|1. Project Data:
ICR Review Date Posted:
|Avian Influenza Control And Human Pandemic Preparedness And Response Project
Project Costs(US $M)
Loan/Credit (US $M)
|Agriculture and Rural Development
Cofinancing (US $M)
Board Approval Date
|General public administration sector (50%), Health (28%), Agricultural extension and research (19%), Solid waste management (3%)|
|Other communicable diseases (25% - P)
Natural disaster management (25% - P)
Rural services and infrastructure (24% - P)
Pollution management and environmental health (13% - S)
Health system performance (13% - S)|
||ICR Review Coordinator:
|2. Project Objectives and Components:|
a. Objectives:Original objective:
The original project objectives were to "strengthen the PISG’s [Provisional Institutions of Self Government] capacity to prevent the spread of Highly Pathogenic Avian Influenza (HPAI) among poultry, to prevent the transmission of avian influenza from birds to other animals and humans, and to prepare for a potential pandemic of avian influenza transmissible between humans." (Financing agreement, Schedule 1).
The objectives in the appraisal document (Technical Annex, page 7) were substantially identical.
After restructuring, the revised objectives were to "minimize the threat posed to humans by highly pathogenic avian influenza (HPAI) infection and other zoonoses to prepare for, control, and respond to influenza pandemics and other infectious disease emergencies in humans". (Project Paper December 18 2009 that restructured the project).
The revised objectives were largely similar to the original objectives, except that they expanded the scope to cover zoonoses other than avian influenza, and pandemics and infectious disease emergencies other than those from avian influenza.
The Provisional Institutions of Self Government were the administrative government set up in Kosovo by the 1999 United Nations Security Council Resolution 1244, which ended the conflict with Serbia and establishing Kosovo as a self-governing entity. Kosovo later declared full independence in 2008.
b. Were the project objectives/key associated outcome targets revised during implementation?
If yes, did the Board approve the revised objectives/key associated outcome targets?
Date of Board Approval: 12/18/2009
c. Components:Original components (and their restructuring):
1. Public awareness ($0.28 at appraisal, $0.24m after restructuring, $0.26m final), aimed at developing and implementing a communication plan to inform the public (particularly those at high risk) about the threat of avian influenza and steps they could take to reduce transmission and spread. It would include development and dissemination of communication materials, communications training, and awareness raising with community groups. After restructuring, the communication materials were expanded to also cover the 2009 influenza pandemic.
2. Animal health ($1.47m at appraisal, $1.00m after restructuring, $1.25m final). This included support for prevention and preparedness capacity, disease control capacity, surveillance and diagnostic capacity, and outbreak containment and control capacity. It would include policy reform, technical assistance for veterinarians, epidemiological studies, laboratory upgrades, equipment and training for culling, and a compensation fund for farmers whose birds were culled. After restructuring the money for the compensation fund was removed, additional civil works and equipment for the animal health laboratory were added to ensure that the laboratory would be operational, and additional technical assistance on field epidemiology and laboratory diagnosis for other zoonoses were added.
3. Human health ($0.97m at appraisal, $1.49m after restructuring, $1.31 final). This included support for coordination and planning, improvements to the national public health surveillance system, and improving heath care response capacity. It included creation of plans, technical assistance and training to set up a surveillance system, laboratory upgrades, treatment facility upgrades, and supply of vaccine and antivirus. After restructuring, additional activities were added to revise the National Pandemic Preparedness Plan, to support hospital preparedness for the 2009 influenza pandemic, to purchase additional protective clothing and laboratory consumable items, and to support additional technical assistance for emergency management, triage, and clinical management.
4. Project management ($0.28m at appraisal, $0.27m after restructuring, $0.29m final). This would cover project support, training, and M&E.
The project restructuring kept most existing activities in place, but shifted funds from the compensation fund to other activities in the public awareness, animal health, and human health components as described above.
d. Comments on Project Cost, Financing, Borrower Contribution, and DatesAs the project used an emergency lending instrument, the operation was to be completed in three years rather than the usual five years. The difference between the US$ value of the grant at appraisal ($3m) and the actual project cost ($3.1m) is driven by exchange rate movements (the grant was denominated in special drawing rights).
The project was entirely financed by an IDA grant of SDR 2 million (US$3 million equivalent). There was no borrower contribution, though government funds were made available to be used for compensating farmers whose birds were culled if necessary.
The project closure date was extended twice, to December 31 2010 and then to June 30 2011. These extensions were made in order to allow time for the completion of activities added under the project restructuring and reallocation.
|3. Relevance of Objectives & Design:|
a. Relevance of Objectives:Relevance of original objectives: Substantial
The project was responding to a global emergency, rather than being motivated by existing Bank or national development strategies for Kosovo. Kosovo was not a formal World Bank Group member until FY09, so no Country Partnership Strategy existed prior to FY12. The project was not particularly relevant to the pillars of interim strategy notes during the project period (it was tangentially relevant to a goal to "create strong, transparent institutions"), but was consistent with the broad World Bank approach of responding to highly pathogenic avian influenza (HPAI).
The original objectives addressed HPAI, which posed a serious risk to Kosovo. The disease was having a significant effect on the poultry industry in many countries, but there was a particular risk for Kosovo as outbreaks had occurred among poultry or wild birds in several nearby countries (Bosnia and Herzegovina, Bulgaria, Croatia, Serbia and Montenegro and Romania). The virus could spread to Kosovo through migration of wild birds or through illegal imports of poultry.
Kosovo faced significant vulnerabilities from avian influenza. Kosovo had 2.6 million poultry, of which 75% were on small rural farms with modest biosecurity. Half of all rural households owned poultry, so there was a significant human population that was potentially vulnerable to exposure to disease transmission from birds.
Veterinary and public health services had a number of weaknesses in capacity, public awareness and ability to fund compensation. Though the Kosovo government had set up HPAI-related plans and UN agencies and donors had provided some support, shoring up these weaknesses was beyond the financial capacity of the government or donors.
The vulnerabilities to avian influenza and the low capacity level meant that the project objectives were relevant for Kosovo. However, the focus on avian influenza was arguably too narrow, particularly in regards to risk of influenza pandemics, which could originate from avian influenza or from other strains of influenza.
Relevance of revised objectives: Substantial
The original objectives were largely encapsulated within the revised objectives, and so the reasons for relevance of the original objective also applied to the the revised objectives.
By 2009, no outbreaks of avian influenza had occurred, and there was a perception that the risk of avian influenza was declining throughout the region and the world. A pandemic of non-avian H1N1 influenza began in 2009, and posed a potential threat to Kosovo.
The revised objectives added attention to other zoonoses, and clarified the objective so as to address non-avian influenza pandemics. These helped the project to remain relevant and to address the unfolding pandemic.
b. Relevance of Design:Relevance of design to original objectives: Substantial
The original project design followed the broad outlines of the Global Program on Avian Influenza. The awareness and information component was designed to communicate risks to the public and to reduce behaviors that might lead to disease transmission from poultry to humans or between humans. The animal health component was designed to improve the ability to identify any avian influenza outbreaks that occurred among poultry and to contain them by culling infected and potentially infected birds, thus limiting the spread of disease. The human health component was designed to increase the capacity to identify and treat humans infected by HPAI, and to build capacity to mitigate a pandemic. However, the project design did little to address biosecurity and thus chance that an outbreak would occur.
Relevance of design to revised objectives: Substantial
The activities supported under the original project design were still in the revised design, and remained relevant to the revised objectives. The newly added activities supported the revised objectives. Additional improvements to the animal health laboratory would contribute to the ability to diagnose avian influenza and other zoonoses. Purchase of consumable supplies for the human health component, revised communication messages and pandemic preparedness plan and additional hospital preparedness would contribute to increasing capacity to respond to the influenza pandemic. Removing the project funds dedicated to compensation did not undermine the objectives, because the likelihood that they would be needed in the short term had declined and because the government had committed to fund compensation as needed. However, the extent to which new activities addressed zoonoses other than avian influenza or infectious disease emergencies other than influenza is unclear.
|4. Achievement of Objectives (Efficacy) :|
Achievement of original objectives:
1. Strengthen capacity to prevent the spread of avian influenza among poultry and to prevent the transmission of avian influenza from birds to other animals and humans: Substantial
- An animal health laboratory with the capacity to diagnose avian influenza and other animal diseases was completed in September 2010, and training was provided in March 2011.
- A compensation mechanism was established, under which farmers would be compensated for the loss of any poultry culled in order to contain avian influenza outbreaks. Funds for compensation were available throughout the project, initially from project funds and then from the government budget after project funds were reallocated. However, no outbreaks occurred and so compensation funds were not drawn on.
- A mobile incinerator, disinfection equipment, protective gear and other materials were procured and distributed. These would have assisted in controlling outbreaks had any occurred.
- An epidemiology unit was established and trained and provided with transport.
- A public awareness campaign was produced targeting poultry producers, veterinary and health personnel and the general public, aimed at informing people of the threat of HPAI and measures they could take to protect themselves.
- It should be noted that project activities in areas with a majority Serb population were carried out and financed by WHO and UNICEF, not by the Bank-financed project.
- No outbreaks of avian influenza occurred in Kosovo during the project period. It is not possible to assess the extent to which the project contributed to this.
- Diagnostic capacity was established in Kosovo by the end of the project, but external assessment of the quality diagnostic capacity had not been done by project closure. The ICR did not contain evidence on the effectiveness of surveillance systems.
- Simulation exercises were carried out to test the readiness of systems for disease reporting and control, but the results of these simulations and the level of preparedness demonstrated was not reported in the ICR.
- Outputs that prevented the spread of avian influenza among poultry would also serve to reduce the risk of transmission from birds to humans.
- Knowledge, Attitude and Practice surveys were conducted in 2008 and 2010, but no baseline survey was carried out (understandably given the emergency nature of the project), so survey responses cover two points both after the communication campaign had commenced. The surveys provided mixed evidence of behavioral change. 80% of the general public reported in 2008 that they changed the manner in which they handled poultry or poultry products, but this had fallen to 50% by 2010; this may have represented declining sensitivity to avian influenza as the perceived risk declined. 22% reported cooking poultry well in 2008, rising to 31% in 2010. There was no significant change in the proportion reporting they avoided contact with dead poultry and wild birds (32%, 33%). The proportion of the population reporting they did not consume poultry (an unnecessary precaution) declined from 21% in 2008 to 10% in 2010. 24% of the population could identify key symptoms of avian influenza. The survey found that healthcare staff had not significantly improved their understanding of avian influenza, and that some farmers reported some improvements in biosecurity on their premises while remaining skeptical that an avian influenza epidemic would occur. Given the declining values of some indicators, the survey evidence does not provide much evidence that the communication campaign was effective.
- Other than some effects from the awareness campaign, the project had little impact on poultry biosecurity.
2. Prepare for a potential pandemic of avian influenza transmissible between humans: Modest
- A pandemic preparedness plan was developed. A crisis management training module was not completed.
- Health staff were trained, but the ICR does not specify how many.
- Surveillance guidelines and procedures were adopted, and an early warning system was established. Transport procedures were established for international testing of specimens.
- A virology laboratory was upgraded in 2010, and provided the ability to diagnose avian influenza. International testing confirmed the accuracy of diagnostic capacity at at least 95%.
- 8,000 doses of seasonal influenza vaccine were procured and distributed.
- An Intensive Care Unit (ICU) was established at Pristina Infectious Disease Hospital.
- 25,000 doses of antivirus were procured and were ready for treatment.
- The early warning surveillance system might have increased the ability to identify and respond to influenza outbreaks, but the ICR does not provide evidence on the effectiveness of the surveillance system.
- Providing diagnostic capacity within Kosovo has decreased the time needed to receive a diagnosis.
- The project vaccinated medical staff during the project period but this seasonal influenza vaccine would have had little impact on protecting against avian influenza, and the project did not establish a sustainable system for procuring vaccine.
- The enhanced ICU increased the ability to treat human cases of avian influenza, though it is likely that a single ICU would be overwhelmed in the event of a serious pandemic.
- The antivirals purchased would have enhanced avian influenza pandemic preparedness during period of the project, but the doses will expire in the new future and so provide no long-term coverage. It is unclear from the ICR whether these doses were used during the 2009-10 pandemic; if no doses were used despite an influenza pandemic, then the stockpile likely had little value.
Achievement of revised objectives:
Outputs and outcomes of the original objectives were also relevant to the revised objectives.
1. Minimize the threat posed to humans by highly pathogenic avian influenza and other zoonoses: Substantial
- The ICR notes (page 23) that the animal health laboratory was capable of diagnosing animal diseases other than avian influenza, but does not specify those diseases or make clear whether reagents, equipment and training were capable of supporting diagnosis for animal diseases other than influenza.
- Support for the epidemiology team and some equipment would be relevant for increasing capacity to prevent zoonoses other than avian influenza.
- The ICR notes that the communication campaign was revised to provide information related to other zoonoses.
- The outcomes of the original avian influenza objective remained relevant to the revised objective.
- There is little evidence of the effects of the project on zoonoses other than avian influenza.
- The impact of the revised communications campaign was not assessed.
2. Prepare for, control and respond to influenza pandemics and other infectious disease emergencies in humans: Modest
- The preparedness plan covered both avian influenza and other infectious diseases.
- The additional supplies would help to replace doses consumed during the pandemic.
- The availability of antivirals increased preparedness for non-avian influenza pandemics and some other infectious diseases.
- The intensive care unit upgrades increased preparedness for a wide range of infectious disease emergencies. During the project, the ICU was used in treatment of 30 patients, mostly cases of H1N1 influenza during the pandemic. Four of these patients died, which is within the expected mortality range.
An economic analysis conducted at appraisal attempted to estimate the benefits of the project from reducing the likelihood of outbreaks among poultry and associated losses in poultry. The analysis calculated an internal rate of return of 18%, but this required highly speculative estimates on the efficacy of project interventions and the likelihood of outbreaks. The analysis did not consider the economic benefits from preventing secondary economic costs of outbreaks (such as through a decline in poultry prices driven by fear) or human mortality and morbidity.
The ICR correctly identified that an ex-post rate of return calculation was unlikely to be meaningful, given the extreme difficulties in making reasonable assumptions and given that the project was designed to build capacity to respond to a disaster that turned out not to occur (but was a reasonable fear at the time). But it noted that the project is likely to have had significant benefits from increased preparedness for influenza outbreaks.
The use of project coordinators from existing government structures rather than a standalone project management unit reduced the financial cost of the project, but also contributed to implementation problems, as the coordinators had substantial workloads from their existing jobs. Supervision missions used local experts which reduced supervision costs.
The preparation and supervision costs of the project were high relative to the $3.1 million project cost, with total staff time of 119 staff weeks and $467,000 of travel expenses. This calls into question whether the Bank's intensive project preparation and supervision requirements are appropriate for very small lending operations.
Project efficiency is rated Modest.
a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return at appraisal and the re-estimated value at evaluation:
* Refers to percent of total project cost for which ERR/FRR was calculated