Document of The World Bank FOR OFFICIAL USE ONLY Report No: 36719-NP TECHNICAL ANNEX ON A PROPOSED Grant IN THE AMOUNT OF SDR 12.1 MILLION (US$18.2 MILLION EQUIVALENT) TO THE GOVERNMENT OF NEPAL FOR AN AVIAN INFLUENZA CONTROL PROJECT UNDER THE GLOBAL PROGRAMFOR AVIAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (GPAI) December 21,2006 Sustainable DevelopmentDepartment (SASSD) Human Development Sector Unit (SASHD) South Asia Region This document has a restncted 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. Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
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Document o f The World Bank
FOR OFFICIAL USE ONLY
Report No: 36719-NP
TECHNICAL ANNEX
ON A
PROPOSED Grant IN THE AMOUNT OF SDR 12.1 MILLION
(US$18.2 MILLION EQUIVALENT)
TO THE
GOVERNMENT OF NEPAL
FOR AN
AVIAN INFLUENZA CONTROL PROJECT
UNDER THE
GLOBAL PROGRAM FOR AVIAN INFLUENZA AND HUMAN PANDEMIC PREPAREDNESS AND RESPONSE (GPAI)
December 21,2006
Sustainable Development Department (SASSD) Human Development Sector Unit (SASHD) South Asia Region
This document has a restncted distribution and may be used by recipients only in the performance o f their of f ic ia l duties. I t s contents may not otherwise be disclosed without Wor ld Bank authorization.
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AI APL BSL CAS CCT CDC CEU CNDRC
C V L DGHS DoHS DoLS EDCD EDP EMP EWARS FA0 FMD GDP GPAI
GIS GoN GPS H P A I H5N1 IBRD
ICB IDA
CURRENCY EQUIVALENTS
(Exchange Rate Effective December 20,2006)
Currency Unit = Nepali Rupee NR. 72 = US$1
US$ = SDR 1.50435
F ISCAL YEAR July 15 - July 14
ABBREVIATIONS AND ACRONYMS Avian Influenza Adaptable Program Loan Bio-Safety Level Country Assistance Strategy Core Coordination Team Center for Disease Control Central Epidemological Unit Central Natural Disaster Relief C o m t t e e
Central Vetennary Lab Director General o f Health Services Department o f Health Services Department o f Livestock Services Epidemology and Disease Control Division External Development Partners Environmental Management Plan Early Warning Reporting System Food and Agnculture Organization Foot and Mouth Disease Gross Domestic Product Global Program for Avian Influenza and Human Pandemc Preparedness and Response Global Information System Government o f Nepal Global Positioning Satellite Highly pathogenic avian influenza Influenza A virus International Bank for Reconstruction and Development International Competitive Bidding
ILI LSDSC M o A C M o H A MoHP N A R C MOLD NAIIPPRP
N C B NGO N P H L OFFLU OIE OP PIP PPE RRT RVLs S A R S SBD
STD TAD UNICEF VBT UNDP USAID
WHO International Development Association WARUN
Influenza-Like Illness Livestock Services Development Centres Ministry o f Apcu l tu re and Cooperatives Ministry o f Home Affairs Ministry o f Health and Population National Agnculture Research Centre Ministry o f Local Development National Avian Influenza and Influenza Pandemc Preparedness and Response Plan National Competitive Bidding Non-Governmental Organization National Public Health Laboratory O I E R A O network for Avian Influenza World Organization for Animal Health Operational Policy Project Implementation Plan Personal Protection Equipment Rapid Response Team Regional Vetennary Labs Severe Acute Respiratory Syndrome Standard Bidding Documents
Sexually Transmtted Disease Trans-border Animal Disease United Nations Children’s Fund Village Based Training United Nations Development Program United States Agency for International Development
World Health Organization Walter Reed Research Unit
C . IMPLEMENTATION .......................................................................................................... 5
1 . 2 . 3 . 4 . 5 .
Partnership arrangements .................................................................................................... 5 Institutional and implementation arrangements .................................................................. 5 Monitoring and evaluation o f outcomes/results .................................................................. 8
Critical r isks and possible controversial aspects ................................................................. 9 Grant conditions and covenants ........................................................................................ 11
D . APPRAISAL SUMMARY ................................................................................................. 11
1 . 2 . 3 . 4 . 5 . 6 . 7 .
Economic and financial analyses ...................................................................................... 11
This document has a restricted distribution and may be used by recipients only in the performance of their off icial duties . I t s contents may not be otherwise disclosed without Wor ld Bank authorization .
Annex 9: Project Preparation and Supervision ....................................................................... 71
Annex 10: Documents in the Project File ................................................................................. 73
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NEPAL
Source Local Foreign
AVIAN INFLUENZA CONTROL PROJECT TECHNICAL ANNEX
SOUTH A S I A SASSDEASHD
Total
Date: December 2 1,2006 Country Director: Kenichi Ohashi Sector Directors: Constance Bernard, Julian Schweitzer Sector Managers: Gajanand Pathmanathan,
Project ID: P100342 Lending Instrument: Adaptable Program
Team Leaders: Daniel Sellen, Sundararajan Gopalan Sectors: General apcul ture, fishing and forestry sector (50%); Health (50%) Themes: Natural disaster management (P); Other communicable diseases (P); Rural policies and institutions
Environmental screening category: B Anabela Abreu (S)
RECIPIENT
Total Bank financing (US$m.): 18.20 Prooosed terms: Standard IDA
0.00 0.00 0.00
Total: 11.00 7.20 18.20
Responsible Agencies: (i) Department o f Health Services, Ministry o f Health and Population, Kathmandu, Nepal Tel: 977-1 -4255796; (ii) Department o f Livestock Services, Ministry o f Agriculture and Cooperatives, Kathmandu, Nepal, Tel: 977-1-5522056
Does the project depart f rom the CAS in content or other significant respects? Avian influenza was not a threat during CASpreparation and is not specijkally mentioned therein. However, theproposed assistance is aligned with a CASpillar i.e., Social Sector Development, as the risk of eroding human capital due to this disease is serious, if the epidemic does strike. Does the project require any exceptions f rom Bank policies? I s approval for any policy exception sought f rom the Board? Does the project include any critical nsks rated “substantial” or “hlgh”?
[ ]Yes [XI N o
[ ]Yes [XI N o [ ]Yes [XI N o [XIYes [ ] N o
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I Does the project meet the Regional cnteria for readiness for implementation? [X]Y~S[INO 1 Project development objective: The overall objectives o f the Project are to minimize the threat in Nepal posed to humans by Highly Pathogenic Avian Influenza (HPAI) infection by controlling such infections among birds, especially domestic poultry, and to prepare for, control, and respond to possible human infections, especially an influenza epidemic and related emergencies. Though the objectives are specific to HPAI, the interventions are expected to contribute to the control o f other zoonotic diseases and other types o f infectious diseases, in terms o f building overall response capacity. These objectives will be achieved through three types o f interventions: (i) prevention; (ii) preparedness and planning; and (iii) response and containment. If these types o f interventions achieve their goals, the proposed Project will reduce the burden o f disease, the consequent economic losses, the risk o f human infechon and the loss o f Droductivitv attributable to human infections in NeDal and limit the nsk o f HPAI to other countnes. Project components: (a) Animal Health: T h i s component will support activities for: (i) enhancing avian influenza prevention and preparedness capability; (ii) strengthening o f vetennary services, disease surveillance, and diagnostic capacity; (iii) strengthening avian influenza control programs and outbreak containment plans, and improving bio-security in poultry production and trade; (iv) the establishment o f an appropnate compensation fund
(b) Human Health: T h i s component aims to prevent human illness due to avian influenza, and in case this cannot be prevented, reduce i t s impact, through: (i) year-round surveillance; (ii) building laboratory capacity to enable effective and accurate methods o f diagnosis / case-detection as part o f the overall public health system response; (iii) prevention and containment activities including social distance interventions and the use o f vaccines where appropnate; (iv) curative interventions (including case management and antiviral drugs) should human infections occur.
(c) communication activities to ensure appropriate behaviours on the part o f poultry farmers, consumers, health care workers and the general public to prepare for and respond to the avian influenza threat.
Communications: This component i s aimed at carrying out information, education, and
(d) Project Management: There will be n o Project Implementation Unit, but instead core coordination teams (CCTs) designated within the l ine departments to coordinate, monitor and report on Project activities. These core teams would be accountable for the implementation o f the Project. This component covers human resource development, technical assistance, logistical, communication, and transportation support for the CCTs in D o L S and DoHS. The overall coordination will be carried out by the Technical Sub-committee o n Avian Influenza (TSCAI), o f the Central Natural Disaster Rel ief Committee, constituted by the Council o f Ministers. This Technical Sub-committee will serve as the steering committee for the Project. Which safeguard policies are triggered, i f any? Environmental Assessment (OP 4.0 1) Significant, non-standard conditions: None. Board presentation: Will be approved at VPU level and approved by Board o n a non-objection basis, since this project falls within the approved Global Program on Avian Influenza. Grant effectiveness conditions: None. Covenants applicable to pro] ect implementation: Standard financial covenants only.
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A. STRATEGIC CONTEXT AND RATIONALE 1. Country and sector issues
Avian influenza: Outbreaks o f Highly Pathogenic Avian Influenza (HPAI) caused by the H 5 N 1 subtype o f influenza A were f i rst recognized in Hong K o n g in 1997. Since late 2003, this subtype has been spreading at an alarming rate, f rom East Asia to Central Asia, and n o w to the Middle East, Europe, Africa, and South Asia. In addition to i ts impact o n animal health, with mill ions of domestic poultry having died or been destroyed worldwide, H 5 N 1 has been causing severe human disease. Of the known 258 humans with confirmed HPAI as o f November 2006, most (1 54) have died. The rapidly expanding area in which HPAI has been discovered and the escalating number o f human infections have raised concerns worldwide over the possible evolution o f the next influenza pandemic and i t s disastrous consequences.’
Nepal’s risk status: Nepal i s a landlocked Himalayan country o f 24 mi l l ion people. The country has so far not had any cases o f HPAI in either avians or humans. However, the country i s at high risk, with the disease recorded in China to the north and in India to the south. The l imi ted border controls with China and India on animal and human population f low increases the potential for spread o f infection to Nepal. In addition, Nepal i s on two routes for migratory birds, which are h o w n carriers o f the disease. The ability to detect avian influenza in the country i s severely handicapped due to access problems related to Nepal’s rugged terrain and widespread security problems.
Poultry sector and veterinary services: There are an estimated 22 mi l l ion chickens and 408 thousand ducks in Nepal. The poultry industry employs roughly 400,000 people, and provides l ivelihood to mill ions o f rural households. Poultry farming takes place within two systems: 45 percent o f (hybnd) birds are found in a few large commercial farms located in peri-urban areas. The remainder consists o f backyard units o f indigenous fow l and ducks in roughly ha l f o f the rural households across Nepal. Whi le most o f the commercial farms have good bio-secunty arrangements in place, poultry meat marketing i s traditional and unorganized, i.e. sold, transported, and butchered in the open air, with n o disposal mechanism for waste material. There i s a well-knit vetennary infrastructure with one central vetennary hospital, 75 distnct livestock service offices, 999 livestock service centres, 132 livestock officers, 178 veterinary officers, 1,000 para-vetennary staff and 6,000 village animal health workers.. There i s considerable experience in the control o f many livestock diseases. However, there i s n o experience with cull ing and disposal o f chicken and related compensation to farmers. Bio-secunty protocols, ring-fencing and foreign border quarantine are under implementation, and there was for a time a ban on imports o f poultry f rom India as a result o f the recent outbreaks o f avian influenza in that country. The Ministry o f Agriculture and Cooperatives (MoAC) i s already suffering f rom capacity constraints for the testing o f suspicious birds (1,800 have been tested thus far). Checking o f trans-border movements o f animals i s a daunting task because o f remoteness o f the borders f rom the capital, insufficient check-posts, and traditional free movement o f animals and people between India and Nepal.
Human health: A public health service delivery system i s reasonably wel l established in Nepal with the Ministry o f Health and Population (MoHP) at the center, five regional health directorates, regional and
Av ian influenza (also called avian flu o r bird flu) refers to a group o f different influenza viruses that primari ly affect birds. An influenza pandemic happens when a new subtype emerges that has no t previously circulated in humans. If H5N1 adapts into a strain that is contagious among humans, it wil l no longer b e a bird virus but a human influenza virus.
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zonal hospitals and district level hospitals. All 75 distncts have health offices and district hospitals with an outreach network o f 188 primary health care centers, 698 village health posts and 3,2 19 sub-health posts. However, the health system i s constrained by quality o f care and access, issues that are being addressed within the IDNDFID-f inanced Nepal Health Sector Program. With respect to a possible pandemic, this system will be required to: (i) detect and characterize human influenza outbreaks promptly through surveillance mechanisms within the existing system for disease control and epidemic management; (ii) be prepared to diagnose and treat large numbers o f people with influenza and i t s complications; (iii) implement a communication strategy to in form the public on the progress o f avian influenza, i ts risks and threats, methods o f self-protection against infection, sources o f treatment, and; (d) ensure inter-sectoral and inter-governmental coordination in prepanng for, and responding to, the threat o f awan influenza and i ts possible spill-over to the human population.
National Preparedness Plan: M o A C and M o H P are we l l aware o f the potential risk o f awan influenza. The Government o f Nepal (GoN) set up an inter-sectoral Task Force under the chairmanship o f the Director-General o f Health Services (DGHS) to coordinate Nepal’s response to avian influenza and i t s potential for human infections. In early 2006, the M o A C and M o H P jo in t ly prepared a National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP) with assistance from the Wor ld Health Organization (WHO) and the Food and Agriculture Organization (FAO). This Plan was formally endorsed by the GoN. After prepanng the plan, the Task Force was dismantled and the coordination function now resides under a technical sub-committee o f the Central Natural Disaster Rel ief Committee (CNDRC). The NAIIPPRP provldes a strong basis o n which to detect and combat possible outbreaks, and outlines the institutional mechanisms for doing so. The plan i s also candid about what capacity and resource constraints exist. T h i s NAIIPPRP was later supplemented with an Operational Plan, which formed the basis for the Wor ld Bank appraisal and this Technical Annex.
2. Rationale for World Bank involvement
First, the growing pandemic risk, and the need for a coordinated international response provides a global public goods argument for Bank involvement. Second, with i t s experience elsewhere, the Bank i s wel l placed to field multi-sectoral teams to tackle the technical, social, economic, and regulatory dimensions o f the problem on a country-by-country basis. Third, while agencies such as W H O and FA0 have the technical expertise to assist the respective l ine departments, the Bank has a comparative advantage in workmg with the Ministry o f Finance (MoF) and the National Planning Commission (NPC) -- critical in any inter-sectoral activity such as preparedness for and response to avian influenza. Fourth, despite donor interest f rom many sides, a considerable financing gap i s l ikely to remain without Wor ld Bank participation. Finally, the Bank has n o w in place an Adaptable Program Loan (APL) to finance the Global Program for A w a n Influenza and Human Pandemic Preparedness and Response (GPAI), which can rapidly support country-specific preparedness using guidelines for accelerated project processing. The current Technical Annex i s consistent with the GPAI guidelines for project processing.
Notwithstanding the comparative advantages o f the Bank, the avian influenza program will require the financial and technical inputs o f al l development partners. Thus, the proposed project i s being tightly coordinated with programs supported by agencies such as the EU, FAO, WHO, UNICEF, UNDP, AusAid, and USAID. For example, U S A I D i s provlding funding through FA0 to build surveillance capacity. UNDP i s workmg with the Ministries o f Local Development (MOLD) and Home Affairs (MoHA) to build disaster preparedness and response capacity. WHO has been instrumental in preparing the NAIIPPRP and Operational Plan which provided the basis for the proposed Project. UNICEF has
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taken the lead in developing the Communication Plan to be implemented by this Project (see Annex 9 for l i s t o f participants).
B. PROJECT DESCRIPTION
1. Project development objective and key indicators
The overall objectives o f the Project are to minimize the threat posed by HPAI to humans in Nepal by controlling such infections among birds, especially domestic poultly, and preparing for, controlling, and responding to possible human infections, especially an influenza epidemic and related emergencies. Though the objectives are specific to HPAI, the interventions are expected to contribute to the control o f other zoonotic diseases and other types o f infectious diseases, in terms o f building overall response capacity. These objectives will be achieved through three types o f interventions: (i) prevention; (ii) preparedness and planning; and (iii) response and containment. If these types o f interventions achieve their goals, the proposed project will reduce the burden o f disease in animal and the consequent economic losses. I t will also lower the risk o f human infection and the loss o f productivity attributable to human infections in Nepal. Finally, i t would limit the nsk o f HPAI in other countnes.
K e y outcome indicators for the development objective will be: (i) Positive behawour change among poultry farmers, health workers, and general population in terms o f key aspects o f howledge, attitudes and practices (assessed through sample surveys); (ii) continued absence o f HPAI in poultry and effective containment o f HPAI infection in poultry in case o f outbreaks. A key output indicator i s a national integrated preparedness, control and response plan prepared and operationalized in accordance with the Global Framework for Avian Influenza, which i s developed by WHO, OIE, and FAO. K e y output indicators for the animal health component will include: (i) percent coverage o f backyard and commercial poultry farms under surveillance; (ii) number o f functional check-posts and active border patrol teams; (iii) percentage o f Nepal laboratory results consistent with international reference laboratory results; (iv) percent o f avian influenza outbreaks (if any) which are controlled, contained, and stamped out; and (v) percentage o f farmers receiving the promised compensation fund on a timely basis. For the human health component, key indicators are: (i) percentage increase in surveillance sites submitting periodic reports; (ii) percentage coverage in quality control tests to diagnose and investigate possible avian influenza outbreaks; (iii) improvement in capacity o f health system to prevent occurrence o f HPAI among human population; and (iv) health care system strengthened and readied to cope with increased demand for critical services and contingency plans for an epidemic. For the communications program, the key indicators are: (i) comprehensive communication program launched; and (ii) evidence o f high level awareness o f program messages among target groups. Performance o f the project coordination component will be measured by: (i) the percentage o f planned activities which take place o n schedule; and (ii) the timely submission o f accurate reporting. (See Annex 2 for details).
2. Financing instrument
The Project i s proposed to be financed under the GPAI’s Adaptable Program Loan, which i s available to countries demonstrating that they have: (i) a national strategic plan; (ii) national commitment; (iii) an implementation strategy through concerted action among ministries, donor community, and c i v i l society; and (iv) a clearly defined monitonng and evaluation system. The preparation team considers that these critena have been satisfied (see Annex 1).
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The proposed project will be financed with $18.2 mi l l ion o f IDA grant. The project implementation period i s four and a ha l f years. The grant i s being processed as an emergency investment operation using procedures under OP 8.50 - Emergency Recovery Loan procedures. In contrast to several avian influenza projects elsewhere, this Project i s not proposed to be financed from existing IDA credits, such as the ongoing Health Sector Program, but will involve new IDA financing. The grant meets al l applicable Bank policies, practices, and standards as discussed below.
3. Project components
(a) finance activities for: (i) enhancing avian influenza prevention and preparedness; (ii) strengthening veterinary services, disease surveillance, and diagnostic capacity; and (iii) strengthening vetennary services and avian influenza control programs and outbreak containment plans, including improving bio- secunty in poultry production and trade. This component will also provide resources for a Compensation Fund to cover poultry owners for loss o f assets caused by mandatory culling o f their birds. The component would be implemented by the Department o f Livestock (DoLS) in M o A C and, where appropriate, through implementing partners such as FAO.
Animal Health: T h i s component will support national prevention and control strategies and will
(b) and in case this cannot be prevented, reduce i t s impact, through: (i) year-round, multifaceted surveillance linked to prompt investigation; (ii) building laboratory capacity to enable effective and accurate diagnosis /case-detection as part o f the overall public health system response; (iii) prevention and containment activities including social distancing measures, the use o f vaccines and antivlrals where appropriate, and an effective quarantine system; and (iv) health care system preparedness should human disease occur, including patient triage, adequate facilities, and standardized case management. I t will support activities for training health workers in the public and private sector o n diagnosing and treating potential cases o f HPAI. I t would help improve public health program planning and coordinating, strengthen the national public health surveillance system, and enhance the health system capacity to deal with the threat o f H P A I and related emergencies in a prompt and effective manner. This component will be implemented in close coordination with the Nepal Health Sector Program, which includes strong donor harmonization, specific sector reforms and results-based programming. The component would primarily be implemented by the Department o f Health Services (DoHS) in M o H P (within which different un i ts are responsible for different sub-components) and, where appropriate, through implementing partners such as WHO.
Human Health: This component aims to prevent a human influenza epidemic caused by HPAI,
(c) Human Health components o f the Project. Within the communication activities, a clear identification o f responsibilities was agreed upon dmng the mission as follows: (i) activities related to animal health, to be implemented by the DoLS; (ii) activities related to human health, to be implemented by DoHS; and (iii) cross-cutting activities such as macro-level inter-sectoral advocacy and coordination, and the conceptualization and development o f communication campaigns and the development o f communication training package, to be implemented through UNICEF. The technical and implementation support o f UN Agencies would be sought by G o N as a last resort, in case G o N capacity i s constrained and the emergency nature o f the program does not permit the approach o f building capacity first. There i s also a National Avian Influenza/Human Influenza Communications Working Group to ensure coordination among the three parts o f this component. This component i s designed to safeguard human health, in particular for extension staff, animal health workers, poultry producers and their families, by improving public awareness and information on avian influenza issues. Information and communication activities are aimed at increasing the attention and commitment o f Government, the private sector and c i v i l society
Communication: This programme i s cross-cutting and underpins both the Animal Health and
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organizations and to raise awareness, and understanding among the general population about the nsk and potential impact o f a pandemic, methods o f self-protection against infection, and sources o f treatment. Communication efforts would also be targeted to poultry farmers on ways o f recognizing the signs and symptoms o f avian influenza, safe methods o f disposing o f infected birds, and steps to protect themselves and their families. This component will be jo int ly implemented by D o L S and DoHS, and in some cases by UNICEF, but will adhere to a single communication strategy and wil l be coordinated by the Project’s steenng committee (see next paragraph).
(d) Project Management: This component will support the strengthening o f public agencies for the coordination and management o f the Project. There will be n o formal Project Implementation Unit, but staff within DoLS and DoHS would be assigned (and trained) to a Core Coordination Team (CCT) to handle key functions including financial management, procurement, and monitoring and evaluation o f Project activities, as wel l as compliance with agreed environmental management frameworks. The overall coordination will be carned out by the Technical Sub-committee on Avian Influenza (TSCAI), o f the Central Natural Disaster Rel ief Committee, constituted by the Council o f Ministers. This Technical Sub- committee will serve as the steering committee for the Project.
C. IMPLEMENTATION 1. Partnership arrangements
The NAIIPPRP and this Project have been prepared by G o N with the support o f several development partners, i.e., the European Union, UNDP, UNICEF, WHO, FAO, USAID, and the Wor ld Bank (see Annex 9). There i s an External Development Partners (EDP) group, focusing solely o n avian influenza issues, which meets regularly and shares information with a v iew to coordinating the various donor- supported actiwties. Whi le a similar group meets to discuss sector-wide health matters, a separate group with a focus o n avian influenza was considered necessary in view o f the inter-sectoral nature o f this problem. This group intends to continue to meet throughout the period o f Project implementation.
2. Institutional and implementation arrangements
Coordination: The Project would fa l l under the umbrella o f the Central Natural Disaster Rel ief Committee (CNDRC) which i s chaired by the Secretary o f the Ministry o f Home Affairs (MoHA). The CNDRC activates only in the case o f outbreak o f disaster. During non-outbreak periods, an TSCAI, chaired jo int ly by the Secretaries for M o H P and MoAC, has been created. The Project must ensure inter- component and inter-sectoral coordination. The TSCAI would play an integral role to ensure coordination between two components, and amongst various development partners that would avail their assistance to implement the National Plan. The TSCAI, through special workmg teams, shall ensure regular monitoring o f the program actiwties, effective coordination between the sectors involved, among the EDPs, and with c iv i l society partners. G o N proposed that the Secretariat for the T S C A I would be located in the Animal Health Directorate under M o A C and related costs for managing the T S C A I coordination will be budgeted under the Animal Health component; in case o f a pandemic, when the focus might shift more towards human health, G o N would revisit this arrangement in close consultation with the development partners. Dunng implementation, coordination efforts and operational modalities described below will be reviewed and where necessary, appropriate adjustments would be made, to ensure that implementation i s effective even if an epidemic occurs. See Annex 5 for further details.
Implementation: There will be two main implementing agencies - the Department o f Livestock Services
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(DoLS) and the Department o f Health Services (DoHS). Operational modalities for project implementation are as follows:
0 The Animal Health component (implemented by DoLS) and Human Health component (implemented by DoHS) would be treated as two separate sub-projects for the purpose o f administrative and financial management requirements. Each will implement the components on communication and implementation/M&E. T w o designated accounts would be created, two project progress reports would be required, and two separate audit reports would be required. However, they are part o f one integrated plan and the activities and work plans o f the two components will be closely coordinated by the TSCAI.
Any resources for activities to be implemented through another ministry, i.e. M o H A which i s responsible for disaster management or the Ministry o f Local Development (MOLD) which i s responsible for disaster preparedness at the district levels, would be included within the DoLS- implemented component. DoLS would be accountable to coordinate with other l ine ministnes for implementation o f activities through such rninistnes. For program implementation by other ministnes in case o f disaster or outbreaks, DoLS would channel required resources to those ministnes. DoLS would ensure that programs to be implemented by those ministries are integrated in i t s work program and budget. D o L S would also ensure that they submit their progresses and statement o f accounts to DoLS so that overall progress managed by DoLS would be appropriately reported and accounted.
0
MOAC actinties I
The following chart illustrates the overall coordination arrangements for the implementation o f the program:
M O W actwities
Central Natural Disaster Relief C o m t t e e
Technical Sub-Cemt tee for Avian Influenza (Jointly chared by M O A C + MOW Secretanes)
epament-level Coordination Comnntte (Animal Health Component)
Activities to be Activities to be implemented by implemented by
& ! DOHS ~ ~~~~
De ament-level C ordination C o m t e I ?Human Health Eomponent)
ReportingiCoordination
Administrative Linkage
Fund Flow and Disbursement Arrangements: DoLS and DoHS will prepare their Annual Work Program and Budgets (AWPBs) for the respective Project components. Fol lowing the approval o f the AWPBs by the National Planning Commission (NPC), the Ministry o f Finance (MoF) wil l release the budget.
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Approved Project budgets for the animal health component and the human health components have already been indicated in the public sector Estimates o f Expenditures (Red Book) under separate budget headings. The IDA Grant will f low through two separate Designated Accounts, one for the animal health component and the other for the human health component. An effective monitonng and oversight system including ex-ante and ex-post revlew will be put in place to monitor the use of the compensahon fund to ensure use o f funds for intended purpose. Disbursements will be made for: (i) civ i l works, (ii) various goods, including laboratory equipment, computers and vehicles; (iii) consulting services; (iv) various training, workshops, and study tours; and (v) incremental operating costs for project coordination.
Financial Management: A Financial Management (FM) capacity assessment o f the implementing agencies (the DoLS and the DoHS) was carried out. The overall FM risk i s “substantial” as there are a few cntical actions such as, staffing, preparation o f Operational Guidelines for use o f Compensation Fund, computerization o f project and financial information, and training of staff, that needs to be implemented. Subject to satisfactory implementation o f these actions and review thereafter, the fiduciary nsk will be reassessed. Of the two implementing agencies, DoHS i s better positioned with slulled staff and experience in implementing donor-financed programs. DoLS, on the other hand, would require substantial efforts in forming a strong team for project management which should include trained financial management and procurement staff. Overall, there will be strong efforts in capacity building both in technical areas as wel l as overall project management which includes procurement and financial management. Since the Project heavily depends o n procurement tasks, i t i s important to ensure that both Departments have sufficient capacity to carry out envisaged procurement o f works, goods and services. T o address certain gaps that have been identified during the assessment, risk mitigation action plans have been agreed. The existence o f the government’s NAIIPPRP which was prepared jo in t ly by M o A C and MoHP, with strong support f rom development partners such as WHO and FAO, the formation o f an Avian Influenza Technical Sub-Committee jo in t ly chaired by two Secretaries o f M o A C and MoHP, and the high pr ionty o f the government to implement this program are some factors that will also mitigate the r isks. The Project will fully align to the government’s financial management system which includes planning, budgeting, fund flow, accounting, reporting and auditing. T w o sets o f annual project accounts for DoLS and DoHS (including Statement o f Expenditures and the Designated Accounts) will be required to be submitted, with audit reports due within six months o f the end o f each fiscal year. DoHS will ensure that project accounts o f the Component as per budget assigned to the specified project code. Project progress reports will also be submitted separately for the two components on a tnmester basis.
Procurement Arrangements: The summary o f the procurement capacity assessment o f the implementing agencies i s presented in Annex 7. Overall, the procurement risk i s rated as “medium” -- the r i s k wil l be reassessed as the implementing agencies implement agreed action plan for improvements o n procurement management. D o L S has very l i t t l e capacity to undertake procurement as per Bank procedures due to lack o f trained and expenenced manpower. Even though DoHS i s currently involved in assisting in implementation o f the Nepal Health Sector Program, i t s performance has not been satisfactory due to a similar paucity o f trained and experienced personnel. This, combined with the inherent overall weak implementation capacity at both the departments would require extensive capacity enhancement measures. These include designating departmental staff as procurement officers who have been specifically selected on the basis o f prevlous exposure to procurement; and ensuring that these officials are trained in the applicable procurement procedures. In addition to the procurement officer, each CCT would hire a procurement consultant for the f i rst year o f the project to prepare a procurement manual and model documents and assist in conducting bidding and bids evaluation and prepanng the evaluation reports, administenng contracts, monitoring procurement activities, maintaining a database o f ongoing procurement actions and preparing up-to-date procurement status reports. If absolutely necessary, the
7
services o f a procurement agent (e.g. specialized UN Agency or pnvate firm) may also be uti l ized to assist both CCTs in their procurement.
Though a draft o f the country’s own Procurement L a w and related Regulations have been prepared, these are yet to be enacted. Therefore, a l l ICB procurement shall be conducted as per the Bank’s procedures and using the Bank’s applicable Standard Bid Documents. Procurement under NCB shall be undertaken in accordance with the procedures as described in the Government’s Financial Administration Regulations with caveats on certain clauses to make these procedures acceptable to the Association, using the model bid documents developed by the Government for use in Bank-funded projects.
3. Monitoring and evaluation of outcomes/results
Monitoring will take place on several levels o f monitoring, i.e., overall program level (inter-sectoral) t o be done by the TSCAI, at the operational central level -by DoLS/DoHS, and at regional, district and local levels -by the respective implementing arms o f the respective departments. The Project will use information already produced by these levels and not create additional reporting systems. The monitonng system would measure the project progress based o n the indicators included in Annex 2. The T S C A I will review and monitor the overall program at least twice a year. Each l ine ministry will monitor i t s respective activities, and feed reports to the TSCAI. Similarly, regional, distnct and local-level committees will monitor progress at their respective levels and feed the information upwards to the T S C A I in aggregated formats to be designed and agreed upon. Findings denved fi-om overall program monitoring by the TSCAI will be fed back to the other levels, thus ensuring a two-way f l ow o f information and accountability. Monitor ing reports will be shared with the external development partners including the Bank, and biannual jo in t review missions will be carried out to review these reports, and agree o n actions to be taken, including mid-course corrections, if necessary.
Evaluation would be done after two years (Mid-Term) and at the end o f the project (after four and a ha l f years) using ngorous methods and independent evaluators. Sufficient resources for this are provlded for in the Project. For the evaluation to be meaningful, baseline data on key indicators wil l need to be collected before project activlties commence. However, certain emergency actions may become necessary if an outbreak occurs and hence not a l l project activities can wait for baseline data collection. The evaluation o f emergency actions will essentially be in terms o f preventing or containing outbreaks - for which the baseline would be zero (e.g. number o f cases, number o f outbreaks).
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Outbreaks are not recognlzed and reported quickly enough to initiate control measures.
Interventions are ineffective in containing the spread o f avian influenza f r o m birds to the human population.
GoN i s unable to react quickly to outbreaks.
S
S
Misuse o f the Compensation Fund facility.
S
I
Activit ies to strengthen surveillance and reportmg, including: (i) imtiat ion o f year-round influenza surveillance in ammals and humans; (ii) training o f f iont-l ine animal and human health workers in identif ication and reporting; (iii) improved communications infrastructure; and (iv) establishment o f BSL-3 laboratories. Activit ies to strengthen response capacity in p n o n t y areas in the short and medium term and to lay the foundation for a broadly based strategy, including: (i) comprehensive awareness and commumcation campaigns; (ii) choosing we l l designed, cost-effective interventions; and (iii) good M&E to flag emerging issues. Procurement plan, training plan, M&E system, and cntical staffing to be in place at negotiations. Tramed Rapid Response Teams in every district and Stockpile o f equipment and vaccines. Appropriate communications and transportation support to ensure rapid response. Implementation arrangements for the Compensation Fund must incorporate principles o f transparency, community involvement, and ex-antelex-post checks.
L=low; M=moderate; S=substantial; H= high. 2
9
From Components to Outputs
Project mplementing agencies lack sufficient authority and capacity to take leading role in avian influenza prevention and control. Inadequacy o r lack o f mulb- sectoral participation.
Controll ing spread o f pandemc may expose GoN to crit icism concerning curtailment o f c i v i l rights due to adoption o f quarantines and related measures. Lack o f laboratory capacity for prompt diagnosis and surveillance and lack o f sufficient quantities o f drugs and other medical inputs needed to address needs o f populat ion during pandemc. Inadequate institutional capacity to manage the project. Lack o f t imely and predictable access to expert advice and technical support. L o w priori ty given to public accountability and transparency. Inadequate capacity for planned surveillance, surveys and momtonng & evaluation.
Overall Risk Rating:
S
M
M
S
S
M
M
M
S
Vigorous advocacy efforts and capacity-building to be launched during preparatory phase to raise necessary awareness and commitment among the leaders and policy-makers in the government, so that sufficient authority and capacity i s vested 111 the appropriate quarters t o enable effecbve and prompt implementation.
Av ian Influenza Technical Sub-committee to ensure coordination and linkages across stakeholders. External Development Partner group as the counterpart team to work with IDA and other donors. Project t o support advocacy and coalit ion bui lding to sensitize key groups including policy-makers and the media. a s wil l be complemented by carefully designed mass communication campaigns to build support for the project among the population.
Laboratory capacity building for rapid diagnosis in Nepal i s a key element o f bo th the a n m a l health and human health components. Project activities to be coordinated with efforts undertaken by WHO and others who have established an mternational anti-viral stockpile. Project activities to be dovetailed with the general health sector development activities under the NHSP, wh ich is supported through a sector-wide approach. Capacity bui lding and institutional development i s one o f the project’s key objectives and substantial resources dedicated to these efforts. Project activities designed with assistance f r o m leading multi lateral agencies such as FA0 and WHO. Such assistance would continue throughout the l i fe o f the Project. Publication o f audit results and achevements; transparency in decision and resource allocation.
Training and technical assistance for nation-wide surveillance and epidemological investigabons; partnership between local and international instituhons to b e provided. M&E plan to include selection o f valid, realistic and measurable indicators, establishment o f mformation systems to y ie ld data o n such indicators, development o f instruments for data collection, identif ication o f agencies responsible and ensuring a mechanism for the analysis and use o f M&E data, with a detailed t ime table for review and action.
Other than the nsks described above, no controversial aspects are foreseen.
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5. Grant conditions and covenants
Standard requirements covering organization and staffing, management arrangements, provisions for procurement and financial management wil l suffice. However, preparation o f approved Standard Operating Procedures for expenditure under the Compensation Fund would be a Disbursement Condition for this activity.
D. APPRAISAL SUMMARY 1. Economic and financial analyses
Economic losses have already been significant in early 2006, due to a precipitous fa l l in poultry and egg prices associated with reported outbreaks o f avian influenza in neighbouring India and concerns over consuming poultry meat and products in Nepal. Prices for broilers decreased in M a y 2006 by approximately 50 percent f rom N R s . 120 to 60 per lulogram. In the case o f commercial broiler production, the national stock o f commercial broilers i s estimated to be 32 mill ion. Assuming an 8 week production cycle there would be 5.3 mi l l ion broilers being produced at any one time. Assuming each broiler weighs 1.5 lulograms, an outbreak o f avian influenza that caused a 50 percent reduction in price per kilogram, would result in as much as a N R s . o f 477 m i l l i on or US$6.8 mi l l ion production cycle loss. In addition, the loss to the backyard poultry production system owned by the marginal farmers and landless who markets some 30 mi l l ion indigenous table birds (valued higher in the markets than broilers) would threaten their livelihoods immensely. In the event o f an avian influenza outbreak within Nepal’s borders, the economic losses can be expected to be even more significant. Similarly, in the event o f human infection turning into an epidemic, there would be significant loss o f human lives, including productive labour, and economic impact o f human illness due to health care costs, lost days at work, and indirect costs to the households concerned. Long term benefits o f the Project, in terms avoiding economic losses, are expected to far outweigh the short term costs o f implementing the Project.
2. Technical
The proposed Project involves a large set of technical issues involv ing capacity o f veterinary semces, laboratory facilities, bio-security measures, epidemiological expertise, and emergency response to avian influenza outbreaks and a possible pandemic. These technical issues are elaborated in Annex 1 (sector issues) and Annex 3 (detailed project description).
3. Fiduciary
The decision to align with the government’s systems and procedures for implementing both components will contribute to enhancing institutional capacity. Whi le the overall fiduciary nsk associated with the Project i s rated as “substantial” for financial management and procurement, the proposed risk mitigation action plans are deemed to be adequate (see Annex 6 and 7 for details). Efforts will be made for capacity building in project coordination that includes procurement and financial management.
4. Social
N o specific social safeguard i s triggered by the Project. However, in case o f outbreaks, the impact o f the mandatory cull ing o f poultry and the consequent threat to livelihoods must be mitigated. In Nepal, non- commercial or backyard poultry accounts for more than h a l f o f the total poultry stock and it i s women and
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often children who are primarily involved in husbandry related tasks such as collecting eggs and raising and selling chicks. In the event o f an avian influenza outbreak in backyard poultry it i s women who will be most l ikely affected by a loss o f income fkom the sale o f eggs and chicks in the case o f culling, or more senously, by contracting influenza in the event o f transmission from poultry to humans. Women in rural savings and credit groups, and such other income generating activities are involved in poultry farming and therefore special consideration for these women needs to be given for protection f rom the impact o f avian influenza outbreaks. These social and gender issues will be dealt with in the Project in two specific ways: by involving women in venfication o f culled poultry and compensation payment meetings; and through ensuring careful targeting o f women and school children in the communication programme.
5. Env i ronmenta l
The Avian Influenza Control Project i s assessed as a B-category project. Bo th the Animal Health and Human Health components have implications that trigger environmental safeguard policies. The disposal o f culled poultry, the clean up o f infected areas and control o f surrounding areas in the case o f Animal Health, and disposal o f laboratory and health care wastes in the case o f Human Health, tngger the Wor ld Bank Safeguard Policy on Environmental Assessment. Measures will be taken to mitigate these environmental impacts by requiring an Enwronmental Management Plan (EMP) be prepared for both the Animal Health and Human Health components. In the case o f the Human Health a Health Care Waste Management Plan already exists under the Health Sector Program (June 2006) and this will form the basis o f environment management for avian influenza activities as wel l (no separate EMP will therefore be prepared for the human health side). The Animal Heath EMP was finalized pr ior to appraisal and submitted to the Wor ld Bank o n June 26,2006. This EMP was disclosed in Nepal o n August 1,2006 and sent to the Infoshop on August 23,2006. Other than Environmental Assessment there are n o safeguard policies triggered.
6. Safeguard policies
Safeguard Policies Triggered by the Project Yes N o Environmental Assessment (OPBP 4.01) [XI [I Natural Habitats (OPBP 4.04) [ I [XI Pest Management (OP 4.09) [ I [XI Cultural Property (OPN 11.03, being revised as OP 4.1 1) [ I [XI Involuntary Resettlement (OPBP 4.12) [ I [XI Indigenous Peoples (OPBP 4.10) [ I [XI Forests (OP/BP 4.36) [ I [XI Safety o f Dams (OPBP 4.37) [I [XI Projects in Disputed Areas (OPBP 7.60) [I [XI Projects on International Waterways (OPBP 7.50) [ I [XI
7. Policy exceptions and readiness
N o policy exceptions are sought.
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Annex 1: Country and Sector Background
NEPAL: Avian Influenza Control Project
Ths section reviews Nepal’s animal health and human health sectors as they relate to avian influenza and the national preparedness and response plan for avian influenza.
A. Animal Health Sector
Structure of the Poultry Sector
The agnculture sector generates 40 percent o f Nepal’s gross domestic product and the poultry sector contributes 10 per cent o f agriculture’s share. Estimates for 2004 indicate that there are more than 23 mi l l ion chickens and 400,000 ducks in Nepal.
(i) Production systems: Poultry farming in Nepal takes place in two distinct systems: (i) an organized commercial poultry industry with high yielding hybrid layers and broilers confined mostly to large peri- urban areas (45 percent o f a l l poultry), and (ii) backyard units o f indigenous f o w l and ducks in mill ions o f rural households across the country (55 per cent o f a l l poultry). Commercial poultry farming has been developing fast over the last decade. These farms are concentrated around urban areas: most o f them (40 percent) in Chitwan, Kathmandu, Pokhara and Biratnagar. The improved commercial birds (10.4 mill ion) are found exclusively in the organized farms. Nepal imports parental stock o f poultry primarily fi-om India (447,000 broilers and 30,000 layers per year). Layers are o f Lehman and Hyl ine breeds and broilers, Vencob, CoblOO, Cob500 and Marshall Breeds. Over 75 registered hatcheries operate in the country. The Department o f Livestock Services (DoLS) operates three farms in Nepalgunj, Pokhara and Birgunj. Astrolop and N e w Hampshire breeds o f poultry reared in Government farms are mostly for distribution among farmers in the hilly areas. In contrast, backyard un i ts comprise fi-ee-ranging, foraging indigenous birds (Sahni breed) which contribute to the livelihoods o f mill ions o f poor farmers. The holding size on average i s f ive birds, but varies f rom two to twenty birds. Roughly ha l f o f rural households in Nepal keep indigenous fowl in their backyards (12.65 mi l l ion birds in some 3 m i l l i on households) spread over the 75 districts. Local birds are sturdy, resistant to most diseases, and survive mostly o n foraging in back yards.
(ii) Marketing system: Meat markets in general and poultry markets in particular are traditional and unorganized in Nepal. Traders visit organized farms and purchase birds at negotiated prices. Birds are then transported by vans, motorbikes, and bicycles to urban areas and sold to consumers as dressed chicken. In Kathmandu, three pnvate agencies deal in frozen chicken but demand i s limited. Traders also buy indigenous chicken from backyard poultry units and sel l them in towns and cities l ive or dressed. Prices o f chicken vary f rom NR 8 0 k g for l ive weight and NR 1 2 0 k g for dressed chicken. Local breeds fetch higher prices: up to NR 2 0 0 k g l ive weight. Farmers also sell local chicken in some 1,450 village haats (bazaars) and a small number in 65 niche markets in urban areas, often in the open air. There are n o organized markets for meat or live birds. There i s great demand for local chicken in urban areas where it i s transported l ive and sold l ive or dressed. The practice o f transportation and sale o f l ive chickens i s one o f the factors responsible for spread o f infectious diseases.
(iii) Value chain in poultry sector: The poultry industry in Nepal comprises organized poultry farms (256 o f varying flock size), hatcheries, and feed mills. Organised poultry farmers buy day-old chicks f rom local hatcheries (35 mi l l ion broilers and 2.5 mi l l ion layers) as wel l as hatcheries in India for f lock replacement. Indigenous fow l in back yard units are self-generating and enable f lock replacement through
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home hatches. Feed manufacturers supply feed, chicks, veterinary medicines and vaccines to farmers, mostly o n credit. Farmers re tu rn the loan out o f sale proceeds. 85 feed mills (small, a l l private) are located in 16 distncts and manufacture about 600,000 MT o f poultry feed annually. Whi le maize, nce polish, and mustard cake are available locally, soybean extract and sunflower cake worth about NR 450 mi l l ion are imported f rom India. Poultry feed i s priced at about NR 18,000 per MT. There i s n o organized pricing mechanism for fixing prices o f birds and eggs; pnces are determined between seller and buyer through mutual negotiation. Nepal imports veterinary drugs and vaccines for poultry worth NR 725 mi l l ion annually.
(iv) Slaughter houses; There are three slaughter houses in Nepal located at Kathmandu and Hetauda. None o f these are functional for various reasons and thus slaughter o f chickens and other animals continues to be carried out in the traditional way: in the open or in make-shift shelters by over 600 butchers across Kathmandu. There i s n o disposal mechanism for waste material in any o f the locations, thus causing senous health hazards. In the villages the slaughter o f birds takes place in households or in village haats, invariably in the open air.
Capacity Assessment of Livestock Institutions and Veterinary Services
(i) Veterinarians: The Department o f Livestock Services has in i t s Directorate o f Animal Health a well- knit veterinary infrastructure geared to undertake al l activities contemplated in the National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP), both in terms o f human resources and equipment. The Directorate has a country-wide network o f vetennary institutions; one central vetennary hospital, 75 district livestock service centres and 999 Livestock Service Centres and Sub-centres provide animal health care, both curative and prophylactic. In addition, there are three other Directorates handling Animal Production, Livestock Market Promotion, and Training & Extension. All four Directorates are grouped under the Director General in DoLS. There i s a Central Training Centre in Kathmandu and five Regional Training Centres. Training programmes are regularly conducted for officers, technicians and farmers. Five Regional Directors function under the Director General, DoLS: one each in Eastern, Central, Western, Mid-Western and Far-West Regions. In each district, there i s a District Livestock Office supported by veterinary and livestock staff, livestock semce centres / sub- centres, village animal health workers and farmers’ groups. There are 178 veterinary officers, 1,000 para- vetennary staff and 6,000 village animal health workers. Farmer groups are voluntary bodies, each having about 20 farmers. In addition to the public sector’s veterinary institutions, there are 160 pnvate vetennarians and some 50 new veterinary graduates. There are also 46 retired veterinarians who can j o i n in dung emergencies. Together, these groups should be able to adequately contain outbreaks o f disease.
(ii) Professional associations and NGOs: Approximately 14 associations o f poultry farmers, hatcheries, manufacturers o f feed, vetennary medicine and vaccines exist and are operating primarily to safeguard their interests, but do provide semces to farmers to some extent. There are many NGOs o f which fifteen are active.
(iii) Accreditation; Rinderpest and Owne Foot Rot have been eradicated and the programmes undertaken in this regard have been accredited by the Wor ld Organisation for Animal Health (OIE). Expenence gained in those eradication programmes will be o f immense use in the prevention and control o f avian influenza. Compliance with fundamental principles o f quality o f the national vetennary service, as defined by OIE, has yet to be carried out.
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(iv) Research infrastructure: All research programmes related to agriculture and livestock fa l l under the mandate o f the Nepal Agncultural Research Council (NARC) which has research laboratories dealing with vanous subjects under it. Departments under the M o A C identify projects for research and refer them to NARC. Epidemiological investigation o f avian influenza i s being carried out by the Vetennary Epidemiology Centre under the Animal Health Directorate. Samples f rom poultry f rom free-range backyard farms around large water bodies and periphenes o f forests are tested periodically. Whenever there i s death o f a bird, a thorough investigation i s carried out. Samples f rom commercial poultry farms are routinely screened. So far, 1,800 samples f rom farms and f ie ld have been tested and al l the samples have been declared negative for avian influenza.
Policy and Regulatory Framework in the Livestock Sector
There are three Acts relevant to aman influenza: the Animal Health and Livestock Services A c t 1998, the Slaughter House and Meat Inspection Act 1998, and the Nepal Veterinary Council A c t 1999. The Vetennary Council A c t deals mainly with registration o f veterinarians and ethical conduct o f vetennary practice. The Slaughter House and Meat Inspection Ac t regulate the slaughter o f animals and sale of meat as wel l as inspection o f animals before and after slaughter. Provisions in this act are seldom enforced. The Animal Health and Livestock A c t deals mainly with quarantine o f imported animals and animal products. The A c t lacks adequate provisions for empowering vetennarians with suitable powers for control o f contagious and infectious diseases. In view o f the threat o f avian influenza, urgent action i s t o be initiated to amend the Act, and to establish effective enforcement mechanisms.
M o A C has been implementing the National Contingency Plan for Highly Pathogenic Avian Influenza since 20043, which details coordination mechanisms and responsibilities. The contingency plan objectives are: (i) to prevent the entrance o f HPAI into the country; (ii) to control avian influenza at the point o f entry in any possible case o f entry; and (iii) to free the country f rom avian influenza.
Most o f the commercial poultry farms have good bio-security arrangements. Some o f the steps adopted are: isolation, traffic control, sanitation / hygiene, treatment / disposal, bio-containment and bio- exclusion. Bio-security measures are moderate in large production uni ts (>I ,000 birds), but seldom practiced in smaller un i ts and market places. National standards for breeding farmshatchenes have been introduced by the Department o f Livestock Services. However, because o f the high investment cost in establishing poultry breeding farmshatcheries and high cost o f land required for appropriate bio-security, these standards are not being followed stnctly.
For non-commercial farms (free-range back yard units), these measures are diff icult to enforce because o f the widely scattered holdings across the country. A model for compartmentalization and zoning, in case o f an outbreak, has been developed. Chechng o f trans-boundary movements o f animals i s a challenging task because o f geographical location, free movement o f animals and people and lack o f adequate check posts. This i s an area o f concern requinng urgent attention and wil l be addressed in the proposed Project.
Systems for reporting o f disease, communication and public information are in position and worlung well. A website on epidemiological reports (www.epivet.aov.np and www.ahd.gov.np) has been opened. Radio/TV programmes on livestock activities (two days a week), distribution o f brochures, posters and calendars have started. Seminars and workshops are being held for departmental staff. Government has
The contingency p lan i s the forerunner o f the National Av ian Influenza and Influenza Pandemc Preparedness and Response Plan (NAIIPPRP).
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issued directives that al l livestock training programmes conducted in the country should have at least one class on avian influenza. These have al l resulted in a high degree o f awareness among the professionals and the general public. Long- term plans for restructuring o f the poultry industry have not been attempted.
B. Human Health Sector
Public health service system
The public health service delivery system o f M o H P i s integrated and wel l established. I t consists o f the central ministry (DoHS) and five regional health directorates with a total o f 11 regional and zonal hospitals. There are also 75 distnct health offices and 68 district hospitals with an outreach network o f 188 primary health centers at the level o f the ilaka constituency, 698 health posts at the village level, and 3,219 sub-health posts. Supporting this network are five central hospitals and a number o f private health facilities including 10 private medical colleges. The total number o f inpat ient beds in the public health care system i s 16,000. The human resources o f the medical colleges could be harnessed in the event o f an influenza pandemic.
The laboratory infrastructure for diagnosis o f diseases o f public health significance i s limited. Peripheral facilities can do basic microbiologic diagnostics (smears, grams stains, rapid k i ts for hepatitis and HIV). The central laboratory National Public Health Laboratory (NPHL) does routine clinical tests (haematology and chemistry), serologies for a variety o f diseases, and conventional Polymerase Chain Reaction (PCR) as a research tool. I t cannot perform virologic tissue cultures. The Walter Reed Research Unit Nepal (WARUN), an affiliate o f the US. Armed Forces Research Institute o f Medical Sciences (AFRMIS) in Bangkok, has done specimen collection and testing for influenza viruses, and does offer referral support for Nepal. WARUN intends to expand i t s current capacity for influenza diagnostics by developing real time PCR (RT PCR) testing. In early 2006, NPHL and WARUN developed a pi lot project for use o f rapid diagnostic h t s for influenza diagnosis in hospitals in Kathmandu and Bharatpur, with samples forwarded to AFRMIS for comparative testing with RT-PCR. T h i s p i lot system will serve as a model for future project activities.
For disease surveillance, several systems are currently operating in Nepal. A basic data collection system known as the Health Management Information System (HMIS) collects information on health care utilization and diagnosis. It operates throughout the country, but H M I S data are o f l imi ted utility for influenza surveillance due to a number o f factors. First, most diagnoses are clinical and are not supported by standardized case definitions or laboratory diagnostics. Second, information f low i s sluggish, and data are not analyzed or disseminated in timely fashion. Due to these limitations in specificity and timeliness, while H M I S data may be useful for monitoring long term trends, they are not for rapid detection o f cases o f possible human illness due to avian influenza or outbreaks o f influenza-like illness.
Several surveillance systems are in place for diseases with specific control programs. These disease- specific surveillance efforts are usually referred to as vertical programs. Examples include surveillance programs for tuberculosis, leprosy, HIV/AIDS, malaria, and kala-azar. In addition to these vertical surveillance systems, two integrated surveillance systems are in operation. One i s the Wor ld Health Organization (WHO) Program for Immunization Preventable Diseases (IPD), which conducts surveillance of acute flaccid paralysis (AFP)/poliomyelitis, measles, neonatal tetanus, and Japanese Encephalitis (E). Surveillance o f Haemophilus influenzae type B (HiB) was recently added to the IPD system. IPD has 10 field offices throughout the country funded by donor resources. I t has several attributes that make i t particularly attractive for awan influenza. For one, IPD runs an active weekly
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reporting system that covers 115 hospitals including both pnvate and public sector facilities. It also receives passive reports f rom 465 public health system facilities. Overall, the IPD system covers 72% o f primary health centers and just under 5% o f health posts and sub-health posts. Secondly, there i s an active diagnostic specimen collection and transport system for any suspected case o f the diseases under surveillance.
The technical and implementation support o f UN Agencies would be sought as a last resort, in case G o N capacity is constrained and the emergency nature o f the program does not permit the approach of building capacity first. Apart f rom the suggested role for UNICEF in the Communications component, WHO and FA0 are potential possibilities for such support. Specifically, the surveillance activities to be supported by the IPD unit would be a natural candidate for WHO assistance, as it i s already being implemented with WHO support.
The other national integrated surveillance system i s the Early Warning and Reporting System (EWARS). This has been in operation since 1996 and i s run by the Epidemiology and Disease Control Div is ion o f the Department o f Health Services (DoHS). It receives reports o f disease outbreaks or other unusual health events f rom the 75 district public health offices, and receives weekly passive reports o n AFP, measles, Japanese encephalitis, malaria, and kala azar. E W A R S operates in 28 public hospitals. In 2004, the EWARS system reported nine outbreaks o f influenza-like illness comprising 5,065 cases and 57 deaths.
Actions against avian influenza taken to date by Ministry of Health and Population
In 2004, M o H P established a jo in t agricultural and health National Influenza Task Force under the chairmanship o f the Director General o f DoHS; this task force includes participation by private organizations such as the Hatchery Association and the Consumer Forum. Under this task force the l ine sectors o f M o H P and M o A C joined forces with FA0 to develop the NAIIPPRP for strengthening surveillance and control o f influenza. The NAIIPPRP aims at building preparedness to contain AI rapidly and mitigate i t s health and socioeconomic impacts in the event o f human-to-human transmission o f H 5 N 1 or other influenza sub-types which may cause a pandemic affecting Nepal. To accomplish this goal, the Plan calls for : (a) detecting and characterizing human influenza virus outbreaks promptly through the M o H P outbreak surveillance system; (b) implementing an effective public health response when an influenza pandemic affects Nepal; (c) preparing the health care delivery system to diagnose and treat large numbers o f people with influenza and i t s complications; (d) implementing a timely communication strategy that will inform the public on the status o f the pandemic in Nepal and how to mitigate i t s impact, and; (e) ensuring inter-sectoral and inter-governmental coordination in preparing and responding to the threat o f avian influenza and human infections.
Health system response
The NAIIPPRP and Operational Plan describe key strategic activities required to ensure that the public health and medical care network are wel l prepared to respond to the challenges o f avian and pandemic influenza. They use WHO’S six global influenza pandemic phases along with the three broader WHO pandemic penods (inter-pandemic, pandemic alert and pandemic). Five areas are defined for preparation and response. Detailed strategic actions with time frames, responsible agencies, cost estimates and indicators to measure the performance by these agencies are presented for each o f the three pandemic
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periods. The Plan indicates that as the pandemic progresses it i s essential t o review the scope and role of vanous sectors, including health and those involved in national disaster response.
A timely and sensitive surveillance system i s crucial t o meeting the public health challenges posed by avian influenza. Recognizing this, the G o N proposes covering two essential aspects: laboratory capacity and epidemiologic monitonng. This i s underscored by the need to build o n the existing surveillance infrastructure and adapting it to achieve systematic identification and reporting o f suspected avian influenza and Influenza-like Illness (ILI) outbreaks, quality data analysis, interpretation, and dissemination, and quality laboratory diagnostic support. The Operational Plan outlines key activities required for strengthening epidemiological and laboratory surveillance, including training needs at a l l levels o f the health care system.
(i) Laboratory strengthening: The Plan calls for strengthening the NPHL central laboratory in three stages. In the first, short-term stage, laboratories will perform rapid screening tests for influenza and any positive samples will be collected, stored and transported to a pre-determined laboratory outside Nepal for confirmatory testing. In the second, intermediate stage the focus will be o n developing advanced testing capacity especially Real Time - Polymerase Chain Reaction (RT-PCR) at NPHL. In the long-term third stage, NPHL will achieve Biosafety level 3 standards so that i t will have the capacity for influenza virus isolation. T h i s three-staged laboratory upgrading approach will not only enhance preparedness for awan and pandemic influenza, but will build overall laboratory capacity for other priority emerging infectious diseases in Nepal.
(ii) Case diagnosis and reporting: A fully integrated surveillance system i s the ultimate goal o f the MoHP, including influenza monitoring. The national plan calls for accomplishing this by building on the existing EWARS system for national influenza surveillance, training surveillance personnel in disease surveillance for avian influenza, improving information technology, and enhancing the capacity o f district and national rapid response teams to conduct investigations related to influenza.
(iii) Information, education and communication: The option exists to tap into the existing national communication strategy, which has been uses successfully for other emergent public health circumstances, such as pol io vaccination campaigns. T h i s strategy i s designed to build partnerships with the media, involve communities in preparedness planning and response, and improve capacity and procedures for r isk communication. In Nepal, there are four TV stations, two public and several pnvate radio stations, six daily newspapers, and thirty-six weeklies with estimated 70% combined geographic coverage. Strengthening partnerships with the media can further enhance communication for nsk mitigation.
C. The National Strategic and Operational Plans for Addressing Avian Influenza in Nepal
Strategic Plan: The National Av ian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP) was prepared jo in t ly by M o H P and MoAC, with support f rom WHO and FAO, and was cleared by GON in December 2005.
I t takes account o f the six phases o f the awan influenza pandemic related periods, and outlines five strategic areas for preparation and response to pandemic influenza, within which specific activities will be undertaken. These are: planning and coordination, surveillance, prevention and control, health system response and communication. The NAIIPPRP articulates common short-term and long-term objectives across both the animal and human health sectors for responding to the threat o f avian influenza.
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Communication strategies have been developed for providing essential messages to key actors involved as wel l as the general population on the nature o f the threat and h o w the country plans to respond. A b n e f work plan and budget estimate (of approximately U S $ 15 mill ion) was also presented.
Fol lowing release o f the NAIIPPRP, several activities took place in early 2006. As a result, a great deal o f awareness has been created at a l l levels, among policy-makers, professionals and general public. Protective materials (PPE) for professionals were purchased out o f government and U S A I D funds. All legislation systems related to the livestock sector have been reviewed and areas requinng immediate acbon have been listed. Donor agencies expressed interest in supporting Nepal in the avlan influenza programs. FAO/OIE sponsored M o A C staff to attend international workshops o n AI in Vietnam and Bangkok. The M o A C has intensified the veterinary inspection system and seized il legally imported ducks and destroyed them. The quarantine system was restructured.
Operational plan: Because the NAIIPPRP i s strategic in nature, an Operational Plan has been developed by the GoN to translate the strategic concepts into measurable activities. T h i s Operational Plan forms the basis for activlties to be conducted under the Wor ld Bank funded project, although the Bank wil l not necessarily finance 100 percent o f the Operational Plan’s activities. Furthermore, the Operational Plan i s considered to be a “living document” which will be reviewed and revised periodically by the TSCAIas required.
For the animal health section, the Operational Plan i s divided into seven components. These include: (i) strengthening the disease surveillance system for influenza; (ii) strengthening quarantine services; (iii) upgrading laboratory capacity; (iv) field veterinary services; (v) a compensation fund; (vi) communications; and (vii) management. Each o f the components i s described in more detail in Annex 3. For the human health section, the Operational Plan i s divided into five components. These include: (i) strengthening the disease surveillance system and laboratory capacity for influenza; (ii) prevention and containment measures (iii) health care delivery system preparedness and response; (d) communications; and (e) management. Each o f the components i s described in more detail in Annex 3.
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Annex 2: Results Framework and Monitoring
NEPAL: Avian Influenza Control Project
Sub-component 2.1: Surveillance and Laboratoly Strengthening
Capacity to identify, report, laboratory diagnose, and investigate possible human avian influenza
by Highly Pathogenic Avian Influenza (HPAI) infection by controlling such infections among birds and to prepare for, control, and respond to possible human infections, especially an influenza epidemic and related emergencies
0 80 percent o f surveillance sites submit reports to E D C D D o H S when required (immediate, weekly, or monthly) At least 90 percent o f quality control tests at NPHL
health workers, and general population in terms o f key aspects o f knowledge, attitudes and practices (assessed through sample surveys)
0 Continued absence o f HPAI in poultry and effective containment o f HPAI infection in poultry in case o f
Component I: ANIMAL HEALTH
Sub-component 1.1 : Surveillance
Animal disease surveillance system strengthened to rapidly detect cases o f avlan influenza in backyard farms and commercial farms Sub-component 1.2: Prevention and Containment
Prevention o f ingress o f pathogens into Nepal f rom outside the countrv Sub-component 1.3: Laboratory Capacity
Achievement o f capacity to accurately diagnose HPAI (H5N1) and other zoonotic diseases on a timely basis Sub-component 1.4: Field Veterinaly Services
Veterinary system trained and equipped in surveillance. wevention. and containment Sub-component 1.5: Compensation Fund
Farmers received fair compensation for culled birds on timelv basis
0 Complete national monitoring o f domestic poultry (backyard and commercial farms) through statistically sound sampling methods
24 functional check posts and 8 patrolling teams active across Nepal-India border
0 90 percent o f BSL-3 laboratory results fully consistent with OIE Reference laboratory results
0 100 percent o f avian influenza outbreaks (if any) are controlled, contained, and stamped out
0 100 percent o f farmers receiving the promised compensation amount within two days f rom the cull ing (for backyard flocks) and within 35 days (for commercial farms)
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anywhere in Nepal Sub-component 2.2: Prevention and Containment
Public information on the recommended practices for control and eradication o f HPAI among key target groups developed, tested, and disseminated Sub-component 3.2: Pandemic Communications
Improved system capacity to prevent the occurrence and spread o f HPAI among human population Sub-component 2.3: Health Care Delivery System Preparedness and Response
0 Comprehensive communication program launched 0 Evidence o f high level awareness o f program
messages among target groups
0 Comprehensive communicatlon program launched
Health care systems strengthened and readied to cope with increased demand for services (including triage and referral) and contingency plans for an epidemic
are correct 0 Personal protective equipment, anti-virals, and
seasonal vaccines available to 80 percent o f targeted high-nsk occupational groups
0 Kathmandu international airport and five border entry points (land routes) have functional minimum acceptable quarantine facilities
0 At least 80 percent o f health care workers in al l publicly-financed health care facilities have adequate knowledge (as indicated by passing test scores in identifying, counselling, managing, and appropriately referring HPAI cases)
endemic plans completed 0 At least 80 percent o f I laka constituencies have
Component 111: COMMUNICATIONS
Public information on the recommended practices for control and eradication o f HPAI among key target groups developed, tested, and disseminated
0 Evidence o f high level awareness o f program messages among target groups
Component IV: PROJECT MANAGEMENT
Sub-component 4.1 : Project Management
Project structure fully functional and has wel l defined administrative, financial management, and procurement system in place Sub-component 4.2: Monitoring and Evaluation
I
Monitoring and information management system in place
0 Timely conduct o f planned activities (measured by % activities delayed beyond one month f rom the planned completion date)
0 Tnmester implementation progress reports (financial monitoring, procurement monitoring and physical progress output monitonng) prepared and submitted in a timely manner; and annual financial audit reports
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Annex 3: Detailed Project Description
NEPAL: Avian Influenza Control Project
COMPONENT 1 : Animal Health
Sub-component 1.1 : Surveillance
(a) Surveillance and epidemiological investigation of domestic poultry: T h i s i s the mechanism for early warning and diagnosis o f HPAI incidence in Nepal. Caged birds in organised poultry farms are not in any direct threat o f infection f rom the migratory birds, unless contaminated people, material or infected birds come into contact with the farm flocks inadvertently. On the other hand, fow l and ducks in back yards are free-ranging birds unrestrained during the day and are constantly exposed to possible fecal infection f rom migratory birds contaminating the land corridors under their fly ways, particularly during migration seasons (end September-December and April-May).
The project proposes surveillance o f backyard poultry with the Regions as the basic unit and sampling frames randomly drawn from within each Region. The sample frame and size will be determined by the Epidemiological Centre and the sample frame changed each month. The total number o f samples proposed for national random sero-sampling programme o f backyard poultry for a year i s 4,000 dunng a l l four years o f Project implementation. There are about 250 organised poultry farms in Nepal with widely diffenng flock size, but mostly concentrated in a few selected distncts. The Epidemiological Centre will randomly choose the farms and the sampling frame within farms and also determine the number o f samples or specimens to be collected. The total number o f samples for farm flocks will be 6,000 per year.
Surveillance o f migratory birds in their natural habitats i s impractical: dead wild birds are ideal for H 5 N 1 virus confirmation but in real time situations, it i s rare to find dead birds, even in their habitats or sanctuaries. Collection o f samples f rom l ive migratory birds i s technically diff icult and undesirable as it would disturb the entire migratory bird population. The frequency o f sampling in al l cases will be once every two months dmng the months o f June to September and January to March; and once a month during September - January and April - M a y (the migration seasons). The actual sample collection will be carned out in al l cases by the technician in charge o f the Livestock Services Development Centres (LSDCs) under the direction and technical guidance o f the D L S O chief or the wild l i fe technicians (in case o f sentinels) personally once in a month or once every two months, as the case may be, f rom the sampling frame fall ing within his jurisdiction and o n the same day for a l l samples allotted to him. The samples or specimen collected would include blood (serum) samples as wel l as tracheal and cloacal swabs. The sampling technician will pack the samples and specimens in bio-safety packages with gel packs for cold chain and the Surveillance Supervision Team o f the regional directorate, for the area, will despatch the packages to the designated Regional Veterinary Laboratory through special messengers.
Time frame for surveillance & epidemiological investigations: February 2007 - July 20 1 1
@) Participatory disease intelligence: Many Nepalese villages are diff icult to reach except f rom the sky: H 5 N 1 infective material may reach them through the migratory birds flying overhead. These villages are used to regular bird mortality, sometimes in very large numbers because o f the recumng ravages o f Newcastle Disease. If H 5 N 1 infection erupts and if birds start dying in these villages they may be construed as deaths due to Newcastle Disease. Cases o f human H5N1 influenza in such villages may therefore never be recognised as such or attributed to diseases o f poultry. With a captive constituency o f
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village Animal Health Workers and farmer members o f the farmer groups D o L S can effectively use them as the communication channel both ways, establishing “Disease Intelligence”.
Nepal has some 6,000 village animal health workers attached to the LSDCs and also several commodity (affinity) farmer groups attached to these institutions. The village Animal Health Workers and Farmer Affinity Groups constitute the participatory disease intelligence groups and would be vigorously encouraged to report on bird mortality, sickness among backyard fowl and ducks to LSDCs and districts. Some 6,000 Animal Health workers and 10,000 farmer members o f the commodity (affinity) groups attached to the LSDCs will be exposed to one-day Vil lage Based Training (VBT) carried out in the villages (in one village for a cluster o f f ive nearby villages) by trained technicians in the LSDCs in their respective areas: the VBTs will for 4,000 participants annually (one per village development committee) and repeated every year during the four year project period.
Timeframe for completing VBTs: February 2007 - June 2007 for batch 1 and every year thereafter.
(c) Capacity-building of veterinary professionals, poultry entrepreneurs and wildlife professionals for surveillance and bio-safety: T o monitor and manage the massive national random sero-surveillance o f domestic poultry and migratory birds; and to enforce the bio-safety regulations (to be set up) by the GoN, the Project proposes to train, in 2-day district level workshops, al l veterinary professionals and para-professionals in the country along with wild l i fe technicians involved with migratory bird habitats. These training workshops will cover 500 veterinary professionals, 2500 para-vets, 500 poultry entrepreneurs and some 100 wi ld l i fe technicians (4,100 in all). Course contents will include: general awareness about HPAI, need for personal bio-secunty safeguards for professionals dealing with the disease, random sero-surveillance, samples and specimens to be collected, hand-on practice in samplehpecimen collection, bio-secunty and safety regulations for poultry farms and certification o f poultry farms annually on bio-security levels pracbsed, prevention, control, and containment of HPAI, equipment required for surveillance and containment including Personal Protective Equipment (PPE).
Time frame for workshops: One 2-day workshop will be organised in each o f the 75 districts by December 2007.
(d) Development o f GIs-based animal disease surveillance and information system: D o L S currently has a disease information system electronically enabled, but it i s confined to the Epidemiological Centre o f the Animal Health Directorate. In order for the massive random sero-surveillance programme under the Project to work effectively i t i s essential to establish a nation- wide, dynamic information system and network electronically enabled, GIs-based and GPS-centnc. The DoLS therefore must structure a disease surveillance and containment programme using satellite imagery and GIS Data Systems. The network should link the Nodal Animal Health Group responsible for HPAI Control and Containment in the DoLS’s Directorate o f Animal Health, the laboratory system, the animal quarantine system; the Department o f National Parks and Wildl i fe Conservation, and in particular the newly proposed B S L 3 Laboratory. The hub o f the network would be in the Epidemiological Centre. The proposal for a system involv ing satellite imagery o f water bodies and wet lands, mapping o f the land corridors beneath the major fly ways, a GIs-based, GPS-enabled, animal disease intelligence / information system including equipping the system and training and running in the system over a three-year period will be designed by a competent consultant.
The Regional Directors will be fully responsible for the implementation, supermion and control o f the national random sero-surveillance o f domestic poultry and migratory birds; the Regional Directorates will set up Mobi le Surveillance Supervision Teams: one in each Region. The Project for this purpose provides for strengthening o f the Regional Directorates. The LSDCs, quarantine check-posts, and wi ld l i fe technicians will continue sero-surveillance without interruption, under the supervision o f the Surveillance
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Supervision Teams. The laboratory system, suitably upgraded under the Project, wil l receive the serum samples f rom the sero-surveillance programme and analyse them using agreed protocols. Suspected samples and specimens will immediately be sent to the dedicated HPAI Laboratory (BSL 3) for diagnosis and possible confirmation o f H 5 N 1 or other HPAI virus strains. The Epidemiology Centre will design the sample frame and sample size for the sero-surveillance and will be in touch with the Regional and Central Veterinary Laboratories for monitonng the sero-surveillance programme. The Epidemiology Centre with suitable consultancy assistance will structure a GIS / GPS based Animal Disease Information System with nodes in al l eight laboratories, the Animal Health Directorate and with the Epicentre in the Epidemiological Centre.
Time frame for establishing and making the system operational: February 2007 - February 2008
Sub-component 1.2: Prevention and Containment
The quarantine border check-posts and the quarantine patrol teams wil l seal the borders in case outbreaks o f HPAI occur in the neighbouring districts in India and China. These posts will seize a l l intruding materials l ike feed, food grains, l ive birds, poultry or other animal products. They will draw samples and specimens from the seized flocks or carcases as the case may be and send them in bio-safety packs with cold chain to the laboratories. They will also disinfect or fumigate the infected premises and materials.
The Project therefore includes strengthening o f the animal quarantine infrastructure in Nepal: including expanding physical facilities in the four existing check-posts: cold rood fumiga t ion room, incinerators; spraying and fogging equipment and communication equipment for a l l 24 check posts, four wheel drive pick-up vans for the eight Quarantine Patrol Teams, and 75 motor-cycles for the.24 check-posts. Finally, the project will finance four years o f operational costs (quarantine consumable, maintenance and propulsion costs o f vehicles, and travel allowances o f the teams) for the eight teams.
Time frame for strengthening check posts and Quarantine Patrol Teams: July 2006 - July 2007
Sub-component 1.3: Laboratory Capacity
Nepal has eight animal disease diagnostic laboratories in the country: the Central Veterinary Laboratory (CVL) , five Regional Veterinary Laboratories (RVLs), National Av ian Disease Investigation Laboratory (NADL) 1 , and the FMD /TADs Laboratory. The scientific manpower available in the laboratory system i s meagre, except in the CVL. Regional laboratones do not have the needed equipment. Procedures followed are satisfactory but financial constraints do not allow staff to implement a l l bio-safety procedures. The laboratory buildings need some repairs or additions to suit the changing needs. There i s no HPAI dedicated laboratory in Nepal. The Veterinary Epidemiology Centre under the Animal Health Directorate i s carrying out epidemiological investigation o f avian influenza. G o N has proposed strengthening disease intelligence and surveillance by enhancement and upgrading o f one existing animal diagnostic investigation laboratory to B S L 3 and the seven laboratories (CVL, f ive RVLs, and NADIL) to B S L 2 for facilitating surveillance under the NAIIPPRF'. The B S L 3 laboratory will be established as an adjunct to the FMD / TAD laboratory as the objectives o f the B S L 3 lab overlap with those o f TAD lab with a stand alone services block. The CVL , NADL and the five RVLs will be suitably strengthened for shanng the work load o f the B S L 3 Lab. Several basic concepts in biological safety and security; and guidelines to develop codes o f practice are described in the WHO Laboratory Safety Manual 2004 and similar manual(s) by OIE, for the safe handling o f highly pathogenic micro-organisms in laboratones. Strict adherence to these guidelines will be followed to establish a safer work environment for laboratory staff and the surrounding community.
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A well-organized network o f diagnostic laboratories forms the basis for the successful surveillance o f avian influenza virus and other infectious diseases. T o overcome the shortcomings and to improve the laboratory testing system, it i s necessary to utilize a l l the above laboratories by networking them and decentralizing the activities related to diagnosis o f HPAI. This national laboratory network will fo l low guidelines and recommendations o f the OIE/FAO network (OFFLU). Whi le networkmg the laboratories the responsibilities o f the national laboratory network for diagnosis and active surveillance will be revised to share the work load and to reduce turn-around time. The eight district labs located in the areas o f the eight refurbished quarantine check posts would also be modestly updated to share the network tasks. For the setting up o f the B S L 3 Laboratory and to streamline the networkmg o f the other labs, technical assistance and consultancy services will be necessary. The costs for the laboratory capacity-building include such costs as wel l (see below).
The Project Coordinator DoLS will be responsible for initiating and coordinating the strengthening and capacity building o f the veterinary laboratories, including the establishment of the B S L 3 Laboratory. H e or she will structure the networking o f the eight laboratones that are upgraded (discussed above) and re- equipped under the Project.
Time frame for completion: February 2007 - December 2008
Sub-component 1.4: Field Veterinary Services
Nepal’s containment and control strategies for HPAI outbreaks in domestic poultry fo l low OIE / FA0 Guidelines and were formulated with the active participation o f the WHO and FA0 Fie ld Offices in Kathmandu. DoLS has issued guidelines to the Regional Directorates and Distnct Livestock Offices for micro-planning and getting ready their own control and containment set up. D O L S currently oversees the operations and coordinates the containment activities, while the Distnct Natural Disaster Rel ief Committees working with the District Administration and the Distnct Livestock Officer executes the containment programme. All through the containment operations district Public Health Teams are to be present in the infected zones and take care o f house-to-house surveillance for identifying human infections / suspected infections if any.
The Plan provides for Rapid Response Teams (RRT) o f veterinary professionals supported by para-vets in the DoLS, sh l led workers for cull ing o f birds, workers for disinfection, sanitation, burying k i l led birds / burning in-contact bird feed, stock piles o f eggs and other materials, disposal o f accumulated bird litter and scores o f other tasks that accompany a control and containment operation which lasts in ordinary cases o f outbreaks some 10 - 15 days until the al l clear i s sounded. The Operational Plan proposes training and equipping one RRT for each distnct in the country: there are 75 districts together in al l the districts and so 75 RRTs. The RRTs wil l undergo a one day full dress rehearsal simulation exercise at their respective district head quarters and a l l training will be completed by end 2007. The training o f RRTs will involve some 1,200 persons together for a l l the 75 distncts. The Project will also support strategic reserves o f essential equipment for stock piling: PPE, fogging machines and vaccination equipment constitute the l i s t o f equipment: and quantities are based on the assumption o f 30 outbreaks in a year. In the second and third year the requirement will only be PPEs, as they plan repeat use o f fogging machines and vaccination equipment.
Project implementation envisages the Regional Director o f Livestock Semces to be fully responsible for the implementation, supervision and control o f the National Random Sero-surveillance o f domestic poultry, the free ranging backyard birds as wel l as organised farm flocks and the migratory birds in their wet land / water body habitats. The Project for this purpose provides for strengthening the Regional Directorates and enabling the Directorate to set up Mobi le Surveillance Supervision Teams: one in each Region.
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The Distnct Livestock Offices, suitably strengthened under the Project, will arrange for the distnct level training workshops (one in each district) for orienting al l professional staff o f the D o L S / Wild L i fe Technicians on HPAI / Random Sero-surveillance and complete their training during the current year: 2006. The D L S O will also proceed on war footing to train and equip the Rapid Response Teams (RRT) for disease control and containment, one each for al l distncts, with teams kept in combat readiness before the end o f 2006 in al l districts.
The D L S O wil l be the prime mover for launching the control and containment campaign, once an outbreak o f HPAI H 5 N 1 i s announced by the Central Vetennary Laboratory and/ GoN. The D L S O will mobilise the RRTs, alert local authorities, the district administration and the national HPAI coordination set up. H e will coordinate with the help o f the district administration the inspection, cull ing and destruction o f infected or possible infected flocks, feed, and eggs stock pile. H e will enforce a l l zoo- sanitary measures (restriction in movement o f humans, material, l ive poultry, bird litter, manure, feed and poultry products) and fumigate infected premises. H e will cordon o f f the areas in the infected zone 0-3 km radius and the surveillance zone (buffer zone) o f 3-10 km radius until the outbreak has been stamped out. The D L S O will also arrange for compensation for birds, feed stocks and eggs stocks actually destroyed.
Time frame for completepreparedness: February 2007 - July 2007
Sub-component 1.5: Compensation Fund
DoLS had two rounds o f discussions with a cross section o f backyard poultry farmers and representatives o f the poultry industry on issues related to compensation and rehabilitation in case cull ing and destruction o f poultry becomes necessary in the face o f an HPAI outbreak. The consensus arrived at deals with the scope and quantum o f compensation for birds, egg stocks, and feed stocks destroyed dunng containment and control campaigns, as wel l as possible support for rehabilitation.
Whi le compensation would be essential to encourage farmers to report suspicious birds and ensure that they can recover their flock, there may not be a case for rehabilitation. Backyard poultry farmers incur n o investments o n their f lock except for the value o f the birds (often home bred), nor do they have any recurring expenses o n their flocks as they are free-ranging birds foraging and fending for themselves. Backyard birds seldom receive hand feeding, except for a fistful o f lutchen waste. Farmers invariably shelter them in large bamboo baskets or make-shift coops during the night. If the backyard poultry farmers are paid a fair compensation to cover the value o f the birds destroyed, that would be more than adequate to make up for their losses, actual as wel l as potential. They seldom stock eggs or feed. In the case o f organised poultry farms, the farmer loses only the current flocks in case o f a mandatory cull ing programme. The current f lock value in a poultry farm, layer or broiler, seldom exceeds 20 per cent o f the total investments for the farm. Therefore there i s l i tt le need for rehabilitation in the case o f organised poultry farmers. Compensating for loss o f flocks, egg stocks, and feed stocks at prevailing market prices should be adequate to cover their losses.
I t i s important to determine a fair and effective value for culled bird. The market price o f an indigenous (backyard) bird i s higher than the market price o f broilers and currently the price for an indigenous bird for meat i s NRs. 150 - 200. Farmers, however, would probably accept a compensation rate at a flat rate equal t o halfthe marketprice of an adult indigenous bird, say NRs.100 per bird, as they would invariably bring in a mixed f lock o f birds made up o f al l age groups for cull ing (adults among them being about a third). So the birds destroyed valued at Rs. 100 per bird and for al l birds culled f rom his flock, i s considered a fair rate o f compensation.
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DoLS has not yet amved at a sound basis for calculating the compensation fund for budgeting purposes. A practical and sound basis would be the poultry population density in the infected distnct (calculated o n the basis o f the district poultry census and i ts area). Using the density in the district, the DoLS can calculate the bird population within the 10 km radius o f infected and surveillance zones. As there i s considerable vanation between districts in the density o f poultry population, the population density o f the infected district i s the most appropriate basis for calculation.
In the case o f the organised poultry farms compensation i s based o n actual numbers culled. The market price for broilers in Nepal i s N R s . 80 per kg l ive weight or N R s . 120 per bird. It i s therefore appropriate to assume average compensation for farm flocks at NRs.100 per bird, regardless o f weight, age, or breed. The only exception to this rule would be culled parental stock which would be compensated at NRs. 500 per bird as they are expensive and cost over N R s . 1,200 per head to procure.
For purposes o f budget estimates the assumptions used are: 30 possible outbreaks per year, each outbreak needing cull ing o f some 50,000 adult equivalents o f birds and valued at N R s . 100 per bird, works out to NRs.0.62 m i l l i on over 3 years. The cost o f egg stocks and feed stocks may be another NRs.0.42 mill ion. Together, the total estimated budget for compensation i s estimated at U S $ 1.04 mill ion. This figure, however, i s a very rough estimate that cannot possibly accurately predict the likely number o f birds to be culled. I t will therefore have to be adjusted during Project implementation.
On the basis o f the regulatory measures proposed in this Project it seems appropriate to bnng in an element of moral hazard in compensation payments to organised poultry farms. Farms have to comply with the GoN's mandatory bio-security norms and be certified for the bio-security level maintained annually, by industry inspectors, and based on the government prescribed norms. If the farms being culled do not have a certificate o f the standard o f bio-security i t follows at prescribed levels, i t would not be eligible for any compensation.
Another aspect t o be examined i s the registration o f a l l larger farms as mandated by the governments. I t should be possible to include in the registration fee a small contribution to an industry-driven (permanent) Compensation Fund. This will make the industry more open to disease reporting and will enable them to cooperate with the authorities in matters pertaining to the public good.
COMPONENT 2: Human Health
Sub-component 2.1: Surveillance and Laboratory Strengthening
The main goal o f this component i s to develop the surveillance capacity within Nepal to detect: (i) the presence o f human avian influenza cases as they occur; (ii) and to monitor and investigate the epidemiology o f influenza and influenza-like illnesses to identify changes in transmission patterns o f avian or other novel influenza viruses; (iii) and be able to track the impact o f an influenza pandemic should it occur. The ultimate goal s to in form decision-making by Nepal i and international health authorities during the different pandemic phases and to guide the prompt and long-term interventions needed to contain or delay the spread o f the disease.
The actions in this sub-component will strengthen the existing disease surveillance capacity o f the public health system o f Nepal at the district, regional, and national level so that i s able to run a functional influenza surveillance system, set up such surveillance building on existing mechanisms, and design and prepare the surveillance tools and methods required to monitor the occurrence o f this disease over the different phases o f the pandemic. This requires strengthening and expanding current capacities in data collection, case investigation, and laboratory diagnostics. Successful implementation o f activities to
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strengthen influenza surveillance will benefit the overall surveillance and control infrastructure in the country for priority diseases and for known and emerging health threats.
Enhance capacity of district and regional rapid response teams
In Nepal, epidemiologc investigations are conducted through a network o f rapid response teams (RRTs) based at the district level. Each o f the 75 distncts has the ability t o field one or more (RRTs), whose number varies based on the circumstances and needs o f each particular investigation. RRT members at the district level are health providers (e.g. physicians, nurses) or allied health professionals (e.g. sanitanans) usually engaged in routine clinical or public health activities. Their sk i l ls and training to conduct epidemiologic investigations and analyze and report their findings are variable. When necessary, the distnct level RRTs are backed up by teams f rom the regional or national level. These teams generally have better capacity and training, and when not involved in investigations they engage in collecting, analyzing, and reporting routine surveillance data. The regional teams also include personnel who can assist wth collection o f clinical specimens for laboratory analysis. At present there are f ive regional RRTs. The Project will support strengthening o f the existing RRT network through training and better equipping these teams. I t will also expand the regional RRT network by adding three additional teams for backup support. T o do this, teams and surveillance cells will be established at BPK Institute o f Health Science in the eastern region; Nepalgunj Medical College in the western region, and at the national surveillance node (Epidemiology and Communicable Disease Control (EDCD) unidNationa1 Public Health Laboratory (NPHL) for the central region. Any time a human case o f avian influenza i s suspected or confirmed one or more o f the regional response teams wil l take over the investigation. The regional RRTs will also conduct f ield investigations any time avian influenza i s detected in poultry. The purpose o f these investigations will be to survey human populations in the area o f the poultry outbreak and to assess the potential for disease among those engaged in cull ing and other outbreak control measures.
Guidelines for the conduct o f case and outbreak investigations related to avian influenza and influenza- l ike i l lness will be developed. Once the guidelines are available, the district and regional RRTs will be trained on how to utilize these guidelines. Periodic refresher training will also be conducted as membership on the teams i s l ikely to change over time and new information concerning avian influenza becomes available. As the surveillance system matures and more possible cases and outbreaks are identified, it i s expected that each team wil l have to conduct more investigations. The project will support these investigations, including expenses to travel to the f ie ld and specimen collection and transport, and proper protective measures (personal protective equipment, vaccination, and antivirals) for the regional teams. RRTs will have rapid diagnostic k i t s available to establish a preliminary diagnosis in the field. The costs for the l u t s are included in the laboratory component. For costing purposes, it i s expected that each district team will conduct three investigations in the f i rst 12-month period o f the project, four in the second, and five in the next two 12-month periods. They wil l require back-up support f rom regional teams o n average 40 times per year (when a l l f ive teams are fully functional, eight investigations per year per team).
Influenza-like illness reporting with an embedded laboratory algorithm through the Early Warning Alert and Response Surveillance (E WARS) network
The current EWARS network consists o f 28 sentinel sites, mostly located in the Tarai region o f southern Nepal. This network can be harnessed to conduct surveillance o f influenza-like illness (LLI), allowing the country to establish systematic baseline rates o f the occurrence o f LI and the seasonal and epidemiologic patterns. This would allow rapid recognition o f aberrations in the normal occurrence o f disease which would then be investigated by the rapid response teams. T o be most beneficial, this ILI surveillance will be coupled to an embedded algorithm for collection o f specimens for laboratory testing, providing data on the types o f influenza strains circulating in the country and the seasonal patterns. I t wil l also allow the
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laboratory network to remain proficient in influenza identification and strain sub-typing. T o be maximally useful, the EWARS sentinel sites must be nationally representative. Because at present the mountain regions are under-represented, the Project will support expansion o f the network to include eight additional sites in this area, for a total o f 36 sites. Each E W A R S site should collect a minimum o f five samples per month f rom patients meeting the case definition for ILI. This would generate a minimum o f 180 specimens per month, or 2,160 specimens annually. As the laboratory capacity at NPHL matures, the number o f monthly specimens may be increased. The project will support technical assistance to develop ILI surveillance guidelines, including case definitions, for the EWARS network, training o f EWARS personnel o n these guidelines and penodic re-training, provision o f rapid diagnostic k i t s (costed separately in the lab component) to the sites, shipment o f specimens, and data collection and transfer.
Human avian influenza and viral pneumonia surveillance through the WEO/Immunization Preventable Diseases (IPD) system
The WHO/IPD system has built an extensive network o f sites that conduct active and passive surveillance for a number o f vaccine-preventable conditions, reporting this information o n a weekly basis (immediately when a case of AFP i s identified). This network also has an infrastructure for specimen collection and shipment. As such, i t i s probably the system which produces the highest quality data in the country. Within six months o f project initiation, this system will incorporate surveillance for cases o f severe Acute Respiratory Infection (ARI) and l ikely viral pneumonia as a means to identify possible human cases o f avian influenza. Information will be collected f rom a l l identified cases to determine if they have risk factors for avian influenza disease (contact with someone with the disease, travel to an area with known avian influenza, or contact with sick and dying poultry). For any person meeting the established case definition, specimens will be immediately collected, tested using rapid diagnostic h t s , and shipped to NPHL. The appropriate rapid response team will also be alerted. The project will support costs associated with surveillance guideline development, training o f IPD personnel with periodic refresher training, specimen collection and shipment, and data collection and management. I t i s diff icult to know how many potential cases may be identified by this system, but as the system matures and if avian influenza occurs in poultry in Nepal, this number would be expected to go up over the course o f the project. For the purposes o f costing, the project estimates that as many as 2,000 cases will be investigated and that 50 o f these will meet the case definition for suspected avian influenza in the f i rs t 12 months o f the surveillance. These numbers could increase by 25 percent per year. In additional t o i t s value for avian influenza, this system will also provide information o n the baseline occurrence o f severe ARI and pneumonia in the country, identify clusters o f such cases for investigation, and should enhance studies o f the etiology o f these cases.
Improving surveillance system data collection, transfer, analysis, and dissemination
It i s important that information collected through the vanous systems being developed for avian and pandemic influenza be integrated, analyzed, disseminated, and reported in systematic fashion. It i s also important that mechanisms be developed to collect data o n the progress o f the epidemic should an influenza pandemic develop. Such data will allow the health care system to gauge the extent and seventy o f the epidemic in Nepal and i ts temporal course. Such information will a l low policy-makers to make informed decisions about allocation o f preventive and health care resources to those areas in greatest need. The project will support development o f surveillance mechanisms for the pandemic phase and distribution and training using these guidelines throughout the surveillance system. The project will also support enhancement o f the current surveillance units at the regional and national level for data collection and transfer to the Surveillance Unit o f EDCD, and the development o f a web site and bulletins for dissemination o f information regarding avian influenza and other surveillance data.
Influenza rapid diagnostic kits for surveillance sites and rapid response teams
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Although they do not provide a definitive diagnosis o f the presence o f human avian influenza, rapid diagnostic kits have an important role to play in the surveillance and investigation of this disease. These lu ts can provide an important early clue to the presence o f avian influenza in someone with a compatible illness, thereby allowing early interventions to be initiated. They also encourage health care providers to participate in surveillance efforts and allow them to better care for persons with regular seasonal influenza. However, studies have shown that these I t s lack sensitivity, particularly for avian influenza sub-types, and are also associated with false positive findings. Therefore specimens must s t i l l be tested using more reliable methods such as PCR and virus isolation. These k i t s are also costly. Given these factors, the project will support distribution o f these lu ts to the E W A R S sites conducting influenza surveillance and to the eight regional RRTs. For most RRT investigations, it would be usual to conduct more than ten rapid tests per investigation. The project will also support training in the proper use o f rapid diagnostic kits and the interpretation o f the results. The project will also support replenishment o f these l u t s over the duration o f the project.
Development of conventional and real time polymerase chain reaction (PCR) testing and ELISA-based serologic diagnosis at the National Public Health Laboratory
PCR has been shown to be a reliable method to diagnose avian influenza. Studies have shown that real time PCR i s more sensitive and rapid than conventional PCR testing. However, even this assay has problems for the diagnosis o f avian influenza in humans, because at present persons with this disease do not have large quantities o f virus in the upper respiratory tract. Serology i s an alternative method to diagnose influenza, including that caused by avian sub-types. But serology i s o f l imited utility in diagnosing this disease, as acute and convalescent specimens must be obtained. As a result, i t i s useful for epidemiologic purposes but i s not t imely enough to guide patient care. I t i s also useful for special epidemiologic investigations, such as serosurveys o f cull ing workers, health care workers, or in communities with outbreaks. Given the l imited laboratory infrastructure in Nepal, the project does not support developing PCR and serology capacity throughout the country. Instead, development o f such capacities in the NPHL is supported. NPHL already has the abil ity t o perform conventional PCR. The project will support the acquisition o f primer, reagents and supplies for conventional PCR until RT-PCR can be put in place. For RT-PCR, the project will support acquisition o f equipment, reagents, and supplies for this test at NPHL. The project will also support acquisition o f E L I S A l u t s for influenza serologic testing. For the purposes o f costing, the project anticipates that 5,000 PCR assays would be conducted annually, and that not more than 500 serologic assays would be performed annually. The project will support laboratory infrastructure to support PCR and serology, including training, staffing, equipment, and renovation for the laboratory. This capacity will not only be uti l ized for influenza, but for other diseases o f public health significance in Nepal that can be diagnosed by RT-PCR.
Virus isolation/BSL3 capacity at NPHL
Several viral diseases present in Nepal require biosafety level 3 capacity. At present, there i s n o laboratory in Nepal that has the capacity to conduct virus isolation or handling o f specimens at the BSL3 level, and al l samples must be shipped outside o f the country for diagnosis. This i s costly, involves proper shipment o f specimens using international specifications, and most importantly, impedes definitive diagnosis. Taking advantage o f this Project, the laboratory capacity in Nepal would be upgraded to provide BSL3 capacity. This feature i s common to animal health and human health components, and therefore close collaboration between the two CCTs would be essential. BSL3 work i s costly and requires a level o f capacity far above that which currently exists in Nepal. The project will support efforts to develop virus isolation and BSL3 capacity at NPHL, recognizing that this will take considerable time to develop and will require a commitment on the part o f the Ministry o f Health and Population to sustain after the project ends. In addition, there i s n o expertise in Nepal t o design or construct a BSL3 facility.
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Therefore, the project will also support an international technical consultant or firm to support NPHL in assessing the abil ity o f current facilities to support a BSL3 lab, help design the facility, and support construction efforts. The project will also support reagents and supplies for virus isolation, training o f personnel in the operation o f the facility and in virus isolation, development o f biosafety protocols, supplies for biosafety and waste disposal (including an incinerator), equipment, and maintenance. Any renovation efforts should include those necessary for the PCR space, even though it i s recognized that PCR does not require BSL3 and should not be conducted in the same physical area as virus isolation. I t i s unlikely that v i r u s isolation capacity will exist at NPHL until at least the second year o f the project. During the interim period, the project will support costs for shipment o f specimens to an international partner for the purposes o f virus isolation and definitive diagnosis. The project will also support NPHL participation in a quality assurance program for both PCR and virus isolation.
GON has agreed to; (i) provide sufficient budgetary allocations fkom i t s own resources for the adequate maintenance, supplies, and other recurrent costs for the satisfactory operation o f the BSL-3 laboratories beyond the l i f e o f the project as long as necessary; (ii) ensure the recruitment, appointment, or assignment o f adequate number o f trained personnel to operate the two laboratories at BSL-3 level as long as necessary; and (iii) take al l necessary actions to obtain and maintain the necessary BSL-3 certification f rom appropriate organizations.
Laboratory Information Management System at NPHL
The laboratory improvements listed above, and the volume o f samples expected to be processed by NPHL require that the laboratory has an information system to manage the data generated as a result. At present NPHL has minimal computerization and electronic data management. The project will support the development and implementation o f such a system, including the necessary hardware, software, and networkmg. Fo r the Laboratory Information Management System (LIMS) to be most useful, it must have seamless linkage to the epidemiologic systems developed in EDCD, so that laboratory information can be integrated into the databases o n cases. Therefore NPHL must work closely with E D C D in the design and development o f the system. Since both are located o n the same campus, NPHL should share the data managerhnformation specialist that wi l l be hired to work on avian and pandemic influenza-related issues. The L I M S should benefit not only work related to avian influenza, but should also benefit information management in the laboratory in general.
Sub-component 2.2: Prevention and Containment
Prevention of avian and seasonal influenza in high risk occupational settings
There are certain occupational settings where the risk o f exposure to avian influenza i s higher than in the general population. These settings include persons engaged in cull ing actiwties i f avian influenza i s discovered in poultry in Nepal, persons engaged in poultry reanng activities, health care workers canng for persons with avian influenza, laboratory workers who wil l be handling specimens containing this virus or working with l ive virus, and those who will be conducting f ie ld investigations as part o f the RRTs. Measures should be taken to reduce risk among such persons. These measures include education and training, barrier precautions to reduce exposure to the virus, disinfection and hygienic measures to reduce surface contamination, and in specific circumstances, antiwral prophylaxis. At present there i s n o human vaccine for avian influenza strains that have produced human disease, and such vaccines may not be available until wel l into an influenza pandemic. With the exception o f antiviral prophylaxis, measures to protect workers engaged in cull ing activities and those working in the commercial poultry sector are part o f the animal health component o f this Project. The project will support measures to protect health care workers l ikely to care for patients with avian influenza (e.g. those workers at referral facilities established as part o f this project), including personal protective equipment, hygienic supplies, and antiviral
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prophylaxis. The same applies to workers at NPHL and members o f the eight RRTs that will conduct investigations o f suspected or confirmed avian influenza, including specimen collection. For the purposes o f costing and estimating needs, this would include 200 persons engaged in health care activities at referral centers, 1,500 persons engaged in cull ing activities (district-level animal health core teams), 80 members o f the regional rapid response teams (two teams o f five per site), and 20 persons working in NPHL. Because patients with avian influenza may be seen or hospitalized at facilities at levels of the health care system below the referral center, i t i s also appropriate for these facilities to have access to personal protective equipment and antiviral prophylaxis. Therefore the project will support a small cache o f PPE and antivirals in each o f the f ive regions that can be distributed on an as-needed basis, along with a reserve maintained at the central level in Kathmandu. The project will support training o f persons in high nsk occupational groups o n measures to reduce exposure nsk, including use o f supplies and equipment.
Seasonal influenza vaccine i s not protective against avian influenza. However, i t i s important to reduce the potential for co-infection with avian and seasonal influenza viruses. Co-infection could result in virus reassortment and acquisition by avian subtypes o f genetic segments f rom human subtypes. If this occurred, the virus could more readily be passed f rom person-to-person, resulting in a pandemic sub-type. T o mitigate this possibility, i t i s recommended that high r i s k groups be vaccinated against seasonal influenza with trivalent influenza vaccine (TIV). Therefore, the Project will support use o f TIV in high risk occupational groups, including health care workers in referral facilities, laboratory workers, and RRT members. If a group o f individuals who will definitely be engaged in cull ing activities can be identified, the Project will also support vaccinating this group.
Prevention of transmission in high risk contacts ofpersons diagnosed with avian influenza
During the pre-pandemic phase, ring antiviral prophylaxis (also known as contact prophylaxis) o f close contacts (usually household members) o f persons diagnosed with avian influenza i s considered an important measure to limit disease spread. Community prophylaxis i s also considered important in circumstances where chains o f person-to-person transmission are evident (when WHO pandemic phase 4 i s recognized) to reduce the r i s k o f spread beyond the affected community. However, in this situation, WHO has indicated that i t s stockpile o f antiviral drugs will be deployed to cover such use. Therefore, the Project will support acquisition o f a l imited stockpile o f antivlral drugs to cover contact prophylaxis during pandemic stage 3 (the current phase). T h i s stockpile can be maintained in the f ive regional centers and at the central level, since they will most l ikely be distributed by the rapid response teams as part o f the case or outbreak investigation. Replenishment o f this stockpile will also be supported. For the purposes o f cosbng, a 25 percent annual replacement will be supported. If the drugs are not used, the additional matenal can be used to build the stockpile for use dunng the pandemic phase. The antiviral medication stockpile will also be used for treatment o f persons with suspected or confirmed disease due to avian influenza.
Planning for acquisition and use ofpandemic influenza vaccine
At present, there are n o human vaccines for avian influenza sub-types that are known to have produced human disease. Efforts are underway in several countries to develop and produce such vaccines. However, until a pandemic strain actually develops, i t i s unknown how effective any o f these vaccines wil l be against the specific pandemic strain. However, if a pandemic vaccine was available, i t s l ikely protective efficacy would be high. Most current planning efforts assume a pandemic vaccine will not be available during the early phases o f a pandemic. However, these planning efforts also assume that not al l areas will be immediately impacted by a pandemic, and that there are l ikely to be multiple waves to a pandemic as there have been in previous pandemics. Therefore, there a pandemic vaccine that i s not available dunng the init ial wave may s t i l l be beneficial. Because o f these many unknowns, including
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when a pandemic may occur, the Project cannot support large scale acquisibon o f vaccines against avian influenza during the pre-pandemic phase. However, the Project does support efforts to develop plans for vaccine acquisition and distribution, including defining pnor i ty groups for use o f vaccine (groups supporting critical infrastructure, persons at risk o f severe disease, etc.).
Development of a quarantine network for Nepal
At present, Nepal does not have an organized quarantine system to prevent importation o f human disease f rom outside the country, either by air or land ports o f entry. For many emerging infectious diseases, including avian influenza, this i s an important gap. In addition, the revised International Health Regulations (IHRs), passed by the Wor ld Health Assembly in 2005, mandate that quarantine facilities exist at major ports o f entry by 2007, including the ability to identify and care for persons who may be carrying communicable diseases covered under the regulations. In the event o f avian influenza exhibiting l imited person-to-person transmissibility, whether within or external to Nepal, authorities may be called upon to screen exiting or entenng travelers, or at the very least to distribute information to travelers. Therefore the project will support activities to develop a modem quarantine system for the country.
The Ministry o f Health has identified eight locations that represent major air and land ports o f entry. One i s at Tribhuvan International Airport. The others are at seven major international land crossings in Nepal, one with China and six with India. The Project will support incremental development o f quarantine facilities at each o f these locations, so that al l are complete by the third year. At each o f these locations, the Project will support identification o f a facility that can serve as a quarantine office and can be used to examine travelers, equipment for these facilities, and staffing and other operational costs. The Project wil also support development o f guidelines and procedures for the quarantine system, along with training o f personnel. Technical assistance will be supported to develop guidelines and procedures. A s per the I H R s : each facility must identify a mechanism for care o f persons with suspected disease requiring quarantine, but such health care facilities may be off-site. Many locations contract for such services rather than provlde them directly.
Legal and regulatory review
Successful containment and prevention o f avian and pandemic influenza may require the use o f tools not often employed by public health authonties, such as quarantine measures, other social distancing measures, use o f expenmental vaccines and therapeutics, and use o f unlicensed health care practitioners. There needs to be a sound legal basis for such measures. The foundation o f such measures for Nepal i s the Communicable Disease Control A c t o f 1964. Whi le this law exists, the regulatory framework for i t s implementation was never written. In addition, i t i s now more than 40 years o ld and l ike ly needs to be updated to reflect the current public health situation. The Project will support a review o f current laws and regulations that might be applicable to avian and pandemic influenza surveillance, prevention, and control measures. The purpose o f the review i s to identify problems and gaps, and propose measures to address them. At a minimum, the review should include the basis for current surveillance activities, quarantine and isolation, use o f unlicensed products, conduct o f other types o f research, use o f a volunteer workforce, and liabil i ty issues. The Project will support a technical consultant t o conduct this review and propose remedies.
Planning for non-pharmacologic interventions (including social distancing) to contain human avian and pandemic influenza
A variety o f non-pharmacological interventions are available for the prevention and containment o f avian and pandemic influenza. Limited studies and some modeling studies suggest that some o f these interventions may substantially impact the occurrence o f disease. These measures include social
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distancing (community quarantine, school closures, suspension o f activities such as social and sporting events, business closures, etc.), use o f masks and other bamer precautions outside o f health care facilities, and community hygienic and disinfection measures. An assessment o f these measures i s required for their appropriateness in Nepal and their relative pnor i ty based on scientific information. After this i s done, plans should then be developed for their application and use during the various pandemic phases. The project will support such an assessment, including technical consultation, and will support development o f plans for their implementation in Nepal. Since these measures require considerable cooperation f rom other parts o f the government, f rom NGOs, from the private sector and f rom the business and religious community, the assessment and planning process should include participation o f these groups.
Sub-component 2.3: Health care delivery system preparedness and response
The health care system must be prepared to care for persons with suspected or confirmed avian influenza during any o f the three major WHO phases (the pre-pandemic phase, the pandemic alert phase, and the pandemic phase). The needs, requirements, and constraints o f the health care system in Nepal differ within these phases. During the pre-pandemic and pandemic alert phase, few cases o f disease will be identified. These can be handled at designated health care facilities that have trained personnel and are outfitted for patient isolation. If the pandemic phase i s reached, the health care system will be stretched and the priority i s to care for large numbers o f ill individuals efficiently and in a manor appropnate for the health care context o f Nepal. I t wil l be especially important t o support the lowest levels o f the health care system, since there are insufficient medical facilities, especially inpat ient facilities (the country has only 16,000 hospital beds) to meet a l l o f the potential needs. In many instances, the diagnosis o f avian influenza may not be made immediately, even with anticipated enhancements to the surveillance and laboratory infrastructure. Some o f these cases may not be able to be confirmed. Therefore any efforts to support and upgrade the health care delivery system should benefit more general public health needs. In the case o f the health care system, this includes acute respiratory illness and other diseases that might benefit f rom patient isolation. The Project will support efforts to develop an acute respiratory disease tnage and referral system, and to provide planning tools and resources to the pnmary health care system for the pandemic phase.
Development of an acute respiratory disease ( A D ) triage and referral system
T o develop and implement ARD triage and referral, a number o f activities must be undertaken. These include development o f standardized guidelines for evaluation, diagnosis, care, and referral o f patients with respiratory disease that might be due to avlan influenza; training o f health care personnel at a l l levels o f the health care system; designation o f referral facilities at the regional and national level and upgrading o f these facilities to care for persons with avian influenza within the context o f the Nepal i health care system; development o f plans for acquisition o f supplies and medications needed to care for large numbers o f patients during the pandemic phase; and l imi ted acquisition o f these supplies and medications. These activities will also improve care o f patients with non-influenza respiratory disease, a major cause o f morbidity and mortality in Nepal.
0 Guidelines: For guideline development and dissemination, the Project will support technical assistance. Such guidelines exist elsewhere, but their relevance to the Nepali health care system must be assessed and they must be adapted appropnately. I t i s important that these guidelines be developed in the early phases o f the Project, since training efforts for health care providers will be extensive, and cannot commence without the guidelines that form the basis o f the training. Guidelines must also be developed for each level o f the health care system, since the level o f care, including diagnostic capacity and slulls, increases from the local to district to regional to national level. Once developed, these guidelines must be periodically re-examined and updated as the scientific knowledge regarding the clinical aspects o f avian influenza increases.
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Training: When the guidelines are available, training should commence using a tiered ‘train the trainer’ approach. Standardized training materials will be developed, approved by the Ministry o f Health; and then disseminated throughout the system. Training at a l l levels should be accomplished during the f i rst year, and then repeated annually in abbreviated fashion. The project will support outside assistance to accomplish training goals. Both guideline development and training materials may benefit f rom a collaborative relationship with a Nepal i academic partner.
Facilities upgrades: T o support acute respiratory disease triage activities, referral facilities must be designated and upgraded. The Project will support designation o f one facil i ty in each region to serve as a referral center with an isolation ward o f at least ten beds. The isolation ward i s most useful during the pre-pandemic and pandemic alert phase, when there are small numbers o f patients with avian influenza, but can also help support severely ill patients dmng the pandemic phase. When there are n o patients with avian influenza hospitalized in these isolation wards, they should be used for other patients with severe acute respiratory disease or for patients with non-respiratory diseases where isolation i s indicated. The project will support facil i ty renovations, staffing support with infection control measures (as outlined in the prevention and containment section), basic equipment (e.g. oxygen generators, suction devices, pulse oximeters), and appropnate waste disposal. The Project wil l also support designation o f one facility as a national reference hospital (NRH) in Kathmandu. The designated facility should have appropriate staffing and infrastructure (laboratory, radiology, pharmacy, waste disposal) to care for severely ill patients. This facil i ty must also designate a location which can support a ten-bed isolation ward. As with the regional facilities, the Project will support renovations, staff support, infection control, basic equipment, and waste disposal. Technical support can be requested for facilities renovations. The facility chosen by the G o N for this purpose i s Shukraraj Tropical Infectious Diseases Hospital (STIDH); however this hospital does not yet have the minimum required infrastructure to be a NRH, and the G o N has agreed to upgrade it to provide such infrastructure, within the next two years using i t s own resources. It has been decided that the Tribhuvan University Teaching Hospital (TUTH) will serve as an interim NRH until ST IDH i s ready to take this function on.
Planning and limited acquisition of medications and supplies: Dunng the pandemic stage, there will be a need for additional supplies and medications to treat large numbers o f ill persons, including the secondary complications o f influenza. Among the additional medications are antimicrobial agents to cover the organisms which produce secondary pneumonias, antipyretic drugs, and cough suppressants. However, because the timing o f an influenza pandemic i s unpredictable, i t i s unwise to procure large quantities o f these medications which may then not be used. The project will support l imited acquisition o f these medications to support the isolation wards o f the referral centers listed above, and will support a planning process to assure access to these medications when needed during a pandemic phase (such as assmng a stockpile bubble among the suppliers and distributors which can be accessed by the government as needed).
Plans and capacities for the primary care system (ilaka and below) to meet health care needs during an influenza pandemic
During an influenza pandemic, health care services will be severely stretched to meet the needs o f large numbers o f ill individuals. Given the l imited capacity o f in-patient health care facilities, the burden o f this care will fall disproportionately to the primary health care system at the ilaka level and below. Therefore it i s important t o develop contingency plans for h o w care will be delivered by this level o f the health care system. The project will support a planning process for each ilaka headed by the primary health care center that will address what will be done and how it wil l be done. These plans should address surge capacity, including use o f volunteers, and home health care provision. The plans should also consider that
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a proportion o f the ill individuals will be the health care workers themselves. Therefore it i s especially important for the plans to focus on a back-up work force. I t i s possible that in Nepal not al l regions will be affected by the pandemic at the same time. It may therefore be possible to shift health workers and other resources to and from areas o f greater and lesser needs. Each PHC will be expected to plan the response applying national assumptions o f impact o f an influenza pandemic to the local level. Since the issues and needs are l ikely to be the same among most o f the ilakas, consideration should be given to developing model guidelines and having each ilaka adapt these to local circumstances and capacities. This planning activity should not only be relevant t o an influenza pandemic, but should strengthen overall preparedness for any public health emergency.
Sub-component 3: Communications
The communications subcomponent aims to reduce the negative social impact and threat to human health posed by the occurrence o f poultry outbreaks o f avian influenza, and in doing so minimize the social disruption and impact o f an influenza epidemic. This will be done through advocacy, behavioural change communication, and social mobilization. A Communications Plan, drafted by UNICEF and WHO, and forms the basis for this component, which will be implemented jo in t ly through DoLS and DoHS.
Overall Goal
The overall goal o f the Communication Plan i s to prevent and reduce the negative social impact and threat to human health f rom the occurrence o f poultry outbreaks o f avian influenza (AI) and minimize the social disruption and impact o f an influenza epidemic through advocacy, behaviour change communication, and social mobilization. The specific purpose o f the plan i s to provide a framework and the roadmap to the implementation o f the communications component o f the NAIIPPRP.
Specific Objectives
T o achieve the goal o f the Communication Plan, three main objectives have been identified. Objective number 1 corresponds to the WHO pandemic phases 1 to 3, which i s applicable to Nepal at present. The specific activities to meet this objective are already known and will require immediate implementation. However, the dissemination o f the behavioural change communication messages related to this objective will not happen automatically but rather accompany the information requirements set by the epidemic developments. Objective number two corresponds to the WHO pandemic phases 4 to 6, which may be less l ikely to affect Nepal in the very near future. Nonetheless, the current proposal outlines a series o f capacity building and preparedness activities to ensure government officials, health workers and other key stakeholders are fully prepared for an effective communication response should a human outbreak strike Nepal or neighbounng countnes. Objective number three i s applicable and relevant to a l l the WHO pandemic phases. Activities to meet this objective will be implemented throughout the l i fe o f the project in Nepal though special attention will be given to i t immediately in order to set the foundations for a suitable avian influenza communication environment.
Objective number 1 will influence behaviours and attitudes o f targeted and general audiences that lead to action to reduce the r i sk o f avian influenza outbreaks in poultry and human avian influenza infections. The sub-objectives are as follows:
Gain commitment f rom key political, social and industnal players to improve quality control o f poultry farming and market chains and reduce the risk o f importation o f the virus.
0 Build the avian influenza communication capacity o f key groups at the community level including, inter alia, teachers, female community health volunteers, village agriculture extension workers,
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NGO/CBOs and UN social mobilizers that will support the mass media communication component with strategic and targeted interpersonal communication activities.
Develop and disseminate behaviour change communication messages and products targeting avian influenza vulnerable groups including, inter alia, women, children, butchers, vetennaries and poultry farmers that will ensure: (i) understanding o f avian influenza risks, critical hygiene, coolung and poultry handling practices; (ii) knowledge and understanding o f compensation packages for cull ing o f poultry; and (iii) early reporting o f animal deaths.
Develop and disseminate behaviour change communication messages and products targeting groups such as families, health workers, health volunteers, traditional healers and traditional birth attendants that will: (i) ensure understanding o f the r isk o f human influenza infection and selflfamily protection mechanisms; (ii) identification and early reporting o f symptoms; and (iii) understanding and cooperation wth surveillance and tracing activities and procedures.
Objective number 2 will build the capacity and establish the mechanisms for a targeted, t imely and effective communication response aimed at reducing the number o f persons getting infected and dying in a human influenza pandemic. The sub-objectives are as follows:
Design a targeted communication strategy that will ensure: (i) the population understands the need for surveillance and tracing actimties; (ii) the population reports cases o f ill persons; (iii) ensure the population i s aware and able to implement self-protection mechanisms; (iv) ensure knowledge and compliance o f quarantine periods, health seelung practices and home care practices; and (v) knowledge and compliance o f directives regarding safe management o f dead bodies.
0 Develop related behawour change communication messages and products ready for immediate release and dissemination should a human influenza outbreak hit Nepal.
Develop training on communication guidelines and protocols for health workers, traditional healers, traditional birth attendants and community health volunteers in order to facilitate their communication with the community during an outbreak enhancing trust and cooperation.
Objective number 3 i s to create a public information environment conducive to behaviour change and reduced public panic and mistrust through a consistent, t imely and accurate f l ow o f information o n avian influenza. The sub-objectives are as follows:
0 Develop and implement training and materials that will strengthen health journalists and ensure informed and responsible media reporting o n avian influenza.
0 Build the capacity o f the public sector at national and local levels to implement a coordinated, transparent and proactive public information strategy related to avian influenza and other epidemics.
0 Establish a forum for regular communication with stakeholders - including the media, private sector and representatives f rom the c iv i l society.
Coordination and Communication Plan Implementation
The GoN has developed both a multi-sectoral coordination committee to guide the Project, and facilitate implementation o f the activities to be camed out by the health and agricultural l ine ministries. This committee will coordinate a l l communication components o f the plan. Other stakeholders will be
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incorporated to the committee as deemed necessary as and when the epidemic evolves. It will be responsible for the coordination and follow-up o f the implementation o f the communication response. I t will also oversee the key messages and materials development done by each stakeholder in order to avoid confusion and duplication within the national response. M o H P and M o A C with support f rom the UN communication team wil l be responsible for dissemination o f the I E C materials and messages to each o f the target groups. The ministries will be responsible for mobil izing their staff and volunteers for the dissemination o f messages through their respective networks.
COMPONENT 4: Project Coordination4
Sub-component 4.1: Animal Health Support
The Core Coordination Team (CCT) wi l l be directly responsible for the implementation o f the entire Animal Health Component o f the Project, including being accountable for a l l information related to the progress, implementation, reporting, monitonng and evaluation. The Director (AH) will orchestrate the Random Sero-surveillance Programme nation wide through the Regional Directors and the Containment Programme through the District Livestock Officers. Monitoring and Evaluation o f the Project will be h isher direct responsibility, and he/she will identify a competent and independent external agency to set up the M&E system and will produce periodic M&E Reports at agreed intervals which will be shared with the Wor ld Bank and other development partners. The Project Director will ensure that al l traininghlull development / capacity building programmes under the Project will be implemented o n time and in the sequence required for unhindered implementation o f the different time bound activities. The Animal Health Directorate in the DoLS i s being strengthened with the addition o f a National HPAI Control and Coordination Cel l in the Directorate to help the Director Animal Health who also happens to be the Project Director for the Animal Health Component o f the Strategic Plan. Monitor ing and evaluation will be the task o f the Epidemiology centre o f the directorate o f Animal Health.
Sub-component 4.2: Human Health Support
A high-level committee that for the human health component o f the Project wil l be established at M o H P level to provide overall guidance for: specific policy related matters; strategic guidance; human resource related approvals; delineation o f roles and responsibilities; capacity building; donors harmonization; getting approvals in condition o f epidemic breakout for resource mobilization including human resources from community and other sectors; keeping an oversight o n program planning; coordination (intersectoral, intrasectoral and with EDPs), monitonng o f the epidemics; periodical reporting to EDPs and internal reporting, and financial management. This Steermg Committee will be chaired by the Minister o f Health and Population, or, in h is absence, by Secretary o f MoHP. The committee members will be the Specialist secretanes o f MoHP, Director Curative Division, Chief Planning Division, Chief Financing Unit o f M o H P the member secretary will be the Director General o f Department o f Health Services (DoHS) who i s overall in-charge for implementation.
The Project Implementation Committee will be led by Director General o f DoHS, with the Director o f Epidemiology and Disease Control Div is ion (EDCD) as Member-Secretary and will include: Directors o f Management Division, National Public Health Laboratory, National Health Training Center, National Health Information , Education and Communication Center, Logistics Management Div is ion and Infectious Diseases Hospital, Chief Account Section o f DoHS and one representative o f Animal Health Directorate (DoLS, MoAC) to ensure liaison with the animal health component. The Directors responsible for respective sub-components (including for procurement o f works, goods and services and the regional directors, regional medical stores and regional training centers including the designated focal
See Annex 5 for more details on coordination and implementation arrangements. 4
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points for curative service structures) will be co-opted by the committee as and when necessary. A few public central hospitals, regional and zonal hospitals, DHOsDPHOs and specified distinct hospitals and some private sector hospitals will be involved during al l the phases o f pandemics for necessary preparation and response in epidemic situation. Coordination issues at the district level and information flows will be responsibility o f the DPHOs and Management division o f DoHS and Monitor ing and Evaluation and Public Health Administration divlsion o f MoHP. A small project support coordination team will be designated at DoHS with a core staff and required office support under the oversight o f DGI DoHS to coordinate inputs, monitor activities carried out by vanous related divisions under DoHS and to produce timely reports including financial management and procurement and track actions at the district and sub-distncts level in addition to community participation and public private partnership and project related research, studies and assessment. Whi le this team will consist o f full-time personnel dedicated to the avian influenza program, it will not be a separate Project Implementation Unit; rather i t will be part o f the regular structure o f DoHS.
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Annex 4: Project Costs
NEPAL: Avian Influenza Control Project
Total U S $million Project Cost By Component and Activity
1. Animal Health 1.1, Surveillance 1.2. Prevention and Containment 1.3. Laboratory Capacity 1.4. Vetennary Services 1.5. Compensation Fund
2. Human Health 2.1. Surveillance and Laboratory 2.2. Prevention and Containment 2.3. Health Care Delivery System
3. Communications 3.1. Animal Health Communications 3.2. Human Health Communications 3.3 Cross-cutting Issues
4. Project Management 4.1. Animal Health Support 4.2. Human Health Support
Total Project Costs 18.20 Interest dunng construction 0.00
Front-end Fee 0.00 Total Financing Required 18.20
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Annex 5: Coordination and Implementation Arrangements
NEPAL: Avian Influenza Control Project
1. Coordination Structure
(I, At the centraZ level, overall coordination will be by the Central Natural Disaster Rel ief Committee (CNDRC), chaired by the Minister o f Home Affairs as established by the Natural Calamity A c t 2039. However, this committee wil l function at the time o f epidemic outbreak and has established an Technical Sub-committee on Avian Influenza (TSCAI) which i s (co-chaired by the Secretary, M o A C and the Secretary, MoHP) to advise on both animal and human health influenza issues. This T S C A I will be responsible for the overall coordination and pol icy decisions regarding avian influenza and a l l related issues (human as wel l as animal health issues, l aw enforcement, etc.) as per the T S C A I recommendations. The TSCAI would meet at least quarterly, with the specific agenda o f avian influenza and/or pandemic preparedness and response. The T S C A I will:
a) Bear responsibility for the formulation o f national policies and implementation o f action plan; b) Collaborate with national and international organizations; c) Approve Annual Work Plans for financial and technical resources (including manpower) required to
implement the Operational Plan; d) Give technical directives regarding avian influenza to the district re l ief committee and other
concerned agencies to mobilize the resources for the implementation o f the Plan.
(ii) At the Regional, District and Local levels natural disaster relief committees, meet as required. The T S C A I would be responsible for coordinating across the concerned agencies required.
2. Implementation by Ministry of Agriculture and Cooperatives
Department of Livestock Services
a) Coordinate with Ministry o f Agnculture and Cooperative in pol icy formulation, resource management and Plan implementation;
b) Coordination and collaboration with national and international concerned agencies; c) Once avian influenza i s detected in poultry or other birds in Nepal, the Department o f Livestock
Services will serve as a focal point in charge o f compiling information f rom the reporting units and releasing periodic reports. I t will produce periodic (weekly/daily) reports to be disseminated to a l l relevant stakeholders at the national and international level. T h i s will be the sole source o f information on poultry aman influenza;
d) T o establish a logistics and supply unit that will support this component for the adequate implementation o f the plan.
Directorate of Animal Health
a) Plan and Implement HPAI Prevention and Control Strategies; b) Technical back step of the D L S O in the control the surveillance and control o f HPAI; c) Reporting o f the situation o f the HPAI to M o A C and international organization; d) Monitonng and evaluation o f the surveillance control plan; e) Regulatory enforcement; f ) Coordinate surveillance; g) Mass communication and public awareness program; h) Information sharing with specialized Organizations and stakeholders;
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i) Prepare compensation rehabilitation scheme o f stamping out i s opted.
Animal Quarantine Section
a) Develop Standard Operating Procedures for quarantine, inspection, certification, testing and disinfection;
b) Develop standards far each imported commodity; c) Provide technical back stoppage to Quarantine Offices and check-posts; d) Enforcement o f existing laws and regulations and amend as per requirement; e) Arrange training and s l u l l development program for quarantine personnel; f) Supervise, monitor and evaluate the quarantine activities; g) Develop an awareness program for the exporter/importers and other stakeholders.
Veterinary Epidemiology Center
a) Design surveillance with sampling procedure; b) Carry out epidemiological investigation o f disease outbreak; c) Carry out risk assessment and import risk analysis; d) Maintain databank and provide technical information to DAH; e) Maintain link with EDCD to assess potential nsk to humans; f) International reporting and communication through DAH.
Animal Quarantine Ofices and Check-posts
a) Active involvement in disease surveillance and reporting; b) Adopt strict import and movement control; c) Increase vigilance and mobile patrolling in the intenor and land border; d) Collection and dispatch o f suspected sample to the nearest veterinary laboratory; e) Report outbreak without any delay; f) Coordinate with other stake holders for the implementation o f the existing Acts.
Central Veterinary Laboratory
a) T o support national disease control and surveillance Programme; b) T o collaborate with national research and international reference laboratory for the diagnosis,
investigation and research; c) T o acquire, adopt, update a different diagnostic tests for HPAI; d) T o assist and advise on control o f disease, epizootics; e) To organize training o n laboratory technology for veterinanans and JT/JTAs; f) Provide technical back stopping to regional and avian disease investigation laboratories.
Veterinary Public Health Office
a) Conduct awareness campaigns; b) I n t e r h t r a sectoral and inter professional cooperation, collaboration and coordination; c) Conduct training and orientation to vetennary health workers at a l l levels.
Regional Directorates of Livestock Sewices
a) Facilitating the regional implementation o f Plan;
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b) Coordinate the Avian Influenza Search Team fall ing under i ts circumscnption and composed of the regional vetennary laboratory, concerned D L S O and warden o f the wild life;
c) Providing logistic support including manpower; d) Program monitoring.
District Livestock Service qffices
a) Participate actively in Distnct Natural Disaster Rel ief Committee o n avian influenza related matters; b) Actively mobilization available resources and network; c) Coordination and implementation o f Contingency Plan as per the guidance of TSCAI; d) Reporting progress to the Regional Directorate.
3. Implementation by Ministry of Health and Population
Division of Public Health Administration and Monitoring and Evaluation
This division will ensure that the plan i s adopted and disseminated amongst key stakeholders including the M o A C and external development partners. I t will ensure that the required resources within the government and other sources are mobil ized and allocated according to the priorities set by the Plan. I t guides decisions regarding the appropnate interventions at the various phases o f the pandemic as it relates to human health, including security issues, coordination with law enforcement agencies, releasing information to the press, review o f relevant policies and regulations needed for the adequate response in the face o f an influenza pandemic. Once avian influenza i s detected in Nepal, this Divis ion will activate the defined command and control structure, including a focal point in charge o f compiling information f rom the M o A C and releasing periodic reports. I t will also liaise with EDCD to fo l low o n suspected cases investigation and confirmation. It wil l produce penodic (weekly/daily) reports to be disseminated to a l l relevant stakeholders at the national and international level, including WHO. This wil l be the sole source o f information on human avian influenza.
Division of Policy Planning and International Afairs
In charge o f coordination o f the implementation o f the plan with international organizations and o f releasing periodic reports to the Ministry o f Foreign Affairs and travel advisories.
Department of Health Sewices
The Secretaries o f MOHP and MOAC will co-chair the National Task Force o n Influenza Preparedness during the inter-pandemic period and pandemic alert period. During the pandemic, the responsibility will fall under the Office o f the Prime Minister or equivalent as proposed by the plan. During the interpandemic and pandemic alert periods the DG will ensure that the membership and scope o f work o f the task force i s reviewed as appropnate for the coordination. I t will also act as secretanat for command and control during the different phases o f the pandemic, ensunng that the relevant institutions are actively involved as the pandemic evolves and o f the national coordination o f response operation.
Epidemiology and Disease Control Division
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This Divls ion will be responsible for initiating v i ra l pneumonia and influenza l ike illness, laboratory supported surveillance system integrated to the present E W A R S system. The system will a im at detecting human infection with influenza M 5 N l virus at the earliest possible time. The rapid response teams at the distncts will be trained in ILI outbreak investigation so that al l outbreaks are investigated and that samples are duly collected and transported to the NPHL. It wil l keep a database with al l cases reported to the system and wil l follow-up cases through the health network until confirmed or discarded.
In the event o f confirmed cases o f human AI, thorough epidemiological f ield investigation will be coordinated by EDCD, the regional directorates and DPHO. I t wil l also be responsible for coordinating the response, including defining close contacts as per guidelines and ensure adherence to national chemoprophylaxis guidelines. It will be providing daily reports (including zero reports) to the responsible information cell at the MoHP. In the event o f the influenza pandemic, E D C D will continue to track the epidemic, identifying the geographical spread, case fatality, and compiling and generating reports to the information cell. Responsibility o f the response coordination will be transferred to the Management Division.
National Public Health Laboratory (NPHL)
The NPHL will develop the capacity for specimen collection, storage, transport and screening for influenza AA3 typing. NPHL will establish a link with a WHO collaborative centre for referral o f samples confirmed to be influenza. I t will develop and disseminate standard lab operating procedures, provide the necessary training and ensure that supplies are available at the local and district levels. Establish a laboratory surveillance database for influenza and ensure the linkage with the influenza surveillance system at EDCD.
Logistic Management Division (LMD)
Based o n the specifications both in quality and quantity as defined by Department o f Drug Administration and Management Division, the LMD will develop the administrative procedures for acquisition and the supply management chain.
Management Division
The Divis ion will perform a rapid assessment o f the hospital network capacity for case management o f influenza l ike illness or if confirmation o f avian influenza as per the Plan. According to the assessment, a referral and counter-referral system for ILI will be developed and implemented. A special referral center with appropnate infection control practices will be in charge o f suspected human cases o f avian influenza. The necessary equipment and training o f human resources will be done in coordination with E D C D and National health Training Center. Clinical Management training leadership will be under the Management Division.
The management division will also coordinate the development/adaptation o f protocols for biosafety measures for health staff dealing with case investigation and case management.
Health Management Information System (HMIS)
H M I S will support the central information unit at the Div is ion o f Public Health Administration that will be created ad-hoc as soon as Avian Influenza i s identified in Nepal.
National Health Education Communication and Information Center
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The Center wi l l develop/adapt a communication strategy for the event o f an influenza pandemic, coordinate training and onentation o f technical expertise, spokespersons and media personnel. It will develop appropnate public health messages and disseminate through the relevant channels.
Department of Drug Administration (DDA)
The DDA will provide specifications o f antivirals, antibiotics, diagnostic tools, PPE and other supplies as defined in the case management o f this Plan. Such information will be the basis on which the procurement shall be done. DDA will also develop guidelines for quality control o f the different pharmaceuticals and others, including storage and distribution requirements.
Regional Directorates: Regional, Sub-regional and Zonal Hospitals
Public Health Response: Support the surveillance network at the district level; strengthen the capacity o f the regional and zonal hospitals according to the standards and guidelines set for each hospital by the management divlsion. At the pandemic phase, regional stockpiling o f cntical supplies will be ensured. The regional Directorates will be responsible for appropriate storage and distribution in collaboration with regional medical stores.
Hospital Preparedness: Oversee the implementation o f the different processes at the hospital level such as training, infection control practices, and other public health measures. They will implement mock drills exercises for an influenza pandemic situation, both at regional zonal and district hospitals.
District Public Health Ofices: District Hospitals and PHC
Public Health Response: Rapid Response Teams will be responsible for f ield investigation o f ILI cases/rumors reported by SHP, HP, PHC and Hospitals. Any outbreak o f ILI should be investigated with the appropnate laboratory support and influenza will be confirmed or discarded with rapid diagnostic tests at the district level. A second sample will be kept and in positive influenza cases it will be sent t o NPHL for confirmation and further charactmzation. Field investigation will include association o f cases with poultry disease suspected or confirmed. Rapid response teams wil l fo l low guidelines for personal protection. They will coordinate with the District Livestock Off ice for continuous interchange o f information on suspected avian influenza cases. Once avian influenza i s reported in Nepal, daily reports should be submitted to EDCD, including zero reporting.
Health Network Preparedness: The DPHO will oversee that the PHC, HP, SHP and F C H V are trained o n the influenza case detection and management guidelines, infection control practices, and other public health measures. They will implement mock drills exercises for an influenza pandemic situation.
4. Implementation by Ministry of Home Affairs
Through the coordinating body o f the Central Natural Disaster Rel ief Committee (CNDRC), M o H A will coordinate disaster response during an event o f avian influenza introduction in poultry or other birds into the country, or in the event o f an influenza pandemic among human population. I t will be the lead agency to ensure mobilization o f required resources, including social mobilization, both for the containment and rehabilitation phases. M o H A will also chair the CNDRC.
5. Implementation by Ministry of Local Development
At the district level, the District Disaster Rel ief Committee i s present i s responsible for re l ief and coordinating al l agencies in the event o f emergencies such as earthquakes, floods, and - n o w - avian
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influenza. Local Bodies are responsible for disaster management at local level. Currently M o L D has designated disaster focal points in DDCs and Municipalities. Given that institutional capacity i s very weak at local level, it i s urgently needed to strengthen the capacity o f the focal points. The proposed project may therefore: (i) strengthen the efficiency and enhance the capacity o f local bodies to address the problem o f natural and man-made disaster at the local level; (ii) conduct public awareness activities through social mobilization at grass root level; and (iii) support for making disaster management plan at district level.
In this regard the following activities are proposed. Activities to be conducted at central level include: (i) designing o f training course regarding concerned training activities; (ii) TOTS (training for trainers) for D D C Focal person about preconceptions o f avian influenza and District Disaster Management Plan Formulation; (iii) fol low up meeting o f worlung committee; (iii) enhance the capacity of focal desk and concerned division in MoLD; (iv) monitoring and evaluation o f program. Activities to be conducted at distnct level may include (i) stakeholder orientation on avian influenza; (ii) orientation to DDC staff, social Mobilizers and NGO people o n avian influenza; (iii) public Awareness activities through social mobilization regarding disaster management; (iv) malung o f DDMP o f selected districts; and (iv) other capacity building trainings to focal points at local level.
These activities may be implemented in different geographical and administrative regions as pi lot project and expand later in al l local bodies (LBs) depending upon the fund available. MOLD’S Municipality Management Div is ion will be the focal division at the central level. The project wil l be implemented through the L B s decided by the MoLD, LBs concerned and the donor agency.
6. Implementation by Civil Aviation Authority and Department of Customs
These agencies will reinforce pol icy directives to prevent the importation and spread o f avian influenza, including quarantine and inspection o n l ive poultry and ducks as guidelines provided by the MoAC.
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Annex 6: Financial Management and Disbursement Arrangements
NEPAL: Avian Influenza Control Project
Country Financial Management Environment
The Nepal Country Financial Accountability Assessment (CFAA), jo int ly conducted by G o N and IDA, was completed in 2002. The assessment concluded that the failure to comply with the impressive legal and regulatory fiduciary framework makes the fiduciary r isk in Nepal “High”, but the risk i s similar t o that in most developing countries. An update o f the C F A A was jo in t ly carried out by GoN, DFID and IDA in M a y 2005 to assess: (i) progress achieved by GON in implementing the Development Act ion Plan (DAP) o f the 2002 CFAA; and (ii) the institutional environment and r i s k for financial accountability in the current polit ical development context. The assessment revealed that the fiduciary r isk continues to be “High” at the country level, and a revised DAP has been agreed to continue to improve financial management.
G o N has computerized an Integrated Financial Management Information System which connects 64 (of which 57 are currently functional) out o f 75 districts and includes receiving o f on-line expenditure reports. Since 2002, the development budget has been pnorit ized as part o f a three-year Medium-Term Expenditure Framework (MTEF), and the number o f projects/programs was significantly reduced. Priority projects are required to prepare trimester work plans with detailed output/physical achievement targets and expected results. For these projects, expenditure reporting and fund release procedures are n o w linked to performance and the system will be extended to a l l other projects/activities. Information o n budget allocations, expenditures and outputs are now published, and made available to the public. A web portal for GON has been created, with links to public sector departments which contain information o n programs and activities.
The Accounting Standards Board and Auditing Standards Board were created in March 2003 and since then these Boards have respectively released 13 Accounting Standards and 30 Auditing Standards. Starting f rom FY2004/05, GON classified i t s budget into Capital and Recurrent categories, and further plans to gradually move towards the IMF’s Government Financial Statistics.
Significant reforms were undertaken in public audit under the Public Audit Reform Project supported by an IDA Institutional Development Fund Grant. The Office o f the Auditor General (OAG) has revised General Audit Guidelines in line with the International Organization o f Supreme Audit Institutions (INTOSAI) standards, and i s gradually changing i t s focus o n audit based o n outputs. Increasingly, emphasis has been placed on performance auditing. OAG n o w has i t s own Human Resource Development Plan, and has been training i t s staff based o n a new set o f guidelines. The recent polit ical transition in April has made possible to reinstate the Parliament, and the Public Accounts Committee has been reconstituted and has begun to play the active role that they played approximately four years ago.
Adequacy of Financial Management Arrangements
Department ofLivestock Services. D o L S i s implementing a Bank-financed project for the f i rs t time. It i s under the Ministry o f Agriculture and Cooperatives (MoAC) and functions under the overall supervision and control o f the Director General. Under DoLS, there are four Technical Directorates and five Regional Directorates. DoLS has one Chief Financial Controller under whom there are two Accounts Officers and approximately eight Accountants / Sub-Accountants. D o L S does not have experience in procurement management; however, has assigned one o f the technical staff to function as the Procurement Specialist. DoLS follows the government’s financial management system, that includes planning budgeting,
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accounting, internal controls, internal audit, reporting and external audit. Due to simplification in the Bank’s disbursement procedure that includes agreement on country financing parameters, accounting ledgers will be maintained as per the country system. For specific purpose o f monitoring the expenses against components and activities, the Department will maintain the Program Ledgers as required by the system. Although this i s a requirement under the system, these ledgers are mostly not complied with, and hence this i s an area which will require close monitonng to ensure compliance. Another challenge that DoLS has i s the need to coordinate the program and activities of other two l ine ministnes that may be involved in the program - the Ministry o f Local Development (MOLD) and the Ministry o f Home Affairs (MOHA). Further, in consideration o f the GON’s proposal to place the Secretariat of the CDNRC’s Technical Sub-committee on Avian Influenza in the Animal Health Directorate under the Ministry o f Agriculture and Cooperatives (MoAC), i t s related costs for managing the sub-committee coordination will be budgeted under the Animal Health component. D o L S wil l also need to coordinate with the Technical Sub-committee.
Besides implementing the activities under the animal health component, D o L S has a challenge to be accountable to ensure the coordination and reporting o f activities to be implemented by other two l ine ministnes and the Technical Sub-committee. T o address these needs, D o L S has agreed to designate one full time Accounts Officer and one Accountant to manage and administer the sub-component project accounts under the overall oversight o f the Chief Financial Controller. For the purpose o f procurement management, D o L S has agreed to deploy one o f full time Procurement Officer either by designating one o f its technical staffs or outsourcing the function to a national consultant. T o manage the animal health component, D o L S will form a core implementation team with full time staff representing at least f ive members - the Project Coordinator, Deputy Coordinator (also responsible for overall component monitoring), one AccountsEinance Officer, One Procurement Officer and one Communications Specialist. DoLS will provide suitable training to its core staff who would be involved in project management, and this includes financial management and procurement staff. For the management o f Compensation Fund, DoLS will prepare guidelines which lay out the process and operational modality for accessing the compensation fund. The Bank will review these guidelines and finalization o f these guidelines satisfactory to IDA will be the disbursement condition for disbursements against compensation fund.
Department of Health Services. The DoHS has experience o f implementing a number o f projects/programs supported by various development partners, and gained adequate institutional capacity as a result. Currently, the DoHS i s implementing a health sector sector-wide program (SWAp) financed jo int ly by IDA and DFID under pooled funding. Overall, DoHS i s performing we l l in sector-wide operations. There are some inherent issues in the area o f t imely reporting in Health SWAp, and this i s primarily due to staffing issues at the Ministry o f Health and Population (MoHP), which coordinates the program. DoHS i s under the Ministry o f Health and Population (MoHP) and functions under the overall supervision and control o f the Director General. Under DoHS, there are five Regional Health Directorates. DoHS have one Chief Financial Controller under whom there are four Accounts Officers, four Accountants, four Sub-Accountants, and two computer operators. DoHS have a few trained procurement staff that have undergone intensive procurement training program in the Nepal Administrative Staff College (NASC). DoHS have agreed to designate one Accounts Officer and one Accountant t o manage and administer the sub-component project accounts under the overall oversight o f the Chief Financial Controller. For the purpose o f procurement management, DoHS has agreed to deploy one trained technical staff. For implementing the sub-component activities and to ensure that component activities are closely monitored, DoHS will form a core implementation team with full time staff representing at least f ive members - the Project Coordinator, Deputy Coordinator (also responsible for overall component monitonng), one AccountsRinance Officer, one Procurement Officer and one Communications Specialist. DoHS wil l provide suitable training to i t s core staff who would be involved in project management, and this include financial management and procurement staff. DoHS fol low the
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government’s financial management system - this includes planning budgeting, accounting, internal controls, internal audit, reporting and external audit. Due to simplification in the Bank’s disbursement procedure that includes agreement on country financing parameters, accounting ledgers will be maintained as per the country system. For specific purpose o f monitoring the expenses against components and activities, the Department will maintain the Program Ledgers as required by the system. Although this i s a requirement under the system, these ledgers are mostly not complied with, and hence this i s an area which will require close monitonng to ensure compliance. Overall, the systems and procedures satisfy the Bank’s minimum financial management requirements; the FM arrangements for the sub-component will be adequate for project implementation.
Risk Analysis
From the financial management perspective, the overall r isk i s “Substantial” as there are a few critical actions such as, staffing, preparation o f Operational Guidelines for use o f Compensation Fund, computenzation o f project and financial information, and training o f staff, that needs to be implemented. Subject t o satisfactory implementation o f these actions and review thereafter, the fiduciary risk wil l be reassessed dunng implementation. Of the two implementing agencies, DoHS comparatively i s better positioned with skilled staff and experience in implementing donor-financed programs. DoLS, o n the other hand, would require substantial efforts in forming a strong team for project management which should include trained financial management and procurement staff. Overall, there will be strong efforts in capacity building both in technical areas as wel l as overall project management which include procurement and financial management. Since the Project heavily constitutes o f procurement tasks, i t i s important to ensure that both the Departments have sufficient capacity to carry out envisaged procurement o f works, goods and services. T o address certain gaps that have been identified dunng the assessment, nsk mitigation Act ion Plans have been agreed. The existence o f the government’s National Strategic Plan for Addressing Avian Influenza which was prepared jo in t ly by M o A C and MoHP, with strong support f rom development partners such as WHO and FAO, the formation o f an Avian Influenza Technical Sub- committee jo int ly chaired by two Secretaries o f M o A C and MoHP, and the high priority o f the government to implement this program are some factors that will also mitigate the r isks. Because this i s a new intervention in Nepal, strong emphasis has been placed upon capacity building that includes: exposure visits, cross country expenence sharing, capacity building both in technical and overall project management, and close supervision o f the operations by the Bank. These measures will reduce the possible nsks. Adequate internal control, monitonng, and safeguard measures have been included.
Strengths
The proposed operation will have the fol lowing strengths in the area o f financial management: (i) high- level government commitment to prevent the outbreak o f avian influenza, (ii) strong support and collaboration f rom various development partners such as WHO and FA0 which have the technical expertise to assist their respective l ine departments, and IDA which has a comparative advantage in working with the Ministry o f Finance and the National Planning Commission; (iii) the government’s National Strategic Plan for Addressing Avian Influenza; (iv) the formation o f an Avian Influenza Technical Sub-committee to oversee and monitor implementation o f the Plan; (v) sufficient funds allocated towards capacity building in DoLS and DoHS; and (vi) relevant staff to be exposed to management o f avian influenza programs in other countries to learn f rom best practices.
Weaknesses and Resolutions
Both the Departments are required to put in place a strong core project support team with competent and qualified individuals, and to be supplemented by specialists/consultants to be outsourced for specific assignments in procurement, financial management and monitoring, as may be required. Capacity
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building and training i s a pnor i ty for overall program implementation. Bo th the Departments will also equip their offices with modem technology and facilitate the use o f computers for information analysis and dissemination to monitor both technical and financial progress. For the purpose o f disbursements under Compensation Fund, the Operational Guidelines (clearly describing criteria for disbursement and internal controls to ensure that funds are disbursed for the intended purpose) duly reviewed and approved by IDA and the Technical Sub-committee, will be the condition o f disbursement under this category. These funds are accessed only at the time o f epidemic outbreak - so the process must be in place before any disaster occurs. Overall, internal audit system i s weak and special review arrangements will have to be put in place.
Project Budgeting
It i s the responsibility o f both the Departments to prepare their Annual W o r k Program and Budget (AWPB) for respective components, and will submit them to MOF and NPC through their respective l ine ministnes. Following the approval o f respective AWPBs, budget authorization will be provided to respective Departments with a copy to the relevant Distnct Treasury and Comptroller’s Offices (DTCOs) by the respective l ine ministries. DTCOs will release budget to respective Departments. Subsequently, respective Departments will issue spending authorization to respective cost centers. In case o f activities to be implemented by other l ine ministries (this usually happens only at the time o f epidemic outbreak) such as, Ministry o f Home Affairs and Ministry o f Local Development, DoLS will include their activities and budget within DoLS work program and budget, and will ensure to authorize payments o n their behalf. Some contingency arrangements will be made by DoLS to disburse funds to these two l ine ministries in case o f outbreaks. Further, DoLS will also include in i t s budget request f rom Technical Sub-committee for overall coordination activities. GON has already assigned a separate budget code in the Government’s Budget (Red Book) for both D o L S and DoHS to enable reporting o f expenditures and accounts under respective components. The Project will fully align with the government’s financial management system. Programming and budgeting wil l fo l low GON’s budgeting system. Both the Departments will operate within the financial management framework o f the public sector. DoLS will be required to finalize the Operational Guidelines to disburse funds against the compensation fund, which i s a Disbursement Condition.
Fund Flow Arrangements
GON releases the budget to the respective Departments as per the approved work program and budget in three tranches as per the fund release procedure o f GON. The budget approved by GON for each component i s indicated in the government’s budget (Red Book) under two separate budget heads - one under the Ministry o f Health and Population for Human Health Component, and the other under the Ministry o f Agriculture and Cooperative for Animal Health Component. Use o f IDA resources for respective components i s through two Designated Accounts. These Accounts will facilitate quick payments in the f o m o f reimbursements to government’s treasury on account o f actual IDA eligible expenditures made for incremental operating costs and compensation fund, and for malung payments to contractors, suppliers and consultants.
Financial Management Staffing
Department of Livestock Services: The D o L S Financial Administration Section i s headed by a Chief Accounts Officer supported by two accounts officers, and eight accountants / sub-accountants. Each o f these staff has the responsibility o f maintaining the accounts o f specific budget headings. In order to meet the minimum FM requirements, DoLS need to form and confirm in writing a core implementation team with full time staff representing at least f ive members - the Project Coordinator, Deputy Coordinator (also responsible for overall component monitoring), one AccountsRinance Officer, One Procurement Officer
52
and one Communications Specialist. Other support staffs as required also need to be added in the core team.
Department of Health Services: The DoHS Financial Administration Section i s headed by a Chief Financial Controller supported by four Accounts Officers, four Accountants, four Sub-Accountants, and two computer operators. Each o f these staff has the responsibility of maintaining the accounts o f specific budget headings. In order to meet the minimum FM requirements, DoHS needs to fo rm and confirm in writing a core implementation team with full time staff representing at least f ive members - the Project Coordinator, Deputy Coordinator (also responsible for overall component monitonng), one Accounts/Finance Officer, One Procurement Officer and one Communications Specialist. Other support staffs as required also need to be added in the core team.
Project Financial Accounting, Reporting and Internal Controls
The financial accounting policies and procedures in place are sufficient to ensure that both the components comply with minimum financial management requirements. These include the establishment o f internal controls and proper accounting procedures described in the Financial Administration Regulations (FAR). DoLS and DoHS are responsible for maintaining their respective accounts o f project components. Both Departments will forward monthly expenditure statements for respective component accounts to the respective l ine minisines and Disctrict Treasury Control Offices. The accounting systems contain the following features: (i) application o f consistent cash accounting principles for documenting, recording, and reporting i t s financial transactions; (ii) a well-defined chart o f accounts that allows meaningful summanzation o f financial transactions for financial reporting purposes; (iii) maintenance o f withdrawal monitonng register, the record o f Statement o f Expenditures (SOEs), and Designated Accounts register; (iv) the use o f an asset register; (v) monthly closing and reconciliation o f accounts and statements; and (vi) the production o f annual financial statements acceptable to IDA. Since the project accounts would be monitored against component and activities, both the Departments would maintain Program Ledgers as per applicable government system. Although maintaining Program Ledgers i s a requirement under the system, these ledgers are mostly not complied with. In order to ensure that this i s complied with, IDA will require to closely monitoring. For the purpose o f disbursements under Compensation Fund, the Operational Guidelines (clearly describing criteria for disbursement and internal controls to ensure that funds are disbursed for the intended purpose) duly reviewed and approved by IDA and the Technical Sub-committee, will be the condition o f disbursement under this category.
Internal Audit
DoLS and DoHS fol low the government system for internal audits. Respective DTCOs are responsible to cany out internal audits o f a l l accounts o f vanous cost centers under respective Departments. Since the government’s internal audit system i s not so effective, both the Departments wil l also carry out their own review process by outsourcing this arrangement starting f rom the second year. In close consultation with IDA, Departments will prepare appropriate TORS for this purpose.
Project Reports from both Components
Each implementing agency-DoLS and DoHS-will produce f rom the outset Project Reports to report o n implementation progress, showing the sources and uses o f funds, output monitonng report, procurement management report and narrative progress report in formats to be agreed upon during negotiations. T o match the public sector planning and reporting cycle, these reports will be produced on a trimester basis and submitted within 45 days f rom the end o f the preceding tnmester.
External Audit
53
The following are the audit requirements under two components:
DoLS
DoHS
Part A (DoLS for Animal Health Component): Annual project financial statements, statements o f expenditure schedule, and Designated Accounts statements will be audited by OAG, which i s considered acceptable by IDA for this purpose, and submitted to IDA within six months after the end o f the fiscal year - January 15. Terms o f reference acceptable to IDA have been discussed and agreed with OAG.
Project Financial Statements, OAG 6 months after the end o f (includes Statement o f Expenditures, fiscal year (January 15') Designated Accounts) Project Financial Statements, OAG 6 months after the end o f (includes Statement o f Expenditures, fiscal year (January 15') Designated Accounts)
Part B (DoHS for Human Health Component): Annual project financial statements, SOE schedules, and Designated Accounts statements will be audited by 'OAG, which i s considered acceptable by IDA for this purpose, and submitted to IDA within six months after the end o f the fiscal year - January 15. Terms o f reference acceptable to IDA have been discussed and agreed with OAG.
For both components, arrangement for performance audit will also be put in place. Such audits will be: (i) carned out by OAG in close consultation with DoLS and DoHS and in the time frame that will be mutually agreed between the auditees and OAG; and (ii) at the discretion o f the Auditor General. GON will ensure adequate budget to OAG to cany out these performance audits that will examine the challenges encountered and tasks accomplished during the course o f project implementation.
The following audit reports would be monitored in the Audit Report Compliance system (ARCS):
Financial Management Action Plan
Act ion plans to strengthen the financial management capacity o f the implementing agencies were agreed between the Recipient and IDA and are summarized below:
Table A: Financial Managemc Action
1. Finalize Standard Operating Procedures for accessing Compensation Fund, satisfactory to IDA
2. Provide orientation and training to DoLS staff and new recruits.
3. Implement Management Information System (MIS) to monitor expenses against component and activities, and to track component expenditures. This needs to be supported with adequate interim accounting and reporting arrangements. Disbursements can take place provided the intenm arrangements, including staffing, are adequate to support the early release o f funds.
it Action P1 Respons -ibility D o L S
DoLS
DoLS
ns for DoLS Completion
Date April 30, 2007
During Project Launch
June 30,2007
Conditions
Disbursement
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Table B: Financial Management Action Plans for DoHS
(1) Animal Health Component (works, goods, consulting services, training, workshop, study tours, incremental operating costs) (2) Human Health Component (works, goods, consulting services, training, workshop, study tours, incremental operating costs) (4) Compensation Fund
Action
8.24 100%
7.49 100%
0.10 100%
I. Provide orientation and training to DoHS staff and new recruits.
(4) Unallocated
!. Implement Management Information System (MIS) to monitor expenses against component and activities, and to track component expenditures. This needs to be supported with adequate interim accounting and reporting arrangements. Disbursements can take place provided the intenm arrangements, including staffing, are adequate to support the early release o f funds.
2.37
Respons- ibility DoHS
DoHS
Completion Date
Dunng Project Launch
June 30,2007
Conditions
Supervision Plan
Project implementation progress will be closely monitored by DoLS, DoHS, the National Av ian Influenza Technical Sub-committee, and IDA. IDA will supervise project implementation f rom the Nepal Country Off ice for the purposes o f supervision on fiduciary aspects (both procurement and financial management). B o t h the Departments will separately report o n project implementation progress through a trimester Project Report. The agreed action plans will be closely monitored to ensure appropriate actions are being implemented. K e y financial management (FM) fiduciary work includes: (i) penodic visits to cost centers for ex-post reviews, and if any ineligible expenditures are noted, (ii) reviews o f implementation progress reports and audit reports and preparing summaries o f such reports; and (c) participating in supervision missions and keeping the team informed o f financial management issues or improvements.
Disbursement
Allocation of Project Financing Proceeds (Table C)
Disbursement under proposed Grant will be made as indicated in Table C, which indicates the percentage o f financing for different categories o f expenditures o f the Project. I t i s expected that the IDA funds will be disbursed over a period o f four years. The Closing Date o f the Credit i s July 3 1, 20 1 1.
Table C: Allocation of Grant Proceeds (in million U S Grant Dollars)
Category Percentage of
Expenditures to be Financed
Amount of the Grant Allocated
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Category
Funds Flow and Disbursement Arrangements
For both components, disbursements f rom IDA will init ially be made in accordance with traditional disbursement procedures, including full documentation for contracts above the Prior Review threshold. T o facilitate disbursements, two Designated Accounts wil l be established, one for D o L S (Animal Health Component) and the other for DoHS (Human Health Component), managed by the Department o f Livestock Services and the Department o f Health Services, respectively. For large payments, exceeding the 20 percent minimum application size threshold o f the authorized ceiling, direct payments may be claimed from IDA, as needed. For al l other payments, including incremental operating costs, disbursements f rom IDA will be made via replenishments o f the Designated Account. During the project mid-term review, the desirability and feasibility o f switching to report-based disbursement will be assessed. Until that time, transaction-based disbursement will be used for both components.
GON prefinances incremental operating costs and compensation funds. The guideline, which i s yet to be developed, will have procedures explained to calculate the funds for compensation. Finalization o f the guidelines that should be acceptable to IDA will be the condition for disbursements under compensation fund. Such funds will be utilized only in case o f avian flu outbreaks to compensate against animals destroyed. All prefinanced expenditures after reconciliation will be reimbursed from respective Designated Accounts to the GON’s Treasury. For other payments to contractors, contractors and suppliers, the Departments will pay directly f rom their Designated Accounts. The f o l l o w n g funds f low chart describes the fimds f low arrangements:
56
Avian Influenza Control Project
1. Animal Health Component
i
i MOHP I DTCO ] i
I I
[ 4
I Technical Sub-committee
Secretariat I j I T" .......
- ..... " .... "
Technical Sub-committee
......
- E % .- E B
W o r l d L""-" .I...._" .-....-.. "...
e? j
DOLS ...... "..I ...... " + : *; .... ........ Designated Accoun t in "."
4 I
NRB
4 + I
Act iv i t ies to b e Act iv i t ies to b e implemented b y implemented by
ContractorsiConsultants ( for transfer o f pre-financed
expenditures and Compensation
- FundFlowi Administrative Linkage
Avian Influenza Control Project
2. Human Health Component
Di rec t Payment to ( for transfer o f pre-financed
- FundFlowi Administrative Linkage
57
U s e of Statement of Expenditures (SOEs)
For both components, SOEs will be used for the following expenditures: (i) al l expenditures made under the Compensation Fund; (ii) al l training, workshop, and study tours; (iii) al l incremental operating costs; (iv) contracts for c iv i l works, costing less than US$lOO,OOO; (v) contracts for equipment and vehicles, costing less than US$200,000 equivalent per contract; (vi) contracts for services o f consulting f i r m s costing less than US$lOO,OOO equivalent per contract; and (vii) contracts for services o f individual consultants costing less than US$50,000 equivalent per contract. During the IDA initial supervision, the mission will closely review the SOE claims to ensure that the funds are uti l ized for the intended purposes. Any ineligible expenditure identified dunng such reviews will need to be refunded to IDA.
Designated Accounts
T o facilitate project implementation and reduce the volume o f withdrawal applications, two Designated Accounts in U S Dollars will be established under the Grant, o n terms and conditions satisfactory to IDA for each Part o f IDA financing. The authorized ceilings will be US$l,OOO,OOO, respectively for designated Accounts A for DoLS (Part 1) and designated account B for DoHS (Part 2). The respective allocations will cover about six months o f eligible expenditures.
For the utilization o f IDA’S share o f project expenditures, D o L S and DoHS may respectively open and maintain the Designated Accounts in U S dollars at the Nepal Rastra Bank or a commercial bank under terms and conditions acceptable to IDA. For DoLS (Part l), the Designated Accounts A will be managed under the jo int signatures o f the Director General and the Chief Finance Controller. Similarly, for DoHS, the Designated Account (Part 2) will be managed under the jo in t signatures o f the Director General and the Chief Finance Controller.
Both implementing agencies wil l ensure that the bankkash books are reconciled with bank statements every month. They will separately submit replenishment applications for their respective Designated Accounts on a monthly basis. Replenishment applications will be accompanied by a reconciliation statement and a Statement f rom the Bank, in which the account i s maintained, showing a l l Designated Account transactions. Supporting documentation will be maintained by the respective cost centers for at least one year after the Association has received the audit report for the fiscal year in which the last withdrawal f rom the credit account was made. The documentation will be made available for review by IDA supermion missions and independent auditors.
A l i s t o f beneficianes receiving Compensation Fund will be submitted o n a Statement o f Expenditures for IDA’S reimbursement to the Designated Account.
Retroactive Financing
Retroactive financing o f up to US$l.O mi l l ion will be available f rom the Project for covering eligible expenditures under al l Categories incurred before the date o f signing but after July 17, 2006. In order to ensure that only eligible expenses are claimed, i t i s important to mitigate key n s k s at project outset before the funds can begin to flow.
58
I R
::: x I_." ............................
ibf ......................... ........... _.-"" .I..I l . ~ l l "
Procurement for the proposed Project would be camed out in accordance with the Wor ld Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated M a y 2004; Guidelines: Selection and Employment o f Consultants by Wor ld Bank Borrowers" dated M a y 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categones are described in general below. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Recipient and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
For the activities that will be financed by the Association, guidelines on the procurement procedures, applicable SBDs to be used for each procurement method are presented in Annexure 1 o f the Operation Plan. This Annexure shall also contain information o n the Wor ld Bank website where the SBDs and relevant model contracts for works and goods can be accessed.
Procurement of Works: Under this project, works procurement would be l imited to the constructiodrenovation o f rooms to house the BSL3 labs, upgrading o f regional and distnct labs under both DoHS and DoLS, small works constructionhenovation, and some staff accommodation facilities. Thelatter are o f small value and shall be procured through quotations or through N C B using the National SBD agreed with or satisfactory to the Association.
Procurement o f Goods: Goods procured under this project would include: specialized fixtures and equipment for the establishment o f BSL3 laboratories such as air handling equipment, reagents and testing accessones, specialized vaccines, medicines and other consumables. The procurement will be done using the Bank's SBD for al l I C B and the National SBD agreed with or satisfactory to the Association. Whi le a summary l i s t o f the expected works contracts, and goods to be procured for the Human Health and Animal Health components o f the project i s provided at the end o f this section, the detailed l i s t shall be included in the final version o f the Operational Plan.
Selection of Consultants: Assignments that require the services o f f i r m s or individual consultants include: developing and propagating the awareness and communication campaigns, studies and training etc. Short l is ts o f consultants for services estimated to cost less than $200,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines.
Incremental Operating Costs: The Project would finance costs o f contracting personnel additionally and specifically appointed under the Project, and costs of transportation, fuel, information technology, utilities, and telecommunications.
B. Assessment of the agency's capacity to implement procurement
Implementation Arrangements: There will be two main implementing agencies - (a) the Department of Livestock Services (DoLS) under the Ministry o f Agnculture and Cooperatives (MoAC) and (b) the
60
Department o f Health Services (DoHS) under the Ministry o f Health and Population (MoHP) and hence procurement activities will be carned out by the designated Core Coordination Teams (CCT) in each o f these agencies. Each CCT shall be headed by a Coordinator and shall include a procurement officer.
An assessment o f the capacity o f the DoLS and DoHS to implement procurement actions under their respective project components (i.e. Animal Health for DoLS and Human Health for DoHS) has been carried out. This assessment reviewed the organizational structure for implementing the project and the interaction between the project’s staff responsible for procurement and the Ministry’s relevant central unit for administration and finance.
The key issues and risks concerning procurement for implementation o f the project and the corresponding agreed corrective measures are provided in the table below:
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h s k s
1 B o t h D o H S a n d D o L S do no t have any designated procurement officer or staff with adequate experience o f procurement as per Wor ld Bank procedures
2 As a majori ty o f goods and equipment requlred for th is emergency project have to be procured wthin one year o f project start, but the CCT do not have sufficient s k i l l s t o organize and implement such a large volume o f procurement in such a short time.
3 Excessive tiers for makmg procurement decisions leading to overall delay in procurement progress.
4 L o w bidder interest and confidence in procurement in Nepal leading to lack o f competition and receipt o f unresponsive bids
Mi t igat ion Measure
The CCTs to mclude procurement officers with hand o n experience o f procurement using external donor h n d e d procedures, and who would receive procurement training early in Project implementation.
In cases where GON and the Association determine that existing GON capacity i s insufficient to undertake certam Project activities, then UN agencies may be employed to provide specialized services. These may include t e c h c a l assistance, training, workshops, communicahon activibes, and procurement o f specialized drugs, personal protective equipment, and vaccines. Such employment o f UN agencies wou ld be subject t o thelr acceptance o f Bank standard provisions relatmg to fraud and corruption, refund o f unused f h d s mcluding any interest accrued, and the Bank’s right to audit thelr accounts for the concerned procurement, unless these provisions are waived by Bank Management. In case these provisions are not acceptable to the UN agencies concerned o r n o waiver i s provided by the Bank Management, GON would use other mechamsms for these activities. Fo r procurement issues including capacity building, GON may decide to employ a specialized Procurement Agent acceptable to the Associahon. Adequate authority ceilings agreed for and delegated to the mdividual Project Coordinator t o evaluate and award contracts. Fo r contracts whose value exceeds the agreed threshold, the concerned Project Coordinator shall present the bid evaluation and award recommendation to the the concerned Director-General withm 25 days o f submission. The concerned Dlrector-General shall complete i t s review and make i t s decision within 7 days o f submission o f the evaluation report and award recommendation Fo r contracts that require prior review, the f inal evaluation report and award recommendation shall b e submitted to the Bank within 45 days f r o m the date o f bid submssion. Each Department shall establish a project website and place therein the detailed l ist o f procurement packages to be invited under the project. The General Procurement Notice to be published in UNDB informing the general bidding opportunities in the project. Ths G P N shall contain mformation o n the address o f the Project website.
Responsible Agency
MOAC NOHP
W o r l d Bank task team to apply for waiver
Project Coordinator s,Dlrectors- General o f D O L S D O H S
CCTs
Deadline date if applicable Staff in place
Traimng before February 28,2007
January 3 1,2007
Jan31, 2007
(a) Jan 31, 2007 (b) Jan 3 1, 2007
62
etc. resulting in need for re-bidding and delays in the procurement process.
Subsequent Specific Procurement Notices shall b e as widely advertised as possible, mcluding through information to foreign embassies and consulates currently in Nepal. Results o f a l l bid evaluations and award recommendations to be published in the Project website and disclosed in the notice boards o f the concerned Department and Ministry o f GON.
With the specified mitigation measures in place, the overall project r i s k for procurement i s assessed as MEDIUM.
C. Procurement Plan
The Recipient has prepared a detailed procurement plan for project implementation based o n the detailed l i s t o f goods, equipment and services provided. T h i s plan provides details o f the contract packages, the procurement methods and review requirements for each procurement package. This plan has been agreed between the Recipient and the Bank by project negotiations and shall be made available at the offices o f the respective CCTs. It will also be available in the project’s website and in the Bank’s external website. The Procurement Plan will be updated in agreement with the Bank annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
Role o f UN Agencies in implementation: Three UN agencies, i.e., FAO, UNICEF, and WHO have been closely involved in the preparation o f the national program as we l l as the Bank-financed project and the Recipient has proposed their continued involvement during the implementation o f this project, in areas where they have specific expertise, for the fo l lowing reasons:
(a) the need for providing technical and operational continuity;
(b) the importance o f international expenence and expertise that they bnng, especially as Av ian Influenza i s not an issue that Nepal has dealt with in the past;
(c) the value added in terms o f synergies with other activities being carried out by these agencies in the area of avian influenza prevention and control - independent o f the project;
(d) the requirement o f the program to fo l low international norms and guidelines, which are generally prepared under the leadership o f these organizations
(e) capacity constraints within the Government system, and;
(0 the emergency nature o f the problem which warrants a rapid reaction and response time, diff icult to envision under the existing Government rules and procedures. For instance, FA0 would support the implementation o f the training activities and the provision o f selected TA under the animal health component (Surveillance, Prevention and Containment, Strengthening Laboratory Capacity and F ie ld Vetennary Service, Communications).
UNICEF would be responsible for cross-cutting communication activities, which do not neatly fa l l into human health or animal health, thus warranting an institutional home other than M o H P or MoAC; and possibly the procurement o f certain vaccines and drugs.
WHO would support the implementation o f surveillance strengthening under the human health component - through the existing surveillance network o f Immunization Preventable Diseases (a WHO- implemented project), which i s proposed to be developed as an integrated surveillance system. WHO would also help carry out the needs assessment for the Referral Hospital, and the technical assistance for the design and supervision o f BSL-3 laboratories, and the procurement o f certain vaccines and specialized drugs.
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D. Frequency of Procurement Supervision
Pkg' No.
In addition to the prior review supervision to be camed out f rom Bank offices, the capacity assessment of the Implementing Agency has recommended three procurement supervision missions during the f i rs t year and two missions a year thereafter to visit the field and to carry out post review o f procurement actions.
Descnption o f Services
E. Summary Details of Procurement Packages and Arrangements
A
B
D
a) All contracts estimated to cost over US$500,000 shall be procured through ICB. All contracts estimated to cost over US$300,000 equivalent per contract and al l direct contracting will be subject to pr ior revlew by the Bank.
$303,000 N C B Y
Antivirals (Total estimated cost = $ 300,000) $300,000 ICBRJN Y
$168,000 N C B N
Direct Purchase $1,000 ShoppingDirect N
I C B Procurement (2 Schedules - one for PPE, one for Chemcal and Reagents)
N C B Procurement 3 schedules (One each for Consumables, Drugs & Medicines, Hygienic Supplies)
(b) Consultancy semces estimated to cost above US$250,000 equivalent per contract and single source selection o f consultants (firms) for assignments estimated to cost above US$ 100,000 equivalent per contract, contracts with specialised UN agencies and contracts with individual consultants estimated to cost above US$25,000 equivalent will be subject t o prior review by the Bank.
Pkg' No.
(c) Short l is ts composed entirely o f national consultants: Short l is ts o f consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines.
Description o f Services
2
Prior Review procurement
$550,000 I C B Y
$25,000 N C B N
Renovation ofkonstruction at N P H L annex lab for BSL-I11 facility
a) Renovation for qurantine room at Kathmandu airport b) Renovation at National Referral center (Teku Hospital)
development including negative pressure and A C M V etc.
4 Renovation for quarentine romm at 1 land crossing point $5,000 Quotation N Design and Renovation o f regional referral centers (5 Nos.) $25,000 Quotation N
Method o f Prior Review Estimated
procurement
5
6
Development o f Isolation Unit Annex at TUTH $4 1,000 N C B N
Waste disposal - installation o f locally made incinerators at 5 centres $10,000 Shopping N
HH - Vehicles, Communicationlother Equipment, Instruments and Accessories $998,629
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8-12
Provide adequate and appropriate communication equipment: Telephone sets (80), fax machines (80), for remote distncts (cell phonesiradios - 40 sets)
Surveillance data management and data transfer at EDCD: Laptop Computers, pnnters, software, GIS positioning (40 units per year for two years)
small appliances) OFFICE EQUIPMENT AND APPLIANCES (2 slices - computers etc.;
Miscellaneous (generator, waste disposal) Equipment: (5 lots in one package)
a) Vehicle x 3 No. (NPHL, EDCD and Project Management) I $100,000 I NCB I Y I I
$225,000 NCB Y
$240,000 NCB Y
$27,000 Shopping N
$44,000 Shopping N
$362,629 NCB Y
7 1 Eauiument for 1 no. BSL 3 and 7 nos. BSL 2 Labs (6 schedules’, I $978.750 I ICB
BSL 3 Lab - Air Handling and fixtures including all civil works related 1 $613,940 1 ICB I Y I I 1 I to installation Y
4 5 6
1 3 I Computers and penpherals, TVs, Office Equipment I $109,542 I NCB I N I Kits and Thermocol Packs for Surveillance $335,720 NCB N Personal Protection Equipment $134,000 NCB N Refrigerators and deer, freezers $109,000 NCB N
7 I Stockpile of Equipment for A I control and containment programme I $73,500 I NCB N R I Avian influenza vaccine (Inactivated Vaccine) Doses I $45.000 I ICBAJN
1 2
Y
Production and insertion of AI prevention related messages on NTV Apculture programme (lump sum)
6 7
C
ss
Miscellaneous Equipment 5000 Shopping N Technical Communication Consultant to support NFP 4000 CQ/SS As appropnate
Communication: Animal Health Pnnting and distribution of guidelines to conduct Orientation / meetings isemmars/ trainings - 2000 NO.
$17,000 Shopping N
Y
. _ 4 I Video editing set - 1 No.
1 3 $6,750 Shopping N
$5,000 Shopping N
Wall painting on main meat markets and municipalities (5 places/distnct for 10 districts)
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Annex 8: Safeguard Policy Issues
NEPAL: Avian Influenza Control Project
1. Environmental Analysis
(i) Has an environmental analysis been done‘? Yes [ ] No [XI.
Both the Animal Health and Human Health components have implications that tngger environmental safeguard policies. The disposal o f culled poultry, the clean up o f infected areas and control o f surrounding areas in the case o f Animal Health, and disposal o f laboratory and health care wastes in the case o f Human Health, trigger the Wor ld Bank Safeguard Policy o n Environmental Assessment. The Avian Influenza Control Project i s assessed as a B-category project. Measures will be taken to mitigate these enmronmental impacts by requiring an Environmental Management Plan (EMP) be prepared for both the Animal Health and Human Health components. In the case o f the Human Health a Health Care Waste Management Plan already exists under the Health Sector Program and this will incorporated pnor to commencing operation. The Animal Heath EMP was finalized pr ior to appraisal. Other than Environmental Assessment there are n o Safeguard Policies triggered.
(ii) Does the project affect natural habitats o f rare fauna and flora species‘? Yes [ ] or No [XI.
(iii) Does the project involve an increase in the use o f pesticides? Yes [ ] or N o [XI.
(iv) Does the project encroach upon forests? Yes [ ] or N o [XI.
(v) Does the project affect other environmentally sensitive areas (beaches, coastal wetlands, other)? Yes [ ] or No [XI.
2. Social Analysis
(i) The main beneficiaries o f the project. Who are they? H o w many?
The main beneficiaries o f the Avian Influenza Control Project are commercial or industnal poultry producers and backyard poultry producers. The industrial poultry producers include 76 hatcheries, 101 registered feed mills, 150 organised integrated layer farms, 30 integrated boiler farms, eight meat processing industries, six poultry medicine producers and more than 10,000 small-scale (i.e. less than 500 birds) producers and associated industries. Whi le accurate data o n the number o f backyard poultry producers are not readily available i t i s estimated that there are in the region o f two mi l l ion producers with some five to ten birds per producer. The majonty o f these producers might be considered “poor” in as far as they rely o n poultry production for subsistence or for sale for small amounts o f cash income. As such, an outbreak o f avian influenza would have disproportionately negative impacts upon the poor.
(ii) Have the beneficiaries been consulted o n the project? Please describe.
Yes, representatives o f the industrial poultry producers have been consulted o n the Project. During Wor ld Bank preparations in April 2006, a meeting was held with international and national NGOs and industry poultry representatives, to provide information and receive feed back o n issues o n preparation o f the Project. W h i l e i t was not feasible to consult backyard poultry producers during preparation it i s noted below that they wil l be consulted and involved in the implementation o f the Project.
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(iii) Has the c iv i l society Concerned with the project been consulted? Please describe.
Yes, the c iv i l society concerned with the Project was consulted, in the aforementioned meeting that was held with relevant international and national NGOs. A number o f issues and perspective were raised including the importance o f involving c iv i l society in preparation and implementation o f the Project, providing compensation for culled poultry, involv ing the media in ensuring accurate and timely information, focusing o n backyard poultry producers and women and children in particular, and developing an appropriate communications programme.
(iv) the project'? Please explain.
Will the beneficiaries and NGO be consulted or involved in the implementation o f
Yes, the beneficiaries including industrial and backyard poultry producers, and NGOs, will be consulted and involved in the implementation o f the Project. The Project will consult with industrial poultry producers, and backyard poultry producers, particularly women and children, by requiring then- involvement in the verification o f culled poultry and compensation payment meetings, and by ensuring the careful targeting o f producers and direct involvement o f NGOs in implementation o f the communication programme.
(v) l ivelihood affected negatively by the project? Yes [ ] or No [XI.
Does the project require that people have to be resettled to other areas or i s their
(vi) Does the project affect the livelihoods o f indigenous peoples? Yes [ ] or No [XI.
3. Other Safeguards
(i) Does the project have a negative impact on cultural property? Yes [ ] or N o [XI.
(ii) Does the project affect the safety o f dams? Yes [ ] or No [XI.
(iii) Does the project affect international waterways? Yes [ ] or N o [XI.
(iv) I s the project carried out in Disputed Areas? Yes [ ] or No [XI.
Executive Summary of Health Sector Environmental Management Plan
Brief Project Description
The Government o f Nepal i s committed to bnnging about tangible changes in the health-sector development process. The aim i s to provide an equitable, high quality health care system for the Nepalese people. The Second Long-Term Health Plan 1997 -201 7 seeks equitable access to quality health care for a l l people. Nepal's Poverty Reduction Strategy Paper (PRSP), the Tenth Plan 2002/3-2006/7, addresses social inclusion - aiming to bnng the poor and marginalized groups into the mainstream o f development, and stresses strategic cross-cutting approaches to: (a) redefining the role o f the State, and limiting public interventions; (b) enlisting the private sector t o play a leading role together with NGOs in complementing government efforts in service delivery; (c) promoting community participation in and management o f activities at the local levels; and (d) accelerating the decentralization process. The Med ium Term Expenditure Framework (MTEF) accords highest pnor i ty to Essential Health Care Services (EHCS). I t proposes a redirection o f public spending towards EHCS and away from tertiary care and lower pnor i ty services.
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A senes o f stakeholder consultations and numerous studies were commissioned to develop a sector-wide approach to health development. The process culminated in the Health Sector Strategy - An Agenda for Change and the drafting o f the Nepal Health Sector Program - Implementation Plan (NHSP-IP) 2003 - 07, which reinforce the above national policies and apply them to the sector. These policies are consistent in their emphasis on (i) pnoritization o f the EHCS and redirection o f public resources to primary care; (ii) strengthened sector management and service delivery; (iii) targeted attempts to reach the poorest and marginal groups; (iv) decentralization to local bodies; and (v) public-private partnerships.
The NHSP-IP envisions the improvement o f the health status o f the entire Nepalese population by ensunng equal opportunity to quality health care services through an effective health system. It i s consistent with the HSS, and Nepal’s Poverty Reduction Strategy as reflected in the Tenth Five Year Plan. Other documents that have guided the development o f NHSP-Ip are the National Health Policy, 199 1 and the Second Long Term Health Plan (1 997-20 17). The main reform actions identified under NHSP-IP are (a) prioritized allocation o f resources and efforts to ensuring access to EHCS, especially for the poor and vulnerable; (b) decentralization o f the management o f health services delivery to the local bodies; and (c) promoting Public-Pnvate Partnerships (PPP) to increase access to and quality o f services. NHSP-IP also identifies specific results f rom the reform measures: such as better value for clients f rom their out-of-pocket health care expenditures; assured access to EHCS for the poor and vulnerable; greater efficiency o f public health services; and more effective monitoring and evaluation o f sector performance. NHSP-IP i s pragmatic in i t s expectations for the EHCS: it recognizes the greater influence o f the ncher population groups o n public pol icy and their increasing demand for the higher cost services outside EHCS. Thus the plan also addresses how services “beyond EHCS” will be delivered. NHP-IP seeks to support the program o f activities planned by the Ministry o f Health (MOH) for the period July 2004 to June 2009 by financing a proportion o f the MOH budget, and through related technical support. More description o f the program components are described in Section-2 o f this document.
Environmental Assessment
As per the environmental regulation o f the country, the proposed health program as such does not require any EIA to be undertaken. However, as the program envisages large number o f activities, which can either directly or indirectly lead to environmental impacts, an environmental assessment o f the entire program has been undertaken. The summary o f findings o f the Environmental Assessment i s provided in the following sections.
Environmental Impacts
Environmental impacts associated with the health sector program have been identified by examining the ways the activities associated with different components o f the program interact with the environment and i t s different components. Out o f the two components o f the program, component 2 exclusively deals with capacity building and management aspects. Therefore, n o environmental issues are anticipated from such activities. Component-1 however has several activities which can either directly or indirectly interact with different components o f the environment leading to environmental issues. The fol lowing three key environmental impacts have been identified to be associated with the program.
H C W Management 0 Use o f hazardous insecticides/pesticides
Construction related environmental issues
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Expansion o f healthcare service delivery i s expected to increase the generation of H C W . Improper handling and disposal o f HCW has several issues associated with it. I t poses significant n s k s to both people and environment as they contain infectious matenals and other hazardous substances. The environmental issues range from increasing the risk o f spreading infections to increasing exposure to toxic emissions f rom poor treatment and disposal practices. Therefore, H C W management i s identified as an important environmental issue in the context o f the program requiring further assessment.
Use o f different types o f insecticides for prevention o f vector borne diseases i s the common practice in many countries. Whi le use o f such insecticides do assist in protecting people f rom vector borne diseases, improper handling and use o f such substances does pose health risk to both general public and persons handling such substances. The range o f healthcare services to be strengthened and expanded also includes control o f vector borne diseases requiring use o f insecticides/pesticides. Health nsks arising f rom improper use o f such substances i s therefore identified as an issue requiring further assessment.
The program envisages expanding the health care service network, which i s expected to involve construction o f new facilities o f different levels at different locations in the country. Construction activities, if not managed properly, often lead to environmental impacts such as air, water, noise and land pollution as wel l as ecological degradation. The extent o f such impacts largely depends upon the location o f such facilities as wel l as the construction practices followed. Therefore, environmental issues arising f rom construction activities are identified as an issue requiring further assessment.
Assessment o f Impacts
The three impacts identified were subjected to qualitative analysis and assessment. The impacts were analysed against broad parameters such as scale, seventy and duration. The analysis concluded healthcare waste management to be the significant environmental problem o f the sector.
H C W M i s an issue associated with a l l kinds o f healthcare facilities including healthcare related laboratones, academic and research institutions etc. Such facilities are spread a l l over the country. The impacts associated with improper management o f HCW can damage the environment and affect the health o f people both directly or/and indirectly. The stakeholders that get impacted due to improper HCW management are many, which include, hospital staff including the workers who handle such wastes; the patients and attendants due to improper handling and storage o f wastes within the healthcare facilities; the municipal workers due to improper containerization o f HCW; the general public due to improper transport, treatment & disposal o f HCW; and the environment, as i t s quality deteriorates due to improper treatment & disposal.
The present practice o f HCW management in almost a l l the healthcare facilities in the country i s very poor barring few piecemeal efforts to improve the situation. The problems range f rom lack o f awareness to technical and financial constraints. Developing and implementing a strategy and action plan i s therefore considered as the mitigation measure for this critical issue. The EA has therefore recommended a larger study as part o f the EA, to develop a strategy and Act ion Plan to achieve gradual improvement in H C W M .
Mitigation Measures: Based on the recommendation o f the EA study a detailed review o f the HCWM across HCFs in the country was undertaken. As part o f the study a review o f a l l earlier relevant studies were undertaken and visits were undertaken to several HCFs. The study found that none o f the HCFs have full proof HCWM system in place and recommended a strategic approach to improve the situation. Salient features o f the recommended strategy and Act ion Plan are provided below.
The HCWM Strategy and Action Plan
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Based o n the recommendations o f the H C W M review study, a strategy and action plan has been developed in consultation with other MOH, DOHS and i t s various divisions, MOPE, N H R C , the private agencies, donor agencies, NGOs and general c iv i l societies. K e y elements o f the strategy for improving H C W M are the as:
Creating appropriate legalh-egulatory framework
Formulation o f a vision & pol icy Creation o f appropriate institutional framework Building awareness and capacity at vanous levels
Targeting phased implementation o f HCWM programs in healthcare facilities Encouraging private sector participation in HCWM Making budgetary provisions for H C W M
Improving HCWM requires significant efforts at various levels ranging f rom creating awareness at grass root level to formulating policy/regulation to improve HCWM. Accordingly a time bound action plan has been developed in line with the recommended strategy. The key activities included in the action plan are the following:
Establishment o f a HCWM co-ordinating agency at the centre Making specific budgetary allocation for H C W M in the overall health budget Enacting HCWM legislation Developing o f H C W M Policy and guidelines Dissemination o f HCWM Policy and guidelines to al l stake holders Detailed feasibility study o f various technical options Establishment o f a funding mechanism for H C W M activities Establishing a H C W Information Management System Implementing HCWM program Monitoring and evaluating the HCWM program.
Cost associated with implementation o f the Act ion Plan has been estimated. The implementation o f the Act ion Plan and actual improvement in HCW management and i t s progress will be monitored and analyzed. Detailed monitoring plan in this regard has been developed.
Consultation
Findings o f the H C W M review study were discussed with several Govt. departments, large number o f private organizations and NGOs. The inputs and comments received during such discussions were incorporated while developing the strategy and an Act ion Plan for improving H C W M in the country. The draft strategy and Act ion Plan was then discussed with several stakeholders in a public workshop conducted at Kathmandu during March 2003. Relevant suggestionshomments received during the workshop have been incorporated into the final document o n strategy and action plan.
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Annex 9: Project Preparation and Supervision
NEPAL: Avian Influenza Control Project
MPG Kurup Mandava Subba Rao
Planned Actual P C N review d a d a Ini t ia l PID to PIC March 27, 2006 March 28, 2006 Ini t ia l ISDS to PIC March 27,2006 M a y 18,2006 Appraisal July 3,2006 November 27,2006 Negotiations July 12,2006 December 19,2006 RVP approval August 1,2006 Planned date o f effectiveness October 1,2006 Planned date o f mid-term review October 1,2008 Planned closing date July31,2011
Key institutions responsible for preparation o f the project:
Dan Vadnjal Lakshman Gautam Sharad Raniit
Ministry o f Agnculture & Cooperatives, Singha Durbar, Kathmandu, Nepal Department o f Livestock Services, Harihar Bhawan, Lalitpur, Nepal (977-1 -5522056) Ministry o f Health & Population, R a m Shah Path, Kathmandu, Nepal Department o f Health Services, Epidemiology and Disease Control Division, Singha Durbar, Kathmandu, Nepal (977-1-4255796)
~ ~ ~~~~~~~ ~~~ ~ ~ ~~ ~ ~~~ -r ~ ~ ~~ ~~- ~ UNICEF Birthe Locatelli-Ross1 Chief o f Health UNICEF Marganta Ronderos Epidemiologist WHO Prakash Ghimire Microbiologist WHO John Quinley C h s t i a n Touwaide
I E.Madhavan I Veterinarian I Consultant I
Health & Chi ld Survival Advisor Attach6 EU
U S A I D
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Rahul Sengupta Mohinder Oberoi
Programme Officer UNDP SAARC Regional Coordinator for avian influenza FA0
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Michael St. Louis Charles Bevan M ido r i Sat0 Drona Ghimire PG Gore
(peer reviewer) Epidemiologist (peer revlewer) C D C Sr. Agriculturalist (peer reviewer) FA0 Project Officer UNICEF Environmental Specialist Consultant Procurement SDecialist Consultant
Annex 10: Documents in the Project File
NEPAL: Avian Influenza Control Project
GON, National Avian Influenza and Influenza Pandemic Preparedness and Response Plan, Kathmandu, February 2006
GON, Avian Influenza Control Project: Operational Plan for Ministry of Agriculture, July 2006.
GON, Environmental Impact Assessment of Nepal Health Sector Program, Implementation Plan, 2004 - 2009 June 2006.
GON, Health Care Waste Management in Nepal, Assessment and Action Plan, June 2006
UNICEF, Communication Strategy for Avian Influenza Control Project, June 2006
World Bank, Avian Influenza - Rapid Assessment, Nepal, January 2006
World Bank, Global Program for Avian Influenza and Pandemic Preparedness, 2006
