Document o f The World Bank

FOR OFFICIAL USE ONLY

Report No: 35720 - TR

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED LOAN

IN THE AMOUNT OF € 27.3 MILLION (US$34.4 MILLION EQUIVALENT)

TO THE

REPUBLIC OF TURKEY

FOR AN

AVIAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (AMP) PROJECT

AS PART OF THE GLOBAL PROGRAM FOR 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. I t s contents may not otherwise be disclosed without World Bank authorization.

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

CURRENCY EQUIVALENTS

(Exchange Rate Effective March 3,2006)

A I A P L AIHP

B S L CDC CE

CEU DIVA EA E C ECA EMP ERA ERL FA0 FMR FY GDP GDPC

Currency Units = New Turkish Lira (YTL) YTL 1.639 = €1

FISCAL YEAR January 1 - December 3 1

ABBREVIATIONS AND ACRONYMS

Avian Influenza Adaptable Program Loan Avian Influenza and Human Pandemic Preparedness and Response Project Bio-Safety Level US Centers for Disease Control Catastrophlc Event

Central Execution Unit Differentiation o f Infected from Vaccinated Animals Environmental Assessment European Commission Europe and Central Asia Region Environmental Management Plan Emergency Recovery Assistance Emergency Recovery Loan Food and Agricultural Organization Financial Management Report Financial Year Gross Domestic Product General Directorate o f Protection and Control (of M A W

GF-TAD Global Framework for Progressive Control o f Trans-boundary Diseases GPAI Global Program for Avian Influenza HIVIAIDS Human Immuno-deficiency VirusIAcquired

Immune Deficiency Syndrome H P A I Highly Pathogenic Avian Influenza H5N1 Avian Influenza a Virus Subtype H5N1 I C B International Competitive Bidding IDA International Development Agency ILI Influenza-like I l lness LDDC Local Disease Crisis Centers MAP Mult icounm APL

MARA Ministry o f Agriculture and Rural Affairs M&E Monitoring and Evaluation MOEF Ministry o f Environment and Forestry

M O H Ministry o f Health NAPA National Advance Purchase Agreements NARES National Agricultural Research and

Extension Systems N C B National Competitive Bidding NPIAP National Pandemic Influenza Action Plan NDCC National Disease Crisis Center N P V Net Present Value OIE OP Operational Policy PDA Provincial Directorate o f Agriculture PHD Provincial Health Directorate PINAP Pandemic Influenza National Action Plan P M R Project Management Report P O M Project Operational Manual PP Procurement Plan NGO Non-governmental Organization

World Organization for Animal Health

S A B I M Ministry o f Health Information Communication Center S A R S Severe Acute Respiratory Syndrome SOE Statement o f Expenditures

SPO State Planning Organization TCP T e c h c a l Cooperation Program TF TrustFund UWDP United Nations Development Program USAID US Agency for International Development WAHIS World Animal Health Information System WHO World Health Organization VCRI Veterinary Control and Research Institute

Vice President: Shigeo Katsu Country ManagerDirector: Andrew Vorkink

Mark R. Lundell Sector Manager: Marjory-Anne Bromhead

Task Team Leader:

TURKEY AVIAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE

CONTENTS

Page STRATEGIC CONTEXT AND RATIONALE .............................................................................................. 1

GLOBAL REGIONAL AND NATIONAL SECTOR ISSUES ........................................................................................ 1 RATIONALE FORBANK MVOLVEMENT ............................................................................................................ 7

B PROJECT DESCRIPTION 7 1 . LENDING INSTRUMENT 7 2 . PROJECT DEVELOPMENT OBJECTIVE ................................................................................................................ 8 3 . PROJECT COMPONENTS .................................................................................................................................... 8 4 . LESSONS LEARNED AND REFLECTED IN THE PROJECT DESIGN ........................................................................ 14 5 . ALTERNATIVES CONSIDERED AND REASONS FOR REJECTION ......................................................................... 16

C . IMPLEMENTATION ..................................................................................................................................... 16 1 . PARTNERSHP ARRANGEMENTS ..................................................................................................................... 16 2 . INSTITUTIONAL AND IMPLEMENTATION ARRANGEMENTS .............................................................................. 17 3 . MONITORING AND EVALUATION OF OUTCOMES/RESULTS .............................................................................. 18 4 . SUSTAINABILITY ........................................................................................................................................... 18 5 . CRITICAL RISKS AND POSSIBLE CONTROVERSIAL ASPECTS ............................................................................ 19 6 . MAIN LOAN CONDITIONS ............................................................................................................................... 20

APPRAISAL SUMMARY .............................................................................................................................. 20 1 . ECONOMIC ANALYSIS .................................................................................................................................... 20 2 . TECHNICAL ................................................................................................................................................... 21 3 . FIDUCIARY .................................................................................................................................................... 22 5 . SAFEGUARD POLICIES .................................................................................................................................... 24 6 . POLICY EXCEPTIONS AND READINESS ........................................................................................................... 25

A . 1 . 2 .

. ............................................................................................................................. ....................................................................................................................................

D .

4 . ENVIRONMENT AND SOCIAL ASPECTS ............................................................................................................ 23

ANNEX 1: KEY FACTS ABOUT AVIAN INFLUENZA AND AVIAN INFLUENZA A (H5N1 VIRUS) ...... 26 ANNEX 2A: SUMMARY OF THE FA0 AND THE OIE GLOBAL STRATEGY FOR THE PROGRESSIVE CONTROL OF HIGHLY PATHOGENIC AVIAN INFLUENZA (HPAI) ........................... 29 ANNEX 2B: SUMMARY OF THE WORLD HEALTH ORGANIZATION (WHO) STRATEGY ................. 32 ANNEX 2C: SUMMARY AND REVIEW OF THE AVIAN INFLUENZA CONTINGENCY PLANS OF THE REPUBLIC OF TURKEY 35

ANNEX 3: RESULTS FRAMEWORK AND MONITORING ............................................................................ 39 ANNEX 4: DETAILED PROJECT DESCRTPTION ............................................................................................ 50 ANNEX 5: PROJECT COSTS ................................................................................................................................ 59 ANNEX 6: IMPLEMENTATION ARRANGEMENTS ........................................................................................ 60 ANNEX 7: PROCUREMENT. FINANCIAL MANAGEMENT. AND DISBURSEMENT ARRANGEMENTS .................................................................................................................................................................................... 61 ANNEX 8: ECONOMIC ANALYSIS ..................................................................................................................... 70

..............................................................................................................................

ANNEX 9: SAFEGUARD POLICY ISSUES ......................................................................................................... 76 ANNEX 10: PROJECT PREPARATION AND SUPERVISION ........................................................................ 78 ANNEX 11: DOCUMENTS IN THE PROJECT FILE ........................................................................................ 79 ANNEX 12: STATEMENT OF LOANS AND CREDITS .................................................................................... 83 ANNEX 13: COUNTRY AT A GLANCE .............................................................................................................. 86 ANNEX 14: MAP ...................................................................................................................................................... 88

TURKEY

AVIAN INFLUENZA & HUMAN PANDEMIC PREPAREDNESS & RESPONSE PROJECT

PROJECT APPRAISAL DOCUMENT

EUROPE AND CENTRAL ASIA

ECSSD

Date: March 29,2006 Country Director: Andrew N. Vorkink Sector Managermirector: Marjory-Anne (30%);Agro-industry (30%) Bromhead Themes: Natural disaster management

Team Leader: Mark R. Lundell Sectors: Animal production (40%);Health

(P);Other communicable diseases (P);Rural policies and institutions (S);Other environment and natural resources management (S) Environmental screening category: Partial Assessment

Project ID: PO96262

Lending Instrument: Emergency Recovery Loan

[XI Loan [ 3 Credit [ ] Grant [ ] Guarantee [ ] Other:

For Loans/Credits/Others: Total Bank financing (US$m.): €27.3 m. (US$ 34.40 m. equivalent) Prouosed terms: VSL

Financing Plan (USsrn) Source Local Foreign Total

BORROWER 7.06 0.00 7.06 INTERNATIONAL BANK FOR 17.20 17.20 34.40 RECONSTRUCTION AND 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: Undersecretariat o f Treasury Ankara Turkey Tel: (90 312) 213 0297 hazine@,hazine.gov.tr

Fax: (90 312) 212 8550

Responsible Agency: Ministry o f Agriculture and Rural Affairs rurkey Ministry o f Health Turkey

Project implementation period: Start June 5,2006 End: July 30,2010 Expected effectiveness date: M a y 3 1,2006 Expected closing date: November 30,2010 Does the project depart from the CAS in content or other significant respects?

As part o f the Global Program for Avian Influenza, this operation i s o f an emergency nature. I t was not foreseen in the CAS, but is not inconsistent with the CAS. Does the project require any exceptions from Bank policies? Ref: PAD 0 . 6 Have these been approved by Bank management? I s approval for any pol icy exception sought from the Board? Does the project include any critical r isks rated “substantial” or “high”? Ref: PAD C.5 Does the project meet the Regional criteria for readiness for implementation? Ref: PAD 0 . 6 Project development objective Ref: PAD B.2 The proposed project aims to minimize the threat in Turkey posed to humans by highly pathogenic avian influenza 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 wil l be supported: (i) prevention, (ii) preparedness and planning and (iii) response and containment. Achieving these goals will contribute to diminishing the burden o f disease and loss o f productivity in Turkey, limiting the regional spread o f AI, and enhancing economic and social prospects at the national, regional, and global levels.

[ ]Yes [XINO

[XIYes [ ] N o [XIYes [ ] N o [ ]Yes [XINO

[XIYes [ ] N o

[XIYes [ ] N o

Project description Ref: PAD B.3, Technical Annex 4 Component I. Animal Health - this component targets the prevention, control and total eradication o f H P A I through: (i) strategy development and epidemiological studies and surveillance programs to inform the improvement o f disease control measures; (ii) strengthening the detection capacity o f reference and regional diagnostic laboratories to follow-up reported AI cases; (iii) support to activities related to the implementation o f the containment plan for AI outbreaks; and (iv) and restructuring o f the poultry sector.

Component 11. Human Health - this component targets the reduction o f the impact o f a pandemic influenza virus through: (i) year-round surveillance; (ii) effective and accurate

nethods o f diagnosis; (iii) social distance interventions; and (iv) strengthened medical services. The project wil l help the Ministry o f Health (MOH) to build its institutional capacity to mplement the recently prepared national pandemic influenza action plan in coordination with :he Ministry o f Agriculture 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, and c iv i l society organizations and to raise awareness, knowledge and understanding m o n g the general population about the risk and potential impact o f the pandemic. I t wil l also ;upport the National Zoonotic Disease in its roles o f triggering emergency responses by the MARA and MOH, monitoring the actions taken by them, coordinating public statements to the media, and executing project evaluation activities.

Which safeguard policies are triggered, if any? Re$ PAD 0 5 , Technical Annex 9 Only the Environmental Assessment safeguard is triggered by the Project. Since the Project i s being processed under emergency procedures and i s assessed as a B-category project, an Environmental Management Plan wil l be prepared during Project implementation under the Animal Health component and implemented with Project support.

Significant, non-standard conditions, if any, for: Re$ PAD C.6 Board presentation: None

Loadcredit effectiveness: The condition o f effectiveness for the Loan would be that the MARA and MOH have appointed their respective Project Coordinators.

Covenants applicable to project implementation: Disbursement conditions:

A disbursement condition for the Animal Health component i s the adoption by the Borrower o f an Environmental Management Plan satisfactory to the Bank. I t i s also required that the payments under the Compensation Fund and the selection and implementation o f Poultry Restructuring sub-projects are made in accordance with criteria and procedures set forth in the Project Operational Manual (POM).

Other covenants applicable to project implementation:

The adoption of a POM by the Borrower is a dated covenant (June 30,2006). In addition, the Borrower shall monitor and evaluate the project and report o n its progress through semi-annual Project Reports and prepare a mid-term review report by M a y 31,2008.

A. STRATEGIC CONTEXT AND RATIONALE

1. Global regional and national sector issues (a) Introduction

1. The continuing outbreaks o f highly pathogenic avian influenza (HPAI), which began in 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 mi l l ion domestic poultry had either died or been destroyed and over 170 people had contracted the infection (of which 92 have died). Recent increases in the number o f known cases o f avian influenza (AI) transmission have raised concerns over the potential emergence o f a pandemic, which could have devastating effects on human health and livelihoods.

2. At the same time, i t i s important to emphasize that there are many uncertainties about whether and when a pandemic might occur, as well as about i t s potential impact. Humans are not very susceptible to the disease, but if infected with the Asian H5N1 strain, 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 Asian poultry sector alone are estimated to date at around $10 billion. Despite control measures the disease continues to spread, causing hr ther economic losses and threatening the livelihood o f 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 re ly for a larger share o f their income on poultry, have been particularly hard hit with income losses.

3. I t is impossible to anticipate when the next influenza pandemic may occur or how severe i t s consequences may be. O n average, three pandemics per century have been documented since the 16th century, occurring at intervals o f 10-50 years. In the 20th century, pandemics occurred in 1918, 1957 and 1968. The pandemic o f 1918 i s estimated to have k i l led almost 50 mi l l ion people in eighteen months, with peak mortality rates occurring in people 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 to l l o f illness and death could result. Air travel might hasten the spread o f a new virus, and decrease the t ime available for preparing interventions. Countries’ health care systems could be rapidly overwhelmed, economies strained, and social order disrupted. With interventions proposed in this Project, and in collaboration with other national and international partners, i t should be possible to minimize a pandemic’s consequences in Turkey through advance preparation to meet the challenge.

(b) Socioeconomic Context

4. The recent epidemics or outbreaks o f animal origin (e.g. S A R S , avian influenza, Lassa virus, Ebola virus, Marburg virus, Nipah virus, West N i l e virus) have demonstrated the potential and real global impact o f zoonotic diseases o n the health and well-being o f the public, as wel l as the enormous humanitarian, socio-economic, and trade damage that this group o f 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 in disease prevention and control, as wel l 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 i s 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 in humans occur annually, as a result o f antigenic drift in the Influence A virus with a severity which varies f rom year to year, but i s typically moderate to mild. Nonetheless, these outbreaks occur in al l countries and exert an impact primarily through morbidity and reduced economic productivity because o f illness. In contrast, severe influenza pandemics occur infrequently, as a result o f antigenic shift, but have been unprecedented in the number o f infections and deaths caused over a short time-period. The worst such event in the 20th Century, the Spanish Flu pandemic o f 1918-19, had the highest mortality rate among healthy young people. Less severe pandemics occurred in 1957-58 and 1968-69, but st i l l had high attack rates, high case fatality, and major impact o n 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 in birds and domestic poultry in East and Central Asia, Europe, the Middle East and Africa creating widespread concern that the risk o f a new and potentially severe human pandemic i s 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. Even if a pandemic does not occur, there could be important socio- economic effects resulting from the response to the perceived risks. Countries confront choices in balancing preparation versus action since both imply economic costs. At least three types o f economic costs or impacts should be considered under a human pandemic scenario: (i) effects o f sickness and mortality o n potential output; (ii) private preventive responses to an epidemic; and (iii) public sector responses.

(c) Key Issues

7. A coordinated global response should involve three types o f strategic activities: (i) preventing the occurrence and spread o f the disease in domesticated animals, thus lowering the

' Antigenic drift refers to a change in surface proteins o f a given strain o f influence virus in response to antibodies in human hosts who have been exposed to it. I t occurs continually in both type A and B influenza 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 wi th the circulating human strain in the process o f moving from an animal to humans. T h i s antigenic shift i s more o f a concern since when it occurs, it results in pandemics due to generalized susceptibility to infection in humans.

2

virus load in the environment; (ii) preventing and/or mitigating the effects o f an outbreak in humans; and; (iii) in the event o f a pandemic, helping affected populations cope with i t s effects. There i s a need to formulate a global response based on a common vision for undertaking these three sets o f activities. Such a vision should entail immediate measures while ensuring that these measures fit within a coherent longer-term strategy with respect to both animal and human health 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 in the areas o f health, agriculture, environment, economics, finance, and planning among others. At the country level, in particular, an integrated, multi and inter-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 H 5 N 1 strain currently affecting several Asian countries has proven highly fatal to humans. The r isk that a pandemic virus wil l emerge depends on opportunities for human exposure and infection, which wil l persist as long as the H5N1 virus continues to circulate in animals. With the present situation, the potential o f the HPAI virus to become transmissible among humans needs to be a serious concern. If the virus adapts i t se l f to human-to-human transmission, 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 The conditions for the emergence and local spread of HPAI have been exacerbated by the intensification and concentration o f livestock production in areas o f high-density human populations. The danger o f 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 o f avian influenza should be the foundation o f a global response.

Market conditions have caused HPAI to spread rapidly.

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 r i sks (countries neighboring infected countries and/or in migratory bird fly way paths). A minimum level o f preparedness i s essential in al l 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 i s to

3

reduce the r isk 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 r i s k o f HPAI in 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, and improve the livelihoods o f the rural poor.

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 wel l as measures to limit the effects o f disease transmission by migratory birds, are trans- boundary issues requiring regional and/or international coordination. Global and regional efforts should build o n existing mechanisms such as the joint OIE/World Bank initiative for the Prevention and Control o f Global Emerging and Re-emerging Diseases o f Animal Origin, and the joint Global Framework for Progressive Control o f Transboundary Animal Diseases (GF- TADs), a jo int FAO/OIE initiative and regional organizations such as the Association o f Southeast Asian Nations and South Asian Association for Regional Cooperation.

(d) The global 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 i s to minimize the global threat and r isk o f HPAI in humans and domestic poultry, through progressive control and eradication o f HPAI, particularly that caused by H5N1 virus, from terrestrial domestic poultry. The global strategy wil l 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 a l l 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 complemented by more detailed country specific HPAI control plans. FAO/OIE have also issued specific recommendations for avian influenza and OIE has recently issued recommendations for each region, in addition to i t s standards and guidelines provided for the prevention and control o f HPAI in animals (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 i s in the process o f developing a model country plan that wil l allow countries to assess their state of preparedness and identify priori ty needs.

4

10. The Bank has developed a global facility through a multi-country adjustable program loan (MAP). In parallel, 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 in conjunction 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 than ten administrative regions, beginning in the Ura l Mountains and moving west to within 200 km o f Moscow. In the f i rst three weeks o f 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 in North-Eastern Europe, where avian influenza in wild and domestic fowl has also been diagnosed.

(Jl The national dimension

12. Up until Januarv 2006, Turkey had experienced one outbreak o f avian influenza, in the 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 migratory birds, which were abundantly present at the time. Most o f 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 H 5 strain (through inoculation and subsequent death in embryonated eggs). The EU reference laboratory in Weybridge (UK) confirmed the presence o f the HPAI H5N1 strain o n October 13.

13. Sanitary measures had been promptly initiated by the provincial veterinary service o n 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 in the remaining two enterprises was slaughtered on October 9. In addition to the protection zone, a 10 km radius 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 l ive 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 o f 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 f i r m s dropped by over 30 percent in the f i rs t week). This i s partly owing to the fact that Balikesir and the nearby regions o f Bursa, Izmir, Manisa, and Sakarya account for over 40 percent o f Turkey’s broiler enterprises and poultry production. Egg production i s similarly concentrated in these provinces, and its demand fel l 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 mi l l ion daily in October-December 2005. (Prior to the outbreak the GDP of the poultry and egg sector ranged US$ 1.2-1.5 bi l l ion annually)

15. In January 2006, a widespread outbreak occurred, starting init ial ly in northeastern Turkey along the border areas with Georgia, Armenia, and Iran. This area i s directly on the flight path o f migrating birds (the so-called Central Asia Flyway) and sits between three large lakes: Sevan in the east (Armenia), Van in the eastern Anatolia (Turkey), and Urmia in the south (Iran). The init ial outbreak in the provinces of Ardahan, Kars, Erzwum, Agn, Igdir, and Van was met quickly with cul l ing o f over 50,000 birds (in the f i rs t week o f January). In the second week o f January, the number of provinces reporting suspected or confirmed cases o f AI in poultry rose quickly. A s o f mid-March, its presence was confirmed in 58 o f Turkey’s 81 provinces. T o 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 in these 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 mi l l ion birds had been culled in the imposed protection zones around villages with confirmed cases.

16. However, a l l these measures have not prevented the occurrence o f animal to human transmission. A s of January 19, there were 21 human cases, including four deaths, although many o f those cases remained to be re-confirmed. Only 38 percent o f the 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 in Van. These cases were the first occurrence and death in humans from the H 5 N 1 strain o f AI outside o f Asia. On the other hand, the case fatality rate in Turkey has been lower compared with other countries due to improved early case detection and effective treatment.

17. Almost al l of the people with confirmed cases have a confirmed history o f close contact with sick birds, and there is st i l l no indication o f human-to-human transmission. Those who had access to antivirals in the f i rs t 48 hours after having been diagnosed with Influenza-like-Illness (ILI) responded relatively well, though treatment o f more severe cases necessitated the usage o f ventilators to aid patients in breathing.

6

2. Rationale for Bank involvement

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. H P A I 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 knowledge base o n multi-disciplinary approaches needed in the 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 high level political coordination.

19. Given the Bank’s work with FAO, WHO, OIE, EU and other partners in country and at the international level to address both preparedness and outbreaks and to assist with institutional assessments, the Bank can assist Turkey in leveraging additional resources from other international and bilateral agencies. In addition to i t s financial role, the technical assistance provided by the Bank has been important in similar global or regional emergency situations such as S A R S , Tsunami relief, and H N / A I D S . 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, and draws heavily on, the global strategies proposed by FA0 and WHO.

B. PROJECT DESCRIPTION

1. Lending instrument

20. The proposed Project i s 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) wil l 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 implementing its response to HPAI. Funds under the GPAI are available to countries which 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;

national commitment and leadership, including wel l structured implementation arrangements;

b)

c) an implementation strategy that includes program execution through multiple ministries and through non-governmental organizations (NGOs), community groups and c iv i l society organizations; and

7

clearly defined institutional arrangements for, and readiness to initiate, monitor and evaluate project progress and impact.

d)

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 st i l l meets a l l applicable Bank policies, practices and standards as discussed below.

2. Project development objective

22. The overall objective o f the Project i s to minimize the threat in Turkey 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 wil l be supported: (i) prevention, (ii) preparedness and planning and (iii) response and containment. Achieving these goals wil l contribute to diminishing the 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. Project components

23. The Project wil l finance activities under three components: (i) animal health; (ii) human health; and, (iii) public awareness and coordination support. Given the urgency o f the situation, 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 refined in more detail as part o f annual project reviews.

I. ANIMAL HEALTH COMPONENT

24. The Project wil l support activities to cover the needs in the short, medium or long-term, and ranging from prevention, to control and eradication o f HPAI, which have been based on an assessment o f the particular conditions, constraints and possibilities in Turkey (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 U S $ 30.86 million:

A. National policy framework and development of a national strategy sub-component

A1 : Policy development and enabling environment. The Project activities’ support will include strategy development and the improvement o f the regulatory framework to address key pol icy issues and ensure that disease control, prevention and eradication measures are implemented in a uniform and effective way in accordance with the Wor ld Organization for Animal Health (OIE) standards and guidelines. It wil l support definition o f disease control options and reviews o f existing regulations and policies and fund related pol icy studies, strategy development and dissemination workshops. The main outputs will be a detailed assessment o f the capacity o f i t s veterinary services and an integration o f the AI contingency plans o f the Ministry o f Agriculture and Rural Affairs (MARA) and the Ministry o f Health (MOH) into a National A I Strategy. (US$ 0.59 mil l ion)

8

A2: Epidemiology and disease information systems. In this area, the Project wi l l support epidemiological studies and surveillance programs to inform the improvement o f disease control measures, which wil l be then adjusted and improved as new information becomes available. I t will also support the linking o f the laboratory information systems o f Turkey’s eight Veterinary Control and Research Institutes (VCRIs) to the existing module o f the World Animal Health Information System (WAHIS) maintained by the MARA General Directorate o f Protection and Control (GDPC). This wil l better enable Turkey to participate in global disease information sharing, complying with their obligations as members o f the OIE. Epidemiological studies wil l include a focus on scaling up the knowledge base o f the Ministry o f Environment and Forestry (MOEF) on movement o f migratory birds in the main areas o f their known transit. The disease information system wil l be linked with rapid and standardized methods o f routine analysis o f surveillance data in order to track important changes in the H 5 N 1 situation and promptly supply this information to field personnel. (US$0.48 million)

B. Strengthening Disease Surveillance and Diagnostic Capacity Sub-component

B1: Strengthening Animal Disease Surveillance and Diagnostic Capacity. Project support in this area wil l aim at strengthening the capacity o f the GDPC and i t s affiliated reference and regional diagnostic laboratories in detection, reporting and follow-up o f reported AI cases. This will cover the formation and equipping o f Bio-Safety Level 3 (BSL3) laboratories in Bornova and Pendik, as well as equipment (incubators, laminar f low 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 o f their relevant roles in the 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 o f the VCRIs and the affiliated staff in the Provincial Directorates o f Agriculture which wil l be expected to form the local Expert Groups o f the Local Disease Crisis Centers (LDCCs). The focus o f the training wil l be o n screening, sampling, and test procedures to be applied in case o f an outbreak, as we l l as on analyzing epidemiological data and performing risk assessments. Supported activities will also cover an init ial self-evaluation o f veterinary services, fol lowing OIE standards on quality and evaluation o f veterinary services to meet international requirements. Increased risk-based AI surveillance activities wil l also be supported at the provincial and district levels, coordinated through the VCRIs. (US$ 2.01 million)

C. Outbreak Containment Plan

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

and Local Expert groups. Section 8 o f the Contingency Plan contains the operational manual for the containment plan. The sub-component wil l include the following activities:

C1: Targeting virus eradication at the source. In order to target the eradication o f the disease at the source o f infection, the Project wil l target the following activities: (i) culling o f 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 A I outbreaks). (US$ 13.1 million)

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 and border controls.

C2: Veterinary personnel safety. Due to the highly pathogenic nature o f the HPAI virus to humans, particularly the Asian H5N1 strain, training o f people in contact with l ive virus would be supported. This would include f ield workers involved in identification o f the disease, farm workers involved in culling and disposing o f manure, laboratory workers involved in virus 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. Restructuring the poultry sector in Turkey 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 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 wil l be piloted under the Project with matching grants to be provided under a competitive proposal submission and award process (with at least 50% co-financing by private beneficiaries). (US$ 9.0 million)

11. HUMAN HEALTH COMPONENT

26. In the public health field, short-and long-term actions need to be taken and an appropriate balance struck between the two. W h i l e 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 in parallel, and efforts should be made to ensure that short-term responses are consistent with and contribute to proposed longer-tern interventions. Setting priorities in both cases i s essential.

27. Building an effective national public health response wil l 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 i t i s unlikely that the global spread o f a pandemic influenza virus could be prevented once i t emerges, the emphasis i s on reducing i t s impact. Several tools can help achieve this aim: (i) year-round surveillance; (ii) effective and accurate methods o f diagnosis; (iii) social distance interventions; (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 wil l be grouped in three sub-components, totaling US$20.84 million.

A. Enhancing Public Health Program Planning and 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 i t s 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 during inter-pandemic, pandemic alert and pandemic periods, and the means o f communication and public information. Finally, i t provides a l i s t o f regional and reference laboratories and telephone numbers o f those who are directly in charge 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 i t to fully implement a l l aspects o f the NPIAP. However, the N P I A P ’ 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 o n a small scale to assess i t s implementability as a coordinated action and put to test the chain and command structure. The Project wil l 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 wil l support the fol lowing activities (US$ 14.88 million):

0

0

0 Improving health information and telecommunication systems at MOH’s Public

Equipping health personnel with protective gear and clothing; Upgrading o f drug storage facilities; and

Information Communication Center (SABIM) and the Crisis Management Center.

11

B. Strengthening of National Public Health Surveillance Systems

30. In Turkey, there i s a hnctional Influenza surveillance monitoring committee and a 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 i s made through virologic surveillance to report the number of clinical specimens tested for influenza and the number o f positive results by virus type and subtype. According to the protocol, al l specimens are to be sent to the two reference public health laboratories where virus isolation and typing could be made. I t i s not clear, however, whether the two BSL-2 laboratories wil l 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 l ow supply o f material for specimen collection, transportation and laboratory supplies, MOH intends to upgrade i t s 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 o f Laboratory Networks; 0

0 Training. Simulation exercises o f ILI case notification and ascertainment; and

C. Strengthening Health System Response Capacity

3 1. 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 wil l be supported, along with increased awareness and promotion o f community participation in slowing the spread of the pandemic. (US$ 0.1 mil l ion)

111. PUBLIC AWARENESS AND COORDINATION SUPPORT COMPONENT

32. This component wil l 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. Public Awareness through Information and Communication Services

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 o f priority populations at the national, provincial and local levels. The strategy wil l 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 fo r in the Environmental Management Plan (EMP) for safe culling and disposal of backyard poultry (US$ 0.81 million).

B. Coordination Support

34. The multi-dimensional problems associated with H P A I infection necessitate collaboration from a wide range o f stakeholders within each country, which in Turkey include: the State Planning Organization (SPO), the Undersecretariat o f the Treasury, the MARA, the MOH, their associated diagnostic laboratories, NGOs and c iv i l 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 wi l l 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 in the MARA and MOH.

B1. National Coordination

35. The National Zoonotic Disease Committee (NZDC) wil l serve as the venue for coordinating the national awareness activities described above. I t wil l review the AIHP Project’s annual work plans and ensure coordination and linkages across relevant agencies and international partners. In AI outbreak situations, the N Z D C i s in charge o f triggering emergency responses by MARA and MOH, monitoring the actions taken, and coordinating public statements to the media. In this last area, the N Z D C wil l be supported by a Public Information and Communication Specialist hired under the AIHP Project.[(US$ 0.21 million).

B2. Project Implementation

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 wil l appoint Project Coordinators to liaise with the MAFL4 C E U and MOH PKJ, respectively, and to prepare annual work programs and budgets as wel l as semi- annual interim un-audited financial reports. The Project Coordinators wil l manage the respective component for which their ministry i s responsible and attend the periodic meetings o f the National Zoonotic Disease Committee. The MARA C E U wil l be responsible for consolidating the annual work plans, budgets and financial reports for submission to the N Z D C 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 wil l guide implementation o f cross-sectoral activities, and if necessary set up local disease crisis centers to ensure cross-sectoral coordination.

13

B3: Monitoring and Evaluation (M&E)

38. Support would be provided to enable project monitoring and impact evaluation assessments. T w o types of M&E are envisaged. First, the MAR4 C E U 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 C E U will be responsible for consolidating the ministerial progress reports into an integrated project monitoring report. (US$0.5 1 million)

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 wil l include both quantitative and qualitative aspects and be conducted on a yearly basis. The quantitative aspects wil l rely o n new information systems and surveys implemented as part o f the various components o f the project, currently existing data sources, and primary evaluative data collection efforts. The goal o f the qualitative aspect o f the evaluation wil l be to document perceptions o f program managers, staff, patients, and local and national leaders. Qualitative information wil l be collected using site-visit interviews, focus groups, and respondent surveys..

4. Lessons learned and reflected in the project design

40. Relevant lessons for the design o f the proposed operation have 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 i s the only project that has been approved by the Bank in response to the Avian Influenza so 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 i s clearly a major factor in limiting the impact o f a crisis and hastening recovery. A performance audit o f some o f the emergency projects supported by the Bank in various regions drew the fol lowing general lessons: (i) emergency projects should avoid pol icy conditionality; (ii) project design must be simple and take into account a realistic assessment o f the existing Borrower’s capacity; (iii) a speedy 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 we l l as o f the effective communications and coordination mechanisms among al l 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 i t s implementation have been the following:

14

Preparedness i s a key factor. W h i l e Vietnam had a national strategy document to control Avian Influenza in the domestic poultry population, i t was not clearly understood and shared by al l relevant agencies and stakeholders and some aspects of the response have been lagging behind. A two-pronged strategy is recommended. This should include: (i) the control o f 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” i s an essential element to obtain real cooperation from affected stakeholders (farmers/producers) and to ensure the efficacy o f the 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 we l l 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 f the disease. There i s an urgent need to organize an effective national response, including al l technical ministries in charge o f agriculture/animal health and human health, as we l l as other relevant sectors, at the national and sub-national level, in case o f a human epidemic. I t i s extremely important to raise awareness in the 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 and the c i v i l 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 a l l trans- boundary animal diseases and other emerging infectious diseases, to increase cost-effectiveness and ensure the harmonization o f activities and responses

43. operations:

In terms o f public health, the following relevant lessons were derived from emergency

Key data needs should be anticipated and infrastructure developed to provide information that reduces the number o f assumptions (“what i s not known i s 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 o n new information. External reviews o f the program should be conducted periodically t o increase objectivity and improve decision making. Ensure that al l 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 f the response. Surveillance systems should be in place, preferably, before starting the program. Communications materials should be developed to educate health care providers and the public.

0 Always keep in mind the principle: “expect and plan for the unexpected”.

0

5. Alternatives considered and reasons for 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 and the 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 pol icy 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 c iv i l society, as well as scaled up efforts to serve the entire population. This will also facilitate advocacy and communication 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 in the response to AI, especially at the country level where there is a need to develop an overall 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 o f 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 wel l as direct collaboration with European Commission counterparts in Brussels and the Ankara delegation. Inputs from the U S Agency for International Development ( U S AID) assessments and technical assistance visits have also helped to 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 E C A region, in which Turkey wil l participate. The program’s primary objective i s 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. In 2005, the European Commission established a task force to address AI which has been active in analyzing assistance options in various countries, including Turkey. In late 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 o f Turkey (a jo int MARA/MOH proposal) for a grant o f US$ 12.7 mi l l ion to parallel finance over U S $ 15 m i l l i on 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 U S A I D has agreed to provide a grant o f approximately US$ 1 .O million to 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 o f Turkey to access multilateral and bilateral funding, the availability o f which 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 in Turkey.

2. Institutional and implementation arrangements

48. The Project wil l be implemented by existing project implementation structures in the MARA and the M O H . However, public information and project coordination arrangements wil l be overseen by the existing National Zoonotic Disease Committee. This Committee has been established jo int ly by the MARA and the MOH to deal with zoonotic emergencies and wil l 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 wil l review annual work plans and ensure coordination and linkages across relevant agencies and international partners.

49. Since the Bank i s financing both agricultural sector and health sector projects in Turkey, the existing project implementation structures within the MARA (the Central Execution Unit o f 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 C E U 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 in charge o f managing implementation o f their relevant ministries’ project activities and liaising with the MARA C E U and MOH PIU, respectively. These Project Coordinators will provide reports to the N Z D C and would be invited as observers to the N Z D C meetings. The N Z D C will also be supported by a Public Information and Communications Specialist (consultant) to support i t s 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 o f outbreaks, the provincial governor wil l guide implementation o f cross-sectoral activities, and if necessary set up local disease crisis centers to ensure cross-sectoral coordination.

5 1. A Project Operational Manual (POM) i s being prepared to integrate the relevant aspects of each o f the Contingency Plans which have been prepared by the MARA and the MOH. This POM will guide the management and implementation o f the Project.

17

3. Monitoring and evaluation of outcomes/results

52. Monitor ing and Evaluation (M&E) activities related to the project will be the responsibility o f the MARA C E U and the MOH PIU, with the participation o f the staff o f the departments o f the two ministries. These two implementation uni ts have built up M&E capacity, but some detailed surveys for M&E would be contracted out. Monitoring project progress and the achievement of objectives wil l entail a process for reviewing continuously and systematically the various project implementation activities. The purpose o f the M&E activities are to: (i) measure input, output and outcome indicators (see Annex 3); (ii) provide information regularly on progress toward achieving results and facilitating reporting to the government and the Bank (iii) alert managers, both in government and the 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 intended by the project; and (v) provide a process whereby the coordinating and executing bodies can reflect and improve on their performance.

53. The results of relevant M&E activities will be reflected in the semi-annual progress reports. The progress reports wil l cover the progress with the works, the institutional activities, training and studies, performance indicators and financial reports. A section o f the progress reports wil l 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, providing information o f the progress during the past year.

54. A comprehensive Mid-term Progress Report will be prepared approximately half-way during the implementation period (by M a y 3 1 , 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 o f this initiative by the various stakeholders, coupled with strong political support and the availability o f an adequate f low 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 r isk regions; (iii) strengthened country capacity to manage at national and local levels the r isk factors associated with the spread of avian influenza and other infectious diseases; and (iv) effectiveness o f programs to control the spread o f avian influenza from birds to the general population.

18

5. C r i t i c a l r i s k s and possible controvers ia l aspects

Project implementing agencies do not have sufficient authority, leadership, and capacity to take leading role in A I prevention and control.

Intervention activities not effective in containing the spread o f Avian Influenza from birds to the human population.

RATING

From Outputs to Objective Decline in political commitment to A I and to the threat o f a global influenza pandemic.

M

S

Inadequate or lack o f multi-sectoral participation M

L o w regionaliprovincial-level commitment means that strong central commitment does not translate into action on .the ground.

From Components to Outputs '

expose the government to criticism for the curtailment o f c iv i l rights due to the adoption o f quarantines and other related measures.

Controlling the spread o f the pandemic may

Lack o f laboratory capacity for prompt diagnosis and surveillance and o f sufficient quantity o f drugs and other medical inputs needed to address the needs o f the general population during a pandemic Inadequate institutional capacity to manage project and perform effectively

Financial resources not accessible in a timely

Lack o f timely and predictable access to expert manner, weak procurement management

advice and technical support

surveys and monitoring and evaluation

M

M

S

M

M

M

Overall Risk Rating:

MITIGATION MEASURE

M

Continuing support for inter-country collaboration through information exchanges, dialogue, and mobilization o f international commitment and resources. Adequate implementation arrangements in place as a pre- condition o f Bank financing; careful monitoring o f leadership and project management during project implementation; technical assistance and training. Project activities will strengthen response capacity in selected priority areas in the short- and medium terms and lay the foundations for a broader-based strategy, including broad awareness and communication campaigns, which w i l l be critical to containing the spread o f a global influenza pandemic. Choosing well designed, cost-effective interventions. Interventions phased and carefully monitored, allowing for modifications and redesign as needed. Service delivery deconcentrated with the maximum use o f local governments and civi l society organizations. Good M&E to flag emerging issues National Zoonotic Disease Committee overseeing the program selected to be representative and given visibility; annual work programming transparent. Implementation mechanisms explicitly address provincial decision making, communication strategies include decentralized authorities as targets.

Project wil l support advocacy and coalition building to sensitize key groups including pol icy makers and the media. This w i l l be complemented by carefully designed mass communication campaigns to build support for the project among the wider population Project activities w i l l be coordinated with efforts undertaken by other international organizations such as WHO, that has established an international antiviral stockpile with donations from the pharmaceutical industry (e.g., Roche's donation o f three mi l l ion treatment courses o f the antiviral oseltamivir). Capacity building and institutional development as one o f the project's key objectives Emphasis on deconcentration and partnerships. Rapid disbursement procedures and simplified public sector procurement in accordance with OP for emergency operations. Project activities are designed and implemented with leading multilateral agencies such as FA0 and WHO; regional bodies such as the European Union; and bilateral and other donor organizations. Publication o f audit results and achievements; transparency in decision and resource allocation. Technical assistance and partnership between local organizations and international institutions wil l be provided. M&E plan will include information on instruments for data collection, agencies responsible and a detailed time table

[ (Modest Risk), N (Negligible or Low Rsk)

19

56. 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 e needed for managing controversies that wi l l undoubtedly arise.

Possible Controversial Aspects.

6. Main loan conditions

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 be that the MARA and M O H have appointed their respective Project Coordinators.

58. A disbursement condition for the Animal Health component i s the adoption by the Borrower o f an Environmental Management Plan satisfactory to the Bank. I t i s also required that the payments under the Compensation Fund and the selection and implementation o f Poultry Restructuring sub-projects are made in accordance with criteria and procedures set forth in the Project Operational Manual (POM). The adoption o f a P O M by the Borrower i s 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 and prepare a mid-term review report by M a y 3 1,2008.

D. APPRAISAL SUMMARY

1. Economic analysis

59. Neither the timing nor the severity o f the next pandemic can be predicted, but with the virus now endemic in bird populations in Asia the r isk will not be easily diminished. Given the recent outbreaks in poultry in the Manyas Lake area and then more widely throughout al l 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 i t s effects and the economic consequences of sickness or death resulting f rom 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 in the poultry sector

60. In this treatment o f 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 l o w 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 i s caused by massive public aversion to poultry consumption leading to a significant and sustained drop in prices and demand for poultry.

61. Under the “with project” scenario, the probability o f the CE i s reduced gradually to less than half that under the “without project” scenario (by year 4 o f the Project). The stream o f expected costs in this scenario i s calculated by multiplying these probabilities with the respective NPVs o f costs. Given project expenditures o f U S $ 55.2 million, the analysis yields an NPV o f US$ 415.9 mil l ion. (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 in different poultry production systems in the 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 and i t s farming systems i s essential for the achievement o f the program objectives.

63. important technical issues and presents substantial challenges. The main issues are:

The implementation o f the program and o f each o f the individual country projects raises

e The capacity o f Veterinary Services. The Gener