Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 43670-IQ

THE MINISTRY OF HEALTH OF THE KURDISTAN REGIONAL GOVERNMENT OF THE REPUBLIC OF IRAQ

PROPOSED TRUST FUND GRANT

IN THE AMOUNT OF US$8.7 MILLION

FOR A

REGIONAL HEALTH EMERGENCY RESPONSE PROJECT

EMERGENCY PROJECT PAPER

June 19, 2008

Human Development Sector

Middle East and North Africa Region

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

CURRENCY EQUIVALENT

(Exchange Rate Effective May 27, 2008)

Currency Unit = US$

US$ 1 = Iraqi Dinar 1,188

FISCAL YEAR

January to December

ABBREVIATIONS AND ACRONYMS

BLS / Basic Life Support / OFFP / Oil for Food Program
CQS / Selection based on Consultants’ Qualifications / PAC / Project Advisory Committee
ECC / EmergencyCoordinationCenter / PCU / Project Coordination Unit
EPP / Emergency Project Paper / PFS / Project Financial Statements
ESSAF / Environmental and Social Screening and Assessment Framework / PIM / Project Implementation Manual
FMR / Financial Monitoring Report / PP / Procurement Plan
GDP / Gross Domestic Product / QCBS / Quality and Cost Based Selection
IBRD / International Bank for Reconstruction and Development / RHERP / Regional Health Emergency Response Project
ICB / International Competitive Bidding / SBD / Standard Bidding Document
IDA / International Development Association / SOE / Statement of Expenses
ITF / World Bank Iraq Trust Fund / TA / Technical Assistance
KRG / Kurdistan Regional Government / FMA / Fiduciary Monitoring Agent
MOF / Ministry of Finance / TOR / Terms of Reference
MOH / Ministry of Health / UNDB / United Nations Development Business
MOI / Ministry of Interior / UNOPS / United Nations Office of Project Services
MOPDC / Ministry of Planning and Development Cooperation / UNOPS IQOC / UNOPSIraqOperationsCenter
NCB / National Competitive Bidding / USAID / United States Agency for International Development
NGO / Non-governmental Organization
Vice President / Daniela Gressani
Country Director / Hedi Larbi
Sector Director / Steen Jorgensen
Sector Manager / Akiko Maeda
Task Team Leader / Jean Jacques Frere

Emergency Project Paper

Table of Contents

EMERGENCY OPERATION PROJECT PAPER DATA SHEET

A.Introduction

B.Emergency Challenge: Country Context and Rationale for Proposed Bank Emergency Project

C.Bank Response: The Project

D.Appraisal of Project Activities

E.Implementation Arrangements and Financing Plan

F.Project Risks and Mitigating Measures

Annex 1: Detailed Description of Project Components

Annex 2: Results Framework and Monitoring

Annex 3: Summary of Estimated Project Costs

Annex 4: Financial Management and Disbursement Arrangements

Annex 5: Implementation and Procurement Arrangements

Annex 6: Project Preparation and Appraisal Team Members

Annex 7: Documents in Project Files

Map No. 33422

EMERGENCY OPERATION PROJECT PAPER DATA SHEET

IRAQ: REGIONAL HEALTH EMERGENCY RESPONSE PROJECT (RHERP)

MIDDLE EAST AND NORTH AFRICA REGION

Date: June 16, 2008
Country Director: Hedi Larbi
Sector Manager: Akiko Maeda
Sector Director: Steen Jorgensen
Lending instrument: Emergency Recovery (Grant) / Team Leader: Jean Jacques Frere
Sectors: Health (100%)
Themes: Health system performance (S)
Environmental category: B
Type of Operation:
New Operation [X] Additional Financing [ ] Existing Financing (restructuring) [ ]
Financing type: Loan [ ] Credit [ ] IDA Grant [ ] Other [X]
Project ID(s): P107698 / Total Amount: US$8.7million
Proposed terms: Grant from the Trust Fund for Iraq (World Bank/Recipient-executed) / Expected implementation period:July1, 2008 –June 30, 2010
Expected effectiveness date: July 1, 2008 / Expected/revised closing date: June 30, 2010
Recipient: Ministry of Health of Kurdistan Regional Government of the Republic of Iraq / Responsible agency: Ministry of Health of Kurdistan Regional Governmentof the Republic of Iraq
Development Objective:
The objective of the RHERP is toassist the Kurdistan Regional Government to build capacity in the establishment of rapid, coordinated and effective response services to health emergencies, including those resulting from acts of violence, accidents, or natural disasters.
Short Description:
The project would achieve its objective through the following four components:
(i) Emergency Coordination Centers. The objective of this component is to strengthen emergency coordination and response in the three Northern Governorates of Erbil, Sulaymaniya and Dohuk through establishment and equipping of Emergency Coordination Centers in each of the three Governorates, and creation of a reliable communication system for pre-hospital emergency services;
(ii) CapacityBuilding and Training in Emergency Procedures. The objective of this component is to build capacity for patient treatment in medical and paramedical staff providing pre-hospital emergency services;
(iii) Blood Banks. The objective of this component is to upgrade the capacity of existing blood transfusion services in the three Northern Governorates to provide a timely supply of safe blood and blood products banks to respond to the needs resulting from an emergency;
(iv) Project Management. The objective of this component is to ensure effective administration and coordination of project activities.
Financing Plan (US$m)
Source / Local / Foreign / Total
Borrower
Total IBRD/IDA
Trust Funds
Others
Total / 2.3
2.3 / 6.4
6.4 / 8.7
8.7
Estimated disbursements (Bank FY/US$m)
2009 / 2010 / 2011 / 2012
Total IBRD/IDA
Trust Funds / 4.5 / 4.2
Does the emergency operation require any exceptions from Bank policies?
Have these been approved by Bank management? / Yes [ ] No [X]
Yes [X] No [ ]
Are there any critical risks rated “substantial” or “high”? / Yes [X] No [ ]
What safeguard policies are triggered, if any? / Yes [ ] No [X]
Significant, non-standard conditions, if any: Conditions of Bank Management approval will be: (i) execution of the Project Implementation Agreement between KRH MOH and UNOPS; and (ii) Project Implementation Manual (PIM) acceptable to the Bank has been adopted by the Recipient.

1

A.Introduction

  1. This Project Paper seeks the approval of the Vice President for the Middle East and North Africa Region to provide a grant from the World Bank Iraq Trust Fund (ITF) in the amount of US$8.7 million for the Regional Health Emergency Response Project (RHERP).
  1. The project will be implemented by the Kurdistan Regional Government Ministry of Health (KRG MOH) and has received approval from the Iraq Strategic Review Board on September 10, 2007,in the amount of US$6 million and again on February 25, 2008, for an additional funding of US$2.7 million.
  1. This grant is being prepared under emergency procedures, like other projects financed through the ITF. In addition, because of the lack of experience in project management, financial management and procurement in the main agency implementing the project (KRG MOH), the Government has requested that the United Nations Office of Project Services (UNOPS)act as Implementing Agent for the project.

B.Emergency Challenge: Country Context and Rationale for Proposed Bank Emergency Project

Country Context

  1. The health system in Iraq was considered as very good in the 1980s in terms of infrastructure, quality of care, and access, and benefited from a well-trained health workforce. However, it was highly centralized, hospital based and costly, requiring large-scale imports of medicines, equipment and service workers such as nurses. The deterioration of the health system which had begun during the Iran-Iraq War (1980-88) when resources became scarce for non-military health services worsened during the first years that followed the 1991 Gulf War and the following imposition on sanctions. In 1989, health sector imports totaled US$500 million and fell dramatically, after the First Gulf War, to US$50 million in 1991 and to US$22 million in 1995. Furthermore, many Iraqi physicians of the “old generation” started to leave the country to practice in neighboring countries or in Europe. However, a steep decline in infant and child mortality took place during the 1980s. The IMR fell from 80 per 1,000 live births[1] in 1974 to 60 in 1982 and to 40 in 1989. Following the 1991 invasion of Kuwait and the First Gulf War, sanctions imposed by the international community further eroded the capacity to deliver essential health services to the Iraqi population. Bombing by coalition forces had put most pumping and sewage treatment plans out of action and “with the loss of water supply, water treatment and electricity –generating capacity, the contamination of the water supply started a whole sequence of events that caused health to deteriorate drastically”[2]. Diarrheal diseases, in particular, spread rapidly.
  1. Data collected in 1999 by donor agencies[3] indicated that the under 5 and maternal mortality rates had risen dramatically between 90 and 100 for infants and 110 to 125 for children under five. These were comparable to the rates found in low-income countries. Within a decade, the health status of Iraqis had changed from that of a relatively advanced middle-income country to a poor and underdeveloped one. Measuring trends in Maternal Mortality always poses a challenge, but it was estimated at 117/100,000 in 1989 and is believed to have reached 294/100,000 during the period 1989-1998. During this time, malnutrition among children became a growing concern. Children born in the 1990s had a much greater risk of becoming malnourished than those born in the 1980s. The prevalence of underweight prior to 1990 was around 12%, somewhat better than the regional average.
  1. The sanctions were amended under the Oil for Food Programme (OFFP) in 1996 to allow the procurement of pharmaceuticals and medical equipment which improved the situation somewhat, although unlike with malnutrition[4], there is very limited evidence about the impact of this program on infant and under 5 mortality. While it can be assumed that there was a decline, it cannot be quantified.
  1. Withthe change of regime that followed the 2003 occupation of Iraq by multinational forces, there were hopes that, with substantial resources, sound management and strong leadership, the Iraqi health system would recover. The Ministry of Health (MOH) completed a health needs assessment with the assistance of UN Agencies and the Coalition Provisional Authority (CPA). The Government also prepared a national health strategy which was approved by the Parliament in 2004. The strategy emphasized family health care as the model to be followed, and in collaboration with several donors, including the World Bank, substantive discussions took place about topics such as health care financing, public-private partnerships, national health accounts and master planning.
  1. However, implementing this vision would have required long lasting stability and commitment. This did not happen and, the health system is itself a casualty of the war. In a climate increasingly dominated by sectarian violence, terrorism, and crime, the health system has almost entirely collapsed. Half of the Iraqi physicians who were registered in 2003 have fled the country, including the best clinicians and those with faculty positions. There are very few qualified nurses, and in some parts of the country, including Baghdad, both providers and patients are too fearful to use existing facilities or to ensure 24 hour emergency services.
  1. Since May 2003, there have been six Ministers of Health in Baghdad with a resulting high turnover of senior staff, including central and provincial directors and hospital managers. At the central Ministry of Health, many competent managers have left or have been forced from their posts. The situation in some provinces less affected by violence and political pressures is thought to be more stable than in the central government, although the managerial capacity of provincial MOH staff remains weak. Several attempts to restructureKIMADIA, the State Company for the Marketing of Drugs and Medical Appliances,have not been successful, and consequently the state capacity to procure and distribute critical drugs, medical devices and supplies remains dysfunctional.
  1. Recentinformation, which has yet to be confirmed,and seems largely anecdotal, suggests that the situation of Iraqi children has deteriorated since 2003. Access to health care has deteriorated during the past 12 months as a result of continuing sectarian and criminal violence and the resulting exodus of qualified medical personnel. However, a recent survey carried out by UNICEF in February 2006 suggested figures[5] less dramatic than previous estimates but the results have not been officially released. According to this survey, which included anthropometric measurement, less than 10% of Iraqi children from 0-59 months suffer from moderate to severe malnutrition (weight for age).[6] During this period, access to qualified obstetric services has become problematic and many Iraqi women are known to deliver at home with the help of poorly qualified traditional midwives (birth attendants).
  1. In 2006 and 2007, the Iraq family Health Survey (IFHS) was conducted by Iraqi institutions with the support of WHO. This survey provides new estimates of violence-related mortality from March 2003 through June 2006. The estimated number of violent deaths is 151,000 (104.000 to 223.00 with 95% uncertainty range), is lower than other recent survey-based estimates but it confirms that violence is a leading cause of deaths for Iraqi adults and the main cause of deaths in men between the ages of 15 and 59 years.
  1. In the face of this challenging environment, implementation of the two on-going health projects financed by the Iraq Trust Fund (Emergency Health Rehabilitation Project (EHRP) and Emergency Disabilities Project (EDP)) has proved especially challenging. The central MOH continues to be highly centralized, and coordination with the regional teams remains weak. Furthermore, the security situation has prevented central MOH staff from traveling outside of Baghdad to the project sites. The continuous turn over and consequent lack of familiarity with Bank guidelines and procedures has also exacerbated the effective implementation of the projects.

Health Sector in the IraqKurdistanRegion

  1. Historically, the three Northern Governorates have been less developed than the rest of the country. The population is more rural, infrastructure is less developed than in the South-Center, and administration of the region has traditionally been under the control of delegates from Baghdad. In addition, the population has suffered from large-scale displacements and isolation. In the first years of the 1990s, the situation deteriorated more rapidly than in the Center/South, but it also has improved more quickly since that time. After the no-fly zone was established at the end of the first Gulf War, the Kurdish region received additional assistance through bilateral channels (US Government congressional program) and the UN, and benefited from the presence of several international NGOs on the ground. Health indicators are thought to be better than those of the rest of Iraq but, again, there are no robust data to support this assertion.[7]
  1. Although the Kurdish Region has generally been protected from the climate of violence and insecurity that affects other regions of Iraq, the health situation generally mirrors that of the rest of Iraq. The Kurdish Regional Government (KRG) MOH manages the health services in three Northern Governorates: Erbil, Dohuk and Sulaymaniya. The population in these three governorates includes internally displaced people (IDP) and totals around 5 million (one-fifth of the population of Iraq). Each Governorate has its own Directorate of Health (DOH), which includes eight departments: planning and health education, technical affairs, preventive health, engineering, administration, finance, central pharmacy, and medical operations and specialized services. This structure is the same in all Iraqi DOHs. The Kurdish Regionalso includes three medical colleges, two colleges of dentistry, one college of pharmacy and two colleges of nursing.
  1. The KRG MOH enjoys a wide degree of autonomy with regard to the management of health facilities, staffing and the organization of health services. However, it is dependent on Baghdad for its budget allocation and for the provision of pharmaceuticals and medical equipment. Since the system does not respond to the actual needs of the population, 70% of essential drugs are purchased by the KRG MOH from the private sector.
  1. KRG MOH manages a network of health facilities comprising 48 secondary or tertiary hospitals, 760 PrimaryCareCenters and Sub-HealthCenters. Shortage of beds is not a major constraint, except for obstetric beds, with ongoing investments supported by donors or by the private sector. The Bed Occupancy Ratio (BOR) is a little less than 70% and with new investments supported by the Government and by donors, the hospital capacity should be adequate within the coming two to three years. Rather, the constraint lies with the lack of qualified staff.: only one-third of the MOH primary health centers are staffed by physicians and many specialist positions in hospitals are vacant. Most physicians in the public sector also have private practices, sometimes using public health facilities to provide their services.
  1. Some facilities, such as the EmergencyMedicalCenter in Erbil which provides emergency care and rehabilitation services to victims of violence and acts of war, were established in 1997 by international NGOs with external donor funding. Following the invasion of Iraq and the fall of the Baghdad regime in 2003, international donor support ceased and such facilities were transferred to the local government. This is also the case for two rehabilitation centers in Erbil and Sulaymaniya where a well-trained staff struggles to continue providing critical services to amputees or patients with spinal cord injuries.
  1. It is important to note that many KRG health facilities, in addition to serving the local population, also serve a relatively large number of patients referred from other parts of Iraq, in particular those evacuated from the neighboring cities of Mosul and Kirkuk. Recently, a large number of victims of the horrific August 2007 bombing of Yazidi villages in Al Sinjar were evacuated to Dohuk and completely overwhelmed the capacity of the recently renovated emergency hospital.

Table 1: IraqKurdistanRegion- Distribution of Physicians by Governorate

ERBIL / DOHUK / SULAYMANIYA / TOTAL
Population[8] / 1,478,426 / 985,946 / 1,534,425 / 3,998,797
Specialists / 160 / 73 / 129 / 362
District Physicians / 212 / 50 / 41 / 303
GPs / 247 / 161 / 104 / 512
Hospital Physicians / 215 / 192 / 287 / 694
Hospital Consultants / 222 / 75 / 177 / 474
Total number of Physicians[9] / 1,056 / 551 / 738 / 2,345
Total number of Nurses and auxiliaries / 6,944 / 1,924 / 8,412 / 17,280
  1. Status of emergency response. Recent emergency events have highlighted the very limited local capacity to respond to emergencies, e.g., assessment, communication, provision of pre-hospital care, referral system. Lack of adequately equipped ambulances, staff (including physicians) unprepared to respond to emergency needs, vulnerability of the communication system, and the disorganized response at the level of hospital emergency departments are a few of the most critical weaknesses. Even with the very limited resources of the existing system, there is considerable scope for improving the quality and effectiveness of emergency responses by providing targeted support to mitigate critical bottlenecks in the system and to make better use of the existing scarce staff resources. In particular, the capacity to provide pre-hospital care can be significantly enhanced by the provision of communication and transportation equipment, the training of staff, and the establishment of a functioning command center in each of the three provinces covered by the project.
  1. Status of blood and blood products supply. Another critical area requiring attention is to ensure a safe supply of blood and blood products through the provision of adequate facilities for collection, testing, storage and distribution. Currently, there is no effective blood bank in Erbil and in the SulaymaniyaProvince: the existing facility is in need of rehabilitation and additional equipment. The blood bank in Dohuk is adequate but requires some rehabilitation[10] . Blood supply is generally stored in refrigerators scattered over several hospitals. Blood is often not adequately tested for HIV/AIDS or Hepatitis. Staff are also poorly trained on collection, management and distribution of blood, leaving the population at great public health risk.
  1. Donor Support to the Health Sector in the Kurdish Region. A number of UN agencies are currently active in the health sector in the Kurdish Region, including UNOPS, UNFPA, WHO, and UNICEF. In addition, the US, Korea and Japanprovide bilateral support to the health sector in the form of reconstruction and/or rehabilitation of several hospitals and primary care centers.

Rationale for the Bank's Involvement