IMPLEMENTATION COMPLETION AND RESULTS REPORTdocuments.worldbank.org/curated/en/913201468311659515/... · 2016-07-12 · FINAL, December 23 IMPLEMENTATION COMPLETION AND RESULTS REPORT

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Document of

The World Bank

Report No: ICR00003330

FINAL, December 23

IMPLEMENTATION COMPLETION AND RESULTS REPORT

ON THE

VIETNAM AVIAN AND HUMAN INFLUENZA AND HUMAN PANDEMIC

PREPAREDNESS PROJECT FINANCING

IDA CREDIT (4273) IN THE AMOUNT OF SDR 13.5 MILLION (US$ 20 MILLION

EQUIVALENT)

(March 13, 2007)

IDA CREDIT (4992) IN THE AMOUNT OF SDR 6.2 MILLION (US$ 10 MILLION

EQUIVALENT)

(October 21, 2011)

AHI FACILITY GRANT (TF057747) IN THE AMOUNT OF US$ 10 MILLION

(April 12, 2007)

PHRD GRANT (TF057848) IN THE AMOUNT OF US$ 5 MILLION

(April 12, 2007)

AHI FACILITY GRANT (TF099841) IN THE AMOUNT OF US$ 13 MILLION

(October 21, 2011)

TO THE

SOCIALIST REPUBLIC OF VIETNAM

UNDER THE FRAMEWORK OF THE

GLOBAL PROGRAM FOR AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC

PREPAREDNESS AND RESPONSE (GPAI)

December 23, 2014

Health, Nutrition and Population Global Practice

Vietnam Country Unit

East Asia and Pacific Region

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CURRENCY EQUIVALENTS

Exchange Rate Effective December 1, 2014

Currency Unit=Vietnamese Dong (VND)

VND 21,397.5 = US$ 1.00

US$ 1.46355 = SDR 1.00

FISCAL YEAR

January 1 – December 31

ABBREVIATIONS AND ACRONYMS

AHI Avian and Human Influenza

AHIF Avian and Human Influenza Facility (World Bank-administered trust funds)

AI Avian Influenza

AIEPED Integrated National Operational Program on Avian Influenza, Pandemic

Preparedness, and Emerging Infectious Diseases, 2011-2015 (Blue Book)

BCC Behavior Change Communication

CAHW Community Animal Health Worker

CDC US Centers for Disease Control and Prevention

DAH Department of Animal Health

DARD Department of Agriculture and Rural Development

DLP Department of Livestock Production

DVO District Veterinary Officer

DPMC District Preventive Medicine Center

EC European Commission

EID Emerging Infectious Disease

FAO Food and Agriculture Organization (UN agency)

FET Field-based epidemiology training

GPAI Global Program for Avian Influenza Control and Human Pandemic Preparedness

and Response

HPAI Highly Pathogenic Avian Influenza (including H5N1)

ICR Implementation completion and results report

ILI Influenza-like illness

ISR Implementation Status Report

KAP Knowledge, attitudes and practices (survey)

LIFSAP Livestock Competitiveness and Food Safety Project (in Vietnam)

MARD Ministry of Agriculture and Rural Development

M&E Monitoring and Evaluation

MOH Ministry of Health

OIE World Organization for Animal Health

OPI National Integrated Operational Program for Avian and Human Influenza, 2006-

2010 (Green Book)

PCU Project Coordination Unit

PDO Project Development Objective

PHRD Policy and Human Resources Development Trust Fund (administered by the

World Bank)

PPE Personal protective equipment

PPCU Provincial Project Coordination Unit

PVS Performance of Veterinary Services (assessment)

iii

RRT Rapid Response Team (for response to outbreaks)

SARS Severe acute respiratory syndrome (disease of animal origin)

UNSIC UN System Influenza Coordination

VAHIP Vietnam Avian and Human Influenza Control and Preparedness Project

WHO World Health Organization (UN agency)

Vice President: Axel van Trotsenburg

Country Director: Victoria Kwakwa

HNP GP Practice Manager: Toomas Palu

Project Team Leader: Anh Thuy Nguyen

ICR Team Leader: Olga B. Jonas

iv

VIETNAM AVIAN AND HUMAN INFLUENZA AND HUMAN PANDEMIC

PREPAREDNESS PROJECT

TABLE OF CONTENTS

Data Sheet

A. Basic Information ................................................................................................................... vi

B. Key Dates ............................................................................................................................. vi

C. Ratings Summary ................................................................................................................... vi

D. Sector and Theme Codes ....................................................................................................... vii

E. Bank Staff ............................................................................................................................ vii

F. Results Framework Analysis ................................................................................................ viii

G. Ratings of Project Performance in ISRs ................................................................................ xi

H. Restructuring .......................................................................................................................... xi

I. Disbursement Profile and Actual Disbursements from All Financing Sources ..................... xii

J. Financing Instrument and Project Components .................................................................... xii

1. Project Context, Development Objectives and Design .............................................................1

2. Key Factors Affecting Implementation and Outcomes ............................................................4

3. Assessment of Outcomes ........................................................................................................10

4. Assessment of Risk to Development Outcome .......................................................................22

5. Assessment of World Bank and Borrower Performance ........................................................24

6. Lessons Learned......................................................................................................................26

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners.........................28

Annex 1. Project Costs and Financing ........................................................................................30

Annex 2. Outputs by Component................................................................................................31

Annex 3. Economic and Financial Analysis ...............................................................................43

Annex 4. Bank Lending and Implementation Support/Supervision Processes ...........................47

Annex 5. Comments on Draft ICR and Recommendations from Borrower’s ICR ....................49

Annex 6. Comments of Cofinanciers and Other Partners/Stakeholders .....................................58

Annex 7. List of Supporting Documents ....................................................................................59

Annex 8. List of Persons Met .....................................................................................................61

Annex 8. List of Persons Met .....................................................................................................61

Map .............................................................................................................................63

Text Boxes, Tables, and Figures

Box 1. The single most important area for productive investment ...................................19

Table 1. KAP survey results (% of target groups) ...............................................................17

Table 2. District-level preventive and curative capacities performance targets were

exceeded .................................................................................................................18

Table 3. Project outcomes: nearly all targets surpassed or met ...........................................21

v

Table A3.1. Poultry destroyed by avian influenza, 2003-14 .....................................................44

Table A3.2. Overview of the economic costs influenced by stronger public health

systems (national benefits only).............................................................................45

Figure 1. Project resources by component ..............................................................................4

Figure 2. Dramatic decline in number of poultry destroyed by AI and by AI disease

control ....................................................................................................................12

Figure 3. Human deaths due to H5N1 avian flu declined dramatically in VAHIP

provinces and in Vietnam ......................................................................................12

Figure 4. An example of market upgrading under VAHIP: poultry are off the ground

and regular cleaning is possible .............................................................................14

Figure 5. Evidence of high risk awareness in paintings by children .....................................17

Figure A2.1. The eleven VAHIP provinces (map) .....................................................................31

Figure A2.2. Little or no biosecurity before improvement of markets .......................................32

Figure A2.3. Examples of improved markets .............................................................................33

Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health .....37

Figure A2.5. District Preventive Health Center managers and staff, along with provincial

officials, and the VAHIP PCU, discuss improvements in local-level public

health capacity. ......................................................................................................41

Figure A3.1. The poorest households suffer larger income declines than wealthier

households with a ban on backyard poultry sales ..................................................46

Figure A5.1. Science of delivery under VAHIP ........................................................................51

vi

A. Basic Information

Country: Vietnam Project Name: VN-Avian & Human Influenza

Control &Prep

Project ID: P101608 L/C/TF Number(s): IDA-42730, IDA-49920, TF-

57747, TF-57848, TF-99841

ICR Date: 12/08/2014 ICR Type: Core ICR

Lending Instrument: ERL Borrower:

Original Total Commitment: XDR 13.50M Disbursed Amount: XDR 18.55M

Revised Amount: XDR 19.26M

Environmental Category: B

Implementing Agencies:

Ministry of Health

Ministry of Agriculture and Rural Development

Cofinanciers and Other External Partners: US -- Centers for Disease Control and Prevention (CDC) US Agency for International Development (USAID) Japanese PHRD Grant European Community - AHIF Food and Agriculture Organization (FAO) WHO

World Organisation for Animal Health (OIE)

B. Key Dates

Process Date Process Original Date Revised / Actual

Date(s)

Concept Review: 10/03/2006 Effectiveness: 08/23/2007 08/23/2007

Appraisal: 12/22/2006 Restructuring(s):

07/19/2010

06/14/2011

06/29/2011

Approval: 03/13/2007 Mid-term Review: 08/15/2008 11/21/2008

Closing: 12/31/2010 06/30/2014

C. Ratings Summary

C.1 Performance Rating by ICR

Outcomes: Highly Satisfactory

Risk to Development Outcome: Moderate

Bank Performance: Satisfactory

Borrower Performance: Satisfactory

vii

C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)

Bank Ratings Borrower Ratings

Quality at Entry: Satisfactory Government: Satisfactory

Quality of Supervision: Satisfactory Implementing

Agency/Agencies: Satisfactory

Overall Bank

Performance: Satisfactory

Overall Borrower

Performance: Satisfactory

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): No NA None

Problem Project at any time

(Yes/No): No NA None

DO rating before Closing: Moderately

Satisfactory

D. Sector and Theme Codes

Original Actual

Sector Code (as % of total Bank financing)

General agriculture, fishing and forestry sector 21 21

General public administration sector 50 50

Health 21 21

Other social services 7 7

Solid waste management 1 1

Theme Code (as % of total Bank financing)

Health system performance 13 20

Natural disaster management 24 20

Other communicable diseases 25 30

Other social protection and risk management 13 10

Rural services and infrastructure 25 20

E. Bank Staff

Positions At ICR At Approval

Vice President: Axel van Trotsenburg James W. Adams

Country Director: Victoria Kwakwa Klaus Rohland

Practice Manager/Manager: Toomas Palu Hoonae Kim

Project Team Leader: Anh Thuy Nguyen Samuel S. Lieberman, Binh Thang Cao, Lingzhi Xu

ICR Team Leader: Olga B. Jonas

viii

ICR Primary Author: Olga B. Jonas

F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document)

The project development objective of VAHIP was "to assist the government to increase the

effectiveness of public services in reducing the health risk to poultry and to humans from avian

influenza in selected provinces, through measures to control the disease at source in domestic

poultry, to detect early and respond to human cases of infections, and to prepare for the medical

consequences of a potential human pandemic."

Revised Project Development Objectives (as approved by original approving authority)

The Project Development Objective was not revised. Most indicator targets were initially set for

the end of the VAHIP-1 period (2007-10) and, after additional financing was approved in 2011,

targets were set for the VAHIP-2 period (2011-14).

(a) PDO Indicator(s)

Indicator Baseline Value Original Target

Values

Formally

Revised

Target Values

Actual Value

Achieved at

Completion or

Target Years

Indicator 1 : Increase in number of annual suspected highly pathogenic avian influenza (HPAI) cases

in poultry reported and fully investigated per project province.

Value 0 10 case reports per

province per year

275 case reports

(11 provinces)

All 39 of 39 reports

of suspected HPAI

investigated.

Date achieved 02/15/2007 12/31/2010 06/30/2014 06/30/2014

Comments

Objective fully achieved in substance. Target of 275 HPAI reports could not be met

because of lower disease prevalence than planned. Performance of reporting system

from village to district level very strong: 11,313 reports of suspected poultry disease

reached provincial level in 2014, and 24,000 reports in 2013.

Indicator 2 : For both veterinary and health sector, reduce reporting time of new outbreaks and return

of laboratory confirmation to the affected commune.

Values 8.7 (veterinary)

10 (human health)

4 (veterinary)

4 (human health)

4 (veterinary)

4 (human

health)

2.4 (veterinary)

3.4 (human health)

Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014

Comments

Targets surpassed. This is an important and substantial achievement in reporting

performance to laboratories and from laboratories to affected communes. Significant

progress was achieved already by 2010, when the times reached 2.9 days

Indicator 3 : Reduced fatality rate of human H5N1 cases compared to 2004/05 in the 11 project

provinces

45% 35% 35% NA

Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014

Comments The indicator was not valid for periods with very low number of cases. In 2014 there

was 1 case, which was fatal. The calculated value of 100% is mathematically correct

ix

but does not measure progress on PDO. See text on human health PDO achievements.

(b) Intermediate Outcome Indicator(s)


Values

Formally

Revised Target

Values

Actual Value

Achieved at

Completion or

Target Years

Indicator 1 : Intermediate Result A1: Veterinary services on disease diagnostic and surveillance

strengthened - Number of laboratories working at ISO 17025 standards for AI testing.

Value 0 6 8 8

Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014

Comments Target surpassed, as the ambitious goal was fully met in 2013, ahead of schedule.

Indicator 2 : Intermediate Result A2.1: Percentage of poultry traders applying good biosecurity

practices at Ha Vy market.

Value 25% 80% 100% 100%

Date achieved 06/30/2006 06/30/2010 06/30/2014 06/30/2014

Comments Target fully met. This was an ambitious target, in view of increasing market trade

volume. Indicator modified in 2012 to measure behaviors (rather than virus prevalence).

Indicator 3 : Intermediate Result A2.2: Percentage of upgraded markets and slaughterhouses

applying practice according to project guidelines.

Value 11% 100% 100%

Date achieved 06/30/2007 06/30/2010 06/30/2014

Comments

Target fully met. There was steady increase from the baseline of only 11 percent in

2006, with progress above interim targets set during implementation. By the end of the

project, the target was met in 76 upgraded markets and slaughterhouses.

Indicator 4 : Intermediate Result A3: Percentage of positive samples for H5N1 virus at markets and

slaughterhouses.

Value NA

35 out of 52

commercial farms

demonstrated

disease-free

less than 2% 7.66%

Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014

Comments

Indicator for VAHIP-2 focused on markets (rather than farms, for which VAHIP-1

target was exceeded). Ambitious target partly met; disease-prevalence outcome was

beyond the control of the project. Improved surveillance yielded key information.

Indicator 5 :

Intermediate Result A5: Number of days that suspect outbreaks are completely

contained (quarantine and culling). NB: In VAHIP-1, this indicator was no. of rapid

response teams performing effectively; target was surpassed by 2011.

Value 4 days 2 days less than 1 day

Date achieved 06/30/2010 06/30/2014 06/30/2014

Comments Target surpassed for this key system performance indicator. Improvements in

performance also exceeded interim targets, reaching 1.1 days already in 2013.

Indicator 6 : Intermediate Result B1: Percentage of reports that are accurately completed and sent on

time to the Provincial Preventive Health Centers

Value 58% 84% 90% 98.6%

Date achieved 06/30/2007 06/30/2010 06/30/2014 06/30/2014

Comments Target surpassed. Indicator reached 95.4% in 2013 and nearly 100% in 2014.

x


Values

Formally

Revised Target

Values

Actual Value

Achieved at

Completion or

Target Years

Substantial improvement in system performance.

Indicator 7 : Intermediate Result B1: Percentage of reports that are accurately completed and

received at the District Preventive Health Centers

Value 82% 90% 97.7%

Date achieved 06/30/2010 06/30/2014 06/30/2014

Comments Target surpassed. Indicator of important aspect of system performance reached 94.8%

in 2013. Indicator used in VAHIP-2 period.

Indicator 8 : Intermediate Result B2: Percentage of project provinces developed the Pandemic

preparedness plan (based on the MOH guideline).

Value 0% 100% 100% (plans

improved)

100% (plans

improved)

Date achieved 02/15/2007 06/30/2010 06/30/2014 06/30/2014

Comments Target fully met in 2010, an important achievement in preparedness of 44 provincial

hospitals. Plans then improved and simulated in exercises.

Indicator 9 : Intermediate Result B2: Percentage of district hospitals developed the pandemic

preparedness plan

Value N/A 100% 100%

Date achieved 06/30/2010 06/30/2010 06/30/2014

Comments Target fully met, improving preparedness during VAHIP-2 period in 124 district

hospitals. Indicator reached 85.4% in 2012.

Indicator 10 : Intermediate Result B3: Percentage of target population that can accurately identify and

have practiced at least one key preventive behavior (divided by the target groups)

Value

Curative HCW: 91%

Preventive HCW: 100%

General population: 56.4%

Curative: 40%

Preventive: 40%

General population:

40%

Curative: 60% Preventive: 60%

General

population: 60%

Curative: 86.2%

Preventive: 88%

General population:

98.8%

Date achieved 06/30/2008 06/30/2010 06/30/2014 06/30/2014

Comments

Targets surpassed for all three groups. Indicator values for knowledge and attitudes (not

shown here) increased as well. Increased/sustained risk awareness despite plummeting

international attention.

Indicator 11 :

Intermediate Result B4.1: Number of DPMCs in 11 provinces fully equipped and have

adequate capacity to implement their responsibilities and functions in compliance with

MOH decisions on Preventive Medicine.

Value 0 16 79 87

Date achieved 02/15/2007 06/30/2010 06/30/2014 06/30/2014

Comments Target surpassed, by a substantial margin. Already in 2010, the achievement was 28

DPMCs, significantly above the interim target of 16.

Indicator 12 : Intermediate Result B4.2: Number of multisectoral simulation exercises conducted and

reviewed at district levels in the project provinces

Value 0 17 30 68

Date achieved 06/30/2007 06/30/2010 06/30/2014 06/30/2014

Comments Target surpassed. Achievement more than double the plan. Interim targets surpassed

every year as well.

xi


Values

Formally

Revised Target

Values

Actual Value

Achieved at

Completion or

Target Years

Indicator 13 : Intermediate Result B4: Number of health staff have been trained and/or capacity built

by the project (cumulative).

Value 11,005 Target value not set 21,905 69,012

Date achieved 06/30/2006 06/30/2010 06/30/2014 06/30/2014

Comments

Target surpassed. VAHIP achieved more than three times the level of training than

initially envisaged. This impacted especially district and local-level veterinary and

human public health systems.

Indicator 14 : VAHIP-1 indicator A4.1. Number of small scale poultry farm models demonstrated.

Value 0 25 80

Date achieved 02/15/2007 06/30/2010 12/31/2010

Comments Target surpassed. 80 demonstration sites provided training to 1,760 small farmers.

G. Ratings of Project Performance in ISRs

No. Date ISR

Archived DO IP

Actual Disbursements

(USD millions)

1 07/21/2007 Satisfactory Satisfactory 0.00

2 09/16/2008 Satisfactory Moderately Unsatisfactory 1.45

3 02/19/2009 Satisfactory Moderately Satisfactory 2.36



6 03/11/2012 Satisfactory Satisfactory 20.72



9 06/20/2014 Moderately Satisfactory Moderately Satisfactory 26.39

H. Restructuring

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

07/19/2010 N S MS 8.75

Reallocation among disbursement

categories; extend closing dates of

VAHIP-1 to 6/30/2011.

06/14/2011 S MS 18.62 Extend closing date of VAHIP-1

to 12/31/2011.

06/29/2011 S MS 18.62 Revise indicators.

xii

I. Disbursement Profile and Actual Disbursements from All Financing Sources

*: Due to the exchange rate differences between SDR and USD, the actual amounts will differ from original and revised amounts.

** Under IDA Credit no. 4492 US$ 1.0 million is undisbursed, and under IDA Credit no. 42730 XDR 0.6 million was cancelled.

J. Financing Instrument and Project Components

The World Bank, other donors, and technical agencies supported the implementation of the

government’s plan. World Bank provided financing in the form of: IDA credits for Emergency

Response Lending (ERL), a cofinancing Japanese Policy and Human Resource Development

(PHRD) grant, and two cofinancing grants from the multidonor Avian and Human Influenza

Facility (AHIF), which received funds from the European Commission, Australia, and eight

other donors. World Bank ERL financing was part of an adaptable program loan (APL) entitled

the Global Program for Avian Influenza Control and Human Pandemic Preparedness and

Response (GPAI).

Project components mirrored the government’s plan, namely: (A) animal health, (B) human

public health, and (C) coordination, monitoring and evaluation, and project management, with

close coordination between the animal health and human health components.

1

1. Project Context, Development Objectives and Design

1.1 Global and Country Contexts at Appraisal

1. In December 2003, Vietnam reported its first cases of Highly Pathogenic Avian Influenza

(HPAI) H5N1. Within four months the disease was detected in 57 of 64 provinces. Some 44

million poultry—17 percent of the nation’s stock—had been culled to prevent further outbreaks

or had died from the disease. This was a severe cost to farmers and to the economy more

broadly. The economic toll was some 0.5 percent of Vietnam’s GDP, or US$250 million. Animal

health and disease surveillance systems were rapidly overwhelmed. Moreover, as 15 human

deaths were recorded in 2004, there was increasing evidence that the H5N1 avian influenza virus

could infect humans. This and the possibility that the virus could become capable of efficient

human-to-human transmission, raised the prospect that an influenza pandemic would result.

2. By 2005 the H5N1 avian flu virus emerged as a global threat. On January 12, 2006 the

World Bank’s Board endorsed the Global Program for Avian Influenza Control and Human

Pandemic Preparedness and Response (GPAI) as a horizontal adaptable program loan (APL) to

provide up to US$500 million of immediate emergency assistance to countries seeking support to

address this threat to public health and economies of all countries.1

The GPAI was based on

guidance from the World Organization for Animal Health (OIE), the World Health Organization

(WHO), and the Food and Agriculture Organization (FAO). Their inputs were coordinated by the

Senior United Nations System Influenza Coordinator (UNSIC), appointed by the UN Secretary

General. The GPAI was one of the World Bank’s contributions to a broad international initiative,

which was launched at the UN General Assembly in 2005. This initiative mobilized US$3.9

billion from 35 donors at a series of five ministerial conferences, starting in Beijing, China, in

January 2006 and concluding in Hanoi, Vietnam in April 2010.

3. Throughout 2006, the virus was spreading 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 of H5N1 avian flu in poultry or wild birds, including in Vietnam and all

neighboring and other South East Asian countries (Cambodia, China, Lao PDR, Myanmar, and

Thailand). The international community was concerned that the response should be prompt and

effective so as to prevent a potentially catastrophic impact on public health and economies. The

2003 outbreak of the severe acute respiratory syndrome (SARS) served as a recent reminder. It

had been quickly contained after 8,000 cases of human infection, of which 800 were fatal, but its

economic costs were very high ($54 billion).2

4. The first World Bank-financed avian flu response project, the Vietnam Avian Influenza

Emergency Recovery Project (AIERP), was approved in August 2004 as an emergency operation

with US$5 million IDA financing. The project thus pre-dated the GPAI. It was fully

1 This amount was subsequently increased to US$1 billion in June 2009; see Extension of the Global Program for

Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) and Increase of the GPAI

Ceiling to $1 billion in Response to Influenza A(H1N1) Pandemic, R2009-0111, May 11, 2009. 2 Estimating the Global Economic Costs of SARS by Jong-Wha Lee and Warwick J. McKibbin in Learning from

SARS: Preparing for the Next Disease Outbreak -- Workshop Summary, Institute of Medicine, Washington, DC,

2004, available at www.ncbi.nlm.nih.gov/books/NBK92473/.

2

implemented in less than three years in 10 provinces badly hit by the virus. The project enhanced

national disease surveillance and diagnostic capacity, strengthened mechanisms in the poultry

sector to contain serious outbreaks, and raised public awareness of risks and how to mitigate

them. The AIERP provided a platform for action, which the government used to articulate and

lead a concerted response from donors, international technical agencies, and civil society.3

The

AIERP was a catalyst for the approach adopted in developing the GPAI in 2005, when the global

threat from the H5N1 avian flu virus became apparent.

5. The Vietnam Avian and Human Influenza Control and Preparedness Project (VAHIP)

was developed to follow the AIERP, which closed on June 30, 2007. VAHIP built on the AIERP

platform and aimed to consolidate the gains made against avian influenza. VAHIP was financed

by an IDA Credit (SDR 13.5 million, US$20 million equivalent), an Avian and Human Influenza

Facility (AHIF) Grant (US$10 million), a Japan PHRD Grant (US$5 million), and the

Government of Vietnam (US$3 million). The Project became effective on August 23, 2007. The

original closing date was December 31, 2010. This was extended twice, initially to June 30, 2011

and then to December 31, 2011.

1.2 Original Project Development Objectives (PDO) and Key Indicators:

Project Development Objective

6. The project development objective (PDO) was “to assist the government to increase the

effectiveness of public services in reducing the health risk to poultry and to humans from avian

influenza in selected provinces, through measures to control the disease at source in domestic

poultry, to detect early and respond to human cases of infections, and to prepare for the medical

consequences of a potential human pandemic.” The project was implemented in eleven

provinces.

7. The PDO was and remains in line with Vietnam government’s plans for the medium and

long-term control of avian influenza and other zoonotic disease threats, as set out in: (i) the

National Integrated Operational Program for Avian and Human Influenza, 2006-2010 (OPI,

called the “Green Book”) and (ii) the Integrated National Operational Program on Avian

Influenza, Pandemic Preparedness, and Emerging Infectious Diseases, 2011-2015 (AIEPED,

called the “Blue Book”). The PDO was fully consistent with the GPAI, which, like the OPI and

the AIEPED, was based on the expert advice of the World Health Organization (WHO), the

World Organization for Animal Health (OIE), Food and Agricultural Organization (FAO), US

Centers for Disease and Prevention (US CDC), and other international agencies.

8. There were three key outcome indicators, aligned with the core aims of infectious disease

control and prevention:

i. Increase in number of suspected HPAI cases in poultry that are reported and fully

investigated, per province.

ii. For both veterinary and human health sectors, reduced reporting time of new outbreaks

and reduced time to return of laboratory confirmation to the affected commune.

3 Vietnam Avian Influenza Emergency Recovery Project, Implementation Completion and Results Report,

December 19, 2007 (Report No. ICR0000664).

3

iii. Reduce fatality rate of human H5N1 cases compared to 2004-5 in the 11 project

provinces.

The third indicator became irrelevant because the number of cases of H5N1 infection in humans

declined dramatically throughout the project period compared to 2004-5; the problematic nature

of this indicator confirms one of the lessons from the review of avian influenza projects by the

Independent Evaluation Group (IEG).4

1.3 Revised PDO

9. The PDO was not revised, but indicators and targets were adapted when additional

financing was provided in 2011 to extend project activities because implementation of the

original project (VAHIP-1) was successful. The second phase (VAHIP-2) had a closing date of

June 30, 2014. The additional financing was from an IDA Credit (SDR 6.2 million, US$10

million equivalent) approved on June 30, 2011, an AHIF Grant (US$13 million) endorsed by the

AHIF Advisory Board on May 31, 2011, and the Government of Vietnam (US$2 million).

1.4 Main Beneficiaries

10. The main direct beneficiaries were in the 11 project provinces. Because the disease threat

does not respect borders, the rest of the country, the region, and the global community benefited

as well. Within the provinces, beneficiaries included the poultry sector, including households

that keep poultry, who comprise a majority of households in rural areas. Other beneficiaries were

persons in contact with poultry who would be exposed to disease risks, (e.g., children, workers

engaged in slaughtering, processing and marketing poultry, consumers shopping at poultry

markets, and cooks). Prevention of disease in poultry would also tend to increase the availability

and affordability of protein (meat, eggs) and thus improve nutrition. Prevention of a severe

influenza pandemic and other infectious disease outbreaks benefited the entire country by

mitigating negative impacts on health, economic activity, and incomes. There were also cross-

border benefits because by controlling disease outbreaks promptly and effectively, Vietnam was

far less likely to export the disease.

11. The main intermediate beneficiaries of the Project were the animal health services in the

Ministry of Agriculture and Rural Development (MARD) and the Ministry of Health (MOH),

including the provincial and district-level departments and staff of these ministries whose

capacities to perform their various functions in infectious disease prevention and control were

strengthened. Staff from these two ministries received a range of training, building stronger

capacity at central, provincial and local levels for project management as well as in technical

competencies.

1.5 Original Components (as approved):

12. World Bank financing5 for the Project’s three components mirrored the government’s

plans, namely: (A) animal health, (B) human health surveillance and response, and (C)

4 World Bank Independent Evaluation Group (2014). Responding to Global Public Bads: Learning from Evaluation

of the World Bank Experience with Avian Influenza, 2006-2013. 5 “World Bank financing” refers to financing for the Project from the International Development Association (IDA),

Japanese PHRD and the AHIF. PHRD and AHIF are World Bank-administered trust fund arrangements. The

4

coordination, monitoring and evaluation, and project management, with close coordination

between the animal health and human health components.

1.6 Revised components

13. Components were not revised during the project life, and there were no other significant

changes in design, scope and scale, and implementation arrangements. Financing was reallocated

among activities as warranted, and several indicators were adapted in 2011 to better support

implementation during VAHIP-2. Such flexibility was foreseen at appraisal since need for

responsiveness to an unpredictable

disease risks would require adapted

response approaches; other projects in

the GPAI had this design characteristic

as well.

14. Figure 1 shows the evolution of

project activities. Initially animal

health services received relatively

more support, but after 2011 the vast

majority of project financing went to

build human public health capacities

overseen by the Ministry of Health.

Close collaboration between the two

sectors was maintained in the entire

2007-14 project period, thanks to

adequate provisions for integration and

coordination. Overall, 34 percent of

the funding was for the animal health

sector, 51 percent was for the human

health sector, and 15 percent was for

project management and coordination

across sectors and levels of

government.

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design, and Quality at Entry

15. The key factors were Vietnam’s leading position in avian influenza control gained from

experience in controlling the disastrous avian influenza outbreaks in 2003-4; the existence of a

global framework and external political and financial support; a robust country-led program with

strong government commitment; coordinated engagement of all partners; emphasis on good

communications; support from senior World Bank management; and a strong World Bank team

responsible for support to preparation and appraisal of the operation. Vietnam’s leadership on

European Commission was the leading contributor to AHIF, which also received funds from Australia and eight

other donors.

5

these aspects substantially influenced the design of the GPAI, which then informed the

preparation of avian and human influenza preparedness and response projects in some 60

countries in all regions.

16. Multisectoral framework and support to country and global objectives. The challenge

posed by the H5N1 avian flu and pandemic threats necessitated a coordinated multisectoral

response. Government plans (the OPI and the AIEPED) set out how multiple sectors and actors

would have to work together and in line with the technical guidance from WHO, FAO, OIE, and

others. The World Bank team provided substantial technical assistance to the preparation of both

OPI and AIEPED to bridge actions across sectors. VAHIP supported this collaboration by

providing adequate resources. The design of VAHIP built also on relevant World Bank

operational experience, including in emergency responses to disasters, the global program to

address HIV/AIDS, the AIERP, and other responses to outbreaks of animal-borne diseases. The

rationale for World Bank involvement was strong not only because of the multisectoral and

global character of the response, but also from the perspective of the country assistance strategy,

which supports risk mitigation so as to sustain the country’s high economic growth and

development achievements. Disease outbreaks, like avian and pandemic influenza, threatened to

undermine progress in this regard.

17. Country-led project preparation and the World Bank’s rapid response. As the AIERP

neared its June 30, 2007 closing date, the government quickly prepared the follow-on plan,

which was informed by implementation experience and the international consensus on avian

influenza control reflected in the GPAI. The VAHIP was prepared and appraised quickly. The

World Bank used both its policy on Rapid Response to Crises and Emergencies (OP 8.00) and an

Adaptable Program Loan (APL) framework to provide financing.

18. Project design. In addition to being based on guidance from the international technical

agencies, the Project aligned to the OPI. The Project monitoring and evaluation (M&E)

framework dovetailed with OPI and thus the government’s monitoring and reporting system. The

design built upon the implementation experience during the AIERP, on the World Bank’s

operational experience in the country, on analytical work done by the Bank and partners on the

role of compensation in animal disease control globally;6 and on the Bank’s in-country working

relationships with UN agencies and other partners. Intersectoral coordination mechanisms were a

key part of the design, not an afterthought. Coordination also benefited from assistance provided

by UNSIC. Such emphasis on systematic coordination was appropriate given the complex

multisectoral challenge and numerous partners involved.

19. Crucial role of communications. The veterinary and human public health components

each included a broad range of communications activities, since control of contagion would

critically depend on the risk awareness and behaviors of farmers, poultry consumers, poultry

traders, government workers, and others. Knowledge, Attitude and Practices (KAP) surveys

gauged the impact of extensive awareness-raising campaigns.

6 World Bank (2006). Enhancing Control of Highly Pathogenic Avian Influenza in Developing Countries through

Compensation: Issues and Good Practice.

6

20. Risk assessment. The major risks identified at appraisal included political commitment,

slow disbursement and procurement, weak provincial-level capacity for project implementation

(especially in financial management), inadequate coordination between the two ministries

concerned, resistance to innovation in MOH, inadequate farm-level surveillance, and increased

virus circulation. These risks were relevant to an evolving disease threat in an environment of

uneven capacity. The mitigation measures were appropriate and proved effective.

2.2 Implementation

21. Consistently strong implementation, contributing to country-wide results. VAHIP was

the follow-on project, in 11 provinces, to a major national emergency response that galvanized

the government and communities. The high cost of inaction in avian flu control – the heavy toll

in the 2004 avian flu outbreaks and associated human infections – was clear to all stakeholders.

The OPI provided a robust and transparent framework for action, coordination, and knowledge

exchange between VAHIP and non-VAHIP provinces. VAHIP introduced some innovations (for

instance in market biosecurity), which were adopted by other provinces. Implementation started

shortly after the effectiveness date and was completed by the VAHIP-2 closing date, without

extensions. There were, however, delays, especially during the early phases in the project, and

procurement and other processing were initially slow (this was not a project-specific problem,

but is common to other projects in the country). Such delays were reflected in conservative

ratings on implementation progress so as to provide incentive to rapid implementation in the face

of the potentially high costs that would arise if the ambitious and comprehensive OPI program

was not rapidly implemented. However, when the project ended, the overall implementation

record was, in retrospect, commendable and achieved highly effective results in an efficient way

(see Section 3. below). Disbursement rates largely mirrored the overall commendable

implementation progress.

22. Intersectoral coordination. MARD implemented Component A and MOH implemented

Component B. An intersectoral committee, chaired by the Prime Minister and receiving support

from UNSIC, provided oversight. Thanks to adequate resources for coordination, strong

leadership from the government, as well as a systematic coordination structure based on the OPI,

there was sharing of information and joint action when warranted. Overall coordination in the 11

VAHIP provinces was assured by MARD during VAHIP-1 and then by MOH during VAHIP-2.

23. Response to the 2009 H1N1 flu pandemic. VAHIP contributed to responding to this

challenge thanks to the concerted efforts to increase preparedness, which was an important part

of the project from its beginning. Though VAHIP preparedness activities were motivated by the

threat of H5N1 avian flu and the severe pandemic that could develop from this particular virus

strain, they were also directly relevant to the response to the 2009 H1N1 influenza pandemic.

The rise in illness in the population put some pressure on health care system, but this was only

temporary as the 2009 H1N1flu pandemic had a short duration and low severity. Preparedness of

health facilities and public health systems was nevertheless tested, with good results.

24. Impact of change in the external environment. International attention to the risk of a

pandemic diminished over the project period, with a marked decline since 2009, when the H1N1

flu pandemic proved to be much less severe than feared. External financing assistance to

developing countries, including Vietnam, declined rapidly in tandem, despite the continuing

7

disease control challenges. Reduced attention and financing have had the unfortunate result of

decreasing external and internal political support for an important risk-reducing multisectoral

activity, where preventative investments continue to fall well short of levels of investments

warranted by the magnitude of the risk. Moreover, a substantial part of the costs of avian flu has

fallen on poor farmers, and reduced international attention only leads to poor farmers bearing an

even greater share of these costs.

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

25. M&E. The results framework served implementation well overall. Values were regularly

reported, though sometimes with delay, and regular M&E reports were thorough and used in

adapting project activities. Several indicators were adapted during implementation to better guide

monitoring of progress. Thus, to monitor progress toward the objective of “surveillance

activities show improved disease status along the poultry marketing chain”, the initial VAHIP-1

indicator was “number of commercial farms in which freedom from infection was

demonstrated.” By the original target date in 2010, 52 farms were inspected and 23 of them

obtained disease-free certification. Based on epidemiological work, monitoring markets became

a higher priority (though monitoring of farms continued), so a new indicator was substituted

starting in 2011: “percentage of positive samples for H5N1 virus at markets and

slaughterhouses.” Both the initial and the latter indicators were, however, challenging, since

diseases outcomes were beyond the control of the project. Their use was nevertheless important

and appropriate, since it served to focus attention to the critical issues of surveillance for disease

in the poultry supply chain. Another modification concerned indicators to track preparation of

pandemic response plans in provinces and districts. Although plans were prepared by 2010 (the

end of VAHIP-1), fully meeting targets, some of the plans were subsequently assessed as

unsatisfactory by the government. Thus, the targets for preparation of these plans in 100 percent

of provinces and districts were maintained for the end of VAHIP-2. The targets were again met,

but all the plans at the end of VAHIP-2 were of higher quality than at the end of VAHIP-1.

26. Data for a few indicators proved difficult to collect, and the selection and definition of

some of these indicators proved problematic. For instance, the selection of one of the key

indicators – the case fatality ratio (CFR) – did not anticipate that a dramatic drop in human cases

would eliminate the information content of this indicator. Final outcome indicators for infectious

diseases are inherently problematic because of influences beyond the control of physicians or

veterinarians, especially when these diseases are new in the animal or human population.

Moreover, the target value for the CFR was unrealistically too low, well below that warranted by

the inherent virulence of the H5N1 avian flu virus and the values registered in all other countries.

The indicators tracking performance of government capacities were, however, useful in gauging

progress. Utilization of the system-performance indicators in this project is evidence that further

supports the recommendations of the review of avian flu operations by IEG (2014) that greater

reliance on intermediate indicators of system performance is warranted in disease control and

prevention programs.7

7 For disease control and prevention projects, final outcomes are driven by multiple unpredictable factors, making

attribution especially challenging. Intermediate indicators are warranted to guide implementation and to assess

results. See: World Bank Independent Evaluation Group (2014). Responding to Global Public Bads: Learning from

Evaluation of the World Bank Experience with Avian Influenza, 2006-2013.

8

2.4 Safeguard and Fiduciary Compliance

27. The safeguards triggered were for the environment, involuntary resettlement, and for

ethnic groups. Compliance was satisfactory overall. Notably, toward the end of the project

monitoring reports revealed that waste water management and treatment in the large Ha Vy

poultry wholesale market, which was reconstructed under VAHIP, resulted in concentrations of

pollutants in the water that were above the set norms.

28. Environmental safeguards. The project was designated as a category B based on the

environmental impacts of project activities. There was environmental monitoring on the

compliance during the operation of the culling/disposal site and live bird markets, and on small

civil works to rehabilitate and upgrade isolation units and intensive care units. The Operational

Policy and Bank Procedure (OP/BP) 4.01 on Environmental Assessment was triggered, and

consequently an Environmental Management Plan (EMP) was developed to address the potential

impacts in accordance with OP/BP 4.01 and national regulations. The PCUs in MARD and

MOH assigned responsibility for environmental safeguard work under their respective

components to dedicated staff. Reports on EMP implementation were periodically submitted for

review to the World Bank. The requirements specified in the EMP were taken into account and

adequately implemented.

29. A major investment under VAHIP was the reconstruction and improved biosecurity at the

Ha Vy wholesale market near Hanoi where about 1 million poultry are traded annually. There

had been no biosecurity before VAHIP (see Annex 2 photos), with solid and liquid wastes posing

risks to humans and the environment. Under VAHIP, reconstruction and other measures to

improve biosecurity reduced these risks. At the appraisal, major upgrade of the solid and waste

water treatment facilities at the market was not foreseen and included for IDA financial support.

Therefore, during implementation when the need arose it was agreed that the government’s

counterpart funds would finance part of the civil works including the solid waste and wastewater

treatment systems. Monitoring of the environmental standards at the market after the

Government-financed works were implemented showed that the solid waste and wastewater

treatment systems were not designed adequately and environmental pollution by poultry waste

remained. The PCUs proactively carried out remedial actions. Addressing this problem proved

challenging and time-consuming, largely because of the need for full cooperation among the

authorities involved (i.e., the central government, the PCU, the Thuong Tin district government,

the Thang Loi Commune government, and Market Management). By the end of the project,

management issues were resolved: the waste treatment system was rehabilitated, and solid waste

was collected and treated properly. The design for the rehabilitation of the wastewater treatment

system of the live bird market was reviewed by the World Bank and found to be satisfactory. The

rehabilitation of the wastewater treatment system was in the 3rd quarter of 2014, after the project

closing date using the counterpart funds. The output of the wastewater treatment system

improved marketly but still not fully meeting national standards. A larger septic tank is required

and this is planned to be installed in 2015. The challenge of a high and growing volume of

poultry trade in this major market will continue; thus continuing monitoring of the performance

of the wastewater and other systems will be required, to rapidly detect and remedy any adverse

impacts on nearby communities and the environment. This experience yielded a lesson for

similar future projects (see para. 80). The overall environmental performance of the project was

therefore moderately satisfactory.

9

30. Financial management: compliance with policies and procedures. The financial

management function of the Project was in compliance with the Bank’s financial management

policies and procedures. Performance was moderately satisfactory, despite the complicated and

decentralized financial management modalities, which were designed to support the

decentralized project implementation arrangements. Project implementation was managed by

PCUs in MOH and MARD, and in provincial implementing agencies (Provincial Departments of

Health/Preventive Health Centers and Animal Health Departments). The PCUs in MOH and in

MARD served as focal points for Project budget approval, financial reporting, and audit. All

other financial management areas (such as planning and budgeting, contract and expenditures

management, expenditures approval, and accounting records maintenance) were decentralized to

11 provinces with 2 implementing agencies in each (one for the human health component and

one for the agriculture component). The PCUs managed the Project designated accounts opened

at commercial banks, separately for the health and agriculture components. In the provinces,

each provincial PCU (PPCU) also opened a bank account in local currency to receive the Project

funds transferred by PCUs based on the approved annual operational plan. PPCU reports on

expenditures were submitted monthly. The PCU in MOH submitted quarterly interim financial

reports to the World Bank. Financial audit by an independent firm was conducted annually and

was unqualified; and all but one audit reports were submitted to the Bank on time before end of

June of the following year in full compliance with the Financing Agreement.

31. Procurement. Procurement activities have been carried out in accordance with the

respective procurement procedures stated in the Financing Agreement and elaborated in the

agreed Procurement Plans. Where appropriate, the government’s cost norms were used to

economize on project resources. After initial delays, procurement performance improved over

time and was successful overall. This was achieved largely thanks to the shifting of the design

for the animal health component from one that was centralized (and relying on a relatively large

number of international and national consultants) in the initial project period, to managing more

activities at the provincial level. This shift was implemented after the midterm review mission.

Key factors behind the satisfactory procurement performance were the commitment and efforts

of staff of all PCUs and PPCUs. Given the emergency and decentralized nature of the project, the

decentralization of procurement functions from PCUs to PPCUs was a good approach and a

lesson to be applied for similar future projects.

32. Disbursement. Performance in terms of the disbursement rate was satisfactory overall.

Disbursements lagged somewhat during the initial VAHIP-1 period but then accelerated to above

projected levels after 2010. There were no major issues.

2.5 Post-completion Operation/Next Phase

33. With contributions from VAHIP and other projects, the Vietnamese authorities have

improved the performance of core animal health and human health capacities and coordination

between the two systems (see outcomes in Section 3 below). The achievements are substantial,

but there are two concerns. First, in some areas capacity is still incomplete and fragile. At the

same time, risks of zoonotic disease outbreaks are still high; for avian flu, such risks are

amplified by the high volumes of trade in live bird markets. Second, adequate operations and

maintenance budgets will be needed for the veterinary and human public health systems to

perform in addressing antimicrobial resistance and other One Health challenges; in the near term,

10

this is particularly relevant for the laboratories and for the equipment in preventive health care

centers. The ongoing USAID-supported projects addressing emerging infectious diseases and

health security and the IDA-financed Livestock Competitiveness and Food Safety project are

providing some relevant support in this regard.

3. Assessment of Outcomes

3.1 Relevance of Objectives, Design and Implementation

34. The Project objectives were clear, relevant, and important to Vietnam’s economy, public

health, and poverty-reduction goals. Though designed as a second emergency operation after the

devastating 2003-4 avian flu outbreaks and in the context of a global emergency response,

VAHIP combined continuation of the emergency response with extensive strengthening of the

veterinary and public health systems by building medium- and long-term capacity. Collaboration

between veterinary and human public health services was deliberately planned and supported,

and this delivered excellent results. Such collaboration will remain critical for prevention and

control of zoonotic diseases. The capacities created by VAHIP are dual-purpose, relevant not

only to a particular strain of avian flu, but to control of other disease outbreaks as well. The

public health system can react better to an introduction of Ebola or the Middle East Respiratory

Syndrome (MERS) into Vietnam, for example, thanks to the preparedness and other

improvements in public health systems that were made in response to the avian flu threat. These

investments supported preparedness at the national, provincial and district levels to respond to

disease outbreak emergencies. Since such outbreaks will continue to occur, the project was and

will remain highly relevant. Veterinary and public health systems need capacity to respond to

outbreaks promptly and effectively, to ensure that contagion does not spread and that substantial

(potentially catastrophic) human and economic costs are prevented.

35. The risk to economies and public health of outbreaks of zoonotic and other infectious

diseases persists and represents a substantial contingent liability on Vietnam’s economy and the

government’s budget. In the future the government will need to resource and coordinate the

veterinary and human public health services to continue to respond rapidly to outbreaks in

poultry (of H5N1 and other types of avian flu such as H7N9), in other livestock, and in wildlife

and to monitor for signs of transmission of zoonotic pathogens (including antimicrobial

resistance) to the human population. The project’s substantial achievements are a valuable

precedent on which the government and its partners can build.

36. Serious new infectious diseases of humans have been emerging steadily over the past 30

years, and this trend is set to continue; notably, 75 percent of the diseases are now zoonotic,

since they originate in animals. Recent examples include Ebola, Middle East Respiratory

Syndrome (MERS), several kinds of avian flu (including H7N9, which caused $15 billion of

damage in China in 2013-14 and infected over 400 humans), and SARS. Though the SARS

outbreak caused 800 deaths in 2003, it also caused $54 billion of economic damage, showing

that the human health toll is far from the only cost of such disease outbreaks. The Ebola

epidemic, too, is having a still-worsening impact on the economies and communities in West

Africa; it may yet spread to other regions. The capacities built under VAHIP provide solid

foundations from which to tackle such disease threats. Improved animal and human disease

11

surveillance systems developed for influenza will allow earlier and more effective detection and

control of outbreaks.

37. Pandemics are infrequent, but the risk is high because of their impact. Capacity for early

detection and control of zoonotic pathogens at their animal source therefore remains an

important goal, with very large benefits because early control will stop exponential escalation of

contagion in the country and across borders. This goal is embodied in the International Health

Regulations (IHR 2005), which Vietnam and all other members of WHO have adopted. Early

detection and prompt effective control reduce risks at the interfaces between animal, human, and

the environmental health – if prompt action does not occur, contagion and associated costs can

grow exponentially and become major crises. Vietnamese authorities have recognized that One

Health approaches are required to reduce these risks: robust veterinary and human public health

systems, with enabled communication and collaboration at the interface between them. Vietnam

has been an international leader in adopting One Health approaches, which were incorporated in

the OPI and the AIEPED.

38. Pandemic preparedness remains relevant to Vietnam as well. A pandemic will occur in

the future; it is not a matter of “if” but “when”. A pandemic is all the more likely because

prevention of pandemics through control of pathogens at their animal source is currently

hindered by pervasive weaknesses of veterinary and human public health systems in most

developing countries. By tackling a threat that does not recognize borders, the project’s

objectives thus remain highly relevant not only to Vietnam, but also from regional and global

perspectives. Reduction of pandemic risk is a valuable global public good.

3.2 Achievement of Project Development Objectives

12

39. The Project achieved its ambitious objectives. It built essential veterinary and human

public health capacities in 11 provinces, and performance of these capacities improved based on

M & E reports. These capacities are required for prevention and control of zoonotic diseases and

those for preparedness to respond to a pandemic or similar public health emergency. By rapidly

and effectively responding to investigate and control outbreaks and other actions, these

capacities already contributed to dramatic and sustained declines in disease prevalence. While

VAHIP supported

implementation of the OPI and

the AIEPED in 11 provinces,

outcomes in these provinces

depended on similar efforts in

other provinces. All activities

were completed by the Project

closing date, which was not

extended. In June 2014, the

national and provincial project

teams came together with their

partners in Danang for a final

project review, to take stock of

the achievements as of the end

of June 2014.

40. Attribution of outcomes.

The main final outcomes

already observed were a

dramatic reduction in disease

prevalence in poultry (Figure 2)

and a large reduction in human

fatalities from H5N1 avian flu

infection (Figure 3). These

trends are equally evident in the

11 project provinces and in the

country as a whole. Attribution

of these successful final

outcomes is at best possible to

OPI and AIEPED, since these programs comprised a coherent set of activities that complemented

and reinforced each other in tackling a problem that does not respect administrative borders. The

substantial strengthening of capacity in veterinary and human public health that was achieved is

a precondition for sustaining such outcomes in years to come.

41. A second attribution issue arises from the inherent uncertainty about the spread and

evolution of a HPAI virus like H5N1. It may be that the virus could have reduced its spread in

Vietnam even if the farmers, poultry workers, the authorities, and the partners had done nothing.

Such a scenario contrasts with the experience in more than a dozen developing countries

struggling with the H5N1 virus becoming enzootic and even causing repeated human cases. This

is still occurring in countries neighboring Vietnam and elsewhere. Based on evidence about the

characteristics of the virus, such a dramatic decrease is highly unlikely without disease control

13

measures, however, especially since the flu virus is always bringing new surprises, according to

virologists. Most important,

however, the downside risk of not

preventing and not controlling

zoonotic outbreaks at their animal

source whenever they occur is very

large considering the exponential

progression of contagion and

infection risks to humans, even in

the absence of pandemics. Reducing

the circulation of H5N1 avian flu

and similar pathogens has been (and

will continue to be) inexpensive

insurance.

42. Risks to both poultry and

humans. The zoonotic nature of

H5N1 avian flu means that the risk

to poultry cannot be neatly

separated from the risk to people,

especially in communities where

people keep poultry and other

livestock un or near their dwelling,

so that humans have frequent

exposure to the avian flu virus and

other zoonotic pathogens but public

health standards are low. Moreover,

when the flu virus originating in

diseased poultry starts a pandemic, people will be rapidly exposed to pervasive health risks as

well as to other shocks. Integration of planned activities across the animal health-human health

interface was a key guiding principle of the Vietnam government’s plans and the GPAI. Close

intersectoral coordination of implementation and integrated monitoring led to integrated

decision-making on reprogramming. This and the inherent connectedness between the risks to

poultry and to people should be kept in mind in interpreting the presentation of the outcomes

below.

43. The impressive achievements of the project are evident in the results obtained toward the

project’s sub-objectives. Five sub-objectives were mainly for animal health, namely:

strengthening of veterinary services, enhanced disease control, disease surveillance and

epidemiologic investigation, preparing for poultry sector restructuring, and emergency outbreak

containment. Four sub-objectives concerned mainly human health: disease surveillance, curative

care, behavior change and risk communication, and the local-level preventive medicine system.

The project devoted deliberate attention and substantial resources to coordination among these

sub-objectives and to monitoring of progress. The achievements are described below.

44. Strengthening of Veterinary Services. The two major aims were strengthening of

veterinary laboratories and strengthening of disease reporting, which covered 144 districts and

14

Figure 4. An example of market upgrading: poultry are

off the ground and regular cleaning is possible (more examples are in Annex 2)

2,686 communes and entailed monthly meetings community animal health workers (CAHWs).

Results were substantial and often exceeded project targets. Whereas not a single veterinary

laboratory met international standards in 2006, there were eight such laboratories by the end of

the project, a major accomplishment that was, moreover, achieved ahead of schedule. There is

now every reason to have full confidence in laboratory test results because tests are being

conducted using testing systems that have been independently accredited. OIE has now accorded

Vietnam its highest rating for the laboratory component of the Performance of Veterinary

Services assessment. Surveillance has improved so that by the end of the project all participating

districts and communes were able to produce reports, with over 97 percent of them providing full

information and using the recommended template. The first PDO indicator, on reporting and

investigation of outbreaks, had high target values to signal the importance of this veterinary

service function (e.g., the target was that 275 case reports of HPAI be fully investigated in the

first 5 months of 2014). Since there were 39 reports of HPAI in this period, this high target

value was not met, although the veterinary authorities did prepare capacity to act effectively in

case there had been more HPAI outbreaks. This improved capacity of the veterinary services

was evident in more rapid response times when HPAI outbreaks did occur (see para. 50).

45. Enhanced Disease Control. The major activities were improvement of the large Ha Vy

live poultry wholesale market near Hanoi (which handles about 1 million poultry annually),

upgrading 42 other markets and 34 slaughterhouses in the 11 project provinces, and construction

of a culling site for holding, humane destruction, and disposal of poultry in the northern border

province of Lang Son to deal with seized poultry smuggled from China. Disease control was

enhanced by use of surveillance data. These data included percentage of poultry traders applying

good biosecurity practices at Ha Vy market and percentage of upgraded markets and

slaughterhouses applying practices according to project guidelines.

46. A range of biosecurity improvements have been implemented at Ha Vy market. Among

these, three specific practices were indicators of the improvements associated with the

reconstruction of the market: (i) keeping poultry for sale on the flooring, (ii) regular cleaning of

selling points, and (iii) cleaning of transport equipment/vehicles before going out of the market.

Starting from a baseline of 25 percent in 2006, all three indicators reached 100 percent by the

end of the project, after uneven progress

during the period as traders were not

readily adopting biosecurity practices

because of their cost. Achieving

behavioral change among poultry

traders was a major challenge, a task

made more complicated by the

increased number of poultry sold

through the market and the need for

payment for cleaning and other services

which was resisted by the traders.

Hence, while the target for this

indicator was met, it is likely that this

will not be maintained on all occasions,

given the huge number of traders

involved. Targets for upgraded markets

15

and slaughterhouses to apply practices according to project guidelines were met as well, reaching

100% by the end of the project; moreover, accomplishments for each year were consistently

ahead of targets.

47. Disease Surveillance and Epidemiologic Investigation. Monthly H5N1 avian flu virus

surveillance activities at Ha Vy market, Lang Son culling site, as well as in 55 other markets and

11 slaughterhouses, were successfully carried out, and 285 outbreaks were investigated.

Provincial and district veterinary staff were trained on outbreak investigation and mapping. The

percentage of positive samples for H5N1 virus at markets and slaughterhouses, with a target of

less than 2% throughout the duration of VAHIP-2, was selected as an overall measure of

improvements in disease control and prevention both in markets and at the farm level within

project provinces. While the indicator was above 2% in 2012-14, this is also a reflection of the

quality of surveillance rather than increased disease prevalence. (Without regular robust

surveillance, disease would not have been detected, which could be misinterpreted as absence of

disease.) A higher prevalence of infection is expected in poultry during the first half of the year,

which coincides with the high-risk Tet Festival period and the cooler winter months, and this

contributes to the high value of 7.7% of samples positive for H5N1 in markets and slaughter

houses for the first half of 2014 (in the same period, the value was 0% in Ha Vy market).

Markets have been modified to markedly reduce the likelihood of becoming persistently

infected. But if infected poultry are brought in to markets and tested, the improvements in

market hygiene will not be apparent from the surveillance results.

48. Surveillance has provided extremely valuable information about the continuing

circulation of avian flu viruses including genetic data and confirmed the importance of measures

in markets to prevent the virus from spreading and persisting. In 2014, only 11 of the 197

positive samples were from the Northern provinces, demonstrating that different risk factors are

present in different parts of the country. This experience confirms IEG findings on the difficulty

with using data on disease or infection status as an indicator, given the confounding factors along

the production and market chains that influence the end result.

49. Preparing for Poultry Sector Restructuring. Studies and training (see Annex 3 for

details) contributed to the capacity of the government and communities to better manage risks

associated with poultry production and marketing, whose rapid growth is driven by increasing

incomes. In 22 districts, 1,760 households received training on biosecure poultry production;

these households then became trainers for others in their communities.

50. Emergency Outbreak Containment. Preparedness was substantially increased thanks to

simulation exercises, training courses on rapid outbreak response, study tours, a communication

program in 367 primary schools involving more than 500,000 students (who in turn

communicated on preparedness to their parents), and equipment and supplies for emergency

response in project provinces. The key indicator chosen was the number of days it took for

suspect outbreaks to be completely contained (quarantine and culling) with a 2-day target.

Responses have progressively become very rapid, with complete containment achieved in less

than 1.5 days. By the end of the project in 2014, it was even possible to do it in less than a day.

This highly satisfactory performance of a key component of the disease control system warrants

particular recognition. It resulted from the training provided in outbreak response, simulation

exercises, rapid availability of the test results from accredited laboratories, changes to protocols

16

Figure 5. Evidence of high risk awareness in paintings by

children (more examples from school-based contests are in Annex 2)

which allowed culling on suspicion, and the excellent leadership of the animal health teams at

the provincial level.

51. Disease Surveillance. VAHIP introduced innovations to the country’s surveillance

system for infectious diseases in humans: shift to considering the village health workers as the

first source of data at the lowest level; private sector, press, and media as an additional data

sources interacting with the district, provincial and national levels; and in line with the One

Health approach, integration of the veterinary centers at all levels, interacting with the Regional

Animal Health Offices (RAHOs), the Pasteur Institutes and NIHE for the confirmation of AI

cases. At the same time, a commune-based online reporting system for infectious diseases was

installed, based on upgrading of existing software developed earlier by the Preventive Health

System Support Project financed by the Asian Development Bank. This was accompanied by

training of several thousand health workers (see Annex 3 for detail). Indicators of timeliness and

completeness of reporting show that the surveillance system is performing well, and performance

targets were exceeded by the end of the project. Extension to other provinces of this type of

surveillance system with online reporting is underway, since compatibility among reporting

systems within the country is important.

52. Curative Care. Provincial

hospitals improved their capacities to

deal with human cases of H5N1 avian

flu and similar acute infections that may

require isolation and intensive care. The

hospital segment of the pandemic

simulation exercise was successfully

developed. For details of the equipment

and training provided, see Annex 3. The

two indicators measured development of

the pandemic preparedness plan by

provincial and district hospitals, an

essential and highly valuable step in

building preparedness. By the end of the

project, targets were exceeded for the 44

provincial hospitals and 124 district

hospitals in the VAHIP provinces: 100%

of all these hospitals have developed

their preparedness plans for an influenza

pandemic.

53. Behavior Change and Risk

Communication. VAHIP included

communication activities for both health

workers and for the general population.

Another important target group were

ethnic minority groups. The coverage

and the volume of the communication

materials produced were enormous:

17

Table 1. KAP survey results on correct knowledge, attitude and practice

toward at least one key preventive behavior (% of target groups)

Target

Group

Aspect

AssessedPHASE 1 PHASE 2

2008 2011 % Relative

Difference2012 Target

2014

2014 %Relative

Difference

Curative

health staff

Knowledge/

Attitudes

87.5 93.1 6.4 92.4 60 100.0 8.2

Practice 91.0 97.2 6.8 74.0 60 86.2 16.5

Preventive

health staff

Knowledge/

Attitudes

74.0 86.5 16.9 84.4 60 96.1 13.9

Practice 100.0 100.0 0.0 82.0 60 88.0 7.3

General

population

Knowledge/

Attitudes

20.8 54.5 162.0 50.0 60 80.0 60.0

Practice 56.4 98.4 74.5 34.0 60 98.8 190.6

20,532 health staff were trained on behavior change communications (BCC) skills, 264,000

posters were disseminated; and 4.2 million leaflets were produced. The range of strategies was

broad and included several types of competitions, which attracted a very large number of

participants. For example, in the provinces of Long An and Tay Ninh, a poster-making contest

among schoolchildren received a total of 18,000 entries (sample entries are in Figure 5 and

Annex 2). An essay-writing contest among adults in Thai Binh attracted hundreds of entries. The

instruments for communications were written (leaflets, handbooks, etc.), verbal (radio and

loudspeaker broadcasts; group discussions, etc.) and visual communication (billboards;

calendars; educational film, etc). Person-to-person communication was used extensively to relay

messages about influenza prevention and control, especially during home visits in communities

with ethnic minority groups.

54. Risk communication entailed development of both writing and oral skills, with 65 and 49

trainees respectively. The project also provided communication equipment, most of it for mass

communication. Notably, the training material on risk communication developed by VAHIP was

recently reviewed and approved by the MOH and recommended for use by academic institutions

and projects conducting training on risk communication. This is the first material on risk

communication to be approved and endorsed for use by the MOH.

55. To evaluate impacts, Knowledge, Attitudes and Practices (KAP) surveys were conducted

among health workers and the general population four times: in 2008 and 2011 for the Phase 1

provinces, and in 2012 and 2014 for the Phase 2 provinces. The results are in Table 1. The

surveys revealed increases in both knowledge and attitudes and in behaviors that are indicated to

prevent infection. The proportion of respondents at the end of the project with such knowledge

and behaviors was above the 60 percent targets set for each of the sub-groups (curative health

workers, preventive health workers, and general public). The target for health workers was,

however, set too

low given their

initial relatively

high level of

knowledge and

protective behavior.

The general

population had the

largest

improvements in

knowledge and

behaviors after the

communication and

training

interventions.

56. Strengthening Preventive Medicine System at Local Level. The training of district level

health staff on communicable diseases, information technology, communications skills, use of

equipment that was provided under the project (see Annex 3), and the conduct of multisectoral

simulation exercises yielded impressive results. The number of District Preventive Medicine

18

Centers (DPMC) that are fully equipped and have capacity to implement their responsibilities

and functions increased dramatically, from just 28 in 2010 to 87 in 2014, above the end-of-

project target of 79. Simulation exercises to build preparedness for outbreak response and

training on planning responses benefited more than 10,000 district-level staff, a significant

achievement in fostering risk awareness and building response capacity at the local level. Post-

graduate training for 90 district-level staff is important in strengthening technical skills at that

level and was an opportunity that is seldom available to staff working at the local levels.

57. Most of the equipment provided has multiple uses since the objective was to strengthen

the district preventive medicine system, rather than to limit equipment to that used for the

management of influenza and similar diseases. The equipment included items which are needed

for other purposes within the core public health functions like reproductive health. A narrow

focus on infectious diseases, or even just influenza, would not have been as effective in building

the capacity of the district preventive medicine system.

58. Multisectoral coordination was a strong feature of the strengthening of the preventive

medicine system (Table 2). The most important activity was conduct of 68 major simulation

exercises involving 15,146 participants, which is highly valuable in building preparedness. In

addition, the project also conducted 24 internal and 3 external experience-sharing activities

where 590 PPCU and district level staff involved in the project visited other provinces in order to

observe their activities and share their

experiences with the various project

components. Local coordination became

more effective thanks to the project

organizing 1,179 workshops involving

29,518 participants. Finally, as part of the

project each of the 11 project provinces

prepared operational guidelines on

multisectoral coordination. This deliberate

and intense effort at building links to

veterinary services and other sectors,

reinforced through multisectoral

simulations of responses to emergencies, is a good practice example.

3.3 Effectiveness and Efficiency

59. The project was exceptionally effective because it produced large economic and health

benefits at a very modest cost. This achievement is all the more notable because it occurred

despite the challenges of an inherently complex and largely unpredictable zoonotic disease

threat. The project tackled an emergency (since major renewed outbreaks were possible) and, at

the same time, made lasting systemic improvements to animal and human public health systems

in 11 provinces. Both of these actions are highly productive investments and an excellent value

for money. The project was highly efficient at the conceptual level, since it tackled a potentially

major threat to human health (widespread infections with H5N1 avian influenza or even

emergence of an influenza pandemic) by reducing contagion at its animal source. Infectious

disease control is far less costly when done early and at the source, because contagion and costs

of containing it can grow exponentially. Containing contagion in poultry is possible at a fraction

Table 2. District-level preventive and curative capacities

performance targets were exceeded

INDICATOR ACTUAL2014

TARGET2014

% DIFFERENCE

Percentage of districts which implemented the revised policy for preventive medicine 80 75 6.7

Number of PPMCs in 11 project provinces fully equipped and have adequate capacity to fully implement their responsibilities and functions in compliance with the MOH decision

87 79 10.1

Number of multisectoral simulation exercises conducted and reviewed at district levels in the project provinces

68 37 83.8

Number of health staff who have been trained 69012 21905 215.1

19

of the cost of containing it once it spreads in the human population. The deliberate One Health

approach was thus the most efficient choice. Moreover, it was also humane, since human cases

did not serve as sentinels of a poultry disease, as was seen in other countries. The project also

used efficient implementation methods, to lower costs and to generate additional productive

outputs with the savings.

60. VAHIP investments (and similar investments in other provinces under the OPI and

AIEPED plans) produced high economic benefits, far above the cost of the investments, and will

continue to do so if the public health capacities created under OPI and AIEPED are maintained.

The analysis in Annex 3 finds that annual spending $77 million on building and operating

veterinary and human public health systems8 would yield an expected annual benefit of $105

million (assuming that future prevented outbreaks and reduced pandemic impacts are just one

tenth of the high-impact outbreaks in 2004). The calculation conservatively assumed that a

severe flu pandemic occurs seldom: once in a hundred years. Therefore the annual risk (expected

value of costs) is just 1 percent of the impact of the event once it happens. Clearly, when

economic benefits exceed costs every year (and do so by a wide margin), these public

investments should have been made, were highly effective, and significantly increase the total

economic resources of the country for years to come.

61. The economic rate of return on the investments is very high and such high net benefits

would by themselves more than justify a highly satisfactory rating for overall outcome. Annex 3

presents the calculations, which assumed that disease risk was not reduced in the first 5 years of

the project, so there were only investment costs in that period. Benefits were thus assumed to

start only in year 6. With these conservative assumptions, the rate of return on the OPI and

AIEPED investments in disease control and prevention is 29 percent annually in real terms. If the

disease risk is reduced by 20 percent from the 2004 value (instead of by only 10 percent), the

expected rate of return is 129 percent annually in real terms. These highly positive rates of return

reflect the very large economic benefit to the country, and are well above the returns on other

public investments. Additional benefits accrued to the rest of the world, from a reduction in

pandemic risk. While these benefits are certain, their valuation is not possible because the shares

of Vietnam in the global avian flu “virus load” before and after VAHIP are unknown. National

benefits alone, however, more than justified the investments. These high rates of return are

consistent with global experience and with the findings of a recent Lancet commission on health,

headed by Harvard University professor Lawrence Summers (Box 1). When an outbreak occurs,

costs can escalate very rapidly so having robust public health systems to prevent preventing the

escalation because they are prepared pays off very well.9

8 This is equivalent to the average annual amount spent during the OPI and AIEPED periods.

9 Most countries neglect public health systems and do not make investments in preparedness. Experts advised

Guinea, Liberia, and Sierra Leone to invest $26 million in disease detection and disease outbreak control

preparedness, during an assessment of preparedness in 2007. These investments were not made, and public health

systems for disease outbreak control remained weak. The Ebola outbreak in West Africa could have been stopped in

March 2014 for less than $200 million. In August, this estimate was $1 billion. At the end of October 2014, the

estimate of cost to stop the outbreak was $4 billion (and rising). In addition, the people of Guinea, Liberia, and

Sierra Leone are hard-hit by disease, food insecurity, loss of jobs, and other disruptions, while their and neighboring

economies suffer. This is a recent stark example of the high costs of weak health sector policies, which are too

common. Unlike Vietnam under VAHIP, most developing countries neglect public health systems for disease

outbreak control.

20

Box 1. The single most important area for productive investment

Harvard University professor and former US Treasury Secretary Lawrence Summers said

that, because pandemic risk is high:

"[veterinary and human public health systems are] probably the single most

important area for productive investment on behalf of mankind."

Source: Video of high-level panel on health, World Bank, April 11, 2014, www.worldbank.org/pandemics

62. Efficiency was evident throughout implementation, to an impressive degree. The project

adopted approaches that generated outputs in a low-cost way. Communications activities

mobilized tens of thousands of communicators at very low cost. For example, in school-based

activities teachers, at minimal additional cost, helped organize a contest for school children, to

paint scenes about avian flu control. The children produced remarkably well-informed images,

showing emotional grasp of the complexities of a zoonotic disease. The children and their 18,000

evocative images conveyed the messages at low cost and far beyond the classroom, to the

families and communities. VAHIP implementation staff also adopted inventive low-cost

solutions that mobilized resources from local and provincial governments, as well as from

organizations and communities. Another cost-efficient approach was to adopt government cost

norms for many activities (rather than higher norms, like those used by some donors), which was

an important efficiency measure, given the numerous programs of training, workshops, and

consultations among provinces. Another illustrative instance was decision to not pay for new

customized software, but rather to generate savings by adapting surveillance software from an

Asian Development Bank-financed project. This lowered costs overall, without reducing

effectiveness and timely availability of the resulting “hybrid” system.

3.4 Justification of Overall Outcome Rating Rating: Highly Satisfactory

63. The Project was and remains highly relevant. It more than achieved the project

development objective of strengthening public health capacity to respond to H5N1 flu outbreaks,

preparing for pandemic influenza and other infectious disease outbreaks, and more generally

building systems for disease prevention and control, especially at district level. The outcome

stands out as unambiguously highly satisfactory within the country and project parameters:

extraordinarily high economic and health benefits were generated by modest investments in

successful emergency operations and in building (and testing) core public health systems. While

modest, the investments were challenging technically and managerially – and these challenges

were met in a way that has been, and can continue to serve as, an example to follow in other

countries. The outcomes in building public health systems are also well above the results

achieved by most other developing countries, where public health systems are weak and

chronically neglected. The Chairman of the Lancet Commission on Health stressed that this is

the area for the most productive investments on behalf of mankind; VAHIP was unambiguously

such an investment that should be replicated widely.

21

64. The project was aligned to the government’s plan and country systems. The development

outcomes were substantial as reflected not only in the very high economic returns but also in the

high achievement rates for the outcome indicators measuring public health system performance.

Targets for many indicators of system performance were surpassed (Table 3). The systemic

capacity improvements were not only done in a relatively brief span of time, but they are also a

much too rare instance of proactive investment in public health systems where the expected

economic returns and impact on population health status are higher than for other public

investments.

Table 3. Project outcomes: nearly all targets surpassed or met

Number of indicators that: Project key

indicators

Indicators of

performance of

veterinary and

human public

health systems

Other intermediate

outcome indicators

(e.g., training, risk

awareness)

Share of all project

indicators

Surpassed target 1 9 2 71%

Fully achieved target 1 1 1 18%

Partly achieved target 1 6%

Target not applicable 1 6%

65. Vietnam showed consistency over a decade in investing in disease prevention, which is

grossly neglected in most countries. Unlike the vast majority of developing countries, under

VAHIP Vietnam succeeded in implementing a health sector policy that is superior to, and far less

costly than, coping with the aftermath of lack of prevention. It is a tribute to the commitment and

sound policy-making of the Vietnam government that the investments in public health systems

were pursued despite growing apathy and neglect among the international community.

Moreover, the overall rating of highly satisfactory is justified by: effective and increasingly swift

responses to outbreaks in poultry, strong improvement in surveillance and reporting of diseases

(including fast turn-around times), upgrading of a large number of preventive health care centers

at local level to meet standards, decision to use project flexibility to expand the use of highly

productive simulation exercises, success of the information and education campaigns, adequate

and timely compensation for culled poultry, a range of biosecurity measures, and exemplary

leadership in sharing knowledge on One Health approaches and avian flu control globally.

Finally, the highly satisfactory overall outcome rating is justified by the remarkable results in

diagnostics capacity and management; these results were recognized by the international

certification of 8 laboratories within a short time span. This is a world-class achievement that

very favorably contrasts with the mismanagement of biosecure laboratories in many other

countries. Finally, the project had no shortcomings.

3.5 Overarching Themes, Other Outcomes and Impacts

66. Poverty impact and gender aspect. H5N1 influenza outbreaks initially affect the poultry

population. But, if not contained, they could directly and indirectly affect the majority of the

human population of the country since nearly all rural households and some periurban

households raise poultry. Among the poor, poultry often live in or very close to the family

dwelling. Poultry is often traded in live-bird markets by women, and raised by women and

22

children (who may thus be most exposed to the virus both in poultry and in poultry droppings);

children tend to suffer the most if the availability of affordable protein declines when large

numbers of poultry die due to disease. Repeated large outbreaks of avian influenza in Vietnam

would thus have devastating impacts on the poor (see Annex 3 for results of a study of

distributional impact). Since small disease outbreaks were promptly controlled and large

outbreaks did not occur at all (in part thanks to control of small outbreaks), the poor benefited.

The Project contributed as well to prevention of pandemic influenza (to an unknowable extent)

and to preparedness. A pandemic would hit the poor the hardest, in Vietnam and elsewhere.

Preparedness to mitigate the impact of this potentially catastrophic shock thus has an important

pro-poor bias; this benefit will be realized when a pandemic occurs.

67. Social development. Without the Project, the spread of H5N1 flu would have been more

likely. A severe pandemic could have occurred instead of, or in addition to, the 2009 H1N1

pandemic. In those events, the entire population of Vietnam would have been affected, possibly

with severe economic and social disruptions and increases in poverty, as mentioned above. The

project created capacity that will help prevent such potentially devastating impacts on the entire

society. The pandemic response plans and use of simulation exercises under VAHIP are

important in this regard. Plans will need to be periodically exercised through simulations and

updated as warranted for the expected benefits (mitigation of pandemic impact on society and the

economy) to materialize.

68. Institutional change/strengthening. The Project contributed substantially to

strengthening animal health and public health systems and, notably, to collaboration between

them. There was significant progress, notably, at the provincial and district levels and in skill-

acquisition by a large number of local-level staff. Collaboration between human and animal

public health services was largely successful, which augurs well for future joint work. Such

collaboration is critical in detecting, reporting, investigating, diagnosing and effectively

controlling zoonotic diseases which are, and will remain, a significant threat in Vietnam and in

neighboring countries. Strengthening of the laboratories and improved management has achieved

capacity that meets rigorous international standards.

69. Other unintended outcomes and impacts (positive and negative). The focus was on

influenza in poultry and humans. However, the systemic improvements can and should be

deployed against other threats. Antimicrobial resistance is already a significant problem; better

surveillance (using the systems improved under VAHIP) in both livestock and humans is already

an urgent need. Pandemic plans, stocks of PPEs, training on infection control, and the many

outbreak response simulation exercises that were carried out put Vietnam in a stronger position

to effectively deal with any imported Ebola cases. Strengthening of preparedness through

planning and simulations will continue to be highly productive, considering the low cost.

4. Assessment of Risk to Development Outcome Rating: Moderate

70. The improvement in performance of veterinary and human public health systems in the

11 VAHIP provinces has been dramatic. Now these systems, and those built in the rest of the

country thanks to the OPI and AIEPED, will need to keep pace with Vietnam’s rapidly growing

economy and popular aspirations for better health. If the performance of the systems worsens (or

23

does not improve sufficiently), the country will be vulnerable to reversal of its development

gains and possibly devastating spread of disease. Such adverse shocks can undo years of

development progress; public health systems are required to deliver the core public service of

protecting the population and the economy from such shocks. The government will require

financial and technical assistance for further development of capacity in disease control and

prevention (including not just avian flu, but also other zoonotic diseases, antimicrobial

resistance, and other One Health challenges). It will also need to give a high priority to the

operations and maintenance of the systems that have been built and improved.

71. It will be difficult to meet the twin challenges of operating the systems already built (and

preventing their erosion) and further increasing veterinary and human public health capacities.

The ongoing AIPED (2011-15) addresses One Health issues, such as influenza and other

zoonotic diseases and food safety. Since 2003, Vietnam has mobilized considerable internal

resources and also received external support from donors that was often above the envelopes

normally available for Vietnam. The significant decline of attention and financing since 2009 has

created a sustainability issue. The government has a contingency in its budget for responding to

disasters. The two ministries’ regular operating and investment budgets (financed by domestic

and donor funds) will have to make adequate allocations for sustained strengthening and

operations of core animal and human public health functions. Ensuring adequate budgets to

sustain and further increase performance standards should remain a priority because of the large

positive economic and health impacts of these expenditures.

72. There are two major risks to the sustainability of the public health systems and the

services they need to deliver to sustainably improve health and economic growth. First, external

assistance has declined and is highly uncertain since strengthening of animal health systems is

not a priority for donor financing. Human public health systems are a low priority in donors’

health sector programs (relative to curative health care). Neither WHO nor OIE have resources

for adequate technical assistance that is needed to carry out authoritative assessments of core

public health capacities for outbreak disease control and prevention, subsequent prioritization of

investments, and definition of other measures to help countries achieve veterinary and human

public health systems that meet international standards. Second, domestic resources for the

operations and maintenance of the public health system capacities may be difficult to mobilize as

well, if Vietnam follows the pattern common in many countries of low health sector interest in

prevention of disease outbreaks, such that funding for prevention usually only materializes

sporadically, after devastating disease outbreaks that occur precisely because of the weak public

health systems.

73. The rating on Risks to Development Outcome suggested by the above could be

“Substantial.” The rating is, however, “Moderate”, for three reasons. First, there is evident

commitment to ensuring operations of high-maintenance capacities like the laboratories, district

preventive health care centers, and surveillance systems. Second, Vietnam has established a

remarkably successful public health system strengthening record, using an approach which has

already served as an example to other countries dealing with zoonotic disease threats. Finally,

Vietnam has a strong record of making sound economic development choices and implementing

policies that benefit the country. Robust veterinary and human public health systems are

unambiguously among policies that are good for economic growth, as well as for health security.

24

5. Assessment of World Bank and Borrower Performance 5.1 Bank

(a) Ensuring Quality at Entry Rating: Satisfactory

74. The Project was prepared rapidly as an emergency operation by the Vietnam government

with support from a strong team from the World Bank, comprising diverse specialists, operation

officers, and an advisor—all with technical skills necessary to guide project design. World Bank

team benefited from collaboration with FAO, WHO, US CDC, UNSIC and other experts who

were actively engaged in the response to the H5N1 flu threat. World Bank support to the

government in preparing the government’s plans (the OPI and AIEPED) was effective and

appreciated by counterparts. The project, in turn, aligned very well with these plans. World

Bank support to project preparation was also informed by the GPAI, which embodied

international best practice and was, in fact, substantially based on Vietnam’s successful

experience in the initial phases of controlling the disease in 2003-2006. The internalization of

this experience by the project team, and incorporation of such best practice into the VAHIP

ensured that quality at entry was highly satisfactory. The mitigation plan for addressing critical

risks was sound and relevant. The rating would be Highly Satisfactory if it were not for the

sharp reduction of the World Bank’s support to the global program during the VAHIP-2 period.

From 2010 when the Human Development Network (HDN) took over responsibility for the

global program (including operations ongoing in 30 countries at the time), engagement of the

Bank in the global program declined sharply and thus made inadequate contributions for global

risk communications, global coordination, and advocacy for preparedness and prevention.10

Since Vietnam was contributing to an important global public good (as well as generating

national benefits), this gap in World Bank support sent unfortunate signals about a dramatic

decline in interest of the global community in pandemic risk reduction.

(b) Quality of Supervision: Rating: Satisfactory

75. The task team was multisectoral and provided effective and well-coordinated

implementation support, with relentless follow-up on the details of implementation of the

numerous and diverse activities in 11 provinces. The decentralized structure of the project

required engagement with counterparts who were not familiar with implementing World Bank-

financed projects. It is a testament to the commitment and inventiveness of the World Bank’s

multisectoral team that ambitious targets were achieved and many were exceeded, despite the

complex multisectoral challenges and decentralized implementation. Environmental issues were

resolved satisfactorily thanks to the team’s support. Since most of the supervision activities were

conducted from the World Bank’s country office, a continuous and intensive effort was possible,

with implementation assistance to the provincial levels. The financial management and

procurement teams were continuously engaged in supporting project activities. Likewise, the

social and environmental safeguards specialists assisted with achieving compliance and

participated in reviews. All activities financed by the World Bank were completed successfully

without the project being extended. In their comments, government counterparts specifically

appreciated Bank flexibility during implementation and the contributions of the Hanoi office-

based team (Annex 5). The strong performance of the task team in providing implementation

10

World Bank, Independent Evaluation Group (2014).

25

support was all the more commendable in view of the World Bank’s weak institutional

incentives for effective operational work that spans multiple sectors.

(c) Justification of Rating for Overall Bank Performance: Rating: Satisfactory

76. Strong World Bank performance during the preparation phase (which entailed support to

formulation of the OPI and then the AIEPED, preparation of a robust multisectoral framework,

alignment to a global program, coordination with partners around a country-owned plan, and an

emergency response with rapid processing) was followed by the team’s relentless attention to the

details of implementation in two major sectors and consistently high and successful coordination

effort in the supervision phase. This exemplary performance offset the gaps in advocacy and

other institutional support and warrants an overall Bank performance rating of Satisfactory.

5.2 Borrower Performance

(a) Government Performance Rating: Satisfactory

77. The project achieved or surpassed all relevant outcome targets. Equally important, nearly

all interim targets were met during implementation and many were exceeded. The veterinary

and human public health systems at provincial and district levels significantly improved their

capacity to perform and deliver core public health services to the country, including for:

surveillance through support to CAHWs, biosecurity, communications on animal diseases to

health care workers, farmers, traders, and others, rapid response to infectious disease outbreaks,

hospital care for the treatment of highly pathogenic diseases, and speed and accuracy of

laboratory testing. The government formulated plans for pandemic response in the health sector,

in other sectors, and across ministries and levels of government; these plans were tested in

numerous simulations, which is a significant result. Vietnam made a timely and substantial

contribution by showing global leadership in the adoption of One Health approaches in

controlling zoonotic diseases at their animal source. The government mobilized to effectively

share its knowledge with the international community on the occasion of the international

ministerial conference on animal and pandemic influenza in Hanoi in 2010. This contribution

was beyond that envisaged in the OPI and AIEPED (or the VAHIP) and added substantial value

to global efforts against the pandemic threat. Commitment to building public health systems is

extremely difficult to sustain, as shown by the common neglect of these systems in most

developing countries. This neglect is highly costly, as evidenced by the ongoing Ebola crisis (and

similar crises to come). The government’s sustained commitment to prevention over a decade is

by itself sufficient grounds for a satisfactory rating.

(b) Implementing Agency or Agencies Performance Rating: Satisfactory

78. As noted above, VAHIP was developed and implemented by MARD, MOH, and other

departments of the government and implemented in a decentralized way. The difficulties created

by a complex project with decentralized implementation were effectively addressed and

overcome thanks to exceptional commitment to improving veterinary and human public health

capacities and openness to innovation. For instance in financial management, VAHIP yielded

valuable lessons for similar future projects. There was strong and highly beneficial engagement

from the People’s Committees, which contributed critical support (for instance for whole-of-

society multisectoral simulation exercises) and also provided tangible assets such as buildings at

the provincial and district levels. VAHIP achievements were facilitated by their commitment and

26

implementation competence. Moreover, implementing agencies made adjustments flexibly,

supported deliberate and successful coordination across sectors at central, provincial and district

levels, and exploited opportunities for additional efficiencies, to stretch the limited resources

available to produce additional results. When the monitoring of environmental impacts showed

problems, the PCU and relevant government departments sought to remedy problems

proactively.

(c) Justification of Rating for Borrower Performance Rating: Satisfactory

79. VAHIP achieved excellent results as a multisectoral project because of strong

government leadership and commitment from the two ministries responsible for implementation.

It was implemented in a significantly decentralized way. The difficulties created by a complex

multisectoral project with decentralized implementation in 11 provinces were effectively

addressed during implementation and overcome thanks to exceptional commitment to improving

veterinary and human public health capacities and openness to innovation. Building the

veterinary and human public health capacity that is required for ensuring high economic and

health benefits within Vietnam and going beyond the project to contribute knowledge to the

global community more than offsets the record in the ISRs of moderately satisfactory ratings of

implementation progress during much of the project period. Altogether, a satisfactory rating is

therefore amply justified.

6. Lessons Learned

80. The following lessons can help inform future programs that build veterinary and human

public health systems for prevention and control of diseases.

An emergency is an opportunity to reduce risks over the medium term. This will help

prevent future costly emergencies. VAHIP was launched in the wake of a major disaster

caused by the 2003-04 avian flu outbreaks and in the context of an unprecedented global

emergency response to a pandemic threat. Vietnam successfully seized the political support

and resources that were mobilized to implement its comprehensive and integrated veterinary

and human public health plans at national, provincial, and district levels. Impressive progress

was made in building a wide range of capacities, such as the outstanding improvement in

animal health laboratories. There is no doubt that thanks to the government’s and donors’

attention to development imperatives (a functioning public health system is essential to

reduce risks to development), performance of the systems needed to prevent and control

zoonotic diseases and similar public health threats has improved, which will bring large

benefits for years to come. Investments in capacity to tackle zoonotic diseases at their source,

including continuing training on biosecurity, strengthening livestock and wildlife

surveillance, communications, and rapid response teams, will substantially lower the costs of

future emergencies and save human lives.

One Health approaches are effective in disease control and prevention. This recognition

grew out of implementation of VAHIP and the concerted coordination between MARD and

MOH in dealing with a dangerous zoonotic pathogen. In view of the benefits of a

multisectoral approach to disease control and prevention in Vietnam, the government hosted

a week-long workshop on One Health approaches for participants from 25 countries ahead of

the Hanoi Ministerial Conference on Animal and Pandemic Influenza in April 2010,

27

providing valuable guidance on implementation of One Health approaches to Ministerial

delegations responsible for animal and human public health in 71 countries.

One Health approaches are feasible when there is good leadership. Overcoming barriers

between the veterinary and human public health services was challenging. It was possible

thanks to deliberate institutionalization (signing an interministerial circular and a

memorandum of understanding and setting up coordination mechanisms and operational

guidelines at all levels). This enabled joint planning and evaluation of results as well as

sharing of information and other resources and conduct of joint activities, where warranted.

The impetus of an emergency situation and interest from senior leaders, technical teams,

agencies, and partner countries help facilitate coordination as well.

Behavior change takes time and resources. Poultry market traders only started adopting safe

behaviors when they understood and accepted the rationale. Working with traders to solve

management problems of the large Ha Vy market was essential and lasted longer than

initially planned.

Upstream attention to environmental impacts helps prevent problems. Technical review of

the design of environmental protection works (such as solid waste and wastewater treatment

systems) should be included from the beginning of project implementation.

Transition from emergency response to systemic improvements is important. Transition to

medium-term system strengthening was envisaged in the OPI and the AIPED and was

successful. This is a solid basis to sustain progress, which will help Vietnam reduce threats

from infectious diseases and similar conditions, such as antimicrobial resistance. Notably,

chronic under-resourcing of veterinary services has not yet been fully overcome and further

substantial investments are warranted. The approach of early disease control at the animal

source is a precedent for public health system capacity-building for prevention of other

zoonotic diseases and similar conditions.

Successful market upgrades. Lessons from slaughterhouse and market upgrades under

VAHIP will be useful in further efforts to reduce disease transmission in similar facilities in

the rest of the country.

M&E indicators. Final outcome indicators (such as disease prevalence and the case fatality

ratio) are by themselves not sufficient to evaluate progress and thus may be misleading. They

need to be complemented by measures of system performance for functions that are required

for disease control and prevention. VAHIP chose useful indicators of “intermediate”

outcomes. Looking ahead, independent assessments of veterinary and human public health

systems according to the methodology and benchmarks established by WHO and OIE can

serve as robust measures of performance, on which the government and its partners can rely.

Technical definitions are critical for M&E. A key lesson was that what constitutes “suspect

cases” of H5N1 avian flu disease in poultry needs to be unambiguously defined for all types

of enterprises and flock sizes. When some communes, districts and provinces use different

definitions, it is exceedingly difficult to aggregate outcomes, compare among locations, and

devise appropriate responses.

Use of consultants. External expertise was essential for the highly technical task of

improving laboratories and their management. Laboratory quality management expertise

from the Australian Animal Health Laboratory had highly satisfactory results. In other areas,

28

too, technical consultants provided good value, especially when they were able to regularly

provide inputs to project management.

Decentralized implementation. This was both necessary (because disease control and

prevention activities occur in numerous districts and villages) and challenging (because local

capacity was uneven and alignment with national policies and programs was required).

Successful implementation required investment in decentralized functions for

implementation and in coordination. These were resources well-spent. Provinces and districts

identified their own needs, procurement plans, and training plans. This improved

implementation performance and reduced demands on the central project management units.

Financial management with decentralized activities. Important lessons were learned. First,

decentralization of activities to provinces and districts helped to increase their capacity in

Project management and also their ownership of implementation of Project activities. The

human resource capacity built up by the Project at the decentralized levels will be available

after Project closing and is a very good resource for the Government to implement similar

activities. Second, close interaction of the PCUs with PPCUs and supervision of the PPCUs

by the PCUs (especially the MARD PCU), enhanced the quality of the financial reporting

function at the local level, reduced mistakes, and reduced errors in use of funds. Third,

comingling of funds from IDA, AHIF, and PHRD was efficient and reduced transactions

costs for the government. Although donors often apply separate cost norms and financial

management procedures, in this Project all the funds were pooled as one source and treated

equally.

Engaging stakeholders beyond MOH and MARD. The provincial political authorities

(People’s Committees), were formally involved in VAHIP. Their contributions to

multisectoral simulation exercises were indispensable and highly successful; they also

provided other substantial assistance, such as funds, land and buildings. Mobilization of

organizations of students, youth, women, farmers and ethnic minorities was part of the IEC

outreach. This helped create pools of community-based educators that could convey

knowledge to their friends and neighbors about avian flu risks and behaviors to reduce them.

School-based IEC proved very successful, with children becoming knowledgeable about

poultry disease and pandemic risk and about ways to prevent infection.

Training health workers on communications, especially risk communications. This helped

extend messages to communities and improved infection control in health care facilities.

There is opportunity to substantially increase the reach of this training by involving more

health workers. Moreover, such training needs to be periodically repeated.

Rule to balance expenditures on training and equipment in health care centers. The use of

the 30-70 rule (30% training, 70% equipment) proved helpful in guiding decisions at the

district level. The rule aims to avoid waste entailed in unused or abused equipment.

Quality of supervision and implementation support. Substantial implementation support

was instrumental to the success of this technically complex, emergency, and multisectoral

operation. Government comments highlighted this aspect as well.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners

(a) Borrower/implementing agencies

29

81. Comments and suggestions made by the PCUs of MARD and MOH are presented in

Annex 5, together with corresponding responses, and alongside recommendations from the

government’s ICR for reducing avian influenza and other zoonotic disease risks in the future.

(b) Partners

82. The Implementation Completion and Results (ICR) mission benefited from discussions

with WHO, FAO, USAID, US CDC and the European Commission about their views of the

implementation and outcomes of VAHIP.

83. FAO and WHO had been actively engaged in the response to avian influenza but their

activities have declined when funding ended. Based on the experience and outcomes of VAHIP,

FAO considered that collaboration on animal health with WHO and with MOH will essential in

the future. Since the European Commission’s (EC) response to avian flu response was managed

from Brussels, the EC delegation in Vietnam was not directly involved in supporting VAHIP,

though their overall impression is that it had been a valuable initiative. USAID’s ongoing

projects related to zoonotic risks have been greatly reduced from previous levels and are now the

only major externally-funded activities addressing these issues.

30

Annex 1. Project Costs and Financing

(a) Project Cost at Appraisal by Component (in US$ million equivalent)

Components VAHIP-1

2007-10

VAHIP-2

2011-14

Total

2007-14

A. Animal Health 17.2 4.31 21.51

B. Human Health 16.0 16.28 32.28

C. OPI Integration & Coordination,

Results M&E, and Project Management 4.8 4.41 9.21

Total Project Costs 38.00 25.00 63.00

Total Financing Required 38.00 25.00 63.00

(b) Financing

Source of Funds Type of

Financing

Appraisal

Estimate

(US$ million)

Actual/Latest

Estimate

(US$ million)

Percentage

of

Appraisal

IDA credit 30.00 30.00 100

AHI Facility grant 23.00 23.00 100

PHRD trust fund grant 5.00 5.00 100

Government budget 5.00 5.00 100

Total 63.00 63.00 100

31

Annex 2. Outputs by Component

84. This section is based on the government’s project completion report, presentations at the

final VAHIP workshop, and the World Bank’s Implementation Status Reports. To achieve

the objective of the project, VAHIP had to deliver inputs and intermediate outputs in 11

project provinces (Figure A2.1), which can be categorized into four major areas, namely:

a. Civil works (e.g., upgrading

of waste treatment systems,

improvement of Ha Vy

Market near Hanoi,

improvement of other

smaller markets and

slaughter houses, and

upgrading of isolation wards

of provincial hospitals);

b. Tools and technology

(computer hardware and

software; upgrading of

veterinary laboratories to

meet ISO standards;

laboratory, hospital and

communication equipment

for provincial and district

hospitals, provincial and

district preventive medicine

centers, and some of the

provincial IEC centers);

c. Capacities (technical

support, training of

veterinary laboratory staff,

animal and human health

workers in quality

management, surveillance,

prevention, control,

detection and management

of infectious diseases,

behavior change and risk

communication; training of

specific sub-groups of the

general population on

prevention and control of

avian influenza and other

infectious diseases, on behavior change, and risk communication; and

Figure A2.1. The eleven VAHIP provinces

32

d. Approach (One Health, strengthening the sub-national level with focus on districts and

communes).

These inputs resulted in outputs, which in turn contributed to the project’s outcomes. The major

outputs produced by each project sub-component are presented in the following sections.

85. Sub-component A1: Strengthening of Veterinary Services. Among the outputs were:

- Supply of laboratory equipment required to perform testing for avian influenza viruses,

including appropriate real time polymerase chain reaction equipment;

- Calibration of major equipment; training in calibration for minor equipment (pipettes, etc.) for

national, regional and some provincial laboratories, including certification of trainees;

- Organization of proficiency testing for nine veterinary laboratories with the national Center

for Veterinary Diagnosis (NCDM) providing the samples for testing. NCDM is also applying

for accreditation for this purpose;

- Installation of a novel waste-handling system at the laboratory in Vinh;

- Regular meetings of staff in the laboratory network to discuss important issues in common

and to share experiences on quality management;

- Establishment of a Quality management and Safety Board in each laboratory and conduct of

regular (quarterly) meetings of the Board;

- Employment of contract staff in laboratories to ensure sufficient trained manpower was

available to perform all testing; and

- Testing of more than 200,000 samples.

86. Another important activity was improving disease reporting, which covered 144 districts

and 2,686 communes. It involved monthly meetings with community animal health workers

(CAHWs). All participating districts and communes were able to produce reports, with over 97%

of them providing full information, using the recommended template.

87. Sub-component A2: Enhanced Disease Control. There were three main civil works and

infrastructure improvement activities under this subcomponent. Examples are shown in Figures

A2.2 and A2.3). First, a major activity was the improvement of the Ha Vy wholesale poultry

market near Hanoi. The outputs included:

- Planning and construction of the market;

- Liaison with traders to implement behavioral changes;

- Provision of equipment and materials to improve the hygiene and biosecurity of the

market;

- Provision of technical advice on upgrading the market and market management; and

- Installation of waste treatment facilities.

Second, upgrading of 42 other markets and 34 slaughterhouses, thanks to the following:

- Support of minor capital works including waste handling;

- Assistance in market design and management;

- Provision of equipment for cleaning and disinfection;

- Training of market stall holders on biosecurity and hygiene; and

- Employment of market managers.

Third, a culling site for holding, humane destruction, and disposal of poultry was constructed in

the northern border province of Lang Son to deal with seized poultry smuggled from China.

33

88. Sub-component A3: Disease Surveillance and Epidemiologic Investigation. The

major outputs were:

- Monthly (A)H5N1 virus surveillance at Ha Vy market, Lang Son culling site as well as

in 55 other markets and 11 slaughterhouses;

- 285 outbreaks investigated; and

- Training on outbreak investigation, disease reporting, and mapping.

Figure A2.3. Examples of improved markets

Figure A2.2. Little or no biosecurity before improvement of markets

Ha Tinh and Dong Thap markets before VAHIP

Ha Vy market

before VAHIP

34

New biosecure features in Dong Thap market. Poultry are off the

ground, and surfaces can be cleaned and disinfected more easily.

Separate space for slaughtering poultry at Dong Thap market. Daily

cleaning and disinfection are now possible.

About 1 million live poultry are traded annually in Ha Vy market.

Poultry for resale leaves Ha Vy market in a cage perched on a small motorcycle. Market biosecurity prevents spread of disease to

customers, traders, and farmers.

Washing trucks as they leave Ha Vy market prevents spread of

disease to the communities and farms where they go next to collect

poultry.

World Bank expert Binh Thang Cao talks about market biosecurity

as VAHIP ends in June 2014. Ha Vy market upgrades are a

substantial achievement, but more effort is needed to protect animal and human health.

35

89. Sub-component A4: Preparing for Poultry Sector Restructuring. Activities were

conducted only during Phase 1 of VAHIP and had the following among the outputs:

- Training, including:

o Master of Science training for 3 DLP officials in the UK and Australia;

o Development of biosecurity standards and methods for examining and assessing poultry

farms and conducting training courses in this area for 49 officials from the livestock

sector;

o 3 training courses for 132 DLP officers on spatial planning and risk assessment;

o Study tour to South Korea for 16 officers of DLP and DARDs of 11 project provinces to

learn about biosafe poultry production;

- Support to 40 small farms in 4 selected provinces for upgrading biosecurity;

- Baseline surveys in 4 provinces participating in poultry sector restructuring to support the

development of spatial planning and risk assessment profiles; and

- Training courses for about 1,760 farm households from 44 communes or 22 districts on

biosecure poultry production; these trained households then became the key poultry producers

and information disseminators in their communes.

90. Sub-component A5: Emergency Outbreak Containment. This sub-component had

among its major outputs the following:

- Simulation exercises in all project provinces

- Training courses on rapid outbreak response

- 11 study tours

- Communication program in 367 primary schools involving more than 500,000 students

- Equipment and supplies for emergency response

91. Sub-component B1: Disease Surveillance. Two innovations were introduced to the

country’s surveillance system for infectious diseases.

a. A new model for a communicable disease surveillance system, which modified the existing

system as follows:

- Community village health workers are considered as the first source of data;

- The private sector is an additional data source, transmitting data to the Commune Health

Centers;

- The press and the media are additional information sources, interacting with the district,

provincial and national levels; and

- In line with the One Health approach, the veterinary centers at all levels are integrated in the

infectious disease surveillance system, interacting basically with the Regional Animal Health

Offices (RAHOs), the Pasteur Institutes and NIHE for the confirmation of AI cases.

b. Installation of a commune-based online reporting system for infectious diseases. This online

reporting system installed by VAHIP is an upgrading of existing software developed earlier

by the Preventive Health System Support Project of the Asian Development Bank (ADB).

The lowest level of online data transmission in the ADB software is the district. VAHIP

modified the software to enable data entry at and transmission from the CHC level. In

36

addition to the software, other outputs under sub-component B1 include several training

activities aimed at strengthening the surveillance system like for example, the training of:

- 4432 health staff on the new model for the infectious disease surveillance system

- 1570 CHC staff on software application

- 103 staff who were sent for the FETP; and

- 67 staff who were sent for overseas training in 6 countries.

92. In addition, vehicles, supplies, and equipment to strengthen the capacity of the district

rapid response teams were also provided. These included, among others, the following:

- 874 computers

- 38 vehicles for outbreak investigation and 301 motorbikes

- 339 specimen collection kits

- 655 special clothing and 14,619 PPEs.

93. Sub-component B2: Curative Care. The outputs included the following:

a. Upgrading of the 12 isolation wards of the provincial hospitals in 11 project provinces;

b. Vehicles and medical equipment for provincial and district hospitals, including:

- 30 ambulances

- 27 ventilators

- 112 monitors

- 28 mobile x-rays

- 360 terifusion syringe pumps and infusion pumps;

c. Training of health workers on various aspects related to the use of the equipment

provided, diagnosis and treatment of infectious diseases, infection control in hospitals,

and the development of hospital pandemic prepared plans. These include, among others:

- 542 staff trained on the use and maintenance of hospital equipment

- 912 staff trained on infection control in hospitals

- 227 staff trained on the development of the district hospital preparedness plan for AI

- 47 staff sent for overseas training

d. Development of guidelines on the following areas:

- Use of sterilized chemicals in health care facilities

- Infection control in health care facilities

- Development of the hospital preparedness plan for AI at the district level

In addition to the above, 4,500 copies of the training material on diagnosis and treatment of

respiratory patients were reproduced and distributed to health workers. A hospital scenario for

the simulation exercise was also developed.

94. Sub-component B3: Behavior change and risk communication. This subcomponent

differed somewhat from communications components of other health projects because health

workers as well as the general population were targeted. Another important target group were

ethnic minority groups.

37

95. The coverage of this sub-component and the volume of the communication materials

produced were enormous: 20,532 health staff were trained on BCC skills, 264,000 posters were

disseminated; and 4.2 million leaflets were produced. The range of strategies was broad and

included several types of competitions, which attracted a very large number of participants. For

example, in the provinces of Long An and Tay Ninh, a poster-making contest among

schoolchildren received a total of 18,000 entries (Figure A2.4). An essay-writing contest among

adults that was conducted in Thai Binh attracted hundreds of entries.

96. Outputs included all types of communication -- written (leaflets, handbooks, etc.), verbal

(radio and loudspeaker broadcasts; group discussions, etc.) and visual (billboards; calendars;

educational film, etc.). Person-to-person communication was used extensively in relaying

messages about influenza prevention and control, especially among ethnic minority groups

where home visits were frequently done. Risk communication was just newly introduced in

Vietnam. Training in this area included the development of writing and oral skills, of 65 and 49

trainees, respectively. The project also provided communication equipment, most of it for mass

communication (for example amplifiers, microphones) and 546 units of other communications

equipment. Outputs included:

- Training of trainers on Behavior Change Communications (BCC)

- Communication skills for ethnic minority groups

- BCC monitoring in the community

- Handbook on Communication for Influenza Prevention in the Community

- Risk communication on emerging infectious diseases prevention

97. Notably, the training materials on risk communication developed by VAHIP were

recently reviewed and approved by the MOH, which recommended them for use by academic

institutions and others conducting training on risk communication. This is the first material on

risk communication to be approved and endorsed for use by the MOH. To evaluate the effects of

the various communication activities conducted by VAHIP, Knowledge, Attitudes and Practices

(KAP) surveys were done among health workers and the general population four times: in 2008

and 2011 for the Phase 1 provinces, and in 2012 and 2014 for the Phase 2 provinces.

38

Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health

Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 1 of 3)

39


Select paintings from among 18,000 entries in competitions for school children, ages 6-15,

VAHIP provinces of Long An and Tay Ninh (page 2 of 3)

40


Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 3 of 3)

41

Figure A2.5. District Preventive Health Center managers

and staff, along with provincial officials, and the VAHIP

PCU, discuss improvements in local-level public health

capacity. They plan for maintenance of equipment and for

further collaboration with veterinary services (June 2014).

98. Sub-component B4: Strengthening Preventive Medicine System at Local Level. The

major outputs included training of health staff in districts, equipment for the DPMCs, and the

conduct of multisectoral simulation exercises. Simulations of outbreak response and training on

planning responses benefited more than 10,000 district-level staff, a significant achievement.

Several thousand district-level health staff were trained in other areas as well, including:

- Newly emerging communicable diseases (7,865 trainees)

- Basic information technology (1,128 trainees)

- Communication skills (4,233 trainees)

Post-graduate training had 90 district-level trainees, who strengthened their technical skills. It

was for them also a learning opportunity that is seldom available to local-level staff.

99. Most of the equipment provided by VAHIP was under sub-component B4. Since the

objective was strengthening of the whole district preventive health system, the range of

equipment was wide, as needed for core public health functions like reproductive health, which

are all in the domain of the district preventive health. Equipment included, for example:

- 74 level 2 biosafety cabinets

- 60 ultralow temperature fridges

- 64 urine biochemical analyzers

- 52 portable ultrasound

- 38 mobile x-ray systems

- 526 chemical sprayers with

shoulder straps

- 62 spectroscopy for water

analysis

- 261 loudspeakers, amplifiers and

cassette players

- 87 digital cameras

100. Multisectoral coordination

included conduct of 68 major

simulation exercises involving

42

15,146 participants. In addition, the project also conducted 24 internal and 3 external experience-

sharing activities where 590 PPCU and district level staff involved in the project visited other

provinces in order to observe their activities and share their experiences with the various project

components. Local coordination became more effective thanks to the project organizing 1,179

workshops involving 29,518 participants. Each of the 11 project provinces prepared operational

guidelines on multisectoral coordination.

43

Annex 3. Economic and Financial Analysis

101. The economic risks posed by H5N1 avian influenza, a poultry disease caused by a

zoonotic (animal-origin) pathogen, fall into five main categories:

i. direct costs to the poultry sector of the disease in poultry and associated disease control

measures in case of disease outbreaks;

ii. indirect effects of losses to producers, processors, and traders as consumers reduce demand

for poultry and poultry products, leading to disruptions and even collapse of markets for

poultry and poultry products;

iii. losses to other sectors of the economy of the country and even the region more broadly in

sectors where perceptions of infection risks are important, such as the tourism sector;

iv. in case of human infections (which have been sporadic and rare to date), human health

costs, including costs of health care for patients and loss of income because of illness and

death; and

v. the risk of an influenza pandemic, which all countries face and which is a top global

catastrophic risk; this risk derives from a small (but non-zero) probability of occurrence in

any year and a potentially large impact on public health, economies, communities, and

national security.

102. Global Public Good. Prevention and control of avian and human influenza deliver an

important global public good to all countries because they reduce the risk of pandemic influenza.

Awareness of pandemic threat was the main driver of global efforts in 2005-13 to prevent spread

of H5N1 avian flu in poultry. The global community realized that the uncontrolled multiplication

of H5N1 avian flu viruses in poultry represented an unacceptably high risk, and that controlling

the virus at its animal source was a feasible, effective, and least-cost means to reduce this risk. If

action was not taken in Vietnam to limit the contagion in poultry, the risk to the world’s

population and the economies of all countries would remain high. Since H5N1 avian flu in

poultry has spread across national borders (it spread to 61 countries in Asia, Europe, and Africa

by 2007), controlling spread in Vietnam also contributed to the global public good of reduced

poultry disease risks in neighboring countries and beyond.

103. A traditional “with and without project” type of cost-benefit analysis offers at best

partial insights. The large global benefit – that a severe influenza pandemic has not emerged to

date – cannot be attributed only to any one country’s or region’s success in controlling the virus.

But if the circulation of the virus had not been reduced in Vietnam and in the VAHIP provinces,

the probability of emergence of a devastating pandemic would be greater than without the

achievements of Vietnam and other countries.

104. VAHIP and Vietnam’s country-wide program can be economically more than justified

solely on the basis of delay or prevention of a pandemic. A severe influenza pandemic would

give rise to costs equivalent to 4.8% of global GDP (World Bank, 2008). This cost would be $3.7

trillion (based on 2013 GDP) globally. Optimistically assuming that the probability of pandemic

onset in any year is just 1%, the economic cost of an influenza pandemic to the world has an

expected annual value of $37 billion. By controlling the disease, Vietnam’s program contributed

44

to reducing this substantial global risk. Benefits from avian flu control to the poultry sector and

the rural economy are not needed to justify the investments in veterinary and human public

health systems because even a small reduction in pandemic risk (for instance, from $37 billion to

$33 billion) is much higher than the global costs of investments in all developing countries for

disease control and prevention.11

105. Vietnam’s plan for avian flu control and pandemic flu preparedness and prevention in

2006-15 (the Green Book and

the Blue Book) was costed at

$634 million or an average of

$63 million per year. VAHIP

(2007-14) contribution was

$23 million, or an average of

$3 million per year. Since

disease spreads across

administrative boundaries and

international borders, outcomes

in VAHIP provinces depended

also on successful

implementation in the rest of

the country -- and in

neighboring countries. It is

therefore more meaningful to

assess the benefits of the

national effort than to attempt

isolating the expected benefits

stemming from VAHIP alone.

106. Measures to prepare for a pandemic and to improve surveillance in both animals and

humans will have been a sound investment even if a human pandemic strain of H5N1 influenza

virus does not emerge. It could have emerged and imposed high costs. There are other benefits as

well. Table 1 shows the dramatic decline in the last 10 years of poultry deaths from H5N1 avian

flu outbreaks; some 50 million poultry died or were destroyed in disease-control efforts. During

the VAHIP period (2007-14) contagion among poultry was much more limited, and 1.6 million

poultry died or were destroyed. The reduction in outbreaks could have been due to chance, but in

the absence of VAHIP and similar efforts in the rest of the country, the risk of disease spread

would have been too high. VAHIP provinces accounted for about 30 percent of the losses. Table

3.2 shows the benefits to Vietnam. There are benefits from reduced poultry deaths, benefits from

reduced human medical costs for patients (not calculated since they are relatively small and

would not affect the totals), and benefits from pandemic preparedness (calculated as a reduction

of pandemic risk in Vietnam). Reduced pandemic risk in Vietnam is an outcome that is not due

11

Annual spending of $3.4 billion on veterinary and human public health systems would be sufficient to bring these

systems in 139 developing countries to the international standard of performance. Current spending on these systems

in all developing countries is less than $500 million annually. World Bank (2012) People Pathogens and Our

Planet, The Economics of One Health. Inadequate systems allow contagion to spread and in the absence of early

control, inflict exponentially rising costs, as shown most recently in the Ebola epidemic.

Table A3.1. Poultry destroyed by avian influenza, 2003-14

Year Whole

country

VAHIP

provinces

Whole

country

VAHIP

provinces

(number) (2003-4=100)

12/2003-04 43,900,000 11,284,418 100.0 100.0

2005 4,457,790 1,259,083 10.2 11.2

2006 - - 0.0 0.0

2007 236,582 65,860 0.5 0.6

2008 106,058 24,667 0.2 0.2

2009 112,847 22,664 0.3 0.2

2010 75,769 48,752 0.2 0.4

2011 151,356 19,163 0.3 0.2

2012 616,109 151,162 1.4 1.3

2013 79,522 49,478 0.2 0.4

01-06/2014 211,573 102,691 0.5 0.9

Total 49,947,606 13,027,938

Sub-total

in 2007-14 1,589,816 484,437 3.6 4.3

45

to the changed probability of a pandemic (this is the same for all countries) but rather results

from the comprehensive and thorough pandemic planning and numerous simulation exercises

carried out under VAHIP (and similar projects in other provinces). If these pandemic

preparedness activities reduce the chaos, delays, lack of coordination, and poor communications

that inevitably derail disaster responses in the absence of planning, then Vietnam’s pandemic

costs could fall by 10 percent. If such a pandemic started in 2015, it would cost the Vietnamese

economy $9 billion (equivalent to 4.8% of GDP). But thanks to preparedness under VAHIP and

other projects, the costs would be $8 billion, or a saving of $1 billion. On an expected value

basis, assuming that the probability of pandemic onset is 1 percent in any year, the annual benefit

to Vietnam from pandemic preparedness through simulation exercises of pandemic response

plans is $10 million since pandemic risk is reduced from $91 million per year to $82 million per

year. This is far more than the expenditures on pandemic plans and simulation exercises,

confirming that the benefits on this component exceed the costs by far.

107. The benefits of control of avian flu in poultry to the poultry sector and the related

economic activities are substantial as well (Table A3.2). Improved veterinary and human public

health system and pandemic preparedness that includes simulation exercises will enable a faster

and more effective control of disease outbreaks and response to a pandemic. The economic

benefits of performing public health systems are large. These systems deliver a highly valuable

public good, which is worth at least $105 million annually (in 2015 terms) to Vietnam.

108. This $105 million value was calculated as follows. If another outbreak like the one in

2004 occurred in 2015, it would cost Vietnam’s economy $945 million. If such an outbreak is

prevented, the $945 million is the benefit of prevention. A much more conservative approach is

to assume that only 10 percent of this amount will actually be prevented by the public health

systems. Thus the benefit of prevention is $95 million for an outbreak in 2015. Similarly, the

value of pandemic risk ($91 million in 2015, based on 1 percent probability of onset) is reduced

only by $10 million (and not the entire $91 million) in the calculations. On this basis and

assuming that government expenditures continue at a real level equivalent to $77 million per

year (same as in the AIEPED), the expected rate of return on the investments in veterinary and

human public health is 29 percent annually. If averted losses in the poultry sector were 20

12

Annual expected value of pandemic influenza impact on the economy in Vietnam, probability 1% per year of a

severe flu pandemic, for example. The same result obtains for a moderate pandemic, with a probability of onset of

2% in any one year.

Table A3. 2. Overview of the economic costs influenced by stronger public health systems (national benefits only)

(1) (2) (3)= (2)/(1)

(4) (5) (6) (7) (8)= (2)+ 0.1*(5) +(7)

GDP ($b) Costs of outbreaks

($ m)

Cost as % of GDP

Sever e pandemic potential cost ($b)

Pandemic risk, annual, $m 12

Number of human cases

Medical costs, treatment of human cases

($ m)

Total costs ($m)

2004 49.4 (actual)

247 (actual)

0.50% (actual)

2.4 (estimated)

24 (estimated)

29 n.a. 250 (actual)

2013 171.4 (actual)

0.49 (actual)

0.00% (actual)

8.2 (estimated)

82 (estimated)

2 n.a. 83

Benefit of (1) an averted outbreak in poultry as severe as the one in 2004 and (2) an averted severe pandemic: 2015 189 945 0.50% 9.1 91 - -

46

Figure A3.1. The poorest households suffer larger income declines than

wealthier households with a ban on backyard poultry sales

Source: FAO case study in Vietnam

percent (instead of 10 percent) of the 2004 value of losses of the outbreak, the internal rate of

return would be 129%. This scenario would be equivalent to prevention of a large outbreak of an

animal disease like that in 2003-4 once every five years.

109. Poverty impacts. The costs of avian influenza differ for different social groups, such as

poor rural households or small commercial poultry producers. The proportion of poultry

production undertaken by backyard and small commercial systems is much higher at lower levels

of per capita income. In Vietnam, where the bulk of poultry production is still by backyard

producers, the impact has fallen mostly on individual rural households, and has only partly been

offset by government compensation

to farmers. Survey data show

that the poorest quintile of

households relies more than 3

times as much on poultry income

than does the richest quintile, so

there are also adverse

distributional effects. Research

has shown that income from

poultry is much more equally

distributed than overall income.

Reductions in poultry income

due to avian flu or to avian flu

control strategies will thus tend

to worsen income distribution in

Vietnam. Since diseases

outbreaks have declined

dramatically since 2004, major

negative impacts on the poor and

rural income distribution have

been prevented (Figure A3.1).

110. Mitigation of global pandemic risk. Vietnam’s effective and prompt control of H5N1

flu outbreaks in poultry and strengthened human health systems to detect and appropriately

handle any human H5N1 flu cases helped mitigate the pandemic flu risk globally. However, the

global pandemic risk may still be rising, notwithstanding the reduction due to the successful

H5N1 flu control in Vietnam. The probability of emergence of a pandemic virus depends on the

virus load in the environment; this would increase with greater unchecked spread of avian flu in

poultry, including in poultry in Vietnam. This contribution of OPI and AIEPED to the global

effort to prevent a severe influenza pandemic was very important, but it is impossible to

quantify.

47

Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/

Specialty

Lending

Anh Thuy Nguyen Operations Officer EASHD

Binh Thang Cao Sr. Agricultural Specialist EASRD

Jan Hinrichs Agriculture Economist FAO

Les D. Sims Animal Disease Management Specialist FAO

Mai Thi Nguyen Senior Operations Officer EASHD

Nguyen Chien Thang Senior Procurement Specialist EASRD

Quynh Xuan Thi Phan Financial Officer EASFM

Samuel S. Lieberman HD Sector Coordinator EASHD TTL

Severin Kodderitzsch Practice Manager GFADR TTL

Thu Thi Le Nguyen Operations Analyst EASRD

Supervision/ICR

Anatol Gobjila Senior Operations Officer GFADR

Anh Thuy Nguyen Operations Officer GHNDR TTL

Binh Thang Cao Senior Agricultural Specialist EASVS TTL

Hai Yen Tran Program Assistant EACVF

Hoi-Chan Nguyen Senior Counsel LEGES

Huy Toan Ngo E T Consultant EASVS - HIS

Huy Toan Ngo Environment EASVS

Jan Hinrichs Agriculture Economist FAO

Jennifer K. Thomson Chief Financial Management Specialist OPSOR

Lan Thi Thu Nguyen Natural Resources Economist GENDR

Les D. Sims Animal Disease Management Specialist FAO

Lingzhi Xu Senior Operations Officers GHNDR

Ly Thi Dieu Vu Consultant GSURR

Mai Thi Nguyen Senior Operations Officer GHNDR

Mai Thi Phuong Tran Financial Management Specialist GGODR

Maya Razat Program Assistant GSPDR

Minh Thi Hoang Trinh Program Assistant AFCNG

Nga Quynh Nguyen Program Assistant GHNDR

Nga Quynh Nguyen Program Assistant GHNDR

Nghi Quy Nguyen Social Development Specialist GSURR

Nguyen Chien Thang Senior Procurement Specialist EASRP-HIS

Nguyen Hoang Nguyen Procurement Specialist GSURR

Nguyen Hoang Nguyen Procurement Specialist EASR2

Quynh Xuan Thi Phan Financial Officer GEFOB

Samuel S. Lieberman Lead Economist EASHD - HIS TTL

Severin L. Kodderitzsch Practice Manager GFADR

Shiyong Wang Senior Health Specialist GHNDR

48

Names Title Unit Responsibility/

Specialty

Thang Chien Nguyen Senior Procurement Specialist EAPPR

Thao Thi Phuong Nguyen Program Assistant EACVF

Thu Thi Le Nguyen Operations Analyst GENDR

Thuy Cam Duong Environmental Specialist GENDR

Tuan Anh Le Social Development Specialist GSURR

Olga Jonas Economic Adviser GHNDR ICR TTL

Laurent Msellati Practice Manager GFADR ICR adviser

Piers Merrick Senior Operations Officer MNADE ICR adviser

(b) Staff Time and Cost

Stage of Project Cycle Staff Time and Cost (Bank Budget Only) USD Thousands

No. of Staff Weeks Travel Consultant Costs

Lending

FY07 72.37 47.42 253.56

FY08 35.15 8.40 0.00

Total: 107.52 55.82 253.56

Supervision/ICR

FY09 38.12 18.59 7.75

FY10 35.08 7.52 0.00

FY11 31.41 6.25 0.00

FY12 14.10 3.23 0.00

FY13 18.84 6.44 16.58

FY14 19.10 19.34 0.41

Total: 156.65 61.37 24.74

49

Annex 5. Comments on Draft ICR and Recommendations from Borrower’s ICR

111. The government’s ICR, VAHIP Consolidated Project Completion Report for the Animal

and Human Health Components from the Ministry of Health and the Ministry of Agriculture and

Rural Development (Ophelia M. Mendoza and Les D. Sims, consultants, October 2014), was

submitted to the World Bank. It is a thorough and well-argued analysis of project outputs,

implementation experience, and achievements. Rather than present a summary of the

government’s entire ICR (which would duplicate much of the main text of this report), the

following sections present: (i) comments from the government on the World Bank’s draft ICR

report, (ii) graph on the science of delivery under VAHIP, and (ii) additional recommendations

for future approaches to zoonotic disease prevention and control from the government’s ICR

report.

Comments from the government on the draft ICR

112. The Ministry of Health and the Ministry of Agriculture and Rural Development reviewed

the draft of this ICR report in November 2014 and kindly provided corrections and suggestions,

which have been reflected in the main text. The comments from the Ministry of Health were:

The VAHIP was successfully implemented. The results of the project have contributed to

strengthening the capacity of the health system backup from the central to local levels in the

prevention of infectious diseases. There are many factors contributing to the success of the

project, including the World Bank. The role of the World Bank is not only in the preparation of

the project, to find funding for the project, but also in the process of project implementation,

specifically as follows:

- World Bank has played a very active role in the process of project implementation. The

regulations and agreements between the World Bank and the investors (General Department

of Preventive Medicine, Ministry of Health) in the project framework were fully implemented.

The documents and management records of projects submitted to the World Bank were

answered in a timely manner.

- In addition to the mission in accordance with the project framework, the World Bank has

actively coordinated regularly with PCUs and PPCUs to find the solutions to the difficulties

encountered during the project implementation.

- The flexibility of the World Bank, especially in terms of making changes in budgetary

allocation, made it easy for the project to transfer unused funds for certain items and transfer

it to other activities, which can benefit from additional financial resources. This flexibility

made it possible for the project to exceed the targets for a number of important activities like

the number of simulation exercises conducted, the number of participants trained, as well as

the number of districts and communes covered under the Additional Financing phase. These

facilitating factors which made it easier for the project implementation.

- There are however factors which slowed some activities of the project such as very low cost

norms often discouraged participation especially in training activities which required

participants to travel from their districts/communes to the training venue.

50

- Because the project must operate within the legal frameworks of the World Bank and

Vietnam governments, sometimes have trouble finding a solution to satisfy both the legal

frameworks. This is an issue that needs to be scrutinized for the project in the future to have

a project manual easy to implement and effective in accordance with the requirements of the

World Bank and the Government of Vietnam.

The World Bank’s draft implementation completion and results report on VAHIP fully reflects

the activities and outcomes of the project. The lessons learned and recommendations are

accurate. We completely agree with the content of the report and sincerely thank the valuable

contribution of the World Bank on the success of the project.

The following feedback was provided by the Ministry of Agriculture and Rural Development

(edited for clarity, with comments added):

- We agree with almost the content mentioned in the draft ICR report, except for analysis of

objective and result indicators because there are some gaps compared with the government’s

M&E reports provided. [Comment: the indicators in this ICR are based on the government’s

ICR and the set of indicators monitored in ISRs, whereas the project’s excellent M&E reports

are more extensive and detailed. The government’s ICR provided a valuable discussion of the

challenges of monitoring progress in control of poultry disease in large geographic areas with

high-volume poultry production and trade; the program was inherently complex both

technically and operationally, which was appropriately reflected in the M&E reports.]

- A project design shortcoming was the capital distribution. A small capital amount was

distributed among 11 provinces and their 144 districts to undertake many diverse activities,

and this slowed progress especially at the beginning. The lesson from this experience was

taken on board in developing LIFSAP project in which the capital is focused and invested in

a certain number of provinces. As a result, much progress can already be seen in the LIFSAP

project implementation. [Comment: this is a good recommendation to consider in other

decentralized programs where there may be risks of spreading effort too thinly.]

- Reimbursement mechanism posed several difficulties. The ceiling of the special account was

too small to distribute funds to 12 project implementation units, causing difficulty in

disbursement, especially in the final stages of the project. The threshold for direct payment

was too high. Exchange rate for refunds of advances from the provinces to the special

account was not specified in the legal agreement or the project implementation manual, and

this complicated processing of disbursement. [Comment: these are valuable observations to

consider in the design of disbursement arrangements in similar future projects.]

- World Bank support to project management and coordination: with authority to make

decisions devolved to the office in Hanoi, the World Bank’s experts have been active and in

very close touch with issues relating the project management and coordination. The World

Bank team members have dealt with the issues promptly and efficiently, therefore, it helps

push the project progress. However, we recommend that after a mission, the management

letter and aide-memoire should be agreed by the two parties in order to ensure higher

accuracy and unanimous understanding between the parties. Thanks for your cooperation.

[Comment: thank you very much for this comment. A shared view of project challenges and

solutions is very important, but so is clarity about disagreements and problems. Errors

51

should, of course, be minimized as much as possible, and the World Bank team has truly

appreciated the corrections and discussions of differing assessments.]

Figure A5.1. Science of delivery under VAHIPSource: Government of Vietnam ICR, p. 29

INPUT OUTPUT OUTCOME IMPACT

I

SMALL CIVIL WORKS

• 12 Isolation Wards of 11

provincial hospitals

upgraded

TOOLS AND TECHNOLOGY

• Online reporting system for

infectious diseases installed

• Provincial and district

hospitals and preventive

medicine centers provided

with hospital, laboratory and

communication equipments

CAPACITIES

• HWs trained on management

and planning; surveillance

software application; disease

surveillance, prevention,

control and management;

and on BCC and risk

communication

• Sub-groups of the population

trained on prevention and

control of AI and EIDs

APPROACH

• MARD and MOH

collaboration

institutionalized at all levels

• Multi-sectoral RRTs formed

and activated

SMALL CIVIL WORKS

• Capacity of 11 provincial

hospitals for infection

control improved

TOOLS AND CAPACITIES

• Completeness and

timeliness of reporting of

infectious diseases at all

levels improved

• Increased access to and

use of upgraded

equipments for diagnosis

and case management of

infectious and other

diseases and conditions

especially at district level

• Human resources

strengthened and capable

of effective and rapid

detection and response to

AI and EIDs

• Heightened community

awareness on prevention

and control of AI and EIDs

APPROACH

• Stakeholders adopt and

implement a multi-sectoral

approach in policy and

practice in relation to

pandemic preparedness

and response to AI and

EIDS

• Rapid and effective

control of AI and EIDs

• Coordinated

institutionalized multi-sectoral response to AI and EIDs at all levels

• Decreased morbidity and mortality due to AI

and EIDs

SMALL CIVIL WORKS

• Upgradiing of provincial

hospital Isolation Wards

TOOLS AND TECHNOLOGY

• Computer hardware and

software

• Laboratory, hospital and

communication

equipments for district

and provincial hospitals

and preventive medicine

departments

CAPACITIES

• Technical support

• Training of HWs on

prevention, surveillance,

control and

management of

infectious diseases;

management and

planning

• Training on BCC and risk

communication for HWs

and subgroups of

population

APPROACH

• One Health

• Strengthening oF

District Health System

Recommendations for next steps after VAHIP (from Part 3 of the government’s ICR)

1. RECOMMENDATIONS ON TACKLING NEWLY-EMERGED ZOONOTIC AVIAN

INFLUENZA VIRUSES

113. VAHIP ends at a time when external events are creating additional pressures on the

poultry sector and new challenges from emerging zoonotic diseases are arising. It is evident that

while many of the gains from VAHIP will be sustained, much still needs to be done to ensure

that livestock reared in Vietnam do not pose a risk to human health locally and globally.

114. In the past 12 months, four new strains of avian influenza virus have caused human

disease in the broader region, including viruses of the H5N6, H7N9, H10N8 and H6N1 subtypes.

Most of these have been linked to live poultry markets. New strains of H5N1 virus continue to

emerge and spread in the region with one particular clade of H5N1 virus now spread across

Vietnam from north to south and into Cambodia over the past 2 years (Clade 2.3.2.1c). This has

complicated control programs, especially in the south where vaccination was targeted at Clade 1

viruses that have been endemic to this area since 2003-4. In addition, H5N8 viruses have

emerged in China and spread to South Korea and Japan. As of yet there have been no known

52

human infections but infection has been reported in dogs with access to infected poultry and

experimentally infection of mammals with an earlier strain of this virus has been reported.

115. Of these viruses, the H7N9 virus has been the most significant causing losses to the

poultry sector in China of more than US$15 billion. This virus first emerged as a problem in

March 2013 in Shanghai but has also caused major losses in eastern and southeastern provinces,

especially Zhejiang and Guangdong. H7N9 spreads more efficiently from poultry to humans than

the H5N1 subtype, with almost 10 times more human cases reported for H7N9 in just over 12

months than for H5N1 in the period from 2003 to 2014. Of the more than 400 cases of human

infection with H7N9 in China, approximately one third of cases have been fatal.

116. Some improvements had been made to live poultry markets in China prior to the

emergence of this virus, but these upgrades were not sufficient to prevent the virus from

becoming established in markets. This virus has resulted in temporary and, in some cases,

permanent closures of live poultry markets. The trend in China at present is to shift away from

live poultry sales in major urban centers because of the emergence of H7N9 virus.

117. While the H5N1 virus can be silent in ducks and may be present in markets without any

apparent increase in mortality, when it gets in to susceptible chickens it causes severe disease.

This is not the case with H7N9, which only produces sub-clinical infection. Unless active

surveillance programs are in place, H7N9 will not be detected in poultry. In China the first

indication of infection with this particular virus was the detection of human cases, although a

related virus was detected in 2010.

118. H7N9 has been a tipping point for live poultry markets in China and if (when) this virus

gets to Vietnam it will probably result in similar effects unless markets are being managed or are

capable of being managed in a manner that prevents this virus from becoming established in

markets. Detection of this virus, especially if associated with fatal or severe human cases, will

almost certainly accelerate the shift from sale of live poultry in markets to centralized slaughter,

unless the markets are extremely well managed with excellent hygiene and strict controls on

sources of poultry. If cases of severe or fatal disease are associated with any particular market in

Vietnam there will be calls, on public health grounds, for a temporary closure of that market. The

current national contingency plan for H7N9 includes temporary market closures as one of the

measures to be taken.

119. VAHIP has been instrumental in reducing the risks associated with live poultry trade in

some markets and many of the small markets improved by VAHIP would pose a very low risk of

remaining infected with H7N9 virus if it were to gain entry to Vietnam. Nevertheless in some of

the existing larger markets where only minor changes have been made, the markets are still at

risk of becoming and remaining infected if this virus does get to Vietnam. If this occurs it will be

necessary to undertake radical changes to the way some existing markets are managed, including

reconstruction, if they get infected. Ha Vy market has many of the changes in place that will help

it to cope if this virus emerges but will still require extreme care and diligence to implement all

of the required biosafety measures if it is to remain a viable part of the live poultry trade. Much

will depend on the capacity of the market management team to control entry of poultry

(preventing birds of unknown origin from entering) and to continue implementing measures that

break any cycles of transmission if the virus became established in the market.

53

120. A shift away from live poultry sales especially in major urban centers should be

implemented over time. In addition, no new live poultry markets should be built (except to

replace existing facilities). However, until such time as this switch occurs it is important for live

poultry markets to operate and to be able to operate in a manner that reduces the public health

risk to traders. This will include measures such as regular market rest days and regular cleaning.

121. Despite the best efforts of veterinary services to prevent viral incursions, new strains of

zoonotic avian influenza virus will be detected in Vietnam. Lao PDR has just detected H5N6

virus and this virus has now been detected in Vietnam across a number of provinces in north and

central Vietnam. H7N9 virus has been detected in Guangxi province adjacent to Vietnam, and it

is only a matter of time before viruses of this subtype are detected in Vietnam based on the past

history of viral incursions.

2. RECOMMENDATIONS ON REDUCING RISKS FROM OTHER PATHOGENS

122. As the global population increases it is almost inevitable that other new agents will

emerge from animal populations to infect humans that either have pandemic potential or cause a

pandemic. One recent example is the emergence of a novel (MERS) coronavirus with likely links

to viruses found in camels and bats. Many of the elements that have been developed under

VAHIP will be very helpful in tackling these diseases and should be built on. Experiences from

elsewhere in the region should also be examined for relevance to parts of Vietnam. The Healthy

Livestock, Healthy Village, Better Life program that formed part of the World Bank avian

influenza project in Cambodia demonstrated that local actions at the village level can be taken to

strengthen biosecurity and disease control measures while at the same time improving

profitability from poultry production. The levels of poverty in villages in Cambodia are greater

than those in Vietnam but elements of this program may be adaptable to parts of Vietnam. This

has been proposed in AIPED.

123. One of the key lessons to be taken from this program is that the activities were not just

directed against one disease and villages played an active role in disease control and prevention.

124. Much still needs to be done to ensure livestock production and marketing in Vietnam is

undertaken in a manner that does not pose a threat to public health and the environment.

Development and modernization of poultry markets and the shift to centralized slaughter will not

occur evenly (it is evident already that certain central slaughter facilities are operating well round

Ho Chi Minh City but others are struggling to gain traction in the market. Market shocks as a

result of emergence of new diseases remain a constant threat to all parties, even to those who

already have biosecure systems of production and marketing in place, based on the experiences

from China. A One Health/Ecohealth approach is needed to these issues in which the factors that

lead to disease emergence are considered, understood and addressed instead of focusing only on

the immediate issues of emergency control of outbreaks when they occur.

3. RECOMMENDATIONS TO REDUCE RISKS FROM H5N1 AVIAN INFLUENZA

125. As expected when VAHIP was first developed, the H5N1 virus has not been eliminated

from Vietnam. However, a new equilibrium has been established. The virus continues to

circulate causing occasional disease outbreaks but nothing like those seen in 2003-04 when

54

H5N1 viruses first emerged as a serious problem. Most outbreaks of disease are localized and

confined to a relatively small number of farms/households and affect terrestrial poultry such as

chickens or quail, and occasionally ducks and wild birds (swifts). Many farms have remained

free from infection for a number of years but the risk of infection has not gone away. Any

problems in implementation of farm biosecurity systems could result in viral incursion. VAHIP

has helped to reduce one problem which is persistence of virus in live poultry markets. The

measures that are being implemented in VAHIP markets are capable of breaking infection

chains. In addition VAHIP has demonstrated that it is possible to maintain disease free farms

despite the persistence of the virus in other parts of the poultry production and marketing system.

126. When cases of disease are recognized in poultry they are generally handled rapidly and

efficiently resulting in culling of diseased flocks but this does not address the root of the

problem. These include the persistence of virus in some duck populations and poorly controlled

movement of poultry including (in the past) considerable smuggling of poultry across

international borders. VAHIP has also demonstrated the risk posed by smuggled spent hens

based on the positive tests for H5N1 virus in the past.

127. If progress is to be made towards eradication of H5N1 virus these issues need to be

addressed. Already we are seeing some improvement in traceability of poultry and controls on

sources in Ha Vy market. This trend needs to continue with continual improvement of the

process. Grazing ducks especially those transported over long distances pose a particular hazard

but it has not yet been possible to prevent infection in all flocks of these ducks using existing

vaccines. Until such time as better duck vaccines are available it will be difficult to make much

progress in shifting from the current equilibrium. Nevertheless there are ways to protect other

types of poultry by reducing their contact with ducks and ways to achieve this should be

assessed, including improvements in farm and village biosecurity measures.

128. Livestock production still offers a powerful means of poverty reduction for the rural poor

but the challenges associated with small scale production are increasing as markets consolidate

and requirements for traceability and residue control increase. Ways need to be found to ensure

that poultry can still play a vital role in addressing poverty. In many rural areas small scale

poultry production is a crucial source of income and food security.

129. A two to three tier livestock sector is developing with the production systems depending

on both the type of farm and the market chain. Larger scale farms are likely to dominate the

market for major cities although opportunities remain for some niche products. This top tier of

producers will adapt to market demands and will likely have the funds needed to ensure they

supply an H5N1 virus- free product. The second tier comprises smaller commercial farms that do

not have the same financial resources to invest in biosecurity measures. They are at risk of being

excluded from major markets unless they can demonstrate that their birds remain free from

infection. The third sector is the small scale village producer with some excess birds for sale on

occasions. They can probably retain local sales but will struggle to gain market share in major

urban centers.

4. RECOMMENDATIONS ON BUILDING RESILIENCE

55

130. When a new disease emerges one of the first questions is: from which species is the agent

derived? Despite moves to try to minimize the use of labels such as ‘bird flu’, when a new

disease emerges and there is evidence that the agent may be derived from poultry, then some

product avoidance will occur. If the agent is found in poultry, all parts of the poultry sector will

be affected, as was the case with H7N9 in China. The H7N9 virus has largely been transmitted

from poultry to humans in live poultry markets. Consumption of poultry has been demonstrated

not to be a risk factor for human cases. Yet there has been avoidance of all poultry products. The

only way to build resilience into the livestock sector is to be prepared for the emergence of new

diseases, including design of appropriate messages for communication. VAHIP has helped to do

this.

5. RECOMMENDATIONS ON DISEASE SURVEILLANCE & REPORTING SYSTEM

131. The following would help the sustainability and utility of the disease surveillance system:

Expansion of the software application for the online reporting system to non-VAHIP

communes, districts and provinces. This is essential for the proper pilot-testing of the online

system and its eventual nationwide adoption.

Implementation of data quality control mechanisms to ensure accuracy and reliability of the

data. While the computer software can be programmed to incorporate built-in checks for

certain elements of accuracy and reliability, the greatest responsibility for data accuracy and

reliability still lies with the health worker who needs to be trained to ensure these aspects of

data quality at the point of data collection, long before the data is entered into the computer.

Further software enhancements should include functions like the incorporation of population

data to enable the computation of rates at lower levels, and the construction of an EPI

CURVE which is a basic tool used by epidemiologists for outbreak investigation.

Training of provincial, district and commune level staff on data analysis and utilization to

convert them from mere data providers to data users. Right now, the district and commune

level staff are merely transmit data to higher levels once it is collected. Providing them with

the skills to analyze and use the data they have collected will make them realize the

importance of maintaining data quality and will improve management of health programs at

lower levels, through effective use of health information.

Conduct of a systematic and thorough assessment of the feasibility and resource implications

of the new disease surveillance model suggested by VAHIP. The new model emphasizes the

use of village health workers and the private health sector as data sources at the peripheral

level, and formally includes the animal health sector in the infectious disease surveillance

system. This has implications for data flow and data quality which need to be studied

thoroughly before the new model can be considered for adoption.

Strengthening the linkage between the national database for emerging infectious diseases

(EIDs) and regional and global databases, to share information with, and learn from

experiences in, other countries.

6. RECOMMENDATIONS ON MOH-MARD COLLABORATION

56

132. VAHIP has been instrumental in activating and institutionalizing the MOH-MARD

collaboration and a lot of benefits have been achieved through this collaboration. As such, it is

important for it not only to be sustained but also to be expanded. For instance:

Replicate process of MOH-MARD collaboration other provinces, prioritizing border

provinces with Cambodia where AI continues to spread, and hence risks to enter Vietnam in

the future.

Continue to develop and conduct short joint training programs for MOH and MARD staff at

province, district and commune levels. This will further strengthen the linkage between staff

of both ministries. Examples of areas where joint training can be conducted are applied basic

epidemiology for human and animal health workers; social determinants of health and their

role in One Health; integrated methods of joint human and animal disease surveillance; and

health promotion and communication within the One Health framework.

Use the process of MOH-MARD collaboration followed by VAHIP as model for other

collaborations needed to enhance MOH functions, for instance with Ministry of Education

and Training for school health; with MOLISA for occupational health or gender-related

programs; and with Ministry of Transportation and the Police for vehicular accidents.

7. RECOMMENDATIONS ON STRENGTHENING THE DISTRICT HEALTH SYSTEM

133. Substantial resources from the human health component of VAHIP were spent to

strengthen the district health system. However, the activities undertaken and the outputs and

outcomes derived were merely the initial seeds of a robust district health system. Many more

measures are needed, including:

Ensure quality control in laboratories conducting new tests/procedures as a result of VAHIP–

provided equipment. A system of monitoring and supervision of district laboratories by the

provincial laboratories may be needed in relation to this.

Develop concrete guidance and norms for future inputs to strengthen district laboratories.

This is important to ensure procurement of appropriate equipment and other resources, which

donors may finance so as to build on the VAHIP achievements and further strengthen the

district preventive medicine system.

Develop policies for the optimum use of equipment in district laboratories and hospitals

Develop policies to minimize the brain-drain of trained district staff to higher levels and to

other institutions like the NGOs.

8. RECOMMENDATIONS ON THE COMMUNICATION PRODUCTS OF VAHIP

134. VAHIP produced useful and interesting communication products like the paintings of the

school children or the essays for essay-writing contests. They can be effective health promotion

materials for the continuing prevention activities for AI and other EIDs. The children’s paintings

can be used as design for health promotion messages on greeting cards, bags, t-shirts,

stationeries, notebook covers, etc. The designs can be used on posters for schools to teach

children about influenza prevention and control. Publication of the winning essays in local

newspapers can sustain people’s interest and remind readers about continuing threat of AI and

other EIDs. Materials used in the large number of simulation exercises could be assembled into a

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compendium of exercises, to serve as reference material for future trainings and simulation

exercises.

9. OPTIONS FOR FUTURE LIVESTOCK PROJECT WITH ONE HEALTH APPROACH

135. It is worth considering a project combining elements of LIFSAP and VAHIP that targets

only a small number of predominantly rural provinces in which the whole livestock sector is

examined and strengthened. This could include activities for village based producers, small scale

commercial producers and large scale producers, aimed at improving all three as well as

activities downstream (markets and slaughterhouses) and upstream (feed supply and breeding

farms). It can involve all types of livestock, not just poultry and build on the experiences from

the two projects. A project of this nature would provide marked economic benefits to the

provinces and reduce the public health and environmental effects of livestock production. It

could focus on provinces that have performed well in either VAHIP or LIFSAP (they have the

experience to make a project work) and would allow the gains made so far from these two

projects to be consolidated. A One Health approach would be adopted and the project would

have a 5 year time frame to allow for appropriate investments. A project of this nature would

undertake work that allows the following:

Understand all aspects of the livestock production and market chains

Identification of points in production and market chains for interventions that are expected to

make a difference to productivity, profitability, animal health and welfare and public health

Further strengthening of veterinary and animal production services within the target provinces

using a strong preventive focus

Ensuring better traceability of livestock and livestock products in the province

Control and prevention of major livestock and zoonotic diseases through better animal

management and vaccination and smart use of antimicrobial compounds

Building resilience for livestock producers in the face of flooding and droughts and

disruptions to markets

Defining the major constraints to production in each system (including diseases)

Prevention of chemical residues

Prevention of environmental degradation as a result of livestock production

Implementing rational livestock development plans covering each production type

Building community resilience to major hazards (for example: floods, fire, and disease

outbreaks) and related market shocks

Improving markets so that they don’t pose a risk to the public or traders

Ensuring adequate food resources for livestock

Build on the gains made in and positive experiences from LIFSAP and VAHIP

Focus on a small number of provinces and doing a thorough job is almost certainly better than

doing a more superficial approach in multiple provinces.

The model developed could then be used for other provinces in the future provided the

process is well documented and key lessons are learned.

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Annex 6. Comments of Cofinanciers and Other Partners/Stakeholders

All comments from partners are presented and addressed in Section 7 of the main text.

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Annex 7. List of Supporting Documents

VAHIP Consolidated Project Completion Report for the Animal and Human Health

Components. October 2014. Ministry of Health and the Ministry of Agriculture and Rural

Development (Ophelia M. Mendoza and Les D. Sims, consultants).

Program Framework Document for Proposed Loans/Credits/Grants in the Amount of

US$500 million Equivalent for a Global Program for Avian Influenza Control and Human

Pandemic Preparedness and Response, Report No. 34388, World Bank, December 5, 2005.

Animal and Pandemic Influenza – A Framework for Sustaining Momentum, Fifth Global

Progress Report, United Nations and the World Bank, July 2010 (http://un-influenza.org).

Integrated National Plan for Avian Influenza Control and Human Pandemic Influenza

Preparedness and Response, January 2006 (Red Book).

National Integrated Operational Program for Avian and Human Influenza (OPI), 2006-2010.

Ministry of Agriculture and Rural Development and Ministry of Health, Government of

Vietnam, May 2006 (Green Book).

Integrated National Operational Program on Avian Influenza, Pandemic Preparedness, and

Emerging Infectious Diseases (AIPED), 2011-2015 - Strengthening responses and improving

prevention through a One Health approach. Ministry of Agriculture and Rural Development

and Ministry of Health, Government of Vietnam, October 2011 (Blue Book).

Five-Year Health Development Plan: 2010 – 2015, Ministry of Health, Government of

Vietnam.

Vietnam National Strategic Framework for Avian and Human Influenza Communications:

2008-2010 ASEAN Medium-Term Plan on Emerging Infectious Diseases (2012-2015).

Asia Hanoi Declaration at the International Ministerial Conference: ”Animal and Pandemic

Influenza: The Way Forward” (IMCAPI 2010) Pacific Strategy for Emerging Diseases

(WHO SEARO and WPRO - 2005; 2010).

European Union (2010), Outcome and Impact Assessment of the Global Response to the

Avian Influenza Crisis, 2005-2010.

Keogh-Brown, M, Wren-Lewis, S, Edmunds, WJ, Beutels, P and Smith, RD (2009), The

Possible Macroeconomic Impact on the UK of an Influenza Pandemic, University of Oxford,

Department of Economics Discussion Paper 431.

World Bank (2008), Evaluating the Economic Consequences of Avian Influenza, by Andrew

Burns, Dominique van der Mensbrugghe, and Hans Timmer, available at

www.worldbank.org/pandemics.

World Bank (2012). People, Pathogens and Our Planet, Volume 2, The Economics of One

Health.

http://un-influenza.org/

http://www.worldbank.org/pandemics

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World Bank (2014). Independent Evaluation Group (IEG) Responding to Global Public

Bads: Learning from Evaluation of the World Bank Experience with Avian Influenza, 2006-

2013.

World Bank (2012). Connecting Sectors and Systems for Health Results. Public Health

Policy Note.

The Lancet Commission on Investing in Health (2013). Global Health 2035: a World

Converging Within a Generation.

Jonas, O. (2013) Pandemic Risk. World Development Report 2014 background paper, World

Bank. Available at www.worldbank.org/pandemics.

Lee, Jong-Wha and McKibbin, Warwick J. (2004). Estimating the Global Economic Costs of

SARS in Learning from SARS: Preparing for the Next Disease Outbreak -- Workshop

Summary, Institute of Medicine, Washington, DC, 2004, available at

www.ncbi.nlm.nih.gov/books/NBK92473/.

http://www.worldbank.org/pandemics

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Annex 8. List of Persons Met

Ministry of Health - Project Coordination Unit (PCU)

Dr. Vu Sinh Nam Director

Mr. Vu Van Quy Coordinator

Mr. Nguyen Manh Hung Planning consultant

Mrs. Tran Minh Thu Technical consultant on B4.2

Mrs. Tran Thi Kim Ngan M&E consultant

Mr. Nguyen Minh Thang Procurement consultant

Mr. Du Quang Thanh Communication consultant

Mrs. Nguyen Hong Trang Curative Care consultant

Ms. Ophelia Mendoza International Consultant on Final Evaluation

Ministry of Agriculture and Rural Development - PCU

Mr. Pham Viet Anh Director

Mrs. Lam Anh Hung Deputy Director

Mrs. Pham Bich Ngoc Chief Accountant

Mrs. Lai Thi Kim Lan Coordinator

Mrs. Le Minh Tam Lab consultant

Mr. Le Van Kiem M&E consultant

Mrs. Cao Phuong Anh Planning officer

World Health Organization

Dr.Kasai Chief Representative

Dr. Nguyen Thi Phuc Acting Team Leader

Food and Agriculture Organization (of the United Nations)

Dr. Jongha Bae - Chief Representative

Dr. Scott Newman

Mrs. Nguyen Thi Phuong

Oanh Operations Officer

Mr. Nguyen Song Ha Assistant to Representative

Ms. Markaday Priya Operations Officer

Ms. Astrid Tripodi Operations Officer

European Commission

Ms. Tran Thuy Duong Poverty Reduction Program Officer

US Centers for Disease Control and Prevention (CDC - Vietnam)

Mr. David B. Nelson Deputy Director

Mr. James C. Kile

Chief, Influenza and Animal-Human Health Interface

Program

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USAID

Mrs. Laurel Fain Director, Office of Health

Mrs. Kim Thuy Oanh Infectious Disease Specialist

Mrs. Huong Infectious Disease Specialist

Department of Animal Health

Mrs. Nguyen Thu Thuy Deputy Director General

Mr. Nguyen Ngoc Tien Epidemiology Specialist

General Department of Preventive Medicine

Dr. Tran Dac Phu Director General

Regional Animal Health Office No. 6 (RAHO6)

Mr. Binh Director General

Mrs. Thai Thi Thuy Phuong Vice Director

Dr. Ngo Thanh Long Director of Animal Health Diagnostic Center

Mr. Phuong Deputy Director of Animal health Diagnostic Center

Mr. Phuong Epidemiology Department

Ho Chi Minh City Public Health Institute

Dr. Le Vinh Deputy Director

Mrs. Kim Anh Deputy Director of Training Center

Ho Chi Minh City Pasteur Institute

Dr. Cao Thi Bao Van Deputy Director

Dong Thap Province People's Committee and PPCU

Mr. Phu Deputy Head of PPC's Cabinet

Mr. Truong Tan Buu Director of PPCU, Deputy Director of DOH

Mr. Vo Be Hien Head of sub-department of Animal Health

Mr. Tran Van Hai Planning Officer

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Map