Ninth Six-month progress report for project

IRFFI/UNDG IRAQ TRUST FUND (UNDG ITF)

EMERGENCY MEDICAL OXYGEN PRODUCTION AND SUPPLY FOR IRAQ, NOW REPROGRAMED FOR EMERGENCY HUMANITARIAN RESPONSE SINCE

10 APRIL 2008

Participating UN Organization:	Old Cluster: Health and Nutrition
World Health Organization	New Sector: Health and Nutrition

Project No. and Project Title:	Report Number:
D2- 11 Emergency Medical Oxygen Production and Supply in Iraq	ATLAS Project Number: 54892 ATLAS Award Number: 66892

Reporting Period:	Project Budget:
1 July – 30 December 2008	US$ 2,824,760

List Implementing Partners:	Geographic Coverage/Scope:
Ministry of Health Iraq - Technical Affairs Directorate (TAD), - National Blood Transfusion Center (NBTC) - First Aid and Ambulance Services Center -National Center for Drug Control and Research (NCDR)	Initially, the project was meant to (1) supply oxygen to hospitals in Baghdad, Mosul and Kirkuk and (2) install 3 oxygen production plants in Basrah, Diwaniyah and Baghdad governorates. Since 10 April 2008, the scope of the project has been changed into emergency humanitarian response with countrywide scope

Abbreviations and Acronyms:	Project Status: Duration/ Timeline Extension/Closed Project:
MDG: Millennium Development Goals MOH: Ministry of Health MOI: Ministry of Industry NCDR: National Center for Drug Control and Research PSA: Pressure Swing Adsorption QC: Quality Control SOPs: Standard Operating Procedures WHO: World Health Organization	- Approved on 29 August 2005, the last project extension was up to 30 Nov. 2006. After this date, due to a series of difficulties encountered during the implementation, it was decided to suspend the project and return the remaining funds. - In April 2008, as a result of emergency needs, the MOH requested to use the funds for emergency response and the project was reactivated to be implemented until December 2008. The first three month extension up to 31 March 2009 was granted in December 2008. A new extension until 31 Oct. 2009 to complete the delivery of procured medicines and medical supplies has been obtained in March 2009.

Report Formatting Instructions:	Number all sections and paragraphs as indicated below.	Format the entire document using the following font: 12point _ Times New Roman & do not use colours.	Attach any available photos relevant to the project.

NARRATIVE REPORT FORMAT

Purpose

a.	Provide the main objectives, outcomes, outputs of the programme/project

The first objective of the original project (a quick impact project) was to provide medical oxygen to all hospitals in Baghdad, Mosul and Kirkuk governorates to meet their six month oxygen needs. This activity was meant to be implemented as a temporary measure, until such time the MOH finds suitable solution for long term oxygen supply system.

The second objective was to provide a reliable, sustainable and long term arrangements for an uninterrupted oxygen supply in Iraq through installation of 3 medium size oxygen production plants/units (1 in Baghdad, 1 in Basra and 1 in Diwaniyah) as a pilot project to be expanded to the entire country with government owned resources.

However, following several obstacles and constraints previously reported, with regard to the procurement and installation of the three oxygen plants, the implementation of the project was interrupted in November 2006; and WHO decided to return the remaining funds in March 2007.

Following acute needs for essential basic emergency medicines in the country in March- April 2008 during Basra and Baghdad Sadr City crisis, the Ministry of Health strongly recommended to use the available funds for the procurement of medical supplies for emergency humanitarian response and capacity building of professionals working in emergency medical services. Based on the Ministry’s request, the Chairperson of the UNDG ITF Steering Committee approved on 10 April 2008 the revival and extension of the project implementation period with changes in project scope putting the strict condition on the project completion by 31 December 2008.

Details regarding the four main activities to be implemented under the revised project are described below.

The main development goal and immediate objectives of the reprogrammed project remain almost the same as in the initial project. These include two aspects:

Increase access to quality health intensive care services especially for vulnerable groups and increase emergency preparedness and response capacity to deal with emergencies;

Reduce disability and mortality, including maternal and children under 5 mortality rate caused by lack of basic emergency medicines and supplies, including oxygen and other anesthetics among patients requiring emergency attention and health care.

The new project outputs are:

Timely response to emergencies in intensive care units through better access to needed emergency medicines and supplies;

Improved outcomes of visits to hospital emergency units with reduced morbidity and mortality

Under the reprogrammed project there are four key activities planned as follow:

Provision of a list of emergency medicines and supplies requested by the MOH.

Replacement of some of the basic life support equipment/supplies in a number of ambulances

Capacity building (training of trainers) of professionals involved in emergencies with focus on workers involved in first aid and ambulance management and blood transfusions

Review and updating the report resulting from the nationwide survey on first aid and medical gases services which was conducted early 2006 but could not be finalized for dissemination.

b.	Explain how the programme/project is relevant to the following benchmarks:

UN Assistance Strategy for Iraq,

Millennium Development Goals,

Iraq National Development Strategy

International Compact for Iraq (ICI)

The project fits well with the UN Assistance Strategy to Iraq as it is contributing to:

Increasing access to quality health care services especially for vulnerable groups and the un-reached

Ensuring emergency preparedness and timely response.

Achieving the contemplated 50% reduction in Under-5 and Infant Mortality

This project contributes in addressing the following MDGs:

Reduce child mortality (MDG4),

Improve maternal health (MDG5)

Develop global partnership for development (MDG8).

With regard to Iraqi National Strategy and ICI, the project contributes to improve administration and emergency management in the health care system which is one of the ICI benchmarks for the health sector.

c. Indicate the main implementing partners, their roles and responsibilities, and their interaction with the Agency

The main partner in this project is the MOH, its technical departments and the end user health facilities receiving medications procured through the project. The main MOH departments involved are:

The Technical Affairs Directorate (TAD) which is mainly involved in providing the list of urgent requirements for humanitarian response and in the review of the results of the survey on first aid and ambulance services which was conducted between Nov-December 2006.

The First Aid and Ambulance Centers at central and governorate levels which are involved in the selection of candidates for training on Basic and Advanced Life Support Techniques

The National Blood Transfusion Center which is involved in the training in emergency blood safety programme.

The National Center for Drug Control and Research which performs the quality control of the pharmaceutical products procured

Kimadia, the State Company for Medicines and Medical Appliances that deals with handling and distribution of procured medicines and medical supplies from Baghdad to other governorates.

Human Resources

a.	National Staff & Consultants: Provide the number and role (operation/programme)

Two national officers (one project manager and one logistician) are involved in supporting the operations and the implementation of the programme. The project manager is constantly liaising with different departments of the Ministry involved in the implementation of the project for needs identification and compilation, facilitation of the training programmes and he will also play an important role at the time of delivery of the goods.

The logistician is involved in supporting the international project manager in the review of the requests and in preparing the invitation to bid for local procurement and in facilitating the shipping of medicines delivered in Amman which have to be forwarded inside Iraq.

In addition to those two national officers, the project is supported, time to time, by other staff within WHO offices of Baghdad and Amman. For specific tasks, short term assignments with regards to capacity building are also awarded to individuals or to institutions to perform specific tasks, particularly in the areas of capacity building. These are in the form of Agreements of Performance of Works (APWs) contracts. Such APWS have been used for the training on Basic and Advanced Life Support training course at the Jordan Civil Defence Directorate and for the training of staff on screening of blood and the management of blood bank services at the Jordan Blood Bank in Amman.

II. b.	International Staff: Provide the number and role (operation/programme)

A WHO international officer is coordinating the overall project implementation and is responsible for every day management of the project (Project manager). He is assisted by other international staff in the office on part time basis, particularly the officer responsible for follow up on Purchase orders and technical specifications of equipment and supplies.

It is important to mention that for the procurement of medicines and supplies, most of them are done through international bidding. In this context, the project is enjoying the support of international staff working in Section of Logistic Support to Countries at the Regional Office in Cairo.

Methods of Operating

a.	Summarize the implementation mechanisms primarily utilized and how they are adapted to achieve maximum impact given the challenging operating context.

This project comprises mainly of two components: Procurement of medicines and medical supplies to respond to emergency humanitarian needs and capacity building of staff involved in emergency medical services, including staff managing ambulances and blood transfusion services.

The project is being implemented primarily by the Ministry of Health, with the technical support of WHO. Specifically, the departments involved are the MOH Technical Affairs Directorate for the component related to the identification of medicines and medical supplies needs, the First Aid and Ambulance Centres and the National Blood Transfusion Centre for the component related to training and capacity building.

With regards to the procurement component, the project is being implemented in accordance with set procedures within WHO rules and regulations (see the process explained in point b of section III.

For the training, the selection of candidates was done using set criteria to ensure the candidates with the right education background and experience are selected. In order to achieve the maximum benefit, the training on Basic and Advanced Life Support Techniques was conducted in Arabic language for a group of trainers (training of trainers) who once trained will in turn train their colleagues inside Iraq. The same principles were applied to the training of trainers in the field of Blood Transfusion Services. This is to ensure ownership and sustainability.

b.	Provide details on the procurement procedures utilized and explain variances in standard procedures.

WHO has well established procurement procedures. Goods are generally delivered to Baghdad under international insurance coverage. The procurement process is being carried out through international bidding process for most of the goods to be procured, based on WHO rules and regulations. These are aimed at ensuring quality, efficiency and cost effectiveness. In few cases, local procurement has been applied. It follows a set of clear and written procedures for bidding according to the amount involved and the delegation of authority conferred by the organisation to the WHO Representative for Iraq.

Organization manuals providing strict guidance and procedures on invitation to bids, bids opening, bids analysis, bids review and contract award, including conditions abiding both parties (the successful bidder and the organization) are available for international and local procurement. There are specific committees at each stage of the bidding process. There are no variances in standard procedures.

To ensure that all goods/supplies that will be procured are of the desired quality, are properly delivered and installed as case may be and that appropriate training for application in the case of equipment usage and maintenance, the following steps are considered by WHO:

A needs assessment is carried out to establish the requirements of the facility for which goods are to be procured.

Extensive consultations between WHO and the concerned health facilities are held to agree on the technical specifications and to ensure they satisfy the users' needs.

The vendors are requested to provide technical specification/data sheets for all equipment components and supplies, including description of all major features and performance specifications. These include: (1) Manufacturer and model name (2) Physical, environmental, and electrical utility requirements (i.e. steam, medical gas, vacuum requirements); and (3) Physical dimensions and weight of the unit.

The vendors are requested to provide documentations and standards related to the Quality assurance and Quality control procedures for all supplies and equipment procured and all procured consignments are covered by insurance valid for 90 days from date of arrival to Iraq till duration of 1 year.

For procurement of equipment the vendors are requested to provide lists for reagents, consumables, and disposables including pricing.

Procured supplies should have a minimum 75% of maximum shelf life at date of shipment.

WHO facilitates direct communication between vendors and end-users to ensure that manufacturer’s pre-installation requirements on the newly procured equipment are met.

Receiving reports for consignments procured and delivered to end users in Iraq are issued, compiled, and reviewed by WHO Country Office and thereafter submitted to WHO Regional and HQ offices to acknowledge the safe receipt and satisfactory functioning of the equipment and supplies.

One year warranty from date of arrival/installation is provided by the manufacturer for all items procured. During this period WHO field staff conduct site visits to assess the performance of the equipment provided, check any fault and malfunction, and report accordingly.

c.	Provide details on the monitoring system(s) that are being used and how you identify and incorporate lessons learned into the ongoing programme/project.

Approaches and methodologies used for monitoring the implementation of this project are similar to those used for other UNDG ITF projects.

There are focal points in the Ministry for each component of the project and the work plan of each component is discussed between WHO team and the focal points, mostly in Baghdad during the visits of the international project manager. To this effect, at least three meetings were held in Baghdad involving the focal points on first aid and ambulances and the focal points from the national blood transfusion centre.

The implementation of the project is also being monitored by a team comprising of representatives from the MOH who are being supported by a WHO Team. It is also important to mention that this project as part of UNDG ITF funded projects is subject to the regular mandatory internal and external audits.

Among the lessons learned is the need the time it takes a lot of time to receive medicines procured abroad. In the case of Iraq, because of several factors (i.e. poor banking services in the country and security situation in the country),

d.	Report on any assessments, evaluations or studies undertaken relating to the project and how they were used in support of the project(s).

The lists of medicines and medical needs for procurement were developed based on the results of an exercise of quantification of emergency medicines and medical supplies needed for year. Given the limited budget compared to the needs, the quantities to be procured have been prorated to the budget available

A study (survey) on first aid and medical gases services in Iraq was conducted between Nov 2005-Feb 2006 and the preliminary findings will be revisited and reviewed in the next few weeks.

Concerning the domains for training and capacity building (Basic and advanced Life Support), these have been defined on the basis of the results of the workshop on Emergency Medical Services which was held in Amman in March 2007.

IV. Results

a. Report on the key outputs achieved in the six month period including # and nature of the activities (inputs), % of completion and beneficiaries. Please also fill the table in section VI on six monthly performance indicators assessment.

As earlier indicated, there are 4 activities retained in the re-programmed funds for emergency humanitarian response. These include:

Provision of a list of emergency medicines and supplies requested by the MOH

Replacement of some of the basic life support equipment and supplies in a number of ambulances

Capacity building (training of trainers) on Basic and Advanced Life Support Techniques and on identified topics in the areas of blood transfusion services

Review and update the report on national survey on first aid and medical gases

Below is a summary of the status of implementation of each activity.

Provision of a list of Emergency medicines and supplies requested by MoH

The initial list of medicines and medical supplies requested by the MoH was received mid-April 2008 and comprised of the four types of items (anesthetics, sutures and external fixators and quadruple blood bags).

The procurement status of each one of these items is as follow:

Sutures: All the 42 different types of sutures ordered have been delivered to Iraq with a total value of $213,780

Purchase orders for all the 10 anesthetics have been issued with a total value of about $500,000. The delivery to Iraq is complete for 8 of them (Ketamine 50mg/ml, Thiopental Sodium 1gm/20ml, Neostigmine 2.5mg/ml, Halothane 100%, Atracurium Besylate 25mg/2.5ml, Pancuronium Bromide 2mg/ml, Propofol Lipuro 10mg/ml (20ml ampule), Propofol Lipuro 10mg/ml (50ml bottle)). Suxamethonium Chloride 50mg/ml is being shipped to Iraq at the time of preparing this report March 2009 whereas Fentanyl 50mcg/ml will be shipped soon to Iraq.

Quadruple blood bags with a total value of $97,200 have been ordered and are expected to be shipped in April 2009. Part of the consignements will be used to reimburse the loan previously given by the Jordan Ministry of Health to Iraqi MOH through WHO and the rest 162 pack of 36 bags will be delivered for use by Iraq National Blood Transfusion Center.

For the external fixation devices as previously indicated, the determination of specifications took longer than anticipated. Correct specifications have now been received from the MOH and a purchase order is being prepared at the time of preparing this report. Also, the supplier has indicated that the delivery will be done in staged installment.

Capacity building (ToT) on professionals involved in emergencies mainly on ambulance management and blood transfusion.

Following the discussion with MoH in June 2008 in Baghdad, the ministry indicated that the training packages should focus on different categories of health professionals in ambulance management and blood transfusion services.

For staff involved in ambulance management, WHO, in collaboration with the Jordanian General Directorate of Civil Defense organized Training of Trainers Course on Basic and Advanced Trauma Life Support which was held in Amman from 19-30 October 2008 for the first group of trainees from Baghdad, and from 2-13 November for the second group of trainees from other governorates (Karbala, Kirkuk, Thi Qar, Diwaniyah, Najaf, Babil, Wasit, Missan, Basrah, Mosul, Diyala, Salah Eldeen, Anbar and Muthana). A total of 29 health professionals working in the field of delivering pre- hospital emergency medical services, among which were nurses and paramedics, participated in these training courses.

For the professionals working at the MOH/Iraq National Blood Transfusion Center (NBTC) the training was conducted in Amman for 15 workers (in three groups of 5 participants each) at the Jordan Directorate of National Center for Blood Bank The programme was a training of trainers tailored to the specific needs expressed by the NBTC. It included a wide range of topics covering blood transfusion services. The training course was held, in collaboration with the Directorate of National Center for Blood bank, in Amman from 14-25 December, 2008 for the first group and from 11-22 January, 2009 for the second group and from 1-12 February for the third group. Trainees were health professional working in the field of Blood Transfusion Services, among which were Directors of Blood Banks from Baghdad and other governorates (Mosul, Anbar Diwaniyah, Basrah, Kirkuk and Karbala).

Replacement of some of the basic life support equipment/supplies in ambulances

WHO has provided technical documentations to assist the MOH/Ambulance Center in assessing the needs and in refining the technical specifications. It has been found that most of ambulances recently received are well equipped but the personnel are not sufficiently trained on the use of the devices in the ambulances

Review and update the report on national survey on first aid and medical gases

The process of the review of the report which was produced in April 2006 has been discussed. The report is under review for possible update before printing and expected to be finalized by July 2009. However, the main challenge is that most of the professionals who have participated in the survey (i.e. data collection, analysis of field data and report writing) are either no longer in the same department or are no longer working for the Ministry of Health. Some have even left the country.

b. Report on progress made toward the achievement of specific medium-term outcomes of the programme/project as a result of the achieved short-term outputs during this reporting period and explain any variance in achieved versus planned outputs and outcomes during the six month reporting period.

The use of delivered emergency medicines and supplies is contributing to (1) a timely response to emergencies in intensive care units through better access to needed emergency medicines and supplies and (2) to improved outcomes of visits to hospital emergency units with reduced morbidity and mortality. It should be noted that it is difficult to measure the specific contribution of these medicines to achieving these mid term outcomes as other products from other sources are also used at each health facility.

c. Explain, if relevant, delays in programme/project implementation, the nature of the constraints and actions taken to mitigate future delays and lessons learned in the process.

Procurements and shipment of project material is a challenge in Iraq and delays due to difficulties at border crossings, processing and remote management is impacting the management of WHO’s programmes.

For some of the items, for example external fixation devices needed for mobilisation of fractures, the suppliers did not respond timely to invitation to bid. Also for some items, the suppliers indicated that the delivery of these items will be made in several instalments as there were no stocks at hand in most of the cases. These delays are compounded also by the fact that the process of Invitation to Bid which cannot be shortened without breaching the rules of fair competitiveness.

Lessons learnt:

The regular process of bidding for the procurement of items on international market is cumbersome and lengthy and therefore defeats and delays the timely response in emergency situations. Pre-positioning of items for emergencies should be privileged. Furthermore, the medical supply management should be organized in a such way that there is always a buffer stock for about 2 to 3 months for use while the processes of re-ordering through the regular channel is underway.

With the globalised pharmaceutical market, it is difficult nowadays to find a supplier which has all items needed in stock at hand. In many cases, the manufacturer requires long period to be able to deliver the quantities requested. In the future, the combination of prepositioning of items considered as emergency items, combined with the possibility of keeping sufficient buffer stock could be a measure that may mitigate the risk of shortages of medical supplies.

d. List the key partnerships and collaborations, and explain how such relationships impact on the achievement of results.

The main partner, as earlier indicated, is the Ministry of Health and its specialized departments. The MOH/Technical Affairs Directorate (TAD) which oversees the work of the First Aid and Ambulance Center as well as the work of the National Blood Transfusion Center will play an important role in ensuring the coordination of all the project activities inside Iraq at central and governorates levels.

The National Center for Drug Control and Research is another partner that is performing the quality testing of goods received before their distribution.

e. Summarize achievements against planned results for cross cutting issues: security, gender, human rights, employment (including # of short and/or long-term jobs created), and environment.

The project is mainly focussing on procurement of emergency medical supplies and hence it does not have substantial implication and impact on most of the cross cutting issues.

However, for capacity building activities, gender balance is taken into consideration whenever possible.

In terms of employment generation, only few positions have been created through short term tasks and tuition fees allocated to the training centres in Jordan.

The improvement in the security situation, will facilitate the timely distribution of goods to the end-users in affected areas.

V. Future Work Plan

a. Summarize the projected activities up to the end of June 2009 indicating any major adjustments in strategies, targets or key outcomes and outputs planned.

Between January and June 2009, the following activities will be given priorities:

Follow up on the delivery of the 2 anesthetics and quadruple blood bags in the process of being delivered in the country

Follow up on the procurement of external fixation devices and their delivery to the MOH.

Preparation and follow up on training activities scheduled to take place on January and February 2009. This have been already completed as indicated in the report above

Follow up on updating the report subsequent to the survey of first aid and medical gases services in Iraq.

Six monthly Performance Indicators assessment

Note: It should be noted that no new logic frame was developed when the project scope was changed. For this reason, the table below on six monthly performance indicators assessment is constructed based on group of activities carried out during the reporting period.

Performance Indicators	Indicator Baselines	Planned Indicator Targets	Achieved Indicator Targets	Means of Verification	Comments (if any)
IP Outcome 1: Improved access to essential medicines through provision of a list of emergency medicines and supplies requested by MOH
IP Output 1.1 A list of 34 sutures procured and delivered	Indicator 1.1.1 Number of sutures delivered	0	34	34	Visit to warehouses and review of records
IP Output 1.2 List of 10 anesthetics procured and delivered	Indicator 1.2.1 Number of anesthetics delivered	0	10	8	Visit to warehouses and review of records	2 are in the process of delivery
IP Outcome 2: Skills of professionals involved in emergencies with focus on workers involved in first aid and ambulance management and blood transfusions improved through capacity building (training of trainers)
IP Output 2.1 15 health professionals trained in blood transfusion techniques	Indicator 2.1.1 Number of staff trained	0	15	15	Records of the Training Center
IP Output 2.2 25 health professionals trained in Basic and advanced life support	Indicator 2.2.1 Number of staff trained	0	25	29	Records of the training center