Projet de contrôle de la grippe aviaire et de préparation et de réponse à une pandémie humaine : Rapport sur l'achèvement de la mise en œuvre et les résultats

Document of The World Bank Report No: ICR2628 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H4190) ON A EMERGENCY RECOVERY GRANT IN THE AMOUNT OF SDR 1.00 MILLION (US$1.557 MILLION EQUIVALENT) TO THE REPUBLIC OF HAITI FOR AN AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE PROJECT UNDER THE GLOBAL PROGRAM FOR AVIAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (GPAI) December 12, 2012 Sustainable Development Department Haiti Country Department Latin America and Caribbean Region Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized CURRENCY EQUIVALENTS (Exchange Rate Effective December 12, 2012) Currency Unit = Gourdes (HTG) HTG 40.48 = US$1 US$ 0.625 = SDR 1 FISCAL YEAR October 1 – September 30 ABBREVIATIONS AND ACRONYMS AHI Avian and Human Influenza AI Avian Influenza APL Adaptable Program Loan CCID Center for Control of Infectious Diseases CDC Centers for Disease and Control Prevention CNIAH National Commission on Avian and Human Influenza DDA Departmental Directorate for Agriculture DELR Department of Epidemiology, Laboratory and Research DPSA Directorate for Animal Production and Animal Health DR Dominican Republic EMP Environmental Management Plan FAO Food and Agriculture Organization GoH Government of Haiti GPAI Global Program for Avian Influe nza Control and Human Pandemic Preparedness and Response GSB Gwoupman Sante Bèt HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HPAI High Pathogenic Avian Influenza IADB Inter-American Development Bank ICR Implementation Completion and Results Report IDA International Development Association IICA Inter-American Institute for Cooperation in Agriculture ISO International Organization for Standardization LPAI Low Pathogenic Avian Influenza LVCQAT Tamarinier Veterinary and Food Quality Control Laboratory MARNDR Ministry of Agriculture, Natural Resources and Rural Development MEF Ministry of Economy and Finance MSPP Ministry of Public Health and Population MTR Mid-Term Review M&E Monitoring and Evaluation NGO Non-Governmental Organization OIE World Organization for Animal Health OP Operational Policy of the World Bank PAHO Pan-American Health Organization PCU Project Coordination Unit PDO Project Development Objectives PP Project Paper TCP Technical Cooperation Project UCS Health Units under MSPP UPS Sanitary Protection Unit of MARNDR USAID United States Agency for International Development WB World Bank WHO World Health Organization Vice President: Hassan Tuluy Country Director: Alexandre Abrantes Sector Manager: Laurent Msellati Project Team Leader: Diego Arias ICR Team Leader: Gabriela Vaz Rodrigues REPUBLIC OF HAITI 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 .......................................................................................... 10 4. Assessment of Risk to Development Outcome......................................................... 17 5. Assessment of Bank and Borrower Performance ..................................................... 18 6. Lessons Learned ....................................................................................................... 20 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 22 Annex 1. Project Costs and Financing .......................................................................... 23 Annex 2. Outputs by Component ................................................................................. 24 Annex 3. Economic and Financial Analysis ................................................................. 26 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 36 Annex 5. Beneficiary Survey Results ........................................................................... 38 Annex 6. Stakeholder Workshop Report and Results................................................... 39 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 40 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 42 Annex 9. List of Supporting Documents ...................................................................... 43 MAP A. Basic Information Country: Haiti Project Name: AVIAN INFLUENZA CONTROL AND HUMAN INFLUENZA EMERGENCY PREPARDNESS AND CONTROL Project ID: P111667 L/C/TF Number(s): IDA-H4190 ICR Date: 12/12/2012 ICR Type: Core ICR Lending Instrument: ERL Borrower: GOVERNMENT OF THE REPUBLIC OF HAITI Original Total Commitment: XDR 1.00M Disbursed Amount: XDR 0.92M Revised Amount: XDR 1.00M Environmental Category: B Implementing Agencies: Ministry of Health and Population Ministry of Agriculture, Natural Resources and Rural Development Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 03/19/2008 Effectiveness: 04/06/2009 04/06/2009 Appraisal: 06/05/2008 Restructuring(s): 05/03/2010 Approval: 07/14/2008 Mid-term Review: 07/18/2011 07/18/2011 Closing: 01/15/2012 06/30/2012 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Unsatisfactory Government: Not Applicable Quality of Supervision: Moderately Satisfactory Implementing Agency/Agencies: Not Applicable Overall Bank Performance: Moderately Unsatisfactory Overall Borrower Performance: Moderately Unsatisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation Performance Indicators QAG Assessments (if any) Rating Potential Problem Project at any time (Yes/No): Yes Quality at Entry (QEA): None Problem Project at any time (Yes/No): Yes Quality of Supervision (QSA): None DO rating before Closing/Inactive status: Moderately Unsatisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Agricultural extension and research 7 5 Animal production 5 20 Health 5 5 Public administration- Agriculture, fishing and forestry 63 60 Public administration- Health 20 10 Theme Code (as % of total Bank financing) Other communicable diseases 25 20 Rural policies and institutions 75 80 E. Bank Staff Positions At ICR At Approval Vice President: Hasan A. Tuluy Pamela Cox Country Director: Alexandre V. Abrantes Yvonne M. Tsikata Sector Manager: Laurent Msellati Ethel Sennhauser Project Team Leader: Diego Arias Carballo Jean-Claude Balcet ICR Team Leader: Diego Arias Carballo ICR Primary Author: Gabriela Vaz Rodrigues F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) To minimize the threat posed to humans by highly-pathogenic avian influenza (HPAI) infection and other zoonoses, and to prepar e for, control, and respond to influenza pandemics and other infectious disease emergencies in humans. Revised Project Development Objectives (as approved by original approving authority) No revision (a) PDO Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : Communal sections remain free of AHI infection in poultry Value quantitative or Qualitative) 0 24 24 Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) 100% Indicator 2 : Communal sections that send weekly surveillance report on time Value quantitative or Qualitative) 2 25 20 Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) 80% Indicator 3 : Decrease in the time taken to report information on poultry diseases at local level (number of days it takes to report information) Value quantitative or Qualitative) 7 4 2 Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) 200% Indicator 4 : Backyard poultry farmers currently applying at least three prescriptions to protect their poultry and/or family Value 0 2800 Not Known quantitative or Qualitative) Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) The indicator likely intended to measure the individual contribution of the project to 2800 vaccinations following the training of farmers (impact of the training). (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : Laboratory staff trained in AHI diagnosis by the project Value (quantitative or Qualitative) 0 12 6 Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) 50% Indicator 2 : Communal sections adequately covered by trained staff Value (quantitative or Qualitative) Not known 40 484 Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) 1000%+ Indicator 3 : Development of communications strategy Value (quantitative or Qualitative) None Approved Approved Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) Accomplished Indicator 4 : Health Personnel receiving training under the project Value (quantitative or Qualitative) 0 42 400 Date achieved 02/04/2008 01/31/2012 06/29/2012 Comments (incl. % achievement) 1000% G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 08/13/2008 Satisfactory Satisfactory 0.00 2 02/20/2009 Moderately Satisfactory Moderately Satisfactory 0.00 3 07/29/2009 Moderately Satisfactory Moderately Satisfactory 0.00 4 11/17/2009 Moderately Satisfactory Moderately Satisfactory 0.35 5 05/07/2010 Moderately Satisfactory Moderately Unsatisfactory 0.35 6 12/02/2010 Moderately Satisfactory Moderately Satisfactory 0.46 7 06/29/2011 Moderately Unsatisfactory Moderately Unsatisfactory 0.46 8 12/28/2011 Moderately Unsatisfactory Moderately Unsatisfactory 0.71 9 06/29/2012 Moderately Unsatisfactory Moderately Unsatisfactory 1.41 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring Amount Disbursed at Restructuring in USD millions Reason for Restructuring & Key Changes Made DO IP 05/03/2010 N MS MS 0.35 Earthquake of 2010 resulted in project extension and reallocation of expenditures. I. Disbursement Profile 1 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1.1.1 The Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response . In 2005, the highly pathogenic avian influenza (HPAI) H5N1 virus emerged as a global threat. On January 12, 2006 the Bank’s Board endorsed the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) as a horizontal, adaptable program providing up to US$500 million of immediate emergency assistance to countries seeking suppor t to address this threat to public health and economic activity world-wide. The GPAI was a Bank contribution to a broad international response launched at the ministerial conferen ce in Beijing, China, in January 2006 with pledges of US$1.9 billion from 35 donors. Throughout 2006, the virus spread rapidly with additional countries reporting cases of HPAI; by the end of the year, 55 countries in Asia, Europe, Africa and the Middle East had reported cases in poultry or wild birds. 1.1.2 Avian Influenza outbreak in Hispaniola: Following detection of the H5N2 subtype of Avian Influenza (AI) in the Dominican Republic (DR) in December 2007, the Bank started preparation of the Project as part of the glob al response effort. In May 2008, the virus was detected at four locations in Haiti. Suspecte d means of introduction of AI in Haiti were through its six ports and two main airports, trade along the Haitian-DR border and internal poultry movements (especially of fighting cocks), and through the migration of infected birds. The H5N2 flu detected in DR and later in Haiti was Low Pathogenic Avian Influenza (LPAI) and thus did not represent a significant threat to animal or human health (i.e., low risk of severe illness and death). However, concern existed over the spread of H5N2 and possible mutation of the virus into a Highly Pathogenic Avian Influenza (HPAI) subtype, which can cause severe illness and death (such as H5N1, see Annex 1). 1.1.3 Country Context. At the time of project appraisal, Haiti ’s population was estimated at 9.5 million, with an annual growth rate of 1.6%. Historically, Haiti was always the poorest country in the Western hemisphere and one ofthe most disadvantaged globally, with 78% of its population living below the poverty line (US$2.00/day). It ranked 146 th out of 177 countries in the 2007 Human Development Inde x. Estimates put the number of poultry in Haiti at approximately 5 million of whic h only 10-20% were owned by commercial enterprises 1 . However, when compared to the resu lts of the 2008-2010 Agricultural Census these numbers turned out to be a significant under-estimation of the actual numbers of poultry (8.9 million) and of the importan ce to livelihoods of traditional poultry farming (99.5% of 775,704 farms were raising poultry nationwide) 2 , increasing the challenge of preventing, controlling and responding to potential outbreaks of AI. Haiti was also exposed to the risk of infection by zoonoses 3 through imports of around 2.5 million chickens per month, including from the DR. 4 The Human health situation also was also quite dire at time of project 1 Project Paper; Plan Haitien de Préparation a une Pandémie d’Influenza 2009. Based on FAO estimates from 2005. 2 See Annex 2 for the preliminary results of the 2008-2010 Agricultural Census, released in September 2012. 3 Zoonoses are infectious diseases that can be transmitted between species, from animals to humans or vice versa. Zoonoses now account for 75% of infectious diseases affecting humans 4 In addition to the AI detected in 2008, many diseas es had historically affected livestock in Haiti including Newcastle disease, Classical Swine Fever, Porcine Enceph alomyelitis (Teschen disease), anthrax, screw-worm, rabies, brucellosis, tuberculosis and varroasis. Of these, only AI, rabies, anthrax, brucellosis and tuberculosis are potentially severe zoonoses . 2 appraisal, with an infant mortality rate of 75 per 1000 births and the highest incidence of HIV/AIDS outside Sub-Saharan Africa. 1.1.4 The National Commission, Steering Committee, and Plan for Avian Influenza. The Haitian Government’s awareness of AHI started in 2003, following cases of human deaths from H5N1 in Asia. A technical body, the National Commission on Avian and Human Influenza (CNIAH), under the Ministry for Public Health and Population (MSPP), was created in 2005 and institutionalized by decree in 2006. Tasked with preparing an Avian Influenza and Human Pandemic Preparedness Plan, CNIAH’s life was short and its activities ceased with a change of Minister in 2006.The follow-on National Steering Committee on Avian Influenza intended to raise resources for surveillance activities and information sharing, but was never institutionalized although it did prepare the National Program for the Epidemiologic Vigilance of Avian Influenza . Under the Global Program for Avian Influenza (GPAI), the Government of Haiti (GoH) then prepared a National Avian Influenza Control and Pandemic Preparedness Plan (National Plan) covering the period 2006-2010, consistent with the global strategies developed by FA O/OIE and WHO-PAHO, and providing the basis for the Project and other donor support. 1.1.5 Animal health sector in Haiti. Key actors in animal health were and remain: (i) local voluntary Animal Health Groups ( Gwoupman Sante Bèt or GSBs); (ii) the Animal and Plant Quarantine Service, legally responsible for surveillance and response at ports, airports, border posts, and internal posts; (iii) the Directorate for Animal Production and Animal Health (DPSA) responsible for coordinating and imp lementing policies on animal health and epidemiological surveillance; and (iv) the Tamarinier Veterinary and Food Quality Control Laboratory (LVCQAT, the National Laboratory), responsible for the diagnosis of animal diseases and food analysis. The last three or ganizations are part of the Ministry of Agriculture, Natural Resources and Rural De velopment (MARNDR). Annex 3 summarizes the roles of these actors and their deficiencies at the time of appraisal. 1.1.6 The Human health sector in Haiti. Concerning human health, expenditures in Haiti were and are among the lowest Latin America, and the sector is characterized by insufficient health workers, essential drugs, and equipmen t. Most hospitals have insufficient isolation rooms and equipment for patients with severe re spiratory diseases. The constraints in the health sector at time of appraisal were mirrored in the National Center for Laboratory and Epidemiology (NCLE), which lacked suff icient human and financial resources and operational facilities. 1.1.7 Project appraisal. At the time of appraisal, USAID support to the GoH to get the AHI program up and running had been completed (US$100,000 between 2006 and 2007). Six approved or ongoing projects were identified in the area of animal and human health (see Annex 3). Project appraisal was conducted in coordination with other donors. The project was part of GPAI under which all projec ts are processed using OP/BP 8.00 on Rapid Response to Crises and Emergencies. Funding was sourced from cancelled undisbursed balances of opera tions financed from Haiti’s IDA -13 allocation, and was limited to the amount available from this source. Based on the GPAI framework and on lessons from Latin America (e.g. Guatemala, Honduras, Mexico and Ch ile) and other Regions in the World, the project adopted a multi-pronged approach, including dissemination of AHI information to the public, strengthening the early detection and warning system at the field level, and improving the capacity for rapid and effective response to an outbreak. At the time of appraisal, two complementary projects, supporting a regional approach for the whole island, had been signed 3 in March 2008 for Haiti and the Dominican Republic, the AHI Prevention and Control Program, a capacity building program financed by the AHI Facility (US$1.0 million per country) 5 . These projects would complement the ID A-financed project and were intended to improve national and bi-national communications and emergency activities not covered by it. 1.1.8 Rationale for Bank involvement. Bank involvement was justified on the following grounds: (i) the urgent need to reduce the threat of AHI and increase preparedness in Haiti; (ii) the regional and global public goodsaspect of controlling AHI and other zoonoses ; (iii) the need for countries to strengthen their ve terinary services, disease surveillance, and the human health system; and (iv) the potential soci al and economic impacts of AHI on Haitian farmers and the Haitian population as a whole. The latter was consistent with general objectives of poverty alleviation and economic growth contai ned in the 2006 Haiti Interim Poverty Reduction Strategy prepared by the government of Haiti. 1.1.9 Implementation arrangements. The project had a clear focus an animal health and as such a Project Coordination Unit (PCU) was established within the Directorate for Animal Production and Health (DPSA) and responsible for coordinating technical execution of the entire Project. DPSA was responsible for the ex ecution of Component 1, while MSPP was in charge of Component 2. Communication activities were to be outsourced and coordinated by the Ministry of Communication. Finally, Component 4, including the project’s financial administration and procurement, was outsour ced to the Inter-American Institute for Cooperation on Agriculture (IICA), which acted as a fiduciary agent 6 . The decision to choose to IICA was due in part to a preferenceexpressed by MSPP in order to have a neutral management of funds, and in part to the Bank team’s assessment (see Annex 4). 1.2 Original Project Development Objectives (PDO) and Key Indicators ( as approved ) 1.2.1 Project Development Objective. To minimize the threat posed to humans by highly- pathogenic avian influenza (HPAI) infection a nd other zoonoses, and to prepare for, control, and respond to influenza pandemics and other infectious disease emergencies in humans. The PDO reflected exactly the GPAI development objective. 1.2.2 PDO indicators. The Results Matrix shows Key Indicators as: (i) the number of communal sections sending weekly reports on time; (ii) the number of days taken to report information on poultry diseases at the local level in a representative sample of communal sections; and (iii) the number of backyard poultry farmers applying at least three prescriptions to protect their poultry and/or family from AHI. In the Main Text however, these indicators are shown as Intermediate Outcome with the Key Indicator being “the number of communal sections that remain free of AHI infection in po ultry”. All four indicators are considered as Key Indicators in this ICR. See Table 1, Section 3.2 for the complete Results Matrix. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification N/A 5 The AHI Facility is a multi-donor grant-making mechanism supported by the European Commission and nine other donors, and administered by the World Bank. 6 IICA is a multilateral agency of the Inter-American system specialized in agriculture. It was contracted by the government as the project’s fiduciary agency, and remu nerated with project funds. The same arrangement was successfully implemented in the AHI project in DR. 4 1.4 Main Beneficiaries 1.4.1 The primary project benefic iaries were expected to be: (i) poultry farmers who would benefit from pilot community in itiatives and from improved anim al health; (ii) the Haitian population in general as potential beneficiaries of improved management of the threat of AHI; (iii) the Gwoupman Sante Bèt (GSBs) 7 ; (iv) professionals of th e DPSA, including of the National Laboratory; (v) health care institutionsand personnel; and (vi) other participants in the animal health and human health systems recei ving strengthening, equipment, training or information through the project. There were also(unquantified but likely substantial) cross- border benefits because by controlling disease ou tbreaks promptly and effectively, Haiti and the Dominican Republic could manage avian flu island-wide. 1.5 Original Components ( as approved ) 1.5.1 Component 1: Animal health (US$ 760,000), which represented approximately 50% of the Grant, financed support for prevention 8 , surveillance, and preparedness for any AI outbreak. It included activities to provide knowledge on the status of AI in Haiti; to strengthen facilities for early detection a nd mitigation of the potential impacts of AI, predominantly quarantine facilities; and to test sanitary measures in the context of small farm poultry production. It was designed to have national coverage and comprised three sub- components: (i) Pilot community actions through GSBs; (ii) Emergency actions (culling); and (iii) Sub-Institutional capacity building (MARNDR). 1.5.2 Component 2: Human health (US$ 212,500) financed support for AHI prevention and mitigation at the national level, through ca pacity building and epidemiologic surveillance in the human health sector, and the establishment of an outbreak response mechanism. Activities included capacity building of healthstaff to improve the surveillance system and integration of routine surveillance systems and data; simulations to assess the state of implementation and effectiveness of public heal th measures; and information campaigns to increase the level of knowledge of public health staff and the population at large. 1.5.3 Component 3: Communications (US$ 379,000) financed support for: (i) raising public awareness of AHI; (ii) securing politicaland civil society support; and (iii) preparing animal and human health institutions for in creased demand for advice , products and services in case of an AHI outbreak. It sought behavioral change to control the spread of the virus, prevent infection, strengthen surveillance, adopt biosafety procedures and reporting mechanisms, and highlight the required investments in infrastructure and institutional reforms. 1.5.4 Component 4: Project administration (US$ 130,000) financed support for the administration of grant activities includingprocurement and disbursement services provided by the fiduciary agency. It also covered project audits. 1.6 Revised Components 7 GSBs are independent, voluntary, local community structures responsible for the local planning and implementation of vaccination programs and for animal clinical surveillance, among other roles. 8 Prevention can be interpreted as actions to avoid the oc currence of any disease (e.g. surveillance, quarantine, risk analysis, biosafety, vaccination, communication); surveillance, reporting and control correspond to the constant monitoring of animal (and human health) to detect virus outbreaks; and preparedness, mitigation and response refer to the readiness of the animal (and human health) systems to react or respond to an outbreak of the highly pathogenic virus, should it occur. 5 N/A 1.7 Other significant changes 1.7.1 Complementary funding and effectiveness. The US$1.0 million grant approved for Haiti from the AHI Facility was cancelled due to the GoH’s failure to meet effectiveness conditions by the three-month deadline and to request an extension of this deadline. The Bank and GoH decided to continue with ex ecution of the IDA project while GoH would continue to seek funds to fill the “financial gap”. IDA financing was reprioritized to achieve project objectives, focusing mainly on animal health capacity building activities and reducing the focus on emergency response actions. The d eadline for project effectiveness (August 18, 2008) was extended to April 2009 in January 2009 to provide more time for signature of the fiduciary agreement between IICA and MARNDR. The project became effective on April 6, 2009. 1.7.2 Extension of the closing date and reallocation of expenditures. On May 3, 2010, the Financing Agreement was amended as following: (i) reallocated US$ 80,000 from Unallocated and US$ 80,000 from Category 1 (Compensation payments) to Category 2 ( Goods, consultants’ services Training and Operating costs for Components 1, 2 and 3); and (ii) the original closing date (January 15, 2012) was extended to January 15, 2013. This restructuring was decided in the aftermat h of the January 2010 earthquake which caused implementation delays in addition to those already caused by poor fiduciary management of the Project. 1.7.3 Early closing of the project . A second change of the closing date (to advance the date) was decided following the Mid-Term Review (MTR) and formalized on July 18, 2011. Despite accelerated implemen tation and improved fiduciary ca pacity, progress was not satisfactory at the time of the MTR. The Bank recommended that GoH advance the closing date to June 30, 2012 and included still-pending activities in another Bank-financed operation under preparation with the MARNDR (RESEPAG II – P126744). 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 2.1.1 Rapid and Global Response. The challenge posed by the H5N1 avian flu and pandemic threats necessitated a coordinated multisectoral response. The GPAI framework set out how multiple sectors and actors would have to work togeth er and provided a template for the design of country responses, based on guidance from WHO, FAO, and OIE. The design built on relevant Bank operational experience, incl uding in emergency responses to disasters, the global program to address HIV/AIDS, and ot her responses to outbreaks of animal-borne diseases. Given the context of the global AHI response, the threat of AHI to Haiti, the detection of H5N2 in the neighboring Dominic an Republic, and despite an absence of Bank engagement with Haiti in the agriculture sector, the Bank responded swiftly to Government’s request by launching project prepar ation and appraisal to prevent AHI – and particularly HPAI – from spreading into the country. The project was prepared and approved under OP 8.0 and was intended to be financed through several sources of funds including Government’s own resources, AHIF Trust Fundsand IDA Grant. 6 2.1.2 Government Commitment. The Government of Haiti took immediate measures - including closing the cross-border trade in li vestock - and allocated their own budgetary resources to support the National Plan. Despite tensions between the DR and Haiti, the Bank supported both Ministries of Agriculture in a technical dialogue to deal with the problem bilaterally (island-wide) in order to achieve the objectives in both countries. With Bank support, both countries were able to maintain technical discussions on AI prevention and control. However, on the human health agenda, MS PP was not actively involved in the design of the project, resulting in: (i) a low level of funding of Human Health activities (Component 2) which only received 14% of the ID A grant and of the AHI grant, and (ii) a lack of commitment from MSPP during project implementation. 2.1.3 Project financing. The project was designed and appraised with three sources of funding: IDA, AHIF and Government Resources (see Table below). This financing structure supported the same PDO and was allocated on a proportional basis per component. In particular, the AHIF TF was central to the desi gn of the project and its cancellation would have a huge impact. Table 1 : Summary Project Costs (US$) Component / Sub-Component IDA Grant (P111667) 9 AHIF TF (TF091637) 10 Government Funds 1. Animal Health 760,000 800,000 300,000 1.1 Pilot community activities 300,000 - - 1.2 Emergency actions 150,000 - 300,000 1.3 Capacity building for prevention and response 310,000 800,000 - 2. Public health 212,500 135,000 - 3. Communication 379,000 - - 4. Administration 130,000 65,000 - 5. Un-allocated 75,500 - - TOTAL 1,557,000 1,000,000 300,000 2.1.4 Quality at entry. Quality at entry is rated Moderately Unsatisfactory. The Global response and the detection of avian flu in neig hboring Dominican Republic created pressure to rapidly submit the Project for Board approval. The Bank allocated a total of US$9,000 for project preparation. The team was composed of agriculture and human health specialists. The quality of Safeguards analysis was satisf actory, however design elements and conditions on the ground merited closer scrutiny, in particular borrower capacity and fiduciary arrangements. Two agencies were identified for fiduciary management during preparation: IICA, and MARNDR. The decision to use IICA was due in part to MSPP’s preference for the neutral management of funds, and in part to the Bank team’s assessment. IICA’s fiduciary capacity was over-estimated (IICA had no experience in managing Bank projects), and with 9 This is the allocation as of project approval (not at restructuring). 10 This funding was approved but TF never became effective and was cancelled. 7 hindsight MARNDR, which had experience in managing several Inter-American Development Bank (IADB) projects (loans), would have been a better choice. 2.1.5 Project development objectives and key indicators. The P roject’s PDO and components were consistent with the GPAI and we re consistent with respect to the overall financing plan (including IDA, AHIF, and Go vernment resources). However, following the cancellation of the AHIF grant (35% of the overall financing plan), the PDO of the IDA Grant was ambitious with respect to the level of fina ncing available. The Project was aligned with the National Plan, and the IDA (and AHIF) funds were expected to provide flexible financing for filling the gaps throughout the course ofits implementation. The Project monitoring and evaluation (M&E) framework was relied on th e government system for monitoring and reporting. T he project’s broad scope allowed the Bor rower and the Bank to refocus project activities during implementation on a more holistic approach extending beyond AHI. Finally, project indicators were appropriate, but over-estimated MARNDR’s M&E capacity to capture outcomes at the local and nationa l levels, such as the use ofsecure and systematic reporting on the status of AHI at communal level. 2.1.6 Risk assessment. The major risks identified at appraisal included political commitment, institutional, fiduciary and tec hnical capacity, and public criticism of social distancing during a pandemic. These risks were relevant, reflecting an evolving disease threat in an environment of limited institutional capacity; however the mitigation measures were not appropriate for risks related to fiduciary capacit y and political commitment. The hiring of IICA as a fiduciary agency did not solve thefiduciary capacity problem and the measures for inter-institutional collaboration were not enough to engage MSPP in executing the human health activities. 2.2 Implementation 2.2.1 Overall Bank portfolio implementation . Performance of the overall portfolio in Haiti is helpful in assessing the outcome of this project. During the project period, the WB's portfolio was characterized by high risk and severe implementation challenges. Very weak institutional capacity combined with limited IDA resources, led to unrealistic expectations with regard to Government leadership and diligence in implementing the bulk of IDA projects over this period. In addition, Haiti was subjectto several external shocks, including 4 severs storms which caused 15% of GDP in losses and the massive earthquake of 2010. These shocks led to further inability on the part of the Government to exercise due diligence in implementation and created substantial obstacles in implementation. 2.2.2 Impact of changes in the external and domestic environment . Diminishing international attention to the risk of a pandemic over the project period (with a marked decline especially since 2009 when the H1N1 flu pandem ic proved to be much less severe than feared) resulted in decreasing support for this kind of multisectoral activity and an increasing focus on animal health to control the disease at source. In response, government and donor partners accorded progressively lower priori ty to implementation of the National Plan. Furthermore, the earthquake that struck Port au Prince on January 12, 2010 affected implementation directly. Obviously survival, relief, and recovery became the first priority in Haiti, but also it affected facilities, commun ication between agencies, and implied changes in personnel and shortages of equi pment. MSPP staff was displaced to a new location; DPSA was not in condition to receive materials to perform epidemiological tests. Providers of goods and services were affected, resulting in a reduced offer from the local markets and procurement delays. Finally, after the eart hquake, in mid-2010, the cholera outbreak further 8 distracted MSPP’s attention from the project and its participation in project activities and follow up further declined. 2.2.3 Government’s Capacity and Commitment . In addition to the external and domestic environment factors (exogenous to the project)mentioned above, the following where some of the factors regarding capacity and co mmitment from the borrower that impacted implementation: a. Ministry of Economy and Finance (MEF).The MEF provided initial funding for the emergency activities related to the project but was quickly disengaged from the avian and human influenza agenda, and did not follo w up on ensuring that the AHIF TF became effective therefore loosing such funding by letting the effectiveness deadline elapsed. b. Ministry of Agriculture (MARNDR) Th e MARNDR was the main counterpart and champion of the AI agenda in the country, and even with the reduction on the Global and Domestic priority dedicated to Avian Flu, they saw the project as an opportunity to strengthen their animal health services. Initially, MARNDR prioritized activities supporting the prevention and control of AI, launching a cullin g campaign in areas where AI was originally detected (with financing from public sector budget resources). Later, the MARNDR focused on broader capacity building on animal health, and quarantine and laboratory services, moving towards a programmatic (rather than pro ject) approach to tackling diseases like AI. This led to activities related to animal health to advance faster than other components. c. Ministry of Public Health (MSPP). Th e MARNDR made significant efforts and showed dynamism and leadership to reach to the MSPP and involve other actors and donors in addressing the problem early on. However, althoug h an inter-institutional agreement on AI was reached between MARNDR and MSPP for project execution, no MSPP staff were appointed to liaise with the project (with the exception of one consultant), despite MARNDR’s efforts to get a counterpart nominated. Given the small amount of resources and the changes in health agenda priorities at the global and national level, MSPP disengaged from the project, resulting in health acti vities underperforming compared to other components. 2.2.4 Poor performance of the fiduciary agency. In the first year, technical and procurement documents held by IICA were not processed due to IICA’s ignorance of Bank procedures and lack of commitment to the projec t, creating serious implementation delays. Procurement requests were frequently incomplete, incorrect or in the wrong format, creating long lead-times for procurement processes. No fiduciary training was anticipated for IICA as the reason for hiring a fiduciary agent was to avoid having to spend resources and time in building fiduciary capacity. Supervision actionshelped address this problem (e.g. hiring of procurement specialists by the PCU and IICA re spectively, and IICA dedicating a project coordination to follow up on project activities). IICA did improve procurement processes and quality, but only towards the end of the project. 2.2.5 Mid-Term Review (MTR). Like for most of the Haiti portfolio the MTR was conducted 1 year later than originally planne d (mid 2011 instead of mid 2010) because the closing date was pushed back by 1 year due to the earthquake and the Bank team didn’t consider appropriate conduct a MTR only months after the earthquake with a cholera outbreak in the country. Recommendations by the Mid-term Review (MTR) helped narrow project activities down to a handful of key outcomes, focus on strengthening general disease surveillance capacity rather than on strengthening AHI surveillance alone (as the actual threat of HPAI proved to be very low during imp lementation), and improve fiduciary performance 9 by identifying problems and recommending me asures to accelerateprocurement. IICA ’s improved pro-activity in leading periodic revi ews of procurement re quests also helped accelerate procurement following the MTR. 2.2.6 Evolution of approach to communications . Initial work centered on the development of a national Avian Influenza Strategic Commun ications Plan, the development of conventional printedmaterials, targeted training of h ealth and veterinary workers and market traders, and an avian influenza phone-in program on national radio. During this phase, activities were principally driven by dedicated funding provided by the project. By 2010, problems with the consultant and dwindlinginterest from MSPP, encouraged MARNDR to take the lead in concluding activities under the communications component, printing communications materials and distributing them throughout the country through GSBs and local MARNDR offices. The Strategic Communica tions Plan is an important contribution in the case of a future outbreak, even if the general population campaigns were not executed. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 2.3.1 M&E design . The Project used the National Plan indicators, which were developed in a collaborative manner, notwithstanding the f act that a number of the indicators related to activities for which financing did not materializ e. This was a deliberate choice to show support to the National Plan and lessen burden on government capacity to manage different sources of funding. The choice of project indicators, which was not based on the GPAI, required a monitoring system that was not yet in place in Haiti. The project lacked a clear M&E methodology, M&E capacity building activities, and clear responsibilities and procedures. The results framework had a mixt ure of output and outcome indicators for each component. In retrospect the Project might have only used indicators which related directly to what the IDA Grant financed, however given th e emergency nature of the Project it is possible that pre-selected Project-specific indicat ors would have had to be revised during the implementation based on the support which the Project ultimately provided. 2.3.2 M&E implementation and utilization . MARNDR used their existing M&E system (based mainly on mobile phone communications with GSBs). Values were regularly reported by MARNDR (though sometimes with delay and only on request), but MSPP was absent from reporting on the human health indicators. The MARNDR maintained the complete set of indicators throughout implementation of the Project and strengthened GSB’s reporting system. The aide-mémoires of supervision missions captured all the indicators, but with some of them, it was difficult to verify indepe ndently given that most of the information was captured through phone conversations and with no written records. Annex 3 provides a critical assessment of each indicator. 2.4 Safeguard and Fiduciary Compliance 2.4.1 Safeguard compliance. The safeguard triggered by the Project was for the Environmental Assessment. Requirements included the preparation of an Environmental Management Plan (EMP), which was drafted during preparation, and finalized within the 6 months after project effectiveness. The EMP was disclosed in Haiti and by the Bank after consultation with key stakeholders. The Project was required to comply with standards of the International Organization for Standardization (I SO) but standards achieved were considered modest, in part due to practical difficulties in complying with such standards in Haiti (limited capacity; lack of infrastructure; resistance to adopting new practices). Supervision at the sites of the quarantine posts revealed a lack of adherence to proper e nvironmental construction 10 etiquette in one of them (Belladere Quarantine Facility). Although the site was not yet operational as of project closing, the issues were raised with MARNDR to be addressed expeditiously before the opening of the post. 2.4.2 Financial management. The Fiduciary Agency (IICA) had suitably qualified financial management staff to support implementation of the Project. Hiring of the audit firm was delayed, but project compliance with the requirement to present Quarterly Intermediate Financial Reports, maintain the financial managem ent system, and present annual financial audits was satisfactory. 2.4.3 Procurement. Procurement under the Project was managed by the Fiduciary Agency (IICA). As mentioned in Section 2.2 above, during the first 2 years of project execution, procurement requests were frequently incomplete, incorrect or in the wrong format, creating long lead-times for procurement processes. No fiduciary training had been anticipated for IICA as the reason for hiring a fiduciary agent was to avoid having to spend resources and time in building fiduciary capacity. Supervision actions helped address this problem and IICA did improve procurement processes and quality, but only towards the end of the project. 2.5 Post-completion Operation/Next Phase 2.5.1 The Project was closed early, on June 30, 2012 with several activities still to be completed. Implementation of the National P lan improved some coreanimal health and human health capacities and allowed for coordination between the two systems. The achievements are, however, modest relative to the remaining capacity gaps. The government will require substantial financial and technical assistance for further development of capacity and for operations and maintenance of the a ssets already acquired. During project implementation, the Bank worked closely with DPSA and Development Partners to develop a programmatic approach to animal health, includi ng pending AI activities within the animal health program of MARNDR (financed by various donors), including the RESEPAG II Project (P126744), to secure funding. However,activities under the responsibility of MSPP were not included in RESEPAG II, and mobilization of such resources for human health systems is not a priority for donor financing, and investments in prevention tend to be grossly neglected. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 3.1.1 The Project objectives were relevant and important to the Haiti economy, public health, and poverty-reduction goals. It was designed qui ckly as an emergency operation and as part of a financial package to meet the needs of the country for rapid support for its response to an emergency and for strengthening of the veteri nary and public health systems, and their capacity to work together in detecting andcontrolling outbreaks of HPAI H5N1 and prepare to respond to pandemics and similar emergencies. These capacities are dual-purpose, relevant to other disease outbreaks as well. It also supported preparedness at the national and local levels to respond to pandemics and similar emergencies. Relevance was maintained even though conditions on the ground (and thus the focus of human health and communications activities, for example) changed throughout implementation. 11 3.1.2 The objectives remain highly relevant even now as outbreaks of HPAI H5N1 in poultry continue in more than 12 countries, incl uding countries like Mexico. The risk to economies and public health of out breaks of zoonotic and other i nfectious diseases persists and represents a substantial contingent liability on the economy and the government’s budget. In the future the government will need to re source and coordinate the veterinary and human public health services to respond rapidly to any HPAI H5N1 outbreaks in poultry, monitor for signs of transmission of the H5N1 virus to the human population, as well as detect and respond to other infectious disease outbreaks. The Project’s lessons learnt in this regard are a precedent on which the government and its partners can build. 3.1.3 The global risk of pandemics that originate in livestock or wildlife is rising; capacity for early detection and control of zoonotic pathog ens at their animal source thus remains an important goal. This goal is embodied in th e International Health Regulations (IHR 2005), which have been adopted by all countries, including Haiti, and in a growing recognition of risks at the interfaces between animal, huma n, and the environmental health. Concern with mitigation of these risks leads to acceptan ce of One Health approaches, which entail strengthening public health systems and animalhealth systems and enabling communication and collaboration at the interface. 3.1.4 Pandemic preparedness remains relevant to Haiti as well since a pandemic could occur in the future. This is all the more likelybecause prevention of pandemics through control of pathogens at their animal source is currentl y hindered by pervasive weaknesses of public veterinary health and human public health syst ems, in Haiti and in many other developing countries . OIE’s assessment of Haiti’s veterinary services in 2011 found that capacities are extremely weak and preclude performance ofnearly all essential functions; moreover, many government staff with veterinary training will beretiring in the next decade and there is no pipeline o