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i
Document of
The World Bank
Report No: ICR00003330
FINAL, December 23
IMPLEMENTATION COMPLETION AND RESULTS REPORT
ON THE
VIETNAM AVIAN AND HUMAN INFLUENZA AND HUMAN PANDEMIC
PREPAREDNESS PROJECT FINANCING
IDA CREDIT (4273) IN THE AMOUNT OF SDR 13.5 MILLION (US$ 20 MILLION
EQUIVALENT)
(March 13, 2007)
IDA CREDIT (4992) IN THE AMOUNT OF SDR 6.2 MILLION (US$ 10 MILLION
EQUIVALENT)
(October 21, 2011)
AHI FACILITY GRANT (TF057747) IN THE AMOUNT OF US$ 10 MILLION
(April 12, 2007)
PHRD GRANT (TF057848) IN THE AMOUNT OF US$ 5 MILLION
(April 12, 2007)
AHI FACILITY GRANT (TF099841) IN THE AMOUNT OF US$ 13 MILLION
(October 21, 2011)
TO THE
SOCIALIST REPUBLIC OF VIETNAM
UNDER THE FRAMEWORK OF THE
GLOBAL PROGRAM FOR AVIAN INFLUENZA CONTROL AND HUMAN PANDEMIC
PREPAREDNESS AND RESPONSE (GPAI)
December 23, 2014
Health, Nutrition and Population Global Practice
Vietnam Country Unit
East Asia and Pacific Region
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CURRENCY EQUIVALENTS
Exchange Rate Effective December 1, 2014
Currency Unit=Vietnamese Dong (VND)
VND 21,397.5 = US$ 1.00
US$ 1.46355 = SDR 1.00
FISCAL YEAR
January 1 – December 31
ABBREVIATIONS AND ACRONYMS
AHI Avian and Human Influenza
AHIF Avian and Human Influenza Facility (World Bank-administered trust funds)
AI Avian Influenza
AIEPED Integrated National Operational Program on Avian Influenza, Pandemic
Preparedness, and Emerging Infectious Diseases, 2011-2015 (Blue Book)
BCC Behavior Change Communication
CAHW Community Animal Health Worker
CDC US Centers for Disease Control and Prevention
DAH Department of Animal Health
DARD Department of Agriculture and Rural Development
DLP Department of Livestock Production
DVO District Veterinary Officer
DPMC District Preventive Medicine Center
EC European Commission
EID Emerging Infectious Disease
FAO Food and Agriculture Organization (UN agency)
FET Field-based epidemiology training
GPAI Global Program for Avian Influenza Control and Human Pandemic Preparedness
and Response
HPAI Highly Pathogenic Avian Influenza (including H5N1)
ICR Implementation completion and results report
ILI Influenza-like illness
ISR Implementation Status Report
KAP Knowledge, attitudes and practices (survey)
LIFSAP Livestock Competitiveness and Food Safety Project (in Vietnam)
MARD Ministry of Agriculture and Rural Development
M&E Monitoring and Evaluation
MOH Ministry of Health
OIE World Organization for Animal Health
OPI National Integrated Operational Program for Avian and Human Influenza, 2006-
2010 (Green Book)
PCU Project Coordination Unit
PDO Project Development Objective
PHRD Policy and Human Resources Development Trust Fund (administered by the
World Bank)
PPE Personal protective equipment
PPCU Provincial Project Coordination Unit
PVS Performance of Veterinary Services (assessment)
iii
RRT Rapid Response Team (for response to outbreaks)
SARS Severe acute respiratory syndrome (disease of animal origin)
UNSIC UN System Influenza Coordination
VAHIP Vietnam Avian and Human Influenza Control and Preparedness Project
WHO World Health Organization (UN agency)
Vice President: Axel van Trotsenburg
Country Director: Victoria Kwakwa
HNP GP Practice Manager: Toomas Palu
Project Team Leader: Anh Thuy Nguyen
ICR Team Leader: Olga B. Jonas
iv
VIETNAM AVIAN AND HUMAN INFLUENZA AND HUMAN PANDEMIC
PREPAREDNESS PROJECT
TABLE OF CONTENTS
Data Sheet
A. Basic Information ................................................................................................................... vi
B. Key Dates ............................................................................................................................. vi
C. Ratings Summary ................................................................................................................... vi
D. Sector and Theme Codes ....................................................................................................... vii
E. Bank Staff ............................................................................................................................ vii
F. Results Framework Analysis ................................................................................................ viii
G. Ratings of Project Performance in ISRs ................................................................................ xi
H. Restructuring .......................................................................................................................... xi
I. Disbursement Profile and Actual Disbursements from All Financing Sources ..................... xii
J. Financing Instrument and Project Components .................................................................... xii
1. Project Context, Development Objectives and Design .............................................................1
2. Key Factors Affecting Implementation and Outcomes ............................................................4
3. Assessment of Outcomes ........................................................................................................10
4. Assessment of Risk to Development Outcome .......................................................................22
5. Assessment of World Bank and Borrower Performance ........................................................24
6. Lessons Learned......................................................................................................................26
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners.........................28
Annex 1. Project Costs and Financing ........................................................................................30
Annex 2. Outputs by Component................................................................................................31
Annex 3. Economic and Financial Analysis ...............................................................................43
Annex 4. Bank Lending and Implementation Support/Supervision Processes ...........................47
Annex 5. Comments on Draft ICR and Recommendations from Borrower’s ICR ....................49
Annex 6. Comments of Cofinanciers and Other Partners/Stakeholders .....................................58
Annex 7. List of Supporting Documents ....................................................................................59
Annex 8. List of Persons Met .....................................................................................................61
Annex 8. List of Persons Met .....................................................................................................61
Map .............................................................................................................................63
Text Boxes, Tables, and Figures
Box 1. The single most important area for productive investment ...................................19
Table 1. KAP survey results (% of target groups) ...............................................................17
Table 2. District-level preventive and curative capacities performance targets were
exceeded .................................................................................................................18
Table 3. Project outcomes: nearly all targets surpassed or met ...........................................21
v
Table A3.1. Poultry destroyed by avian influenza, 2003-14 .....................................................44
Table A3.2. Overview of the economic costs influenced by stronger public health
systems (national benefits only).............................................................................45
Figure 1. Project resources by component ..............................................................................4
Figure 2. Dramatic decline in number of poultry destroyed by AI and by AI disease
control ....................................................................................................................12
Figure 3. Human deaths due to H5N1 avian flu declined dramatically in VAHIP
provinces and in Vietnam ......................................................................................12
Figure 4. An example of market upgrading under VAHIP: poultry are off the ground
and regular cleaning is possible .............................................................................14
Figure 5. Evidence of high risk awareness in paintings by children .....................................17
Figure A2.1. The eleven VAHIP provinces (map) .....................................................................31
Figure A2.2. Little or no biosecurity before improvement of markets .......................................32
Figure A2.3. Examples of improved markets .............................................................................33
Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health .....37
Figure A2.5. District Preventive Health Center managers and staff, along with provincial
officials, and the VAHIP PCU, discuss improvements in local-level public
health capacity. ......................................................................................................41
Figure A3.1. The poorest households suffer larger income declines than wealthier
households with a ban on backyard poultry sales ..................................................46
Figure A5.1. Science of delivery under VAHIP ........................................................................51
vi
A. Basic Information
Country: Vietnam Project Name: VN-Avian & Human Influenza
Control &Prep
Project ID: P101608 L/C/TF Number(s): IDA-42730, IDA-49920, TF-
57747, TF-57848, TF-99841
ICR Date: 12/08/2014 ICR Type: Core ICR
Lending Instrument: ERL Borrower:
Original Total Commitment: XDR 13.50M Disbursed Amount: XDR 18.55M
Revised Amount: XDR 19.26M
Environmental Category: B
Implementing Agencies:
Ministry of Health
Ministry of Agriculture and Rural Development
Cofinanciers and Other External Partners: US -- Centers for Disease Control and Prevention (CDC) US Agency for International Development (USAID) Japanese PHRD Grant European Community - AHIF Food and Agriculture Organization (FAO) WHO
World Organisation for Animal Health (OIE)
B. Key Dates
Process Date Process Original Date Revised / Actual
Date(s)
Concept Review: 10/03/2006 Effectiveness: 08/23/2007 08/23/2007
Appraisal: 12/22/2006 Restructuring(s):
07/19/2010
06/14/2011
06/29/2011
Approval: 03/13/2007 Mid-term Review: 08/15/2008 11/21/2008
Closing: 12/31/2010 06/30/2014
C. Ratings Summary
C.1 Performance Rating by ICR
Outcomes: Highly Satisfactory
Risk to Development Outcome: Moderate
Bank Performance: Satisfactory
Borrower Performance: Satisfactory
vii
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)
Bank Ratings Borrower Ratings
Quality at Entry: Satisfactory Government: Satisfactory
Quality of Supervision: Satisfactory Implementing
Agency/Agencies: Satisfactory
Overall Bank
Performance: Satisfactory
Overall Borrower
Performance: Satisfactory
C.3 Quality at Entry and Implementation Performance Indicators
Implementation
Performance Indicators
QAG Assessments (if
any) Rating
Potential Problem Project
at any time (Yes/No): No NA None
Problem Project at any time
(Yes/No): No NA None
DO rating before Closing: Moderately
Satisfactory
D. Sector and Theme Codes
Original Actual
Sector Code (as % of total Bank financing)
General agriculture, fishing and forestry sector 21 21
General public administration sector 50 50
Health 21 21
Other social services 7 7
Solid waste management 1 1
Theme Code (as % of total Bank financing)
Health system performance 13 20
Natural disaster management 24 20
Other communicable diseases 25 30
Other social protection and risk management 13 10
Rural services and infrastructure 25 20
E. Bank Staff
Positions At ICR At Approval
Vice President: Axel van Trotsenburg James W. Adams
Country Director: Victoria Kwakwa Klaus Rohland
Practice Manager/Manager: Toomas Palu Hoonae Kim
Project Team Leader: Anh Thuy Nguyen Samuel S. Lieberman, Binh Thang Cao, Lingzhi Xu
ICR Team Leader: Olga B. Jonas
viii
ICR Primary Author: Olga B. Jonas
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document)
The project development objective of VAHIP was "to assist the government to increase the
effectiveness of public services in reducing the health risk to poultry and to humans from avian
influenza in selected provinces, through measures to control the disease at source in domestic
poultry, to detect early and respond to human cases of infections, and to prepare for the medical
consequences of a potential human pandemic."
Revised Project Development Objectives (as approved by original approving authority)
The Project Development Objective was not revised. Most indicator targets were initially set for
the end of the VAHIP-1 period (2007-10) and, after additional financing was approved in 2011,
targets were set for the VAHIP-2 period (2011-14).
(a) PDO Indicator(s)
Indicator Baseline Value Original Target
Values
Formally
Revised
Target Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : Increase in number of annual suspected highly pathogenic avian influenza (HPAI) cases
in poultry reported and fully investigated per project province.
Value 0 10 case reports per
province per year
275 case reports
(11 provinces)
All 39 of 39 reports
of suspected HPAI
investigated.
Date achieved 02/15/2007 12/31/2010 06/30/2014 06/30/2014
Comments
Objective fully achieved in substance. Target of 275 HPAI reports could not be met
because of lower disease prevalence than planned. Performance of reporting system
from village to district level very strong: 11,313 reports of suspected poultry disease
reached provincial level in 2014, and 24,000 reports in 2013.
Indicator 2 : For both veterinary and health sector, reduce reporting time of new outbreaks and return
of laboratory confirmation to the affected commune.
Values 8.7 (veterinary)
10 (human health)
4 (veterinary)
4 (human health)
4 (veterinary)
4 (human
health)
2.4 (veterinary)
3.4 (human health)
Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014
Comments
Targets surpassed. This is an important and substantial achievement in reporting
performance to laboratories and from laboratories to affected communes. Significant
progress was achieved already by 2010, when the times reached 2.9 days
Indicator 3 : Reduced fatality rate of human H5N1 cases compared to 2004/05 in the 11 project
provinces
45% 35% 35% NA
Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014
Comments The indicator was not valid for periods with very low number of cases. In 2014 there
was 1 case, which was fatal. The calculated value of 100% is mathematically correct
ix
but does not measure progress on PDO. See text on human health PDO achievements.
(b) Intermediate Outcome Indicator(s)
Indicator Baseline Value Original Target
Values
Formally
Revised Target
Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : Intermediate Result A1: Veterinary services on disease diagnostic and surveillance
strengthened - Number of laboratories working at ISO 17025 standards for AI testing.
Value 0 6 8 8
Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014
Comments Target surpassed, as the ambitious goal was fully met in 2013, ahead of schedule.
Indicator 2 : Intermediate Result A2.1: Percentage of poultry traders applying good biosecurity
practices at Ha Vy market.
Value 25% 80% 100% 100%
Date achieved 06/30/2006 06/30/2010 06/30/2014 06/30/2014
Comments Target fully met. This was an ambitious target, in view of increasing market trade
volume. Indicator modified in 2012 to measure behaviors (rather than virus prevalence).
Indicator 3 : Intermediate Result A2.2: Percentage of upgraded markets and slaughterhouses
applying practice according to project guidelines.
Value 11% 100% 100%
Date achieved 06/30/2007 06/30/2010 06/30/2014
Comments
Target fully met. There was steady increase from the baseline of only 11 percent in
2006, with progress above interim targets set during implementation. By the end of the
project, the target was met in 76 upgraded markets and slaughterhouses.
Indicator 4 : Intermediate Result A3: Percentage of positive samples for H5N1 virus at markets and
slaughterhouses.
Value NA
35 out of 52
commercial farms
demonstrated
disease-free
less than 2% 7.66%
Date achieved 06/30/2006 12/31/2010 06/30/2014 06/30/2014
Comments
Indicator for VAHIP-2 focused on markets (rather than farms, for which VAHIP-1
target was exceeded). Ambitious target partly met; disease-prevalence outcome was
beyond the control of the project. Improved surveillance yielded key information.
Indicator 5 :
Intermediate Result A5: Number of days that suspect outbreaks are completely
contained (quarantine and culling). NB: In VAHIP-1, this indicator was no. of rapid
response teams performing effectively; target was surpassed by 2011.
Value 4 days 2 days less than 1 day
Date achieved 06/30/2010 06/30/2014 06/30/2014
Comments Target surpassed for this key system performance indicator. Improvements in
performance also exceeded interim targets, reaching 1.1 days already in 2013.
Indicator 6 : Intermediate Result B1: Percentage of reports that are accurately completed and sent on
time to the Provincial Preventive Health Centers
Value 58% 84% 90% 98.6%
Date achieved 06/30/2007 06/30/2010 06/30/2014 06/30/2014
Comments Target surpassed. Indicator reached 95.4% in 2013 and nearly 100% in 2014.
x
Indicator Baseline Value Original Target
Values
Formally
Revised Target
Values
Actual Value
Achieved at
Completion or
Target Years
Substantial improvement in system performance.
Indicator 7 : Intermediate Result B1: Percentage of reports that are accurately completed and
received at the District Preventive Health Centers
Value 82% 90% 97.7%
Date achieved 06/30/2010 06/30/2014 06/30/2014
Comments Target surpassed. Indicator of important aspect of system performance reached 94.8%
in 2013. Indicator used in VAHIP-2 period.
Indicator 8 : Intermediate Result B2: Percentage of project provinces developed the Pandemic
preparedness plan (based on the MOH guideline).
Value 0% 100% 100% (plans
improved)
100% (plans
improved)
Date achieved 02/15/2007 06/30/2010 06/30/2014 06/30/2014
Comments Target fully met in 2010, an important achievement in preparedness of 44 provincial
hospitals. Plans then improved and simulated in exercises.
Indicator 9 : Intermediate Result B2: Percentage of district hospitals developed the pandemic
preparedness plan
Value N/A 100% 100%
Date achieved 06/30/2010 06/30/2010 06/30/2014
Comments Target fully met, improving preparedness during VAHIP-2 period in 124 district
hospitals. Indicator reached 85.4% in 2012.
Indicator 10 : Intermediate Result B3: Percentage of target population that can accurately identify and
have practiced at least one key preventive behavior (divided by the target groups)
Value
Curative HCW: 91%
Preventive HCW: 100%
General population: 56.4%
Curative: 40%
Preventive: 40%
General population:
40%
Curative: 60% Preventive: 60%
General
population: 60%
Curative: 86.2%
Preventive: 88%
General population:
98.8%
Date achieved 06/30/2008 06/30/2010 06/30/2014 06/30/2014
Comments
Targets surpassed for all three groups. Indicator values for knowledge and attitudes (not
shown here) increased as well. Increased/sustained risk awareness despite plummeting
international attention.
Indicator 11 :
Intermediate Result B4.1: Number of DPMCs in 11 provinces fully equipped and have
adequate capacity to implement their responsibilities and functions in compliance with
MOH decisions on Preventive Medicine.
Value 0 16 79 87
Date achieved 02/15/2007 06/30/2010 06/30/2014 06/30/2014
Comments Target surpassed, by a substantial margin. Already in 2010, the achievement was 28
DPMCs, significantly above the interim target of 16.
Indicator 12 : Intermediate Result B4.2: Number of multisectoral simulation exercises conducted and
reviewed at district levels in the project provinces
Value 0 17 30 68
Date achieved 06/30/2007 06/30/2010 06/30/2014 06/30/2014
Comments Target surpassed. Achievement more than double the plan. Interim targets surpassed
every year as well.
xi
Indicator Baseline Value Original Target
Values
Formally
Revised Target
Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 13 : Intermediate Result B4: Number of health staff have been trained and/or capacity built
by the project (cumulative).
Value 11,005 Target value not set 21,905 69,012
Date achieved 06/30/2006 06/30/2010 06/30/2014 06/30/2014
Comments
Target surpassed. VAHIP achieved more than three times the level of training than
initially envisaged. This impacted especially district and local-level veterinary and
human public health systems.
Indicator 14 : VAHIP-1 indicator A4.1. Number of small scale poultry farm models demonstrated.
Value 0 25 80
Date achieved 02/15/2007 06/30/2010 12/31/2010
Comments Target surpassed. 80 demonstration sites provided training to 1,760 small farmers.
G. Ratings of Project Performance in ISRs
No. Date ISR
Archived DO IP
Actual Disbursements
(USD millions)
1 07/21/2007 Satisfactory Satisfactory 0.00
2 09/16/2008 Satisfactory Moderately Unsatisfactory 1.45
3 02/19/2009 Satisfactory Moderately Satisfactory 2.36
4 04/12/2010 Satisfactory Moderately Satisfactory 6.90
5 03/21/2011 Satisfactory Moderately Satisfactory 16.70
6 03/11/2012 Satisfactory Satisfactory 20.72
7 03/31/2013 Satisfactory Moderately Satisfactory 21.96
8 10/23/2013 Satisfactory Moderately Satisfactory 23.50
9 06/20/2014 Moderately Satisfactory Moderately Satisfactory 26.39
H. Restructuring
Restructuring
Date(s)
Board
Approved PDO
Change
ISR Ratings at
Restructuring
Amount
Disbursed at
Restructuring
in USD millions
Reason for Restructuring & Key
Changes Made DO IP
07/19/2010 N S MS 8.75
Reallocation among disbursement
categories; extend closing dates of
VAHIP-1 to 6/30/2011.
06/14/2011 S MS 18.62 Extend closing date of VAHIP-1
to 12/31/2011.
06/29/2011 S MS 18.62 Revise indicators.
xii
I. Disbursement Profile and Actual Disbursements from All Financing Sources
*: Due to the exchange rate differences between SDR and USD, the actual amounts will differ from original and revised amounts.
** Under IDA Credit no. 4492 US$ 1.0 million is undisbursed, and under IDA Credit no. 42730 XDR 0.6 million was cancelled.
J. Financing Instrument and Project Components
The World Bank, other donors, and technical agencies supported the implementation of the
government’s plan. World Bank provided financing in the form of: IDA credits for Emergency
Response Lending (ERL), a cofinancing Japanese Policy and Human Resource Development
(PHRD) grant, and two cofinancing grants from the multidonor Avian and Human Influenza
Facility (AHIF), which received funds from the European Commission, Australia, and eight
other donors. World Bank ERL financing was part of an adaptable program loan (APL) entitled
the Global Program for Avian Influenza Control and Human Pandemic Preparedness and
Response (GPAI).
Project components mirrored the government’s plan, namely: (A) animal health, (B) human
public health, and (C) coordination, monitoring and evaluation, and project management, with
close coordination between the animal health and human health components.
1
1. Project Context, Development Objectives and Design
1.1 Global and Country Contexts at Appraisal
1. In December 2003, Vietnam reported its first cases of Highly Pathogenic Avian Influenza
(HPAI) H5N1. Within four months the disease was detected in 57 of 64 provinces. Some 44
million poultry—17 percent of the nation’s stock—had been culled to prevent further outbreaks
or had died from the disease. This was a severe cost to farmers and to the economy more
broadly. The economic toll was some 0.5 percent of Vietnam’s GDP, or US$250 million. Animal
health and disease surveillance systems were rapidly overwhelmed. Moreover, as 15 human
deaths were recorded in 2004, there was increasing evidence that the H5N1 avian influenza virus
could infect humans. This and the possibility that the virus could become capable of efficient
human-to-human transmission, raised the prospect that an influenza pandemic would result.
2. By 2005 the H5N1 avian flu virus emerged as a global threat. On January 12, 2006 the
World Bank’s Board endorsed the Global Program for Avian Influenza Control and Human
Pandemic Preparedness and Response (GPAI) as a horizontal adaptable program loan (APL) to
provide up to US$500 million of immediate emergency assistance to countries seeking support to
address this threat to public health and economies of all countries.1
The GPAI was based on
guidance from the World Organization for Animal Health (OIE), the World Health Organization
(WHO), and the Food and Agriculture Organization (FAO). Their inputs were coordinated by the
Senior United Nations System Influenza Coordinator (UNSIC), appointed by the UN Secretary
General. The GPAI was one of the World Bank’s contributions to a broad international initiative,
which was launched at the UN General Assembly in 2005. This initiative mobilized US$3.9
billion from 35 donors at a series of five ministerial conferences, starting in Beijing, China, in
January 2006 and concluding in Hanoi, Vietnam in April 2010.
3. Throughout 2006, the virus was spreading rapidly, with additional countries reporting
cases of HPAI; by the end of the year, 55 countries in Asia, Europe, Africa and the Middle East
had reported cases of H5N1 avian flu in poultry or wild birds, including in Vietnam and all
neighboring and other South East Asian countries (Cambodia, China, Lao PDR, Myanmar, and
Thailand). The international community was concerned that the response should be prompt and
effective so as to prevent a potentially catastrophic impact on public health and economies. The
2003 outbreak of the severe acute respiratory syndrome (SARS) served as a recent reminder. It
had been quickly contained after 8,000 cases of human infection, of which 800 were fatal, but its
economic costs were very high ($54 billion).2
4. The first World Bank-financed avian flu response project, the Vietnam Avian Influenza
Emergency Recovery Project (AIERP), was approved in August 2004 as an emergency operation
with US$5 million IDA financing. The project thus pre-dated the GPAI. It was fully
1 This amount was subsequently increased to US$1 billion in June 2009; see Extension of the Global Program for
Avian Influenza Control and Human Pandemic Preparedness and Response (GPAI) and Increase of the GPAI
Ceiling to $1 billion in Response to Influenza A(H1N1) Pandemic, R2009-0111, May 11, 2009. 2 Estimating the Global Economic Costs of SARS by Jong-Wha Lee and Warwick J. McKibbin in Learning from
SARS: Preparing for the Next Disease Outbreak -- Workshop Summary, Institute of Medicine, Washington, DC,
2004, available at www.ncbi.nlm.nih.gov/books/NBK92473/.
2
implemented in less than three years in 10 provinces badly hit by the virus. The project enhanced
national disease surveillance and diagnostic capacity, strengthened mechanisms in the poultry
sector to contain serious outbreaks, and raised public awareness of risks and how to mitigate
them. The AIERP provided a platform for action, which the government used to articulate and
lead a concerted response from donors, international technical agencies, and civil society.3
The
AIERP was a catalyst for the approach adopted in developing the GPAI in 2005, when the global
threat from the H5N1 avian flu virus became apparent.
5. The Vietnam Avian and Human Influenza Control and Preparedness Project (VAHIP)
was developed to follow the AIERP, which closed on June 30, 2007. VAHIP built on the AIERP
platform and aimed to consolidate the gains made against avian influenza. VAHIP was financed
by an IDA Credit (SDR 13.5 million, US$20 million equivalent), an Avian and Human Influenza
Facility (AHIF) Grant (US$10 million), a Japan PHRD Grant (US$5 million), and the
Government of Vietnam (US$3 million). The Project became effective on August 23, 2007. The
original closing date was December 31, 2010. This was extended twice, initially to June 30, 2011
and then to December 31, 2011.
1.2 Original Project Development Objectives (PDO) and Key Indicators:
Project Development Objective
6. The project development objective (PDO) was “to assist the government to increase the
effectiveness of public services in reducing the health risk to poultry and to humans from avian
influenza in selected provinces, through measures to control the disease at source in domestic
poultry, to detect early and respond to human cases of infections, and to prepare for the medical
consequences of a potential human pandemic.” The project was implemented in eleven
provinces.
7. The PDO was and remains in line with Vietnam government’s plans for the medium and
long-term control of avian influenza and other zoonotic disease threats, as set out in: (i) the
National Integrated Operational Program for Avian and Human Influenza, 2006-2010 (OPI,
called the “Green Book”) and (ii) the Integrated National Operational Program on Avian
Influenza, Pandemic Preparedness, and Emerging Infectious Diseases, 2011-2015 (AIEPED,
called the “Blue Book”). The PDO was fully consistent with the GPAI, which, like the OPI and
the AIEPED, was based on the expert advice of the World Health Organization (WHO), the
World Organization for Animal Health (OIE), Food and Agricultural Organization (FAO), US
Centers for Disease and Prevention (US CDC), and other international agencies.
8. There were three key outcome indicators, aligned with the core aims of infectious disease
control and prevention:
i. Increase in number of suspected HPAI cases in poultry that are reported and fully
investigated, per province.
ii. For both veterinary and human health sectors, reduced reporting time of new outbreaks
and reduced time to return of laboratory confirmation to the affected commune.
3 Vietnam Avian Influenza Emergency Recovery Project, Implementation Completion and Results Report,
December 19, 2007 (Report No. ICR0000664).
3
iii. Reduce fatality rate of human H5N1 cases compared to 2004-5 in the 11 project
provinces.
The third indicator became irrelevant because the number of cases of H5N1 infection in humans
declined dramatically throughout the project period compared to 2004-5; the problematic nature
of this indicator confirms one of the lessons from the review of avian influenza projects by the
Independent Evaluation Group (IEG).4
1.3 Revised PDO
9. The PDO was not revised, but indicators and targets were adapted when additional
financing was provided in 2011 to extend project activities because implementation of the
original project (VAHIP-1) was successful. The second phase (VAHIP-2) had a closing date of
June 30, 2014. The additional financing was from an IDA Credit (SDR 6.2 million, US$10
million equivalent) approved on June 30, 2011, an AHIF Grant (US$13 million) endorsed by the
AHIF Advisory Board on May 31, 2011, and the Government of Vietnam (US$2 million).
1.4 Main Beneficiaries
10. The main direct beneficiaries were in the 11 project provinces. Because the disease threat
does not respect borders, the rest of the country, the region, and the global community benefited
as well. Within the provinces, beneficiaries included the poultry sector, including households
that keep poultry, who comprise a majority of households in rural areas. Other beneficiaries were
persons in contact with poultry who would be exposed to disease risks, (e.g., children, workers
engaged in slaughtering, processing and marketing poultry, consumers shopping at poultry
markets, and cooks). Prevention of disease in poultry would also tend to increase the availability
and affordability of protein (meat, eggs) and thus improve nutrition. Prevention of a severe
influenza pandemic and other infectious disease outbreaks benefited the entire country by
mitigating negative impacts on health, economic activity, and incomes. There were also cross-
border benefits because by controlling disease outbreaks promptly and effectively, Vietnam was
far less likely to export the disease.
11. The main intermediate beneficiaries of the Project were the animal health services in the
Ministry of Agriculture and Rural Development (MARD) and the Ministry of Health (MOH),
including the provincial and district-level departments and staff of these ministries whose
capacities to perform their various functions in infectious disease prevention and control were
strengthened. Staff from these two ministries received a range of training, building stronger
capacity at central, provincial and local levels for project management as well as in technical
competencies.
1.5 Original Components (as approved):
12. World Bank financing5 for the Project’s three components mirrored the government’s
plans, namely: (A) animal health, (B) human health surveillance and response, and (C)
4 World Bank Independent Evaluation Group (2014). Responding to Global Public Bads: Learning from Evaluation
of the World Bank Experience with Avian Influenza, 2006-2013. 5 “World Bank financing” refers to financing for the Project from the International Development Association (IDA),
Japanese PHRD and the AHIF. PHRD and AHIF are World Bank-administered trust fund arrangements. The
4
coordination, monitoring and evaluation, and project management, with close coordination
between the animal health and human health components.
1.6 Revised components
13. Components were not revised during the project life, and there were no other significant
changes in design, scope and scale, and implementation arrangements. Financing was reallocated
among activities as warranted, and several indicators were adapted in 2011 to better support
implementation during VAHIP-2. Such flexibility was foreseen at appraisal since need for
responsiveness to an unpredictable
disease risks would require adapted
response approaches; other projects in
the GPAI had this design characteristic
as well.
14. Figure 1 shows the evolution of
project activities. Initially animal
health services received relatively
more support, but after 2011 the vast
majority of project financing went to
build human public health capacities
overseen by the Ministry of Health.
Close collaboration between the two
sectors was maintained in the entire
2007-14 project period, thanks to
adequate provisions for integration and
coordination. Overall, 34 percent of
the funding was for the animal health
sector, 51 percent was for the human
health sector, and 15 percent was for
project management and coordination
across sectors and levels of
government.
2. Key Factors Affecting Implementation and Outcomes
2.1 Project Preparation, Design, and Quality at Entry
15. The key factors were Vietnam’s leading position in avian influenza control gained from
experience in controlling the disastrous avian influenza outbreaks in 2003-4; the existence of a
global framework and external political and financial support; a robust country-led program with
strong government commitment; coordinated engagement of all partners; emphasis on good
communications; support from senior World Bank management; and a strong World Bank team
responsible for support to preparation and appraisal of the operation. Vietnam’s leadership on
European Commission was the leading contributor to AHIF, which also received funds from Australia and eight
other donors.
5
these aspects substantially influenced the design of the GPAI, which then informed the
preparation of avian and human influenza preparedness and response projects in some 60
countries in all regions.
16. Multisectoral framework and support to country and global objectives. The challenge
posed by the H5N1 avian flu and pandemic threats necessitated a coordinated multisectoral
response. Government plans (the OPI and the AIEPED) set out how multiple sectors and actors
would have to work together and in line with the technical guidance from WHO, FAO, OIE, and
others. The World Bank team provided substantial technical assistance to the preparation of both
OPI and AIEPED to bridge actions across sectors. VAHIP supported this collaboration by
providing adequate resources. The design of VAHIP built also on relevant World Bank
operational experience, including in emergency responses to disasters, the global program to
address HIV/AIDS, the AIERP, and other responses to outbreaks of animal-borne diseases. The
rationale for World Bank involvement was strong not only because of the multisectoral and
global character of the response, but also from the perspective of the country assistance strategy,
which supports risk mitigation so as to sustain the country’s high economic growth and
development achievements. Disease outbreaks, like avian and pandemic influenza, threatened to
undermine progress in this regard.
17. Country-led project preparation and the World Bank’s rapid response. As the AIERP
neared its June 30, 2007 closing date, the government quickly prepared the follow-on plan,
which was informed by implementation experience and the international consensus on avian
influenza control reflected in the GPAI. The VAHIP was prepared and appraised quickly. The
World Bank used both its policy on Rapid Response to Crises and Emergencies (OP 8.00) and an
Adaptable Program Loan (APL) framework to provide financing.
18. Project design. In addition to being based on guidance from the international technical
agencies, the Project aligned to the OPI. The Project monitoring and evaluation (M&E)
framework dovetailed with OPI and thus the government’s monitoring and reporting system. The
design built upon the implementation experience during the AIERP, on the World Bank’s
operational experience in the country, on analytical work done by the Bank and partners on the
role of compensation in animal disease control globally;6 and on the Bank’s in-country working
relationships with UN agencies and other partners. Intersectoral coordination mechanisms were a
key part of the design, not an afterthought. Coordination also benefited from assistance provided
by UNSIC. Such emphasis on systematic coordination was appropriate given the complex
multisectoral challenge and numerous partners involved.
19. Crucial role of communications. The veterinary and human public health components
each included a broad range of communications activities, since control of contagion would
critically depend on the risk awareness and behaviors of farmers, poultry consumers, poultry
traders, government workers, and others. Knowledge, Attitude and Practices (KAP) surveys
gauged the impact of extensive awareness-raising campaigns.
6 World Bank (2006). Enhancing Control of Highly Pathogenic Avian Influenza in Developing Countries through
Compensation: Issues and Good Practice.
6
20. Risk assessment. The major risks identified at appraisal included political commitment,
slow disbursement and procurement, weak provincial-level capacity for project implementation
(especially in financial management), inadequate coordination between the two ministries
concerned, resistance to innovation in MOH, inadequate farm-level surveillance, and increased
virus circulation. These risks were relevant to an evolving disease threat in an environment of
uneven capacity. The mitigation measures were appropriate and proved effective.
2.2 Implementation
21. Consistently strong implementation, contributing to country-wide results. VAHIP was
the follow-on project, in 11 provinces, to a major national emergency response that galvanized
the government and communities. The high cost of inaction in avian flu control – the heavy toll
in the 2004 avian flu outbreaks and associated human infections – was clear to all stakeholders.
The OPI provided a robust and transparent framework for action, coordination, and knowledge
exchange between VAHIP and non-VAHIP provinces. VAHIP introduced some innovations (for
instance in market biosecurity), which were adopted by other provinces. Implementation started
shortly after the effectiveness date and was completed by the VAHIP-2 closing date, without
extensions. There were, however, delays, especially during the early phases in the project, and
procurement and other processing were initially slow (this was not a project-specific problem,
but is common to other projects in the country). Such delays were reflected in conservative
ratings on implementation progress so as to provide incentive to rapid implementation in the face
of the potentially high costs that would arise if the ambitious and comprehensive OPI program
was not rapidly implemented. However, when the project ended, the overall implementation
record was, in retrospect, commendable and achieved highly effective results in an efficient way
(see Section 3. below). Disbursement rates largely mirrored the overall commendable
implementation progress.
22. Intersectoral coordination. MARD implemented Component A and MOH implemented
Component B. An intersectoral committee, chaired by the Prime Minister and receiving support
from UNSIC, provided oversight. Thanks to adequate resources for coordination, strong
leadership from the government, as well as a systematic coordination structure based on the OPI,
there was sharing of information and joint action when warranted. Overall coordination in the 11
VAHIP provinces was assured by MARD during VAHIP-1 and then by MOH during VAHIP-2.
23. Response to the 2009 H1N1 flu pandemic. VAHIP contributed to responding to this
challenge thanks to the concerted efforts to increase preparedness, which was an important part
of the project from its beginning. Though VAHIP preparedness activities were motivated by the
threat of H5N1 avian flu and the severe pandemic that could develop from this particular virus
strain, they were also directly relevant to the response to the 2009 H1N1 influenza pandemic.
The rise in illness in the population put some pressure on health care system, but this was only
temporary as the 2009 H1N1flu pandemic had a short duration and low severity. Preparedness of
health facilities and public health systems was nevertheless tested, with good results.
24. Impact of change in the external environment. International attention to the risk of a
pandemic diminished over the project period, with a marked decline since 2009, when the H1N1
flu pandemic proved to be much less severe than feared. External financing assistance to
developing countries, including Vietnam, declined rapidly in tandem, despite the continuing
7
disease control challenges. Reduced attention and financing have had the unfortunate result of
decreasing external and internal political support for an important risk-reducing multisectoral
activity, where preventative investments continue to fall well short of levels of investments
warranted by the magnitude of the risk. Moreover, a substantial part of the costs of avian flu has
fallen on poor farmers, and reduced international attention only leads to poor farmers bearing an
even greater share of these costs.
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization
25. M&E. The results framework served implementation well overall. Values were regularly
reported, though sometimes with delay, and regular M&E reports were thorough and used in
adapting project activities. Several indicators were adapted during implementation to better guide
monitoring of progress. Thus, to monitor progress toward the objective of “surveillance
activities show improved disease status along the poultry marketing chain”, the initial VAHIP-1
indicator was “number of commercial farms in which freedom from infection was
demonstrated.” By the original target date in 2010, 52 farms were inspected and 23 of them
obtained disease-free certification. Based on epidemiological work, monitoring markets became
a higher priority (though monitoring of farms continued), so a new indicator was substituted
starting in 2011: “percentage of positive samples for H5N1 virus at markets and
slaughterhouses.” Both the initial and the latter indicators were, however, challenging, since
diseases outcomes were beyond the control of the project. Their use was nevertheless important
and appropriate, since it served to focus attention to the critical issues of surveillance for disease
in the poultry supply chain. Another modification concerned indicators to track preparation of
pandemic response plans in provinces and districts. Although plans were prepared by 2010 (the
end of VAHIP-1), fully meeting targets, some of the plans were subsequently assessed as
unsatisfactory by the government. Thus, the targets for preparation of these plans in 100 percent
of provinces and districts were maintained for the end of VAHIP-2. The targets were again met,
but all the plans at the end of VAHIP-2 were of higher quality than at the end of VAHIP-1.
26. Data for a few indicators proved difficult to collect, and the selection and definition of
some of these indicators proved problematic. For instance, the selection of one of the key
indicators – the case fatality ratio (CFR) – did not anticipate that a dramatic drop in human cases
would eliminate the information content of this indicator. Final outcome indicators for infectious
diseases are inherently problematic because of influences beyond the control of physicians or
veterinarians, especially when these diseases are new in the animal or human population.
Moreover, the target value for the CFR was unrealistically too low, well below that warranted by
the inherent virulence of the H5N1 avian flu virus and the values registered in all other countries.
The indicators tracking performance of government capacities were, however, useful in gauging
progress. Utilization of the system-performance indicators in this project is evidence that further
supports the recommendations of the review of avian flu operations by IEG (2014) that greater
reliance on intermediate indicators of system performance is warranted in disease control and
prevention programs.7
7 For disease control and prevention projects, final outcomes are driven by multiple unpredictable factors, making
attribution especially challenging. Intermediate indicators are warranted to guide implementation and to assess
results. See: World Bank Independent Evaluation Group (2014). Responding to Global Public Bads: Learning from
Evaluation of the World Bank Experience with Avian Influenza, 2006-2013.
8
2.4 Safeguard and Fiduciary Compliance
27. The safeguards triggered were for the environment, involuntary resettlement, and for
ethnic groups. Compliance was satisfactory overall. Notably, toward the end of the project
monitoring reports revealed that waste water management and treatment in the large Ha Vy
poultry wholesale market, which was reconstructed under VAHIP, resulted in concentrations of
pollutants in the water that were above the set norms.
28. Environmental safeguards. The project was designated as a category B based on the
environmental impacts of project activities. There was environmental monitoring on the
compliance during the operation of the culling/disposal site and live bird markets, and on small
civil works to rehabilitate and upgrade isolation units and intensive care units. The Operational
Policy and Bank Procedure (OP/BP) 4.01 on Environmental Assessment was triggered, and
consequently an Environmental Management Plan (EMP) was developed to address the potential
impacts in accordance with OP/BP 4.01 and national regulations. The PCUs in MARD and
MOH assigned responsibility for environmental safeguard work under their respective
components to dedicated staff. Reports on EMP implementation were periodically submitted for
review to the World Bank. The requirements specified in the EMP were taken into account and
adequately implemented.
29. A major investment under VAHIP was the reconstruction and improved biosecurity at the
Ha Vy wholesale market near Hanoi where about 1 million poultry are traded annually. There
had been no biosecurity before VAHIP (see Annex 2 photos), with solid and liquid wastes posing
risks to humans and the environment. Under VAHIP, reconstruction and other measures to
improve biosecurity reduced these risks. At the appraisal, major upgrade of the solid and waste
water treatment facilities at the market was not foreseen and included for IDA financial support.
Therefore, during implementation when the need arose it was agreed that the government’s
counterpart funds would finance part of the civil works including the solid waste and wastewater
treatment systems. Monitoring of the environmental standards at the market after the
Government-financed works were implemented showed that the solid waste and wastewater
treatment systems were not designed adequately and environmental pollution by poultry waste
remained. The PCUs proactively carried out remedial actions. Addressing this problem proved
challenging and time-consuming, largely because of the need for full cooperation among the
authorities involved (i.e., the central government, the PCU, the Thuong Tin district government,
the Thang Loi Commune government, and Market Management). By the end of the project,
management issues were resolved: the waste treatment system was rehabilitated, and solid waste
was collected and treated properly. The design for the rehabilitation of the wastewater treatment
system of the live bird market was reviewed by the World Bank and found to be satisfactory. The
rehabilitation of the wastewater treatment system was in the 3rd quarter of 2014, after the project
closing date using the counterpart funds. The output of the wastewater treatment system
improved marketly but still not fully meeting national standards. A larger septic tank is required
and this is planned to be installed in 2015. The challenge of a high and growing volume of
poultry trade in this major market will continue; thus continuing monitoring of the performance
of the wastewater and other systems will be required, to rapidly detect and remedy any adverse
impacts on nearby communities and the environment. This experience yielded a lesson for
similar future projects (see para. 80). The overall environmental performance of the project was
therefore moderately satisfactory.
9
30. Financial management: compliance with policies and procedures. The financial
management function of the Project was in compliance with the Bank’s financial management
policies and procedures. Performance was moderately satisfactory, despite the complicated and
decentralized financial management modalities, which were designed to support the
decentralized project implementation arrangements. Project implementation was managed by
PCUs in MOH and MARD, and in provincial implementing agencies (Provincial Departments of
Health/Preventive Health Centers and Animal Health Departments). The PCUs in MOH and in
MARD served as focal points for Project budget approval, financial reporting, and audit. All
other financial management areas (such as planning and budgeting, contract and expenditures
management, expenditures approval, and accounting records maintenance) were decentralized to
11 provinces with 2 implementing agencies in each (one for the human health component and
one for the agriculture component). The PCUs managed the Project designated accounts opened
at commercial banks, separately for the health and agriculture components. In the provinces,
each provincial PCU (PPCU) also opened a bank account in local currency to receive the Project
funds transferred by PCUs based on the approved annual operational plan. PPCU reports on
expenditures were submitted monthly. The PCU in MOH submitted quarterly interim financial
reports to the World Bank. Financial audit by an independent firm was conducted annually and
was unqualified; and all but one audit reports were submitted to the Bank on time before end of
June of the following year in full compliance with the Financing Agreement.
31. Procurement. Procurement activities have been carried out in accordance with the
respective procurement procedures stated in the Financing Agreement and elaborated in the
agreed Procurement Plans. Where appropriate, the government’s cost norms were used to
economize on project resources. After initial delays, procurement performance improved over
time and was successful overall. This was achieved largely thanks to the shifting of the design
for the animal health component from one that was centralized (and relying on a relatively large
number of international and national consultants) in the initial project period, to managing more
activities at the provincial level. This shift was implemented after the midterm review mission.
Key factors behind the satisfactory procurement performance were the commitment and efforts
of staff of all PCUs and PPCUs. Given the emergency and decentralized nature of the project, the
decentralization of procurement functions from PCUs to PPCUs was a good approach and a
lesson to be applied for similar future projects.
32. Disbursement. Performance in terms of the disbursement rate was satisfactory overall.
Disbursements lagged somewhat during the initial VAHIP-1 period but then accelerated to above
projected levels after 2010. There were no major issues.
2.5 Post-completion Operation/Next Phase
33. With contributions from VAHIP and other projects, the Vietnamese authorities have
improved the performance of core animal health and human health capacities and coordination
between the two systems (see outcomes in Section 3 below). The achievements are substantial,
but there are two concerns. First, in some areas capacity is still incomplete and fragile. At the
same time, risks of zoonotic disease outbreaks are still high; for avian flu, such risks are
amplified by the high volumes of trade in live bird markets. Second, adequate operations and
maintenance budgets will be needed for the veterinary and human public health systems to
perform in addressing antimicrobial resistance and other One Health challenges; in the near term,
10
this is particularly relevant for the laboratories and for the equipment in preventive health care
centers. The ongoing USAID-supported projects addressing emerging infectious diseases and
health security and the IDA-financed Livestock Competitiveness and Food Safety project are
providing some relevant support in this regard.
3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation
34. The Project objectives were clear, relevant, and important to Vietnam’s economy, public
health, and poverty-reduction goals. Though designed as a second emergency operation after the
devastating 2003-4 avian flu outbreaks and in the context of a global emergency response,
VAHIP combined continuation of the emergency response with extensive strengthening of the
veterinary and public health systems by building medium- and long-term capacity. Collaboration
between veterinary and human public health services was deliberately planned and supported,
and this delivered excellent results. Such collaboration will remain critical for prevention and
control of zoonotic diseases. The capacities created by VAHIP are dual-purpose, relevant not
only to a particular strain of avian flu, but to control of other disease outbreaks as well. The
public health system can react better to an introduction of Ebola or the Middle East Respiratory
Syndrome (MERS) into Vietnam, for example, thanks to the preparedness and other
improvements in public health systems that were made in response to the avian flu threat. These
investments supported preparedness at the national, provincial and district levels to respond to
disease outbreak emergencies. Since such outbreaks will continue to occur, the project was and
will remain highly relevant. Veterinary and public health systems need capacity to respond to
outbreaks promptly and effectively, to ensure that contagion does not spread and that substantial
(potentially catastrophic) human and economic costs are prevented.
35. The risk to economies and public health of outbreaks of zoonotic and other infectious
diseases persists and represents a substantial contingent liability on Vietnam’s economy and the
government’s budget. In the future the government will need to resource and coordinate the
veterinary and human public health services to continue to respond rapidly to outbreaks in
poultry (of H5N1 and other types of avian flu such as H7N9), in other livestock, and in wildlife
and to monitor for signs of transmission of zoonotic pathogens (including antimicrobial
resistance) to the human population. The project’s substantial achievements are a valuable
precedent on which the government and its partners can build.
36. Serious new infectious diseases of humans have been emerging steadily over the past 30
years, and this trend is set to continue; notably, 75 percent of the diseases are now zoonotic,
since they originate in animals. Recent examples include Ebola, Middle East Respiratory
Syndrome (MERS), several kinds of avian flu (including H7N9, which caused $15 billion of
damage in China in 2013-14 and infected over 400 humans), and SARS. Though the SARS
outbreak caused 800 deaths in 2003, it also caused $54 billion of economic damage, showing
that the human health toll is far from the only cost of such disease outbreaks. The Ebola
epidemic, too, is having a still-worsening impact on the economies and communities in West
Africa; it may yet spread to other regions. The capacities built under VAHIP provide solid
foundations from which to tackle such disease threats. Improved animal and human disease
11
surveillance systems developed for influenza will allow earlier and more effective detection and
control of outbreaks.
37. Pandemics are infrequent, but the risk is high because of their impact. Capacity for early
detection and control of zoonotic pathogens at their animal source therefore remains an
important goal, with very large benefits because early control will stop exponential escalation of
contagion in the country and across borders. This goal is embodied in the International Health
Regulations (IHR 2005), which Vietnam and all other members of WHO have adopted. Early
detection and prompt effective control reduce risks at the interfaces between animal, human, and
the environmental health – if prompt action does not occur, contagion and associated costs can
grow exponentially and become major crises. Vietnamese authorities have recognized that One
Health approaches are required to reduce these risks: robust veterinary and human public health
systems, with enabled communication and collaboration at the interface between them. Vietnam
has been an international leader in adopting One Health approaches, which were incorporated in
the OPI and the AIEPED.
38. Pandemic preparedness remains relevant to Vietnam as well. A pandemic will occur in
the future; it is not a matter of “if” but “when”. A pandemic is all the more likely because
prevention of pandemics through control of pathogens at their animal source is currently
hindered by pervasive weaknesses of veterinary and human public health systems in most
developing countries. By tackling a threat that does not recognize borders, the project’s
objectives thus remain highly relevant not only to Vietnam, but also from regional and global
perspectives. Reduction of pandemic risk is a valuable global public good.
3.2 Achievement of Project Development Objectives
12
39. The Project achieved its ambitious objectives. It built essential veterinary and human
public health capacities in 11 provinces, and performance of these capacities improved based on
M & E reports. These capacities are required for prevention and control of zoonotic diseases and
those for preparedness to respond to a pandemic or similar public health emergency. By rapidly
and effectively responding to investigate and control outbreaks and other actions, these
capacities already contributed to dramatic and sustained declines in disease prevalence. While
VAHIP supported
implementation of the OPI and
the AIEPED in 11 provinces,
outcomes in these provinces
depended on similar efforts in
other provinces. All activities
were completed by the Project
closing date, which was not
extended. In June 2014, the
national and provincial project
teams came together with their
partners in Danang for a final
project review, to take stock of
the achievements as of the end
of June 2014.
40. Attribution of outcomes.
The main final outcomes
already observed were a
dramatic reduction in disease
prevalence in poultry (Figure 2)
and a large reduction in human
fatalities from H5N1 avian flu
infection (Figure 3). These
trends are equally evident in the
11 project provinces and in the
country as a whole. Attribution
of these successful final
outcomes is at best possible to
OPI and AIEPED, since these programs comprised a coherent set of activities that complemented
and reinforced each other in tackling a problem that does not respect administrative borders. The
substantial strengthening of capacity in veterinary and human public health that was achieved is
a precondition for sustaining such outcomes in years to come.
41. A second attribution issue arises from the inherent uncertainty about the spread and
evolution of a HPAI virus like H5N1. It may be that the virus could have reduced its spread in
Vietnam even if the farmers, poultry workers, the authorities, and the partners had done nothing.
Such a scenario contrasts with the experience in more than a dozen developing countries
struggling with the H5N1 virus becoming enzootic and even causing repeated human cases. This
is still occurring in countries neighboring Vietnam and elsewhere. Based on evidence about the
characteristics of the virus, such a dramatic decrease is highly unlikely without disease control
13
measures, however, especially since the flu virus is always bringing new surprises, according to
virologists. Most important,
however, the downside risk of not
preventing and not controlling
zoonotic outbreaks at their animal
source whenever they occur is very
large considering the exponential
progression of contagion and
infection risks to humans, even in
the absence of pandemics. Reducing
the circulation of H5N1 avian flu
and similar pathogens has been (and
will continue to be) inexpensive
insurance.
42. Risks to both poultry and
humans. The zoonotic nature of
H5N1 avian flu means that the risk
to poultry cannot be neatly
separated from the risk to people,
especially in communities where
people keep poultry and other
livestock un or near their dwelling,
so that humans have frequent
exposure to the avian flu virus and
other zoonotic pathogens but public
health standards are low. Moreover,
when the flu virus originating in
diseased poultry starts a pandemic, people will be rapidly exposed to pervasive health risks as
well as to other shocks. Integration of planned activities across the animal health-human health
interface was a key guiding principle of the Vietnam government’s plans and the GPAI. Close
intersectoral coordination of implementation and integrated monitoring led to integrated
decision-making on reprogramming. This and the inherent connectedness between the risks to
poultry and to people should be kept in mind in interpreting the presentation of the outcomes
below.
43. The impressive achievements of the project are evident in the results obtained toward the
project’s sub-objectives. Five sub-objectives were mainly for animal health, namely:
strengthening of veterinary services, enhanced disease control, disease surveillance and
epidemiologic investigation, preparing for poultry sector restructuring, and emergency outbreak
containment. Four sub-objectives concerned mainly human health: disease surveillance, curative
care, behavior change and risk communication, and the local-level preventive medicine system.
The project devoted deliberate attention and substantial resources to coordination among these
sub-objectives and to monitoring of progress. The achievements are described below.
44. Strengthening of Veterinary Services. The two major aims were strengthening of
veterinary laboratories and strengthening of disease reporting, which covered 144 districts and
14
Figure 4. An example of market upgrading: poultry are
off the ground and regular cleaning is possible (more examples are in Annex 2)
2,686 communes and entailed monthly meetings community animal health workers (CAHWs).
Results were substantial and often exceeded project targets. Whereas not a single veterinary
laboratory met international standards in 2006, there were eight such laboratories by the end of
the project, a major accomplishment that was, moreover, achieved ahead of schedule. There is
now every reason to have full confidence in laboratory test results because tests are being
conducted using testing systems that have been independently accredited. OIE has now accorded
Vietnam its highest rating for the laboratory component of the Performance of Veterinary
Services assessment. Surveillance has improved so that by the end of the project all participating
districts and communes were able to produce reports, with over 97 percent of them providing full
information and using the recommended template. The first PDO indicator, on reporting and
investigation of outbreaks, had high target values to signal the importance of this veterinary
service function (e.g., the target was that 275 case reports of HPAI be fully investigated in the
first 5 months of 2014). Since there were 39 reports of HPAI in this period, this high target
value was not met, although the veterinary authorities did prepare capacity to act effectively in
case there had been more HPAI outbreaks. This improved capacity of the veterinary services
was evident in more rapid response times when HPAI outbreaks did occur (see para. 50).
45. Enhanced Disease Control. The major activities were improvement of the large Ha Vy
live poultry wholesale market near Hanoi (which handles about 1 million poultry annually),
upgrading 42 other markets and 34 slaughterhouses in the 11 project provinces, and construction
of a culling site for holding, humane destruction, and disposal of poultry in the northern border
province of Lang Son to deal with seized poultry smuggled from China. Disease control was
enhanced by use of surveillance data. These data included percentage of poultry traders applying
good biosecurity practices at Ha Vy market and percentage of upgraded markets and
slaughterhouses applying practices according to project guidelines.
46. A range of biosecurity improvements have been implemented at Ha Vy market. Among
these, three specific practices were indicators of the improvements associated with the
reconstruction of the market: (i) keeping poultry for sale on the flooring, (ii) regular cleaning of
selling points, and (iii) cleaning of transport equipment/vehicles before going out of the market.
Starting from a baseline of 25 percent in 2006, all three indicators reached 100 percent by the
end of the project, after uneven progress
during the period as traders were not
readily adopting biosecurity practices
because of their cost. Achieving
behavioral change among poultry
traders was a major challenge, a task
made more complicated by the
increased number of poultry sold
through the market and the need for
payment for cleaning and other services
which was resisted by the traders.
Hence, while the target for this
indicator was met, it is likely that this
will not be maintained on all occasions,
given the huge number of traders
involved. Targets for upgraded markets
15
and slaughterhouses to apply practices according to project guidelines were met as well, reaching
100% by the end of the project; moreover, accomplishments for each year were consistently
ahead of targets.
47. Disease Surveillance and Epidemiologic Investigation. Monthly H5N1 avian flu virus
surveillance activities at Ha Vy market, Lang Son culling site, as well as in 55 other markets and
11 slaughterhouses, were successfully carried out, and 285 outbreaks were investigated.
Provincial and district veterinary staff were trained on outbreak investigation and mapping. The
percentage of positive samples for H5N1 virus at markets and slaughterhouses, with a target of
less than 2% throughout the duration of VAHIP-2, was selected as an overall measure of
improvements in disease control and prevention both in markets and at the farm level within
project provinces. While the indicator was above 2% in 2012-14, this is also a reflection of the
quality of surveillance rather than increased disease prevalence. (Without regular robust
surveillance, disease would not have been detected, which could be misinterpreted as absence of
disease.) A higher prevalence of infection is expected in poultry during the first half of the year,
which coincides with the high-risk Tet Festival period and the cooler winter months, and this
contributes to the high value of 7.7% of samples positive for H5N1 in markets and slaughter
houses for the first half of 2014 (in the same period, the value was 0% in Ha Vy market).
Markets have been modified to markedly reduce the likelihood of becoming persistently
infected. But if infected poultry are brought in to markets and tested, the improvements in
market hygiene will not be apparent from the surveillance results.
48. Surveillance has provided extremely valuable information about the continuing
circulation of avian flu viruses including genetic data and confirmed the importance of measures
in markets to prevent the virus from spreading and persisting. In 2014, only 11 of the 197
positive samples were from the Northern provinces, demonstrating that different risk factors are
present in different parts of the country. This experience confirms IEG findings on the difficulty
with using data on disease or infection status as an indicator, given the confounding factors along
the production and market chains that influence the end result.
49. Preparing for Poultry Sector Restructuring. Studies and training (see Annex 3 for
details) contributed to the capacity of the government and communities to better manage risks
associated with poultry production and marketing, whose rapid growth is driven by increasing
incomes. In 22 districts, 1,760 households received training on biosecure poultry production;
these households then became trainers for others in their communities.
50. Emergency Outbreak Containment. Preparedness was substantially increased thanks to
simulation exercises, training courses on rapid outbreak response, study tours, a communication
program in 367 primary schools involving more than 500,000 students (who in turn
communicated on preparedness to their parents), and equipment and supplies for emergency
response in project provinces. The key indicator chosen was the number of days it took for
suspect outbreaks to be completely contained (quarantine and culling) with a 2-day target.
Responses have progressively become very rapid, with complete containment achieved in less
than 1.5 days. By the end of the project in 2014, it was even possible to do it in less than a day.
This highly satisfactory performance of a key component of the disease control system warrants
particular recognition. It resulted from the training provided in outbreak response, simulation
exercises, rapid availability of the test results from accredited laboratories, changes to protocols
16
Figure 5. Evidence of high risk awareness in paintings by
children (more examples from school-based contests are in Annex 2)
which allowed culling on suspicion, and the excellent leadership of the animal health teams at
the provincial level.
51. Disease Surveillance. VAHIP introduced innovations to the country’s surveillance
system for infectious diseases in humans: shift to considering the village health workers as the
first source of data at the lowest level; private sector, press, and media as an additional data
sources interacting with the district, provincial and national levels; and in line with the One
Health approach, integration of the veterinary centers at all levels, interacting with the Regional
Animal Health Offices (RAHOs), the Pasteur Institutes and NIHE for the confirmation of AI
cases. At the same time, a commune-based online reporting system for infectious diseases was
installed, based on upgrading of existing software developed earlier by the Preventive Health
System Support Project financed by the Asian Development Bank. This was accompanied by
training of several thousand health workers (see Annex 3 for detail). Indicators of timeliness and
completeness of reporting show that the surveillance system is performing well, and performance
targets were exceeded by the end of the project. Extension to other provinces of this type of
surveillance system with online reporting is underway, since compatibility among reporting
systems within the country is important.
52. Curative Care. Provincial
hospitals improved their capacities to
deal with human cases of H5N1 avian
flu and similar acute infections that may
require isolation and intensive care. The
hospital segment of the pandemic
simulation exercise was successfully
developed. For details of the equipment
and training provided, see Annex 3. The
two indicators measured development of
the pandemic preparedness plan by
provincial and district hospitals, an
essential and highly valuable step in
building preparedness. By the end of the
project, targets were exceeded for the 44
provincial hospitals and 124 district
hospitals in the VAHIP provinces: 100%
of all these hospitals have developed
their preparedness plans for an influenza
pandemic.
53. Behavior Change and Risk
Communication. VAHIP included
communication activities for both health
workers and for the general population.
Another important target group were
ethnic minority groups. The coverage
and the volume of the communication
materials produced were enormous:
17
Table 1. KAP survey results on correct knowledge, attitude and practice
toward at least one key preventive behavior (% of target groups)
Target
Group
Aspect
AssessedPHASE 1 PHASE 2
2008 2011 % Relative
Difference2012 Target
2014
2014 %Relative
Difference
Curative
health staff
Knowledge/
Attitudes
87.5 93.1 6.4 92.4 60 100.0 8.2
Practice 91.0 97.2 6.8 74.0 60 86.2 16.5
Preventive
health staff
Knowledge/
Attitudes
74.0 86.5 16.9 84.4 60 96.1 13.9
Practice 100.0 100.0 0.0 82.0 60 88.0 7.3
General
population
Knowledge/
Attitudes
20.8 54.5 162.0 50.0 60 80.0 60.0
Practice 56.4 98.4 74.5 34.0 60 98.8 190.6
20,532 health staff were trained on behavior change communications (BCC) skills, 264,000
posters were disseminated; and 4.2 million leaflets were produced. The range of strategies was
broad and included several types of competitions, which attracted a very large number of
participants. For example, in the provinces of Long An and Tay Ninh, a poster-making contest
among schoolchildren received a total of 18,000 entries (sample entries are in Figure 5 and
Annex 2). An essay-writing contest among adults in Thai Binh attracted hundreds of entries. The
instruments for communications were written (leaflets, handbooks, etc.), verbal (radio and
loudspeaker broadcasts; group discussions, etc.) and visual communication (billboards;
calendars; educational film, etc). Person-to-person communication was used extensively to relay
messages about influenza prevention and control, especially during home visits in communities
with ethnic minority groups.
54. Risk communication entailed development of both writing and oral skills, with 65 and 49
trainees respectively. The project also provided communication equipment, most of it for mass
communication. Notably, the training material on risk communication developed by VAHIP was
recently reviewed and approved by the MOH and recommended for use by academic institutions
and projects conducting training on risk communication. This is the first material on risk
communication to be approved and endorsed for use by the MOH.
55. To evaluate impacts, Knowledge, Attitudes and Practices (KAP) surveys were conducted
among health workers and the general population four times: in 2008 and 2011 for the Phase 1
provinces, and in 2012 and 2014 for the Phase 2 provinces. The results are in Table 1. The
surveys revealed increases in both knowledge and attitudes and in behaviors that are indicated to
prevent infection. The proportion of respondents at the end of the project with such knowledge
and behaviors was above the 60 percent targets set for each of the sub-groups (curative health
workers, preventive health workers, and general public). The target for health workers was,
however, set too
low given their
initial relatively
high level of
knowledge and
protective behavior.
The general
population had the
largest
improvements in
knowledge and
behaviors after the
communication and
training
interventions.
56. Strengthening Preventive Medicine System at Local Level. The training of district level
health staff on communicable diseases, information technology, communications skills, use of
equipment that was provided under the project (see Annex 3), and the conduct of multisectoral
simulation exercises yielded impressive results. The number of District Preventive Medicine
18
Centers (DPMC) that are fully equipped and have capacity to implement their responsibilities
and functions increased dramatically, from just 28 in 2010 to 87 in 2014, above the end-of-
project target of 79. Simulation exercises to build preparedness for outbreak response and
training on planning responses benefited more than 10,000 district-level staff, a significant
achievement in fostering risk awareness and building response capacity at the local level. Post-
graduate training for 90 district-level staff is important in strengthening technical skills at that
level and was an opportunity that is seldom available to staff working at the local levels.
57. Most of the equipment provided has multiple uses since the objective was to strengthen
the district preventive medicine system, rather than to limit equipment to that used for the
management of influenza and similar diseases. The equipment included items which are needed
for other purposes within the core public health functions like reproductive health. A narrow
focus on infectious diseases, or even just influenza, would not have been as effective in building
the capacity of the district preventive medicine system.
58. Multisectoral coordination was a strong feature of the strengthening of the preventive
medicine system (Table 2). The most important activity was conduct of 68 major simulation
exercises involving 15,146 participants, which is highly valuable in building preparedness. In
addition, the project also conducted 24 internal and 3 external experience-sharing activities
where 590 PPCU and district level staff involved in the project visited other provinces in order to
observe their activities and share their
experiences with the various project
components. Local coordination became
more effective thanks to the project
organizing 1,179 workshops involving
29,518 participants. Finally, as part of the
project each of the 11 project provinces
prepared operational guidelines on
multisectoral coordination. This deliberate
and intense effort at building links to
veterinary services and other sectors,
reinforced through multisectoral
simulations of responses to emergencies, is a good practice example.
3.3 Effectiveness and Efficiency
59. The project was exceptionally effective because it produced large economic and health
benefits at a very modest cost. This achievement is all the more notable because it occurred
despite the challenges of an inherently complex and largely unpredictable zoonotic disease
threat. The project tackled an emergency (since major renewed outbreaks were possible) and, at
the same time, made lasting systemic improvements to animal and human public health systems
in 11 provinces. Both of these actions are highly productive investments and an excellent value
for money. The project was highly efficient at the conceptual level, since it tackled a potentially
major threat to human health (widespread infections with H5N1 avian influenza or even
emergence of an influenza pandemic) by reducing contagion at its animal source. Infectious
disease control is far less costly when done early and at the source, because contagion and costs
of containing it can grow exponentially. Containing contagion in poultry is possible at a fraction
Table 2. District-level preventive and curative capacities
performance targets were exceeded
INDICATOR ACTUAL2014
TARGET2014
% DIFFERENCE
Percentage of districts which implemented the revised policy for preventive medicine 80 75 6.7
Number of PPMCs in 11 project provinces fully equipped and have adequate capacity to fully implement their responsibilities and functions in compliance with the MOH decision
87 79 10.1
Number of multisectoral simulation exercises conducted and reviewed at district levels in the project provinces
68 37 83.8
Number of health staff who have been trained 69012 21905 215.1
19
of the cost of containing it once it spreads in the human population. The deliberate One Health
approach was thus the most efficient choice. Moreover, it was also humane, since human cases
did not serve as sentinels of a poultry disease, as was seen in other countries. The project also
used efficient implementation methods, to lower costs and to generate additional productive
outputs with the savings.
60. VAHIP investments (and similar investments in other provinces under the OPI and
AIEPED plans) produced high economic benefits, far above the cost of the investments, and will
continue to do so if the public health capacities created under OPI and AIEPED are maintained.
The analysis in Annex 3 finds that annual spending $77 million on building and operating
veterinary and human public health systems8 would yield an expected annual benefit of $105
million (assuming that future prevented outbreaks and reduced pandemic impacts are just one
tenth of the high-impact outbreaks in 2004). The calculation conservatively assumed that a
severe flu pandemic occurs seldom: once in a hundred years. Therefore the annual risk (expected
value of costs) is just 1 percent of the impact of the event once it happens. Clearly, when
economic benefits exceed costs every year (and do so by a wide margin), these public
investments should have been made, were highly effective, and significantly increase the total
economic resources of the country for years to come.
61. The economic rate of return on the investments is very high and such high net benefits
would by themselves more than justify a highly satisfactory rating for overall outcome. Annex 3
presents the calculations, which assumed that disease risk was not reduced in the first 5 years of
the project, so there were only investment costs in that period. Benefits were thus assumed to
start only in year 6. With these conservative assumptions, the rate of return on the OPI and
AIEPED investments in disease control and prevention is 29 percent annually in real terms. If the
disease risk is reduced by 20 percent from the 2004 value (instead of by only 10 percent), the
expected rate of return is 129 percent annually in real terms. These highly positive rates of return
reflect the very large economic benefit to the country, and are well above the returns on other
public investments. Additional benefits accrued to the rest of the world, from a reduction in
pandemic risk. While these benefits are certain, their valuation is not possible because the shares
of Vietnam in the global avian flu “virus load” before and after VAHIP are unknown. National
benefits alone, however, more than justified the investments. These high rates of return are
consistent with global experience and with the findings of a recent Lancet commission on health,
headed by Harvard University professor Lawrence Summers (Box 1). When an outbreak occurs,
costs can escalate very rapidly so having robust public health systems to prevent preventing the
escalation because they are prepared pays off very well.9
8 This is equivalent to the average annual amount spent during the OPI and AIEPED periods.
9 Most countries neglect public health systems and do not make investments in preparedness. Experts advised
Guinea, Liberia, and Sierra Leone to invest $26 million in disease detection and disease outbreak control
preparedness, during an assessment of preparedness in 2007. These investments were not made, and public health
systems for disease outbreak control remained weak. The Ebola outbreak in West Africa could have been stopped in
March 2014 for less than $200 million. In August, this estimate was $1 billion. At the end of October 2014, the
estimate of cost to stop the outbreak was $4 billion (and rising). In addition, the people of Guinea, Liberia, and
Sierra Leone are hard-hit by disease, food insecurity, loss of jobs, and other disruptions, while their and neighboring
economies suffer. This is a recent stark example of the high costs of weak health sector policies, which are too
common. Unlike Vietnam under VAHIP, most developing countries neglect public health systems for disease
outbreak control.
20
Box 1. The single most important area for productive investment
Harvard University professor and former US Treasury Secretary Lawrence Summers said
that, because pandemic risk is high:
"[veterinary and human public health systems are] probably the single most
important area for productive investment on behalf of mankind."
Source: Video of high-level panel on health, World Bank, April 11, 2014, www.worldbank.org/pandemics
62. Efficiency was evident throughout implementation, to an impressive degree. The project
adopted approaches that generated outputs in a low-cost way. Communications activities
mobilized tens of thousands of communicators at very low cost. For example, in school-based
activities teachers, at minimal additional cost, helped organize a contest for school children, to
paint scenes about avian flu control. The children produced remarkably well-informed images,
showing emotional grasp of the complexities of a zoonotic disease. The children and their 18,000
evocative images conveyed the messages at low cost and far beyond the classroom, to the
families and communities. VAHIP implementation staff also adopted inventive low-cost
solutions that mobilized resources from local and provincial governments, as well as from
organizations and communities. Another cost-efficient approach was to adopt government cost
norms for many activities (rather than higher norms, like those used by some donors), which was
an important efficiency measure, given the numerous programs of training, workshops, and
consultations among provinces. Another illustrative instance was decision to not pay for new
customized software, but rather to generate savings by adapting surveillance software from an
Asian Development Bank-financed project. This lowered costs overall, without reducing
effectiveness and timely availability of the resulting “hybrid” system.
3.4 Justification of Overall Outcome Rating Rating: Highly Satisfactory
63. The Project was and remains highly relevant. It more than achieved the project
development objective of strengthening public health capacity to respond to H5N1 flu outbreaks,
preparing for pandemic influenza and other infectious disease outbreaks, and more generally
building systems for disease prevention and control, especially at district level. The outcome
stands out as unambiguously highly satisfactory within the country and project parameters:
extraordinarily high economic and health benefits were generated by modest investments in
successful emergency operations and in building (and testing) core public health systems. While
modest, the investments were challenging technically and managerially – and these challenges
were met in a way that has been, and can continue to serve as, an example to follow in other
countries. The outcomes in building public health systems are also well above the results
achieved by most other developing countries, where public health systems are weak and
chronically neglected. The Chairman of the Lancet Commission on Health stressed that this is
the area for the most productive investments on behalf of mankind; VAHIP was unambiguously
such an investment that should be replicated widely.
21
64. The project was aligned to the government’s plan and country systems. The development
outcomes were substantial as reflected not only in the very high economic returns but also in the
high achievement rates for the outcome indicators measuring public health system performance.
Targets for many indicators of system performance were surpassed (Table 3). The systemic
capacity improvements were not only done in a relatively brief span of time, but they are also a
much too rare instance of proactive investment in public health systems where the expected
economic returns and impact on population health status are higher than for other public
investments.
Table 3. Project outcomes: nearly all targets surpassed or met
Number of indicators that: Project key
indicators
Indicators of
performance of
veterinary and
human public
health systems
Other intermediate
outcome indicators
(e.g., training, risk
awareness)
Share of all project
indicators
Surpassed target 1 9 2 71%
Fully achieved target 1 1 1 18%
Partly achieved target 1 6%
Target not applicable 1 6%
65. Vietnam showed consistency over a decade in investing in disease prevention, which is
grossly neglected in most countries. Unlike the vast majority of developing countries, under
VAHIP Vietnam succeeded in implementing a health sector policy that is superior to, and far less
costly than, coping with the aftermath of lack of prevention. It is a tribute to the commitment and
sound policy-making of the Vietnam government that the investments in public health systems
were pursued despite growing apathy and neglect among the international community.
Moreover, the overall rating of highly satisfactory is justified by: effective and increasingly swift
responses to outbreaks in poultry, strong improvement in surveillance and reporting of diseases
(including fast turn-around times), upgrading of a large number of preventive health care centers
at local level to meet standards, decision to use project flexibility to expand the use of highly
productive simulation exercises, success of the information and education campaigns, adequate
and timely compensation for culled poultry, a range of biosecurity measures, and exemplary
leadership in sharing knowledge on One Health approaches and avian flu control globally.
Finally, the highly satisfactory overall outcome rating is justified by the remarkable results in
diagnostics capacity and management; these results were recognized by the international
certification of 8 laboratories within a short time span. This is a world-class achievement that
very favorably contrasts with the mismanagement of biosecure laboratories in many other
countries. Finally, the project had no shortcomings.
3.5 Overarching Themes, Other Outcomes and Impacts
66. Poverty impact and gender aspect. H5N1 influenza outbreaks initially affect the poultry
population. But, if not contained, they could directly and indirectly affect the majority of the
human population of the country since nearly all rural households and some periurban
households raise poultry. Among the poor, poultry often live in or very close to the family
dwelling. Poultry is often traded in live-bird markets by women, and raised by women and
22
children (who may thus be most exposed to the virus both in poultry and in poultry droppings);
children tend to suffer the most if the availability of affordable protein declines when large
numbers of poultry die due to disease. Repeated large outbreaks of avian influenza in Vietnam
would thus have devastating impacts on the poor (see Annex 3 for results of a study of
distributional impact). Since small disease outbreaks were promptly controlled and large
outbreaks did not occur at all (in part thanks to control of small outbreaks), the poor benefited.
The Project contributed as well to prevention of pandemic influenza (to an unknowable extent)
and to preparedness. A pandemic would hit the poor the hardest, in Vietnam and elsewhere.
Preparedness to mitigate the impact of this potentially catastrophic shock thus has an important
pro-poor bias; this benefit will be realized when a pandemic occurs.
67. Social development. Without the Project, the spread of H5N1 flu would have been more
likely. A severe pandemic could have occurred instead of, or in addition to, the 2009 H1N1
pandemic. In those events, the entire population of Vietnam would have been affected, possibly
with severe economic and social disruptions and increases in poverty, as mentioned above. The
project created capacity that will help prevent such potentially devastating impacts on the entire
society. The pandemic response plans and use of simulation exercises under VAHIP are
important in this regard. Plans will need to be periodically exercised through simulations and
updated as warranted for the expected benefits (mitigation of pandemic impact on society and the
economy) to materialize.
68. Institutional change/strengthening. The Project contributed substantially to
strengthening animal health and public health systems and, notably, to collaboration between
them. There was significant progress, notably, at the provincial and district levels and in skill-
acquisition by a large number of local-level staff. Collaboration between human and animal
public health services was largely successful, which augurs well for future joint work. Such
collaboration is critical in detecting, reporting, investigating, diagnosing and effectively
controlling zoonotic diseases which are, and will remain, a significant threat in Vietnam and in
neighboring countries. Strengthening of the laboratories and improved management has achieved
capacity that meets rigorous international standards.
69. Other unintended outcomes and impacts (positive and negative). The focus was on
influenza in poultry and humans. However, the systemic improvements can and should be
deployed against other threats. Antimicrobial resistance is already a significant problem; better
surveillance (using the systems improved under VAHIP) in both livestock and humans is already
an urgent need. Pandemic plans, stocks of PPEs, training on infection control, and the many
outbreak response simulation exercises that were carried out put Vietnam in a stronger position
to effectively deal with any imported Ebola cases. Strengthening of preparedness through
planning and simulations will continue to be highly productive, considering the low cost.
4. Assessment of Risk to Development Outcome Rating: Moderate
70. The improvement in performance of veterinary and human public health systems in the
11 VAHIP provinces has been dramatic. Now these systems, and those built in the rest of the
country thanks to the OPI and AIEPED, will need to keep pace with Vietnam’s rapidly growing
economy and popular aspirations for better health. If the performance of the systems worsens (or
23
does not improve sufficiently), the country will be vulnerable to reversal of its development
gains and possibly devastating spread of disease. Such adverse shocks can undo years of
development progress; public health systems are required to deliver the core public service of
protecting the population and the economy from such shocks. The government will require
financial and technical assistance for further development of capacity in disease control and
prevention (including not just avian flu, but also other zoonotic diseases, antimicrobial
resistance, and other One Health challenges). It will also need to give a high priority to the
operations and maintenance of the systems that have been built and improved.
71. It will be difficult to meet the twin challenges of operating the systems already built (and
preventing their erosion) and further increasing veterinary and human public health capacities.
The ongoing AIPED (2011-15) addresses One Health issues, such as influenza and other
zoonotic diseases and food safety. Since 2003, Vietnam has mobilized considerable internal
resources and also received external support from donors that was often above the envelopes
normally available for Vietnam. The significant decline of attention and financing since 2009 has
created a sustainability issue. The government has a contingency in its budget for responding to
disasters. The two ministries’ regular operating and investment budgets (financed by domestic
and donor funds) will have to make adequate allocations for sustained strengthening and
operations of core animal and human public health functions. Ensuring adequate budgets to
sustain and further increase performance standards should remain a priority because of the large
positive economic and health impacts of these expenditures.
72. There are two major risks to the sustainability of the public health systems and the
services they need to deliver to sustainably improve health and economic growth. First, external
assistance has declined and is highly uncertain since strengthening of animal health systems is
not a priority for donor financing. Human public health systems are a low priority in donors’
health sector programs (relative to curative health care). Neither WHO nor OIE have resources
for adequate technical assistance that is needed to carry out authoritative assessments of core
public health capacities for outbreak disease control and prevention, subsequent prioritization of
investments, and definition of other measures to help countries achieve veterinary and human
public health systems that meet international standards. Second, domestic resources for the
operations and maintenance of the public health system capacities may be difficult to mobilize as
well, if Vietnam follows the pattern common in many countries of low health sector interest in
prevention of disease outbreaks, such that funding for prevention usually only materializes
sporadically, after devastating disease outbreaks that occur precisely because of the weak public
health systems.
73. The rating on Risks to Development Outcome suggested by the above could be
“Substantial.” The rating is, however, “Moderate”, for three reasons. First, there is evident
commitment to ensuring operations of high-maintenance capacities like the laboratories, district
preventive health care centers, and surveillance systems. Second, Vietnam has established a
remarkably successful public health system strengthening record, using an approach which has
already served as an example to other countries dealing with zoonotic disease threats. Finally,
Vietnam has a strong record of making sound economic development choices and implementing
policies that benefit the country. Robust veterinary and human public health systems are
unambiguously among policies that are good for economic growth, as well as for health security.
24
5. Assessment of World Bank and Borrower Performance 5.1 Bank
(a) Ensuring Quality at Entry Rating: Satisfactory
74. The Project was prepared rapidly as an emergency operation by the Vietnam government
with support from a strong team from the World Bank, comprising diverse specialists, operation
officers, and an advisor—all with technical skills necessary to guide project design. World Bank
team benefited from collaboration with FAO, WHO, US CDC, UNSIC and other experts who
were actively engaged in the response to the H5N1 flu threat. World Bank support to the
government in preparing the government’s plans (the OPI and AIEPED) was effective and
appreciated by counterparts. The project, in turn, aligned very well with these plans. World
Bank support to project preparation was also informed by the GPAI, which embodied
international best practice and was, in fact, substantially based on Vietnam’s successful
experience in the initial phases of controlling the disease in 2003-2006. The internalization of
this experience by the project team, and incorporation of such best practice into the VAHIP
ensured that quality at entry was highly satisfactory. The mitigation plan for addressing critical
risks was sound and relevant. The rating would be Highly Satisfactory if it were not for the
sharp reduction of the World Bank’s support to the global program during the VAHIP-2 period.
From 2010 when the Human Development Network (HDN) took over responsibility for the
global program (including operations ongoing in 30 countries at the time), engagement of the
Bank in the global program declined sharply and thus made inadequate contributions for global
risk communications, global coordination, and advocacy for preparedness and prevention.10
Since Vietnam was contributing to an important global public good (as well as generating
national benefits), this gap in World Bank support sent unfortunate signals about a dramatic
decline in interest of the global community in pandemic risk reduction.
(b) Quality of Supervision: Rating: Satisfactory
75. The task team was multisectoral and provided effective and well-coordinated
implementation support, with relentless follow-up on the details of implementation of the
numerous and diverse activities in 11 provinces. The decentralized structure of the project
required engagement with counterparts who were not familiar with implementing World Bank-
financed projects. It is a testament to the commitment and inventiveness of the World Bank’s
multisectoral team that ambitious targets were achieved and many were exceeded, despite the
complex multisectoral challenges and decentralized implementation. Environmental issues were
resolved satisfactorily thanks to the team’s support. Since most of the supervision activities were
conducted from the World Bank’s country office, a continuous and intensive effort was possible,
with implementation assistance to the provincial levels. The financial management and
procurement teams were continuously engaged in supporting project activities. Likewise, the
social and environmental safeguards specialists assisted with achieving compliance and
participated in reviews. All activities financed by the World Bank were completed successfully
without the project being extended. In their comments, government counterparts specifically
appreciated Bank flexibility during implementation and the contributions of the Hanoi office-
based team (Annex 5). The strong performance of the task team in providing implementation
10
World Bank, Independent Evaluation Group (2014).
25
support was all the more commendable in view of the World Bank’s weak institutional
incentives for effective operational work that spans multiple sectors.
(c) Justification of Rating for Overall Bank Performance: Rating: Satisfactory
76. Strong World Bank performance during the preparation phase (which entailed support to
formulation of the OPI and then the AIEPED, preparation of a robust multisectoral framework,
alignment to a global program, coordination with partners around a country-owned plan, and an
emergency response with rapid processing) was followed by the team’s relentless attention to the
details of implementation in two major sectors and consistently high and successful coordination
effort in the supervision phase. This exemplary performance offset the gaps in advocacy and
other institutional support and warrants an overall Bank performance rating of Satisfactory.
5.2 Borrower Performance
(a) Government Performance Rating: Satisfactory
77. The project achieved or surpassed all relevant outcome targets. Equally important, nearly
all interim targets were met during implementation and many were exceeded. The veterinary
and human public health systems at provincial and district levels significantly improved their
capacity to perform and deliver core public health services to the country, including for:
surveillance through support to CAHWs, biosecurity, communications on animal diseases to
health care workers, farmers, traders, and others, rapid response to infectious disease outbreaks,
hospital care for the treatment of highly pathogenic diseases, and speed and accuracy of
laboratory testing. The government formulated plans for pandemic response in the health sector,
in other sectors, and across ministries and levels of government; these plans were tested in
numerous simulations, which is a significant result. Vietnam made a timely and substantial
contribution by showing global leadership in the adoption of One Health approaches in
controlling zoonotic diseases at their animal source. The government mobilized to effectively
share its knowledge with the international community on the occasion of the international
ministerial conference on animal and pandemic influenza in Hanoi in 2010. This contribution
was beyond that envisaged in the OPI and AIEPED (or the VAHIP) and added substantial value
to global efforts against the pandemic threat. Commitment to building public health systems is
extremely difficult to sustain, as shown by the common neglect of these systems in most
developing countries. This neglect is highly costly, as evidenced by the ongoing Ebola crisis (and
similar crises to come). The government’s sustained commitment to prevention over a decade is
by itself sufficient grounds for a satisfactory rating.
(b) Implementing Agency or Agencies Performance Rating: Satisfactory
78. As noted above, VAHIP was developed and implemented by MARD, MOH, and other
departments of the government and implemented in a decentralized way. The difficulties created
by a complex project with decentralized implementation were effectively addressed and
overcome thanks to exceptional commitment to improving veterinary and human public health
capacities and openness to innovation. For instance in financial management, VAHIP yielded
valuable lessons for similar future projects. There was strong and highly beneficial engagement
from the People’s Committees, which contributed critical support (for instance for whole-of-
society multisectoral simulation exercises) and also provided tangible assets such as buildings at
the provincial and district levels. VAHIP achievements were facilitated by their commitment and
26
implementation competence. Moreover, implementing agencies made adjustments flexibly,
supported deliberate and successful coordination across sectors at central, provincial and district
levels, and exploited opportunities for additional efficiencies, to stretch the limited resources
available to produce additional results. When the monitoring of environmental impacts showed
problems, the PCU and relevant government departments sought to remedy problems
proactively.
(c) Justification of Rating for Borrower Performance Rating: Satisfactory
79. VAHIP achieved excellent results as a multisectoral project because of strong
government leadership and commitment from the two ministries responsible for implementation.
It was implemented in a significantly decentralized way. The difficulties created by a complex
multisectoral project with decentralized implementation in 11 provinces were effectively
addressed during implementation and overcome thanks to exceptional commitment to improving
veterinary and human public health capacities and openness to innovation. Building the
veterinary and human public health capacity that is required for ensuring high economic and
health benefits within Vietnam and going beyond the project to contribute knowledge to the
global community more than offsets the record in the ISRs of moderately satisfactory ratings of
implementation progress during much of the project period. Altogether, a satisfactory rating is
therefore amply justified.
6. Lessons Learned
80. The following lessons can help inform future programs that build veterinary and human
public health systems for prevention and control of diseases.
An emergency is an opportunity to reduce risks over the medium term. This will help
prevent future costly emergencies. VAHIP was launched in the wake of a major disaster
caused by the 2003-04 avian flu outbreaks and in the context of an unprecedented global
emergency response to a pandemic threat. Vietnam successfully seized the political support
and resources that were mobilized to implement its comprehensive and integrated veterinary
and human public health plans at national, provincial, and district levels. Impressive progress
was made in building a wide range of capacities, such as the outstanding improvement in
animal health laboratories. There is no doubt that thanks to the government’s and donors’
attention to development imperatives (a functioning public health system is essential to
reduce risks to development), performance of the systems needed to prevent and control
zoonotic diseases and similar public health threats has improved, which will bring large
benefits for years to come. Investments in capacity to tackle zoonotic diseases at their source,
including continuing training on biosecurity, strengthening livestock and wildlife
surveillance, communications, and rapid response teams, will substantially lower the costs of
future emergencies and save human lives.
One Health approaches are effective in disease control and prevention. This recognition
grew out of implementation of VAHIP and the concerted coordination between MARD and
MOH in dealing with a dangerous zoonotic pathogen. In view of the benefits of a
multisectoral approach to disease control and prevention in Vietnam, the government hosted
a week-long workshop on One Health approaches for participants from 25 countries ahead of
the Hanoi Ministerial Conference on Animal and Pandemic Influenza in April 2010,
27
providing valuable guidance on implementation of One Health approaches to Ministerial
delegations responsible for animal and human public health in 71 countries.
One Health approaches are feasible when there is good leadership. Overcoming barriers
between the veterinary and human public health services was challenging. It was possible
thanks to deliberate institutionalization (signing an interministerial circular and a
memorandum of understanding and setting up coordination mechanisms and operational
guidelines at all levels). This enabled joint planning and evaluation of results as well as
sharing of information and other resources and conduct of joint activities, where warranted.
The impetus of an emergency situation and interest from senior leaders, technical teams,
agencies, and partner countries help facilitate coordination as well.
Behavior change takes time and resources. Poultry market traders only started adopting safe
behaviors when they understood and accepted the rationale. Working with traders to solve
management problems of the large Ha Vy market was essential and lasted longer than
initially planned.
Upstream attention to environmental impacts helps prevent problems. Technical review of
the design of environmental protection works (such as solid waste and wastewater treatment
systems) should be included from the beginning of project implementation.
Transition from emergency response to systemic improvements is important. Transition to
medium-term system strengthening was envisaged in the OPI and the AIPED and was
successful. This is a solid basis to sustain progress, which will help Vietnam reduce threats
from infectious diseases and similar conditions, such as antimicrobial resistance. Notably,
chronic under-resourcing of veterinary services has not yet been fully overcome and further
substantial investments are warranted. The approach of early disease control at the animal
source is a precedent for public health system capacity-building for prevention of other
zoonotic diseases and similar conditions.
Successful market upgrades. Lessons from slaughterhouse and market upgrades under
VAHIP will be useful in further efforts to reduce disease transmission in similar facilities in
the rest of the country.
M&E indicators. Final outcome indicators (such as disease prevalence and the case fatality
ratio) are by themselves not sufficient to evaluate progress and thus may be misleading. They
need to be complemented by measures of system performance for functions that are required
for disease control and prevention. VAHIP chose useful indicators of “intermediate”
outcomes. Looking ahead, independent assessments of veterinary and human public health
systems according to the methodology and benchmarks established by WHO and OIE can
serve as robust measures of performance, on which the government and its partners can rely.
Technical definitions are critical for M&E. A key lesson was that what constitutes “suspect
cases” of H5N1 avian flu disease in poultry needs to be unambiguously defined for all types
of enterprises and flock sizes. When some communes, districts and provinces use different
definitions, it is exceedingly difficult to aggregate outcomes, compare among locations, and
devise appropriate responses.
Use of consultants. External expertise was essential for the highly technical task of
improving laboratories and their management. Laboratory quality management expertise
from the Australian Animal Health Laboratory had highly satisfactory results. In other areas,
28
too, technical consultants provided good value, especially when they were able to regularly
provide inputs to project management.
Decentralized implementation. This was both necessary (because disease control and
prevention activities occur in numerous districts and villages) and challenging (because local
capacity was uneven and alignment with national policies and programs was required).
Successful implementation required investment in decentralized functions for
implementation and in coordination. These were resources well-spent. Provinces and districts
identified their own needs, procurement plans, and training plans. This improved
implementation performance and reduced demands on the central project management units.
Financial management with decentralized activities. Important lessons were learned. First,
decentralization of activities to provinces and districts helped to increase their capacity in
Project management and also their ownership of implementation of Project activities. The
human resource capacity built up by the Project at the decentralized levels will be available
after Project closing and is a very good resource for the Government to implement similar
activities. Second, close interaction of the PCUs with PPCUs and supervision of the PPCUs
by the PCUs (especially the MARD PCU), enhanced the quality of the financial reporting
function at the local level, reduced mistakes, and reduced errors in use of funds. Third,
comingling of funds from IDA, AHIF, and PHRD was efficient and reduced transactions
costs for the government. Although donors often apply separate cost norms and financial
management procedures, in this Project all the funds were pooled as one source and treated
equally.
Engaging stakeholders beyond MOH and MARD. The provincial political authorities
(People’s Committees), were formally involved in VAHIP. Their contributions to
multisectoral simulation exercises were indispensable and highly successful; they also
provided other substantial assistance, such as funds, land and buildings. Mobilization of
organizations of students, youth, women, farmers and ethnic minorities was part of the IEC
outreach. This helped create pools of community-based educators that could convey
knowledge to their friends and neighbors about avian flu risks and behaviors to reduce them.
School-based IEC proved very successful, with children becoming knowledgeable about
poultry disease and pandemic risk and about ways to prevent infection.
Training health workers on communications, especially risk communications. This helped
extend messages to communities and improved infection control in health care facilities.
There is opportunity to substantially increase the reach of this training by involving more
health workers. Moreover, such training needs to be periodically repeated.
Rule to balance expenditures on training and equipment in health care centers. The use of
the 30-70 rule (30% training, 70% equipment) proved helpful in guiding decisions at the
district level. The rule aims to avoid waste entailed in unused or abused equipment.
Quality of supervision and implementation support. Substantial implementation support
was instrumental to the success of this technically complex, emergency, and multisectoral
operation. Government comments highlighted this aspect as well.
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners
(a) Borrower/implementing agencies
29
81. Comments and suggestions made by the PCUs of MARD and MOH are presented in
Annex 5, together with corresponding responses, and alongside recommendations from the
government’s ICR for reducing avian influenza and other zoonotic disease risks in the future.
(b) Partners
82. The Implementation Completion and Results (ICR) mission benefited from discussions
with WHO, FAO, USAID, US CDC and the European Commission about their views of the
implementation and outcomes of VAHIP.
83. FAO and WHO had been actively engaged in the response to avian influenza but their
activities have declined when funding ended. Based on the experience and outcomes of VAHIP,
FAO considered that collaboration on animal health with WHO and with MOH will essential in
the future. Since the European Commission’s (EC) response to avian flu response was managed
from Brussels, the EC delegation in Vietnam was not directly involved in supporting VAHIP,
though their overall impression is that it had been a valuable initiative. USAID’s ongoing
projects related to zoonotic risks have been greatly reduced from previous levels and are now the
only major externally-funded activities addressing these issues.
30
Annex 1. Project Costs and Financing
(a) Project Cost at Appraisal by Component (in US$ million equivalent)
Components VAHIP-1
2007-10
VAHIP-2
2011-14
Total
2007-14
A. Animal Health 17.2 4.31 21.51
B. Human Health 16.0 16.28 32.28
C. OPI Integration & Coordination,
Results M&E, and Project Management 4.8 4.41 9.21
Total Project Costs 38.00 25.00 63.00
Total Financing Required 38.00 25.00 63.00
(b) Financing
Source of Funds Type of
Financing
Appraisal
Estimate
(US$ million)
Actual/Latest
Estimate
(US$ million)
Percentage
of
Appraisal
IDA credit 30.00 30.00 100
AHI Facility grant 23.00 23.00 100
PHRD trust fund grant 5.00 5.00 100
Government budget 5.00 5.00 100
Total 63.00 63.00 100
31
Annex 2. Outputs by Component
84. This section is based on the government’s project completion report, presentations at the
final VAHIP workshop, and the World Bank’s Implementation Status Reports. To achieve
the objective of the project, VAHIP had to deliver inputs and intermediate outputs in 11
project provinces (Figure A2.1), which can be categorized into four major areas, namely:
a. Civil works (e.g., upgrading
of waste treatment systems,
improvement of Ha Vy
Market near Hanoi,
improvement of other
smaller markets and
slaughter houses, and
upgrading of isolation wards
of provincial hospitals);
b. Tools and technology
(computer hardware and
software; upgrading of
veterinary laboratories to
meet ISO standards;
laboratory, hospital and
communication equipment
for provincial and district
hospitals, provincial and
district preventive medicine
centers, and some of the
provincial IEC centers);
c. Capacities (technical
support, training of
veterinary laboratory staff,
animal and human health
workers in quality
management, surveillance,
prevention, control,
detection and management
of infectious diseases,
behavior change and risk
communication; training of
specific sub-groups of the
general population on
prevention and control of
avian influenza and other
infectious diseases, on behavior change, and risk communication; and
Figure A2.1. The eleven VAHIP provinces
32
d. Approach (One Health, strengthening the sub-national level with focus on districts and
communes).
These inputs resulted in outputs, which in turn contributed to the project’s outcomes. The major
outputs produced by each project sub-component are presented in the following sections.
85. Sub-component A1: Strengthening of Veterinary Services. Among the outputs were:
- Supply of laboratory equipment required to perform testing for avian influenza viruses,
including appropriate real time polymerase chain reaction equipment;
- Calibration of major equipment; training in calibration for minor equipment (pipettes, etc.) for
national, regional and some provincial laboratories, including certification of trainees;
- Organization of proficiency testing for nine veterinary laboratories with the national Center
for Veterinary Diagnosis (NCDM) providing the samples for testing. NCDM is also applying
for accreditation for this purpose;
- Installation of a novel waste-handling system at the laboratory in Vinh;
- Regular meetings of staff in the laboratory network to discuss important issues in common
and to share experiences on quality management;
- Establishment of a Quality management and Safety Board in each laboratory and conduct of
regular (quarterly) meetings of the Board;
- Employment of contract staff in laboratories to ensure sufficient trained manpower was
available to perform all testing; and
- Testing of more than 200,000 samples.
86. Another important activity was improving disease reporting, which covered 144 districts
and 2,686 communes. It involved monthly meetings with community animal health workers
(CAHWs). All participating districts and communes were able to produce reports, with over 97%
of them providing full information, using the recommended template.
87. Sub-component A2: Enhanced Disease Control. There were three main civil works and
infrastructure improvement activities under this subcomponent. Examples are shown in Figures
A2.2 and A2.3). First, a major activity was the improvement of the Ha Vy wholesale poultry
market near Hanoi. The outputs included:
- Planning and construction of the market;
- Liaison with traders to implement behavioral changes;
- Provision of equipment and materials to improve the hygiene and biosecurity of the
market;
- Provision of technical advice on upgrading the market and market management; and
- Installation of waste treatment facilities.
Second, upgrading of 42 other markets and 34 slaughterhouses, thanks to the following:
- Support of minor capital works including waste handling;
- Assistance in market design and management;
- Provision of equipment for cleaning and disinfection;
- Training of market stall holders on biosecurity and hygiene; and
- Employment of market managers.
Third, a culling site for holding, humane destruction, and disposal of poultry was constructed in
the northern border province of Lang Son to deal with seized poultry smuggled from China.
33
88. Sub-component A3: Disease Surveillance and Epidemiologic Investigation. The
major outputs were:
- Monthly (A)H5N1 virus surveillance at Ha Vy market, Lang Son culling site as well as
in 55 other markets and 11 slaughterhouses;
- 285 outbreaks investigated; and
- Training on outbreak investigation, disease reporting, and mapping.
Figure A2.3. Examples of improved markets
Figure A2.2. Little or no biosecurity before improvement of markets
Ha Tinh and Dong Thap markets before VAHIP
Ha Vy market
before VAHIP
34
New biosecure features in Dong Thap market. Poultry are off the
ground, and surfaces can be cleaned and disinfected more easily.
Separate space for slaughtering poultry at Dong Thap market. Daily
cleaning and disinfection are now possible.
About 1 million live poultry are traded annually in Ha Vy market.
Poultry for resale leaves Ha Vy market in a cage perched on a small motorcycle. Market biosecurity prevents spread of disease to
customers, traders, and farmers.
Washing trucks as they leave Ha Vy market prevents spread of
disease to the communities and farms where they go next to collect
poultry.
World Bank expert Binh Thang Cao talks about market biosecurity
as VAHIP ends in June 2014. Ha Vy market upgrades are a
substantial achievement, but more effort is needed to protect animal and human health.
35
89. Sub-component A4: Preparing for Poultry Sector Restructuring. Activities were
conducted only during Phase 1 of VAHIP and had the following among the outputs:
- Training, including:
o Master of Science training for 3 DLP officials in the UK and Australia;
o Development of biosecurity standards and methods for examining and assessing poultry
farms and conducting training courses in this area for 49 officials from the livestock
sector;
o 3 training courses for 132 DLP officers on spatial planning and risk assessment;
o Study tour to South Korea for 16 officers of DLP and DARDs of 11 project provinces to
learn about biosafe poultry production;
- Support to 40 small farms in 4 selected provinces for upgrading biosecurity;
- Baseline surveys in 4 provinces participating in poultry sector restructuring to support the
development of spatial planning and risk assessment profiles; and
- Training courses for about 1,760 farm households from 44 communes or 22 districts on
biosecure poultry production; these trained households then became the key poultry producers
and information disseminators in their communes.
90. Sub-component A5: Emergency Outbreak Containment. This sub-component had
among its major outputs the following:
- Simulation exercises in all project provinces
- Training courses on rapid outbreak response
- 11 study tours
- Communication program in 367 primary schools involving more than 500,000 students
- Equipment and supplies for emergency response
91. Sub-component B1: Disease Surveillance. Two innovations were introduced to the
country’s surveillance system for infectious diseases.
a. A new model for a communicable disease surveillance system, which modified the existing
system as follows:
- Community village health workers are considered as the first source of data;
- The private sector is an additional data source, transmitting data to the Commune Health
Centers;
- The press and the media are additional information sources, interacting with the district,
provincial and national levels; and
- In line with the One Health approach, the veterinary centers at all levels are integrated in the
infectious disease surveillance system, interacting basically with the Regional Animal Health
Offices (RAHOs), the Pasteur Institutes and NIHE for the confirmation of AI cases.
b. Installation of a commune-based online reporting system for infectious diseases. This online
reporting system installed by VAHIP is an upgrading of existing software developed earlier
by the Preventive Health System Support Project of the Asian Development Bank (ADB).
The lowest level of online data transmission in the ADB software is the district. VAHIP
modified the software to enable data entry at and transmission from the CHC level. In
36
addition to the software, other outputs under sub-component B1 include several training
activities aimed at strengthening the surveillance system like for example, the training of:
- 4432 health staff on the new model for the infectious disease surveillance system
- 1570 CHC staff on software application
- 103 staff who were sent for the FETP; and
- 67 staff who were sent for overseas training in 6 countries.
92. In addition, vehicles, supplies, and equipment to strengthen the capacity of the district
rapid response teams were also provided. These included, among others, the following:
- 874 computers
- 38 vehicles for outbreak investigation and 301 motorbikes
- 339 specimen collection kits
- 655 special clothing and 14,619 PPEs.
93. Sub-component B2: Curative Care. The outputs included the following:
a. Upgrading of the 12 isolation wards of the provincial hospitals in 11 project provinces;
b. Vehicles and medical equipment for provincial and district hospitals, including:
- 30 ambulances
- 27 ventilators
- 112 monitors
- 28 mobile x-rays
- 360 terifusion syringe pumps and infusion pumps;
c. Training of health workers on various aspects related to the use of the equipment
provided, diagnosis and treatment of infectious diseases, infection control in hospitals,
and the development of hospital pandemic prepared plans. These include, among others:
- 542 staff trained on the use and maintenance of hospital equipment
- 912 staff trained on infection control in hospitals
- 227 staff trained on the development of the district hospital preparedness plan for AI
- 47 staff sent for overseas training
d. Development of guidelines on the following areas:
- Use of sterilized chemicals in health care facilities
- Infection control in health care facilities
- Development of the hospital preparedness plan for AI at the district level
In addition to the above, 4,500 copies of the training material on diagnosis and treatment of
respiratory patients were reproduced and distributed to health workers. A hospital scenario for
the simulation exercise was also developed.
94. Sub-component B3: Behavior change and risk communication. This subcomponent
differed somewhat from communications components of other health projects because health
workers as well as the general population were targeted. Another important target group were
ethnic minority groups.
37
95. The coverage of this sub-component and the volume of the communication materials
produced were enormous: 20,532 health staff were trained on BCC skills, 264,000 posters were
disseminated; and 4.2 million leaflets were produced. The range of strategies was broad and
included several types of competitions, which attracted a very large number of participants. For
example, in the provinces of Long An and Tay Ninh, a poster-making contest among
schoolchildren received a total of 18,000 entries (Figure A2.4). An essay-writing contest among
adults that was conducted in Thai Binh attracted hundreds of entries.
96. Outputs included all types of communication -- written (leaflets, handbooks, etc.), verbal
(radio and loudspeaker broadcasts; group discussions, etc.) and visual (billboards; calendars;
educational film, etc.). Person-to-person communication was used extensively in relaying
messages about influenza prevention and control, especially among ethnic minority groups
where home visits were frequently done. Risk communication was just newly introduced in
Vietnam. Training in this area included the development of writing and oral skills, of 65 and 49
trainees, respectively. The project also provided communication equipment, most of it for mass
communication (for example amplifiers, microphones) and 546 units of other communications
equipment. Outputs included:
- Training of trainers on Behavior Change Communications (BCC)
- Communication skills for ethnic minority groups
- BCC monitoring in the community
- Handbook on Communication for Influenza Prevention in the Community
- Risk communication on emerging infectious diseases prevention
97. Notably, the training materials on risk communication developed by VAHIP were
recently reviewed and approved by the MOH, which recommended them for use by academic
institutions and others conducting training on risk communication. This is the first material on
risk communication to be approved and endorsed for use by the MOH. To evaluate the effects of
the various communication activities conducted by VAHIP, Knowledge, Attitudes and Practices
(KAP) surveys were done among health workers and the general population four times: in 2008
and 2011 for the Phase 1 provinces, and in 2012 and 2014 for the Phase 2 provinces.
38
Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health
Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 1 of 3)
39
Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health
Select paintings from among 18,000 entries in competitions for school children, ages 6-15,
VAHIP provinces of Long An and Tay Ninh (page 2 of 3)
40
Figure A2.4. Indicators of awareness of ways to reduce risks to human and poultry health
Select paintings from among 18,000 entries in competitions for school children, ages 6-15, VAHIP provinces of Long An and Tay Ninh (page 3 of 3)
41
Figure A2.5. District Preventive Health Center managers
and staff, along with provincial officials, and the VAHIP
PCU, discuss improvements in local-level public health
capacity. They plan for maintenance of equipment and for
further collaboration with veterinary services (June 2014).
98. Sub-component B4: Strengthening Preventive Medicine System at Local Level. The
major outputs included training of health staff in districts, equipment for the DPMCs, and the
conduct of multisectoral simulation exercises. Simulations of outbreak response and training on
planning responses benefited more than 10,000 district-level staff, a significant achievement.
Several thousand district-level health staff were trained in other areas as well, including:
- Newly emerging communicable diseases (7,865 trainees)
- Basic information technology (1,128 trainees)
- Communication skills (4,233 trainees)
Post-graduate training had 90 district-level trainees, who strengthened their technical skills. It
was for them also a learning opportunity that is seldom available to local-level staff.
99. Most of the equipment provided by VAHIP was under sub-component B4. Since the
objective was strengthening of the whole district preventive health system, the range of
equipment was wide, as needed for core public health functions like reproductive health, which
are all in the domain of the district preventive health. Equipment included, for example:
- 74 level 2 biosafety cabinets
- 60 ultralow temperature fridges
- 64 urine biochemical analyzers
- 52 portable ultrasound
- 38 mobile x-ray systems
- 526 chemical sprayers with
shoulder straps
- 62 spectroscopy for water
analysis
- 261 loudspeakers, amplifiers and
cassette players
- 87 digital cameras
100. Multisectoral coordination
included conduct of 68 major
simulation exercises involving
42
15,146 participants. In addition, the project also conducted 24 internal and 3 external experience-
sharing activities where 590 PPCU and district level staff involved in the project visited other
provinces in order to observe their activities and share their experiences with the various project
components. Local coordination became more effective thanks to the project organizing 1,179
workshops involving 29,518 participants. Each of the 11 project provinces prepared operational
guidelines on multisectoral coordination.
43
Annex 3. Economic and Financial Analysis
101. The economic risks posed by H5N1 avian influenza, a poultry disease caused by a
zoonotic (animal-origin) pathogen, fall into five main categories:
i. direct costs to the poultry sector of the disease in poultry and associated disease control
measures in case of disease outbreaks;
ii. indirect effects of losses to producers, processors, and traders as consumers reduce demand
for poultry and poultry products, leading to disruptions and even collapse of markets for
poultry and poultry products;
iii. losses to other sectors of the economy of the country and even the region more broadly in
sectors where perceptions of infection risks are important, such as the tourism sector;
iv. in case of human infections (which have been sporadic and rare to date), human health
costs, including costs of health care for patients and loss of income because of illness and
death; and
v. the risk of an influenza pandemic, which all countries face and which is a top global
catastrophic risk; this risk derives from a small (but non-zero) probability of occurrence in
any year and a potentially large impact on public health, economies, communities, and
national security.
102. Global Public Good. Prevention and control of avian and human influenza deliver an
important global public good to all countries because they reduce the risk of pandemic influenza.
Awareness of pandemic threat was the main driver of global efforts in 2005-13 to prevent spread
of H5N1 avian flu in poultry. The global community realized that the uncontrolled multiplication
of H5N1 avian flu viruses in poultry represented an unacceptably high risk, and that controlling
the virus at its animal source was a feasible, effective, and least-cost means to reduce this risk. If
action was not taken in Vietnam to limit the contagion in poultry, the risk to the world’s
population and the economies of all countries would remain high. Since H5N1 avian flu in
poultry has spread across national borders (it spread to 61 countries in Asia, Europe, and Africa
by 2007), controlling spread in Vietnam also contributed to the global public good of reduced
poultry disease risks in neighboring countries and beyond.
103. A traditional “with and without project” type of cost-benefit analysis offers at best
partial insights. The large global benefit – that a severe influenza pandemic has not emerged to
date – cannot be attributed only to any one country’s or region’s success in controlling the virus.
But if the circulation of the virus had not been reduced in Vietnam and in the VAHIP provinces,
the probability of emergence of a devastating pandemic would be greater than without the
achievements of Vietnam and other countries.
104. VAHIP and Vietnam’s country-wide program can be economically more than justified
solely on the basis of delay or prevention of a pandemic. A severe influenza pandemic would
give rise to costs equivalent to 4.8% of global GDP (World Bank, 2008). This cost would be $3.7
trillion (based on 2013 GDP) globally. Optimistically assuming that the probability of pandemic
onset in any year is just 1%, the economic cost of an influenza pandemic to the world has an
expected annual value of $37 billion. By controlling the disease, Vietnam’s program contributed
44
to reducing this substantial global risk. Benefits from avian flu control to the poultry sector and
the rural economy are not needed to justify the investments in veterinary and human public
health systems because even a small reduction in pandemic risk (for instance, from $37 billion to
$33 billion) is much higher than the global costs of investments in all developing countries for
disease control and prevention.11
105. Vietnam’s plan for avian flu control and pandemic flu preparedness and prevention in
2006-15 (the Green Book and
the Blue Book) was costed at
$634 million or an average of
$63 million per year. VAHIP
(2007-14) contribution was
$23 million, or an average of
$3 million per year. Since
disease spreads across
administrative boundaries and
international borders, outcomes
in VAHIP provinces depended
also on successful
implementation in the rest of
the country -- and in
neighboring countries. It is
therefore more meaningful to
assess the benefits of the
national effort than to attempt
isolating the expected benefits
stemming from VAHIP alone.
106. Measures to prepare for a pandemic and to improve surveillance in both animals and
humans will have been a sound investment even if a human pandemic strain of H5N1 influenza
virus does not emerge. It could have emerged and imposed high costs. There are other benefits as
well. Table 1 shows the dramatic decline in the last 10 years of poultry deaths from H5N1 avian
flu outbreaks; some 50 million poultry died or were destroyed in disease-control efforts. During
the VAHIP period (2007-14) contagion among poultry was much more limited, and 1.6 million
poultry died or were destroyed. The reduction in outbreaks could have been due to chance, but in
the absence of VAHIP and similar efforts in the rest of the country, the risk of disease spread
would have been too high. VAHIP provinces accounted for about 30 percent of the losses. Table
3.2 shows the benefits to Vietnam. There are benefits from reduced poultry deaths, benefits from
reduced human medical costs for patients (not calculated since they are relatively small and
would not affect the totals), and benefits from pandemic preparedness (calculated as a reduction
of pandemic risk in Vietnam). Reduced pandemic risk in Vietnam is an outcome that is not due
11
Annual spending of $3.4 billion on veterinary and human public health systems would be sufficient to bring these
systems in 139 developing countries to the international standard of performance. Current spending on these systems
in all developing countries is less than $500 million annually. World Bank (2012) People Pathogens and Our
Planet, The Economics of One Health. Inadequate systems allow contagion to spread and in the absence of early
control, inflict exponentially rising costs, as shown most recently in the Ebola epidemic.
Table A3.1. Poultry destroyed by avian influenza, 2003-14
Year Whole
country
VAHIP
provinces
Whole
country
VAHIP
provinces
(number) (2003-4=100)
12/2003-04 43,900,000 11,284,418 100.0 100.0
2005 4,457,790 1,259,083 10.2 11.2
2006 - - 0.0 0.0
2007 236,582 65,860 0.5 0.6
2008 106,058 24,667 0.2 0.2
2009 112,847 22,664 0.3 0.2
2010 75,769 48,752 0.2 0.4
2011 151,356 19,163 0.3 0.2
2012 616,109 151,162 1.4 1.3
2013 79,522 49,478 0.2 0.4
01-06/2014 211,573 102,691 0.5 0.9
Total 49,947,606 13,027,938
Sub-total
in 2007-14 1,589,816 484,437 3.6 4.3
45
to the changed probability of a pandemic (this is the same for all countries) but rather results
from the comprehensive and thorough pandemic planning and numerous simulation exercises
carried out under VAHIP (and similar projects in other provinces). If these pandemic
preparedness activities reduce the chaos, delays, lack of coordination, and poor communications
that inevitably derail disaster responses in the absence of planning, then Vietnam’s pandemic
costs could fall by 10 percent. If such a pandemic started in 2015, it would cost the Vietnamese
economy $9 billion (equivalent to 4.8% of GDP). But thanks to preparedness under VAHIP and
other projects, the costs would be $8 billion, or a saving of $1 billion. On an expected value
basis, assuming that the probability of pandemic onset is 1 percent in any year, the annual benefit
to Vietnam from pandemic preparedness through simulation exercises of pandemic response
plans is $10 million since pandemic risk is reduced from $91 million per year to $82 million per
year. This is far more than the expenditures on pandemic plans and simulation exercises,
confirming that the benefits on this component exceed the costs by far.
107. The benefits of control of avian flu in poultry to the poultry sector and the related
economic activities are substantial as well (Table A3.2). Improved veterinary and human public
health system and pandemic preparedness that includes simulation exercises will enable a faster
and more effective control of disease outbreaks and response to a pandemic. The economic
benefits of performing public health systems are large. These systems deliver a highly valuable
public good, which is worth at least $105 million annually (in 2015 terms) to Vietnam.
108. This $105 million value was calculated as follows. If another outbreak like the one in
2004 occurred in 2015, it would cost Vietnam’s economy $945 million. If such an outbreak is
prevented, the $945 million is the benefit of prevention. A much more conservative approach is
to assume that only 10 percent of this amount will actually be prevented by the public health
systems. Thus the benefit of prevention is $95 million for an outbreak in 2015. Similarly, the
value of pandemic risk ($91 million in 2015, based on 1 percent probability of onset) is reduced
only by $10 million (and not the entire $91 million) in the calculations. On this basis and
assuming that government expenditures continue at a real level equivalent to $77 million per
year (same as in the AIEPED), the expected rate of return on the investments in veterinary and
human public health is 29 percent annually. If averted losses in the poultry sector were 20
12
Annual expected value of pandemic influenza impact on the economy in Vietnam, probability 1% per year of a
severe flu pandemic, for example. The same result obtains for a moderate pandemic, with a probability of onset of
2% in any one year.
Table A3. 2. Overview of the economic costs influenced by stronger public health systems (national benefits only)
(1) (2) (3)= (2)/(1)
(4) (5) (6) (7) (8)= (2)+ 0.1*(5) +(7)
GDP ($b) Costs of outbreaks
($ m)
Cost as % of GDP
Sever e pandemic potential cost ($b)
Pandemic risk, annual, $m 12
Number of human cases
Medical costs, treatment of human cases
($ m)
Total costs ($m)
2004 49.4 (actual)
247 (actual)
0.50% (actual)
2.4 (estimated)
24 (estimated)
29 n.a. 250 (actual)
2013 171.4 (actual)
0.49 (actual)
0.00% (actual)
8.2 (estimated)
82 (estimated)
2 n.a. 83
Benefit of (1) an averted outbreak in poultry as severe as the one in 2004 and (2) an averted severe pandemic: 2015 189 945 0.50% 9.1 91 - -
46
Figure A3.1. The poorest households suffer larger income declines than
wealthier households with a ban on backyard poultry sales
Source: FAO case study in Vietnam
percent (instead of 10 percent) of the 2004 value of losses of the outbreak, the internal rate of
return would be 129%. This scenario would be equivalent to prevention of a large outbreak of an
animal disease like that in 2003-4 once every five years.
109. Poverty impacts. The costs of avian influenza differ for different social groups, such as
poor rural households or small commercial poultry producers. The proportion of poultry
production undertaken by backyard and small commercial systems is much higher at lower levels
of per capita income. In Vietnam, where the bulk of poultry production is still by backyard
producers, the impact has fallen mostly on individual rural households, and has only partly been
offset by government compensation
to farmers. Survey data show
that the poorest quintile of
households relies more than 3
times as much on poultry income
than does the richest quintile, so
there are also adverse
distributional effects. Research
has shown that income from
poultry is much more equally
distributed than overall income.
Reductions in poultry income
due to avian flu or to avian flu
control strategies will thus tend
to worsen income distribution in
Vietnam. Since diseases
outbreaks have declined
dramatically since 2004, major
negative impacts on the poor and
rural income distribution have
been prevented (Figure A3.1).
110. Mitigation of global pandemic risk. Vietnam’s effective and prompt control of H5N1
flu outbreaks in poultry and strengthened human health systems to detect and appropriately
handle any human H5N1 flu cases helped mitigate the pandemic flu risk globally. However, the
global pandemic risk may still be rising, notwithstanding the reduction due to the successful
H5N1 flu control in Vietnam. The probability of emergence of a pandemic virus depends on the
virus load in the environment; this would increase with greater unchecked spread of avian flu in
poultry, including in poultry in Vietnam. This contribution of OPI and AIEPED to the global
effort to prevent a severe influenza pandemic was very important, but it is impossible to
quantify.
47
Annex 4. Bank Lending and Implementation Support/Supervision Processes
(a) Task Team members
Names Title Unit Responsibility/
Specialty
Lending
Anh Thuy Nguyen Operations Officer EASHD
Binh Thang Cao Sr. Agricultural Specialist EASRD
Jan Hinrichs Agriculture Economist FAO
Les D. Sims Animal Disease Management Specialist FAO
Mai Thi Nguyen Senior Operations Officer EASHD
Nguyen Chien Thang Senior Procurement Specialist EASRD
Quynh Xuan Thi Phan Financial Officer EASFM
Samuel S. Lieberman HD Sector Coordinator EASHD TTL
Severin Kodderitzsch Practice Manager GFADR TTL
Thu Thi Le Nguyen Operations Analyst EASRD
Supervision/ICR
Anatol Gobjila Senior Operations Officer GFADR
Anh Thuy Nguyen Operations Officer GHNDR TTL
Binh Thang Cao Senior Agricultural Specialist EASVS TTL
Hai Yen Tran Program Assistant EACVF
Hoi-Chan Nguyen Senior Counsel LEGES
Huy Toan Ngo E T Consultant EASVS - HIS
Huy Toan Ngo Environment EASVS
Jan Hinrichs Agriculture Economist FAO
Jennifer K. Thomson Chief Financial Management Specialist OPSOR
Lan Thi Thu Nguyen Natural Resources Economist GENDR
Les D. Sims Animal Disease Management Specialist FAO
Lingzhi Xu Senior Operations Officers GHNDR
Ly Thi Dieu Vu Consultant GSURR
Mai Thi Nguyen Senior Operations Officer GHNDR
Mai Thi Phuong Tran Financial Management Specialist GGODR
Maya Razat Program Assistant GSPDR
Minh Thi Hoang Trinh Program Assistant AFCNG
Nga Quynh Nguyen Program Assistant GHNDR
Nga Quynh Nguyen Program Assistant GHNDR
Nghi Quy Nguyen Social Development Specialist GSURR
Nguyen Chien Thang Senior Procurement Specialist EASRP-HIS
Nguyen Hoang Nguyen Procurement Specialist GSURR
Nguyen Hoang Nguyen Procurement Specialist EASR2
Quynh Xuan Thi Phan Financial Officer GEFOB
Samuel S. Lieberman Lead Economist EASHD - HIS TTL
Severin L. Kodderitzsch Practice Manager GFADR
Shiyong Wang Senior Health Specialist GHNDR
48
Names Title Unit Responsibility/
Specialty
Thang Chien Nguyen Senior Procurement Specialist EAPPR
Thao Thi Phuong Nguyen Program Assistant EACVF
Thu Thi Le Nguyen Operations Analyst GENDR
Thuy Cam Duong Environmental Specialist GENDR
Tuan Anh Le Social Development Specialist GSURR
Olga Jonas Economic Adviser GHNDR ICR TTL
Laurent Msellati Practice Manager GFADR ICR adviser
Piers Merrick Senior Operations Officer MNADE ICR adviser
(b) Staff Time and Cost
Stage of Project Cycle Staff Time and Cost (Bank Budget Only) USD Thousands
No. of Staff Weeks Travel Consultant Costs
Lending
FY07 72.37 47.42 253.56
FY08 35.15 8.40 0.00
Total: 107.52 55.82 253.56
Supervision/ICR
FY09 38.12 18.59 7.75
FY10 35.08 7.52 0.00
FY11 31.41 6.25 0.00
FY12 14.10 3.23 0.00
FY13 18.84 6.44 16.58
FY14 19.10 19.34 0.41
Total: 156.65 61.37 24.74
49
Annex 5. Comments on Draft ICR and Recommendations from Borrower’s ICR
111. The government’s ICR, VAHIP Consolidated Project Completion Report for the Animal
and Human Health Components from the Ministry of Health and the Ministry of Agriculture and
Rural Development (Ophelia M. Mendoza and Les D. Sims, consultants, October 2014), was
submitted to the World Bank. It is a thorough and well-argued analysis of project outputs,
implementation experience, and achievements. Rather than present a summary of the
government’s entire ICR (which would duplicate much of the main text of this report), the
following sections present: (i) comments from the government on the World Bank’s draft ICR
report, (ii) graph on the science of delivery under VAHIP, and (ii) additional recommendations
for future approaches to zoonotic disease prevention and control from the government’s ICR
report.
Comments from the government on the draft ICR
112. The Ministry of Health and the Ministry of Agriculture and Rural Development reviewed
the draft of this ICR report in November 2014 and kindly provided corrections and suggestions,
which have been reflected in the main text. The comments from the Ministry of Health were:
The VAHIP was successfully implemented. The results of the project have contributed to
strengthening the capacity of the health system backup from the central to local levels in the
prevention of infectious diseases. There are many factors contributing to the success of the
project, including the World Bank. The role of the World Bank is not only in the preparation of
the project, to find funding for the project, but also in the process of project implementation,
specifically as follows:
- World Bank has played a very active role in the process of project implementation. The
regulations and agreements between the World Bank and the investors (General Department
of Preventive Medicine, Ministry of Health) in the project framework were fully implemented.
The documents and management records of projects submitted to the World Bank were
answered in a timely manner.
- In addition to the mission in accordance with the project framework, the World Bank has
actively coordinated regularly with PCUs and PPCUs to find the solutions to the difficulties
encountered during the project implementation.
- The flexibility of the World Bank, especially in terms of making changes in budgetary
allocation, made it easy for the project to transfer unused funds for certain items and transfer
it to other activities, which can benefit from additional financial resources. This flexibility
made it possible for the project to exceed the targets for a number of important activities like
the number of simulation exercises conducted, the number of participants trained, as well as
the number of districts and communes covered under the Additional Financing phase. These
facilitating factors which made it easier for the project implementation.
- There are however factors which slowed some activities of the project such as very low cost
norms often discouraged participation especially in training activities which required
participants to travel from their districts/communes to the training venue.
50
- Because the project must operate within the legal frameworks of the World Bank and
Vietnam governments, sometimes have trouble finding a solution to satisfy both the legal
frameworks. This is an issue that needs to be scrutinized for the project in the future to have
a project manual easy to implement and effective in accordance with the requirements of the
World Bank and the Government of Vietnam.
The World Bank’s draft implementation completion and results report on VAHIP fully reflects
the activities and outcomes of the project. The lessons learned and recommendations are
accurate. We completely agree with the content of the report and sincerely thank the valuable
contribution of the World Bank on the success of the project.
The following feedback was provided by the Ministry of Agriculture and Rural Development
(edited for clarity, with comments added):
- We agree with almost the content mentioned in the draft ICR report, except for analysis of
objective and result indicators because there are some gaps compared with the government’s
M&E reports provided. [Comment: the indicators in this ICR are based on the government’s
ICR and the set of indicators monitored in ISRs, whereas the project’s excellent M&E reports
are more extensive and detailed. The government’s ICR provided a valuable discussion of the
challenges of monitoring progress in control of poultry disease in large geographic areas with
high-volume poultry production and trade; the program was inherently complex both
technically and operationally, which was appropriately reflected in the M&E reports.]
- A project design shortcoming was the capital distribution. A small capital amount was
distributed among 11 provinces and their 144 districts to undertake many diverse activities,
and this slowed progress especially at the beginning. The lesson from this experience was
taken on board in developing LIFSAP project in which the capital is focused and invested in
a certain number of provinces. As a result, much progress can already be seen in the LIFSAP
project implementation. [Comment: this is a good recommendation to consider in other
decentralized programs where there may be risks of spreading effort too thinly.]
- Reimbursement mechanism posed several difficulties. The ceiling of the special account was
too small to distribute funds to 12 project implementation units, causing difficulty in
disbursement, especially in the final stages of the project. The threshold for direct payment
was too high. Exchange rate for refunds of advances from the provinces to the special
account was not specified in the legal agreement or the project implementation manual, and
this complicated processing of disbursement. [Comment: these are valuable observations to
consider in the design of disbursement arrangements in similar future projects.]
- World Bank support to project management and coordination: with authority to make
decisions devolved to the office in Hanoi, the World Bank’s experts have been active and in
very close touch with issues relating the project management and coordination. The World
Bank team members have dealt with the issues promptly and efficiently, therefore, it helps
push the project progress. However, we recommend that after a mission, the management
letter and aide-memoire should be agreed by the two parties in order to ensure higher
accuracy and unanimous understanding between the parties. Thanks for your cooperation.
[Comment: thank you very much for this comment. A shared view of project challenges and
solutions is very important, but so is clarity about disagreements and problems. Errors
51
should, of course, be minimized as much as possible, and the World Bank team has truly
appreciated the corrections and discussions of differing assessments.]
Figure A5.1. Science of delivery under VAHIPSource: Government of Vietnam ICR, p. 29
INPUT OUTPUT OUTCOME IMPACT
I
SMALL CIVIL WORKS
• 12 Isolation Wards of 11
provincial hospitals
upgraded
TOOLS AND TECHNOLOGY
• Online reporting system for
infectious diseases installed
• Provincial and district
hospitals and preventive
medicine centers provided
with hospital, laboratory and
communication equipments
CAPACITIES
• HWs trained on management
and planning; surveillance
software application; disease
surveillance, prevention,
control and management;
and on BCC and risk
communication
• Sub-groups of the population
trained on prevention and
control of AI and EIDs
APPROACH
• MARD and MOH
collaboration
institutionalized at all levels
• Multi-sectoral RRTs formed
and activated
SMALL CIVIL WORKS
• Capacity of 11 provincial
hospitals for infection
control improved
TOOLS AND CAPACITIES
• Completeness and
timeliness of reporting of
infectious diseases at all
levels improved
• Increased access to and
use of upgraded
equipments for diagnosis
and case management of
infectious and other
diseases and conditions
especially at district level
• Human resources
strengthened and capable
of effective and rapid
detection and response to
AI and EIDs
• Heightened community
awareness on prevention
and control of AI and EIDs
APPROACH
• Stakeholders adopt and
implement a multi-sectoral
approach in policy and
practice in relation to
pandemic preparedness
and response to AI and
EIDS
• Rapid and effective
control of AI and EIDs
• Coordinated
institutionalized multi-sectoral response to AI and EIDs at all levels
• Decreased morbidity and mortality due to AI
and EIDs
SMALL CIVIL WORKS
• Upgradiing of provincial
hospital Isolation Wards
TOOLS AND TECHNOLOGY
• Computer hardware and
software
• Laboratory, hospital and
communication
equipments for district
and provincial hospitals
and preventive medicine
departments
CAPACITIES
• Technical support
• Training of HWs on
prevention, surveillance,
control and
management of
infectious diseases;
management and
planning
• Training on BCC and risk
communication for HWs
and subgroups of
population
APPROACH
• One Health
• Strengthening oF
District Health System
Recommendations for next steps after VAHIP (from Part 3 of the government’s ICR)
1. RECOMMENDATIONS ON TACKLING NEWLY-EMERGED ZOONOTIC AVIAN
INFLUENZA VIRUSES
113. VAHIP ends at a time when external events are creating additional pressures on the
poultry sector and new challenges from emerging zoonotic diseases are arising. It is evident that
while many of the gains from VAHIP will be sustained, much still needs to be done to ensure
that livestock reared in Vietnam do not pose a risk to human health locally and globally.
114. In the past 12 months, four new strains of avian influenza virus have caused human
disease in the broader region, including viruses of the H5N6, H7N9, H10N8 and H6N1 subtypes.
Most of these have been linked to live poultry markets. New strains of H5N1 virus continue to
emerge and spread in the region with one particular clade of H5N1 virus now spread across
Vietnam from north to south and into Cambodia over the past 2 years (Clade 2.3.2.1c). This has
complicated control programs, especially in the south where vaccination was targeted at Clade 1
viruses that have been endemic to this area since 2003-4. In addition, H5N8 viruses have
emerged in China and spread to South Korea and Japan. As of yet there have been no known
52
human infections but infection has been reported in dogs with access to infected poultry and
experimentally infection of mammals with an earlier strain of this virus has been reported.
115. Of these viruses, the H7N9 virus has been the most significant causing losses to the
poultry sector in China of more than US$15 billion. This virus first emerged as a problem in
March 2013 in Shanghai but has also caused major losses in eastern and southeastern provinces,
especially Zhejiang and Guangdong. H7N9 spreads more efficiently from poultry to humans than
the H5N1 subtype, with almost 10 times more human cases reported for H7N9 in just over 12
months than for H5N1 in the period from 2003 to 2014. Of the more than 400 cases of human
infection with H7N9 in China, approximately one third of cases have been fatal.
116. Some improvements had been made to live poultry markets in China prior to the
emergence of this virus, but these upgrades were not sufficient to prevent the virus from
becoming established in markets. This virus has resulted in temporary and, in some cases,
permanent closures of live poultry markets. The trend in China at present is to shift away from
live poultry sales in major urban centers because of the emergence of H7N9 virus.
117. While the H5N1 virus can be silent in ducks and may be present in markets without any
apparent increase in mortality, when it gets in to susceptible chickens it causes severe disease.
This is not the case with H7N9, which only produces sub-clinical infection. Unless active
surveillance programs are in place, H7N9 will not be detected in poultry. In China the first
indication of infection with this particular virus was the detection of human cases, although a
related virus was detected in 2010.
118. H7N9 has been a tipping point for live poultry markets in China and if (when) this virus
gets to Vietnam it will probably result in similar effects unless markets are being managed or are
capable of being managed in a manner that prevents this virus from becoming established in
markets. Detection of this virus, especially if associated with fatal or severe human cases, will
almost certainly accelerate the shift from sale of live poultry in markets to centralized slaughter,
unless the markets are extremely well managed with excellent hygiene and strict controls on
sources of poultry. If cases of severe or fatal disease are associated with any particular market in
Vietnam there will be calls, on public health grounds, for a temporary closure of that market. The
current national contingency plan for H7N9 includes temporary market closures as one of the
measures to be taken.
119. VAHIP has been instrumental in reducing the risks associated with live poultry trade in
some markets and many of the small markets improved by VAHIP would pose a very low risk of
remaining infected with H7N9 virus if it were to gain entry to Vietnam. Nevertheless in some of
the existing larger markets where only minor changes have been made, the markets are still at
risk of becoming and remaining infected if this virus does get to Vietnam. If this occurs it will be
necessary to undertake radical changes to the way some existing markets are managed, including
reconstruction, if they get infected. Ha Vy market has many of the changes in place that will help
it to cope if this virus emerges but will still require extreme care and diligence to implement all
of the required biosafety measures if it is to remain a viable part of the live poultry trade. Much
will depend on the capacity of the market management team to control entry of poultry
(preventing birds of unknown origin from entering) and to continue implementing measures that
break any cycles of transmission if the virus became established in the market.
53
120. A shift away from live poultry sales especially in major urban centers should be
implemented over time. In addition, no new live poultry markets should be built (except to
replace existing facilities). However, until such time as this switch occurs it is important for live
poultry markets to operate and to be able to operate in a manner that reduces the public health
risk to traders. This will include measures such as regular market rest days and regular cleaning.
121. Despite the best efforts of veterinary services to prevent viral incursions, new strains of
zoonotic avian influenza virus will be detected in Vietnam. Lao PDR has just detected H5N6
virus and this virus has now been detected in Vietnam across a number of provinces in north and
central Vietnam. H7N9 virus has been detected in Guangxi province adjacent to Vietnam, and it
is only a matter of time before viruses of this subtype are detected in Vietnam based on the past
history of viral incursions.
2. RECOMMENDATIONS ON REDUCING RISKS FROM OTHER PATHOGENS
122. As the global population increases it is almost inevitable that other new agents will
emerge from animal populations to infect humans that either have pandemic potential or cause a
pandemic. One recent example is the emergence of a novel (MERS) coronavirus with likely links
to viruses found in camels and bats. Many of the elements that have been developed under
VAHIP will be very helpful in tackling these diseases and should be built on. Experiences from
elsewhere in the region should also be examined for relevance to parts of Vietnam. The Healthy
Livestock, Healthy Village, Better Life program that formed part of the World Bank avian
influenza project in Cambodia demonstrated that local actions at the village level can be taken to
strengthen biosecurity and disease control measures while at the same time improving
profitability from poultry production. The levels of poverty in villages in Cambodia are greater
than those in Vietnam but elements of this program may be adaptable to parts of Vietnam. This
has been proposed in AIPED.
123. One of the key lessons to be taken from this program is that the activities were not just
directed against one disease and villages played an active role in disease control and prevention.
124. Much still needs to be done to ensure livestock production and marketing in Vietnam is
undertaken in a manner that does not pose a threat to public health and the environment.
Development and modernization of poultry markets and the shift to centralized slaughter will not
occur evenly (it is evident already that certain central slaughter facilities are operating well round
Ho Chi Minh City but others are struggling to gain traction in the market. Market shocks as a
result of emergence of new diseases remain a constant threat to all parties, even to those who
already have biosecure systems of production and marketing in place, based on the experiences
from China. A One Health/Ecohealth approach is needed to these issues in which the factors that
lead to disease emergence are considered, understood and addressed instead of focusing only on
the immediate issues of emergency control of outbreaks when they occur.
3. RECOMMENDATIONS TO REDUCE RISKS FROM H5N1 AVIAN INFLUENZA
125. As expected when VAHIP was first developed, the H5N1 virus has not been eliminated
from Vietnam. However, a new equilibrium has been established. The virus continues to
circulate causing occasional disease outbreaks but nothing like those seen in 2003-04 when
54
H5N1 viruses first emerged as a serious problem. Most outbreaks of disease are localized and
confined to a relatively small number of farms/households and affect terrestrial poultry such as
chickens or quail, and occasionally ducks and wild birds (swifts). Many farms have remained
free from infection for a number of years but the risk of infection has not gone away. Any
problems in implementation of farm biosecurity systems could result in viral incursion. VAHIP
has helped to reduce one problem which is persistence of virus in live poultry markets. The
measures that are being implemented in VAHIP markets are capable of breaking infection
chains. In addition VAHIP has demonstrated that it is possible to maintain disease free farms
despite the persistence of the virus in other parts of the poultry production and marketing system.
126. When cases of disease are recognized in poultry they are generally handled rapidly and
efficiently resulting in culling of diseased flocks but this does not address the root of the
problem. These include the persistence of virus in some duck populations and poorly controlled
movement of poultry including (in the past) considerable smuggling of poultry across
international borders. VAHIP has also demonstrated the risk posed by smuggled spent hens
based on the positive tests for H5N1 virus in the past.
127. If progress is to be made towards eradication of H5N1 virus these issues need to be
addressed. Already we are seeing some improvement in traceability of poultry and controls on
sources in Ha Vy market. This trend needs to continue with continual improvement of the
process. Grazing ducks especially those transported over long distances pose a particular hazard
but it has not yet been possible to prevent infection in all flocks of these ducks using existing
vaccines. Until such time as better duck vaccines are available it will be difficult to make much
progress in shifting from the current equilibrium. Nevertheless there are ways to protect other
types of poultry by reducing their contact with ducks and ways to achieve this should be
assessed, including improvements in farm and village biosecurity measures.
128. Livestock production still offers a powerful means of poverty reduction for the rural poor
but the challenges associated with small scale production are increasing as markets consolidate
and requirements for traceability and residue control increase. Ways need to be found to ensure
that poultry can still play a vital role in addressing poverty. In many rural areas small scale
poultry production is a crucial source of income and food security.
129. A two to three tier livestock sector is developing with the production systems depending
on both the type of farm and the market chain. Larger scale farms are likely to dominate the
market for major cities although opportunities remain for some niche products. This top tier of
producers will adapt to market demands and will likely have the funds needed to ensure they
supply an H5N1 virus- free product. The second tier comprises smaller commercial farms that do
not have the same financial resources to invest in biosecurity measures. They are at risk of being
excluded from major markets unless they can demonstrate that their birds remain free from
infection. The third sector is the small scale village producer with some excess birds for sale on
occasions. They can probably retain local sales but will struggle to gain market share in major
urban centers.
4. RECOMMENDATIONS ON BUILDING RESILIENCE
55
130. When a new disease emerges one of the first questions is: from which species is the agent
derived? Despite moves to try to minimize the use of labels such as ‘bird flu’, when a new
disease emerges and there is evidence that the agent may be derived from poultry, then some
product avoidance will occur. If the agent is found in poultry, all parts of the poultry sector will
be affected, as was the case with H7N9 in China. The H7N9 virus has largely been transmitted
from poultry to humans in live poultry markets. Consumption of poultry has been demonstrated
not to be a risk factor for human cases. Yet there has been avoidance of all poultry products. The
only way to build resilience into the livestock sector is to be prepared for the emergence of new
diseases, including design of appropriate messages for communication. VAHIP has helped to do
this.
5. RECOMMENDATIONS ON DISEASE SURVEILLANCE & REPORTING SYSTEM
131. The following would help the sustainability and utility of the disease surveillance system:
Expansion of the software application for the online reporting system to non-VAHIP
communes, districts and provinces. This is essential for the proper pilot-testing of the online
system and its eventual nationwide adoption.
Implementation of data quality control mechanisms to ensure accuracy and reliability of the
data. While the computer software can be programmed to incorporate built-in checks for
certain elements of accuracy and reliability, the greatest responsibility for data accuracy and
reliability still lies with the health worker who needs to be trained to ensure these aspects of
data quality at the point of data collection, long before the data is entered into the computer.
Further software enhancements should include functions like the incorporation of population
data to enable the computation of rates at lower levels, and the construction of an EPI
CURVE which is a basic tool used by epidemiologists for outbreak investigation.
Training of provincial, district and commune level staff on data analysis and utilization to
convert them from mere data providers to data users. Right now, the district and commune
level staff are merely transmit data to higher levels once it is collected. Providing them with
the skills to analyze and use the data they have collected will make them realize the
importance of maintaining data quality and will improve management of health programs at
lower levels, through effective use of health information.
Conduct of a systematic and thorough assessment of the feasibility and resource implications
of the new disease surveillance model suggested by VAHIP. The new model emphasizes the
use of village health workers and the private health sector as data sources at the peripheral
level, and formally includes the animal health sector in the infectious disease surveillance
system. This has implications for data flow and data quality which need to be studied
thoroughly before the new model can be considered for adoption.
Strengthening the linkage between the national database for emerging infectious diseases
(EIDs) and regional and global databases, to share information with, and learn from
experiences in, other countries.
6. RECOMMENDATIONS ON MOH-MARD COLLABORATION
56
132. VAHIP has been instrumental in activating and institutionalizing the MOH-MARD
collaboration and a lot of benefits have been achieved through this collaboration. As such, it is
important for it not only to be sustained but also to be expanded. For instance:
Replicate process of MOH-MARD collaboration other provinces, prioritizing border
provinces with Cambodia where AI continues to spread, and hence risks to enter Vietnam in
the future.
Continue to develop and conduct short joint training programs for MOH and MARD staff at
province, district and commune levels. This will further strengthen the linkage between staff
of both ministries. Examples of areas where joint training can be conducted are applied basic
epidemiology for human and animal health workers; social determinants of health and their
role in One Health; integrated methods of joint human and animal disease surveillance; and
health promotion and communication within the One Health framework.
Use the process of MOH-MARD collaboration followed by VAHIP as model for other
collaborations needed to enhance MOH functions, for instance with Ministry of Education
and Training for school health; with MOLISA for occupational health or gender-related
programs; and with Ministry of Transportation and the Police for vehicular accidents.
7. RECOMMENDATIONS ON STRENGTHENING THE DISTRICT HEALTH SYSTEM
133. Substantial resources from the human health component of VAHIP were spent to
strengthen the district health system. However, the activities undertaken and the outputs and
outcomes derived were merely the initial seeds of a robust district health system. Many more
measures are needed, including:
Ensure quality control in laboratories conducting new tests/procedures as a result of VAHIP–
provided equipment. A system of monitoring and supervision of district laboratories by the
provincial laboratories may be needed in relation to this.
Develop concrete guidance and norms for future inputs to strengthen district laboratories.
This is important to ensure procurement of appropriate equipment and other resources, which
donors may finance so as to build on the VAHIP achievements and further strengthen the
district preventive medicine system.
Develop policies for the optimum use of equipment in district laboratories and hospitals
Develop policies to minimize the brain-drain of trained district staff to higher levels and to
other institutions like the NGOs.
8. RECOMMENDATIONS ON THE COMMUNICATION PRODUCTS OF VAHIP
134. VAHIP produced useful and interesting communication products like the paintings of the
school children or the essays for essay-writing contests. They can be effective health promotion
materials for the continuing prevention activities for AI and other EIDs. The children’s paintings
can be used as design for health promotion messages on greeting cards, bags, t-shirts,
stationeries, notebook covers, etc. The designs can be used on posters for schools to teach
children about influenza prevention and control. Publication of the winning essays in local
newspapers can sustain people’s interest and remind readers about continuing threat of AI and
other EIDs. Materials used in the large number of simulation exercises could be assembled into a
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compendium of exercises, to serve as reference material for future trainings and simulation
exercises.
9. OPTIONS FOR FUTURE LIVESTOCK PROJECT WITH ONE HEALTH APPROACH
135. It is worth considering a project combining elements of LIFSAP and VAHIP that targets
only a small number of predominantly rural provinces in which the whole livestock sector is
examined and strengthened. This could include activities for village based producers, small scale
commercial producers and large scale producers, aimed at improving all three as well as
activities downstream (markets and slaughterhouses) and upstream (feed supply and breeding
farms). It can involve all types of livestock, not just poultry and build on the experiences from
the two projects. A project of this nature would provide marked economic benefits to the
provinces and reduce the public health and environmental effects of livestock production. It
could focus on provinces that have performed well in either VAHIP or LIFSAP (they have the
experience to make a project work) and would allow the gains made so far from these two
projects to be consolidated. A One Health approach would be adopted and the project would
have a 5 year time frame to allow for appropriate investments. A project of this nature would
undertake work that allows the following:
Understand all aspects of the livestock production and market chains
Identification of points in production and market chains for interventions that are expected to
make a difference to productivity, profitability, animal health and welfare and public health
Further strengthening of veterinary and animal production services within the target provinces
using a strong preventive focus
Ensuring better traceability of livestock and livestock products in the province
Control and prevention of major livestock and zoonotic diseases through better animal
management and vaccination and smart use of antimicrobial compounds
Building resilience for livestock producers in the face of flooding and droughts and
disruptions to markets
Defining the major constraints to production in each system (including diseases)
Prevention of chemical residues
Prevention of environmental degradation as a result of livestock production
Implementing rational livestock development plans covering each production type
Building community resilience to major hazards (for example: floods, fire, and disease
outbreaks) and related market shocks
Improving markets so that they don’t pose a risk to the public or traders
Ensuring adequate food resources for livestock
Build on the gains made in and positive experiences from LIFSAP and VAHIP
Focus on a small number of provinces and doing a thorough job is almost certainly better than
doing a more superficial approach in multiple provinces.
The model developed could then be used for other provinces in the future provided the
process is well documented and key lessons are learned.
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Annex 6. Comments of Cofinanciers and Other Partners/Stakeholders
All comments from partners are presented and addressed in Section 7 of the main text.
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Annex 7. List of Supporting Documents
VAHIP Consolidated Project Completion Report for the Animal and Human Health
Components. October 2014. Ministry of Health and the Ministry of Agriculture and Rural
Development (Ophelia M. Mendoza and Les D. Sims, consultants).
Program Framework Document for Proposed Loans/Credits/Grants in the Amount of
US$500 million Equivalent for a Global Program for Avian Influenza Control and Human
Pandemic Preparedness and Response, Report No. 34388, World Bank, December 5, 2005.
Animal and Pandemic Influenza – A Framework for Sustaining Momentum, Fifth Global
Progress Report, United Nations and the World Bank, July 2010 (http://un-influenza.org).
Integrated National Plan for Avian Influenza Control and Human Pandemic Influenza
Preparedness and Response, January 2006 (Red Book).
National Integrated Operational Program for Avian and Human Influenza (OPI), 2006-2010.
Ministry of Agriculture and Rural Development and Ministry of Health, Government of
Vietnam, May 2006 (Green Book).
Integrated National Operational Program on Avian Influenza, Pandemic Preparedness, and
Emerging Infectious Diseases (AIPED), 2011-2015 - Strengthening responses and improving
prevention through a One Health approach. Ministry of Agriculture and Rural Development
and Ministry of Health, Government of Vietnam, October 2011 (Blue Book).
Five-Year Health Development Plan: 2010 – 2015, Ministry of Health, Government of
Vietnam.
Vietnam National Strategic Framework for Avian and Human Influenza Communications:
2008-2010 ASEAN Medium-Term Plan on Emerging Infectious Diseases (2012-2015).
Asia Hanoi Declaration at the International Ministerial Conference: ”Animal and Pandemic
Influenza: The Way Forward” (IMCAPI 2010) Pacific Strategy for Emerging Diseases
(WHO SEARO and WPRO - 2005; 2010).
European Union (2010), Outcome and Impact Assessment of the Global Response to the
Avian Influenza Crisis, 2005-2010.
Keogh-Brown, M, Wren-Lewis, S, Edmunds, WJ, Beutels, P and Smith, RD (2009), The
Possible Macroeconomic Impact on the UK of an Influenza Pandemic, University of Oxford,
Department of Economics Discussion Paper 431.
World Bank (2008), Evaluating the Economic Consequences of Avian Influenza, by Andrew
Burns, Dominique van der Mensbrugghe, and Hans Timmer, available at
www.worldbank.org/pandemics.
World Bank (2012). People, Pathogens and Our Planet, Volume 2, The Economics of One
Health.
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World Bank (2014). Independent Evaluation Group (IEG) Responding to Global Public
Bads: Learning from Evaluation of the World Bank Experience with Avian Influenza, 2006-
2013.
World Bank (2012). Connecting Sectors and Systems for Health Results. Public Health
Policy Note.
The Lancet Commission on Investing in Health (2013). Global Health 2035: a World
Converging Within a Generation.
Jonas, O. (2013) Pandemic Risk. World Development Report 2014 background paper, World
Bank. Available at www.worldbank.org/pandemics.
Lee, Jong-Wha and McKibbin, Warwick J. (2004). Estimating the Global Economic Costs of
SARS in Learning from SARS: Preparing for the Next Disease Outbreak -- Workshop
Summary, Institute of Medicine, Washington, DC, 2004, available at
www.ncbi.nlm.nih.gov/books/NBK92473/.
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Annex 8. List of Persons Met
Ministry of Health - Project Coordination Unit (PCU)
Dr. Vu Sinh Nam Director
Mr. Vu Van Quy Coordinator
Mr. Nguyen Manh Hung Planning consultant
Mrs. Tran Minh Thu Technical consultant on B4.2
Mrs. Tran Thi Kim Ngan M&E consultant
Mr. Nguyen Minh Thang Procurement consultant
Mr. Du Quang Thanh Communication consultant
Mrs. Nguyen Hong Trang Curative Care consultant
Ms. Ophelia Mendoza International Consultant on Final Evaluation
Ministry of Agriculture and Rural Development - PCU
Mr. Pham Viet Anh Director
Mrs. Lam Anh Hung Deputy Director
Mrs. Pham Bich Ngoc Chief Accountant
Mrs. Lai Thi Kim Lan Coordinator
Mrs. Le Minh Tam Lab consultant
Mr. Le Van Kiem M&E consultant
Mrs. Cao Phuong Anh Planning officer
World Health Organization
Dr.Kasai Chief Representative
Dr. Nguyen Thi Phuc Acting Team Leader
Food and Agriculture Organization (of the United Nations)
Dr. Jongha Bae - Chief Representative
Dr. Scott Newman
Mrs. Nguyen Thi Phuong
Oanh Operations Officer
Mr. Nguyen Song Ha Assistant to Representative
Ms. Markaday Priya Operations Officer
Ms. Astrid Tripodi Operations Officer
European Commission
Ms. Tran Thuy Duong Poverty Reduction Program Officer
US Centers for Disease Control and Prevention (CDC - Vietnam)
Mr. David B. Nelson Deputy Director
Mr. James C. Kile
Chief, Influenza and Animal-Human Health Interface
Program
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USAID
Mrs. Laurel Fain Director, Office of Health
Mrs. Kim Thuy Oanh Infectious Disease Specialist
Mrs. Huong Infectious Disease Specialist
Department of Animal Health
Mrs. Nguyen Thu Thuy Deputy Director General
Mr. Nguyen Ngoc Tien Epidemiology Specialist
General Department of Preventive Medicine
Dr. Tran Dac Phu Director General
Regional Animal Health Office No. 6 (RAHO6)
Mr. Binh Director General
Mrs. Thai Thi Thuy Phuong Vice Director
Dr. Ngo Thanh Long Director of Animal Health Diagnostic Center
Mr. Phuong Deputy Director of Animal health Diagnostic Center
Mr. Phuong Epidemiology Department
Ho Chi Minh City Public Health Institute
Dr. Le Vinh Deputy Director
Mrs. Kim Anh Deputy Director of Training Center
Ho Chi Minh City Pasteur Institute
Dr. Cao Thi Bao Van Deputy Director
Dong Thap Province People's Committee and PPCU
Mr. Phu Deputy Head of PPC's Cabinet
Mr. Truong Tan Buu Director of PPCU, Deputy Director of DOH
Mr. Vo Be Hien Head of sub-department of Animal Health
Mr. Tran Van Hai Planning Officer
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