Completion Report

Project Number: 3966201 Grant Number: 0041 March 2014

Prevention and Control of Avian Influenza in Asia and

the Pacific

This document is being disclosed to the public in accordance with ADB's Public Communications Policy 2011.

ABBREVIATIONS

ADB – Asian Development Bank ADF – Asian Development Fund AIREF – Avian Influenza Response Facility ASEAN – Association of Southeast Asian Nations APSED – Asia Pacific Strategy for Emerging Diseases DMC – developing member country EID – emerging infectious disease FAO – Food and Agriculture Organization of the United Nations FETP – Field Epidemiology Training Program HPAI – highly pathogenic avian influenza OIE – World Organization for Animal Health SARS – severe acute respiratory syndrome UNSIC – United Nations System Influenza Coordination WHO – World Health Organization

NOTES

In this report, “$” refers to US dollars.

Vice President B. Lohani, Knowledge Management and Sustainable Development Director General W. Um, Officer-in-Charge, Regional and Sustainable Development

Department (RSDD) Director B. Édes, Poverty Reduction, Social Development, and Governance,

RSDD Team Leader P. Moser, Lead Health Specialist, RSDD Team Member M. Lagmay, Operations Assistant, RSDD

In preparing any country program of strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.

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Contents

Page Basic Data

I. PROJECT DESCRIPTION 1

II. EVALUATION OF DESIGN AND IMPLEMENTATION 1

A. Relevance of Design and Formulation 1 B. Project Outputs 2 C. Project Costs 8 D. Disbursements 8 E. Project Schedule 9 F. Implementation Arrangements 9

G. Conditions and Covenants H. Related Technical Assistance 10 I. Consultant Recruitment and Procurement 10 J. Performance of Consultants, Contractors, and Suppliers 10

K. Performance of the Borrower and the Executing Agency L. Performance of the Asian Development Bank 10

III. EVALUATION OF PERFORMANCE 11

A. Relevance 11 B. Effectiveness in Achieving Outcome 11 C. Efficiency in Achieving Outcome and Outputs 12 D. Preliminary Assessment of Sustainability 12 E. Impact 13

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS 13

A. Overall Assessment 13 B. Lessons 14 C. Recommendations 14

APPENDIXES

1. Project Framework and Project Performance 2. Actual Project Costs and Financing Plan 3. Overall Assessment 4. Project Management and Implementation Structure 5. Technical Assistance Completion Report

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BASIC DATA

A. Grant Identification 1. Region Asia and the Pacific 2. Grant Number 0041

3. Project Title Prevention and Control of Avian Influenza in Asia and the Pacific

4. Executing Agency Asian Development Bank 5. Amount of Grant $25 million 6. Project Completion Report Number PCR: REG 1433 B. Grant Data

1. Appraisal - Date Started 17 January 2006 - Date Completed 17 February 2006

2. Date of Board Approval 14 March 2006 3. Date of Grant Agreement 14 March 2006

4. Date of Grant Effectiveness

In Grant Agreement 14 March 2006 Actual 14 March 2006 Number of Extensions 0

5. Closing Date In Grant Agreement 28 February 2009 Actual 31 July 2012 Number of Extensions 1

6. Grant Disbursements

a. Dates Grant 0041 Initial Disbursement

22 May 2006 Final Disbursement

16 May 2012 Time Interval

74 months Effective Date 14 March 2006

Original Closing Date 28 February 2009

Time Interval 35 months

RETA 6313

Initial Disbursement 31 May 2006

Final Disbursement 18 October 2011

Time Interval 64 months

Effective Date 14 March 2006

Original Closing Date 28 February 2009

Time Interval 35 months

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b. Amount in US$

Grant 0041 Category Name Original

Allocation Last Revised

Allocation Amount

Disbursed Undisbursed

Balance

Consultants 13,000,000 11,380,033 11,379,975 58 Equipment 1,500,000 1,617,200 1,614,398 2,803 Training 400,000 3,061,711 2,905,801 155,910 Drugs, supplies 2,500,000 22,258 22,258 0 Information, data management 1,000,000 1,182,234 864,000 318,234 Incremental cost, administration, logistics Contingencies

1,785,000

1,215,000

7,710,154

26,410

7,607,196 102,958

26,410

Total 25,000,000 25,000,000 24,393,627 606,373

RETA 6313

Category Name Original Allocation

Last Revised Allocation

Amount Disbursed

Undisbursed Balance

Consultants 8,900,000 8,396,932 7,407,336 989,596 Equipment 400,000 300,228 281,886 18,342 Training 2,800,000 3,361,790 2,827,527 534,263 Drugs, supplies 1,200,000 31,584 31,584 Information, data management 800,000 81,835 81,835 Incremental cost, administration, logistics Contingencies

2,422,000

700,000

5,049,631 3,458,239 1,591,392

Total 17,222,000 17,222,000 13,974,988 3,247,012

C. Project Data 1. Project Cost ($ million) Cost Appraisal Estimate Actual

Foreign Exchange Cost 38.00 42.22 Local Currency Cost 0.00 0.00 Total 38.00 42.22

2. Financing Plan ($ million) Cost Appraisal Estimate Actual

ADF grant 25.00 25.00 JSF grant 10.00 10.00 TASF 3.00 3.00 Government of Canada 0.00 4.22 Total 38.00 42.22

ADF = Asian Development Fund, JSF = Japan Special Fund, TASF = Technical Assistance Special Fund.

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3. Cost Breakdown by Project Component Component Appraisal

Estimate

Revised

A. Base Costs 1. Regional Capacity Building a. Support containing infection- at-source 5.088 7.828 b. Support for preventing for potential pandemic 7.668 11.278

Subtotal 12.756 19.106 2. Regional Coordination a. Improved technical coordination 2.665 4.100 b. Rapid field response and containment capacity 5.186 6.901 c. Risk communication .200 .700

Subtotal 8.051 11.701

3. Avian Influenza Response Facility 14.500 8.700

4. Project Management .800 1.300 B. Contingencies 1. Price contingencies .320 .325 2. Physical contingencies 1.573 1.090

Subtotal 1.893 1.415 Total 38.000 42.222

4. Project Schedule

Item Appraisal Estimate Actual Dates of grant agreements with implementing agencies

ASEAN Secretariat April 2006 12 April 2006 Food and Agriculture Organization April 2006 28 April 2006 World Health Organization

April 2006 28 April 2006

5. Project Performance Report Ratings

Implementation Period

Ratings

Development Objectives Implementation Progress

From March 2006 to June 2006 From July 2006 to September 2006 From October 2006 to January 2007 From February 2007 to May 2007 From July 2007 to September 2007 From October 2007 to April 2008 From May 2008 to November 2009 From December 2009 to August 2010

Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory

Highly Satisfactory Satisfactory Highly Satisfactory Highly Satisfactory Satisfactory Satisfactory Highly Satisfactory Satisfactory

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D. Data on Asian Development Bank Missions

Name of Mission

Date

No. of Persons

No. of Person-Days

Specialization of Members

a

Fact-finding 7-9 Nov 05 3 9 a-3, b-3, c-3 7-9 Dec 05 1 3 c-3 Appraisal 12-13 Jan 06 1 2 c-2 17-18 Jan 06 2 3 b-1, c-2 7-8 Feb 06 2 4 b-2, c-2 9-10 Feb 06 2 4 b-2, c-2 Inception 9-11 Oct 06 1 3 c-3 Review 1 13-15 Feb 08 4 4 c-2, d-2 Review 2 16-17 Nov 09 2 2 c-2 Review 3 30 Nov-1 Dec 09 1 2 c-2 Review 4 3-5 Mar 10 2 6 c-2, d-2

a a = Vice President for Knowledge Management and Sustainable Development, b = lead economist, c = health

specialist, d = project consultant.

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I. PROJECT DESCRIPTION

1. The Asian Development Bank (ADB) carried out the Prevention and Control of Avian Influenza in Asia and the Pacific Project as part of an international effort to respond to the outbreak of avian influenza during 2005-2010 and to prepare for a potential human influenza pandemic.1 The project was implemented during the height of the avian influenza outbreak.2 Avian influenza, commonly called bird flu, had been responsible for a short epidemic in Hong Kong in 1997, and has reappeared in Asia— in Thailand and Vietnam in 2003. Bird flu continued spreading, posing threats to public health, threatening the livelihoods of millions of poor livestock farmers, hampering international trade and market opportunities, and causing further economic losses. The World Health Organization (WHO) had warned that avian influenza can cause a human influenza pandemic, which could kill millions of people worldwide. An ADB study released in November 2005 confirmed that avian influenza had the potential to affect the social and economic growth of the region, and can slow progress toward achieving poverty reduction targets.3 Further, human influenza pandemic could lead to some 3 million deaths in Asia, and result in $113.4 billion to $296.9 billion in economic losses. ADB has decided to help developing member countries (DMCs) respond to the challenge of avian influenza through this project. 3. The project’s intended impact was a reduction in the social and economic disruption caused by avian and human influenza outbreaks in Asia and the Pacific. The intended outcomes of the project were (i) the containment of infection by avian influenza H5N1 at source, and (ii) enhancement of preparedness for a potential human influenza pandemic in the region. The project’s targeted outputs were grouped under four components. The first related to regional capacity building and comprised the strengthening of national capacities (i) to contain avian influenza outbreaks, and (ii) to prevent human influenza and prepare for a potential human influenza pandemic. Intended outputs under component 2, which involved regional coordination in addressing the problem, were (i) improvement of coordination between affected countries and technical agencies in a regular exchange of epidemiological information, laboratory specimens, and supplies; (ii) the creation of rapid regional field response and containment capacity; and (iii) the enhancement of risk communication efforts. Component 3 involved the establishment of the Avian Influenza Response Facility (AIREF) and a flexible, fast-disbursing mechanism to address the demands that an evolving and uncertain avian influenza epidemic would create. The output under component 4, which involved project administration, was to be the development of capacity to administer an investment project with a number of different implementing agencies.

II. EVALUATION OF DESIGN AND IMPLEMENTATION A. Relevance of Design and Formulation

4. The project was clearly relevant at appraisal, when the threat of a human influenza pandemic was growing. The project was designed to strengthen national and regional capacities to conduct surveillance and respond to the avian influenza and other infectious diseases that

1 ADB. 2006. Report and Recommendation of the President to the Board of Directors: Proposed Grant Assistance

for Prevention and Control of Avian Influenza in Asia and the Pacific. Manila. 2 Avian influenza or bird flu is an infectious viral disease of birds. The avian influenza H5N1 virus subtype can cause

infections in humans. 3 ADB. Bloom et al, November 2005. Potential Economic Impact of an Avian Flu Pandemic on Asia. ERD Policy Brief

No.42. Manila

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might emerge in the future. It supported a regional public good and recognized that, due to high volumes of people and poultry moving across the region’s borders, international collaboration was essential to contain the outbreak. Strong collaboration with specialized and regional organizations, including the Food and Agriculture Organization (FAO), the WHO, and the Association of Southeast Asian Nations (ASEAN) was a critical feature of the project’s design. 5. Given its significant role and presence in the region, ADB was in a unique position to engage key technical and regional organizations in the effort to address the bird flu outbreak. In October 2005, ADB established an avian influenza task force to lead and coordinate ADB’s response to the disease in the region, which was to include the development of this project. The task force began a dialogue with international development partners. At an international pledging conference in Beijing in January 2006, ADB offered up to $468 million in financing for the effort, including $68 million in grant assistance. The international community agreed to adopt a strategic and coordinated approach to strengthen disease surveillance and diagnostics, develop capacity in human and veterinary health systems, increase public awareness and address social and economic impacts, and prepare all sectors for a possible human influenza pandemic. It was agreed that three organizations would serve as the technical leaders in organizing the global response. WHO would take the lead in the area of human health and the FAO and the World Organization for Animal Health (OIE) would lead on animal health matters. ADB had assumed a regional initiative which would fill an important gap by strengthening regional capacity through the project. The project would help in boosting DMC preparedness to deal with the bird flu without overwhelming local absorptive capacity. 6. The major strength in the project’s design was the flexibility built in so it could remain relevant as the bird flu threat and the need for suitable regional responses evolved. The AIREF component was included in the design based on lessons learned during the SARS outbreak. This experience had shown that administration had to be nimble if support at country and regional levels was to be provided swiftly as urgent needs arose. The project was developed in accordance with ADB’s Disaster and Emergency Assistance Policy to enable flexible application of guidelines and procedures and thereby help implement project activities rapidly. 7. The project design also included formal partnerships between ADB and regional and specialized organizations that were intended to improve collaboration and avoid duplication of efforts. The project financed a team of experts to respond rapidly to the needs of DMCs and provide them with quality technical support. The team’s work was coordinated by WHO, the FAO, and the Secretariat of ASEAN. These agencies also served as coordinating agencies by working with governments to ensure that information was shared and responses were consistent.

8. Finally, the project design broadened the focus beyond the immediate bird flu outbreak to include pandemic preparedness more broadly. This helped the Asian region be better prepared when an influenza pandemic (H1N1) occurred in 2009.4 B. Project Outputs

9. The project delivered most of its intended outputs under the four components and achieved most of its targets. The design and monitoring framework is in Appendix 1.

4 The influenza pandemic was caused by a novel influenza A (H1N1) virus of swine origin.

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1. Capacity Building in the Region

10. The project’s implementing agencies were the ASEAN Secretariat, the FAO, and the WHO. They served both as coordinators, working with governments to plan their responses, and as technical resource centers to build capacity and support implementation at the country level. Through the project, ASEAN and FAO collaborated with OIE to jointly organized training and workshop sessions for ASEAN countries. The project provided funds to expand the human resources at the regional and subregional offices of these organizations and at some of their country offices. This helped them better meet DMC needs, detect disease outbreaks early, and provide quick coordinated responses not only in the country affected but also in neighboring DMCs. For example, project funds helped build the FAO’s Emergency Center for Transboundary Animal Diseases (ECTAD) for Asia and the Pacific and helped it evolve from its original emergency response mode into a provider of medium- and long-term support for strengthening and harmonizing regional approaches to emerging infectious disease (EID) preparedness. 11. The FAO conducted studies based on data from the region to develop new surveillance tools and strategies for risk containment. Outputs included the development of indicators to forecast avian influenza outbreaks among backyard poultry and wild birds, the identification of vulnerable agricultural zones through the use of geographic information systems and epidemic models, and the development of targeted culling approaches based on economic impact data.

12. The FAO helped countries assess their needs for new policy and legislation to facilitate rapid responses, make their early warning systems more robust, improve collaboration between laboratory networks, and enhance capacity to conduct infection control. It also reviewed the region’s plans for responding to animal disease emergencies, putting special emphasis on cross-border issues. Ten participating DMCs were able to identify design and implementation readiness gaps. Constraints included administrative barriers to accessing the resources that would be necessary to launch a rapid response. Handbooks and toolkits for prompt detection and response protocols were developed and formed the basis of curricula used in regional training of trainers and subsequent training at the country level. 13. The project supported WHO in the development and dissemination of the Asia Pacific Strategy for Emerging Diseases (APSED), which now serves as the regional and country road map for implementing pandemic preparedness plans.5 The APSED calls for developing and strengthening the key systems that should be in place in each country, event-based surveillance, indicator-based surveillance, and response capacity. Because it was the primary focus, WHO convened an informal working group in 2009 that developed and published practical guidelines for event-based surveillance. 14. The field epidemiology training program (FETP) model developed by the United States Centers for Disease Control and Prevention (CDC) was adopted by the project as an important regional mode of training. The FETP combines classroom training in outbreak investigations with practical field experience and ongoing mentoring support to train groups of field epidemiologists. The project supported the CDC in establishing an FETP program for Central Asia, and seven field epidemiologists completed their 2 years of training. The Southeast Asia regional office of WHO and the India National Institute of Communicable Disease trained 21 field epidemiologists from eight DMCs in a 3-month FETP course. Regional capacity for

5 World Health Organization. 2011. Asia Pacific Strategy for Emerging Diseases. Manila.

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responding to bird flu outbreak was further strengthened under the project by the establishment of a regional field epidemiology training program for veterinarians in Bangkok. 15. In addition to training, project-supported staff at the FAO’s ECTAD provided technical advice and backstopping to a number of country rapid response teams in Bangladesh, Bhutan, Cambodia, India, the Lao PDR, Nepal, and Myanmar during bird flu outbreaks. Advice was also provided to strengthen related veterinary health policy and legislative frameworks in countries within the key zonal hot spots in the Indo-Gangetic Plain and the Greater Mekong Subregion. An important project effort supported greater collaboration between institutions that deal with the control of human diseases and those specializing in animal disease. Training was provided for community-based animal health workers as a way to augment the limited veterinary services in many Asian countries.

16. Nongovernment organizations (NGOs) that partnered with the project helped strengthen community-level management of the avian influenza in communities in Cambodia, Indonesia, the Lao PDR, Myanmar, the Philippines, Thailand, and Viet Nam.6 Their work included the development of a regional resource kit with easy-to-use guidelines; information, education, and communication materials; and case studies for field workers. In all, 42 participants from NGOs, community-based organizations, and the Red Cross were trained. 17. The project also strengthened local pandemic response capacity in the Philippines, during the influenza pandemic (H1N1) in 2009. The project mobilized the village health emergency response teams, which had been first created during the 2003 SARS outbreak. Project capacity building benefitted 992 team members and 302 staff members at health facilities, who were later able to help communities deal with the H1N1. The project also helped mitigate the impact of the H1N1 pandemic in Mongolia and built up the country’s capacity to address future pandemics. Activities implemented in Mongolia were consistent and relevant to the government’s current priorities, including strengthening health services. 18. WHO focused under the project on developing and maintaining updated guidelines and training materials for pandemic preparedness. It supported the implementation of the new guidelines through multiple workshops in the region during 2006–2007. This included regional training of trainers and subsequent national workshops to build capacity for use of the material it had developed. WHO also provided technical support to individual DMCs as they created their national preparedness plans. By conducting rapid containment exercises to test country preparedness, it helped identify gaps in national plans and provided valuable lessons that were used to modify the protocols for containment operations. With OIE assistance, WHO and the FAO jointly organized multicountry training sessions that facilitated cross-border coordination. 19. WHO worked under the project with vaccine manufacturers in the People’s Republic of China (PRC), India, Indonesia, Thailand, and Vietnam to diversify the sources of influenza vaccine in Asia. It reviewed their capacity and readiness to respond to an influenza pandemic, addressed intellectual property rights issues, and facilitated the transfer of technologies for producing flu vaccine. Three manufacturers in India, Thailand, and Vietnam were given grants through the project to pilot domestic production of flu vaccine. WHO has also worked with national governments in the region to strengthen their capacity for vaccine regulation. The project convened consultations between regulators and manufacturers to achieve consensus on

6 The NGO Partnership comprises the Asian Disaster Preparedness Center, Cooperative for Assistance and Relief

Everywhere, the International Rescue Committee, and the International Federation of the Red Cross and Red Crescent Societies. See http://www.adpc.net/communityAHI-Asia.

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standards for ensuring vaccine quality, safety, and efficacy. Guidelines were developed for the rapid deployment of a pandemic vaccine. They covered operations, management support, multisector planning and coordination, and command and control functions. 20. WHO also addressed national preparedness under the project by strengthening laboratory networks, early warning surveillance systems, and infection control. WHO’s Western Pacific regional office (WHO-WPRO) organized a biosafety consortium for WHO-WPRO member countries to harmonize biosafety standards in responding to bird flu and other EIDs. In collaboration with the ASEAN Secretariat, WHO conducted a workshop on strengthening laboratory surveillance and networking on infectious diseases for ASEAN countries. An initiative aimed at building capacity in laboratory-based surveillance paired laboratories in Fiji, Papua New Guinea, and Tonga with laboratories in Australia. 21. The project also developed guidelines on hospital infection control procedures and organized community health worker field teams to help national health services respond to the clinical impact of a pandemic influenza. WHO developed early warning and alert surveillance guidelines and established a regional surveillance working group on EIDs. The project also helped the FAO mobilize additional resources from United States Agency for International Development (USAID), and the European Union to build diagnosis and surveillance networks.

2. Regional Coordination

22. The project aimed to improve regional coordination and communication between countries and technical agencies on emerging and communicable diseases affecting animals and humans. This was intended to include the establishment of regular exchanges of epidemiological information, laboratory specimens, and supplies; rapid regional field response and containment capacity; and better risk communication. 23. The project helped establish a regional coordination mechanism unit at the ASEAN Secretariat that provides multisector collaboration and oversight on issues related to transboundary transmission of animal diseases, zoonoses (diseases communicable from animals to humans), and other EIDs. Through the project and working with the ASEAN member countries, the Secretariat updated its regional strategy for the progressive control and eradication of highly pathogenic avian influenza. The strategy promotes collaborative arrangements for detecting and responding to disease outbreaks and providing veterinary services needed in the ASEAN region. The ASEAN Secretariat conducted an assessment in five countries and convened three workshops to measure progress in each of the eight key areas of the strategy. Participants included representatives of the ASEAN Secretariat, the ASEAN countries, and such international agencies as Australian Agency for International Development, Canadian International Development Agency, Japan International Cooperation Agency, United Nations System Influenza Coordination (UNSIC), USAID, United States Department of Agriculture, and WHO. 24. ASEAN under the project reformulated the regional framework for 2008–2010 and committed to maintaining a regional coordination unit to harmonize activity within ASEAN on the bird flu and other animal diseases communicable from animals to humans. Several knowledge materials were published under the project such as a book on successes in the prevention, and control of bird flu in ASEAN; a directory of ASEAN experts on avian influenza; a summary of the joint accomplishment of ASEAN and ADB under the project to enhance regional cooperation in

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dealing with avian influenza; and a roadmap for an avian influenza-free ASEAN community by 2020.7 25. A regional coordination mechanism was established between WHO, the FAO, and OIE in 2008. It was based on a guide on collaboration at the country level between the animal and human health sectors on zoonotic diseases they jointly published in 2008. The guide also helped several countries establish mechanisms to share zoonotic disease surveillance information for early warnings, alerts, and rapid responses, as well as coordinated risk reduction at the animal–human interface. The Lao PDR, Malaysia, Mongolia, the Philippines, and Viet Nam have formally established coordination mechanisms to address zoonoses. 26. The project established several schemes that allow organizations to share knowledge and coordinate their key goals in the complex fight against bird flu. ADB assigned a long-term consultant to the UNSIC regional office in Bangkok to facilitate coordination between implementing agencies and other development partners, and help monitor regional progress in tackling the bird flu. A system for regular sharing of epidemiological and laboratory information between DMCs was established under the project in 2009 to coordinate rapid detection and containment of public health emergencies. A field information management system (FIMS) for the investigation of case clusters was adopted by WHO and FAO to disseminate bird flu risk information. FIMS also served as a repository of case-based data and a platform for discussions.

27. The project supported the regional extension of WHO’s Global Outbreak Alert and Response Network (GOARN) to allow it to react quickly, provide clinical management, and address logistical challenges during outbreaks of avian influenza and other EIDs. GOARN covers all disease outbreaks of international concern and provides links to international experts and resources. WHO has held meetings with DMCs and other development partners to raise awareness of GOARN, identify options for collaboration and training opportunities, and develop further links with regional partners, such as ASEAN +3.8

28. The FAO developed a toolkit under the project for rapidly assessing the potential for the spread of bird flu in border areas. It also produced a map of border areas in the region that posed a high risk of spread. They had been determined based on the spatial and temporal distribution of outbreaks and known poultry flows and market chains. A comprehensive list of the high-risk border areas was produced with the agreement of the participants in each subregion 29. The project helped establish satellite or land telecommunication connections to the WHO Global Private Network in nine DMCs. Support was also provided to train staff, provide maintenance, and purchase back-up equipment to ensure these systems continue to function properly. The project funded the provision of emergency kits that enable greater use of internet, radio, and satellite phone communications during emergency deployment. It also provided WHO offices in Delhi and Bangkok with human resources and essential equipment to enable smoother communications during outbreak investigations.

7 ASEAN. 2010. Prevention and Control of Avian Influenza in ASEAN: Strategies and Success Stories. Jakarta;

ASEAN. 2010. Directory of ASEAN Avian Influenza Experts. Jakarta; ASEAN. 2010. ASEAN-ADB Project Summary of Accomplishments. Jakarta; ASEAN. 2010. Roadmap for an Avian Influenza free ASEAN community by 2020.

8 ASEAN plus three refers to the PRC, Japan and the Republic of Korea.

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30. WHO-WPRO developed a three-level risk communication training strategy and training materials for basic risk communication. The materials were used for country-level training in the PRC, Lao PDR, Malaysia, Mongolia, and Vietnam. WHO also supported the translation of risk communication messages for minority ethnic groups in the Lao PDR. In Indonesia, collaboration between the Ministry of Health, FAO, German Society for International Cooperation, United Nations International Emergency Children’s Fund, USAID, and WHO helped establish a communicable disease command post that is responsible for responding to public inquiries, preparing briefings, and working with the media. Within the regional FETP, risk communication is also included as a standard module in training for field epidemiologists.

3. Avian Influenza Response Facility

31. The project aimed to respond to the evolving epidemic expeditiously and flexibly by creating the AIREF as a mechanism to swiftly disburse emergency funds urgently needed to contain the avian influenza outbreak, react to human influenza outbreaks in a pandemic or a pre-pandemic scenario, and establish a regional stockpile of drugs and equipment. 32. As the bird flu spread, ADB met DMC funding requests from Bangladesh in 2007, Myanmar in 2006, the Lao PDR in 2009, and Mongolia in 2010 through the AIREF.9 The facility provided bridging assistance to the Government of the Lao PDR at a time when government and donor funds were limited and the need to contain the virus was critical. An emergency AIREF grant has helped provincial teams in the country investigate and provide appropriate local responses to outbreaks of the disease. It has also maintained surveillance, management, and reporting systems at the local, provincial, and central levels.

33. The project played a key role in improving control of the epidemic in Bangladesh by enhancing diagnostic capacity and surveillance of communicable diseases. It supported the establishment of an avian influenza technical unit at the government’s Department of Livestock Services and the training of staff in applied veterinary epidemiology and transboundary animal disease information system Training was provided and standard operating procedures developed to improve decontamination, biosecurity, culling of birds, and disposal of carcasses. The project taught community animal health workers how to carry out farm and backyard surveillance. It strengthened capacity at the National Reference Laboratory at the Bangladesh Livestock Research Institute, particularly in the diagnosis of avian influenza and in good laboratory practices and operating procedures. It also supplied the laboratory with basic equipment, reagents, and rapid detection kits. 34. Emergency assistance provided to Myanmar under the project through the WHO country office improved pandemic preparedness in the DMC after repeated H5N1 outbreaks in 2006 and 2007. The project (i) helped Myanmar update its national strategic plan for avian influenza and pandemic preparedness and response, (ii) provided training materials and conducted workshops to train rapid response teams in 17 states, and (iii) supported the national stockpiling of personal protective equipment and antivirals. Project funds were used to upgrade the National Health Laboratory and Avian Influenza Reference Laboratory at the Department of Medical Research, which is now able to perform accurate diagnosis of H5N1 in human and animals. The project also supported field monitoring and supervisory visits for infection control at state and divisional hospitals undertaken by the Department of Medical Care of the Ministry of

9 Emergency support to Myanmar of $1.0 million was approved in July 2006 and provided through WHO. Emergency

support to Bangladesh of $1.5 million was approved in April 2007 and provided through the FAO. The $250,000 in emergency support to the Lao PDR government and the $350,000 in emergency support to the Mongolia government were provided through the governments respective health ministries.

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Health. ADB and other development partners recognized the government for its open and transparent handling of avian influenza outbreaks before the emergency funding was provided and throughout the project. Myanmar’s experiences demonstrated how avian influenza readiness and capacity strengthening also contribute to coordination in and the strengthening of the overall health system. 35. ADB provided AIREF funds to Mongolia to support the national response to the H1N1 in 2009. The funds supported an assessment of hospital readiness, the training of health care workers, procurement of essential drugs and supplies, the establishment of a supervisory mechanism for more than 100 hospitals and clinics in infection control procedures, and the creation of a laboratory-based surveillance system. 36. At the international conference on avian influenza in New Delhi in December 2007, a consensus emerged that management of avian influenza should evolve into a medium- and long-term initiative with more focus on strengthening animal and human health systems. In keeping with its commitment to DMCs at the meeting, ADB Management approved the reallocation of $5.8 million of AIREF funds to regional capacity building and regional coordination in July 2008. This provided the opportunity to further improve pandemic preparedness planning, expand research for vaccine production, strengthen veterinary services, and develop human resources.

4. Project Management

37. The project was directly administered by a secretariat established at the Poverty Reduction, Social Development, and Governance Division of the Regional and Sustainable Development Department. The secretariat was headed by the practice leader (health), supported by a regional coordinator, and managed by a project administrator. The secretariat was also responsible for regional and national coordination with other project partners and for the project’s financial management. The project’s implementing partners—the ASEAN Secretariat, the FAO, and the WHO—managed their own operations in accordance with their own procedures. ADB focused on the project’s overall coordination and harmonized the activities of the technical implementing partners and DMC governments in the region. The ADB secretariat prepared project quarterly and progress reports that were submitted to an ADB steering committee and ADB Management as periodic updates on the key activities carried out and on the overall avian influenza situation in the region. C. Project Costs

38. The estimated project cost at appraisal was $38.0 million, which was to be financed by $25.00 million from the ADF, $10.00 million from the Japan Special Fund (JSF), and $3.00 million from ADB’s Technical Assistance Special Fund (TASF). In March 2007, an additional grant of $4.22 million was provided by the Government of Canada, which brought the total project amount to $42.22 million. Appendix 3 shows the actual project costs and use of funds. D. Disbursements 39. At project closing, the project had disbursed $38,368,615, or 100.97% of the original appraisal cost and 90.89% of the current grant value. Total disbursements were $24,393,627 from the ADF, $8,708,411 from the JSF, and $1,270,558 from ADB’s TASF. Total disbursements from the ADB-administered grant from the Government of Canada at closing were $3,996,019 (excluding administration fee and other charges). The project’s extensive use

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of the imprest account contributed to efficiency in project implementation. To simplify documentation requirements for liquidation and replenishment, statement of expenditures procedure was used. WHO, one of the three implementing agencies, experienced delays in submitting statement of expenditures. This subsequently caused delays in the project’s reporting of actual disbursements. The grant account was financially closed on 31 July 2012. E. Project Schedule

40. The project was approved on 14 March 2006 and was completed on 31 August 2010. The grant agreements with the implementing agencies were approved and declared effective in April 2006 (ASEAN Secretariat, 12 April 2006; FAO, 28 April 2006; WHO, 28 April 2006). The grant agreement with the Government of the Lao PDR was signed on 4 January 2010 and declared effective on 14 January 2010. The grant agreement with the Government of Mongolia was signed on 30 December 2009 and declared effective on 14 January 2010. The project’s original completion date was 31 August 2008. This was extended to 31 August 2010 in recognition by ADB of the need for a longer engagement. Health security had become a priority to DMCs, and the project activities helped develop a regional approach to health security. F. Implementation Arrangements

41. ADB administered the project through the secretariat established in RSDD (para. 40). The secretariat provided guidance to the implementing agencies and was responsible for overall supervision of activities and the project’s administrative aspects. 42. A project steering committee was established at ADB to provide overall policy guidance for project implementation. It was headed by the director general of the RSDD. The members comprised the directors general of the regional departments and the Strategy and Policy Department and the chair of the Health Community of Practice. The steering committee held quarterly meetings during the first year of the project to guide project implementation and ensure quick ADB action in the event of a DMC request for emergency assistance. In the succeeding years, the steering committee met intermittently to decide on urgent issues. 43. The project was implemented through two specialized organizations—the FAO and WHO—and a regional organization, the ASEAN Secretariat. The project also engaged with such regional partners as the National Foundation for the Center for Disease Control and Prevention, Inc. (CDC Foundation) and a regional coalition of NGOs—Asian Disaster Preparedness Center, Cooperative for Assistance and Relief Everywhere, the International Rescue Committee, and the International Federation of the Red Cross and Red Crescent Societies. The implementing agencies were able to deliver all expected project outputs effectively, thus enabling the project to achieve its intended outcomes of containing infection at source from avian influenza and enhancing preparedness for a potential human influenza pandemic in the region. No major changes were required in the implementation arrangements. High-level involvement by the regional offices of implementing agencies made interventions at the regional level more effective and efficient and ensured commitment and policy leadership in the region. The project implementation structure is in Appendix 4.

G. Conditions and Covenants

44. Implementing agencies complied with all covenants. The covenants related to the maintenance of separate accounts for the project, auditing of financial statements in accordance

10

with appropriate auditing standards, provision of certified copies of audited accounts and financial statements, and certification on the use of ADF funds. H. Related Technical Assistance

45. The main objective of the related technical assistance (TA) was to ensure that all DMCs were prepared to cope with avian influenza outbreaks and a human influenza pandemic. The avian influenza outbreak was a regional problem that required a regional response covering all DMCs. The TA guaranteed that DMCs not eligible for ADF funding would also be covered by the project. Its cost was initially projected at $13,000,000, to be financed by ADB’s TASF ($3,000,000) and the JSF ($10,000,000). An additional grant of $4,222,000 from the Government of Canada was approved in 2007, which brought the total TA amount to $17,222,000. Of this, $13,975,000 was disbursed. The TA completion report is in Appendix 5. I. Consultant Recruitment and Procurement

46. ADB engaged individual consultants directly to support project management, including monitoring and evaluation. These consultants were selected and engaged in accordance with ADB’s Guidelines on the Use of Consultants (2013, as amended from time to time). When recruiting consultants, the three implementing agencies used their own recruitment procedures, which were acceptable to ADB. The procurement of goods and services was carried out in accordance with ADB’s Procurement Guidelines and the implementing agencies’ own procurement procedures, which were acceptable to ADB. Consistent with ADB’s Disaster and Emergency Assistance Policy, ADB and its partner agencies ensured that selection and engagement of consultants and procurement of goods and services were done in a timely manner. J. Performance of Consultants, Contractors, and Suppliers

47. The performance of the international and national consultants was generally satisfactory. Two long-term project consultants were recruited shortly after approval of the project. One long-term consultant was assigned to UNSIC Bangkok to help coordinate and monitor activities related to the avian influenza, including the assistance being provided by other development partners and donors in the region. The second long-term consultant was assigned to the Central Asia Regional Economic Cooperation secretariat in Almaty, Kazakhstan to coordinate project activities and ensure that Central Asia Regional Economic Cooperation members participated in the bird flu control activities of other development partners. K. Performance of the Asian Development Bank and Implementing Partners

48. ADB and the implementing agencies provided the institutional guidance and support necessary to enhance coordination between development partners. The perception of stakeholders was that the project was successful in working within the organizational and political frameworks of the region to develop sustainable long-term plans and mechanisms that harmonize with the efforts of development partners. Stakeholders report that the project helped define the roles of international technical agencies in the coordinated response to avian influenza. The direct outcomes of this have been regional harmonization, timely technical support, and improved resource mobilization. 49. Relations between ADB and the implementing agencies were generally satisfactory. It helped that the implementing partners did not change their focal point personnel during the

11

project period. A change in the FAO’s project leadership in the third year of implementation had no adverse impact. Timely project performance reports from partners facilitated regular project reports to ADB Management.

50. The ministries of health were the implementing agencies responsible for administering the project activities in the Lao PDR and Mongolia. They demonstrated strong ownership of the project efforts and their performance was satisfactory. The ADB resident missions in the two countries provided technical and administrative guidance as necessary.

III. EVALUATION OF PERFORMANCE

A. Relevance

51. The project is rated highly relevant. This was the case both at appraisal, given the emergency nature of bird flu epidemic in the region, and throughout implementation, when the need for long-term support to DMCs to help contain avian influenza and strengthen pandemic preparedness became apparent. The project was highly relevant in addressing the evolving emergence of infectious diseases in the region, supporting regional and country policy for communicable disease control, and building capacity and improving coordination for the prevention and control of emerging infectious diseases. The project was in line with ADB’s operational plan for improving health access and outcomes under its Strategy 2020.10 52. The project was also consistent with ADB’s Regional Cooperation and Integration Strategy, since fighting the avian influenza and other emerging infectious diseases is a regional public good.11 It was well designed to deliver its intended impacts, with two of the project components focusing on long-term development and the third enabling rapid mobilization of emergency funding through the AIREF to fill gaps or meet urgent needs in the work to contain outbreaks. The project required a multifaceted approach and combined immediate interventions, such as improving laboratory and health-related communication infrastructure, with capacity building and reforms in the health systems to better integrate surveillance, prevention, and follow-up. 53. The project fit within a framework discussed at a high-level global meeting in Beijing in January 2006 at which the international community pledged its commitment to fight avian influenza (para. 7). The project took an innovative regional approach to avian influenza and made a sound strategic contribution to harmonizing regional efforts. This helped make the region better prepared for the H1N1 pandemic that emerged in June 2009. B. Effectiveness in Achieving Outcome

54. The project is rated effective. It increased regional capacity, improved regional coordination, and strengthened the regulatory framework to support harmonized surveillance and response mechanisms in disease control. The 2009 H1N1 pandemic demonstrated that such mechanisms are in place and worked well. 55. Reports from technical agency partners have confirmed that the number of reported avian influenza outbreaks in poultry and the number of newly affected countries declined in

10

ADB. 2008. Strategy 2020 The Long-Term Strategic Framework of the Asian Development Bank 2008-2020. Manila; ADB. 2008. An Operational Plan for Health under Strategy 2020. Manila.

11 ADB. 2006. Regional Cooperation and Integration Strategy. Manila.

12

2007–2009 during the project’s implementation. The bird flu does remain entrenched in some poultry sectors in Bangladesh, the PRC, Indonesia, and Viet Nam, which poses a persisting risk that humans will be infected. The number of human cases peaked in 2006 and has trended unevenly lower since. No new countries recorded human cases of avian influenza in 2009, culminating a steady drop in the number of new countries affected since 2006. 12 Project effectiveness was enhanced by the fact that it stimulated cross-border work and regional coordination. C. Efficiency in Achieving Outcome and Outputs

56. The project is rated highly efficient. Based on its intended outputs and those actually delivered, the project’s resource allocation was efficient in terms of both cost and timeliness. Apart from some delayed reporting by implementing agencies, the implementation arrangements worked effectively and implementing agencies delivered all expected project outputs by the project completion date. No major changes were needed in these arrangements, although AIREF requests became more difficult to approve in the final year due to a requirement that proposed activities be completed before the completion date. 57. The only adjustment to the original time schedule was the 2-year extension approved in August 2008 to further strengthen regional capacity within the remaining project resources. A portion of the AIREF resources were reallocated to regional capacity building and regional coordination.

58. The project components supporting regional capacity building and coordination absorbed 91% of the project cost, emergency response absorbed 8%, and 1% went to project management. D. Preliminary Assessment of Sustainability

59. Sustainability is rated likely. In general, the sustainability of programs for controlling avian influenza and emerging infectious diseases will depend on the extent to which institutional and human capacity is systematically strengthened. Infectious diseases remain a public health problem in the region and will continue to emerge and reemerge. In the long term, the countries and the region as a whole will control infectious diseases only by strengthening their health systems. 60. Formulating the project in close consultation with technical partners ensured that it was closely aligned at inception with regional strategies for avian influenza control. This generated a high level of regional and DMC ownership throughout implementation. The project also built DMC ownership both by focusing on strengthening DMC government preparedness through the country-level capacity building of its implementing agencies and by filling emergency gap requests from individual DMCs through the AIREF. Feedback confirms that the ASEAN Secretariat, acting through the avian influenza task force, helped ASEAN member states develop long-term mechanisms to address avian influenza. 61. The need for transparency and for sharing information on infectious diseases is now well recognized. Regional capacity to respond not only at the country level but also in a coordinated regional manner alongside neighboring countries has been strengthened. Countries have realized the benefits of such collaboration for the region’s common good and know better how to

12

2010. United Nations and World Bank. Fifth Global Progress Report on Animal and Pandemic Influenza

13

achieve it. A new complementary approach has been explored but not fully developed under the project. This involves collaboration with the private sector to strengthen health security for the benefit of both public health and regional economic development. 62. The novel cooperation fostered by the project between the animal health and human health sectors is likely to be lasting, given the ongoing threat from emerging infectious diseases. Cross-border cooperation and regional coordination is also likely to be lasting. They have become the norm under the project and are supported by regional political institutions such as ASEAN. E. Impact

63. The project contributed significantly to reducing the social and economic disruption resulting from the outbreak of avian influenza. It did so by containing infection at source, enhancing the region’s capacity to respond to this and future outbreaks, and strengthening preparedness for pandemics. As conceived, the project contributed to the strengthening of regional and DMC surveillance and response capacities by aligning itself with the long-term regional strategies of the FAO, WHO, and ASEAN. This alignment facilitated mechanisms for regional alliances to combat avian influenza and other emerging infectious diseases. While no impact evaluation was conducted at the project level, some preliminary assessments can be drawn from the reports of development partners, such as the Global Progress Report on Animal and Pandemic Influenza in 2010.13 The report stated that countries in the region have strong, established, and operational multisector coordination mechanisms in place, and that early warning systems and response to avian influenza have improved.

IV. OVERALL ASSESSMENT AND RECOMMENDATIONS

A. Overall Assessment

64. The project is rated highly successful, both strategically and operationally. The project focused on promoting regional cooperation, implementing through technical and regional partners who shared a regional focus, while building capacity at the country level. Such positioning enabled the project to leverage ADB’s critical advantages of proven capacity for interdisciplinary approaches and its convening power to bring together its partners in the animal health and the human health sectors. The project observed the right balance between regional coordination and country-level capacity building, and even in a context of rapidly evolving regional and DMC requirements for EID prevention and control, was able to address short-term gaps while not losing sight of long-term preparedness strategy. 65. Through the activities of its technical implementing agencies, the project achieved its aims of providing significant support to help DMCs contain the bird flu and strengthen pandemic preparedness. It contributed to the substantial progress made during 2006-2008 in controlling and preventing avian influenza in the region and, during the 2-year project extension, in strengthening capacity to respond to all EID outbreaks. This proved useful during the 2009 H1N1 pandemic.

13

United Nations System Influenza Coordination and the World Bank. 2010. Animal and Pandemic Influenza: A Framework for Sustaining Momentum.

14

B. Lessons

66. ADB was able to use its convening power effectively because it had the necessary in-house technical expertise. Public health experts on ADB’s staff with knowledge of emerging infectious diseases were involved in designing and implementing the project. This in-house expertise made the dialogue with the technical and regional agencies to strengthen regional collaboration within and across the animal health and human health sectors possible. This dialogue also highlighted the advantages of using a multisector approach to address the problem of emerging and reemerging infectious diseases to provide national and regional economic development benefits. For partnerships between ADB and technical agencies, ADB needs to have strong in-house technical capacity in the relevant areas. Equally important is to have a dedicated team to support the in-house experts in coordinating and monitoring the implementation of the regional activities. Given the range of technical and regional implementing partners involved, the project did well by fielding experts in key geographical areas (Bangkok and Almaty) to facilitate regional collaboration. 67. ADB’s high-level steering committee demonstrated ADB’s institutional support, which enhanced coordination between development partners (para. 45). The committee, comprising the heads of all regional departments and the Strategy and Policy Department and chaired by the director general of RSDD, provided prompt policy guidance and expedited decisions and actions. It also ensured that the needs of the DMCs were ascertained and that DMCs had adequate access to project resources.

68. The project supported the One Health concept, which emphasizes the links between animal health and human health and emerging animal and human diseases. One Health provided a platform for unprecedented integration of animal, human and ecosystem health issues to fight the threat of avian influenza. The systematic collaboration of technical agencies across disciplines, such as FAO (veterinarians) and WHO (medical doctors) and civil society organizations (community health workers) supported by the project has promoted this concept since the beginning of the project. ADB’s financial and convening power and its high flexibility and responsiveness under the project helped build up links and strengthen collaboration between WHO, the FAO, and OIE. 69. The rapid launch and accelerated implementation of the project made necessary by the threat that avian influenza would become a pandemic made it difficult to define verifiable indicators for a number of the outputs under the regional capacity building and regional coordination components. A mid-term review of the project would have facilitated a review and updating of the design and monitoring framework. 70. Each new outbreak of disease confronts projects such as this one, as well as the implementing partners and global community, with a fresh challenge, because its early spread outpaces the gathering of scientific evidence needed to formulate containment policies. Each successive outbreak is followed by an initial opaque period characterized by a frustrating lack of scientific evidence on which to base policies and technical guidance. In the early days of SARS, the avian influenza, and throughout the H1N1 pandemic, uncertainty hindered decision making, including the decisions on the timing of changing policy from containment to mitigation. C. Recommendations

71. ADB should continue to dialogue with its DMCs, technical organizations, and regional partners on improving the prevention and control of avian influenza and other emerging or

15

reemerging infectious diseases. It should also continue efforts through regional partners to determine whether DMC governments are integrating pandemic preparedness plans into their broader risk management programs and allocating sufficient domestic financing for the implementation of these plans. 72. ADB should sustain a dialogue with technical and regional organizations on the further development of regional surveillance and laboratory networks and on a timely information flow between sectors to provide early warning of EIDs and other health security threats. ADB should always keep in mind the potential adverse impact that health security threats have on economic development. WHO’s innovative proposal in APSED in 2010 to establish a regional indicator-based surveillance system for priority diseases may be useful in this regard.

73. ADB should continue to leverage its comparative advantages at the regional level, including its proven convening power and role as an honest broker, to support the multisector and multidisciplinary responses that are essential for strengthening health security in the region. ADB should meet the challenge of sustaining the momentum in the strengthening of regional health security by committing to longer-term support, focusing on a more sustainable approach to preparedness. Further broadening of partnerships, including the engagement of the private sector, should be an essential part of fostering regional health security.

16 Appendix 1

PROJECT FRAMEWORK AND PROJECT PERFORMANCE

Design Summary Performance Targets/

Indicators Data Sources/ Reporting

Mechanisms Assumptions and Risks

Results

Impact Assumptions

Reduced social and economic disruption caused by avian and human influenza outbreaks in Asia and the Pacific region

Economic growth in the region remains as projected in Asian Development Outlook (ADO) Trends in poverty reduction do not slow down

ADO 2009 ADB poverty reduction progress report 2009

No other epidemic affects the region Other natural calamities or/and economic and political problems may affect the trends in economic growth and poverty reduction

Impact on social and economic disruption was difficult to ascertain due to the effects of the 2008-2009 global economic crisis. ADO 2009 projected slower economic growth to the crisis.

Outcome Assumption Containing infection at source from H5N1 avian influenza

Enhanced preparedness for a potential human influenza pandemic in Asia and the Pacific region

Number of H5N1 influenza outbreaks in poultry; poultry mortality remain below 2004–2005 levels in the region

Response mechanisms for human influenza pandemic are in place in the region

Reports from WHO and FAO

Sufficient resources and coordination mechanism will be in place without undue delay

The number of H5N1 influenza outbreaks and mortalities in poultry dropped steadily from 2004 to mid-2008. The project aligned with the long-term regional EID control strategies and pandemic preparedness of regional partners, such as the FAO’s GFTADs, which provide the framework for regional and country-level approaches for animal and public health cooperation, and WHO’s APSED 2010, which provides a road map for implementation of the International Health Regulations. In addition, the joint FAO–OIE–WHO Global Early Warning and Response System platform coordinates

Appendix 1 17

Design Summary Performance Targets/

Indicators Data Sources/ Reporting

Mechanisms Assumptions and Risks

Results

early warning and timely response.

Outputs Assumptions Component 1: Regional capacity building

1.1. Strengthened national capacities for containing avian influenza outbreaks through support from ASEAN and FAO

Improved surveillance systems for avian influenza Trained and well-resourced teams in place to rapidly stamp out any reported outbreaks in all countries by the end of the first year

Reports from ASEAN and FAO

Adequate resources will be available for compensating poultry farmers to encourage quick reporting

Surveillance systems, rapid response, and containment protocols have been established. The Emergency Centre for Transboundary Animal Disease Unit of the FAO has established networks of national diagnostic laboratories and teams to provide surveillance, veterinary services, laboratory diagnosis, and training for local teams for effective response. Resourced and tested national plans for pandemic influenza outbreaks have increased, and standard operating procedures were developed by the end of 2006.

1.2. Strengthened national capacities to prevent H5N1 human influenza and prepare for a potential human influenza pandemic with support from WHO

National plans for influenza pandemic preparedness drawn up, rehearsed, and resourced in all DMCs by the end of 2006

Reports from WHO and FAO

Uncertainty of outbreak will not dilute the high level political commitment

Pandemic preparedness plans were developed and tested until mid-2007. These plans enabled an effective response to the H1N1 pandemic (2009).

18 Appendix 1

Component 2: Regional coordination

2.1. Improved coordination between affected countries and technical agencies for regular exchange of epidemiological information, laboratory specimens, and supplies

A system for regular sharing of epidemiological and laboratory information in place by the end of 2006. Regular meetings of border and quarantine officials

Project progress reports Government and donors will coordinate exchange of information Government and donors will provide regular updates on support

An information management system for regular sharing of epidemiological and laboratory information between DMCs was adopted, using both the FAO Transboundary Animal Diseases Information System and the ASEAN Regional Animal Health Information System, which is linked to the OIE World Animal Health Information System.

2.2. Rapid regional field response and containment capacity

A cadre of about 100 national and international professionals trained by the end of 2006 All countries and WHO linked through telecommunications systems by the end of September 2006 Field information management system adopted A regional global outbreak and response network developed by the end of the project period

Project progress report Appropriate national professionals will be available and willing to participate

A total of 117 regional experts in Asia were trained in rapid response and containment strategy by training completion in July 2007. WHO established the Global Private Network, which provided video conferencing, voice, and data communications via satellite and terrestrial links between its headquarters in Geneva and DMCs (through WHO country offices). Regional extension of the Global Outbreak Alert and Response Network was established to respond quickly to epidemiology and clinical management needs and logistical challenges in the region.

Appendix 1 19

2.3. Enhanced risk communication efforts in all countries

Messages related to avian influenza risks communicated to different target groups according to WHO and FAO guidelines by the end of the Project

Reports from WHO and FAO

Countries have resources for well-designed communication activities Target groups have basic access to health care

Under the GFTAD and APSED Framework, avian influenza and H1N1 pandemic risk communication messages were disseminated to different target groups. However, feedback based on the H1N1 experience suggests that more work is required on risk communication.

Component 3: Avian influenza response facility

Assumptions

3.1. A flexible and fast-disbursing mechanism in place to address the needs of an evolving and uncertain avian influenza epidemic, particularly to support regional stockpiles of drugs and equipment, national efforts for containing avian influenza outbreaks, and national response to potential pandemic

Regional stockpile of drugs and equipment established by the end of 2006 Avian influenza outbreak containment efforts not constrained by lack of administrative budget in low-income countries Quick support provided for early action to contain the pandemic

Reports from WHO and FAO Project progress reports

WHO will be able to quickly develop guidelines and logistics arrangements for regional stockpiles ADB resident missions will be able to quickly respond to countries’ needs Risks Containment of avian influenza outbreaks hampered by lack of resources in low-income countries

AIREF provided assistance through WHO to Myanmar in 2006, through FAO to Bangladesh in 2007, and directly to the Lao PDR and Mongolia in 2009–2010. This ensured that containment efforts were not constrained by a lack of administrative budget in low-income countries. WHO has established stockpiles of drugs and other supplies at the regional level, including rapid shipments and replenishment. The stockpiles proved critical at the onset of 2009 H1N1 pandemic.

Component 4: Project administration

4.1. ADB develops capacity to administer an investment project with a number of different implementing agencies

Disbursement targets Coordination meetings and review missions

Internal ADB records Risks ADB cannot contract appropriate consultants (too few specialists available). Delays are caused by incompatibility of procurement and consultant guidelines

Disbursement projections were achieved. Coordination meetings and review missions were conducted regularly with implementing partners.

20 Appendix 1

Project Activities Consultant Services Provision of Equipment Training, Research and Development, Conferences Information, Data Management Incremental Cost, Administration, Logistics and Supply Management Total

ADB = Asian Development Bank, ADO = Asian Development Outlook, AIREF = avian influenza response facility, APSED = Asia Pacific Strategy for Emerging Diseases, ASEAN = Association of Southeast Asian Nations, DMC = developing member country, EID = emerging infectious disease, FAO = Food and Agriculture Organization, GFTAD = Global Framework for Transboundary Animal Diseases, IT = information technology, Lao PDR = Lao People’s Democratic Republic, OIE = World Organization for Animal Health, WHO = World Health Organization

Appendix 2 21

Actual Project Costs and Financing Plan ($'million)

ADF TASF JSF Government of Canada

Total Cost

Item

A. Base Costs 1. Regional capacity building a. Support containing infection at source 4,420 320 1,991 1,500 8,231 b. Support for preventing for potential pandemic 12,009 162 2,884 1,061 16,116 Subtotal (1) 16,429 482 4,875 2,561 24,347 2. Regional coordination a. Improved technical coordination 3,624 206 1,891 1,000 6,721 b. Rapid field response and containment capacity 1,929 82 1,442 435 3,888 Subtotal (2) 5,553 288 3,333 1,435 10,609 3. Avian Influenza Response Facility 1,969 500 500 2,969 Subtotal (3) 1,969 500 500 2,969 4. Project management 443 443 Subtotal (4) 443 443 Subtotal Total 24,394 1,270 8,708 3,996 38,368

Source: Asian Development Bank estimates. ADF = Asian Development Fund, JSF = Japan Special Fund, TASF = Technical Assistance Special Fund

22 Appendix 3

Overall Assessment

Criterion Weight Rating Rating Value Weighted

Rating

Relevance 20% Highly Relevant 3 0.6

Effectiveness 30% Effective 3 0.9

Efficiency 30% Highly Efficient 3 0.9

Sustainability 20% Likely 2 0.4

Overall Rating Highly Successful

2.8

Source: Asian Development Bank.

Appendix 4 23

PROJECT MANAGEMENT AND IMPLEMENTATION STRUCTURE

WHO Regional Office

FAO Regional Office

ADB Resident

Missions

Other International

Agency (Regional

Office)

Government Ministries and Programs

WHO Country Offices

FAO Country Offices

Other International

Agencies

(Country Offices)

ASEAN

Secretariat

ADB

Project Steering

Committee Director General (RSDD)

Strategy and Policy Department

(SPD)

Director General (Regional

Departments)

Regional Coordinator

Principal Health Specialist

Project Secretary

Training and Capacity Building Specialist

Project Administration

Specialist

Chair, Health CoP

Avian Influenza

Secretariat

(in RSPG)

Lead Health Specialist

Project Secretary

24 Appendix 5

TECHNICAL ASSISTANCE COMPLETION REPORT

TA No., Country and Name Amount Approved: $17,222,000

TA 6313-REG: Prevention and Control of Avian Influenza in Asia and the Pacific

Revised Amount:

Executing Agency:

Asian Development Bank

Source of Funding:

JSF, TASF, Government of Canada

Amount Undisbursed:

$3,247,012

Amount Utilized:

$13,974,988

TA Approval Date:

TA Signing Date:

Fielding of First Consultants: TA Completion Date

Original: 31 August 2008 Actual: 31 August 2010

14 March 2006 14 March 2006 1 April 2006 Account Closing Date

Original: 28 February 2009 Actual: 31 July 2012

Description. RETA 6313: Prevention and Control of Avian Influenza in Asia and the Pacific (“TA”) was part of an international

effort to respond to the threat of avian influenza, and to prepare for a possible human influenza pandemic. The TA was approved on 14 March 2006, with a total financing of $13,000,000 financed through Japan Special Fund for $10,000,000, and Technical Assistance Special Fund for $3,000,000. Additional grant from the Government of Canada, amounting to $4,222,000 equivalent was approved on 3 March 2007, which brought the total TA cost to $17,222,000. The TA was designed to complement the grant project Grant 0041: Prevention and Control of Avian Influenza in Asia and the Pacific, ensuring the comprehensive coverage of the region for regional capacity building against avian influenza and other emerging infectious diseases. The TA was implemented at the height of the avian influenza threat, which was impacting an increasing number of developing member countries (DMCs) and requiring both emergency and long-term interventions. Strong coordination with technical and regional agencies working at the regional level, such as FAO, WHO, and ASEAN, were critical features of the TA. Expected Impact, Outcome and Outputs. The impact of the TA was to reduce the social and economic disruption caused by

avian and human influenza outbreaks in Asia and the Pacific region. The outcomes of the project were (i) containing infection at source from avian influenza, and (ii) enhanced preparedness for a potential human influenza pandemic in Asia and the Pacific region. The TA consisted of the following outputs, (i) strengthened national capacities for containing avian influenza outbreaks; (ii) strengthened national capacities to prevent human influenza and prepare for a potential human influenza pandemic; (iii) improved coordination between affected countries and technical agencies for regular exchange of epidemiological information, laboratory specimens, and supplies; (iv) rapid regional field response and containment capacity; (v) enhanced risk communication efforts; (vi) flexible and fast-disbursing mechanism in place to address the needs of an evolving and uncertain avian influenza epidemic; and (v) developed capacity to administer an investment project with a number of different implementing agencies. Delivery of Inputs and Conduct of Activities. ASEAN, FAO and WHO were the main implementing partners serving both as

coordinating bodies, working with governments to plan their response and as technical resource centers to build capacity and support implementation at the country level. The TA increased human resource capacity at regional, sub-regional, and selected country level offices of these organizations to better meet the needs of DMCs and strengthen capacity for early detection of diseases outbreaks, and rapid and coordinated response not only in the country affected but also in coordination with neighboring countries. FAO conducted a number of studies to develop new surveillance tools and strategies for risk containment; supported countries in conducting needs assessments addressing policy and legislation to facilitate rapid responses, robustness of early warning systems, connectivity of laboratory networks, and capacity to conduct infection control; and provided technical advice and backstopping to a number of country rapid response teams during outbreak situations and for related-veterinary health policy and legislative frameworks in countries. Field epidemiology training program (FETP) model, developed by the US Centers for Disease Control, was adopted as an important regional mode of training for Central Asia. The FETP combines classroom training in outbreak investigations with practical field experience and ongoing mentoring support to train cohorts of field epidemiologists. NGO partners (Asian Disaster Preparedness Center, CARE, International Rescue Committee and the International Federation of the Red Cross and Red Crescent Societies) enabled strengthening of community-level management of avian influenza in cross-border communities in Cambodia, Indonesia, Lao PDR, Myanmar, Philippines, Thailand and Vietnam, including the development of a regional resource kit with easy-to-use guidelines, IEC materials, and case studies for field workers in cross-border areas. The TA also strengthened local capacity response to pandemic influenza in the Philippines, by mobilizing the barangay health emergency response teams to help capacitate the communities. WHO updated pandemic preparedness guidelines and training materials, including training of trainer workshops; provided technical support to DMCs as they developed their national preparedness plans; rapid containment exercises were conducted to test country preparedness; facilitated expanding influenza vaccine supply in Asia through working with vaccine manufacturers in India, Indonesia, China, Thailand and Vietnam to review their capacity and readiness to respond to an influenza pandemic, addressing intellectual property rights issues and technology transfer for influenza vaccine production; established regional network of national laboratories and connecting liaison officers between national laboratories and international/regional reference laboratories; and developed/disseminated the Asia Pacific Strategy for Emerging Diseases, which now serves as the regional and country roadmap for implementing pandemic preparedness plans. The TA supported the regional extension of WHO Global Outbreak Alert and Response Network to respond quickly to regional emergencies in epidemiology, clinical management, and logistical

Appendix 5 25

challenges during outbreaks. The TA supported satellite or terrestrial telecommunication connections to the WHO Global Private Network in nine countries in the region. Intra-country connectivity was enhanced in fifteen countries. Support was also provided to train staff, engage in maintenance contracts, and purchase back up equipment to ensure this communication system continues to function properly. ASEAN Secretariat updated its regional strategy for the progressive control and eradication of avian influenza, which promotes collaborative arrangements for early disease detection and response to outbreaks, and the provision of veterinary services needed in the ASEAN region. The TA engaged several inter-organizational collaborative schemes to enable knowledge sharing and the integration of key outcomes to address the complexities of avian influenza, such as regional coordination mechanism between the regional offices of WHO, FAO, and OIE; and greater collaboration with the regional office of UNSIC (United Nations System Influenza Coordinator). The TA emergency facility (AIREF) facilitated quick support to Bangladesh (2007), Myanmar (2008), Lao PDR (2009), and Mongolia (2010). AIREF provided bridging assistance to the Government of Lao PDR at a time where government and donor funds are limited and efforts to contain the virus was critical. The Project has played a key role in improving control of the epidemic in Bangladesh through enhanced diagnostic capacity and surveillance of communicable disease. Emergency Assistance to Myanmar through the WHO country office supported country pandemic preparedness. Emergency funds were released to Mongolia in support of the national response to the 2009 pandemic H1N1, which strengthened through hospital level assessment of readiness, training of health care workers, procurement of essential drugs and supplies, and establishing a supervisory mechanism for more than a hundred hospitals and clinics in infection control procedures, and creating a laboratory-based sentinel surveillance system. The TA was directly administered by a secretariat established at the Poverty Reduction, Gender, and Social Development Division of RSDD. The Secretariat was headed by the Practice Leader (Health) and supported by a Regional Coordinator and a Project Administrator. It facilitated project quarterly and progress reports were produced and submitted to the steering committee and ADB management as periodic updates on key activities carried out and on the overall avian influenza situation in the region. Evaluation of Outputs and Achievement of Outcome.

The project contributed to the strengthening of regional and DMC surveillance and response capacities by aligning itself with the long-term regional strategies of FAO, WHO and the ASEAN, which facilitated mechanisms for regional alliances to combat avian influenza and other emerging infectious diseases. Preliminary assessment can be drawn from partners’ reports, such as the Global Progress Report on Animal and Pandemic Influenza 2010, which cited that countries in the region have strong, established and operational multisector plans in place. The TA strengthened the regulatory framework to support harmonized surveillance and response mechanisms and the 2009 H1N1 pandemic demonstrated that such mechanisms are in place and worked well. Reports from partners confirmed that in 2007-2009 the number of reported avian influenza outbreaks in poultry and number of newly infected countries declined. The number of human cases peaked in 2006, with an inconsistent decline thereafter. No new countries recorded human cases of avian influenza in 2009, representing a steady decline in the number of new countries recording human cases since 2006. TA effectiveness was increased as it stimulated cross-border work and regional coordination. Given the transboundary nature of avian influenza, such strategic concept had improved reporting, surveillance and laboratory networks, epidemiological analyses and response systems. Overall Assessment and Rating. The TA is rated as highly successful, both strategically and operationally. The TA contributed significantly to reducing social and economic disruption due to avian influenza by containing infection at source and enhancing outbreak response capacity and pandemic preparedness, and was implemented as it was conceived. It focused on making global assistance from development partners, technical agencies and bilateral donors to DMCs, and on regional and cross-border coordination and collaboration. Through the activities of its technical implementing partners, the project achieved its original aims of providing significant support to DMCs to help contain avian influenza and strengthen pandemic preparedness. Major Lessons. ADB was able to use its convening power effectively because it had in-house technical expertise. Public

health experts with knowledge in emerging infectious diseases were involved in designing and in implementing the project. This in-house expertise facilitated the dialogue with technical and regional agencies to strengthen regional collaboration within each sector (animal health and human health) and also across sectors, and to highlight the benefits of a multisector approach to address emerging/re-emerging infectious diseases as a regional public good with benefits for national and regional economic development. For partnerships to be successful there is a need to have a strong in-house technical capacity. Recommendations and Follow-Up Actions. ADB should rise to the challenge of sustaining momentum by committing to a

longer term effort on regional health security, focusing to a more sustainable approach to preparedness. ADB should sustain dialogue with technical and regional organizations for further development of regional health security. ADB should continue to leverage its comparative advantages at the regional level, including proven convening power and an honest broker role, to support the multisectoral and multidisciplinary responses that are essential for strengthening health security in the region. Broadening of partnerships with the engagement of the private sector should be an essential part of regional health security.

Prepared by: Patricia Moser Designation: Lead Health Specialist

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intent to make any judgments as to the legal or other status of any territory or area.