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Document of The World Bank

FOR OFFICIAL USE ONLY

Report No: 55267-IQ

PROJECT PAPER

ON AN

ADDITIONAL FINANCING GRANT

IN THE AMOUNT OF US$4.5 MILLION

TO THE

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

FOR THE

REGIONAL HEALTH EMERGENCY RESPONSE PROJECT

June 29, 2010

Human Development Sector Middle East and North Africa Region

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

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CURRENCY EQUIVALENTS(Exchange Rate Effective June 17, 2010)

Currency Unit = US$US$1.00 = Iraqi Dinar 1,168

FISCAL YEARJanuary – December

ABBREVIATIONS AND ACRONYMS

ALS Advanced Life SupportDOH Directorate of HealthECC Emergency Coordination CenterEMS Emergency Medical SystemFMA Fiduciary Monitoring AgentIDP Internally Displace PeopleIP Internet ProtocolISR Implementation Status and Results ReportITF Iraq Trust FundKRG Kurdistan Regional GovernmentMOH Ministry of HealthMTR Mid-Term ReviewNGO Non Governmental AgencyPCU Project Coordination UnitPDO Project Development ObjectivePIA Project Implementation AgreementPIM Project Implementation ManualRHERP Regional Health Emergency Response ProjectTOR Terms of ReferenceUN United NationsUNFPA United Nations Population FundUNICEF United Nations Children’s FundUNOPS United Nations Office for Project ServicesVHF Very High FrequencyWHO World Health Organization

Vice President Shamshad AkhtarCountry Director Hedi Larbi

Sector Director Steen Lau JorgensenTask Leader Mira Hong

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TABLE OF CONTENTS

PROJECT PAPER DATA SHEET........................................................................................................I

I. INTRODUCTION..................................................................................................................1

II. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING.....................1

III. PROPOSED CHANGES.......................................................................................................4

IV. APPRAISAL OF SCALED-UP ACTIVITIES....................................................................6

ANNEX 1. RESULTS FRAMEWORK AND MONITORING...................................................................11ANNEX 2. PROJECT RISKS...........................................................................................................16ANNEX 3. EXPENDITURE BY COMPONENT – APPRAISAL ESTIMATES...........................................18ANNEX 4. EXPENDITURE BY COMPONENT – REVISED ESTIMATES..............................................19

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PROJECT PAPER DATA SHEET

Date: June 28, 2010Country: IraqProject Name: Regional Health Emergency Response Project Original Project ID: P107698AF Project ID: P121577

Team Leader: Mira HongSector Director/Manager: Akiko MaedaCountry Director: Hedi LarbiEnvironmental Category: B

Borrower: Ministry of Health of Kurdistan Regional Government of the Republic of IraqResponsible agency: Ministry of Health of Kurdistan Regional Government of the Republic of IraqRevised estimated disbursements (Bank FY/US$m)(Original Project + AF)FY 2009 2010 2011 2012Annual 0.45 2.50 6.70 3.55Cumulative 0.45 2.95 9.65 13.20Current closing date: June 30, 2010Revised closing date: December 31, 2011 Does the restructured or scaled-up project require any exceptions from Bank policies? Have these been approved by Bank management?Is approval for any policy exception sought from the Board?

○ Yes No○ Yes No○ Yes No

Revised project development objectives/outcomes

Not applicable

Does the scaled-up or restructured project trigger any new safeguard policies? NoFor Additional Financing

[ ] Loan [ ] Credit [] Grant For Loans/Credits/Grants:

Total Bank financing (US$m.): 4.5 Proposed terms: Grant from the Trust Fund for Iraq (World Bank/Recipient-executed)

Financing Plan (US$m.)(AF)Source Local Foreign Total

BorrowerIBRD/IDATrust FundsOthersTotal

0.2-

0.2

4.3-

4.3

4.5-

4.5Financing Plan (US$m.)(Original project +AF)

Source Local Foreign TotalBorrowerIBRD/IDATrust FundsOthersTotal

2.5

2.5

10.7

10.7

13.2

13.2

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I. INTRODUCTION

1. This Project Paper seeks the approval of the Regional Vice-President to provide additional financing in the amount of US$4.5 million to the Regional Health Emergency Response Project (RHERP) (TF092237) to scale up project activities and extend the current Project Closing Date of June 30, 2010 to December 31, 2011, to enhance the project impact and allow sufficient time to implement the expanded activities. The funding will be from the Iraq Trust Fund (ITF) which is being administered by the World Bank, and which is currently providing US$8.7 million for the RHERP. The additional financing would provide needed funding to cover the cost of: (a) establishing an up-to-date and effective emergency telecommunications system; and (b) expanding the technical training of emergency medical and paramedical staff to maximize the efficiency and yield of Kurdistan’s Emergency Medical System (EMS), and to better align the system with the new Kurdistan Regional Government Ministry of Health (KRG MOH) vision.

II. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING

A. Background

2. Before 1980, the Iraq health sector was one of the most advanced in the region, although it was based on a highly centralized system focusing largely on hospital care, and depended on large scale imports of medicines, equipment and skilled service workers. During the 1990s, the health status of the Iraqi population deteriorated steadily and became among the poorest in the region, well below levels found in countries of comparable income. The physical infrastructure has suffered from severe deterioration due to neglect, compounded by the effects of war and looting, and most of the health facilities are in poor condition and critically lacking essential equipment. The procurement and distribution system for pharmaceuticals and medical equipment is largely dysfunctional. A large number of health workers have fled the country and the shortage of qualified physicians, nurses and midwives is unlikely to be solved in the short term. The Ministry of Health (MOH) has limited capacity to formulate national policies and programs and has limited control of and access to information on issues affecting the governorates.

3. Although per capita share of the health sector’s allocations has risen since 2004, it is still less than half of that of 1990. Moreover, this increase should not be taken as an indicator of improvement in the quality of health services, as the greater portion of this increase came to cover the share of salaries of health sector workers. This explains why households continue allocating a significant portion of their expenditure (equal to 3 percent) for health care. This proportion rises in the Kurdistan Region where health care exceeds 5 percent of total household expenditure. 1

4. With the improved security and political stability, the Government is expected to enter into a period of intensive reconstruction and rehabilitation of the health sector. This will require an articulation of a National Health Strategy which sets national priorities and vision for the health sector, and identifies specific short and medium-term investment programs and a sector reform agenda.

5. Government Program and Reform Objectives: in the National Roundtable on Health which took place in 2009, the MOH identified the following six priority areas for the health

1 2009 National Strategy for Poverty Reduction

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sector reform: (i) meeting urgent needs of the population and improving basic health services; (ii) strengthening management of the health system; (iii) developing and implementing a master plan for reconstruction of the health care delivery system; (iv) training and capacity building in public health programs and management of health services; (v) reforming the pharmaceutical sector; and (vi) developing public-private partnerships in the provision of health services. Given the current capacity of the MOH, there will be a need for substantial technical assistance and capacity building programs to translate these broad priorities into actionable programs and measurable results in the short and medium-term framework.

6. Health Sector in the Iraq Kurdistan Region: historically, the three Northern Governorates have been less developed than the rest of the country. The infrastructure is less developed than in the South-Center, and administration of the region has traditionally been under the control of delegates from Baghdad. In addition, the population has suffered from large-scale displacements and isolation. In the early 1990s, the situation deteriorated more rapidly than in the Center/South, but it also has improved more quickly since that time. After the no-fly zone was established at the end of the first Gulf War, the Kurdistan Region received additional assistance through bilateral channels (e.g., US Government programs) and the UN, and benefited from the presence of several international NGOs on the ground.

7. Although the Kurdistan Region has generally been protected from the climate of violence and insecurity that affects other regions of Iraq, the health situation generally mirrors that of the rest of Iraq. The Kurdistan Regional Government (KRG) MOH manages the health services in three Northern Governorates: Erbil, Dohuk and Sulaymaniya. The population in these three governorates includes internally displaced people (IDP) and totals around 5 million. Each Governorate has its own Directorate of Health (DOH), which includes eight departments: planning and health education, technical affairs, preventive health, engineering, administration, finance, central pharmacy, and medical operations and specialized services. This structure is the same in all Iraqi DOHs.

8. The KRG MOH enjoys a wide degree of autonomy with regard to the management of health facilities, staffing and the organization of health services. However, it is dependent on Baghdad for its budget allocation and for the provision of pharmaceuticals and medical equipment. Since the system does not respond to the actual needs of the population, about 70 percent of essential drugs are purchased by the KRG MOH from the private sector.

9. Status of Emergency Response: Recent emergency events have highlighted the very limited local capacity to respond to emergencies, e.g., assessment, communication, provision of pre-hospital care, referral system. Lack of adequately equipped ambulances, staff (including physicians) unprepared to respond to emergency needs, vulnerability of the communication system, and the disorganized response at the level of hospital emergency departments are a few of the most critical weaknesses. Even with the very limited resources of the existing system, there is considerable scope for improving the quality and effectiveness of emergency response by providing targeted support to mitigate critical bottlenecks in the system and to make better use of the existing scarce staff resources. In particular, the capacity to provide pre-hospital care can be significantly enhanced by the provision of communication and transportation equipment, the training of staff, and the establishment of a functioning command center in each of the three provinces covered by the project.

10. Donor Support to the Health Sector in the Kurdistan Region: a number of UN agencies are currently active in the health sector in the Kurdistan Region, including UNOPS, UNFPA, WHO, and UNICEF. In addition, the US, Korea and Japan provide bilateral support to

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the health sector in the form of reconstruction and/or rehabilitation of several hospitals and primary care centers.

11. The project would respond to two of the three thematic areas of the Third Interim Strategy Note for Iraq for the Period mid-FY09-FY11, namely: (i) continuing to support ongoing reconstruction and socioeconomic recovery; and (ii) improving governance and management of public resources, including human, natural and financial resources.

12. The original project is supported by an ITF Grant of US$8.7 million. The Grant was approved on June 18, 2008 and became effective on June 30, 2008. The Project Closing Date is June 30, 2010. The Project Development Objective (PDO) is: to assist the Kurdistan Regional Government to build capacity in the establishment of rapid, coordinated and effective response services to health emergencies, including those resulting from acts of violence, accidents, or natural disasters. The PDO is still valid, and therefore will remain unchanged. The Project has four components: (1) Emergency Coordination Centers (US$4.38 million), including construction of 3 ECCs, emergency telecommunications system, and ambulances; (2) Capacity Building and Training in Emergency Procedures (US$0.33 million), including design and carrying out of a technical training program for emergency responders; (3) Blood Banks (US$2.22 million), including civil works construction and provision of laboratory equipment; and (4) Project Management (US$1.77 million), including UNOPS implementation support, office equipment and supplies, and operating costs.

13. The Bank health team, from November 2009 through the Mid-term Review (MTR) in January 2010, undertook a thorough technical assessment of the project status. A report was subsequently produced outlining a plan to expand the scope of the project to ensure that the emergency medical response system being supported by the project is sufficiently up-to-date to meet the PDO. The MTR provided the opportunity for the Bank and the KRG MOH counterparts to take stock of the achievements as well as the challenges ahead in implementing the project, and to discuss possible restructuring to make the project more effective. Discussions focused mainly on the technical aspects of the project – the medical and paramedical staff training and the emergency telecommunications system – including ways to strengthen project performance and impact. Since the project design phase in 2007/2008, the context on the ground has changed. Because this was among the first free-standing projects to be financed by the Bank in Kurdistan, and because of logistical and security challenges during the preparation phase, the project structure as originally agreed reflected a minimalist approach, small in scope and simple in design. Stakeholder consultations were not feasible during the project preparation. As a result of the technical analysis carried out during the Mid-term Review and the follow-up field visit in February 2010, it was concluded that the scope of work will need to be expanded to meet the client’s request for a more comprehensive emergency response system. In order to meet this request for scaling up the project, it will be necessary to increase the project budget and to extend the project Closing Date to ensure sufficient resources and time to implement all planned activities.

14. After a slow start, the project is now making good progress. As of February 2010, two withdrawals totaling US$2.9 million have taken place. Actual disbursement of funds against project activities totals US$823,000, and commitments against contracts amount to another US$2.1 million, mostly in civil works and procurement of ambulances. Procurement of Blood Bank equipment in the next three months is expected to commit another US$840,000. The selection of a telecommunications expert to help the KRG MOH design and procure the telecommunications system is being finalized, as is selection of a medical training expert to plan and implement the training program for the emergency responders.

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15. Management of the project is the responsibility of the KRG MOH, which has a Project Coordination Unit (PCU) that oversees and coordinates project activities. The KRG MOH has contracted UNOPS as the Implementing Agent for the Project to provide support in management of the works, goods, consultants, workshops and training activities under a Project Implementation Agreement. The recently appointed Minister of Health is committed to ensuring that the project is successful, and is fully engaged with the RHERP team. The PCU receives full support from UNOPS as implementing agent for the project. In the past several months, UNOPS and the PCU have been managing the RHERP quite effectively. Project management skills have improved, and the PCU receives the full support of the Minister of Health. The current ISR rating for the RHERP Implementation Progress is “moderately satisfactory”.

16. Throughout implementation, the RHERP has been fully compliant with the conditions and legal covenants included in the Grant Agreement. The project has no unresolved fiduciary or safeguards issues. The first audit report will be due by June 30, 2010 covering the period from date of effectiveness up to December 31, 2009. The rating of safeguard compliance and environmental assessment is “moderately satisfactory”.

B. Rationale for Additional Financing and Project Extension

17. The January 2010 mid-term review provided the opportunity to take an in-depth assessment of where the project now stands, and to agree on next steps. A close technical review of the emergency medical system needs during this mission concluded that an expansion and scaling up of the original design will enable the project to meet its project objectives. The original design for the emergency telecommunications system is now outdated and the technical training of the medical emergency staff is too limited in scope. Based on this assessment, additional funds, estimated at US$4.5 million, are need to cover the cost of: (a) establishing an up-to-date and effective EMS; and (b) expanding the technical training of emergency staff to effectively operationalize the emergency medical system. In order to provide sufficient time for these expanded and scaled-up activities to be fully implemented, the project Closing Date would need to be extended by another 18 months, from June 30, 2010 to December 31, 2011.

18. In this context, the KRG MOH has requested Bank support in a letter dated April 19, 2010, for additional financing of US$4.5 million and an 18-month extension of the Project Closing Date.

19. The modifications requested are as follows: (a) the emergency telecommunications system, which is now considered out of date and inappropriate, will require a 100 percent increase in current allocation of US$3.0 million provided in the project for the system, (b) IT equipment and furniture for the ECCs and the BBs, (c) modifications and additions to the training programs, (d) design and implementation of a public education campaign for the use of 3-digit citizen access number (a “911” type), (e) extension of the project closing date from June 30, 2010 to December 31, 2011 (18 months), and (f) additional funds for management by UNOPS and PCU during the extension period of 18 months.

III. PROPOSED CHANGES

20. The Project Development Objective for the RHERP is: to assist the Kurdistan Regional Government to build capacity in the establishment of rapid, coordinated and effective response services to health emergencies, including those resulting from acts of violence, accidents, or natural disasters. The PDO is still valid and will remain unchanged.

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21. The PDO-level outcome indicators will not change. However, to reflect expansion of the training activities and the telecommunications system, some intermediate outcome indicators and target values have been refined and added. The revised Results Framework is attached as Annex 1.

22. Proposed activities to be included involve Components 1, 2, 3 and 4, as follows:

(a) Component 1: Emergency Coordination Centers (original estimate US$4.38 million). This component will need consulting services for the design of the telecommunications system and for the procurement of a different set of equipment (software and hardware), than what was envisaged at appraisal. A minimum of US$6.0 million is what is roughly estimated at this stage for a trunked communications system that provides backward compatibility with radio equipment used by hospitals and public safety agencies, and forward compatibility with modern, Internet Protocol (IP) based voice and data communications. The original project design was based on a basic radio service using VHF (Very High Frequency) type radio equipment which, it has now been determined, will not be adequate. The ECCs will also need IT equipment and furniture which was also not provided in the original design. A public education campaign will also be supported through in the project to raise public awareness for the 3-digit citizen access number, in cooperation with the Ministry of Communications and the Communications and Media Commission. The additional funding required to cover these items is estimated at US$3.23 million.

(b) Component 2: Capacity Building and Training in Emergency Procedures (original estimate US$0.33 million). Improved training programs for medical and paramedical staff and addition of other programs that are now considered essential for the proper operation of the system will require additional funding of about US$0.48 million. The number of staff to be trained will increase from the original 293 (master trainers, physicians, nurses, paramedics and drivers) to 1,418 (master trainers, emergency medical dispatchers, physicians, paramedics, nurses and drivers). Some training activities have been expanded and the number increased, for example, an additional 600 ambulance crews will be trained in basic life support, an additional 45 emergency dispatchers will be trained, and the number of ambulance drivers receiving training has been increased from 90 to 400 (See Annex 1, Table 2 Arrangements for Results Monitoring, Component 2). The Mid-Term Review, as a result of discussions with the medical focal points and the PCU and UNOPS team, led to some revision of the training activities to ensure that these activities can full support the Emergency Medical Services framework being established under the project. In this regard, with a few exceptions, all training programs under the project have been modified to reflect the current needs. Two more programs – Emergency Medical Dispatcher Training and Emergency Management System Training – have also been added to ensure that all aspects of the Emergency Management System are covered within the revised training framework. As originally planned, a medical training expert is in the process of being hired to prepare a detailed program which will include the expanded scope of the training.

(c) Component 3: Blood Banks (original estimate US$2.22 million). The restructured project will include IT equipment and furniture for the three Blood Banks. These items are considered essential and are included in this additional

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financing proposal. However, the cost of these items will be covered by an estimated $0.11 million savings within this component.

(d) Component 4: Project Management . The project will require an additional 18-month implementation period, which in terms of costs is estimated at US$900,000. The additional costs would include operating expenditures for the PCU and UNOPS management fees.

Estimated Project Costs by Component (US$ million) – Appraisal and Current Estimates

Component Appraisal Current Estimate Current Estim./

AppraisalDiff.

Component 1. Emergency Coordination Centers

4.38 7.61 + 3.23

Component 2. Capacity Building 0.33 0.81 + 0.48Component 3. Blood Banks 2.22 2.11 - 0.11Component 4. Project Management 1.77 2.67 + 0.90

Total 8.70 13.20 + 4.50

Allocation of Grant Proceeds: Current and Proposed

CategoryCurrent

AllocationUS$

Proposed Allocation (including Additional Financing)

US$

Percentage of Expenditures to

be Financed

1. Goods 4,450,000 7,515,000 100%2. Works 1,620,000 1,300,000 100%3. Consultants’ Services 200,000 400,000 100%4. Training 320,000 715,000 100%5. UNOPS service fee 415,000 591,000 100%6. Operating costs(a) UNOPS(b) PCU

1,185,00075,000

1,745,000116,000

100%

7. Unallocated 435,000 818,000 100%TOTAL 8,700,000 13,200,000

IV. APPRAISAL OF SCALED-UP ACTIVITIES

A. Technical

23. The pre-hospital component of a fully functional emergency care system comprises the handling of incoming calls and service requests, the dispatching of appropriate resources, the efficient pre-hospital stabilization of patients, and their safe transport to the most appropriate facility. This requires a highly performing communications system, staff trained to use agreed upon recognized intervention protocols, a well managed and appropriately equipped ambulance

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fleet, and data driven clinical, operational and financial quality improvement programs and organizational management of the system.

24. The following elements will be needed to build a functioning EMS in Kurdistan Region: (a) introduction of a standard 3-digit number (whether for general emergency or medical emergency) to be used for all of Kurdistan; (b) provision of a trunked communications system that provides backward compatibility with modern, Internet Protocol (IP) based voice and data communications; (c) IT equipment and specialized software, and office equipment and furniture for the ECCs; (d) training for the ECC staff in use of the new system; and (e) public information for use of the 3-digit citizen access number.

25. Presently, there is no direct public telephone access to the ambulance systems. The calls are routed through the Joint Communication Center for police, fire, and health emergencies through the Departments of Health in each Governorate, and through hospitals. The existing (experimental) ECC in Erbil is based on direct communication between the Department of Health and ambulance operators mainly by cellular phone. Communication between the Department of Health and ambulances is either via cellular phone or two-way radio. There are no formal call triage or vehicle dispatch functions at present.

26. Although accurate assessment of the size, operations, equipment and maintenance of the present fleet is not yet available, there are currently three categories of ambulances - those belonging to the military, to private hospitals, or to the MOH, located either at the Directorate of Health in each Governorate or at the hospitals. Except for disaster situations, the present project concerns only the latter fleet. This fleet is managed in small clusters and is not integrated. There are no unified standards for equipment, maintenance and operation of the ambulance fleet.

27. The overall size of the fleet is estimated in the project at being 120 plus 12 ambulances that have been purchased under Component 1. The number may be much higher (over 200) but it may include a variety of vehicles of a multitude of brands, ages, quality and condition. Some segments of the fleet, such as a recent donation of 35 ambulances by the Japanese Government, are very recent and equipped for advanced life support (ALS) interventions. The equipment in many ambulances is rudimentary, however, and may consist of little more than a stretcher.

28. The on-site interventions by ambulance crews at present are very limited, and essentially consist of patient transport. In some cases, it is stated that in the absence of even basic training for many staff, dangerous techniques are used, such as the absence of protection of the cervical spine, and may result in serious injury or death caused by the intervention in addition to the initial accident. There are some ALS trained paramedics operating in the system.

29. There is no systematic orientation or dispatch of patients to hospitals of destination chosen by the services available or their availability, given the absence of training of many of the staff intervening in the field. In disaster situations, however, there are procedures that allow to pre-alert the hospital of destination and to re-direct non trauma patients to other hospitals so that they will not be overwhelmed by trauma cases.

30. Through Additional Financing, the technical training of emergency responders will be further expanded, both in terms of courses provided and number of persons trained. The objective of this expanded training program is to provide the skills needed for the entire system to function effectively. The technical appraisal concluded that the original plan for technical training was not sufficient to upgrade effectively the skills needed for all persons functioning as emergency responders. The original plan involved training of 12 master trainers (physicians), 37 additional physicians, 150 nurses and paramedics, and 90 ambulance drivers, for a total of 289

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trainees. The proposed revised plan would involve the training of a total of 1,418 trainees, and the addition of two new training programs: emergency medical dispatcher training and emergency management system training.

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B. Institutional

31. The ongoing project is being implemented by the KRG MOH through UNOPS under a project implementation agreement entered into between the KRG MOH and UNOPS. The PCU is established and functioning within the Ministry, and serves as the central point to coordinate project activities and communicate with the Bank, UNOPS and other relevant agencies involved in the project. This is the first Bank-financed project to be implemented by the KRG MOH which before this project had no experience with Bank policies and procedures. This represents a significant risk to achieving the project outcomes, and therefore the implementation model includes substantial support through a contract with UNOPS as Implementing Agent to assist with implementation of the project activities, including civil works, goods and training. UNOPS, which has staff dedicated to the project in both its Erbil office and its Amman office, works closely with the PCU and provides capacity building support in project management. The activities originally implemented under RHERP will continue to be implemented by the KRG MOH PCU, with support from UNOPS. The PCU will continue to carry out monitoring of project results indicators on a quarterly basis, using the revised Results Framework monitoring tool agreed with the Bank.

C. Fiduciary

32. The current fiduciary arrangement is deemed adequate. Therefore, UNOPS will continue to handle the financial and procurement management.

33. The arrangements for financial management will remain the same as those for the ongoing Project. UNOPS will continue carrying out the financial management for the Project in coordination with KRG MOH as stipulated in the signed Project Implementation Agreement. In addition, the Bank’s Fiduciary Monitoring Agent (FMA) will also continue monitoring the Project to ensure that funds are used for the purposes intended and help carry out Project supervision on the ground.

34. The existing financial management arrangements continue to be adequate and the control procedures are in place. The Project operates on UNOPS’s established accounting package called “ATLAS” that has adequate security levels. Its outputs are used to prepare the Interim Un– audited Financial Reports (IFRs) of the Project. UNOPS has been submitting timely IFRs in an acceptable format and content. The financial management staff has experience and qualifications to continue managing and implementing the financial management aspects of the Project.

35. The Project has completed negotiations for the recruitment of an external auditor and agreed in principle with an independent external auditor to perform the financial audit of the RHERP project covering the period from effectiveness up to the current closing date of June 30, 2010. The Project is required to remit the audit report by no later than September 30, 2010. Under this proposed additional financing and Project extension, the closing date will be extended up to December 31, 2011. In this respect, UNOPS will subsequently arrange for the auditing of the additional period up to December 31, 2011 plus the four months grace period.

36. Disbursement. The disbursement arrangements of the Project under the proposed additional financing will follow the same arrangements, including the use of a Blanket Commitment. The disbursements will be IFR-based and a Blanket Commitment will be used for the Project Implementing Agency, as it is a UN Organization. The disbursement rate is considered low but this relates to project implementation rather than financial management.

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Risk factors

Description of risk Ratinga

of riskMitigation measures Ratinga of

residual risk

Financial Management Possibility of limited coordination between UNOPS and KRG MOH with regard to the FM responsibilities, coupled with the involvement of the FMA. Lack of knowledge of Bank policies and guidelines, on the part of UNOPS and KRG MOH.

H The PIA and the PIM define all related terms, including FM responsibilities and accountabilities. A relatively good working relationship has been established between UNOPS staff, KRG MOH, and the FMA.

S

UNOPS entity-wide audit might not be useful to get project specific audited information. UNOPS may have restrictions on the sharing of audit reports and providing access to auditors.

S The project audit TORs are part of the PIM. KRG MOH will ensure that the project is audited by an independent external auditor who will be given full access to the project documents.

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D. Environmental and Social

37. No new environmental safeguard policies are envisaged to be triggered; therefore, the project rating remains as Environmental Category “B”. The same measures being applied to the current project (RHERP) are applicable to the project activities to be supported by the additional financing. UNOPS has recently completed and submitted to the Bank the required questionnaire for Environmental and Social Screening and Assessment Framework for each project site. No environmental or social issues have emerged from this exercise.

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ANNEX 1. RESULTS FRAMEWORK AND MONITORING

* There are no changes in PDO and project outcome indicators. The wording for some intermediate outcome indicators have been changed to reflect expanded activities..

Project Development Objective

Project Outcome Indicators Use of Outcome Information

To assist the Kurdistan Regional Government to build capacity in the establishment of rapid, coordinated and effective response services to health emergencies, including those resulting from acts of violence, accidents, or natural disasters.

Utilization rate at the 3 Emergency Coordination Centers: number of people transported and appropriately referred by the emergency ambulance system

Reduction in response time: between call and admission to a health facility2

To track progress of project outcomes and identify corrective measures as needed.

Intermediate Outcomeby Component

Intermediate Outcome Indicators Use of Outcome Monitoring

Component One: Emergency Coordination Centers Emergency coordination and response in the three Northern Governorates of Erbil, Sulaymaniya and Dohuk strengthened

A functional emergency medical system with a standardized response to emergencies established in 3 centers.

At least 1 coordinator, 1 paramedic, and 1 driver with an ambulance on duty 24/7 per center

System of data collection in place and number of patients registered at each center


Component Two: Capacity Building and Training in Emergency Procedures Capacity built in medical and paramedical staff providing pre-hospital emergency services.

Technical staff trained in pre-hospital emergency services and applying skills learned in their daily work.


2 Reliability of present data is hampered by the fact that the volumes are very low and concern almost exclusively trauma cases (road accidents vs. cardiac arrest or respiratory).

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Intermediate Outcomeby Component

Intermediate Outcome Indicators Use of Outcome Monitoring

Component Three: Blood Banks Capacity upgraded in existing blood transfusion services to provide a timely supply of safe blood and blood products to respond to the needs resulting from an emergency.

3 blood banks have been built/rehabilitated, equipped and operating.

# of blood units collected and supplied for emergency use.


Component Four: Project ManagementEffective administration of project activities.

The project activities are implemented according to the implementation plan.


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Arrangements for Results Monitoring

Project Outcome Indicators Baseline Target ValuesCurrent Proposed Original Proposed Year 1 Year 2 Data Collection

InstrumentsResponsibility for Data Collection

Utilization rate at the 3 Emergency Coordination Centers: number of people transported and appropriately referred by the emergency ambulance system

N/C3 0 4 0 ECC functioning at least 50% of its capacity

ECC call documentation database.

KRG MOH/UNOPS

X% lower response time at the 3 centers than average in other facilities in the governorates: between call and admission to a health facility

N/C N/A Baseline will be collected as soon as possible, but before the centers are completed.

Reduction of 50%

ECC call documentation database.

KRG MOH/UNOPS extrapolated from existing data and collected systematically.

Intermediate Outcome Indicators

Baseline Target Values

Current Proposed Original Proposed Year 1 Year 2 Data Collection Instruments

Responsibility for Data Collection

Component 1.1,1 Construction completed in the emergency coordination center sites

N/C 0 0 3 sites Site visitsMonthly project implementation briefs

KRG MOH/UNOPS

1.2 Communications equipment in place and functioning

ECC Communications equipment in place and functioning

0 0 3 sites Site visitsMonthly project implementation briefs

KRG MOH/UNOPS

1.3 Ambulances in place and equipped with radio equipment.

Ambulances in place 0 0 12 Site visitsMonthly project

KRG MOH/UNOPS

3 No change.4 Projected maximum capacity of each center equipped with 4 ambulances would be around 40 interventions per day.

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implementation briefsCommunications equipment installed on Ambulances

0 0 12 Site visitsMonthly project implementation briefs

KRG MOH/UNOPS

Intermediate Outcome Indicators

Baseline Target Values

Current Proposed Current Proposed Year 1 Year 2 Data Collection Instruments

Responsibility for Data Collection

Component 2.2.1 Planning workshop completed and training plan finalized for TOT program

Training plan finalized 0 0 1 Monthly project implementation briefs

KRG MOH/UNOPS

2.2 Number of trainers trained 1. Number of trainers trained 5

0 0 16 Monthly project implementation briefs

KRG MOH/UNOPS

2. Number of emergency medical dispatchers trained


KRG MOH/UNOPS

3. Number of ambulance crew trained in BLS


KRG MOH/UNOPS

2.3 Number of ambulance drivers trained

4. Number of ambulance drivers trained in safe driving and mech/maintenance


KRG MOH/UNOPS

2.4 Number of paramedics trained in BLS

5. Number of paramedical staff trained in ALS


KRG MOH/UNOPS

2.5 Number of physicians trained in emergency clinical procedures

6. Number of physicians trained


KRG MOH/UNOPS

7. Workshop on emergency management system (#of trainees: 16)


KRG MOH/UNOPS

2.6 Number of senior Physicians trained in management of

8. Number of KRG MOH staff trained in


KRG MOH/UNOPS

5 To carry out #2-5 activities.

14

emergencies medical emergency management 9. Number of KRG MOH staff trained in Emergency management system


KRG MOH/UNOPS

Component 3.3.1 Renovation of Sulaymaniya Blood Bank completed

N/C 0 0 1 Site visits and Monthly project implementation briefs

KRG MOH/UNOPS

3.2 Reparation of ventilation system in Dohuk Blood Bank completed


KRG MOH/UNOPS

3.3 Construction of Erbil Blood Bank completed


KRG MOH/UNOPS

3.4 Equipment delivered and installed in the three Blood Banks

N/C 0 0 3 sites Site visitsMonthly project implementation briefs

KRG MOH/UNOPS

Baseline Target ValuesCurrent Proposed Current Proposed Year 1 Year 2 Data Collection

InstrumentsResponsibility for Data Collection

Component 44.1 PCU established and staff in place by Project Effectiveness.*

N/C PCU established

Monthly project implementation briefs

KRG MOH/UNOPS

4.2 Contract between KRH MOH and UNOPS finalized and signed by Project Effectiveness.*

N/C Contract finalized and signed

Monthly project implementation briefs

KRG MOH/UNOPS

*Indicators for 4.1 and 4.2 have been achieved.

15

ANNEX 2. PROJECT RISKS

Risk factors Description of risk Ratinga of risk

Mitigation measures Ratinga of residual risk

I. Country and/or Sub-National Level Risks Administration changes in MOH may impact

current commitment to project design and inputsM Simple project design, with well-focused

priorities and activities. Maintaining UNOPS for management support. Working closely with MOH officials to ensure commitment and continuity

L

II. Sector Governance, Policies and Institutions Sector Specific Risks Multiple efforts and parallel tracking by the

various agencies and bilateral donors causing fragmented reform effects.

M Maintain close communication with key donor agencies active in Iraq and in particular in the Kurdish Region.

L

III. Operation-specific Risks Technical Design Implementation Capacity And Sustainability

Lack of experience of KRG MOH in implementing Bank-financed projects

S Building into the project design substantial support from UNOPS as Implementation Agent. Bank supervision of the project at regular intervals, both in Amman and in the Kurdish Region.

M

Limited technical capacity of UNOPS staff to implement a health sector project

S Close supervision from the Bank side on quality of technical consultants recruited under the project.

M

Collection of comprehensive information on the status of facilities to enable planning and priority setting may not be collectable within the time constraints of the project.

S KRG MOH has already identified the sites, and the Bank is helping to identify the types of data needed for planning purposes through field visit and desk analysis. UNOPS will also provide support in this respect.

M

Failure of government to meet the incremental operating and maintenance costs of the investments under the Project

S Establish with KRG MOH what the O&M costs would be through the costing exercise and substantial discussions already took place with KRG MOH in operationalizing facilities

M

and equipment. Project Implementation Agreement between KRG MOH and UNOPS is not extended

M The World Bank is facilitating the amendment of the PIA. The signing of the PIA is an effectiveness condition of the Additional Financing

L

Financial Management

Possibility of limited coordination between UNOPS and KRG MOH with regard to the FM responsibilities, coupled with the involvement of the FMA. Lack of knowledge of Bank policies and guidelines, on the part of UNOPS and KRG MOH.

H The PIA and the PIM define all related terms, including FM responsibilities and accountabilities. A relatively good working relationship has been established between UNOPS staff, KRG MOH, and the FMA.

S

UNOPS entity-wide audit might not be useful to get project specific audited information. UNOPS may have restrictions on the sharing of audit reports and providing access to auditors.

S The project audit TORs are part of the PIM. KRG MOH will ensure that the project is audited by an independent external auditor who will be given full access to the project documents.

M

Procurement Social And Environmental Safeguards

IV. Overall Risk (including Reputational Risks) Overall Risk M

Memo items:

a Rating of risks on a four-point scale – High, Substantial, Moderate, Low – according to the likelihood of occurrence and magnitude of potential adverse impact.

17

ANNEX 3. EXPENDITURE BY COMPONENT – APPRAISAL ESTIMATESComp. 1 Comp. 2 Comp. 3 Comp. 4

FeeC

5.884%

1. Goods1 Computers and Peripherals 20,100 20,100 20,1002 Computers and Peripherals for UNOPS 0 0 03 Telecommunications Equipment 3,033,000 3,033,000 3,033,0004 Ambulances 730,000 730,000 730,0005 Laboratory Equipment 843,200 843,200 843,2006 Furniture 0 0 0 0

Subtotal 2. Goods 3,763,000 0 843,200 20,100 4,626,300 4,626,300 0 272,211

2. Civil Works1 Erbil 190,600 629,300 819,900 819,9002 Sulaymaniyah 179,700 434,500 614,200 614,2003 Dohuk 182,400 168,800 351,200 351,2004 PCU office 0 0 05 Other 0 0

Subtotal 1. Civil Works 552,700 0 1,232,600 0 1,785,300 1,785,300 0 105,047

3. Consultancy Services1 Architectural & Engineering Design 28,300 65,400 93,700 93,7002 QA & QC (Supervision) 35,200 78,600 113,800 113,8003 Consultancy services for medical

equipment ($6,000)0 0 0

4 Consultancy services local telecommunications expert ($13,980)

0 0 0

5 Consultancy services for telecommunications International Expert ($180,000)

0 0 0

6 Audit 21,100 21,100 21,100Subtotal 3. Consultancy Services 63,500 0 144,000 21,100 228,600 228,600 0 13,451

4. Training1 Training 331,400 331,400 331,4002 Other, training consultant charges 0 0 0

Subtotal 4. Training 0 331,400 0 0 331,400 331,400 0 19,500

5. UNOPS Fee 414,451 414,451

6(a). Operating Costs (UNOPS)1 Personnel - Local 364,900 364,900 364,9002 Personnel - International 316,400 316,400 316,4003 Direct Operation Cost 312,900 312,900 312,9004 Security 107,700 107,700 107,7005 Travel 141,800 141,800 141,8006 Other (rounding correction) -1,851 -1,851

Subtotal 6(a). Project Management 0 0 0 1,243,700 1,241,849 0 1,241,849 0

6(b). Operating Costs (PCU)1 Travel & Subsistence (Review Missions) 50,400 50,400 50,4002 Other, project launch workshop 21,700 21,700 21,700

Subtotal 6(b). Project Management 0 0 0 72,100 72,100 72,100 0 4,242

Contingency Allowance 0 0 0 0 0

TOTALS (All Categories) 4,379,200 331,400 2,219,800 1,771,451 8,700,000 7,043,700 1,241,849 414,451

A B Fee

Notes: Total UNOPS Operating Costs Including the Copenhagen Fee (B + Fee) =

1/ Fee of 5.884% on all Project Inputs (A) Above Total as % of A (C / A) =

2/ Direct Operating Costs by UNOPS (B)

3/ Total UNOPS Costs (B+Fee=C) Current Allocation of Grant Funds = 8,700,000

1,656,300

23.51%

C = B + Fee

Disbursement Categories& Descriptions

TotalProjectCosts

Analysis of UNOPS Costs

Emerge-ncy

Coordi-nation

Centers

Capa-city

Building and

Training

BloodBanks

ProjectManage-

ment

ProjectInputs

A

UNOPSOpera-

tingCosts

B

ANNEX 4. EXPENDITURE BY COMPONENT – REVISED ESTIMATES

Expenditure by Component – Revised Estimates

Comp. 1 Comp. 2 Comp. 3 Comp. 4

FeeC

5.884%

1. Goods1 Computers and Peripherals 15,000 15,000 16,055 46,055 46,0552 Computers and Peripherals for UNOPS 11,714 11,714 11,7143 Telecommunications Equipment 6,000,000 6,000,000 6,000,0004 Ambulances 675,000 675,000 675,0005 Laboratory Equipment 900,000 900,000 900,0006 Furniture 75,000 103,000 178,000 178,000

Subtotal 2. Goods 6,765,000 0 1,018,000 27,769 7,810,769 7,810,769 0 459,586

2. Civil Works1 Erbil 206,669 597,760 804,429 804,4292 Sulaymaniyah 165,101 166,548 331,649 331,6493 Dohuk 164,950 157,663 322,613 322,6134 PCU office 9,600 9,600 9,6005 Other 0 0

Subtotal 1. Civil Works 536,720 0 921,971 9,600 1,468,291 1,468,291 0 86,394

3. Consultancy Services1 Architectural & Engineering Design 14,087 24,673 38,760 38,7602 QA & QC (Supervision) 62,716 73,207 135,923 135,9233 Consultancy services for medical

equipment ($6,000)6,000 6,000 6,000

4 Consultancy services local telecommunications expert ($13,980)

13,980 13,980 13,980

5 Consultancy services for telecommunications International Expert ($180,000)

200,000 200,000 200,000

6 Audit 52,600 52,600 52,600Subtotal 3. Consultancy Services 290,783 0 103,880 52,600 447,263 447,263 0 26,317

4. Training1 Training 629,904 629,904 629,9042 Other, training consultant charges 122,400 122,400 122,400

Subtotal 4. Training 0 752,304 0 0 752,304 752,304 0 44,266

5. UNOPS Fee 623,691 623,691

6(a). Operating Costs (UNOPS)1 Personnel - Local 617,000 617,000 617,0002 Personnel - International 562,428 562,428 562,4283 Direct Operation Cost 430,000 430,000 430,0004 Security 118,572 118,572 118,5725 Travel 105,000 105,000 105,0006 Other

Subtotal 6(a). Project Management 0 0 0 1,833,000 1,833,000 0 1,833,000 0

6(b). Operating Costs (PCU)1 Travel & Subsistence (Review Missions) 99,450 99,450 99,4502 Other, project launch workshop 21,700 21,700 21,700

Subtotal 6(b). Project Management 0 0 0 121,150 121,150 121,150 0 7,128

Contingency Allowance 30,000 53,532 30,000 30,000 143,532

TOTALS (All Categories) 7,622,503 805,836 2,073,851 2,697,810 13,200,000 10,599,777 1,833,000 623,691

A B Fee

Additional Financing Required = 3,243,303 474,436 -145,949 926,359 4,500,000

Total UNOPS Operating Costs Including the Copenhagen Fee (B + Fee) =

Above Total as % of A (C / A) =

Notes:

1/ Fee of 5.884% on all Project Inputs (A) Current Allocation of Grant Funds = 8,700,000

2/ Direct Operating Costs by UNOPS (B)

3/ Total UNOPS Costs (B+Fee=C) Additional funds required to complete the Project = 4,500,000

Disbursement Categories& Descriptions

Emerge-ncy

Coordi-nation

Centers

Capa-city

Building and

Training

23.18%

2,456,691

BloodBanks

TotalProjectCosts

UNOPSOpera-

tingCosts

B

ProjectInputs

A

ProjectManage-

ment

C = B + Fee

Analysis of UNOPS Costs

19

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