Document of The World Bank

Report No: ICR00001749

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-42060)

ONA

CREDIT

IN THE AMOUNT OF SDR 3.5 MILLION (US$ 5.0 MILLION EQUIVALENT)

TO

ALBANIA

FORAN

AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE PROJECT

June 20, 2011

Sustainable Development Department South East Europe Country Unit Europe and Central Asia Region

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ALBANIA

Avian Influenza Control and Human Pandemic Preparedness and Response Project

CONTENTS

Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph

1. Project Context, Development Objectives and Design ............................................. 1 2. Key Factors Affecting Implementation and Outcomes ........................................... 5 3. Assessment of Outcomes .......................................... ' ................................................. 9 4. Assessment of Risk to Development Outcome ...................................................... 16 5. Assessment of Bank and Borrower Performance .................................................. 17 6. Lessons Learned ..................................................................................................... ,19 7. Comments on Issues Raised by Borrower/Implementing AgencieslPartners ........ 20 Annex 1. Project Costs and Financing ......................................................................... 21 Annex 2. Outputs by Component ................................................................................ 23 Annex 3. Economic and Financial Analysis ............................................................... 34 Annex 4. Bank Lending and Implementation Support/Supervision Processes ........... 40 Annex 5 .. Beneficiary Survey Results ......................................................................... 42

, Annex 6. Stakeholder Workshop Report and Results .................................. ~ .............. 43 Annex 7. Summary of Borrower's ICR ....................................................................... 44 Annex 8. Comments of Cofinanciersand Other Partners/Stakeholders ..................... 46 Annex 9. List of Supporting Documents .................................................................... 47 MAP IBRD No.33359 ......................................................................... 48

Avian Influenza Control,

iCountry: Albania iProject Name: land Human Pandemic iPreparedness and

!R~sponse Pr()ject

;Proje~t ID: P]00273 \LICffF Number(s): IDA-42060, TF-S6728

IICRDate: 106/24/20] ] ICR Type: Core ICR

iLending Instrument: 'ERL Borrower: :REPUBLIC OF

ALBANIA ...... __ ._.- _ ... -.....

lOriginal Total XDR3.SM Disbursed Amount: XDR2.5M

(Commitment:

IRevised Amount: XDR2.SM

!!!!i.!~_n~!!~~~~!~g~!1L!! · .. ____ ... _._ ... ___ .... ___________ . __ .. __ . _______ ... _. _____ .. _____ .. _______ . __ . ___ .. ________ ._._ .. __ .. ___ _

IImplementing Agencies: Task Force on AI in Albania

ICofinanciers and Otber External Partners:

_g~~~!!!~~!!!.~f~~J~_~. ~~!!~ __ ... ____ .~_ .. _~_ .. ______ ...

Process Date Process Original Date Revised 1 Actual

..... ~~te(s) go.!!c~p~ R.evi~w.: 03/31/2006 :Effectiveness: 1011 6/2006 1011 6/2006

~~l'_l!!i~~L ___ ._.~ __________ O~~l_~{~~~~. __ ~~~~~~~!:!!!g~~_: ______ .. ___ .. ____________ . ______ .~_ .. ] O/I_~~QQ~ __ .. ._~Eproval: _. __ .Q~~_?!~QQ~ ____ ~~i~::!~~_~~y~w._: ... _ OS/2112008 07/03/2008

]2/3112010 06/30/2009

<?t1t~()Jll~~: __ _______ .......... _ ... __ . !Sa!isfact()ry.

__ ~i_s~.to Dey_t?!0p~~!2!!!~I!!~~ ____ .. _._. _____ . ___ ._. iM~<!~!~~~ ______ .. _._. ____ .. _______ .. ~ _____ ~ ______ . __ .. __ }~~k ~ert:<!I!l.~~~~_: ___________ . _________ ~ __________ . ___ l~_~i.s!~~!~ry _ ........ __ .. ____ .. __ ~----.... --.. -.... -----.-- .. ____ _ .. Borrower Performam~~: _____ ... ____ .~_-__ ~.l~()~~!~!~!y.~_~!~!a.£~ry_~ __ .. ~ .. _~_. ___ " ... _."

.~~2 Detailed.~!i_ngs ofJ:lank,!.nd~())·rower p'~""'orm~nce (byICR) . ____ .. _______ !!~~ ____ . ___ ..._ . ___ . __ ~~!'g~___ __ ._____ .. ~_ .......... _ ... !!~!:r:~!".~r ... . .." ... ____ ~~~i_J)gs :Q!l!Ji!>'_!!~I!~:. ______ .. __ '~~!!~f~~!~rL ________ .. _._:Q()y~~'!!~_~.~:_. ____ ... _ ...~_~t~s.fa~t()ry_

Q I· fS .. ·S· &: . ilmplementing : ua Ity 0 upervlslon:: atIslactory A ency/ Agencies: .. _ ..... ___ ..... _______ .. __ ._ .... _ .. ___ ._ .... ____ .... _____ ._. ___ ... _ ... _ .. _._ .. _. ___ ...... _ .... __ .Jt ............... _.. ._ ..... _ .... _ ........ .

Moderately Satisfactory

'Overall Bank Overall Borrower Performance: Satisfactory 'Performance: Moderately Satisfactory

:C.3 Quali!Lf!t ~~!.I1."~!<!!!Dpl!~.!~.t~!!!~!~,!'!~~!!I.!~~!!I:~~~Il~~!!","_,~ __ ., ... ,., .. , .. Implementation Indicators :QAG Assessments (if Rating

""_, ___ ~~_t!~~~f!!lce ... ___ any) Potential Problem Project y 'Quality at Entry

i~t_~y_ti,I!!~_(X~s.~,~):_ .. , es ....... ___ .KQ~J'\): ..

Sector C~as~~_~!,!~!f!!,J.Jal.!k f'!~f!~c,illg), .. ___ "',___'_,.__ .... ,

_~~i~':ll_!!!~~~~~~~s..i<?ll_a!l~.~es.earch

_Q~Il~ralp_':l~!i~_.~~!11i~!s.!J:~~!<?ll .. sec!~~ _____ .... _ ... ____ .... ____ .___. Health

Other social services

18

9

45

27

None

18

9

45

27

Theme Code (as % oftotal,Jjank !,,!!!!!.~!ng) _,_. ___ ~ .. ",. __ ",.~ .. ~ ___ "._,,. .. ___ . __ ,. __ ,_. , _____ . __ ,._ .. ,.".,

_J:l~_~!!J1_s.Y!!~~J>~rformance ....... _ __ _ __ 14 14

Other communicable diseases 29 , 29

_!:l~i~jp~ti~.!!_~~_~i..,.i~_~~~~~e.~_~ll!_, __ . _____ .. _________ _____________ _____~_~ ___________________ !~ ____ ,_ .. ~<?~I.':lti~ll_~~ll,~g~!11~n!_.~.~ .. ~nv:ironm~llt~1 hel:llt~, Rural services and infrastructure

Positions AtleR

_Vice _!!~s.ide.ll!: ______ ... ___ i!:l~~!~,p~_ H:_~ .1I~lle_~~u

__ g~.':l!1:~.!?!!!~!<?~:_____;~Ll!le_ ~f!!li_~~~ __ ._. __ ., _. _.~~~!~!_~~~~~E_ __ ____ :~!ll~_!:!l!l~I!~!?~!ll_ill~e~ __ :.

_!:It:.~..e.~t T~~!_~~~~~: __ ,!~!_I:l~i!l1!!I:l~~~L,, _______ ,_'_ ___ _' _____ _

14

29 14

29

AtApprov~1

~higeo Katsu

. _ic:>r~_l:llia Kalan~poulos

_._ .~~llIj_~!y:::~nne ~~<?~~ead Julian A. Lampietti

•• _.. • ....... ~_._ •• _ •• __ ._. '" _ ••• ~_, •• _. __ •• _"_ ., .... ,.A ___ •• '" _'-;"'" •• _.'W" "

, I~~.'f~~,~~~!:. . ... :Malathi,S: Jaya~!~~~~_____ _

.J>ri~~_Allt.~~r~:_ . ._iDa..,}~}:ladrill.~_~lllllthi S. Jlly~~ic~aJJlll

ii

F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document) The project development objective is to strengthen the country's capacity to prevent the spread of avian influenza 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.

Revised Project Development Objectives (as approved by original approving authority) The revised PD~ was to minimize the threat posed to humans by Highly Pathogenic Avian Influenza (HPAI) infection and other zoonoses and to prepare for, control, and respond to influenza pandemics and other infectious disease emergencies in humans.

(a) PDO Indicator(s)

Indicator Baseline Value

Original Target Formally Values (from Revised

Actual Value Achieved at

Completion or approval 'T t V I .arge a ues' _ _ ______________ .... _ d~«!~f!l~nts) ___ _TargetYears

Indicator 1: '_,Behavior changes among key veterinary and public health personnel

Value quantitative or Qualitative)

'Low level of knowledge ,and poorly documented procedures to follow in 'case of outbreak. Estimated at 25%

'N/A

Procedures for Function inter- taking specimens sector and culling of surveillance animals are in place. system in There are improved place for behaviors and animals and 'practices of good humans poultry and other 'endorsed by 'animal breeding, OlE, FAO ~d usage ofPPE, 'WHO disinfectants and

_______ ... _____ . ___________ ... _________ . ________ . __ .. ___________ .. _____ .. _____ .. ____ .. ____ . ___ ... _ _ _______ .. __ ._ .. _ .. _________ "_' ________ .. ______ .. _________ . ~~~!!lplin.s __ __ Date achieved ;06/0112006 ,06/30/200610115/2009 ;06/30/2010 Comments (incl. % achievement) lndicator 2 :

The intersectoral surveillance system in place for animal and humans endorsed by the OIE,F AO, WHO

-- "_ .. , ".,.,-,.

,Public awarene~s of ho~ t<?prev~nt spread increas~s an~ behavi()r changes_ 55% more of

55% more of at-at-risk risk population population

Value :Low level of public practicing safe practicing safe ,handling handling 70% procedures with procedures

quantitative or awareness (estimated at Qualitative) 25%) .

'respect to poultry with respect to :and poultry meat poultry and

______ .. ____________ . _______ .... _..:. ___ .. ______ ... _. ____ ... _______________________________________ .:P<?.!l_!!!Y mtl~! _______________________ .... Date achieved '06/0112006 :06/30/200610/15/200912/17/2010

v_."._ .• _.. "_"

Comments High level~( p~~lic~~a.ren~ss reached ~~_i~ __ ~usta~!l~bltl_tl1~_~0II!~_~J'lication

iii

.. -..... -.. -.... -.----.-.-- .. _ ...... _" ...... __ ..... _._ .... _ .... _ ....... __ .. , ... _ ..... - ...•. _ ... -'_ .... _ ... _.-...•. __ ._ .... - _._. .. ........... _ .. _, .... -

:(incl, % Working Group will continue working with the broad base including vet service !El:c::~!~~~!Il~E:t) _____ ____ ___ ..... _ ._______ __ .__ ____________ .. _.. __ ._. _ .... 'Indicator 3 : Enhance laboratory diagnostic capacity of zoonotic diseases

Laboratory testing capacity and bio­safety level

Value quantitative or . Biosafety level -2 Qualitative)

upgraded to meet Bio safety needs of enhanced level 2+

Bio safety level 2+

Date achieved '06/01/2006

disease 'surveillance and . monitoring 06/3'0/2006 .10/15/2009 12/17/2010

:Comments Rehabilitation of virology lat at IPH, upgraded with new equipment (RT-PCR» {inel. % (and staff capacity, More accurate diagnostic testing confirmed in 100% of :~~i~~~!Il!I1!>_~~lll1!pl~~_~~~t.!o illt.t'I!l~ti~Il~! ~f~~~llc~ lEl:~_C::()llfirms h!~ _s.~dard ()f lah.c::ap~cities .

'Strengthen surveillance of zoonotic diseases on the ground, including modalities _ Indicator 4 :

.. _.. . .. ... __ _ _ :f()! ~p()t:t~ng, r~c::()~~!I!g_ ~11~}I1_v~s.!iJ~!t.~ng~l!sp_(il~!C::~(il~~_ ______ _ _ __ __

Value Public health system quantitative or unable to respond to Qualitative ) suspected or actual cases

New indicator

A system that cis able to respond to cases

The establishment tofthe NVEU, upgrading of labs, diversified training of veterinary staff and the provision of IT and other equipment to field

_____ ._. _______ . _______ . ______ ._._.________________________ _______________ ____ ______________ . ... _____\lV()~~_~d reporting:. Date achieved :06/01/2'006 Comments {incl. %

06/30120'06 10/15/2009 12117/2010

,a(:hievem~l1_t) _. __ _. _ .... __ . _ '. __ .. Indicator 5 : Ensure prompt and efficient preventionicontroVeradiation of prevalent zoonoses,

_}l1c!uding r~sourc~s andpr()Cedtires for compensation ..

Value IS days minimum to quantitative or Qualitative) ;provide compensation

7-15 days minimum

Compensation to beneficiaries. paid within 10 , d fi II ' CompensatlOn ays 0 owmg. d· fi

'fil' fth secure rom I mg 0 e 'I .

I' t' d:natlOna resources app Ica Ion an supporting documentation _._--_ ... _-------_. __ ._-_ ... _ .. _- ... __ ._._._._--_. __ .... _--_. __ .... _------_._-- ....... _-_._.- - -_ ... _._----_._.-_._-_ .. _._ .. _---_._ .. _ ..... __ ._.- ----_._. __ . '-'---

Date achieved \'06/0112006 :06/3'0/2006 10/15/2'009 .12117/2'010 Comments (incl. % achievemeJ!t) . ~ . ... -_..... .. ~- .

Indicator 6 : National Influenza Preparedness Plan (NIPP) for control and response to outbreak and pandemic prepared in accordance with

Value quantitative or No level 6 (No baseline) N/A Qualitative)

iv

WHO recommendations New NIPP Prepared NIPP developed and including level6, endorsed by based on WHO WHO(added recommendations

due to WHO and their updating level 6 with the latest news pandemic declaration) Target is to complete for levels 0-6 and post pandemic

--". .. 'p(lriod Date achieved 06/0112006 ,06/30/2006 10115/200912/17/2010

........... ---.............. _ ..

Comments (incl. % achievemeJlt)

" (b) Intermediate Outcome Indicator(s)

Indicator Baseline Value

._"-

Original Target Formally Actual Value Value-Ii (from Revised Achieved at

approval Completion or Target Values' documents) Target Years

iIndicator 1 : '55% more of at-risk population practicing safe handling procedures with respect to poultry. and poultry meat with respect to poultry and poultry meat. Pandemic

""_ , ____ ._,_."_(;:~r.n!I!"l:I'!i(;:f!.!i~!l: 1J1~~~8e~ P!:.()~"l:I~_e~ ~~,,~~liyer.ed t()"~S~~I1~~!~Il~~ __ , .,__,

Value (quantitative or Qualitative)

Est. 25 %

Date achieved :06/30/2006 Comments (incl. %

55%

06/30/2006 - -.. _ .......... .

ac~i(lYf:r.n"~nt) __ .'" " ""'

55%

10115/2009 - ., .......... ,.

Wash hands after touching poultry :(16.4 % to 63.S %); cooking poultry products well (21.7 % to 59%); know to avoid contact with dead poultry and wild birds (13.4 % to 50.2%); wear gloves when cooking poultry (9.4 '%to 16.5 %) 12/17/2010

~llc:li~t~~2: .'. Pl1Ddemi(;:comm~nicati()ns m.es~.I1~es produced and deHveredt()!/lI:s.e!ed audiences 55.3% have read brochures; 67.S %

Value (quantitative or Qualitative)

Est. 10 % (new indicator introduced at restructuring)

v

70%

say leaflets and the ideas were clearly formulated, easily understandable; 75.9 % responded that they have seen

ry_~.e.()~

Date achieved 07/1112006 10/05/2009 10/05/2009 12/17/2010 Comments (inc!. % achievement) Indicator 3 :

Although a baseline value does not exist, the KAP survey in 2006 can be regarded as a baseline. The 2006 numbers were: 12.7%, 28% and 72.1 % respectively for· the 3 areas mentioned under actual achievements New Framework Veterinary Law adopted, in line with EU acquis and practices

The new draft Veterinary Law introducing clear and more

Value By-laws not developed. New sub-laws New draft effective provisions (quantitative Current veterinary service developed and veterinary law in line with EU or Qualitative) and inspectorate law passed adopted acquis and practices

has been completed and sent to line

Date achieved 06/1112006 06/30/2006 10/15/2010

Ministries for review 12117/2010

Comments (inc!. % achievement) Indicator 4 :

Value (quantitative or Qualitative)

all risk groups have been vaccinated and the target has been met since June 30, 09.

New contingency plan for HPAI adopted, in line with EU acquis and practices A new EU

Clearer and . I· t .comp Ian more effectIve . t d· contmgency plan

s an mg for HP AI was arrangements

Emergency Plan in place 2nd revision

for combating HPAI

Date achieved :06/0112006 Comments

06/30/2006 10/15/2009

prepared, approved and published in MAFCP webpage 12/30/2010

(inc!. % achievement)

National Veterinary Epidemiological Unit established and achieving an increase of Indicator 5 : the number of suspect cases of animal diseases reported and investigated by

Value (quantitative ,or Qualitative)

means of clinical exams andlor epidemiological inquiries NVEU incorporated into State

N/A NVEU incorporated into SVS

Veterinary Service and implementing enhanced disease surveillance and control activities

NVEU has been established, equipped, and staff trained

Date achieved 06/01/2006 06/30/2006 10115/2009 1211712010 Comments (inc!. % achievement)

The NVEU is pursuing various activities including, compilation of historical data on prevalence and incidence of relevant diseases, i.e. brucellosis, TB etc, and collection and evaluation of regular epidemiological returns from the field

VI

Indicator 6 :

Value '(quantitative :or Qualitative)

..... "~ .. -.-.,~ ... _, ..... - ............ ~-... -..... --... .., ........ , ...... --Animal Health Laboratory testing capacity and bio-safety level upgraded andl achieving an increase in the number of suspected cases of animal diseases :investigated by means of laboratory tests and techniques

Sio-safety level -2 N/A

A'· I H 'Ith The lab is equipped mma ea . L b t wIth, and capable of t a /r8 ory routinely carrying es m~out RT-PCR for

capacIty and 'HPAI d th b· Co ty an 0 er 10-sale . I I d d relevant dIseases. teve utpgra de Lab staff trained in o mee nee s . . f h ed ,lmplementmg

o en anc . . qualIty assurance

disease .surveillance and monitoring

:syst~m and SOP, to enhance stability :and improve

-". - _.,- ., ,_:biosafet)'.

Date achieved 0610 1 12006 06/30/2006 10/15/2009 ]2/17/2010 Comments {incl. %

'll~i~.Y~!n.~.!1t >.,'"

Indicator 7 :

Value '(quantitative or Qualitative)

._.... . ...... -... .

'100 % of veterinary field staff trained in diagnosis, investigation and control :methods for HP AI and other diseases

original indicator was 100 % of veterinary and :extension field staff ,100% trained in safety protocols. 'Estimated at 10%.

......... -..

100%

. ... , ....•.

100 % (250) of all regional field veterinarians have been trained on AI ' and Newcastle disease .

06/30/2006 10/15/2009 .12/17/2010 Date achieved 06/01/2006 Comments Additional training' was provided to them on various diseases upon request from (incl. % .

the regions, such as brucellosis, TB, anthrax, rabies, and enterotoxaemia ach~evement)

Indi~"_~~-:~: . .f~~ensation secu~~Jr~f!1 ~llti~!1al resources

Value (quantitative :or Qualitative)

'original indicator was lCompensation Fund (CF) :US$20 ·11· iof US$2.0 million ' . ml Ion :established

Compensation CF is guaranteed to beneficiariesfrom the budget of paid within 10 the Ministry of days following 'Finance. In case of filing of the outbreak, the application and:beneficiaries will be, supporting compensated

._ ... --_ .. ""'--"'--- ._"._.. . " .. - -, .. _- .. .. '" _ .. _ ... - .. ~ -~ .. ,.".- .'._,". - .... _- doc~1"I!en~tion wititin.l QdaYs Date achieved 06/0112006 ,06/30/2006 10115/2009 12/17/2010 Comments (incl. % :achievement) Indicator 9 :

Value (quantitative or Qualitative)

Based on the 2006 experience, they were compensated in 6 days

.Samples ship~d in conformity to IA T A procedures " 9-10 days between collection of As per IA T A samples and the procedures

.i\.pprox. ] 5 days

,results from the

vii

505 samples shipped in conformity to lATA

"pro~edur~s and sent

UK reference lab (previous indicator)

- ..

. . - - -

to Cantacuzino laboratory (Romania) within 5 days which include times of informing the transport 'Operator, delivery to reference lab, :sample analyses and· delivery of test .r~p.()rt _ .

Date achieved 06/0112006· 06/30/2006 10115/2009 12/17/2010 Comments {inc!. %

~~~~~'ye!l!~!lt).. .............. . 'Indicator 10 : Anti-viral drugs stockpiled

Value (quantitative :or Qualitative)

'200.treatinents

Date achieved 06/01/2006

3000 treatinents

_ .......

06/3012006

- . .. "'" ~ ..... - "- - ., - -

Asper National Plan

14,200 antiviral doses procured by the AI Project. Around 7,000 doses :ofTamiflu (expiry date 2017) are available for the next expected wave of influenza

10/15/2009 12/17/2010 Comments (inc!. % iachieve.IJl~nt ) Indicator 11 : :System to rapidl), procurea.ntivi~1 for pa.nderni.c .-- .-...

Value (quantitative :or Qualitative)

Not existing

Date achieved 06130/2006

In place

06/30/2009 Comments (inc!. % ;~chievemen~)

Indicator 12 : " .. " .. , ..... - . -. __ . ... ..

Establish an Intensive Care Unit

Value '(quantitative None or Qualitative)

N/A(new indicator)

viii

System enhanced to speed .procurement by November 2009

. Procure~ent system

.is in place. There is only one producing company (Roche) that has two main distributors in Albania, that guaranties very quick procurement process.

10/15/2009 12/17/2010

A very modem ICU ·is inaugurated and is.

Establish ICU fully functional since December 2009

Date achieved '06/0112006 06/30/2006 10/15/2009 12/1712010 . _____ ._H~_._ .•.... __ .. __ .. _ ... __ ._. _____ ._ .. _._ .. __ . ___ . _____ .. _." ..... ____ .. __ ". __ ,,,. __ •. . .. _ .. ". '" .. "H ...•. _ H·.H·.··_·._·H ... .... .. ..

Comments The new leu was upgraded according to the international standards, and fully (incl. % :equipped, with negative pressure in 4 isolation rooms. It started work in ,achievement). December 2009 Indicator 13: Triage procedure established in regional hospitals

Value (quantitative N/ A 'or Qualitative)

.... · .. ·H·

Date achieved !06/01/2006

N/A. (new indicator)

'06/30/2006

Triage procedures established in regional :hospitals

10/15/2009

Local assessment of . triage procedures of regional hospitals was undertaken. Training was also carried out 12/17/2010

:j~:t>-.~~;;~~! =~~~~ ~=:!!::~~i=~~;:~!ing :!~~~~!~!"J_~_~. T~~gep~~~durtle~tablish~ ill reg~o.ll~1 ho~pitals ..... Value (quantitative or Qu~litative) Date achieved Comments (incl. % achj~vel1l~J'lt) ...

G. Ratings of Project Performance in ISRs

No. DO IP Actual

Disbursements DateISR Archived

... __ . __ .. ..', ...... _____ JySJ) :,I1l!~~!«?~~) .. 11/08/2006 Satisfactory .

2 O~D.?,-?gQ?' . _ Mode~ately ~atisfactory 3 08/22/2007 Moderately Satisfactory 4 02/03/2008 Moderately Sa!isfactory 5 09/29/2008 Satisfactory 6 05/19/2009 .Satisfact()ry

Satisfactory ryt()de~ately Satisfact()ry Moderately Satisfactory rytoderately Satisfactory

Satisfactory Satisfac!o.ry

..... ! .. .1~/14/20.09 Satisfact()1}' _ ......... __ S~t!~~ll~!()1}' 8 101.12/20 I 0 Satisfact<>.ry M.oderately ~atis.f~c!ory

ix

0.00 0.61 0.81 0.90 1.56 2.09

_"'H"

2.76 4.09

H. Restructuring (if any)

ISR Ratings at Amount Restructuring Disbursed at

Restructuring Date(s)

Board Approved

PDOChange

Reason for Restructuring & Restructuring Key Changes Made

DO IP in USD millions

10115/2009 y S S 2.43

IfPDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below:

Against Original PDOlTargets Against Formally Revised PDOlTargets Overall (weighted) rating

I. Disbursement Profile

Outcome Ratings Satisfactory Satisfactory Satisfactory

- Original ---- Formally Revised -- Anual 6-r----------------------------------------------~------------__,

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1. Project Context, Development Objectives and Design

1.1 Context at Appraisal

1. Albania was considered to be at "imminent risk" for highly pathogenic avian influenza (lIP AI) at the time of appraisal, as defined in the Global Program for Avian Influenza (GPAI) Project Framework Document of December 5, 2005. This risk status followed two confirmed HP AI outbreaks in March 2006, which occurred in domestic poultry.

2. Outbreaks of lIP AI had great potential to spread if left unchecked. More than half of 323 wild bird species recorded in the country are migratory, including species that frequent wetlands adjacent to farming communities. Albania's poultry population was estimated at about 6.3 million birds, of which over 85 percent were reared as free-range poultry on small household farms across the country. The potential consequences of an undetected or unchecked outbreak, including transmission of the virus to humans and the possible emergence of a virus transmissible between humans, were well-documented in the GPAI PAD.

3. There was an urgent need to improve Albania's capacity to prevent, identify, contain and eradicate lIP AI outbreaks, and deal with a potential pandemic should· this contingency develop. The Government of Albania (GoA) had effectively contained the 2006 outbreaks in poultry, with support of the international donor community, focusing on mounting a rapid response, improving surveillance, detection, and containment measures. Its efforts included: (i) adjusting legislation in line with international standards for control and prevention of communicable diseases, including influenza pandemics; (ii) establishing a National Influenza Pandemic Committee,or ''Task Force," as an inter-ministerial and inter-sectoral decision-making body; and (iii) establishing a working group between the Ministry of Health (MOH) and the Ministry of Agriculture, Food and Consumer Protection (MAFCP). However, several needs were identified for further support, including strengthening institutional capacities, increasing public awareness, and ensuring that potential compensation funds were in place.

4. The rationale for this project included specific. benefits to the medical and veterinary services, and building on initiatives of the United Nations (UN) agencies and the GoA. The project's design focused on strengthening veterinary and public health services and mitigating the social and economic fallout of ~ potential influenza pandemic. It built on prior work conducted by the GoA and UN agencies: the World Health Organization (WHO) and other UN agencies had taken the lead in mounting 'the technical response to Albania's avian influenia, (AI) crisis. The World Bank anticipated that these UN agencies would continue to take the lead in providing technical assistance. However, the scale of the response needed to contain and eradicate potential avian influenza (AI) outbreaks and prevent transmission to humans required mobilization of financial resources· beyond the mandate and means of these organizations, and well beyond the government's emergency reserves.

5. The World Bank was able to bring critical assistance to these efforts in the form of a financing framework consisting of IDA credits and Japanese PHRD grant money.' In addition, with the Bank's operational experience in assisting other countries under the GPAI

I Japanese Grant for Co-financing of Avian Influenza Control and Human Pandemic Preparedness Project, Grant Number TF056728, not exceeding U8$800,000.

umbrella, and in mounting emergency response operations,it was able to draw on valuable lessons learned from other countries facing similar threats and operating in related environments. The Albania AI project was approved by the Bank's Board on June 27, 2006 and became effective on October 16, 2006.

1.2 Original Project Development Objectives (PDO) and Key Indicators

6. The PDO was to strengthen the country's capacity to prevent the spread of avian influenza 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.

7. The Key Indicators were: With regard to awareriess ofHPAI threat and how to prevent it:

i. Behavior changes among key veterinary and public health personnel; ii. Public awareness of how to prevent spread increases and behavior changes.

With regard to HP AI outbreaks among pOUltry: i. Government culls birds at the infection points following international best practice;

ii. Government provides timely compensation to farmers for culled birds

With regard to HP AI outbreaks among humans: i. Infection diagnosed and contained;

ii. Patients receive appropriate treatment for HPAI infection.

1.3 Revised PD~ and Key Indicators, and reasons/justification

8. The project was restructured (see Project Paper dated September 17,2009, approved by the Board on October 15, 2009). The revised PDO was to minimize the threat posed to humans by HP AI infection and other zoonoses and to prepare for, control, and respond to influenza pandemics and other infectious disease emergencies in humans.

9. The revised Key Indicators were: With regard to awareness of the HP AI threat and how to prevent it:

i. Behavior changes among key veterinary and public health personnel ii. Public awareness of how to prevent spread increases and behavior changes.

With regard to outbreaks ofHPAI and other zoonoses among animals: i. Enhance laboratory diagnostic capacity of zoonotic diseases,

11. Strengthen surveillance of zoonotic diseases on the ground, including modalities for reporting, recording and investigating suspect cases.

iii. Ensure prompt and efficient prevention/control/eradiation of prevalent zoonoses, including resources and procedures for compensation.

With regard to HP AI outbreaks among humans: i. National Influenza Preparedness Plan for control and response to outbreak and

pandemic prepared in accordance with WHO recommendations. ii. Contained and diminishing pattern of HPAI and other zoonotic viral threats and

infections in humans.

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10. There was no disease outbreak during the project's first two years. At the Mid-Tenn Review (MTR) in July 2008, GoA suggested re-directing the funds reserved for compensation for culling birds in the event of an AI epidemic (about US$2 million, which was still intact) to other eligible activities. A preliminary risk assessment at MTR had shown that the relative risk of incursion of HPAI had diminished since the project began, due to: (i) favorable containment of the epidemic in the wider region; and (ii) better preparedness of the Albanian authorities to deal with an epidemic.2 Other reasons for restructuring were: the declaration of pandemic level 6 by WHO and the need to respond to mitigate consequences of the pandemic; and the need to adjust resources for the construction of the Animal Health (AH) laboratory in the Institute of Food Safety and Veterinary (IFSV). The project's scope broadened from only HPAI to include other zoonotic diseases of concern such as brucellosis, rabies, tuberculosis. While vigilance for HPAI remained a priority, the government had been simultaneously combating other prevalent animal diseases of public health concern, and many of the Project activities intended to control HP AI . were also considered effective for preventing and controlling other zoonotic diseases.3

1.4 Main Beneficiaries

11. (i) The smallholders keeping poultry in their backyards, through preventing destruction of their animals due to disease by strengthening veterinary services, and through targeted. messages particularly to women and children who manage birds; and (ii) the wider community in Albania and globally who would be affected by potential human pandemic influenza of avian origin and other zoonoses, through public awareness raising and strengthening health services.

1.5 Original Components -

12. Component 1: Public Awareness and Information Campaign (US$460,OOO) aimed to help develop and implement a communications plan to infonn the public, particularly those more likely to be exposed to HPAI, about the threat ofHPAI and how they could minimize the risk of transmission and spread of disease. Its two subcomponents were: (i) Risk Communication, and (ii) Communication for Behavior Change.

13. Component 2: Animal Health (US$3,698,200) was to support a national program to develop and implement short- and long-tenn HPAI prevention, containment, and control and eradication activities in animals. Its three subcomponents were: (i) Enhancing HP AI Prevention and Preparedness Capacity; (ii) Strengthening Disease Control Capacities, and Improving Surveillance, Diagnostic Capacities, and Applied Research; and (iii) Strengthening HP AI Control Programs and Outbreak Containment Programs.

14. Component 3: Human Health (US$I,600,000) was to support a national program to develop and implement short- and medium-tenn prevention of an outbreak of HP AI among humans and reduce the impact of pandemic virus. Its subcomponents were: (i) Enhancing Coordination and Program Planning; (ii) Strengthening the National Public Health Surveillance System; and (iii) Strengthening Health Care Response Capacity.

2 See Restructuring Project Paper, September 17,2009, and the MTR Aide Memoire, July 3-8,2008. 3 The revised PDO was more aligned with the OPAl PD~, "to minimize the global threat posed to humans by HPAI infection and other zoonoses and to prepare for, control, and respond to an influenza pandemic and other irifectious disease emergencies in humans" (Report No. 34386, January 12,2006).

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15. Component 4: Support to AvianInfluenza Task Force (TF)(US$341,200) was to support the Avian Influenza TF in implementation of the government's AI response strategy (including. components 1 to 3 above), through: (i). strengthening the TF by establishing a Permanent Secretariat; and (ii) enhancing Monitoring and Evaluation (M&E) capacity.

1.6 Revised Components (after restructuring)4

16. Component 1: Public Awareness and Communication (US$500,600) aimed to.address the remaining knowledge gaps within the population concerning influenza-like diseases, zoonoses and AlHINI pandemic knowledge within the population. The areas in need of focus were to be detailed following the second Knowledge Attitude Practice (KAP) survey.

17. Component 2: Animal Health (US$3,238,200) was to finance the construction of a new . (as opposed toreconstruction ofthe existing) AH laboratory foreseen a Project approval. The new

laboratory was to provide benefits beyond AI, and was viewed as being consistent with both the original PDO and revised PDO, and represented a feasible, proportionate and sustainable solution responsive to the original and expected laboratory diagnostic needs of Albania.

18. Component 3: Human Health (US$2,660,000) was to: (i) support the revisions of the NIPP according to WHO recommendations; (ii) take the needed time to capitalize on completed and ongoing activities, and, in particular, to raise preparedness in the regions for diagnosis, referrals, and management of outbreaks and pandemic; (iii) improve triage and intra-hospital procedures for infection control, specifically for regional hospitals; and (iv) enhance knowledge of primary health care workers.. .

19. Component 4: Support to Avian Influenza Task Force (US$38I,200) did not change except for expanding M&E to include pandemic preparedness and response.

1.7 Other significant changes

20. Reallocation of funds and Amendment to the Development Credit Agreement (DCA). The Compensation Fund (US$2,000,000) and the Emergency Eligible Imported Goods (EEl) finance (US$300,000) were reallocated especially to the Animal Health and Human Health Components' activities due to the absence of disease in the first two years. The estimated cost for the new AH lab was about US$I.9 million compared to .about US$0.3 million for the originally

. planned reconStruction. The redirection of the CF and the EEl contributed about US$1 million, while GoA contributed additional financing of about US$0.68 million. US$I million was earmarked for all additional human health component activities (US$570,000) and for activities that went beyond the original cost estimates (US$490,OQO) under this component. Schedules 1 and 2 of the original DCA, dated July 11,2006 were amended on December 17,2009.

21. Revised/enhanced activities. These included: (i) Additional support for disease emergency management, which included procuring additional outbreak control and personal protective equipment to ensure that adequate stocks were available; and additional measures for managing disease emergencies, and especially for the pandemic; (ii) Training and technical assistance, where the scope of activities was expanded to include a broader capacity building for

4 See Annex I of the ICR for Project Costs by Component before and after restructuring. See Annex 2 for details on how the new components and indicators relate to the original components and indicators.

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animal and human health emergency management, triage, field epidemiology, clinical diagnosis of a list of several important animal diseases, especially zoonoses; and (iii) Animal disease surveillance and information system, which was modified to include the needs of AI and other zoonoses control programs without significant additional financing needs.

22. Cancellation. of Funds. As the building permit for the AH laboratory was not issued, and consequently the lab and related furniture were not procured, approximately US$I.3 million was cancelled. Of the Japanese Grant (ofUS$0.8 million) for co-financing the project, US$198,876 equivalent was cancelled as of April 30, 2011.

23. Closing Date Extension. In order to complete the revised action plan, the original closing date was extended by 18 months to December 31, 2010.

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry

24. The project was a rational response to Albania's specific needs in the context of global concern for mitigating a potential influenza pandemic. Project preparation included analysis in applying the Bank's global experience in good practice in HPAl response and mitigation to the specific situation (poultry management practices,recent outbreak experience, projected cost of a large-scale culling program) in Albania. This analysis built on the Bank's expertise in assisting other countries under the GPAI umbrella consistent with the GPAI PAD.

25. Overall, the preparation and design stage could be considered a good example of efficient and effective collaboration among relevant stakeholders in situations of public health threats such as the AI. The donor community, led by USAID, and the UN Family under the one-UN Approach lead by UNDP,initially encouraged GoA to organize and plan how to properly respond to the emergency. USAID provided the initial funding for a rapid planning and response during the emergency phase, and the Bank team was able to build on the existing mechanisms and plans to further elaborate a longer-term response without losing much time. All the activities and planned interventions followed a thorough consultative discussion and consensus building process during the project design phase, sharing a common strategic approach among all players. This helped synergize efforts and optimize the available resources.

26. Project design incorporated lessons from Albania's experiences in 2006 of outbreaks in domestic birds. These included: (i) paying compensation rapidly to boost public confidence in government control activities; (ii) gaps in community outreach of the behavioral change campaign; (iii) the importance of rapid implementation of movement control and biosecurity measures; and (iv) the need to address bottlenecks in surveillance and diagnostics. Specifically, the design identified ways to improve capacity to prevent, identify, contain and eradicate HPAI outbreaks and deal with a potential pandemic should that contingency develop.

27. The Government actively participated in project design, through consultation with the Task Force, which included representatives from the Ministries of Agriculture (Chair), Health, Education, Environment, Interior and Finance.

28. Gender and social development aspects, that is, the role of women and children in poultry management, were clearly described. These groups were identified and integrated into

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the project's design, especially in the Public Awareness component, which specified targeting farmers and children in wetland areas for behavior change messages.

29. The project's PD~ and four components corresponded well to the assessed needs at project formulation. (Subsequently, revision became justified, as anticipated further HPAI outbreaks did not occur and, therefore, the compensation fund was not drawn upon. In addition, the risk of an HSNI influenza pandemic was surmounted by the actual HINI pandemic that occurred during implementation.) The project's organization, with particular Ministries responsible for specific components, was entirely logical and fitted with the mandates of respective Ministries. The project had a comprehensive list of 28 key indicators. There might have been scope to streamline project supervision,· had a more refined list of indicators been defined during project preparation.

30. Due to urgency of launching the project, however, fiduciary aspects at entry were based on utilization of an existing Project Management Unit (PMU), namely the Water Resource Management Project PMU. Lines of responsibility and reporting were not clearly defined and became a problem in the first period of project implementation (see Section 2.2).

2.2 Implementation

31. The Task Force and its Secretariat demonstrated strong commitment to the project, which helped to overcome the many day-to-day challenges reported in regular Supervision Mission Aide-Memoires. .

32. There were implementation issues in the first years of the project's life, related mainly to fiduciary aspects and delays in hiring staff. For example, a year into implementation, the Task Force Secretariat (TFS) was still hiring Financial Management (FM) staff that should have been in place at the onset. There were also some procurement and disbursement delays.s The FM review made clear recommendations for the staff, which were taken on board and resulted in improved project implementation.6

33. The lack of involvement and ownership by the Central Veterinary Service as counterpart contributed to implementation issues in the Animal Health Component in the early stages of the project.7 The National Veterinary Epidemiology Unit (NVEU) remained unutilized at ~he end of December 2007. Poor involvement by the Chief Veterinary Officer was identified as "a major constrictive/delaying factor". 8 To resolve this, during and between Supervision Missions, the Bank team gave encouragement to follow the action plan and training scheme that had been developed by the Veterinary Epidemiology international expert. .

34. By mid-2008, these issues had been resolved, and the MTR reported that the project was on the right path to achieve its objectives. In particular, the MTR noted: (i) that the appointment of an FM expert had helped to keep FM satisfactory; (ii) significant progress with

7 The procurement function was commonly shared between the procurement expert and the animal health coordinator, which created overlapping of tasks and delays. See ISR #1-3, which refer to delays in frocurement and ISR # 1, 2, 3 and 4, which refer to slow disbursement.

See ISR#9, April 201 1. 7 Project Supervision Mission, Aide-Memoire, December 10-14,2007. 8 See comments by the Country Director in ISR #4, February 14,2008.

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implementation including iJiprocurement and disbursement; and (iii) significant progress in the Animal Health Component.

~5. The restructuring and the redirection of funds to more relevant activities, given that . there was no lIP AI outbreak, was a timely response. The subcomponents were implemented as planned after the restructuring, with the exception of the construction of the veterinary lab bUilding. The HINI pandemic in 2009 tested the equipment and procedures thathad been put in place by the project, which proved to be fit for the purpose. In particular, the isolation facility at :central level was very effective.

36. The failure to obtain a building permit to construct the new veterinary diagnostic lab facility within the project's life a,nd resources affected implementation of this component.9 This failure is not attributable to negligence on the part of either the Bank or the Client. On May 19, 2010, the Client informed the Bank that the civil works had commenced prior to obtaining a building permit. The Bank, in its response of June 7, 2010, indicated that construction should cease until such time as the building permit is issued. Otherwise, the Financing Agreement (FA) would be breached as the Project is to be implemented consistent with the national laws and regulations of Albania. These factors prevented the timely consideration of alternative outlets of project resources, and have been used as an excuse to defer upgrading the laboratory bio-safety level by introducing quality assurance systems and standard operating procedures. Newly procured laboratory diagnostic equipment was installed in the existing laboratory, infrastructure and made functional. At the end of the project, the building remained partially constructed on the selected site and fenced off by the contractor, and funds allocated for the laboratory building and related equipment were returned to the Bank as discussed above.

37. Project management deteriorated somewhat towards the end of the project. M&E deteriorated due to the M&E expert position being unfilled for a period. 1O Since June 2010, the TFS had focused mainly on obtaining the AH lab building permit, and hence in the six months that followed, project implementation suffered. The procurement rating was downgraded in June 2010 to MU. However, by the final Supervision Mission, several activities had been launched (related to post review contracts), and project implementation and procurement were considered moderately satisfactory and FM was rated satisfactory.11 '

2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization

38. Design. The M&E system and the list of key indicators (original and revised) covered the POO adequately both in quantitative and qualitative terms. During restructuring, the indicators were modified,to also capture the preventative outcomes rather than only the previous readiness outcomes, and to meet the revised POO.

39. Project monitoring was complicated by the Results Framework having as many as 28 intermediate outcome indicators, some of which were activity/output indicators. The design

9 Project Supervision Mission, Aide Memoire, December 13-17, 20 I 0, p.1 ~d 6. Although a1\ supporting documentation required for the building permit had been submitted on time to the Municipality of Tirana, the Tirana Council of Territory Adjustment did not meet for more than one year. Although GoA amended the Urban Planning Law (May 2010) to provide an alternative solution, this did not materialize due to the fact that the approval of the regulatory framework of this law was postponed until January 2011. 10 Supervision Mission, Aide Memoire, May 31 to June 04, 2010. \I Supervision Mission, Aide Memoire, December 13 -17, 2010.

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could have been simpler with fewer key indicators. As indicators are simply a measurement, they are compared over time to assess change. However, after restructuring, some indicators that did not have a baseline were retained." Removing indicators against which outcomes could not be assessed could have enabled better measu~ment of project achievements.

40. Implementation and Utilization. Under Component 4, the TFS· undertook project monitoring and faced some challenges in implementing and utilizing the outcome-based M&E system. Unfortunately, the change and lack of staffing during the project life undermined the effective use of the M&E system for proper project management. Project reporting improved on~e a part-time M&E specialist was hired.12

41. There were two KAP surveys, in 2006 and in 2009, carried out by UNICEF and funded by USAID (see details in paragraph 55). The 2006 survey, which was considered the baseline, was important for follow-up surveys (2009) for comparison and for addressing unforeseen needs. One finding of the 2009 KAP survey was the need to increase communication skills and health promotion activities of teachers. Training was organized for about 216 people (biology and biochemistry teachers, school directors and deputy directors, and education inspectors) on AlH5Nl and AlHINI symptoms, prevention and transmission.

2.4 Safeguard and Fiduciary Compliance

42. The project was classified as Environmental Category B as it supported investments in carcass disposal for culled poultry and investments in laboratories, and civil works related to the rehabilitation of laboratories and hospitals. The planned construction of the AH lab, instead of the originally foreseen reconstruction, required some additional measures to comply with the Bank's safeguards policies. It was confirmed that OP 4.12 would not be triggered as the Social Assessment indicated no social safeguard issues.

43. The Project carried out a legal review to ensure that the land where the AH Lab was to.be constructed was owned by MAFCP, registered at the Immovable Property Registration Office, and that there were no outstanding legal claims. GoA also undertook the necessary Environmental Assessment (EA) and subsequent update of the existing Environmental Management Plan (EMP). The EA was disclosed on the website of the MAFCP and in the Bank's Infoshop on August 6,2009.

44. Overall Safeguard Compliance is rated as satisfactory. Procurement and FM were found to be moderately satisfactory and satisfactory by the end of the project. Although there were issues for about a·one-year period prior to the MTR, these were resolved following the MTR. The FM expert improved his performance and pro activity not only in doing his tasks but helping the TF when the Project coordinators were promoted to other ministerial tasks.

45. There were procurement delays in training activities under Components 1,2, and 3 that resulted in some activities not being implemented, i.e. the crisis management module. However, most were accomplished though with severe delays, for example: (i) intra-hospital infection control and bacterial resistance; (ii) zoonotic diseases management; and (iii) crisis communication management. The project was regularly supervised by the FM and procurement

12ISR #6 May 2009. M&E was downgraded from HS to MS as the M&E expert left the project and reporting started to fall behind schedule. Although the mission suggested replacing the expert, the TFS preferred to use those responsible for each component. See Supervision Report of February 16-21,2009.

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specialists at the World Bank country office in Albania: Audit reports were delivered on time and were not qualified.

2.S Post-completion Operation/Next Phase

46. GoA ensured that an appropriate state budget allocation for 2011 was in place, so that the facilities and services upgraded by the project could remain in continuous and efficient use. The IFSV, -as the unique national reference center for veterinary laboratories in Albania, will be supported by the veterinary budget in appropriate amounts through different programs. The budget allocated to the AFSV for the programs of animal health and food safety for 2011 was 35 million ALL. Budget allocations for 2012,2013 and 2014 show a steady increase at 33.5, 38 and 40 million ALL respectively, and point to likely sustainability of the project's achievements after project closing (ISR 9, 23 April 2011). MoH committed funds for the IPH budget for 2011 (42.25 million ALL) to address the sustainability issue for kits, reagents and basic consumables.·

47. With respect to future improvements, it would be very useful for the ICU personnel to get hands-on training on intra-hospital infection control,' use of equipment and safe -medical interventions, including safe injections. Special focus needs to be paid to the team of nurses and their capacity building in mentioned areas. To this end, the MoH should consider generating the req~ests to potential donors, as deemed necessary, to improve capacity of medical personnel with special focus on nurses. In addition, the relevant authorities should bear in mind that the consumables purchased by the proje~t will be sufficient only for a 6-month period. Various donor agencies show interest in further support to build on the momentum of outcomes achieved in the health sector. Furthermore, the Bank's Health System Modernization Project, approved on March 14,2006 (and closing on March 31, 2012), is complementary to the Health component of this project, and has a strong potential to build on the outcomes of this project.

3. Assessment of Outcomes

3.1 Relevance of Objectives, Design and Implementation

48. The original PDO reflected proper diagnosis of Albania's priorities. The PDQ was revised to align it to the GPAI PDO and to the country's needs, as discussed in Section 1.3. The central element of the revised PDQ, that is, to minimize the threat posed to humans by both avian and human pandemic disease caused by A/H5Nl and HPAI, remains very valid, as the risk of this contingency continues up to and beyond project completion. The enhanced project -activities are also in accordance with the principles of the 'One World, One Health' Strategic Framework for reducing the risk of emerging infectious diseases' (endorsed by four specialized agencies-that is, WHO, FAO, UNICEF, and the World Organization for Animal Health). The objectives and design are consistent with Albania's Country Partnership Strategy (CPS, for the period 2011-14), which emphasizes broadening and sustaining social gains by improving education and health services and establishing an adequate safety net.

49. Project implementation was responsive to changing needs. The revised PD~ and activities enabled project resources to be used more appropriately, given the altered scenario. The project's overall relevance in terms of both design and· implementation was clearly demonstrated by the efficient response to the HINI influenza pandemic that occurred during 2009.

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3.2 Achievement of Project Development Objectives

50. This section discusses the mechanisms through which project interventions helped to achieve the key outcomes and the PD~. Figures 1 and 2 below illustrate causal linkages from the project's main outputs to the elements of the PD~ before and after project restructuring. The three .basic elements of the original PD~ were: (i) to strengthen the country's capacity to prevent the spread of AI; (ii) to prevent the transmission of AI from birds to other animals and to humans; and (iii) to prepare for a potential pandemic of AI transmission between humans.

51. Project activities/outputs emphasized three areas: (i) effective communication; (ii) support to the veterinary sector; and (iii) support to the human health sector. Together these were expected to help the beneficiaries (poultry smallholders and the wider public susceptible to potential pandemic influenza) and the project achieve the intermediate outcomes and the PD~.

52. After restructuring (Figure 2), the aim was broadened from solely the HP AI threat to include minimizing the threats of other zoonoses and infectious human diseases. While interventions under Components I and 4 remained largely unchanged, activities under Components 2 and 3, related to animal and human health respectively, were modified. Therefore, this ICR considers the achievement of the PD~ "in two stages: before (Stage I) and after (Stage2) restructuring. (See Annex 2 Part I for details on activities before and after restructuring and on outputs by component. See Annex 2 Part 2 for achievement of objectives by component.)

Figure 1: Causal mechanism connecting outputs to outcomes and the original PD~

Original outputs (i) Effective communication. (ii) Support to the veterinary sector (iii) Support to the human health sector

Intermediate PDO Outcomes (i) Increase awareness and bring about behavior change in target population (ii) Control poultry outbreaks by culling and compensation (iii) Diagnose, contain and treat human disease

Original PDO elements (i) Strengthen Albania's capacity to prevent AI spread among pOUltry (ii) Prevent transmission of AI from birds to other birds and humans (iii) Prepare for potential human pandemic

Stage 1 PD~: Strengthen the country's capacity to prevent AI spread among poultry by creating greater awareness and behavior cbange. (Activities did" not change significantly· after restructuring.)

53. The project conducted a wjdespread public awareness and information campaign under Component 1, focused on Risk Communication and Communication for Behavior Change.

54. Outputs-- Effective .Communication: Under overall coordination of an inter-sectoral communication working group, the project cooperated closely with USAID and UNICEF (who funded the activities) to produce, in the first year, many communication materials, for example, 120,000 printed leaflets, posters, field worker communication guides and television messages. Communication outputs· after restructuring were tailored more to communication needs of the influenza AlHINI epidemic.

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55. As detailed in Annex 2, many training sessions were held in Tirana and other cities. Health-related public awareness and communication activities also targeted school teachers to maximize effectiveness, not only when children were identified as key beneficiaries, but also because children can influence their families and others. This was shown to be extremely successful in raising awareness among the Albanian population. Similarly, training programs for health care workers and teachers have assisted in reinforcing the preventive work. .

56. Outcomes-- Greater awareness and behavior change in the target population; Two Knowledge, Attitude Practice (KAP) surveys were carried out by UNICEF (and funded by USAID) in 2006 and in 2009. The intention was to; (i) detect any change due to the project; and (ii) define needs and thus improve the relevance of communication interventions. Due to ethical and humanitarian reasons, the urgency of the situation did not allow· waiting for the first KAP survey to be conducted and then starting the communication activities. Rather, the rapid communication response for AIIHP AI was built on similar experiences from other countries and previous communication experience oil other health-related issues in Albania. Therefore, although the 2006 survey took place after the communication activities had started, this survey can still be used as the baseline, as the short time period between the first communication activities and the survey is not considered sufficient to change behavior of the population and influence the survey results.

57. Two outcome indicators were specified to measure the achievement of greater awareness and behavior change, and the PD~ in terms of preventing the spread of AI, and the transmission of AI from birds to other animals and humans. These were;

i. '30 % more of at-risk population practicing safe handling procedures with respect to poultry and poultry meat', revised (a/restructuring) due to typographic error to, '55 % more of at-risk population practicing safe handling procedures with respect to poultry and poultry meat'. "

ii. (introduced at restructuring) 'Pandemic communications messages produced and delivered to targeted audiences'.

58. Indicator (i). The survey results show an increase in safe handling practices from 2006 to 2009 as follows: wash hands after touching poultry, or poultry products (16.4 % to 63.8 %); cooking poultry products well (21.7 % to 59%); (iii) know to avoid contact with dead poultry and wild birds (13.4 % to 50.2%); and (iv) wear gloves when cooking"poultry (9.4 % to 16.5 %).

59. Indicator (ii). Survey results show the following in 2009: 55.3% (12.7% in 2006) have seen and read leaflets and brochures; 67.8 % (28 %, in 2006) responded that the leaflets and the ideas therein were clearly formulated, easily understandable and expressed in an attractive way; and 75.9 % (72.1% in 2006) responded that they have seen many TV spots and advertising. The KAP surveys show that messages have been produced and delivered.

Knowledge and behavioral change have clearly increased .between the two surveys. There was a reported "noticeable change" in positive answers to awareness of TV messages, and a "significant increase" in the proportion who knew the signs of AI in poultry. Overall, not only have these activities helped to strengthen Albania's capacity to prevent AI spread among poultry, but we could also safely assume that they have contributed to the other two areas of the PD~ (i.e. prevention and preparation) through greater awareness and behavior change.

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Stage IPDO (before restructuring): Prevent the transmission of AI from birds to other animals and humans through controlling poultry outbreaks by culling and compensation

60. Activities .in this area focused on: (a) Enhancing HPAI Prevention and Preparedness Capacity; (b) Strengthening Disease Control Capacities, and Improving Surveillance, Diagnostic Capacities, and Applied Research; and (c) Strengthening 'HPAI Control Programs and Outbreak Containment Programs. The extensive list of interventions and achievements of outputs in these areas is discussed in Annex 2.

61. The eventuality envisaged' in this intermediate outcome did not occur: there were no outbreaks. This explains, in part, why the project was restructured.

Figure 2: Causal mechanism connecting outputs to outcomes, and the revised PD~

Revised outputs Intermed/4te PDO Outcomes Revised final PDO (i) Effective (i) Greater awareness and elements communication. behavior change in target (i) Threat ofHPAI & (ii) Veterinary laboratory ::::::> pop~lation. c::=::::: other zoonoses minimized. built and equipped; (ii) Enhanced veterinary lab (ii) Influenza epidemics & epidemiology unit staff diagnosis; strengthened other infectious disease salaried & active. disease surveillance; zoonoses emergencies in humans (iii) NIPP completed; prevented and controlled. prepared for ~d civil works for hospital (iii) NIPP; contained and controlled. and laboratory; antiviral diminishing threats of HP AI drugs and vaccine. and other human diseases.

Stage 2 PD~ (after restructuring): Minimize the threat posed to humans ofHPAI infection and other zoonoses through enhanced veterinary lab diagnosis, strengthened disease surveillance; and prevention and control of zoonoses. . .

62. Disease control capabilities were not tested for HP AI as there was no outbreak during the project; however, it is reasonable to assume that the interventions in this area have contributed to achieving the PDO of reducing the probability of both contained and widespread outbreaks. The main outputs and outcomes are listed below, and described further in Annex 2. These include: establishment of the NVEU and the strengthened diagnostic capacity and enhanced surveillance; the upgrading of laboratory diagnostic capacity; the extensive and diversified training of veterinary staff; the introduction of a new legal and regulatory framework allowing more efficient disease prevention/control and contingency planning; and the provision, of IT and other permanent and disposable equipment and materials necessary for field veterinary work (which has significantly increased MAFCP capacity and expertise to effectively combat animal diseases). These have all contributed to minimizing the threat of HP AI and other zoonoses, and the prevention and/or control of zoonoses such as brucellosis and anthrax.

63. Strengthened laboratory diagnostic capacity of zoonoses diseases, through for example, the rehabilitation of the virology laboratory at IPH, upgrading with new equipment (RT-PCR amongst others) and staff capacity. This upgraded lab started its work in November 2009, in the peak of the HINI pandemic human influenza. According to data collected, more accurate diagnostic testing was confirmed in 100 percent for all samples that were sent to an international reference . lab in Cantacuzino (Romania), confirming high standard of laboratory capacities and

12

laboratory staff capabilities of the IPH. The routine implementation of RT -PCR for HP AI and other diseases have allowed molecular diagnosis in real time reducing diagnostic time, while the diversified training of veterinary staff improved the quality and reliabjlity of the testing results. These activities 'have also contributed to enhanced bio-safety of the lab personnel by reducing their exposure to risk and creating possibilities for accreditation of other individual laboratories.

64. Enhanced surveillance of zoonotic diseases on the ground. The National Veterinary Epidemiological Unit (NVEU) was established. as an integral part of the state veterinary service. The monitoring and diagnosing of animal disease have improved substantially and been consistent with OlE standards. An important outcome was the fulfillment of the legal agreement to have this unit under the regular budget to ensure continuity and sustainability after the project.

65. The introduction of a new legal and regulatory framework, which has allowed increased capacity of the veterinary services in controlling and efficiently eradicating zoonoses at the source of infection before it becomes endemic. This has resulted in costs savings (as discussed in Annex 3). The culling at infection points now follows international best practice, and national resources. have been secured for compensation to farmers for culled birds. In case of outbreak, the compensation mechanism provides an incentive for livestock owners to report sick and dead animals to veterinarians. The MoF is able to provide timely compensation within 10 days.

66. It must be noted that the failure to build the new AHlab did not affect the achievement of the overall POO, as the specific objectives of the AH Component did not refer to; or depend on, the actual building of the new lab facility. Instead, the PDOs focused on strengthening lab diagnostic and surveillance capacity.

Stage 2 PDO (after restructuring): Prepare Cor, control, and respond to influenza epidemics and other inCectious disease emergencies in humans

67. Activities under the human health component aimed to, "strengthen capacity to isolate and treat patients with severe communicable diseases".

68. Outputs and outcome achievements before and after restructuring are listed in Annex 2. These include preparing a new NIPP that includes Level 6 endorsed by WHO, vaccinating vulnerable groups as per WHO definition against seasonal influenza-- providing vaccines (14,200 anti-viral drugs procured by 2009)· and staff inoculation (100 percent of the 201 IPH personnel and all ICU staff); and rapidly procuring stockpiling of antiviral drugs for pandemics.

69. Surveillance and Detection. As stated above in paragraph 63, the rehabilitated IPH lab has helped to respond to suspected or actual HPAI in humans as tested during simulations and real situations. The regions are regularly sending specimens to IPH for testing. The IPH lab has made excellent progress. More than 3,100 samples have been received by the lab, and about half of this amount has been tested locally at the IPH lab. The majority of the tests were performed by using the immunofluorescent technique that has been substituted from last fall by the PCR method. Since then, the rate of the confirmed cases by the reference lab is 100% (all 5ltests sent to the reference lab have been confirmed as positives). Lab staff have been trained extensively with the project funds and by different international agencies, and are capable to perform various tests (Le. hepatitis, measles, rubella, etc). The virology lab has been certified by the WHO and is a part of the Global Flu Lab network, while the National Influenza Lab is under the process of accreditation.

13

70. Health System Response. An Intensive Care Unit (lCU) at Tirana Hospital was constructed. The new ICU was upgraded according to the international standards, and fully equipped, with negative pressure in 4 isolation rooms. It started work in December 2009, at the peak of the HI N 1 pandemic human influenza. The ICU is managing a wide range of complicated cases (i.e. various neuro-infections, tetanus, meningitis, septicemia and hepatitis) as well as patients with HIV / AIDS that are in need of the intensive care, pulmonary ventilation, etc. All these cases have been very well documented and experience shared during the trainings organized by the project for the larger audience, including medical personnel from the regional hospital. There is recorded enhancement in treatment, management of the patients, and in the bed use rate.

71. The improvements in the health system and in the health care workers' performance has generated an additional benefit, which is the percentage reduction of the human population infected by HP AI, HI A I and other infectious diseases, and consequent reduction of the number of hospitalizations and the number of deaths attributed to other infectious disease other than HPAI. Particularly, the establishment of the ICU has contributed in reducing human suffering and some deaths; out of 400 patients, only 12 deaths have been recorded.

Achievement of final (after restructuring) ~DO

72. HPAI did not occur in humans, but the threat of this and other diseases has been diminished by good planning, better and earlier diagnosis capability, and upgraded ICU facilities. The 2009 influenza AlHINI pandemic experience showed that Albania was better able to respond to this epidemic, with fewer deaths than expected (as indicated by the General Director of Health Policies during the ICR mission of February 2011). Overall, the project's interventions have undoubtedly helped to achieve the key outcomes and the PDO.

3.3 Efficiency

73. The project cost benefit analysis at the time of appraisal was based on short-term financial implications of the spread of the virus and the loss of poultry stock during contained sporadic and/or widespread outbreaks. The analysis appraised an internal rate of return (IRR) of 44 percent. The project investments were justified on the basis of the positive externalities associated with prevention and containment of a highly infectious disease such as HP AI.

74. Given that a HPAI outbreak did not occur and that the PDO was revised to encompass other zoonotic diseases, a re-estimated cost and benefit stream comparison was not deemed relevant as it is not counterfactual. In addition, the project did not collect comprehensive quantitative data to enable conventional calculations of economic rates of return and to reasonably attribute overall changes to the project. Therefore, this ICR carries out a qualitative analysis of project impacts and benefits (see Annex 3 for details).

75. The project's major long-term economic benefits stem from strengthened capacity in early response management for both human health and veterinary systems for epidemic emergencies. The better preparedness of the Albanian authorities was proven during the last pandemic influenza that occurred in 2009 when many patients were also treated for other infectious diseases such as tetanus, septicemia and meningitis. Another major benefit was the increased intensive care capacity through the establishment of first ICU for infectious diseases

14

and training. Trained key staff have been actively engaged and contributed as trainers tothe other groups to better manage AI, pandemic influenza and other diseases.13

76. The increased capacity of the veterinary service to control and eradicate zoonoses before they become endemic has resulted in costs savings. Although analysis did not re-calculate the financial projection of the possible losses due to an AI epidemic, it is reasonable to partly attribute to the project lower financial losses and lower use of funds for compensation should an epidemic occur now.

77. A measure of project efficiency may be the cost effectiveness (only 5 percent of total costs) of the public awareness component due to the valuable collaboration with USAID and UNICEF (both in terms of funds and human resources). A final measure of project efficiency was the proportion of overhead or administrative, of about 10 percent (USD) 0.55 million of total project costs (USD 4.59 million). (See Annex 3 presents for details.)

3.4 Justification of Overall Outcome Rating Rating: Satisfactory

78. The project followed a template under GPAI PAD for Bank projects in a number of countries to address the threat of HP AI. It proved to be relevant for Albania and was aligned with the CPS. Flexibility was shown in Illstructuring the project when HPAIoutbreaks did not occur. Thus, objectives and design maintained their relevance throughout the project. As concluded in Section 3.2, the project successfully achieved its revised PD~.

79. The project was efficient, although, as described in Section 3.3, counterfactual comparisons could not be made between the IRR calculated at appraisal and another calculated at the end. However, consideration of qualitative benefits leads to the conclusion that the project's investments were justified and that it will have long-term economic benefits. ,

3.5 Overarching Themes, Other Outcomes and Impacts

(a) Poverty Impacts, Gender Aspects, and Social Development 80. Women and children are key actors in backyard poultry sector and, thus, key beneficiaries of the project. The Public Awareness campaign specifically targeted school children, amongst others. Backyard poultry are important contributors to rural livelihoods for poorer people. When sensitizing the public -in awareness campaigns, efforts were taken to ensure avoidance of panic and market shocks for poultry products, thus safeguarding this important source of income and nutrition.

(b) Institutional Change/Strengthening

81. Two European Union-funded projects (Large Ruminants Surveillance and Identification and Small Ruminants Surveillance and Identification) had established regional epidemiology units. However, these units operated within the respective project objectives and within Regional Veterinary Inspectorates. For the first time since Albania's transition to a market economy, this project created a Veterinary Epidemiology Unit under MAFCP with national coverage.

13 Source: ICR Borrower report corroborated by the field visit.

IS

82. . In the human health sectbr, four distance-learning activities were organized by the Bank and the WHO with world-renowned health experts, linking them to Albanian health specialists: these technical expertise contacts have potential to be maintained and built upon. Long-term benefits from the project in terms of knowhow, infrastructure and equipment enhanced capacity to detect, prevent and control/treat infectious diseases.

(c) Other Unintended Outcomes and Impacts (positive or negative)

83. Positive. The strengthened health service and the communication strategies have had a positive impact on effective management of human AlHINI cases. In addition to preparing Albania for AlHI Nl, emergency planning has prepared the authorities for other severe emergencies, including floods. The new ICU and training has helped to create specialist medical practitioners in the field. The ICU also improved academic curricula for medical students' training. The supply of influenza vaccines required the authorities to collaborate with pharmaceutical companies and helped to develop public-private partnerships to bring more vaccine into the market.

84. Guidelines for inter-agency communication with cooperation among ministries (MAFCP, MoH,) helped to build and strengthen the channels of communication, which were crucial for facing the pandemic. The project also developed close coordination and cost savings, through good cooperation with other agencies, namely, WHO, UNICEF, FAO and USAID. For example (i) UNICEF (with USAID support) was closely involved with the Public Awareness and Information Campaign, (ii) simulation exercises were organized with WHO (with USAID funding), (iii) guidelines for using the national Public Health Surveillance system were developed with WHO assistance, (iv) USAID funded PPE, rapid test kits and reagents, (v) FAO regional AI program coordinated with the Albania project and provided practical assistance, such as rapid test kits and training. The donor community participated in TF meetings and supervision missions .

. , 85. Cooperation developed between this Bank project and a similar Bank project in Kosovo, which brought cost savings to both projects, strengthened technical cooperation and benefitted implementation by the Kosovo team, who learned from Albania's example. Specifically, (i) veterinary epidemiologists from the Albania NVEU and the Kosovo Veterinary Epidemiology Unit joined together for training held in Albania, (ii) Kosovo staff participated in a simulation exercise that was held in Albania, (iii) Chief Veterinary Officers of Albania and Kosovo forged stronger links, (iv) the TFS from Albania shared experiences with the Project Team from Kosovo. 86. Negative. Cumbersome project procedures for an emergency project increased the workload of GoA personnel who did not receive additional stipend to carry out the extra tasks, which some reported to have significantly increased their workload without any remuneration.

3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops (Not Applicable)

4. Assessment of Risk to Development Outcome

87. Rating: Moderate. The risk at the time of evaluation that development outcomes will not be maintained varies across project components. For Component I, Public Awareness and Information Campaign, the risk is low: the continued functioning of the Communications Working Group was stated to be "ensured" under the lead of MoH and UNICEF mandates. For Component 2, Animal Health, the risk is significant as regular Bank Supervision Missions throughout the project have described management deficiencies, particularly with regard to the

16

NVEU. The sustainability of key project outcomes in this Component is affected by the reported legaVadministrative vacuums, internal institutional reshuffling and budgetary restrictions. For Component 3, Human Health, the risk is low: MoH committed funds for the IPH budget for 20 II to address the sustainability issue for kits, reagents and basic consumables. Furthermore, various donor agencies show interest in further to support ~roject accomplishments, building on the momentum of outcomes achieved in the health sector. 4

88. Overall and across all components, the institutional risk to development outcome is moderaie for reasons highlighted in the preceding paragraph; the economic and financial risk is moderate (for governance reasons, it is low in the health sector, but higher in the veterinary sector); and the social risk to development outcome is low, as: (i) strong public awareness programs have sensitized to key issues and averted the public's potential for panic around

. infectious, zoonotic diseases, particularly influenza; and (ii) reduction of the threat from diseases such as HP AI contributes to safeguarding the economic status of poor poultry producers.

5. Assessment of Bank and Borrower Performance

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Satisfactory

89. As discussed in Section 2.1, the project was very relevant, and its preparation and design stages could be considered a good example of efficient and effective collaboration among relevant stakeholders. The Bank team brought knowledge of global good practice as defined in the GPAI PAD and applied it according to the specific country scenario, that is, in the context of recent HPAI outbreaks in a diffuse poultry sector with predominantly smallholder, backyard management. The project was planned at a time of urgency and uncertainty about HP AI. Despite this, technical aspects were well planned and appropriate at the time of project formulation.

90. The role of women and children in poultry management in Albania was clearly identified at appraisal, and incorporated into the design of behavior change and communication activities. Environmental aspects were adequately considered at entry, with regard to civil wor~s for laboratories and hospitals,. handling of hazardous laboratory waste and disposal of culled poultry.

(b) Quality of Supervision Rating: Satisfactory

9i. Throughout the project, supervision miSSions effectively identified and, with the exception of the construction of the new veterinary laboratory, resolved any threats to achievement of the PD~. The Bank fielded six supervision missions between the summer 2007 and winter 2010; they all included health and veterinary specialists, a communication/operations specialist, and procurement and FM specialists. The same team, except·the health expert, has been involved in the project supervision and implementation support providing continuity and guidance throughout the project. Specifically, the Bank: (i) recognized and promptly clarified early confusion regarding ~ reporting lines in project management and implementation; and (ii) identified the issue of the planned new veterinary laboratory's requirement for a building permit at restructuring, and retained the services of a local JegaJ expert to carry out a detailed review, and

14 Supervision Mission, Aide-Memoire, December 13 -17, 2010.

17

generally did all they could to encourage the authorities to resolve the problem. The Bank was also responsive to the Government's needs and showed flexibility in tenns of restructuring.

92. Aide-Memoires were comprehensive and articulated agreed actions for each project component. Where implementation issues were identified, ratings were fair and there was agreement between Aide Memoires and ISR ratings. One weakness in monitoring, however, was that the ISRs following the restructuring do not report on the revised Results Framework listed in

. Annex 1 of the Restructuring Paper. Instead, the ISRs report on the original perfonnance indicators and some revised indicators. This inconsistency made it more difficult and time­consuming for the ICR team to gather data on a coherent set of perfonnance indicators. IS Bank support missions were locally organized, and this 'decentralized task management' brought savings. Some mission Aide-Memoires were entered late into the system due mainly to delays of the client comments and the long process of clearance from the management. The Bank met all safeguard requirements in-a timely and· efficient manner and. provided assistance and training for the procurement and financial management throughout the project.

(c) Justification of Rating for Overall Bank Performance Rating: Satisfactory 93. The rating reflects'S' rating for Ensuring Quality at Entry and'S' rating for Quality of Supervision.

S.l Borrower Performance (a) Government Performance Rating: Satisfactory

94. The Government was closely engaged in project identification and preparation, and appointed two fuH-time Component Coordinators responsible for implementation. There was a sense of urgency at the time of project preparation, in the face of HP AI outbreaks in poultry in the country, and all parties worked to avoid delays in the process.

95. A successful feature of GoA's perfonnance was cooperation between Ministries, i.e. Health and Agriculture: this was a challenge, but was essential for effective public health strategy through the project's zoonoses control activities. With different Ministries involved as stakeholders, some friction regarding budget allocation occurred, but these were resolved through meetings, and project implementation did not suffer. GoA committed to additional funds of US$0.68 mi])jon (tripling its contribution to the Project) to partiaHy cover the veterinary laboratory construction, however, it was unable to resolve the impasse over the construction.

96. Regarding fiduciary perfonnance, GoA carried out FM and several procurement contracts in compliance with the Bank's guidelines. The Ministry of Finance coordinated the audit of all Bank-financed projects in Albania, including AI Pr(,>ject. Accurate and timely project records and accounts and financial statements were prepared and made available for auditing.

'(b) Implementing Agency or Agencies Performance

IS The ICR's Data Sheet reports on the Results Framework Indicators listed in Annex I of the Board­approved Restructuring Paper of October 15,2009, and not on the indicators listed in the finallSR.

18

Rating: Moderately Satisfactory 97. Overall, the implementing agencies demonstrated strong commitment to achieving the objectives across all components. Through the KAP surveys, there was adequate beneficiary and stakeholder involvement in the preparation and delivery of communication messages. The TF Secretariat played a key role in coordinating stakeholders and project activities across the human and animal health sectors.

98. There were delays in the appointment of some key staff, namely, (i) the Procurement Specialist who was hired only in October 2007 left and needed to be replaced (contributing to a slow project fund disbursement profile); (ii) an additional staff member was hired to take over the FM responsibilities of the Water Resource Management Project (WRMP), but was lacking the required experience or English language skills for this role in a Bank project; and (iii) NVEU members were hired and salaried, but their employment status and inclusion in the MAFCP payroll was ambiguous.

99. There was also poor involvement of and ownership by the Chief Veterinary Officer, and poor management of the NVEU until late in project implementation. The Animal Health lab building permit issue remained unresolved, however, construction of the laboratory commenced in 2010 and had to be suspended, and the building remained partly constructed.

100. FM arrangements in place at the TFS including staffing, internal controls, project accounting, financial reporting, flow of funds and auditing arrangements met the Bank requirements and the recommendations of the Bank missions were fully implemented. Although M&E functions were performed, reporting was slow and the quality was uneven.

101. Relationships and coordination with key partners were excellent, including with USAID, WHO, UN, UNICEF and F AO, all of whom were actively involved with implementation of the public awareness and communications, and the animal and human health components. The donor community was part of the TF and participated at the regular and emergency TF meetings. The TF shared donor reports and the Bank supervision aide memo ires, which avoided overlapping, brought synergy among the donor community, and helped in the best use of resources.

(c) Justification of Rating for Overall Borrower Performance 102. Rating: Moderately Satisfactory. The rating reflects'S' rating for Government Performance and 'MS' rating for Implementing Agencies' Perfor"!ance.

6. Lessons Learned

103. A global template can enable rapid, good project design. The GPAI PAD was ill place and was used as the basis for the preparation of this project. The existence of a sound, global plan ensures that an effective project .can be formulated relatively rapidly at a time of urgency, due to uncertain circumstances related to an emerging infectious disease.

104. Projects formulated for a specific disease can prove to have too narrow a PD~ and, therefore, require restructuring. The project was formulated specifically to address HP AI, but some of its outputs, such as the enhanced veterinary epidemiology unit and the ICU had from the outset wider applications to other diseases. In projects primarily concerning a specific disease, the PDO should be broadened to include other diseases of concem that may emerge or become problematic during implementation.

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105. Close coordination with specialized UN agencies can enhance the quality of technical assistance. WHO, UNICEF and F AO gave technical assurance for project implementation by working together with the Bank's implementing partners and agencies. This is applicable to a wide range of Bank projects, depending on their particular technical areas.

106. Too many key indicators for an emergency project can make monitoring and evaluation cumbersome. Data collection and analysis can be a daunting task, particularly when there are no full-time staff responsible for it. The project's M&E system could have been simpler, with fewer key indicators, and, during the restructuring, indicators that did not have a baseline need not have been retained.

107. School teachers can play an important role in behavior change and health promotion. Health-related public awareness and communication activities in Albania should target school teachers to maximize effectiveness, not only when children are identified as key beneficiaries, but also because children can influence their families and others.

108. Video conference and training with a health expert can be very cost effective. Linking in-country specialists with international experts was successful and should be considered in other projects.

7. Comments on Issues Raised by BorrowerlImplementing Agencies/Partners (a) Borrower/implementing agencies The TFS comments have been incorporated in the ICR. See Annex 7 for the Borrower's ICR.

(b) Co-financiers UNICEF's comments have been included in the ICR. See Annex 8 for USAID's comments.

(c) Other partners and stakeholders Not Applicable.

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Annex 1. Project Costs and Financing

{at !,_ .. ()jec:t~ost by Compon~nt (in USD M~lIion equivalent)

Components Appraisal ActuallLatest Percentage of

Appraisal Public Awareness (excluding UN and USAID .

Animal Health ••• n ........... _ ••••• ,. __ ".e ___ ' _ .. _ ,_. __ •

Human Health A vian Influenza Task Force •••• _._ ••• _ •• _--_ ........... - '"' -- .. "-"-"_ .. _ ••• » ••

Total Baseline Cost

:Physical Contingencies

:Price Contingencies

Total Project Costs Front-end fee PPF

Estimate * Estimate**

0.46

3.70 1.60 0.34 6.10

0.00

0.125

0.865 0.982 0.314 2.286

0.00

0.00 0.00 0.00 0.00

0.00 0.00

Total Financing Required 6.1 2.286

...... _ .... _._ ...... _ ....... .

• Exchange rate in 2006 = ALLIOl.6 = US$I; US$1.46 = SDR I; *oil As of April 30, 2011.

27.17

23.37 61.37 92.35 37.47

0.00

0.00

.00

(b) J~r(~j~t~ostJ)y Co~pt)neJlt (inJ!~D Million_eqlliV"~~eJltlA.f~er ~e~~ .. ucturil!g.

Components

Public Awareness (excludingVN and VSAID Animal Health Human Health A vian Influenza Task Force

Total Baseline Cost

:Physical Contingencies

Price Contingencies

_____ :rotal PI'()Ject Costs Front-end fee PPF

_ .!otalFinancing _Requil'ed

Restructuring Actual/Latest Percentage of ~~~imate Estimate .. Appraisal

0.5

3.24 2.66 0.24

6.78 ___ .n.

0.00

0.00 0.00 0.00

6.78

0.30

1.29 2.69 0.44 4.72*

0 ............. _. _ ....... _ .... ~ •• _

0.00

0.00 0.00

0.00 4.72

60.0

39.8 101.1 115.8

69.61

0.00

0.00

0.00 69.61

• ALL 99.99 = US$I; US$1.56 = SDR 1 (as of March 31, 2011) ·The public awareness was cost effective due to the valuable collaboration with USAID and UNICEF (both in tenns of funds and human resources). In early 2006, the Government successfully eradicated the AI twice and paid farmers for the culled chickens within one week from its own budget funds, before approval of this Project. Since then there has been no outbreak of the AI during the Project life,· the Project Compensation Fund (CF) was not used. During Project implementation the need emerged to construct a new, rather than reconstruct the existing, Animal Health laboratory to ensure that the capacity to handle adequately activities related to both Aland other zoonotic diseases. To this end, in August 2008, the Government requested the reallocation of the Project's CF (US$2 million) and the Emergency Eligible Imported Goods (US$0.3 million) to finance the construction of this new laboratory as well as a few new

21

activities under an adjusted scope of the Project, especially the Animal and Human Health components activities. Approximately US$1.3 was cancelled due to the fact that the building permit for the AH lab was not issued and consequently the lab and the related furniture were not procured.

Appraisal Estimate

Revised Estimate

ActuallLatest Percentage Estimate of Appraisal

(USD ! .(USD 1 :

Sonrce of FUI!«!~ ___ J_!"iI~~~!!&""L_l!!illiol!~l.~D II!.~~~ __ ~_.___ l ~orrowe~ .. __ . ____ . __ -:l-.~ __ . __ . 0.3 __ ._._ .... 0.~~_: ___ ._._ .. _. ___ Q.~~.?~ ... ___ ... __ ~~.3~ __ _ IQ.A Gran_t __ . __ .. _ .. ~._. __ . __ ._._J __ . ______ ._~:.Q __ ____ ~:QQ ~ ____ . __ .. __ ._.}.~!. ____ . _ ._ ... _}) :19 __ _ __ T~~! Ful!.~l~l!!!~~~.E~_. ___ . 0.8 0.80 0.60 75.00

Totai 6.1 6.78 4.72 . 77.37

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Annex 2. Outputs by Component

Part 1. Original Indicators and Indicators after Restructuring and Outputs by Component

The Restructuring Paper of September 17, 2009 describes changes to the project as follows: (i) align the PDO to the GPAI PDO, that is, broaden the scope from HP AI to encompass other zoonoses; (ii) cancel the 'Compensation Fund (CF) and Emergency Eligible Imports (EEl) Fund and reallocate the funds particularly to Animal and Human Health Component activities; (iii) use Japan PHRD funds for new activities; (iv) revise project activities. The revised activities were:

• Public Awareness and Communication. Address gaps in knowledge in influenza-like diseases, zoonoses and influenza AIH I N I ;

• Animal Health Component. Finance construction of a new Animal Health (AH) Laboratory; .

• Human Health Component. Revise the NIPP; build on ongoing activities (especially raising regional preparedness for diagnosis, referrals and management of outbreaks/pandemic);

• . Disease emergency management. Additional control equipment and PPE. • Training and technical assistance, including

1. Broader capacity building for animal and human health emergency management, 2. Triage, 3. Field epidemiology, 4. Clinical diagnosis of "several important animal diseases", especially zoonoses,

• Animal disease surveillance and information system. Modify to include diseases other than AI.

Component I: Public Awareness and Information

Achievements under this component are rated satisfactory.

The indicators specified under this component were: i. '30 % more of at-risk population practicing safe handling procedures with respect

to poultry and poultry meat', revised (at restructuring) due to typographic error to, '55 % more of at-risk population practicing safe handling procedures with respect to poultry and poultry meat' .

ii. (introduced at restructuring) 'Pandemic communications messages produced and delivered to targeted audiences'.

Indicator (i). KAP surveys were carried out (by UNICEF) in 2006 and 2009. They report an increase in safe handling practices as follows: wash hands after touching poultry, or poultry products (16.4 %in 2006 increased to 63.8 % in 2009); cooking poultry products well (21.7 % to 59%); (iii) know to avoid contact with dead poultry and wild birds (13.4 % to 50.2%); (iv) wear gloves when cooking poultry (9.4 % to 16.5 %).

Indicator (ii). The two KAP surveys show the following: 55.3% (12.7% in 2006) have seen and read leaflets and brochures; 67.8 % (28 %; in 2006) responded that the leaflets and the ideas therein were clearly formulated, easily understandable and expressed in an attractive way; 75.9 % (72.1 % in 2006) responded that have seen many TV spots and advertising. The KAP surveys show that messages have been produced and delivered. Later in the project, uptake of human flu vaccine increased due to effective awareness-raising.

23

Achievements/Outputs

The Public Awareness and Infonnation Component had two subcomponents, namely Risk Communication, and Communication for Behavior Change. Under overall coordination of an inter-sectoral communication working group, the project cooperated closely with USAID and UNICEF. In project year 1 many communication materials were produced, for example, 120,000 printed leaflets; posters, field worker communication guides and television messages.

The project carried out training for teachers and school directors as planned and this has been very well received. About 216 people have been trained among biology and biochemistry teachers, school directors and deputy directors, and education inspectors on AlH5N I and AIH I N I symptoms, prevention, and transmission. Training sessions were held in Tirana (2 sessions), Durres, Fier, Vlora, Lezha, and Shkodra (l session in each city), and a joint session for Korca and Pogradec. The training was conducted by staff of IPH, IFSV and HH component coordinator, in cooperation with the Ministry of Education and the Institute of Curricula. The implementation of this training addressed one of the findings of the 2009 Knowledge and Attitude Practices (KAP) survey, indicating the need to increase communication skills and health promotion activities of teachers. Further public awareness activities agreed with the MOH, IPH and the CWG regarding providing information to the population thru TV spots, as assessed by the 2009 KAP survey as the best mean of communication, are continuing. Broadcasting in 3 national TV stations of 2 TV spots on personal hygiene and care for persons affected by influenza is currently ongoing. These spots will also be used as vehicles to publicize the need for vaccination against seasonal flu.

Overall, all the activities planned to be carried out during the life of the project have either been or are about to be completed, and there has been progress as measured also by the 2009 KAP survey in improving the population awareness on HPAI, knowledge on safe handling procedures, and on how to prevent the spread of disease (AlH5N I) as well as influenza pandemics.

Component II: Animal Health

Achievements under this component are rated moderately satisfactory, due to various shortcomings in management under this component, such as the lack of involvement and ownership by the Central Veterinary Service, and the poor involvement of the Chief Veterinary Officer, and the failure to complete the AH lab.

The Animal Health Component's three subcomponents are: (a) Enhancing HPAI Prevention and Preparedness Capacity; (b) Strengthening Disease Control Capacities, and Improving Surveillance, Diagnostic Capacities, and Applied Research; and (c) Strengthen HPAI Control Programs and Outbreak Containment Programs. Indicators specified were:

Subcomponent II (a) i. 'Satisfactory sub-laws, regulations, protocols and guidelines developed' revised to

'New Framework Veterinary Law adopted, in line with EU acquis and practices'. ii. 'Annual updating of HP AI influenza and preparedness and response plan' revised to

'New contingency plan for HPAI adopted, in line with EU acquis and practices'.

Subcomponent II (b) i. 'National Veterinary Epidemiological Unit established' revised to 'National

Veterinary Epidemiological Unit established and achieving an increase in the number

24

of suspect cases of animal diseases reported and investigated by means of clinical examinations and/or epidemiological inquiries'.

ii. 'Institute of Veterinary Research testing capacity and bio-safeo/ level upgraded' revised to 'Animal Health Laboratory testing capacity and bio-safety level upgraded and achieving an increase in the number of suspected cases of animal diseases investigated by means of laboratory tests and techniques' .

Subcomponent II (c) i. 'Two emergency response mobile eradication units established and operating' (not

r.evised). ii. '100% of veterinary and extension field staff trained in safety protocols' revised to

'100% of veterinary field staff trained in diagnosis, investigation and control methods for HP AI and other dise~es' .

iii. 'Compensation Fund (CF) of US$2,000,000 established' revised to 'Compensation secured from national resources'.

Indicator II (a) i. By the end of the project, a new draft Veterinary Law (introducing clearer and more effective provisions for general disease control), based on advice from the AI project veterinary legislation expert, had been completed and sent to the Government for consuItations.

Indicator II (a) ii. A new EU-compliant contingency plan for HPAI was prepared, approved and posted on the MAFCP website.

Indicator II (b) i. The NVEU was established and equipped. Its mandate was expanded from HP AI to include other zoonoses, for example, brucellosis and tuberculosis.

Indicator II (b) ii. The AH laboratory was equipped with, and capable of routinely carrying out, RT-PCR for HPAI and other relevant diseases.

Indicator II (c) i. There was no need for the mobile eradications units,since the main disposal method for infected birds remained burial into a pit and apart from the two HP AI outbreaks in February and March 2006, no outbreaks were reported in the country: the units were not provided.

Indicator II (c) ii. Seventy resource persons from 12 Districts were trained by a multi-sectoral team of national trainers in safety protocols by July 2007: by July 2008, this had been extended to 1,000 frontline workers (85% of State Veterinary Inspectors) from 12 Districts, and by end March 2009, 100% of State Veterinary Inspectors had been trained. 100 % of all regional field veterinarians (250 persons) were trained on AI and Newcastle disease. Additional training was provided to them on various diseases based on request from the regions, such as brucellosis, TB, classical swine fever, anthrax; rabies, and enterotoxaemia: this training was carried out by December 2010.

Indicator II (c) iii. By the end of the project, the CF was guaranteed from the budget of the Ministry of Finance.

Achievements/Outputs

Technical assistance was provided to review existing veterinary legislation and propose revisions. Contingency plans and AI Regulations were updated by July 2008 and Veterinary Law amendments proposed to MAFCP.

25

NVEU staff were trained with project support. NVEU activities included compilation of historical (3-year) data on prevalence and incidence of relevant diseases, i.e. brucellosis and TB, collection and evaluation of regular epidemiological returns from the field, updating the poultry census, and monitoring of the occurrence of animal disease. A Simulation Exercise was organized (December 7, 2006) that gave epidemiological and other veterinary personnel hands-on experience and built capacity and preparedness. The project also supported a livestock census, which provided numerical data on populations at risk of animal diseases.

AH Laboratory staff were trained in implementation of quality assurance system and SOP, to enhance stability and improve biosafety. RT-PCR equipment was installed by July 2008 and staff were trained in its use. The new AH Laboratory planned in the restructured project was not constructed due to insurmountable problems with securing a building permit.

The project also provided IT and other permanent and disposable equipment and materials necessary for field veterinary work, which significantly increased the Ministry of Agriculture Food and Consumers Protection capacity and expertise to effectively combat animal diseases and fulfill the project's PDOs and intermediate outcome indicators. Operational Manuals outlining best practice for disease control/culling and procedures for timely compensation were developed by July 20, 2007.

Component III: Human Health Achievements under this component are rated highly satisfactory.

The Human Health .Component's three subcomponents are: (a) Enhance Coordination and Program Planning; (b) Strengthen the National Public Health Surveillance System; and (c) Strengthen Health Care Response Capacity. Specified indica~ors are:

Subcomponent III (a) i. 'New National Pandemic Preparedness Plan developed and endorsed by WHO' [New

indicator, post-restructuring]. Subcomponent III (b)

i. 'Number of days between collection of samples and results from the UK reference laboratory' revised to 'Samples shipped in conformity to lATA procedures'.

Subcomponent III (c) i. ' 100 % of IPH and 30 % of hospital and PHC service personnel vaccinated against

seasonal influenza' revised to 'Vulnerable groups as per WHO definition vaccinated against seasonal influenza'.

ii. '3,000 units of anti-viral drugs stockpiled' revised to 'Anti-viral drugs stockpiled'. iii. 'System to rapidly procure antivirals' revised to 'System to rapidly procure antivirals

for pandemic'. iv. '15 isolation rooms established' revised to 'Establish an intensive care unit'. v. 'Triage procedure established in regional hospitals' [New indicator, post­

restructuring] .

Indicator III (a) i. Under technical support of WHO, a NIPP was prepared, that includes Level 6, based on WHO recommendations.

Indicator III (b) i. 505 samples were shipped in accordance with lATA procedures. Laboratory at IPH: As per last influenza season, in total more than 3,100 samples have been received by the lab, and about half of this amount has been tested locally at the IPH lab premises. The majority of the tests were performed by using the immunofluorescent technique that has been substituted

26

from last fall by the PCR method. Since then, the rate of the confirmed cases by the reference lab is 1 00% (all 51 tests sent to the reference lab have been confirmed as positives).

Indicator m (c) i. IPH personnel were vaccinated. (see below).

IndicatGr m (c) ii. A stock of antiviral drugs was made (see below).

Indicator m (c) iii. A procurement system for antiviral drugs was established.

Indicator In (c) iv. A very modem ICU was inaugurated and has been fully functional since December 2009 (see below).

Indicator m (c) v. Triage has been strengthened in regional hospitals (see below).

Achievements/Outputs

In additional to preparing the NIPP, regional training (supported by WHO) was carried out for Hospital Pandemic Preparedness, based on the Preparedness Checklist for pandemic influenza, and clinical management of AlHlNl. Four distance learning events concerning pandemic

. preparedness and latest WHO guidelines were organized in autumn 2009 by the project with WHO.

From November 15, 2007 lATA procedures (e.g. triple-packaging) were in place for packaging potentially dangerous specimens. Two human health personnel were trained and lATA-certified. 505 samples were shipped in conformity to lATA procedures and sent to Cantacuzino laboratory, Romania. Results were turned around within five days (including time for informing the transport operator, delivery to reference laboratory, sample analysis and informing the test report).

2,000 doses of vaccine were administered to medical personnel by July 2007. There were 3,000 antiviral does procured by the AI project until June 2008 (as it was required to have a stockpile of 3,000 doses). 100 % ofIPH personnel (201 persons) were vaccinated against seasonal influenza. An additional 11,200 doses were procured in 2009. Therefore, the total number of antiviral drugs procured by the AI Project was 14,200. Around 7,000 doses ofTa~iflu (expiry date 2017) are available for the next expected wave of influenza.

The ICU was completed at Tirana University Hospital Center and equipment was procured and installed. The ICU and the upgraded IPH laboratory were fully functional by 2010. Outputs to develop triage procedures in regional hospitals includes the local assessment of triage procedures of regional hospitals was undertaken. Training was also carried out. This covered, first, hospital procedures for infectious diseases and, second, zoonoses and antibacterial resistance.

Specific training was given to 320 health personnel in 2010 on subjects including hospital infection control, bacterial resistance and zoonotic disease management.

Component IV: Support to Avian Influenza Task Force for Project Implementation

Achievements under this component are rated moderately satisfactory.

The two subcomponents of this component are: (a) Strengthen the TF by establishing a Permanent Secretariat and (b) Monitoring and Evaluation.

27

Achievements/outputs No outcome indicators are specified for this component in the project Technical Annex (Appendix 2. Results Framework and Monitoring). However. subcomponent (a) concerned establishing the TF with full-time staff to manage the project. The government's AI TF established a permanent Secretariat in MAFCP. led by two Project Coordinators. responsible for coordinating activities. work plans and project reports. Most of the TFS staff has been mainstreamed to the ministerial bodies as follows: i) the AH Coordinator. promoted as the Chief Veterinary .Officer; ii) the HH Coordinator has been promoted to the MoH position of Public Health Specialist, Sector for HygienelEpidemiology. Directory of Public Health. as of November 1 st 2010; iii) the FM expert of the project has been selected as the first candidate and will continue to work at the new WRIP as FM expert. This is a very good outcome of the project showing that good cooperation of the TFS with both ministries and the respect of the latter toward TFS staff. which have been rewarded with their promotions.

Subcomponent (b). Monitoring and Evaluation, concerned M&E activities at all levels. Overall, project reporting improved since a part time M&E specialist has been hired.

Part 2. Tabulated Indicators and Targets/Objectives for Components 1 to 3

Component I: Public Awareness and Communication (US$460,600): to develop and implement a communications plan to inform the public. particularly those more likely to be exposed to HPAI, about the threat ofHPAI and how they can minimi~ the risk of transmission and spread of dise~se. Its two subcomponents are: (i) Risk Communication; and (ii) Communication fot Behavior Change.

Indicators Tare:ets Year 4 (end ofProiect) . Original Revised Indicators Baseline Plan Actual Indicators (from Project (from Paper) Technical Annex) CompOnent I 30 % more of 55 % more of at-risk Estimated 55% KAP survey conducted at-risk population practicing 25% December 2009. population safe handling (i) 63.8 % (16.4 % in practicing safe procedures with 2006) use to wash hands handling respect to poultry after touching poultry, or procedures with and poultry meat . poultry products; respect to (ii) 59% (21.7 % 2006) poultry and cooking well poultry poultry meat products;

(iii) 50.2% (13,4 % 2006) know to avoid the contact with dead poultry and wild birds; (iv) 16.5 % (9,4 % 2006) cooking poultry with gloves

28

Pandemic NA 70% of (i) 55.3% (12.7% in communications targeted 2006) have seen and read messages produced audience leaflets and brochures and delivered t.o receive about AI pandemic targeted audiences relevant (ii) 67.8 % (28 %, in

information 2006) refer that have learned enough from the leaflets and the ideas there have been clearly formulated, easily understandable and expressed in an attractive way. (iii) 75.9 % (72.1% in 2006) refer that have seen many TV spots and advertising dedicated to AI, which have transmitted the messages like: "avoid contact with dead poultry", ''wash your hands", "cook well poultry" etc . . . Vaccmatlon uptake mcreased due to awareness ralsmg

Component II: Animal Healtb (US$3,698,200): to support a national program to develop and implement short and long term HP AI prevention, containment, and control and eradication activities in animals. Its three subcomponents are: (i) Enhancing HP AI Prevention and Preparedness Capacity; (ii) Strengthening Disease Control Capacities, and Improving Surveillance, Diagnostic Capacities, and Applied Research; and (iii) Strengthen HP AI Control Programs and Outbreak Containment Programs.

Indicators Targets Year 4 (end of Project) Original Revised Baseline Plan Actual Indicators Indicators (from Tecbnical (from Project Annex) Paper) Sub-Component II A Satisfactory sub- New Framework Current Clearer and The new draft laws, Veterinary Law Veterinary more effective Veterinary Law regulations, adopted, in line Service and provisions for introducing, clearer . protocols and with EU acqui~ Inspectorate general disease and more effective guidelines and practices Law control provisions for developed purposes general disease

control purposes, has been completed and sent to various ministries for opinions

29

Annual updating New contingency Emergency Clearer and AnewEU ofHPAI plan for HP AI plan in place more effective compliant influenza and adopted, in line standing contingency plan for preparedness and with EU acquis arrangements HP A I was prepared, response plan and practices for combating approved and

HPAI published in MAFCP webpage

Sub-Component II B National National NA NVEU NVEU has been Veterinary Veterinary incorporated established, Epidemiological Epidemiological into State equipped, and also Unit established Unit established Veterinary staff has been

and achieving an Service and trained by the AI increase of the implementing project support. The number of suspect enhanced NVEU is pursuing cases of animal disease various activities diseases reported surveillance and including, and investigated control compilation of by means of activities historical (3-year) clinical exams data on prevalence and/or and incidence of epidemiological relevant diseases, inquiries e.g. brucellosis, TB

etc, collection and evaluation of regular epidemiological returns from the field, updating the poultry census, monitoring of the occurrence of animal disease

Institute of Animal Health Bio-safety Animal Health The laboratory is Veterinary Laboratory testing level 2(-) Laboratory equipped with, and Research testing capacity and bio- testing capacity capable of routinely capacity and bio- safety level and bio-safety carrying out RT-safety level upgraded and level upgraded PCR for HP AI and upgraded achieving an to meet needs of other relevant

ihcrease in the enhanced diseases. Laboratory number of disease staff trained in suspected cases of surveillance and implementation of animal diseases monitoring quality assurance investigated by system and SOP, to means of enhance stability laboratory tests and improve and techniques biosafety

30

Sub-Component n C Two emergency There was no There was no need response mobile need for the for the mobile units, eradication units mobile since the main established and eradications disposal way of operating units. Apart infected birds

from the two remained burial into HPAI a pit and apart from outbreaks in . the 2 AI outbreaks 2006, no in February - March outbreaks 2006, there were no were reported other outbreaks in the country reported in the

coul!!!Y 100 % of 100%of

.,

Estimated 100% 100 % (250) of all veterinary and veterinary field 10% regional field extension field staff trained in veterinarians have staff trained in diagnosis, been trained on AI safety protocols investigation and and Newcastle

control methods disease for HP AI and other Additional training diseases was provided to

them on various diseases upon request from the regions, such as brucellosis, TB, classical swine fever, anthrax, rabies, and enterotoxaemia

Compensation Compensation 0 Compensation CF is guaranteed Fund (CF) of secured from to beneficiaries from the budget of US$2.0 million national resources paid within 10 the Ministry of established days following Finance. In case of

filing ofthe outbreak, the application and beneficiaries will be supporting compensated within documentation 10 days. Based on

the 2006 experience, they were compensated in 6 days

Component ill: Human Health (US$I,600,OOO): to support a national program to develop and implement short- and medium-term prevention of an outbreak of HP AI among humans and reduce the impact of pandemic virus. Its subcomponents are: (i) Enhance Coordination and Program Planning; (ii) Strengthen the National Public Health Surveillance System; and (iii) Strengthen Health Care Response Capacity.

31

Indicators Tal1!ets Year 4 (end of Project) Original Revised Baseline Plan Actual Indicators Indicators (from (from Project Technical Paper) Annex) Sub-Component In A

New National NA Completed Under technical support of Pandemic for levels 0 - WHO, NIPP has been prepared, Preparedness 6 and post that includes Level 6. In Plan developed pandemic additional to that, WHO and endorsed period supported regional training for by WHO Hospital Pandemic

Preparedness based on the Preparedness Checklist for pandemic influenza, and Clinical management of AlHINI

Sub-Component ill B Number of Samples Approx 15· As per lATA 505 samples shipped in days between shipped in days procedures conformity tolAT A procedures collection of conformity to and sent to Cantacuzino' samples and lATA . laboratory(Romania) results from procedures Within 5 days which include the UK times of informing the transport reference operator, delivery to reference laboratory lab, sample analyses' and

delivery of test report Sub-Component ill C 100 % ofIPH Vulnerable IPH 50% - 100 % of IPH personnel was and 30 % of groups as per 100 % and vaccinated against seasonal hospital and WHO Hospital influenza (201 persons) PHC service definition Staff personnel vaccinated uncertain vaccinated against against seasonal seasonal influenza influenza 3000 units of Anti-viral 200 Asper 14,200 antiviral doses procured anti-viral drugs drugs treatments National Plan by the AI Project. Around stockpiled stockpiled 7,000 doses ofTamiflu (expiry

date 2017) are available for the next expected wave of influenza

System to System to Not System Procurement system is in place. rapidly procure rapidly procure existing enhanced to . There is only one producing antiviral antiviral for speed company (Roche) that has two

pandemic procurement main distributors in Albania, by November that guaran~ies very quick 09 procurement process

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15 isolation Establish an 0 Completed A very modem ICU is rooms Intensive Care inaugurated and is fully established Unit functional since December

2009 Triage NA Completed Triage procedures in regional procedure hospitals includes: established in (i) was undertaken local regional assessment of triage procedures hospitals of regional hospitals;

(ii)stafftrained in hospital procedures for infectious diseases (iii) staff trained for zoonoses and antibacterial resistance

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Annex 3. Economic and Fin~ncial Analysis

INTRODUCTION

The Project Development Objective is to mInImIze the threat posed to humans by Highly Pathogenic Avian Influenza (HPAI) infection and other zoonoses and to prepare for, control, and respond to influenza pandemics and other infectious disease emergencies in humans.

The project focused on communication & awareness programs concerning both human health and poultry management, on training/capacity building of key staff in the health and veterinary systems, laboratory renovation and rehabilitation and triage and intra-hospital operational and safety procedures.

FINANCIAL ANALYSIS

The project cost benefit analysis at the time of appraisal was based on short-term financial implications of the spread of the virus and the loss of poultry stock during contained sporadic and/or widespread outbreaks. The analysis appraised an internal rate of return (IRR) of 44 percent. The project investments benefits stream was based on the positive externalities associated with prevention and containment of a highly infectious disease such as HPAI. 16

Given that a HP AI outbreak did not occur during the life of the project and that the development objective was revised to encompass other zoonotic diseases, a re-estimated project cost and benefit stream comparison was not deemed relevant as it is not counterfactual17 • In addition, the project did not collect comprehensive quantitative data to enable conventional calculations of economic rates of return and to reasonably attribute overall changes to the project. Still, the Project's efficiency can be evaluated on the basis of early indications of improved efficiency of the early response management of health and veterinary systems, efficiency in implementing the hospital procedures for emergency, and efficiency gains in the stocking and distribution of vaccines. Therefore, a qualitative analysis of project impacts and benefits has been carried out for this IeR.

PROJECT BENEFITS

The project's major long-term economic benefits stem from strengthened capacity in early response management for both human health and veterinary systems for epidemic emergencies. The better preparedness of the Albanian authorities in detection, prevention and treatment, was proven during the last pandemic influenza that occurred in 2009 when many patients were treated also for other infectious diseases such as tetanus, meningitis, septicemia and hepatitis. The creation of a stockpile of antiviral drugs also served for the treatment of the. patients at the

16 See section D of the PAD, May 2006. The total number of poultry (including turkeys) in Albania is over 6 million, of which approximately 85 percent is owned by small holders. Small poultry farming is scattered across the country. and the average price of a mature bird (weighing approximately 2.5kg) was US$7 in the market in early 2006. Prices have been stable in recent years. There were two types of event associated with the spread of HPAI in the poultry sector: (1) sporadic contained outbreaks (similar to what is already going on in Albania) where a limited number of birds must be culled; and (2) widespread outbreaks, where a significant percentage of the poultry stock is decimated at one time. 17 Counterfactual thinking is a conditional (or "if-then") statement indicating what would be the case if its antecedent were true.

34

beginning of the pandemic influenza in summer 2009. Another major benefit was the increased intensive care capacity through the establishment of first leu for infectious diseases and training. Trained key staff have been actively engaged and contributed as trainers for a better management of AI, pandemic influenza and other diseases situation18•

The increased capacity of the veterinary service in control, end eradicate zoonoses at the source of infection before it becomes endemic has resulted in enormous costs savings. Although the analysis did not re-calculate the financial projection of the possible losses due to an AI epidemic, it is reasonable to partly attribute to the project the lower financial losses and lesser funds for compensation should an epidemic occur now .

. The project invested heavily in national and regional capacity building. Strengthening local planning and emergency response delivery capacities would include developing the synergies between different interventions and donors activities.

The Project contributed to good cooperation among relevant stakeholders and to "One Health" agenda (veterinary public health) in which Government took real ownership of the prevention campaign. Another major benefit was ensuring sustainability beyond the project lifespan through the. mainstreaming of project staff to tlte ministerial bodies (MoA and MoH), revealing good cooperation between the Task Force Secretariat and both ministries. as well as incorporating maintenance and running costs of laboratories and other infrastructures procured under the project into the national budget allocation.

Component 1: Public Awareness and Information

This component contributed to raise awareness and improve knowledge in the prevention of the spread of Avian Influenza and other zoonoses and infectious diseases in animals and humans among key veterinary and public health personnel. popUlation and commercial farms. The TFS and the MoH response to pandemic have been well focused and timely.

Health-related public awareness and communication activities in Albania targeted school teachers to maximize effectiveness, not only when children are identified as key beneficiaries, but also because children can influence their families and others. This was extremely successful in raising awareness among the Albanian population. Similarly, training programs to health care workers and teachers have assisted in reinforcing the preventive work.

During 2006 outbreaks in the region, farmers slaughtered healthy oirds due to panic and misinformation. An interesting feature of the project campaign, which was instrumental as economic damage control for both backyard and commercial poultry, was the tailored training for the media (supported by UNICEF) on how to deliver information on avian influenza, to avoid unnecessary financial losses in the country economy.

An inter-sectoral communication-working group (CWG) was established and periodically met to revive the public awareness process. Its sustainabiIity is ensured under the lead of UNICEF, MoH . mandates and close cooperation with the veterinary service. 19 The better coordination and complementarity in responding to threats between the various agencies20 (in terms of both funds

18 Source: ICR Borrower report corroborated by the field visit. 19 ISR 9, 23 April 201 1. 20 WHO, UNICEF, USAID, UNDP, FAO and PHRD Japanese Fund.

35

and human resources) resulted in cost savings from the project. The cost effectiveness of this component allowed unspent funding for additional training of key staff, reiteration of the campaigns and fund the second KAP survey. The actual costs of this component were US$0.25 million, 50 percent of the amount allocated at design.

Component 2: Animal Health

At MTR, the supervision mission conducted a preliminary risk assessment on the relative risk of incursion of HPAI, which showed that the risk had diminished since the Project started due to: (i) favorable containment of the epidemic in the wider region, and (ii) better preparedness ·of the Albanian authorities to deal with an epidemic.21 Then, the project was restructured and the scope of the project was broadened from only HP AI to include other zoonotic diseases of concern such as brucellosis, rabies, tuberculosis among others.

Quantification of benefits of the overall project was considered impractical and not counterfactual; however, simple re-calculation of the appraisal analysis related only to the poultry sector, has been carried out. The analysis has been updated with actual project costs and market prices leaving the assumptions of events of incidence and spread of HP AI unchanged. 22 Two types of outbreaks were assumed: (i) sporadic contained outbreaks -limited number of birds culled; and (ii) widespread outbreaks, significant percentage of the poultry stock culled. The analysis yields a NPV ofUS$1,745,671 confirming the investment as financially sound; and also suggesting that should an outbreak occur would probably cause lower financially losses than it would have in the without- project situation because of readiness of authorities in the containment of the epidemic.

It is reasonable to assume that the project contributed partially to reduce the probability of both contained and widespread outbreaks by (i) enhancing surveillance of zoonotic diseases on the ground; (ii) strengthening laboratory diagnostic capacity of zoonoses diseases; and (iii) ensuring timely and efficient prevention and eradication of prevalent zoonoses before it becomes endemic, including resources and procedures for compensation.

Strengthening laboratory diagnosti~ ~apa~ity of zoonoses diseases. The virology laboratory at the Institute of Food Safety and Veterinary was rehabilitated, upgraded with new equipment (RT­PCR amongst others) and staff capacity. The routine implementation of RT-PCR for HPAI and other diseases allowed molecular diagnosis in real time reducing diagnostic time while the diversified training of veterinary staff improved the quality and reliability of the testing results. According to the data collected, more accurate diagnostic testing was confirmed 100 percent for all samples sent to an international reference laboratory. This subcomponent has also contributed to improve the bio-safety of the laboratory personnel reducing their exposure to risk and creating possibilities for accreditation of other individual laboratories. .

Enhan~ement of surveillan~e of zoonoti~ diseases on the ground. The National Veterillary Epidemiological Unit (NVEU) was established as an integral part of the state veterinary service. The monitoring and diagnosing animal disease have impro.ved substantially and been consistent with OlE standards. An important outcome was the fulfillment of the legal agreement to have this unit under the regular budget to ensure continuity and sustainability after the project life.

21 MTR, report, 2009. 22 Please see Appendix 1 at the end of this annex.

36

Ensuring timely and efficient prevention and eradication of prevalent zoonoses. The introduction of a new legal and regulatory framework allowed increased capacity of the veterinWy·services .in controlling and efficiently eradicating zoonoses at the source of infection

. before it becomes endemic; which has resulted in enormous costs savings. The culling at . infection points now follows international best practice and national resources have been secured for compensation to farmers for culled birds. In case of outbreak, the compensation mechanism provides an incentive for livestock owners to report sick and dead animals to veterinarians. The MoF is able to provide timely compensation within 'I 0 days.

,

The actual costs of this component were US$I.25 million, 39 percent of the amount allocated at design. This variance is related to the activity of laboratory construction and related laboratory furniture, which could not be procured due to lack of the building permit by the authorities.

Component 3: Human health

As there have been many projects on health in the country, authorities, and key health ministerial staffs have been highly proactive enabling the project achieve all planned outputs. Equally, the project was very flexible in adapting to changing needs and the holistic approach of provision of infrastructure, equipment and training proved very successful23•

The component activities have had a great impact on the improvement of early response to influenza pandemic through the development of the National Integrated Preparedness Plan for control and response to outbreak and pandemic.24 The major benefit of this component is the enhanced core capabilities and functions of the health system. The project contributed to face the pandemic in terms of:

• Preparation of public health structure procedures and revision of all protocol which allowed early diagnosis;

• Tamiflu provision; • Provision of new laboratory and new technology as traditional· methodology was

reliable but not fit for facing emergency; • Supported life-threatening diseases though the provision ofRT-PCR; • Centralization of emergency procurement system for antivirals; • Supported diagnostic and epidemiology unit. The project investment including

complete restructuring of the facility, intensive training including abroad of medical staff25 and upgraded the bio-safety to level 3 contributed to enhanced laboratory staff capabilities of the IPH enabling to face efficiently twice the peak of HINt pandemic human influenza in 2009. Time savings reduced from 3 weeks to just 2-3 hours as avoided shipping samples to a reference laboratory (Cantacuzino-Romania);

• Provision of vaccines (150 000 sold in 20 II) and staff inoculation (100 percent for ICU staff); and

• Supported reconstruction of the Intensive Care Unit (lCU) in Infective Hospital at the Tirana University Hospital Center. The newly leu was upgraded according to the international standards, with negative pressure in 4 isolation rooms, fully equipped.

23 Included Infection control, Diagnostic, clinical management, use of new machine and equipment, new hospital triage and protocols 24 Plan was prepared in accordance with WHO recommendations. 25 Training at the Istituto Nazionale di Malattie Infettive (INMI), Spallanzani, Roma, Italy.

37

Severe cases have been treated in the ICU, also for other infectious diseases such as tetanus, meningitis, septicemia, and hepatitis. It was recorded improvement in treatment, management of the patients as well of improved bed use rate.

The improvements in the health system and in the health care workers' performance generated another major benefit which is the percentage reduction of the human population infected by HPAI, HI Al and other infectious diseases, and consequent reduction of the number of hospitalizations and the number of deaths attributed to other infectious disease other than HPAI. Particularly, the establishment of ICU contributed in reducing human suffering and some deaths; out of 400 patients, only 12 deaths have been recorded?6

Generally, in health projects, the proj~ct benefits stream is calculated in terms of(i) resource cost savings which is a· reduction in out-of-pocket expenses for health care as a result of reforms in health financing; and/or (ii) productivity gains are the result of less time lost to illness. Productivity gains are also realized when less time is spent for the care of sick family members.

The economic value of averting hospitalization costs, income loss from days lost to illness, and income loss from fatal cases are the main costs to assess. The assumption for the hospitalization costs are calculated taking into account daily cost per bed for an average stay, which in case of influenza is about 7 days while for special cases is longer, for example for tetanus can be some weeks. For the income loss, it is assumed a number of income days per an average percentage of population. While, for fatal cases, it is considered average remaining lifetime earning actualized for a year period and at a discount rate, generally between 10 and 12 percent.

The affected human population (Gross Attack Rate) for an outbreak of HP AI was estimated at 3 percent of the popUlation by the Government while WHO estimated 10 percent, with 10 percent of the affected popUlation being hospitalized and a 3 percent death rate for those affected. 27

Unfortunately, due to lack of data on dail~ cost per bed and average daily wage (latest statistics is around 900 Lek per day back to 2007) 8 , the mission could not make guess estimate of the economic cost savings for the Albanian economy. As health projects are often not revenue­generating, an analysis of public expenditures becomes critical for determining the sustainability of the project.

There is an on-going Bank-financed project on modernizing the health system, synergetic to the Alone that included an expenditure review for the health sector. However, this information was not analyzed and available at the time of the mission (February 2011). It would be worthwhile for the Government to pursue a more in-depth expenditure review of the sector,. to ensure that the right investm'ent decisions are made from an economic point of view.

26 Interviews with Head of Department of Public Health (Mr. Roshi) and Director of Infectious Diseases (Dr. Craya) at the Mother Teresa Hospital. 27 Other similar World Bank projects used Gross Attack Rates as high as 30percent. 28 http://www.instat.gov.al/. Average Monthly Wage in Public Sector and Official Minimum Wage.

38

Appendix 1. Re-calculation of the Financial Analysis of the poultry sector carried out at appraisal

Price Birds Total Value • Poultry Sector $ 6.00 6,000,000 $ 36,000,000

Pereent of stock lost during sporadic contained outbreaks 5% Percent otstock lost during catastrophic Outbreaks 25%

Year 1 Year 2 Year 3 Pl'f)bability of outbreaks without the project

Continued sporadic contained outbreaks 100% 100% 100% Catastophic outbreak 40% 45% 50%

Number of poultry lost from sporadic contained outbreaks 300,000 285,000 270,750 Number of poultry lost from catastophic outbreak 600,000 607,500 599,063

Total value of poultry loss without project $ 5,400,000 $ 5,355,000 $ 5,218;875

Probability ofoutbreak with project 90% Continued sporadic contained outbreaks 80% 70%

Catastophic outbreak 36% 33% 29",4

Number of poultry lost from sporadic' contained outbreaks 270,000 229,206 192,528 Number of poultry lost from catastophic outbreak 546,000 447,228 365,494

Total value of poultry loss with project $ 4,896,000 $ 4,058,568 $ 3,348,134

Incremental benefit from project (without-with) $ 504,000 $ 1,296,432 $ 1,870,741 Cost of project $ 486,350 $ 828,350 $ 83,500

Net benefit $ 17,650 $ 468,082 $ 1,787,241

NPV @ 10 percent discount rate $1,745,671

In the original analysis, the market price of birds was US$7 and the project costs were Y 1 US$I,500,000; Y2 US$I,OOO,OOO; and Y3 US$500,000. Two types of outbreaks were assumed and retained in this analysis: (i) sporadic contained outbreaks -limited number of birds culled; and (ii) widespread outbreaks, significant percentage of the poultry stock culled. Another important assumption was the percentage loss of stock during the two events, which were 5 and 25 percent respectively.

The analysis yields a NPV of US$I,745,671 confirming the investment as financially sound; and also suggesting that should an outbreak occur would probably cause lower financially losses than it would have in the without- project situation because of readiness of authorities in the

. containment ofthe epidemic for diseases other than AI.

This analysis is only partial and indicative of the overall project benefits. However, economic damage control of the poultry sector and reducing human exposure to the disease can be said to justify such project.

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Annex 4. Bank Lending and Implementation Support/Supervision Processes ~(~t!~~!~;t!!!!!!~!!!l>e~" "~~~~~"~. " .. " .. _~~~~"""~~_~." .. "~~"~~ __ .. " . Names Title Unit Lending Amelia Branczik Aleksandar Nacev Bekim Ymeri Belita Manka David Lugg Elona(}ji~8:

,~I~i~a .. ~a,gyn~8:~"a Francois Decaillet

I~rlll1i~ I:Ia,'*8:j Junian A. L8:~pi~tti Mariana Bukli Mirela Kellezi Natalia Otel Oscar Samso Robert Carr Sabina Serlc

SupervisonllCR Amelia Branczik Arben Maho Artan Guxho Belita Manka Benedicta T. Oliveros-Miranda Brian G. Bedard Cesar Niculescu Coral Bird David Hadrill Dionisis Panagiotatos Drite Dade Elona Gjika Ibrahim Hackaj Ida N. Muhoho

J lllillI1A:!-:llll1pi~tti .. Lindita Kosumi

;!-:i~a,~a,gli~t:t! . ,M~}ll.~hi.~~.~8:y8:~i()~8:Il18: . Nedim Jag8:l!jac Nino V. Moroshkina Sarah Leigh Hammill Silvia Mauri Tamer Samah Rabie

Consultant Senior Agriculturalist Consultant Procurement Analyst Agricultural Officer Financial Management Analyst Deputy Resident Representative, Albania Lead Public HealthSp~cialist Senior ()perations Officer Senior Economist Health Officer Technical ~)(pert, Albania Junior Professional Associate Project Manager Prowam Coordinator Consultant

Consultant Procurement Specialist .

Pr<?j~c!~()m()~~ Counsel

Procurement AI18:1yst Senior Livestock Specialist Environmental ~pecialist . Program Assistant Consultant Consultant Senior Projects Officer Financial Management Specialist Senior ()perations Officer, Project TTL Sr Financial Management Specialist Lead Procurement Coordinator

~C?~()ll~c:C?f\!18:I18:g~Il1C?l1tAI18:lyst Consultant

~C?Il}"()~()p~~ti<?l1sgftic:C?r, ICR TTL. Senior Health Specialist E T Consultant Senior Program Assistant Consultant Senior Health Specialist

40

.. " .... " ..... " ....

ECSSD

ECSSD ECSPS TCIE ECSPS UNDP ECSHD ECSSD ECSSD UNICEF WHO ECSSD WHO UNICEF ECSSD

ECSSD ECS02 ECSSS LEGOP ECS02 ECSSI ECSS3 ECSSD FAO ECSSD ECSS3 ECSOQ ECSSI ECS03 MNSAR ,ECACA

FAO ECSSD ECSHI ECSHI ECSSD ECSSD ECSHI

(b) Staff Time and Cost

Stage of Project Cycle

'Lending ... . FY06 ._ ... _._._._.

FY07 ·--FYOS--- -_ ... -__ HH ______ _

;s~~~~i!i~~9! ..... . ·····FY06 ., "N" _ H. __ '.H_ "H' __ " ••• _. ___

FY07 FY08 FY09

To~al:

Total:

Staff Time and <:;ost (lJank Blidget Olll~) .... .... .... .. USD Thousands (IncludlDg

No. of staff weeks travel and consultant costs)

41

24

24

28 17 24 69

". -0 ........ _.H.' .•........

93.93 -0.73 0.00 .

,. _ •••• __ •• __ • __ ••• _H"'~'_

93.~~_ .... __ ...

0.00 93.51 85.83

0.00

179.34

Annex S. Beneficiary Survey Res~lts (Not Applicable)

42

Annex 6. Stakeholder Workshop Report and Results (Not Applicable)

43

Annex 7. Summary of Borrower's ICR

The Executive Summary of the Borrower's Implementation Completion and Results report is shown below, verbatim. '

Executive Summary

This is the Borrowers Report for the completion of Avian Influenza Control and Human Pandemic Preparedness and Response Project from October 2006 to December 2010.

Albania has started to implement the Avian Influenza (AI) project. after the confirmation of two outbreaks of Highly Pathogenic Avian Influenza (Hi> AI) in March 2006. Government of Albania with support of the international donor, was focused on mounting a rapid response to improve surveillance, detection and containment measures. The Avian Influenza Task Force was established by the Order of Council of Ministers No. 168, date October 28th, 2005, as an inter-ministerial and inter-sectoral decision-making body. .

The AI project .has had good progress and significant impact. The project was focused to improve surveillance, detection and containment measures, in line with international standards.

Positive impacts and outputs were observed in the following areas:

• With project support the country has improved the capacities to prevent, identify, contain and eradicate HP AI outbreaks. Albania also has proved that it can manage, in a pandemic situation, based in its own resources and capacities. This was proved in the last pandemic situation occurred in Albania (2009).

• The Virology Laboratory at the Institute of Public Health (WH), has undergone complete reconstruction to upgrade it at the BSL2 level and one laboratory upgraded to BSL3 level. Upgrading of the laboratory facility was accompanied with the supply of laboratory equipment and furniture aswell·as training of laboratory personnel to comply with the upgraded level of laboratories. The upgraded virology laboratory at WH started its work in November 2009, in the peak of the HINI pandemic human influenza. All positive samples that were isolated in this laboratory were confirmed by the reference laboratory in Cantacuzino (Romania), confirming high standard of laboratory capacities and . laboratory staff capabilities of the WHo The total investment at the WH virology laboratory from the AI project is approximately 850,000 USD.

• The AI project also supported reconstruction of the Intensive Care Unit (ICU) in Infective Hospital at the Tirana University Hospital Center. The newly ICU was. upgraded according to the international standards, with negative pressure in 4 isolation rooms, fully equipped. The· upgraded ICU started its work in December 2009, in the peak of the HINI panqemic human influenza. Many patients were treated on the course of the pandemic influenza, but also from other infectious diseases. The total investment at ICU from the AI project is approximately 600,000 USD.

• Antiviral stockpile was created and served for the treatment of the patients at the beginning of the pandemic influenza in summer 2009. Following the spread of the

44

pandemic and increase in human cases, another stock of antivirals was purchased using the AI project funds through direct contract.

• The National Veterinary Epidemiological Unit was established for the 1st time as an integral part of the state veterinary service. NVEU members received basic epidemiological trainings, conducted by the international veterinary epidemiological consultant. The AH. Project Coordinator, since mid April 2010, was promoted as Chief Veterinary Officer, in the MoAFCP. Positive achievements and improvements were made in monitoring and diagnosing animal disease consistent with OlE standards.

• Both virology laboratories at the Institute of Public Health and at the Institute of Food Safety and Veterinary, received for the 1st time the RT-PCR equipment, allowing molecular diagnosis in real time. The RT-PCR technique has 'been extensively and successfully used for diagnosis of patients during the pandemic influenza in winter of 2009 - 2010 and still being used for diagnosis during the season of influenza (winter 2010 - 2011 ).

• Public awareness campaign covered both Avian influenza and the pandemic human' influenza, through TV and radio spots, leaflets, posters, trainings with schools teachers and students, aiming to increase information and awareness of public on the disease, and how to prevent the spread of the disease.

• Trainings focused on Avian Influenza and other zoonoses and infectious diseases in animals and humans have contributed in keeping the key staff updated on the developments and progress in poultry situation in Albania, region and world. The trained staff have been actively engaged and has contributed as trainers to the other groups to better management AI, pandemic influenza and other diseases situation.

45

Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders

(Comments from USAID) -- The AI Response in general in Albania can be considered a good . example of efficient and effective collaboration among relevant stakeholders in situations of

Public Health Threats such as the AI. Donor's community, led by USAID, and the UN Family under the one-UN Approach lead by UNDP, initially encouraged GoA to get organized and plan how to properly respond to the emergency. USAID made possible the initial funding for a rapid planning and response, during the emergency phase. The merit of the WB initial assessment team was in being able to build upon the existing mechanisms and plans to further elaborate a longer term response, without losing too much time.

All the activities and planned interventions of the WB project, followed a thorough consultative discussion and consensus building process during the project design phase, sharing this way a common strategic approach among all players, GOA, Donors etc. This helped synergize efforts and optimize the available resources.

WB was an important partner not just as a financing body, but also in its technical assistance efforts participating actively in the National Task Force, in inter-sectoral technical communication working groups, organized by GOA and lor Donors.

In general, USAID evaluates high the level of cooperation with the WB during this particular phase and considers the WB project very successful, in the most of its components.

46

· Annex 9. List of Supporting Documents

World Bank Documents

Project Appraisal Document on a Proposed Credit to Albania for an Avian Influenza Control and Human Pandemic Preparedness and Response Project under the GPAI, May 1, 2006.

Technical Annex on a Proposed Credit to Albania for an Avian Influenza Control and Human Pandemic Preparedness and Response Project under the GPAI, Report No: T7677-AL, June I, 2006.

Financing Agreement between Albania and International Development Association, Credit Number 4206 ALB, July 11,2006.

Albania - Avian Influenza Control and Human Pandemic Preparedness and Response Project (PI 00273) - Project Mid Term Review Mission Aide Memoire - 3 to 8 July 2008.

Project Paper on a Project Restructuring for Albania Avian Influenza Control and Human Pandemic Preparedness and Response Project, September 17,2009.

Aide Memoires ofImplementation Support Missions, 2006 to 2010.

Implementation Status and Results (lSR) Reports, 2006 to 2010.

Albania - Avian Influenza Control and Human Pandemic Preparedness and Response Project (PI00273) - Implementation Support and Implementation Completion and Results Report (lCR) Mission Aide Memoire - December 13 to 17, 2010.

OPCS: Implementation Completion and Results Report Guidelines, August 2006 (updated 11110/2010)

Government Documents

Implementation Completion and Results Report for Avian Influenza Control and . Human Pandemic Preparedness and Response Project October 2006 to December 2010 (Borrower's Report), December 2010, Tirana, Albania.

Ministry of Health, Development and Institutionalization of National Health Accounts (NHA). Albania- Executive Summary, Tirana, July 27, 2010.

Other Documents

KAP Survey to Assess Impact of Public Awareness and Communication for Behavior Change Interventions to Prevent Spread of AI - UNICEFINAPH -2009.

WHO European Region, Albania E-health Statistics.

47

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