Turkey - Avian Influenza and Human Pandemic Preparedness and Response (AIHP) (APL) Project

Documentof The World Bank FOR OFFICIAL USEONLY ReportNo: 35720 TR - PROJECTAPPRAISAL DOCUMENT ONA PROPOSEDLOAN IN THEAMOUNT OF 27.3 MILLION (US$34.4 MILLION EQUIVALENT) TO THE REPUBLIC OF TURKEY FOR AN AVIAN INFLUENZA AND HUMANPANDEMIC PREPAREDNESSAND RESPONSE(AMP) PROJECT AS PART OF THE GLOBAL PROGRAMFOR AVIAN INFLUENZA (GPAI) March 21,2006 This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCYEQUIVALENTS (ExchangeRateEffectiveMarch3,2006) CurrencyUnits = New Turkish Lira (YTL) YTL 1.639 = 1 FISCALYEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS AI Avian Influenza MARA MinistryofAgriculture andRuralAffairs APL Adaptable ProgramLoan M&E Monitoring andEvaluation AIHP Avian Influenza and HumanPandemic Preparedness MOEF Ministry o f Environment and Forestry andResponse Project BSL Bio-Safety Level M O H MinistryofHealth CDC USCenters for DiseaseControl NAPA National Advance PurchaseAgreements CE Catastrophlc Event NARES National Agricultural Researchand Extension Systems CEU Central Execution Unit NCB National Competitive Bidding DIVA Differentiation o fInfectedfrom VaccinatedAnimals NPIAP National Pandemic InfluenzaAction Plan EA Environmental Assessment NDCC National Disease Crisis Center EC European Commission NPV Net PresentValue ECA Europe and Central Asia Region OIE World Organization for Animal Health EMP EnvironmentalManagement Plan OP Operational Policy ERA Emergency Recovery Assistance PDA Provincial Directorate o f Agriculture ERL Emergency Recovery Loan PHD Provincial Health Directorate FA0 FoodandAgricultural Organization PINAP Pandemic Influenza National Action Plan FMR Financial Management Report PMR Project Management Report FY Financial Year POM Project Operational Manual GDP Gross Domestic Product PP Procurement Plan GDPC General Directorate o f Protectionand Control (of NGO Non-governmental Organization M A W GF-TADGlobalFramework for Progressive Controlo f SABIM Ministryo fHealthInformation Trans-boundary Diseases Communication Center GPAI Global Programfor Avian Influenza SARS Severe Acute Respiratory Syndrome HIVIAIDS Human Immuno-deficiency VirusIAcquired SOE Statement o f Expenditures ImmuneDeficiency Syndrome HPAI Highly Pathogenic Avian Influenza SPO State Planning Organization H5N1 Avian Influenza a Virus Subtype H5N1 TCP T e c h c a l Cooperation Program ICB International Competitive Bidding TF TrustFund IDA InternationalDevelopment Agency UWDP UnitedNations DevelopmentProgram ILI Influenza-like Illness USAID US Agency for InternationalDevelopment LDDC Local Disease Crisis Centers WAHIS World Animal HealthInformation System MAP Multicounm APL WHO World Health Organization VCRI Veterinary Control and ResearchInstitute Vice President: Shigeo Katsu Country ManagerDirector: Andrew Vorkink Sector Manager: Marjory-Anne Bromhead Task Team Leader: Mark R. Lundell  TURKEY AVIAN INFLUENZA AND HUMANPANDEMIC PREPAREDNESSAND RESPONSE CONTENTS Page A. STRATEGIC CONTEXTANDRATIONALE .............................................................................................. 1 1. GLOBALREGIONAL AND NATIONAL SECTORISSUES ........................................................................................ 1 7 B.2 . RATIONALE FORBANK MVOLVEMENT ............................................................................................................ PROJECTDESCRIPTION ............................................................................................................................. 7 1 . LENDING INSTRUMENT .................................................................................................................................... 7 2. PROJECT DEVELOPMENT OBJECTIVE ................................................................................................................ 8 3. PROJECT COMPONENTS .................................................................................................................................... 8 4 . LESSONS LEARNED AND REFLECTEDINTHE PROJECT DESIGN ........................................................................ 14 5. ALTERNATIVES CONSIDERED AND REASONSFORREJECTION ......................................................................... 16 C. IMPLEMENTATION ..................................................................................................................................... 16 1. 16 2. PARTNERSHPARRANGEMENTS..................................................................................................................... INSTITUTIONAL AND IMPLEMENTATION ARRANGEMENTS .............................................................................. 17 3. MONITORING EVALUATION OFOUTCOMES/RESULTS .............................................................................. AND 18 4. SUSTAINABILITY 5 . CRITICAL RISKS AND POSSIBLE CONTROVERSIAL ASPECTS............................................................................ ........................................................................................................................................... 18 19 6. MAINLOANCONDITIONS ............................................................................................................................... 20 D. APPRAISALSUMMARY .............................................................................................................................. 20 1 . 20 2. ECONOMICANALYSIS .................................................................................................................................... TECHNICAL ................................................................................................................................................... 21 3 . 22 4. FIDUCIARY.................................................................................................................................................... ENVIRONMENT AND SOCIAL ASPECTS ............................................................................................................ 23 5. 24 6. SAFEGUARD POLICIES .................................................................................................................................... POLICY EXCEPTIONS AND READINESS ........................................................................................................... 25 ANNEX 1:KEYFACTSABOUT AVIANINFLUENZAAND AVIANINFLUENZA A (H5N1VIRUS) ......26 ANNEX 2A: SUMMARYOF THE FA0AND THE OIE GLOBAL STRATEGYFORTHE PROGRESSIVECONTROLOFHIGHLYPATHOGENICAVIANINFLUENZA(HPAI) ........................... 29 ANNEX 2B: SUMMARYOF THE WORLD HEALTHORGANIZATION (WHO) STRATEGY .................32 ANNEX 2C: SUMMARYAND REVIEW OF THE AVIANINFLUENZA CONTINGENCYPLANSOF THE REPUBLICOF TURKEY .............................................................................................................................. 35 ANNEX3: RESULTSFRAMEWORKANDMONITORING ............................................................................ 39 ANNEX 4: DETAILEDPROJECTDESCRTPTION ............................................................................................ 50 ANNEX5: PROJECTCOSTS ................................................................................................................................ 59 ANNEX 6: IMPLEMENTATIONARRANGEMENTS ........................................................................................ 60 ANNEX 7: PROCUREMENT.FINANCIAL MANAGEMENT. AND DISBURSEMENTARRANGEMENTS .................................................................................................................................................................................... 61 ANNEX 8: ECONOMICANALYSIS ..................................................................................................................... 70  ANNEX 9: SAFEGUARDPOLICYISSUES ......................................................................................................... 76 ANNEX 10: PROJECT PREPARATIONAND SUPERVISION ........................................................................ 78 ANNEX 11:DOCUMENTS INTHE PROJECTFILE ........................................................................................ 79 ANNEX 12: STATEMENTOF LOANSAND CREDITS .................................................................................... 83 ANNEX 13:COUNTRY AT A GLANCE .............................................................................................................. 86 ANNEX 14: MAP...................................................................................................................................................... 88  TURKEY AVIANINFLUENZA & HUMAN PANDEMIC PREPAREDNESS & RESPONSEPROJECT PROJECT APPRAISAL DOCUMENT EUROPE AND CENTRAL ASIA ECSSD Date: March29,2006 Team Leader: Mark R.Lundell Country Director: Andrew N.Vorkink Sectors: Animalproduction (40%);Health Sector Managermirector: Marjory-Anne (30%);Agro-industry (30%) Bromhead Themes: Natural disaster management (P);Other communicable diseases (P);Rural policies andinstitutions (S);Other environment andnatural resourcesmanagement(S) Project ID: PO96262 Environmental screening category: Partial Assessment LendingInstrument: EmergencyRecovery Loan [XILoan [ 3 Credit [ ] Grant [ ] Guarantee [ ] Other: For Loans/Credits/Others: Total Bank financing (US$m.): 27.3 m. (US$ 34.40 m. equivalent) Prouosedterms: VSL Financing Plan (USsrn) Source Local Foreign Total BORROWER 7.06 0.00 7.06 INTERNATIONAL BANKFOR 17.20 17.20 34.40 RECONSTRUCTIONAND I I I DEVELOPMENT US: AGENCY FOR INTERNATIONAL 0.00 1.oo 1.oo DEVELOPMENT (USAID) EC: EUROPEAN COMMISSION 2.73 10.00 12.73 Financing Gap 0.00 0.00 0.00 Total: 26.99 28.20 55.19 Borrower: Undersecretariatof Treasury Ankara Turkey Tel: (90 312) 213 0297 Fax: (90 312) 212 8550 hazine@,hazine.gov.tr  ResponsibleAgency: Ministryo fAgriculture andRuralAffairs rurkey Ministryo fHealth Turkey Project implementationperiod: Start June 5,2006 End: July 30,2010 Expected effectiveness date: M a y 31,2006 Expected closing date: November 30,2010 Does the project depart from the CAS incontent or other significant respects? As part o fthe GlobalProgram for Avian Influenza, this operation i s of an [ ]Yes [XINO emergency nature. It was not foreseen inthe CAS, but is not inconsistent with the CAS. Does the project require any exceptions from Bank policies? Ref: PAD 0.6 [XIYes [ ]No Have these beenapproved by Bank management? [XIYes [ ]No I s approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any critical risks rated"substantial" or "high"? Ref: PAD C.5 [XIYes [ ]No Does the project meet the Regional criteria for readiness for implementation? Ref: PAD 0.6 [XIYes [ ]No Project development objective Ref: PAD B.2 Theproposed project aims to minimize the threat inTurkey posedto humansbyhighly pathogenic avian influenza infection and other zoonoses indomestic poultry andpreparefor the control and response to an influenza pandemic and other infectious disease emergencies in humans.To achieve this, three areaswillbe supported: (i) prevention, (ii)preparedness and planningand (iii) response andcontainment. Achieving these goals will contribute to diminishingthe burdeno fdisease and loss o fproductivity inTurkey, limitingthe regional spread o fAI, and enhancing economic and socialprospects at the national, regional, and global levels. Project description Ref: PAD B.3, TechnicalAnnex 4 Component I. Health - this component targets the prevention, control andtotal Animal eradication o fHPAIthrough: (i) strategy development and epidemiological studies and surveillance programs to inform the improvement o f disease control measures; (ii) strengthening the detection capacity o freference and regional diagnostic laboratories to follow-up reportedAI cases; (iii) to activities related to the implementation o fthe containment plan for AI support outbreaks; and (iv) andrestructuring o fthe poultry sector. Component 11.Human Health - this component targets the reduction o f the impact o f a pandemic influenzavirus through: (i) year-round surveillance; (ii)effective and accurate  nethods o f diagnosis; (iii) distance interventions; and (iv) strengthened medical services. social The project will help the Ministry o fHealth (MOH) to buildits institutional capacity to mplement the recently prepared national pandemic influenza action plan incoordinationwith :he Ministry o fAgriculture and Rural Affairs (MARA). Component 111.Public Awareness and Information - this component supports information and :ommunication activities to increase the attention and commitment o f government, the private ;ector, andcivil society organizations and to raise awareness, knowledge andunderstanding m o n gthe general population about the risk andpotential impact o fthe pandemic. It will also ;upport the National Zoonotic Disease inits roles o f triggering emergency responses bythe MARA andMOH, monitoring the actions taken bythem, coordinating public statementsto the media, and executing project evaluation activities. Which safeguard policies are triggered, ifany? Re$ PAD 05, TechnicalAnnex 9 Only the Environmental Assessment safeguard is triggered by the Project. Since the Project i s beingprocessed under emergency procedures andis assessedas a B-categoryproject, an Environmental Management Planwill be prepared duringProject implementationunderthe Animal Health component andimplementedwith Project support. Significant, non-standard conditions, if any, for: Re$ PAD C.6 Boardpresentation: None Loadcredit effectiveness: The condition o f effectiveness for the Loan would be that the MARA andMOHhave appointed their respective Project Coordinators. Covenants applicable to project implementation: Disbursement conditions: A disbursementcondition for the Animal Healthcomponent is the adoptionbytheBorrower o f an Environmental Management Plan satisfactory to the Bank. It is also required that the payments under the CompensationFundandthe selection andimplementation o fPoultry Restructuring sub-projects are made inaccordance with criteria andprocedures set forth inthe Project OperationalManual (POM). Other covenants applicable to project implementation: The adoption of a POMbythe Borrower is a dated covenant (June 30,2006). Inaddition, the Borrower shall monitor and evaluate the project and report on its progress through semi-annual Project Reports andprepare a mid-termreview report by M a y 31,2008.   A. STRATEGICCONTEXT AND RATIONALE 1. Globalregionalandnationalsector issues (a) Introduction 1. The continuing outbreaks o f highly pathogenic avian influenza (HPAI), which beganin late 2003 in several Southeast Asian countries and have occurred more recently in Central Asia, Europe, the Middle East and Africa, have been disastrous to the poultry industry in the these regions and have raised serious global public health concerns. As o f February 2006, nearly 200 million domestic poultry had either died or been destroyed and over 170 people had contracted the infection (of which 92 have died). Recent increases inthe number o f known cases of avian influenza (AI) transmission have raised concerns over the potential emergence o f a pandemic, which could have devastating effects on humanhealthand livelihoods. 2. At the same time, it is important to emphasize that there are many uncertainties about whether and when a pandemic might occur, as well as about its potential impact. Humans are not very susceptible to the disease, but ifinfected with the Asian H5N1strain, they could exhibit a high case fatality rate. The geographical spread o f HPAI, the human dimension, and the potential enormous social and economic impact are unprecedented. Economic losses to the Asianpoultry sector alone are estimated to date at around$10 billion. Despite control measures the disease continues to spread, causing hrther economic losses and threatening the livelihood of hundreds o f millions o f livestock farmers, jeopardizing smallholder entrepreneurship and commercial poultry production, and seriously impeding regional `and international trade, and market opportunities. The rural poor, who rely for a larger share of their income on poultry, have beenparticularly hardhit with income losses. 3. It is impossible to anticipate when the next influenzapandemic may occur or how severe its consequences may be. On average, three pandemics per century have been documented since the 16thcentury, occurring at intervals o f 10-50 years. Inthe 20thcentury, pandemics occurred in 1918, 1957 and 1968. The pandemic o f 1918 i s estimated to have killed almost 50 million people ineighteen months, with peak mortality rates occurring inpeople aged 20-45 years. The pandemics o f 1957 and 1968 were milder, but many countries nevertheless experienced major strains on health care resources. If a major pandemic were to appear again, similar to the one in 1918, even with modem advances in medicine, an unparalleled toll o f illness and death could result. Air travel might hasten the spread o f a new virus, and decrease the time available for preparing interventions. Countries' health care systems could be rapidly overwhelmed, economies strained, and social order disrupted. With interventions proposed inthis Project, and incollaboration with other national and internationalpartners, it should be possible to minimize a pandemic's consequences inTurkey through advance preparation to meet the challenge. (b) Socioeconomic Context 4. The recent epidemics or outbreaks o f animal origin (e.g. SARS, avian influenza, Lassa virus, Ebola virus, Marburg virus, Nipahvirus, West Nile virus) have demonstrated the potential and real global impact o f zoonotic diseases on the health and well-being o f the public, as well as the enormous humanitarian, socio-economic, and trade damage that this group of diseases can cause to both developed and developing countries. They have also underscored the important 1  role o f official veterinary and public health services indisease prevention and control, as well as the importance o f strengthening the capacity o f these services in compliance with the World Health Organization (WHO) and the World Organization for Animal Health (OIE) international standards (e.g. the local, regional, and global quarantine powers under the International Health Regulations; and the international standards, guidelines and recommendations under the OIE Terrestrial Animal Health Code). The epidemics have also demonstrated that there i s an urgent need for a global response to improve the local and regional preparedness and rapid response capacity to the threat from zoonotic disease. 5. Influenza is a zoonotic disease (animal to human transmission) o f international importance because o f the ability o f the virus that causes the disease to mutate for a potential wide-scale human-to-human transmission. Outbreaks o f influenza inhumans occur annually, as a result o f antigenic drift inthe Influence A virus with a severity which varies from year to year, but is typically moderate to mild. Nonetheless, these outbreaks occur in all countries and exert animpact primarilythrough morbidity and reduced economic productivity because o fillness. In contrast, severe influenza pandemics occur infrequently, as a result o f antigenic shift, but have been unprecedented inthe number o f infections and deaths caused over a short time-period. The worst such event in the 20th Century, the Spanish Flu pandemic of 1918-19, had the highest mortality rate among healthy young people. Less severe pandemics occurred in 1957-58 and 1968-69, but still had high attack rates, high case fatality, and major impact on economic activity. The severity o f these influenza pandemics resulted from infection with a sub-type o f influenza virus to which humans had not been previously exposed and so had no immunity. Such a new sub-type o f influenza (known as H5N1) i s currently causing large outbreaks inbirds and domestic poultry in East and Central Asia, Europe, the Middle East and Africa creating widespread concern that the risk o f a new andpotentially severe humanpandemic is high'. 6. Addressing economic and social impacts must be an integral part o f a comprehensive response. A pandemic would have devastating economic and social consequences, including large-scale loss o f livelihoods as well as lives. The potential economic costs o f avian influenza are apparent in countries such as Vietnam, where impacts are already evident on the poultry sector, associated input and distribution channels, and the rural poor who rely on poultry for a larger share o f their income. Evenif a pandemic does not occur, there could be important socio- economic effects resulting from the response to the perceived risks. Countries confront choices inbalancingpreparation versus action since both imply economic costs. At least three types of economic costs or impacts should be considered under a human pandemic scenario: (i) effects o f sickness and mortality on potential output; (ii) private preventive responses to an epidemic; and (iii) sectorresponses. public (c) Key Issues 7. A coordinated global response should involve three types o f strategic activities: (i) preventingthe occurrence and spread o f the disease in domesticated animals, thus lowering the 'Antigenic drift refers to a change insurface proteins o fa given strain o finfluence virus inresponse to antibodies inhuman hosts who have been exposed to it. It occurs continually inboth type A and Binfluenza strains, thus the reason to re-engineer the influenza vaccine on a regular basis to prevent seasonal outbreaks or epidemics. Antigenic shift refers to the reassortment o f the animal influenza strain with the circulating human strain inthe process o f moving from an animal to humans.This antigenic shift ismore o f a concern since when it occurs, it results inpandemics due to generalized susceptibility to infection inhumans. 2  virus load in the environment; (ii) preventing and/or mitigating the effects o f an outbreak in humans; and; (iii) the event of a pandemic, helpingaffectedpopulations cope with its effects. in There is a need to formulate a global response based on a common vision for undertakingthese three sets of activities. Such a vision shouldentail immediate measures while ensuring that these measures fit within a coherent longer-term strategy with respect to both animal andhumanhealth considerations. Key issues that have been identified include: e Prevention and control of avian influenza is multi-sectoral in nature. It involves many players, including those inthe areas of health, agriculture, environment, economics, finance, and planningamong others. At the country level, inparticular, an integrated, multiandinter-sectoral response is needed based on shared objectives. Responses must address both the animal health and human health dimensions and also appropriate social measures (quarantines, transport restrictions, mass communication strategies). e The risk of a human pandemic is real. The H5N1 strain currently affecting several Asian countries has proven highly fatal to humans. The risk that a pandemic virus will emerge depends on opportunities for human exposure and infection, which will persist as long as the H5N1 virus continues to circulate in animals. With the present situation, the potential o f the HPAIvirus to become transmissible among humans needs to be a serious concern. Ifthe virus adapts itself to human-to-humantransmission, lives may be threatened on a large scale. e Avian Influenza virus is constantly evolving with unpredictable results. The HPAI viruses are o f particular concern because they undergo constant genetic change that can have unpredictable results. The constant and rapid evolution o f the virus necessitates a global approach to controlling the disease. a Market conditions have caused HPAI to spread rapidly. The conditions for the emergence and local spread of HPAI have been exacerbated by the intensification and concentrationo f livestock production inareas of high-density humanpopulations. The danger of international spread o f HPAI has increased by the dynamics o f regional and international trade and the movement of people. A global approach to avian influenza, therefore, will have relevance to strategic control o f other livestock diseases, including zoonoses. Nevertheless, country strategies developed and owned by the governments facing the threat of avian influenza should be the foundation o f a global response. e The geographic coverage of a response should be determined by both immediate and anticipated needs. Asia i s today the most affected region, but the disease i s currently spreading to other areas o f the world at an alarming rate and recent scientific evidence indicates that wild birds play a role in the spread o f the virus from one country or region to another. The response should, therefore, combine control measures in countries where the virus has been already detected, with prevention measures in countries at risks (countries neighboring infected countries and/or in migratory bird fly way paths). A minimum level o f preparedness i s essential in all countries. e An appropriate balance between short and long-term actions needs to be taken. Immediate action is needed in a number o f areas. The immediate to short-term objective is to 3  reduce the risk to humans by preventing further spread o f HPAI in those countries that are currently infected. The long-term vision o f the strategy i s to minimize the global threat and risk o f HPAIin domestic poultry and humans, through progressive control and eradication o f HPAI. Achieving this goal will diminish the global threat o f a human pandemic, stabilize poultry production, enhance a robust regional and international trade in poultry and poultry products, increase human and food safety, andimprove the livelihoods o fthe ruralpoor. e Global and regional aspects of the response need to be addressed and coordinated. Actions to secure borders and control international tradehravel in the event o f a pandemic, as well as measures to limit the effects o f disease transmission by migratory birds, are trans- boundary issues requiring regional and/or international coordination. Global andregional efforts should build on existing mechanisms such as the joint OIE/World Bank initiative for the Prevention and Control o f Global Emerging and Re-emergingDiseases o f Animal Origin, and the joint Global Framework for Progressive Control o f Transboundary Animal Diseases (GF- TADs), a joint FAO/OIE initiative and regional organizations such as the Association o f Southeast Asian Nations and South Asian Association for Regional Cooperation. (d) Theglobal dimension 8. The FAO/OIE's Global Strategy. The long-term vision o f the strategy prepared by FA0 and OIE in collaboration with WHO is to minimize the global threat and risk of HPAIin humans and domestic poultry, through progressive control and eradication o fHPAI, particularly that caused by H5N1 virus, from terrestrial domestic poultry. The global strategy will be implemented over three time frames: immediate to short (1-3 years), short to medium (4-6 years) and medium to long-term (7-10 years). During this period the spread o f HPAI, mainly of the H5N1 strain, will have been progressively controlled in domestic poultry o f all infected countries, and prevented from affecting those countries not currently infected, but at high risk. The strategy originally prepared to control HPAI in Asia is being revised by FA0 and OIE to take into account the current spread on the disease outside Asia. The strategy will be complementedbymore detailed country specific HPAIcontrol plans. FAO/OIEhave also issued specific recommendations for avian influenza and OIE has recently issued recommendations for each region, inaddition to its standards and guidelines provided for the prevention and control o f HPAIinanimals (see Annex 2a for more details). 9. The Recommended Strategic Action plan prepared by WHO for "Responding to the Avian Influenza Pandemic Threat" lays out activities for individual countries, the international community, and WHO to prepare for a pandemic and mitigate its impact. The objectives o f the plan correspond to the opportunities and capacities to intervene and are structured in three phases: (i)pre-pandemic - supporting the FAO/OIE's control strategy; increasing collaboration between animal and health services; (ii) emergence o f a pandemic - containing or delaying spread at the source - and (iii) pandemic declared and spreading internationally - reducing morbidity, mortality and social disruption; conducting research to guide response measures (see Annex 2b). WHO has also prepared a global plan and guidelines for pandemic preparedness and is inthe process o f developing a model country plan that will allow countries to assess their state of preparedness and identifypriorityneeds. 4  10. The Bank has developed a global facility through a multi-country adjustable program loan (MAP). Inparallel, the Bank has initiated with the EU, WHO and FAO/OIE, and bilateral donors the establishment o f a multi-donor trust fund (TF) that primarily supports country level activities inconjunction with a smaller and complementary role at the regional and global level. (e) The regional dimension 11. Cases o f avian influenza have already occurred in over twenty countries, including most recently in Western Europe, after having appeared in October 2005-January 2006 in Croatia, Romania, Ukraine, Greece, and Turkey. The earlier (mid-2005) Russian outbreak o f HPAI H5N1 has to date affected more thanten administrative regions, beginning inthe UralMountains and moving west to within 200 km o f Moscow. In the first three weeks of August 2005, outbreaks in poultry o f HPAI H5N1 were reported in four regions o f northern and central Kazakhstan. Other countries in the Balkan region and the Caucasus have experienced outbreaks as well due to their proximity to two main flyways, the East Africa-West Asia Flyway, which crosses Turkey, and the Central Asia Flyway. Both flyways cross areas inNorth-Eastern Europe, where avian influenzainwild anddomestic fowl has also been diagnosed. (Jl nationaldimension The 12. Up until Januarv 2006, Turkey had experienced one outbreak of avian influenza, inthe Manyas district o f Balikesir province. This outbreak was detected on October 1, 2005 when three turkeys died in a flock o f 1,800 turkeys being raised by a medium sized poultry contract farmer in an outdoor grazing environment facility three kilometers south o f Manyas Lake. This lake i s a natural habitat for migratorybirds, which were abundantly present at the time. Most of the rest o f the flock died over the next three days, during which time the district veterinary service and a private veterinarian working for the poultry sector developed the diagnosis o f avian influenza. Dead and live animals were sent to the Bornova reference laboratory (in Izmir), which detected the presence o f the H5 strain (through inoculation and subsequent death in embryonated eggs). The EUreference laboratory inWeybridge (UK) confirmed the presence o f the HPAIH5N1 strain on October 13. 13. Sanitary measures had been promptly initiated by the provincial veterinary service on October 7, when a three kilometers protection zone was established with road signs and the presence o f the military police. All backyard poultry (over 10,000 head) within the protection zone were culled between October 8-16, and compensation was granted by the private poultry industry itself to the affected farmers. Within the protection zone, there were also nine larger commercial holdings, seven o f which were empty. The flock o f almost 16,000 inthe remaining two enterprises was slaughtered on October 9. Inaddition to the protection zone, a 10 kmradius surveillance zone was established, which contained roughly 45,000 backyard poultry, and 10 active larger poultry farms with a stock o f over 130,000 animals. Measure taken in the surveillance zone included a ban on the movement o f live poultry, regulation o f the transport o f table and hatching eggs, prohibition o f bazaar market trade o f poultry and o f hunting o f wild birds, and an immediate local awareness campaign to instruct farmers to confine backyard poultry and avoid contact with wild birds. 5  14. Although the avian influenza outbreak was quickly contained, and there were no signs o f any transmission to humans, the economic impact has been severe. Within two weeks of the outbreak, the consumption of poultry in Turkey (roughly 1.2 kilogram per capita per month) had dropped substantially and retail poultry prices had fallen by 30 percent. (The market capitalization o f the traded Turkish poultry firms dropped by over 30 percent inthe first week). This i s partly owing to the fact that Balikesir and the nearby regions o fBursa, Izmir, Manisa, and Sakarya account for over 40 percent o f Turkey's broiler enterprises and poultry production. Egg production is similarly concentrated in these provinces, and its demand fell from 12 eggs per capita per month by a rate similar to that o f poultry demand. As a result, the poultry and egg sector incurred losses o f roughly US$0.9 million daily inOctober-December 2005. (Prior to the outbreak the GDP of the poultry and egg sector ranged US$ 1.2-1.5 billion annually) 15. InJanuary2006, awidespread outbreak occurred, startinginitiallyinnortheasternTurkey along the border areas with Georgia, Armenia, and Iran. This area is directly on the flight path o f migrating birds (the so-called Central Asia Flyway) and sits between three large lakes: Sevan inthe east (Armenia), Van inthe easternAnatolia (Turkey), and Urmia inthe south (Iran). The initial outbreak in the provinces of Ardahan, Kars, Erzwum, Agn, Igdir, and Van was met quickly with culling o f over 50,000 birds (in the first week o f January). Inthe second week o f January, the number of provinces reporting suspected or confirmed cases o f AI in poultry rose quickly. As o f mid-March, its presence was confirmed in 58 o f Turkey's 81 provinces. To combat the intensification of the spread o f AI, the Government o f Turkey moved quickly ahead with the culling and the monitoring of any possible spread in the surveillance zones around villages inthese provinces. A phone hotline was set up for people to report loose or sick poultry, and bazaar market trade of live poultry has been prohibited throughout the country. By mid- March, over 2.3 million birds had been culled in the imposed protection zones around villages with confirmed cases. 16. However, all these measures have not prevented the occurrence o f animal to human transmission. As of January 19, there were 21 human cases, including four deaths, although manyo fthose casesremainedto bere-confirmed. Only 38 percent o fthe cases were female, and seventeen o f the 21 patients were younger than 15 years old. The higher rate o f disease incidence in children i s believed to have occurred as a result o f their being directly involved in slaughtering, plucking and cooking the chickens infected with the HPAI virus (H5N1 strain). Most o f the cases were transferred to, and treated at, the University Hospital inVan. These cases were the first occurrence and death inhumans from the H5N1 strain o f AI outside o f Asia. On the other hand, the case fatality rate inTurkeyhas been lower comparedwith other countries due to improved early case detection and effective treatment. 17. Almost all of the people with confirmed cases have a confirmed history o f close contact with sick birds, and there is stillno indication o fhuman-to-human transmission. Those who had access to antivirals in the first 48 hours after havingbeen diagnosed with Influenza-like-Illness (ILI)responded relatively well, though treatment ofmore severe casesnecessitated the usage of ventilators to aid patients inbreathing. 6  2. Rationalefor Bankinvolvement 18. The justification for the Bank is the Global Public Goods aspect o f the HPAI, one o f many emerging and re-emerging zoonoses, and its strong link to poverty reduction. HPAI control programs require a multi-disciplinary approach to integrate technical, social, economic, political, policy, and regulatory issues in addressing a complex problem. The Bank i s well placed to build upon its knowledgebase on multi-disciplinary approaches needed inthe proposed Project, which draws on evidence and lessons learned in the various regions regarding emergency preparedness responses and multi-disciplinary approaches. The Bank's experience in Turkey in multi-sectoral, emergency response, and risk-mitigation projects gives it considerable qualifications in bringing together the relevant ministries, government agencies, and the donor community, in understanding and addressing the social and economic impact, and in assuring highlevelpolitical coordination. 19. Given the Bank's work with FAO, WHO, OIE, EU and other partners in country and at the international level to address bothpreparedness and outbreaks andto assist with institutional assessments, the Bank can assist Turkey in leveraging additional resources from other international and bilateral agencies. In addition to its financial role, the technical assistance provided by the Bank has beenimportant insimilar global or regional emergency situations such as SARS, Tsunami relief, and HN/AIDS. The Bank's national and regional support will be closely linked with the activities o f FAO, WHO, OIE and the EU, and the proposed Project i s fully consistent with, anddraws heavily on, the global strategies proposedbyFA0andWHO. B. PROJECTDESCRIPTION 1. Lendinginstrument 20. The proposed Project is supported by the Bank's Multi-country Adaptable Program Loan (MAP) instrument, similar to the instrument already used to support the HIV/AIDS' efforts in Africa and the Caribbean. The funds supplied from the M A P for the Global Program for Avian Influenza (GPAI) will complement activities supported by other international organizations and donor agencies and help ensure the availability o f adequate resources to fund the priority investments and technical assistance which Turkey has identified as critical needs in implementingits response to HPAI. Fundsunderthe GPAIare available to countrieswhich have demonstrated satisfactory preparation to implement an expanded response by preparing a project which has the following characteristics: 4 a national strategic plan showing understanding o f the issues and goals for addressing them; b) national commitment and leadership, including well structured implementation arrangements; c) an implementation strategy that includes program execution through multiple ministries and through non-governmental organizations (NGOs), community groups and civil society organizations; and 7  d) clearly defined institutional arrangements for, andreadiness to initiate, monitor and evaluate project progress andimpact. 21. Loan Processing. The loan i s being processed as an emergency investment operation using procedures under OP 8.50 - Emergency Recovery Loan (ERL) Procedures. However, the loan still meets all applicable Bank policies, practices and standards as discussed below. 2. Projectdevelopmentobjective 22. The overall objective o f the Project is to minimize the threat inTurkey posed to humans by HPAI infection and other zoonoses in domestic poultry and prepare for the control and response to an influenza pandemic and other infectious disease emergencies in humans. To achieve this, three areas will be supported: (i) prevention, (ii)preparedness and planning and (iii)response and containment. Achieving these goals will contribute to diminishingthe burden of disease and loss of productivity in Turkey, limiting the regional spread o f HPAI, and enhancing economic and social prospects at the national, regional, and global levels. 3. Projectcomponents 23. The Project will finance activities under three components: (i) health; (ii) animal human health; and, (iii) awareness and coordination support. Given the urgency o f the situation, public following the recent experiences with HIV/AIDS projects in Africa and the Caribbean, priority has been given to detailing the activities to be included in the first year o f the project with subsequent activities for later years to be refinedinmore detail as part of annualproject reviews. I. ANIMALHEALTHCOMPONENT 24. The Project will support activities to cover the needs inthe short, medium or long-term, andranging from prevention, to control and eradication o f HPAI, which have been based on an assessment o f the particular conditions, constraints and possibilities inTurkey (including a rapid assessment o f veterinary services and recent assessments o f the poultry sector). These activities fall into the main components and sub-components described below and total US$ 30.86 million: A. Nationalpolicyframeworkanddevelopmentof anationalstrategysub-component A1: Policy development and enabling environment. The Project activities' support will include strategy development and the improvement of the regulatory framework to address key policy issues and ensure that disease control, prevention and eradication measures are implemented in a uniform and effective way in accordance with the World Organization for Animal Health (OIE) standards and guidelines. It will support definition of disease control options and reviews o f existingregulations and policies and fund related policy studies, strategy development and dissemination workshops. The main outputs will be a detailed assessment o f the capacity o f its veterinary services and an integration o f the AI contingency plans o f the Ministry of Agriculture and Rural Affairs (MARA) and the Ministry o f Health (MOH) into a National AI Strategy. (US$ 0.59 million) 8  A2: Epidemiology and disease information systems. In this area, the Project will support epidemiological studies and surveillance programs to inform the improvement o f disease control measures, which will be then adjusted and improved as new information becomes available. It will also support the linking o fthe laboratory information systems o f Turkey's eight Veterinary Control and Research Institutes (VCRIs) to the existingmodule o f the World Animal Health Information System (WAHIS) maintained by the MARA General Directorate o f Protection and Control (GDPC). This will better enable Turkey to participate in global disease information sharing, complying with their obligations as members o f the OIE. Epidemiological studies will include a focus on scaling up the knowledge base o f the Ministry o f Environment andForestry (MOEF) on movement o fmigratory birds inthe main areas o f their known transit. The disease information system will be linked with rapid and standardized methods o f routine analysis o f surveillance data in order to track important changes in the H5N1 situation and promptly supplythis information to field personnel. (US$0.48 million) B. StrengtheningDisease SurveillanceandDiagnosticCapacity Sub-component B1: Strengthening Animal Disease Surveillance and Diagnostic Capacity. Project support in this area will aim at strengthening the capacity o f the GDPC and its affiliated reference and regional diagnostic laboratories in detection, reporting and follow-up o f reported AI cases. This will cover the formation and equippingo fBio-Safety Level 3 (BSL3) laboratories in Bornova and Pendik, as well as equipment (incubators, laminar flow cabins, etc.) for two regional laboratories (in Ankara and Konya). Consumables and reagents will be funded as needed for the implementation o f the National AI Surveillance Program and for regional laboratories and Provincial Directorates o f Agriculture linked to these laboratories for the execution of their relevant roles inthe MARA AI Contingency Plan (rapid serological tests and screening surveys and virological tests for confirmation and serotyping o f AI strains). (US$ 2.85 million) B2: Veterinary Services Training and AI Surveillance. Training will target the personnel o f GDPC, including those of the VCRIs and the affiliated staff in the Provincial Directorates o f Agriculture which will be expected to form the local Expert Groups o f the Local Disease Crisis Centers (LDCCs). The focus o f the training will be on screening, sampling, and test procedures to be applied incase o f an outbreak, as well as on analyzing epidemiological data andperformingrisk assessments. Supported activities will also cover an initial self-evaluationof veterinary services, following OIE standards on quality and evaluation o f veterinary services to meet international requirements. Increased risk-based AI surveillance activities will also be supported at the provincial and district levels, coordinated through the VCRIs. (US$ 2.01 million) C. OutbreakContainmentPlan 25. The sub-component will provide support to activities related to the implementation o f the MAFL4 Contingency Plan for Avian Influenza which details the containment plan for AI outbreaks. The Contingency Plan details the roles o f the National Disease Crisis Center (NDCC) coordinated by the Animal Health Department o f GDPC, the Local Disease Crisis Centers (LDCCs) set up on the basis o f Animal Health Sections o f the PDAs, and the National 9  andLocalExpert groups. Section 8 o fthe ContingencyPlancontains the operational manual for the containment plan. The sub-component will includethe following activities: C1: Targeting virus eradication at the source. Inorder to target the eradication ofthe disease at the source o f infection, the Project will target the following activities: (i) o f culling infected and at-risk poultry and compensation to farmers and producing companies (at a reasonable market price); and (ii) disposal o f carcasses and potentially infective materials in a bio-secure and environmentally acceptable manner (through roughly 15 mobile incineration plants deployed to districts with AI outbreaks). (US$ 13.1million) Policies associated with virus eradication that the Government o f Turkey has already introduced and would trigger in outbreak areas include: enhanced bio-security at poultry farms and associated premises, through bio-containment and bio-exclusion, and control o f movement o f birds and products that may be infected, including controls at the interface o f infectednon- infected areas andborder controls. C2: Veterinary personnel safety. Due to the highly pathogenic nature o f the HPAI virus to humans, particularlythe AsianH5N1strain, training o f people in contact with live virus would be supported. This would include field workers involved inidentification o f the disease, farm workers involved inculling and disposingo f manure, laboratory workers involved invirus isolation and diagnosis. Adequate resources would be allocated for training and equipment (bio- safety hoods and appropriate personal protective clothing). (US2.85 million) C3: Restructuring the Poultry Sector. Restructuringthe poultry sector inTurkey will focus on the reduction of the practice o f backyard poultry raising, improving the opportunity for slaughtering o f layers (and subsequent processing and rendering), and promoting manure management o f backyard poultry that is in conformity with existing environmental regulations. Reduction of backyard poultry farming could take the form o f banning such farming in protection zones around known areas of high prevalence o f migratory birds and investments in improving bio-security (penning o f animals and closing up o f barns) in small contracted poultry farms. Since it would be extremely costly for the state to fund widespread programs for poultry sector restructuring, the introduction o f restructuring modalities will be piloted under the Project with matching grants to beprovided under a competitive proposal submission and award process (with at least 50% co-financing byprivatebeneficiaries). (US$ 9.0 million) 11. HUMANHEALTHCOMPONENT 26. Inthepublic healthfield, short-and long-term actions needto betaken andan appropriate balance struck between the two. While immediate steps can be taken to address the crisis, there is also a longer-term agenda given systemic shortcomings with respect to core public health fbnctions. Work on both the short- and long-term fronts, therefore, needs to proceed inparallel, andefforts shouldbemadeto ensure that short-term responses are consistent with and contribute to proposed longer-tern interventions. Setting priorities inboth cases is essential. 27. Building an effective national public health response will require an enabling environment and the necessary resources to bring proven interventions quickly up to nationwide scale. Thus, the Project will help to operationalize some elements that are contemplated as part 10  o f the global strategic plan, expanding and intensifying the responses rapidly. As it i s unlikely that the global spread o f a pandemic influenza virus could be prevented once it emerges, the emphasis i s on reducing its impact. Several tools can help achieve this aim: (i)year-round surveillance; (ii)effective and accurate methods o f diagnosis; (iii) distance interventions; social (iv) vaccines (once they become available); (v) anti-viral drugs; and (vi) strengthened medical services. The interventions supported under the Project are based on Turkey's epidemiological and programmatic needs, and well-assessed options for meeting them. The interventions will be grouped inthree sub-components, totaling US$20.84 million. A. EnhancingPublicHealthProgramPlanningand Coordination 28. The Ministry o f Health (MOH) in Turkey has recently prepared a National Pandemic Influenza Action Plan (NPIAP). The NPIAP i s very comprehensive in scope, with detailed sections on the context and epidemiological underpinnings o f an eventual influenza pandemic, the current legislative and regulatory basis for intervention, vigilance through routine surveillance and its implementation arrangements, case finding and ascertainment through serological testing and virological subtyping, prevention through immunization, symptomatic case management with anti-viral drugs. Most importantly, the plan details how the emergency response will be coordinated, the logistics involved, the protocols and algorithms to be followed for surveillance, diagnosis, immunization and anti-viral therapy duringinter-pandemic, pandemic alert and pandemic periods, and the means o f communication and public information. Finally, it provides a list o f regional and reference laboratories and telephone numbers of those who are directly incharge o f the operations. 29. The plan clearly indicates that the MOH will be in charge o f command and control and that the current laws and regulations are sufficient for it to fully implement all aspects o f the NPIAP. However, the NPIAP's focus on inter-sectoral cooperation and collaboration could be emphasized to go beyond a mere reference to MARA as a source o f information during Inter- pandemic Phase 11. There is also a need to estimate resource and training requirements for effective implementation and make the necessary arrangements that they are in place. Finally, the NPIAP should be subject to simulation exercises on a small scale to assess its implementability as a coordinated action and put to test the chain and command structure. The Project will help MOH to build its institutional capacity to command and control in a coordinated fashion with MARA the implementation o f the NPIAP and assist the National Committee for the Control of Zoonotic Diseases, which has hitherto been a consultative entity, to become a truly functioning supra-ministerial coordinating agency between the two ministries and partnering with other sector representatives (Environment, Transportation, Interior, etc.). To this end, the proposed Project will support the following activities (US$ 14.88 million): 0 Equippinghealthpersonnel withprotective gear and clothing; 0 Upgrading o f drug storage facilities; and 0 Improving health information and telecommunication systems at MOH's Public Information Communication Center (SABIM) and the Crisis Management Center. 11  B. Strengtheningof NationalPublicHealthSurveillanceSystems 30. InTurkey, there is a hnctional Influenza surveillance monitoring committee anda well- defined protocol for surveillance in 10 health centers in each o f the 14 sentinel provinces, including a case notification form for ILI and a template on how to collect and transport specimen to laboratories. The committee monitors case reports on a bi-weekly basis in winter and monthly basis in summer. Case ascertainment is made through virologic surveillance to report the number of clinical specimens tested for influenza and the number o fpositive results by virus type and subtype. According to the protocol, all specimens are to be sent to the two reference public health laboratories where virus isolation and typing could be made. It i s not clear, however, whether the two BSL-2 laboratories will be able to cope with the increased demand in times of a pandemic. In addition, because of their location (Istanbul and Ankara) valuable time could be lost due to transportation of specimens from far away provinces. Cognizant o f the limited laboratory capacity and potential o f low supply o f material for specimen collection, transportation and laboratory supplies, MOH intends to upgrade its network o f seven regional public health laboratories to cope with the increased demand in case o f a pandemic. To this end, the proposed Project will support the following activities (US$ 5.86 million): 0 Improvements of LaboratoryNetworks; 0 Simulation exercises o f ILIcase notification and ascertainment; and 0 Training. C. StrengtheningHealthSystemResponseCapacity 31. Non-pharmaceutical containment measures such as social distancing may contain pandemic spread and allow time for response measures. Therefore, the project will indirectly support through the implementation of the NPIAP, "social distancing measures" -- such as quarantine, ban on mass gatherings and travel restrictions, backed up by a well-designed communication strategy. Additional preventive actions for health care workers involved in case detection, transportation and management such as distribution and use o f protective gear and masks will be supported, along with increased awareness and promotion o f community participation inslowing the spread of the pandemic. (US$ 0.1 million) 111. PUBLICAWARENESSAND COORDINATION SUPPORTCOMPONENT 32. This component will support strategic communication activities for stakeholders and beneficiaries. Similarly, resources will be allocated for improved coordination between MARA's regulatory framework and contingency plans, and the MOH's NPIAP. A. PublicAwareness throughInformationandCommunicationServices 33. Support under this sub-component will be provided for the research, design, implementation and evaluation o f an integrated communications strategy, addressing the needs of priority populations at the national, provincial and local levels. The strategy will elevate knowledge and promote behavior-change in populations at-risk, to control the spread o f the virus, prevent infection, foster timely reporting and support containment actions. At the same 12  time, the strategy will educate vulnerable groups on preparedness plans and mitigation measures across pre-pandemic and pandemic phases. The communications strategy will incorporate measures called for inthe Environmental Management Plan (EMP) for safe culling and disposal of backyardpoultry (US$ 0.81 million). B. CoordinationSupport 34. The multi-dimensional problems associated with H P A Iinfection necessitate collaboration from a wide range o f stakeholders within each country, which in Turkey include: the State PlanningOrganization (SPO), the Undersecretariat of the Treasury, the MARA, the MOH, their associated diagnostic laboratories, NGOs and civil society organizations, and private sector companies and associations (e.g. large poultry production companies, farmers' associations, veterinarians and farmer involvement at the grass roots level). The sub-component will support activities to improve the effective coordination and collaboration among these stakeholders and to bolster project implementation and monitoring capacity at existing project implementation structures inthe MARA and MOH. B1. NationalCoordination 35. The National Zoonotic Disease Committee (NZDC) will serve as the venue for coordinating the national awareness activities described above. It will review the AIHP Project's annual work plans and ensure coordination and linkages across relevant agencies and international partners. InAI outbreak situations, the NZDC i s in charge o f triggering emergency responses by MARA and MOH, monitoring the actions taken, and coordinating public statements to the media. Inthis last area, the N Z D C will be supported by a Public Information andCommunication Specialist hiredunderthe AIHP Project.[(US$ 0.21million). B2. ProjectImplementation 36. The Central Execution Unit (of the Agricultural Reform Implementation Project) in the MARA and the Project Implementation Unit (responsible for the Health Transition Project) in the MOH will be entrusted with the fiduciary tasks o f procurement and financial management. The relevant structures will be strengthened with 3-4 additional fiduciary staff in each Unit. Both the MARA and the M O H will appoint Project Coordinators to liaise with the MAFL4CEU and MOH PKJ, respectively, and to prepare annual work programs and budgets as well as semi- annual interim un-audited financial reports. The Project Coordinators will manage the respective component for which their ministryis responsible and attend the periodic meetings o f the National Zoonotic Disease Committee. The MARA CEU will be responsible for consolidating the annual work plans, budgets and financial reports for submission to the NZDC and the Bank. (US$ 1.25 million) 37. At the local level, implementation would be the direct responsibility o f each Provincial Directorate o f Agriculture (PDA) and Provincial Health Directorate (PHD). At times o f outbreaks, the provincial governor will guide implementation o f cross-sectoral activities, and if necessary set up local disease crisis centers to ensure cross-sectoral coordination. 13  B3: MonitoringandEvaluation(M&E) 38. Support would be provided to enable project monitoring and impact evaluation assessments. Two types of M&E are envisaged. First, the MAR4 CEU and the MOH PIU would collect relevant data from their ministries and other implementation agencies and then compile them into semi-annual progress reports focusing on output indicators and the status o f physical implementation by component and use o f project funds. For some output indicators, specific surveys will need to be conducted to obtain data for this purpose. These would be financed by the Project. As for the financial reports (noted above), the MAR4 CEU will be responsible for consolidating the ministerial progress reports into an integrated project monitoring report. (US$0.5 1million) 39. Impact evaluation reports. The aim o f evaluation i s to find out whether the interventions are effective or the program is having the desired impact. The evaluation will include both quantitative and qualitative aspects and be conducted on a yearly basis. The quantitative aspects will rely on new information systems and surveys implemented as part o f the various components o f the project, currently existing data sources, andprimary evaluative data collection efforts. The goal of the qualitative aspect o f the evaluation will be to document perceptions of program managers, staff, patients, and local and national leaders. Qualitative information will be collected usingsite-visit interviews, focus groups, andrespondent surveys.. 4. Lessonslearnedandreflectedinthe projectdesign 40. Relevant lessons for the design o f the proposedoperationhave been drawn from previous World Bank/IDA and FAO-supported emergency recovery projects. All these experiences and lessons learned have been taken into account in the design o f the proposed GPAI operation. These included the Vietnam Avian Influenza Emergency Recovery Project (approved in early FY05 under OP 8.50 procedures), which is the only project that has been approved by the Bank inresponse to the AvianInfluenzaso far. 41. These lessons learned indicate that project success depends to a large extent on the speed o f the response provided and, particularly when dealing with smallholders' production systems, a speedy, efficient and transparent distribution o f suitable key inputs is clearly a major factor in limiting the impact o f a crisis and hastening recovery. A performance audit o f some o f the emergencyprojects supported by the Bank invarious regions drew the following generallessons: (i) emergency projects should avoid policy conditionality; (ii) design must be simple and project take into account a realistic assessment o f the existing Borrower's capacity; (iii)speedy a appraisal and approval are crucial to provide a prompt response and a substantial contribution to project success; (iv) procurement arrangements need to be flexible and should be finalized at an early stage; (v)mitigation and prevention measures should be included in the design to minimize impacts of a possible recurrence of the disaster; and (vi) realistic assessments should be made o f counterparts absorption capacity, as well as o f the effective communications and coordination mechanisms among all relevant stakeholders. 42. Even though the Vietnam Avian Influenza Emergency Recovery Project has been in implementation for only about one year (effective on November 9, 2004), the main recommendations arising from its implementation havebeen the following: 14  Preparedness i s a key factor. While Vietnam had a national strategy document to control Avian Influenza in the domestic poultry population, it was not clearly understood and shared by all relevant agencies and stakeholders and some aspects of the response havebeen lagging behind. A two-pronged strategy is recommended. This should include: (i) control o f the Avian Influenza at the source in high-risk regions (through aggressive measures including culling, movement control and vaccination campaigns for poultry); and (ii)simultaneously prepare with short and medium-term measures to minimize the risks to humans and prepare for an eventual pandemic. A revised "compensation framework" is an essential element to obtain real cooperation from affected stakeholders (farmers/producers) and to ensure the efficacy o fthe surveillance and diagnosis mechanisms. The importance o f strengthening the technical, scientific and operational capacity of the relevant participating agencies should not be overlooked. The AI crisis highlighted several weaknesses in the animal health as well as public health services systems, including: poor surveillance at the local level, weak diagnostic capacity, lack o f epidemiological expertise and information system, and inadequate operating budget to bear the additional costs o f physical and human cost to contain the spread o fthe disease. There i s an urgent need to organize an effective national response, including all technical ministries in charge o f agriculture/animal health and human health, as well as other relevant sectors, at the national and sub-national level, in case o f a humanepidemic. It is extremely important to raise awareness inthe public and private sectors from the initial moments, and to strengthen effective coordination mechanisms for the implementation o f the necessary technical responses, involving the Government, the donor community, the private sector andthe civil society. Attention should be given to support the integration o f each country to a regional and global framework for the control o f HPAI, and more broadly o f all trans- boundary animal diseases and other emerging infectious diseases, to increase cost-effectiveness and ensure the harmonization o f activities andresponses 43. Interms of public health, the following relevant lessons were derived from emergency operations: Keydata needs shouldbe anticipatedand infrastructure developedto provide information that reduces the number o f assumptions ("what i s not known is as important as stating what i s known"). The program should include mileposts for periodic re-evaluation, so that necessary changes can be made based on new information. External reviews o f the program should be conducted periodically to increase objectivity and improve decision making. Ensure that all localities are able to respond to a pandemic and implement mass vaccination programs effectively. Provide funding to regional and local levels for preparedness and infrastructure development coupled with guidance and technical 15  support. National oversight and assistance i s important to assure nationwide protection and consistency o fthe response. 0 Surveillance systems should be in place, preferably, before starting the program. Communications materials shouldbe developed to educate health care providers and the public. 0 Always keep inmindthe principle: "expect andplan for the unexpected". 5. Alternatives considered and reasonsfor rejection 44. Restructure of and "additional financing" to existing projects. An alternative that was considered was only to restructure ongoing projects and inject financing, in the form o f additional financing (loans) to support the implementation o f the activities contemplated under this Project. After considering this option, it was decided that the importance o f the issue andthe need to scale-up the response at the country-level, requires additional focus and impetus to facilitate the implementation o f priority activities. A separate project option allows for the establishment o f a broader policy framework and alternative mechanisms to manage resource use and monitor the implementation o f activities. More specifically, a separate project allows the preparation o f a multi-sectoral national plan that includes the engagement o f different governmental institutions and civil society, as well as scaled up efforts to serve the entire population. This will also facilitate advocacy andcommunication to mobilize political support at the highest political level needed for mounting effective and sustainable prevention and control efforts. C. IMPLEMENTATION 1. Partnership arrangements 45. The international community and the World Bank can play a key role inthe response to AI, especially at the country levelwhere there is aneedto develop anoverall framework to guide national action plans that can be the basis for government and donor support. Such a framework should address both animal and public health aspects as well as economic impact. This project document and the associated documents which detail the description of activities under the broader program developed by the Government o f Turkey and cooperating donors are an example o f a move in this direction. The overall design o f this program has been informed through the direct input from FAO, OIE, and WHO fact finding missions and assessments as well as direct collaboration with European Commission counterparts inBrussels and the Ankara delegation. Inputs from the U S Agency for International Development (USAID) assessments and technical assistance visits have also helpedto form the overall program. 46. Turkey i s receiving support on the technical content o f an Avian Influenza response from key technical agencies -- WHO for public health and FAO/OIE for animal health. For example, FA0 has a regional Technical Cooperation Programs (TCPs) in the ECA region, in which Turkey will participate. The program's primary objective is to strengthen the capacity for generating and sharing HPAI disease intelligence and emergency preparedness planning. The program's interaction with Turkey will, among other activities, target improved knowledge o f migratory birds' role in HPAI transmission, strengthened laboratory capacity for HPAI diagnosis, and support for development o f Turkey's National AI Strategy. 16  47. In2005, the European Commissionestablished atask force to addressAI whichhasbeen active in analyzing assistance options in various countries, including Turkey. Inlate January 2006 immediately following the Beijing conference on Avian Influenza (January 17-20, 2006), the European Commission gave preliminary approval to a request from the Government of Turkey (a joint MARA/MOH proposal) for a grant o f US$ 12.7 million to parallel finance over US$ 15 million o f the activities covered under the A M P Program. This grant covers a substantial number o f the activities under both the Animal Health and Human Health components. At the same time, the USAID has agreed to provide a grant o f approximately US$ 1.O millionto co-finance training under the Public Information and Coordination component and the poultry sector restructuring fund under the Animal Health component. Taking the AMP Project as a base, the Bank will continue to support the efforts o f the Government of Turkey to access multilateral and bilateral funding, the availability o fwhich i s expected to be clarified over the coming months. This i s especially important in view o f the evolving nature o f the AI challenge inTurkey. 2. Institutionalandimplementationarrangements 48. The Project will be implemented by existing project implementation structures in the MARAandthe MOH. However, public information andproject coordination arrangements will be overseen by the existing National Zoonotic Disease Committee. This Committee has been established jointly by the MARA and the MOH to deal with zoonotic emergencies and will provide general policies and guidelines for Project implementation. The Committee comprises representatives o f the MARA, the MOH, and other relevant ministries, agencies, and academic institutions. The Committee will review annual work plans and ensure coordination and linkages across relevant agencies andinternational partners. 49. Since the Bank i s financing both agricultural sector and health sector projects inTurkey, the existingproject implementation structures within the MARA (the Central Execution Unit of the Agricultural Reform Implementation Project, MARA CEU) and the MOH (the Health Transition Project Unit, M O H PIU) will be entrusted with fiduciary tasks o f procurement and financial management. (Additional staff will to be recruited in the MARA CEU and the MOH PIU as needed for these fiduciary tasks.) One senior officer from the MARA and one from the MOH will be designated as Project Coordinators incharge of managing implementation o f their relevant ministries' project activities and liaising with the MARA CEU and MOH PIU, respectively. These Project Coordinators will provide reports to the NZDC andwould be invited as observers to the NZDC meetings. The NZDC will also be supported by a Public Information and Communications Specialist (consultant) to support its public information efforts. 50. At the local level, implementation would be the direct responsibility o f the respective Provincial Directorates o f Agriculture and Health. At times of outbreaks, the provincial governor will guide implementation o f cross-sectoral activities, and if necessary set up local disease crisis centers to ensure cross-sectoral coordination. 51. A Project OperationalManual (POM) is beingpreparedto integrate the relevant aspects of each o f the Contingency Plans which have been prepared by the MARA and the MOH. This POMwill guidethe management and implementation o fthe Project. 17  3. Monitoring and evaluation of outcomes/results 52. Monitoring and Evaluation (M&E) activities related to the project will be the responsibility o f the MARA CEU and the MOH PIU, with the participation o f the staff o f the departmentso fthe two ministries. These two implementationunits havebuiltupM&Ecapacity, but some detailed surveys for M&E would be contracted out. Monitoringproject progress and the achievement of objectives will entail a process for reviewing continuously and systematically the various project implementation activities. The purpose of the M&E activities are to: (i) measure input, output and outcome indicators (see Annex 3); (ii) information regularly provide on progress toward achieving results and facilitating reporting to the government and the Bank (iii)alert managers, bothingovernment andthe Bank, to actual or potential problems in implementation so that adjustments can be made; (iv) determine whether the relevant stakeholders are responding as expected and intendedby the project; and (v) provide a process whereby the coordinating and executing bodies can reflect andimprove on their performance. 53. The results of relevant M&E activities will be reflected in the semi-annual progress reports. The progress reports will cover the progress with the works, the institutional activities, training and studies, performance indicators and financial reports. A section of the progress reports will be devoted to issues identified during project implementation and the strategies and actions to be taken to resolve such issues that affect progress. The second semi-annual report o f each year will be an annual report, providinginformation o fthe progress duringthe past year. 54. A comprehensive Mid-term Progress Report will be prepared approximately half-way duringthe implementation period (by May 31,2008). This report would support the Mid-tern Review exercise to be carried out by the Borrower and the Bank to discuss the experience accumulated during the first two years o f implementation and to discuss possible adjustment to the project design, implementation schedule and expected outcomes/results. Similarly, a final Evaluation Report should be prepared after the project completion (expected by July 31, 2010) providing detailed information on the accumulated impacts achieved by the project as well as the main lessons learned that could serve for similar operations outside the country. 4. Sustainability 55. Critical to the sustainability o f the Project would be the continuous ownership of this initiative bythe various stakeholders, coupled with strongpolitical support and the availability o f an adequate flow of financial resources to carry out project activities. In addition, institutional sustainability would be ensured by: (i) strengthening o f programs to maintain public awareness of the threat o f avian influenza and other rapid spreading infectious diseases; (ii) sustained surveillance and prevention and control activities, particularly in high risk regions; (iii) strengthened country capacity to manage at national and local levels the risk factors associated with the spread of avian influenza and other infectious diseases; and (iv) effectiveness o f programs to control the spread of avian influenza from birdsto the general population. 18  5. Critical risks andpossible controversialaspects RATING MITIGATION MEASURE FromOutputsto Objective Decline inpolitical commitment to AI and to the Continuing support for inter-country collaboration through threat o f a global influenzapandemic. information exchanges, dialogue, and mobilization o f international commitment andresources. Project implementing agencies do not have M Adequate implementation arrangements inplace as a pre- sufficient authority, leadership, and capacity to condition of Bank financing; careful monitoring o f leadership take leadingrole in AIprevention and control. and project management duringproject implementation; technical assistance and training. Intervention activities not effective incontaining S Project activities will strengthenresponse capacity in selected the spread o f Avian Influenzafrom birds to the priority areas inthe short- and medium terms and lay the human population. foundations for abroader-based strategy, includingbroad awareness and communication campaigns, which will be critical to containing the spread o f a global influenza pandemic. Choosing well designed, cost-effective interventions. Interventions phasedand carefully monitored, allowing for modifications and redesign as needed. Service delivery deconcentratedwith the maximum use of local governments and civil society organizations. Good M&Eto flag emerging issues Inadequateor lack o f multi-sectoral participation M National Zoonotic Disease Committee overseeingthe program selected to be representative and given visibility; annual work programmingtransparent. Low regionaliprovincial-level commitment M Implementationmechanisms explicitly addressprovincial means that strong central commitment does not decision making, communication strategies include translate into action on.the ground. decentralized authorities as targets. FromComponents to Outputs ' Controllingthe spread o f the pandemic may M Project will support advocacy and coalition building to sensitize expose the government to criticism for the key groups including policy makers and the media. This will be curtailment o f civil rights due to the adoption of complementedby carefully designed mass communication quarantines and other related measures. campaigns to build support for the project among the wider population Lack o f laboratory capacity for prompt diagnosis S Project activities will be coordinated with efforts undertaken by and surveillance and o f sufficient quantityof other internationalorganizations such as WHO, that has drugs and other medical inputs neededto address established an international antiviral stockpile with donations the needs ofthe generalpopulationduring a from the pharmaceutical industry(e.g., Roche's donation o f pandemic three milliontreatment courses o fthe antiviral oseltamivir). Inadequateinstitutional capacity to manage Capacity building and institutional development as one o f the project andperform effectively M project's key objectives Emphasis on deconcentration and partnerships. Financialresources not accessible ina timely M Rapiddisbursementprocedures and simplified public sector manner, weak procurement management procurement inaccordance with OP for emergency operations. Lack o f timely and predictable access to expert M Project activities are designed and implemented with leading advice and technical support multilateral agencies such as FA0 and WHO; regional bodies such as the EuropeanUnion; andbilateral and other donor organizations. Publication o f audit results and achievements; transparency in decision and resource allocation. Technical assistance andpartnership between local surveys and monitoring and evaluation organizations and internationalinstitutionswill be provided. M&Eplanwill include information on instruments for data collection, agencies responsible and a detailed time table OverallRiskRating: M [ (Modest Risk), N(Negligible or Low Rsk) 19  56. Possible ControversialAspects. The Project will support the implementation o f immediate term responses to an influenza pandemic -- the classic "social distancing measures"-- such as quarantine, bans on mass gatherings, and travel restrictions that may be politically and socially controversial. This means that dialogue and compromises are needed among different stakeholders, backed by a well-designed communication strategy. A high degree o f political commitment to preventing and controlling the spread o f infectious diseases such as an influenza pandemic would b eneededfor managing controversies that will undoubtedly arise. 6. Main loanconditions 57. The key conditions needed to minimize the risks to the Project have been addressed by Turkey's meeting the eligibility requirements for entering the GPAI (noted in para. 20 above). Specific provisions have been developed to meet the standard requirements covering organization and staffing of program units, management arrangements, and provisions for procurement and financial management. These were confirmed during Project appraisal. In addition, the MARA and MOH have prepared Annual Action Plans, satisfactory to the Bank, for the first year o f their respective components. The condition o f effectiveness for the Loan would bethat the MARA andM O Hhave appointed their respective Project Coordinators. 58. A disbursement condition for the Animal Health component is the adoption by the Borrower o f an Environmental Management Plan satisfactory to the Bank. It i s also required that the payments under the Compensation Fund and the selection and implementation o f Poultry Restructuringsub-projects are made in accordance with criteria and procedures set forth in the Project Operational Manual (POM). The adoption o f a POM by the Borrower is a dated covenant (June 30, 2006). In addition, the Borrower shall monitor and evaluate the project and report on its progress through semi-annual Project Reports andprepare a mid-term review report byMay 31,2008. D. APPRAISAL SUMMARY 1. Economicanalysis 59. Neither the timing nor the severity o f the next pandemic can be predicted, but with the virus now endemic inbirdpopulations inAsia the risk will not be easily diminished. Given the recent outbreaks in poultry in the Manyas Lake area and then more widely throughout all o f Turkey's regions, and in view of the spread to humans which is now occurring, the situation faced by Turkey i s urgent. The emergence o f a human influenza pandemic caused by a lethal virus would have a social and economic impact many times greater than the impact on the poultry sector. This would be through the costs associated with public and private efforts to prevent the emergence or spread o f the disease in humans and to treat its effects and the economic consequences of sickness or death resulting from the disease outbreaks. However, the much more uncertain predictability o f a human pandemic has caused the economic analysis o f the Project to focus on the economic losses inthe poultry sector 60. Inthis treatment of HPAI as an animal health issue, actions to be taken by Turkey are analyzed using the traditional "without project" and "with project" scenarios. These costs and 20  benefits estimated on the basis o f the recent outbreak in Manyas. Under the "without project" case, the low capacity o f government and the poultry industry to deal with outbreaks causes the sector to be increasingly vulnerable to a catastrophic AI occurrence. This catastrophic event (CE) would be characterized by multiple, simultaneous outbreaks leading to a spread o f the disease to large sections o f the country's poultry flock, and eventually to a long-term reduction of the sector by 20-40%. This is caused by massive public aversion to poultry consumption leading to a significant and sustained drop inprices and demandfor poultry. 61. Under the "with project" scenario, the probability o f the CE is reduced gradually to less than half that under the "without project" scenario (by year 4 of the Project). The stream of expected costs inthis scenario is calculated bymultiplyingthese probabilities with the respective NPVs of costs. Given project expenditures of US$ 55.2 million, the analysis yields an NPV of US$ 415.9 million. (Annex 8 presents a detailed discussion o f the economic analysis and calculation o f the project's NPV.) 2. Technical 62. Animal Health. The successful implementation o f the program depends on a phased multi-disciplinary strategy based on a sound epidemiological approach to control HPAI outbreaks. This strategy has to take into consideration a broad range o f epidemiological scenarios that exist indifferent poultry production systems inthe affected countries and different levels o f incidence (ranging from high incidence with variable flock outbreaks, though low frequency disease outbreaks with partial flock immunity, to sporadic outbreaks). A balanced combination o f appropriate disease-control options, tailored to the specific characteristics o f each country andits farming systems i s essential for the achievement of the program objectives. 63. The implementation o f the program and o f each o f the individualcountry projects raises important technical issues andpresents substantial challenges. The main issues are: e The capacity of Veterinary Services. The General Directorate for Protection and Control (and its associated regional laboratories) i s under-equippedto deal with the scope, severity and rapid spread o f the HPAIoutbreaks. This i s particularly evident in the area o f surveillance and diagnostic capacity needed for the early detection andreporting o f anoutbreak and to monitor the disease. e Bio-security measures. These are essential to prevent the spread o f the virus from infected premises (bio-containment) and to exclude the virus from uninfected locations (bio-exclusion). These have proven to be successful to date in Turkey, but local capacity and experience in practicing effective measures still needs strengthening. e Epidemiological expertise. The incorporation o f epidemiological studies linked to disease control programs, to generate quantitative and geo-referenced data on infection and transmission dynamics, i s another key success factor. These are part o f the Project's supported activities. e Harmonized disease information systems. The importance o f harmonized disease information systems, linked to disease surveillance and epidemiological programs i s widely accepted. Turkey participates inthe WAHIS, and the upgrading o f Turkey's WAHIS module under the Project will support long-term control programs. e Wildlife species and reservoirs are a source of HPAI. Epidemiological studies suggest that some species of migratory wild birds have played a role in the transmission of H5N1 viruses to domestic poultry. There is major difficulty in applying bio-security measures aiming at avoiding the 21  contact between the migratory andother wild birds and domestic poultry. However, the small share o f backyard poultry (less than 5 percent) inTurkey appears to indicate that the eradication o f the virus to prevent H P A Iinfection may achievable. e Poor coordination between public agencies and weak linkages with the private sector. Less than efficient coordinationbetween government ministries and agencies, as well as weak linkages with private sector actors, have hampered long-term planning for infectious disease control in a number o f countries. Giventhe zoonotic and transboundary nature ofthis disease, a well coordinated public-private response i s essential. Turkey is expected to build on the close cooperation which was evidenced duringthe October 2005 AI outbreak. 64. Public Health - Technical Considerations. In terms o f public health, the swine influenza experience provides a benchmark for decision-making and public health response to the threat o f an influenza pandemic. Yet, how relevant are the experiences and lessons o f 1976 for a pandemic response today? Substantial changes in public health preparedness and infrastructure, in vaccine manufacturing and delivery, and in society have occurred which will affect a pandemic response. International surveillance for influenza and the strains that cause infection is much stronger than in 1976. The additional surveillance data available today will provide a much stronger basis for assessing the likelihood of a pandemic. Experience has shown that new influenza strains can cause clusters o f human diseases without becoming widespread. Improvements also have been made inpublic health preparedness planning, and communications betweenthe different levels o f a health system. 65. Despite these changes, many o f the lessons from the swine influenza experience remain relevant and, as demonstrated by the experience implementing smallpox vaccination, remain as significant challenges. The needto identify adverse effects following vaccination as coincidental or causal also remained problematic. Separating risk assessment and risk management, conduct o f external program reviews, improved communications planning, and strong surveillance for vaccine safety all are areas where the lessons o f swine influenza were appropriately applied in the smallpox program. 66. Lessons from swine influenza also were considered indeveloping the pandemic influenza preparedness and response planunder the GPAI. The importance o fplanningby Turkey's M O H at the different levels o f the system during the inter-pandemic period o f strengthening key infrastructures, and of exercisingresponse plans needs greater emphasis andwill be addressedby the Project. 3. Fiduciary 67. Financial management. The financial management functions o f the project will be handled by the Central Execution Unit (CEU) in MARA and the Health Transition Project ImplementationUnit (MOH PIU) inMOH. The M O H PIU and the C E U will be responsible for the flow o f funds, accounting and reporting in their respective ministries. Both units will be coordinating their work, but the overall responsibility for reporting purposes will lie with the CEU. An action plan i s prepared to bringthe financial management arrangements inbothunitsto a satisfactory level and i s presented inAnnex 7 o f the PAD. 22  68. A financial management assessment o f the MOH PIU, responsible for financial management o f the HTP, was undertaken in 2004 to determine whether the financial management arrangementsare acceptable to the Bank. The financial management arrangements o f the MOH PIU have beenreviewed periodically as part o f project supervision, and have been satisfactory. The MOH PIU has established and maintained a good financial management system for the implementation o f HTP. The financial management arrangements are considered capable of supporting the implementation o f the Avian Influenza Control and HumanPandemic Preparedness andResponse Loan after the action plan, presented inAnnex 7, i s implemented. 69. Procurement assessments o f the MARA CEU and the MOH PlU have been made in accordance with the requirements o f OP 11.OO. The agreements covering procurement methods and thresholds have been determined for Turkey according to its capacity and experience with Bank procurement and are consistent with ERA assistance guidelines. The procurement agreements have been appraised and detailed in the procurement plan for the first three years of the Project (summarized in Annex 7). The General Procurement Notice i s to be issued on or about April 15,2006. 70. Procurement will be accelerated in the first six months o f the Project by allowing Shopping procedures to be used for a certain number of emergency contracts, whose size would usually be above the normal ceiling for Shopping. These cover mainlythe following: safety gear for veterinary andhealthservices personnel; equipment andrapid test kits, and other reagents for MARA reference laboratories and MOH laboratories; and, two mobile incineration plants and related containers for culling. 4. Environmentand social aspects 71. Activities under the Project are not expected to generate any adverse environmental effects as they are focused largely on public sector capacity building and improved readiness for dealing with outbreaks of avian influenza in domestic poultry. These prevention-focused activities are expected to have a positive environmental impact as the Project's investments in facilities, equipment, and training for laboratories will improve the effectiveness and safety over existing avian influenza handling and testing procedures by meeting international standards established by the OIE. This would be reinforced by the mainstreaming o f environmental safeguards into protocols and procedures for the culling and disposal o f animals during AI outbreaks. In addition, whatever waste i s generated in laboratory facilities will be managed using existing guidelines inTurkey. 72. Though no social safeguard policy is triggered by the Project, the Project is designed to mitigate the negative impacts of mandated culling o f poultry on small scale backyard poultry producers. Even though this impact i s not expected to be large (likely no more than 5% o f backyard poultry producers' value of household consumption), mitigation measures have been designed, and their further refinement is envisaged during the initial implementation period o f the Project. First, a state compensation fund will be set up under the Project (with an initial reserve o f US$ 5 million) to pay producers roughly the full current value o f their culled poultry. A second project reserve (an additional US$ 4.5 million) will also be established to target the restructuring needs of the poultry sector which arise as a result of the enforcement o f the culling policy inareas affected by AI. This will be designed to mitigate the mediumto long-term effects 23  on producers (mainly of the backyard type) who are requiredto discontinue poultry production in areas which have been affected byAI. 73. Third, the project team agreed with the Ministry o f Agriculture andRural Affairs on the desirability o f using part o f the Village-based Participatory Investments Program (under the existing Agricultural Reform ImplementationProject) on the needs o fpoultry producers affected by the culling of poultry in affected areas. Lastly, during the initial stage of project implementation, the project team will pursue with the representatives of the commercial poultry sector a voluntary initiative by the commercial poultry sector to provide poultry products free of charge to backyard producers who have been forced to discontinue poultry raising. This would be at the level o f household consumption formerly raised by backyard poultry producers and extended for a two to three year period. 5. Safeguard policies Environmental assessment Environmental Category B 74. Environmental Assessment and Environmental Management Plan. Since the Project supports investments in incineration capacity for culled poultry (and potentially for disposal o f other livestock and laboratory wastes), the Project i s assessed as a B-category project. An Environmental Assessment (EA) and an Environmental Management Plan (EMP) for the deployment o f incineration capacity (mainly mobile but also potentially through stationary incineration units) will be necessary. This EMP will also cover the clean up o f animal wastes o f culled poultry by the local public veterinary services supported under the Project. The scope o f this EMP will be specified in early project implementation, as a waiver for the requirement to complete the EA and EMP during project preparation has been sought and obtained per para. 12 of OP 4.01. Preparation of the EA and EMP is expected early inproject implementation, and the EMP's adoption by the Government is set as a disbursement condition for the Animal Health component o f the Project. Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OPBP/GP 4.01) [X1 [I Natural Habitats (OPBP 4.04) [I [XI PestManagement(OP 4.09) [I [ XI Cultural Property(OPN 11.03, beingrevisedas OP 4.11) [I XI Involuntary Resettlement (OPBP 4.12) [I IndigenousPeoples (OD 4.20, beingrevisedas OP 4.10) [I [X1 [X1 Forests(OPBP 4.36) [I [X1 Safety of Dams (OPBP 4.37) [I [X 1 ProjectsinDisputedAreas (OP/BP/GP 7.60)* [I X[ 1 [X 1 Projects on InternationalWaterways (OPBP/GP 7.50) [I * By supporting theproposedproject, the Bank does not intend toprejudice theJinal determination of theparties' claims on the disputedareas 24  6. Policy Exceptions andReadiness 75. The only policy exception requestedhas beenwith regard to the waiver o fthe completion o f the EA and EMP per para. 12 of OP 4.01. This waiver has been approved by Bank senior management. The project meets the regional criteria for readiness for implementation, 25  ANNEX1:KEY FACTS ABOUT AVIAN INFLUENZAAND AVIAN INFLUENZAA (H5N1VIRUS) TURKEY: AVIAN INFLUENZA AND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT What is Avian Influenza(birdflu)? 1. Bird flu is an infection caused by avian (bird) influenza (flu) viruses. These flu viruses occur naturally among birds. Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. However, bird flu is very contagious among birds and can make some domesticated birds, including chickens, ducks, andturkeys, very sick andkillthem. Do bird flu virusesinfecthumans? 2. Bird flu viruses do not usually infect humans, but several cases of human infection with birdfluviruses have occurredsince 1997. What is an avianinfluenzaA (H5N1)virus? 3. Influenza A (H5N1) virus - also called "H5N1 virus" - is an influenza A virus sub-type thanoccurs mainly inbirds. Itwas first isolatedfrombirds(terns) inSouthAfrica in 1961. Like all bird flu viruses, H5N1 virus circulates among birds worldwide, i s very contagious among birds, and canbe deadly. What is the H5N1birdflu that has recentlybeenreportedinAsia? 4. Outbreaks of influenza H5N1 occurred among poultry in eight countries in Asia (Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam) during late 2003 and early 2004. As that time, more than 100 million birds in the affected countries either died from the disease or were killedin order to try to control the outbreak. By March 2005, the outbreak was reported to be under control. Beginning in late June 2004, however, new deadly outbreaks o f influenza H5N1 among poultry were reported by several countries in Asia (Cambodia, China, Indonesia, Malaysia {first time reports}, Thailand, and Vietnam). It is believed that these outbreaks are ongoing. Human infections o f influenza A (H5N1) have been reportedinThailand, Vietnam and Cambodia. What is the riskto humanfromthe H5N1virus inAsia? 5. The H5N1 virus does not usually infect humans. In 1997, however, the first cause o f spread from a bird to a humanwas seen during an outbreak of bird flu inpoultry inHong Kong. The virus caused severe respiratory illness in 18 people, 6 of which died. Since then, there have been other causes of H5N1 infection among humans. Most recently, human cases o f H5N1 infection have occurred in Thailand, Vietnam and Cambodia during large H5N1 outbreaks in poultry. The death rate for these reported cases has been about 50 percent. Most of these cases occurred from contact with infectedpoultry or contaminated surfaces; however, it i s thought that a few cases o f human-to-human spread o fH5N1 may have occurred. 26  6. So far, spread o f H5N1 virus from person to person has been rare and spread has not continued beyond one person. However, because all influenza viruses have the ability to change, scientists are concerned that the H5N1 virus could one day be able to infect humans and spread easily from one person to another. Because these viruses do not commonly infect humans, there is little or no immuneprotection against them in the human population. Ifthe H5N1 virus were able to infect people and spread easily from personto person, "influenzapandemic" (worldwide outbreak o f disease) could begin. N o one can predict if and when a pandemic might occur. However, experts from around the world are watching the H5N1 situation in Asia very closely and are preparing for the possibility that the virus may begin to spread more easily andwidely from personto person. How are bird flu viruses different fromhumanflu viruses? 7. There are many different sub-types o f type A flu viruses. These sub-types differ because of certain protection on the surface o f the flu A virus (hemagglutinin {HA} and neuraminidase {NA} proteins). There are 16 different HA sub-types and 9 different NA sub-types of flu A viruses. Many different combinations o f HA andNA proteins are possible. Each combination i s a different sub-type. All sub-types o f flu A viruses can be found inbirds. However, when one talks about "bird flu" viruses, one usually refers to flu A sub-types that continue to occur mainly inbirds. They do not usually infect humans, even though we know they can do so. Humanflu viruses are referred to as those sub-types that occur widely in humans. There are only three known sub-types o f human flu viruses (HlN1, HlN2, and H3N2); it i s likely that some genetic parts of current humans flu A viruses came from birds originally. Flu A viruses are constantly changing, andthey might adapt over time to infect and spread amonghumans. What are the symptomsofbirdflu inhumans? 8. Symptoms of bird flu in humans have ranged from typical flu-like symptoms (fever, cough, sore throat and muscle aches) to eye infections, pneumonia, severe respiratory diseases (such as acute respiratory distress), and other severe and life-threatening complications. The symptoms of bird flu may depend on which virus caused the infection. How does birdflu spread? 9. Infected birds shed flu virus intheir saliva, nasal secretions, and feces. Susceptible birds become infected when they have contact with contaminated excretions or surfaces that are contaminated with excretions. It is believed that most causes o f bird flu infection in humans have resulted from contact with infectedpoultry or contaminated surfaces. What is the riskto humansfrombirdflu? 10. The risk from bird flu is generally low to most people because the viruses occur mainly among birds and do not usually infect humans. However, during an outbreak o f bird flu among poultry (domesticated chickens, ducks, turkeys), there i s a possible risk to people who have contact with infected birds or surfaces that have been contaminated with excretions from infected birds. The current outbreak o f avian influenza A among poultry in Asia is an example o f a bird flu outbreak that has caused human infections and deaths. In such situations, people should 27  avoid contact with infected birds or contaminated surfaces, and should be careful when handling and cooking poultry. How i s infectionwith H5N1virus inhumanstreated? 11. The H5N1 virus currently infecting birds inAsia that has causedhumanillness and death i s resistant to amantadine and rimantadine, two antiviral medications commonly used for influenza. Two other antiviral medications, oseltamavir and zanamavir, would probably work to treat flu causedby the H5N1 virus, though studies still needto be done to prove that they work. I s there a vaccine to protecthumansfromH5N1virus? 12. There is currently no vaccine to protect humans against the H5N1 virus that is being seen inAsia. However, vaccine development efforts areunderway. Researchstudies to test avaccine to protect humans against H5N1 virus began in April 2005. Researchers are also working on a vaccine against H9N2, another bird flu virus sub-type. What does CDC recommendregardingthe H5N1birdflu outbreak inAsia? 13. In February 2004, CDC provided US. health departments with recommendations for enhanced surveillance ("detection") in the US. of avian influenza A (H5N1). Follow-up messages (Health Alert Network) were sent to the health departments on August 12, 2004, and February 4, 2005, both reminding health departments about how to detect (domestic surveillance), diagnose, and prevent the spread of avian influenza A (H5N1). It also recommended measures for laboratory testing for H5N1 virus. CDC currently advises that travelers to countries inAsia with known outbreaks of influenza A (H5N1) avoid poultry farms, contact with animals in live food markets, and any surfaces that appear to be contaminated with feces from poultry or other animals. 28  ANNEX 2A: SUMMARY OF THE FA0AND THE OIE GLOBAL STRATEGYFORTHE PROGRESSIVE CONTROL OFHIGHLY PATHOGENICAVIAN INFLUENZA (HPAI) TURKEY: AVIAN INFLUENZAAND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT 1. Vision and goal. The long-term vision o f the strategy is to minimize the global threat andrisk of HPAIinhumans anddomestic poultry, through progressive control anderadication o f HPAI, particularly that caused by the H5N1 virus, from terrestrial domestic poultry in Asia, Achieving this goal will diminish the global threat o f a pandemic, stabilize poultry production, enhance a robust regional andinternational trade inpoultry and poultry products, increase human andfood safety, andimprove the livelihoods ofthe ruralpoor. 2. A phased approach. The global strategy will be implemented over three time frames: immediate to short (1-3 years), short to medium (4-6 years) and medium to long term (7-10 years). During this period the spread o f HPAI, mainly o f the H5N1 strain, will have been progressively controlled indomestic poultry o f all infected countries o f Asia, andpreventedfrom affecting those Asian countries not currently infected, but at highrisk. 3. The immediate to short-term objective is to reduce the risk to humans by preventing W h e r spread of HPAIinthose countries that are currentlyinfectedby H5N1. 4. Over the medium to long-term (7-10 years), a more focused approach to HPAI will be mounted to progressively eradicate the disease from the remaining compartments o f infected domestic terrestrial poultry in the region. The medium-to-long term strategy will consider all control measures, including vaccination, zoning and compartmentalization as defined inthe OIE Terrestrial Animal Health Code. For the long-term success o f this strategy, restructuring of the poultry sectors inthe region will needto be seriously considered. 5. To prevent the threat o f HPAIfrom spreadingto avian influenza-free countries, the long- term strategy supports the development o f active surveillance programs and emergency preparedness plans for non-infected, at risk countries. The application o f OIE standards relating to the international trade o f poultry and poultry products will further assist in preventing the spread o f HPAIvirus across continents. 6. Capacitybuilding. Inadequate capacity inmany countriesis the principal limitingfactor for effectively and quickly stamping out and controlling infectious diseases. Thus, the strategy suggests buildinga strong and sustainable humanandphysical resource capacity inthe countries, to respond in a more effective and timely manner in stamping out not only HPAI outbreaks, but also other newly-emerging infectious zoonotic and trans-boundary animal diseases. Capacity building will be wide ranging and include all aspects o f disease control as well as policy development and socio-economic impact analysis. 7. Strategic research. The global strategy recognizes that the dynamics ofthe current rapid spread and persistence o f HPAI remain unclear. Therefore, the strategy will facilitate strategic research to investigate the epidemiology o f avian influenza, evaluate the efficacy o f vaccines in 29  domestic ducks to reduce the virus shedding in domestic duck reservoirs, and work in close collaboration with regional and international advanced research institutions to promote the development o f improved vaccines and rapid diagnostic tests. Risk analysis o f various poultry production systems and along marketing chains will be carried out to better target effective disease control. 8. Implementation. Implementation will be at the national, regional and international levels. At the national level, well-defined country specific projects will be formulated, which will be underpinned by the formation o f sub-regional HPAIsupport units. Through these units, sub-regional disease diagnosis and surveillance and socio-economic and policy analysis networks will be established. These sub-regional networks will provide the lead in the development o f harmonized technical standards and regional policies related to the management of live animal movement, compensation plans, capacity building, disease reporting requirements and longterm planningto restructure poultry sectors. 9. At the international level, coordination o f the national programs and sub-regional networks will be under the umbrella o f GF-TADs (global framework for the control o f trans- boundary animal diseases), a joint FAO/OIE initiative. The international coordination will provide technical backstopping to the sub-regional networks and national programs, promote international cooperation, and mobilize and coordinate resources for H P A Icontrol. 10. Partners. The mainpartners inimplementation o f the strategy will be infected andnon- infected at-risk countries, and regional organizations, all o f which are committed to controlling trans-boundary animal and zoonotic diseases. Given the zoonotic nature o f the HPAI, and the complex interface between fanning systems, livestock trade, food safety and public health, a strong international partnership among FAO, OIE and WHO will be continued. A number o f other partners will be involved, important among these would be the private sector, NGOs, and regional national agriculture extensions systems (NARES). 11. Resources. The implementation of the strategy will require funding to support the national, regional andinternational HPAIcontrol programs as outlined above. Frameworkfor Implementation 12. A Framework for Implementationhas been developed by FAO/OIE, promoting national, regional andinternational initiatives. It includes the following: Nationa1initiatives: 0 Development o f a National Strategy for each country specific to its own conditions. It would address farming systems, presence/absence o f ducks, presence o f human cases or not, trade orientation, implementationcapacity, andwildlife migration patterns; 0 Preparation o f contingency and emergency preparedness plans; 0 Development o f economic impact andpolicy frameworks; 0 Prevention o f avian influenza to non-infected at-risk countries through awareness, reporting, and early detection; and 30  0 Improvement inepidemiological information on source o f infection and transmission dynamics in farmingsystem andmarketplaces. Regional initiatives: 0 Standardization o f diagnosis andreportingtechniques among countries; 0 Sharing o f disease informationbetweencountries; 0 Development of a regulatory framework for management o f animal movements; and Promotion o f adherence to OIE guidelines to facilitate regionaltrade. Global initiatives: Strengthening of partnerships (FAO, OIE, WHO, UNDP, donors); Support for global networks (OIE Global Service Center supported by WB/DGF and donors); Support for sub-regional networks -- OIE/FAO epidemiology collaborating centers and Avian InfluenzaNetwork; Further development of control strategies for trans-boundary animal diseases (utilizing the GF- TADs mechanism); Development of a Global Early Warning System (FAO/OIE/WHO); Coordination of research on improved tools for avian influenza control; Provision of global vision for avian influenza control; and Mobilization of resources through donor liaison and advocacy. 31  ANNEX2B: SUMMARY OFTHEWORLDHEALTH ORGANIZATION (WHO) STRATEGY TURKEY: AVIAN INFLUENZAAND HUMANPANDEMICPREPAREDNESSAND RESPONSEPROJECT 1. The strategic planlays out activities for individual countries, the international community and WHO to prepare for a pandemic and mitigate its impact. The objectives o f the plan correspond to the opportunities to intervene and are structure inthe following three phases: Phase Pre-Pandemic: - (i) opportunitiesfor humaninfection. Animmediatepriorityistohaltspreadin Reduce poultry to reduce human exposure to the virus. More intensive collaboration i s needed between the animal and health sectors. Communication activities targeting stakeholders, particularly rural poultry holders, should be strengthened. Workers carrying out the culling o f poultry must be protectedagainst infection by clothing and equipment. (ii)Strengthentheearly warningsystem. To assessriskstopublichealthandguide protective measures, information i s needed on the extent o f influenza infection in animals and humans andon circulating viruses. National surveillance systems must be improved urgently in potentially affected countries. When outbreaks in animals occur, active human case detection should be pursuedby a coordinated animal-human health team. Phase Emergenceof a Pandemic: - (iii)Containordelayspreadatthesource. Aggressivecontainmentmeasuressuchas isolation and prophylactic use of antiviral drugs may slow pandemic spread and allow time for response measures. An international stockpile o f antiviral drugs for an emergency response should be established, startingwith a stockpile for targeted early use. Phase-PandemicDeclaredandSpreadingInternationally: (iv) Reduce morbidity, mortality, and social disruption. Although mass vaccination is the preferred intervention, serious issues related to the time lag between emergence o f the virus and vaccine production as well as production capacity constraints must be addressed. Anti-viral supply andproduction capacity are also limited. Therefore, the mainresponses inthe immediate term should be classic "social distancingmeasures" such as quarantine, bans on mass gatherings, qnd travel restrictions, backed up by a well-designed communication strategy. For the longer term, options with industry to improve antiviral and vaccine capacity needto be explored. (v) Conduct research duringpandemic. Research is needed for policy development and adjustments for current and future epidemics. The main elements include: assessing the epidemiologic characteristics; monitoring the effectiveness o f the interventions; and evaluating the medical and economic consequences. 32  Recommended Strategic Actions 2. In view o f the immediacy of the avian influenza threat, WHO recommends that all countries undertake urgent action to prepare for a pandemic. Advice on doing so is contained in the recently revised W Oglobal influenza preparedness plan (2005) and a new IYHO checklist for influenza pandemic preparedness planning (2005). Table 1 describes the phases o f increasing public health risk associated with the emergence o f a new influenza virus subtype that may pose a pandemic threat, and the overarching public health goals under eachphase. Table 1: Phases of IncreasingPublicHealthRiskAssociated with the Emergencyof aNew InfluenzaVirus Subtypethat May Pose a PandemicThreat PHASES OVERARCHING PUBLIC HEALTH GOALS Interpandemic period ~~ Phase1.N o new influenza virus subtypes have beendetected in Strengtheninfluenza pandemic preparedness at humans. An influenza virus subtype that has caused human infection the global, regional, national and sub-national may be present inanimals. If present inanimals, the risko f human levels. infection or disease is consideredto be low. Phase 2. No new influenza virus subtypes have beendetected in Minimize the risk o f transmission to humans; humans. However, a circulating animal influenza virus subtype poses a detect and report such transmission rapidly ifit substantial risk o f human disease. Pandemic alert period Phase3. Humaninfection(s) with a new subtype, butno human-to- Ensure rapid characterization o f the new virus human spread, or at most rare instances o f spread to a close contact. subtype and early detection, notification and response to additional cases. Phase4. Small cluster(s) with limited human-to-human transmission Containthe new virus withn limited foci or but spread is hghly localized, suggesting that the virus is not well delay spread to gain time to implement adapted to humans. preparedness measures, including vaccine develoDment. Phase5. Larger cluster(s) buthuman-to-human spread still localized, Maximize efforts to contain or delay spread, to suggesting that the virus i s becoming increasingly better adapted to possibly avert a pandemic, and to gain time to humans, butmay not yet be hlly transmissible (substantial pandemic implement pandemic response measures. Pandemicperiod Phase 6. Pandemic: increased andsustained transmission ingeneral Minimize the impact o f the pandemic. population. a The distinction between phase 1and phase 2 i s based on the risk oj iumaninfection or disease resulting fiom circulating strains inanimals.-The distinction i s based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity inanimals and humans,occurrence indomesticated animals and livestock or only inwildlife, whether the virus is enzootic or epizootic, geographically localized or widespread, andor other scientific parameters. b The distinctionbetween phase3, phase4 andphase5 is basedon an assessmento fthe risk o fa pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include rate o f transmission, geo-graphical location and spread, severity o f illness, presence of genes fromhuman strain (ifderived from an animal strain), andor other scientific parameters. Source: WHO 2005 3. In order to accomplish the public health goals described for each phase, WHO recommends strategic actions that can be undertaken to capitalize on each opportunity to 33  intervene. Given the many uncertainties about the evolution o f the pandemic threat, including the amount o f time left to prepare, a wise approach involves a mix o f measures that immediately address critical problems with longer-term measures that sustainably improve the world's capacity to protect itself against the recurringpandemic threat. 4. The strategic actions are: Reduceopportunitiesfor humaninfection,including: 0 Support to the FAO/OIE control strategy; 0 Intensifycollaboration between the animal andpublic health sectors; 0 Strengthen risk communication to rural residents; and 0 Improve approaches to environmental detection o f the virus Strengthenthe early warningsystems,including: 0 Improve the detection o fhumancases; 0 Combine detection o fnew outbreaks inanimals with active searches for humancases; 0 Support epidemiological investigation; 0 Coordinate clinical research; 0 Strengthen risk assessment; 0 Strengthen existing national influenza centers throughout the risk-prone regions; and 0 Give risk-prone countries an incentive to collaborate internationally. Containor delay spreadat the source, including: 0 Establishan international stockpile o f anti-viral drugs; 0 Develop mass delivery mechanisms for anti-viral drugs; and 0 Conduct surveillance o f antiviral susceptibility. Reducemorbidity,mortalityand social disruption,including: 0 Monitor the pandemic inreal time; 0 Introduce non-pharmaceutical interventions; 0 Use o f antiviral drugs to protect priority groups; 0 Augment vaccine supplies; 0 Ensureequitable accessto vaccines; and 0 Communicate risks to the public. Conductresearchto guideresponse measures,including: 0 Assess the epidemiological characteristics o f an emergingpandemic; 0 Monitor the effectiveness o f humaninterventions; and 0 Evaluate the medical and economic consequences. 34  ANNEX 2C: SUMMARY AND REVIEW OFTHE AVIAN INFLUENZACONTINGENCYPLANSOFTHE REPUBLIC OF TURKEY TURKEY: AVIAN INFLUENZAAND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT 1. To have maximum impact on reducing the spread and cost o f a pandemic influenza, it i s critical that Turkey begin implementing its own country preparedness and response plans. Achieving this is one o f the development objectives o f the proposed project. As a first step, the Avian Influenza contingency planso f Turkey have been reviewed and summarized. PandemicPreparednessAssessment Tool 2. To evaluate the preparedness status and readiness in Turkey, the existing tools prepared bythe European Center for Disease Preventionand Control (ECDC), incollaborationwith WHO and the European Commission have beenused2. Inusing these tools, the objectives have been to: a) To evaluate the status o fpandemic influenzapreparedness inthe country b) To determine a baseline o f preparedness, or to determine progress made since an earlier assessment. c) To identify weaknesses and strengths o fpandemic influenza preparedness. d) To identify steps for improvement. 3. The assessment has focused on the following issues: I.AvianInfluenzaPreparedness(AnimalComponent) 0 I s there awareness o f the current situation in the work regarding avian influenzdconcern about its introduction into the country? YES 0 Contingency plan for an outbreak among birds available, including protection o f people living inthe area andworkers handlingor killingaffectedbirds? YES 0 Collaboration arrangements established with international agencies such as FAO? YES 0 I s there laboratory capacityto test animal specimens for influenza? YES 0 I s the Ministry of Agriculture involved in pandemic preparednesdmember o f national pandemic committee? YES 0 Have exercises been conducted on how to respond to an outbreak inbirds? YES ECDCwith WHO andthe EC, 2005, draftAssessment Toolfor National Pandemic Influenza Preparedness. 35  11. PublicHealthPreparedness SeasonalInfluenza: 0 Seasonal influenza surveillance systems in place and functional? YES (only in 14 provinces) 0 Seasonal influenza vaccination program for target groups inplace? YES PandemicInfluenza(nationallevel) PlanningandCoordination Relevance of pandemic planning recognized by decision makers and preparedness policies developed and adopted?YES Legal and ethical frameworks established coherent with international legislation (International HealthRegulations)? YES National Pandemic PlanningCommittee established? YES Command and control structure in place outlining management and decision-making processes o f all organizations involved inresponse to a health emergency? YES Country has national influenza pandemic preparedness plan that i s consistent with international plans andperiodically updated? YES3 SituationMonitoringandAssessment 0 National system available for influenza surveillance in both humans and animals? YES (humans) 0 Access to at least one laboratory able to offer routine influenza diagnosis, typing and sub- typing, butnot necessarily strainidentification? YES 0 Outbreakinvestigationcapacity available (inventory o fresources available)? LIMITED 0 Contingency plans developed for ongoing monitoring o f impact and resources needs duringthe pandemic phase. PARTIALLY (resources not identifiednor costed) PreventionandContainment 0 National guidance for public healthresponse developed? YES 0 National guidance for civil emergency response developed? NEEDS STRENGTHENING 0 Anticipated resource implications for implementation addressed? YES, DURINGAMP PREPARATION 0 Tabletop exercises conducted andresults usedto improve planning? YES 0 Strategy to access antivirals for national use (e.g., stockpiling) developed? YES PendingMinister'sapproval. 36  0 Priorities and criteria for deployment and use o f antivirals defined?YES 0 Strategy to access pandemic vaccines exploreddeveloped; regulatory issues, liability, intellectual property rights addressed?YES 0 Priorities and criteria for use o f pandemic vaccines defined; preliminary priorities for pandemic vaccines use developed, based on expected availability? NO 0 Logistic and operational needs for implementation o f pandemic vaccines strategy reviewed? N O HealthSystemResponse 0 Health services are informed about national pandemic influenza policies including preparedness plan? N O 0 Contingency plans developed on how to maintainessential services? NO 0 Authorities, responsibilities and pathways identified for command and control o f health systems inthe event o f a pandemic? YES 0 Pharmaceutical and other material supplyneeds estimated; arrangements to secure supply commenced? YES 0 Plans for healthworkers training inpandemic influenza response developed? NO Communication 0 National communication strategy for pandemic influenza established? YES 0 Capacity planned and tested for meeting expected domestic information demands for diverse audiences, including professionalkechnical groups, the news media and general public? NO 0 Networks among key response stakeholders established, including risk communicators, non-health government departments, and professional and technical groups? NO 0 News media with national plans familiarized, including preparedness activities and decision-making related to seasonal and pandemic influenza? NO Categorizationof CountryReadiness 4. On the basis o f the results o f the preparedness assessment, Turkey is assessed as: MODERATE 5. Advanced: An eligible country would have a well developed and approved national preparedness and response plan showing understanding o f the issues and goals for addressing them, actions adapted from internationalguidelines andbest practices to meet nationalpriorities, evidence o f strong public support and a well balanced range o f stakeholders. It would have identified investment priorities to support the implementation o f the plans, have included financing estimates of the needs; defined key indicators for monitoring and evaluating the 37  implementation of national programs; and be conducting ongoing public dialogue andor involvement. 6. Moderate: As for "Advanced" but missing some key elements inthe plans andwithout reliable financial estimations. 7. Low: Many key aspects missing, especially public dialogue and establishment of goals, requiring significant additional identification ofimplementable actions anddirection. 38  ANNEX 3: RESULTSFRAMEWORK MONITORING AND TURKEY: AVIANINFLUENZAAND HUMAN PANDEMIC PREPAREDNESSAND RESPONSEPROJECT ResultsFramework ProjectDevelopmentObjectives ProjectOutcomeIndicators Use of ProjectOutcome Information To minimize the threat inTurkey Evidence* o f improvedeffectivenessofparticipating To determinewhether or not Dosedto humansby HPAIinfection animal andpublic healthservicesinlimiting the spreadof an the projectobjectivehas been md other zoonoses indomestic HPAI outbreak and consequentpandemicinTurkey; achieved. poultryand preparefor the control Evidence*of widespread adoption ofrecommended 2ndresponseto an influenza practicesfor the preventionandcontrolof HPAIamongpoultry pandemicand other infectious producers, distributors,andretail vendors; jisease emergenciesinhumans. Improvingtrend inpoll of experts designedto gauge HPAI readiness inTurkey IntermediateOutcomes IntermediateOutcomeIndicatorsFor EachComponent Use of Intermediate OutcomeMonitoring LAnimalHealthComponent Component1.A:National Policy ComponentLA: Component1.A: framework and development of a Evidence*oftimely and satisfactoryprogresstoward deliveryof To verify satisfactoryand national strate0 - A country- Component 1.A outputs, as comparedto the original plan, timelyprogress in,or specific strategy (and its including specific indicatorsas follows: completionof Component corresponding information system) Detailedassessment ofthe Animal HealthDepartmentof LA. was developed, adopted, and the MARA GeneralDirectoratefor ProtectionandControl disseminatedto control and NationalAI Strategydevelopedandadoptedby eradicateHPAIinareas at risk. govemment. Linkingof Veterinary ControlResearchInstitutes to the WAHIS maintainedby the GeneralDirectoratefor Protection I andcontrol Component 1.B: Strengthening Component 1.B: Component 1.B: ~~ Disease Surveillance and Evidence*o ftimely andsatisfactoryprogress toward deliveryof To verify satisfactoryand Diagnostic Capacity - Animal Component 1.B outputs, as comparedto the original plan, timely progressin, or disease surveillance anddiagnostic including specificindicatorsas follows: completionof Component capacities strengthenedandtraining BSL-3 attainedintwo reference laboratoriesandother I.B. ofthe veterinaryservicesdesigned regionallaboratoriesupgradedto reach75% coverageof at- andcompleted. threat areas; Self-assessmentofthe veterinaryservices executed; I1 100%monitoringofpoultry breedingstock farms. Component 1.C: Outbreak ComponentI.C: Component 1.C: Containment Plan -suppliesand Evidence*oftimely and satisfactoryprogresstoward delivery of To verify satisfactoryand incinerationinvestmentsdeployed Component 1.C outputs, as comparedto the original plan, timely progressin, or infield andcertificationofreadiness including specific indicatorsas follows: completionof Component for rapidresponse (necessaryto Emergencysuppliesprocuredand availableat strategic I.C. control anderadicate an outbreak of locationsinthe field; HPAI) attainedinareas at risk 15 mobile incinerationunitsdeployedand accessibleby areas at risk; Certificationofreadinessrating obtainedfromFAOIOIE (following readinessreview). Significantreductioninunconfinedbackyardpoultry farming CompensationFundestablishedwith clear operating 39  IntermediateOutcomes IntermediateOutcomeIndicatorsFor EachComponent I Use of Intermediate 11. HumanHealthComponent Component 1I.A: Enhancing Component1I.A: Zomponent 1I.A: Program Planning and Evidence* o f timely and satisfactory progress toward delivery o f To verify satisfactory and Coordination-Improved command Component 1I.A outputs, as compared to the original plan, including imely progress in, or and control structures for quarantine specific indicators as follows: :ompletion o f anddisease control inahealth Inter-institutional andmulti-sectoral coordination arrangements Zomponent 1I.A. emergency were developed and inplacewith MARA implemented. National Zoonotic Disease Committee fully operational; National strategic plans for improvement o fpublic health I surveillance and disease control systems prepared according to WHO recommendations, approved and hllyresourced for implementation. Component 1I.B: Strengthening Component 1I.B: Component 1I.B: NationalPublic Health Surveillance Evidence* o ftimely and satisfactory progress toward delivery o f To verify satisfactory and Systems -Measurestoimprove Component ILB outputs, as compared to the original plan, including :imely progress in, or communicable disease surveillance specific indicators as follows: :ompletion o f and control inhumanpopulations at Increased surveillance and outbreak investigation capacity; Clomponent1I.B. riskwere developed, tested and Numbero fpublic healthlaboratories available for routine implemented. influenzadiagnosis and typing rehabilitated and equipped, and with improved biomedical waste management systems; Number ofpublic healthlaboratoriesthat qualifies as national influenzacenter (NIC); [Number o fprovincialpublichealth directorates with a computerized informationand telecommunications systems inplace and operational;] [Number o f provincialpublic health laboratories with a computerized informationand telecommunications systems inplace and operational;] Numberofhealthpersonnel trained in influenzavirus surveillance and control; Numberof sentinel site provinces complyingwith bi-weekly (winter) and monthly (summer) reporting on influenza occurrence; Increasedlaboratory capacity to collect and analyze specimens per day for viral typing, sub-typingand isolation intimes o f surging specimen load; % of specimens tested positive and sub-typed; % ofpositive tests confirmed byreference laboratory; Evidence o f improvedbio-safety in NICs; Biweeklyreport from NICs through M O H to provincialhealth departments on compiled results o f national surveillance (ILIs and confirmed cases) introduced as feedback mechanism. Component 1I.C. Healthcare Component1I.C: Component 1I.C: System Response Capacity - Evidence* o f timely and satisfactory progress toward delivery o f To verify satisfactory and - "Social distancingmeasures" such Component 1I.C outputs, as compared to the original plan, including timely progress in, or as quarantine, bans on mass specific indicators as follows: completion o f gatherings, and travel restrictions, Number ofprofessionals andsupport personneltrained for Component 1I.C. were developed and implemented active surveillance, case finding, and proper diagnosis, treatment and backed up by a communication care to contain outbreaks and reduce occurrence and case fatality -strategy. during both pre-epidemic and pan-endemic phases ; Criticalmedical care networks Cumulative incidence rate (CIR) were strengthened andreadied to m % change inthe AI case fatality rate. cope with increased demand for services, and to prevent the spread o f infection among high-risk populations and health careworkers. 40  IntermediateOutcomes IntermediateOutcomeIndicatorsFor EachComponent Use of Intermediate OutcomeMonitoring 111. PublicAwarenessand Coordin Component1II.A: Public Component1II.A: Component1II.A: Awareness- Evidence* o ftimely and satisfactory progress toward delivery o f To verify satisfactory and -- Coordinated communications Component 1II.A outputs, as comparedto the original plan, including timely progress in, or process involving MARA, MOH, specific indicators as follows: completion o f Ministry o f Interior addressing Political and civic leadership organized around a national Component 1I.A. information/communication needs strategic risk communication plan; o f priority audiences, duringpre- Research-based risk communication strategies and products, pandemic andpandemic A-I phases; -- Informed at-risk communities responding to the needs of priority audiences; Consistent awareness-raising and behavior change interventions adopting safe healthpractices, with population at risk usingappropriate communications channels; reporting, and contributing to % change inreported hygiene and sanitationbehaviors; outbreak control actions; -- Educated citizenry, aware of the Communications strategies and products highlightingthe action sand investments o fparticipatingministries and the mobilizationo f impact and social containment group resources to contain the epidemic, generating social trust and measures needed if AI escalates credibility; across pandemic phases Evidence o f consistent communication and information technologies, to promote reporting o f outbreaks, fast response and an uninterrupted social dialogue; Productionand dissemination o f informational products that educate priority audiences about possible scenarios and mitigation and control actions to beundertaken. Component 1II.B: Coordination Component 1II.B: Component 1II.B: Support-Coordination and Evidence* of timely and satisfactory progress toward delivery o f To verify satisfactory and management o fproject Component 1II.Boutputs, as compared to the original plan, including timely progress in, or implementationand M&E activities specific indicators as follows: completion of carried out in a professional manner Programreports, financial monitoring, procurement and Component I1I.B. disbursement reports, audits, management and financial reports prepared and submitted periodically Methodology defined and monitoring and evaluation L * - viareports from technical and social audit teams (as required). The actual composition o f teams TBD, but likely would draw Periodically und;.i;taken - 41  te 0 E $ 2 0 8 N d  f: 0 N a8 I,. .  3 4 y: cc 1 ; Y 1 i : ; 1 * i 1 I ." .-E 0 Y 0 0  1 3 -9 m P N n 3 9 3 3  ? I t 4  8 -t-- 0 m N    ANNEX4: DETAILEDPROJECT DESCRIPTION TURKEY: AVIAN INFLUENZA AND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT I. ANIMALHEALTHCOMPONENT 1. The Project will support activities proposed by Turkey.to cover the needs in the short, medium or long-term, and ranging from prevention, to control and eradication o f HPAI. These proposedmeasures comprise an integrated package maximizing the possibilities of successbased on a detailed assessment of the particular conditions, constraints and possibilities o f the country (including a rapid assessment o f veterinary services and recent assessments o f the poultry sector). Ingeneral, these activities fall into three major areas: 0 Improvements to the national policy framework, development o f strategies and increasingpreparedness. 0 Strengthening disease surveillance, diagnostic capacity and appliedresearch. 0 Carrying out outbreak containment plans andrestructuring o fthe poultry sector. A. Nationalpolicyframework anddevelopmentof a nationalstrategy A1: Policydevelopmentandenablingenvironment 2. To ensure that disease control, prevention and eradicationmeasures are implementedina uniform and effective way and inaccordance with OIE standards and guidelines, improvement in the regulatory framework and the harmonization andrationalization o f animal health governance and policy issues will be addressed. These are related to bio-security, vaccination, control of animal movement, border control, culling and disposal o f carcasses, compensation, restructuring o fpoultry industry, compartmentalizationandzoning, and other regulations relatedto the poultry sector. Thus, the Project will support definition o f disease control options and reviews and strengthening o f existing regulations and policies, and will fund related policy studies and dissemination workshops. The main outputs will be a detailed assessment o f the capacity o f its veterinary services and an integration o f the AI contingency plans o f the MARA and the M O H into a National AI Strategy. (US$ 0.59 million) A2: Epidemiologyanddisease informationsystems 3. Inthis area, the Projectwill support epidemiological studies andsurveillance programsto inform the improvement of disease control measures, which will be then adjusted and improved as new information becomes available. It will also support the linking o f the laboratory information systems of Turkey's eight Veterinary Control Research Institutes (VCRIs) to the existing module o f the World Animal Health Information System (WAHIS) maintained by the MARA General Directorate for Protectionand Control (GDPC). This will better enable Turkey to participate inglobal disease information sharing, complying with their obligations as members o fthe OIE. Epidemiological studies will include a focus on scaling up the knowledge base o fthe MinistryofEnvironment andForestry onmovement ofmigratory birdsinthe mainareasoftheir known transit. The disease information system will be linked with rapid and standardized 50  methods o f routine analysis of surveillance data in order to track important changes inthe H5N1 situation and promptly supply this informationto field personnel. (US$ 0.48 million) B: Strengthening Disease Surveillance and Diagnostic Capacity B1: StrengtheningAnimal Disease Surveillanceand DiagnosticCapacity 4. Project support in this area will aim at strengthening the capacity o f the MARA GDPC and its affiliated reference and regional diagnostic laboratories in detection, reporting and follow-up o freportedAI cases. This will cover the formation and equipping o f Bio-Safety Level 3 laboratories in Bornova and Pendik, as well as equipment (incubators, laminar flow cabins, etc.) for six regional laboratories (Ankara, Konya, Adana, Samsun, Erzurum and Elazig). Consumables and reagents will be fbnded as needed for the implementation o f the National AI Surveillance Program and for regional laboratories and Provincial Directorates o f Agriculture PDA linked to these laboratories for executing their roles in the MARA AI Contingency Plan (rapid serological tests and screening surveys and virological tests for confirmation and serotyping o f AI strains). The costs o f funded activities (US$ 2.85 million) are composed as follows: Cost inUS$ Needs of National Reference Laboratory (Bornova, Pendik) Laboratory Equipments 957,400 RapidTest Kits and Consumables 318,528 Laboratory Rehabilitation 650,000 Needs of Regional Laboratories (Etlik, Konya, Adana, Samsun, Erzurumand Elazig) Laboratory Equipments 485,600 Test Kits 133,650 Laboratory Rehabilitation 300,000 Total 2.845.178 B2: Veterinary Services Training and AI Surveillance 5. Training will target the personnel o f the MARA General Directorate for Protection and Control, including those o f the VCRIs and the affiliated staff in the Provincial Directorates o f Agriculture which will be expected to form the local Expert Groups o f the Local Disease Crisis Centers (LDCCs). The focus o f the training will be on screening, sampling, and test procedures to be applied in case o f an outbreak, as well as on analyzing epidemiological data and performing risk assessments. Supported activities will also cover an initial self-evaluation o f veterinary services, following OIE standards on quality and evaluation o f veterinary services to meet international requirements. Increased risk-based AI surveillance activities will also be supported at the provincial and district levels, coordinated through the VCRIs. (US$ 2.01 million) C. Outbreak Containment Plan 6. The sub-component will provide support to activities related to the implementation o fthe MARA Contingency Plan for Avian Influenza which details the containment plan for AI 51  outbreaks. The Contingency Plan details the roles o f the National Diseases Crisis Center (NNDC) coordinated by the Head o f the Animal Health Department o f the MARA Protection and Control General Directorate (GDPC), the Local Disease Crisis Centers (LDCCs) set up on the basis o f Animal Health Sections o f the Provincial Directorates o f Agriculture (PDAs), and the National and Local Expert groups. Section 8 o f the Contingency Plan contains the operational manual for the containment plan. The sub-component will include the following activities: C1: Targeting virus eradication at the source 7. Turkey's HPAI control programs include the principle o f targeting the disease at the source o f infection. This refers predominantly to the backyard poultry sector. Wild birds are also implicated as reservoirs o f disease, but the Project does not address the eradication o f avian influenza viruses in avian wildlife. Policies associated with this sub-component that the Government o f Turkey has already introduced and would trigger in outbreak areas include: enhanced bio-security at poultry farms and associated premises, through bio-containment and bio-exclusion, and control o f movement of birds and products that may be infected, including controls at the interface o finfectednon-infected areas andborder controls. 8. Inorder to target the eradicationof the disease at the source ofinfection, the Projectwill support the following activities: (a) culling o f infected and at-risk poultry and compensation to farmers and producing companies (at the full current value of their culled poultry) through the establishment o f a US$ 5 million compensation fund; (b) disposal o f carcasses and potentially infective materials in a bio-secure and environmentally acceptable manner through roughly 15 mobile incineration plants deployed to districts with AI outbreaks. (approximately US$ 500,000 per plant, plus related containers, totaling US$ 8.09 million) 9. Assumingproducerprices o froughly2.3 TLkg, live weights o f 1.5 kgper animal, and a 75 percent compensation rate, the initial $5 million reserve .fundwould be able to cover the culling o f 2.5 million birds (about 1percent o f average poultry stocks). However, the role of the reserve is to assure the public (both producers and consumers) that a formal compensation policy has beendevised, with operational procedures well defined andpublicized, andready to be used. Over time once producers are assured that the reserve fund is well organized, administered in a timely manner, and effective in attracting backyard producers to bring forth potentially infected poultry animals, the Government o f Turkey may work out a mechanism whereby commercial poultry producers pay into the reserve fund, basically as a form o f "insurance premia". Given the high potential losses from even a small, localized outbreak, commercial poultry producers would likely be willing to pay a small insurance premia o f this type if the overall AI Strategy were being well implemented. 10. The incineration plants to be deployed for disposal o f infected and suspect poultry in an outbreak situation would be owned and managed by the GDPC. The costs o f running these incinerators would be shared by the national budget and provincial budgets (with a relevant 52  policy on this cost sharing to be worked out). In times o f outbreak, disposal o f infected and suspect animals wouldbe done without costs to poultry producers. C2: Veterinarypersonnelsafety 11. Due to the highly pathogenic nature o f the HPAI virus to humans, particularly the Asian H5N1strain, training ofpeople incontact with livevirus willbe supported. This would include field workers involved in identification o f the disease, farm workers involved in culling and disposing o f animal carcasses and manure, laboratory workers involved in virus isolation and diagnosis. Adequate resources will be allocated for training and equipment (biosafety hoods and appropriate personalprotective clothing). (US$ 2.85 million). Cost inUS$ EquipmentNeeds of2946 Staff (70 items) 1,071,091 EquipmentNeedsof982Teams(222 items) 1,527,754 Disinfections for the Teams (40 items) 255,320 Total 2,854,165 C3:Restructuringthe PoultrySector 12. Restructuring the poultry sector i s an important strategy to guard against the damaging effects o f HPAI, but also one o f the most complicated interventions to be undertaken since it requires taking into account the structure o f backyard versus commercial poultry production, marketing characteristics, and potential socioeconomic impact. Although backyard poultry accounts for no more than 15 percent o f production in Turkey, the ban on marketing of live backyard poultry has necessitated a ban on the marketing o f live poultry layers (which are mainly in the commercial sector) in order to ensure compliance by backyard poultry producers. Thus, restructuring policy needs to carefblly consider this linkage. In any case, restructuring should be a gradual process, coordinated with an overall disease control strategy that includes bio-security, zoning and/or compartmentalization, andpossibly vaccination, and be based on the following factors andprinciples: 0 Well-defined socio-economic impact analysis, taking into account the interests o f all stakeholders, particularly smallholder poultry farmers; 0 Public awareness to gain full support from these stakeholders (producers, consumers, government agencies, private sector institutions); 0 Market forces should drive the restructuring strategy taking into account commercial and smallholder poultry producers. 0 Public and private sectors should collaborate and be transparent in implementing restructuring strategies. 13. Inthis context, restructuring the poultry sector inTurkey will focus on the reduction of the practice o f backyard poultry raising, improving the opportunity for slaughtering o f layers (and subsequent processing and rendering), and promoting manure management o f backyard poultry that is in conformity with existing environmental regulations. Reduction o f backyard poultry farming could take the form of banningsuch farming inprotection bands around known 53  areas o f highprevalence of migratory birds and investments in improving bio-security (penning o f animals and closing up of barns) in small contracted poultry farms. Since it would be extremely costly for the state to fund widespread programs for poultry sector restructuring, the introduction o f restructuring modalities will be piloted under the Project with matching grants to farms and enterprises providedunder a competitive proposal submission and awardprocess (with at least 50% co-financing byprivate beneficiaries). (US$9.0 million) 11. HUMANHEALTHCOMPONENT 14. Inthe public healthfield, short-and long-termactions needto betaken andanappropriate balance struck between the two. Immediate action is needed in a number o f areas, but there i s also a longer-term agenda given systemic shortcomings with respect to core public health functions. Work on both the short- and long-term fronts, therefore, needs to proceed inparallel, and efforts should be made to ensure that short-term responses are consistent with and contribute to proposedlonger-term interventions. Setting priorities inbothcases is essential. 15. Building an effective national public health response will require an enabling environment and the necessary resources to bringproven interventions quickly up to nationwide scale. Thus, the Project will help to operationalize some elements that are contemplated as part o f the global strategic plan, expanding and intensifying the responses rapidly. As it i s unlikely that the global spread of a pandemic influenza virus could be prevented once it emerges, the emphasis i s on reducing its impact. Several tools can help achieve this aim: (i) year-round surveillance; (ii) effective and accurate methods of diagnosis; (iii) distance interventions; social (iv) vaccines (once they become available); (v) anti-viral drugs; and (vi) strengthened medical services. The interventions supported under the Project are based on Turkey's epidemiological and programmatic needs, and well-assessed options for meeting them. The interventions will be grouped inthree broad categories: A. EnhancingProgramPlanningandCoordination 16. The Ministry o f Health in Turkey already has a draft National Action Plan for Influenza (NIAF'). The NIAF' foresees the establishment of inter-sectoral command and control system structures andprovides the legal basis for an effective response. The project will support meeting the resource requirements for field-testing (e.g., simulation exercises) and implementation involving regional and local levels, as well as supranational levels. More specifically, the project will support training of healthpersonnel, provincial and local level meetings and workshops and procurement o fprotective gear, clothing and sample transportation containers, upgrading o f drug storage facilities, and improving health information and telecommunication systems through the Public Information Center (SASIM) and the Crisis Management Center at the Ministry o f Health. (US$ 14.88 million) 54  Cost inUS$ Protective Gear and Clothlng 7,778,000 Notebook Computers for staff involvedinAI-PI interventions 50,000 Training for Province Health Managersand CommunicableDiseasesDivision Chiefs 40,000 NationalEIS training 500,000 Regional, Provincial and Scientific Meetings 400,000 Preparation,Publication, andDissemination ofTraining Materials 300,000 FieldSupervisionTrips 200,000 Sample Transportation Containers 165,060 Preventionand Case Management(Drug Storage Facility) 1,250,000 SABIMFacilities Rehabilitation 500,000 SABIMICTHardware andSoftware 1,500,000 Crisis Management Center Facilities Rehabilitation 1,000,000 Crisis Management Center CommunicationsEquipment and Software 1,200,000 Total 14,883,060 B. StrengtheningNational Public Health Surveillance Systems 17. The detection o f novel influenza strains is done through clinical and virological surveillance of humanand animal influenza disease. Expanding influenza surveillance i s needed to provinces and areas where outbreaks o f HPAI was reported, specifically including: (i) active surveillance for influenza-like illness (ILI)inareas with reported HPAI outbreaks; (ii) collection of specimens for diagnostic testing and virus sub-typing; (iii) confirmation o f positive and a certain proportion o f negative results ina reference laboratory; and (iv) outbreak investigation in areas with confirmedhumancases. To this end, the proposedProject will support: B1: Improvement of LaboratoryNetworks 18. InTurkey there are two national reference public health laboratories for virology which act as National Influenza Center (NIC). Under this sub-component, financing will be available to upgrade existing national reference laboratories (NRL), including design, renovation and upgrade to Bio-Safety Level 3 (BSL-3) laboratory with concomitant physical containment requirements (P3), required for virus isolation and sub-typing to determine various strains. In addition, financial support will be provided to upgrade 7 regional public health laboratories to BSL-2 for rapid diagnosis and cell culture. Finally support will be provided for procurement o f consumables and laboratory supplies (US$5.3 1million). Cost inUS$ P3 Laboratories 1,398,600 Laboratory Equipment for Reference andRegional Laboratories 699,728 Additional Equipmentfor Regional Laboratories 900,000 Test Kits, Reagents, and Laboratory Supplies 1,708,072 Central LaboratoryRehabilitation 600,000 Total 5,306,401 55  B2: Training 19. Assistance will be provided to train staff at different levels o f the healthcare system in outbreak investigation and surveillance, case finding, laboratory diagnosis, laboratory bio-safety to improve the coordination between the public health agencies and the veterinary departments andfacilitatejoint simulationactivities (US$ 0.55 million). CostinUS$ LabTechnicians Training 51,125 Training of SABIMCall Operators 500,000 Total 551,125 C. StrengtheningHealthcareSystemResponseCapacity 20. Non-pharmaceutical containment measures such as social distancing may contain pandemic spread and allow time for response measures. Therefore, the project will indirectly support through the implementation o f the NPIAP, "social distancing measures" -- such as quarantine, ban on mass gatherings and travel restrictions, backed up by a well-designed communication strategy. Additional preventive actions for health care workers involved in case detection, transportation and management such as distribution and use o f protective gear and masks will be supported, along with increased awareness and promotion o f community participation inslowingthe spread o f the pandemic. (US$ 0.1 million) 111. PUBLICAWARENESSAND COORDINATION SUPPORT 21. This component will support strategic communication activities for stakeholders and beneficiaries. Similarly, resources will be allocated for improved coordinationbetweenMARA's regulatory framework and contingency plans, and the MOH's National Pandemic Influenza Action Plan(NPIAP) (US$ 2.78 million) A. PublicAwareness throughInformationandCommunicationServices 22. Support under this sub-component will be provided for the research, design, implementation and evaluation o f an integrated communications strategy, addressing the needs o f priority populations at the national, provincial and local levels. The strategy will elevate knowledge and promote behavior-change in populations at-risk, to control the spread o f the virus, prevent infection, foster timely reporting and support containment actions. At the same time, the strategy will educate vulnerable groups on preparedness plans andmitigationmeasures across pre-pandemic and pandemic phases. The communications strategy will incorporate measures called for inthe Environmental Management Plan (EMP) for safe culling and disposal ofbackyardpoultry. (US$ 0.81 million) 23. Specific actions to be supported under this sub-component include: a) create communications capacity and allocate resources in the MARA and MOH to research, design, produce and implement communication strategies, according to the needs o f priority 56  audiences. This i s intendedto generate trust and credibility inthe public response; preparedness for possible scenarios; foster an enabling environment for rapid reporting and containment efforts; promote understanding o f public policies to be enacted; provide for informed public participation; enable accurate and fast response to mediarequests; etc. b) produce educational materials and products to support the activities o f the agricultural, rural development and health staff o f MARA,MOH and provincial authorities, working inat-risk and vulnerable regions; secure the participation o f community-based organizations inthe design and testing o f materials to insure their effectiveness; research, inform and change risk- behaviors/practices; address the socio-economic and gender dimensions o f the rural poor. c) invest inthe existing infi-astructure of the call-in centers (such as SABIM), to facilitate social engagement, monitoring and evaluation o fthe agricultural and healthinterventions. d) develop informational and educational material for vulnerable populations about preventive health practices, containment measures and preparedness plans, during outbreaks and pandemic phases; highlight the investments and actions undertaken by the public and private sector to reduce the risk; assign spokespersons to the different "crisis management centers," to manage a transparent disclosure policy at all times; provide training courses in communications methodology to staff responsible for these activities; prepare and be ready to implement "risk- communication" activities when necessary. e) negotiate in advance, with broadcasting and local communication agencies (formal and informal), media plans, budgets, responsibilities and designated spoke-persons; train the media on the nature o f A-I and likely scenarios; involve the private sector, specially the eommercial- poultry sector, inthe communications efforts; facilitate donor-coordination inthe communication response. B. CoordinationSupport 24. The multi-dimensional problems associated with H P A Iinfection necessitate collaboration from a wide range of stakeholders within each country, which in Turkey include: the State Planning Organization, the Undersecretariat o f the Treasury, the MARA, the MOH, their associated diagnostic laboratories, provincial authorities, NGOs and civil society organizations, andprivate sector companies and associations (e.g. large poultry production companies, farmers' associations, veterinarians and farmer involvement at the grass roots level). The sub-component will support activities to improve the effective coordination and collaboration among these stakeholders and to bolster project implementation and monitoring capacity at existing project implementation structures inthe MARA andMOH. B1. NationalCoordination 25. The National Zoonotic Disease Committee will be responsible for reviewing annual work plans and ensure coordination and linkages across relevant agencies and international partners. InAI outbreak situations, it will be incharge o ftriggering emergency responses byMARAand MOH, monitoring the actions taken, and coordinating public statements to the media. The 57  NZDC will be assisted by a Public Information and Communication Specialist,. (US$ 0.21 million) B2. Project Implementation 26. The Central Execution Unit (of the Agricultural Reform Implementation Project) in the MARA and the Project ImplementationUnitofthe HealthTransitionProject (MOHPIU) inthe MOHwill be entrusted with the fiduciary tasks of procurement and financial management. The relevant structures will be strengthened with 3-4 additional fiduciary staff at most in each Unit. Both the MARA and the M O H will appoint Project Coordinators to liaise with the MARA CEU andMOHPIU, respectively, andto prepare annual work programs andbudgets as well as semi- annual project reports. The Project Coordinators will manage the respective component for which their ministry i s responsible and attend the regular meetings o f the National Zoonotic Disease Committee. The MARA CEU will be responsible for consolidating the annual work plansandbudgets for submission to the NZDC and the Bank.(US$ 1.25 million) 27. At the local level, implementation would be the direct responsibility o f each Provincial Directorate of Agriculture (PDA) and Provincial Directorate o f Health (PDH). At times o f outbreaks, the provincial governor will guide implementation o f cross-sectoral activities, and if necessary set up local disease crisis centers to ensure cross-sectoral coordination. B3: Monitoring and Evaluation (M&E) 28. Support would be provided to enable project monitoring and impact evaluation assessments. Two types o f M&E are envisaged. First, the MARA CEU and the M O H PIU would collect relevant data from their ministries and other implementation agencies and then compile them into semi-annual progress reports focusing on output indicators and the status o f physical implementation by component and use of project finds. For some output indicators, specific surveys will need to be conducted to obtain data for this purpose. These would be financed by the Project. The MARA CEU will be responsible for consolidating the ministerial progress reports into an integratedProject progress report. (US$0.51 million) 29. Impact evaluation reports. The aim o f evaluation i s to find out whether the interventions are effective or the program i s having the desired impact. The evaluation will include both quantitative andqualitative aspects and be conducted on a yearly basis. The quantitative aspects will rely on new information systems and surveys implemented as part o f the various components o f the project, currently existing data sources, andprimary evaluative data collection efforts. The goal of the qualitative aspect of the evaluation will be to document perceptions o f program managers, staff, patients, and local andnational leaders. Qualitative information will be collectedusing site-visit interviews, focus groups, andrespondent surveys. 58  ANNEX 5: PROJECTCOSTS TURKEY: AVIANINFLUENZA AND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT Project Cost By Component and/or Activity Local Foreign Total U S $million U S $million U S $million 1.Animal HealthComponent 15.36 15.50 30.86 2. HumanHealth Component 9.35 11.49 20.84 3. Public Awareness and Communication Support 1.93 0.85 2.78 Total Baseline Cost 26.64 27.84 54.48 Contingencies 0.35 0.36 0.71 TotalProjectCosts 26.99 28.20 55.19 Front-endFee 0.09 0.09 TotalFinancingRequired 26.99 28.29 55.28 59  ANNEX6: IMPLEMENTATION ARRANGEMENTS TURKEY: AVIAN INFLUENZA AND HUMANPANDEMICPREPAREDNESSAND RESPONSEPROJECT 1. The Project will be implemented by existing project implementation structures in the MARAandthe MOH. However, public information andproject coordinationarrangements will be overseen by the existing National Zoonotic Disease Committee. This Committee has been established to deal with zoonotic emergencies and will provide general policies and guidelines for Project implementation. This Committee has been established jointly by the MARA and the MOH to deal with zoonotic emergencies and will provide general policies and guidelines for Project implementation. The Committee comprises representatives o f the MARA,the MOH, and other relevant ministries, agencies, and academic institutions. The Committee will review annual work plans and ensure coordination and linkages across relevant agencies and international partners. 2. Since the Bank i s financing both agricultural sector and health sector projects inTurkey, the existing project implementation structures within the MAR4 (the Central Execution Unit of the Agricultural Reform Implementation Project, CEU) and the MOH (the Health Transformation Project ImplementationUnit, MOH PIU) will be entrusted with fiduciary tasks of procurement and financial management. (Additional staff will to be recruited in the MARA CEU andthe MOH PIUas needed for these fiduciary tasks.) One senior officer from the MARA and one from the M O H will be designated as Project Coordinators in.charge o f managing implementation of their relevant ministries' project activities and liaising with the MARA CEU and MOH PIU, respectively. These Project Coordinators will make reports to the NZDC. A Public Information and Communication Specialist (consultant) will be recruited to support the public information efforts o f the NZDC. 3. The Project Coordinators will be responsible for the preparation o f annual work programs and budgets and monitoring project implementation at the central and local levels. The MARA CEU andthe MOH PIUwill assist the Project Coordinators inpreparation o f semi-annual project progress reports for the two ministries. The MARA CEU will be responsible for consolidating the annual work plans and budgets for submission to the NZDC and the Bank. 4. At the local level, implementation will be the direct responsibility o f each Provincial Directorates o f Agriculture and Health, both o f whom should report to the same Deputy Governor o f the province (currently these Departments report to separate Deputy Governors). The Deputy Governor will be the key provincial official to be incontact with the NZDC intimes o f AI outbreak or other emergency situations. The existing provincial level coordination units comprising officials from the Provincial Directorates o f Agriculture and Health will work under the supervision and guidance o fthe NZDC. 5. A Project OperationalManual (POM) is being prepared to integrate the relevant aspects o f each o f the Contingency Plans which have been prepared by the MARA and the MOH. This POMwill guide the management and implementation o f the Project and be updated as Turkey's National Strategy for Avian Influenza and Human Pandemic Preparedness and Response is finalized and updated periodically duringthe course o fthe Project. 60  ANNEX7: PROCUREMENT,FINANCIAL MANAGEMENT, AND DISBURSEMENT ARRANGEMENTS TURKEY: AVIAN INFLUENZAAND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT A. Procurement 1. General. Procurement under the Project will be carried out in accordance with the Bank's "Guidelines: procurement Under BRD Loans and IDA Credits" dated M a y 2004, and "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers" dated May 2004, and the provisions enumerated below and stipulated in the Legal Agreement. The agreements covering procurement methods and thresholds have been determined for Turkey according to its capacity and experience with Bank procurement. The procurement agreements have been appraised and detailed in the procurement plan for the entire project period and summarized below. The General Procurement Notice i s to be issued on or about April 15,2006. 2. Procurement will be accelerated in the first six months o f the Project by allowing Shopping procedures to be used for a certain number of emergency contracts, whose size would usually be above the normal ceiling for Shopping. These cover mainly the following: safety gear for veterinary personnel; protective materials kits for M O H staff; two mobile incineration plants andrelatedcontainers for culling and other goods with highurgency. 3. Goods andWorks andNon-consulting(Technical) services a) PriorReview Threshold:Procurement Decisions subject to Prior Reviewbythe Bankas stated inAppendix 1to the Guidelinesfor Procurement: Procurement ProcurementMethodThreshold PriorReview Comments Method Threshold 1. ICB >$ 1,000,000 -goods All > $ 10,000,000 -works 2. LIB All 3. NCB <$1,000,000 -goods Goods>$500,000 <$ 10,000,000 -works Works >$5Million Plus-Firsttwo contractsof Goods andWorks 3. Shopping <$100,000 -goods None <$ 100,000 -small works 4. Shopping <$2,000,000 -goods in urgent All contracts With Bank (for emergency) needs above <$500,000 Prior approval 5. Direct All Contracting 6. Commercial 10 % of the total practices contracts b) Pre-qualification:Not applicable 61  c) ProposedProceduresfor CDD Component:Not applicable d) Referenceto ProjectOperationaYProcurementManual:Not applicable e) Any Other SpecialProcurementArrangements:Inorder to address emergency needs; for highurgency items, goods estimated cost up to $2,000,000 per contract, may be procured under "Shopping" procedures with the Bank's prior approval. Procurement o f goods, works and services for restructuring o f poultry sector under the sub-projects (maximum o f $25,000) to be implementedby small farmers (with a maximum o f $ 25,000 per sub-project) and sub-projects to be implementedby small andmedium sized enterprises (with a maximumo f $ 1,250,000 per sub-project) shall be carried out through commercial practices (CP) established in the country in accordance with paragraph 3.12 o fthe Procurement Guidelines. Logistic services required for the International and National Symposium, Seminars, Workshop, and other training programs shall be procured by Shopping procedures. In case o f very large International Symposiums and training programs shopping thresholdmay be increase on a caseby case basis subject to Bank's no objection. The works contracts to cost less than $10,000,000 per contract and the Goods manufacturedwithin the country and readily available in the local market to cost less than $ 1,000,000 per contract may be awarded through NCB. Any ambiguity regarding predominance o f the Bank's procurement rules below from paragraph (i) to (xi) shallbe discussed at the negotiations andmadepart ofthe LoanAgreement. i)Eliaibilitv Biddingshall not be restricted to domestic bidders.N o restriction shall be applied to foreign bidders who wish to submit abid. ii)Procedures Invitations to bid shall be advertised in the Official Gazette or in at least one widely circulated national daily newspaper or inan electronic portal o f free access allowing a minimumo f 30 days for the preparation and submission ofbids. iii)Assessmentofthebidder'squalifications Where pre-qualification i s not used, the qualifications o f the bidder who is recommended for award of contract shall be assessed by post-qualification, applying minimum experience, technical and financial requirements which shall be explicitly stated inthe biddingdocuments and which shall be determined by a `pasdfail' method. 62  iv) ParticipationbvGovernment-owned Enternrises Government-owned enterprises in the Republic o f Turkey shall be eligible to participate in bidding only if they can establish that they are legally and financially autonomous, operate under commercial law and are not a dependent agency of the Government. Furthermore, they will be subject to the same bid and performance security requirements as other bidders. v) ParticipationbyJoint Ventures Participation shall be allowed from joint ventures on the condition that suchjoint venture partners will bejointly and severally liable under the Contract. vi) BiddingDocuments Procuring entities shall use the Bank's sample N C B documents for ECA Region for Works and Goods and shall draft contract and conditions of contract acceptable to the Bank. vii) BidEvaluation Evaluation of bids shall be made instrict adherence to the monetarily quantifiable criteria declared in the bidding documents and a merit point system shall not be used. Extension o f bid validity shall be allowed once only for not more than 30 days. No hrther extensions should be requested without the prior approval of the Bank. Contracts shall be awarded to qualified bidders having submitted the lowest evaluated substantially responsive bid.N o domestic preference shall apply under National Competitive Bidding. viii) Price Adjustment Works contracts o f long duration (e.g. more than eighteen (18) months) shall contain an appropriate price adjustment clause. ix) Reiection o fAll Bids All bids shall not be rejected and new bids solicited without the Bank's prior written concurrence. x) Contracts All contracts shall be inwriting, signed and stamped by authorized signatories o f the Purchaser and the Supplier and contain identical terms and conditions o f contract to those included inthe tender documents. xi) Securities 63  Bid Securities should not exceed 3 % (three percent) o fthe estimated cost o fthe contract; Performance Securities not more than 10 % (ten percent). No advance payments shall be made to Contractors or Suppliers without a suitable Advance Payment security. The wording o f all such securities shall be included into the biddingdocuments andshall be acceptable to the Bank. 4. Selectionof Consultants a) Prior Review Threshold: Selection Decisions subject to Prior Review by Bank as stated inAppendix 1to the Guidelines Selection and Employment o f Consultants. Selection Method Prior Review Comments Threshold 1. Competitive Methods (Firms) > $350,000 The first two QCBS contracts are QCBS/QBS/LCS/CQS subject to prior review irrespective of contract amount 2. Single Source (Firms) All 3. Individual Consultants >$100,000 The first two individual consultant contracts and all single source contracts are subject to Bankprior review irrespective of contract amount b) Short list comprisingentirely of national consultants: Shortlist o f consultants for services, estimated to cost less than $ 200,000 equivalent per contract, may comprise entirely o f national consultants inaccordance with provisions o f paragraph2.7 o f the Consultant Guidelines. c) Any other SpecialSelectionArrangements: Not Applicable 5. ImplementingAgency Capacity BuildingActivities with Time Schedule. MOH PIUwill be supported by the Project Management Support Unit (PMSU) of the MOH in executing procurement o f the M O H portion o f the project. The PMSUhave procurement specialists inplace for the HTP and these arrangements will be relied until procurement specialist recruited for the MOH PIUfrom the proceeds of the AIHP Loan. The Central Execution Unit (CEU) o f MARAis currently responsible for the implementation o f some o f the components o f the Agricultural Reform Implementation Project (ARIP)and will be responsible for the implementation o f the Animal Health component o f the AIHP project. The MARA C E U and MOH PIU will recruit a procurement specialist, disbursement officer and FMS consultants and relevant support staff for the implementationo f the AIHP project. No. Expectedoutcome/ Estimated Estimated Activity Description Cost ($) Duration Comments 1 ProcurementTrainingduringProject - Two days To beprovidedbyPAS LaunchWorkshop 64  B. FinancialManagementandDisbursement 6. FinancialManagementArrangements. The Animal Healthcomponent will be implementedby the Ministryo fAgriculture andRural Affairs (MARA), the HumanHealth component by Ministryo fHealth (MOH) and the Public Awareness and Communication Support component bythe National Zoonotic Disease Committee. The Project Implementation Unit(PIU) inMOHwillberesponsible for the implementationofthe HumanHealthcomponent o fthe AIHP project. 7. The Central Execution Unit (CEU) o f MARA is currently responsible for the implementation of some of the components of the Agricultural Reform Implementation Project (ARIP) and will be responsible for the implementation o f the Animal Health component o f the AMP project as well as the project's overall financial management. The Public Awareness and Communication Support component of the project will be overseen by the NZDC. This component forms a very small portion of the project and therefore the financial management arrangements for this component will be carried out through the CEU at MARA. Therefore, to ensure effective flow of funds, it is important to have the budget for this component under the MARAbudget as well. 8. The MOH PIU and CEU will be responsible for assuring that the Project establishes and maintains: (i)adequate accounting systems and procedures; (ii)funds flow mechanisms including timely disbursement o f funds, andtimely payments for goods and services; (iii)regular reporting on the use o f funds; and (iv) appropriate arrangements for regular financial audits. These responsibilities will be described in detail in a financial management manual by each ministry. The MOH PIU is currently one o f the implementing agencies o f Health Transition Project and has established key internal control mechanisms on the application and use o f finds. The staff inthe MARA CEUhas experience inaprior IBRD financed project and established the necessary mechanisms for the AIHP project. The CEU will also be responsible from the payments made under the third component and for the reporting of such transactions. Each ministry will be responsible for project financial management and will submit reports to the Bank. Additionally, the CEU will have the responsibility for establishing internal control procedures for the compensation payments to fanners, which will be developed to respond to specific risks associated with this sub-component o f the project. 9. DisbursementandFundsFlow Arrangements. There will be two SpecialAccounts for the project for disbursements from the World Bank loan one for MOH and one for MARA.The Special Accounts will be in Euro and will be opened at the Central Bank o f Turkey. Disbursementsfrom the loan will follow the transaction-based method i.e. the traditional Bank procedures (Statements o f Expenditure (SOEs), Direct Payments, Special Commitments). The financing percentage for the project will be 100 %, and therefore all payments to the contractors, suppliers and consultants will be made from this account. For certain payments, above the MinimumApplication Size, as specified in the Disbursement Letter, the MOH PIU and CEU would submit withdrawal applications to the Bank for payments to suppliers and consultants directly from the Loan Account. Both the MOH PIU and CEU will specify authorized signatories, and payments from the special accounts will be made with the approval o f these authorized staff. 65  Allocation ofLoanProceedsand FinancingPercentage Expenditure Category Amount inEuro Financing Percentage (1) Goods 100% (a) under Part Io f the Project 7,970,000 (b) underPart I1ofthe Project 6,290,000 (c) under Parts 111.1and 111.2 o fthe Project 370,000 (2) Works 100% , I (a) under Part Io f the Project 760,000 (b) underPart I1o fthe Project 2,700,000 I I I (3) Consultants' services 100% (a) under Part Io f the Project 530,000 (b) underParts I1and111.3 o fthe Project 1,820,000 (c) under Parts 111.1 and 111.2 o f the Project 1.130.000 (4) CompensationFundunderPart I. o fthe Project 3(a) I 3,970,000~ 100% (5) Poultry Restructuring Sub-projects 990,000 50% (6) Operating Costs 100% (a) under Parts 111.2 o f the Project 120,000 (b) underPart 111.3 ofthe Project 100,000 (7)Unallocated 550,000 100% 10. The project includes a compensation payment for farmers sub component to be used if such a need arises. Under this component, the CEU will receive and process requests for payments to the eligible farmers. The CEU will document the procedures to verify the eligibility o f the farmers and the accuracy o f the requests, as well as the payment procedures and the accounting o f such transactions in a manual. The General Directorate o f Protection and Control (GDPC) o f MARA has prepared a contingency plan for avian influenza. The planincludes basic guidelines for actions to be taken when an avian influenza pandemic arises. However, currently, it does not include any financial management components since compensation payments were not envisaged. The CEU will review the documents included in this plan and will integrate the related internal control procedures for registering payments. Documents such as the `AI Epidemiological Inquiry Form' completed by the Official Veterinarians o f PDA and the 66  Laboratory Veterinarians can be used as an internal control tool as they include detailed information on the farm andthe number o fbirds and species present inthe farm. 11. Inaddition to that, when a farm is put underrestrictionfor suspicion ofAI, the document also includes a section providing information relating to the total number o f birds, total number o f illbirds, total number o f dead birds and total number o f birds depopulated. A pre-audit is not envisaged since these payments will not be made on a regular basis but only when the animals are declared and submitted to the authorities for culling. These procedures will be detailed inthe compensation payments section o f the financial manual. 12. Internal controls. The MOH PlU and the CEU will maintain an effective internal control system to ensure that project expenditures are properly authorized, supporting documents are maintained; accounts are reconciled periodically; project assets are safeguarded, and compensation payments are properly accounted for. Although project accounting will in on the cash basis, detailed assethnventories register will be maintained as part o f the project internal control procedure. The PIU and MARA CEU will implement appropriate controls over inventories o f drugs, vaccines, medical equipment, and other sensitive andor expensive assets will be especially important for the project. 13. In connection to the Compensation Payments to Farmers component, the minimum internal control procedures to be implemented before the flow o f funds would include the following: 0 The CEU will document in the financial management manual, mechanisms for identifying those eligible for compensation payments, as explained in paragraph 14 above, ensuringthat there will be no multiple claims. 0 Inthe eventofa verified outbreak ofAI amongpoultry, the necessary culling and carcass disposal will be done under the supervision of the General Directorate o f Protection and Control (GDPC) o f the MARAGDPC. The CEU will determine which documentation produced by local authorities will be used for processing compensation requests for condemned animals. The procedures that will be included in the financial management manual, should detail the guidelines to be followed both by the registered farms/commercial poultry producers and by smallholders/peasants/individual livestock owners separately. 0 Compensation payment to livestock owners will be in through bank transfers. There will be no vouchers or animal replacements. The most appropriate find flow would be channeling funds directly to the beneficiaries through Ziraat Bankasi upon receipt o f eligible requests. These flow o f funds arrangements still need to be agreed upon with MARA for making compensation payments, but such arrangements would needto be ready before disbursement for this component. The CEU will allocate staff to perform periodic visits to the community/village level to review claims for compensation payment requests submitted and paid by the C E U and the results o f these visits will be documents and filed at the CEU. 0 Inaddition, the external auditors will be asked to perform an operational audit o f the effectiveness and efficiency o f compensation payments which will include a review o f the reasonableness o f the accounting, reporting and internal controls for that component. 67  14. Staffing. The M O H PIU has a two financial management staff experienced in World Bank procedures and these staffs will be responsible for the AMP financial management in MOH. However, there are no designated financial management staff currently working at the CEU even though the staff o f CEU are experienced in World Bank financial management procedures. There is a needto hire additional staff to the CEU to strengthen the existing capacity andto allow for periodic visits to the community/village level to reviewclaims for compensation payments. The financial management staff o fthe CEUwill report to the head o f C E U andwill be responsible for disbursement functions, as well as project accounting - maintaining books o f accounts, reporting day-to-day transactions and preparing accounting reports and financial statements including the semi-annual interim un-audited financial reports. 15. FinancialReporting.Boththe MOHPIUand CEUwill maintainrecords andwill ensure appropriate accounting for the funds provided. The MOH PIU has currently an accounting software inuse for HTP and will either use this software or excel spreadsheets for the accounting and reporting o f AMP project. The CEU will use integrated excel worksheets for project accounting as well as for generatingthe semi-annual andyearly reports. 16. Both the M O H PIU and CEU will prepare interim un-audited financial reports for the project. The interim un-audited financial reports will include: (a) Project Sources and Uses o f Funds, (b) Uses of Funds by Project Activity, (c) Special Account Statement, (d) Physical progress report, and (e) Procurement report. Interimun-audited financial reports will be prepared semi annually and will be submitted to the Bank no later than 45 days after the end o f period. The first report will be submitted after the end o f the first full six months after initial disbursement. The format and content o f the interim un-audited financial reports will be incorporatedto the FMmanuals that will be prepared by eachministry. 17. Financial Audits. There will be annual audits of the project financial statements, covering all aspects o f the project, including specific requirements for the compensation payments to farmers component. The audits will be performed by the Treasury Controllers, in accordance with International Standards on Auditing (ISA), and the World Bank's guidelines on auditing as stated in the guidelines: Annual Financial Reporting and Auditingfor World Bank- Jinanced Activities (June 2003). The audit will include both the audit o f financial transactions, an assessment o f the internal control, funds flow mechanisms, and the reasonableness o f the accounting, reporting and internal controls in respect o f compensation payments. There will be two annual audit reports for the project; one for M O H and one for MARA and each will provide an opinion on the financial statements prepared by each ministry. The financial statements will incorporate the project accounts, including Special Accounts Reconciliation, and SOE Withdrawal Schedules; as well as Management Letters. The audit reports will be submittedto the Bank not later than six months after the end of the fiscal year to which they relate. Both the MOH PIU and the CEU will provide the auditor with full access to project-related documents and records. Sample TORS for project audit will be included in the Financial Procedures Manuals. 18. Operational Audits. There will be annual operational audits in order to obtain a professional opinion on the efficiency and effectiveness in implementation o f the Compensation Payments to Farmers component. Specifically, the review should include a review of the 68  mechanism for identifying the farmers who are eligible for receiving compensation payments and the procedures used affecting the payments to the beneficiary farmers. The verification should cover transactions on a sample basis to ascertain that the procedures actually used are transparent and comply with the Agreed Manuals, including selection o f beneficiaries, and that adequate tracking and monitoring mechanisms are inplace for the transfer o f financial support to beneficiaries. The operational audit will be carried out by Treasury Controllers. 19. National Compensationfund. The Government will establish a national compensation fbnd from which the owners of animals culled will be compensated. However, there are still uncertainties relating to the specific regulations, procedures and operational guidelines for establishing, financing and operating this fund. The Government's operational instructions for the Compensation Fundwould be completed inMarcWApril in consultation with the Bank. The Project will provide US$5 millionto establish this find which will be disbursed only inthe event o f actual need. It will be a condition o f disbursement for this sub-component that the modalities for operating the fund have been established and approved by the Bank, so as to provide sufficient resources for immediate needs. Procedures to be established for this purpose are detailed inparagraph 11above. Action I Responsibility Due Date 1.Budget. Take actionto havethe projectbudget includedinthe 2006 - - - - I CEU,MOH January investment program PIU, andPMSU 31,2006 2. Budget. Ensure that the budget for the Public Awareness and Coordination CEU January component is included inthe MARA budget 31,2006 3. Staffing o f the FMUnito f the CEU.Recruitment o f CEU M a y 31, FinanciaYDisbursement Specialist. 2006 4. FMProcedures Manuals. FMManuals to fully document the procedures MOHPIUand March 27, for accounting and internal control, including disbursement and flow o f hnds MARA CEU 2006 (including flow chart), financial reporting, including interim un-audited financial statements, annual reports and audit. 5. Project Accounting and Financial ReportingSystem. Develop an MOHPIU and April 15, accounting and reporting system- integrated excel worksheets- MARACEU 2006 (CEU)/upgrade existing accounting sofbvare or create integrated excel worksheets (MOH PIU), to reflect requirements o f the new project, including capacity to generate interimun-audited financial reports. Test the accounting and reporting systembyproducing sample financial reports for submission to the Bank for review and comments. FinancialManagementAction Plan: There are a number o f actions required to ensure that the financial management arrangements o fboth the M O H PIUand CEU are fully satisfactory for the proposed project. 69  ANNEX8: ECONOMICANALYSIS TURKEY: AVIAN INFLUENZAAND HUMANPANDEMICPREPAREDNESSAND RESPONSEPROJECT 1. Evidence shows that the H5N1 strain o f Highly Pathogenic Avian Influenza (HPAI) i s now endemic in parts of Southeast Asia, where Cambodia, Indonesia, Laos, Thailand and Indonesia are the worst-affected countries. The continuing outbreaks that began inlate 2003 and early 2004 have been disastrous for the poultry industry inthe region. By mid-2005, more than 140 million birds had died or been destroyed and losses to the poultry industry are estimated to be in excess o f US$10 billion. The costs were related to the death of poultry from the disease itself, the culling of poultry to stem its spread, and the costs to governments o f containing the epidemic interms o f equipment, materials, transport andpersonnel. 2. InVietnam, one of the most seriously affected countries, some 44 million birds or 17 percent o f the total population of poultry, were culled at an estimated cost o f $120 million (0.3 percent o f GDP)4. The costs would have been substantially higher if there had been a serious impact on tourism, where an estimated 5 percent drop in tourist and business arrivals would reduce GDP by a further 0.4 percent. (Fortunately, there has been only a small impact on tourism so far; the number o f tourist arrivals in Vietnam increased by 20.5 percent in 2004 and rose further by 23 percent in the first seven months o f 2005.) In Indonesia, an FA0 survey indicates that in the most seriously affected parts o f the country, more than 20 percent of permanent industrial and commercial farm workers lost their jobs. So although the overall macro-economic effects have been relatively small, the impact on the poultry sector and on associated input and distribution channels has been severe. 3. Although HPAI i s mainly an animal health problem, more than half o f the 120 human cases have been fatal. Moreover, it is widely believed in the scientific community that a global pandemic o f humaninfluenza i s overdue. Such a pandemic would be the result o f the emergence of a strain o f virus to which the world's population had little or no immunity. A widespread epidemic needs not be severe or particularly deadly; the pandemics o f 1957-1958 and 1968-1969 were relatively mild. However, there i s the possibility that the H5N1 strain could, through genetic re-assortment or a more gradual process o f adaptive mutation, become readily transmissible from human-to-human and become the basis o f a global pandemic comparable to that of 1918-1919, the "Spanish" influenza, which recent research has shown to have had its origin inan avian influenza virus. 4. Neither the timing nor the severity o f the next pandemic can be predicted, but with the virus now endemic inbirdpopulations inAsia the risk will not be easily diminished. Given the recent outbreak inTurkey inManyas, the situation faced by Turkeyis urgent but uncertain, given the unpredictability of a human epidemic or pandemic. It is clear, however, that containing and eradicating the virus will be a desirable objective even if the problem were restricted to one o f animal health in Turkey. Thus, economic analysis o f the Project, which will be completed at World Bank. (2004). Avian Influenza Emergency Recovely Project. TechnicalAnnex. Appendix 2. Other earlier and widely cited estimates by Oxford Economic Forecasting had been rather higher, suggesting costs o f over $200 million or around 0.6 percent of GDP for Vietnam, and costs of $10-15 billion for East Asia as a whole, about 0.3-0.5 percent of regional GDP. 70  Project Appraisal, will take into account the two main categories o f economic impacts: (a) the economic consequences and costs associated with public and private efforts to prevent the emergence or spread of the disease and to treat its effects; and (b) the economic consequences andcosts o f sickness or death resultingfromthe disease outbreaks. 5. These two are clearly related as a greater effort at prevention and/or treatment for a given severity o f epidemic would be expected to reduce the spread o f sickness and/or the percentage of mortality and thus reduce the economic impact and costs. There are also two "levels" o f potential economic costs. The present spread o f HPAIo f the H5N1strain involves transmission between animals and (so far) a limited incidence o f transmission between animals and humans; as such, given the lethal nature o f the virus, especially in poultry, it i s principally an animal health crisis. However, the emergence o f a human influenza pandemic caused by a lethal virus would have a social and economic impact many times greater. 6. Thus, actions to be taken by Turkey are analyzed usingthe traditional "with project" and "without project" scenarios when the issue i s to treat HPAI as an animal health issue. These costs and benefits are to be estimated on the basis of the recent outbreak in Manyas. However, the impact o f actions to be taken Turkey inthe wider context of the prevention or slowing down of a humaninfluenza pandemic are much more difficult to estimate, since the actions undertaken inone countrywill haveimplications for the well-beingofthe rest oftheworld's population. Losses to the PoultrySector,RelatedIndustries,andInvolvedPopulations. 7. The economic analysis follows a with-project scenario / without-project scenario approach to estimate net benefits of the Project to Turkey. The analysis focuses on the benefit of averting significant expected costs to the economy o f a catastrophic spreading o f the disease in Turkey's poultry flock due to a reduction in the probability o f such a catastrophic event. The main costs averted that are considered inthis analysis are: 0 dramatic reductions in poultry prices and quantities demanded resulting in large-scale decreases in value added in the poultry sector (adjusted however for the positive substitution effect into other sources o fprotein, notably redmeat and fish); 0 loss o f capital assets due to decommissioning as a result long term-decreases in demand and o fpoultry stock due to culling; and 0 the cost o f culling in outbreak areas itself (and other activities to stem the further spreading above and beyond what would be done inthe with project scenario). 8. Costs related to illness or death o f humans (either inTurkey or internationally) as a result of infection from continual AI outbreaks inTurkey are not estimated owing to the current lack o f adequate information on the probabilities o f virus mutation and transmissibility. Given the time constraints and unavailabilityo f precise data on some o f the variables used in the analysis, this should be treated as a simulation exercise that indicates that even under very conservative assumptions and with only few o f the benefits quantified, the returns on the project investments are sizeable. 71  Scenarios Considered 9. The without-Proiect scenario: As a result o f the low capacity o f government and the poultry industry to deal with outbreaks, the sector i s vulnerable to a catastrophic AI occurrence. This catastrophic event (CE) would be characterized by multiple, simultaneous outbreaks leading to a spread o f the disease to large sections o f the country's poultry flock. Significant numbers o f poultry would have to be culled with associated costs o f culling and compensation to the farmers incurred by the state and the private sector. Subsequently, there would be massive public aversion to poultry consumption leading to a significant and sustained drop inprices and demand for poultry. 10. Inturn, the poultry sector remains depressedinthe medium term, leading to large sunk costs inthe form of abandoned facilities. The public substitutes red meat, fish and other sources of protein for poultry. Prices o f such substitutes go up, leading to increased net revenues for those sector^.^ Overall consumer surplus decreases.6 (In the long term the sector recovers partially.) The economic analysis assigns the CE described above an annual probability o f occurrence.' Under this scenario, this probability increases annually as the virus in the environment becomes endemic. 11. The with-proiect scenario. The project builds capacity on the part o f local government agencies and the private sector to respond effectively to outbreaks in such a way that multiple and simultaneous outbreaks may be contained with much higher efficiency, leading to a lower annual probability o f the worst case scenario occurring. This is achieved through: (i) the adoption o f a country-specific strategy (andits corresponding information system) to control and eradicate HPAI in areas o f risk; (ii) strengthening o f disease surveillance and diagnostic the capacity; (ii) the implementation o f an outbreak containment plan, including deployment o f supplies and incineration investmentsinfield and certification o f readiness for rapidresponse in areas at risk (all under Component 1:Animal Health). 12. Significant support to public awareness raising (under Component 3: Public Awareness and Coordination Support) will also help to: (i) the level o finformation amongproducer increase groups and their families and hence support the containment o f the disease inrisk areas; and, (ii) increase public confidence that the outbreaks will be contained effective and hence not lead to widespread illness among humans, which should reduce the risk o f significant drops in demand for poultry products. The positive impact under this withproject scenario is measured through a decrease inthe annual probability of a CE. Inthe mediumrun,the redmeat sector may expand, leadingto areductioninprice levels. CS o f those consumers who have to switch to substitutes decreases because (i) those products are not their first choice; (ii) price the increase inthe other products. Consumers who are risk averse and continue to consume poultry products experience an increase inCS in the short run as poultry prices go down before the sector adjusts and supply decreases. Consumer surplus related to substitutes decreases as a result o f price increases, at least in the short runbefore the sector adjusts and supply expands. The overall impact on CS i s expected to be negative as consumers are forced to consume a mix that does not represent their first preference. 'There are several reasons for the focus in this analysis on a catastrophic event rather than multiple events o f varying degrees of severity: (i)probability distribution for events of varying severity is not available; (ii) to the first point, employing an approach a related of the worst case scenario allows for simplicity in the analysis through the use a single variable probability. One can vary the assumed probability and see the impact on the net benefit due to the project. 72  EstimationofBenefits andCosts ofthe Project 13. Inthis section we present the methods usedto estimate the maincosts andbenefitsofthe project, including assumptions made in this process. It i s underlined that the objective o f the analysis i s to provide an order o f magnitude approximation rather than precise estimates. Table 1summarizes base case assumptions on key parameters which are discussed below. 2004 GDP contribution values are used. An annual average exchange rate o f 1,340,000 TW$ for 2004 is used to convert these figures into U S Dollars. The period o f analysis is 15 years, beginningin 2006. An annual discount rate o f 12% i s usedincalculating the NPV. Parameter Value 1 Annual probability o f CE occurring infirst year o f w/out project scenario (2006) 10.0% 2 Annual increase inprobability o f CE occurring 1.O% 3 Probability reduction factor due to project 12% 4 Decrease o f poultry sector addedvalue due to CE, inyear o f CE and inlong term 40%, 20% new market eauilibrium ~~. ~~~ ~~ 5 One time loss o f capital inpoultry sector 20% 6 Increase invalue added o fredmeat and fish sectors, inyear o f CE and inlong I I term new market eauilibrium - 11 20%, 5% I 14. Without Project Scenario In this scenario, the main costs to the economy o f multiple, simultaneous outbreaks that cannot be contained properly due to insufficient public and private sector capacity i s the net cost incurred as a result o f significant decrease in demand for poultry products, including meat and eggs.8 The net cost represents cost to the poultry sector and the positive impact on alternative protein sources, notably the redmeat and fish sub-sectors. (9 It is assumed that inthe year inwhich the CE occurs, the impact on the poultry sector is a 40% decrease inthe added o f production o f meat and eggs. This i s a reasonable, albeit conservative assumption, in light o f price falls reaching 50% in the aftermath o f the Manyas outbreak in October 2005 and in Vietnam following a series o f outbreaks in 2004. Inthe subsequent three years, the value added inthe poultry sector i s assumed to regain 80% o fthe pre-CE level. (ii) Afurther,one-time costtothepoultrysectoroccurs intheformofabandonedcapital production assets as a result o f the permanent decrease in demand and poultry stock that has to be culled inresponse to the outbreaks. This loss i s estimated at 20% o f the capital stock. The value o f the poultry sector capital stock itself i s assumed to be equal to three times the value o f annual production it the poultry sector. (iii) Gainstotheredmeatandfisheriessub-sectorsthatarealternativesourcesofproteinare assumed to be 20% o f the value added in the year in which the CE occurs, gradually decreasing to 5% over the following 3 years. 15. The Government and the private sector would also incur incremental cost associated to the administration o f containing the outbreaks. However, these costs are extremely difficult to estimate and are hence not included in this analysis. As discussed above, there i s a significant loss o f consumer surplus resulting from the perceived risk associated with poultry product * In the aftermath of the November 2005 Manyas outbreak, Turks showed clear aversion to eggs for fear of being contaminated and egg consumption returnedto normal at the pace at poultry meat consumption.. 73  consumption. These losses are not captured in the GDP data uses since the latter reflect production values. However, shortage o f data makes it impossible to quantifythis loss. 16. The stream of total annual costs due to a CE in a particular year thus obtained i s summarized inthe form on present value as of the year o f the CE. This value i s then multiplied with the probability o fthe CE occurring inaparticular year to arrive at the expected cost. Inthe without project scenario, the probability of the CE occurring is assumed to be 10% in 2006, increasing annually at a rate o f 1.0% due to increasingpresence of the virus inthe environment. This process results in an increasing stream o f expected costs for the period 2006 - 2020, as presented inTable 2. Table 2. Values ex-wessed inmillionUS$ Year `06 `07 `08 `09 `10 ... `16 `17 `18 `19 `20 Costs due to a 1,195 1,195 1,195 1,195 1,195 1,195 1,195 1,195 1,195 1,195 CE (InNPV terms ) Probability of 10 11 12 13 14 20 20 20 20 20 CE occurring (%) inthe w/out project scenario Expectedcosts 119.5 131.4 143.4 155.3 167.3 239.0 239.0 239.0 239.0 239.0 inthe w/out project scenario Probability o f 10 11 12 10.6 9.3 7.2 7.2 7.2 7.2 7.2 CE o c c d g (%) inthe with project scenario Expectedcosts 119.5 131.4 143.4 126.2 111.0 86.0 86.0 86.0 86.0 86.0 inthe with project scenario Expected costs 0 0 0 29.2 56.2 153.0 153.0 153.0 153.0 153.0 averted due to project Project cost 5.0 15.0 21.0 12.0 2.2 17. With-project Scenario It i s assumed that the positive impact of the project will be felt starting in forth year o f project, 2009. In other words, the probability of the full impact of the catastrophic event being felt i s assumed to be the same from 2006 - 2008, as under the without project scenario. From year 4, the annual probabilities are halved thanks to the project. The stream of expected costs in this scenario are calculated by multiplying these probabilities with respective NPVs o f costs and presented inTable 2. 18. The total project cost is estimated at US$ 55.2, which would disburse over five calendar years: $5.0, $15.0, $21.0, $12.0, and $2.2 million in 2006, 2007, 2008, 2009, and 2010, respectively. Resultsof the Analysis 19. Based on the above assumptions, the analysis yields an NPV o f $ 415.9 million and an internal rate o f returno f 80.8 %. 74  Sensitivity Analysis 20. A sensitivity analysis was carried out to gauge the impact o f varying assumptions on the results o f internal rate o f return of the project. The analysis indicates that the model i s robust as substantial reductions (or increases) inthe assumed values are necessary for the IRR decrease to 12%, notably, 0 Holding all other values constant, assuming a reduction o f capital loss in the poultry sector o f 7.22% (as opposed to the base case 20%); 0 Holding all other values constant, assuming a value added loss in the poultry sector to 20% in the CE year and 13.4% in the long term (as opposed to the base values o f 40% and20% ); 0 Reducing the losses sustained by the poultry sector in terms o f value added loss (from 20% to 10% inthe CE year and from 20% to 7% inthe long term), the capital loss from 20% to lo%, while also reducing the gain inthe red meat an d fisheries sectors (from 20% to 10% inthe first year and from 10%to 5% inthe longrun); 0 Reducing the probability o f the CE in 2006 to 1%(from the base case value o f 10%) and the annual increase inprobability to 0.1% (from 1%). 21. The IRR was not found to be sensitive to variations in the value o f the CE occurrence probability reduction factor. 75  ANNEX9: SAFEGUARD POLICYISSUES TURKEY: AVIAN INFLUENZAAND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT 1. Activities under the Project are not expected to generate any adverse environmental effects as they are focused largely on public sector capacity buildingand improved readiness for dealing with outbreaks of avian influenza in domestic poultry. These prevention-focused activities are expected to have a positive environmental impact as the Project's investments in facilities, equipment, and training for laboratories will improve the effectiveness and safety over existing avian influenza handling and testing procedures by meeting international standards established by the OIE. This would be reinforced by the mainstreaming o f environmental safeguards into protocols and procedures for the culling and disposal o f animals during AI outbreaks. In addition, whatever waste i s generated in laboratory facilities will be managed using existing guidelines inTurkey. 2. Though no social safeguard policy i s triggeredby the Project, the Project i s designed to mitigate the negative impacts of mandated culling of poultry on small scale backyard poultry producers. Even though this impact is not expected to be large (likely no more than 5% o f backyard poultry producers' value o f household consumption), mitigation measures have been designed, and their further refinement i s envisaged during the initial implementation period o f the Project. First, a state compensation hnd will be set up under the Project (with an initial reserve of US$ 5 million) to pay producers roughly the full current value of their culled poultry. A second project reserve (an additional US$ 4.5 million) will also be established to target the restructuring needs o f the poultry sector which arise as a result o f the enforcement o f the culling policy inareas affected by AI. This will be designed to mitigate the medium to long-term effects on producers (mainly o fthe backyardtype) who are required to discontinue poultry production in areas which have been affectedby AI. 3. Third, the project team agreed with the MARA on the desirability o f using part of the Village-Based Participatory Investments Program (under the existing Agricultural Reform Implementation Project) on the needs of poultry producers affected by the culling o f poultry in affected areas. Lastly, during the initial stage o f project implementation, the project team will pursue with the representatives o f the commercial poultry sector a voluntary initiative by the commercial poultry sector to provide poultry products free o f charge to backyard producers who have been forced to discontinue poultry raising. This would be at the level o f household consumption formerly raised by backyard poultry producers and extended for a two to three year period. Environmentalassessment EnvironmentalCategory B 4. Environmental Assessment and Environmental Management Plan. Since the Project supports investments in incineration capacity for culled poultry (and potentially for disposal o f other livestock and laboratory wastes), the Project i s assessed as a B-category project. An Environmental Assessment (EA) and an Environmental Management Plan (EMP) for the deployment o f incineration capacity (mainly mobile but also potentially through stationary 76  incineration units) will be necessary. This EMP will also cover the clean up o f animal wastes of culled poultry by the local public veterinary services supported under the Project, The scope o f this EMP will be specified in early project implementation, as a waiver for completing the EA andEMP duringproject preparationhas been sought and obtained perpara. 12o f OP 4.01. (The EA andEMPspecificationwere launched inmid-January2006, andwouldbecompletedno later thanMay31,2006.) Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [X 1 [I Natural Habitats (OP/BP 4.04) [I [XI Pest Management(OP 4.09) 11 [XI Cultural Property (OPN 11.03, beingrevisedas OP 4.11) [I [I [X 1 [XI Involuntary Resettlement (OP/BP 4.12) IndigenousPeoples(OD 4.20, beingrevisedas OP 4.10) [I [X 1 Forests(OPBP 4.36) [I [X1 SafetyofDams (OP/BP 4.37) [I [X 1 ProjectsinDisputedAreas (OP/BP/GP 7.60)* [I X[ 1 [X 1 Projectson International Waterways (OP/BP/GP 7.50) [I aBy supporting theproposedproject, theBank does not intend toprejudice thefinal determination of theparties' claims on the disputed areas 77  ANNEX10:PROJECTPREPARATIONAND SUPERVISION TURKEY: AVIAN INFLUENZAAND HUMANPANDEMICPREPAREDNESSAND RESPONSE PROJECT Planned Actual PCNreview December 2005 December 2005 Initial PID to PIC December2005 December 2005 Initial ISDS to PIC December 2005 December 2005 Appraisal December 2005 December 2005 Negotiations January 25,2006 March 20,2006 Board approval February 21,2006 Planneddate o f effectiveness March 3,2006 Planneddate ofmid-termreview June, 2008 Plannedclosing date November 30,2010 Keyinstitutions responsible for preparationo fthe project: MinistryofAgriculture andRuralDevelopment, MinistryofHealth Bankstaffandconsultants who worked ontheproject included: Name Title Unit Mark Lundell LeadAgricultural Economist ECSSD Halil Agah Senior Rural Development ECSSD Specialist Keith Sumption Animal Health Specialist FA0 Enis Barig Senior Public HealthSpecialist ECSHD Mario Bravo Senior Communications Officer EXTRO IbrahimAkqayoglu Operations Officer ECSHD IbrahimSirer Sr. Procurement Specialist ECSPS Elmas Arisoy Sr. Procurement Specialist ECSPS Ayge Seda Aroymak Sr. Financial Mngmt.Specialist ECSPS Dilek Barlas Senior Counsel LEGEC Tijen Arin Senior Environmental Economist ECSSD Andrina Ambrose-Gardiner Senior Finance Officer LOAGl Furuzan Bilir Finance Officer LOAGl EbruOcek Research Consultant ECSSD Zeynep Lalik Mete FMConsultant ECSPS PhillipMetcalfe Animal Waste Specialist Consultant, ADAS Nedret Durutan-Okan Consultant ECSSD Amy Evans Consultant ECSSD Bankfunds expendedto date onprojectpreparation: 1. Bank resources: us$120,000 2. Trust funds (FAO/CP): US$9,000 3. Total: US$129,000 EstimatedApproval and Supervision costs: 1. Estimated annual supervision cost: US$lOO,OOO 78  ANNEX 11:DOCUMENTSTHE PROJECTFILE IN TURKEY: AVIAN INFLUENZAAND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT A. BANK a Guidance notes to country teams on respondingto AI a Rapid assessment of the economic impact o f public health emergencies of international concern- the example o f SARS -MilanBrahmhatt a Vietnam Avian Influenza Emergency Recovery Project - Memorandum o f the President and Technical Annex a Minutes o f the meeting on the Emergingzoonoses andpathogens: A Global public goods concern - implication for the World Bank, April 19,2005 a Issues Note on Avian Influenza in Africa, September 27, 2005. - Franqois L e Gall and Ok Pannenborg B. OTHER DONORS a A global strategy for the progressive control o f HPAI- FAO/OIE incollaboration with WHO -May 2005 e FAO's response to the avian influenza crisis - September 19,2005 e Technical Cooperation Program - Project descriptions for East Africa, West Africa, Europe and Central Asia, NorthAfrica, andthe MiddleEast -WHO 2005 C. PUBLIC HEALTHRELATED a Global avian influenza information from WHO Web site at www.who.int/csr/disease/avian influenza a Information on U.S. influenza preparedness available at: www.hhs. gov/nvpo/pandemics/dhhs.htmland www.cdc.aov/flu/avian a WHO. 2005. Responding to the avian influenza pandemic threat. Recommended strategic actions. Geneva. a WHO. 2005. WHO global influenza preparedness plan. The role o f WHO and recommendations for national measures before and duringpandemics. Geneva. a United States Department o f Health and Human Services. 2005. Pandemic Flu Fact Sheet. a United States Department o f Health and Human Services. 2004. Pandemic Influenza Preparedness andResponse Plan. Draft. a Browner, J., and Chalk, P. 2003. The Global Threat of New and Reemerging Infectious Diseases. Reconciling U.S. National Security and Public Health Policy. Santa Monica, CA: RAND. a Dowdle, W.R. 1997. The 1976 Experience. J. Infect Dis 1997; 176 (suppl. 1): S69-72. a Garcia-Abreu, A., Halperin, W., Dane1 I.2002. Public Health Surveillance Toolkit. A guide for busytask managers. Washington, D.C.: World Bank. 79  0 Huffman, S., on the basis of report by Daniel Miller and Asel Ryskulova. 2005. Epidemiologic Surveillance Systems in Eastern Europe and Central Asia: An Overview. Washington, D.C.: World Bank. 0 Neustadt, R.E.,Fineberg H.V. 1982. The EpidemicThat Never Was. Policy Making and the Swine FlueScare. Vintage Books. D. ANIMALHEALTHRELATED OIE website on Avian Flu Official reporting, Scientific information, Standards, Guidelines, and Recommendations (www.oie.int) FA0 website on Avian Flu General information, Communication, Publications, Projects proposals andreports (www.fao.org) FAO/OIE. February 2005. Second FAO/OIE Regional Meeting on Avian Influenza Control in Asia. Ho Chi MinhCity. FAO/OIE. February, 2004. Recommendations of the Joint FAO/OIE Emergency Regional Meeting on Avian Influenza Control in Animals in Asia. Bangkok. FAO/OIE. March2005. Summary Report of the First Regional Steering Committee of GF-TADS (Global Frameworkfor the Progressive Control of Transboundary Animal Diseases) in Asia and the Pacijk. Tokyo. FAO/OIE/WHO. February, 2004. FAO/OIE/WHO Technical Consultation on the Control of Avian Influenza, 3-4 February, 2004: Conclusions and Recommendations. OIE. May, 2005. OIE Report of the First Meeting of the Steering Committee of the Joint OIE/FAONetwork of Expertise on Avian Influenza (OFFLU). OIE. Paris. OIE/ASEAN. August 2005. The Southeast Asia Foot and Mouth Disease Campaign: Business Planfor PhaseIII(2006-2008). OIE/FAO. Network of Expertise on Avian Influenza (OFFLU).Paris. OIE/FAO. April, 2005. International Scientijk Conference on Avian Influenza, OIE Paris, France 7-8 April 2005: Recommendations.Pans. E. BIBLIOGRAPHY OF RECENT REPORTS& OTHER DOCUMENTS Bell, Clive andMaureenLewis. October 2004. TheEconomic Implications of Epidemics Old and New. Working Paper Number 54, Center for Global Development. Washington, DC. (see also Powerpointpresentation, "Economic Implications of Epidemics Old and New"). 80  OIE. 2004. Emerging Zoonoses and Pathogens of Public Health Concern. Rev. sci. tech. Off. int.Epiz., 2004,23 (2). FAO/OIE. February 2005. Second FAO/OIE Regional Meeting on Avian Influenza Control in Asia. Ho Chi MinhCity. FAO/OIE. February, 2004. Recommendations of the Joint FAO/OIE Emergency Regional Meeting on Avian Influenza Control in Animals in Asia. Bangkok. FAO/OIE. March 2005. Summary Report of the First Regional Steering Committee of GF-TADS (Global Frameworkfor the Progressive Control of TransboundaryAnimal Diseases) in Asia and the Paczjk. Tokyo. FAO/OIE/WHO. February, 2004. FAO/OIE/DWO Technical Consultation on the Control of Avian Influenza, 3-4 February, 2004: Conclusions and Recommendations. Ferguson, Neil et al. 2005. Strategies for Containing an Emerging Influenza Pandemic in Southeast Asia. Nature. OIE. May, 2005. OIE Report of the First Meeting of the Steering Committee of the Joint OIE/FAO Network of Expertise on Avian Influenza (OFFLU). OIE. Paris. OIE/ASEAN. August 2005. The Southeast Asia Foot and Mouth Disease Campaign: Business Planfor Phase III(2006-2008). OIEIFAO. Network of Expertise on Avian Influenza (OFFLU).Paris. OIEBAO. April, 2005. International Scientijk Conference on Avian Influenza, OIE Paris, France 7-8April 2005: Recommendations. Paris. Sandman, Peter and Jody Lanand.2005. Bird Flu: Communicating. Perspectives inHealth, Vol. 10, No. 2. PanAmerican HealthOrganization. Washington, DC. Schudel, A. August 2005. Tackling Avian Influenza at Source. Avian Influenza Technical Discussion& Coordination Meeting (powerpointpresentation). Washington, DC. Smolinski, Mark, Margaret A. Hamburg, and Joshua Lederburg (Editors). 2005. Microbial Threats to Pandemic Influenza. NationalAcademies Press. Washington, DC. WHO. 2005. W O Global Influenza Preparedness Plan: The Role of W O and Recommendations for National Measures Before and During Pandemics. Department of Communicable Disease Surveillance and Response, Global InfluenzaProgram. Geneva. WHO. January 2005. Influenza Pandemic PreparednessandResponse: Report by the Secretariat. Executive Board, 115thSession, Agenda Item4.17. Geneva. 81  World Bank. July 2, 2004. Technical Annex for a Proposed Credit of SDR3.5 million to the Socialist Republic of Vietnamfor an Avian Influenza Project. Washington, DC. 82  ANNEX12: STATEMENTOFLOANS CREDITS AND TURKEY: AVIAN INFLUENZA AND HUMANPANDEMIC PREPAREDNESSAND RESPONSEPROJECT 83  84  85  ANNEX13: COUNTRYAT A GLANCE T li%4 6$.$ 16.2 tS"8 18.; -1.61 3.1 38.1 33.c 1386434 Ibtr4.O.l. 421 543 3.1 1.4 11.1 86  87  MAP SECTION  TURKEY PROVINCE CAPITALS* NATIONAL CAPITAL RIVERS TURKEY MAIN ROADS Prut RAILROADS PROVINCE BOUNDARIES* This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information INTERNATIONAL BOUNDARIES shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. *Province names are the same as their capitals. 26