Document of The World Bank Report No: ICR00001885 IMPLEMENTATION COMPLETION AND RESULTS REPORT (TF-54052) ON A GRANT FROM THE WORLD BANK IRAQ TRUST FUND IN THE AMOUNT OF US$19.5 MILLION TO THE MINISTRY OF HEALTH OF IRAQ FOR AN EMERGENCY DISABILITIES PROJECT July 25, 2011 Human Development Sector MNSHD Middle East and North Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective June 17, 2011) Currency Unit = Iraqi Dinar Iraqi Dinar 1,000 = US$0.85 US$1.00 = Iraqi Dinar 1,164 FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS DWG Disabilities Working Group ECOP Environmental Codes of Practice EDP Emergency Disabilities Project EHRP Emergency Health Rehabilitation Project ESSAF Environmental and Social Screening and Assessment Framework FMA Fiduciary Monitoring Agent FMR Financial Monitoring Report ICB International Competitive Bidding IPR Independent Procurement Review ITF World Bank Iraq Trust Fund MIM Master Implementation Manual MOF Ministry of Finance MOH Ministry of Health NCB National Competitive Bidding NGO Non-governmental Organization PDO Project Development Objective PIM Project Implementation Manual PMT Project Management Team PWD Persons with Disability TOT Training of Trainers Vice President: Shamshad Akhtar Country Director: Hedi Larbi Sector Director: Steen Lau Jorgensen Sector Manager: Enis Baris Project Team Leader: Afrah Al-Ahmadi ICR Team Leader: Eileen Brainne Sullivan REPUBLIC OF IRAQ EMERGENCY DISABILITIES PROJECT CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 1 3. Assessment of Outcomes ............................................................................................ 2 4. Assessment of Risk to Development Outcome........................................................... 2 5. Assessment of Bank and Borrower Performance ....................................................... 3 6. Lessons Learned ......................................................................................................... 3 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ............ 3 Annex 1. Project Costs and Financing ............................................................................ 4 Annex 2. Outputs by Component ................................................................................... 5 Annex 3. Economic and Financial Analysis ................................................................... 6 Annex 4. Bank Lending and Implementation Support/Supervision Processes .............. 7 Annex 5. Beneficiary Survey Results ............................................................................. 8 Annex 6. Stakeholder Workshop Report and Results..................................................... 9 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 10 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 11 Annex 9. List of Supporting Documents ...................................................................... 12 MAP A. Basic Information Emergency Country: Iraq Project Name: Disabilities Project Project ID: P096774 L/C/TF Number(s): TF-54052 ICR Date: 07/25/2011 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: ERL Grantee: IRAQ Original Total USD 19.50M Disbursed Amount: USD 16.71M Commitment: Revised Amount: USD 16.80M Environmental Category: B Implementing Agencies: Ministry of Health Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept 04/28/2005 Effectiveness: 11/23/2005 Review: Appraisal: 11/17/2005 Restructuring(s): 03/08/2009 Mid-term Approval: 11/23/2005 04/02/2008 04/02/2008 Review: Closing: 09/30/2007 12/31/2010 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Grantee Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Moderately Quality at Entry: Government: Unsatisfactory Unsatisfactory Quality of Implementing Moderately Satisfactory Supervision: Agency/Agencies: Unsatisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Satisfactory Performance: Unsatisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Quality at Entry Project at any time Yes None (QEA): (Yes/No): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health 50 100 Other social services 50 Theme Code (as % of total Bank financing) Conflict prevention and post-conflict reconstruction 25 Injuries and non-communicable diseases 50 100 Other social protection and risk management 25 E. Bank Staff Positions At ICR At Approval Vice President: Shamshad Akhtar Christiaan J. Poortman Country Director: Pilar Maisterra Joseph P. Saba Sector Manager: Enis Baris Akiko Maeda Project Team Leader: Eileen Brainne Sullivan Jean-Jacques Frere ICR Team Leader: Eileen Brainne Sullivan ICR Primary Author: Paul Geli F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective of the Project is to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability. Revised Project Development Objectives (as approved by original approving authority) The objective of the Project is to improve access of the disabled population in the targeted areas in Iraq to rehabilitation and prosthetic services. (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Number of disabled who have used the newly constructed and equipped Indicator 1 : facilities. Value 500 clients quantitative or 0 N.A. per facility 1000 Qualitative) per month Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Comments Target exceeded by 100 percent. For the six rehabilitation centers, the (incl. % average number of clients is 1,000 per center per month (see figures for achievement) the six centers in Section 3.2). Indicator 2 : Number of disabled who received medical aids through the Project. Value 39,900 quantitative or 0 N.A. Not available clients Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Distribution to disabled persons is slow due to bottlenecks in MOH Comments validation and allocation of medical aids to respective Directorates of (incl. % Health. Monitoring and reporting capacity of MOH is very limited. achievement) Number of disabled that received aids is unknown. (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Indicator 1 : Number of new basic rehabilitation centers constructed. Value (quantitative 0 9 6 6 or Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Construction target met. Rehabilitation and workshop equipment, medical Comments and non-medical furniture delivered and installed in the new centers. (incl. % Another set of rehabilitation equipment has been delivered and installed achievement) for a 7th center, Al Hakim Hospital Baghdad Indicator 2 : Number of new prosthetic workshops constructed. Value (quantitative 0 3 2 2 or Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Comments Target met. An additional set of workshop equipment and tools has been (incl. % procured for a third workshop at the existing Al Hakim Hospital in achievement) Baghdad. Indicator 3 : Number of staff trained in the area of physical rehabilitation. (i) 70 physio- therapists (regular training) and 8 (i) 65 hospital- physiothera- based Value pists physiotherapists. (quantitative 0 N.A. (specialized or Qualitative) additional (ii) 16 hospital- training); based physicians (ii) 30 physicians (specialized training) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 % of achievement: 93% for hosp-based physiotherapists and 53% for Comments hosp-based physicians. For physicians, plans were made for training of (incl. % 20, but 4 did not attend due to lack of permission. MOH declined further achievement) proposals for training (see section 3.2) Number of staff trained in the area of production and fitting of prostheses Indicator 4 : and orthoses. 47 staff 59 prosthetics trained technicians Value outside Iraq trained overseas (quantitative 0 N.A. and 30 and 18 or Qualitative) technicians technicians trained trained in- locally. country. Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 % of achievement: 125% for staff trained overseas and 60% for Comments technicians trained locally. In-country training was dependent on training (incl. % equipment being installed and materials being delivered. The training of achievement) technicians is a significant achievement. Indicator 5 : Number of facility managers trained in the area of facility management. Value 0 N.A. 20 managers 15 managers (quantitative or Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Comments Number of medical aids (wheelchairs, crutches, walking sticks, walking (incl. % frames, walking rollators, tripods) procured. achievement) Number of medical aids (wheelchairs, crutches, walking sticks, walking Indicator 6 : frames, walking rollators, tripods) procured. Value (quantitative 0 N.A. 39,900 38,697 or Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Comments Target basically met (percentage of achievement: 97%) # 38,697 medical (incl. % aids have been procured and distributed to the DOH warehouses in the achievement) respective Governorates. Indicator 7 : Number of quarterly progress monitoring reports. Value 6 semi-annual (quantitative 0 N.A. 18 reports or Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Target basically met. Target of 18 has to be adjusted downward; at Comments restructuring PMT/MOH had already submitted 7 reports and could not (incl. % be expected to submit an additional 11 reports (whether quarterly or semi- achievement) annual) between March 2009 and end of 2010. Indicator 8 : Submission of Project Completion Report. Value (quantitative 0 1 1 1 or Qualitative) Date achieved 11/01/2005 09/30/2007 12/31/2010 12/31/2010 Comments Target met. PMT/MOH submitted a revised/final Project Completion (incl. % Report in February 2011. achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 06/13/2006 Satisfactory Satisfactory 0.00 Moderately Moderately 2 10/31/2006 0.09 Unsatisfactory Unsatisfactory Moderately Moderately 3 05/23/2007 0.33 Unsatisfactory Unsatisfactory 4 11/30/2007 Moderately Moderately 1.36 Unsatisfactory Unsatisfactory Moderately Moderately 5 05/24/2008 2.02 Unsatisfactory Unsatisfactory 6 12/24/2008 Moderately Satisfactory Moderately Satisfactory 4.15 7 05/26/2009 Moderately Satisfactory Moderately Satisfactory 5.85 8 12/25/2009 Moderately Satisfactory Moderately Satisfactory 10.55 9 05/20/2010 Moderately Satisfactory Moderately Satisfactory 13.37 10 01/11/2011 Moderately Satisfactory Moderately Satisfactory 15.65 11 03/26/2011 Moderately Satisfactory Moderately Satisfactory 16.23 H. Restructuring (if any) ISR Ratings Amount Board at Disbursed at Restructuring Reason for Restructuring Approved Restructurin Restructurin Date(s) & Key Changes Made PDO Change g g in USD DO IP millions There were serious implementation delays and increases in the scope of works and unit costs. In addition to the revision of the PDO, the following were cancelled: (1) Component 1 03/08/2009 N MS MS 4.81 on policy development and partnerships; (2) US$2.7 million of the Grant; and (3) 8 of the original 14 project sites, to retain only those that could be implemented within the revised closing date. I. Disbursement Profile 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1.1.1 Country and Sector Background. Iraq attained the status of a middle-income country in the 1970s. Since those times, successive wars, international trade sanctions and a state-dominated economic system have stifled growth and development and debilitated basic infrastructure and social services. Despite the country’s rich resource endowment, Iraq’s human development indicators had become among the lowest in the region. At the time of appraisal, Iraq had had two political transitions, and was taking steps toward a constitutionally elected government. Nevertheless, persistent violence had affected most parts of the country, and continued to hinder reconstruction efforts. The following had emerged as significant issues over the past two decades: (i) The lack of social services and the decrease in income (per capita income, which was around US$3,600 in the early 1980s, had fallen to about US$770 by 2001 with a slight increase to US$940 in 2005). (ii) Once considered one of the best in the region, the Iraqi health system had declined significantly in terms of quality of care and resource allocations and health outcomes were among the poorest in the region, and well below levels found in countries of comparable income. (iii) The many successive wars increased the burden of disability. The cumulative number of persons suffering from physical disabilities (excluding blindness, deafness, and disabilities resulting from chronic diseases) was estimated at 250,000 (the number of amputees was 80,000 to 100,000 in 2002, with 80 percent from lower limb amputations, and the number of people suffering from spinal cord damage was 8,000). (iv) Care of the disabled had deteriorated as a result of the conflicts and mismanagement (existing centers dedicated to the rehabilitation of disabled patients and the manufacturing of prosthetic limbs had been looted and most of the facilities had suffered heavy physical damage). 1.1.2 Rationale for Bank Assistance. The breakdown of community support systems and the limited access to health services and rehabilitation services had had a devastating effect on the disabled. Through the Emergency Health Rehabilitation Project (EHRP), the Bank had already begun to focus on supporting the recovery of the health system in Iraq. The Ministry of Health (MOH) approached the Bank in October 2004 concerning support to people with physical disabilities resulting from the war and related accidents. This was an area which had obvious and direct links to the recent conflict and which could unambiguously be considered as an urgent priority for the Government, especially considering the continuous increase in the number of victims as a result of instability and violence. The Project was 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. It was 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. The Bank had a comparative 1 advantage in working in conflict and emergency contexts, and it also had some experience in dealing with disability assistance (Bosnia and Kosovo). 1.1.3 Detailed information on the context at appraisal is included in Annex 10. The World Bank Iraq Trust Fund (ITF) 1.1.4 In 2003, the International Reconstruction Fund Facility for Iraq (IRFFI) was established to help donors channel their resources and coordinate their support for reconstruction and capacity building development activities in Iraq within its priority program. IRFFI comprises two trust funds: (i) the World Bank Iraq Trust Fund (ITF) administered by the Bank; and (ii) the UN Development Group Iraq Trust Fund administered by the United Nations Development Programme (UNDP). 1.1.5 The ITF is a multi-donor trust fund; as such, all funds are commingled in one account. The ITF finances grants for rehabilitation/reconstruction and capacity building technical assistance projects. The vast majority of ITF projects are implemented by Iraqi agencies to help the Government of Iraq (GOI) develop effective institutions. To ensure country ownership and that the ITF finances Iraq’s development priorities, the potential recipient submits a proposed project to the Iraqi Strategic Review Board (ISRB), chaired by the Ministry of Planning and Development Cooperation. ITF-funded projects are reviewed by the Bank Ad Hoc Advisory Committee and are approved by the Regional Vice-President. 1.1.6 The recipient entity typically establishes a Project Management Team (PMT) to be responsible for day-to-day project implementation. The projects are supervised by the Bank in accordance with its policies and procedures, with the same internal controls to ensure that funds are properly used for the purposes intended and that the objectives of each project are achieved. Since the difficult security situation prevents Bank staff from visiting project sites, the Bank engaged a Fiduciary Monitoring Agent (FMA) for the ITF; the FMA verifies the physical implementation of projects and monitors compliance with fiduciary policies, including financial management and procurement procedures. 1.2 Original Project Development Objectives (PDO) and Key Indicators 1.2.1 According to the World Bank Iraq Trust Fund (ITF) Grant Agreement and the Technical Annex dated November 23, 2005, the original objective of the Project was to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability. 1.2.2 According to the Grant Agreement, there were four key performance indicators: (1) Policy framework for the disabled developed and adopted by Iraq. (2) At least three non-governmental organizations (NGO) have an official agreement with Iraq to deliver services to disabled and their families. (3) Number of disabled persons who received prosthetic devices, medical aids and physical therapy from rehabilitation facilities. No baseline - No target set. 2 (4) The Ministry of Health (MOH) is capable of managing, supervising and monitoring the Project. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 1.3.1 When the Project was restructured on March 8, 2009 (first order restructuring), the PDO was revised as follows: ―The objective of the Project is to improve access of the disabled population in the targeted areas in Iraq to rehabilitation and prosthetic services‖. 1.3.2 The reason the PDO was revised and other changes were made is that the Project had experienced serious delays in implementation. These delays were caused by a number of factors, including the unstable political and security context in the country, lack of continuity in MOH leadership and project management, lack of familiarity of the MOH, contractors and consultants with Bank guidelines and procedures, and devaluation of the Iraqi Dinar coupled with high domestic inflation. 1.3.3 At restructuring, the Results Monitoring Framework was revised: the four original performance indicators included in Schedule 5 of the Trust Fund Grant Agreement were replaced by a list of 10 performance indicators (two outcome indicators and eight output indicators). The list included in the Restructuring Project Paper had targets for the end of project, but the letter amending the Trust Fund Grant Agreement included only the list, and not the targets. However, prior to the signing of the amendment letter, the draft restructuring Project Paper and the draft amendment letter had been submitted to the MOH for its endorsement. The 10 revised performance indicators and their achievement are shown in the Data Sheet. 1.4 Main Beneficiaries 1.4.1 According to the Technical Annex, the 14 facilities to be constructed/renovated and equipped in thirteen governorates would serve the needs of up to 250,000 persons with disability (PWD). These PWD would otherwise not have access to quality rehabilitation services and would be denied the right to work and to lead a productive life. In addition, a total of approximately 1.4 million Iraqis, representing the families of the disabled, would be direct beneficiaries of the Project. 1.4.2 When the Project was revised at restructuring, it was not expected to have the same social and economic impact on beneficiaries as originally planned because the number of rehabilitation centers dropped significantly from 14 to 6 in six governorates only. As revised, the Project would provide access to 500 disabled clients per month per facility for rehabilitation services and would provide 39,900 disabled clients with medical aids. 1.5 Original Components 1.5.1 The Project had three components: 3 Component 1, or part A in the Grant Agreement: Policy Development and Partnerships (US$0.8 million total, including contingencies). It included the development of a comprehensive policy and legislative framework, and of partnerships between the MOH, other ministries, and civil society in the area of disabilities. Component 2, or part B in the Grant Agreement: Delivery of Services to Disabled Persons (US$18.0 million total, including contingencies). The component supported: (i) the construction of nine new rehabilitation facilities (three would have workshops for the production and repair of prostheses and orthoses); (ii) the renovation of five existing facilities; (iii) procurement of equipment, materials for prosthetic workshops and medical aids; and (iv) training activities to improve the services for physical rehabilitation. Component 3, or part C in the Grant Agreement: Project Management (US$0.7 million total, including contingencies). Overall project coordination would be carried out by a Project Management Team (PMT) in the MOH; responsibility for implementation of the components would rest with the relevant departments of the MOH. 1.5.2 A detailed project description is included in Annex 11. 1.6 Revised Components 1.6.1 Because of the political and security context, and the lack of capacity within the MOH, the activities under component 1 (Policy Development and Partnerships) could not be implemented within the available time frame of the Project. At restructuring on March 8, 2009, Part A (Component 1) was canceled, and parts B and C were re-numbered as Parts A (Component 1) and B (Component 2), respectively. 1.6.2 The high domestic inflation made coverage of all the planned construction and equipping difficult, so changes were also made to the new Component 1 for delivery of services to persons with disability (PWD). Eight1 of the original fourteen project sites in thirteen governorates were canceled, so that the revised component consisted of six new rehabilitation facilities (including two facilities with prostheses and orthoses workshops) in six governorates. Reallocated funds were used to purchase electric wheelchairs for adults and children. These electric wheelchairs were very much in demand and were considered a priority by MOH staff. The project revision at restructuring reduced the scope of the investment. However, although narrower, the focus was more on the access and availability of rehabilitation services and prosthetics to the targeted population of disabled people to ensure that the project objectives and activities were better aligned with the realities on the ground. 1.7 Other significant changes 1 Two of the planned new rehabilitation facilities were dropped due to security reason, one was canceled due to land dispute issue, and the renovation of all the five existing facilities was canceled. 4 1.7.1 Other significant changes during the project life included three extensions of the project closing date, two amendments of the Trust Fund Grant Agreement and three reallocations of the proceeds of the Grant. Detailed information on these ―other significant changes‖ is included in Annex 12. 1.7. 2 Although there was a significant reduction in the number of rehabilitation facilities and workshops to be constructed/renovated, more funds were required for civil works because of increases in the scope of works and unit costs. This was partly compensated by a reduction in the amount for goods due to the cancellation of the purchase of prosthesis and orthosis materials. There were significant savings in consultants’ services, but the amounts for training and operating costs were higher than the original estimates. Finally, at restructuring, great care was taken to retain in the Project only the facilities and activities that could be completed within the revised closing date; as a result, an amount of US$2.7 million was cancelled from the ITF Grant. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 2.1.1 Soundness of the Background Analysis. The original PDO was to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability. The Iraq Transitional Government had placed high priority on improving its services for the rehabilitation of PWD and their re-entry into productive life. A reform of the physical and psycho-social rehabilitation services was recognized as one of the priority areas of the MOH. In November 2004, the MOH had prepared a draft national strategy for the physically disabled which included an outline of planned interventions to improve the quality of and access to care for PWD and identified the key challenges for those interventions. Main areas of the plan were identified as: (i) medical rehabilitation of individuals who have suffered serious physical injuries; and (ii) psychological rehabilitation of both the individual and the community involved. The Technical Annex mentioned that the Project, which would meet only a very small portion of the real needs in the area of medical rehabilitation, could be followed by a more comprehensive project, provided sufficient resources and donor partnerships and support were available, and the security context in the country improved. 2.1.2 Assessment of Project Design. This Project was prepared in accordance with Emergency Recovery Assistance Procedures (Operational Policy 8.50)2. Contrary to what is stated in the Technical Annex, project preparation did not take into account the main lesson from the Bank’s recent experience in post-conflict countries, namely that for emergency recovery projects a simple project design that can be quickly and visibly implemented is most effective3. With its mix of (a) policy development/partnerships, and (b) civil works rehabilitation/construction for fourteen facilities in thirteen governorates, 2 OP 8.50 was replaced in March 2007 by OP 8.00 on ―Rapid Responses to Crises and Emergencies.‖ 3 On the other hand, the Project included capacity building for the implementing entities in order to improve their ability to implement programs, which is another important lesson of the Bank experience in post-conflict countries. 5 provision of equipment and training activities, the original project scope was ambitious, considering the prevailing security conditions and the client capacity. The implementation period of 22 months was also unrealistic. With the wisdom of hindsight, the original project scope and implementation time frame were not tailored to the realities on the ground. The section on Bank performance in ensuring quality at entry discusses the political economy context of project preparation and explains why certain choices were made at appraisal. 2.1.3 Another issue is the inclusion of the policy component in the emergency project. The Ad Hoc Committee Appraisal/Negotiations Review Meeting4 held on October 27, 2005 acknowledged that ―the Project will be substantially a physical rehabilitation project with the policy component limited to creating an enabling environment that will contribute to eventual integration of disabled people in society5‖. The project was designed primarily to support immediate needs for physical construction, renovation and equipping of the rehabilitation centers and workshops and staff training as a first step in supporting the needs of PWD. It was understood that the lack of progress in the policy development component would not jeopardize the successful completion of the project. The assumption that MOH would be interested in implementing activities which aimed to enhance partnerships with NGOs was no longer valid with the changes in MOH leadership in the early stages of project implementation. On balance, the decision to include a policy component in the project design was not a good one. 2.1 4 With respect to the original Component 2 on the delivery of services to disabled persons, the Technical Annex listed the facilities to be constructed or rehabilitated and included procurement plans for goods and consultant services that were not detailed 6 and showed global costs that turned out to be underestimated. The Project was to be designed and implemented within the framework of the excellent Master Implementation Manual (MIM) developed by the Bank to be used by Iraqi Ministries for all ITF-financed projects, and of a specific Project Implementation Manual (PIM) for the Project. No PIM had been prepared for the Project before project approval, but according to a dated covenant in the Grant Agreement it was to be prepared by February 28, 2006. 2.1.5 Monitoring and Evaluation (M&E) was another weak point of the project design. The focus on output indicators made sense given the short time-line and the urgent nature of the operation. However, arrangements for M&E were not described in the Technical Annex7, and the only indicator for the delivery of services to the disabled (i.e., the number of disabled beneficiaries) had no baseline8 and no target. 4 This was the equivalent of what is now the decision meeting. 5 The full participation of PWD in society would include access to education and the labor force as well as participation in decision making. 6 This is in contrast with the Technical Annex for the previous health emergency project (the Emergency Health Rehabilitation Project - EHRP) which included detailed lists of medical equipment, furniture and drugs to be purchased and delivered. 7 The Bank Task Team had to use a template for the Technical Annex which did not include a section for M&E. 8 Since the Government at that time wanted to list all physically disabled and base its policy on physical instead of functional disabilities, the absence of a baseline may not have been a bad thing. 6 2.1.6 Government Commitment. When the MOH approached the Bank in October 2004 for support to PWD, this was clearly a priority for the Government, considering the continuous increase in the number of people with physical disabilities as a result of the prevailing violence. The Project was also approved by the Iraq Strategic Review Board. Responsibility for disability services had just been transferred from the Ministry of Defense to the MOH, and MOH wanted to build the necessary capacities in this area. Government commitment was strong at the time the Project was appraised and the Grant was approved. 2.1.7 Assessment of Risks. In designing the Project, the Bank was fully aware of the high security and fiduciary risks and took reasonable actions to mitigate these risks. According to the Technical Annex, which included a detailed and candid discussion on risks, the Project would be implemented in a high-risk environment. The main risks were related to the unstable political environment and the deterioration of security conditions, making access by contractors to sites and supervision difficult. To mitigate these risks, procurement and disbursement arrangements were developed to make implementation as straightforward as possible, and supervision would be undertaken by independent consultants and a Fiduciary Monitoring Agent (FMA) on behalf of the Bank. Security conditions turned out to be much worse than expected originally, but generally the mitigation measures proposed appeared adequate at the design stage. 2.2 Implementation 2.2.1 The implementation arrangements for the Project were basically similar to those being followed under the EHRP, taking into consideration the specific activities under the Project and the hurdles being faced during the implementation of the EHRP. 2.2.2 The main factor outside the control of Government or implementing agencies that influenced project implementation and ultimately the project outcomes was the critical security situation in the country, which had a major impact on all aspects of life. The ITF Grant was approved, signed and became effective at a time when security conditions in the country had already begun to deteriorate. The situation remained extremely fragile for about two years, during which the MOH was virtually non-functioning. Ownership/commitment greatly diminished due to the lack of security in many parts of the country, which made it difficult for MOH staff and contractors to move about in the country and carry out their assignments. 2.2.3 The following factors subject to Government control influenced project implementation: a) The volatile political situation during the transitional stage in establishing the new Iraqi Government, and the intense political struggle and instability within the MOH. The continued sectarian conflict had a major impact on the MOH. There were frequent changes of Ministers and Deputy Ministers. 7 b) The lack of capacity within the MOH to manage project implementation, which was made worse by the security situation and the consequent loss of staff. Staffing of the PMT was unstable and the PMT staff needed a significant amount of training because of their limited experience in project management and Bank policies and procedures. c) The only part of the PIM9 that was prepared dealt with financial management and disbursements. The Project benefited from an excellent MIM developed by the Bank to be used by Iraqi Ministries for all ITF-financed projects. However, a complete PIM would have provided more details on project components and might have facilitated their implementation. d) Difficulties in recruiting good consultants, particularly for design and supervision services for facility rehabilitation. e) The weak capacity of the private sector due to years of isolation, wars and the security environment. f) Recruitment of an international procurement advisor; cooperation between the advisor and the PMT produced better results in procurement. g) Inability of the Bank Task Team to visit the country and of the PMT to visit the project sites. However, this shortcoming was offset somewhat by the work of the FMA. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 2.3.1 M&E design. In this emergency Project to be implemented quickly in a difficult country context of post-conflict, or even in-conflict, the focus on outputs was the right approach. The Ad Hoc Committee Appraisal/Negotiations Review Meeting held on October 27, 2005 decided that ―the M&E indicators for the project would measure project outputs, but would not measure outcome and impact because of the short timeframe of the project. Instead, the indicators would reflect the fact that this project is a pilot activity that could be scaled up through future support‖. However, the indicator for the number of PWD who were to receive prosthetic devices, medical aids and physical therapy from rehabilitation facilities had no quantified targets. Also, the indicator on MOH’s capability to manage, supervise and monitor the project was somewhat vague and difficult to measure. The arrangements for monitoring and evaluation were not described in the Technical Annex. Although the PMT did not include a specific M&E Specialist, the M&E functions were to be carried out by the PMT Technical Coordinator who was responsible for monitoring project progress. 9 According to A(a) of Schedule 4 of the Trust Fund Grant Agreement, the MOH should have prepared, no later than February 28, 2006, a PIM setting out details of all procedures, guidelines, timetables and criteria required for the Project, including the technical, financial, environmental, social and operational arrangements for the carrying out of the Project. The PIM is mentioned in several sections of the Technical Annex. 8 2.3.2 M&E implementation. During implementation, the Bank Task Team helped the MOH/PMT Team to monitor the implementation of the project components through the preparation of detailed output monitoring tables for each rehabilitation facility and workshop. This is important for a project focused on outputs. The Technical Coordinator left the PMT in early 2006, and subsequently, the Bank recommended that the MOH contract an M&E Specialist for the Project, but this did not occur. Also, on many occasions, the Bank drew the attention of senior MOH officials to the need to track the project achievements more closely in terms of improvements in access. 2.3.3 M&E utilization. Monitoring tables were prepared and used by the PMT to monitor the implementation of the component for delivery of services to PWD. It is not known whether M&E data were evaluated or used to inform decision-making and resource allocation at the ministry level. 2.4 Safeguard and Fiduciary Compliance 2.4.1 Detailed information on ―Safeguards and Fiduciary Compliance‖ is included in Annex 13. The main points are as follows: a) An FMA engaged by the Bank helped the Bank to monitor physical delivery/progress and the Recipient’s compliance with financial management and procurement procedures. The FMA visited all EDP sites throughout Iraq every month and carried out physical verification with digital photographs of ongoing works and goods supplied and the production of a fact sheet for each contract, alerting the Bank to deficiencies in quality and implementation. The FMA performance demonstrates that, in contexts where the Bank team cannot carry out normal supervision missions, the Bank can mitigate risks for its program by employing a monitoring agent to monitor physical implementation of projects and verify that funds are spent for the purpose intended and in accordance with Bank rules. b) The Bank prior-reviewed over 90% of all procurement under the Project, and the remaining contracts were reviewed by the FMA. An Independent Procurement Review (IPR) carried out in 2009 as a ―desk review‖ commented that record keeping and filing by PMT were not up to standards, and identified a few shortcomings for which satisfactory explanations could be provided. Since the Bank Task Team made full use of the FMA which carried out 100 percent site inspection for all goods and works delivered, the FMA function was an essential part of the procurement supervision process. The Bank Task Team followed up on the Action Plan proposed by the IPR. During implementation, the PMT/MOH recruited an international procurement advisor. The PMT, in consultation with the Bank procurement staff and the international procurement advisor, performed well in finding practical solutions to many difficult procurement issues. Project procurement under Bank Guidelines contributed to introducing transparency and breaking the existing monopoly by allowing other suppliers to enter the Iraq market. 9 c) The financial management arrangements for the Project were similar to those being followed under the EHRP. Once authorized by the MOH, payments above the threshold of US$10,000 were made by the Bank directly into the bank account of the contractor, supplier or consultant. There was no special/designated account. Payments below the threshold of US$10,000 were made by the MOH from its own resources and were reimbursed, on a periodic basis, by the Bank to the MOH upon presentation of proof of payment and a signed withdrawal application. The absence of a special/designated account was not as big a problem as for the EHRP, because the PMT/MOH managed to establish and maintain throughout the EDP life a project account for payments of small amounts to avoid shortages and delays in payments and reimbursements. The EHRP had experienced delays in payments in Iraqi Dinars (IQD), but this was not a problem for the EDP because only one contract was denominated in IQD; there was no problem with payments made in US Dollars. Financial Monitoring Reports (FMRs) were satisfactory and were submitted in a timely manner. Generally, audit reports were submitted on time and were unqualified. d) With respect to Safeguards, the Project had an environmental category rating of ―B‖. Impacts would be those associated mainly with construction of new rehabilitation facilities. Based on the Environmental and Social Screening and Assessment Framework (ESSAF), the following standards were applied during implementation: (i) inclusion of standard environmental codes of practice (ECOP) in the bid documents for civil works; (ii) use of Safeguard Procedures for Inclusion in the Technical Specifications of Contracts; and (iii) use of the Checklist of likely Environmental and Social Impacts of Subprojects. There was no involuntary relocation of populations or expropriation of privately owned land, and no cultural finds were discovered during excavations. Although compliance with the environmental safeguards was the responsibility of the MOH’s Maintenance Department, the PMT designated two of its staff to act as Environmental Safeguards Focal Points, to follow up at the project sites with the consultants and contractors to ensure that they were adhering to their obligations regarding the environmental safeguards. Construction activities were closely monitored. Checklist forms for all the project sites were completed by the Environmental Safeguards Focal Points and were submitted to the Bank during the April 2010 implementation support mission. 2.5 Post-completion Operation/Next Phase 2.5.1 The delivery of health services by the MOH is a continuous operation independent of the duration of any project, so that there is not really a need for explicit transition arrangements. 2.5.2 The new facilities have been completed and equipped, and the trained doctors and physiotherapists are back on site and available. The rehabilitation centers and workshops are operational, and their recurrent costs are met from the MOH operational budget. 10 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 3.1.1 The objectives, design and implementation of the Project were and remain highly relevant to Iraq’s priorities to rebuild its essential infrastructure and services. Unfortunately, with the ongoing insecurity and violence, the need for more effective rehabilitation facilities for PWD continues to exist at present. The objectives are also consistent with the Interim Strategy Notes (ISN) for Iraq. The third ISN, which is dated February 19, 2009, covers the period FY10-FY11, and envisages three thematic areas of engagement, the first theme being continuing support to ongoing reconstruction and socio-economic recovery efforts. That theme responds to the goals of the International Compact with Iraq which are related to Iraq’s reconstruction and recovery efforts. Activities under this theme support Government policies and public investments that will help restore and modernize Iraq’s physical and human capital. According to the ISN, the Bank program will be decided through Annual Business Planning exercises to support reforms and/or sectors for which ―champions‖ have been identified, and when there is a commitment to engage with the Bank Group to achieve concrete results on the ground. 3.2 Achievement of Project Development Objectives 3.2.1 Since the Project was formally restructured (first order restructuring), the ICR will assess the project outcome ―before‖ and ―after‖ restructuring, in accordance with the Bank ICR Guidelines. Achievement of PDO before restructuring Rating: Moderately Unsatisfactory 3.2.2 Original Component 1 on Policy Development and Partnerships did not progress beyond some initial support to the establishment of the Disabilities Working Group (DWG) whose members included representatives of the Ministries of Health, Labor and Social Affairs, Education and Defense. No policy framework was developed10, and MOH did not enter into any agreement with NGOs to deliver services for the disabled and their families. However, the Project contributed to a dialogue on the definition of disability (medical aspects versus other aspects) and informed decisions on the eligibility of the different categories of disabled. 3.2.3. Even before restructuring, Component 2 on the Delivery of Services to Disabled Persons had been substantially reduced for a variety of reasons, including security concerns, escalating costs and increased scope of work for the facilities. At the time of restructuring, all the originally planned training under the project was completed. In addition, almost all items on the original list of medical aids had been procured, civil 10 The Bank team did put considerable effort into obtaining support from the Italian Government to help the Government develop the legal and policy framework for disabilities. Unfortunately, the dialogue between the various parties broke down before engagement was achieved. 11 works construction for the facilities remaining in the Project was well underway (with one contract completed and the remaining contracts expected to be completed by October 2009), and progress had also been made on the procurement of equipment. Achievement of PDO after restructuring Rating: Moderately Satisfactory 3.2.4 The restructuring was undertaken to ensure that the Project would meet the revised PDO and implement activities successfully within the project timeframe. The revised key performance indicators included two outcome indicators (number of disabled using the facilities and number of disabled who received medical aids), but also included eight output indicators. In the revised PDO wording, the terms ―to improve access of the disabled population in the targeted areas to rehabilitation and prosthetic services‖ meant ensuring the availability of equipped rehabilitation facilities with workshops and trained staff as well as the availability of medical aids. The output indicators are thus proxy indicators for access to services. This is in line with Iraq’s priorities to rebuild its essential infrastructure and services, and with the ISN approach. 3.2.5 The Data Sheet includes information on the indicator values at completion and Annex 2 provides detailed information on all outputs. The Project’s achievements have been substantial in terms of both the number of PWD benefitting from the Project and the availability of services. (1) Use of the facilities. Target exceeded by 100 percent for the number of PWD who have used the newly constructed and equipped facilities. For the six rehabilitation centers, the average number of clients is 1,000 per center per month, compared to the target of 500 clients per center per month. (2) Availability and distribution of medical aids: i. Target basically met for the procurement of medical aids (wheelchairs, crutches, walking sticks, walking frames, walking collators, and tripods); compared to the target of 39,900, 38,697 medical aids (97 percent) were procured and distributed to the warehouses of the Directorates of Health in the respective Governorates. ii. Number of disabled receiving medical aids. Distribution of medical aids to disabled persons is a slow process because of bottlenecks in MOH validation and allocation of the medical aids to the respective Directorates of Health. Moreover, MOH has very limited monitoring and reporting capacity so that, as of this writing, the total number of disabled that received medical aids is not known. (3) New rehabilitation facilities and workshops. Construction target met. The six new basic rehabilitation centers and the three prosthetic workshops were constructed. Rehabilitation and workshop equipment, as well as medical and non-medical furniture, were delivered and installed in the new facilities which are operational. An additional set 12 of rehabilitation and workshop equipment was procured for a seventh center, the existing Al Hakim Hospital in Bagdad. (4) Staff training. One target exceeded, one target almost met and three targets not met, but with explanations: i. Management training: 15 center managers (target: 20) were trained overseas. ii. Training in physical rehabilitation: 65 hospital-based physiotherapists (target: 78) and 16 hospital-based physicians (target: 30) were trained overseas. iii. Training in the production and fitting of prostheses and orthoses: 59 prosthetics workshop technicians (target: 47) were trained overseas, and 18 technicians (target: 30) were trained locally. Since there were a limited number of qualified prosthetics technicians in Iraq, this training was an important project achievement. 3.2.6 As discussed in Annex 2, there are valid reasons why some targets were not met. Eight physiotherapists and ten physicians who had received regular training on physical rehabilitation were also scheduled for some additional specialized training, but MOH declined to accept the proposal from the firm that was selected because of its high cost and logistical problems. The training was canceled due to insufficient time to select an alternative training provider. As to the in-country training of technicians in the production and fitting of prostheses and orthoses, it could not take place until the training equipment and material had been delivered and installed. Three technicians received training-of-trainer (TOT) training overseas; the fees for the training courses were covered by the MOH budget, and project funds financed the per diems and accommodations. On their return to Iraq, the three technicians provided training locally to 18 technicians who were to then train their colleagues in the rehabilitation centers and workshops. 3.2.7 All the completed rehabilitation facilities and workshops have been handed over to the MOH and are operational. The table below shows the numbers of patients for the six rehabilitation facilities. New Rehabilitation Centers Average Number of patients (per month) Amara 900 Basrah 1,500 Dewaniyah 750 Karbala 1,050 Kut 1,050 Samawa 750 Total for Six Centers 6,000 Average per Center 1,000 13 3.2.8 Other achievements. The Project supported redefining the roles and responsibilities within Government for disabilities, i.e., the shift in disability services delivery from the Ministry of Defense to the MOH, including improved transparency. That was a significant achievement. 3.3 Efficiency Rating: Not Rated 3.3.1 During preparation/appraisal, the lack of reliable statistics, the limited economic information, and the speed with which the Project was prepared prevented the carrying out of a detailed financial and economic analysis, a constraint in such operations. PWD living within the catchment areas of the six new rehabilitation facilities now have access to high quality rehabilitation and prosthetic services that otherwise would not have been adequately delivered. This facilitates their re-entry into productive life. However, no economic evaluation of the Project has been carried out upon completion, and none is planned. Economic evaluation is an area where Iraqi expertise is not strong, so that if such an evaluation were to be done, it would have to be carried out by Bank staff; this is not possible for the time being because of the security situation. Annex 3 provides a more detailed discussion of efficiency. 3.4 Justification of Overall Outcome Rating Rating: Moderately Satisfactory 3.4.1 During project implementation, the country faced an extremely difficult security environment which had a major impact on all aspects of life. Both the Bank Task Team and PMT staff worked under conditions of great danger and stress. In addition, years of isolation and instability led to weak implementing capacity by the Government (including weak capacity to make decisions) and the private sector. Thus, the Iraq context is a unique situation that needs to be acknowledged and considered in any evaluation of the Project. 3.4.2 The Project’s objectives, design and implementation were and remain highly relevant to current country priorities and the ISN. The achievement of the PDO is rated ―Moderately Unsatisfactory‖ before restructuring and ―Moderately Satisfactory‖ after restructuring. Since the PDO was formally revised (first order restructuring, approved by the Regional Vice-President) when only US$4.81 million (about 29 percent of the revised US$16.80 million grant amount) was disbursed, the overall outcome rating must take into account the achievements before and after restructuring11. As shown in the Table below, the weighted value of 3.70 corresponds to a rating between ―Moderately Satisfactory‖ and ―Moderately Unsatisfactory‖, but closer to ―Moderately Satisfactory‖. The overall rating is rounded to ―Moderately Satisfactory‖; this is the same rating as the rating for progress towards achievement of the PDO in the last ISR. 11 ICR Guidelines – OPCS – August 2006 (last updated on 2/9/2007) - Page 25 and Appendix B. 14 Against Against Overall original PDOs revised PDOs 1. Rating Moderately Moderately - Unsatisfactory Satisfactory 2. Rating value* 3 4 - 3. Weight** 29% 71% 100% 4. Weighted value 0.87 2.84 3.71 5. Final rating (rounded) Moderately Satisfactory *Highly Satisfactory = 6; Satisfactory = 5; Moderately Satisfactory = 4; Moderately Unsatisfactory = 3; Unsatisfactory = 2; and Highly Unsatisfactory = 1. **% disbursed before/after PDO change 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 3.5.1 As a group, disabled people are disproportionately represented among the world’s poorest. The Project may have had a significant poverty reduction impact, not only for PWD, but also for their entire families. Given the high unemployment rates and poor community services, becoming disabled poses a serious risk for the entire family to slip into poverty. Although statistics are not available, it is likely that the Project facilitated the re-entry of disabled persons into productive life. (b) Institutional Change/Strengthening 3.5.2 The Bank was the only development partner that worked through Iraqi institutions, which did help to build institutional capacity and was appreciated by Iraqi officials. Following on the work initiated under the EHRP, the Project continued to build the technical and management capacity of the MOH and PMT. Through on-the-job training and interaction with Bank and FMA staff, PMT capacity was strengthened. Now that the PMT is dissolved, the PMT staff who did receive considerable training through the project in procurement, financial management and project management, have brought their new skills to other parts of the MOH. The increase in the number of skilled medical technicians and prosthetics technicians in the area of disabilities has strengthened the MOH technically. (c) Other Unintended Outcomes and Impacts (positive or negative) 3.5.3 The successful completion of the EHRP and the EDP has paved the way for the Bank’s future dialogue with the Iraqi authorities on health. Albeit as short term responses to emergencies, these projects have an added value beyond project outcomes and outputs. They have a demonstration effect, proving the reliability of partnership with the client; they provide the foundation for a subsequent engagement on a longer term basis. 15 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops Not applicable 4. Assessment of Risk to Development Outcome Rating: Significant 4.1 The rehabilitation facilities and workshops have been built and equipped, doctors and technicians have been trained, and the centers are operational with recurrent costs met by MOH budget. Based only on these considerations, the risk to development outcome could be assessed as ―low‖. However, the situation in Iraq remains fragile, and there is a risk of collapse for lack of security. The ICR rates the overall risk to development outcome - i.e., the risk that development outcomes will not be maintained – as ―Significant.‖ 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Unsatisfactory 5.1.1 The Bank strategy in Iraq was to ensure Iraqi ownership and strengthen institutional capacity by financing operations that are implemented by Iraqi Ministries and other recipient entities. The Project was prepared as part of the interim strategy of the World Bank in addressing the pressing needs of the sector and according to the emergency recovery assistance procedures (OP 8.50). It was prepared in seven months. The main concern was to obtain concrete results and to obtain them quickly. The original PDO (to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability) rightly emphasized outputs. During preparation/appraisal, the Bank did a good job in focusing on outputs and on assessing risks. 5.1.2 When rating the quality at entry, one has to keep in mind the history and context of the project preparation, in addition to assessing the project design. The need to move quickly to prepare the Project (using the Bank’s rapid response procedures), and the reality of having to appraise the Project from a distance required the Bank team to take a calculated risk of moving ahead with a best-case scenario design. When the Project was designed, Iraq was at the edge of breaking into several ethnic states, with political instability and fragmentation of leadership. The selection of fourteen sites for rehabilitation facilities in thirteen governorates was a high risk, but selecting a smaller number would have been politically difficult. Another point worth noting is that the Bank first engaged with the MOH in preparing a project on disabilities at a time when the responsibility for disability had been recently transferred from the Ministry of Defense to the MOH, and the MOH leadership itself was committed to building the ministry’s capacity to provide improved services to the disabled. A few months into project implementation, the political environment changed completely, and the new leadership of the MOH had a different agenda which did not include serious commitment to the Project or to working with the Bank. 16 5.1.3 As discussed in Section 2.1, with its mix of policy development/partnerships and civil works/equipment for fourteen facilities in thirteen governorates, the original project scope was ambitious. Including a policy component in such an emergency operation in a fluid political environment was a calculated risk on the part of the Bank and, on balance, that decision was not a good one. The implementation period of 22 months was unrealistic. The Project was not fully prepared when it was approved by the Regional Vice-President (RVP). Project costs turned out to be significantly underestimated. Finally, the arrangements for monitoring and evaluation were not detailed and the main output indicator (number of PWD benefitting from the Project) had no quantified target. Based on this relatively low quality work, a rating of ―Unsatisfactory‖ would be justified for the Bank performance. However, taking into consideration the history and context of project preparation, the Bank performance in ensuring quality at entry is rated ―Moderately Unsatisfactory.‖ (b) Quality of Supervision Rating: Satisfactory 5.1.4 The Bank Task Team for this Project worked under difficult conditions with great stress. Its ability to respond to implementation problems was constrained by the security conditions on the ground which prohibited on-site supervision, and the team had to operate from Amman, with the PMT and MOH staff traveling to Amman. Also, Bank efforts were not productive when the MOH was nearly paralyzed for more than two years. To substitute for the lack of on-site supervision, the task team made good use of the FMA, which worked on all ITF-financed projects, by maintaining close communication with the FMA personnel during implementation and inviting them to participate in all supervision missions. 5.1.5 Management gave high priority to this Project, and invested a great deal of time in assisting the task team. The budget was appropriately large for this difficult project (US$317,000 for lending and US$730,000 for the five years of supervision). There has been some continuity in staffing, with an acceptable skills mix. In aide memoires and ISRs, the candor, degree of detail, and meticulous reporting of project progress or lack thereof were of high quality. In the ISRs, the ratings for DO and IP were appropriate. The Bank Task Team was very pro-active in dealing with the implementation problems; for example, early on, the Bank suggested the cancelation of the first component which was not performing at all. Overall, the Bank Task Team paid good attention to financial management, procurement and safeguards, with extensive coverage in the aide memoires and ISRs. Through the preparation of detailed output monitoring tables for each rehabilitation facility, the Bank Task Team helped the MOH/PMT Team monitor project implementation. Regarding the restructuring, because of the continual changes in MOH leadership, the opportunity for a dialogue with the counterpart did not present itself until late in the project implementation, when the Bank team was able to reach agreement with the MOH on downsizing the project, through cancellation of US$2.7 million, to make it more achievable. 17 5.1.6 The Bank introduced great flexibility in moving the Project forward, despite difficult circumstances, and eventually engaged more productively with the MOH in the latter part of 2008. The quality of supervision is rated ―Satisfactory.‖ (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory 5.1.7 The rating for quality at entry is in the unsatisfactory range and the rating for quality of supervision is in the satisfactory range. In accordance with the Bank’s ICR Guidelines, the rating for Overall Bank Performance depends on the outcome rating. Since the outcome is in the satisfactory range, Overall Bank Performance is rated as ―Moderately Satisfactory.‖ 5.2 Borrower Performance (a) Government Performance Rating: Moderately Unsatisfactory 5.2.1 During preparation and appraisal, the Iraq Transitional Government had placed high priority on improving its services for the rehabilitation of PWD and their re-entry into productive life. After 2003, the responsibility for disabilities shifted from the Ministry of Defense to the MOH; ―disabilities‖ was therefore a new responsibility for MOH. In 2005, the political and security situation had already begun to deteriorate, and soon the MOH was engulfed and engaged in the sectarian conflict and barely functioned for a prolonged period (up to the end of 2007). The MOH leadership was seriously affected by the political context, and this resulted in periodic gaps in leadership at the Minister and Deputy Minister level. Even when present, they were often unable or unwilling to provide the leadership required for project implementation. This lack of effective leadership is one of the reasons why Component 1 on Policy Development and Partnerships did not progress beyond initial support for the establishment of the DWG. One needs to acknowledge that the PMT staff and the FMA faced very dangerous situations such as: death threats, kidnappings, the constant potential for random harm, or to be discovered as being associated with an international organization; yet, most still worked displaying great courage and dedication during this period, literally risking their lives (in 2006, the Deputy Minister of Health was kidnapped and has never been seen again). 5.2.2 Starting in late 2007, with the appointment of new leadership in the MOH, the Project began to be implemented more smoothly, due to the increased attention of the Ministry leadership (both the Minister and the Deputy Minister for Donor Affairs) and the stability and growing effectiveness of the PMT which, by this point, had gained experience in project management. 5.2.3 The positive role of the PMT (which was a requirement for ITF-financed projects) is an important feature of the Project. With Bank support, the MOH/PMT Team was able to monitor the implementation of the project components on the basis of detailed output monitoring tables for each rehabilitation facility. On the other hand, going beyond the 18 focus on outputs, the MOH/PMT was not able during the project life to satisfactorily track the project outcomes with respect to access and quality of services. 5.2.4 Because of the instability within the MOH during the 2005-2007 period and the lack of security in the country, it took five years (and not 22 months, as planned) to complete the project. But, in the end, the revised Project was satisfactorily completed despite all the problems and difficulties. (b) Implementing Agency or Agencies Performance Rating: Moderately Unsatisfactory 5.2.5 The implementing agency was the MOH. Since the MOH is part of the Government, the assessment of its performance is included in 5.2 (a) above. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Unsatisfactory 5.2.6 The Government’s implementation performance has varied over the five-year project period. Because of the very fragile political and security context, the Government performed poorly in the early years of the Project. With the increased stability in the MOH leadership, the increased capacity of the PMT in project management and the significant improvement in the PMT’s performance, the situation improved in the last two years of the Project. However, the disbanding of the full PMT before the Project was completed was another sign of the Government’s low commitment to the Project. In view of the deterioration of MOH oversight at critical phases in the Project, the Overall Recipient Performance is rated ―Moderately Unsatisfactory.‖ 6. Lessons Learned (1) Giving more time for a solid preparation work would save time in implementation. The Project was designed to provide rehabilitation services as a matter of urgency. Speeding up the preparation process does not always allow for developing some project aspects in details. Experience from many countries shows that implementation delays during the early years are common, especially with recipients that are not familiar with Bank requirements and procedures, and that the preparation process often spills over into the first years of implementation. (2) Project design needs to take into consideration the particular characteristics of the country, aiming not necessarily for the assumed best practice but for the best fit. The Project was designed in 2005 based on similar projects financed by the Bank in other countries. With the many years of isolation and the current lack of security and political stability, the context in Iraq was different. At the design stage, it is necessary to involve the client fully in the discussions and studies to identify the project’s essential requirements. (3) An emergency project to provide disability assistance should not have a policy component. 19 (4) In fragile states, the design of emergency projects in conflict-affected situations should be very simple, manageable in scope and suitable to the context and should include satisfactory M&E arrangements, with a primary focus on outputs. The Bank should always assume low institutional capacity and high turnover in a conflict, post- conflict, fragile situation. The Bank should support the counterparts in establishing an M&E system to ensure effective project oversight; Bank support for monitoring outputs may be very valuable to project management. (5) In contexts where normal supervision missions are not possible, the Bank can mitigate risks for its program by recruiting an FMA to help in monitoring physical implementation of projects and verifying that funds are spent for the purpose intended and in accordance with Bank rules. The Bank Task Team should keep close communication with the monitoring agent during implementation, and invite the monitoring agent to participate in all supervision missions. This has been good practice for building the capacity of the PMT. 7. Comments on Issues Raised by Grantee/Implementing Agencies/Donors (a) Grantee/Implementing agencies None (b) Cofinanciers/Donors None (c) Other partners and stakeholders None 20 Annex 1. Project Costs and Financing (a) Project Cost by Component Components Appraisal Estimate Actual/Latest Actual/Latest Estimate Revised at Estimate estimate as a restructuring percentage of (USD million) (USD million) (USD million) Appraisal 1. Policy Development and Partnerships 0.75 0.00 0.00 0.00 2. Delivery of Services to Disabled Persons 18.04 (1) 16.27 90% 3. Project Management 0.71 (1) 0.43 61% Total Baseline Costs 19.50 16.80 16.70 86% Physical Contingencies (2) 0.00 0.00 0.00 Price Contingencies (2) 0.00 0.00 0.00 Total Project Costs 19.50 16.80 16.70 86% Project Preparation Costs 0.00 0.00 0.00 Total Financing Required 19.50 16.80 16.70 86% (1) The Restructuring Project Paper did not include the revised costs by component. (2) Contingencies were included in the total costs. (b) Financing Source of Funds Type of Appraisal Actual/Latest Percentage of Cofinancing Estimate Estimate Appraisal (USD million) (USD million) Government N/A 0.00 0.00 0.00 World Bank Iraq Trust Fund N/A 19.50 16.70 86% 21 Annex 1 (continued) - Actual Costs of the Revised Components The table below provides more detailed information on the actual costs of the revised components: Revised Components Actual Costs (US$ million) Revised Component 1- Delivery of Services to Disabled Persons New Rehabilitation Centers Design and supervision services 0.62 Construction of six new rehabilitation centers 6.00 Sub-total new rehabilitation centers 6.62 Equipment, Medical Aids and Materials Rehabilitation Equipment 1.66 Workshop Equipment 1.50 Medical Aids 4.67 Training Materials 0.16 Sub-total equipment, medical aids and materials 7.99 Training Overseas Training 1.64 In-country training 0.03 Sub-total training 1.66 Sub-total Component 1 16.27 Revised Component 2 – Project Management Equipment 0.03 PMT Consultants 0.06 Capacity building for the PMT - External Audit 0.06 Operating Costs 0.37 Sub-total Component 2 0.43 TOTAL 16.70 22 Annex 2. Outputs by Component When the project was restructured and the original Component 1 on policy development and partnerships was canceled in March 2009, the following proposed contracts were canceled: (i) national and international consultants for the DWG; (ii) conferences/workshops with NGOs; (iii) service contracts with NGOs; and (iv) public awareness campaigns. This Annex will discuss the outputs for the revised components. Revised Component 1. Delivery of Services to Disabled Persons (appraisal estimate: US$18.04 million; actual cost: US$16.27 million) New Rehabilitation Centers (appraisal estimate: US$5.63 million; actual cost: US$6.62 million) Design and Supervision Services (appraisal estimate: US$0.85 million – actual cost: US$0.62 million). Of the 14 civil works packages, only six were retained in the project. Design and supervision services for the six centers were contracted to four firms. Regarding the eight centers that were canceled, no consultancy was needed for the four centers that were cancelled early on in the project; for the other four centers that were canceled later, consultancy services were provided only for the design and the supervision parts of these contracts were cancelled. The final cost of design and supervision services is about US$0.62 million. Construction (appraisal estimate: US$4.78 million; actual cost: US$6 million). Of the original 14 construction packages, the following 8 were cancelled (figures in parentheses are appraisal estimates):  Baquba New Rehab Center (US$0.36 million)  Ramadi New Rehab Center (US$0.36 million)  Karkh New Rehab Center and Workshop (US$0.61 million)  Hamza Renovation of Existing Rehab Center (US$0.17 million)  Nasiriyah Renovation of Existing Rehab Center (US$0.29 million)  Hilla Renovation of Existing Rehab Center (US$0.17 million)  Kirkuk Renovation of Existing Rehab Center (US$0.09 million)  Tikrit Renovation of Existing Workshop (US$0.09 million) The US$2.13 million allocated for the eight packages canceled were made available to cover cost overruns for the remaining six Centers. The final cost was US$6.00 million mainly due to inflation. There were no exchange rate risks as in the case of the EHRP, as all contracts were awarded in US Dollars—a lesson learned from EHRP. 23 The following six contracts have been completed (figures in parentheses are adjusted final contract values including variation orders), and the six centers have been handed over to the MOH and are functioning:  Amara New Rehab Center (US$0.66 million)  Basra New Rehab Center (US$0.84 million)  Samawa New Rehab Center (US$0.68 million)  Karbala New Rehab Center (US$0.81 million)  Dewaniyah New Rehab Center and Workshop (US$1.36 million)  Kut New Rehab Center and Workshop (US$1.66 million). Equipment, Medical AIDS and Materials (Appraisal Estimate: US$11.4 million; actual cost: US$7.99 million) The Project provided funding for: (i) rehabilitation equipment; (ii) workshop equipment; (iii) medical aids; (iv) training materials for Prosthetics; and (v) prosthesis and orthosis materials. During 2010, there were delays in the availability of raw materials for the workshops, and the MOH decided to provide the raw materials by permitting the Directorates of Health to procure the raw materials locally, up to a ceiling per package of 50 million Iraqi Dinar (about US$42,500 equivalent). The consumable category of raw materials under (v) above was cancelled. Below is a summary of the goods procured through the Project for the revised Component 1. (a) Rehabilitation Equipment (appraisal estimate: US$1.54 million; actual cost: US$1.66 million). About 23 generic items (448 items in total) were procured under ICB and direct contracting, and awarded in four packages (ranging from US$0.16 million to US$0.68 million). All equipment has been delivered to the six new centers and Al Hakim Hospital (64 items each) and has been installed. (b) Workshop Equipment (appraisal estimate: US$1.29 million; actual cost: US$1.50 million). Equipment for the Prosthetic Workshops at three centers (Kut, Dewaniyah and Al Hakim Hospital), around 166 generic items (6,222 items in total, about 2,074 per center) were procured from Otto Bock under ICB at US$1.5 million. All items were initially delivered and stored at the port of Basra, until the centers were ready to receive them. All items have now been installed in the designated workshops centers. (c) Medical Aids (appraisal estimate: US$4.62 million; actual cost: US$4.67 million). Medical aids were procured in four packages: (i) ICB (7 generic items: wheel chairs, toilet wheel chairs, arm crutches, walking sticks, walking frames, walking rollators, tripods; 34,000 in total) at US$1.92 million; 24 (ii) ICB (2 generic items: electrical wheel chairs for adults and children; 523 in total) at US$2.05 million; (iii) Shopping (1 generic item: forearm crutch for child; 4,000 in total) at US$0.07 million; and (iv) Direct Contracting (to the same supplier for electrical wheel chairs through contract extension for1 generic item: electrical wheelchair for adults; 174 in total) at US$0.63 million. (d) Packages (i) and (iii) above had been distributed to the respective directorate warehouses until the civil works of the six centers were completed and operational; they have since been distributed to the rehabilitation centers. The 523 electrical wheelchairs in package (ii) and the 174 electrical wheelchairs in package (iv) were delivered to the Central MOH warehouse. In summary, for medical aids, 38,697 items have been procured and distributed to the DOH warehouses in the respective Governorates or to the Central MOH warehouse. The target indicator for medical aids procurement was set at 39,900, and therefore the actual number represents 97% achievement. (e) A special ministerial committee was set up to speed up the process of dispensing all the medical aids to PWD by April 30, 2011. According to the information available as of this writing, only 18,508 medical aids (48% of the number procured) have been dispensed to PWD. Delays have been caused primarily by bottlenecks in MOH validation and allocation of the medical aids to the respective DOHs, and dispensing of electrical wheelchairs is slow because it requires examination and certification by medical personnel. (f) Training Materials. Procurement of training materials has been completed under three shopping contracts ranging from US$12,000 to US$90,000. Total cost was US$156,000. (g) Prosthesis and Orthosis Materials (estimated value of US$2.78 million and US$0.93 million, respectively). Procurement of these materials was cancelled from the project following an agreement reached during the April 2008 supervision mission that the MOH would procure this equipment with its own resources. MOH has its own contracts for the continuous supply of these materials. However, there is a lag in the supply because the contracts need to go through the complex procedures of Kimadia (the procurement agency for MOH). The MOH provides the raw materials by permitting the Directorates of Health to procure the raw materials locally, up to a ceiling per package of 50 million Iraqi Dinar (about US$42,500 equivalent). 25 (h) Medical Furniture. Most medical furniture was supplied as separate lots under the Rehabilitation Equipment and Workshop Equipment packages. (i) Non-Medical Furniture. Non-medical furniture was provided under the civil works contracts. Training (appraisal estimate: US$0.99 million; actual cost: US$1.67 million) The training courses are summarized below. (a) Overseas Training (actual cost: US$1.64 million) (j) Between March 2007 and August 2009, Prosthesis and Orthosis training was provided at the Otto Bock Health Care Academy in Germany for 47 technicians in six batches, including the last batch of 3 technicians who were trained as trainers (see notes under in-country training below). There was also overseas training tied to equipment procurement, i.e., Workshop Technician training (contract value US$200,000). This training for 12 prosthetics workshop technicians was provided by Otto Bock Germany on a sole source basis from June 29-August 14, 2009. In summary, a total of 59 prosthetics technicians were trained. The course duration varied between 37 and 47 days. (k) In September 2007, Management training was provided at the Center for International Rehabilitation (CIR) – University Clinical Center in Tuzla / Bosnia for 15 center managers (the target was 20 managers trained). The course duration was 12 days. (l) Between September and December 2007, Physiotherapy training was provided at the CIR in Bosnia for 65 technicians in three batches. The course duration was about 30 days. (m) Between December 2007 and February 2008, training of Hospital-Based physicians was provided at the CIR in Bosnia for 16 physicians (original plans were made for 20 physicians to attend the training, but four were unable to attend due to lack of permission). The course duration was 15 days. Other free-standing programs were less successful as in the case of Physiotherapist and Physician Training (estimated cost US$231,000). This training was planned for two groups: (a) physiotherapists working on rehabilitation of spinal cord injuries; and (b) physicians on orthosis prescription. Eight physiotherapists, all of whom received training in Bosnia under the project, and ten physicians were expected to receive training in their respective specializations through one training program. Eurohealth was selected, and provided a proposal which the MOH eventually declined to accept, after lengthy negotiations, due to high cost and logistical challenges. This training was cancelled due to insufficient time to select an alternative training provider. 26 (b) In-country Training (actual cost: US$0.03 million) All the trainings were dependent on the procurement of training equipment and material being delivered and installed. Otto Bock provided training-of-trainers (TOT) to three of the previously trained technicians in November/December 2009. The fees for the training courses were covered by the MOH budget, and the per diems and accommodations in the amount of US$31,300 were covered by the project funds. Following their return, the three Trainers conducted the following centralized training courses in Baghdad:  Production of prosthetics for above knee for six MOH staff (a 10-day course).  Production of prosthetics for below knee for six MOH staff (a 10-day course).  Assembling myoelectric prosthetics below elbow for six MOH staff (a 10-day course). The 18 staff trained in the above courses are expected to train their colleagues at their respective centers. In addition, the MOH plans to continue to provide several rounds of centralized trainings in Baghdad. Revised Component 2: Project Management (appraisal estimate: US$0.71 million; actual cost: US$0.52 million) The project financed some computers and peripherals, PMT consultants, external audits and operating costs. 27 Annex 3. Economic and Financial Analysis 3.1 The Project was prepared as part of the interim strategy of the World Bank in addressing the pressing needs of the sector and according to the emergency recovery assistance procedures (OP 8.50). The lack of reliable statistics, the limited economic information, and the speed with which the project was prepared have prevented more detailed analysis, a familiar constraint in such operations. However, the benefits of the project’s investment were expected to be substantial compared to its costs, as it addressed urgent needs in an environment of devastated infrastructure, deteriorating quality and escalating needs. 3.2 PWD living within the catchment areas of the six new rehabilitation facilities now have access to high quality rehabilitation and prosthetic services that otherwise would not have been adequately delivered. This facilitates their re-entry into productive life. The burden of disability for Iraqi society is huge. Given the high unemployment rates and poor community services, becoming disabled poses a serious risk for the entire family to slip into poverty. However, no economic evaluation of the Project has been carried out upon its completion, and none is planned. Economic evaluation is an area where Iraqi expertise is not strong, so that if such an evaluation were to be done, it would have to be carried out by Bank staff; this is not possible for the time being because of the security situation. 3.3 The majority of the goods were procured under International Competitive Bidding (ICB). There were an acceptable number of bidders for each contract, and the ICB method enabled the PMT to attract better firms, qualities and prices. The civil works were procured under National Competitive Bidding (NCB). Unfortunately, the ICR mission could not obtain information on the efficiency12 of the construction of the new rehabilitation facilities financed by the ITF Grant. In the circumstances, although there is no reason to believe that Iraq did not also get good value for money for the new rehabilitation facilities, the rating for efficiency is: ―Not rated.‖ 12 For example, comparisons with the costs of similar rehabilitations carried out under other projects. 28 Annex 4. Grant Preparation and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending/Grant Preparation Jean-Jacques Frere Sr. Health Specialist MNSHD Task Team Leader Virginia H. Jackson Sr. Operations Officer/Consultant MNSHD Operations Sr. Implementation Vasilios C. Demetriou MNSHD Implementation Specialist/Consultant Sr. Procurement and Environmental Mario Zelaya MNSSD Implementation Specialist / Consultant Health and Disabilities Nedim Jaganjac ECSH1 Health Specialist/Consultant Goran Cerkez Rehabilitation Specialist/Consultant MNSHH Health Mira Hong Operations Officer MNSSP Operations Emma Paulette Etori Language Program Assistant MNSHD ACS Nazaneen Ismail Ali Procurement Specialist/Consultant MNAPR Procurement Lead Finance Officer, Fiduciary David Weber LOAG1 Finance Assurance Mona El-Chami Financial Management Specialist MNAFM Finance Hiroko Imamura Sr. Counsel LEGES Legal Vikram Raghavan Legal Counsel LEGES Legal Colin Scott Lead Social Safeguards Specialist MNSSO Safeguards Supervision/ICR Jean-Jacques Frere Sr. Health Specialist MNSHD Task Team Leader Francisca Avodeji Akala Sr. Health Specialist MNSHD Task Team Leader Afrah Alawi Al-Ahmadi Sr. Human Development Specialist MNSHD Task Team Leader Eileen Brainne Sullivan Health Specialist MNSHH Task Team Leader Nazaneen Ismail Ali Senior Procurement Specialist MNAPR Procurement Vasilios C. Demetriou Consultant MNSHD Implementation Majed El-Bayya Lead Procurement Specialist ECSC2 Procurement Sr. Financial Management Mona El-Chami MNAFM Finance Specialist Emma Paulette Etori Language Program Assistant MNSHD ACS Mira Hong Operations Officer MNSSP Operations Virginia H. Jackson Consultant LCSHH Operations Nedim Jaganjac Sr. Health Specialist ECSH1 Health Layla Gumer Kuleib Local Coordinator/Consultant MNSHD Operations Maisam M. Al-Hayali Sr. Operations Officer/Consultant MNCIQ Operations Antonio C. Lim Operations Officer ECSS2 Operations Jad Raji Mazahreh Financial Management Specialist MNAFM Finance Claudine Kader Senior Program Assistant MNSHD ACS Mario Antonio Zelaya Consultant MNSSD Implementation Paul Geli Consultant MNSHD ICR 29 (b) Staff Time and Cost Staff Time and Cost (Bank Budget and Trust Fund) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY06 15* 317.10 Total: 15* 317.10 Supervision/ICR FY07 n.a. 230.47 FY08 n.a. 187.77 FY09 n.a. 137.47 FY10 n.a. 116.42 FY11 n.a. 57.96 Total: 730.09 *The number of staff weeks is known only for the very small part of the cost financed by the Bank budget. 30 Annex 5. Beneficiary Survey Results Not applicable 31 Annex 6. Stakeholder Workshop Report and Results Not applicable 32 Annex 7. Summary of Grantee's ICR and/or Comments on Draft ICR Summary of borrower’s ICR Implementation Completion Report (ICR) EMERGENCY DISABILITY PROJECT (EDP) February 2011 Prepared by Project Management Team (PMT) Ministry of Health (MOH) Republic of Iraq Acronyms 1. CIR ……….. Center for International Rehabilitation. 2. DWG ……... Disability Working Group. 3. EDP ………. Emergency Disability Project. 4. EHRP …….. Emergency Health Rehabilitation Project. 5. ICB ……….. International Competitive Bid. 6. MOH …….. Ministry Of Health. 7. NCB ……… National Competitive Bid. 8. NGO ……… Non-Governmental Organization. 9. PMT ……… Project Management Team. 10. PWD …........ Persons with Disability. 11. TOT ………. Training Of Trainers. 12. WB ……….. World Bank. 13. WHO ……... World Health Organization. Executive Summary This report is prepared by Project Management Team PMT/ MOH, to reflect an overview of project implementation experience focusing on the points of strength and weakness confronted by the PMT/MOH throughout implementing the project and the impact of factors affected the progress. 33 The ongoing violence, large number of war veterans from conflicts, and breakdown of community support systems with limited access to health rehabilitation services are having devastating effect on persons with disabilities (PWD) in Iraq, and increasing the already high burden of disease. The burden imposed on Iraqi society by disabilities is huge. Given the high unemployment rates and poor community services, becoming disabled poses a serious risk for entire family to slip into poverty. The Iraq government placed high priority on improving its services to support rehabilitation of disabled persons and their re-entry into productive life. In November 2004, the MOH prepared a draft national strategy for physically disabled which includes an outline of planned interventions to improve the quality of and access to care for people with disabilities. In this context, the MOH has developed a broad framework for care of disabled, with realistic targets to be achieved within five years. The MOH approached the World Bank in October 2004 concerning support to PWD resulting from war and related accidents. This meeting yielded an agreement between World Bank and MOH set the priorities to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability. Specifically, support the development of a national policy on disabilities; increase the capacity of Iraqi institutions to meet the needs of disabled persons, strengthen the partnerships between the Government and civil society in provision of services to disabled persons; and upgrade the infrastructure and equipment of selected rehabilitation and prosthetic centers throughout Iraq. Based on the meetings mentioned above, Grant Agreement with amount of $19,500 million was allocated to MOH/Iraq under the Iraqi Trust Fund for an Emergency Disability Project on Nov.23th, 2005. Then reduced to $16,800 million (after final reallocation) when$ 2,700 million had been cancelled and project restructuring done in Nov 2008. In details, the activities which actually had been executed under each component of the project are to be demonstrated herein. Introduction The community of persons with disability (PWD) is one of the most critical components of populations; especially in Iraq, after two decades of conflicts and its ensuing complications; the health sector’s infrastructure -as a vital component of country structure components- was heavily affected, causing a tangible deterioration and mismanagement in providing the essential services to the disabled people as well as decreasing the capacity of this component to achieve minimum daily requirements, affecting their education, workforce, and of course their income as a consequence to the overall deterioration. The number and status of the centers and hospitals dedicated to disability care was also too modest to meet the expanding needs of the society of disabled people, in addition to the low-level services provided and the availability of raw materials, equipments, and vocational training for staffs involved in it. Also, the limited experience of the government in cooperation and working with NGOs was another factor 34 to keep or downgrade the services and its resources to the lowest levels without updating or upgrading the status of the activities performed in this course. The project as a result was planned to address the main points that affect the key requirements to serve the persons with disability considering the spectrum of services to be for those with physical disability, as well as supporting emergency priorities to be associated with capacity building for the implementing institutions and entities so as to improve their capacity to achieve needed objectives and programs, and through rehabilitating and renovating current centers and hospitals for the sake of mitigating and lessening the impact of years of mismanagement and lack of experience and resources. And, of course not to neglect the active role the World Bank has played, throughout the implementation and along its experience. Purpose and Objective The consecutive conflicts over the past twenty years have left a noticeable defect in delivering Disability care services that suffered an increasing deterioration in its level, since Iraq was one of the countries in the region with well-developed and well- performing healthcare infrastructure. The purpose of this project was to focus the light on the points in need to stand upon in order to enhance the services, to illustrate a schedule of the actions needed to raise the level of healthcare services functionality, to mitigate the intensity burden on the People with Disability (PWD), and to specify weakness points of previous actions taken; not only to develop but to set a base for a continuous pattern to be adopted throughout performing the implementation of this project’s components. In addition to setting the steps for gradual reduction in the instability of the institutional duties and the shortages in necessary resources that distinctly affected serving the community of Disabled persons through hospitals and specialized centers over the past years. The objective of the Project; was to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability. Specifically; (a) developing a national policy on disabilities (cancelled later; see project implementation experience described by components); (b) increasing the capacity of Iraqi institutions and other stakeholders to meet the needs of disabled persons; (c) strengthening the cooperation and partnerships between the Government and civil society in provision of services to disabled persons; and (d) upgrading the infrastructure and equipment of selected rehabilitation and prosthetic centers throughout selected sites all over Iraq. Project components The main structure of the project comprised three components; namely: 1. Policy development and partnership. 2. Delivery of services to disabled persons. 3. Project management. 35 Component 1: Policy development and partnership The objectives of this component were: (i) develop a comprehensive policy and legislative framework for disabilities; and (ii) initiate an enabling environment for development of partnerships between the MOH, other ministries, and civil society in the area of disabilities. And that throughout supporting the establishment of multi-sectoral Disability Working Group as a first step in the policy development process, in addition to providing the technical assistance to organize the DWG and preparing its work program. As well as, encompassing the medical aspects of rehabilitation process taking into consideration the aspects of disability in Iraq: main causes of disability, economic and social consequences of disabilities, prevention and risk mitigation mechanisms, and policies and strategies to create the enabling environment which permits PWD full participation in society, including access to education and labor force, and participation in decision making. Supporting data collection and assessment of existing NGOs in the area of Disabilities in Iraq was to be provided under Partnership aspect as a basis for understanding what kind of services the NGOs are currently providing throughout the country. The NGOs were to be enrolled in the activities of the abovementioned through contracting for provision of a selected number of specific services, e.g., community- based surveys, assistance with registration of disabled persons, and distribution of medical aids and services. This component has not progressed beyond initial project support to the establishment of the Disabilities Working Group whose members included representatives of the Ministries of Health, Labor and Social Affairs, Education and Defense. Reasons for lack of progression include: lack of effective leadership of the activity from 2005 to 2007; inadequate technical professional support; and insufficient political support to move the component forward .The option of cancellation of this component has been discussed with Ministry of Health. In September 2008, the Minister of Health sent the Bank a letter requesting cancellation of component 1, indicating that the government would carry out the activities through its own resources. Preliminary agreement to restructure the EDP was reached during April 2008 supervision mission and documented in a Restructuring project agreement signed by the Bank and the MOH at the conclusion of that mission. The restructuring was undertaken to ensure that the project will meet its project Development objective (PDO) and implement activities successfully within the revised timeframe of the project. Component 2: Delivery of services to disabled persons. The objective of this component was to improve the delivery of community-oriented rehabilitation and prosthetic services for disabled persons in selected sites throughout the country, in line with international best practice and with WHO recommendations for the development of community-oriented services for the disabled, and represents a change in direction from the current unsustainable and discriminatory practice in Iraq where rehabilitation, isolation in specialized institutions and primary health care services are provided in large institutions, separate from services for the general population. The new 36 approach promotes provision of services in the community, increasing access and efficiency as well as promoting an inclusive environment. If positive results are achieved during this Project, the next phase would include establishment of a network of additional small community-oriented rehabilitation centers, and further strengthening of the production workshop. The Project supported the construction and renovation of six basic rehabilitation centers, some of them with prosthetic workshops; other existing rehabilitation centers are in satisfactory condition and therefore will benefit only from training and limited equipment, while the others will receive support in civil works renovation, equipment and training. The Project also supported the procurement of specialized equipment and materials for prosthetic workshops, equipment for rehabilitation centers, computer workstations for management and registration of beneficiaries, and office equipment and furniture for the selected locations, as well as supporting the procurement of medical aids, such as wheelchairs and walking aids. Supporting training activities to improve the services for physical rehabilitation was one of project’s activities, including: (a) specialized training for production and fitting of prostheses; (b) training for physiotherapists; (c) management training for workshop and rehabilitation center managers; and (d) specialized training in physical therapy for hospital-based physicians. Training for technicians in the prosthetics workshops was in link to the procurement of equipment, and any tenders for equipment would include the relevant training. Training of trainers for staff in existing facilities had been organized in global highly experienced centers in addition. Procurement of Prosthesis and Orthosis Materials was cancelled from the project as a result of agreement in April 2008 supervision mission, with the agreement that the MOH would procure them with its own resources. Component 3: Project management The objective of this component was to ensure effective administration and coordination of the project activities. Overall project coordination was carried out by a Project Management Team (PMT) in the MOH. The lead implementing agency for the Project was MOH. The PMT was built on the capacities already established under the Emergency Health Rehabilitation Project (EHRP), sharing a Director and the ―business office‖ functions, e.g., procurement, financial, and secretarial/logistical. One PMT Director was responsible for both EHRP and EDP. Likewise, the Technical Coordinator had shared by the two projects and will report directly to the PMT Director. Terms of Reference for this position have included day-to-day management of the Project. Procurement, financial management and administrative staff of the PMT have 37 increased to absorb the additional work of the EDP. The DWG was meant to play an advisory role on policy issues relating to the Project. Project implementation experience described by components The services and goods procured under the project and the activities implemented were as follows: Civil works: Six Disability project sites have been implemented throughout Iraq under the category of civil works, and the method of tendering was the NCB, as follows: 1. Karbala disability rehabilitation center. The initial contract period of implementation was to be 7 months with initial contract amount of $809,978.00 to be handed over on Dec.25, 2008 but actually accomplished with additional 120 days of working period, the preliminary hand over was on June 16, 2009 with 100% completion rate, then the final handing over was on July 18, 2010. The implementation hadn’t encountered any hurdles. 2. Kut disability rehabilitation center and workshop. The initial contract period was 10 months with initial contract amount of $1,656,822.00 to be handed over on June 10, 2009 but actually accomplished on Oct.20, 2009 with additional 39 days of working period, the preliminary hand over was on Oct.21, 2009 with 100% completion rate, and the final hand over shall be on Oct.21, 2010. The works at the site had encountered some problems related to the health directorate policies with the supervision undertaken by the consultant bureau, solved later in coordination with the health directorate and the consultant. 3. Amara – Missan disability rehabilitation center. The initial contract period was 8 months with initial contract amount of $660,573.00 to be handed over on April 4, 2009 then accomplished with additional 46 days of working period, the preliminary hand over was on Aug.10, 2010. There were no problems reported throughout the implementation of this site. 4. Samawa – Muthana disability rehabilitation center. The initial contract period was 8 months with initial contract amount of $679,581.00 to be handed over on April 10, 2009 but the works accomplished with additional 149 days of working period, preliminarily handed over on Oct.28, 2009 with %100 of completion rate. The works at the site encountered two problems throughout the implementation; the rejection of the health directorate to the lamination technique of the ground floor on the southern area of the center which solved later, and the disputes with the focal point on contractor’s payments approval which also solved later with the heath directorate by changing the focal point. 38 5. Basra disability rehabilitation center. The initial contract period was 8 months with initial contract amount of $975,357.85 to accomplish works on July 10, 2010 after addition of the optional items. The site was handed over on Jan.11, 2010, and that after additional 120 days of the working period. 6. Diwaniya disability rehabilitation center and workshop. The initial contract period for this site was 10 months with initial amount of $1,431,249.00 to be accomplished on June 15, 2009. Then actually accomplished %100 and handed over on Dec.10, 2009. There was a dispute raised between the health directorate – focal point and the contractor on the ceiling slab concrete lab test, solved later by the PMT through retesting the concrete cubes in order to verify its compliance with the technical specifications. Medical Aids: 38523 medical aids had been procured under the category of Goods/ medical aids in 3 packages, and the method applied to this activity was the ICB in order to ensure global well known companies’ participation and field expertise, as follows:  34,000 aid including 7 items (classical wheel chair (adult), toilet wheel chair, adult forearm crutch, walking stick, adjustable walking frame, walking rollator and tripod with forearm support).  4,000 forearm crutches (child).  697 electrical wheel chairs (523 for adult and 174 for child) with different electronic control. All the aids mentioned above had been distributed countrywide basing on population number and estimated data of disabled people in each governorate. Rehabilitation equipment: Nine full sets of physical rehabilitation equipment had been procured to six newly established rehabilitation centers through the project with three additional sets delivered to Baghdad, Najaf and Nasiriya sites. Workshop equipment: Three full set of tools, machines and related Prosthesis / Orthosis manufacturing equipments had been procured for two newly established workshops in Kut and Dewaniya rehabilitation and workshop center plus additional set for Al- Hakim hospital / Baghdad. Training and capacity building: 4 training courses had been implemented in different physical rehabilitation competencies outside Iraq; 3 courses by Center for International Rehabilitation University CIR / 39 Clinical Center – Tuzla /Bosnia, including training of 15 rehabilitation center managers, 20 specialized rehabilitation hospital based physicians, 65 hospital based physiotherapist. 65 prosthesis manufacturing technicians had been trained in Otto Bock health Care Academy / Germany. One training course inside country implemented by the trained technician (T.O.T) in the field of prosthesis manufacturing, the total number of trainees was (18). The needed training raw materials for prosthesis manufacturing were procured under the project too. All the trainees have acquired additional technical skills concerning their field of work and retained in physical rehabilitation and prosthesis workshop facilities, and still in job. Financier (World Bank) performance: As a donor and supervisor, the World Bank has always provided its close and intensive support and backup to the PMT through; monitoring agents, supervision missions, training courses prepared for PMT at the WB office in Amman and on-job training, adopt the responsibility to facilitate and expedite hindered project transactions inside and outside Iraq. As a first time for Iraq to deal with international contexts and guidelines of modern procurement and project management methodologies; the World Bank also provided Iraq with the opportunity to get in close and parallel range with modern aspects through all the above mentioned and take on its own the responsibility to ensure consistency of knowledge acquired by PMT and the continuous encouragement for PMT to transmit this knowledge to MOH’s staffs so as to spread a wide ranged and enriched knowledge and experience, this is to elevate the level of technical expertise and revise the methods applied to implement project under the health sector. Factors affected the implementation of the project activities: 1. Country’s exceptional circumstances and the instability of security situation. 2. Conflicts with the governmental procedures which sometimes caused hindrance to project’s activities: - Lab tests for constructional materials and its related procedures and approvals. - Some elongated and complicated custom procedures which sometimes have hindered supplying goods. - Interim security authorities and health directorates’ policies also caused hurdles to the distribution of aids and goods. - Authorizations granted to the consultant bureau (under civil works category) which have used to be given to health directorate’s engineers were a subject of conflict in some occasions between consultant site engineers and health directorate’s. 40 3. On same course with EHRP; the EDP was also affected by the lack of familiarity with World Bank’s guidelines. 4. Instability in country level governmental framework causing repeated changes in governmental managements and turbulence to governmental hierarchy directly transmitted to ministry level frameworks. 5. Need for intensive training at early stages of the project also had played a role in affecting the planned and expected rate of implementation. Lessons learned: Throughout the implementation of the project it was easy to identify some points necessary for a successful implementation of a project, summarized below: 1. Preparation of a comprehensive feasibility study for the project. 2. Necessity of involving the client in the discussions and studies to identify the essential requirements before the design phase. 3. Assembling a completely committed team under clear and precise framework for a work that does not conflict with donor and client’s work contexts. 4. Providing a suitable work place and necessary requirements (transportation and telecommunication means, training, etc.). 5. Taking the variance in currency exchange rate into consideration during project’s cost estimate phase. 6. Expertise of personnel and authorization level should be included in the criteria applied to select and assembling the team, and that to maintain fast and effective implementation and decision making which consequently ensures successful outcomes throughout projects management. 7. Focal points provided a clear and effective vision on project’s site progress and related issues, and the capacity building through conducting training courses for them on World Bank’s guidelines and procedures also provided a boost for their performance. 41 Annex 8. Comments of Co financiers and Other Partners/Stakeholders None 42 Annex 9. List of Supporting Documents a) Integrated Safeguards Data Sheet – Concept Stage – Report No. AC1835 – October 12, 2005. b) Project Information Document (PID) – Concept Stage – Report No. AB1847 – September 23, 2005. c) EDP - Minutes of Ad Hoc Committee Appraisal/Negotiations Review Meeting – October 27, 2005. d) EDP (Iraq Trust Fund) – Agreed Minutes of Negotiations – November 17, 2005. e) EDP – Environmental and Social Screening and Assessment Framework – ESSAF – E1252 – November 17, 2005. f) EDP – Technical Annex – Report No. T7663-IQ – November 23, 2005. g) EDP – World Bank Iraq Trust Fund Grant Agreement - Grant Number TF054052 – November 23, 2005. h) Master Implementation Manual (MIM) – ITF – July 2005. i) Project Implementation Manual (PIM) for EDP and EHRP on Finances and Disbursements – not dated. j) Letter of March 16, 2007 to MOH on amendment of trust fund grant agreement re: deadline for audit report submission. k) Memo to Country Director and letter to MOH of June 15, 2007 on extension of grant closing date and reallocation of grant proceeds. l) Restructuring package: (i) Summary of agreements reached for the project restructuring during November 2008 mission; (ii) MOH request for restructuring dated December 1, 2008; (iii) Letter from the country Director to MOH transmitting the draft project paper and the draft amendment letter and asking for endorsement of those documents; (iv) Memo to RVP and Project Paper dated January 21, 2009; and (v) Letter dated February 9, 2009 amending the Grant Agreement. m) Restructuring Paper (level two restructuring) and Memo to RVP of June 11, 2010, and letter to MOH of June 21, 2010 on closing date extension and reallocation of grant proceeds. n) Aide-memoires of Bank missions for implementation support. o) Implementation Status and Results Report (ISR) – Numbers 1 to 11. p) Fact Sheets – ITF – Projects – EDP – prepared by Etiman Management Consulting services (EMCS) – Procurement Management. q) Interim Strategy Note for the Republic of Iraq for the Period Mid FY09-FY11 – World Bank Group Report No. 47303-IQ – February 19, 2009. r) Implementation Completion Report (ICR) – Emergency Disabilities Project (EDP) – February 2011 –Project Management Team– PMT (MOH). 43 Annex 10. Context at Appraisal Background 10.1 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 among 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 further toll on the economy. Per capita income fell to US$770 by 2001, with a slight increase to US$940 in 2005 - only a quarter of what Iraqis enjoyed 25 years ago. 10.2 At the time of appraisal, Iraq had had two political transitions, taking steps toward a constitutionally elected government. Nevertheless, persistent violence had affected most parts of the country, and continued to hinder reconstruction efforts, economic recovery, and institutional reform. The ongoing violence, large number of war veterans from recent conflicts, and the breakdown of community support systems with limited access to health and rehabilitation services were having a devastating effect on persons with disabilities (PWD) in Iraq, and increasing the already high burden of disease. The burden imposed on Iraqi society by disabilities was huge, posing serious risks for entire families to slip into poverty. The cumulative number of persons suffering from physical disabilities (excluding blindness, deafness, and disabilities resulting from chronic diseases) was estimated at 250,000, including 80,000 to 100,000 amputees mostly from lower limb amputations and 8,000 people suffering from spinal cord damage. 10.3 Key issues for disabled persons included the following: (a) Once considered one of the best in the region, the Iraqi health system had declined significantly over the past two decades because of budget cuts, poor management, neglect, looting due to recent conflicts, and lack of training opportunities for health professionals, many of whom chose to leave the country. (b) Care of disabled people had also deteriorated significantly as a result of conflicts and mismanagement. The capacity of the Government to provide treatment to the victims of war and other violent acts was limited; many complications occurred and reconstructive surgery was almost impossible. (c) Existing centers dedicated to the rehabilitation of disabled patients and the manufacture of prosthetic limbs had been looted and most of the facilities had suffered heavy physical damage in recent years. (d) There had 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 had also taken a toll on the mental health of the population. The Project would not focus directly on mental health and depression, but these dimensions of disability would be taken into account in the development of the national framework on disabilities. 44 (e) Many NGOs were now operating in Iraq to help disabled people, but most had been created recently, were small and lack resources and capacity. (f) An inter-ministerial oversight commission for disabilities had been proposed but not yet formally established under the new Government. 10.4 One of the four pillars of the July 2005 National Development Strategy of Iraqi Transitional Government was improving the quality of life through, among other things, investing in the social sectors. In November 2004, the MOH had prepared a draft national strategy for the physically disabled which included an outline of planned interventions to improve the quality of and access to care for people with disabilities13. Main areas of the plan were identified as: medical rehabilitation of individuals who have suffered serious physical injuries; and psychological rehabilitation of both the individual and the community involved. In this context, the MOH had developed a broad framework for care of disabled people, with realistic targets to be achieved within the next five years. The Project, which would meet only a very small portion of the real needs in the area of medical rehabilitation, could be followed by a more comprehensive project, provided sufficient resources and donor partnerships and support are available, and the security context in the country has improved. 10.5 Donors had pledged very large amounts (about US$1 billion) for the health sector, mostly for improving the infrastructure. However, the security situation on the ground in Iraq was significantly impeding progress in implementing the various donor programs. Rationale for Bank Assistance 10.6 The World Bank Second Interim Strategy Note for Iraq was aligned with the Iraqi Transitional Government's National Development Strategy. The strategy relied on the ITF and the International Development Association to finance projects, and on the World Bank budget for the economic and sector work and policy advice that was needed. The World Bank had already begun to focus on supporting the recovery of the health system in Iraq. The first project - EHRP financed through the ITF - aimed to improve access to quality emergency services in selected health facilities to serve the urgent needs of the Iraqi population. The MOH approached the Bank in October 2004 concerning support to PWD resulting from the war and related accidents. This is an area which could 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 prevailing instability and violence. Improving the rehabilitation of the physically disabled can have an immediate and visible impact. This area had not yet been specifically addressed by the donor community, and the Government had recently signaled that this is an urgent priority. The proposed project was 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. It was also in line 13 Rehabilitation and Caring for the Disabled in Iraq, MOH, November 2004. 45 with the MENA region's current efforts to develop a strategy to support PWD as a group disproportionately represented among the world's poorest.14 10.7 The Bank had extensive global experience in supporting these types of interventions in post conflict and emergency contexts. The Bank's priority was not only to provide immediate assistance in areas of particular need, but also 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. 14 ―A Note on Disability Issues in MENA Region, MNSHD working paper, April 2005. 46 Annex 11. Detailed Project Description (From pages 8 to 10 of the Technical Annex) Project Objectives 11.1 The original objective of the Project was to support the delivery of improved rehabilitation and prosthetic services that reduce the burden of physical disability. Specifically, the Project will: (i) support the development of a national policy on disabilities; (ii) increase the capacity of Iraqi institutions and other stakeholders to meet the needs of disabled persons; (iii) strengthen the partnerships between the Government and civil society in provision of services to disabled persons; and (iv) upgrade the infrastructure and equipment of selected rehabilitation and prosthetic centers throughout Iraq. Project Description 11.2 There were three original project components, namely: (i) Policy Development and Partnerships; (ii) Delivery of Services to Disabled Persons; and (iii) Project Management. Component 1: Policy Development and Partnerships (US$0.8 million total, including contingencies). 11.3 The objectives of this component are to: (i) develop a comprehensive policy and legislative framework for disabilities; and (ii) initiate an enabling environment for development of partnerships between the MOH, other ministries, and civil society in the area of disabilities. 11.4 Policy Development. The Project will support the establishment of a multi-sectoral DWG as a first step in the policy development process. Technical assistance will be provided under the Project to assist in organizing the DWG and preparing its work program. The technical assistance will also support the preparation of a draft national policy framework on disabilities, to be presented to the Prime Minister's Office and the National Assembly for review and adoption. 11.5 This policy framework will encompass the medical aspects of the rehabilitation process, and will take into account the following aspects of disability in Iraq: prevalence and main causes of disability, economic and social consequences of disabilities, prevention and risk mitigation mechanisms, and policies and strategies to create the enabling environment which permits PWD full participation in society, including access to education and the labor force, and participation in decision making. It will take stock of current knowledge of disability issues in the country, and open the door to new ideas and initiatives that will help mainstream disability as a theme across sectors. 11.6 Partnerships. The Project will support data collection and assessment of existing NGOs in the area of disabilities in Iraq, as a basis for understanding what kinds of 47 services the NGOs are currently providing throughout the country. To begin building partnerships between NGOs and Government, the Project will also finance a series of conferences/workshops for NGOs and Government officials at an early stage of project implementation. These meetings will provide a forum for exchanging information on ongoing strategies and activities for disabled people, and identifying areas of potential cooperation. The workshops will also be an opportunity to learn more about the current capabilities and resources of the NGOs operating in the field. The Project will also support a public awareness campaign to sensitize the public about the needs of disabled people. 11.7 In addition, the Project will provide support, on a limited pilot basis (not to exceed US$50,000 in total), to the MOH to contract NGOs for provision of a selected number of specific services, e.g., assisting with registration of disabled persons, distribution of wheelchairs, and community-based surveys. Component 2: Delivery of Services to Disabled Persons (US$18.0 million total, including contingencies) 11.8 The objective of this component is to improve the delivery of community-oriented rehabilitation and prosthetic services for disabled persons in selected sites throughout the country. The approach is in line with international best practice and with WHO recommendations for the development of community oriented services for the disabled, and represents a change in direction from the current unsustainable and discriminatory practice in Iraq where rehabilitation, isolation in specialized institutions and primary health care services are provided in large institutions, separate from services for the general population. The new approach promotes provision of services in the community, increasing access and efficiency as well as promoting an inclusive environment. If positive results are achieved during this Project, the next phase would include establishment of a network of additional small community-oriented rehabilitation centers, and further strengthening of the production workshops. 11.9 The Project will support the construction of six new basic rehabilitation centers, and three new rehabilitation centers with prosthetic workshops. In addition, five existing rehabilitation centers will be renovated. Another four existing rehabilitation centers are in satisfactory condition and therefore will benefit only from training and limited equipment, while the others will receive support in civil works renovation, equipment and training. 11.10 The Project will support procurement of specialized equipment and materials for prosthetic workshops, equipment for rehabilitation centers, computer workstations for management and registration of beneficiaries, and office equipment and furniture for the selected locations. The Project will also support procurement of medical aids, such as wheelchairs and walking aids. 11.11 The Project will support training activities to improve the services for physical rehabilitation, including: (i) specialized training for production and fitting of prostheses; 48 (ii) training for physiotherapists; (iii) management training for workshop and rehabilitation center managers; and (iv) specialized training in physical therapy for hospital-based physicians. Training for technicians in the prosthetics workshops will be linked to the procurement of equipment, and any tenders for equipment would include the relevant training. Training of trainers for staff in existing facilities will be organized in appropriate centers in neighboring countries. In addition, the Project will support the training of new physiotherapists to be employed in the new centers. Component 3: Project Management (US$0.7 million total, including contingencies) 11.12 The objective of this component is to ensure effective administration and coordination of the project activities. Overall project coordination will be carried out by a Project Management Team (PMT) in the MOH. The lead implementing agency for the Project will be the MOH. Responsibility for implementation of the components will rest with the relevant departments of the MOH and other agencies involved in the project. The PMT will build on the capacities already established under the Emergency Health Rehabilitation Project (EHRP), sharing a Director and the "business office" functions, e.g., procurement, financial, and secretarial/logistical. One PMT Director will be responsible for both EHRP and EDP. Likewise, the Technical Coordinator will be shared by the two projects and will report directly to the PMT Director. Terms of Reference for this position will include day-to-day management of the Project. An Assistant Technical Coordinator will be selected solely for the EDP, and this individual's responsibilities will involve supporting the Technical Coordinator and monitoring and evaluation of the Project. Procurement, financial management and administrative staff of the PMT will be increased to absorb the additional work of the EDP. The DWG will play an advisory role on policy issues relating to the Project. 11.13 The Project will finance: (i) adequate office equipment and supplies, and one project vehicle; (ii) technical assistance and training for PMT staff in project management, procurement and financial management; (iii) annual external audits of the project; and (iv) operating costs for the PMT, including vehicle and equipment operation and maintenance, communications costs, banking fees, transportation costs, meeting expenses, advertisement fees, representation, and office security arrangements. 49 Annex 12. Other Significant Changes 12.1 Other significant changes included three extensions of the project closing date, two amendments of the Trust Fund Grant Agreement and three reallocations of the proceeds of the Grant. Extension of closing date 12.2 The original project closing date of September 30, 2007 was extended three times for a total of 39 months: (a) In an amendment letter dated June 15, 2007, the project closing date was first extended to September 30, 2009. The two-year extension was needed to provide sufficient time to complete the workshops/rehabilitation centers civil works and equip the facilities, carry out the agreed training activities, develop a national policy on disabilities, complete contract payments, and enable the Iraqi team and the task team to evaluate the project. (b) When the project was restructured on March 8, 2009, the closing date was extended a second time to June 30, 2010, in order to allow for the completion of all the revised activities agreed at restructuring. (c) On June 21, 2010, the project closing date was extended a third time to December 31, 2010. The purpose of that last extension was two-fold: (i) to provide an additional six months to permit use of unallocated funds to procure additional electric wheelchairs which are in high demand in Iraq and urgently needed for the disabled population, as well as to fully complete remaining contracts; and (ii) to give extra time for detailed data collection and analysis of project outputs and outcomes. Amendments of the Trust Fund Grant Agreement 12.3 The Trust Fund Grant Agreement was amended twice during the project life: (a) In response to a request made by the MOH during the implementation support mission of September 2006, the Trust Fund Grant Agreement was amended on March 16, 2007 to change the deadline for audit report submission from four months to six months after the end of the relevant fiscal year. A six-month deadline for submission of an audit report is standard. (b) As part of the project restructuring, the Trust Fund Grant Agreement was amended on March 8, 200915: (i) to revise the PDO, the performance indicators, the allocation of the 15 The restructuring package was approved by the RVP on February 2, 2009, and the letter amending the Grant Agreement was signed by the Country Director on February 9, 2009 and countersigned by the Executive Secretary of the Iraqi Strategic Review Board (ISRB) on February 24, 2009 and by the Minister of Health on March 8, 2009. The amendment letter states that it ―shall become effective once it has been executed by all parties‖. 50 proceeds of the Grant, and the project description; (ii) to cancel US$2.7 million from the Grant; and (iii) to extend the project closing date from September 30, 2009 to June 30, 2010. Reallocation of the Proceeds of the Trust Fund Grant 12.4 Over the project life, there were three reallocations of the proceeds of the Grant, on June 15, 2007, March 8, 2009 and June 21, 2010. Each time, these funding reallocations were needed to meet current commitments by disbursement category. 12.5 The table below shows the various changes and the final/actual allocation. Although there was a significant reduction in the number of rehabilitation facilities and workshops to be constructed/renovated, more funds were required for civil works because of increases in the scope of works and unit costs. This was partly compensated by a reduction in the amount for goods due to the cancelation of the purchase of prosthesis and orthosis materials. There were significant savings in consultants’ services, but the amounts for training and operating costs were higher than the original estimates. Finally, at restructuring an amount of US$2.7 million was canceled from the Grant. Category Appraisal Reallocation Restructuring Reallocation Final / estimates of June 15, Reallocation of June 21, Actual 2007 March 8, 2010 Allocation* 2009 ---------------------------- In thousands US Dollars --------------------------- Civil works 4,700 4,700 6,700 6,100 6,003 Goods 11,230 11,230 6,400 7,900 8,015 Consultants’ 1,920 1,920 800 735 services 729 Training 1,190 1,300 2,200 1,750 1,663 Operating costs 110 170 250 315 286 Unallocated 350 180 450 - - Total 19,500 19,500 16,800 16,800 16,696 51 Annex 13. Safeguards and Fiduciary Compliance Fiduciary Monitoring Agent (FMA) 13.1 When the ITF was created in 2003, the ITF donors required that the Bank, as Administrator of the ITF, engage an FMA. The main purpose of the FMA was to help the Bank monitor physical delivery/progress, and the recipients’ compliance with financial management and procurement procedures. As part of this function, the FMA provided on-the-job training to the PMTs. 13.2 The FMA is a Baghdad-based management consultant firm that deploys about two dozen Iraqi professionals (mainly engineers and accountants) recruited from the private sector with experience in procurement and financial management and accounting. The FMA visited all EDP sites throughout Iraq every month and carried out physical verification with digital photographs of ongoing works and goods supplied and the production of a fact sheet for each contract, alerting the Bank to deficiencies in quality and implementation. The Bank Task Team for EDP kept close communication with the FMA during implementation, and invited the FMA to participate in all supervision missions. The performance of the FMA, including the quality of the personnel, has improved over time. 13.3 The work of the FMA has been very beneficial to the Project. The cost of the FMA fluctuated over the years, in the US$200,000–US$250,000 range per project per year. This is a substantial amount, which had to be spent since there was no alternative worth considering. The FMA performance demonstrates that, in contexts where the Bank cannot carry out normal supervision missions, the Bank can mitigate risks for its program by employing a monitoring agent to monitor physical implementation of projects and verify that funds are spent for the purpose intended and in accordance with Bank rules; the detailed terms of reference should also encourage quality professional advice on technical issues and follow-up until these issues are resolved, rather than simple mechanical reporting. Procurement 13.4 As mentioned above, the Bank employed a FMA to assist in monitoring procurement transactions, including conducting physical checks of all civil works and all deliveries of goods. This 100 percent check done on behalf of the Bank is a very interesting feature of the Project; usually, under the best of circumstances, the Bank is able to check only 15 percent or so of the outputs. The Bank prior-reviewed over 90% of all procurement under the Project, and the remaining contracts were reviewed by the FMA. During implementation, MOH recruited an international procurement adviser who, over time, helped in resolving procurement issues and in producing better results in procurement. 52 13.5 An Independent Procurement Review (IPR) was carried out in 2009 as a ―desk review,‖ based on procurement documentation provided at the Bank’s Headquarters. It indicated a lack of information, even for contracts subject to prior review, which affects the accuracy of the assessment of both the PMT and the Bank Team. However, the Bank Task Team made full use of the FMA which carried out 100 percent site inspection for all goods and works delivered, and the FMA function was an essential aspect of the supervision process. The Bank Task Team followed up on the Action Plan proposed by the IPR. There has been no case of misprocurement. In addition to commenting that record keeping and filing by PMT were not up to standards, the IPR identified a few shortcomings for which satisfactory explanations could be provided. For example, because of the security issues, it was not possible to have short lists of six consultants. Also, the review commented that the minimum qualifying criteria prescribed in the bidding documents for works were not adequate to ensure that the lowest evaluated and substantially responsive bidder who meets the post qualification test has the required capacity to complete the works in a timely and efficient manner. The Bank staff clarified that, in order to encourage the participation of the private sector which had been weakened by years of isolation, instability and insecurity, the Bank had decided to lower the qualification criteria to allow more competition. This was reflected in the Standard Bidding Documents (small works) included in the MIM16 developed by the Bank for the use of Iraqi Ministries for all ITF-financed projects. It is interesting to note that, in response to the IPR’s draft report, the PMT/MOH stressed that ―almost all procurement packages were implemented with Bank prior review for each decisive step, related documents had been submitted to the Bank and steps implemented only after Bank No Objection, even if some may not be fully in compliance with Bank procedures.‖ 13.6 There have been significant gaps between the physical completion of civil works and the physical delivery of goods, and payments to contractors/suppliers. This was due in part to the security problems, as well as inadequate contract management by the PMT/MOH. It contributed to the slow disbursement under the Project and was raised by the Bank as an issue requiring urgent attention by the PMT and the MOH. There was a high turnover of procurement officers (POs) in PMT (three POs during the life of the EDP)17. The situation improved towards the end of the Project when PMT had three assistant POs (one for works, one for goods and one for consultants/training) working under the procurement manager. Financial management and disbursements 16 Volume 3 of the MIM – SBDs - Bid Data Sheet – 3.2a & 3.2c refer to the minimum required annual volume of construction work and to the list of essential equipment to be made available for the contract, respectively. 17 This contributed to delays. As an example, the tender process for medical aids and prosthetic equipment has been delayed because of the disappearance of the PMT procurement specialist responsible for the preparation of the bidding documents, which resulted in significant loss of work (equipment lists and specifications). 53 13.7 The financial management arrangements for the Project were basically similar to those being followed under the EHRP, taking into consideration the specific activities under the Project and the hurdles being faced during the implementation of the EHRP. According to the Technical Annex, disbursements would be made primarily through direct payment by the Bank to the contractors, suppliers and consultants. Once authorized by the MOH, payments above the threshold of US$10,000 would be made by the World Bank directly into the account of the contractor, supplier or consultant in a commercial bank capable of receiving funds transferred from the international banking system. There would be no special/designated account. Payments for the project management component and payments below the threshold of US$10,000 would normally be made by the MOH/Recipient from its own resources. These payments made from the MOH/Recipient’s own resources would be reimbursed, on a periodic basis, by the Bank to the MOH upon presentation of proof of payment and a signed withdrawal application. 13.8 Financial management (FM) risk mitigation measures described in the Technical Annex were put into place. There were no major changes to FM during project implementation. It is worth noting that the only part of the Project Implementation Manual (PIM) that was prepared dealt with financial management and disbursements. The absence of a special/designated account was not as big a problem as for the EHRP, because the PMT/MOH managed to establish and maintain a project account throughout the EDP life for payments of small amounts (less than US$10,000) to avoid shortages and delays in payments and reimbursements. 13.9 The disbursement rate lagged significantly during the project life. The main reasons for the disbursement lag included: (i) unrealistic implementation period (24 months); (ii) slow physical implementation; (iii) lack of capacity within the PMT/MOH for contract management; and (iv) lack of familiarity of consultants and contractors with internationally accepted business practices, especially the monthly submission of invoices and full documentation of invoices. 13.10 The PMT/MOH staffing for financial management was adequate. The FM team consisted of a Financial Officer (FO), an internal auditor and two accountants; the team worked on a full time basis on two ITF-financed Projects (EHRP and the Project under review). The performance of the financial management team improved during project implementation, and the team did a relatively good job overall. The EHRP had experienced delays in payments in Iraqi Dinars, but this was not a problem for the EDP because only one contract was denominated in Iraqi Dinars; there was no problem with payments made in US Dollars. 13.11 The FMA that was hired by the Bank for fiduciary purposes was effective. FMA staff visited the PMT/MOH two to three times per month on average to: (i) review the PMT’s FMRs and reconcile the PMT records to the Bank records; (ii) monitor unclaimed expenditures; (iii) verify disbursement plan updates; and (iv) provide on-the-job training in FM matters. The FMA included the PMT-prepared financial monitoring reports (FMRs) in their quarterly reports, as well as the adjusted FMRs (with their review 54 comments and recommendations for the PMT FMRs). FMRs were usually submitted in a timely manner. The FMA also conducted, on a sample basis, pre-screening and post- review of withdrawal applications for direct payments and reimbursements. 13.12 During the project period, there have been issues related to weaknesses in the internal control system of the PMT, budgeting, and failure of the PMT to reconcile regularly the EDP records with the Bank client connection. Most of these problems were progressively resolved thanks to the high commitment and pro-activity of the PMT and FO and the implementation support provided by the Bank Task Team and the FMA. 13.13 FMRs were satisfactory and were submitted in a timely manner. Audit reports18 were submitted on time, except for the 2006 audit report which was submitted late. They have been unqualified except for 2008. The 2008 audit report was qualified due to identified ineligible expenditures; it had a number of shortcomings (missing elements, instances of inconsistency, inaccurate amounts, as well as incomplete disclosures in the notes to the financial statements) so that the report had to be revised and resubmitted. In its management letter, the auditor made recommendations in order to avoid such cases of ineligible expenditures and other problems in the future. As requested by the Bank, in January 2010 the PMT submitted an action plan to remedy the weaknesses identified by the external auditor. The next EDP audit report will cover the year 2010 plus the four- month grace period and is due by June 30, 2011. An escrow account has been established for that audit report. Safeguards 13.14 The Project was appropriately rated environmental category ―B‖. The Technical Annex had a number of interesting sections and documents on safeguards, including: (i) A summary of the Environmental and Social Screening and Assessment Framework (ESSAF); (ii) Codes of Practice for Prevention and Mitigation of Environmental Impacts; and (iii) Safeguards Procedures for Inclusion in the Technical Specifications of Contracts. The ESSAF was devised and approved by Bank management to provide practical procedures of environmental assessment and control to be included in the ITF-financed projects carried out in a ―post-conflict‖ country situation, similar to the frameworks prepared for post-conflict reconstruction programs in Afghanistan and Kosovo. 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 was waived. However, for sub-projects with possible moderate or minor adverse environmental impacts, a limited Environmental Analysis would be done during project design for World Bank approval prior to execution of such works. 18 During negotiations of the Grant, the IDA team emphasized the need for annual audits, and the Iraqi delegation agreed that the Recipient engage an external independent auditor with international experience to perform the project audits and issue an independent opinion on the project financial statements. 55 The ESSAF was disclosed in Iraq and in the World Bank’s Infoshop on November 17, 2005. 13.15 Based on the ESSAF, the following standards were applied during implementation: (i) inclusion of standard environmental codes of practice (ECOP) in the bid documents for civil 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 Subprojects; (iv) review and oversight of any major construction 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. Regarding the construction of new facilities, there was no involuntary relocation of populations or expropriation of privately owned land, and no cultural finds were discovered during excavations. 13.16 Capacity building on safeguards and on the implementation of the ESSAF had already been undertaken with the Ministry of Environment and MOH under the EHRP. In addition, the plan was that 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; unfortunately, the MOH safeguards specialist left after six months and was not replaced. Also, for most of the project period there was no Bank safeguards specialist assigned to the Project. However, Bank’s implementation support missions discussed with PMT/MOH the need for regular monitoring of the civil works sites to ensure that the environmental safeguards were being followed. Although compliance with the environmental safeguards was the responsibility of the MOH’s Maintenance Department, the PMT designated two of its staff to act as Environmental Safeguards Focal Points, to follow up at the project sites with the consultants and contractors to ensure that they were adhering to their obligations regarding the environmental safeguards. Relevant safeguards attachments were on all consultant and construction contracts, and construction activities were closely monitored. Checklist forms for all the project sites were completed by the Environmental Safeguards Focal Points and were submitted to the Bank during the April 2010 implementation support mission. As expected, the Environmental Safeguards Focal Points have also been in contact with the Ministry of Environment on any issues arising. For example the use of refrigerant Freon22 was questioned during a Bank mission and the PMT consulted the Ministry of Environment which responded by letter, certifying that the use of the refrigerant Freon has no adverse effects on the environment and is permissible in Iraq. This letter was forwarded to the Bank on December 24, 2009 by the PMT. 56 MAP 57 IBRD 33422 IRAQ SELECTED CITIES AND TOWNS MAIN ROADS GOVERNORATE CAPITALS RAILROADS NATIONAL CAPITAL GOVERNORATE BOUNDARIES RIVERS INTERNATIONAL BOUNDARIES 40E 42E 44E 46E 48E TU R K EY To Urmia To Urmia - - Zakhu 0 50 100 150 Kilometers To - DAHUK - Al Qamishli Tig - Dahuk 'Aqrah 0 50 100 Miles r r r R. is Haji Ibrahim - - Rayat (3,600 m) - Mosul - Sinjar ARBIL - Arbil 36N Euphr ates - 36N R. To Dayr az Zawr N I N AW � As - - Sulaymaniyah ISLA MI C Al Hadr - - REPUBLI C AT Kirkuk - AS SULAYMANIYAH S YRIAN - TA'MIM O F IRA N To Dayr A RAB az Zawr - Bayji Ja ba RE P. l - H - 'Anah - Tikrit SALAH AD am - - ri - - Al Qa'im - - DIN Samarra' n To Kermanshah 34N - Al Hadithah 34N - - Tharthar To Hims Lake - - - 'Akashat Ba'qubah - - - Ar Ramadi - DIYAL� Al Fallujah - - Habbaniyah BAGHDAD BAGHDAD - Lake AL ANBAR JORDAN Razzaza - WA S I T To Trebil S y r i a n Lake - Karbala - BABIL - Al Kut Tigr is R. Amman - Al Hillah KARBALA' - To Dezful D e s e r t - - - Al Hayy 32N Ad Diwaniyah 32N Nukhayb An Najaf - - - Al 'Amarah AL QADISIYAH - Eu phr MAYSAN ates R . - Ash Shatrah - As Samawah Al 'Uzayr To Ahvaz S AN NAJAF - - a DHI QAR h - - An Nasiriyah ra ' a l Al Basrah H ij - As Salman ar AL Az Zubayr ah Umm AL MUTHANN� BASRAH Qasr 30N 30N To Ad IRAQ Damman KUWA IT S A UDI A RA BIA This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 28N 40E 42E 44E 46E 48E FEBRUARY 2005