have either become sick or have died from the disease), and over 4 million bird deaths attributed to AHI. On the human health side, since 2003 to date, there have been 230 cases reported in Cambodia, China, Indonesia, Thailand, and Vietnam, resulting in 143 deaths attributable to AHI. 2. Objectives Rationale for Bank Involvement A key justification for the Bank s involvement is the global public goods aspect of controlling AHI. There is also a national public goods perspective for countries to strengthen their veterinary services, disease surveillance, and human health system as planned in this operation. AHI control programs require a multi-disciplinary approach to integrate technical, social, economic, political, policy, and regulatory issues in addressing a complex problem. The Bank is well placed to draw on its knowledge-base concerning multi-disciplinary approaches needed in the proposed operation, and to apply the evidence and lessons learned in various regions during emergency preparedness responses. The Bank can also be helpful in bringing together the relevant ministries, government agencies and the donor community, and in helping ensure high level political coordination. The Bank has been working with WHO, FAO, OIE, multilateral, bilateral, and other partners incountry and at the international level to prepare the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI). In Cambodia, the Bank has been working with UNDP (the convenor of the donor round table), other agencies of the UN system (FAO, WHO, UNICEF), the EU, and other partners to help the government assess and improve the National Comprehensive AHI Plan. The Bank can assist Cambodia in leveraging additional resources from other bilateral and international agencies. In addition, the technical assistance provided by the Bank has been important in similar global or regional emergency situations such as SARS, and post-disaster reconstruction. The Bank has a proven comparative advantage in providing integrator skills and multi-sectoral perspectives and in addressing the institutional dimensions of the response to such emergencies. It can also contribute extensive experience and skills in understanding and addressing the social and economic impact. Country eligibility under GPAI The proposed project falls under the Global Program for Avian Influenza and Human Pandemic Preparedness and Response (GPAI), approved by the Bank s Board of Directors on January 16, GPAI support is to be provided using the horizontal Adaptable Program Loan (APL) instrument and within a global coordination framework. Under the global APL, individual countries may obtain separate loans, credits and grants, as they become available, to finance their own national projects, up to the global aggregate limit of US$500 million. Since the GPAI is 3

4 designed to provide emergency financing to participating countries to contain outbreaks of avian flu through early detection and rapid response measures, the country specific operations will be processed under the Bank s emergency policy OP/BP The GPAI will treat specific emergency response projects in each country as phases of a horizontal APL (similar approaches include the Multi-Country HIV/AIDS Programs for the African and Caribbean Regions). Cambodia clearly meets the eligibility criteria specified in the GPAI document, given that: (i) it is a country in endemic situation (with repeated outbreaks in poultry and six human deaths); (ii) the National Comprehensive AHI Plan (see above paragraph), integrating both the animal and the human health sectoral plans, has been prepared and approved by Government; and (iii) the activities included under this proposed Project are fully consistent with the objectives and provisions of GPAI. 3. Country and Sector Issues Cambodia has achieved political and macroeconomic stability and, since 1993, has been experiencing rapid economic growth. Nevertheless, Cambodia's economy remains vulnerable and economic growth has not translated into widespread poverty reduction. With a GDP per capita of US$390 (in 2005) and social indicators showing limited progress since the 1960s, Cambodia remains one of the poorest countries in the world. About 35% of the population has expenditure levels below the national poverty line, with about 15% living in extreme poverty. Poverty in Cambodia is overwhelmingly located outside Phnom Penh, with poverty incidence of more than 50% in the worst affected areas. Cambodia was one of the first countries in Southeast Asia to experience AHI infection. The first case of AHI in Cambodia was reported on December 2003, and the first wave of the outbreak during January to May 2004 had a severe impact on smallholder farmers who raise the majority of the country's poultry under subsistence conditions and on small-scale commercial poultry farms. AHI cases emerged again in late 2004 and early 2005, and four human cases (all of which were fatal) were reported in There has been one confirmed outbreak among chicken, ducks and fighting cocks in February 2006, and this case was quickly contained (about 2500 birds were killed by disease or culling during the February 2006 outbreak), resulting in two human deaths in One additional human death due to contamination with the AHI virus was confirmed in The repeated outbreaks and associated loss of human life and livelihoods highlight the country's still inadequate disease surveillance system and limited capacity to control the disease. Cambodia is situated between two large poultry producing countries -- Vietnam and Thailand -- both of which have experienced far greater outbreaks of avian influenza and significant human infection. The sub-region is a potential flashpoint for an expansion of avian influenza and the emergence of a human pandemic strain of influenza. The Government is now focused on the development of an integrated AHI control and human pandemic preparedness and response plan, and is working closely with the international community to build its capacity for disease surveillance, outbreak investigation, and emergency response. 4

5 4. Project Description Consistent with the GPAI, the Project s overall development objective is to support the implementation of the Cambodia Comprehensive AHI National Plan, which is designed to minimize the threat posed to humans and the poultry sector by AHI infection in Cambodia, and to prepare for, control, and respond if necessary to a human influenza pandemic. More specifically, the Project is expected to provide direct support to the implementation of the National Comprehensive AHI Plan to produce the following outcomes: (a) contain the spread of the disease, thus reducing losses in the livelihoods of commercial and backyard poultry growers and damages to the poultry industry and diminishing the viral load in the environment; (b) prevent or limit human morbidity and mortality by stemming opportunities for human infection, and strengthening curative care capacity; and (c) prevent or curtail macroeconomic disruption and losses by reducing the probability of a human pandemic and improving emergency preparedness and response. Project components The proposed Project would finance activities fully consistent with the objectives and the description of the National Comprehensive Plan, with a focus on the financing of items not already covered by other financiers (technical and financial gaps). The Project would include three components, which are summarized below: Component A -- Animal Health Systems (total cost of about US$5.80 million). The objective of the animal health component is to minimize the levels of infection with H5N1 HPAI viruses in Cambodia 3. The component objective would be achieved through six subcomponents (four major and two minor). The first subcomponent will strengthen veterinary services from the central to the village level so as to enhance the capacity to prevent, recognize and respond to avian influenza and other emergency animal diseases. This will be achieved through strengthening and consolidation of training resources, reviews of training needs and curricula for village animal health worker (VAHW) training, enhanced reporting by trained VAHWs to District Veterinary Services, provision of resources to support disease responses for district and provincial level veterinary services, and development of appropriate animal health laws. The second subcomponent will provide training in emergency vaccination, and necessary resources to implement emergency responses. Some additional epidemiological studies including studies in wild birds will also be conducted under this subcomponent. The third subcomponent will review high risk practices in production in marketing that facilitate persistence and transmission of infection, and implement appropriate measures to reduce these risks. The fourth subcomponent will include some additional epidemiological studies including studies in wild birds, and will strengthen existing animal health IEC programs. The fifth subcomponent will enhance pandemic preparedness response for animal health staff, and the sixth subcomponent will provide support for management of the animal health component. 3 The ultimate goal is eradication but, even if achieved, this is unlikely to be sustainable as long as infection persists in the region and illegal or uncontrolled cross border movement of poultry and poultry products occurs. Minimizing the levels of infection in poultry will reduce the risk of human infection and protect the poultry sector and the livelihoods of many small holders and poor farm households. Additionally, upgrading the animal health system will improve livestock sector productivity with benefits for commercial and backyard producers alike. 5

6 Component B -- Human Health Systems (total cost of about US$3.50 million). The overall component objective is to prevent the emergence of a human pandemic in Cambodia through the rapid identification and effective management of human cases. Strengthening public health systems will enhance national pandemic preparedness, and help reduce the loss of life that would result from a human pandemic caused by influenza. The first subcomponent will focus on training of health care workers and the development of materials for use by health care providers and Village Health Volunteers. To improve surveillance, investigation and response, the second subcomponent will support training of Provincial Rapid Response Teams; the operating costs associated with surveillance, investigation and response; and the transportation for those undertaking both activities in the field, as well as supervision costs by each level. International experts will be hired to identify activities necessary to ensure compliance with the International Health Regulations, and these findings will be disseminated. To support case management and infection control, the third subcomponent will finance the procurement and distribution of medicine, medical equipment and PPE. Clinical training on case management and infection control will be supported, as well as the identification of and support to activities necessary to ensure appropriate health care waste management and infection control. The fourth subcomponent will support laboratory activities through the development of a national laboratory strategy and continuous education and refresher training for laboratory staff on site (using international trainers) or at the local level using existing trainers in the country; and the provision of equipment, specimen collection kits, laboratory consumables and reagents and transport for specimen transport inside Cambodia, as well as shipment abroad to WHO reference laboratories. Activities associated with pandemic preparedness for the health sector will be supported under subcomponent 5, and include preparation and dissemination of the plan, training provincial level staff to prepare their plans, and simulation exercises. Subcomponent 6 will support activities on rapid containment of an outbreak with a novel influenza virus that has the potential to create pandemic influenza: case management, infection control, isolation/quarantine, and equipment and supplies. Activities under this subcomponent include rapid containment training curriculum development, workshops for rapid containment plan implementation, and rapid containment training for province, district and health center/hospital staff and Rapid Response Teams and also of military, police and local authorities. The final subcomponent under Human Health consists of the support necessary for overall implementation of the component, such as staff, travel costs, transport and its operation and maintenance costs, and other consumables. Component C Interministerial Cooperation for Pandemic Preparedness and Project Coordination (total cost of about US$1.70 million). The objective of the interministerial cooperation for pandemic preparedness component is to strengthen Cambodia s capacity to quickly and efficiently mobilize a coordinated multisectoral and society-wide response to an influenza pandemic. Strengthening the coordinated response capacity for an influenza pandemic would also improve the effectiveness of Cambodia s response to floods, droughts, and other natural disasters. This objective would be achieved through five subcomponents. First, the National Committee for Disaster Management s (NCDM) current Terms of Reference would be modified to better include interministerial cooperation for pandemic influenza preparedness, and NCDM s capacity to oversee this cooperation would be strengthened through training, staffing and other measures. Second, NCDM will prepare and test a Pandemic Preparedness, Response, and Recovery Program (PPRRP). Third, an NCDM emergency MIS system and an M&E system (for the overall national PPRRP) will be designed, developed and established. Fourth, pandemic 6

7 preparedness, response and recovery activities would be integrated into the ongoing Community Based Disaster Risk Reduction Programs (CBDRM). Finally, the fifth subcomponent will comprise support for overall implementation of the component. Since NCDM will take overall responsibility for overseeing and coordinating institutional and implementation arrangements for the project as a whole (including overall project coordination, ensuring linkages across relevant agencies and with international partners, and for guiding and monitoring project implementation at the central level), the fifth subcomponent will also provide support for these important coordination functions. 5. Financing Source: ($m.) IDA Grant 6.0 JAPAN: MINISTRY OF FINANCE - PHRD GRANT 3.0 AVIAN AND HUMAN INFLUENZA FACILITY GRANT 2.0 Total Implementation Partnership arrangements Effective and suitable partnership arrangements for this Project have been developed in Cambodia with the international technical agencies, as well as with bilateral donor agencies currently providing assistance to the country, building on productive collaborative arrangements developed over time in both the agricultural and health sectors under previous projects. During project preparation and appraisal, close consultations with local staff of the multilateral and bilateral donors represented in Cambodia was maintained, mainly with the agencies involved in supporting the implementation of the National Plan (i.e., UNDP, FAO, WHO, and UNICEF, EU, Agence Francaise de Development, USAID, and AusAID). Round tables were organized prior and during the appraisal mission to brief these partners on the intended program of working with the Government to strengthen its National Comprehensive Plan and to ascertain their interest in providing financial and/or technical support for the project, as well as coordinating the activities to be supported by each agency to improve overall effectiveness of the combined actions and programs. The Government of Japan has already approved a PHRD Co-financing Grant (PHRD Grant) of US$3 million for the Project. Some of the major donors (e.g., UNDP, FAO, WHO, GTZ, Japan/JICA, USAID, and AusAID) have already approved, or are planning to approve shortly, technical assistance projects to complement and to help jump-start the activities proposed under the National Plan, which are consistent with this proposed Project. A multi-donor trust fund --the AHI Facility-- has been established to provide financial support for HPAI preparedness to individual countries. This facility is managed by the World Bank and a total amount of US$2 million has been approved to cofinance the proposed project. Institutional and implementation arrangements 7

8 Implementing Agencies. The Government has decided that implementation of the project would be the responsibility of three Implementing Agencies (IAs), as follows: a) Component A: The Animal Health component would be implemented by the Animal Health and Production Department (DAHP) of MAFF through its existing structure and with the support of a small unit in charge of the coordination function for the component. This unit will be staffed with specialists in financial management, procurement and M&E, as well as external technical advisors. It is expected that MAFF will sign a Service Agreement with FAO, under which this international agency will provide (i) the institutional strengthening needed for the implementation of the component; and (ii) technical assistance in key areas, its broad international experience in animal health in general, as well as in the wide-world efforts being implemented to control the spread of avian influenza. FAO has been recognized as one of the technical leading agencies in the implementation of the animal health strategy to stop the spread of H5N1. b) Component B: The Human Health component will be implemented by MOH through the existing PIU in charge of the on-going Health Sector Support Project (HSSP). This PIU already has sufficient human resources and expertise to assume these new responsibilities. However, several additional consultants will be hired to strengthen its institutional capacity to implement this component (financial management and accounting, administration). In addition, it is expected that MOH will sign a Service Agreement with WHO to receive technical assistance and capacity building to implement the component. WHO is an internationally recognized specialized agency of the UN system, that is supporting the response to the avian influenza threat in many countries around the world, and is in charge of supporting key areas of the National Comprehensive Plan in Cambodia. c) Component C: NCDM, through its General Secretariat, will be in charge of the Inter- Ministerial Coordination for Pandemic Preparedness, as well as responsible for the overall coordination and management of the Project. The current staff of the General Secretariat will be strengthen by the hiring of consultants in key areas, mainly financial management, procurement, human resources, and M&E. Similarly to the other components, it is expected that NCDM will sign a Service Agreement with UNDP to receive technical assistance during implementation. This Service Agreement will extend and complement the current capacity building program being supported by other agencies of the UN System. Under this implementation approach, the RGC (as the Recipient of the grant financing) will enter into a Financing Agreement with the Bank for the IDA funds, as well as into corresponding Grant Agreements for the grants from the PHRD and the AHI Facility. These institutional implementation arrangements would contribute to fast and cost-effective implementation, providing assurances that the surveillance and response systems are fully operational in a short period, therefore, able to produce an effective response in the even of an outbreak in poultry or a large number of human cases. For the implementation of these activities, the funds from the three sources (IDA, PHRD and AHI Facility) will be advanced by the World Bank directly to the Designated Accounts opened by each IA (one for MAFF, and two for MoH and NCDM), in a manner acceptable to IDA. 8

9 Each IA will prepare and submit to NCDM, as the agency in charge of overall coordination: (i) a Project Implementation Plan (PIP) for all project activities included in its component; (ii) annual work plans (with budgets) for each calendar year; (iii) annual physical progress reports and financial statements covering the preceding calendar year; and (iv) Interim Financial Reports (IFRs) for each quarter. From the IFRs for the 4 th quarter, NCDM will prepare the annual financial statements for the entire Project to be audited by independent auditors under Terms of Reference acceptable to IDA. In addition to its responsibilities as implementing agency for Component C, NCDM will be responsible for overall project coordination and management, ensuring linkages across relevant agencies and with international partners, and for guiding and monitoring project implementation at the central level, as well as for acting as the main counterpart for IDA. For this purpose, NCDM will rely on its existing structure, using its General Secretariat as the main unit in charge and having its Secretary General and its Deputy Secretary General as Project Director and Project Manager, respectively. To perform these functions, NCDM will recruit consultants to strengthen its capacity, mainly in the areas of general administration, financial management, procurement, M&E, training, and human resources. The Service Agreement expected to be entered into between NCDM and UNDP will also contribute to the institutional strengthening of NCDM to perform this function. Monitoring and evaluation of outcomes/results (M&E) NCDM would be responsible for the establishment and maintenance of the Monitoring and Evaluation (M&E) system for the overall project. Within this overall framework, each of the IAs will be responsible for the establishment and operationalization of the M&E system for their respective project component. Depending on the specific situation in each case, these activities could be carried out by the regular staff of the IAs (with training and technical assistance provided by the Project), or by specialized agencies or institutes contracted for this purpose under the Project. In the case of the Animal Health component, M&E will be supported by the appointment of regionally based project managers who will conduct regular monitoring of project activities along with a central M&E officer in the Animal Health component project management team. Monitoring progress in implementation and towards the achievement of the intended objectives entails a process of continuous and systematic review of the various project activities. M&E activities are intended to: (i) measure input, output and outcome indicators; (ii) provide regular and up-to-date information on progress toward achieving the intended results and facilitate reporting to the government and IDA; (iii) alert the government authorities and the Bank to actual or potential problems in implementation so that adjustments can be made; and (iv) determine whether the relevant stakeholders are responding as expected and intended. The findings of relevant M&E activities will be reflected in quarterly and annual progress reports. The progress reports will cover the implementation of activities related to civil works, institutional activities, training and studies, performance indicators, and IFRs. They also will cover issues identified during implementation and the strategies and actions proposed to be taken to resolve such issues that affect progress. The fourth quarterly report of each year will 9

10 be an annual report, covering progress during the past year. In addition, a Mid-Term Progress Report will be prepared approximately half-way through implementation, and form one of the inputs into the Mid-Term Review, which will provide an opportunity for joint (Government, implementers, partners and donors/financiers) review of the experiences and lessons to-date and discuss adjustments of design, implementation schedule and expected outcome/results, if necessary. An Implementation Completion Report will be prepared by both the IAs and the World Bank within six months of the closing date of the support. 7. Sustainability Critical to the project sustainability will be the continuous ownership of this initiative by the various stakeholders, coupled with strong political support and an adequate flow of financial resources to carry out project activities. Institutional sustainability will be ensured by: (i) strengthening of programs to maintain public awareness of the threat of HPAI and other rapidly spreading infectious diseases; (ii) sustained surveillance and prevention and control activities, particularly in high-risk regions; (iii) strengthened country capacity to manage at national and local levels the risk factors associated with the spread of HPAI and other infectious diseases; and (iv) effectiveness of programs to control the spread of HPAI from birds to the general population. 8. Lessons Learned from Past Operations in the Country/Sector Previous World Bank/IDA supported emergency recovery projects provide a number of relevant lessons for project design. Lessons learned of particular relevance for an emergency AHI project include: (a) emergency projects should avoid policy conditionality, (b) project design must be simple and take into account a realistic assessment of the Borrower s capacity and other stakeholders capacity, (c) a speedy appraisal and approval are crucial to provide a prompt response and a substantial contribution to project success, (d) procurement arrangements need to be flexible and should be finalized at an early stage, and (e) realistic assessments should be made of counterparts absorption capacity, as well as of the effective communications and coordination mechanisms among all relevant stakeholders. The experiences gained through the implementation of other emergency projects provide additional important lessons. These projects include the Vietnam Avian Influenza Emergency Recovery Project, projects in response to the SARS epidemic, and projects in response to the HIVAIDS epidemic. These key additional lessons learned include: Preparation of a good quality national strategy is a key factor. For implementation arrangements, it is important to have a coordination structure which is empowered with multisectoral responsibilities, for instance at the Prime Minister s Office level, and to have full time project coordinators to implement activities in a crisis situation. Strengthening the technical, scientific and operational capacity of the relevant participating agencies is very important. It is crucial that awareness in the public and private sectors be raised as early as possible, and to strengthen effective coordination mechanisms for the 10

11 implementation of the necessary technical responses, involving the Government, the donor community, the private sector and the civil society. Good quality national surveillance is clearly vital in preventing the spread of diseases. There is a need for high level and sustained political commitment and leadership. A comprehensive multisectoral approach of prevention, treatment, care and support services has the best likelihood of success. While emphasis must still be placed on prevention as the most cost-effective means of managing the AI threat, programs should seek to address the whole spectrum of prevention, treatment, care and support services. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.01) [X] [ ] Natural Habitats (OP/BP 4.04) [ ] [X ] Pest Management (OP 4.09) [ ] [X ] Cultural Property (OPN 11.03, being revised as OP 4.11) [ ] [X ] Involuntary Resettlement (OP/BP 4.12) [ ] [X ] Indigenous Peoples (OP/BP 4.10) [X] [ ] Forests (OP/BP 4.36) [ ] [X ] Safety of Dams (OP/BP 4.37) [ ] [X ] Projects in Disputed Areas (OP/BP 7.60) * [ ] [X ] Projects on International Waterways (OP/BP 7.50) [ ] [X] 10. Contact point Contact: Alan Piazza Title: Senior Economist Tel: (202) Fax: (202) apiazza@worldbank.org 11. For more information contact: The Infoshop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) pic@worldbank.org Web: * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas 11

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