Documentof The World Bank FOR OFFICIALUSEONLY ReportNo:T7674 TECHNICALANNEX ONA PROPOSEDGRANT INTHEAMOUNTOF SDR3.8 MILLION (USS6.0MILLIONEQUIVALENT) TO THE ROYALKINGDOMOF CAMBODIA FORAN AVIANAND HUMAN INFLUENZACONTROLAND PREPAREDNESSEMERGENCYPROJECT UNDERTHE GLOBALPROGRAMFORAVIAN INFLUENZAAND HUMAN PANDEMICPREPAREDNESS AND RESPONSE(GPAI) FORELIGIBLECOUNTRIESUNDERTHE HORIZONTALAPL February27,2008 Rural Development, Natural Resources and Environment Sector Unit SustainableDevelopmentDepartment EastAsia andPacific Region This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective September 2007) Currency Unit = Cambodian Riels (KHR) 1 Cambodian Riel = US$0.00025 US$l.OO = 4,015 Riels US$l.OO = 1S2647 SDRs FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS AH1 Avian and HumanInfluenza AI Avian Influenza AIDS Acquired Immuno-Deficiency Syndrome APL Adaptable Program Loan ARI Acute Respiratory Infection AWP Annual Work Program CAM-EWAR Cambodia Early Warning System CBDRM Community BasedDisaster Risk ReductionPrograms CDCD Communicable Disease Control Department DAHP Department o f Animal Health and Production EMP Environmental Management Plan EMPF Ethnic Minorities Planning Framework EU European Union FA0 Food andAgriculture Organization FM Financial Management GDP Gross Domestic Product GPAI Global Program for Avian Influenza Control and HumanPandemic Preparedness and Response HSSP Health Sector Strengthening Project HIV Human Immuno-Deficiency Virus HPAI Highly Pathogenic Avian Influenza H5N1 is one strain o f the HPAI virus MIAs Implementing Agency/Implementing Agencies IBRD InternationalBank for Reconstruction and Development IDA International Development Association IEC Information, Education and Communication IFR InterimFinancial Report ILI Influenza-Like Illness IPA InternationalProcurement Agent IPC The Pasteur Institute MAFF Ministryo fAgriculture, Forestry andFisheries MEF Ministryo fEconomyand Finance M&E Monitoring and Evaluation MIS Management Information System M O H MinistryofHealth N B C National Bank o f Cambodia N C D M NationalCommittee for Disaster Management N I C National Influenza Center NGO Non-Government Organization NVRI NationalAnimal Veterinary ResearchInstitute OAHP Offices o f Animal Health and Production OIE Animal HealthWorld Organization PDO Project Development Objective PDR People's Democratic Republic PHRD Policy and Human Resources Development PIP Project Implementation Plan PPE Personal Protection Equipment PPRRP Pandemic Preparedness, Response and Recovery Program RC Rapid Containment RGC Royal Government of Cambodia RRT RapidResponse Team SARS Severe Acute Respiratory Syndrome UN UnitedNations UNDP UnitedNations Development Program UNICEF UnitedNations InternationalChildren' EducationFund VAHW Village Animal HealthWorkers VHV Village Health Volunteers WHO World HealthOrganization Vice President: James Adams, EAPVP Country Director: Ian Porter, EACTF Sector Director: Christian Delvoie, EASSD Sector Manager: Rahul Raturi, EASRE Task Team Leader: Alan Piazza, EASRE CAMBODIA Avian andHumanInfluenzaControl andPreparednessEmergencyProject CONTENTS Page A. STRATEGIC CONTEXT AND RATIONALE ................................................................. 1 1 Introduction....................................................................................................................... 1 2 Country and Sector Issues................................................................................................ 2 3 Rationale for World Bank involvement.......................................................................... 3 4.... Country Eligibility under GPAI...................................................................................... 3 B CAMBODIA: COMPREHENSIVE NATIONALAH1PLAN......................................... . 4 1 General Objectives............................................................................................................ 4 2 Components of the National Plan.................................................................................... 4 3 Institutional Aspects ......................................................................................................... 6 4.... Financing Requirements.................................................................................................. 7 C. PROJECT DESCRIPTION ................................................................................................. 8 1 Project Development Objective ....................................................................................... 8 2 Project Components.......................................................................................................... 8 3... Lessons Learned and Reflectedinthe Project Design................................................. 10 D IMPLEMENTATION........................................................................................................ . 10 1. Partnership Arrangements ............................................................................................ 10 2 Institutional and Implementation Arrangements........................................................ 11 3.. Monitoring and Evaluation (M&E) of Outcomes and Results ................................... 13 4 Sustainability, Critical Risks and Possible ControversialAspects............................. 14 5.. Grant Conditions and Covenants .................................................................................. 16 E APPRAISAL SUMMARY ................................................................................................. . 16 1 Economic and FinancialAnalyses................................................................................. 16 2.. Technical.......................................................................................................................... 17 3 Financial Management................................................................................................... 19 4.. Procurement.................................................................................................................... 19 5 Social................................................................................................................................ 19 6.. Environmental and Social Safeguard Policies.............................................................. 20 7 SafeguardPolicies...........................................................................................................20 8.. PolicyExceptionsandReadiness................................................................................... 21 Appendix 1: ResultsFrameworkandMonitoring................................................................... 22 Appendix2: DetailedProjectDescription................................................................................ 26 Appendix3: ProjectCosts.......................................................................................................... 38 Appendix4: FinancialManagementandAssessment Report................................................ 40 Appendix 5: ProcurementArrangements................................................................................ 51 Appendix6: EnvironmentalAnalysis ...................................................................................... 65 Appendix 7: SocialAnalysis...................................................................................................... 77 Appendix8: EconomicAnalysis................................................................................................ 79 Appendix9: DiscussionNotes.................................................................................................... 83 Appendix 10: GoodGovernanceFramework.......................................................................... 91 Appendix 11: Statementof Loans andCredits...................................................................... 100 Appendix 12: Country at a Glance.......................................................................................... 101 Map No. IBRD/IDA 34707R CAMBODIA AVIAN AND HUMANINFLUENZACONTROL AND PREPAREDNESS EMERGENCY PROJECT PROJECT APPRAISAL DOCUMENT EASTASIA AND PACIFIC EASRE Date: February 27, 2008 Team Leader: Alan L.Piazza Country Director: IanC. Porter Sectors: Health(50 percent);Animal Sector ManagedDirector: Rahul production (50 percent) RatudChristian Delvoie Themes: Other communicable diseases (P);Rural services and infi-astructure (P);Natural disaster management(P) Project ID: P100084 Environmental screeningcategory: Partial Assessment Lending Instrument: Emergency Recovery Loan ProjectFinancingData [ ] Loan [ ] Credit [XI Grant [ ] Guarantee [ 3 Other: For Loans/Credits/Others: IDA Grant SDR 3.8 million (US$6.0million equivalent) Total Bank financing (USsm.): 6.0 million Proposedterms: IDA Grant Total: 5.05 5.95 11.00 Borrower: Royal Kingdom of Cambodia ResponsibleAgency: MinistryofEconomy andFinance(MEF) St. 92 Sangkat Wat Phnom, KhanDaun Penh Cambodia Tel: (855) 1286-1355 Fax: (855) 2342-87798 Estimateddisbursements(Bank W/US$m) ?Y I 09 I 10 I 11 12 ~~ ~~ h u a l 3.00 3.50 4.00 0.50 kmulative 3.00 6.50 10.50 11.00 Project implementationperiod: Start July 1,2008 End:June 30,201 1 Expectedeffectiveness date: June 30, 2008 Expectedclosing date: December 30,201 1 Does the project depart from the CAS incontent or other significant respects? Re$ TechnicalAnnex (TA) Section A. [ ]Yes [XINO Does the project require any exceptions from Bank policies? Re$ TA Section E.8 [XIYes [ ] N o Have these been approved by Bank management? [XIYes [ ] N o Is approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any critical risks rated "substantial" or "high"? Re$ TA Section 0.4 [ ]Yes [XINO Does the project meet the Regional criteria for readiness for implementation? Re$ TASection E.8 [XIYes [ ] N o Project development objective; Re$ TASection C.1 and Appendix 2. Consistent with the Global Program for Avian Influenza and HumanPandemic Preparedness and Response (GPAI), which was approvedby the Bank inJanuary 2006, the project's overall development objective i s to support the implementation o f the Cambodia ComprehensiveAvian andHumanInfluenza (AHI) National Plan(the AH1Plan), contributing to minimize the threat posedto humans and the poultry sector by an AH1infection inCambodia, and to prepare for, control and respond (ifnecessary) to a human influenza pandemic. More specifically, the project i s expected to provide direct support to the implementation o f the National Comprehensive AH1 Planto produce the following outcomes: (a) to contain the spread o fthe disease, thus reducing losses inthe livelihoods of commercial andbackyard poultry growers and damages to the poultry industry and diminishingthe viral load inthe environment; (b) to prevent or limit human morbidity and mortality by stemming opportunities for human infection, and strengthening curative care capacity; and (c) to prevent or curtail macroeconomic disruption and losses by reducing the probability o f a humanpandemic andimproving emergency preparedness and response. Project description; Re$ TASection C.2 and Appendix 2. ComponentA AnimalHealth.The objective o fthe component is to reduce and, eventually, - eradicate the H5N1 virus from the poultry sector inCambodia. This will reduce the risk o f humaninfectionwith avian andhumaninfluenza(AHI)andprotect the poultry sector andthe livelihoods o fmany small-holders and poor farm households. Additionally, upgrading the animal health system will improve livestock sector productivity with benefits for commercial and backyardproducers. ComponentB HumanHealthSystems.The component objective is to prevent the emergence - o f a humanpandemic inCambodia through the rapid identification and effective management o f human cases. Strengthening public health systems will enhance national pandemic preparedness andhelpto reduce the loss o flife that would result from ahumanpandemic caused by influenza. ComponentC Inter-MinisterialCooperationfor PandemicPreparednessand Overall - ProjectCoordinationandManagement. The objective o fthe component is to strengthen Cambodia's capacity to mobilize quickly and efficiently a coordinated multisectoral and society- wide response to an influenzapandemic. Strengthening the coordinated response capacity for an influenza pandemicwill also improve the effectiveness o f Cambodia's response to floods, droughts and other natural disasters. Inaddition, the component will provide support to the overall coordination o fproject implementation, ensuring linkages across relevant agencies and partners, andto implement the project's Monitoringand Evaluation (M&E) System. Which safeguard policies are triggered? Re$ TASection E.6 and Appendices 7and 8. The Environmental Assessment (OP4.01) and Indigenous Peoples (OP4.10) are triggered. The design incorporates the necessary mitigation measures for the adverse impacts associated with the activities involved inresponding to AH1outbreaks. An Environmental Management Plan (EMP) and Ethnic Minorities PlanningFramework (EMPF) will be finalized duringproject implementation after consultationwith various stakeholders (government agencies, the commercial poultry associations, mass organizations, andNGOs) and subsequently disclosed in Cambodia and Washington D.C. (Infoshop). Significant, non-standard conditions for: Re$ TASection D.5 Crediteffectiveness: These will include: (a) the legal agreements regardingthe cofinancing resources from the PHRD Grant and the AH1Facility Grant are signed with the Recipient and all the conditions for their effectiveness (other than the effectiveness o fthe IDA Grant)have been met; (b) each ImplementingAgency (IA)has hiredthe key staffresponsible for project coordination and management, as required for their components (including government officials responsible for the coordinationo feach component and staff incharge o ffinancial management and procurement), ina manner satisfactory to IDA; and (c) the Annual Work Program (AWP) for the first year o fproject implementation has beenprepared by the Recipient and it i s acceptable to IDA. Covenantsapplicableto projectimplementation: DatedCovenants. These include: (a) byJuly 31,2008, the project EnvironmentalManagement Plan(EMP) andthe Ethnic Minorities' Planning Framework (EMPF), both satisfactory to IDA, have been approvedby the Recipient, and have beenproperly disclosed inthe country; (b) by September 30,2008, the Project Implementation Plan(PIP), satisfactory to IDA, has been prepared by the National Committee for Disaster Management (NCDM) incoordination with the IAs, including arrangements for implementation, procurement, accounting, financial management, auditing procedures, M&E andreporting arrangements; (c) the Ministryo f Agriculture, Forestry and Fisheries (MAFF) and the N C D M will establish complete financial management systems acceptable to IDA, includingthe establishment o f computerized accounting software, not later than September 30, 2008; (d) AWPs (withbudgets) for each calendar year will bepresented not later than 30 o f September o fthe previous year for discussionwith IDA; (e) annual physicalprogress reports and financial statements, not later than April 30 of each year and covering the precedingcalendar year, will be presentedto IDA for discussions and approval; (f) InterimFinancialReports (IFRs) for each quarter, not later than 45 days after the end o f the quarter, will be presented to IDA; (g) a Mid-Term Progress and Assessment ReporZwill be presented by the NCDM, incollaboration with the implementing agencies (IAs), for discussion with IDA, at the end ofthe second year ofimplementation; and (h) annual audits o fthe financial statements for the entire project will be submittedto IDA,together with the management letter, by independent auditors under Terms o fReference acceptable to IDA,within six monthso fthe end o f each financial year. Inaddition, the Recipient shall ensure that the project is carried out inaccordance withtheprovisionsofthe GoodGovernance Framework (Appendix 10) andthe "Anti-Corruption Guidelines on Preventingand Combating Fraud and Corruption inProjects Financedbv IBRDLoans and IDA Credits and Grants", dated October 15,2006. A. STRATEGICCONTEXT AND RATIONALE 1. Introduction 1. The continuing outbreaks o f highly pathogenic avian influenza (HPAI) in recent years have caused substantial damage to the poultry industryin several regions of the world, resulted in some loss of human life and raised concerns about a possible human pandemic.' Large-scale outbreaks began in 2003 inseveral SoutheastAsian countries, and HPAI has now reached Europe, the Middle East and West Africa. More than 150 million birds have died from the disease or have been killed as part of the effort to contain HPAI. Economic losses to the Asian poultry sector alone are estimated at around US$10billion. Much of these losses have been sufferedby millions o f poor farm households that depend uponpoultry for home consumptionand some cash income. referred to as Avian and Human Influenza - AHI) since 2003, and 228 of these infected people 2. There have been 363 laboratory-confirmed human cases of infection with HPAI (hereafter have died. Nearly all of the confirmed cases are known to have had contact with birds and, so far, AH1 does not transmit easily from human to human. However, the virus is evolving and it is believed that it may acquire the characteristics that would enable efficient human-to-human transmission.* Each additional human case gives the virus an opportunity to improve its transmissibility in humans and thus to develop into a pandemic strain. The recent spread o f the virus to poultry and wild birds in new areas further broadens opportunities for human cases to occur. While neither the timing nor the severity of the next pandemic can be predicted, the probability that a pandemic will occur has increased. If the virus achieves high transmissibility between humans and i s highly pathogenic, then a severe human pandemic could result with very large losses of human life and enormous economic disruptions and losses on a global scale. 3. The global response to the threat of AH1in humans and domestic poultry comprises four key strategies: (a) progressively controlling and eradicating the spread o f the disease in animals, thus lowering the animal-origin virus load in the environment and reducing the risks of human infection; (b) preventingand limiting the spread o f the disease among humans, thereby reducing the opportunity for the virus to improve its human transmissibility; (c) in the event of a pandemic, helping affected populations cope with its effects; and (d) minimizing the social and economic impacts from the threat of AHI. The prevention and control o f AH1involves many players in the areas of health, agriculture, natural disaster response, finance and planning, and a multi-sectoral approach i s therefore essential. It i s also recognized that the actions of individual countries are ' Avian influenza, or "bird flu", i s a contagious disease o f animals caused by viruses that normally infect only birds and, less commonly, pigs. Avian influenza viruses are generally species-specific but have, o n occasion, crossed the species barrier to infect humans. Indomestic poultry, infection with avian influenza viruses causes two mainforms o f disease, distinguished by low and high extremes o f virulence. The low pathogenic form commonly causes only mild symptoms and may go undetected. The highlypatogenic HPAIform causes disease affecting multiple internal organs and has a mortality rate that can approach loopercent, often within 48 hours inthe case o f chickens. H5N1i s one strain o f the HPAIvirus. 2 The virus can improve its transmissibility among humans via two principal mechanisms. The first is "reassortment", inwhich genetic material i s exchanged between human and avian viruses duringco-infection o f a human being or a pig. Reassortment could result ina fully transmissible pandemic virus, announced by a sudden surge o f cases with explosive spread. The second mechanism i s a more gradual process o f "adaptive mutation", whereby the capability o f the virus to bindto human cells increases during subsequent infections o f humans. Adaptive mutation, expressed initially as small clusters o f human cases with some evidence o f human-to-human transmission, would probably give the world some time to take defensive action. 1 central to a coordinated and effective global response. Country strategies should be developed in accordance with country-specific needs and circumstances, and the strategies should be owned by the individual governments facing the threat o f AHI. 4. Regional Dimension. In East Asia and the Pacific, cases o f AH1 have occurred in a number o f countries including Cambodia, China, Lao People's Democratic Republic, Indonesia, Japan, Korea, Malaysia, Myanmar, Thailand and Vietnam. Responses to the outbreaks indomestic and wild fowl have included screening, surveillance, precautions at the borders, movement control inside the country, culling programs, vaccination, enhancements in farm biosecurity, and changes to marketing and production practices. The World Organization for Animal Health (OIE) reports that, in 2004, over 60 million birds were destroyed and approximately 131 million were vaccinated. This response was the result o f over 800 outbreaks with over 22 million cases (this number includes the number o f fowl which have either become sick or have died from the disease), and over 4 million bird deaths attributed to AHI. On the human health side, since 2003, there have been 292 cases reported in Cambodia, China, Indonesia, Thailand and Vietnam, resulting in 195 deaths attributable to AHI. At the regional level, there are critical cross-country issues related to the implementation o f AH1 plans, mainly in terms o f coordination, the transmission and dissemination o f information, and the sharing o f experiences and lessons. The country specific strategies have been adapted to the specific conditions incountry. 2ountry and Sector Issues 5. Cambodia has achieved political and macroeconomic stability and, since 1993, has been experiencing rapid economic growth. Nevertheless, Cambodia's economy remains vulnerable and economic growth has not translated into widespread poverty reduction. With a GDP per capita o f US$390 (in 2005) and social indicators showing limited progress since the 1960s, Cambodia remains one o f the poorest countries in the world. About 35 percent o f the population has expenditure levels below the national poverty line, with about 15percent living inextreme poverty. Poverty in Cambodia i s overwhelmingly located outside Phnom Penh, with poverty incidence o f more than 50 percent inthe worst affectedareas. 6. Cambodia was one o f the first countries in Southeast Asia to experience AH1 infection. The first case was reported inDecember 2003, and the first wave o f the outbreak duringJanuary to M a y 2004 had a severe impact on smallholders who raise the majority o f the country's poultry under subsistence conditions and on small-scale commercial poultry farms. AH1 cases emerged again in late-2004 and early 2005, and four human cases (all o f which were fatal) were reported in 2005. There have been a few confirmed outbreaks among chicken, ducks and fighting cocks in 2006, and these cases were quickly contained (about 2,500 birds were killed by disease or culling during the February 2006 outbreak); however, two additional human deaths were confirmed in 2006. In2007, another human death was confirmed. The repeated outbreaks and associated loss o f human life and livelihoods highlight the country's inadequate disease surveillance system, the limited capacity to control the disease and the persistence o f infection inthe region. Thailand -- both o f which have experienced far greater outbreaks o f AH1 and significant human 7. Cambodia is situated between two large poultry producing countries -- Vietnam and infection. The region i s a potential flashpoint for an expansion o f avian influenza and the possible emergence o f a human pandemic strain o f influenza. The government i s now focused on the development o f an integrated AH1 control and human pandemic preparedness and response plan, and i s working closely with the international community to build its capacity for disease surveillance, disease control and prevention, outbreak investigation and emergency response. 2 3. Rationale for World Bank involvement 8. A key justification for the Bank's involvement is the global public goods aspect of controlling AHI. There i s also a national public goods perspective for countries to strengthen their veterinary services, disease surveillance and human health system as planned in this operation. The potential social and economic impacts of AH1 cannot be over-emphasized; this is an area where the Bank has extensive expertise and has been playing a key role. AH1 control programs require a multi-disciplinary approach to integrate technical, social, economic, political, policy and regulatory issues in addressing a complex problem. The Bank is well placed to draw on its knowledge-base concerning the multi-disciplinary approaches needed in the proposed operation, and to apply the evidence and lessons learned in various regions during emergency preparedness responses. The Bank can also be helpful in bringingtogether the relevant ministries, government agencies and the donor community, and inhelping ensure high-level politicalcoordination. 9. The Bank has been working with the World Health Organization (WHO), the Food and Agriculture Organization (FAO), the Animal Health International Organization (OLE), multilateral, bilateral and other partners in-country and at the international level to prepare the Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI). In Cambodia, the Bank has beenworking with the United Nations Development Program (UNDP; the convener o f the donor round table), other agencies of the UniteNations (UN)system (FAO, WHO, and UNICEF), the European Union (EU), and other partners to help the government assess and improve the National Comprehensive AHI Plan. The Bank can assist Cambodia in leveraging additional resources fi-om other bilateral and international agencies. In addition, the technical assistanceprovidedby the Bank has been important in similar global or regional emergencies such as Human Immuno-Deficiency Virus (HIV), Acquired Immuno-Deficiency Syndrome (AIDS), Severe Acute Respiratory Syndrome (SARS), and post-disaster reconstruction. The Bank has a proven comparative advantage inproviding integrator skills and multi-sectoral perspectives and in addressing the institutional dimensions of the response to such emergencies. It can also contribute extensive experience and skills inunderstanding and addressing the social and economic impact. 4. Country Eligibility under GPAI 10. The proposed project falls under the GPAI, approvedby the Bank's Board of Directors on January 16, 2006. GPAI support i s to be provided using the horizontal Adaptable Program Loan (APL) instrumentand within a global coordination fi-amework. Under the global APL, individual countries may obtain separate loans, credits and grants, as they become available, to finance their own national projects up to the global aggregate limit o f US$500 million. Since the GPAI i s designed to provide emergency financing to participating countries to contain outbreaks of AH1 through early detection and rapid response measures, the country-specific operations will be processed under the Bank's emergency policy OPBP 8.50. The GPAI will treat specific emergency response projects in each country as "phases" o f a horizontal APL (similar approaches include the Multi-Country HIV/AIDS Programs for the African and Caribbean Regions). Cambodia clearly meets the eligibility criteria specified inthe GPAI document, given that: (a) it i s a country in"endemic situation" (withrepeated outbreaks inpoultry and six human deaths); (b) the National Comprehensive AHI Plan (see above paragraph), integrating both the animal and the human health sectoral plans, has been preparedand approved by government; and (c) the activities included under this project are fully consistent with the provisions and objectives o f GPAI. 3 B. CAMBODIA: COMPREHENSIVENATIONAL AHI PLAN 1. GeneralObjectives 11. The overall objectives o fthe Royal Government o f Cambodia's response to AH1are to: Controloutbreaks of Avian Influenzainpoultry and thus to limit the economic costs o f the disease and the potential for its expansion into humans. 0 Prevent transmission of Avian Influenzafrom birds to humans, and thus to limit the opportunities for mutation o f the virus into one capable o f human-to-human transmission. 0 Minimizethe risks and consequencesof a pandemic by planning for such an outbreak, both interms o f human health services and o f the preparedness o f the society as a whole. 12. The human health planning i s consistent with Responding to the avian influenza pandemic threat: recommended strategic actions prepared by WHO, and the pandemic planning done to date has followed the WHO Checklist for Influenza Pandemic Preparedness Planning. The animal health planning i s consistent with The Global Strategy for the Progressive Control of Highly PathogenicAvian Influenza (FAO, OIE incollaboration with WHO, March2007) 2. Componentsof the NationalPlan 13. The Comprehensive National Plan on Avian and Human Influenza brings together the previously separate Animal and Human Health Plans and adds an Inter-Ministerial Cooperation Plan and a National AI Communications Strategy. The integratedNational Plan: (a) builds on, and complements, existing plans; and (b) provides support to the two lead technical ministries while further clarifying the coordination roles o f the government and other ministries in filling any remaining resource gaps and improving the effectiveness o f overall prevention and response activities. This National Plan will be the single point o f reference for avian and human influenza response in Cambodia. 14. Animal Health. The Ministry o f Agriculture, Forestry and Fisheries (MAFF), with the support o f FAO, has developed The National Strategy on Highly Pathogenic Avian Influenza Control and Eradication and The Action Plan for Implementing the Control of Avian Influenza (2006-2008). These were approved by the Minister o f MAFF in late December 2005. The key components o f the Strategy and the Action Plan are: National capacities in animal disease control; National animal disease information system; Research and diagnostic capacity; Public awareness and education; and Rehabilitation and restructuring o f the poultry sector. The Action Plan aims at controlling the H5N1 strain at the level o f the farm gate by: enhancing biosecurity measures; strengthening the surveillance and monitoring capacities supported by enhanced laboratory and diagnostic capacities; strengthening the relevant legal framework on the control of the movement o f live and dead birds; providing support for rehabilitation and restructuring o f the poultry sector (where this i s appropriate), including the up-grading o f markets; and seeking greater partnerships with stakeholders, including Village Animal Health Workers (VAHWs) and competent NGOs. The Action Plan i s for three years (2006-2008) and was estimated to require US$15,885,500. 15. Since this plan was prepared in2005 there has been a marked increase inknowledge on the control and prevention o f avian influenza (see for example the conclusions and recommendations 4 from the Technical Workshop inRome 20073). Not only do countries need to be ready to respond to emergencies, they also need to examine their poultry production and marketing systems for potential high-risk practices. Where these are considered to present an unacceptable risk they should be modified or, if this i s not possible for economic, social, environmental or technical reasons, then other interventionsneed to be considered to reduce the risk these represent. 16. The precise infection status o f Cambodia i s not known. Some surveillance studies have been and are being conducted but are hampered by difficulties incollecting sufficient quantities of samples over an extended period o f time and reluctance on the part o f poultry owners to allow birdsto be sampled. However, based on experiences from neighboring countries, it is highlylikely that infection i s present in the domestic duck population even if only intermittently. The role o f wild birds inthe spread and maintenance o f H5N1 HPAIviruses in Cambodia is not known. The epidemiology o f avian influenza in Cambodia i s also poorly understood. As most poultry are reared in small village flocks it i s likely that most o f these remain free from infection most o f the time. The country's population o f domestic ducks could potentially act as a reservoir o f infection. In addition there is some poorly regulated movement of poultry and poultry products from neighboring countries across Cambodia's long land borders. 17. HumanHealth. The Ministryo fHealth (MOH), with the support o fWHO, has developed the Action Planfor Avian Influenza in Cambodia, which was endorsed by the Minister o f Health in December 2005. The plan contains five key action areas: Education and Communication; Surveillance; Investigation and Response; Case Management; Laboratory Support and Pandemic Preparedness Planning for the Health Sector. 18. The focus o f this sectoral plan i s to address the short- to medium-term needs, using this opportunity to strengthen the overall systems for surveillance and response to emerging infectious diseases, including Avian Influenza. The specific activities requiring fundingwill include training o f rapid response teams, stockpiling medicines, and training and simulation exercises and outbreak response funds for a rapid intervention should a pandemic emerge inCambodia. 19. The Human Health Plan was estimated to require US$13,210,000 over a three year period. This includes detailed estimates for surveillance and response activities, case management and infection control as well as preliminary estimates for pandemic preparedness planning within the health sector. 20. Information, Education and Communications. The information, education and communications (IEC) component o f the government's response requires coordination across both the technical ministries and the government agencies that are involved in information dissemination. Duringthe Pandemic Alert Period, and even more so duringany possible Pandemic Period, there must be clear, accurate and consistent communication messages, addressed to the general population, as well as specific targeted groups - chicken farmers, health workers, etc. 21. Messages and media for the general public- leaflets, press releases, and radio and TV spots -arebeingpreparednow,forboththePandemicAlertPeriodsand,onacontingencybasis, forthe possible Pandemic Period. UNICEFhas been the agency working closely with MAFF and MOHto develop E C materials to meet the requirements o f the government. A complete IEC strategy and program i s being developed with the assistance o f the United Nations International Children's 3Available at htt~://www.fao.or~/docs/eims/u~load//232786/ah671 e.Rdf 5 Education Fund (UNICEF), which will allow improved coordination o f communications/public awareness activities. The preliminary estimate o f the cost o f the program was US$2,250,000. 22. Integrated Pandemic Preparedness. Recognizing that a pandemic outbreak is both likely and will affect Cambodia irrespective o f its origin, the government is developing a pandemic preparedness component. Cambodia i s drawing upon its response to the SARS outbreak in 2002 and 2003 in which numerous government agencies were mobilized to support surveillance, screening, communications, response and other activities. Inthe case o f an emergence of a novel influenza virus, an even broader preparedness and response is likely to be required. Inany case, it i s clear that potential pandemic diseases are likely to be a continuing risk for which the government must prepare itself to ensure effective and efficient response to both threat and outbreaks. Under the emerging coordination structure, the Royal Government will draw upon its experience with natural disasters, animal and human health emergencies and the provisions already reflected in the Animal and Human Health Plans to specify and cost out an integrated, pandemic preparedness plan over the coming two months. A preliminary estimate o f needs for pandemic preparedness was US$1,500,000, excluding those activities already covered under the Animal and Human Health Plans. The estimate for integrated pandemic planning will support business continuity planning and inter-ministerial facilitation and coordination. Inaddition, the government i s developing simulations to estimate technical and financial needs under different pandemic scenarios which will be integrated into the plan. One o f the key issues anticipated for future funding i s to ensure an adequate food supply duringa pandemic. 23. Program Management. The cost o f the coordination and management o f the implementation o f the program, along with the costs o f technical assistance, institutional building and training, as well as the enhancement o f the legal and regulatory framework, has been estimated as US$4.3 million. 3. InstitutionalAspects NationalCoordination. 24. On 22 January 2004, the RGC established the Inter-Ministerial Committee on the Prevention and Control o f Avian Influenza chaired by the Minister o f Agriculture, Forestry and Fisheries, with vice-chairs being the Minister o f Health and the Minister of Commerce. MAFF issued a "Prakas" for each province to form a Multisectoral Provincial Committee on Avian Influenza. This committee i s chaired by the Governor o f each province and has representatives from various sectors o f government, including agriculture and health. At a national level there i s also a Joint Technical Working Group on Avian Influenza, which meets every week to coordinate and discuss technical issues. Under this structure, the government has engaged with donors and NGOs with strong support from the UN system, to develop plans and coordinate donor-funded, immediate activities such as strengthening surveillance systems, laboratory testing, culling and planning. InstitutionalArrangementsfor PandemicPreparednessandResponse. 25. There i s a consensus acknowledgement that a human pandemic will involve many sectors and interests beyond those represented by the line ministries o f health and agriculture. Such an event could significantly affect travel, trade, employment and the economy, security and social order, and even basic services such as utilities, and food and water supply. For this reason, and also because there are cross-cutting issues in the animal and human health response plans and a need for a harmonized emergency response, the need for high-level governmental coordination i s 6 clearly recognized. The government has decided to assign the overall coordination responsibility o f the activities required to respond in the event o f a pandemic (Phase VI) to the National Committee for Disaster Management (NCDM). NCDMwas originally established by a sub-decree (No. 54 ANKR-BK) signed by the Prime Minister in 1995, and later amended in 1999. The Prime Minister i s the PresidendChairman o f NCDM, and NCDM i s integrated through the inclusion o f the Ministers in charge o f all ministries, the Provincial Governors and representatives o f the Armed Forces, National Police and Civil Aviation Authority. 4. FinancingRequirements 26. Cost Estimates. At the time o f preparation, it was estimated that the implementation o f the proposed activities would require US$37,090,500. Fundingrequirements have been estimated with detailed analysis for animal and human health activities for a three-year period, including provisions for limited stockpiling o f equipment and supplies likely to be required inthe event o f a significant outbreak. However, as indicated in the plans, additional contingencies will have to be anticipated inthe event o f a major outbreak or pandemic. 27. Financing Commitments and Gaps. As summarized below, the RGC has received financing commitments for implementation during the 2006 to 2008 period o f about US$7.8 million, including: US$5.9 million for the animal health sector; US$1.1 million for the human health sector; and about US$0.75 million committed by UNICEF for integrated communication. Therefore, the RGC estimated an overall financing gap o f around US$29.3 million for the three year implementation period, inrelation to the original cost estimates at the time o f preparation of the Plan. The proposed Bank-financed Avian and Human Influenza Project will cover US$11 million o f this estimated gap (about 38 percent) and will include all the core activities that are considered essential for the achievement o f the basic objectives o f strengthening the country's ability to carry out effective surveillance and responding to an eventual outbreak in an efficient manner. The remaining gap could be even reduced further if new commitments from international donors materialize. Financing FinanceGap Sectionsof the Plan Approved or Committed A. ANIMAL HEALTH: Control and 7 C. PROJECTDESCRIPTION 1. ProjectDevelopment Objective 28. Consistent with the GPAI, the project's overall development objective i s to support the implementation o f the Cambodia Comprehensive AH1 National Plan, which i s designed to minimize the threat posed to humans and the poultry sector by AH1infection in Cambodia, and to prepare for, control, and respond if necessary to a human influenza pandemic. More specifically, the project i s expected to provide direct support to the implementation o f the National Comprehensive AH1 Plan to produce the following outcomes: (a) to contain the spread o f the disease, reducing losses in the livelihoods o f commercial and backyard poultry growers and damages to the poultry industryand diminishingthe viral load inthe environment; (b) to prevent or limit human morbidity and mortality by stemming opportunities for human infection and strengthening curative care capacity; and (c) to prevent or curtail macroeconomic disruption and losses by reducing the probability o f a human pandemic and improving emergency preparedness and response. 2. ProjectComponents 29. The project will finance activities fully consistent with the objectives and the description o f the National Comprehensive Plan, with a focus on items not already covered by other sources o f funding(technical and financial gaps). The project will include three components that are detailed inAppendix 2, as summarizedbelow: 30. Component A -- Animal Health Systems (estimated cost: SDR 2.75 million and US$1.45 million; total of US$5.80 million equivalent). The objective o f the component is to minimize the levels o f infection with H5N1 HPAI viruses in Cambodia4 and it will be achieved through six subcomponents. The first subcomponent will strengthen veterinary services from the central to the village level to enhance the capacity to prevent, recognize and respond to avian influenza and other emergency animal diseases. This will be achieved through the strengthening and consolidation o f training resources, reviews o f training needs and curricula for VAHW training, enhanced reporting by trained VAHWs to District Veterinary Services, provision o f resources to support disease responses for district and provincial level veterinary services, and development o f appropriate animal health laws. The second subcomponent will provide training in emergency vaccination and necessary resources to implement emergency responses. Some additional epidemiological studies, including studies in wild birds, will also be conducted under this subcomponent. The third subcomponent will review high-risk practices in production and marketing that facilitate the persistence and transmission o f infection and implement appropriate measures to reduce these risks. The fourth subcomponent will include some additional epidemiological studies, including studies in wild birds, and will strengthen existing animal health IEC programs. The fifth subcomponent will enhance pandemic preparedness response for animal health staff, and the sixth subcomponent will provide support for the management o f the component. 4 The ultimate goal i s eradication but, even ifachieved, this is unlikely to be sustainable as long as infection persists inthe regionandillegalor uncontrolled crossborder movement ofpoultry andpoultryproducts occurs. Minimizing the levels of infectioninpoultry will reduce the risk o fhumaninfection andprotect the poultry sector and the livelihoods o f many smallholders and poor farm households. Additionally, upgrading the animal health system will improve livestock sector productivity with benefits for commercial and backyard producers alike. 8 31. Component B Human Health Systems (estimated cost: SDR 670,000 and US$2.44 - million; total of US$3.50 million equivalent). The objective of the component is to prevent the emergence of a human pandemic in Cambodia through the rapid identification and effective management of human cases. Strengthening public health systems will enhance national pandemic preparedness and help to reduce the loss o f life that would result from a human pandemic caused by influenza. The first subcomponent will focus on the training of health care workers and the development o f materials for use by health care providers and Village Health Volunteers (VHV). To improve surveillance, investigation and response, the second subcomponent will support the training o f Provincial Rapid Response Teams; the operating costs associated with surveillance, investigationand response; and the transportation for those undertaking both activities inthe field, as well as supervision costs by each level. International experts will be hired to identify activities necessary to ensure compliance with the International Health Regulations, and these findings will be disseminated. To support case management and infection control, the third subcomponent will finance the procurement and distribution of medicine, medical equipment and Personal Protection Equipment (PPE). Clinical training on case management and infection control will be supported, as well as the identification of and support to activities necessary to ensure appropriate health care waste management and infection control. The fourth subcomponent will support laboratory activities through the development o f a national laboratory strategy and continuous education and refresher training for laboratory staff on-site (usinginternational trainers) or at the local level using existing trainers in the country; and the provision of equipment, specimen collection kits, laboratory consumables and reagents, and transport for specimen transport inside Cambodia, as well as shipment abroad to WHO reference laboratories. Activities associated with pandemic preparedness for the health sector will be supported under subcomponent 5, and include the preparation and dissemination o f the plan, training provincial level staff to prepare their plans, and simulation exercises. Subcomponent 6 will support activities on rapid containment of an outbreak with a novel influenza virus that has the potential to createpandemic influenza: case management, infection control, isolatiodquarantine, and equipment and supplies. Activities under this subcomponent include rapid containment training curriculum development, workshops for rapid containment plan implementation, and rapid containment training for province, district and health centedhospital staff, border quarantine staff, and the Rapid Response Team (FWT), as well as for military, police and local authorities. The subcomponent 7 consists of the support necessary for overall implementation of the component (including staff travel costs, transport, operation and maintenance costs, and consumables). 32. Component C - Inter-ministerial Cooperation for Pandemic Preparedness and Project Coordination(estimated cost: SDR 383,000 and US$1.11 million; total of US$1.70 million equivalent). The objective of the component is to strengthen Cambodia's capacity to quickly and efficiently mobilize a coordinated multisectoral and society-wide response to an influenza pandemic. Strengtheningthe coordinated response capacity for an influenza pandemic will also improve the effectiveness o f Cambodia's response to floods, droughts, and other natural disasters. This objective will be achieved through five subcomponents: (a) under the first subcomponent the NCDM's current Terms o f Reference will be modified to better include inter- ministerial cooperation for pandemic influenza preparedness, and NCDM's capacity to oversee this cooperation will be strengthened through training, staffing and other measures; (b) inthe second subcomponent, NCDM will prepare and test a Pandemic Preparedness, Response, and Recovery Program (PPRRP); (c) in the third subcomponent, a N C D M emergency management information system (MIS) and an M&E system (for the overall national PPRRP) will be designed, developed and established; (d) under the fourth subcomponent, pandemic preparedness, response and recovery activities will be integrated into the existing Community Based Disaster Risk Reduction Programs (CBDRM); and (e) the fifth subcomponent will comprise support for the overall implementation o f the component. Since NCDM will take overall responsibility for overseeing 9 and coordinating institutional and implementation arrangements for the project as a whole (including overall project coordination, ensuring linkages across relevant agencies and with international partners, and for guiding and monitoring project implementation at the central level), the fifth subcomponent will also provide support for these important coordination functions. 3. LessonsLearnedandReflectedinthe ProjectDesign. 33. Previous World BanWIDA-supported emergency recovery projects provide a number o f relevant lessons for project design. Lessons learned o f particular relevance for an emergency AH1 project include: (a) emergency projects should avoid policy conditionality; (b) project design must be simple and take into account a realistic assessment o f the Borrower's capacity and other stakeholders' capacity; (c) a speedy appraisal and approval are crucial to provide a prompt response and a substantial contribution to project success; (d) procurement arrangements need to be flexible and should be finalized at an early stage; and (e) realistic assessments should be made o f counterparts' absorption capacity, as well as o f the effective communications and coordination mechanisms among all relevant stakeholders. 34. The experience gained through the implementation o f other emergency projects provides additional important lessons. These projects include the Vietnam Avian Influenza Emergency Recovery Project, projects in response to the SARS epidemic, and projects in response to the HIV/AIDSepidemic. These key additional lessons learnedinclude: Preparation o f a good quality national strategy i s a key factor. For implementation arrangements, it i s important to have a coordination structure empowered with multisectoral responsibilities, for instance responding directly to the Prime Minister's Office, and to have full-time project coordinators to implement activities ina crisis. Strengthening the technical, scientific and operational capacity o f the relevant participating agencies i s very important. It is crucial to raise awareness inthe public and private sectors as early as possible, and to strengthen effective coordination mechanisms for the implementation o f the necessary technical responses, involving the government, the donor community, the private sector and civil society. Good quality national surveillance i s clearly vital inpreventing the spread o f diseases. There i s a need for high-level and sustainedpolitical commitment and leadership. A comprehensive multi-sectoral approach o f prevention, treatment, care and support services has the best likelihood o f success. While emphasis must still be placed on prevention as the most cost-effective means o f managing the AI threat, programs should seek to address the whole spectrum o fprevention, treatment, care and support services. D. IMPLEMENTATION 1. Partnership Arrangements 35. Effective and suitable partnership arrangements for this project have been developed in Cambodia with the international technical agencies as well as with bilateral donor agencies currently providing assistance to the country, building on productive collaborative arrangements 10 developed over time in both the agricultural and health sectors under previous projects. During project preparation and appraisal, close consultations with local staff o f the multilateral and bilateral donors represented in Cambodia was maintained, mainly with the agencies involved in supporting the implementation o f the National Plan (i.e., UNDP, FAO, WHO, and UNICEF, EU, Agence Franqaise de Ddveloppement, USAID and AusAID). Roundtables were organized prior to and during the appraisal mission to brief these partners on the intended program o f working with the government to strengthen its National Comprehensive Plan, to ascertain their interest in providing financial andor technical support for the project and to coordinate the activities to be supported by each agency to improve overall effectiveness o f the combined actions and programs. 36. The Government o f Japan has already approved a PHRD Co-financing Grant (PHRD Grant) o f US$3 million for the project. Some o f the major donors (e.g., UNDP, FAO, WHO, GTZ, JapadJICA, USAID and AusAID) have already approved, or are planning to approve shortly, technical assistance projects to complement and to helpjump-start the activities proposed under the National Plan that are consistent with this project. A multi-donor trust fund, the AH1Facility, has been established to provide financial support for HPAIpreparedness to individual countries. This facility i s managed by the World Bank, and a total amount o f US$2 million has been approved to cofinance the proposedproject. 2. InstitutionalandImplementationArrangements 37. Implementing Agencies. The government has decided that implementation o f the project will be the responsibility o f three Implementing Agencies (IAs), as follows: ComponentA: The Animal Health component will be implementedby the Department o f Animal Health and Production (DAHP) o f MAFF through its existing structure and with the support o f a small unit incharge o f the coordination function for the component. This unit will be staffed with specialists in financial management, procurement and M&E, as well as external technical advisors. It is expected that MAFF will sign a service agreement with FA0 under which this international agency will provide: (a) the institutional strengthening needed for the implementation o f the component; and (b) technical assistance in key areas, its broad international experience in animal health in general, as well as in the wide-world efforts being implemented to control the spread o f avian influenza. FA0 i s recognizedas one o f the leading technical agencies inthe implementation of the animal health strategy to stop the spread o fH5N1. ComponentB: The HumanHealth component will be implementedby MOHthrough the existing PIU in charge of the existing Health Sector Support Project (HSSP). This PIU already has sufficient human resources and expertise to assume these new responsibilities. However, several additional consultants will be hired to strengthen its institutional capacity to implement this component (financial management and accounting, administration). Inaddition, it i s expected that MOH will sign a Service Agreement with WHO to receive technical assistance and capacity building to implement the component. WHO is an internationally recognized specialized agency of the UN system that i s supporting the response to the avian influenza threat in many countries around the world and i s in charge o f supporting key areas o f the National Comprehensive Plan in Cambodia. Component C: NCDM, through its General Secretariat, will be incharge o f the Inter-Ministerial Coordination for Pandemic Preparedness and will be responsible for the overall coordination and management o f the project. The current staff o f the General Secretariat will be strengthened by consultants in key areas, mainly financial management, procurement, human resources and M&E. Similarly to the other components, it i s expected that NCDM will sign a Service Agreement with 11 an agency o f the UN System to receive technical assistance during implementation. This Service Agreement will extend and complement the current capacity building program being executed by the UNSystem. 38. Under this implementation approach, the RGC (as the Recipient o f the grant financing) will enter into a Financing Agreement with the Bank for the IDA funds and into corresponding Grant Agreements for the grants from the PHRD and the AH1 Facility. These institutional implementation arrangements will contribute to fast and cost-effective implementation, providing assurances that the surveillance and response systems are fully operational in a short period and, therefore, able to produce an effective response inthe event o f an outbreak o f the disease inpoultry or a large number o f human cases. For the implementation o f these activities, the funds from the three sources (IDA, PHRD and AH1 Facility) will be advanced by the Bank directly to the Designated Accounts opened by each IA (one for MAFF, and two for MOH and NCDM), in a manner acceptable to IDA. 39. Each IA will prepare and submit to NCDM, as the agency in charge o f overall coordination: (a) a Project Implementation Plan (PIP) for all project activities included in its component; (b) annual work plans (with budgets) for each calendar year; (c) annual physical progress reports and financial statements covering the preceding calendar year; and (d) Interim Financial Reports (IFRs) for each quarter. From the IFRs for the 4* quarter, NCDM will prepare the annual financial statements for the entire project and these will be audited by independent auditors under Terms o f Reference acceptable to IDA. 40. Overall Project Coordination and Management. Overall responsibility for overseeing and coordinating institutional and implementation arrangements will be vested with the NCDM. NDCM was originally established by a sub-decree (No. 54 ANKR-BK) signed by the Prime Minister in 1995, and later amended in 1999. The Prime Minister i s the PresidenUChairman of NCDM,andthis Committee is integratedbythe Ministers incharge o fall ministries, the Provincial Governors and representatives o f the Armed Forces and National Police. 41. Inaddition to its responsibilities as implementing agency for Component C, NCDMwill be responsible for overall project coordination and management, ensuring linkages across relevant agencies and with internationalpartners, and for guiding and monitoring project implementation at the central level; it will be IDA'Smain counterpart during project implementation. For this purpose, NCDMwill rely on its existing structure, usingits General Secretariat as the main unit in charge. Its Secretary General and Deputy Secretary General will serve as Project Director and Project Manager, respectively. To perform these functions, NCDM will recruit consultants to strengthen its capacity, mainly in the areas o f general administration, financial management, procurement, M&E, training and human resources. A consultant service agreement i s expected to be entered into between N C D M and an agency o f the UN System to contribute to the institutional strengthening o f N C D Mto perform this function. 42. The mainresponsibilities o fNCDMas Project Coordination Agency will be: 0 The preparation o f the Project Environmental Management Plan (EMP) and the Ethnic Minorities Planning Framework (EMPF), both satisfactory to IDA, to be approved and adopted by the RGC, as well as properly disclosed inthe country. 0 The preparation o f the PIP from inputs from the respective IAs, ensuringits adoption by the RGCand monitoring its implementation, suggesting adjustments when needed; 12 The compilation o f the Annual Work Plans (AWPs) prepared by each IA into an AWP for the whole project, ensuring consistency with national policies and the overall strategy for avian influenza, as well as with the available resources. This AWP will be submitted to IDA every year, not later than September 30. The establishment and maintenance o f an M&E System for the entire project, making sure that the I A s are fully capable o f implementing the systems for each component, which will be essential inputsto this system. Assessing the project's progress status, identifying constraints and limitations, as well as suggesting ways to improve project performance and realigning activities accordingly. Acting as IDA'Smain counterpart for project implementation, supervision and evaluation, as well as for other donors and international partners for matters related to its implementation. Based on inputs from the IAs, the preparation and submission to IDA o f (a) annual physical progress reports and financial statements, not later than April 30 o f each year, covering the preceding calendar year; (b) IFRs for each quarter, not later than 45 days after the end o f each quarter; (c) annual financial statements for the entire project, based on the IFRs for the 4* quarter received from each IA; (d) annual auditing reports o f the annual financial statements and accounts consolidated for the project, as well as the corresponding management letters, will have to be submitted to IDA by independent auditors under Terms o f Reference acceptable to IDA within six months o f the end o f each financial year; (e) a Mid-Tern Progress Report; and (f)a final Borrower's Implementation Completion Report, to be sent to IDAnot later than two months after the closing date o f the project. 3. MonitoringandEvaluation (M&E) of OutcomesandResults 43. The NCDMwill be responsible for the establishment and maintenance o f the M&E system for the overall project. Within this overall framework, each IA will be responsible for the establishment and operationalization o f the M&E system for its respective project component. Depending on the specific situation in each case, these activities could be carried out by the regular staff o f the I A s (with training and technical assistance provided by the project), or by specialized agencies or institutes contracted for this purpose under the project. In the case o f the Animal Health component, M&E will be supported by the appointment o f regionally based project managers who will conduct the regular monitoring o f project activities along with a central M&E officer inthe Animal Health component project management team. 44. Monitoring progress in implementation and towards the achievement o f the intended objectives entails a process o f continual and systematic review o f the project activities. M&E i s intendedto: (a) to measure input, output and outcome indicators; (b) to provide regular and up-to- date information on progress toward achieving the intended results and facilitate reporting to the government and IDA; (c) to alert the government authorities and the Bank to actual or potential problems in implementation so that adjustments can be made; and (iv) to determine whether the relevant stakeholders are responding as expected and intended. 45. The findings o f relevant M&E activities will be reflected in quarterly and annual progress reports. The progress reports will cover the implementation o f activities related to civil works, institutional activities, training and studies, performance indicators, and IFRs. They also will cover issues identified during implementation and the strategies and actions proposed to be taken to resolve such issues that affect progress. The fourth quarterly report o f each year will be an annual report, covering progress during the past year. Inaddition, a Mid-Term Progress Report will be 13 prepared approximately half-way through implementation and will form one o f the inputs into the Mid-TermReview. This Review will provide an opportunity for joint review (by the government, implementers, partners and donordfinanciers) review o f the experiences and lessons to-date and for discussion of adjustments to the design, implementation schedule and expected outcome/results, if necessary. A Recipient's Implementation Completion Report will be prepared by the I A s and sent to IDA. Basedon this report, IDA will prepare an ImplementationCompletion and Results Report within six months o f the closing date o f the project. 4. Sustainability,Critical Risksand PossibleControversialAspects 46. Sustainability. Critical to the project's sustainability will be the ownership o f this initiative by the stakeholders, coupled with strong political support and an adequate flow of financial resources to cany out project activities. Institutional sustainability will be ensured by: (a) the strengthening o f programs to maintain public awareness o f the threat o f HPAI and other rapidly spreading infectious diseases; (b) the sustained surveillance and prevention and control activities, particularly in high-risk regions; (c) the strengthened country capacity to manage at national and local levels the risk factors associated with the spread o f HPAI and other infectious diseases; and (c) the effectiveness o f programs to control the spread of HPAI from birds to the human population. Critical Risks Rating FromOutputsto Objective Decline inpolitical commitment to addressing s clontinuing support for inter-sectoral HPAI and the threat o f a Global Influenza :ollaboration through information exchanges Pandemic and other infectious diseases as a md dialogue and the operationalization o f the iationalpriority. Vational Comprehensive Plan and the Pandemic PreparednessPlan, which are to provide general 3olicies and guidance for avian influenza :ontrol. 3overnment agencies do not have sufficient s 4ssistance from the UN System Agencies mthority, leadership and capacity to take a through service contracts will strengthen leading role inavian influenza prevention and government's capacity in management, :ontrol. :oordination and specific technical areas. [ntervention activities not effective in s 4ctivities will strengthen response capacity in :ontaining the spread o f avian influenza from ?riority areas in the short and mediumterm and 9irds to the humanpopulation. will lay the foundation for a more broadly based strategy, including: Comprehensive awareness and communication campaigns, critical to containing the spread o f an influenza pandemic. Choosing well designed, cost-effective interventions. 0 Interventions phased and carehlly monitored, allowing for modifications and redesign as needed. Service delivery deconcentrated with the maximum use o f local governments and civil society. 0 Good M&E to flag emerging issues. 14 [nadequacy or lack o f multi-sectoral M The I A s will coordinate through the Inter- participation (ineffective coordination) ministerial Committee on the Prevention and Control o f AI and, for pandemic preparedness, with NCDM. High-level central commitment does not Implementation mechanisms explicitly address translate into action on the ground. the link between the required centralized decision-making (the principle o f `direct chain o f command') with the needed local-level implementation; communication strategies will include local-level implementing actors as targets; capacity building includes periphery. Lack o f independentinternal audit function Robust internal audit function by each IA, plus external independent auditing financed by the project, both providing reports to government and co-financiers. FromComponentsto Outputs Controlling the spread o f the pandemic may S The project will support advocacy and coalition expose the government to criticism building to sensitize key groups including concerning the curtailment o f civil rights due policy makers and the media. This will be to the adoption o f quarantines and other complemented by carefully designed mass related measures. communication campaigns to build support for the project among the population. Lack o f laboratory capacity for prompt S Project activities will be coordinated with diagnosis and surveillance and o f sufficient efforts undertaken by WHO (and other quantities o f drugs and other medical inputs international organizations) that have needed to address the needs o f the general established an international anti-viral stockpile population during a pandemic. with donations fiom the pharmaceutical industry. Inadequate institutional capacity to manage S Capacity building and institutional development the project. i s one o f the project's key objectives. Financial resources not accessible in a timely M Procurement and financial management manner; weak procurement management. arrangements will be handled by experienced staff or consultants from the IAs. Lack o f timely and predictable access to M Project activities have been designed with expert advice and technical support. assistance from leading specialized international agencies, some o f which have long experience on avian influenza issues (e.g., FAO, WHO, UNICEF, etc.), and their assistance will be always available during implementation. Inadequate capacity for planned surveillance, M I A s will be responsible for the design and surveys and M&E. operationalization o f surveillance, surveys, and M&E. Lack o f a comprehensive system to S Institutional capacity building and strengthening compensate farmers for culled infected birds o f the monitoring and surveillance capacity, makes more difficult the detection o f an together with the planned communication outbreak. campaigns and the increased farmer awareness about the long-term effects o f a larger outbreak, mitinate these risks. OverallRiskRating: S RiskRating- H(HighRisk),S (SubstantialRisk), M(ModestRisk),N(Negligibleor LowRisk) 15 5. Grant Conditions and Covenants 47. Conditions of Effectiveness. These will include: (a) the legal agreements regarding the cofinancing resources from the PHRD Grant and the AH1 Facility are signed with the Recipient and all the conditions for their effectiveness (other than the effectiveness o f the IDA Grant) have been met; (b) each IA has hired the key staff responsible for project coordination and management, as required for their components (including government officials responsible for the coordination o f each component, as well as for financial management and procurement), in a manner satisfactory to IDA; and (c) the Annual Work Program for the first year o f project implementation (2008) has beenprepared by the Recipient and it i s acceptable to IDA. 48. ImplementationCovenants. The main nonstandard covenants include: (a) by July 31, 2008, the project's Environmental Management Plan (EMP) and the Ethnic Minorities' Planning Framework (EMPF), both satisfactory to IDA, have been approved by the Recipient, and have been properly disclosed in the country; (b) by September 30, 2008, the Project Implementation Plan (PIP), satisfactory to IDA, has been prepared by N C D M in coordination with the IAs, including arrangements for implementation, procurement, accounting, financial management, auditing procedures and M&E and reporting arrangements; (c) MAFF and NCDM will establish complete financial management systems acceptable to IDA, including the establishment o f computerized accounting software, not later than September 30, 2008; (d) annual work plans (with budgets) for each calendar year, will be presented not later than 30 o f September o f the previous year for discussion with IDA; (e) annual physical progress reports and financial statements, not later than April 30 o f each year and covering the precedingcalendar year, will be presented to IDA for discussions and approval; (f)IFRs for each quarter, not later than 45 days after the end o f the quarter, will be presented to IDA; (g) a Mid-Term Progress and Assessment Report will be presented by NCDM, in collaboration with the IAs, for discussion with IDA, at the end o f the second year o f implementation; and (h) annual audits o f the financial statements for the entire project (together with the management letter) will be submitted to IDA by independent auditors, under Terms o f Reference acceptable to IDA, within six months o f the end o f each financial year. In addition, the Recipient shall ensure that the project is carried out in accordance with the provisions of the Good Governance Framework (Appendix lo), and the "Anti-Corruption Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants", dated October 15, 2006. E. APPRAISALSUMMARY 1. EconomicandFinancialAnalyses 49. The project and Cambodia's National Comprehensive Plan will reduce the risk o f AH1 outbreaks among poultry and humans. While it i s possible to undertake a "with and without project" comparison o f the social benefits and costs o f the Plan, this analysis i s complicated by uncertainties about the numbers o f humans and poultry that might be affected by the disease and the efficacy o f the control measures employed. The extent o f protection achieved will depend upon the efficacy o f the prevention, containment and treatment measures undertaken. For the purposes o f costhenefit ratio analysis, protection rates varying from 30 to 100 percent for humans have been assumed. The likely impact o f an AH1pandemic on unprotected humans (that is, the "without project" situation) was derived using WHO estimates o f human-to-human transmission: (a) 30 percent o f unprotected humans are likely to be affected; (b) 10 percent o f those will require hospitalization; and (c) 1.5 percent o f all human cases will be fatal. The costs of implementing the National Comprehensive Plan were assumed to remain unchanged for each scenario. 16 50. Major economic outcomes were modeled based on protection rates o f 30, 80 and 100 percent (see Appendix 8). The scenario o f 80 percent protection results in an estimated 50,400 human lives saved and 420,000 hospitalizations averted. With the most conservative assumptions, the protection rate o f 30 percent saves 18,900 lives. The net economic effect i s massive, and ranges from benefits o f between U S 7 0 . 6 million (30 percent protection rate) to US$165.1 million (80 percent protection rate). The costbenefit ratios for these two scenarios, which range from 2.2 to 5.1, are strongly favorable. 51. While the quantification o f indirect benefits i s problematic, some o f these indirect benefits may be as important as those estimated in the costbenefit analysis. For example, a considerable benefit will be the reduction or avoidance o f shocks to the service sectors (including tourism, mass transportation, and retail sales). Other important benefits o f the National Comprehensive Plan include the strengthening o f the Ministries and other units involved in natural disaster avoidance and response. 2. Technical 52. Animal Health. A balanced combination o f appropriate disease control and preventive options, tailored to the specific characteristics o f Cambodia, i s essential for the achievement o f the project objectives. Successful implementation o f both o f these elements in the project depends on a properly functioning veterinary service that has well developed links to poultry producers and the poultry trade. In many cases, these will have to be built up during the life o f the project. The overall national disease control strategy has taken into consideration the range o f epidemiological scenarios that exist or may arise in Cambodia, as well as the different poultry production systems inthe country and differentlevels ofinfection. 53. The implementation o f the project raises important technical issues and presents substantial challenges. Key issues include the following: The capacity of the public and private veterinary services. The veterinary services at present are inadequately resourced and trained to deal with HPAI and other emergency diseases This i s evident across the entire range o f critical capabilities: surveillance and diagnostic capacity for early detection and reporting o f outbreaks, monitoring disease, rapid response and implementation o f the required control measures within and around outbreak sites (including enforcement capacity), and essential investigations to understand how the disease developed. This will be addressed progressively inthis project. Adequacy of the regulatory and incentiveframework. The current legal and regulatory framework is incomplete, not fully consistent internally, and in many instances poorly aligned with actual physical, technical and staff capacities on the ground. Amendments will be needed to the Veterinary Law, to various decrees governing emergency animal diseases, and to regulations concerning institutionalresponsibilities. Diseaseprevention measures. Measures to prevent the spread o f the virus from infected premises and measures to exclude the virus from uninfected locations are essential, but have often proven to be difficult to implement effectively, in part because o f the nature o f the traditional production and marketing systems which lead to extensive poorly-regulated poultry movements. Poor coordination among public agencies and weak linkages with the private sector. Ineffective coordination among ministries and public agencies, and weak linkages with the private sector (especially the owners o f poultry), are major impediments to long-term 17 planning for infectious disease control that need to be addressed during the life o f the project. Coordination within the livestock sector. There are many active projects sponsored by agencies in the livestock sector involved in HPAI control andor sector development. Limited coordination amongst these agencies and projects represents a potential impediment to development o f the sector and long-term planning for effective and efficient infectious disease control. The project will seek to play a strategic role in coordination and will develop improved coordination arrangements and mechanisms with other agencies, especially FAO. 54. Human Health. According to WHO, the current epidemiological situation o f avian influenza corresponds to "a Pandemic Alert Period, Phase 3, with human infection(s) with a new sub-type, but no human-to-human spread or, at most, rare instances o f spread by close contact." Compared with previous influenza pandemics that took the world by surprise and gave health services little time to prepare for the abrupt increases in cases and deaths that characterized these events, the present situation i s markedly different for several reasons: (a) the world has been warned inadvance; (b) this advance warning has brought an unprecedented opportunity to prepare for a pandemic and develop ways to mitigate its effect; (c) apart fkom stimulating national preparedness activities, the present situation has opened an important opportunity for international intervention aimed at delaying the emergence o f a pandemic virus or forestalling its international spread. 55. The risk to human health posed by the recent avian influenza outbreaks has led to the preparation o f a Global Technical Framework (as part o f the GPAI) to guide action against an increasing pandemic threat. It recognizes that there are areas that require further development and that specific actions to be included and supported under country projects need to reflect the epidemiological conditions, institutional capacity, needs and priorities o f the specific country. In case a true human AH1 pandemic and emergency were to develop, separate procedures may be decidedupon, especially with regardto sole-source financing o f anti-virals and AH1vaccines. 56. Not knowing which influenza virus strain i s going to cause the next pandemic makes planning for it very challenging. The likely impact o f a pandemic depends upon characteristics o f the virus such as its infectivity, attack rates in different age groups (i.e., the proportion o f the population infected for each age group) and the severity o f disease it causes. The three pandemics o f the 20th century demonstrate the variation inmortality, severity o f illness and patterns o f spread that can occur. 57. A critical element o fpre-pandemic planning, however, is ensuring that the buildingblocks are in place ahead o f an actual pandemic threat. The two major strategies to be supported under the GPAI are technically sound. The first focuses on containment measures to prevent transmission and spread o f the virus through social distancing measures, judicious use o f anti-viral medication, and strengthening o f surveillance and public health laboratory systems to ensure that capacity and capability are in place to allow early detection o f virus sub-types and rapid and accurate identification o f emerging virus sub-types are in place. The second emphasizes the maintenance o f essential medical services and the mobilization o f international emergency health care and staffing for low-income and low-capacity situations if there i s an explosive spread o f the virus within the general population and containment i s no longer possible, coupled with preparedness for pandemic vaccination development and administration. In addition, support i s considered for ensuring that appropriate decision-making bodies are in place and have the necessary expertise and authority to make decisions quickly and effectively. 18 58. The project will support short- and longer-term actions in the public health field, while ensuring that an appropriate balance i s struck between the two. The project i s fully consistent with WHO'Srecommendations. The aim o f the proposed interventionsi s to minimize the morbidity and mortality associated with a pandemic event. 3. FinancialManagement (see Appendix 4). 59. Financial management (FM) arrangements will be carried out by each IA for its respective component. Financial management capacity assessments were carried out at each IA in September 2007; the risks identified need to be addressed by remedial measures and action plans were developed to ensure that the project's financial management arrangements meet the Bank's minimumrequirements. 60. The inherent financial management (FM) risk to the project from the country environment i s assessed as high because o f the weak financial control environment and systems o f the public sector. The recommendations o f the Cambodian fiduciary review have been taken into account in designing the FM arrangements for the project, including the disclosure o f project information. The risks have been mitigated by: (a) annual activities planning and budgeting; (b) the establishment o f a separate computerized accounting and financial management system for the project; (c) the sound accounting control and procedures to be adopted; (d) the appointment o f an adequate number o f suitably qualified staff to manage implementation; (e) regular financial reporting to MEF and IDA; (f) internal audit review o f the project activities and financial operations; and (g) annual financial audits and specific purpose reviews by independent auditors. Most o f these project specific arrangements are already operational, and an FMAction Plan (as set out inAnnex 4) has been developed and agreed to address outstanding issues. Taking into account the riskmitigation measures proposedunder the project, the FMriskrating i s considered moderate. 4. Procurement (see Appendix 5). 61. Procurement for the project will be carried out in accordance with the World Bank's Procurement and Consultant Guidelines (dated May 2004, revised October 2006) and the provisions stipulated in the Legal Agreements (Financing and Grant Agreements), including the agreed Procurement Plans. To address the weak procurement capacity o f the project IAs, and consistent with the government's decision agreed by the Bank to require an International Procurement Agent (PA) for all Bank-financed projects in Cambodia, procurement under the project will be carried out by the P A on behalf o f the project implementing agencies, with the exception o f procurement agreed with the Bank to be undertaken through the Single Source Selection and Procurement from United Nations Agencies methods, which will be carried out by the project I A s themselves. To mitigate the broader fiduciary risks resulting from the weak governance environment, including procurement, inthe country, extensive measures for improving governance in project implementation and increasing transparency and accountability in the procurement process have been incorporated in the project's design. Details are provided in Appendix 5, and the Good Governance Framework agreed with the three I A s i s included as Appendix 10. 5. Social 62. The project i s expected to contribute to minimizing the impact o f outbreaks and a human pandemic by having in place a surveillance and response system to minimize the potential impact of an unchecked outbreak in the avian population. Ensuringthat there i s a proper response to any outbreak in animals (including poultry) should help to ameliorate the potential o f humans 19 contracting the disease and possibly passing it on to others. The project's support to improving the surveillance, conducting public awareness campaigns (including translation o f messages into ethnic languages), and having in place a preparedness plan, should help to prevent or, in the event o f a pandemic, reduce the impact on the population. The integrated surveillance system to be supported by the project will reinforce the multi-sectoral response necessary to this threat. 6. Environmentaland Social SafeguardPolicies 63. The project i s not expected to have any large-scale, significant or irreversible environmental impacts as activities focus largely on public sector capacity building and ensuring readiness for tackling outbreaks o f AH1 in domestic poultry as well as preventing or reducing possible human infections by strengthening emergency preparedness and response. The project design incorporates other beneficial measures such as improved biosecurity in farms and live markets, and control o f poultry movement within and between countries. The preventive activities (funding o f facilities, equipment, laboratories, procedures, and training programs), aimed at improving the effectiveness and safety over the existing AH1practices, will have positive human health and environmental impacts. Among the Bank's safeguards policies, only the Environmental Assessment (OP4.0 1) and Indigenous Peoples (OP4.10) are triggered. The project design incorporates the necessary mitigation measures for the potentially adverse impacts associated with the activities involved in responding to AH1outbreaks. A draft EMP has already been prepared (see Appendix 6). Immediately after effectiveness, the I A s will engage specialized consultants to: (a) complete the EMP; and (b) prepare an EMPF. The EMP and the EMPF will be revised after consultation with various stakeholders (government agencies, commercial poultry associations, mass organizations, ethnic minorities groups and NGOs) and, once found acceptable to IDA, will be appropriately disclosed in Cambodia and Washington D.C. (Infoshop). The legal agreements include specific dated covenants reflecting these arrangements for those safeguards documents. In addition, these operational procedures resulting from the EMP/EMPF will be incorporated in the Project Implementation Plan (Operational Manual), also to be finalized by the implementing agencies duringearly the stages o f implementation and formally adopted by the Recipient's IAs. 7. Safeguard Policies Safeguard PoliciesTriggeredby the Project EnvironmentalAssessment (OP/BP4.01) Natural Habitats (OP/BP4.04) Pest Management (OP 4.09) Cultural Property (OPN 11.03,beingrevised as OP 4.11) Involuntary Resettlement (OP/BP 4.12) IndigenousPeoples (OP/BP 4.10) Forests (OP/BP4.36) [I [XI Safety o fDams (OP/BP 4.37) [ I [XI 3Projects inDisputed Areas (OP/BP 7.60)* [ I [I [XI [XI * By supporting theproposedproject, the Bank does not intend toprejudice thefinal determination of theparties' claims on the disputed areas 20 8. Policy Exceptions and Readiness 64. Given that the project i s being processed following emergency procedures (OP/BP 8.50- ERL) and grant financing will be covering 100percent o fproject costs to be incurredby the U s , a waiver has been granted by the RVP of the EAP Region for delaying the preparation and disclosure o f the EMF and the EMPF to a date early in the implementation stage. This is consistent with the exemptions allowed under paragraph 12 o f OP 4.01, related to Environmental Assessment o f Emergency Recovery Projects, and also allowed under paragraph 15 o f OP.4.10 relatedto Indigenous Peoples, and with the general procedures specified under GPAI for individual country projects to be processed under this global program. A specific dated covenant indicating when the EMP and the EMPF must be completed and disclosed i s included in the Financing Agreement. 65. On August 3, 2007, a Batch Waiver was approved by the corresponding Managing Director endorsing the request to waive Bank's policies inthe contracts between the Recipients of Bank fundingand the UNagencies participating as providers o f technical assistant services under a group o f twelve Bank-funded Avian Influenza Projects (including this AH1project in Cambodia). This waiver endorsed the use by government agencies o f contracts to be negotiated with the UN agencies (namely, FAO, WHO, UNICEF, OiE, and UNDP) that do not include: (a) the Bank's policy to impose sanctions in the event o f fraud and corruption involving an UN Agency; and (b) the Bank's right to require provisions inthese contracts allowing the Bank to inspect and audit records and accounts o f these UNagencies. 21 Appendix 1:ResultsFrameworkandMonitoring CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject ResultsFramework U T o minimize the threat posedto 1 N o cases o f H5N1 HPAI in -0 verify that the PDO was humans and the poultry-sector by an periurbancommercial poultry chieved. AH1infectioninCambodia, andto flocks once control and prepare for, control, and respond, if preventive measures are necessary, to a human influenza implemented. pandemic. 9 Evidence* o f improved effectiveness o fparticipating animal and humanhealth services inrespondingto the riskofavian influenza inpoultry and a human pandemic o f influenza. Component One: Animal Health Systems Strengthenedveterinary services I I 1 Number o f new V A H W s trained T o verify satisfactory and timely usingthe revisedcurriculum and progress in, or completion of, percentage o f these providing Component 1. disease reports at commune meetings AH1outbreak rapid response system Number o f reports o f suspected T o verify improvement o f disease H P A I from VAHWs. reporting 1 Targets for training inemergency vaccination met and government advised o f findings. Avian Influenza prevention 1 Percentage o f farms or markets a T o evaluate whether o n which recommended risk recommendations o n disease mitigation measures to prevent control are being applied avian influenza are hlly implemented'. Training o f health workers Evidence* o f timely and satisfactory 1 To assess the progress o f progress toward delivery o f interventions Component 2 outputs, as compared to the original plan, including specific indicators as follows: 9 percentage o f provincial and district rapid response teams trained 1 percentage o f VHV trained in avian influenza monitoring, reporting and control measures Establish, train and make operational Percentage o f warning signals - 1 T o evaluate the effectiveness o f 'Based o n surveys following the technical study o n highrisk practices and their mitigation 22 interventions including training reams on time EnhancedAH1case management . percentage o f targeted hospital 1 T o assess the progress o f andinfection control staff trained for infection control . interventions To evaluate the effectiveness o f interventions including training control and case management guidelines (Incase o f outbreaks) Laboratory strategy 1 percentage o f laboratory staff 1 T o assess the progress o f trained o n lab techniques for interventions avian influenza and other respiratory pathogens and on lab management 9 Laboratory strategy and plan developed Pandemic preparedness planning 1 Pandemic preparedness plan T o assess the progress o f developed and desk-top exercise interventions and evaluate the implemented effectiveness o f intervention Rapid containment activities ...Number o f rapid containment T o assess the progress o f (RC) exercises completed interventions percentage o f staff trained inRC RCplandeveloped Component Three: Inter-ministerial Coordinationfor Pandemic PreparednessRroject Coordination and Management Improvedmultisectoral cooperation .. To assess the progress o f interventions To evaluate the effectiveness o f interventions NCDMstaffhired andtrained Coordination and management o f .. PPRRP prepared and tested . To assess the progress o f pandemic preparedness activities NCDMemergency MIS and interventions M&Esystems designed, developed and established 1 PPRRPactivities integratedinto 1 T o evaluate the effectiveness o f the ongoing CBDRM interventions * Via reports from independenttechnical and social audit teams that visit the field, review available self-reporting data, interview stakeholders, andjudge the results. 23 g g r-00 r- 0 7 5 L L m 0 4 I ? 3 5 n rl 3 7 3 P I 1 e23 3 e2 z" 0 0 rn 0 w " i ? , , I Appendix 2: DetailedProjectDescription CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject ProjectDevelopmentObjectives. 1. Consistent with the GPAI, the overall development objective i s to minimize the threat posedto humans and the poultry sector by AH1infection inCambodia and to prepare for, control and respond (if necessary) to a human influenza pandemic. The specific project development objectives are: (a) to reduce damage to the poultry industryand losses to the livelihoods o f commercial and backyard poultry growers by containingthe spread o fthe disease inanimals; (b) to prevent or limit human morbidity andmortality by diminishingthe viral loadinthe environment, stemming opportunities for human infection, and strengthening the curative care capacity; and (c) to prevent or curtail macroeconomic disruption and losses by reducingthe probability o f a human pandemic and improving emergency preparedness and response. ProjectComponents 2. The project will finance activities under three components: (a) control and preventive measures minimizing the risk o f HPAI in the animal population; (b) health systems preparedness and response to possible human infections; and (c) strengthening management systems, including institutional and legal frameworks, as well as M&E. This multi-sectoral approach will also focus on short-term activities to assist with immediate needs as well as medium-term actions to help strengthen capacity inthe animal and human health sectors. Project ComponentA: Animal Health(estimatedcost: SDR 2.75 million and US$1.45million; totalof US$5.8 millionequivalent). 3. Background. The Animal Health component o fthe National Comprehensive Planfor the control o f HighlyPathogenic Avian Influenza (HPAI) i s a comprehensive and flexible plan with four major (Al, A2, A3 and A6) and two minor (A4 and A5) subcomponents. Most o f the resources will be devoted to Subcomponent A1: 0 A1 Strengthening Veterinary Services 0 A2 Enhancingsurveillance, investigationofandresponse to outbreaks 0 A3 Addressing highriskpractices inpoultry production and trade 0 A4IEC 0 A 5 Pandemic preparedness 0 A 6 Coordinationand Management 4. The project aims to address some o f the current weaknesses in the veterinary services that limit the capacity to recognize, control and prevent highly pathogenic avian influenza and other diseases. A number of other projects have contributed and continue to contribute to the implementation of various activities o f the Plan. The project will finance gaps in the funding o f the current Plan, provide longer-term enhancement o f veterinary services and provide the impetus for development o f future comprehensive plans. 26 5. Subcomponent A1: Strengthening Veterinary Services. Veterinary services in Cambodia consist mainly o f the government veterinary services (which extends to District level) and private sector Village Animal Health Workers (VAHWs). The government veterinary services include the national Department o f Animal Health and Production (DAHP), and Offices o f Animal Health and Production (OAHP) in each o f the 21 provinces and 3 municipalities, and some 184 district centers staffed by a District Veterinary Officer (see Appendix 6 for hrther details o f the structure o f the animal-related services inMAFF). Most o f the strengthening o f veterinary services inCambodia inthe near term will be achieved by increasing the number o f appropriately trained VAHWs. However, this system will not function properly unless the trainers o f these VAHWs are competent and supported by a properly resourced public veterinary service. Improved training requires assessment and consolidation o f the current training programs and a strong training system. Inaddition, there i s a need for better legislation to support the disease control activities o f field staff. This subcomponent will focus on the following activities: 6. Ala Improving Veterinary Legislation. A Veterinary Law i s urgently needed to clarify the - duties, obligations and responsibilities o f the official veterinary services and farmers with respect to a list o f important diseases and to define the roles and responsibilities o f the veterinary service and other public sector agencies and private entities in disease control. Under this activity, assistance will be provided for drafting and implementing appropriate basic national laws and regulations that will require notification o f certain serious diseases. These laws will afford animal health staff the right to take action inthe event o f a suspicion o f a disease and will provide protection for animal health staff in such cases to enter property to investigate suspicious cases and to implement disease-control measures (such as movement controls) in the event o f detection o f a disease. This will also address the regulation and administration o f the VAHW system. 7. Alb - Strengthening the Training System. One o f the main methods used for training of VAHWs is a `cascade' system in which trainers inDAHP (first tier trainers) provide training for staff at provincial or district level (second-tier trainers in OAHP), who subsequently train the VAHWs. This system has been widely used but will always be constrained by the quality o f the personnel at each level inthis cascade. The system will not achieve its objective ofproviding highquality training: (a) unless the knowledge and skills o f the trainers at the top o f the system are highquality; (b) if these first-tier trainers do not understand the needs and learning methods o f second-tier trainers and trainee VAHWs; or (c) ifthe wrong candidates are chosen as trainers at the first or second-tier. 8. This activity aims to consolidate the central training unit (including the first tier o f trainers) by: (a) strengthening the quality and skills o f these trainers; (b) revising and reviewing the curricula, training materials and training methods used for training second-tier trainers and VAHWs after conducting a training needs analysis; and (c) ensuring that all suitable training resources currently inuse or produced in this activity are digitized and available through the training unit. It will build on the foundations laid by the FAD-funded activities under the Bank-financed Agricultural Productivity Improvement Project (APW. 9. The above objectives will be achieved through the appointment o f two international consultants (specialists in education and veterinary science indeveloping countries) and two national consultants with well-developed veterinary and training skills. These consultants will also provide an assessment o f the quality o f the training being delivered at the provincial and district level by conducting regular audits o f training and also conducting needs assessments. On the basis o f these findings, they will suggest modifications to the training methods for second-tier trainers and the selection criteria for provincial and district staff who apply to become second tier-trainers (i-e., trainers o f VAHWs). T o enhance the knowledge and skills o f trainers, two post-graduate scholarship awards will be made available for trainers working in the central training unit (on a competitive basis) to undertake training in a distance-based 27 course at the Masters level covering veterinary public health, epidemiology and disease investigations (e.g., the course offered inVeterinary Public Healthby the University o f Sydney). 10. The international consultants will be employed immediately on commencement o f the project for an eight-month period. After an intensive review o f existing training methods and materials, and o f training needs and curriculum development, the consultants will oversee training o f the first batch o f second tier trainers within eight months o f effectiveness. The national consultants will continue to provide support for this activity and for monitoring the quality o f training throughout the duration o f the project. Both international consultants will return for a review o f activities after 18 months to consolidate the gains and implement appropriate modifications to the training system. 11. Alc - Training of Trainers. Using the skills developed in the central training unit and the revised training curriculum for second-tier trainers, a series o f training courses at the provincial and district level will be conducted during the life o f the project. Selection for these training courses will be competitive and based on merit and aptitude; not all provincial and district staff will automatically receive training as trainers. 12. Ald Training of VAHWs and Disease Reporting by VAHWs. There are two main reasons - for investing inthe training o f VAHWs. One i s to ensure that village-level producers have access to basic animal health support while the other i s for district, provincial and central public veterinary services to obtain intelligence on disease occurrence through reports from VAHWs. This system has been in place for some time, but the extent and quality o freportinghas been variable. 13. This activity will provide appropriate basic training for VAHWs in disease recognition, prevention and control, and disease reporting, including AI and other diseases o f poultry. VAHWs will be trained at the rate o f approximately 400 every six months using the revised curriculum. This will gradually replace the need for specific supplementary training in AI recognition, reporting, control and prevention currently being provided to existing VAHWs as an emergency response to the avian influenza epidemic. 14. This process will be required throughout and beyond the life o f the project, given the apparent highattrition rate o f trained VAHWs, many o f who only remain active as VAHWs for a short period o f time after receiving training. However, the skills imparted to these VAHWs are not lost as they are applied by individuals intheir day-to-day farming activities and can be called upon inthe event o f animal disease emergencies. All trained VAHWs will receive a basic kit o f supplies. 15. Part o f the revised training curriculum will provide information on the trigger points for notification o f district authorities about animal diseases, ways o f collecting and recording basic information on disease, and the reasons for and importance o f collecting and providing information on the types o f diseases seen during field activities (by clinical symptoms). Ultimately, the goal o f the animal health services i s to assist farmers. This can only be done if there i s better information on the occurrence o f diseases inthe field. 16. As a condition o f receiving training, all VAHWs trainees will be expected to attend regular commune meetings for a minimum two year period after receiving the training. This will serve the dual purposes o f allowing VAHWs to report on findings and to learn o f new diseases or regulations that could affect farmers intheir village. 17. These reports will be collated by district staff attending the meetings and will be forwarded to provincial staff and regional project coordinators for collation and follow up. This material will be consolidated and eventually made available (ideally via the internet, especially as the reach o f the internet 28 increases) as a resource for all animal health workers. The possibility o f establishing an alert system for district staff and VAHWs in the event o f detection o f a disease that warrants extra precaution in an area will be explored (for example, through the use o f SMS messages if appropriate). Untilsuch a system can be established, the regular meetings will be usedto disseminate such information. 18. All VAHWs (including those newly trained and active VAHWs invited to attend meetings) will be provided with a meal allowance when attending monthly meetings. The project will also provide some seed money to support development o f VAHW associations to improve linkages between VAHWs. 19. Ale Supporting District Veterinary Staff. District veterinary staff forms the link between - private sector VAHWs and the public veterinary system. To fulfill this role properly they need to be provided with resources and additional training indisease investigation, risk and hazard identification and emergency responses. Under this activity they will be provided with resources to travel to communes for regular meetings and to undertake investigations in the event o f emergency reports and other disease reports from VAHWs. 20. All field activities undertaken will be reported to the relevant provincial office and the regional project coordinators who will conduct regular audit checks o f activities to ensure that district staff i s complying with reporting requirements by regional consultants (see Subcomponent A2c). Although not all district staff will attend courses for "training o f trainers," all will be eligible for additional training through the training unit in matters relating to animal diseases and disease investigation, disease prevention, emergency response disease reporting and other issues relating to conducting regular meetings with VAHWs at commune level. District staff will also be provided with funds for telephone and electronic communications. 21. Alf Strengthening DAHP. At present, limitedoperational budgets, equipment and supplies are - available within DAHP. This project will provide a range o f resources to support staff at the central level in the National Veterinary Research Institute (NVRI), the Animal Health Office, and the Animal Production Office (all o f which are involved inavian influenza control and prevention, including vehicles, computers and funds for communication. This activity will also include a short-term international consultant and full-time national consultant in disease information management to ensure that the information from VAHWs i s properly recorded, analyzed and made available to all animal health staff usingthe resources already inplace for disease recording (such as TAD Info.). 22. Alg - Strengthening Capacity of Provincial and Municipal Offices. As with the central offices, OAHPs at provincial and municipal levels require additional facilities and vehicles to allow them to perform their duties effectively, to supervise the training and to collate/disseminate disease reports. This activity will also provide funds to support travel required by provincial staff to oversee district staff and to undertake travel for disease emergencies. Each office will be provided with a vehicle and operating funds for vehicles and communications, and an LCD projector for training, building on the resourcesprovidedby other projects. 23. Alh - Strengthening Laboratory Capacity. Through a number o f other initiatives, the laboratory capacity o f DAHPWRI has already been strengthened. An extension to the laboratory i s planned but requires appropriate ventilation and air-flow system, without which this facility and the equipment and supplies acquired elsewhere cannot be fully utilized. 24. This activity will fund the design and installation o f a ventilation system for the laboratory extension. Funds will also be provided to rejuvenate three small regional laboratories to facilitate specimen transfer from the field to the central laboratory. These laboratories will be provided with basic equipment (such as refrigerators and a centrifuge) to allow for preliminary specimen processing and 29 storage. Each regional laboratory will be provided with a stock o f transport boxes meeting international standards for transport o f specimens containing infectious material. 25. SubcomponentA2: HPAI Investigationand Response. This subcomponent aims to support effective national investigation and response systems and to manage outbreaks effectively. In addition, better information on the epidemiology o f HPAI, based on investigations o f outbreaks and specific studies, will improve strategies for disease control. (A discussion note on Cambodia's surveillance strategy i s inAppendix 9 - see Note 2.) This subcomponent comprises the following activities: 26. A2a RapidResponseto Disease Outbreaks. When new cases o f HPAI (or other emergency - diseases) are reported they must be investigated quickly and an appropriate rapid emergency response mounted to prevent additional spread o f infection. The standard approach to this disease i s based on culling o f the infected flock, cleaning and disinfection at the infected site, and movement controls. This i s supported by investigations o f the disease outbreak to ascertain the most likely source o f infection and to allow tracing o f infectedpoultry or contaminated materialthat may have moved from the infected area. 27. This project activity will establish an emergency contingency fund to facilitate rapidresponses to outbreaks that will allow rapid mobilization o f the necessary funds for payment o f workers involved in containing the disease. Villagers are more likely to report disease if they know that they or their neighbors will not be disadvantaged by doing so. Therefore, part o f the contingency fund will cover the cost o f buyingpoultry taken as a result o f disease investigatiodsurveillance activities. A small fund will also be established for purchase o f animal vaccine for use inemergencies. 28. A2b Trials onEmergencyVaccination. Ifan outbreak o f disease is reportedearly, emergency - vaccination around a focus o f infection can help to prevent the local spread o f disease. By including emergency vaccination around an outbreak site as a part o f the response mechanism, the number o f poultry culled can be kept to a minimumand villagers will be reassured that early reporting will not lead to mass slaughter o f poultry intheir village. Currently, this practice i s not used as part o f the emergency response inCambodia. However, once trials o f emergency vaccination have been conducted and found to be operating smoothly it can be incorporated into the standard operating procedures for disease control. 29. Preliminary trials and training will be conducted in each o f the four regions in emergency vaccination. This activity will be ledby regional co-coordinators and will involve selected provincial and district staff and VAHWs. The objectives o f this training are to teach proper techniques for vaccination, determining the extent o f vaccination, and infection control during vaccination. These training exercises will be repeated in each year o f the project so that sufficient appropriately trained staff can be mobilized rapidly to respond to any outbreak and undertake emergency vaccination. If emergency vaccination i s included as a part o f the standard response to outbreaks then the training program for VAHWs will be modifiedto include this training inthis technique. 30. Emergency vaccination (and all other vaccination) depends on the availability o f an appropriate cold chain. This project will provide refrigerators to all provinces and selected districts to allow for the proper storage o f vaccines. For places where power supply i s intermittent, solar powered or other suitable refrigerators will be supplied. 3 1. A2c RegionalCoordinationand Supervision of OutbreakResponses. Each o f four regions6 - will be provided with a regional coordinator who will report to the national animal health project coordinator. These regional coordinators will have two main functions: to support and monitor rapid The country will be dividedinto four "regions" and each ofthe four regional coordinators will supervise activities in5 to 7provinces andmunicipalities contained withinhdher region. 30 responses to reports o f emergency disease, and to ensure that disease reports from VAHWs are being received by district staff and also acted on and sent upwards to the national level (see Subcomponent A 6 - Project Management). 32. The regional coordinators will be equipped with a rapid response vehicle that can be used inthe event o f an emergency disease outbreak to provide required emergency supplies to outbreak sites and also to transport specimens from outbreak sites to the central laboratory. Regional coordinators will also play a role in overseeing the responses and ensuring these follow approved guidelines and procedures established relating to mobilization o f funds and teams for emergency disease control. They will attend some meetings o f district staff with VAHWs to assess the quality o f the information that i s being obtained and delivered and to understand the issues faced by both district staff and VAHWs. 33. A2d Support for Additional Surveillance and EpidemiologicalStudies. Funds are required - to ensure that important existing or planned studies on the epidemiology o f H 5 N 1 HPAI are conducted, including support for market surveillance and wild bird studies. These studies will also monitor changes inthe levelsofinfection followingimplementationofmeasures underactivity A3b. 34. Subcomponent A3: ReducingRiskinProductionandMarketingSystems. Itis unlikelythat the threat o f H P A I could be eliminated from Southeast Asia in the medium term; even if Cambodia manages to eradicate infection, it i s likely to return, leading to further outbreaks and emergency responses. To mitigate this, an assessment o f the risks posedby different farming systems and production and marketing techniques will be conducted so that appropriate preventive measures can be determined and applied. This strategy i s consistent with the approach proposed at a recent UNtechnical workshop in Rome in June 2007. Under this approach, high-risk practices are identified and, where practical, eliminated; ifthis i s not feasible ,other riskmitigation measures are implemented. 35. A3a Study on risks and riskreductionin production and marketingsystems. This activity - will review the production and marketing systems in Cambodia and provide recommendations on appropriate longer-term measures to be implemented to reduce high-risk poultry production and marketing practices that are likely to result in the spread or the persistence o f infection. This will consider all options including vaccination, stamping out, modification or elimination o f certain practices, movement controls, cleaning and disinfection, and enhancement o f farm biosecurity measures. This study will examine the economic, social and environmental aspects o f the measures proposed and only recommend those that are technically feasible and cause the least possible collateral damage. The results of this study will be used to guide adjustment o f the National Avian Influenza Comprehensive National Planbeyond 2008. 36. A3b - Implementationof Risk ReductionMeasures. The study on risk mitigation will be followed by promotion o f the agreed strategies for reducing the risk posed by these production and marketing practices by staff o f DAHP supported by a national consultant. This will cover each o f the production and marketing systems: village-level smallholders, small commercial chicken flocks, extensive duck production, large commercial farms, and marketing and transport. 37. The Animal Production Office will use the information obtained from the study to promote appropriate changes to poultry production and marketing systems which, depending on the sector involved, will likely include but will not be limited to enhancements to farm biosecurity. Staff will be involved indeveloping and demonstrating appropriate productionmodels for small commercial flocks. 38. Subcomponent A4: IEC. This subcomponent will focus on improving knowledge and understanding o f the disease among the general public and specific targeted audiences, including poultry producers, traders, processors, teachers, local authorities, police and other government staff. The project 31 will provide limited additional funds to support IEC material development through the Extension Office o f DAHP as most plannedIEC activities are already funded under other activities. 39. Subcomponent A5: PandemicPlanning. DAHPwill holdworkshops to discuss its role andthe roles o f Provincial and District veterinarians inthe event o f a Phase 4 or Phase 5 and 6 occurrences, and to prepare a sectoral pandemic preparedness and response plan. DAHP will participate in all planning sessions conducted under NCDMauspices. 40. Subcomponent A6: Project Management. The quality o f service delivery in this project will depend heavily on the management and direction provided by the IA. DAHP will be the IA for the Animal Health component o f the project, with NVRI as the coordinator. The government intends to sign a service contract with FA0 for the provision o f technical assistance to support the implementation o f this project. The IA will implement this component following the provisions o f established legal agreements and will present quarterly reports to the World Bank, including physical progress and financial management reports, and it will be subject to periodic supervision by the Bank. In addition, project accounts and financial statements kept by the IA will be audited annually by independent auditors acceptable to IDA, together with other components. 41. For effective implementation o f the activities, a small coordinating unit will be established within DAHP. The project will provide funding for: (a) the technical assistance, including a part-time Chief Technical Advisor and various short-term and long-term specialists in key areas in support o f good project management; (b) additional support to the procurement and financial management functions to be carried out by hiring local consultants in these two areas; (c) the administrative support by hiring a secretary and two drivers; (d) the provision o f office equipment (computers, printers, photocopiers, desks, etc.); and (e) the provision o f funding for incremental operating costs for the field work o f the technical advisors and specialists, as well as for the activities o f the coordinating unit. This includes purchase o f satellite telephones and GPS equipment to be used to enhance field communication and epidemiological information. 42. As part of the activities to be carried out, a management system will be established and operated to ensure close communication at all levels o f DAHP (at the central, provincial and operational district levels), as well as with the Avian and Human Influenza Inter-ministerial Committee, the MOH and the NCDM. Provincial committees will facilitate horizontal linkages to relevant entities, which will be essential for supporting regulatory activities on disease control. This will be supported by the four regional coordinators who will play a key role in overseeing the activities in this project. Similar structures will be explored at the district and commune levels (see organizational and operational chart). 43. M&E will be underpinnedby base-line studies that will assess the situation at project inception. An international expert inM&Ewill be appointed for three months to establish the M&E system and to assist inthe base-line studies. Project Component B: HumanHealth(estimatedcost: SDR 670,000 and US$2.44 million; total of US$3.50 millionequivalent). 44. Background. Inthe 1990s, the government introduced health system reforms to improve and extend primary care through the implementation o f a district health system that focuses on the distribution o f facilities in accordance with a health coverage plan and the allocation o f financial resources to the Provinces. Operational Districts were designated and are composed o f 100,000 to 200,000 people, with a referral hospital providing a "comprehensive package o f activities" and health centers delivering primary health care to a target population o f 10,000 through a "minimum package o f activities." The first National Health Strategic Plan, a medium-term expenditure framework and an M&E framework were 32 developed and approved in2002. The main challenges identified were: (a) improving the quality of care; (b) increasing the utilization of cost-effective healthcare; (c) improving the distribution of staffwithin the health sector; and (d) improving reproductive and adolescent health services. 45. In2004, outbreaks of avianinfluenza inpoultry occurredinCambodia. Since the first confirmed human case inJanuary 2005, there have been a total o f seven confirmed cases (all sevenpatients died). In response, the government has prepared the National Avian Influenza Control and Human Pandemic Influenza Preparedness Planfor Cambodia (presented at the Beijing Conference inJanuary 2006), which includes plans fi-om MAFF, MOH and NCDM; a road-map for communication i s also described. Using experience gained during the Severe Acute Respiratory Syndrome (SARS) outbreak, M O H has prepared its Avian Influenza Action Plan in Cambodia. The purpose of MOH's plan i s to highlight the current surveillance and response activities in Cambodia and to identify areas where key action i s needed to fill gaps inthe system. 46. MOH conducts communicable disease surveillance using the C A M EWAR System (Cambodia Early Warning System), which consists of data collection and analysis on 12 syndromes and diseases. Data are collected at the Health Center level on each o f these conditions, and sent through the Operational District and Provincial Health Department levels to the Communicable Disease Control Department (CDCD) at the national level. The system i s now implemented nationally. Acute respiratory infection (ARI)is one of the diseases under surveillance and would theoretically capture human cases of influenza. To further supplement the data collectedthrough the C A M EWAR System, M O H expanded the operation o f the existing hotline established during the SARS outbreak. The hotline was used by health care professionals to report suspectedcases to the central authorities, but with the activity of AH1inCambodia it was deemed necessary to expand the role to enable the public to report to MOH. It is also used more broadly for reporting outbreaks o f any communicable disease. Under the direction of, and incooperation with, the CDCD, the Provincial Rapid Response Teams (RRTs), created during the SARS outbreak respond inthe event of suspected (or confirmed) human cases. In order to monitor influenza-like illness (ILI) epidemiology in Cambodia, MOH has been establishing an ILIsystem which is expected to be crucial for detecting increased activity of ILIinthe community. 47. Inaddition to conducting surveillance, arming the public with knowledge relating to the disease (such as how it i s transmitted and how it can be controlled and prevented) is an important aspect of prevention. Informing the public about what to do in the event of a suspected case i s also an important measure for prevention (for example, ensuringthat the public are aware of the hotline). M O Hhas an IEC plan targeted at health service providers, and relevant stakeholders are in the process o f preparing an integrated National IEC Strategy to include inputs from MOH, MAFF and others, that will be integrated into the National Comprehensive Avian and Human Influenza (AHI) Plan. 48. The project support to MOH's Plan for Avian and Human Influenza comprises seven subcomponents, and mirror the key action areas in the Plan: (a) education for health workers and the public; (b) surveillance, investigation and response; (c) case management and infection control; (d) laboratory support; (e) pandemic preparednessplanning for the health sector; (f)rapid containment; and (g) management and coordination. These subcomponents are described below. 49. care workers - including Village Health Volunteers (VHV) and local authorities -- must have the Subcomponent B1: Education for Health Workers. Inorder to improve surveillance, health necessary knowledge to ensure that appropriate questions are asked when a person presents with a fever and a cough. This will include ascertaining whether the patient has been in contact with sick or dead poultry or healthy ducks, and for the health service provider to know the appropriate subsequent actions to take. They will need to be trained on Avian Influenza Awareness, community surveillance and rapid containment measures. Complementary to providing information to the health care workers, M O H also 33 has a role to play in ensuring that the correct information i s provided to the public with respect to AHI. (MOH is working with WHO and UNICEF to develop IEC materials for a mass media education campaign on avian and seasonal influenza, and this activity i s separately funded.) MOH also intends to develop documentary style television spots to cover the breadth o f issues related to avian influenza. This subcomponent supports the design, production and printing o f training and IEC materials for health care workers, as well as the development and broadcasting o f television spots targeting professionals (rather than the general population) at this stage. Financing for the majority o f these activities under the Plan i s beingprovidedby UNICEF (with funding from Australia and Japan), AusAID and USAID. Support from the project will cover development and distribution o f the training materials, the IEC materials, and the radio and television spots. Financing from the project will also be provided for the development and dissemination o f a training strategy. 50. Subcomponent B2: Surveillance, Investigation, and Response. This subcomponent will support serological investigations o f clusters and strengthen the national disease information system as well as the RRTs. 0 Emergency AI outbreak investigations and response. Financing requirements for investigations include travel costs for staff conducting the response, the consumables necessary for the investigations, and the shipping costs for blood samples collected. Project support will cover all o f these activities. National Level Disease Information System Management. An information technology consultant will also be supported to ensure that the implementation o f the CAM EWAR System will be standardized in terms of reporting and analyzing surveillance data through the use of a customized data application. Financing for many of these activities i s covered by WHO, USAID, US-CDC and AusAID. Support from the project will include technical assistance for the information technology, refresher training to VHV on AI andP Iawareness, and communitiesbased surveillance, RRTtraining o fprovinces and district levels. Strengthening early detection and rapid response. Activities for strengthening early detection and rapid response include the costs associated with office supplies, communication tools and a workshop on lessons learned from the affected provinces. Financing for a number o f these activities i s being provided through ADB, AusAID, and CDC-USA. Financing from the project will cover the incremental operating costs for provinces not covered by support available from other donors (including office supplies, operation and maintenance of vehicles, staff travel and travel per diem). 5 1. Subcomponent B3: Case Management and Infection Control. There are five national referral hospitals designated to handle avian influenza cases: Calmette Hospital in Phnom Penh and the Referral Hospitals inKampot, Kampong Cham, Stung Treng, and Siem Reap. These hospitals have basic isolation facilities and training has been provided to the staff ininfection control; therefore, they can manage cases o f suspected avian influenza. Inreality, suspected cases often go to the referral hospital closest to their residence, prior to being referred to these designated hospitals. In some cases, people have crossed the border to seek care in Vietnam. As a consequence, the Plan includes strengthening the capacity o f referralhospitals inCambodia to manage suspected cases prior to their referral to the five national referral hospitals. Support under the National Plan for this subcomponent includes rehabilitationo f infrastructure, purchasing medical equipment, ambulances, and PPE stocks for five hospitals, and evaluation o f training effectiveness and infection control training. Financing for these are being supported by ADB, WHO, URC, USAID and AusAID. Activities proposed for project financing are the development o f the case management training curriculum; training on clinical case management; equipment and supplies for infection control and waste management; training o f public and private health care workers in infection control; and activities associated with health care waste management. 34 52. Subcomponent B4: Laboratory Support. InCambodia, the Pasteur Institute (IPC) is the only laboratory at present that can perform rapid, reliable and sensitive testing for H5N1 and other respiratory pathogens. Givenits current functions as one o f the national referral laboratories for avian influenza and also as it i s the National Influenza Center (NIC), its workload has increased significantly. Other public health laboratories at the central level will have to be strengthened to relieve the IPC o f their routine work, specifically to handle triagehapid testing of specimen before reference to IPC and to perform quality diagnosis. The IPC will remain the national reference laboratory for final confirmation. Activities under the National Plan in support o f this subcomponent include: technical assistance; continuous educationhefresher training of laboratory staff on site (using international trainers) or at the local level using existing trainers in the country; training on new laboratory techniquedmanagement; equipment; specimen collection kits; laboratory consumables and reagents; and transport costs for specimen transport inside Cambodia and shipment abroad to WHO reference laboratories. Financing for all of these activities i s being provided by US-CDC, the government o f the United States and AusAID. Project financing will support the development o f a national laboratory strategy and work plan, as well as the strengthening of identifiedpublic healthlaboratories. 53. Subcomponent B5: Pandemic Preparedness Planning. Inthe event of the declaration of a pandemic, M O Hwill have a key technical role to play. M O Hwill have to concentrate on two issues to be prepared for a pandemic: home-based care (basic drugs treatment, PPE) and the hospital referral system (patient transport, PPE, Tamiflu, physicians, and equipment). Activities under this subcomponent include the development of a sector policy guideline and training at the provincial level so that they can prepare their own pandemic preparednessplans. 54. SubcomponentB6: RapidContainment. Rapid Containment strategy refersto MOHefforts to stop or slow down the human-to-human spread of a novel influenza virus that has the potential to create a pandemic influenza. Along with routine public health measures (e.g., patient treatment, infection control, contact tracing and intensified surveillance), the following exceptional containment measures are needed for successful rapid containment: quarantine at home or in a designated facility; social distancing such as closing of schools and workplaces; preventing public gatherings; and mass administration of antiviral drugs. MOHincollaboration with WHO has developed aplan specifically for outbreak containment with 4 points: case management, infection control, isolatiodquarantine, andequipment and supplies (logistics). Financing for all of these activities i s being provided by WHO. Activities under this subcomponent include: rapid containment; training curriculum development; workshop for rapid containment plan implementation; and rapid containment training for provincial, district and health centedhospital staff, border quarantine staff, and RRT, as well as for military, police and local authorities. Desktop exercises and simulation exercises will also be supported. 55. Subcomponent B7: Management, Coordination, and Strategy Development. Implementation o f the Human Health component, including financial management and procurement, will be undertaken by the government. Upon signing of the technical services contract between government and WHO, WHO'Sin-country staff will provide support for component management, coordination and strategy development. This support will be complemented by specialized consultants in key areas, additional fixed-term staff for financial management and procurement, and administrative and support staff (including a secretary and drivers). Financing will also be provided for laptop computers, GPS units, a satellite phone, office equipment and supply, vehicles and their operation and maintenance, meeting costs and management training for CDCD staff, 35 Project Component C: Inter-ministerial Coordination for Pandemic Preparedness (estimated cost: SDR 383,000 andUS$1.11 million;total of US$1.70 millionequivalent). 56. Background. The National Plan (Plan) buildsupon the country's inter-ministerial arrangements for natural disaster management which are entrusted to NCDM. The Plan recognizes that the current Terms o f Reference (TOR) for NCDM, focused on flood and drought, do not adequately cover AHI. To address AHI, the Plan proposes to modify NCDM's TOR and strengthen NCDM as an institution without creating unnecessary bureaucracy. In addition, the Plan proposes that NCDM address four major objectives: (a) develop an operational, inter-ministerial, Pandemic Preparedness, Response, and Recovery Plan (PPRRP); (b) implement the PPRRP; (c) establish an effective Emergency Management Information System (MIS) including an M&E system; and (d) incorporate Pandemic Preparedness activities into Community Based Disaster Risk Reduction Programs (CBRDM). The Inter-ministerial Cooperation for Pandemic Preparedness Component will support the Plan in each o f the above areas, including the objective o f modifying NCDM's TOR and strengthening N C D M as an institution. It will have the following five subcomponents: 57. Subcomponent C1: NCDM Capacity Building. The subcomponent will support: (a) development o f legislation requiring pandemic preparedness planning as part o f national policy for emergency management with sub-decrees based on this legislation assigning roles and responsibilities to NCDM; and (b) establishment o f a full-time N C D M General Secretariat and various internal units to oversee implementation o f coordination activities among ministries and external partners (including international organizations, NGOs, and bilateral mechanisms) for pandemic preparedness programs and projects. 58. Towards obtaining the appropriate TOR for NCDM, the subcomponent will review NCDM's current roles and responsibilities, discuss changes in workshops, and formulate draft legislation for submission to Parliament. Upon approval o f the legislation, the subcomponent will support the issuance o f appropriate sub-decrees mandating that NCDM facilitate inter-ministerial coordination and other relatedpandemic preparedness activities. 59. Towards the establishment o f the N C D M General Secretariat and various internal units, the subcomponent will undertake a review o f NCDM's organization structure and develop its new staffing requirement. For the staff, it will assess the training needs and create a human resources development strategy and training program. A key area o f expertise to be developed i s financial accountability o f the institutions and individuals involved in an emergency operation. The subcomponent i s expected to provide some IT related support to NCDM's infrastructure. In addition, it will establish an Emergency Operations Center, which will serve as a communications and logistics hub for pandemic preparedness, response and recovery. Lastly, the subcomponent will create within NCDM an ability to conduct field operations through the purchase o f four 4-WD vehicles and six motorcycles with operating costs. 60. Subcomponent C2: Pandemic Preparedness, Response, and Recovery Program. The subcomponent will support: (a) preparation and implementation o f the PPF2RP; and (b) testing o f the PPRRP. 61. For PPRRP preparation, the project will review the existing draft National Policy o f Emergency Management, prepare a draft PPRRP, and facilitate its discussions inseveral workshops. Based upon the discussions, the subcomponent will develop a training program for staff in all ministries to introduce their staff to pandemic preparedness. The preparation o f the PPRRP will be followed by multiple workshops carried out nationwide. In parallel to the training and discussions, the subcomponent will facilitate Business Continuity Planning (BCP) for the maintenance o f essential services for all relevant public institutions. It will then make field assessments of pandemic preparedness plan at sub-national levels to 36 guide further plan development. All the above activities will be enhanced with study tours to neighboring countries. 62. Towards PPRRP Testing, the subcomponent will conduct simulations (from desktop to full field scale) o f Disaster Preparedness and Emergency Response. In addition to evaluating the country's capacity to pick up and amplify early warning signals and to institute damage containment mechanisms early in a crisis; the simulation exercises will assess the factors that represent a constraint to an effective preparedness, response, and recovery program. 63. Subcomponent C3: NCDM Emergency M I S and M&E Systems. The subcomponent will support: (a) the design, development, and implementation o f reporting systems for emergency management information flow; and (b) the establishment o f the M&E system for the National Comprehensive AH1Plan. 64. Towards emergency management reporting design, the subcomponent will review current NCDM disaster data gathering and reporting flow through, among other things, a consultative workshop. Based upon the review, it will assign detailed responsibilities to various institutions (ministries and NGOs). It will standardize reporting formats, and provide training on them across commune, district, province and national levels. In addition, it will provide IT equipment for Provincial emergency data systems and District and Commune-level emergency communication systems (including cell phones). 65. The subcomponent will develop an M&E system for the overall national effort based on Pandemic Preparedness, Response, and Recovery needs and data management capacities. It will conduct workshops with stakeholders to identify gaps for the improvement o f the M&E system. Lastly, it will undertake external evaluations, including one after project implementation completion, and validation o f processes and performance. 66. Subcomponent C4: IncorporatePandemic PreparednessActivities into Community Based Disaster RiskReductionPrograms. The subcomponent will review existingpublic awareness programs being implemented by NCDM and other public institutions including MOH and DAHP, through nine consultative review sessions. It will also carry out 30 consultation-sessions with various village associations, NGOs, and international organizations on their current public awareness programs and community based disaster risk reduction programs. It will support three training courses, three workshops and follow-up operations. 67. Subcomponent C5: Project Management and Administration. Implementation o f the component, including administrative support, financial management and procurement, will be undertaken by NCDM. This will be done by using NCDM's existing in-country staff, complemented with specialized consultants in key areas, a project advisor, an independent procurement coordinator, an independent auditor, a financial management consultant and administrative and support staff (including a secretary and drivers). 37 Appendix 3: Project Costs CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject TOTALPROJECTCOSTBY COMPONENT TOTAL PROJECTCOST BY EXPENDITURE CATEGORY (IN US$THOUSAND) FinancingbySource PROJECTTOTAL (US$Thousand) Expenditurecategory TOTAL IDA AHIF PHRD 1.Civilworks 110 83 27 2. Goods 2,254 1,691 563 3. TrainingMrorkshops 1,657 1,078 359 220 4. Consultant Services 4,439 1,244 415 2,780 5. IncrementalOperating 2,540 1,905 635 costs TOTAL PROJECTCOSTS 11,000 6,000 2,000 3,000 Note: Identifiable taxes and duties are US$506 thousand (4.6percent) and the total project cost, net of taxes, is US$10.49 million. 38 COMPONENT k ANIMAL HEALTH PROJECTCOST BY EXPENDITURE CATEGORY (US$THOUSAND) Expenditure Category World Bank AH1 PHRD Project (IDA) Facility Total 1.Civilworks 82.5 27.5 -- 110.0 2. Goods 963.4 321.1 -- 1,284.5 3. Training and Workshops 751.0 250.3 -- 1,001.3 4. Consultant Services 1,244.3 414.8 -- 1,659.1 5. IncrementalOperating Costs 1,308.9 463.3 -- 1,745.2 Component Total 4,350.0 1,450.0 5,800.0 COMPONENT B: HUMANHEALTH PROJECTCOST BY EXPENDITURE CATEGORY (US$THOUSAND) Expenditure Category World AHI Facility PHRD Project Total Bank 1.Goods 557.6 I 185.9 I -- 743.5 2. Training and Workshovs 220.0 I 220.0 3. Consultant Services ---- ---- 1,868.7 1,868.7 4. IncrementalOperating Costs 500.9 167.0 -- 667.8 Component Total 1,058.5 352.8 2,088.7 3,500.1 COMPONENT c:PANDEMICPREPAREDNESSAND PROJECTCOORDINATIONAND MANAGEMENT PROJECTCOST BY EXPENDITURE CATEGORY (US$THOUSAND) Expenditure Category World AHI Facility PHRD ProjectTotal Bank 1.Goods 169.5 I 56.5 I 226.0 2. Training and Workshops 326.9 I 109.0 I ---- 435.9 3. Consultant Services -- -- 911.3 911.3 4. IncrementalOperating Costs 95.3 31.8 _- 127.0 Comuonent Total 591.7 197.2 911.3 1.700.2 39 Appendix4: FinancialManagementandAssessment Report CAMBODIA: AVIAN AND HUMANINFLUENZA CONTROL AND PREPAREDNESS EMERGENCY PROJECT Summaryof the FinancialManagementAssessment 1. An assessment o fthe project financial management arrangements was carried out by the Bank's financial management team duringproject appraisal inM a y 2006 andre-appraisal in September 2007. In view o f the emergency nature o f the project and the limitedFMcapacity o f all implementing agencies (MAFF,MOHandNCDM), an actionplanto strengthening project financial management arrangements was agreed with RGC. With the implementation of the agreed actions, the project financial management arrangements are considered adequate to meet the World Bank's minimumrequirements. CountryIssues 2. The Country Financial Accountability Assessment (CFAA), which was carried out in M a y 2003 as part o f the Integrated Fiduciary Assessment and Public Expenditure Review, concluded that the overall fiduciary risk inCambodia i s high.Inspite o f the multiplicity o f controls and the centralized nature o f the public expenditure management system, weak financial management practices pose serious fiduciary risks. The control environment i s weak, especially inthe area of cash management, and both internal and external auditing capacity needs strengthening. These systemic weaknesses provide opportunities for corruption and misuse o f funds, which were confirmedby recent Bank INT investigations. 3. The US$ 14 million IDA grant for a Public Financial Management and Accountability project (PFMAP) to address the most serious governance issues, which were recognized in the 2005 CAS as being the primary obstacle to poverty reduction and aid effectiveness, has just become effective on 2gth June 2007. The PFMAP provides support to the government PFMReformProgram, which a PFMMulti- donor Trust Fund (MDTF) administered by the Bank i s already supporting. The MDTF co-finances the PFMAP. Actions in progress and to be undertaken under the project include assistance to improve revenue management; budget formulation and integration; budget execution (including the development and implementation o f an integrated financial management system and strengthening public procurement system); to implement reforms in the Ministry o f Economy and Finance's (MEF) personnel management through establishing merit-based selection and promotion and performance management through a merit based pay initiative for selected MEF staff and developing the capacity o f internal audit o f government and of the external audit under the country's supreme audit institution, the National Audit Authority. 4. While these actions have started to address specific fiduciary issues, the country financial management environment for externally funded projects remains weak. RiskAnalysis 5. InherentRisk.The inherentrisk to the project from the country environment is considered to be highdue to the weak financial control environment and systems inthe public sector. This highlevel o f inherent risk has been mitigatedby the actions describedbelow. 6. Control Risk. Overall control risk at the project level is assessed as high due to weak financial accounting and management information systems, limited financial capacity and lack o f effective internal control oversight, but i s considered to be reduced to moderate after implementation o f the risk mitigation measures described below. 40 Risk Risk RiskMitigationMeasures Residual Rating Risk InherentRisk Country level H To address the high level o f country risk, a S government led PFM Reform Program i s under implementation, and i s being supported by a Bank- administered MDTF and the PFMAP (as described above). Entitylevel S Project specific financial management arrangements M will be tlut indace for this moiect. ControlRisk Implementing H The financial management arrangements for the M entities proposed AH1 project will be through the establishment o f a separate financial management unit, within a PIU, staffed by consultants for MAFF and NCDM, and through the financial unit o f the on- going HSSP for MOH. Budgeting H Annual budgets based on project annual work plans M will be preparedby each IA and agreed by the Bank. Funds flow H Each IA will maintain its own Designated Accounts M to be opened at an acceptable commercial bank. IDA and AHIF sources of funds will flow to one designated account, and PHRD to a separate DA. Staffing H For MOH, the FM tasks will be handled by the M existing finance unit in-charge o f the on-going HSSP with some additional staffrequired. For MAFF and NCDM, a financial management consulting firm will be contracted to install computerized accounting software and provide training. In addition, a FM consultant will be recruited at both I A s to strengthen the FMunit. Accounting H Each IA will follow accounting procedures described M in the Financial Management Manual acceptable to MEF and IDA. They will account for projects funds and activities in their accounting systems and maintain their accounts and records. The project accounting records will match each expenditure with the appropriate source o f funding to account and report on uses by source of funds. Reporting H Each IA will produce quarterly IFRs in line with an M agreed format and submit to the Bank within 45 days after the end o f each quarter. External Audit H The NCDM will be responsible for compiling the M annual project financial statements and have it audited by an independent auditor under TORSacceptable to the Bank, including review o f internal controls. Overall financial H M management risk. 41 StrengthsandWeaknesses 7. Strengths: The FM arrangement o f the Human Health component will be handled by MOH through the existing finance unit in charge of the on-going Health Sector Support Project (HSSP), which has developed financial management capacity that can be made available to the proposed project. In Framework (see Appendix lo), as well as the "Guidelines on Preventing and Combating Fraud and addition, the project will be carried out in accordance with the provisions o f the Good Governance Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants" (the "Anti-Corruption Guidelines"), dated October 15, 2006. 8. Weaknesses: Limited FM experiences and capacities at MAFF and NCDM. There will be no consolidated project financial reporting, each component will be managed and reported separately. ImplementingEntities 9. The government has decided that implementation o f the project will be the responsibility of three Implementing Agencies (IAs), as follows: ComponentA: The Animal Healthcomponent will be implementedbythe Animal Health and ProductionDepartment (DAHP) of MAFFthrough its Animal Health Office, Animal Production Office, and the NVRI. A small unit will be created within DAHP to provide support in procurement, financial management, M&E, and overall administration for the component (with technical assistance). 0 ComponentB:The HumanHealthcomponent will be implementedbyMOHthrough the existing PIUincharge o f the on-going Health Sector Support Project (HSSP). An additional Financial Management consultant will be recruited to assume these new responsibilities. Component C: NCDM, through its General Secretariat, willbe incharge o fthe Inter-Ministerial Coordination for Pandemic Preparedness component, as well as the overall project coordination and management (with technical assistance). ProjectFinancingArrangements 10. The project i s being financed by grants from IDA, the multi-donor fund for avian influenza AHIF and the Japanese PHRDFund, as follows (see Attachment Ito this Appendix): The PHRD Grant (US$3 million) will finance 100 percent o f the expenditures (including taxes) corresponding to: (i) all Training and Workshops under Component B; and (ii) the Consulting all Services for Components B and C. The IDA Grant (US$6 million) and the AHIF Grant (US$2 million) will cofinance (in 75/25 percent proportion) all eligible expenditures not covered by the PHRD grant for all project components. These financing shares of IDA and AHIF (75 and 25 percent, respectively) have been determined factoring inthat no taxes and duties should be financed from the AHIF grant (see computation in Table 1below). All taxes and duties on these categories will be fully covered by IDA.' 7The Cambodia country financing parameters allow for IDA financing o f all taxes and duties. IDA has appraised that taxes and duties do not constitute an excessive share of project costs (estimated at about 4.6percent o f project expenditures on these categories). 42 Table 1: ComputationofFinancingArrangements for ExpendituresCo-financedby IDA andAHIF: ComponentsA, B and C for atotalofUS$8 million TOTAL FINANCINGARRANGEMENTS COSTS IDA AH1Facility (%'000) $'OOO % $'OOO YO Costs excluding taxes 7,632 5,632 73.8 2,000 26.2 Estimated taxes (fully IDA- 368 368 100.0 -- -- financed)' Costsincludingtaxes 8,000 6,000 75.0 2,000 25.0 11. The project accounting system used by each IA will record the appropriate source o f funding for different expenditures, to account and report on their uses by source o f funds. The project financial statements and audit will confirm adherence to the stipulated financing shares, thereby also confirming that taxes and duties have not been financed from the AHIF proceed^.^ 12. The following Tables 2 and 3 indicate the amounts allocated per component and per category and the percentage o f project expenditures financed by each financing source. Table 2 -Total ProjectCostper Componentandby FinancingSource. (US$ thousands) Activity World AH1 PHRD Project Bank Facility Total (IDA) Component A: Animal Health 4,350 1,450 -- 5,800 Component B: HumanHealth 1,058 353 2,089 3,500 Component C: Pandemic 592 197 911 1,700 Preparedness and Project Coordinationand Management Project total: 6,000 2,000 3,000 11,000 'These estimated taxes have been computedbased o n the different tax rates applicable to each expenditure category and taking into account the items expected to be exempted from local taxes. 9 For clarity, the Notes to Project Financial Statements will state that the financing shares between IDA and AHIF financing stipulated at the beginning have been determined ina manner as to exclude any financing o f taxes and duties from the AHIF; and confirm that these agreed financing shares have been adhered to, and therefore no taxes and duties have been financed from the AHIF. 43 Table 3 -Total Project Cost Financing by Expenditure Category and by Source. 3. Trainingand 1,657 1,078 359 220 65 22 13 Workshops 4. ConsultantServices 4,439 1,244 415 2,780 28 9 63 5. Incremental 2,540 1,905 635 75 25 OperatingCosts TOTAL PROJECT 11,000 6,000 2,000 3,000 55 1s 27 COSTS 13. The tables included inthe Attachment 1to this Appendix, present the allocation o f funds from the three sources by ExpenditureCategory and by Component. FundsFlow (see Attachment 2) 14. As indicated above, funding for the project will be derived from three different sources: (i)IDA grant, US$ 6 million; (ii) and Human Influenza Facility grant, U S $2 million; and (iii) Avian Japanese PHRD grant, U S $3 million. 15. Each IA will open and maintain two Designated Accounts, one for the IDA and AHIF grants (pooled together inthe same DA), and a second DA for the funds from the PHRD grant, all in commercial banks acceptable to IDA. All funds from each source will be separately identified and accounted for by each IA in the accounting records and systems. The project accounting records will match each expenditure with the appropriate source o f fundingto account and report on uses by source o f funds. The project chart of accounts and reporting formats will be developed to make this possible. DesignatedAccount for IDA andAHIF Designated (US$) ImplementingAgency Account for PHRD FromIDA Grant FromAHIF Grant (US$) MAFF-ComponentA 450,000 150,000 N.A. MOH -ComponentB 105,000 35,000 210,000 NCDM- ComponentC 75,000 25,000 100,000 44 Disbursement Arrangements 17. The flow o f funds will be through the Ministryo f Economy and Finance's pass-through account (Single Treasury Account) inthe National Bank o f Cambodia (NBC) for further credit to the project Designated Accounts (DAs) to be opened by the I A s incommercial banks acceptable to IDA. The detailedprocedures and mechanisms for operation o f the pass-through account inNBC and for the establishment o f DAs incommercial banks will be mutually agreed betweenthe IDA and MEF. Until these details are agreed, duringearly stages o f implementation the project will continue to use the existing arrangements consisting indisbursingto respective DAs for each IA inthe NBC. 18. The withdrawal applications to be submitted will indicate clearly how much project expenditures will be claimed under each source o f funds with the requiredreconciliations o f the ledger accounts to the bank account balances. The withdrawal applications will clearly indicate that the AHIF financing (25percent o f combined IDNAHIF financing for Components A, B and C) does not include any taxes and duties. The project will use transaction based disbursement procedures, using the designated accounts for most expenditures, with replenishment on the basis o f statements o f expenditures (SOEs). Direct payment methods may also be used for expenditures above the levels for SOEs (see below). 19 Use of SOEs. Some o f the expenditures o f the grants are expected to be disbursed on the basis of SOEs as follows: (i) works contracts costing less than $100,000 equivalent each; (ii) contracts civil goods costing less than $100,000 equivalent each; (iii) service contracts for firms costing less than $100,000 equivalent each and for individual consultants costing less than $50,000 equivalent each; (iv) training and workshops; and (v) operating costs. Disbursement for civil works, goods and services exceeding the foregoing limits will be made inaccordance with respective procurement guidelines and provisions in the Financing Agreement against submission o f full documentationand signed contracts. 20. As indicated in Tables 4, 5 and 6 (see also Attachment 1to this Appendix), disbursements will cover the following: Disbursements from the PHRD Grant (US$3 million) will finance 100percent o f the expenditures (including taxes) corresponding to: (i) all Training and Workshops under Component B; (ii) all the Consulting Services for Components B and C; Disbursements from the IDA grant (US$6 million) will cover 75 percent of: (i) expenditures all for Component A for all categories; (ii) goods and incremental operating costs for Component B; and (iii) training/workshops, and incremental operating costs for Component C. The IDA goods, fundingwill cover all taxes and duties for these categories. Disbursements from the AHIF grant (US$2 million) will cover 25 percent o f the same expenditures financed by the IDA grant for Components A, B and C. The AHIF funds will not cover taxes and duties. Retroactive Financing 21. Retroactive financing up to aggregate amounts not to exceed 10 percent o f the funds available from each source o f fundingmay be used for eligible expenditures incurred after February 15, 2008. The procurement o f these activities should be done in accordance with the procedures agreed for the proposed project, as established inAppendix 5 to this document, as well as inthe negotiated legal agreements. This provision will allow the project to be able to respond more forcefully to an eventual outbreak o f the disease, or to strengthen surveillance activities at any moment when the risk o f resurgence may be considered high. The Recipient i s aware o f the conditions o f the retroactive financing and the risks associated with payments made in expectation o f this retroactive financing. This provisional agreement 45 does not commit IDA to the repayment o f the expenditures, if the proposed grants are not approved, or to financing these payments ifthey are found non-eligible. Table 4: IDA Grant Financing DisbursementCategories andDisbursementPercentages. DisbursementCategoriedSubcategories IDA Grant Percentageof Allocation Expenditures (US$ thousand) ( Y O ) 1. COMPONENT A: ANIMALHEALTH 4,350 75 (a) Civil works 83 (b) Goods 963 (c) TrainingiWorkshops, 751 (d) Consulting Services 1,244 (e) Incremental Operating Costs 1,309 2. COMPONENT B: HUMANHEALTH 1,058 75 (a) Goods 558 (b) Incremental Operating Costs 500 3. COMPONENT C: PANDEMIC PREPAREDNESS I 592 75 and PROJECTCOORDINATION/MANAGEMENT (a) Goods 170 (b) TrainingiWorkshops 327 (c) Incremental Operating Costs 95 TOTAL IDA FINANCING 6,000 75 Table 5: AHIF Grant Financing DisbursementCategories andDisbursementPercentages. DisbursementCategories/Subcategories AHIFGrant Percentageof Allocation Expenditures (USS thousand) ( Y O ) 1. COMPONENT A: ANIMALHEALTH 1,450 25 (a) Civil works 28 (b) Goods 321 (c) TrainingiWorkshops 250 (d) Consulting Services 415 (e) Incremental Operating Costs 436 2. COMPONENT B: HUMANHEALTH 353 25 I(a) Goods I 186 I (b) IncrementalOperating Costs 167 3. COMPONENT C: PANDEMIC PREPAREDNESS I 197 25 andPROJECTCOORDINATION/MANAGEMENT (a) Goods 56 (b) TrainingiWorkshops 109 (c) Incremental Operating Costs 32 TOTAL AHIF FINANCING 2,000 25 46 DisbursementCategories/Subcategories PHRD Grant Percentageof Allocation Expenditures (US$ thousand) (YO) 1. COMPONENTB:HUMANHEALTH 2,089 100 (a) TrainingandWorkshops 220 (b) Consulting Services 1869 2. COMPONENT C: PANDEMIC 911 100 PREPAREDNESS and PROJECT COORDINATION/MANAGEMENT (a) Consulting Services 911 TOTAL PHRDFINANCING 3,000 100 Staffing be responsible for FM tasks o f the Component B - Human Health. However, one additional financial 22. For MOH, the existing finance unit incharge o f the FM arrangements o f the on-going HSSP will management consultant will be added for this project. For MAFF and NCDM, a qualified consulting firm will be hired to install a computerized accounting software considered capable o f producing the financial reports required, and to provide training to the designated project financial staff. Inaddition, a financial consultant will also be recruited to support the day-to-day activity (2 years for MAFF and 18 months for NCDM). Two government staff at NCDM has been designated to the project. At least one government staff will have to be designated by MAFF. AccountingPoliciesand Procedures 23 The existingfinance unit o f the on-going HSSP has established accounting system (using Quickbook) and procedures satisfactory to the Bank. For MAFF and NCDM, a consulting firmwill be employed to install a computerizedaccounting software and provide training untilthe system i s infull operation. Their FMmanuals cover requests for expenditure processing and describe financial policies and procedures for (a) planning and budgeting; (b) internal controls; (c) financial accounting systems; (d) control of petty cash; and (e) all routine financial management and related administrative activities. InternalAudit 24. The Internal Audit Departments (IAD)under MAFF and MOHwere already established and currently staffed with 40 and 21personnel respectively. KPMG was contracted to provide technical support and on-the-job training to the IADo f MOH since year 2005. To address financial risks and to provide management with advice on the effectiveness o f financial systems and internal controls o f the project, it is recommendedthat MAFFand MOHmake arrangements for the project to be included inthe program o freview by their IADand that the audit findings from review o f the project be provided to the Bank. External Audit 25. The annual financial statements and designated accounts for the I A s corresponding to the three components will be audited by independent auditors acceptable to IDA, working to terms o f reference acceptable to IDA. The audit TORSwill cover both the annual audit o f the project financial statements including their consistency with the quarterly IFRs, and a review o f internal controls and compliance with 47 the legal grant agreements. The Auditor will be required to issue a management letter providing an assessment o f the financial management system, including the adequacy of internal controls. The cost o f audit i s provided in the project budget for Component C and it will be paid out o f project funds as an authorized expenditure. 26. At the end o f each year, the NCDM finance unit will be responsible for compiling the consolidated project financial statements for three I A s and to have it audited by the auditor. The audited financial statements must be submitted to the RGC and the Bank within six months o f the end o f the financial year. ReportingandMonitoring 27. Interim financial reports (IFRs) will have to be submitted to RGC and the Bank quarterly within 45 days after the end o f each quarter by each implementing agency. As the IFRs will also be used as a monitoring tool, it will report project progress with adequate description and explanation and analysis o f variances. IFRs will include reports on sources and uses o f funds, the project financial position; project expenditures, physical progress compared with plan; and procurement monitoring. They will not be subject to audit. The three implementing agencies will follow the required format o f the IFRs, which will be agreed at negotiations. FinancialManagement Action Plan 28. The following actions have been agreed upon: Actions ResponsibleAgency Completion date Prepare and agree on a format for the EachIA and Bank To be agreed at Negotiations InterimFinancial Reports (IFRs). Recruit a qualified FMstaff for each IA Each LA Condition for Effectiveness Adopt a FinancialManagementManual, NCDM, incoordination Before June 30,2008. as part o f the project's PIP, with withthe three IAs. accounting, financial management and audit procedures for the implementation o f the project. Establisha computerizedaccounting MAFFandNCDM Before June 30,2008 system satisfactory to IDA at MAFFand at NCDM, to operationalize the procedures specified inthe Financial Management Manual. Appoint independent auditor acceptable to N C D M Prior to the first audit period. IDAto carry out the audit o fthe annual financial statements for the entire project, under Terms o f Reference satisfactory to IDA. SupervisionPlan 29. Financial management supervision will be undertaken twice a year by members o f the regional FM team. Physical supervision on the ground will be supplemented by reviews o f the quarterly interim financial reports and the annual audit reports, including the management letters describing the status o f internal controls. Intensity o f supervision will be reassessed after the first year o f implementation. 48 ATTACHMENT 1 DISBURSEMENTSBY COMPONENT, BY CATEGORYAND SOURCE. PercentageFinancedby FinancingAllocated bySource Source PROJECTTOTAL (US$Thousand) (YO) Component and Disbursement Category TOTAL IDA AHIF PHRD IDA AHIF PHRD A. ComponentA: Animal Health (MAFF) I I I I I I I I TOTAL PROJECT 11,000.0 6,000.0 2,000.0 3,000.0 55 18 27 COST 49 ATTACHMENT 2 FLOW OF FUNDS lo PROJECTACCOUNT TOTAL =$11million IDA=$ 6 million -t AHIF = $ 2 million PHRD = $ 3 million $. MEF Pass-throughAccount ComponentA ComponentB ComponentC MAFF M o H NCDM One Designated Two Designated Two Designated Account: Accounts: Accounts: 1 IDNAHIF IDNAHIF $140,000 IDNAHIF $100,000 $600,000 PHRD $210,000 PHRD $100,000 Contractors Contractors Suppliers Suppliers Suppliers loDoesnotincludethedirectpaymentstobedonedirectlybyIDAfromtheGrantAccountstosuppliersandContractors,asrequestedbythe Recipient, above the SOE thresholds.Untilall detailedprocedures and mechanismsfor operationof the pass-throughaccountinNBC and for establishment of DesignatedAccounts (DAs) incommercialbankshavebeenmutually agreedbetweenthe IDA and MEF, the status quo of having Das inNBC will continue to be implemented to allow for early project execution. 50 Appendix 5: Procurement Arrangements CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergency Project A. General 1. Procurement for the proposedproject will be carried out inaccordance with the World Bank's "Guidelines: Procurement Under IBRDLoans and IDA Credits" dated M a y 2004, revised October 2006, and "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers" dated M a y 2004, and revised October 2006. The general descriptiono fvarious items under different expenditure categories are described below. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for prequalification, post-qualification, estimated cost, prior review requirements and time frame are agreed between the Recipient and the Bank project team in the Procurement Plan. The ProcurementPlan will be updated at least annually or as requiredto reflect the actual project implementation needs and improvements ininstitutional capacity. 2. Procurement of Goods: Goods under the project are expected to include vehicles, motorcycles, office equipment and furniture, communications equipment, etc. Goods estimated to cost equal or more than US$lOO,OOO shall be procured through the International Competitive Bidding (ICB) method and the procedures set forth in the Bank's Procurement Guidelines and using the Bank's applicable Standard Bidding Documents; except that motorcycles (for MAFF and MOH under Components A and B) and vehicles (for NCDM under Component C), estimated to cost less than US$150,000 equivalent per contract, may be procured under the method Procurement from United Nations Agencies (UNOPS). Goods estimated to cost less than US$ 100,000 equivalent per contract may be procured through the National Competitive Bidding (NCB) method and the procedures, including standard biddingdocuments, set forth in the Sub-decree 14 on Promulgating of the Standard Procedurefor Implementing the World Bank and the Asian Development Bank Assisted Projects dated February 26,2007 and relevant provisions o f the Royal Government of Cambodia Externally Assisted Project Procurement Manual for Goods, Works and Services, subject to the improvements listed in the Annex to the DGA. Goods estimated to cost less than US$20,000 equivalent per contract may be procured through the Shopping method and the procedures, including standard request for quotation documents, set forth inthe aforesaid Sub-decree and Procurement Manual. 3. Procurement of Works: Works under the project are expected to include fitting and commissioning o f new laboratory facilities and renovation o f laboratory buildings under the Animal Health Component. The nature and small value o f the works i s not likely to attract international competition. Works shall be procured through National Competitive Bidding (NCB) method and the procedures, including standard bidding documents, set forth in the aforesaid Sub-decree 14 and Procurement Manual subject to the improvements listed in the Annex to the DGA. Works estimated to cost less than US$40,000 equivalent per contract, may be procured through the Shopping method and the procedures, including standard request for quotation documents, set forth in the aforesaid Sub-decree and Procurement Manual. 4. Selectionof Consultants:Consulting services under the project are expected to include technical tasks, project management support including Financial Management and Procurement Specialists, project evaluation, external audit services, etc. Services requiring hiring o f firms will generally be procured through Quality-and Cost-based Selection (QCBS) method. However, for assignments estimated to cost less than US$50,000 equivalent per contract the method Selection Based on Consultants' Qualifications (CQS) may be used, and for external audit assignments the Least Cost Selection Method may be used. 51 Services for tasks under circumstances which meet the requirements o f paragraph 3.10 o f the Consultant Guidelines may, with the Bank`s prior agreement, be procured through the Single Source Selection method. Services requiring hiring o f individual consultants may be procured in accordance with the provisions o f Section V o f the Consultant Guidelines, whereas Single Source Selection o f individual consultants may be done only with the Bank's prior agreement and under the circumstances described in paragraph 5.4 o f the Consultant Guidelines. Shortlists o f consultants for consulting services estimated to cost less than US$lOO,OOO equivalent per contract may be composed entirely o f national consultants. The Bank's Standard Request for Proposals (RFP) document, including contact forms, shall be used for all assignments requiring international competition. Consulting Services contracts with UN agencies will follow the Standard Form o f Agreement between IDA Borrowers and UN Agencies concerning the carrying out o f consultants' services financed by IDA, revised October 2007 for use only with Specific Avian Influenza Projects in accordance to the Batch Waiver approved by the Bank's MD on August 3, 2007. B.Assessment of the agency's capacityto implementprocurement 5. The three Implementing Agencies (IAs) under the project are: (i)MinistryofAgriculture, Forestry, and Fisheries (MAFF), through its Department o f Animal Health and Production (DAHP), for the Animal Health component; (ii) Ministry of Health, though its existing implementing unit o f the on- going Health Sector Support Project, (HSSP) for the Human Health component; and (iii) National Committee for Disaster Management (NCDM), through its General Secretariat, for the Pandemic Preparedness component. It was reconfirmed that NCDMwill take overall responsibility for overseeing and coordinating the institutional and implementation arrangements for the project including overall project coordination and management, ensuring linkages across relevant agencies and with international partners, and for guiding and monitoring project implementation at the central level. 6. An assessment o f the existing capacity o f the three IAs to implement procurement under the project was carried out by the Bank in September 2007. It indicates that two IAs, MAFF and NCDM, have no prior experience incarrying out procurement under the Bank's Procurement Guidelines and also do not have suitable qualified staff dedicated for procurement. The third IA, MOH, by virtue o f its existing implementation unit for the ongoing HSSP project, has adequate experience inthe World Bank's procurement procedures but relies largely on one individual procurement consultant who was hired primarily for providing procurement support to that project. T o address the inadequate o f procurement capacity o f the IAs, and consistent with the government's decision to require the IPA for all WB-financed projects in Cambodia, it was agreed that all procurement under the project, with the exception o f single source selection and procurement from UNagencies, will be carried out by the International Procurement Agent (PA). Single source selection and procurement fi-om UN agencies has been excluded fi-om the IPA's scope because the use o f these methods, once agreed by the Bank, does not involve undertaking a competitive process and therefore using the P A and paying its service fee for procuring these contracts would not be an effective use o f the available resources and would also go against the principles o f economy o f the Bank's Guidelines. It was also agreed that at least one qualified individual would be appointed by each IA as Procurement Coordinator to serve as the focal point for coordination and follow- up o f procurement activities between the implementing agency, PA, MEF, and the Bank. Incase that qualified government staff are not available a local individual consultant will be engaged by the IA. In addition Bank staff will provide training as needed during the life o f the project. 7. The high fiduciary risks in Cambodia in the context o f the weak governance environment in the country, including procurement, are expected to be mitigated through a range o f strengthening measures that have been built into the project's design. These include implementation o f a Good Governance Framework (anti-corruption action plan) - included in Appendix 10 to this Technical Annex, which has been endorsed by all three project I A s and includes elements for increasing public disclosure, complaints 52 mechanism, integrity pacts, involvement o f civil society, strengthened financial management and procurement arrangements, and redress o f project-specific implementation needs. The strengthened procurement arrangements include required use o f the PA, application o f Kingdom o f Cambodia's Standard Procurement Manual for Externally Assisted Projects, including Standard Bidding Documents, which in itself requires numerous measures for further enhancing transparency and accountability in NCB, Shopping and nationally competitive consulting services procurement, an NCB-Annex requiring additional procedural improvements, rationalized thresholds to reduce use o f less competitive methods such as Shopping, bulk o f the competitive procurement by value to be done through ICB, expanded scope o f post-reviews by the Bank to include checks for indicators o f collusion and end-use deliveries in addition to verifying procedural compliance, and oversight by RGC's Anti-Corruption Working Group for World Bank financed projects. 8. With incorporation o f the capacity strengthening measures and widespread requirements for improving governance and increasing transparency and accountability in the procurement process, the residual procurementrisk under the project i s Moderate. C.ProcurementPlan 9. For project implementation the Recipient has developed the initial procurement plans, attached to this Appendix 5, which provide the basis for the selectedprocurement methods. This planhas been agreed between the Recipient and the Bank. The plan will be updated in agreement with the Bank at least annually as required to reflect the actual project implementation needs and improvements in institutional capacity. D.FrequencyofProcurementSupervision 10. Inadditionto the prior review supervision to be carriedout bythe Bank, the capacity assessment o f the Implementing Agency recommends that procurement supervision missions, including ex-post review, be conducted at least twice per year. E.PriorReview Requirement 11. The following contracts will be subject to prior review by the Bank: (a) each contract for goods and works estimated to cost the equivalent o f US$lOO,OOO or more; (b) the first contract each for goods and works procured by each implementing agency under National Competitive Bidding (NCB) procedures; (c) each contract for consultants' services providedby a firm estimated to cost the equivalent o f US$ 100,000 or more; (d) each contract for the employment o f individual consultants estimated to cost the equivalent o f US$ 50,000 or more, and (e) each contract involving Single-Source Selection o f firms, organizations, or individual consultants, irrespective o f value, shall be subject to prior review by IDA. All other contracts shall be subject to ex-post review by the Bank. The percentage to apply for contracts subject to ex-post review i s 30 percent. 53 Appendix 5 Attachment 1 Details of the procurement involvingInternational Competition, Direct Contracting, Procurement from UNAgencies, or Single Source Selection Goods: (a) List of contract packages which will be procuredfollowing ICB, Direct Contracting or Procurement from UNAgenciesmethods. 4 nponent A Ministry of Agriculture, Forestry, and Fisheries - 2 13 14 I 5 16 17 I s 19 Contract Estimated Procurement P-Q Domestic Review Expected Comments (Description) cost Method Preference byIDA Bid- (US%m) (yedno) (Prior / Invitation Post) Date Station 790,000 ICB No Yes Prior Jan 08 wagons and Pick-up Vehicles Motorcycles 110,000 1UNO;;? I Prior I Jan 08 No I No 1 2 3 4 5 6 7 8 9 Ref. Contract Estimated Procurement P-Q Domestic Review Expected Comments No. (Description) cost Method Preference by IDA Bid- (US$ m) (yes/no) (Prior / Invitation Post) Date 1.1 Pickupvehicles 525,000 ICB No Yes Prior Feb08 1.2 Motorcycles 115,500 UNAgency No No Prior Feb08 (UNOPS) 1 1 Component C National Committee for Disaster Management - 1 12 13 14 15 16 17 I s 19 Ref. Contract Estimated Procurement P-Q Domestic Review Expected Comments No. (Description) cost Method Preference byIDA Bid- (US%m) (yesho) (Prior / Opening Post) Date 1.1 4 WD Vehicles 100,000 UNAgency Prior Jan 08 (UNOPS) I I 54 @) All contracts procured under ICB, Direct Contracting or Procurement from UN Agencies methods shall be subject to prior reviewby IDA. ConsultingServices (a) List of consulting assignments which will be selected following international competition or Single Source Selection method. ComponentA -Ministryof Agriculture,Forestry,andFisheries 1 2 3 4 5 6 7 Ref. Description of Estimated Selection Review Expected Duration No. Assignment cost (US$) Method by IDA Proposals 1(Prior / Invitation Post) Date 1 Technical Assistance Prior Services contract with the Food and Agriculture Organization (FAO) * Subject to satisfactory justification for SSS being provided by MAFF in accordance with the Consultant Guidelines Paras.3.10 ComponentB-Ministryof Health 3 4 7 Estimated Selection Duration No. Assignment cost (US$) Method Post) 1 ITechnical 1,378,306 sss* Prior 3 years Assistance I Jano8 Services Contract with World Health Organization (WHO) * Subject to satisfactory justification for SSS being provided by MOH in accordance with the Consultant Guidelines Para.3.10. 55 ComponentC NationalCommitteefor Disaster Management - 4 5 6 7 I Selection Review Expected Duration cost (US$) Method by IDA Proposals 7 (Prior / Submission Post) Date 1 Technical Assistance 292,950 sss* Prior Jan 08 3 Years Services Contract with agency from the UnitedNations System * Subject to satisfactory justification for SSS being provided by NCDM in accordance with the Consultant Guidelines Para.3.10. (b) Each contract for consulting services exceeding $100,000 for firms and $50,000 for individuals, and each contract involving Single-Source Selection of firms, organizations, or individual consultants, irrespective of value, shallbe subject to prior review by IDA. 56 Appendix 5 Attachment 2 NationalCompetitive BiddingProcedures 1. The procedure to be followed for National Competitive Bidding shall be those set forth in the Sub-decree 14 on Promulgating o f the Standard Procedure for Implementing the World Bank and the Asian Development Bank Assisted Projects dated February 26,2007 and relevant provisions o f the Royal Government o f Cambodia Externally Assisted Project Procurement Manual for Goods, Works and Services with modifications set forth below inorder to ensure economy, efficiency and transparency and broad consistency with the provisions o f Section Io f the o f the Guidelines for Procurement under IBRD Loans and IDA Credits published by the Association in M a y 2004 and revised in October 2006 (the Guidelines) as required by paragraph 3.3 and 3.4 o f the Guidelines. Eligibility 2. The eligibility o f bidders shall be as defined under Section Io f the Guidelines; accordingly, no bidder or potential bidder shall be declared ineligible for contracts financed by the Association for reasons other than those provided in Section Io f the Guidelines. Foreign bidders shall not be asked or required to formjoint ventures with national bidders inorder to submit a bid. Bidders locatedinthe same province or city as the procuring entity shall not be given preference over bidders located outside that city or province. QualificationCriteria 3. The assessment o f the qualification o f a bidder shall be conducted separately from the technical and commercial evaluation o f the bid and in strict adherence to the qualification criteria that shall be clearly specified in the bidding documents. Such assessment shall only take into account a bidder's capacity and resources to perform the contract, specifically its experience and past performance on similar contracts, capabilities with respect to personnel, equipment and construction and manufacturing facilities, and financial capacity. BidSubmission, BidOpening andBidEvaluation 4. The evaluation o f a bid shall be made in strict adherence to the criteria that shall be clearly specified in the bidding documents and quantified in monetary terms for evaluation criteria other than price; merit points shall not be used inbid evaluation. 5. No bidder shall be rejectedon the basis o f a comparisonwith the Borrower's estimate and budget ceiling without the Association's prior concurrence. 6. A copy o f the minutes o f the public bid opening shall be promptly provided to all bidders and to the Association with respect to contracts subject to prior review. 7. Neither shall all bids be rejected nor shall new bids invited without Association's prior written concurrence. Complaints byBiddersand Handlingof Complaints 8. The Borrower shall implement an effective and independent protest mechanism allowing bidders to protest and to have their protests handled ina timely manner. 57 Fraudand Corruption 9. The Association shall declare a firm or individual ineligible, either indefinitely or for a stated period, to be awarded a contract financed by the Association, if it at any time determines that the firm or individual has, directly or through an agent, engaged in corrupt, fraudulent, collusive, coercive or obstructive practices in competing for, or inexecuting, a contract financed by the Association. Rightto InspectlAudit 10. Each bidding document and contract financed from the proceeds o f a Credit shall include a provision requiring bidders, suppliers, contractors and subcontractors to permit the Association, at its request, to inspect their accounts and records relating to the bid submission and performance o f the contract and to have said accounts and records audited by auditors appointed by the Association. The deliberate and material violation by a bidder, supplier, contractor or subcontractor o f such provision may amount to obstructive practice. 58 1 1 II I za % 00 .r B VI VI VI I I I+ r z r N n b E Y 0 0 w .,- 6 C fa 00 0 0 N E.. Y c e W a.- r5 U U 8 9i g z 8 3 I8 Id 18 8 9i 5i 2i L +-I- L Pi Ei - - 8em rn 5 Appendix 6: EnvironmentalAnalysis CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject 1. Cambodia's ExperiencewithRespondingto AvianInfluenzaOutbreaks 1. Two distinct systems inthe Cambodianpoultry sector exist: the small-scale backyard system, and the commercial system. The backyard system dominates the poultry sector in terms of the number of farms and overall number of poultry. This includes the subsistence farmers who own a small number o f poultry mainly for personal consumption and also some sales inlocal markets. Of those households with poultry, some 80 percent keep only chicken, 19 percent keep chicken and duck, and 1percent keep only duck. The commercial sector has less than 1percent ofthe total number of farms, and about 10percent o f the national flock, which i s estimated to be about 16.3 million birds. The Thai firm CP has the largest farm inCambodia (inKandal) with 100,000 layers. This company also dominates the broiler sector. The most important poultry populations in Cambodia are found in Pursat (15 percent), Takeo (11 percent), Kampong Cham (10 percent), Kandal (8.6 percent), Prey Veng (8.6 percent), Kampot (7 percent), and Kampong Speu (7 percent). 2. Cambodia was one o f the first counties in Southeast Asia to experience HPAI infection. The first case of HPAI in Cambodia was reported in December 2003 in the Takmao Wildlife Rescue Center (45 km south of Phnom Penh), and the first wave of outbreaks occurred during January to May 2004 in five provinces (Takeo, Kandal, and Siem Reap, and Kampong Cham) and Phnom Penh, having severe impacts on smallholder farmers who raise the majority of the country's poultry under subsistence conditions and on small-scale commercial poultry farms. HPAI cases emerged again in late 2004 and early 2005. Subsequently, there was one confirmed outbreak among chicken, ducks and fightingcocks in February 2006, and this outbreak was quickly contained (about 2,500 birds were lulled by disease or culled). Four human cases in Kampot (2005) and two human cases in Kompong Speu and Prey Veng (2006) occurred. All these human cases were fatal. 3. Provincial and district animal health officers, and VAHWs under the supervision of DAHP, implemented a number of animal health measures in order to contain these disease outbreaks. These measures included control of the movement o f poultry and poultry products, culling, disinfection, field investigation, field epidemiological surveillance and sampling. The procedures used to carry out these measures were as follows: Use of personal protection equipment (PPE) and disinfection/disuosal of used PPE. PPE was usedat farms where AH1outbreaks occurred and were suspectedto occur (i.e. those farms where poultry was culled). Each worker wore one plastic coverall. There was no change of coveralls duringthe day as the workers did not leave the work area or take any breaks (e.g. lunchbreak) untilthey finishedtheir daily work. Other PPEusedincluded gloves, masks, goggles, andboots. All used PPE, except for goggles and boots, were disposed of at the end of the daily work by placing them in plastic bags, which were tightly closed and buried on site." However, goggles and boots were disinfectedwith TH4 to bereused. After finishingwork, all workers washed their hands, although there were no shower facilities in the field. The above-mentioned procedures relate to culling o f poultry during AH1 outbreaks. However, to carry out their regular AH1 surveillance work, each VAHW was distributed a PPE lut, which i s reused after washing in a disinfectant solution. The VAHWs have been trained on the use and disinfection of the PPE kits. 11 I t is important that the PPE or the disinfectant be free of chlorine ifthe disposal method for used PPE involves cremation or incineration. 65 Culling ofpoultry. At all reported locations with AH1outbreaks, poultry were killed (culled) by breaking their necks and, in a few instances, by lethal injection. All culled poultry were put in plastic bags for disposal. Disinfection of farm surfaces, equipment and materials. All potentially infected surfaces, materials and equipment at farms with outbreaks were sprayed with TH4 (a disinfectant recommended by FAO). Management of poultry feces. At semi-commercial and commercial farms with suspected or confirmed AH1 cases, feces were collected from the poultry houses and placed in a pit for composting. The composted materials will then be sold as fertilizer. On-site disuosal of carcasses. For locations where the groundwater table was low, the carcasses were disposed o f on site or within the village area. At the disposal site, a pit was dug using an excavator. Bags containing carcasses were placed into the pit and then cremated using kerosene. After cremation, the ash was covered first with lime and then with soil to the ground level. The disposal area was sprayed with an FAO-recommended disinfectant (TH4) and then covered with a mesh-wire to prevent disturbance o f the disposal area by animals. Transuortation and offisite disposal of carcasses. For locations where the groundwater table was high, the carcasses were transported by a pick-up truck to another location for disposal. The pickup truck was disinfected before placing the bags into the truck (at the first location, before transportation) and also after removal o f the bags from the truck (at the disposal location, after transportation). The off-site disposal procedure was the same as the on-site disposal procedure. Transportation of animal specimens to the NVRT laboratory. All animal specimens were placed inan icebox andcarefully taped beforebeingshipped to the NVRIlaboratoryinPhnomPenhfor testing. Wastemanagement at the NVRT laboratory. The NVRI laboratory personnel testing for AH1use PPE based on WHO training. Needles are separately collected inbottles and incinerated on site along with other wastes (including animal carcasses, cotton swabs, used PPE). Overall, waste management practices are inadequate, and waste segregation i s not properly implemented. There are no written guidelines on the use o f PPE and waste management. The design o f the incinerator i s rudimentary and maintenance i s inadequate (the chimney i s in disrepair, and the surroundings o f the incinerator are littered with ashes, plastic bags, and empty bottles). As proper waste segregation i s not practiced and the incinerator i s not equipped with adequate controls, incineration o f any chlorinated materials (withinthe composition o f PPE or disinfectants) might generate dioxins or furans. MAFF,with FAO's support, published a manual entitled "Surveillance andControl o fBirdFluat Village Level-Guide for VAHW'. This manual, which contains useful information, would benefit from updating, with some reorganizationbased on specific targeted audiences. 2. InstitutionalFramework 5. Environmental Management. The Ministryo f Environment (MOE) i s the key agency responsible for environmental protection and natural resources conservation, while MAFF i s responsible for forest management. Since its creation in 1993, MOE has developed and enhanced a policy system and legal framework to strengthen environmental protection and natural resources conservation. Within MOE, the General Technical Directorate i s responsible for coordinating and managing the Ministry's line departments, including the Departments o f Planning and Legal Affairs, Nature Conservation and Protection, Pollution Control, Natural Resource Assessment and Environmental Data Management, and 66 Environmental Impact Assessment. The Provincial Environmental Departments and District Environmental Offices are responsible for the implementation and coordination o f MOE's activities at the local level. Approximately, one third o f MOE's staff works in Phnom Penh, while the remaining two- third is employed in the provincial and district offices. MOE shares some environmental management responsibilitieswith MOH and the Ministry o f Water Resources Management. 6. Animal Health Services. MAFF comprises a central level organization, a provincial level organization, and public institutions (a university, colleges, a research institute, and companies). The central level organization i s headed up by the Minister and consists o f the General Inspector's Office and 12 departments, one o f which is DAHP. DAHP i s responsible for animal health services and has the major role in the management o f animal health disease outbreaks. The national structure provides technical support to the Offices for Animal Health and Production (OAHP) in the 24 provinces and municipalities. 7. DAHP consists o f the Animal Health Office (AHO) and Animal Production Office (APO) in addition to finance, planning and administration units.Veterinary epidemiological and diagnostic services are provided by NVRI. The mandate o f NVRI i s to conduct surveillance and research, investigate disease outbreaks, and consolidate information on all matters pertainingto animal health and production and food safety. NVRI functions as a national reference center for diagnostic and epidemiological services. N V R I ' s diagnostic services encompass a total o f 28 staff in the serology, epidemiology, parasitology, pathology, bacteriology, hematology, and biochemistry laboratories, and the administration unit. 8. Public Health Services. MOH i s in charge o f human health services in Cambodia. Under the Directorate General o f Health, the Department o f Communicable Disease Control (CDC) i s responsible for the management o f AH1inCambodia. There are 24 provincial health departments and 76 operational districts for health services. The health infrastructure includes 8 specialized hospitals with a total o f 1,770 beds, 68 district/first level referral hospitals with 5,712 beds, and 961 primary healthcare centers. The health workforce includes 2,122 doctors, 241 dentists, 4,5 16 nurses, 4,449 other nursing/auxiliary staff, 160 paramedical staff (e.g. medical assistants, laboratory technicians, and x-ray technicians), 1,836 other health personnel (e.g. healthinspectors, assistant sanitarians), and 1,754 midwives. AHI Surveillance. The influenza surveillance system i s designed to collect information on a sample o f persons with ILI, which may include persons with suspected AHI. Through surveillance, the infectious agent may be identified with confirmation o f any circulating strains o f influenza. In addition, the influenza surveillance system provides background epidemiological data on ILIand identifies severe cases o f the influenza disease through pneumonia surveillance. The ILI (including HPAI) surveillance system i s currently being established at one hospital at each o f the four sentinel locations in Cambodia (in Battambang, Kampong Cham, Takeo, and Phnom Penh), relying on the existing structure and processes o f dengue fever sentinel surveillance based on the existing partnership between the MOH's Communicable Disease Control (CDC) and the Pasteur Institute (IPC) in Phnom Penh. Currently IPC i s the only laboratory in Cambodia that can perform rapid and reliable testing for H5N1 and other respiratory pathogens, with confirmation within 24 hours. IPC also sends all samples to the Pasteur Institute inParis, which i s a WHO Collaborating Center, for comparisono f the test results with the global strains and confirmation o f the test results. AHI Investigation. Once an HPAIalert has been raised through the hotline or through detection o f a severe pneumonia case at a hospital, two CDC staff from the province ("Rapid Response Team") visit the village to assess the situation and take a sample. The sample i s then sent to IPC in Phnom Penh by taxi under preserved conditions for analysis. If the sample is found to be positive, then an investigation i s launched immediately in the field by the staff of MOH's CDC, IPC, and WHO jointly with the provincial and operational district staff. Inthe field, the survey 67 fondquestionnaire i s filled out. IPC staff takes samples and take along the preserved samples to IPC at PhnomPenh for analysis. HPAI Infection Control. There are two national referral hospitals for AH1 in Cambodia: (1) Calmette Hospital (in Phnom Penh), and (2) Siem Reap Referral Hospital. In addition, the provincial hospitals from the following high riskprovinces will be upgraded as referral hospitals to admit potentially AHI-infected patients: (1) Kampong Cham, (2) Kampot, and (3) StungTreng. Five isolation rooms to receive five patients in the Calmette Hospital, which were dedicated to receive SARS patients, are now available for AH1 patients (although currently used by the Cardiology Department). In addition, at the Siem Reap Hospital there are six isolation rooms. Sewerage from the isolation rooms in both hospitals i s collected and chlorinated before joining the sewerage from the other sections ofthe hospital. 3. Legal Framework 9. Environmental Asvects. Between 1993 and 1996, the Government of Cambodia enacted several key pieces of environmental legislation to establish the legal framework to control, use and manage its natural resources and urban environment. These include: Law on the Environmental Protection and Natural Resources Management (January 9, 1977) Sub-decree on environmental Impact assessment Process (August 11, 1999) EIAProcessfor ProposedProject ApprovedbyRoyal Governmentor CDC Prakas (Declaration) on Guideline for Conducting Environmental Impact Assessment Report (March 9,2000) Guidelinefor Conducting Environmental ImpactAssessment (EIA) Report Base of EnvironmentalImpact Assessment inCambodia Sub-decreeon Water Pollution Control (April 6, 1999) Sub-decreeon Solid Waste Management (April 27, 1999) Sub-decreeon Air andNoise Pollution Control Prakas (Declaration) No. 1033 on Protected Areas (June 3, 1994). 10. The sub-decree on Solid Waste Management lists "infectious diseases wastes" as hazardous wastes. 11. Animal Aspects. The legal measuresto control AH1inCambodia are as follows: 0 On January 12, 2004, MAFF issued the movement control measure of poultry and its products from neighboring countries and ordered the field investigation on poultry farms in Cambodia. 0 On January 16, 2004, the control checkpoints were re-established and MAFF issued a declaration for nationwide prevention of introductiono f HPAI. 0 On January 22, 2004, the PM announced creation of an inter-ministerial committee on AH1 at the national level. 0 InMay2005, the MinisterofMAFFannouncedallprovincesto establish aprovincialmulti- sectoral committee on AH1control. 68 12. Human Hvaiene/Environmental Aspects. 0 MOH's "Infection Safety Guidelines for Referral Hospitals" (January 31, 2001) includes guidelines for the distribution, use, collection, and safe destruction o f disposable syringes and safety boxes. 0 MOH's Directive to Head of Healthcare Establishments (January 3, 2003) regarding segregation o f healthcare wastes at their establishments into (i)sharps, (ii) infectious wastes, and (iii) common wastes (garbage); and cooperation with the national, provincial, district or municipal authorities for safe management o f these wastes. 0 MOH's Directive (December 22,2003) regardingthe requirements for: (i) development the o f a healthcare waste management plan at each healthcare establishment, (ii) the segregation o f wastes into infectious wastes, sharps and common waste (garbage) at these establishments; and (iii) the collection o f sharps wastes in safety boxes and destruction of filled safety boxes by incineration at the premises o f the healthcare establishments. The Directive states that the responsibility for the destruction o f safety boxes i s with the provincial or city Health Department Director, and the expenses will be covered from either the national budget or funds from partner organizations. The Directive also indicates that the segregated wastes generated by the private healthcare establishments may be destroyed by the public healthcare establishments for a fee. 4. PotentialEnvironmentalImpacts. 13. The project i s not expected to have any large-scale, significant and/or irreversible environmental impacts as it i s focused largely on public sector capacity buildingand strengthening readiness for dealing with outbreaks o f avian influenza (AHI) in domestic poultry as well as preventing or reducing possible human infections by strengthening emergency preparedness and response. Inaddition, the project design incorporates other beneficial measures such as improved biosecurity in farms and live markets, and control o f poultry movement within and across countries. The project's preventive activities (funding o f facilities, equipment, laboratories, procedures, and training programs), aimed at improving the effectiveness and safety over the existing the AH1practices, will have positive human health and environmental impacts. As such the project i s assigned an Environmental Category B. 14. The project only triggers the Bank's safeguards policies on Environmental Assessment (OP 4.01) and Indigenous Peoples (OP 4.10). The project i s being processed under OP 8.50, Emergency Recovery Assistance, and the task team has received concurrence from the EAP Vice President to delay preparation and disclosure of the Environmental Management Plan (EMP) and Ethnic Group planning framework (EGPF) under the exception granted under OP 4.01, paragraph 12, and OP4.10, paragraph 15. Environmental Assessment (OP 4.01). The key environmental and personal hygiene issues include: (i) disease transmission from animals during response to AH1 outbreaks in the field (e.g. culling o f poultry; selection o f appropriate disinfectants for disinfection o f contaminated farm areas; transportation o f farm wastes and carcasses (if necessary); management and disposal of farm wastes, animal carcasses and used PPE; and packaging and shipment o f specimens); (ii)management o f wastes and personal hygiene at the laboratories o f NVRI (iii)management o f wastes and personal hygiene as well as cleaning o f hospital grounds at five hospitals to be receiving potentially AHI-infected patients; and (iv) civil works associatedwith the expansion o f the NVRI laboratory and construction o f isolation rooms at three hospitals to be receiving potentially AHI-infected patients. A draft EMPhas beenprepared and will be finalizedbythe government. 69 Pest Management (OP 4.09). This Bank policy i s not applicable because the project will not procure pesticides nor will increase use o f pesticides will result from the project. However, the chemicals to be used for the disinfection o f farm facilities/personal protection equipment will be evaluated on a case by case basis for conformity with the OP 4.09 for Pest Management. The selected disinfectants will conform to the Bank's Pest Management Policy. Use o f hazardous disinfectants will necessitate providing training in safe transport, handling, and application. Physical Cultural Resources (OP 4.11). This Bank policy is not triggered because the project will not affect sites with archeological, paleontological, historical, religious, or unique natural values inthe project area. However, appropriate clauses will be included in all construction contracts regarding the procedures to be followed in the event o f chance findo fculturally significant artifacts or sites. Public Disclosure (BP 17.50). Because the project i s being processed under OP 8.50, Emergency Recovery Assistance, safeguards issues will be addressed through the use o f accepted good practice and sound design principles. Safeguards documents will not be prepared prior to appraisal. The draft documents will be disclosed as they are prepared and again when they are finalized. 5. Environmental and Human Health Impacts and Mitigatory Measures to be addressed under the Government's AHI Programandthe Project 15. The potential environmental impacts and mitigation measures to be addressed under the government AH1 Program, including this project, are described below. All o f these mitigation measures have been incorporated into the design o f this program/project. A draft Environmental Management Plan (EMP) has been prepared. The draft EMP will be revised after consultation with various stakeholders (government's agencies, the commercial poultry associations, mass organizations, and NGOs) and finalized during project implementation. The finalized EMP will then be disclosed within Cambodia and in Washington D.C. (at the Infoshop), and the project legal grant agreement will reflect implementation o f the EMP. 16. ComDonent 1: Animal Health. The main environmental and personal hygiene issues under the Animal Health Component o f the government's AH1 Program and the project are associatedwith the following activities: Design and construction o fthe buildingextension for NVRI. Personal hygiene at N V R I ' s laboratories Shipment o f animal specimens locally and to an international laboratory 0 Management o f wastes generated at NVRI's laboratories Response to AH1outbreaks. 17. Design and Construction o f the building;extension for NVRI. The existing NVRIbuilding will be expanded for the serology/virology laboratory. The new laboratory will be able to perform a range o f internationally approved diagnostic tests for both Highly Pathogenic Avian Influenza (HPAI) virus and antibody. The adverse impacts during construction will include dust and noise emissions, generation o f construction waste, and disturbance o f traffic. These adverse impacts will be mitigated by including in the construction contract a clause regarding observation o f standards for good constructionpractices. Construction will be supervised to observe compliance with these good constructionpractices. 70 18. Personal hygiene at N V R I ' s laboratories. The safety and quality assurance/quality control (QA/QC) systems at NVRI's laboratories (particularly, the serology/virology laboratory) will be assessed to bring the laboratory in line with international bio-safety and quality standards. The necessary personal protection equipment (PPE) will be procured and the serology/virology staff will be trained on test methods, personal hygiene, and QA/QC systems. 19. Shiument o f animal suecimens to an international laboratory. SOPs will be prepared for packaging, labeling, and shipment o f animal specimens from NVRI to an international laboratory (e.g. in Geelong, Australia) for analysis. These SOPs will be fully compatible with the IATA regulations. The NVRI personnel will be trained on these SOPs. 20. Management o f wastes generated at NVRI's laboratories. Waste management practices at the NVRI laboratories will be strengthened. This will require that the current waste management practices at NVRI laboratories be assessed to identify the needs. A written waste management plan for NVRI's laboratories will be prepared with segregation and treatment/disposal o f wastes. The most suitable waste treatment/disposal system for NVRI will be determined after assessment o f the existing incineration system and consideration o f state of-the-art treatment/disposal technologies. Specifications for the recommended technology will be prepared for purchase. The proposed system will be procured, installed, and test run (with pollutant sampling and analysis). The necessary waste management supplies will be purchased. The personnel operating the waste management system will be trained. 21. Resuonse to AH1 outbreaks. The information contained in MAFFDAHP's manual for response to AH1 outbreaks will be updated for different audiences, including: (i) the VAHW; (ii)MAFFDAHP's district and provincial veterinary staff, (iii) commercial farm owners; and the (iv) backyard farm owners. Inaddition, the general public will be informed about AH1through the information, education and communication (IEC) campaigns. The manual to respond to AH1 outbreaks by DAHP's provincial and district veterinarians will be presented in the form o f Standard Operating Procedures (SOPs). The manual will address, at a minimum, the following i ssues: (a) Packaging and shipment of animal specimens to NVRI. It i s important that the animal specimens be packaged, labeled, and shipped in such a manner to avoid the spread o f AHI. Animal specimens will be shipped for analysis at NVRI inPhnomPenh. The international regulations for packaging, labeling and shipment o f biological specimens will be adopted and included in the SOPs. Provincial and district veterinarians will be trained on these SOPS. (b) Culling of poultry. It i s important that culling o f poultry be conducted in a humane, safe, and efficient manner. The following methods for culling poultry were identified from the OIE/FAO guidelines: (a) neck breaking (manual), (b) neck cutting (using mechanical devices), (c) gassing with inhalation agents (e.g. carbon dioxide), (d) electrocution, or (e) poisoning. Based on consideration for humane, safe and efficient culling and experience from the previous AH1outbreaks in Cambodia, the most appropriate culling methods will be selected for chickens and ducks in backyard farms with few numbers o f birds, and for commercial farms with large number o f birds. The SOPs will specify the criteria for using one versus the other method; and will provide the design and operating requirements ifthe gassing systems are selected (e.g. specific locations and quantities o f stocked carbon dioxide). (c) Selection of disinfectants. It i s important that the disinfectants to be selected for the disinfection o f farm surfaces, equipment, materials, and wastes do not have adverse 71 impacts on the environment and human health. The selection o f disinfectants will be based on such criteria as effects o f disinfectants on human health and the environment, availability and costs o f the disinfectants in Cambodia, and compatibility o f the disinfectants with the disposal methods o f the wastes (e.g. chlorinated disinfectants should not be used ifthe disposal method i s crematiodincineration). The selected disinfectant, which will be specified inthe SOPs, will comply with the World Bank's Pest Management Policy (OP4.09). (d) Disinfection of farm surfaces, equipment and materials. Based on selected disinfectant, the equipment and procedures for preparing (e.g. dilution with water) and applying the disinfectant will be specified inthe SOPs. (e) Disposal of animal carcasses. It i s important that the selected disposal method(s) for animal carcasses does(do) not have adverse impacts on human and the environment. For example, improper burial practices may cause contamination o f ground or surface water, and poorly designed and/or operated cremation or incineration systems may create particulate emissions and objectionable odors. The following options for the disposal o f poultry carcasses were considered: (i) burial in a pit, (ii) air burning(cremation), (iii) open composting, (iv) incineration at a fixed location, and (iv) mobile incineration. Incineration (mobile or at a fixed location) was eliminated based on cost considerations. Among the remaining options, based on experience from the previous AH1 outbreaks in Cambodia, cremation in a pit was selected as the disposal method for animal carcasses. However, criteria will be developed and included in the SOPs for the applicability o f this disposal option for specific sites. These criteria will include such considerations as: (i)the height o f the water table (the base o f the pit must be at least 1 meter above the water table), (ii) dry weather conditions (dry season), (iii) prevailing wind direction (for odor emissions), (iv) availability o f space for temporary storage o f excavated soil, and (v) accessibility o f site by digging equipment (e.g. excavator). For those situations where the criteria for on-site cremation are not met (wet weather conditions, highwater table), the SOPs will specify the most appropriate, environmentally-safe, and cost-effective disposal option for Cambodia (e.g. transportation and cremation at another site). The SOPs will provide the design (depth o f the pit) and construction requirements for cremation o f carcasses and burial o f ashes. (f) Treatment of poulty feces. I s important that composting - as the selected method for treatment and reuse o f poultry feces - does not have adverse impacts on human and the environment. The SOPs will specify the procedures and the minimumtime for composting o f feces before use as a fertilizer. (g) Disinfection/disposal of used PPE. Used PPE- except for boots and gloves - duringAH1 outbreaks have been disposed o f through on-site burial. This option along with cremation will be evaluated for the disposal o f (disposable) used PPE. It is important that the PPE or the disinfectant not to contain any chlorine if the cremation method i s selected. The SOPs will describe step-by-step procedures for the disinfection (including preparation o f the disinfection solution) o f usedPPE. (h) Transportation of animal carcasses andfarm wastes (ifnecessa y). Ifproper measures are not taken, transportation o f AH1 infected animal carcasses and farm wastes would likely spread the virus outside of the infected farm areas. Under this project, transportation o f carcasses and farm wastes to another site for disposal will be avoided to the maximum extent possible. However, if transportation i s required, then the SOPs will specify the specific requirements for vehicle design and operation as well as containment o f carcasses and farm wastes for transportation. These SOPs will also include decontamination o f 72 vehicle surfaces (e.g. tires) prior to exiting the farm and after unloading the animal carcasses at the new site. (i)Personal hygiene. If proper hygiene measures are not taken, AH1may spread to humans. For this reason, for each o f the above-mentioned activities to be conducted during AH1 outbreaks, the SOPs will specify the level o f protection (e.g. gloves, masks, coveralls, boots) to be used. 22. DAHP's provincial and district veterinarians will be trained on these SOPs. 23. Component 2: Human Health. The main environmental and personal hygiene issues under the Human Health Component o f the government's AH1 Program and the project are associated with the following activities: Personal hygiene and waste management at sentinel surveillance locations Personal hygiene and waste management by the RapidResponse Teams Shipment o f samples from sentinel locations to the Pasteur Institute inPhnom Penh Personal hygiene and waste management at Pasteur Institute inPhnom Penh International shipment o f samples. Personal hygiene at the referral hospitals Construction o f isolationrooms at three referral hospitals Healthcare waste management at hospitals to be receiving potentially AHI-infected patients Personal hygiene during a potential pandemic. 24. Personal hygiene and waste management at sentinel surveillance locations. Based on MOWWHO/IPC's guidelines, written guidelines have been developed for the surveillance o f ILIat the sentinel locations in Battambang, Kampong Cham, Takeo, and Phnom Penh. The personnel at each sentinel location are being trained on these guidelines and will be provided with PPE. These guidelines will be expanded to include waste management at these locations. Personnel at each sentinel surveillance location will be trained on these guidelines. 25. Personal hygiene by the Rapid Response Teams. Ifproper hygiene measures are not taken, AH1 may spread to humans through contact with the AHI-infected poultry or contaminated environment. For this reason, members o f the Rapid Response Teams who are conducting the investigation will be provided with PPE. The Rapid Response teams will be trained on the use o f PPE. 26. Shipment o f samples from sentinel locations to the Pasteur Institute in Phnom Penh. The ILIsurveillance system, which is based on the existing dengue surveillance system, has written procedures for storage (at 4"C), packaging (in liquid nitrogen) with the appropriate information (laboratory forms), and shipment o f the samples by the Pasteur Institute-hired taxi (each week with the dengue samples) from the sentinel locations to the Pasteur Institute inPhnom Penh. The staff has already been trained on these procedures. No additional strengthening will be required in this area. 27. Personal hygiene and waste management at Pasteur Institute (IPC). If proper hygiene measures are not taken, AH1may spread to humans. For this reason, IPC in Phnom Penh, which already has four biosafety Level 2 laboratories, i s constructing a new biosafety Level 3 laboratory (microbiology and retrovirology laboratory for AHI, SARS, and dengue) through its own resources 73 for analyses o f human and animal specimens.12 IPC has developed written guidelines for testing o f specimens, including personal protection. The personnel at IPC have been trained on these guidelines. IPC procures PPE through various resources, including its own funds generated from laboratory services and funds received from international sources (Government o f France, Government o f USA, and European Commission). Waste management procedures, which have already been developed at IPC, will be strengthened through IPC's own resources. However, the current infectious waste disposal practice, which i s by incineration in a poorly designed incinerator, will be improved through "joint" treatmentldisposal o f infectious wastes from the neighboring Calmette Hospital. As discussedbelow under item 8, a consultant will be engaged to estimate the infectious waste quantity from IPC and Calmette Hospital, and determine the optimum treatment/disposal technology for the infectious wastes from both institutions. The recommended treatment/disposal system will be procured and installed, and the operating personnel for this system will be trained. 28. International shipment o f samples. Samples from IPC in Phnom Penh are packaged, labeled and shipped to the Pasteur Institute in Paris for confirmation testing or to Hong Kong for serological testing. The procedures used by IPC in Phnom Penh comply with the IATA regulations, and the IPC personnel have already been trained on these procedures. No additional strengthening will be required in this area, except that funds will be provided for shipment o f samples. 29. Personal hygiene at the referral hospitals. Written infection control guidelines at hospitals throughout Cambodia have been developed by MOH based on WHO Guidelines and will be applied at the Calmette Hospital in Phnom Penh as well as the Siem Reap, Kampong Cham, Kampot, and Stung Treng Referral Hospitals. PPE and supplies will be procuredto these hospitals (e.g. masks, disposable gloves). Procurement will be initiated after auditing o f the Central Medical Store (CMS) in Phnom Penh and preparationo f the PPE kits by CMS and distribution o f these kits to each o f the five referral hospitals. Staff at each o f the five hospitals will be trained on the use of PPE. 30. Construction o f isolation rooms at three referral hospitals. The Calmette and Siem Reap Referral Hospitals have been equipped with isolation rooms (with dedicated sewage control systems) to receive potentially-AH1 infected patients. Five isolation rooms will be constructed at each o f the following referral hospitals: Kampong Cham, Kampot, and Stung Treng. Inaddition, the sewage treatment (disinfection) system for the isolation rooms at each o f the three hospitals will be procured and installed. The adverse impacts during construction would include dust and noise emissions, generation o f construction waste, and disturbance o f traffic. These adverse impacts will be mitigated by including in the construction contract a clause regarding observation o f standards for good construction practices. Construction will be supervised to observe compliance with these good construction practices. 31. Healthcare waste management at hospitals to be receiving potentially AHI-infected patients. AH1virus may spread to humans if proper waste management measures are not taken at hospitals treating potentially AHI-infected patients. The following five hospitals have been designated to receive AHI-infected (or potentially AHI-infected) patients at Phase 3: Calmette, Siem Reap, Kampong Cham, Kampot, and Stung Treng. This subcomponent aims at instituting proper waste management procedures at each o f these hospitals. In addition, the waste treatmentldisposal system for the Calmette Hospital will include the infectious wastes generated by the Pasteur Institute inPhnomPenh (IPC). The main activities will include: 12Animal specimens are received fromNVRIfor confirmation testing. 74 Consulting services for determining waste quantities by type (especially infectious wastes and sharps) from each o f the five hospitals and IPC, selecting the optimum technology for infectious waste treatment/disposal through evaluation of alternative technologies (autoclave, microwave, incineration) and providing the specifications of the selected technology (in the case of Calmette Hospital, jointly with IPC), and preparing detailed healthcare waste management plan for each of the five hospitals. Inaddition, for each of the three hospitals (Kampong Cham, Kampot, and Stung Treng), consulting services will include the design o f the sewage treatment (disinfection) system associated with the isolationrooms. Healthcare waste management investment. This will include procurement, installation, and testing (with sampling and analysis of pollutants) o f the solid waste treatment technology at each o f the five referral hospitals. The waste system at Calmette Hospital will also treat wastes from IPC. Inaddition, the sewage treatment (disinfection) system at Kampong Cham, Kampot and StungTreng hospitals will be procured, installed, and tested. Training o f the operating staff at each hospital will be provided by the equipment supplier. Equipment and supplies (trolleys, containers, bins, plastic bags, labels) for each of the five hospitals will also be procured. Consulting services for healthcare waste management training to the local trainers as well as the staff of the five referral hospitals. The local trainers will be training the healthcare staff after the first year. (d) Procurement of consumables. This will cover the operating costs for the waste management systemat eachofthe five hospitals (e.g. steadelectricity for the treatment technology) and supplies (e.g.bags, plastic labels). (e) Hospital grounds cleanup. Some o f the five referral hospital grounds are inpoor hygienic conditions, with garbage thrown away haphazardly and poultry breeding in potentially infectious waste areas on hospital grounds. Such unhygienic areas on hospital grounds at these five hospitals will be corrected. 32. Personal protection during a potential AH1pandemic. The stockpiling o f PPE i s envisaged for the frontline workers as well the central, provincial, and district level MOHpersonnel who are involved inthe management o f an AH1pandemic. PPE will be stored at the Central Medical Store (CMS). 6. ConsultationandDisclosureof the Project'sEnvironmentalManagementPlan 33. This preliminary draft Environmental Management Plan (EMP) has been discussed with the representatives of M O H and MAFF. The I A s will engage specialized consultants to help inthe finalization o f this EMP during early stages o f implementation. It will also be discussed with other participating government agencies (e.g., NCDM, Ministry of Information, MOE, and the Inter- Ministerial Committee on Avian Influenza) and non-governmental organizations (NGOs). The draft EMP will be finalized upon incorporation of comments by these government agencies and NGOs. The finalized EMF' will be disclosed at publicly accessible locations in Cambodia and at InfoShop inWashington D.C., as well as formally adopted by the I A s for use under the project. 75 7. Reporting on the Implementation Progress of the Project's Mitigation and Monitoring Measures 34. Procedures for providing information on the progress o fproject implementation and results o f mitigation and monitoring measures have been structured to facilitate project supervision and review. Accordingly, each national implementation agency will prepare and submit biannual progress reports to N C D M which will submit a summary biannual report to the World Bank. The biannual reports will indicate the activities conducted, the remaining activities to be conducted, the products generated, the major issues encountered and how these issues have been resolved as well as the outstanding issues, the expenditures incomparison with the budget. NCDMwill also submit a copy o f the EMP-related specific activity reports (e.g. the waste management plan) to the World Bank for review, comments, and no objection (if satisfactory). 76 Appendix7: SocialAnalysis CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject Safeguards Policies. 1. Based on the social analysis carried out, the project's activities only trigger one social safeguard policy, this i s OP4.10, Indigenous Peoples. This Bank policy applies because the ethnic minorities, who form the poorest sector o f the population in Cambodia, would be most vulnerable to loss o f poultry and the income derived from it. Accordingly, an Ethnic Minorities Planning Framework (EMPF) will be developed by specialized consultants outlining the principles to be used for project activities that might take place in ethnic communities. A communication strategy will be incorporated into project design to address concerns about any large-scale project activities and to disseminate information in local languages and inculturally appropriate and accessibleways. 2. Involuntary Resettlement Policy (OP4.12) i s not triggered as any involuntary land acquisition or displacement of people i s expected under the project. Government i s consideringwhether it will purchase from farmers those poultry taken as a result of disease investigation and surveillance activities. Project Beneficiaries 3. Project activities will cover all of Cambodia, and will benefit commercial and backyard poultry farmers, traders, and processors in improving their poultry management practices to reduce the risk o f an outbreak of avian influenza. Backyard poultry farmers are, in many cases, poor farmers living at subsistence levels, and include ethnic minorities. Women play a key role in the backyard poultry sector as they often are responsible for poultry production and obtain food products and income from their poultry flocks. A national campaign will provide information and educate farmers as well as the general public about the risks of avian influenza. This information and education campaign will be designed to take into account the diverse stakeholders and characteristics of the sectors covered (that is, commercial and backyard producers, traders and processors). Multiple media tools will be used and relevant campaign material will be translated into key ethnic minorities' languages. 4. The project's animal health component will establish an emergency contingency fundto facilitate rapid responses to outbreaks that will allow rapid mobilization o f the necessary funds for payment o f workers involved in containing the disease. Villagers are more likely to report disease if they know that they or their neighbors will not be disadvantaged by doing so. Therefore part o f the contingency fund will cover the cost of buying poultry taken as a result of disease investigatiodsurveillance activities. A small fundwill also be established for purchase o f animal vaccine for use inemergencies. 5. Key beneficiaries o f the project will be government agencies and staff, particularly in the agricultural and health sectors. These will benefit from training exercises, institutional strengthening and enhanced management practices. The general population of Cambodia will benefit from enhanced institutional set-up, management practices and awareness concerning poultry production and the health sector. The risk for an outbreak o f avian influenza and subsequent pandemic will be minimized and the ability o f key stakeholders (e.g. health practitioners and poultry farmers) to address a possible outbreak and pandemic will be enhanced. Consultation 6. Preliminary consultations have been held with a large number of government representatives in the respective sectors receiving support under the project. These consultations have taken place at 77 national as well as provincial levels. MAFF has held consultations with commercial and backyard poultry farmers concerning measures to avoid and address outbreaks o f avian influenza. Feedback from these consultations has been incorporated into the government's strategy supported by the project. Further consultations and information and education campaigns will be undertaken with various stakeholders duringimplementation, including commercial andbackyard poultry farmers. EMPFConsultationandDisclosure 7. An Ethnic Minorities Planning Framework (EMPF) will be prepared by specialized consultants hired by the I A s during implementation phase. The draft EMPF will be revised after appropriate consultation with various stakeholders (government agencies, the commercial poultry associations, mass organizations, ethnic minorities groups, and NGOs) and completed to be properly disclosed within Cambodia and in Washington D.C. (at the Infoshop), once it has been found acceptable to IDA. The Financing and Grant Agreements include specific dated covenants reflecting these arrangements for the final compliance with Bank's policies. Beneficiary and NGO Consultation and Involvement in Project Implementation 8. Many development NGOs in Cambodia work with poor farmers, including activities supporting small livestock such as poultry. Several such NGOs, including CARE Australia, have been consulted duringproject preparation. These NGOswill be an important target group for increasing their awareness o f national policy and measures to address the risk o f avian influenza, and will continue to be consulted during implementation. Civil society organizations will participate in project implementation, mainly concerning the public information campaign. District and village facilitators will be trained and participate inimplementingthe public information campaign. Resettlement, Land Acquisition and Livelihoods. 9. No land acquisition or resettlement will take place under the project. The project's animal health component will establish an emergency contingency fund to facilitate rapid responses to outbreaks that will allow rapid mobilization o f the necessary funds for payment o f workers involved in containing the disease. Villagers are more likely to report disease if they know that they or their neighbors will not be disadvantaged by doing so. Therefore part o f the contingency fund will cover the cost o f buying poultry taken as a result o f disease investigatiodsurveillance activities. A small fund will also be established for purchase o f animal vaccine for use inemergencies. Impact on the Livelihoods of Ethnic Minorities 10. The project does not adversely affect ethnic minorities. Instead, project activities will take place in all areas o f the country and ethnic groups will benefit from an enhanced understanding o f the AHI, o f ways to improve biosecurity, o f measures to be taken in case o f outbreaks, and o f the compensation for loss o f poultry due to an outbreak. The public information campaign will be designed to ensure it is also appropriate for the ethnic minorities in Cambodia, and the campaign will be translated into ethnic languages. 78 Appendix8: EconomicAnalysis CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject 1. GlobalPublic Good and Pro-poor. The proposed intervention's human health objective comes closest to the definition of a pure public good at the global level in that protecting Cambodian farmers from a pandemic human influenza also improves the probability o f prevention of the disease worldwide, and one cannot exclude anyone from deriving the benefit. The project thus creates a "good" that i s both non-rival, and non-excludable. The intervention achieves this objective by addressing, among other things, the lack of incentives at the individual level and at the country level: Farmers have the incentive to hide any outbreak and even transport diseased chicken to markets for sale. At the country level, for Cambodia as a whole, similar incentives exist to hide outbreaks from fear of trade and travel restrictions. The project addressesboththese incentivesby setting upproper surveillance and other mechanisms, apart from providing the knowledge about how to go about prevention. 2. The project's animal health component, apart from creating public goods, also addresses poverty. While every citizen will benefit from the project's protection against AH1 developing into a pandemic human influenza, the benefits during the current phase will accrue mainly to the rural poor who are involved in backyard chicken farming. Even within this group, it i s the very poor who succumb to the temptation of eating chickens which die from disease or which are sick (possibly due to AHI). Other diseases bring similar conditions to the chicken and it i s not uncommon among the very poor to consume disease-affected chickens. This will be addressed under the project and, consequently, the project will helpthe verypoor. 3. Large Potential Benefits and Considerable Uncertainty. Although AH1 is still mainly an animal health problem, it i s widely considered that a global pandemic o f human influenza may be both overdue and likely. Various analyses have therefore beenundertaken to examine economic consequences o f human-to-human transmission at the national and global level. In the case o f efficient human-to- human transmission (that is, WHO Phase IV and beyond), the losses and costs from fatalities and hospitalization expenses for Cambodia, a country of 14 millionpeople, are conservatively estimated to be around US$195 million. According to WHO, the likely impact o f an AH1 pandemic on unprotected humans during Phase IV human-to-human transmission are as follows: (a) 30 percent of unprotected humans are likely to be infected (4.2 million Cambodians), (b) one tenth o f them will require hospitalization (420,000 Cambodians), and(c) one and a half percent o f all human infection cases will be fatal (63,000 Cambodians). With a per capita income US$350, the present value o f the loss o f income due to fatalities i s conservatively estimated at US$3,000 per person; and the cost of hospitalization, which includes lost income for 10 days, i s estimated at US$15 per person. The above figures leadto an estimate o f the total cost of US$195.3 million for Cambodia from fatalities (US$189 million), and hospitalization (US$6.3 million). 4. As an animal health problem, the economic consequences relate mainly to a loss o f income to farmers from poultry death and culling, and the decline in prices when consumers avoid eating chicken. The income loss i s estimated at US$7.6 million assuming poultry death from disease or culling could be similar to that of avian influenza outbreaks in Vietnam in 2003 (17.5 percent o f the stock), cost of each bird at US$l.50, and putting current stock for poultry in Cambodia at 29 million (extrapolating FA0 estimated3o f poultry in Cambodia for 2002 o f 23 million at the 6.1 percent average annual growth rate which occurred during 1990-2000). Ifthe situationbecomes worse, and all activities inthe rural area are l3FA0 Livestock Sector Brief, CambodiaJuly 2005. 79 affected, every one percent fall in the agricultural output would result in losses of US$16 milli~n'~ per year. 5. Benefit Cost Analysis. The project and Cambodia's National Comprehensive Plan are expected to be a partial "insurance" against the large potential losses indicated above. Of course, estimated benefits would be even larger if the insurance i s assumed to prevent disruption at the regional level (including neighboring economies o f Vietnam, Thailand, and Laos), or at the global level. In addition, the SARS epidemic in Asia during 2003 led to substantial additional costs to economies from excess avoidance behavior o f individuals (such as curtailing movement in public, postponing purchases, etc.), which could be as high as 1-2 percent o f quarterly output. While in a true pandemic such costs could increase to very great levels, this analysis does not include either the (a) benefits to countries other than Cambodia, or (b) benefits from averting damage to other economic activities within Cambodia such as tourism and trade. Inan initiative such as Cambodia's National Comprehensive Plan, the eventual results will accrue for the prevention o f the focal disease if the entire program holds together because o f the integrated risk (both animal and human). Therefore, it may be appropriate to view only the benefit-cost ratios for the Plan as a whole as summarized inTable 1: Table 1:BenefitCost Analysis Summary Humanpopulation 14,000,000 Potential human attack rate 30.0% Number o f infected humans 4,200,000 Hospitalizationrate(% o f infected) 10.O% Number o f hospitalization 420,000 Costs per hospitalizations $15 Total cost o f hospitalization $6,300,000 Human fatality rate (% o f infected) 1.5% Number o f fatalities 63,000 Cost o f each human fatality $3,000 Total cost o f human fatalities $189,000,000 Benefits inthe human health sector $195,300,000 Poultry population 29,000,000 Potential poultry death rate 17.5% (from disease and culling) Number of poultry death 5,075,000 Cost o f each poultry loss $1.50 Total cost o f poultry death $7,6 12,500 Benefits inthe animal health sector $7,612,500 Total Plan benefits $202,912,500 Total Plan costs $32,545,000 Overall Benefit-CostRatio 6.23 6. Sensitivity Analysis. The extent o f protection achieved through implementation o f the National Comprehensive Plan will depend on the efficacy o f the prevention, containment and treatment measures. l4CambodiaGDP (2004) was US$4.9 billion andAgriculturevalue added was about US$1.6 billion (32.9 percento f GDP). 80 Assumed levels o f efficacy o f these measures determine the range o f protection scenarios, with the protection rates varying between 100 percent (Base Case), 80 percent (Scenario 2) and 30 percent (Scenario 3). As summarized inTable 2, this analysis shows that the benefit-cost ratio remains favorable even under the most conservative assumptions: Table 2: SensitivityAnalysis Base Case Scenario 2 Scenario 3 Human population 14,000,000 14,000,000 14,000,000 7. Potential human attack rate 30.0% 30.0% 30.0% Number o f infectedhumans 4,200,000 4,200,000 4,200,000 8. Hospitalizationrate(% o f infected) 10.0% 10.0% 10.0% Numbero fhospitalization 420,000 420,000 420,000 Costs per hospitalizations $15 $15 $15 Total cost o f hospitalization $6,300,000 $6,300,000 $6,300,000 Human fatality rate (% o f infected) 1.5% 1.5% 1.5% Protection Rate 100% 80% 30% Number o f fatalities 63,000 50,400 18,900 Cost o f each human fatality $3,000 $3,000 $3,000 Total cost o fhuman fatalities $189,000,000 $151,200,000 $56,700,000 Benefits inthe human health sector $195,300,000 $157,500,000 $63,000,000 Poultry population 29,000,000 29,000,000 29,000,000 Potential poultry death rate 17.5% 17.5% 17.5% (from disease and culling) Number o f poultry death 5,075,000 5,075,000 5,075,000 Cost o f eachpoultry loss $1.50 $1.50 $1.50 Total cost o fpoultry death $7,6 12,500 $7,6 12,500 $7,6 12,500 Benefits inthe animal health sector $7,612,500 $7,612,500 $7,612,500 Total Plan benefits $202,9 12,500 $165,112,500 $70,612,500 Total Plan costs $32,545,000 $32,545,000 $32,545,000 OverallBenefit-CostRatio 6.23 5.07 2.17 9. Efficiencies from Multiple-use of Resources and Piggybacking Private Sector Activities. The most important efficiency enhancing measure inproject design i s from strengthening the capacity o f the National Comprehensive Plan ministries and other units not only for AH1but also for other similar diseases in the future and for regular sectoral services. Inthese regard, the project has substantial benefits not estimated for this economic analysis, over and above the benefits calculated from avoidance o f a pandemic shown in the preceding sections. For example, in the Animal Health component, N V R I ' s diagnostic capacity will be strengthened to respond more effectively to the existing demand for AH1 testing and to respond to future increases in demand. This strengthening o f NVRI, when not used for AH1 testing, can be used for other animal health testing. With this project, NVRI will be able to implement internationally acceptable and recognized Quality Assurance (QA) and Quality Control (QC) procedures to ensure that the testing o f large numbers o f samples i s undertaken both accurately and rapidly primarily for HPAI but when not used for that purpose for other animal diseases as well. In parallel, the Animal Health Office (AHO)will be strengthened to support and coordinate the management of the village animal health service delivery system, which includes VAHWs, VAHW trainers, the cold chain for vaccine storage in both the public and private sectors, and the use o f vaccines. The 81 establishment o f the effective cold chain system will also support vaccination in cattle, buffalo, pigs and poultry, and promoting production technologies that can improve farmer income. Promoting vaccination inpoultry helps to reduce outbreaks ofNewcastle Disease and Fowl Cholera (deaths from these diseases significantly confound the HPAI surveillance program). Farmers also learn about HPAI through participation inoverall vaccination and extension activities. 10. Inthe Human Health component, MOH conducts communicable disease surveillance using the Outbreak Reporting System, which consists o f data collection and analysis on 12 syndromes and diseases. Acute respiratory infection (ARI) i s one o f the diseases under surveillance and would theoretically capture human cases o f influenza. In order to monitor influenza-like illness (ILI) epidemiology in Cambodia, MOH has been establishing an ILI system, which i s expected to be crucial for detecting increased activity o f ILIin the community. Consequently, the project will support monitoring o f general influenza not related to AH1 and will strengthen the capacity o f referral hospitals to manage suspected cases prior to their referral to Calmette or Siem Riep hospitals. 11. The Inter-ministerial Cooperation for Pandemic Preparedness component will build up Cambodia's capacity for other disasters as well, for example, floods. Towards the establishment o f the N C D M General Secretariat and various internal units, the project will undertake a review o f NCDM's organization structure, and develop its new staffing requirement. For the staff, it will assess the training needs and create a human resources development strategy and training program. A key area o f expertise to be developed i s financial accountability o f the various institutions and individuals involved in all emergency operations. 12. Another efficiency enhancing measure i s to incorporate the help o f essentially private sector workers. For example, in the animal health component, the project i s expected to develop the VAHW system to rapidly respond to HPAIoutbreak investigations but, absent such outbreaks, they will be useful for extension services for livestock. VAHWs, who are private sector workers, make their income from providing vaccination and other services for the farmers. Inthis project, they will also be the frontline o f surveillance o f HPAIwith minimal long-term expenditure from the project. 82 Appendix 9: DiscussionNotes CAMBODIA: Avian and HumanInfluenzaControland PreparednessEmergencyProject DiscussionNote 1:Vaccination of PoultryinCambodia for HPAI 1. FAO's guide on the control and prevention of highlypathogenic avian influenza, issued in2004, stressedthat there i s a range of measures available for controlling andpreventinghighlypathogenic avian influenza. The most appropriate combination of these measures should be selectedby infected and at risk countries, based on the local disease situation, socio-economic, environmental and technical factors, and implementation capacity. This document also recommended that the approach to control and prevention of this diseasecan vary over time depending on changes inthe disease situation or better knowledge o f its epidemiology. 2. Among the measures available for control and prevention o f H5N1 HPAI i s vaccination, which can be used as an aid in controlling, eradicating and preventing infection and disease. Vaccination can be applied in three ways: (a) emergency vaccination around disease outbreaks, (b) vaccination in infected places to reduce the levels of infection and to aid invirus elimination, and (c) prophylactic vaccination in places at high risk o f infection. The validity o f these methods in controlling and preventing highly pathogenic avian influenza was reaffirmed at a joint OIE/FAO international meeting on vaccination for avian influenza inVerona inMarch 2007. 3. So far Cambodia has chosennot to include vaccination as an element of its control program. This i s based on the relatively low number of recorded outbreaks and observations that current control measures (and perhaps the relatively low poultry density inthe country) appear to be keeping the disease incheck. However, it is extremely unlikelythat H5N1 influenza viruses will be eliminated from Asia in the mediumterm ,which means that virus could return to Cambodia at any time. It i s also possible that virus continues to circulate silently indomestic ducks inthe country, as it i s inneighboringcountries. 4. At this stage, there is limited information available on the infection status of domestic ducks and the role ducks areplayinginspreado f infection inCambodia. Iffuture diseaseoutbreaks are traced to the domestic duck population, then targeted vaccination inthis population should be considered as one of the strategies for reductionininfection. 5. Currently, there is limitedinformation on the riskposed to and by other production systems, such as large periurban poultry farms. Vaccination should be considered for these as one of the possible control options if it assists inpreventingdisease in these farms, especially if farmers are prepared to pay for the vaccine and appropriate post-vaccination monitoring strategies are put inplace. A combination of enhanced biosecurity and vaccination has been used successfully in commercial farms in Hong Kong to minimize the risk of infection. Blanket vaccination o f the millions o f smallholder poultry does not currently make economic sense due to the relatively low prevalence o f disease, but targeted vaccination in areas subject to repeated outbreaks should be considered (along with other alternative measures), especially ifchangesto the production system cannot be implemented. 6. Concerns have been raised that the use of vaccination will lead to silent excretion of virus by infected poultry. Although short term excretion can occur in some vaccinated poultry subsequently infected with virus, the quantity of virus excreted i s far lower than that excreted by unvaccinated, infected poultry. In addition vaccinated poultry are more resistant to infection than their unvaccinated counterparts. Inplaces where the `coping strategy' for poultry owners inthe face o f a disease outbreak i s to either sell or consume their diseased or at risk flock, spread o f virus from uncontrolled sale of 83 unvaccinated poultry represents a much greater risk than potential low level excretion by a small percentage o f vaccinated poultry. 7. If vaccination is used, some post-vaccination monitoring appropriate to the local situation is recommended to determine whether vaccines are providing adequate protection and to assess whether H5N1 viruses are still circulating in vaccinated populations. This should include thorough investigations o f all cases o f disease in poultry that have already been vaccinated to assess for evidence o f antigenic change inviruses that may require changes invaccine composition. 8. Ifvaccines are usedina controlprogramthe followingneedto be inplace: 0 an effective, reliable and sustainable cold-chain for vaccine transport and delivery exists to ensure that vaccine potency i s maintained from initialproduction to the final recipient (chicken); 0 sufficient stocks o f vaccine originating from a reputable manufacturer, produced according to international standards o f QAand QC , 0 sufficient appropriately trained vaccinators capable o f delivering vaccine to poultry without spreading disease throughpoor hygiene practices. 0 sufficient field and laboratory capacity to perform appropriate post-vaccination monitoring and surveillance. 9. This project will test and develop capacity to implement emergency vaccination in the face o f outbreaks o f H5N1 HPAI. It will also conduct a review o f current production and marketing practices to determine the most appropriate set o f measures to minimize or mitigate the effects o f highrisk practices. This will consider all available control and preventive measures. Ultimately the decision to use vaccination as part o f the control and prevention program for H5N1 HPAIlies with disease authorities in Cambodia who, through this project, will be provided with the best possible advice on the benefits and drawbacks o f vaccination, based on studies conducted under local conditions. Discussion Note 2: Surveillance Strategy for HPAI Background 10. The FA0 guiding principles for highly pathogenic avian influenza surveillance and diagnostic networks inAsia) state that the objectives o f HPAI surveillance and diagnostic networks include: > To detect clinical disease and infection; > T o understand the epidemiology and ecology o f HPAI, as well as its socioeconomic impact; > To help to design effective control programs for poultry production systems; > To assess the temporal and spatial patterns and thereby to improve the effectiveness o f control efforts; 9 To understandthe evolutioninAsia ofHPAIvirusvariants; > To help define and control risks to public health; 9 Tomonitorfor antigenic driftinAI viruses; > T o maintain the viability o f subsistence level poultry production and help assure food security; and, 84 k To demonstrate freedom from clinical disease and absence of infection in a country or compartment and thereby facilitate trade. Surveillancein Cambodia 11. The surveillance system for H P A I in Cambodia was established in early 2004 in response to outbreaks o f HPAI in the region. The surveillance system i s aimed primarily at the smallholder poultry sector since this sector contains 90 percent o f the poultry population, and i s still evolving and expanding. Itconsists o ftwo basic areas: k a hot-line for reporting o f suspected HPAI outbreaks by farmers and the public has been distributed throughout the country, supported by public awareness programs; and, k Village Animal Health Workers (VAHWs) in many provinces have been trained on HPAI and are being paid or encouraged by projects to report suspected outbreaks either through the hot-line or to the local veterinary services. 12. The development o f a comprehensive surveillance plan i s a high priority for Cambodia. This document i s not a detailed surveillance plan, but presents some general issues that are relevant to H P A I surveillance within Cambodia. 13. There i s currently no legal requirement for owners to report suspicion o f HPAIto MAFF. PoultryPopulationat Risk Table 1. PoultryPopulationat Risk of HPAIin Cambodia System Numberof farms Population('000) Chicken Duck Total % Chicken Duck Total % Backyard 1,881,000 380,000 1,900,000 99.94 11,955 2,727 14,682 90.07 Commercial broilers 92 92 0.00 379 379 2.32 Commercial Layers 52 52 0.01 400 400 2.45 Duck systems 951 951 0.05 841 841 5.16 Hatcheries, parent stock 1 30 31 0.00 0.00 Total 1,901,126 100.0 16,301 100.00 I Backyard 14. There are approximately 1.9 million backyard poultry flocks in Cambodia in 13 000 villages. The goal i s to have the primary scanning surveillance system delivered by the village animal health workers (VAHWs) in each village. Their primary task will be case detection and reporting to the district veterinary officer for investigation. A case definition (trigger points) o f suspect HPAI cases within the 85 village system will need to be agreed by MAFF as the basis for reporting by VAHW and investigation by district and provincial staff. 15. Inaddition to reportingby VAHWs, there is a hotline that receives calls from members of the general public (including farmers) who wish to report suspect cases o f HPAI disease. The detection sensitivity o f the hotline has been increased by raising awareness o f HPAI in the community via information, education and communication activities. Commercial Broilers and Layers and Chicken Hatcheries and Parent Stock 16. Disease surveillance relies on privately employed veterinarians and other animal health staff who monitor mortality rates within these production systems. Duck Systems 17. About 29 percent o f duck production i s in commercial farms in Cambodia." Most commercial duck production i s concentrated in the provinces o f Takeo, Kampong Cham, Sihanoukville, Siem Reap, Prey Veng, and Battambang. Commercial duck raising i s much less standardized than the raising o f chickens and about 35 percent o f farms raise broilers and 70 percent raise layers. Most o f these ducks are reared under conditions o fminimal farm biosecurity. 18. Scanning surveillance in the commercial duck sector will also rely on VAHWs. However, targeted surveillance within the commercial duck production sector i s necessary since, in contrast to chickens, ducks may be infected with HPAIand tend to show little or no clinical signs o f H5N1 infection. Targeted Surveillance (active) 19. Targeted surveillance focuses sampling on high-risk populations (that is, targeted populations). Inthe context of HPAI, these areas of high risk include domestic waterfowl (such as ducks), live bird markets, slaughterhouses and selected farms in Production Sector 3 and 4, especially those near roads or wetlands. Further targeting o f farms i s possible taking into account marketing and movement pattems- both within Cambodia and between Cambodia and neighboring infected countries-of poultry and poultry products. Surveillance as Part of Response Activities Suspect case investigation 20. A detailed protocol, which includes standardized data collection, should be followed for all suspect HPAI case investigations (see FAO/OIE guidelines). Ideally the protocol will include SOPSfor all district and provincial animal health staff to follow. This protocol should include details for tracefonvard and traceback procedures, completion o f comprehensive data forms and, if appropriate, the use o f rapid antigen tests to confirm a diagnosis o f HPAI. Only rapid antigen tests that have been evaluated and recommended by international agencies should be used. It needs to be recognized that reported outbreaks may only represent a small proportion o f all cases o f infection. It i s essential to ascertain whether the reported case is the first case o f infection inthat area or just the first one reported in a place where infection i s already endemic. The response by animal health authorities to these two different scenarios may vary. l5Review o fthe poultry production and assessment o f the socio-economic impact o f the highly pathogenic avian influenza epidemic in Cambodia (VSF 2004). 86 ConfirmedHPAIcase 21. Enhanced scanning and targeted surveillance i s necessary in areas surrounding any newly detected outbreaks o f HPAI. Such surveillance will involve more focused surveillance by VAHWs, district and provincial staff. Targeted surveillance will include active sampling o f at risk bird species. The disease investigation protocol for confirmed cases should detail specific surveillance activities. If human cases are detected, surveillance activities will be delivered in conjunction with human health counterparts and will include active sampling o f a larger range o f at risk species and may including sampling pigs for example. DiscussionNote3: EnhancingControlof HPAI through Compensation 22. The culling o f infected birds or those that are in regions immediately around infected animals i s the most practiced control method for limiting the spread o f Highly Pathogenic Avian Influenza (HPAI) and the international practice i s to provide farmers and producers - whose birds are being culled - with compensation for their losses. The payment o f compensation encourages producer cooperation in disease reporting and compliance with culling requirements. When carefully developed, a compensation system can help to reduce the time lag between an outbreak and the initiation o f containment actions and hence reduce the overall cost o f control. To the extent that compensation reduces the virus load in the environment, it also contributes to reducing the risk o f the virus mutating to a form that i s readily transmissible to and between humans. 23. The principal objective o f compensation schemes i s to enhance early reporting and enable culling of diseased birds or those that are suspected o f being diseased. Additionally, compensation serves to reimburse the losses o f private individuals who have complied with a disease control process that has been undertaken for the public good. While compensation i s driven by the imperative o f disease containment, it i s important to recognize that culling activities are likely to have a significant impact on the very poor, but compensation cannot cover all livelihood losses that result from livestock control or replace the essential role that must be playedby social safety nets. Preparednessis Key 24. An effective and efficient compensation system will compensate the appropriate beneficiaries for the appropriate losses, at an appropriate level with the shortest possible interval between culling and the payment o f the compensation. But achieving these criteria requires a highdegree o fpreparationbefore an outbreak takes place, mainly to ensure: (i) an appropriate legislation that details the rights and responsibilities o f government, the livestock sector, marketing personnel and farmers, in disease control; (ii)widespread awareness o f the dangers posed by the disease and clear guidance as to how these risks can be mitigated; (iii) for compensation readily available and procedures established for disbursing funds them rapidly and ina transparent manner. 25. Unless there i s clarity on who should be compensated (a requirement that requires significant effort from government especially when a majority o f beneficiaries are operating in small scale enterprises or backyard production systems), when they should be compensated and how much they should receive, there i s a risk that the compensation system will not be perceived by stakeholders as credible and this may undermine its role in disease control. In the event that a country experiences an outbreak before these measures are in place, the imperative for effective disease control will force many of the oversight tasks to be undertaken at a later date - further complicating the already complex governance issues related to compensation schemes. 87 Identificationof Beneficiaries 26. Ingeneral terms, the beneficiaries of compensation are the owners of the animals. Other input suppliers in the production network (for example feed suppliers, and market operators) do not normally benefit from compensation schemes even though they may incur losses when livestock production and sales are disruptedby disease. 27. The structure o f the compensation scheme i s largely determined by the prevailing production system. Large and highly bio-secure poultry farms can be expected to have good inventory records and these farmer documents provide a reliable basis for culling. Incontract farming situations, ownership o f the birds determines the beneficiary. If the contractor is the owner of the birds, he/she should be compensated and take responsibility for reimbursing the integrator. If the integrator i s the owner o f the birds,then he/she shouldreceive the compensation. Ina few cases, arrangements can be made to pay the contractor for lost income on a wage per day basis, with funds subtracted from the integrator's share before payment. Incorporating contract growers inthe compensation scheme i s problematic but essential to avoid this issue becoming a loophole that limitseffective disease control. 28. Identifying beneficiaries where small enterprises and backyard farming predominates i s also complex. Unlike large producers, farmer records are rarely available and factors such as differential ownership by gender (where the heads o f household - often men - receive compensation even though it may be female household members that have taken actual responsibility for raising the birds) can also come into play. In these circumstances it is essential to conduct surveys as part o f the overall preparedness planning (and not after the disease emerges) to identify ownership patterns, to help raise awareness o f the existence o f the compensation scheme and to ensure that small scale producers play a fullroleinthe stamping out exercise. Types of Compensations 29. Innormal circumstances, compensation covers only direct losses, which include the value o f the animals and sometimes the costs related to the disposal o f dead animals, cleaning and disinfection. Farm- level "consequential losses" resulting from business interruption, the introduction o f movement controls, and price effects are not covered, although in some developed countries they can be coveredunder private insurance schemes. 30. Animals that die (from disease) before culling can take place are often not compensated except where these dead birds retain a market value (and thus there i s a danger that they will be sold) or where disease control teams, once notified of a potential outbreak are unable to respond to within 72 hours o f disease reporting by the farm in question. The accurate computation o f losses i s assisted greatly by having good farm-level records o f poultry holdings available (again, best developed before the outbreak - see section on Preparedness above) and underscores the importance o f developing a comprehensive database o f these records wherever possible. 31. It is important to recognize that the greatest economic losses suffered by countries experiencing HPAIare likely to be indirect: lost feed sales, diminished tourism, absenteeism from work, and so forth. These losses are never covered by public compensation although, in principle, they could be insurable under private sector contracts outside the livestock sector if(as is rarely the case) the risks are well known and can be quantified. 88 Setting CompensationRates 32. Compensation rates can be set on the basis o f (a) market value; (b) budget availability; and, (c) production costs. However, setting the cost on the basis o f market value i s the preferred option as basing the cost on the budget available often leads to underpayment and thus poor compliance. Basing rates on production costs i s problematic as these costs are often difficult to establish accurately and are likely to reward inefficiencies. 33. Where compensation rates are based on market rates, the following principles should be borne in mind: Firstly, compensation rates should represent a percentage o f the reference market rate. The reference market rate i s the farm-gate price appropriately adjusted for seasonality and reflective o f the transport costs from the local community relative to the reference market. The market reference rate should be set before disease outbreaks are experienced as part o f the overall preparedness plan. For special category birds (rare breeds, indigenous poultry, fighting cocks, grandparent stock, and other bird types) where market prices are not readily available, reasonable levels should be determined in consultation with stakeholders. 34. Secondly, uniformity o f rates across the country and for different types o f birds improves the implementation efficiency o f the program and should be pursued where movement control i s effective. However, where this i s not the case, data by type o f bird, weight and age may be needed to set the compensation rate as close as possible to prevailing market prices. Thirdly, compensation rates should be no less than 50 percent o f reference market value at the farm gate and no more than 100percent, with the preferred range being 75-90percent. Rates should be considerably lower for diseased birds and even less (but something) for dead birds, to provide sufficient incentives for early and complete reporting. Careful attention needs to be paid to bird movements while compensation payments are being made to ensure that an incentive i s not being created for an influx o f healthy birds to disease zones or o f diseased birds to disease-free zones. 35. Finally, when dealing with small farmers (and backyard producers), compensation should ideally be paid within 24 hours o f the culling and incash. Where handling o f cash presents a security threat, and where credible local financial institutions exist, a voucher system could be used. It i s important to note that any delay in payment i s likely to have a significant effect on the timeliness and completeness o f reporting. EstablishingAwareness 36. Experience confirms that communication on disease control and compensation i s an absolute necessity, and further, when this i s done in a comprehensive manner, it can account for between 10 to 20 percent o f the total package cost. Awareness raising messages should explain to affected farmers why mandatory culling i s needed to protect the health o f the human population in cases where HPAI i s suspected. Farmers should also receive information that clearly explains the principles, procedures and grid o f compensation levels, precise information on the amounts for which they are eligible and an explanation o f how they will be paid. As with much related to compensation, these messages should be prepared in advance o f outbreaks and with the input o f technical and communications specialists. Once developed, messages shouldbe consistent over time or riskundermining the credibility o f the program. PaymentSystems 37. Inorder to promote early notification o f suspected outbreaks, compensation for culledbirdsmust be paid promptly after the birds have been destroyed. Access to adequate funding to cover the cost o f compensation i s essential. Typical sources o f these funds are the National Treasury, farmers' 89 contributions and those o f donor partners. National Budgets should allow for a contingency o f at least 3- 5 percent o f total budget to ensure that sufficient funds can be rapidly mobilized in the event o f an outbreak. 38. It is estimated that compensation costs can represent up to 45 percent o f total animal disease control expenditures, although the central tendency was around 35 percent. Holding a large contingency implies significant cost, so it i s suggested (for planning purposes) that the contingency be capped at a sum representing no more than 10 percent o f the national flock (representing a severe outbreak). Many outbreaks can be controlled with culling o f less than 1percent of the national flock, and once the share of infected and closely associated birdsreaches 5 percent o f the flock vaccination typically starts substituting for culling and compensation. Countries that rely on significant poultry exports (and that will wish to avoid vaccination), should plan at the 10 percent limit, while those with moderate poultry exports and a highlevel o fsmallholder poultry producers, at 5 percent. Countries with little or no export business, high levels o f bio-security and creditworthy public finances, should plan at the 1percent level. 39. Since the system will be tested in difficult field situations it should be simple and make use, wherever possible, o f existing institutions. Responsibilities for the different aspects o f the system should be defined clearly and in advance to ensure the cross-agency arrangements can be made and contingency funding established. If these arrangements cannot be put in place before an outbreak, authorities will needto shift to a greater reliance on ex post independent scrutiny in order to avoid delays inpayment. 40. There are important roles to be played at every stage o f the payment process: by the veterinary services who should assess the needs and reliability o f the culling, by the Ministryo f Finance who need to arrange for sufficient funds to be available, by the civil authorities who should ensure the security o f the compensation transactions, and by community leadership whose review and oversight will help ensure transparency and fairness. To the extent possible, maximumuse should be made o f local banking entities, producers' organizations, veterinary services, and NGOs making their fiduciary assessment an integral part o f the planningprocess. Greater detail on compensation can be found in the joint World BanWFAO/IFPRI/OiE report, "Enhancing Control of Highly Pathogenic Avian Influenza in Developing Countries through Compensation: Issues and GoodPractice" from which this summay has been developed. 90 d d Q h 3 3 z 48 8 & z 4 e Y c a %a 8a8 B Y -80 0 Y cd 3 hl cd h U 0 aN x 0 E 5lx s a, v1 .3 N a, ncd e e e e e e e e e e *0 M $ 5 C a B s c, '$ 8E 8E aw a w a 5E8 E 8z s 9 cd v1 .3 E '5 8z 0x z 0 0 0 0 cd - '.l I , ~ n ! Y m u , e, '7 a ' 2 I a B i m ' ~l , .3 2 m l ' m m Appendix 11: Statement of Loansand Credits CAMBODIA: Avian andHumanInfluenzaControlandPreparednessEmergencyProject Differencebetween expectedand actual Original Amount in US$ Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd PO89196 2005 KH-TradeFacilitation&Competitiveness 0.00 0.00 0.00 0.00 0.00 9.16 1.14 0.00 PO70668 2005 KH-CambodiaEducationSector Support 0.00 8.00 0.00 0.00 0.00 25.34 4.66 0.00 PO64844 2004 KH-Rural Electrif. & Transmn 0.00 40.00 0.00 0.00 0.00 37.60 18.69 0.00 PO71591 2004 KH-GEF RuralElectrification & Transmiss 0.00 0.00 0.00 5.75 0.00 5.43 -0.39 0.00 PO71207 2004 KH-PROVL& RURAL INFRA 0.00 20.00 0.00 0.00 0.00 9.18 -0.47 0.00 PO73311 2003 KH-PROV & PEN-URB WATER 0.00 16.90 0.00 0.00 0.00 16.23 5.15 0.00 PO70542 2003 KH-Health Sector Support Project 0.00 17.20 0.00 0.00 0.00 21.19 8.26 0.00 PO71146 2003 KH-RURAL WESTMENT & LOCAL 0.00 22.00 0.00 0.00 0.04 10.30 1.11 0.00 GOVERNANCE PO71247 2002 KH Eco.& PS CapacityBuildingProject - 0.00 5.50 0.00 0.00 0.00 5.26 4.40 0.00 PO70875 2002 KH-Land Managementand Administration 0.00 24.30 0.00 0.00 0.00 16.72 6.44 1.99 PO65798 2000 KH-BIO & PROTEC AREAS M 0.00 1.91 0.00 0.00 0.00 0.44 0.36 0.37 PO52006 2000 KHBIO&PROTAREA M 0.00 0.00 0.00 2.75 0.00 0.64 2.84 0.64 PO04030 1999 KH-ROAD REHAB 0.00 45.31 0.00 0.00 0.00 2.07 2.08 1.55 Total: 0.00 201.12 0.00 8.50 0.04 159.56 54.27 4.55 CAMBODIA STATEMENT OF IFC's HeldandDisbursedPortfolio InMillionsofUS Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 2005 CanadiaBank 5.00 0.00 0.00 0.00 2.50 0.00 0.00 0.00 2004 SCA Cambodia 9.53 0.00 0.00 0.00 9.53 0.00 0.00 0.00 2000 SEF ACLEDA Bank 0.00 0.49 0.00 0.00 0.00 0.49 0.00 0.00 2004 SEF ACLEDA Bank 6.00 1.10 0.00 0.00 6.00 1.10 0.00 0.00 ~ Total portfolio: 20.53 1.59 0.00 0.00 18.03 1.59 0.00 0.00 Approvals PendingCommitment FY Approval Company Loan Equity Quasi Partic Totalpendingcommitment: 0.00 0.00 0.00 0.00 100 Appendix 12: Countryat a Glance CAMBODIA: Avian and HumanInfluenzaControland PreparednessEmergencyProject East POVERTY and SOCIAL Asia a LOW- Cambodla Pacific Income 2004 Population.mid-year(miiiions) 0.6 1870 2.338 GNIpercapita (Atiasmefhod, US$) 350 1280 5x) Lifeexpectancy GNI(Atlas method, US$ biiiions) 4.8 2,389 134 - Average annual growth, 1998.04 Population (%) 19 0.9 16 Laborforce (%) 2.4 11 2.1 GNI Gross per i pnmary Most recent estlmate (latest year available, 1998-04) capita enrollment Poverty (% of population baiownatio naipovedyline) 36 Urbanpopulation(%of totaipopuiation) B 41 31 Lifeexpectancyat birth(pars) 54 70 58 Infant mortalitylper KJOOiivabirths) 97 32 79 Child malnutrition(%of chiidrenunder5) 45 15 44 Access to improvedmtersource Access to an improvedmter source (%ofpopulation) 34 78 75 Literacy(%ofpopuiation age W+) 74 90 61 Gross primaryenrollment (%of schooi-agepopuiation) P 4 10 94 -Cambodia Male 00 10 01 Low-income group Female Iff 1P 86 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1984 1994 2003 2004 Economic ratios. GDP (US$ biiiions) 2.8 4.3 4.9 Gross capital formation1GDP 118 25.2 25.6 Exports of goods andServicesIGDP ...... 25.8 58.6 64.7 Trade Gross domestic savingsIGDP -11 16.0 14.7 Gross nationalsavings1GDP .. 5.4 22.7 8.7 Currentaccount balance1GDP .. -5.6 -2.4 -5.4 Interest payments1GDP 0.1 0.2 0.2 Total debtIGDP .... 68.5 722 66.7 Total debt servicelexports .. 0.3 0.9 0.8 Present value of debt1GDP 50.2 Present value of debtlexports 716 Indebtedness 1984.84 1994.04 2003 2004 2004-08 (averageannuaigroMh) GDP .. 7.0 7.0 7.7 6.0 - Cambodia GDP percapita 4.1 5.2 6.1 4.3 Exports of goods and services .... 8.4 9.1 22.4 STRUCTURE of the ECONOMY 1984 1994 2003 2004 (%ofGDP) Growth of capltal and GDP (%) Agnculture 47.6 35.1 32.9 I IW T Industry .... 14.4 27.8 29.2 Manufacturing 9.3 20.5 215 Services .... 36.0 37.1 37.9 Householdfinal consumption expenditure .. 94.2 78.4 80.4 Generalgov't final consumption expenditure .. 8.9 5.6 4.9 Imports of goods andservices .. 36.7 67.6 75.6 -GCF -GDP 1984.94 1994.04 2003 2004 (averageannual gmMh) Agnculture 2.7 P.2 -2.0 Industry .... 15.7 11.9 16.1 Manufacturing 8.8 P.l ff.4 Services .... 6.6 0.2 9.2 Householdfinal consumption expenditure 4.4 -0.6 7.2 Genera gov't final consumption expenditure 5.8 5.3 -6.5 Gross capital formation ...... 14.9 417 14.1 Imports of goods andsewices .. 0.8 9.8 21.1 Note:2004 data are preliminaryestimates 'Thediamonds showfourkeyindicators inthecountry(in bo1d)comparedwithits incomegroupaverage.K data aremissing,thediamondMll be IncomDlete. 101 PRICES andGOVERNMENT FINANCE 1984 1994 2003 2004 Domestic prices (,~) (%change) Consumer pnces 4.2 0.5 5.6 1: -4.4 H 5.3 !::A Implicit GDP deflator Government finance (%of GDP,includes current grants) I Current revenue 8.3 n.1 112 .s Current budget balance .. -12 -0.6 15 Overall surplusldeficit .. -5.9 -7.6 -5.0 ----GDPde(lator -CPI TRADE (US$ millions) Export and Import levels (US$ mill.) Totalexports (fob) .. 490 2,027 2,479 Rubber 98 115 Logs and s a w timber 23 B 3000 Manufactures 20 1,640 2,048 Total imports (cif) 737 2,560 3,228 2ooo Food #O I000 Fueland energy 480 0 603 Capital goods 750 963 0 Evort priceindex(2000=00) Import priceindex(2000=WO) Terms of trade (2000=00) BALANCE o f PAYMENTS 2004 (US$ millions) [Currentaccount balance to GDP (%) I Evorts of goods and services 544 2,553 3,246 0 Imports of goods and services 884 2,950 3,705 Resource balance -340 -397 -460 Net income -47 -183 -226 -2 Net current transfers 230 475 423 Current account balance -157 -r)5 -262 -4 Financing items (net) I71 341 Changes in net reserves -66 -79 -B Memo: I I Reserves including gold (US$ millions) 799 890 Conversionrate(DEC,locai/US$) 2,545.3 3,980.0 4,029.0 EXTERNAL DEBT and RESOURCE FLOWS 1984 1994 2003 2004 (US$ millions) Composltlon of 2004 debt (US$ mlll.) Total debt outstanding and disbursed 5 1,909 3,739 3,356 iBRD 0 0 0 0 IDA 0 39 400 467 Total debt service 0 2 25 26 IBRD 0 0 0 0 IDA 0 0 2 5 Composition of net resourceflow Official grants 8 8 3 1B8 Official creditors 0 58 5 5 156 Private creditors 0 0 0 0 Foreigndirect investment (net inflow) 0 82 87 0 7 Portfolio equity(net inflows) 0 0 -8 -8 World Bank program Commitments 0 I7 76 E-Bilateral Disbursements 0 38 63 Principal repayments 0 0 0 Net flow 0 38 63 46 Interest payments 0 0 2 Net transfers 0 38 60 42 Development Economics 910105 102 MAP SECTION 103° E 104° E 105° E 106° E 107° E 0 20 40 60 80 Kilometers L A O P . D . R . CAMBODIA T H A I L A N D AVIAN AND HUMAN 0 20 40 60 Miles INFLUENZA CONTROL AND PREPAREDNESS O D D A R Kong EMERGENCY PROJECT Phumi Samraong Phumi Samraong M E A N C H E Y Cheom Ksan Cheom Ksan Siem Pang Siem Pang RATANAKIRIRA ANAKIRI 14° N Sreng Kompong Sralao Kompong Sralao Kong 14° N P R E A H V I H E A R CONFIRMED HUMAN DEATHS BANTEAYBANTEA 4 DUE TO H5N1 Phum Kompadou Phum Kompadou MEANCHEY MEANCHEY S I E M R E A P Phnum Tbeng Phnum Tbeng Melouprey Melouprey San MeancheyMeanchey S T U N G T R E N G BoungBoung AVIAN INFECTIONS ONLY LongLong Sisophon Sisophon KralanhKralanh BOTH AVIAN AND HUMAN Stung Treng Stung reng Srepok LumphatLumphat INFECTIONS Siem Reap Siem Reap SELECTED CITIES AND TOWNS Rovieng Rovieng PROVINCIAL CAPITALS Batdambang Batdambang Tonle NATIONAL CAPITAL 13° N B AT TA M B A N G Sen g Sap KohniehKohnieh 13° N RIVERS Pailin Pailin Chas Poron K A M P O N G T H O M Mekong M O N D O L PROVINCIAL BOUNDARIES Kampong Thom Kampong Thom K R A T I E K I R I INTERNATIONAL BOUNDARIES ChbarChbar Pursat Pursat KratieKratie SenmonoromSenmonorom Peam Tonle P U R S AT KAMPONGKAMPONG KAMPONGKAMPONGpaS CHAMCHAM KampongKampong 12° N CHHNANGCHHNANG Mekong ChamCham 1 12° N PHNOM PENH PHNOM PENH Krong Koh Kong Krong Koh Kong K A M P O N G PHNOM PENH PHNOM PENH S P E U K O H K O N G Kampong Speu Kampong Speu Prey Veng Prey eng SVAYSV Gulf of KANDALKANDAL PREYPREY RIENGRIENG V I E T N A M Thailand 1 ChambakChambak Bass VENGVENG SvaySvay ka RiengRieng 11° N Ta eo Tak Chhak 1 11° N Kampong TAKEO AKEO Saom K A M P O T This map was produced by CAMBODIA the Map Design Unit of The World Bank. The boundaries, Sihanoukville KampotKampot colors, denominations and any other information shown 4 on this map do not imply, on S I H A N O U K - IBRD the part of The World Bank V I L L E MA Group, any judgment on the legal status of any territory, 34707R Y or any endorsement or 2007 a c c e p t a n c e o f s u c h boundaries. 103° E 104° E 105° E 106° E 107° E