Document of The World Bank Report No: ICR00001990 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-41880 IDA-H2330 TF-56630 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 CURRENCY EQUIVALENTS (Exchange Rate Effective November 1, 2011) Currency Units = MDL, USD MDL 1.00 = US$0.0863 US$1.00 = 11.58 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AI Avian Influenza APL Adaptable Program Loan CAPMU Consolidated Agricultural Project Management Unit CDC Center for Disease Control EC European Commission ECA Europe & Central Asia Region EU European Union FAO Food and Agriculture Organization FM Financial Management GDP Gross Domestic Product GPAI Global Program for Avian Influenza and Human Pandemic Preparedness and Response HPAI Highly Pathogenic Avian Influenza (H5N1) H1N1 Influenza A Virus KAP Knowledge-Attitudes-Practices IDA International Development Association ICU Intensive Care Unit ISR Implementation Status and Results IT Information Technologies MAFI Ministry of Agriculture and Food Industry MDL Moldovan Leu MOH Ministry of Health OECD Organization for Economic Cooperation and Development PHRD Policy & Human Resources Development POM Project Operations Manual QAG Quality Assurance Group QER Quality Enhancement Review RCVD Republican Center of Veterinary Diagnosis RISP Rural Investment and Services Project SANCO European Commission Health & Consumer Protection Directorate-General SARS Severe Acute Respiratory Syndrome SIL Standard Investment Loan SOPs Standard Operating Procedures ii TACIS Technical Assistance for Commonwealth of Independent States UNDP United Nations Development Program UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO 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 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 ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 6 3. Assessment of Outcomes .......................................................................................... 11 4. Assessment of Risk to Development Outcome......................................................... 15 5. Assessment of Bank and Borrower Performance ..................................................... 15 6. Lessons Learned ....................................................................................................... 17 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 18 Annex 1. Project Costs and Financing .......................................................................... 19 Annex 2. Outputs by Component ................................................................................. 20 Annex 3. Economic and Financial Analysis ................................................................. 23 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 26 Annex 5. Beneficiary Survey Results ........................................................................... 28 Annex 6. Stakeholder Workshop Report and Results................................................... 29 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 35 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 51 Annex 9. List of Supporting Documents ...................................................................... 60 MAP .............................................................................................................................. 61 iv MOLDOVA Avian Influenza Control and Human Pandemic Preparedness and Response (AIHP) Project as Part of the Global Program for Avian Influenza (GPAI) DATA SHEET A. Basic Information Avian Influenza Control & Human Pandemic Country: Moldova Project Name: Preparedness & Response Project IDA-41880,IDA- Project ID: P099841 L/C/TF Number(s): H2330,TF-56630,TF- 58241 ICR Date: 11/14/2011 ICR Type: Core ICR REPUBLIC OF Lending Instrument: ERL Borrower: MOLDOVA Original Total XDR 5.60M Disbursed Amount: XDR 5.60M Commitment: 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 Revised / Actual Process Date Process Original Date Date(s) Concept Review: 03/23/2006 Effectiveness: 09/12/2006 09/12/2006 04/20/2010 Appraisal: 04/19/2006 Restructuring(s): 02/08/2011 03/30/2011 Approval: 06/09/2006 Mid-term Review: 05/01/2008 09/15/2008 Closing: 12/31/2009 05/15/2011 v C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Moderate Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Rating Performance any) Potential Problem Project Quality at Entry Yes None at any time (Yes/No): (QEA): Problem Project at any time Quality of Supervision No None (Yes/No): (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Agricultural extension and research 12 12 Animal production 3 3 General public administration sector 43 43 Health 39 39 Other social services 3 3 Theme Code (as % of total Bank financing) Health system performance 14 14 Other communicable diseases 29 29 Participation and civic engagement 14 14 Pollution management and environmental health 14 14 Rural services and infrastructure 29 29 vi 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: Anatol Gobjila ICR Primary Author: 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) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years A Moldovan Government laboratory identifies the presence of HPAI in case of an Indicator 1 : outbreak of HPAI among poultry. Within 48 hours of Value sample collection, Capacity for quantitative or Zero diagnosis capacity. with 95% diagnosis exists. Qualitative) confidence. Date achieved 05/03/2006 03/31/2011 01/12/2010 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 05/03/2006 03/31/2011 12/01/2010 Comments Substantially achieved. (incl. % vii achievement) The Government compensates small farmers for culled birds in case of an outbreak of Indicator 3 : HPAI among poultry. Functionality of the compensation system Farmers are was fully tested Value No compensation compensated within during all three quantitative or mechanism in place. 10 days after simulation exercises Qualitative) containment. and farmers can be compensated within 10 days. Date achieved 05/30/2006 03/31/2011 12/01/2010 Comments (incl. % Achieved. achievement) A Moldovan Government laboratory identifies the presence of HPAI in case of an Indicator 4 : 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 05/30/2006 03/31/2011 12/01/2010 Comments (incl. % Achieved. achievement) Patients are transported safely and hospitalized in protected rooms in case of pandemic Indicator 5 : of HPAI among people. 100% of projected 100% of projected Value capacity for capacity for quantitative or Zero capacity. transportation and transportation and Qualitative) hospitalization is in hospitalization is in place. place. Date achieved 05/30/2006 03/31/2011 12/01/2010 Comments (incl. % Performance tested during H1N1 influenza outbreak. Achieved. achievement) Patient receives treatment appropriate to HPAI infection in case of pandemic of HPAI Indicator 6 : 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 05/30/2006 03/31/2011 12/01/2010 Comments The events related to the H1N1 pandemic indicate that the project contributed to (incl. % enhanced preparedness for patient treatment. achievement) viii (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised Target approval Completion or Values documents) Target Years Indicator 1 : Health facilities constructed, renovated and/or equipped. Value (quantitative 0 2 2 or Qualitative) Date achieved 05/30/2006 03/31/2011 12/01/2010 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. 500 500 or Qualitative) Date achieved 05/30/2006 03/31/2011 12/01/2010 Comments (incl. % 500 key staff in both ministries trained. achievement) Indicator 3 : Detailed and operational response plan delivered, simulation exercises conducted. 3 full simulation exercises on animal health response Value 3 simulation undertaken. Two full (quantitative Zero plans, 1 simulation. exercises. table-top exercises on or Qualitative) human health response have taken place. Date achieved 05/30/2006 03/31/2011 12/01/2010 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. A fully functional A fully functional and adequately Value and adequately funded (quantitative No fund exists. funded compensation compensation or Qualitative) mechanism is in mechanism is in place. place. Date achieved 05/30/2006 03/31/2011 12/01/2010 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. ix A very effective awareness and Value 15% of the activities under communications (quantitative a communication plan have Continuous. program was or Qualitative) been delivered. implemented for three years by UNICEF. Date achieved 05/30/2006 03/31/2011 12/01/2010 Comments Awareness and communications activities were implemented through respective (incl. % component activities. Fully delivered with raised awareness for communication by all achievement) 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. Equipment was delivered and installed in three Value Surveillance and refurbished (quantitative None delivered or trained. diagnosis capacity laboratories. or Qualitative) fully in place. Personnel trained by foreign specialists and laboratories are now fully functional. Date achieved 05/30/2006 03/31/2011 12/01/2010 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. All containment systems are operational. Equipment and materials have been Value Limited delivery and All containment procured and training (quantitative training. systems operational. on their use or Qualitative) delivered. Response capacity was tested successfully in a series of simulation exercises. Date achieved 05/30/2006 03/31/2011 12/01/2009 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 x (quantitative trained. fully in place. fully in place. or Qualitative) Laboratory personnel received training and the laboratories are fully functional. Date achieved 05/30/2006 03/31/2011 12/01/2009 Comments Rechecking of samples at London WHO reference lab has shown 98% accuracy of tests. (incl. % Substantially achieved. achievement) Equipment for the isolation intensive care room delivered to and installed in Toma Indicator 9 : Ciorba Hospital, Personnel trained. All systems for care and treatment are Value All systems for care operational. The ICU No equipment delivered, no (quantitative and treatment are was commissioned staff trained. or Qualitative) operational. and is now functional. Training of staff completed. Date achieved 05/30/2006 03/31/2011 12/01/2009 Comments (incl. % Capacity building and training for hospitals continues. achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 12/11/2006 Satisfactory Satisfactory 0.50 2 06/20/2007 Satisfactory Satisfactory 0.67 3 05/06/2008 Satisfactory Moderately Satisfactory 1.90 4 11/23/2008 Satisfactory Moderately Satisfactory 2.65 5 07/04/2009 Satisfactory Satisfactory 4.83 6 11/30/2009 Satisfactory Satisfactory 5.25 7 06/15/2010 Satisfactory Satisfactory 6.38 8 01/04/2011 Satisfactory Satisfactory 7.23 H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Restructuring Disbursed at Reason for Restructuring & Key Approved PDO Date(s) Restructuring Changes Made Change DO IP in USD millions Reallocation of resources for compensation fund towards further 04/20/2010 N S S 6.23 investments in animal and human health in line with PDO Reallocation of resources from the 02/08/2011 N S S 7.43 compensation fund category towards further investments in xi ISR Ratings at Amount Board Restructuring Restructuring Disbursed at Reason for Restructuring & Key Approved PDO Date(s) Restructuring Changes Made Change DO IP in USD millions animal and human health in line with PDO. 03/30/2011 S S 7.91 Closing date extension. I. Disbursement Profile xii 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 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 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 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 sub- component 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 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, on- going 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, 2009. 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 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 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 2009-10, 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 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 micro- biological 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 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 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 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 3.2 Achievement of Project Development Objectives The Project substantially achieved its objective in preparing the ground to mitigate the impact from an epizootic outbreak by taking measures to minimize contagion in animals and humans, and developed the necessary inter-sector surveillance and diagnostic systems for this purpose. There is strong evidence that procedures introduced under this Project have improved the country’s overall response in handling epidemiological emergencies. The promptness with which Moldova managed to properly diagnose H1N1 virus in the fall of 2009 and take measures to treat patients and mitigate contagion is a reflection of the human health system’s improved capacity. The links that were established across the various concerned subsectors, the raised awareness with a view of zoonoses not only as animal-health related issue but of concern for public health will be crucial to improve the manage the waves of chronic diseases such as rabies or brucellosis that affect animal and humans if infected animals are improperly handled. Component I - Animal health – The activities under the animal health component have dramatically improved the capacity for sampling, diagnosis and analysis at the regional and central level. The Project has also helped in helping to establish a better baseline of information with the completion of the wild fowl study and the expanding of the existing livestock registry to also include poultry. Such a registry is the foundation for effective disease tracking and animal movement control necessary for containment in case of an epidemic outbreak. They are increasingly becoming a basic requirement for the trade of animal by-products with the EU but also to abide by the “codex alimentarius�. The strategic approach in establishing regional laboratory capacity and converting district laboratories into sampling stations ensures adequate flows of samples and brings economies of scale that ensure adequately trained personnel with adequately equipped and laboratories capable of handling highly pathogenic material and provide accurate diagnosis. This approach in strengthening capacity has been backstopped with effective containment and eradication measures. A series of three simulations have shown that in a case of a pandemic outbreak, diagnosis, management of contagion and culling measures, and compensation of farmers are all achieved in an acceptable timeframe to successfully contain it. Component II - Human Health – All activities under this component have been substantially delivered. The health sector had already undergone substantial reforms to optimize the resources available by increasing family preventive care. The Project supported this ongoing effort with substantial legislation, implementation of regulation and updated SOPs so as to improve planning and coordination efforts among the various players in the health sector, and emergency services. Improved collection, transport, and testing of samples, improved ambulance and ICU services, as well as reporting with computerized interconnection have dramatically enhanced surveillance and cut down response times to health emergencies in general. The Project imported critically needed vaccine quantities to safeguard the most at risk personnel of the health services and to treat patients who have been diagnosed and those who fall in high risk categories, elderly and children. 12 Component III- Public Information and Awareness - The public awareness component is considered to have largely satisfactory outcomes that are confirmed buy KAP surveys. These surveys were carried out with regularity and aimed to gauge the efficiency of various project- supported information delivery techniques, as well as the attitudinal impact they had on target audiences. The final KAP survey done at the end of the Project (March, 2011) showed generally elevated levels of knowledge, cognizance and behavior change on matters related to AI, H1N1 and seasonal influenza. The last KAP survey also indicated solid quantitative improvements on selected reported awareness and behavior parameters (two to threefold) compared to levels at the beginning of the Project. At closing, a share of 90% of the respondents reported awareness about all three types of influenza assessed during the study, and were able to identify their main symptoms. Seventy percent of those reached by the project-supported media interventions have reported behavior and attitude changes at least for some key prevention aspects. Specifically for AI, more than 50% of the respondents were able to correctly identify the main symptoms and the main prevention measures. Reported adoption rates for prevention practices related to bio-safe handling of backyard poultry have stabilized at 30% - 60%, down from earlier assessments, but in line with expectations resulting from a general reduction in salience of AI risks since 2008. More information on the results of the last KAP survey is presented in Annex 5. 3.3 Efficiency The original project economic analysis took a probabilistic approach of events and used relatively low probability factors to make a quantitative estimation of project benefits mitigating the impact of potential outbreaks in the veterinary and human health sector. The factors were then applied to estimate the value of lost work, hospitalization, and loss of life in case of a pandemic outbreak. It would be reasonable to assume that these figures would be valid for all other cases where the investments have reduced any other of the above factors. Using this very conservative methodology, the Project had an estimated rate of return of 23%. The calculation did not attempt to quantify separately the benefits stemming from improved awareness and information, nor the improved response to emergencies as a result of the Project, although they are likely to be substantial. Experience shows that adequate public awareness resulting in behavioral response can play a major role in limiting disease contagion. This similarly applies to the animal health sector where farmers who are aware of good animal husbandry practices can play a key role in the containment of zoonoses and reduce contagion. The benefits in the health care system from the investments in hospital ICU, laboratory, ambulances and respirators are already credited for having saved a number of lives. The development of a modern IT based health information system will not only help improve tracking of disease, but also play a role in effective matching of capacities with demand for resources in case of pandemic. The statistical information from the system will eventually provide the basis for a more risk based approach in strategic deployment of health sector investments. The refurbished veterinary facilities and laboratories provide benefits beyond the ability to diagnose and manage an AI outbreak. The reforms underway concentrating resources on two well-equipped and staffed regional veterinary laboratories that will have a broader mandate to also play a key role in the implementation of EU compliant food safety measures will ensure a 13 revenue stream to these facilities. In addition they will also play a key role in opening the EU markets to exports in livestock products originating from Moldova. As such their economic impact will be far beyond the limited impact they are playing in preventing the spread of epidemics and directly contribute to income generation in the country. Due to lack of a baseline, and unclear data on current trade, the ICR did not attempt to calculate the quantitative benefit from this improved opportunity. Finally, implementation was primarily executed through the concerned ministries and agencies assigning staff dedicated to ensuring the implementation of project activities under their mandate. This substantially reduced implementation costs and helped with embedding capacity. 3.4 Justification of Overall Outcome Rating Rating: Satisfactory The achievement of the outcomes of the Project is generally satisfactory. The objectives and design were and remain relevant. In spite of some delays and a project closing date extension of 16.5 months, the development objective was substantially achieved. The project components made a significant contribution towards strengthening capacity in animal and human health, and the equipment installed with the country’s emergency response services helps improve preparedness and response capacity. The country has substantially improved diagnostic capacity thanks to the improved laboratories. With its newly developed health information system, Moldova is able to participate as an effective partner in the WHO’s international flu reporting systems that play a key role in locating, alerting and triggering measures worldwide to prevent emerging pandemics. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development Pandemics and disasters hit the poor the hardest. Loss of health or loss of their livestock is often catastrophic for the poor even if the total financial value of the loss might be less than for wealthier households or commercial operations. This Project, by mitigating theses losses de facto is pro poor. Since rural areas in Moldova like much of the rest of ECA have substantial migration to the cities and abroad for employment, the interventions under this project substantially benefit poor rural households. It needs to be further noted that backyard poultry are primarily under the care of the women in the household, and the sale of eggs often is one of the very few opportunities for them to earn some money. (b) Institutional Change/Strengthening The Project investments were used as catalyst to build capacity in both animal and human health. In the human health sector this was achieved by targeting assistance towards improved diagnostic, ambulatory and ICU services, and establishing a modern health information system that links districts with the center to reduce epidemiological response time. 14 In the animal health sector, the improved laboratory capacity will help with the emerging agenda related to improved food safety in the country but also as a tool to improve access of livestock products and live animals to EU export markets. (c) Other Unintended Outcomes and Impacts (positive or negative) A major positive outcome from the Project is the increased awareness at MAFI and MOH that animal health and human health are not mutually exclusive disciplines. There is a growing realization that poor animal health and lack of knowledge of zoonooses can have nefarious impacts on humans as well. This increased awareness will help both ministries to develop campaigns that can more effectively address public health as it relates to the handling of diseased animals, animal waste, or dead livestock. Also, simple precautionary measures are much better disseminated to the public than they were before the Project. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops A summary of such findings is provided in Annex 6. 4. Assessment of Risk to Development Outcome Rating: Moderate Because the Project investments were made with a strategic view towards further development and modernization and closer integration towards the EU, the risk to the development outcome remain moderate. The investments are integrated in a greater reform agenda that benefits from support by the Bank but also other donors and the EU specifically. The veterinary laboratories will play a key role toward meeting EU sanitary and phytosanitary requirements and the Codex Alimentarius. In human health investments in better diagnostic capacity and emergency patient care and ambulance services, as well as the health information system will all contribute to better health outcomes and improved capacity to deal with emergency epidemiological outbreaks while providing opportunities for cost savings by targeting resources where they are most needed. In both cases, as part of bigger ongoing reforms the necessary resources to maintain the investments that have been made under the Project are likely to be assured. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Satisfactory The Project did not undergo a formal assessment of its quality at entry by QAG. Nonetheless, while the Project itself was complex, overall coordination across sectors and ministries was successful due to in no small part the appointment of the multi agency Technical Working Group 15 and the decision to have implementation coordinated through a strong unit with extensive experience. Ultimately, the project helped develop regulations and operating procedures that improve the capacity of the country to tackle future emergencies. While coordinating with international agencies, the WHO, FAO, UNICEF, USAID and the EC proved complicated and time consuming, these agencies not only provided funding but helped bring the country into the international sphere with improved disease information exchange and assurance of longer term sustainability of Project investments in the framework of overall reforms. Overall, project risks were assessed properly and adequate mitigation measures were taken to ensure that the Project remained on track and delivered against the PDO. (b) Quality of Supervision (including fiduciary and safeguards policies) Rating: Satisfactory With the Task Team Leader based in the country, the supervision team was able to provide immediate responses to troubleshoot implementation problems. Supervision of the Project was regular and frequent, based on good working relationships with partner agencies. Visiting supervision teams were composed of subsector specialists with practical experience and advice. Mission aide-memoires were informative and well prepared, highlighting implementation problems to Government and implementing partners in a timely manner. Project restructuring late in the implementation cycle to reallocate the resources under the Compensation Fund responded to a real need for scaling up basic laboratory equipment, ambulances and vehicles for safe transportation of samples, strengthening the impact of the Project towards it development objectives. Overall the project management correctly focused on critical priorities, yet remained strategic with its investments, well coordinated with activities funded by other donors and properly geared toward the needs and implementation capacities of targeted institutions. (c) Justification of Rating for Overall Bank Performance Overall Bank performance for the Project as a whole is rated satisfactory. The Bank was a responsive partner and provided useful guidance when required, while leaving the client in charge of the overall selection of priorities within the overall project development objective. 5.2 Borrower Performance (a) Government Performance Rating: Satisfactory The Government overall performance has been satisfactory. The Project was implemented during quite turbulent political times with a number of changes at the top, however, the purposes and objectives of the Project and decisions for retargeting investments and activities were supported at the political level throughout the implementation period. 16 (b) Implementing Agency or Agencies Performance Rating: Satisfactory Project management was entrusted to a strong management unit that had a lot of experience and did a good job at managing processes and contracts supported by dedicated coordinators that were appointed early in the Project by both MAFI and MOH. Albeit the start was a bit slow until everyone knew their function and role, the Project managed to substantially complete its activities and even more than originally envisaged. The performance of MAFI and MOH was constructive and highly facilitative, leading to solid results on all components. (c) Justification of Rating for Overall Borrower Performance Rating: Satisfactory Overall decisions and inputs were timely. The Borrower played an active role in structuring the Project in such a manner as to maximize its impact, and gear it towards providing a step stool for further important reforms or consolidating reforms that have been on-going. Implementation decisions and continuity of staffing at key posts responsible for implementation have been in line with project objectives, and with overall reforms the health and veterinary sector have been going through. 6. Lessons Learned Effective coordination of operations such as this one that are conceived more along the shape of emergency interventions might have a substantially higher impact when integrated in overall sector reforms. In Moldova, the investments in veterinary laboratories provide the footing for increased food safety testing to help improve trade with it European neighbors. In the health sector, the information system will help with early detection of contagious outbreaks and target response and resources to where they are most needed. In both cases the impact is well beyond the immediate and limited project objectives and provides assurances towards effective use and sustainability of the investments. While effective coordination between all stakeholders leads to greater impact and sustainability, reaching consensus is time consuming. Optimizing coordination cannot be effectively completed within the typical timeframe of an emergency project. The Project’s original implementation period of less than 3 years for what essentially was an institutional reform project was unrealistic. While it may appear desirable and pragmatic to take advantage of already available buildings and infrastructure, in cases of facilities such as laboratories and hospital wards, the actual remedial costs of structural issues can be prohibitive. This is particularly applicable to laboratories and hospital facilities that deal with highly pathogenic and contagious materials that have to abide by international standards not only on processing samples and treating patients in relatively clean environment, but also concerning the handling and disposal of potentially 17 contagious waste materials. A new construction with new footers and ground structure, designed with layouts that correspond to very detailed work flow processes might be preferable financially when longer term costs for maintenance are also taken into account. Procurement of laboratory and hospital equipment is highly specialized and depends on adequate technical knowledge at the level of implementation units and counterpart ministries or agencies. It is advisable to have specialized technical consultants at hand to help with developing precise technical specifications for such equipment in line with national and international requirements. Multi-sector operations such as this one even though prepared as emergency support require sufficient time to be implemented. While many specific emergency response activities (e.g., procurement of protective gear, equipment, consumables) can be carried out quickly, institutional strengthening and coordination and capacity building take time. Critical response mechanisms can be put in place in three years, however, unless tied into an overall program, significant institutional reforms that require yearly budget commitments carry a significant risk in terms of sustainability. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies A summary of the Borrower’s assessment of the implementation of the Project is contained in Annex 7. No specific issues were raised by the Borrower. (b) Co-financiers No issues were raised by co-financiers. (c) Other partners and stakeholders UNICEF has provided a report on its public awareness building activities undertaken as part of the Project. It is attached in Annex 8. 18 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) Total Baseline Cost 9.15 10.75 Physical Contingencies 1.25 0.00 0.00 Price Contingencies 0.20 0.00 0.00 Total Project Costs 10.60 10.75 Front-end fee PPF 0.00 0.00 0.00 Front-end fee IBRD 0.00 0.00 100.01 Total Financing Required 10.60 10.75 (b) Financing Appraisal Actual/Latest Type of Percentage of Source of Funds Estimate Estimate Co-financing Appraisal (USD millions) (USD millions) US: Agency for International 0.35 0.35 100.00 Development (USAID) Borrower 0.75 0.00 0.00 EC: European Commission 1.00 1.00 100.00 International Development 4.00 4.45 111.25 Association (IDA) IDA Grant 4.00 4.45 111.25 JAPAN: Ministry of Finance - PHRD 0.50 0.50 100.00 Grants 19 Annex 2. Outputs by Component Below are the actual outputs of the project, detailed contract lists have been provided as part of the client’s contribution to the ICR in Annex 5. Human Health: The Ministry of Health and the National Center for Preventive Medicine (NCPM) were the lead implementing agencies for this project component, with a Component Coordinator to manage day-to-day tasks and keep the overall work program on track 1. Development of SOPs, Intra-Hospital Infection Control and Infection Treatment Guidelines. SOPs, clinical management and intra-hospital infection control guidelines were prepared. The clinical guidelines and clinical pathways were completed and include clinical management of pandemic influenza. These guidelines were the basis for training of field epidemiologist, rapid response teams and primary health care workers. A series of table-top exercises where implemented to train health practitioners in the application of the new guidelines and procedures. 2. Rapid Response Teams. MOH has established regional and local rapid response teams for outbreak investigation. These teams were trained raining and equipped with vehicles and personal protective equipment and kits of sampling equipment and coolers and containers to safely transport samples. 3. Shipment of Specimens to Reference Laboratory. Moldova has sent several suspected HPAI specimens to the WHO reference laboratory in the UK. Three specialists from the human health and two from the animal health sector attended International Air Transport Agency (IATA) training in Ankara and obtained their IATA certificate to package contagious specimens for shipment by air. 4. Training of Human Resources for the National Viral Laboratory. The project supported training in Naval Medical Research Unit 3, where two technicians were trained in the use of Polymerase Chain Reaction (PCR) equipment; WHO provided PCR training in Copenhagen in August 2008; and USAID organized training in quality management (for ISO standards). 5. Refurbishment of the ICU at Toma Ciorba Republican Hospital. Plans for construction of the ICU and the laboratory facilities were prepared and underwent lengthy consultations to agree on an adequate buildings where the medical treatment of suspected HPAI cases should take place, where specimens are to be taken, and what procedures are to be performed in the laboratory. The result of this extensive consultation led to the conclusion of the following investments in this sector: • The complete reconstruction of the infectious disease ward at the Toma Ciorba Hospital with modern ICU facilities and accommodations also for patient transport. This included the acquisition of modern ambulances for patient transport from regional hospitals. • The renovation of the country’s National Viral Laboratory NVL was completed in March 2010, and it is now amongst the most modern laboratories in the region. Extensive training to laboratory staff was provided by individual consultants and through training visits to laboratories in other countries. 6. Computer-Based Surveillance System. Although the Project provided only modest financial support for IT surveillance, the results of these investments are outstanding and provide the structure for further IT development in the human health sector. A reporting system from the primary care level was 20 installed at more than 250 locations, including laboratories, Public Health Centers (PHC) clinics and all raion-level epidemiological services. With this system in place, Moldova is now able to monitor the status of infectious diseases at the central level in “real time�. The system development included (i) the training for administrators, (ii) the development of data formats and software modules for data import/export, and (iii) the production of the final version of the software for distribution. 7. Vaccines. Altogether some 500,000 doses of vaccine were obtained as a donation from Romania and an additional 120.000 doses were obtained with support from the WHO. Some six hundred and twenty thousand people were vaccinated, which is among the highest in the world. This achievement was due to coherent and coordinated response from the government, an effective public information campaign that involved the highest authorities in the country who used TV and other mass media to quell rumors and concerns about vaccination safety. The vaccination of a number of high-level officials was televised, demonstrating leadership and commitment. Animal Health: 8. Regional Laboratory Renovations. The southern regional laboratory in Cahul and the northern regional laboratory in Drochia, have both been rehabilitated and in the case of Drochia expanded. This includes the provision of a trailer in each location to pick up suspect animals or carcasses. 9. Incinerators. Diesel-fired incinerators with a load capacity of 100 kg for the Cahul and Drochia laboratories and 200 kg capacity for the central laboratory for safe disposal of laboratory wastes were procured and made operational in line with prevailing environmental conditions. 10. Generators and Voltage Regulators. Diesel-powered stand-by generators were installed at both regional laboratories and the central laboratory. The electrical equipment at the laboratories included the installation of voltage regulators in both regional laboratories. 11. Veterinary Border Quarantine Posts. Upgrades of seven border quarantine posts have been completed. Disinfectant spraying devices have been installed and include (i) water pumps and their connection to available water supplies, (ii) plastic disinfectant tanks, and (iii) effluent drainage facilities. 12. Training Epidemiologists in Computerized Analysis of Disease Information. Basic computer training was completed, and six central and 27 raion-level epidemiologists were trained in case study management and basic epidemiology, respectively. Six desk-top computers were procured and placed in the Central Epidemiology Unit at the Epidemiology Department of the University of Agriculture, where they are used for hands-on training of government epidemiologists and of veterinary students. 13. Epidemiology and Risk Assessment. A package of training and teaching modules was developed in collaboration with the Department of Epizootology of the Faculty of Veterinary Medicine at the State Agricultural University of Moldova. The State Veterinary Department was the primary beneficiary. This included a capacity-building package in epidemiology delivered by an international institution from Finland. 14. Poultry Sector Bio-security and Risk Management Study and Training. A bio-security training program, based on a comprehensive study on risks and supported by a directive from MAFI was completed for veterinary stakeholders and commercial poultry holders. 15. Module linking poultry producers with the Animal Identification and Tracing System (SITA). The SITA database developed with support from EU has been complemented with a module to integrate poultry holders in to the registry, and to link it with the animal disease surveillance system so as to facilitate the detection of HPAI and other disease outbreaks. 21 16. Central Veterinary Laboratory Renovation. The project contributed to the completion of the full renovation of the Animal Health Laboratory of the Republican Center for Veterinary Diagnostics. The works included installation of utilities, water, heating and electrical systems, refurbishing floors and walls, and installing an elevator. 17. Culling Compensation. The necessary documentation and procedures for compensation of households in case of the need for a culling campaign have been developed. No funds were disbursed from the fund and resources were reallocated. 18. Disease Control and Containment. Real-time simulation exercises have been undertaken by the State Veterinary Department, in conjunction with human health counterparts, and other primary stakeholders for containing and managing HPAI outbreaks. Public Awareness and Information 19. Public awareness campaign. Under contract through MOH, UNICEF Moldova has designed and implemented a multi-pronged and effective public awareness and information program within the project framework including: (a) a media campaign for radio and television, including graphic materials on basic sanitation, preventing seasonal influenza, and bio-safety at the backyard level, using animation techniques and video dramatizations; (b) workshops for health managers, veterinarians, local public administrators, church leaders, and peer educators (students, school children, journalists) on effective communication for health promotion, healthy lifestyles and basic outbreak management procedures; (c) capacity building for high-level officials, civil servants in various ministries, health officials, medical professors, family health practitioners and veterinarians in basic communication skills regarding “Behavior Change and Risk Communication�, (d) publications and training for MOH, the National Rural Developemnt Agency, physicians, journalists, virologist, epidemiologists, veterinarians, mayors, peer educators and school children, and (e) support for developing the MOH information and response system through the establishment of a hot-line service for public health emergencies. 20. A Knowledge-Attitude-and-Practices (KAP) survey was carried out with about 1100 individuals in August 2009. Another KAP was conducted 2 years later targeting communities with high risk of HPAI and high past communication and information efforts. 21. A series of training events by international media experts for high-level officials and senior specialists on effective public information and media contacts was organized with MOH as lead agency. Information guidelines on (i) seasonal influenza and (ii) pandemic influenza, for which MOH and NCPM were also printed. 22 Annex 3. Economic and Financial Analysis (including assumptions in the analysis) The original project economic and financial analysis focused on the probability of events and used relatively low probability factors to make a quantitative estimation of project benefits. The prevention and control of outbreaks could be regarded as probabilistic events. The project would reduce the costs of an outbreak (among poultry, or human), should it occur, by minimizing the chances of it from spreading further. Whether wild birds in Moldova would infect poultry was and still remains uncertain, and this uncertainty remains defined as a probability, as is the spread of the Avian Influenza to the general poultry population. Similarly, the infection rate of people directly exposed to the virus would also be a probability estimate. Unfortunately, there were not then, nor are there now any reliable estimates for these probabilities. The original economic analysis further recognized the attribution problem related to the difficulty to assess the impact of the Project on outcomes for either poultry or people Estimates for Infection of poultry were based on the chain of probabilities involved in the spread of HPAI to poultry and the potential for the Project to reduce these probabilities. The probabilities were subjective estimates of the Appraisal Mission. The column labeled ‘main’ shows the most likely scenario. Table 1 presents a ‘Low’ case scenario in line with the mandate to conduct a sensitivity analysis. In the Low case scenario, risks of an outbreak were considered relatively low and the impact of the Project on reducing these risks were similarly estimated on the low side. Table 1. Probabilities of the Spread of HPAI in Poultry, With and Without Project (in percentage points) Scenarios Main Low Without Project, assumptions about probabilities Single & limited outbreak among poultry 95% 90% Generalized spread of the outbreak among poultry 50% 40% With Project, reduction in without Project probabilities Reduction in mortality of generalized spread of outbreak 0% 0% Reduction in probability of a single limited outbreak among poultry 50% 25% Joint probabilities: Without Project: Generalized outbreak among poultry 47.5% 36.0% With Project: Generalized outbreak among poultry 23.8% 27.0% Source: World Bank. In the Main scenario, implementation of the project was to lead to a fall in the probability of a generalized outbreak among poultry from about 48% to 24%. In the low scenario the proportional impact of the project is smaller; implementation of the project was to lead to a fall in the probability of a generalized outbreak among poultry from 36% to 27%. The impact of implementation of the project was expressed in terms of a reduction in the expected value of poultry lost to Avian Influenza and to culling (Annex Table 9.2). In the main scenario, the loss of poultry falls from $69 to $35 million (this is computed by applying the probabilities from Table 1 to the market value of the birds). Using these probability estimates the rate of return for a US$10.6 million project is high, even when only the cost in lost poultry is considered and combined with a relatively low 23 risk reduction resulting from the project. In the main case, the rate of return is 226%, and in the low case the rate falls to 23%. Table 2. Expected Value of Lost Poultry With and Without Project and Rates of Return (in millions of U S dollars) Scenarios Main Low Without Project $69 $52 With Project $35 $39 Project rate of return from loss of poultry avoided 226% 23% Source: World Bank. It was assumed that humans usually resist infection by existing strains of HPAI (Source: WHO), and the number of infections and deaths from an outbreak in Moldova would probably be small. There had not been and there are still no recorded fatalities from HPAI in the ECA region. However, a possible mutation of the virus could raise infection and mortality rates significantly, to the estimated figures shown in Table 3 below. The Project was to reduce modestly the probabilities of infection, hospitalization, and mortality, by some 30% to 15%. Given these assumptions, the Project would reduce the probability of death of exposed people from 0.5% to 0.2% as reflected in the main scenario. Table 3. Probabilities of Mortality and Morbidity in case of a Worldwide Pandemic (in percentage points) Scenarios Main Minus Without Project, assumptions about probabilities Infection o f exposed people 30% 50% Hospitalization o f infected people 10% 15% Mortality of hospitalized people 15% 25% With Project, reduction in without Project probabilities Reduction in probability of infection 30% 15% Reduction in probability of hospitalization 30% 15% Reduction in probability of mortality 30% 15% Compound probabilities: Without Project: Probability of mortality of exposed people 0.5% 1.9% With Project: Probability of mortality of exposed people 0.2% 1.2% Source: World Bank. The probabilities in Table 3 were used to compute estimated economic costs of a generalized pandemic among people (Table 4). The scenarios are speculative since this is an evaluation of costs of infection by a virus which may become infectious between human through adaptation and mutation and does not yet exist. Te assumption was that that about half the residential population of 3.5 million would be exposed to a new form of Avian Influenza and that on average, infected people would lose 6 days of work, and that hospitalization would also last for six days. Lost labor was evaluated at the average daily wage and the cost of hospitalization was evaluated at the average daily cost of hospital treatment for pneumonia. Lives lost are valued as the present discounted value of 20 years of earning of the average national wage, discounted at 8%. The results are illustrative, but do show that implementation of the Project, under the assumptions of Table 3 and 4, would reduce total costs in both the main and low case scenarios. Table 4. Expected Value of Lost Work, of Hospitalization, and of Lost Life, During a General Human Pandemic, With and Without Project (in millions of US dollars) Scenarios Main Low 24 Without Project Labor income lost $ 9 $ 15 Life lost $148 $618 Total without Project $162 $644 With Project Labor income lost $ 6 $ 13 Life lost $ 51 $380 Total with Project $ 59 $400 Cost of hospitalization $ 4 $ 11 Cost of hospitalization $ 2 $ 8 Efficiency. The Project has not contemplated significant new hiring as part of its activities. The Government continues to pay the salaries of the veterinarians, technicians, nurses, doctors, and other staff engaged in prevention and containment of Avian Influenza. However, the restructuring of the veterinary laboratory structure to two regional and one central laboratory, as well as the improvements resulting from an improved health information system will both help in refocusing and optimizing budgetary resources to where the needs are greatest and capacity is most readily available. The refurbished veterinary facilities and laboratories provide benefits beyond the ability to diagnose and manage an Avian Influenza outbreak. The reforms underway concentrating resources on two well equipped and staffed regional veterinary laboratories that will have a broader mandate to also play a key role in the implementation of EU compliant food safety measures will have benefits well beyond the project. They will play a key role in opening the EU markets to exports in livestock and poultry products originating from Moldova. As such their economic impact will be far beyond the limited impact they are playing in preventing the spread of epidemics and directly contribute to the generation of income in the country. The benefits in the health care sector from the investments in hospital ICU, laboratories, ambulances are already credited for having saved lives of people suffering from various respiratory and infectious. 25 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Anatol Gobijla Senior Operations Officer ECSS3 Task Team Leader Rob Coenraad de Rooij Consultant ECSSD Animal Health Gotz A. Schreiber Consultant ECSSD Compensation Fund Anna L Wielogorska Senior Procurement Specialist EAPPR Procurement Irina Babich Financial Management Specialist ECSO3 Financial Management Daria Goldstein Sr. Counsel LEGAF Team Lawyer Natalia Cherevatova Operations Analyst SEGOM Team Assistant Arcadii Capcelea Sr. Environmental Spec. ECSS3 Safeguards Menahem Prywes Sr. Economist ECSH3 Human Health Jose-Manuel Bassat Communications Advisor WBIOP Communications Supervision/ICR Anatol Gobijla Senior Operations Officer ECSS3 Task Team Leader Nedim Jaganjac Sr. Health Specialist ECSH1 Human Health Rob Coenraad de Rooij Consultant ECSSD Animal Health John Bashiruddin Consultant ECSSD Laboratory Expert Abraham C. Brandenburg Consultant EASNS Animal Health Jose-Manuel Bassat Communications Advisor WBIOP Communications Mario E. Bravo Sr. Communications Officer EXTOC Communications Zlatan Sabic Consultant ECSSD Information Systems Gotz A. Schreiber Consultant ECSSD Compensation Fund Natalia Cherevatova Operations Analyst SEGOM Team Assistant Arcadii Capcelea Sr. Environmental Spec. ECSS3 Safeguards Anna L Wielogorska Senior Procurement Specialist EAPPR Procurement Yingwei Wu Senior Procurement Specialist LCSPT Procurement Kashmira Daruwalla Senior Procurement Specialist ECSO2 Procurement Andrei Busuioc Financial Management Specialist ECCAT FM Supervision Ruxandra Costache Counsel LEGEM Team Lawyer Daniel Gerber Rural Development Specialist ECSS1 ICR Author (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY06 138.84 FY07 0.00 FY08 0.23 Total: 139.07 26 Supervision/ICR FY06 1.80 FY07 137.91 FY08 104.53 Total: 244.24 27 Annex 5. Beneficiary Survey Results KAP surveys were undertaken under the project as part of the public awareness work financed under the project (all surveys are contained in the project files). The final KAP survey was carried out in March, 2010. It focused on assessing the Project’s efficiency in reaching the public with information on avian, seasonal and pandemic (H1N1) influenzas and the ensuing impact. The first KAP survey served as the baseline. The last one generally indicates solid (two to threefold) quantitative improvements in reported awareness. The main conclusions of the last KAP survey are as follows: • A share of 90% of the respondents was aware of all three types of influenza assessed during the study: avian, pandemic and seasonal; • Close to 90% of the respondents have correctly identified the main influenza symptoms; • More than 50% of the respondents have correctly identified the main AI symptoms and the main prevention measures; • Over 85% of the respondents have indicated that they have heard or seen radio, TV and other media supported information on avian, seasonal and pandemic influenzas (entirely project interventions); • Approximately 70% of those that were reached by these media messages have reported behavior and attitudinal changes for some key prevention aspects. • Unfortunately, some prevention aspects for AI, mainly confinement of poultry and sanitary practices, have only reportedly changed for 30 to 50% of those reached by awareness messages. An explaining factor is the diminishing salience of AI risks since 2008, and the advent of other non-zoonotic influenza strains. • Awareness about risks, symptoms and prevention measures amongst health practitioners is at 90-95% rates, as a result of the Project supported interventions. 28 Annex 6. Stakeholder Workshop Report and results (presentation on human health achievements to stakeholders at regional level) Evaluation of the Objective, Proposal, Implementation and Operational Experience  Purpose: To strengthen the response capacity of Republic of Moldova to potential outbreak of avian influenza and pandemic influenza.  The overall objective: to minimize the damages of HPAI to the population. The project will support the monitoring of disease outbreaks, preparation for responding to potential disease outbreaks in humans and animals and their control. 1.Unsatisfactory 2. Average 3.Satisfactory 4. Highly satisfactory X Expected Project Outcomes under Human Health Component  Revision and implementation of the regulatory system;  A state laboratory in Moldova will identify the existence of HPAI;  Purchase of testing equipment and staff training to use it, purchase of protective clothing and materials, and  Patients are transported safely and hospitalized in protected rooms;  Patients receive appropriate treatment for HPAI;  Public awareness and information campaign about HPAI. 29 Human Health Outcomes: • National Pandemic Preparedness Plan – revised and updated according to WHO recommendations and approved by the Government ( GD no.824, of 15.12.2009); Regulatory • Development of practical guidelines necessary for the surveillance, diagnosis and treatment of avian, System seasonal and pandemic flu; • “Laboratory Biosafety Guidelines� and “Guidelines for the Safe Transport of Infectious Substances� – developed according to WHO recommendations. • A specialized information system was developed and implemented for the epidemiologic surveillance of infectious diseases; Surveillance System • 287 people trained within the training program “Using the operationsystem and the specialized software� in 2009. • Specialized website www.gripa.md developed, • Audio and video spots broadcasted Communication • Information materials and posters - distributed, activities • Specialized publications developed and placed on the website; • Messages on health promotion (mobile phones) – sent; • “Attention! Flu!� – produces. Human Health Outcomes: • Viral Respiratory Infections Laboratory – renovated and provided with equipment and furniture meeting BSL 2 requirmenets; • Module for the molecular diagnosis of avian influenza built and supplied with equipment and new furniture according to BSL 2+ requirements Strengthening • Laboratory staff - trained in sample collecting, biosecurity, isolation and typing of viruses; laboratory capacity • POS in laboratory techniques and biosafety manual - developed; • Participation in WHO programs of external quality control of laboratory investigations (4 rounds); • Over 200 clinical samples sent to WHO Collaborating Centres for Influenza in London (three times). • Intensive Care Unit renovated and equipped with specialized medical equipment and furniture; • 3 ambulances with specialized medical equipment; Strengthening • 3 field vehicles for rapid intervention teams - purchased; the capacity of quick • A car with oven - purchased; intervention • 20 fans for ICU and 38 pulse-oxymetres - purchased; and infection control • 2 termoscanners – purchased; • EPP and device for hands disinfection – purchased; • Antiflu vaccine and antiflu medicines – purchased; • Standards procedures for infection control – developed. 30 Evaluation of Project Outcomes against the Objectives Set Out under the Human Health Component 1.Unsatisfactory 2. Average 3.Satisfactory 4. Highly satisfactory X Expected Project Outcomes under Animal Health Component  A state laboratory in Moldova will identify the existence of HPAI;  The government will cull the poultry from the point of infection and will establish a protection zone with the participation of local authorities and population;  Testing equipment and staff training to use it, purchase of protective clothing and materials, and  The Government provides compensation to small farmers for the culled poultry. 31 Animal Health Outcomes: •Renovation and modernization of three laboratories: Laboratory of Veterinary Diagnostic Center in Chisinau and two satellite laboratories in Cahul and Drochia; • Reconstruction of the necropsy room of Veterinary Diagnostic Center; Fortificarea capacităţilor • Imuno-tester ELISA, Disinfectant (30 tons), putties and diagnosis devices for the laboratory, de laborator Computers and office equipment for central laboratory and the 2 regional laboratories, office furniture for the laboratories, electric generators and UPS for central and regional laboratories; • 2 units for samples‘ transportation. • Installation of disinfection systems in 7 customs checkpoints (Briceni, Leuseni, Sculeni, Tudora, Giurgiulesti, Lipcani, Criva); Fortificarea capacităţilor • Personal protective equipment, disinfection equipment: manual and motor sprinklers and 3 high de intervenţie pressure washing machines with hot water; rapidă şi controlul • Four trucks for disinfection; infecţiei • 3 incinerators with the capacity of 50 kg/hour for the 3 laboratories. Animal Health Outcomes: • 2 Avian flu simulation seminars with one week duration; •Applied epidemiology and data analysis training (in 2008,2009 and 2010) for central and rayonal level epidemiological staff; Training •Seminar for veterinarians on implementation of new animal health legislation; •Aviculture research and inventorying of migration birds on the territory of the Republic of Moldova; •Training abroad (România, Russia, Turkey, Letonia, Egipt etc.) for staff of the state veterinary service. • The Government proved its preparedness for provision of Compensation Fund compensations to small partners for the culled poultry despite the economic crisis. 32 Evaluation of Project Outcomes against the Objectives Set Out under the Animal Health Component 1.Unsatisfactory 2. Average 3.Satisfactory 4. Highly satisfactory X Evaluation of own performance during project preparation and implementation, with particular emphasis on lessons learned that may be useful in the future 1.Unsatisfactory 2. Average 3.Satisfactory 4. Highly satisfactory X 33 Evaluation of Bank and other partners' performance during project preparation and implementation, including the effectiveness of their relations 1.Unsatisfactory 2. Average 3.Satisfactory 4. Highly satisfactory X 34 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE PROJECT (AIHP) 1. INTRODUCTION Emergence of Avian Flu. Outbreaks of Highly Pathogenic Avian Influenza (HPAI) began in several Southeast Asian countries in 2003 and spread to Europe in 2005. Significantly for Moldova, outbreaks in the neighboring Danube delta region of Romania and in the Crimea peninsula of the Ukraine in 2005 obliged governments to cull (kill) poultry. New outbreaks of avian flu were registered in the Danube delta of Romania as recently as February 2006. International response. In November 2005, concerned governments, technical agencies, and donors met in Geneva to plan an international response to the risks that Avian Influenza will harm human health and cause large-scale economic losses. In January 12, 2006, the World Bank’s Board of Directors approved up to $US 500 million in financing for the Global Program for Avian Influenza (GPAI) that will assist eligible countries. The GPAI is an Adapted Program Loan (APL) that operates horizontally, across countries. Also in January, governments and donors met in Beijing, China and pledged $US1.9 billion to the fight against Avian Influenza. Government response. The Government of Moldova has organized emergency teams, at both the local and national levels, to respond to any outbreak 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 National Action Plan for Avian Influenza Mitigation Measures. The Bank’s Team reviewed the plans and these appeared adequate and in line with recommendations of the World Organization for Animal Health, the Food and Agriculture Organization, and the WHO. State of the poultry sector. The poultry sector in Moldova represents circa 80% of the livestock and poultry population, at roughly 16 million heads (as of January 2006). Poultry meat is a nutrition staple generally, but more importantly, it is so in rural areas where poverty incidence is high. Twelve million birds are owned by households (backyard poultry) and small commercial farmers. The number of backyard poultry is highly variable, with peak season (summer and early fall) population reaching approximately 20 million birds. Backyard farming patterns are characterized by unsafe bio management practices, such as maintenance of multiple species in confined space and free range roaming for grazing. The country’s commercial poultry industry is characterized by the predominance of 5 large producers. Since independence, commercial poultry has suffered a severe drop in output, but has been on a strong rebound since 2002, with an average output (meat and eggs) growth of 10%. Adequate bio-safety standards are enforced at all commercial producers. State of the human health system. The Ministry of Health is responsible for health care planning and regulation. However, most health care providers are directly accountable to their rayon (local) administration. Each Rayon Health Authority, led by a chief doctor, is composed of the primary and secondary providers. The Government focuses on retraining of primary care doctors and equipment in health centers – and has achieved good geographical coverage of primary care. 2. AIM OF THE PROJECT The overall objective of the Project was to minimize the threat posed to humans by HPAI. To achieve this, the Project has been supported surveillance for outbreaks of such diseases, preparation for outbreaks, and control of outbreaks among humans and animals. The initial outcome indicators were as follows: If there is an outbreak of HPAI among poultry following implementation, then  A laboratory identifies the presence of HPAI;  The Government culls birds at the infection point and establishes a protection zone, with participation of local governments and the population; and 35  Compensates small farmers for culled birds. If there is poultry to human infection following implementation; then  A laboratory identifies the presence of HPAI;  Patients are transported safely and hospitalized in protected rooms.  Patients are provided with adequate HPAI relevant treatment. With regard to intermediate outputs, the key indicators were as follows: The Moldovan government:  Plans for each stage of response to an outbreak of HPAI and conducts simulation exercises;  Procures, delivers, and trains personnel in use of testing equipment, protective clothing, and other equipment and materials;  Conducts a public awareness and information campaign on HPAI. The project consisted of three components plus support for project management: (i) Animal Health Component  Animal disease surveillance and diagnosis;  Animal HPAI control and outbreak containment;  Compensation Fund; (ii) Human Health Component  Human Health capacity building;  Human HPAI testing;  Human health system response; (iii) Public Information & Awareness Component  Pre-epidemic campaign to promote health and safe behaviors to reduce risks to children, families, households, communities, and to promote responsible media reporting to avoid panic and misinformation;  Intensive communication campaign during the pandemic alert to begin immediately if and when human transmission is confirmed;  Post epidemic communication support to promote recovery. (iv) Implementation Support, M&E Component. 3. MAIN PROJECT INDICATORS Donors: The World Bank, European Commission, Government of Japan. Total Project amount: 10.0 million USD (actual 10.4 million USD) Loan amount: 4.0 million USD (actual 4.5 million USD) Financial conditions: 0,75% a year for 40 years, grace period 10 years Date of signing: June 16, 2006 Date of coming into effect: September 12, 2006 Date of closing: December 31, 2009 (actual May 15, 2011) Implementation Agency on behalf of Donors: The World Bank; Government Implementation Agencies: Ministry of Agriculture and Food Industry and Ministry of Health Executing (Fiduciary) Agency (PIU): Consolidated Agricultural Projects Management Unit 36 4. PROJECT COMPONENTS. FINANCING AND EXPENDITURES OF FUNDS There were two implementing agencies. The Ministry of Agriculture and Food Industry implemented the Animal Health Component, while the Ministry of Health implemented the Human Health Component. The Ministry of Health also coordinated implementation of the Public Information and Awareness Component, although implementation and administration of the component activities have been contracted to UNICEF. Component 1: Animal Health (The total size for this component is US$3.9 million; of which US$3.6 million is financed through the IDA Credit IDA Grant). Sub-component 1.A. Animal disease surveillance & diagnosis. The sub-component strengthened the Republican Center for Veterinary Diagnosis (RCVD) and its two regional satellite laboratories in Cahul town (south) and Drochia town (north). The key investments were in essential equipment for testing for the presence of HPAI in animals, for consumables and reagents. Technical assistance focused on building human resources in the use of database programs (including the global information system) 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 supported training on collection and analysis of epidemiological data and on risk assessments. Project-supported technical assistance built institutional capacity for serology and virology tests for the disease. Sub-component 1.B: Animal HPAI control and outbreak containment. This sub-component supported 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 invested in control of movement of birds and products that may be infected. The sub-component trained and equipped staff and external workers, and delivered personal protective clothing. In addition, it supported technical assistance to review and assess the Government’s contingency plans for HPAI preparedness and response. Sub-component 1.C: Compensation Fund. The purpose of the Fund was to encourage farmers to report possible outbreaks of Avian Flu. Luckily, no outbreaks of Avian Flu have been reported, so the Compensation Fund has been reallocated to other project components. During project implementation within Animal Health Component the following Goods (lab and IT equipment, PPE, consumables, disinfectants, furniture, incinerators, trucks etc.), civil works and consultant services have been procured: Table 3. Goods procured for the Republican Center for Veterinary Diagnosis (RCVD) as final beneficiary No. Amount Description of Completion spent, Name and quantity of goods procured Goods date USD This package is the 1-st procurement of PPE. - Protective clothing = 5,000 units; - Protective goggles = 5,000 units; - Face masks = 5,000 units; Personal Protective 1 82,640 May 29, 2007 - Gloves = 11,000 pairs; equipment - Apron = 5,000 units; - Boots = 700 pairs; - Boot cover = 5,000 pairs; - Bag for bio waste = 5,000 units. The following quantity of disinfectants has been procured: 2 Disinfectants 177,500 July 17, 2007 - Disinfectant for Avian Flu prophylaxis VIRUQUAT 240 = 25 tons; - Disinfectant for Avian Flu prophylaxis Virkon S 37 = 5 tons. The following quantity of disinfection devices has been procured: - Manually Powered Backpack Pressure Sprayer = Disinfection sprayers August 01, 3 31,381 135 units; and cleaning devise 2007 - Engine powered sprayer = 45 units; - Electric hot water high-pressure cleaning device = 3 units. Elisa immune- September 14, For the Central Laboratory 1 unit of Elisa immune- 4 52,287 analyzer 2007 analyzer has been procured. For the Central and regional laboratories the following IT equipment has been procured: PCs and office IT March 20, - Notebook = 2 units; 5 18,390 equipment 2008 - Multimedia projector = 1 unit; - PC desktops = 6 units and - Laser printers = 6 units. Disinfection special October 24, 4 units of disinfection trucks for infectious disease 6 179,800 trucks 2008 outbreak control have been procured. This package is the 1-st procurement of PPE. - Protective clothing = 8,800 units; - Protective goggles = 7,000 units; - Face masks = 7,000 units; - Gloves = 24,000 pairs; Personal Protective December 15, - Apron = 7,000 units; 7 109,884 equipment 2008 - Boot cover = 29,000 pairs; - Bag for bio waste = 7,000 units; - Sticks = 11,000 units; - Smocks = 140 units; - Single use smocks = 1,000 units; - Germicidal disposable wipe = 7,000 units. The following equipment has been procured: - Advanced microscopes = 3 units; - ELISA line = 3 units; Laboratory - PH Meter = 4 units; equipment for January 05, - Analytical balance = 6 units; 8 353,837 Central and regional 2009 - Pipettes = 20 units; laboratories - Freezing and incubating equipment = total 29 units; - Washing equipment, ovens, mixers etc. = total 33 units. Laboratory and office For the regional laboratory in Cahul town 62 units furniture for the of special furniture (laboratory tables, chairs etc.) 9 57,048 June 11, 2009 southern regional and 68 units of office furniture (tables, chairs, veterinary laboratory shelves, cabinets etc.) have been procured. The following IT equipment for the Ministry of Agriculture and Food Industry training center PCs and office IT (Agrarian University) has been procured: 10 equipment for the 13,535 June 19, 2009 - PC desktop = 12 units; MAFI - Laser printer = 4 units; - Multifunction unit MFU = 1 unit; - UPS = 3 units. Household electric The following electric equipment for the RCVD 11 19,507 June 09, 2009 equipment for the and regional labs (Cahul and Drochia) have been 38 RCVD and regional procured: laboratories - Microwave Oven = 15 units; - Hermetic containers = 53 units; - Gas and electric stoves = 8 units; - Refrigerators/freezers = 22 units. Laboratory and office For the regional laboratory in Drochia town 86 furniture for the November 02, units of special furniture (laboratory tables, chairs 12 77,644 northern regional 2009 etc.) and 107 units of office furniture (tables, veterinary laboratory chairs, shelves, cabinets etc.) have been procured. Laboratory December 20, 100,000 units of diagnostic kits have been 13 diagnostic kits and 16,535 2009 procured for the RCVD. consumables 100,000 units of face masks and 150,000 units of Face masks and February 18, 14 23,900 powder-free disposable gloves have been procured gloves for RCVD 2010 and delivered to RCVD. Diagnostic kits for November 02, 5 different types of 480 doses each for ELISA tests 15 8,960 ELISA 2010 have been procured for the RCVD. Ecological 3 units of ecological incinerators for burning of all incinerators for waste December 16, kind of animal origin and laboratory waste have 16 destruction for the 135,000 2010 been procured and successfully installed at RCVD RCVD and regional and regional laboratories. laboratories Electric generators 2 units of stationary electric generators and 2 units and voltage of interruptible power supplies have been procured February 17, 17 regulators (UPS) for 113,000 for the RCVD. 2 units of mobile electric 2011 the RCVD and generators have been procured for the regional regional laboratories laboratories. Special trucks for 2 units of special trucks for transportation of 18 lab samples 120,000 April 27, 2011 pathologic materials and laboratory samples for transportation the RCDV have been procured. TOTAL All the mentioned Goods have been procured 1,590,848 Goods for AH from IDA Credit IDA Grant source of finance. component Table 4. Civil works completed within AH component (final beneficiary – RCVD) No. Amount Completion Name of works spent, Short description of performed works date USD The necropsy laboratory (center) of the Republican Necropsy laboratory September 18, 1 24,648 Center of Veterinary Diagnosis has been refurbishment 2008 refurbished. Disinfection installations at 7 sites 7 customs have been equipped with special 2 92,826 June 30, 2009 of country border disinfection installations. crossing Reconstruction of the August 03, The southern regional veterinary laboratory in 3 southern regional 247,314 2009 Cahul town has been rehabilitated. laboratory in Cahul Construction of the November 28, The northern regional veterinary laboratory in 4 549,653 northern regional 2009 Drochia town has been constructed. 39 veterinary laboratory in Drochia Rehabilitation of the January 31, The existent heating system of the RCVD has been 5 heating system of 28,416 2010 rehabilitated. RCVD Construction of December 20, 3 sheds for incinerators have been constructed at 6 special sheds for 48,707 2010 RCVD and regional laboratories incinerators Refurbishment of the main building of the RCVD building 7 775,118 April 28, 2011 Republican Center for Veterinary Diagnosis in refurbishment Chisinau. TOTAL Civil All the mentioned civil works have been Works for AH 1,766,682 financed from the IDA Credit IDA Grant Component source of finance. Table 5. Studies and assessments carried out by international and local consultants for successful implementation of AH component No. Amount Completion Name of assignment spent, Short description of consultant services date USD The Institute of Zoology (Academy of Science) has been contracted to perform this assignment. Inventory of This study provided: available October 01, - Information about the aquatic birds and waders, 1 information/data 2,640 2007 their migrations and wintering on the Republic of about wild birds’ Moldova territory; monitoring - Importance of the bird migration study results for the prophylaxis of the bird flu, etc. An international consultant has been selected to provide support to the project’s animal health component. The main tasks were: Training of Disease September 30, - Preparation of the simulation exercise; 2 Control Centers on 16,688 2007 - Training of participants at Local Disease Control Simulation Exercises and National Disease Control Centers, pre- and post-simulation; - Preparation of a “lessons learned� document. Logistic support for A local company has been selected to provide organization of avian August 15, logistic and administrative support for Animal 3 43,381 influenza simulation 2007 Health Component for implementation of the 1-st exercise Avian Influenza Simulation Exercise. One national animal disease control specialist and one national veterinary regulatory specialist both Revision and update have been selected to provide support to the of the existing project’s animal health component. The main task 4 veterinary legislative 10,000 July 31, 2008 was to review and update the existing veterinary and regulatory legislative and regulatory statutes pertaining to the statutes legal and regulatory aspects of emergency animal disease response etc. Preparation, revision An international legislative consultant has been and update of the selected to provide support to the project’s animal 5 24,292 July 31, 2008 Veterinary Law health component. The main task was to prepare, regarding Avian review and update the present Veterinary Law 40 Influenza control regarding Avian Influenza control measures, measures Contingent Plan, Operational and Diagnostic Books, reporting them to the legal and regulatory aspects of the emergency animal disease response. Logistic and A local company has been selected to provide administrative logistic and administrative support in organizing of 6 support in organizing 5,965 June 10, 2008 training on ELISA for central and regional of the training for laboratory technicians. laboratory staff Technical design of A technical design company has been selected to an diagnosis module elaborate technical design of an avian influenza September 24, 7 & rehabilitation of 26,400 diagnosis module and the rehabilitation of the 2008 the veterinary veterinary laboratory in Drochia town. northern lab in A local company has been selected to provide Logistical and logistical and administrative support to the training administrative “State and Private veterinarians informing process support to the September 15, 8 47,095 regarding the activity and implementation of the training on Law for 2008 new Law for sanitary veterinary activity in the sanitary veterinary Republic of Moldova in the context of activity harmonization of the EU requirements. Community–Based A local company has been contracted to carry out a Early Warning December 31, feasibility study on Community–Based Early 9 System to Monitor 29,268 2008 Warning System to Monitor Migratory Bird Migratory Bird Habitats. Habitats Training of the A local consultant has been selected to conduct central veterinary October 31, 10 3,100 training for the central veterinary staff in personal staff in personal 2009 computer usage. computer usage Logistic and administrative A local company has been selected to provide 11 support in organizing 10,614 July 31, 2009 logistic and administrative support in organizing of of the training for training for epidemiology staff of RCVD. epidemiology staff Logistic support for A local company has been selected to provide organization of the 2- November 30, logistic and administrative support for 12 42,007 nd avian influenza 2009 implementation of the 2-nd Avian Influenza simulation exercise Simulation Exercise. An international consultant has been selected to Training of Disease provide support to the project’s animal and human Control Centres on health components. The main tasks were: the 2-nd simulation December 25, - Preparation of the simulation exercise; 13 exercise 34,360 2009 - Training of participants at Local Disease Control and National Disease Control Centers, pre- and post-simulation; - Preparation of a “lessons learned� document. An international consultant on Laboratory Capacity building in Specifications and Training has been selected to December 31, 14 laboratory design and 47,768 deal with the refurbishment, equipping and 2010 management specific staff training at the central and regional animal health laboratories. 15 Veterinary 62,902 December 31, An International Veterinary 41 epidemiology 2010 epidemiologist/Trainer has been selected to capacity building develop and conduct a series of training sessions in applied epidemiology for state and rayon level epidemiologists. An international consultant has been selected to carry out a study on risk estimation and Poultry sector risk December 15, 16 40,132 administration of the poultry sector in the Republic assessment study 2010 of Moldova. A bio-security guideline for the poultry farms has been published. National and international An international seminar for 8 central laboratory seminars/training for During project specialists has been held in Latvia. Local training 17 central and regional 29,462 implementation for regional laboratory specialists has been carried lab specialists and out. component coordinator Logistic support to A local company has been selected to provide in-service refresher November 30, 18 22,906 logistic and administrative support in organizing training for all rayon 2010 training for all rayon veterinarians. veterinarians Logistic support to A local company has been selected to provide the bio-security February 15, 19 34,045 logistic and administrative support in organizing a training for private 2011 bio-security training for private poultry producers. poultry producers A local civil engineer has been hired to provide March 31, 20 Civil engineer 17,000 services of civil engineer for Animal health and 2011 Human health project components. Total consultant Above mentioned consultant services have been services for AH 550,025 financed from IDA Credit IDA Grant as well as Component from Japan PHRD Grant. Component 2: Human Health (The total size of this component was US$4.6 million, of which US$3.9 million was financed by IDA Credit IDA Grant). The stock of medical equipment deteriorated over past decades because of lack of spending on rehabilitation and investment. The focus of the human health component was therefore on procurement and training in use of key equipment. Sub-component 2.A: Human health capacity building. The sub-component brought technical assistance and trained government staff in epidemiology at the national and rayon level. It also procured epidemiological surveillance software and trained staff in its use. Importantly, it supported training in crisis preparedness and management. Moreover, it supported assessment & planning, and training in the information and telecom systems. Finally, the sub-component supported review and update of the regulatory system and development of guides for use of personal preparedness equipment. Sub-component 2.B: Human HPAI testing. This sub-component procured key testing equipment for the Laboratory for Respiratory Diseases, which is the only viral laboratory in Moldova. Sub-component 2.C: Human health system response. This sub-component procured equipment for the intensive care unit of the National Infectious Disease Hospital in Chisinau. Furthermore, the sub- component purchased WHO accredited influenza kits (including vaccines) and Oseltamvir (Tamiflu), to increase the national stockpile. During project implementation within Human Health Component the following Goods (lab and IT equipment, PPE, consumables, disinfectants, furniture, incinerators, trucks etc.), civil works and consultant services have been procured: 42 Table 6. Goods procured for the Public Health National Center (PHNC) as final beneficiary No. Amount Description of Completion spent, Name and quantity of goods procured Goods date USD Seasonal influenza November 21, Procurement of 6,500 units of seasonal vaccines 1 51,000 vaccines 2006 for 2006 year. Pharmaceuticals February 01, Procurement of 1,700 units (box of 10 caps) of 2 41,187 (Tamiflu) caps 75 mg 2007 Tamiflu. Procurement of antibiotics for prophylaxis and therapy of human cases of avian influenza: Pharmaceuticals 3 9,099 April 02, 2007 - Amoxicillin and Clavulanic acid = 500 boxes; (antibiotics) - Ciprofloxacin = 500 boxes; - Azithromycin = 500 boxes. Procurement of PPE. - Protective clothing = 7,000 units; - Protective goggles = 670 units; - Face masks = 7,000 units; Personal Protective 4 80,535 May 23, 2007 - Gloves = 14,420 pairs; equipment - Apron = 5,500 units; - Boots = 360 pairs; - Boot cover = 4,000 pairs; - Bag for bio waste = 8,500 units. The following quantity of disinfection devices has been procured: Disinfection 5 3,537 May 05, 2007 - Manually Powered Backpack Pressure Sprayer = equipment (sprayers) 80 units; - Engine powered sprayer = 80 units; 3 units of vehicles (All terrain vehicles 4WD Vehicles for the rapid 6 143,483 June 26, 2007 Nissan Pathfinder SE) for the rapid response team response team have been procured. Disinfectant product effective against Avian Rapid response team August 01, 7 5,000 Influenza virus, for use by Rapid Response Teams supplies 2007 has been procured Seasonal influenza October 23, 18,000 doses of seasonal influenza vaccine 8 156,402 vaccines (2007) 2007 “Vaxigrip� have been procured. 3 emergency ambulances have been procured for 3 emergency November 15, 9 217,044 the Republican Hospital for Infectious diseases ambulances 2007 “Toma Ciorba�. For the PHNC 3 notebooks and 3 multimedia IT equipment for November 16, 10 10,214 projectors for the training courses have been training courses 2007 procured. Pharmaceuticals September, Procurement of 4,000 units (box of 10 caps) of 11 107,200 (Tamiflu) caps 75 mg 01, 2008 Tamiflu. Sterilizer car (mobile October 24, One sterilizer vehicle (steam sterilizer) for rapid 12 disinfection room) 52,381 2008 response team has been procured. for RRT Seasonal influenza November 04, 10,000 doses of seasonal influenza vaccine 13 115,000 vaccines (2008) 2008 Agripal have been procured. Special laboratory The following laboratory equipment has been 14 486,037 April 07, 2009 procured: equipment Freezing, refrigerating, crybiological and 43 isothermal equipment; Biohazard cabinets, bactericide lamps, autoclaves, lamps etc. ; Thermo and vortex mixers, centrifuges, test tube racks etc; ELISA Station, automatic and channel pipettes, microscopes etc.; Incubators, ovens, pH Meter, electronic balance, pumps etc. Improved The Operational Acceptance protocol between Surveillance System August 28, CAPMU and the IT system developer - DAAC 15 development (ISS) 454,268 2009 System Integrator Ltd. has been signed on August and implementation 28, 2009. The owner of the system is PHNC. (IT system) IT equipment for November 30, 3 notebooks, 2 laser multifunctional devices and 2 16 8,951 RRT 2009 digital photo cameras have been procured. The following special furniture for the Intensive Care Unit (Toma Ciorba hospital) has been Special furniture for procured: Intensive Care Unit December 23, Semi-Electric Hospital Bed = 10 units; 17 37,945 (ICU), Toma Ciorba 2009 Cart with Detachable Stretcher = 2 units; hospital Stainless dressing trolleys = 4 unis; Medicine trolley = 3 units; Medical Bedside Table = 10 units. 90 units of special furniture (laboratory chairs, lab. tables etc.) and 84 units of office furniture Office furniture for (computer tables, cabinets for docs, chairs, Intensive Care Unit December 24, wardrobes etc.) for viral laboratory have been 18 and viral laboratory 104,699 2009 procured. 45 units of office furniture (medical and special furniture cabinets and tables, kitchen cabinets and tables, for viral laboratory chairs, wardrobes for clothes etc.) for ICU has been procured. Hand sanitizer 1,500 units of hand sanitizer dispensers and 3,000 dispensers and hand December 30, 19 43,510 units of additional dispensers refill have been sanitizer dispensers 2009 procured. refill Total of 86 units of the following medical equipment has been procured: Intensive therapy cardio-monitors; Electric defibrillators; Medical electric January 30, Laryngoscopes; Portable surgical aspirators; 20 equipment for 237,181 2010 Syringe pumps; Portable electrocardiographs; Intensive Care Unit Central stations; Intensive care ventilator for adults, children and newborns; Medical wards systems ATI; Handheld pulse oxi-meters. A big quantity of laboratory consumables and Laboratory reagents (diagnostic reagents, biochemical 21 consumables and 87,168 May 20, 2010 reagents, glassware and supplies etc.) has been reagents procured. February 18, 300,000 units of face masks (cup model and folded 22 Face masks 46,250 2010 model) have been procured. Monitoring cameras February 25, A monitoring system has been installed at ICU, 23 and monitors for 2,328 2010 Toma Ciorba hospital. Intensive Care Unit 44 Intensive care 10 units of intensive care respirators have been 24 118,739 June 30, 2010 ventilators procured. Diagnostic specimen case 15-20 liters = 50 units; Specimen kits & Bio-safety containers, 2.0 liters = 50 units; containers for viral Bio-safety bins = 70 units August 13, 25 laboratory and 42,227 Electric sterilizers for microbiological loop = 10 2010 medical equipment units; Portable burners = 10 units; for RRTs Cooling containers (portable refrigerator) = 2 units. 2 units (fixed and portable version) of infrared Infrared scanners November 24, 26 33,771 cameras for scanning body temperature have been (cameras) 2010 procured. 1 passenger minibus for the PHNC has been 27 Passenger minibus 55,000 February 22, procured. 2 desktop computers March 15, 2 desktop PCs for the IT administrators from 28 for IT administrators 5,700 2011 Public Health National Center have been procured. from PHNC Printing of national guide for laboratory bio- Printing of bio- March 16, security and national guide for transportation of 29 security guides 8,445 2011 infected materials in 1,000 copies each for the (brochures) Public Health National Center, Expansion and 4 new servers and 1 storage, 2 units of network lan installation of the switches, 2 units of routers, 86 PCs, 86 UPSs, 86 March 29, 30 system platform 183,000 printers and 1 notebook for PHNC have been 2011 equipment (new procured in order to expand and improve the servers and PCs) existing Improved Surveillance System. FC Host Bus 2 units of FC host bus adapters for the new servers 31 2,950 April 20, 2011 Adapters have been procured. Implementation of the additional requirements for Application software 32 171,149 April 25, 2011 “Improved Surveillance System� managed by the (ISS) development National Public Health Center. All above mentioned goods have been procured TOTAL from IDA Credit IDA Grant funds, except Improved Surveillance System development 3,121,400 Goods for HH (ISS) and implementation (IT system) component procurement in amount of USD454,268 from EC AHI Facility Grant. Table 7. Civil works completed within HH component (final beneficiary – PHNC) No. Amount Completion Name of works spent, Short description of completed works date USD Construction of a new module for avian influenza Refurbishment of December 31, diagnosis and renovation of the ground floor of the 1 444,911 Viral Laboratory 2009 National Laboratory for Viral Respiratory Infections in Chisinau municipality Ventilation and Ventilation and power supply networks have been power supply December 31, 2 94,521 installed at National Laboratory for Viral networks installation 2009 Respiratory Infections at Viral laboratory 3 Renovation of 530,288 February 28, Rebuilding the intensive care and reanimation unit 45 intensive care unit of 2010 of the Republican Infectious Disease Hospital “Dr. the Toma Ciorba Toma Ciorba� hospital All the mentioned civil works have been TOTAL civil works 1,069,720 financed from the IDA Credit IDA Grant for HH Component source of finance. Table 8. Studies and assessments carried out by international and local consultants for successful implementation of HH component No. Amount Completion Name of assignment spent, Short description of consultant services date USD Logistical support in A local company has been selected to provide the organization of logistical and administrative support in the the integrated October 12, 1 13,765 organization of the integrated desktop simulation desktop simulation 2007 exercise for avian influenza in animal and human exercise for HH population. Component. Design and supervision for A local civil engineer has been selected to refurbishment of supervise civil works for both components AH and March 31, 2 Viral lab and ICU 25,000 HH, including supervision for refurbishment of 2010 and regional Viral lab and ICU and regional veterinary veterinary laboratories. laboratories A local company has been selected to design of rebuilding the intensive care and reanimation unit Technical design for of the Republican Infectious Disease Hospital “Dr. 3 rebuilding of viral lab 57,652 July 25, 2008 Toma Ciorba� and design of a new module for and ICU Avian Flu diagnosis attached to the National Laboratory for Viral Respiratory Infections. A local company has been selected to provide logistical and administrative support in the Logistical support in organization of series of training courses for rapid the organization of response teams and for medical staff, including: series of training February 13, - 4 training courses for rayon’s rapid response 4 140,000 courses for rapid 2009 teams in case of avian influenza in human response teams and population; for medical staff - 4 training courses for medical staff in clinical management of possible human cases of H5N1 and infection control practices. Reviewing the draft An international consultant has been selected to to form of standard provide support to the project’s human health operating procedures component, specifically to: for adequate response - provide support to the project’s human health of the health care component; system to the threat December 31, - carry out a training needs analysis (TNA) for 5 32,190 of HPAI with focus 2009 different levels of health care system in clinical on clinical management etc; management and - provide guidance for Toma Chorba staff to infection control develop framework and action plan for the practices in implementation of the guidelines and procedures healthcare facilities for nosocomial infection control focusing on 46 patient admittance, management, etc. Enhancing HPAI Prevention and Preparedness An international consultant has been selected to Capability trough provide consultancy on Enhancing HPAI November 30, 6 upgrading the 25,042 Prevention and Preparedness Capability trough 2009 institutional and staff upgrading the institutional and staff capacity of the capacity of the National Viral Laboratory. National Viral Laboratory A local translator has been selected to translate key Translation of printed December 31, Project materials under human and animal health 7 8,200 materials 2009 components. “Cantacuzino� Institute from Romania has been Training courses for contracted to carry out a series (3 seminars) of strengthening overall training courses for strengthening overall management of management of Influenza Surveillance and Influenza 8 21,000 July 31, 2010 laboratory capacities for influenza virus diagnosis Surveillance and (avian, A H1N1-2009 and seasonal) , including laboratory capacities one evaluation field visit made by an Romanian for influenza virus Laboratory specialist. Totally, 15 specialists from diagnosis National Viral Laboratory have been trained. Logistical support for A local company has been selected to provide organizing a 9 5,813 July 31, 2010 Logistical and management support for organizing workshop for a workshop for journalists within AIH project. journalists A local company has been selected to provide logistical and administrative support in organizing of series (4 trainings) of training courses for the Training for PHC medical staff who are involved in the surveillance staff in pandemic January 18, and reporting of influenza. The training courses 10 49,632 influenza 2011 have been organized for the specialists from the management following four regions of the Republic of Moldova: the northern region, the central-west region, the southern region and the central- east region in Chisinau. A local IT specialist has been selected being responsible for: - “Improved Surveillance System� system design, including organizational reengineering processes Improved and system relevance to project stakeholders' Surveillance System needs. Assuring that development team(s) work in 11 36,000 April 30, 2011 Project Manager (IT full capacity and in good cooperation with specialist) institutional/government team(s) and project stakeholders; - Coordinating and monitoring of systems implementation, including quality assurance of subcontracts. International International workshops, meetings, seminars and workshops, meetings, During project 12 20,000 conferences with participation of Human Health seminars and implementation Component Coordinator conferences 47 Total consultant Above mentioned consultant services have been services for AH 434,294 financed from IDA Credit IDA Grant as well as Component from Japan PHRD Grant. Component 3: Public Information and Awareness. (The total size of this component was US$1.1, of which US$0.45 financed by the IDA credit). Institutional capacity building and training needs have been covered from the PHRD grant. The component has successfully implemented 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. Table 9. Goods procured for the Public Health National Center (PHNC) within Public Information and Awareness Component No. Amount Description of Completion spent, Name and quantity of goods procured Goods date USD - Development and production of two audio spots (in Romanian and Russian) on DVD mp3 high Production of audio quality = 200 DVDs; & video spots and September 20, 1 21,525 - Development and production of one video spot in design and printing 2010 Romanian with translation in Russian and English of posters for PHNC languages on DVD HD Quality = 200 DVDs; - Design and print of one poster = 20,000 units. Production of an additional November 24, Production of an additional documentary film for 2 1,000 documentary film for 2010 PHNC PHNC TOTAL All above mentioned goods have been procured 22,525 Goods for PAI from IDA Credit IDA Grant funds. Component Table 10. Studies and assessments carried out by international and local consultants for successful implementation of Public Awareness and Information component No. Amount Completion Name of assignment spent, Short description of consultant services date USD Implementation of Public Awareness December 31, Implementation of Public Awareness and 1 950,300 and Information 2009 Information Component by UNICEF Moldova Component National December 31, A local consultant - National Communication 2 Communication 17,040 2010 Consultant on Media has been contracted Consultant on Media National A local consultant - National Communication December 31, 3 Communication 17,040 Consultant on Capacity Building has been 2010 Consultant on contracted 48 Capacity Building Activities at A local NGO has been selected to organize December 4 community level for 29,983 activities at community level for children and 24,2010 children and youth youth within AIHP Coordinator for KAP A local consultant has been contracted to prepare March 31, 5 study and closing 5,100 TORs, coordinate and monitor KAP study and 2011 conference project closing conference Knowledge, attitude March 31, A local company has been selected to conduct 6 and practices (KAP) 13,800 2011 Knowledge, Attitude and practices (KAP) study study Logistic support for A local company has been selected to provide organizing the March 31, 7 14,600 logistic and administrative support for organizing project closing 2011 the AIHP closing seminar. seminar Above mentioned consultant services have been Total consultant financed from IDA Credit IDA Grant, except services for PAI 1,047,863 USD 137,400 from Japan PHRD Grant and Component USD 363,000 from EC AHI Facility Grant, both amounts have been allocated for UNICEF. Component 4: Implementation support and monitoring & evaluation. (The total size of this component was US$0.3 million, fully financed by IDA). The Consolidated Agricultural Project Management Unit (CAPMU) assumed responsibility for procurement, financial management and disbursement. The CAPMU has demonstrated its capacity to successfully manage fiduciary tasks under the Project. It provided qualitative fiduciary support to the two agencies and facilitated the work of the Component Coordinators. Furthermore the CAPMU prepared bidding documents, contracts, executed payments upon instruction of the implementation agencies, submitted in time financial reports and project progress reports. World Bank Performance The Ministry of Health and the Ministry of Agriculture and Food Industry are highly satisfied with the Bank's supervision over the implementation of the project. The Project Task Team Leader and his team also demonstrated high activity and flexibility to solve all issues quickly. The results achieved during project implementation are noticeable. Main Lessons Learned: • The successful achievement of project goals and objectives were due to good partnership and cooperation between the Ministry of Health, Ministry of Agriculture and Food Industry and their governmental agencies (Public Health National Center and Republican Center for Veterinary Diagnosis), the World Bank, as well as the project team and CAPMU fiduciary support. • Institutional capacities of surveillance, laboratory diagnosis and clinical management of avian and pandemic influenza were significantly strengthened. The trained staff is now ready to control, prepare for and intervene in case of outbreaks among humans and animals. • Raising public awareness about avian, pandemic and seasonal flu prevention was a key element in the communication component. The involvement of media, civil society and the support provided by the Ministry of Health and the Ministry of Agriculture and Food Industry were of major importance in the awareness campaign. 49 Main Conclusions: Animal Health • Veterinary legislation has been reviewed and updated. The Law on Veterinary, regarding the Avian Influenza control measures, Contingent Plan, Operational and Diagnostic Books have been reviewed, updated, and prepared. • The Republican Center for Veterinary Diagnosis (RCVD) and its two regional satellite laboratories in Cahul and Drochia have been renovated and equipped. Civil works were conducted. Lab and IT equipment, consumables, furniture, incinerators and trucks were purchased and distributed. • Human resources capacities to use database programs (including the global information system) and the analysis of data to support decisions on prevention and control of animal diseases have been strengthened. • Specialized staff trained and equipped with protecting clothing within 2 Avian Influenza Simulation Exercises in case of any outbreak of HPAI. Capacity has been strengthened on issues like: veterinary epidemiology, bio-security, IT, etc. Human Health • The Public Health National Centre has been equipped with protective clothing, disinfection equipment, seasonal influenza vaccines, pharmaceuticals, 3 emergency ambulances, etc. • Government staff has been trained in epidemiology at the national and rayon level. The epidemiological surveillance software called “Improved Surveillance System�.has been developed and all the staff involved at central and regional level has been trained to use it. • The regulatory system has been reviewed and updated. Guides for laboratory bio-security and transportation of infected materials have been printed. • The National Laboratory for Viral Respiratory Diseases, which is the only viral laboratory in Moldova, has been refurbished and equipped with key testing equipment. • The intensive care unit of the National Infectious Disease Hospital in Chisinau has been refurbished. Specialized equipment, furniture, laboratory consumables, monitoring cameras and monitors, intensive care ventilators has been provided. Public Information & Awareness • Awareness Information campaign comprising a pre-epidemic campaign, an intensive communication during pandemic alert and post epidemic communication support to promote recovery has been implemented. 50 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders UNICEF final report – Public awareness activities I. Statement of Problem Since 2003 there are globally 436 confirmed human cases of avian influenza with 262 deaths, given this high mortality ratio of 60% it is imperative to continue activities on building the capacities of the Government, increasing knowledge and awareness of specialists and general public in responding correctly to the threat and being prepared to emergencies. In 2007, in its effort to support Moldova, WB started together with the Government of Moldova a project on Avian Influenza Control and Human Pandemic Preparedness and Response. The overall objective of the Project is to minimize the threat posed to humans by HPAI. The project has three main components: − Component 1. Animal Health − Component 2. Human Health − Component 3. Public Information and Awareness. Public awareness and information component of the Project is implemented by the Ministry of Health and UNICEF, based on the National Strategy and Communication Plan on Prevention of Avian and Human Influenza in the Republic of Moldova, approved by the Ministry of Health on July 4, 2006, focusing on communication and other supportive measures that inform, educate and enable families and communities to protect themselves from illness and death caused by avian and pandemic influenza or its consequences. The rapidly spreading outbreaks of New Type Influenza A (H1N1) among people at the global level is alarming, the virus is contagious, spreading easily from one person to another, and from one country to another. II. Project Objectives The objective of this Project is to implement the Component 3: Public Information and Awareness, of the Avian Influenza Control and Human Pandemic Preparedness and Response (AIHP) Project. The overall objective of this component is to minimize the risk of avian influenza spreading throughout the Republic of Moldova by ensuring that citizens are aware of the symptoms, understand the threat and are willing and able to engage in behaviours that will protect themselves and their community. III. Communication Strategy The communication response has three planned stages: I. A pre-outbreak campaign to promote safe and responsible behaviour 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 a pandemic, to begin immediately if and when human infection is confirmed. III. Post pandemic communication support to promote recovery and help those who need it. The present Project addresses the first and second stage at the time of reporting. 51 The pre-outbreak campaign in 2009 was focused on activities aiming at preventing social denial in case of an outbreak and increasing trust in the capacity of the health authorities to respond to an eventual pandemic. The second stage occurred in June with the H1N1 pandemic becoming a threat worldwide. Even though the first case of H1N1 was confirmed on the 29th of July, UNICEF has provided already in April full support to the Ministry of Health to develop a communication strategy and plan to enable specialists and general public correctly respond to the pandemic situation. The communication strategy and plan was presented and approved by the Prime-minister on April 30, 2009. The strategy and plan foresees two intervention phases: 1. communication / information activities when there are no confirmed cases in the country 2. communication / information activities starting with the first confirmed case As a result of this effort UNICEF together with the experts from the Ministry of Health and National Centre for Preventive Medicine has developed and approved within the working group the communication materials addressed to general population distributed to every household followed by communication interventions through mass media. IV. Planned activities and achieved results The activities of the project were designed according to the Aide Memoirs of World Bank Missions, recommending to facilitate through communication activities, behavioural change in target audiences and the demand for products and services, ensuring at the same time rapid reporting of suspected cases of HPAI, and community support for containment and control activities. The project activities were aimed to ensure: • capacity building in communications in the priority ministries (MOH and MAFI); • mobilization of community resources, with particular reference to grassroots support for control and containment actions; • a communication mechanism to assist the Government in building trust and credibility around HPAI issues, as well as facilitate reporting and feedback mechanisms using information and communication technologies exists; • the media is trained in professional reporting on HPAI and ensuring that HPAI issues remain on the public’s agenda. The main achievements during the reporting period are described below. Target 1.1: MOH and MAFI have the capacity to communicate effectively in times of emergencies related to Avian Influenza and Human Pandemic Building communication skills of Governmental decision makers: To prevent social denial in case of an outbreak, it is important to select and train spokespersons from the health sector in behavior change communication (BCC) and risk communication (RC). It is also important that all the sectors involved in a potential risk communication will speak with one voice and in timely and professional manner about standard operational procedures to be implemented by clearly identified actors. All communication activities undertaken in case of outbreaks should be baked by firm political support. In order to improve communication skills and coordination of activities and messages for different groups of population in 52 case of risk or crisis situation were provided trainings for health managers at rayon/ municipal level by national experts and for public officials by international communication experts with extensive experience. Implementing partners: State University of Medicine and Pharmacy, National Center of Preventive Medicine Achievements: • 9 high level officials have increased their skills in risk communication • 17 representatives from the key ministries have increased their knowledge and skills in risk communication. • 19 leading health specialists have increased their knowledge and skills in behavior change and risk communication. • 175 health managers at rayon and municipal levels have increased their knowledge and skills in communication for health promotion and in crisis situation • A communication consultant was supported for the whole year of 2008 to support the Ministry in its communication activities related to pandemic emergencies. Support the quarterly meetings of the Inter-sector Working Group: The effective coordination between the various actors in health area is crucial for the success of the project. An Inter-sector Working Group in Communication was established through an internal decision of the Minister of health and Social Protection in 2006 and stopped functioning after a number of resignation and new appointments of key decision makers in the Ministry of Health. Periodical meeting were organized on the request of the UNICEF, and on an ad hoc basis the group members meet in 2009. After the new round election in July 2009 the political situation has not stabilized, new Deputy Ministers were named in November that not allowed to organize the Regular meeting of the Inter-sector Working Group in Communication. Capacity building of family doctors and residents of family medicine: Family doctors are one of the most important and most credible sources of information in health matters. The last KAP study (October, 2009) reveal that 53% of the population trust health workers in matter related to avian and pandemic influenza. Given the low coverage of the mainstream printed media in the rural areas, the health workers remain extremely valuable and credible information channel. At the same time they play active role in community and can use their power, knowledge and skills to enable others, from individual, to the group to the broader community. To introduce family doctors in the field of communication and prepare them to communicate effectively during the eventual flu pandemic, health managers at rayon and municipal levels provided one-day training in inter-personal communication techniques for behavior change and communication in health emergencies related to influenza. All training was monitor and assisted by Medical University lecturers. In order to ensure sustainability the group of national trainers was created as well as was developed and integrated in the curricula of the Medical University the module on BCC and RC. In 2007 the National Centre of Preventive Medicine and the Ministry of Agriculture and Food Industry have developed contents for three publications: • Practical Guide for Doctors: Infection with influenza viruses – epidemiological, clinical, laboratory, treatment, and prevention aspects. • Practical Guide for Doctors: Avian influenza – etiological, clinical and epidemiological, evolution, diagnosis, treatment, and prevention peculiarities. • Guide for veterinaries: Collection of normative acts on preventing, diagnosing, and combating avian influenza and other infectious diseases. 53 Methodological instructions were developed for epidemiologists, virologists, family doctors, resident physicians, internists, laboratory assistants and can be used in trainings for doctors. Implementing partners: State University of Medicine and Pharmacy, National Center of Preventive Medicine Achievements: • BCC and RC module integrated in the Medical University curricula to ensure sustainability and government ownership. • 8 lecturers from the Medical University have necessary skills to train different target groups on communication for health promotion, behavior change, risk and crisis communication. • 1,919 family doctors (100%) have increased their knowledge and skills in inter-personal communication techniques for behavior change and communication in health emergencies related to influenza. 105 training sessions provided in all medical settings of the country. • 160 residents and family doctors passed specialized trainings in communication for health promotion, behavior change, risk and crisis communication in the framework of Medical University. • 700 guides for family doctors “Communication in health promotion, risk and crises communication� and 20 guides for trainers were developed and published. Target 1.2: Population has trust in the authorities preparedness and response capacity related to HPAI and epidemics and pandemics Community events with children and youth: Children and youth are the most open minded and mobile population groups; they do usually report to adults various incidents, including the ones related to dead and sick birds, and they are important for ensuring the rapid reporting of suspected cases of HPAI. Through peer-to-peer networks trained children can empower others and mobilize the communities. Implementing partner: The Association of Medical Students and Residents Achievements: • 600 peer educators from six raions learned about prevention measures of TB, HIV, protection and threat of avian influenza in framework of 20 training sessions. • Over 1400 school children from 26 schools/ lyceums from different raions have increased their knowledge in healthy lifestyle related to Avian Influenza prevention. • 690 young people from 23 communities learned about prevention, protection and threat regarding the influenza (seasonal, new type, avian and swine influenza) in framework of 20 training sessions. • 440 scouts from two summer camps learned about prevention, protection and threat regarding the different types of influenza in the framework of 10 training sessions. • 220 most active youth identified and selected to organize peer-to-peer activities in their own communities • 220 most active youth in 22 communities, supported by medical students and residents organized diverse information activities (flash-mobs, shows, concerts, etc) regarding the prevention of influenza Local public authority and veterinarians are prepared to AI epidemics: Public authorities have the key role in preparation and response to an outbreak, epidemic or other public health emergencies that require coordination of activities and information at all levels and among different services that are involved. In AI outbreak local authorities and veterinarians have primary responsibility for responding to an outbreak. 54 Implementing partner: National Agency for Rural Development (ACSA) Achievements: • 747 mayors and 110 representatives of Local Public Administration learned about identification and management of AI outbreak and improved their knowledge in interpersonal communication and health promotion for AI prevention, as well as 51 presidents and vice presidents of the rayon/municipal Councils, 19 specialists from the Civil Protection Service and Exceptional Situations cases and 37 from other departments of rayon/municipal Councils. • 1221 veterinarians at community level and from major poultry breeding enterprises have improved their knowledge in prevention of appearance and spread of AI, and in interpersonal communication. Improvement of communication capacities of local veterinarians from 70 communities in Moldova and creating demand for animal health services. Creating a demand for products and animal health services is essential for enforcing control and containment activities. Veterinarians from 70 communities that are in highest risk of avian influenza appearance provided free of charge consultations to bird and animal breeders; monitoring at the same time the epizootology situation in the selected communities through keeping a bird registry. Implementing partner: National Agency for Rural Development (ACSA) Achievements: • 110 veterinarians and 24 ACSA consultants trained in interpersonal communication techniques. • A birds’ registry developed and approved by Agency for Animal Health and Safety of Products of Animal Origin and MAFI. • 9952 free of charge consultations at home and 6249 in the veterinary office provided to bird and animal breeders. • 70 public meetings with participation of family doctors, veterinarians and mayors organized in selected communities. • Dissemination of best practices was done through 3 specialized TV programs (Bastina), 2 articles at national and 14 at rayon levels. Information of population about AI and PI through church leaders. The church leaders are powerful opinion leaders in the rural area: according to BOP, the church enjoys the trust of nearly 80% of the population. Implementing partners: National Center of Preventive Medicine Achievements: • 300 church leaders learned about prevention and protection measures regarding avian and pandemic influenza and will disseminate this information to the general population. Target 1.3: Communication mechanisms that promote Inter-sector cooperation and facilitate reporting are created The development of information and response system of the Ministry of Health: It is essential to secure the social response to manage, control and contain an epidemic, through a feedback-hot-line mechanism that promotes and encourages rapid reporting, facilitates community based surveillance as well as manage information regarding suspected and confirmed cases, exposed contacts, and related laboratory findings. 55 An early warning system (hot line) was created that serve as a communication and response channel between the various groups, at different levels. Hot line for general public and early warning system and response to prevent and control hazards to public health according to the international standards were established and is functional. The value of the National Strategy in health promotion and disease prevention is worldwide recognized; it is both effective and cost-effective in reducing the burden of disease and in mitigating the social and economic impact of diseases. In the framework of the project the National Strategy in health promotion and disease prevention for 2011-2015 developed and the National Program on promotion of healthy lifestyle is submitted to Government for approval. Implementing partners: National Center of Preventive Medicine Achievements: • Hot line for the general public (080012300) and for the health authorities (022 739847) were created and are functional • Notification mechanism of risk situation for public health and plan of actions for 2010 year were developed • 248 health specialists from medical institutions and 360 persons from customs service and border guards trained on communication in risk situations to National Focal Point • National Strategy in health promotion and disease prevention for 2011-2015 developed • National Program on promotion of healthy lifestyle will be revised and submitted to Government for approval Target 1.4: Media trained in professional reporting on AI and HP and ensuring that HPAI issues remain on public agenda Building media skills in emergency reporting, especially related to avian influenza (AI) epidemics: Since crisis situations became top subjects, the need has emerged to train the journalists from printed and electronic press about how to report in emergencies, including pandemic. UNICEF worked with the faculty of journalism at the State University of Moldova and introduced a module on pandemic emergencies communication in the university curriculum. Implementing partner: Moldova State University Young journalists promoting healthy lifestyle: Youth are learned about the importance of reporting of suspect sickness or death cases of birds and adopting a responsible behaviour in pandemic situations by producing a “Live healthy� program at the national TV and radio. The TV programme is broadcasted on a monthly basis and the Radio programme -on a weekly basis. Both programs have national coverage and are produced entirely by youth, aged 16-18. Implementing partner: National public company “Teleradio Moldova� Development and update of www.gripa.md website: Inconsistent messages have led to a widespread sense among the general public that there is no HPAI threat. The website on pandemic and avian flu is a focal point of credible and consistent information to the general public, but also journalists, doctors and veterinarians. The website www.gripa.md served as a knowledge management tool and a point of reference for the most up to date information in all matters related to pandemic and avian flu. The website is regularly updated with news and relevant press releases, interviews, Q&A, guidelines for population and specialists. 56 Work with the media: Society at large needs to know that the Government is implementing preparedness plans and modernizing its human and animal health management capabilities. Media coverage has been given information about the upgrading of medical and veterinary facilities, including service capabilities, the availability of medicines, ambulances and trained staff to deal with possible outbreaks. Video, animation, and audio spots to encourage reporting in case of outbreaks: Video and audio spots are an important behaviour change communication tool, as the TV is the main source of information for over 2/3 of the population, followed by radio. The broadcasting of video and audio spots in prime time is an important communication channel for the rural population, having no access to alternative sources of information. Achievements: • Communicating/reporting in pandemic emergencies integrated in the curriculum of the Journalism and Communication Sciences Department of the State University of Moldova. • 45 students from Journalism and Communication Sciences Department of the State University of Moldova trained in Communicating in pandemic emergencies by “Reuters Foundation�. • 170 young journalists trained at the TV and Radio on producing videos on emergency preparedness in pandemic situation. • Since its launch in April, the web-page had over 300.000 thousand clicks, with over 100.000 thousand unique visitors: http://www.gripa.md/statistika/ • More than 10 TV programs and 25 Radio programs broadcasted, more than 40 articles, programs, interviews etc were produced yearly in 2008/2009 as a result of the events organised by the project. • 4 Video spots “Avian Influenza symptoms in birds�, “Reporting sick or dead birds to local authorities and veterinarians�, “Flu Prevention� and “Pandemic Flu Home Care� produced and broadcasted during 2008/2009 • 5 Audio spots on AI prevention and Pandemic Flu ( Symptoms of A(H1N1), Wash Your Hands and Respect Etiquette, Be Informed, Respect Distance, Pandemic Flu home care) produced and broadcasted during 2008/2009. Target 1.5: The stakeholders are able to draw lessons and make adjustments to their future emergency preparedness and response plans Evaluate the project by measuring knowledge, attitudes and practices regarding AI prevention and response: UNICEF conducted a KAP study to assess changes in public awareness including the level of trust the population has in the public spokespersons. Monitor the activities of the project: UNICEF team continuously monitored the activities of the project. Regular visits organised to check the progress and provide guidance and advise on as needed basis. UNICEF produced a documentary film about the implementation process, results achieved of the Avian Influenza and Human Pandemic Project Communication emergency response in A(H1N1) pandemic: On June 11, 2009 the WHO has decided to raise the level of influenza pandemic alert to phase 6. UNICEF used the opportunity to support the Ministry of Health to make adjustments to its emergency communication plans and produce some related 57 communication materials, and re-printed in December 2009 Info flyer for travellers, Info flyers for general population, and Poster for general population. UNICEF supported elaboration of the 2 guides for family doctors and other medical staff – “Pandemic Influenza – treatment, diagnosis and prophylaxis� and “Human Influenza - treatment, diagnosis and prophylaxis�, distributed nationwide by National Center of Preventive Medicine. Achievements: • A communication strategy developed to support the H1N1 response activities of the Ministry of Health approved by the National Antiepidemic Commission chaired by the Prime-minister. • A series of printed communication materials developed and distributed nationwide, other country offices have asked the permission to use them for their own H1N1 awareness raising campaigns: • Info flyer for travellers (total 280,000 copies) • Info flyers for general population (total 2,000,000 copies) • Posters for general population (20,500 copies) • Stickers for public transportation (460,000 copies) • 2 guides for family doctors and other medical staff – “Pandemic Influenza – treatment, diagnosis and prophylaxis� and “Human Influenza - treatment, diagnosis and prophylaxis�. • Two studies to determine the level of Knowledge, Attitudes and Practices regarding Avian and Pandemic Influenza among the population of the Republic of Moldova were conducted in 2009. Quantitative data was collected via 1101 interviews conducted on the entire territory of the republic, besides Transnistria. • A documentary film about the implementation process, results achieved of the Avian Influenza and Human Pandemic Project Video spots produced in the previous years were adjusted to reflect the new pandemic situation. V. Constraints 1. Elections and following political crisis The activities related directly to the Ministry of Health and National Centre for Preventive Medicine suffered long implementation delays, related to the change of the key people in the ministries, followed by electoral campaign and the political crisis that occurred after the April 2009 parliamentary elections. Frequent changes in the Ministry of Health and the Centre for Preventive Medicine in the period preceding the elections have also caused delays in implementation. The institutional memory of the Ministry of Health is low, and the resignation of the key decision makers of the Ministry of Health and the Centre for Preventive Medicine, including the ones directly involved in the project, slowed down most of the project activities. 2. Low reach of the media TV is the main source of information for over 2/3 of the population, according to the Barometer of Public Opinion. Printed media, both regional and national, has very limited circulation and rarely reaches the rural area. There are up to 10 mainstream newspapers in Moldova and 3 TV station with national coverage. Rural population especially has little or no access to information channels, alternative to Moldova 1 public TV. 58 Media has very little understanding about the need to communicate about pandemic preparedness and response, as well as about health issues in general. It has as well very little capacity to respond to the needs of the emerging pandemic threats. 3. Emergency situation caused by new pandemic flu Another delay of some initially planned activities was caused by the emergency situation related to H1N1 pandemic. A lot of time and effort was invested, at the request of the Ministry of Health, in emergency communication. At the same time, the H1N1 pandemic was an opportunity to work with our counterparts on their further systematic efforts to communicate about health issues, including threats related to avian and pandemic flu. On the other hand, having all material and capacity in place, developed by the project, help the country to be prepared for the pandemic flu. 59 Annex 9. List of Supporting Documents World Bank documentation: • Project Identification Document (March 7, 2006) • Integrated Safeguards Datasheet (April 3, 2006) • Project Appraisal Document (Report No. 36158-MD) • Financing Agreement (June 16, 2006) • Country Assistance Strategy FY05-08, November 12, 2004. (Report No. 28556-MD) • Country Partnership Strategy FY09-12, December 23, 2008. (Report No. 46822-MD) • Aide-memoires (2006-2011) • Back-to-office reports and letters to Government (2006-2011) • Implementation Status and Results Reports (2006-2011) • Procurement Plans (2006-2011) • Project Procurement Post Reviews (2007-2011) • Project Financial Audits (2007-2011) Project and Background papers: • Migratory Birds from the Republic of Moldova (July, 2007) • Report on Setting up a National Community-based Early Warning Network (December, 2008) • Simulation exercises reports (2007-2010) • Knowledge, Attitude and Practices Study (2008,2011) • Annual CAPMU Progress Reports (2007-2011) • Various consultant reports on animal and human health (2007-2010). 60 IBRD 33448R 27°E 28°E 29°E 30°E Dnes tr To Vinnytsya UKRA INE To Chernivtsi Moghiliov- To Vinnytsya Ocnita Podolski Briceni MOLDOVA Donduseni B To Chernivtsi Edinet Soroca e Drochia s s 48°N Camenca 48°N Rîscani s Floresti Nist ru a Costesti Soldanesti ˘ r r Glodeni Balti Rîbnita Rezina Balatina a a Pr Sîngerei ut To Voznesens'k r Falesti ˘ Telenesti 0 10 20 30 40 Kilometers a Chiperceni b Orhei 0 10 20 30 Miles RO MAN I A Sculeni Dubasari ˘ TRANSNISTRIA i i To Pascani Mt. Balanesti Calarasi ˘˘ Criuleni (430 m) a Ungheni Straseni ˘ Grigoriopol Nisporeni ˘ Stauceni To Zhmerynka 47°N ˘ CHISINAU 47°N ˘ Lapusna Ialoveni Anenii Noi Tiraspol Hîncesti Bender Leuseni (Tighina) Slobozia ˘ Cainari Causeni ˘ To Odesa Plain Cimislia c Stefan-Voda N ˘ ist To Birlad ea ru g Leova Bu This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Comrat Basarabeasca Group, any judgment on the legal status of any territory, or any To Birlad endorsement or acceptance of such boundaries. Cantemir 27°E ˘ ˘ GAGAUZIA Ceadîr- To Artsyz UKRA INE Lunga MO LDO VA 46°N 46°N Prut SELECTED CITIES AND TOWNS Cahul Taraclia AUTONOMOUS TERRITORIAL UNIT CAPITALS ˘ ˘ GAGAUZIA RAIONS OR MUNICIPALITIES CAPITALS* ˘ Vulcanesti NATIONAL CAPITAL RIVERS MAIN ROADS RAILROADS To Imayil B l ack AUTONOMOUS TERRITORIAL UNIT BOUNDARIES To Bucharest Sea and Constanta RAIONS OR MUNICIPALITIES BOUNDARIES INTERNATIONAL BOUNDARIES *Names of the raions or municipalities are identical to their capitals. 28°E 29°E 30°E MAY 2007