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PROJECT INFORMATION DOCUMENT (PID) 
CONCEPT STAGE 
Report No.:  AB1847 
Project Name 
Emergency Disabilities Project 
Region 
MIDDLE EAST AND NORTH AFRICA 
Sector 
Health (50%); Other social services (50%) 
Project ID 
P096774 
Borrower(s) 
GOVERNMENT OF IRAQ 
Implementing Agency 
 
Environment Category 
[
]
A
[X] B   [ ] C   [ ] FI   [ ] TBD (to be determined) 
Date PID Prepared 
September 23, 2005 
Estimated Date of Appraisal 
Authorization 
October 12, 2005 
Estimated Date of Board 
Approval 
December 29, 2005 
1.  Key development issues and rationale for Bank involvement 
 
Abundant natural and human resources enabled Iraq to attain the status of a middle-income 
country in the 1970s. The country developed good infrastructure and well-performing healthcare 
and education systems, widely regarded as the best in the Middle East. Income per capita rose to 
over US$3,600 in the early 1980s. Since that time, successive wars and a repressive, state-
dominated economic system have stifled growth and development and debilitated basic 
infrastructure and social services. International trade sanctions imposed in 1991 took a toll on the 
economy. Despite the country’s rich resource endowment, Iraq’s human development indicators 
are now among the lowest in the region and income per capita dropped to about US$770 by 
2001, with continued decline thereafter.  
 
Key Issues 
 
Poverty and lack of social services have emerged as significant issues over the past two decades.
 
In 1980, Iraq’s income, education and health measures were high compared to regional averages.  
However, in the intervening years, the situation reversed itself.  The latest GDP estimate for Iraq 
is US$21.1 billion. Per capita income, which was around US$3,600 in the early 1980s, fell to 
about US$770 by 2001, with continued decline thereafter
1
.
Unemployment is very high, with 
estimates of between 25 and 50% of the workforce.  At the same time, due largely to the 
conflicts and mismanagement of resources, social sector services have declined steadily, in terms 
of quality of care and resource allocations.  This has had the greatest impact on those groups 
which are the most vulnerable, including people with disabilities.  
 
Once considered one of the best in the region, the Iraqi health system has declined significantly 
over the past two decades.
 During the 1980s, Iraq’s health sector consisted of a highly advanced 
curative system, with minimal focus on public health. During the 1990s, funds available for 
1
Current 2005 per capita income estimate indicates a slight rise to US$780.  
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health were reduced by 90 percent and health outcomes became among the poorest in the region, 
and well below levels found in countries of comparable income. According to the 2003 
UNICEF/WHO Health and Nutrition Watching Brief, Iraq has the region’s second highest infant 
mortality (83/1,000 live births in 2002) and under-five mortality rates (117/1,000 in 2001), a 
stark reversal from the improvements in these areas in the late 1970s and early 1980s. During the 
1990s, maternal mortality grew three-fold, with about 30 percent of women giving birth without 
a
qualified health worker in attendance.  
 
Care of the disabled has deteriorated significantly over the past two decades as a result of the 
conflicts and mismanagement.
 The breakdown of community support systems and the limited 
access to health services and rehabilitation services have had a devastating effect on the disabled. 
The Government’s difficulties in providing basic health services have had a particularly negative 
impact on recent victims of acts of violence.  Complications from injuries are common and can 
result in severe additional disabilities due to lack of appropriate treatment. The capacity of the 
Government to provide treatment to the victims of war and other violent acts is limited; many 
complications occur and reconstructive surgery is almost impossible.  In the current context, the 
Government has the double burden of providing adequate care to the recent victims of violence, 
as well as maintaining care of those whose disabilities are not related to the recent and on-going 
conflicts.   
 
Existing centers dedicated to the rehabilitation of disabled patients and the manufacture of 
prosthetic limbs have been looted and most of the facilities have suffered heavy physical damage 
over recent years.  Prior to May 2003, there were 12 centers of rehabilitation in Iraq, and 12 
prothesis workshops, including 4 in the Kurdistan region, most of which have suffered damage. 
Several workshops are operated with the assistance of international NGOs such as Handicap 
International and ICRC but in most facilities, equipment is obsolete, and medical supplies and 
raw materials are insufficient. Moreover, it must be noted that the technology has dramatically 
evolved during recent years, and once the centers are rehabilitated, new equipment reflecting 
updated technology will need to be provided and the staff retrained.   
 
There are also three hospitals for spinal injuries (located in Baghdad and Salah-il-Deen) and one 
former army hospital that provide special care for the disabled.  The existing capacity in-country 
for the manufacture of artificial limbs could reach 5,000 per year if raw materials were available. 
This is far below the annual requirement of 20,000 protheses.  
 
In addition to the services provided through the Ministry of Health, the Ministry of Labor and 
Social Affairs (MOLSA) provides welfare services to people with disabilities and their families 
in addition to some equipment and vocational training.  The MOLSA operates several 
specialized institutes for the physically handicapped, the deaf, the blind, and the mentally 
disabled.  It employs most of the social workers in Iraq and was traditionally responsible for the 
social protection systems put in place in the 1980s.  It is not apparent that close coordination of 
activities for the disabled exists between the MOH, MOLSA and other ministries and agencies 
providing services to the disabled, especially in the absence of a coherent national policy on 
disabilities.  Therefore, active participation of the MOLSA in the preparation of the project is 
necessary in order to avoid duplication and ensure optimal coordination with the MOH. 
 
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The inter-ministerial oversight commission for disabilities has not been formally established 
under the new Government.
 
Before the 2003 war, a special commission established by the 
armed forces was responsible for the care of the physically handicapped.  When this commission 
was abolished and the facilities operated by the army were transferred to Ministry of Health 
(MOH) authority, the responsibilities for the care of the handicapped became unclear. Through 
the leadership of the Directorate of Medical Operations and Specialized Services of the MOH, a 
commission 
–
the Iraqi Commission for the Disabled – to be attached to the Council of 
Ministers, was being considered by the interim Government in 2004.  Members of the Board of 
Directors were to include representatives from eight ministries, representatives of community 
groups, and representatives of the disabled.  This commission, however, has not yet been 
formally established under the new Government. 
 
There has been a dramatic increase in the incidence of Post Traumatic Stress Disorder (PTSD) 
as a result of the recent conflict.
 
Poverty, instability and the recent conflict have also taken a toll 
on the mental health of the population, with a dramatic increase in the incidence of depression 
and Post Traumatic Stress Disorder (PTSD). It is difficult to assess the extent of mental health 
burden in Iraq, but research under the recent Bank-financed Post-conflict Mental Health Project 
showed that in post-conflict societies, mental disorders are widespread and represent a major 
obstacle to economic development.  Poor mental health also reduces job opportunities for 
affected individuals and stands in the way of development of human and social capital.   
 
For the proposed project, however, given the breadth of the disabilities area and the constraints 
imposed by available resources and the two year time frame, the project will not focus directly 
on mental health and depression. Addressing the needs of people with these disabilities will also 
require stabilization of the general security situation, personal safety and job security, strong 
community support and social support as well as the restoration of adequate health and 
rehabilitation services.  However, the Bank is actively seeking donors to provide parallel support 
in this area and is also exploring options for supporting these activities with future IDA 
financing.  
 
Rationale for Bank Involvement 
 
The Bank has already begun to focus on supporting the recovery of the health system in Iraq.  
The first project – Emergency Health Rehabilitation (EHRP) - is providing support to improving 
access to quality emergency services in selected health facilities to serve the urgent needs of the 
Iraqi population.  This objective is being carried out through rehabilitation and equipping of 
selected emergency services units throughout the country, provision of emergency 
pharmaceuticals to these units, and strengthening of the planning and management capacity of 
the central and provincial health administrations.  
 
The Ministry of Health approached the Bank in October 2004 concerning support to people with 
physical disabilities resulting from the war and related accidents. This is an area which has 
obvious and direct links to the recent conflict and which can unambiguously be considered as an 
urgent priority for the Government, especially considering the continuous increase in the number 
of victims as a result of the current instability and violence.  Improving the rehabilitation of the 
physically disabled can have an immediate and visible impact. The rehabilitation will in 
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particular include disabled ex-combatants who are unlikely to be reintegrated into a community 
if they do not acquire some physical capabilities making it possible for them to carry out 
professional activities. This area has not yet been specifically addressed by the donor 
community, and the Government has recently signaled that this is an urgent priority.  The 
proposed project is consistent with the objectives of the Bank’s Human Development Strategy 
for Iraq, including helping to stem the deterioration of health services, in terms of infrastructure, 
human resources, and management, and builds logically on the support being provided through 
the EHRP to restore key services to the most vulnerable in the society.  It is also in line with the 
World Bank Middle East and North Africa (MENA) Department’s current efforts to develop a 
strategy to support the disabled as a group of people disproportionately represented among the 
world’s poorest.
2
The Bank, through its extensive global experience in supporting these types of interventions in 
post-conflict and emergency contexts, has a comparative advantage.  The Bank’s priority is not 
only to provide immediate assistance in areas of particular need, but to ensure that sector 
development takes place through establishment of a sound policy framework that will provide 
the basis for sustainability and for further reform measures.  In addition, decision-makers in Iraq 
will have the benefit of the Bank’s understanding of global good practices in supporting equity, 
quality, access and accountability in health system reform.   
 
2. Proposed objective(s) 
 
The overall objective of the proposed project is to help prevent the disabled from falling deeper 
into poverty, as well as to help reduce the burden of physical and psycho-social disabilities 
through targeted and cost-effective rehabilitation services in a community setting.  Specifically, 
the project will increase the capacity of the Government and stakeholders to: 
 
·
Upgrade the infrastructure and equipment of 11 specialized rehabilitation centers 
throughout the country, including improving capacity to produce high-quality prosthetics 
and orthotics for amputees. 
·
Improve the ability of policy-makers to assess disabilities requirements, ensure quality 
specialized care for the disabled, and provide opportunities for them to return to 
productive lives in their communities.   
·
Improve the information base on the disabled, including collecting and analyzing 
information on the current status of disabilities services, establishing assessment and 
registration capacities for the country, and developing a long term strategy for support to 
the disabled, including a focus on community-driven services.  
 
3. Preliminary description 
 
The proposed project, which is consistent with the Government’s priority to provide effective 
and high quality rehabilitation services to the disabled and help them return to society as 
productive individuals, comprises four components:  
 
2
“A Note on Disability Issues in MENA Region”, MNSHD working paper, April 2005. 
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Component 1: Service Delivery to the Disabled (estimated cost US$13.2 million) 
 
The objective of this component is to upgrade the services to the disabled throughout the 
country.  Support will be provided to improving the physical infrastructure of 11 specialized 
centers, located throughout the country, most of which have been seriously damaged and 
neglected.  Technical assistance and training will be given to technical staff in up-to-date 
rehabilitation approaches and techniques, in particular, drawing on the substantial regional 
capacity that exists in this field.  The project will also provide a one-year supply of raw materials 
for the prosthetics/orthotics production units. 
 
Component 2: Development of a Long-term Strategy and Action Plan for the Disabled 
(estimated cost US$.5 million) 
 
The objective of this component is to prepare a long-term strategy, legal framework, and action 
plan, based on a community-driven services approach.  As a basis for the strategy, an inventory 
of the current status of infrastructure and equipment, staffing, technical capacity, and national 
planning for services to the disabled will be carried out. Technical assistance and training will be 
provided by the project to support these activities. 
 
Component 3: Capacity Building to Support Implementation of the Long-term Strategy for 
the Disabled (estimated cost US$3 million) 
 
The objective of this component is to support capacity building activities, through technical 
assistance and training, for key Government staff responsible for disabilities policy and 
programs, and NGOs operating at the community level in delivery of services to the disabled.  
The technical assistance and training, which would be carried out both within Iraq and in 
neighboring countries, would be focused on developing capacity to assess disabilities 
requirements and provide specialized care, including physical therapy. A national assessment 
and registration system will also be developed to provide an integrated database on the disabled.         
 
Component 4:  Monitoring and Evaluation and Project Management (estimated cost US$.5 
million)   
 
The objectives of this component are two-fold: (i) to put in place a framework for monitoring 
and evaluation of project and Government program performance, through tracking of project and 
program outputs and impact, based on key indicators and relevant baseline data; and (ii) to put in 
place a project management function, building on the capacities of the Project Management 
Team (PMT) which is coordinating the activities of the on-going Emergency Health 
Rehabilitation Project (EHRP) in the Ministry of Health.  
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4.  Safeguard policies that might apply 
 
Applicable?
 
Safeguard Policy 
If Applicable, How Might It Apply? 
[x] Environmental 
Assessment
(OP
/BP
4.01) 
[
]
Natural Habitats
(OP
/BP
4.04) 
[
]
Pest Management
(OP 4.09
)
[
]
Involuntary Resettlement
(OP
/BP
4.12) 
[
]
Indigenous Peoples
(OD 4.20
)
[
]
Forests
(OP
/BP
4.36) 
[
]
Safety of Dams
(OP
/BP
4.37) 
[
]
Cultural Property
(draft OP 4.11 - OPN 11.03
)
[
]
Projects in Disputed Areas
(OP
/BP
/GP
7.60)
*
[
]
Projects on International Waterways
(OP
/BP
/GP
7.50) 
Environmental Safeguards
:
The Project is rated category “B”. Impacts would be those associated 
mainly with (i) construction of rehabilitation and new Disability Rehabilitation Centers (e.g., 
safety, dust, noise, waste material, and vehicular traffic); (ii) provision of sanitary services, water 
supply and waste management; and (iii) operation and maintenance of Disability Rehabilitation 
Centers. Because of the emergency conditions, the requirement to carry out a limited 
Environmental Analysis as part of project preparation will be waived.  However, for sub-projects 
with possible moderate or minor adverse environmental impacts, a limited Environmental 
Analysis will be done during project design for World Bank approval prior to execution of such 
works. The Environmental and Social Screening and Assessment Framework (ESSAF) would be 
disclosed in the country and in the Infoshop in November 2005.  Based on the ESSAF, the 
following standards will be applied during implementation: (i) inclusion of standard 
environmental codes of practice (ECOP) in the bid documents for rehabilitation and extension 
works; (ii) use of Safeguard Procedures for Inclusion in the Technical Specifications of 
Contracts; (iii) use of the Checklist of likely Environmental and Social Impacts of Subproject; 
(iv) review and oversight of any major reconstruction works by specialists; (v) implementation 
of environmentally and socially sound options for civil works; and (vi) provision for adequate 
budget and satisfactory institutional arrangements to monitor effective implementation and 
adequately operate and maintain sanitary facilities after project completion. Capacity building on 
*
By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the 
disputed areas
 
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Safeguards and on the implementation of the ESSAF has already been undertaken with the 
Ministry of Environment and other line Ministries under the EHRP. 
 
Resettlement and Land Acquisition
:
There will be construction of about eight new facilities in 
government owned land without squatters and rehabilitation and extension of about ten existing 
facilities in the Project.  The building extensions would be done within existing plots of land 
owned by MOH and without squatters. Therefore, World Bank Operational Policy (OP 4.12) 
would not be triggered since there should not be any involuntary relocation of populations or 
expropriation of privately owned land.  However, the ESSAF, specifically elaborated for due 
diligence of emergency projects in Iraq, should be used to ensure that this is indeed the case and 
should there be any need for expropriation of privately owned land or/and involuntary relocation 
of population, the same guidelines will be followed. 
 
The MOH/PMT would employ a safeguard specialist who would be trained on World Bank 
safeguard policy and procedures for monitoring compliance with World Bank policy during 
project implementation and for reporting. Quarterly and annual implementation progress reports 
should include a section for reporting compliance with World Bank safeguard policy. 
 
5. Tentative financing 
Source: ($m.)
BORROWER 0 
SPECIAL FINANCING 
17.2
Total 17.2
6. Contact point 
Contact: Jean Jacques Frere 
Title: Sr. Public Health Spec. 
Tel: (202) 473-6274 
Fax: (202) 477-0036 
Email: jfrere@worldbank.org