The World Bank Report No: ISR10609 Implementation Status & Results Iraq Second Emergency Assistance Program for Primary Health Care (P123689) Public Disclosure Copy Operation Name: Second Emergency Assistance Program for Primary Health Project Stage: Implementation Seq.No: 4 Status: ARCHIVED Archive Date: 27-May-2013 Care (P123689) Country: Iraq Approval FY: 2011 Product Line: Recipient Executed Activities Region: MIDDLE EAST AND NORTH AFRICA Lending Instrument: Emergency Recovery Loan Implementing Agency(ies): Key Dates Board Approval Date 14-Apr-2011 Original Closing Date 31-May-2013 Planned Mid Term Review Date 07-Jan-2013 Last Archived ISR Date 31-Dec-2012 Effectiveness Date 23-Jun-2011 Revised Closing Date 31-May-2013 Actual Mid Term Review Date 07-Jan-2013 Project Development Objectives Project Development Objective (from Project Appraisal Document) The overall objectives of the proposed project are: (i) to improve the availability of basic health services in a fragile social and political environment - the southern Iraqi marshlands and Babil through selected health facilities, with a particular focus on vulnerable groups, including pregnant women and children; and (ii) support a partnership between public providers, an international NGO, and community representatives for improvement of community-based health services in a conflict affected country. This objective would be achieved through: (i) improving service delivery and community outreach, including civil works rehabilitation, provision of essential equipment, furniture and supplies, and outreach activities to communities; and (ii) health education and promotion of behavior change, including training of medical professionals in provision of primary health care, and training of school instructors and the women volunteers involved in providing information to the community on basic health and hygiene practices; and (iii) improving the monitoring of health status of the population and building the capacity of the ministry and local authorities for regional and local planning in the health sector. The proposed project would aim to achieve the following outcomes: (i) sustain present capacity and further increase availability of quality primary health care services, based on international best practice, in the southern Iraqi marshlands; (ii) expand the present project#s primary health care activities into Babil Governorate; (iii) enhance the skills of Iraqi primary health care professionals in southern Iraq through regular training and continuous professional development; (iv) increase the level of health awareness among communities within the catchment areas of AMAR#s primary health care services; (v) increase the capacity of the Ministry of Health (MOH) and local health authorities and secure their increased ownership of primary health care activities within the areas covered by the project. The project cost is estimated at US$1.3 million, and the project implementation period will be two years. Public Disclosure Copy Has the Project Development Objective been changed since Board Approval of the Project? Yes No Page 1 of 8 The World Bank Report No: ISR10609 Component(s) Component Name Component Cost Improving Service Delivery and Community Outreach 0.80 Public Disclosure Copy Health Education and Promotion of Behavior Change 0.10 Health Monitoring and Engaging Local Health Authorities 0.06 Project Management 0.20 Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Satisfactory Satisfactory Overall Risk Rating Low Implementation Status Overview Project implementation in the four target Governorates (Babel, Basra, Maysan, and Thi-Qar) is proceeding well, with all project activities nearly completed and the major procurements, both civil works and goods, completed. The following are the main accomplishments of the Project to-date: I) Progress Under Component 1: Improving Service Delivery and Community Outreach - Twelve Primary Health Care Centers (PHCCs) have been rehabilitated, equipped and are currently fully operational -- four in Babel and eight in Basra Governorates -- in addition to the eleven previously established and rehabilitated PHCCs under the First Emergency Assistance Program (FEAP) preceding the current operation. This brings the total catchment area of the 23 PHCCs to about 430,000. - Four dedicated TB clinics attached to the PHCCs in Basra, Maysan, Thi-Qar and Babil have been established, equipped and operational. - Since the beginning of the project, 923 health staff in the PHCCs, TB clinics and mobile clinics have been trained in areas pertaining to primary healthcare service delivery. Further, these PHCC doctors provide training in primary healthcare service delivery to the other health staff in the PHCCs, in addition to 25 women health volunteer (WHV) supervisors and mobile clinic staff. - The WHV Program, which was established under FEAP, has been increased substantially in size. In addition to the 360 WHVs in place from FEAP, an additional 240 female volunteers were recruited bringing the total number of WHVs to 600. - The three mobile clinics established under FEAP continue to provide services, including prevention, therapeutic and health education, to the remote populations of the Marshlands. The population served by these three mobile clinics is about 17,715. Noteworthy to mention is the productive collaboration that has been established with the DOHs under the Project, where they also have been providing pharmaceuticals for the mobile clinics on a regular basis. Public Disclosure Copy II) Progress Under Component 2: Health Education and Promotion of Behavior Change Under this component two programs have been supported: Health Education in Schools Program (HES); and Health Education in the Community (HEC) Program. - The HES program includes a total of 69 schools across the four Project Governorates. Since the beginning of the Project, the HES program has conducted 322 teacher training sessions, as well as providing training to another 400 teachers not directly supported under the Project. - The HEC program has delivered a total of 1298 sessions to communities in Project Governorates. Topic areas have included inter alia the importance of sterilized water and basic hygiene, treatment of sunstroke and infectious diseases. III) Progress Under Component 3: Health Monitoring and Engaging Local Health Authorities - The Project has been collecting monitoring data to develop health profiles for the intervention sites, including data on: socio-economics; demographics; mortality and morbidity; vaccinations, etc. This data is being fed into the databases of the respective Directorates of Health (DOH), and will serve the purpose of conducting a follow-up survey at the end of the Project. From another perspective, under this component, a group of 18 medical doctors participated in a training course on health management at the American University Beirut. - A technical specialist has been hired under the Project to further analyze data from the baseline survey, design follow-up survey questionnaires and carry out the analysis of survey Page 2 of 8 The World Bank Report No: ISR10609 results. Specifically three questionnaires have been developed and are currently being administered to elicit findings at the school, household and clinic levels (aligned with Project activities under the school health program, women health volunteers, and trainings of health professionals in PHC and TB clinics). AMAR field staff are responsible for implementing the survey on the ground. It is expected that the results of the survey analysis will be made available by May 22, 2013. It should be noted that the survey is targeting both Project and non-Project sites for comparability purposes. Public Disclosure Copy IV) Progress Under Component 4: Project Management - Project management has been proceeding satisfactorily. Under this component AMAR has commissioned an independent evaluation of the Project to assess realization of Project Development Objectives (PDOs) and overall implementation performance. This evaluation is to be completed by May 20, 2013, and would feed into the Bank's Implementation Completion Memorandum (ICM) due by November 30, 2013. * Safeguards Monitoring In addition to the above, safeguards monitoring has been shown to be adequate and monitoring has been done on a regular basis for each of the sites. The Ministry of Health (MOH) has shown an interest in all the above community based programs, and has indicated a desire to scale them up at a national level. Regular liaison meetings are being held between AMAR staff and DOH and MOH officials, along with management training. Locations No Location data has been entered Results Project Development Objective Indicators Public Disclosure Copy Page 3 of 8 The World Bank Report No: ISR10609 Indicator Name Core Unit of Measure Baseline Current End Target • % of live births attended by skilled Percentage Value 94.70 66.40 75.00 healthcare provider Date 25-Mar-2012 15-May-2013 31-May-2013 Public Disclosure Copy Comments The percentage needs to be - The reported percentage is The end result for this taken with care as this is well based on official DOH data indicator will be verified in the above the national average. since AMAR does not follow-up survey scheduled to Data will need to be cleaned periodically collect this data; be completed by May 22, and analyzed. - Given that Al-Mehaweel, 2013. Babil seems to be an outlier with 0%, the average percentage across all project districts in the 4 governorates was calculated both with and without it. Therefore, if included, the average stands at 59%. This said, the median (including Al-Mehaweel) is in fact 68%, while the range was 11% (in Qurna, Basra) to 100% (in Al-Kifil, Babil).; - While the Baseline reflected a much higher percentage, this needs to be interpreted with caution since the sample size was extremely small, not providing enough power to the study, hence the reliance on official data. • % of pregnant women receiving at Percentage Value 94.40 66.00 84.00 least one antenatal care session with a skilled Date 25-Mar-2012 15-May-2013 31-May-2013 healthcare provider Comments The percentage needs to be - The reported percentage is - The end result for this taken with care as this is well based on official DOH data indicator will be verified in the above the national average. since AMAR does not follow-up survey scheduled to Public Disclosure Copy Data will need to be cleaned periodically collect this data; be completed by May 22, and analyzed.It would be - While the Baseline reflected 2013. useful in the next round to a much higher percentage, - Appropriate indicator include questions as to 3 and this needs to be interpreted definition has been 4 antenatal visits by pregnant with caution since the sample established and will be women. size was extremely small, not applied in the follow-up providingenough power to the survey. study, hence the reliance on official data; - Another point to be Page 4 of 8 The World Bank Report No: ISR10609 considered relates to the indicator definition used in the baseline survey, which was not specific enough Public Disclosure Copy mandating assessment following a full term pregnancy, which could affect the overall percentage. - The median percentage across all project governorates, per official statistics, stands at 71%, while therange was 25% (in Al Mijer, Maysan) to 100% (in Al- Kifil, Babil). • % of children age 0-1 year immunized Percentage Value 70.30 78.00 83.00 for measles Date 25-Mar-2012 15-May-2013 31-May-2013 Comments The percentage needs to be - The reported percentage is - The end result for this taken with care as this is well based on official DOH data indicator will be verified in the above the national average. since AMAR does not follow-up survey scheduled to Data will need to be cleaned periodically collect this data; be completed by May 22, and analyzed. - While the Baseline reflected 2013. a lower percentage, this - The follow-up survey will needs to be interpreted with focus on children aged 0-12 caution since the sample size months exclusively. was extremely small, not providing enough power to the study, hence the reliance on official data; - Another point is that the reported percentage for the baseline was in fact related to children aged 0-60 months and not 0-12 months. This Public Disclosure Copy has been verified with field team, who re-analyzed the data for the correct age-group (i.e. 0-12 months), and reported a similar percentage which corresponds to the official statistics. Page 5 of 8 The World Bank Report No: ISR10609 • % of population using improved Percentage Value 72.10 75.20 73.00 sanitation, as measured by regular hand Date 25-Mar-2012 15-May-2013 31-May-2013 washing Comments Handwashing after using the - This indicator was not - The end result for this Public Disclosure Copy toilet is 75.2%. The appropriately defined at the indicator will be verified in the percentage needs to be outset. It refers to the follow-up survey scheduled to taken with care as this is well population with improved be completed by May 22, above the national average. sanitation, while claiming to 2013. Data will need to be cleaned measure this through hand - The follow-up survey will and analyzed. washing. The two are distinct: measure hand washing after the population may have using the toilet. access to improved sanitation (e.g. flush toilet, ventilation improved pit latrine, etc.), but may not necessarily have high hand washing rates. Therefore, it is the team's interpretation that this indicator actually refers to hygiene (rather than sanitation) and that the indicator focuses on estimating the percentage of handwashers. - Given that hand washing after defecation is one of the critical junctures, the reported percentage (which is derived from the baseline survey) relates to hand washing after using a toilet. • % of children age 0-5 years with Percentage Value 60.10 93.00 95.00 health cards Date 25-Mar-2012 15-May-2013 31-May-2013 Comments (Those that did not show card - This includes both those The end result for this Public Disclosure Copy but have are 33%, and who showed the card to the indicator will be verified in the previously had were 4.6%). surveyor, and those who did follow-up survey scheduled to The percentage needs to be not, but indicated that they did be completed by May 22, taken with care as this is well have a health card. 2013. above the national average. Data will need to be cleaned and analyzed. Intermediate Results Indicators Page 6 of 8 The World Bank Report No: ISR10609 Indicator Name Core Unit of Measure Baseline Current End Target • Number of TB clinics established and Number Value 0.00 4.00 4.00 equipped Date 01-Dec-2011 15-May-2013 31-May-2013 Public Disclosure Copy Comments Target met. Target met. • Number of WHVs trained in Number Value 360.00 600.00 600.00 community outreach Date 01-Jun-2011 15-May-2013 31-May-2013 Comments Target met. Target met. • Number of primary healthcare Number Value 0.00 12.00 12.00 facilities refurbished and equipped Date 01-Dec-2011 15-May-2013 31-May-2013 Comments Target met. Target met. • Number of household visits per month Number Value 10000.00 23952.00 30000.00 by WHVs in project areas Date 01-Dec-2011 15-May-2013 31-May-2013 Comments per month - The reported figure To be verified based on final corresponds to the average AMAR monitoring data. number of visits per month since project effectiveness through to March 1, 2013. -This average figure is based on a total number of visits (during the said duration) of 431,142. Data on Financial Performance (as of 06-May-2013) Financial Agreement(s) Key Dates Project Ln/Cr/Tf Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P123689 TF-99542 Effective 17-Jun-2011 23-Jun-2011 23-Jun-2011 31-May-2013 31-May-2013 Disbursements (in Millions) Public Disclosure Copy Project Ln/Cr/Tf Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P123689 TF-99542 Effective USD 1.20 1.20 0.00 1.11 0.09 92.00 Disbursement Graph Page 7 of 8 The World Bank Report No: ISR10609 Public Disclosure Copy Key Decisions Regarding Implementation NA Restructuring History There has been no restructuring to date. Related Projects There are no related projects. Public Disclosure Copy Page 8 of 8