document of the world bank...guidelines. date achieved 12/31/2006 12/10/2007 09/30/2008 comments...

Document of The World Bank

Report No: ICR0000111

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-45500)

ON A LOAN

IN THE AMOUNT OF US$87.0 MILLION

TO THE

ISLAMIC REPUBLIC OF IRAN

FOR A

SECOND PRIMARY HEALTH CARE AND NUTRITION PROJECT

July 30, 2009

Human Development Sector MNCO2 Middle East and North Africa Region

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CURRENCY EQUIVALENTS

(Exchange Rate Effective June 16, 2009)

Currency Unit = Iranian Rial (IRR) IRR 1000 = US$ 0.1020 US$ 1.00 = IRR 9,805

FISCAL YEAR

March 21 – March 20

ABBREVIATIONS AND ACRONYMS ANSC Anthropometric Nutritional Status of Children AUB American University of Beirut CAS Country Assistance Strategy CDC-I Center for Disease Control and Management-Iran CFO Chief Financial Officer CHV Community Health Volunteer DHC District Health Center EMS Emergency Medical Services FC Financial Controller FM Financial Management FP Family Planning FPP Family Physician Program FY Fiscal Year GOI Government of Iran HH Health House HMIS Health Management Information System HSR Health Sector Reform ICB International Competitive Bidding ICR Implementation Completion and Results Report IEC Information, Education, and Communication IS International Shopping LA Loan Agreement MOEAF Ministry of Economic Affairs and Finance MOHME Ministry of Health and Medical Education MOU Memorandum of Understanding MPO Management and Planning Organization NCB National Competitive Bidding NCL National Control Laboratory NHSRU National Health Sector Reform Unit NPMC National PHC Management Center NRA National Regulatory Authority OC Oversight Committee PAD Project Appraisal Document PDO Project Development Objective PBO Planning and Budget Organization

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PHC Primary Health Care PHCFPP Primary Health Care and Family Planning Project PIP Project Implementation Plan PIU Project Implementation Unit PMR Project Management Report QCBS Quality and Cost-based Selection RHC Rural Health Center SA Special Account SBD Standard Bidding Document SOE Statement of Expenditure SPHCNP Second Primary Health Care and Nutrition Project STC Short Term Consultant TOR Terms of Reference TOT Training of Trainers UHC Urban Health Center UMSHS University of Medical Sciences and Health Services UNICEF United Nations Children's Fund WBI World Bank Institute WHO World Health Organization WHV Woman Health Volunteer

Vice President: Shamshad Akhtar

Country Director: Hedi Larbi

Sector Manager: Akiko Maeda

Project Team Leader: John C. Langenbrunner

ICR Team Leader: Jean-Jacques Frère

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ISLAMIC REPUBLIC OF IRAN Second Primary Health Care and Nutrition Project

TABLE OF CONTENTS

Data Sheet A. Basic Information………………………………………………………………………….v B. Key Dates…………………………………………………………………………………..v C. Ratings Summary…………………………………………………………………………..v D. Sector and Theme Codes………………………………………………………………….vi E. Bank Staff…………………………………………………………………………………vi F. Results Framework Analysis………………………………………………………………vi G. Ratings of Project Performance in ISRs…………………………………………………..ix H. Restructuring………………………………………………………………………………x I. Disbursement Graph……………………………………………………………………....xi

1. Project Context, Development Objectives and Design ............................................... 12. Key Factors Affecting Implementation and Outcomes .............................................. 53. Assessment of Outcomes .......................................................................................... 134. Assessment of Risk to Development Outcome ......................................................... 205. Assessment of Bank and Borrower Performance ..................................................... 206. Lessons Learned ....................................................................................................... 237. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 24Annex 1. Project Costs and Financing .......................................................................... 25Annex 2. Outputs by Component ................................................................................. 26Annex 3. Economic and Financial Analysis ................................................................. 40Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 41Annex 5. Beneficiary Survey Results ........................................................................... 43Annex 6. Stakeholder Workshop Report and Results ................................................... 44Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 45Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 61Annex 9. List of Supporting Documents ...................................................................... 62

MAP: IRN 33421……………………………………………………………………...64

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A. Basic Information

Country: Iran, Islamic Republic of

Project Name: Second Primary Health Care and Nutrition Project

Project ID: P069943 L/C/TF Number(s): IBRD-45500

ICR Date: 07/30/2009 ICR Type: Core ICR

Lending Instrument: SIM Borrower: GOVERNMENT OF IRAN

Original Total Commitment:

USD 87.0M Disbursed Amount: USD 86.2M

Revised Amount: USD 87.0M

Environmental Category: B

Implementing Agencies: Ministry of Health and Medical Education (MOHME)

Cofinanciers and Other External Partners: B. Key Dates

Process Date Process Original Date Revised / Actual

Date(s)

Concept Review: 04/21/1999 Effectiveness: 02/22/2001

Appraisal: 05/11/1999 Restructuring(s): 06/20/2004

Approval: 05/18/2000 Mid-term Review: 03/03/2004

Closing: 12/31/2005 09/30/2008 C. Ratings Summary C.1 Performance Rating by ICR

Outcomes: Moderately Satisfactory

Risk to Development Outcome: Moderate

Bank Performance: Moderately Unsatisfactory

Borrower Performance: Moderately Satisfactory

C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings

Quality at Entry: Unsatisfactory Government: Moderately Satisfactory

Quality of Supervision: Moderately Unsatisfactory

Implementing Agency/Agencies:

Overall Bank Performance:

Moderately Unsatisfactory

Overall Borrower Performance:

Moderately Satisfactory

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C.3 Quality at Entry and Implementation Performance IndicatorsImplementation

Performance Indicators

QAG Assessments (if any)

Rating

Potential Problem Project at any time (Yes/No):

Yes Quality at Entry (QEA):

None

Problem Project at any time (Yes/No):

Yes Quality of Supervision (QSA):

Satisfactory

DO rating before Closing/Inactive status:

Moderately Satisfactory

D. Sector and Theme Codes

Original Actual

Sector Code (as % of total Bank financing)

Central government administration 5 5

Health 95 95

Theme Code (as % of total Bank financing)

Child health 29 60

Health system performance 28 30

Nutrition and food security 29 10

Participation and civic engagement 14 E. Bank Staff

Positions At ICR At Approval

Vice President: Shamshad Akhtar Kemal Dervis

Country Director: Hedi Larbi Inder K. Sud

Sector Manager: Akiko Maeda George Schieber

Project Team Leader: Jean-Jacques Frere Eva Jarawan

ICR Team Leader: Jean-Jacques Frere

ICR Primary Author: Paul Geli F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document) The objectives of the project are to assist the Government of Iran in sustaining and improving health conditions in rural and urban areas through: (i) ensuring access to and quality of health care; and (ii) improving the nutritional status of children under 3 years of age and pregnant and lactating women.

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Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s)

Indicator Baseline Value

Original Target Values (from

approval documents)

Formally Revised Target Values

Actual Value Achieved at

Completion or Target Years

Indicator 1 : Increased patient satisfaction with EMS (due to greater comfort in new vehicles and faster response time).

Value quantitative or Qualitative)

Data on each site provided in the April 2005 Project Status Report.

10% increase in patient satisfaction with EMS services.

Satisfaction rate almost tripled.

Date achieved 04/30/2005 12/31/2007 12/31/2007 Comments (incl. % achievement)

Services greatly improved and users satisfied. Percentage of village council that are satisfied with the referral system increased from 17% to 46%.

Indicator 2 : Physicians learn about public health approaches to nutrition during nutrition training workshops.


Zero - physicians do not receive health oriented nutrition training during their medical training.

Significant difference between pre/post test scores for more than 75% of the training workshop participants.

An evaluation has been planned, but delivery of the product is uncertain.


Training workshops completed. Sixty five nutritionists trained overseas, with 4 PhDs to teach future nutrition programs.

Indicator 3 : Improved management skills of participants in training programs of three weeks or more.


Zero - people who would benefit from management training selected to participate.

Improved management skills exhibited by more than 50% of the participants.

All ratings were either average, high or very high (none were below average).


A survey was carried out to assess the opinions of the superiors of the participants regarding the impact of the courses on the quality of the work of the participants in these jobs positions.

Indicator 4 : Percentage of hospital health workers at the District and Provincial Hospitals trained on Avian Influenza infection control guidelines.


Zero

Number of hospital health workers trained, based on survey to

All the health workers in the public sector have been trained on

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determine knowledge level of hospital health workers.

Avian Influenza infection control guidelines.


More than 44,000 individuals have been trained. In addition, 7.5% of poultry farms have been trained in terms of personal protection and controlling of the farms against AI infection and transfer of disease.

Indicator 5 : Percentage of selected provinces that implemented simulation exercises, based on the revised preparedness plan.


Zero

Three provinces were selected to carry out simulation exercises.

Simulation exercise has been carried out in one province only.


Of the three simulation plans that were to be launched during 2008, only one was carried out in Tehran with the Veterinary Organization and the CDC-I.

(b) Intermediate Outcome Indicator(s)

Indicator Baseline Value

Original Target Values (from

approval documents)

Formally Revised

Target Values

Actual Value Achieved at

Completion or Target Years

Indicator 1 : EMS call volume increased in areas which receive a new ambulance due to higher number of ambulances. Note: "Call volume" in EMS terminology refers to the number of emergency responses.

Value (quantitative or Qualitative)

No data. Call volume increased by 10%.

Call volume in 2007 increased by 21% compared to 2006.


Ambulances delivered. Satisfaction overall.

Indicator 2 : Average national response time on rural roads has been reduced significantly. Value (quantitative or Qualitative)

Average response time: 25 minutes (2005).

No quantified target.

Average response time: 14 minutes (2007).


Response time has been reduced by 44%.

Indicator 3 : Average national response time in cities with a population of 500,000 has been reduced significantly.

Value Average response time: No quantified Average response

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(quantitative or Qualitative)

15 minutes (2005). target. time: 7 minutes (2007).


Response time has been reduced by 53%.

Indicator 4 : Coverage of flour fortification with iron in Bousher, Golestan, and Sistan and Baluchistan.


Zero - flour fortification was not practiced.

100% flour fortification with iron in all three pilot provinces (Bousher, Golestan, and Sistan and Baluchistan).

90% flour fortification with iron in Bousher, and 94% in Golestan.


National program under implementation.

Indicator 5 : Graduate nutrition training program available.


Zero - graduate nutrition training programs not available.

4 graduate nutrition training programs developed.

A curriculum for nutrition has been developed.


A nutrition curriculum has been developed but it needs to be integrated into the university program.

Indicator 6 : WHO certification of the Government's ability to monitor quality of vaccines .


Programs do not meet WHO standards for certification .

WHO positive assessment of certification.

A recent assessment indicate conditional passing for full functionality of NRA and NCL.


Pending formal WHO certification. All criteria have been fulfilled.

G. Ratings of Project Performance in ISRs

No. Date ISR Archived

DO IP Actual

Disbursements (USD millions)

1 06/27/2000 Satisfactory Satisfactory 0.00 2 12/21/2000 Satisfactory Satisfactory 0.00 3 03/02/2001 Satisfactory Satisfactory 0.87

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4 08/03/2001 Unsatisfactory Unsatisfactory 0.87 5 01/22/2002 Unsatisfactory Unsatisfactory 0.87 6 04/11/2002 Unsatisfactory Unsatisfactory 0.87 7 05/30/2002 Unsatisfactory Unsatisfactory 0.87 8 09/12/2002 Unsatisfactory Unsatisfactory 0.92 9 11/27/2002 Unsatisfactory Unsatisfactory 2.93

10 03/26/2003 Unsatisfactory Unsatisfactory 2.93 11 09/16/2003 Unsatisfactory Unsatisfactory 3.02 12 03/11/2004 Unsatisfactory Unsatisfactory 3.21 13 04/26/2004 Unsatisfactory Unsatisfactory 3.47 14 10/26/2004 Unsatisfactory Satisfactory 4.78

15 04/20/2005 Moderately

Unsatisfactory Satisfactory 15.73

16 05/31/2005 Moderately Satisfactory Satisfactory 22.24 17 06/30/2005 Moderately Satisfactory Satisfactory 25.07 18 12/10/2005 Moderately Satisfactory Satisfactory 61.95 19 06/21/2006 Moderately Satisfactory Satisfactory 73.44 20 12/14/2006 Moderately Satisfactory Satisfactory 74.10 21 05/25/2007 Moderately Satisfactory Moderately Satisfactory 75.92 22 08/14/2007 Moderately Satisfactory Moderately Satisfactory 76.02 23 02/24/2008 Satisfactory Satisfactory 79.61 24 09/29/2008 Moderately Satisfactory Satisfactory 82.82

H. Restructuring (if any)

Restructuring Date(s)

Board Approved

PDO Change

ISR Ratings at Restructuring

Amount Disbursed at

Restructuring in USD millions

Reason for Restructuring & Key Changes Made

DO IP

06/20/2004 N U U 3.95

The restructuring was submitted to the RVP for approval, but a "formal" restructuring was not submitted to and approved by the Board of Directors of the Bank.

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I. Disbursement Profile

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1. Project Context, Development Objectives and Design

1.1 Context at Appraisal The country context Iran was an active borrower until the early 1970s when, following the oil revenue windfall, it graduated from borrower status. Lending was resumed in 1990 following an earthquake when, as a result of the long war with Iraq, incomes had again declined and the Government had initiated a program of economic reform and major reconstruction. During the period 1990-1993, the Bank made six loans to Iran for earthquake recovery, flood works rehabilitation, drainage, irrigation, power, and health (Primary Health Care and Family Planning Project - Ln 25840-IRN). When the Bank Loan was made in 2000 for this Second Primary Health Care and Nutrition Project (SPHCNP), there had been no lending to Iran since 1993 and there was no current CAS. Iran was a challenging country in which to work: the country had limited knowledge of the Bank and few staff trained to work on Bank-financed projects. Likewise, Bank staff was initially not very familiar with Iranian administrative regulations and procedures. The sector context The delivery of primary health care had been at the heart of the country's successes in raising the health status of the population and reducing fertility rates over the previous decade (1990s). The Ministry of Health and Medical Education (MOHME) presides over the management of the State’s health system and regulates the provision of private and NGO health care services. The Ministry is also responsible for the planning and management of medical education through a unified structure that brings together the health network and the universities, responsible for medical education at the provincial level, in a single management arrangement. The ability of the MOHME to train qualified paramedical personnel and the satisfactory supply and use of medicines and other consumable items were among the main strengths of the PHC network. However, in a period of economic hardship, MOHME was encountering difficulties in securing the budget necessary to sustain and upgrade rural and urban health centers in terms of physical infrastructure, vehicles and essential equipment in some of the poor and remote areas. The health sector was a high priority for the government. Through the Primary Health Care and Family Planning Project (PHCFPP), the Bank supported the GOI's policy on health care which, in the short run, emphasized the extension of PHC to underserved areas and the expansion of family planning (FP) services and, in the long run, sought to expand the types of services offered by the PHC network, and to adopt measures for the financial sustainability of the health system. When the project was appraised in May 1999, the under-five malnutrition rate was high. One out of every five children was chronically malnourished or stunted (low height for age); this figure was even higher for rural areas. Seven percent of all children under the

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age of five suffered from acute malnutrition or wasting (low weight for height), the prevalence being higher in urban areas. Iron deficiency was a widespread problem, and Iran has always been an endemic area for iodine deficiency. Malnutrition was mainly a result of intra-household mal-distribution of food, inadequate care, and nutrition illiteracy. Iran lacked a concrete National Nutrition Program. However, the Government of Iran (GOI) was working on a comprehensive action plan for the reduction of malnutrition. Government Strategy. Since the early 1980s, the Government's health sector policies focused on the delivery of PHC as the main strategy by which to improve health conditions in the country; these policies received strong political support. The positive relationship between the development of the PHC network and recent improvements in health outcomes has been clearly established. According to MOHME, when the project was appraised 85 percent of the rural and 60 percent of the urban population were covered by the Government's PHC network. In cities, the population was also served by the private sector (except in a few peri-urban areas). While Government policy aimed at 100 percent coverage under its PHC scheme, some rural areas posed a problem due to remoteness, the existence of nomads and, in some cases, difficulty in recruiting behvarzes (community health workers). Nevertheless, coverage was more or less complete. Therefore, the Government was moving to ensure that existing services were sustained and, where necessary, upgraded. Rationale for Bank assistance Although the previous Primary Health Care and Family Planning Project had its share of problems, its achievements were significant. When the new project was appraised, the Bank believed it was important to continue a dialogue with Iran on health sector issues. The new project focused on maintaining the gains achieved in primary health care, in addition to badly needed interventions in nutrition.

1.2 Original Project Development Objectives (PDO) and Key Indicators According to the Loan Agreement (LA), the objectives of the project were to assist the Government of Iran in sustaining and improving health conditions in rural and urban areas through: (i) ensuring access to and quality of health care; and (ii) improving the nutritional status of children under 3 years of age and lactating and pregnant women. This is the definition of the PDO that matters for the purpose of the ICR, but it should be noted that the definition of the PDO was slightly different in the Project Appraisal Document (PAD)1.

1 According to the PAD, the PDO is “to assist the Government of Iran (GOI) in improving health conditions in rural and urban areas through: (i) sustaining access to, and the quality of, primary health care; and (ii) improving the nutritional status of children under 2 years of age and pregnant and lactating women”.

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According to the PAD, the following key performance indicators were to be monitored through periodic surveys:

To sustain and improve health conditions in rural and urban areas through: (i) ensuring access to and quality of health care.

Increased level of client satisfaction with PHC services.

Increased utilization rates. (ii) improving the nutritional status of children under 3 years of age and of pregnant and lactating women.

Reduction by 30% in the targeted provinces of the proportion of children under 3 years of age who are malnourished.

Reduction by 25% of the proportion of pregnant women with iron deficiency anemia.

1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification When the project was substantially restructured in June 2004, the Bank team considered revising the PDO, but Bank management decided that the PDO would not be revised due to country relations considerations.

1.4 Main Beneficiaries The project was designed to help sustain and improve the delivery of PHC by the public sector, which covers about 85 percent of the rural and 60 percent of the urban population. The PHC facilities to be rehabilitated would serve about 18 million people in rural and peri-urban areas, mostly women and children. The project would improve health and child development, thereby reducing the consequences that malnutrition and poor health impose in terms of schooling and productivity. Children under 3 years of age2 and pregnant and lactating women were the targeted population of the nutrition component, which focused on both rural and urban areas in the 14 provinces (out of 27 provinces) where malnutrition rates (based on the latest survey results) were higher than the national average. The project included poverty-targeted interventions and had been designed to disproportionately benefit the poor. One of the criteria for the selection of health centers to be rehabilitated was the "extent of region deprivation". This is a regional index that is determined on a yearly basis by the Planning and Budget Organization and is therefore available. Similarly, the nutrition component would benefit disproportionately the poor population based on available stunting data.

2 In practice, the monitoring is done for children under 5 years of age.

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1.5 Original Components According to the Loan Agreement (LA), the project had three parts (or components): Part A. Sustained access to and qualitative improvement of health care, through: (i) the physical rehabilitation of selected health facilities; and (ii) the renewal of the medical equipment for selected health facilities (US$91.2 million; 74 percent of project costs according to the PAD). Part B. Improvement of the nutritional status of children under 3 years of age and of pregnant and lactating women, through: (i) training of primary health care personnel focusing on interpersonal counseling, information, education and communication (IEC) so as to improve the effectiveness of ongoing nutrition services in the health sector; (ii) provision of technical assistance for the strengthening of children-growth monitoring and ongoing nutrition activities; (iii) provision of office space, equipment and technical assistance for the institutional strengthening of the MOHME’s nutrition department; and (iv) studies on needs assessments, and operational and situation analyses (US$21.5 million; 17 percent of project costs according to the PAD). Part C. Capacity building, through: (i) provision of technical assistance to improve management of primary health care services; (ii) study tours and technical assistance for Medical Services Insurance Organization staff aimed at improving the health insurance scheme; and (iii) strengthening the Project Implementation Unit (PIU) implementation capacity through the provision of technical assistance, travel, training and equipment (US$11.3 million; 9 percent of project costs according to the PAD).

1.6 Revised Components The project components were revised twice: first, in connection with the 2004 restructuring, and second, in December 2006 to add a subcomponent on Avian Influenza. A. Under the June 2004 restructuring, the PDO was not changed but the project description was amended to ensure that what remained under the project could realistically be implemented in the time remaining. The amendment included the following changes:

1) In Part A - Sustained Access to and Qualitative Improvement of Health Care: adding the acquisition of new medical equipment, vehicles and ambulances.

2) In Part B – Improvement of the Nutritional Status of Children under 3 Years of Age and Lactating and Pregnant Women: (i) broadening the definition of training (training in nutrition science); (ii) deleting the studies, the provision of technical assistance, office space and equipment; but (iii) adding the acquisition of micro-nutrients, including provision of services for flour fortification.

3) In part C – Capacity building: (i) focusing the training on the improvement of management skills; (ii) referring to the strengthening of the PIU implementation capacity; (iii) building capacity for better health policy through targeted health

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sector reform pilot projects; and (iv) improving the quality of vaccine production by strengthening the National Regulatory Authority and the National Control Laboratory.

B. Following the Avian Influenza crisis in the region, including neighboring countries such as Azerbaijan, the Government requested assistance to refine and assist in the implementation of the Government’s Preparedness and Surveillance Plan. Therefore, at the request of the Government, the project was amended in December 2006 to include the development of an Avian Influenza Preparedness and Surveillance Plan (AI Plan) with an allocation of US$6 million. The PDO did not need to be changed since the objective of the new subcomponent was to assist the government in strengthening its preparedness for a potential outbreak of Highly Pathogenic Avian Influenza (HPAI), to which Iran is susceptible, through strengthening its capacity to prevent, diagnose and manage any suspected or confirmed human cases. The new subcomponent included five activities: (1) strengthening the surveillance system; (2) strengthening the health system response capacity; (3) communication and coordination; (4) capacity building and knowledge sharing; and (5) project management and monitoring and evaluation.

1.7 Other significant changes There were some changes in implementation arrangements and funding allocations. GOI financed the rehabilitation of health centers (which originally were to be financed by the Bank Loan), and all vehicles and ambulances were financed by the Bank Loan instead of by counterpart funds.

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry The health sector was a high priority for the government and the project addressed a key social need in the country: it targeted those rural areas where health conditions were particularly poor and existing health services were relatively inadequate. However, with about 13 distinct, somewhat unrelated project sub-components without a central theme, the project was complicated and difficult to manage. Some initial preparation work for the project was carried out under technical assistance, but overall the preparation process was undertaken with minimal resources and in a very short period of time. The design of the components and the allocation of the Bank Loan to various components were not based on a needs assessment and a clear understanding of the priorities in the health sector. Furthermore, preparation faced constraints due to the challenging country relations context which included uncertainties regarding the Bank lending program. When the project was submitted to the Bank’s Board of Directors a number of sub-components were not ready for implementation, which taxed scarce procurement and project implementation resources and posed a risk to overall project implementation. The project components were designed to address some of the prevailing sectoral issues in three important areas: (i) sustaining GOI’s PHC services, particularly in rural areas; (ii) providing families with the needed knowledge, skills, and motivation to take proper

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care of their children’s nutritional needs; and (iii) building capacity at both the central and regional levels in terms of management, financing, and health economics through training, study tours, and operational studies. As this project was, to a large extent, a continuation of the Primary Health Care and Family Planning Project (PHCFPP), the ongoing institutional and implementation arrangements were extended to the new project. However, there were problems with project ownership and design, and there were critical project implementation issues. On the government side, there was a lack of necessary coordination and consent with the Planning and Budget Organization (PBO) before the finalization of the project and the signing of the Loan Agreement. A lesson learned is that it is important for the Bank to ensure that there is a consensus within the country on a proposed project before seeking approval for it. The project design tried to take into account some lessons of the PHCFPP, but it turned out that some of those lessons were not fully thought through or were not relevant. First, it was felt that in a large country, like Iran, it was important to decentralize civil works management to the Medical Universities, but the design did not take into account the implications of that decision, i.e. the need to define the implementation and training arrangements for the Medical Universities3 and their financial controllers. Second, in view of the Government's policies regarding imports, it was decided that the GOI would purchase the vehicles needed for this new project with counterpart funds. It turned out that the Government accepted the Bank procurement guidelines for the procurement of vehicles (including ambulances) that were financed under the Bank Loan, whereas GOI funds financed the rehabilitation of health facilities that originally were intended to be financed under the Bank Loan. The major alternative under consideration was a project with much wider scope, both in addition to PHC and nutrition, and with respect to the nutrition component. This would have required a greater preparation effort and longer time. It was decided to proceed with a smaller operation to meet pressing needs. The participatory processes included site visits and discussions with communities and local groups. The Behvarzes and the Community Health Volunteers (CHVs) come from the local communities served by the PHC facility where they work, and provided valuable feedback during preparation. For nutrition, there were extensive consultations with UNICEF, which was an active partner in project preparation relying heavily on community and NGO feedback when designing pilot projects. Critical risks (related to possible shifts in priorities, budget allocations and inadequate coordination) and mitigation measures were identified and included in the PAD. The overall risk rating was “modest”. However, the project team should have done a better job of foreseeing the problems that arose. The first project had numerous problems and they were not accounted for fully or candidly in the PAD for this second project.

3 According to the Health Sector review report dated June 2008, there are 39 Medical Universities in Iran.

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There was no adequate system for monitoring and evaluation. The definition of the project development objective (PDO) was too broad, with no clear baseline data and, in some cases, no quantified targets. There were no agreed upon arrangements to monitor the achievement of the PDO. A lesson learned is that PDOs should be defined in more precise and concrete terms with corresponding measurable quantitative key performance indicators (KPIs). A clear results chain is critical, and the PDO should not include items that are not going to be influenced by activities or will not be measured by the project. Bank staff had a limited understanding of the country system and of what the Bank was allowed to finance in the country (because of import restrictions or other regulations). Overall, the Project was not ready for implementation when it was approved by the Bank’s Board of Directors. The fact that the quality at entry was unsatisfactory explains in great part the implementation difficulties and delays in the first few years of the project.

2.2 Implementation The SPHCNP was approved on May 18, 2000 and declared effective on February 22, 2001. The project launch workshop was held in Tabriz on January 25-26, 2001. The difficulties of working in Iran had some negative effects on the project. Implementation from February 2001 until mid 2004 was extremely slow; there was little progress on most subcomponents. Implementation delays related to poor project design, lack of ownership, and critical project implementation issues due to conflicts between Bank policies and procedures and Iranian administrative regulations and procedures. There were high turnover rates at the senior level of MOHME, which resulted in the need to increasingly build capacity in the MOHME. An important factor was the lack of knowledge of Iranian staff about Bank policies and procedures. A lesson learned is that arrangements must be made to ensure that the Borrower’s key project staff are hired and familiarized with Bank processes and procedures before the actual start of project implementation. Likewise, Bank staff must familiarize themselves with the unique characteristics of the country. On the financial side, there were delays in opening the Special Account (SA) for the Bank Loan, and the Management and Planning Organization (MPO) failed to include counterpart funding in the MOHME budget allocation. Counterpart funding was finally included in the budget for FY 2002/2003, and made available in May 2002. Counterpart funds allocated by the MPO have generally been insufficient, and allocated funds have not been released in a timely manner. On the other hand, the Government provided substantial amounts to finance the Family Physician Program (FPP). Very early in project implementation, it became apparent that the PIU needed to be strengthened in many areas (procurement, financial management and MIS) and to be better integrated into the MOHME with improved collaboration and routine coordination among MPO, MOEAF, MOHME and the PIU. Project management has continued to be problematic. There has been a high turnover of managers at the PIU with four PIU managers in the first three and a half years of project implementation. There was a lack of proactivity on the part of Iranian staff who lacked experience in working with the World

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Bank, and a lack of clarity and communication4 between the Bank and the GOI regarding project direction. Getting a person stationed in Tehran for about 6 to 12 months was necessary in order to get the project off the ground. The language barrier has also been a problem. Some component managers and PIU staff had limited knowledge of English, and Bank staff had to rely on translators. Finally, the Oversight Committee (OC)5, to be established to monitor project progress and advise on measures to be taken to ensure its implementation, was not established until 2003 and did not meet frequently; therefore, the OC’s objective of ensuring a smooth coordination with all departments at the MOHME was not achieved. As of June 30, 2003, or 28 months after effectiveness, only about US$200,000, or 0.23% of the loan amount had been disbursed. The SPHCNP was a problem project (with a rating of unsatisfactory) until the June 2004 restructuring, by which point only US$3.95 million of the Loan had been disbursed. The restructuring marked a turning point for the project. The Government and the Bank reassessed project activities to address critical project implementation issues and restructured the project to ensure that what remained under the project could realistically be implemented in the time remaining. The components were modified, and some changes were made regarding the specific inputs to be financed from the Bank Loan (vehicles including ambulances) versus government resources (rehabilitation of health facilities). A lesson learned is that it is inefficient for a Bank project to finance, procure and monitor a large number of low cost small works scattered over a large geographic area, but very efficient in procuring large numbers of equipment or vehicles where a centralized tender process is possible. The Loan Agreement was amended accordingly. Although the Bank team considered revising the project development objective (PDO) to bring it more in line with the revised components and to facilitate monitoring of achievements, Bank management decided that the PDO would not be revised because of country relations considerations. Following the restructuring, project implementation improved considerably, because there was greater clarity about, and ownership of project activities, detailed implementation plans were available, and an international implementation and procurement expert (as of April 2004) and an M&E consultant were recruited to support implementation. However, even after restructuring, the project remained complex, requiring the involvement of several departments of MOHME who were not familiar with World Bank guidelines and procedures. On the Bank side, the high turnover of Task Team Leaders was also a hindrance.

4 The fundamental basis for this communication is a component description, a work plan, a procurement plan and a monitoring and evaluation plan. 5 To be chaired by the Minister of Health and Medical Education with membership from the various departments of MOHME, MPO and the Ministry of Finance.

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In 2002, the Ministry of Health established a Health Sector Reform (HSR) Committee with a secretariat reporting directly to the High Council of Health and the Minister. The Health Sector Reform Unit in the ministry was supported through technical assistance under the project and provided the technical inputs to the Committee. According to the Aide Memoire of the Bank Health Sector mission in June 2002, the main focus of the Health Sector Reform strategy was in seven priority areas, which included the development of a Family Physician model. In 2003/2004, the Government of Iran (GOI) introduced the Family Physician Program (FPP), which established a system of family physicians functioning as gatekeepers to the health care delivery network, and included measures to improve clinical and ethical practices by family physicians. The FPP had a positive effect on the project’s outcome, and the project provided complementary support to the implementation of the FPP, including rehabilitation of health facilities and physician houses, provision of medical equipment and vehicles, and medical staff training. Moreover, in 2003/2004, the project funded the World Bank Institute (WBI) Flagship Course on Health Sector Reform and Sustainable Financing (delivered by the American University of Beirut) which included a senior policy seminar (“Wise Men Seminar”) and a series of technical workshops aimed at informing key policy makers and technical staff on essential policy tools and instruments for implementing and evaluating the GoI’s Health Sector Reform Strategy. The HSR Unit played a key role in the articulation of the Ministry’s Health Sector Strategy, and also contributed technical studies, including a study on the referral program which defined the relationship between family physicians and higher levels of care. The Health Sector Reform program was later incorporated into the Government’s Five Year Development Plan (2005/6). The HSR Unit also worked jointly with the Bank to prepare the Iran Health Sector Review Study (2007), which provided a comprehensive assessment of the GoI’s health sector reform program to date, and identified the next generation of reforms, including further refinements in the family physician model and extending insurance coverage to provide better financial protection against a wider range of illnesses, including chronic diseases. GOI’s original intention was to design and pilot the FPP only in selected provinces. However, the GOI proceeded to expand the FPP in all rural areas of the country. As a result, more than 23 million rural dwellers are covered by this scheme, which employs 5,492 family physicians (of which 3,042 new recruits) and 4,546 midwives (of which 4,162 new entrants). The FPP increased the salary and employment benefits of doctors and midwives as an incentive for them to transfer to rural areas. As an example, the salary of doctors was increased from about US$300.00 per month to about US$2,500.00 per month, which corresponds to additional expenditures of about US$145 million per year; in addition, doctors were provided with free housing and utilities. These steps were aimed at improving the quality of primary care services in the rural areas. Implementation of training activities and consultancies continued to face a number of challenges, including the difficulty of finding Iranian training candidates with acceptable language skills to study abroad, the lengthy procedures for securing visas to travel, and the challenge of finding qualified international consultants willing and able to travel to Iran.

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The new component for the Avian Influenza Plan which was added at the end of 2006 was slow to start due to the implementing agency’s (Center for Disease Control and Management - Iran) lack of familiarity with Bank procedures. As a result of the delays in project implementation, the closing date was extended three times. The first extension (for 12 months) was approved on July 1, 2004; the second extension (also for 12 months) was approved on November 8, 2005; and the third extension (for 9 months) was approved on December 26, 2007.

2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization Monitoring of activities was supposed to be done using existing systems, which would ensure complete documentation. There were problems with the design of the project and, with the exception of the nutrition component, the PAD did not include any satisfactory arrangements for monitoring and evaluation (M&E). A lesson learned is that a well functioning M&E system with agreed-upon indicators is very important and should be established early on in project preparation for a systematic follow up of PDO and component outcome indicators. The project financed an international M&E consultant who helped component managers and the PIU identify and introduce the use of simplified outcome indicators for the components. The consultant delivered workshops to a wider audience in the MOHME to raise the level of awareness and interest in the use of M&E indicators and management by results. This was a very useful capacity building exercise. In order to assess whether the PDO had been achieved, plans were made to recruit consultants to evaluate the level of satisfaction with the delivery of services, the utilization rate of health facilities and the impact of the nutrition activities; however, not all results are available on time to be incorporated into this ICR. In conclusion, the monitoring and evaluation (M&E) function remained weak, despite the fact that the PIU recruited an international M&E consultant to help develop and measure component outcome indicators.

2.4 Safeguard and Fiduciary Compliance Environment The project had limited adverse environmental impact and was, therefore, classified as a Category "B" project. The major environmental issues were the proper disposal of clinical waste and the provision of water and sanitation. In October 2005, the Bank produced a Policy Note on Health Care Waste Management (HCWM). The note presents a diagnosis of the main issues and barriers toward improvements of a well structured HCWM system, and recommended an action plan for better performance. The policy note focused on sector actions to increase efficiency of the institutional framework, at both the national and municipal levels. The main issue for HCWM in municipalities, which are subsidizing waste management and collection, is the quality of implementation. A new

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Waste Management Law (WML) which includes a “polluter pays” principle was enacted in June 2004. There have been unjustifiable delays in the completion of the environmental management plan (EMP) for the project. Because of other pressing issues in the health sector, it seems that addressing environmental concerns was not a high priority. The MOHME contracted the services of the Tehran University of Medical Sciences, School of Public Health, to carry out the EMP for 112 selected primary health care centers in five regions. The Phase I report was submitted to the Bank in March 2008. The Phase II report of the EMP which includes an analysis of environmental issues by Primary Health Center and a section on mitigation measures was received in December 2008. Provision of water and sanitation was undertaken as part of the engineering design of health centers and was included in the bidding documents. The equipment and infrastructure component of the project took into consideration elements of environmental health in the formulation of the subprojects (e.g., septic tanks). Financial management With respect to fiduciary aspects, the project had a difficult start. Both the Bank staff and the Iranian project staff had to spend time to understand each other’s systems better. Initially, the financial management arrangements within the Financial Controller Departments did not completely meet the Bank’s minimum requirements. An action plan was developed to ensure that the Financial Controllers (FCs) at the universities complied with Bank regulations on all project matters, and in particular on procurement and financial management issues. It would have been easier if only one Financial Controller (instead of one financial controller for the PIU plus one for each medical university) had been involved with the project. Financial management oversight was insufficiently proactive in finding solutions to issues that remained pending for many months. The fact that for the PIU there were three financial controllers in the last two years did not help. There have been significant delays for the processing of some payments, particularly for consultants and training activities. Part of the problem was the sheer number of steps required to process a payment request (for example, there are ten steps from receipt of the consultant’s report in the PIU to submission of the payment request to the Financial Controller of the MOHME). Another part of the problem was the lack of accountability to complete each of the steps in a timely manner. In the end, the project managed to put in place and continue to operate a financial management system which is able to follow up on project accounts and generate project management reports (PMRs). All payments made under the project have been subject to the approval of the respective directorate within MOHME, the verification by the PIU and the signature by the Financial Controller. The introduction in 2007 of the Euro currency with a new Special Account, which rendered the accounting system obsolete (as it can only deal with two currencies while the project was now dealing with three), affected the timeliness of the financial management reports. SOE reviews were performed regularly by the Bank Financial Management Specialist and a consultant.

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Because of the Government decision to increase the length of a fiscal year by four months (for the purpose of closing the accounts), audit reports have been submitted late by several months. As an example, the audit report for the period ended March 20, 2008 (plus the four-month grace period) which should have been submitted by September 20, 2008 was received by the Bank on June 16, 2009, a delay of almost nine months. Audits for the project have been unqualified, apart from some problems with minor travel expenditures that could not be justified since the persons that benefited from travel advances could not be traced. Procurement Regarding procurement, MOHME and the PIU had to become familiar with the Bank Procurement Guidelines. Also, Bank staff had to understand the country systems, particularly the import restrictions. The procurement timetable could have been better managed in a more realistic manner, so that launching of activities would have been expedited. Even during the last year of the project, it took the PIU six months to take action on pending procurement activities for the Avian Influenza Plan (due to the fact that the CDC-I was a new entity to the project). However, one reason for the procurement delays is that instead of continuing with the work at the required pace, the procurement activities slowed down before every loan extension (and there were three extensions of the closing date) as the officers involved at the PIU were not certain whether the extensions would be agreed. Moreover, project activities were quite different from the normal day-to-day business of the ministry, which explains the delays in recruiting consultants and in obtaining authorizations to import equipment. To ensure full compliance with the Bank Procurement Guidelines, the procurement staff was fully trained in World Bank financed procurement, and the Bank’s standard bidding documents were used. To facilitate the use of the National competitive bidding (NCB) method, a generic NCB package specifically prepared for Iran on the basis of the Bank’s standard bidding documents was used during the last two years of the project. Ex-post procurement reviews carried out by Bank missions/consultants found out that, even though there have been shortcomings in contract management of some packages, there has been a gradual and positive trend in improvements to the procurement process because of additional training during project implementation. The reviewed procurement activities substantially complied with the provisions in the Loan Agreement. Procurement activities are rated as moderately satisfactory.

2.5 Post-completion Operation/Next Phase There are no explicit transition arrangements since the delivery of health services is a continuous operation. Iran has been committed to primary health care since the early nineteen eighties and, due to the successes engendered by its policies, is an example for many countries around the world. As discussed in Section 4, the sustainability of the investments may be problematic but the Government has managed in the past to provide the resources needed for the operation and maintenance of health facilities. The guidelines that have been issued for the preparation of the Fifth Five-Year Development Plan (2010-2015) indicate that the health sector remains a priority for the Government. However, the future of nutrition activities is unclear at this stage.

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There is no Bank-financed follow-up operation planned at this stage.

3. Assessment of Outcomes

3.1 Relevance of Objectives, Design and Implementation In approving the Loan, the Bank’s Executive Directors requested that management prepare a strategy note reviewing the current development situation and the challenges and prospects faced by the country, the progress of economic reform and the Bank Group assistance strategy. The report (No. 22050 IRN, dated April 16, 2001) outlined an Interim Assistance Strategy to be followed by the Bank while preparing a Country Assistance Strategy (CAS) for consideration by the Executive Directors. The interim assistance strategy included, inter alia, targeted lending in key social and environment areas consistent with the Third Five-Year Development Plan (FYDP) for 2000-2005. Regarding health, the Plan emphasized the need to develop a nationwide nutritional education program, and to improve the geographical coverage of basic health services, the efficiency of the health system and the quality of services at all levels. A CAS was not presented in the Bank’s Board of Directors. The revised project which addresses some key social needs is relevant to current country priorities, including the need to sustain Iran’s past achievements for primary health care. The Health Sector Review (Report No. 39970-IR dated June 2008) confirmed that health remains a high priority for the Government. More recently, the Guidelines issued in January 2009 by Iran’s Supreme Leader for the preparation of the Fifth Five-Year Development Plan (2010-2015) emphasize the promotion of physical and psychological health. They mention the promotion of clean air (through a reduction of risks and pollutants that threaten health), food security and improvements in the composition and wholesomeness of food products, and the development of health insurance and expansion of the social security system with a reduction of the population’s health care share of costs to 30 percent by the end of the Fifth Plan.

3.2 Achievement of Project Development Objectives The analysis of the achievement of objectives deals first with the primary objective (sustaining and improving health conditions in rural and urban areas) and then with the two secondary objectives (ensuring access to and quality of health care, and improving the nutritional status of children under 3 years of age and of pregnant and lactating women). Primary objective - Sustaining and improving health conditions in rural and urban areas: significant. The primary objective refers to both “sustaining” and “improving” health conditions in the country. Although the World Bank loan financed health facilities (rehabilitation and equipment) in both rural and urban areas, the Government decided to give particular emphasis to the rural areas through the FPP. It would have been better to delete “urban areas” from the PDO but, as mentioned earlier, Bank management had decided that the

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PDO would not be revised due to country relations considerations. The analysis shows that the physical outputs of the project made a contribution to the “improvement” of health conditions of the rural population, whereas the health sector reform sub-component and the health sector review were initial steps to ensure that in the future the health conditions of the population were “sustained” despite changes in the burden of diseases with the growing importance of non-communicable diseases. A. Since the project benefitted mostly Iran’s rural areas and focused on primary health care which concerns mostly women and children, the ICR looks at the trends between 2000 and 2007 for a few indicators particularly relevant for children and women’s health in rural areas, based on a November 2008 study of trends of main health indicators for rural Iran.

Indicators for Iran’s Rural Areas

2001 2002 2003 2004 2005 2006 2007

Maternal Mortality Rates - MMR (Per 100,000 live births)

38.7

32.4

37.5

31.9

34.3

34.5

34.8

Infant Mortality Rates - IMR (Per 1,000 live births)

25.2

25.1

24.2

22.3

21.0

19.8

18.7

Under-5 Mortality Rates – U5MR (Per 1,000 live births)

30.5

30.0

29.7

26.7

25.0

23.4

21.8

Percentage of deliveries assisted by untrained persons

14.5

12.3

10.9

8.8

7.5

5.7

3.9

Source: “Trends and Geographical Inequalities of the Main Health Indicators for Rural Iran”, Health Policy and Planning, MOHME, November 28, 2008.

The above table shows that, over the last seven years (i.e., the project period), the health conditions of the population in rural areas have improved. The improvements are significant for IMR, U5MR and deliveries assisted by untrained persons. The above-mentioned study of November 2008 on the main indicators for rural Iran indicates that the reduction in child mortality is a result of the health system’s success in controlling infectious diseases, previously the most common cause of death. The picture is not as clear for the MMR, which shows wide variations in trends and a lack of strong positive correlation with unskilled attendance at birth. According to the study, one possible explanation is the fact that current maternal deaths are mostly due to high-risk pregnancies. Generally, high-risk pregnancies cannot be managed in rural health centers, requiring specialist care at secondary and tertiary levels. More attention to these care levels and to the referral system is needed for further improvements in the MMR. The main factor that contributed to the improvements in infant and under five mortality rates is the Government’s Family Physician Program (FPP) which led to health facilities in rural areas being adequately staffed with doctors and midwives. Although financed entirely by the government, the FPP was linked to the Bank project. As discussed in

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section 2.2 on Implementation, the FPP concept was fully supported by the Health Sector Reform (HSR) Unit which was supported by the Bank project. The Bank Loan financed the rehabilitation of health facilities and the provision of much needed equipment and vehicles/ambulances, all of which were essential for the introduction of the family physician model. The variety of medical equipment that was purchased enabled the medical personnel to do a professional job both in terms of prevention (such as vaccination campaigns) and the diagnosis and treatment of diseases. Thanks to the availability of vehicles, doctors could regularly visit the health houses to provide services (the number of visits by doctors to the Health Houses increased tenfold from 2003 to the end of the project), and midwives could physically assist pregnant women’s deliveries. The Bank has recently received summary data from MOHME on project results. The report stressed that clients and staff were most satisfied with the improvements in medical equipment and the physical environment. This indicates that the population and the staff are sensitive to these changes and improvements. In addition, the report reflected the following changes in service delivery during the project life: (i) increase in the number of doctors from 2450 in 2004 to 5492 in 2007; (ii) increase in the number of midwives from 384 in 2004 to 4546 in 2007; (iii) increase in the number of patients visited by a doctor per day from 14 in 2005 to 17 in 2007; (iv) increase in the number of visits/patient/year from 1.23 in 2005 to 1.38 in 2007; (v) increase in the number of people visiting rural health centers per day from 23 in 2005 to 26 in 2007; and (vi) increase in the percentage of people registering and establishing a family file at rural health centers from zero in 2004 to 70% in 2007. Life expectancy indicators are not available for rural areas, but it is interesting to note that nationwide, the average life expectancy (for both men and women) increased from 69 in 2001 to 72 in 2007 (MOHME Vital Horoscope statistics). B. According to the health sector review, the country is currently experiencing a youth bulge but in the next two decades its demographic profiles will be aging. The changing mix of population can be expected to impact the epidemiologic profile and the burden of diseases. Iran will face a burden of disease increasingly predominated by non-communicable diseases and accidents. Over time, the increasingly complex pattern of mortality and morbidity will place greater demand on the health system, straining the existing structure and resources available in the sector. Faced with these new challenges, the health sector might restructure and modernize across five strategic interventions to address issues of efficiency and equity. These include: (i) governance; (ii) delivery system, including primary care, specialized care, and hospital services; (iii) financing; (iv) pro-poor programs; and (v) evidence-based policy development. The health sector review and the health sector reform (HSR) sub-component highlighted some of the measures and reforms that will have to be carried out in order to sustain the health conditions in the country. To conclude on the primary objective regarding health conditions, the achievements are rated as “significant”.

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Secondary objective - Ensuring access to and quality of health care: modest At appraisal, the following two indicators had been selected to assess the achievement of this secondary objective: (i) increased level of client satisfaction with PHC services; and (ii) increased utilization rates in primary care facilities. There were no pre-determined, quantified targets regarding the extent of the increases to be achieved. Regarding this secondary objective, it is also clear that the rehabilitation works and the provision of medical equipment, vehicles and ambulances were very timely and complemented the family physician initiatives introduced in the rural areas of Iran. Increased level of client satisfaction with PHC services. In 2007, an independent local consulting firm carried out an evaluation of the satisfaction rates among the population (members of village councils that are representative of the rural population, but also some women) as well as health providers with regard to physical facilities, equipment and referral system (transfer of patients to hospitals). The report shows very positive outcomes with increases in the level of client satisfaction. Some satisfaction rates are shown in the table below: Satisfaction rates of council members and women regarding:

Physical Environment

Equipment Referral system (transfer of patients to hospitals)

I. Village council members - before intervention 38% 15% 17% - after intervention 60% 52% 46% II. Women 60% 57% 48% Increased utilization rates MOHME is funding a study to assess the utilization rates of health centers. According to the terms of reference, the study will analyze 112 PHC centers that benefitted from the project, compared to a control group of another 112 PHC centers that were not major beneficiaries under the project. There have been delays in the start-up of the study and problems with the retrieval of baseline data. Pending the results of the study, which are not likely to be available before September 2009, there is some anecdotal evidence that the number of visits increased and that the quality and accessibility of services (including the referral system) improved. Also, a recently completed study on the analysis of health expenditures in Iran shows that during the period 2001-2006 health insurance coverage in rural areas increased by 2.3 times (from 33.3% of households to 76.3 % of households), whereas in urban areas the proportion of households with health insurance has remained unchanged at about 61%. These finding show that, for the rural population, there is better financial protection against catastrophic health events. To conclude on the secondary objective regarding access and quality of health care, the achievements are rated as “modest”.

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Secondary objective - improving the nutritional status of children under 3 years of age and of pregnant and lactating women: not rated At appraisal, the following two indicators had been selected to assess the achievement of this secondary objective: (i) reduction by 30% in the targeted provinces of the proportion of children under 3 years of age6 who are malnourished; and (ii) reduction by 25% of the proportion of pregnant women with iron deficiency anemia. According to the PAD, the 1998 nutrition survey would be used as baseline data, and subsequent surveys would be conducted in targeted areas at both mid-term and project completion in order to evaluate the achievements of the nutrition component. Similarly, a rapid assessment of compliance with iron supplementation efforts would be conducted at the start of the project, and follow-up assessments would occur at both mid-term and project completion. Nutrition literacy would be evaluated at the beginning and end of the project by comparing nutrition knowledge and behavior before and after the intervention. UNICEF would conduct technical audits on the growth monitoring and behavior change strategies and implementation throughout the project. However, those arrangements were not implemented, and the nutrition component was restructured in June 2004, with activities geared toward fortification and capacity building. Proportion of children who are malnourished Data from the Anthropometric Nutritional Status of Children (ANSC) for 1998 and 2004 shows positive trends in malnutrition rates for children under 5-years (see table below) with significant reductions of 24% to 69% depending on the category.

Category % for 1998 (ANSC I)

% for 2004 (ANSC II)

% reduction in 2004 compared

to 1998 Stunting 15.4 4.7 69 Underweight 10.9 5.2 52 Wasting 4.9 3.7 24 Source: The Nutritional Status of Children, MOHME/UNICEF

The next ANSC will provide data for 2009 or 2010, too late to be used for this ICR. The significant reduction percentages listed above may be reduced, since there is concern that malnutrition rates are on the rise due to the current food crisis, increased economic difficulties, and revisions to health protocols, including environmental and external factors. Proportion of pregnant women with iron deficiency anemia Fortification has been implemented in the whole country (with the exception of Tehran proper). However, the success of the nationwide program cannot be attributed to the 6 Although Bank documents always refer to children under 3 years, the monitoring is only done for children under 5 years.

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project which included only a pilot operation in three provinces, all the more so given that the 54 micro feeders that were purchased under the Bank Loan have not yet been used. A program evaluation of flour fortification with iron in Bushehr and Golestan provinces was carried out in 2009. The flour fortification program appears to have had beneficial effects on the ferritin levels (iron deficiency) in both provinces. However, the prevalence of anemia (low hemoglobin) was significantly higher after intervention in women from both Bushehr and Golestan provinces. The lack of apparent beneficial effects of this program on the prevalence of anemia in Iran may be due to a number of factors, such as parasitic and infectious diseases, and the low availability of other micronutrients (e.g., vitamin A). Therefore, it seems that other interventions besides flour fortification with iron will be needed to substantially reduce the prevalence of anemia in Iran. In view of the uncertainties regarding the results of the next ASNC in 2009 or 2010, the achievement of the secondary objective regarding the nutritional status of women and children cannot be rated at this stage. Causal linkages between outputs and outcomes Annex 2 lists all the outputs of the project; these outputs have been substantial in terms of rehabilitation of health facilities, delivery of vehicles and equipment, training and consultancies. They were perfect complements to the Government’s Family Physician Program that was introduced nationwide, so that together they contributed to the achievement of the Project Development Objectives. Other achievements

a) Regarding the Emergency Medical Services (EMS), call volume increased, call response time decreased and patient satisfaction with EMS increased.

b) Capacity building has been a very positive aspect of the project. Qualitative information reflects perceived improvements in management capacity and upgrade of technical skills for all components.

c) A mid-term and a long-term national nutrition strategy and nutrition training programs have been developed.

d) Regarding the quality of vaccine production, the last WHO assessment shows a significant increase in scores and conditional passing for full functionality of the National Regulatory Authority (NRA) and National Control Laboratory (NCL).

e) The Avian Influenza Subcomponent helped MOHME prepare the health sector for a possible pandemic of influenza: (a) health staff continues to be trained through a training of trainers approach; (b) hospitals have been designated for case management and isolation of possible human cases in each province; and (c) each hospital has dedicated rooms specially equipped to handle human cases. This may turn out to be very useful if Iran is affected by a pandemic of influenza.

f) The Health Sector Review is a good practice example with a quality report and a good dissemination strategy. This sector work was rated “satisfactory” on all

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dimensions by a QAG Panel. The report of the health sector review is now on the WEB site of the MOHME.

3.3 Efficiency It is likely that the cost savings due to the improved efficiency and effectiveness of the PHC system that were estimated at appraisal (see Annex 3) have materialized; however, they are not documented since no economic analysis has been carried out after project completion. The implementation arrangements allowed the Borrower to get good value for money. The rehabilitation of health centers financed by GOI funds was procured at competitive prices following national competitive bidding (NCB). The use of international competitive bidding (ICB) was also very cost effective since it enabled MOHME to obtain low prices for the vehicles and ambulances financed by the Bank Loan.

3.4 Justification of Overall Outcome Rating Rating: Moderately satisfactory. On balance, the assessment of overall outcomes is positive. The project’s PDO remained relevant, the objectives have been basically achieved, and Iran got good value for money. The overall outcome is rated “Moderately Satisfactory”.

3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development The project had a positive social impact since it targeted those regions where health conditions are poor and existing health services relatively inadequate. The "deprivation rate" updated yearly by sector, and according to the poverty line, was one of the criteria for selecting PHC facilities for rehabilitation. By focusing on primary health care for women and children, the project had a clear gender focus. (b) Institutional Change/Strengthening MOHME already had a good track record for the delivery of health services and some experience in implementing projects such as the PHCFP. The nutrition department had shown that it could manage successful programs such as the iodine deficiency program. The project’s institutional strengthening concerned mainly three areas. First, it increased the knowledge available in Iran on Bank-financed projects and their implementation modalities. Second, it built capacity on management at different levels of the health system. Component managers learned to carry out their activities on the basis of a work plan and a procurement plan. Third, it built capacity on nutrition among the management and staff of the MOHME and Medical Universities. However, the nutrition department that consisted of 24 professionals has decreased substantially in importance and size,

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having been incorporated into the Population, Family and Schools Health Department (PFSHD) of the MOHME. Capacity building has been seen by Iranian authorities as a very positive aspect of the project. The impacts from the capacity building component have led to a reorganization of services and departments within the MOHME and the Medical Universities in revisiting how health care and health care reform measures are being programmed and implemented. (c) Other Unintended Outcomes and Impacts (positive or negative) Although not part of the SPHCNP, the health sector review that was carried out during the project implementation provided an opportunity for improved dialogue between the GOI and the Bank on sector issues. The findings and recommendations of the health sector review are being used for the preparation of the Fifth Five-Year Development Plan (2010-2015). The report of the health sector review is now on the WEB site of the MOHME.

3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops There has been no beneficiary survey or stakeholder workshop.

4. Assessment of Risk to Development Outcome Rating: Moderate The priority that GOI gives to the health sector should help ensure that the development outcomes that have been achieved are maintained. However, the sustainability of the investments in rural and urban health centers may be problematic because of persistent weaknesses in the maintenance management capacity and budget allocations at the provincial and district levels. In the past, the government has managed to provide, albeit with some delays, the resources needed for the operation and maintenance of health facilities. The risk is mostly financial but is counterbalanced by a strong government commitment. Based on the above considerations, the ICR rates the overall risk to development outcome – i.e. the risk that development outcomes will not be maintained - as “Moderate”.

5. Assessment of Bank and Borrower Performance

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Unsatisfactory According to the PAD, the Bank and the Government agreed to start with a simple operation focused on primary health care, while collaboratively developing a broad health reform strategy. In particular, given the immediate needs of the country, the GOI's mature

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PHC strategy, and the Bank's knowledge of the sector through the ongoing project, it was decided that this operation be limited to the PHC sector and be specifically focused on nutrition. Other sector issues were equally important, but there was no well conceived strategy on the part of the GOI for addressing those issues at the time. In a situation where only UN agencies were providing very limited assistance to Iran for its social sector activities, the Bank operation was intended to help: (i) improve living conditions for low-income groups through rehabilitating health centers in deprived regions and improve the nutritional status of children; and (ii) consolidate achievements in basic social services despite tight fiscal constraints. Actually, there was no real agreement on the part of GOI on the project scope and contents, and some Bank staff had misgivings about the project contents. As discussed in Section 2.1 on “project preparation, design and quality at entry”, the project was complex, with too many, somewhat unrelated sub-components without a central theme. The definition of the project development objective (PDO) was too broad, with no clear baseline data and no agreed upon arrangements to monitor the achievement of the PDO. When the project was submitted to the Bank’s Board of Directors, it was not ready for implementation. The preparation time was too short; the Bank did not invest enough to understand the country system, constraints and regulations, and to ensure that the Iranian side was fully knowledgeable about the Bank implementation requirements and procedures. The ICR rates the Bank performance in ensuring quality at entry as “Unsatisfactory”. (b) Quality of Supervision Rating: Moderately Unsatisfactory At the supervision stage, the Bank project team realized early on that the project was in serious trouble and began to take immediate action to try to resolve problems. It worked with the client to restructure the project as it became clear that the project as appraised was not viable. The October 2002 Quality of Supervision Assessment (QSA5) rated the overall quality of project supervision as “satisfactory” because the Bank staff was working very closely and intensively with MOHME on the restructuring. However, the restructuring was politically sensitive, and was hampered by a challenging country relations context. Moreover, for reasons mentioned above the project development objective (PDO) was not changed at restructuring to bring it in line with the revised components and to facilitate the monitoring of its achievement. In recent years, Bank staff made a lot of effort to establish a relationship of trust and policy dialogue with Iranian counterparts. Those efforts were successful in dealing with procurement and financial issues. Attempts were also made to strengthen the monitoring and evaluation (M&E) system for the project, but with mixed results. From preparation to Loan closing, there were five Bank Task Team Leaders (TTL) who had to familiarize themselves with project issues, and two sector managers. Supervision budgets were quite high; in the staffing of missions, however, nutrition was somewhat neglected, and there

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were very few field visits. There were three extensions between loan effectiveness and closing date. The rating for the quality of supervision is “moderately unsatisfactory”. (c) Justification of Rating for Overall Bank Performance Rating: Moderately Unsatisfactory The rating for ensuring quality at entry is “Unsatisfactory” and the rating for quality of supervision is “Moderately Unsatisfactory”. The Overall Bank Performance is rated “Moderately Unsatisfactory”.

5.2 Borrower Performance

a) Government Performance Rating: Moderately Satisfactory Project preparation A fully staffed preparation team was appointed during identification and met regularly at MOHME, under the Deputy Minister's leadership, to follow up on project preparation. As this project was, to a large extent, a continuation of the Primary Health Care and Family Planning Project (PHCFPP), the ongoing institutional and implementation arrangements (including the Project Implementation Unit - PIU) were extended to the new project. According to the PAD, the objectives, scope, and content of the project were a subset of the Government's strategy. However, there was a lack of ownership, and the Government was not committed to the project as approved. Regarding the project scope and content, there was a lack of necessary coordination and consent with the planning and budget organization (PBO) before the finalization of the project and the signing of the Loan Agreement with the Bank. This explains why at the beginning of the project counterpart funds were not included in the MOHME budget allocation. The Government shares some responsibility with the Bank (but probably on a much smaller scale than the Bank) for the unsatisfactory quality at entry of the project (as discussed above). Project Implementation When it became evident that the project could not be implemented as planned and had to be modified, Government did not want to cancel any part of the Loan and it took about two years to reach agreement on project restructuring. Over the project period, GOI counterpart funds have not been released in a timely manner, which had an impact on completion of the facility rehabilitation program, financed exclusively by Government resources. On the other hand, the Government provided substantial amounts to finance the Family Physician Program (FPP). The introduction of the FPP in all rural areas in 2004 (i.e., at about the same time as the beginning of actual implementation of the SPHCNP) had a big impact on the delivery of medical services in those rural areas. Complemented by the project’s outputs in terms of

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health centers rehabilitation, medical equipment and vehicles/ambulances, the FPP helped achieve the project development objective (PDO). Throughout project implementation, there were a number of weaknesses in MOHME Departments and the PIU: (i) audit reports have been submitted several months late; (ii) the procurement timetable could have been better managed, in a more realistic manner; (iii) there have been significant delays for the processing of some payments, particularly for consultants and training activities; (iv) the monitoring and evaluation (M&E) function remained weak; and (v) there were unjustifiable delays in the completion of the Environmental Management Plan – EMP. In the first two to three years of the project, project management was unsatisfactory. However, after the restructuring of June 2004, project management improved in many respects. The PIU managed to effectively launch all ICB contracts, all the management training studies abroad, and the recruitment of consultants. All the capacity building and training activities have been completed. These achievements are to the credit of both the managers of the components and subcomponents and the Project Implementation Unit (PIU) in MOHME. In the end, despite all the initial difficulties and problems, the project was successfully implemented with 99.3 percent of the loan disbursed. (b) Implementing Agency or Agencies Performance Rating: The implementing agency for this project is the Ministry of Health and Medical Education (MOHME), which is part of the Government. The assessment of its performance is included in 5.2(a) above. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory The above assessment shows that the identified shortcomings of Government (including MOHME) are more than offset by the Government support for the Family Physician Program (FPP) which was linked to the project and which contributed to the achievement of the PDO. In the end, the project was successfully implemented and basically the entire loan was disbursed. The performance of the Government is rated “Moderately Satisfactory”. 6. Lessons Learned

1. It is important for the Bank to ensure that there is a consensus within the country on the proposed project before seeking approval for it, even when the Bank is time constrained to take a project to the Board.

2. Especially when the Bank is trying to move quickly on a project or country

relationship, arrangements must be made to ensure that the Borrower’s key project staff are hired and familiarized with Bank processes and procedures before the actual start of project implementation.

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3. At the preparation stage, it is very important that Bank staff understand the unique

system, regulations, procedures and institutional characteristics of the country in order to design a viable project.

4. During implementation, special efforts must be made to establish a relationship of trust with the Borrower’s staff.

5. In a country like Iran where nothing can be done without the approval of the

relevant Financial Controller who must therefore be familiar with World Bank guidelines and requirements, it is advisable to design a project that is simple and can be managed and implemented under the jurisdiction of only one Financial Controller.

6. It is inefficient for a Bank project to finance, procure and monitor a large number of low cost small works scattered over a large geographic area, but very efficient in procuring large numbers of equipment or vehicles where a centralized tender process is possible.

7. PDOs should be defined in precise and concrete terms with corresponding measurable quantitative key performance indicators. A clear results chain is critical, and the PDO should not include items that are not going to be influenced by activities or will not be measured by the project.

8. A well functioning M&E system with agreed upon indicators is very important

and should be established early in the project cycle for a systematic follow up of PDO and component outcome indicators.

9. Attribution of results must take into account parallel programs and the synergy must be acknowledged.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies (b) Co financiers (c) Other partners and stakeholders

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Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent)

Components Appraisal Estimate

(USD millions)

Actual/Latest Estimate (USD

millions)

Percentage of Appraisal

Sustained Access and Qualitative Improvement of Health Care

75.20 94.03 125.0%

Improvement of the Nutritional Status of Children under Three years of age and Lactating and Pregnant Women

15.50 8.15 52.6%

Capacity Building 8.10 20.86* 257.5%

Total Baseline Cost 98.80 123.04 124.5% Physical Contingencies 6.20 0.00 0.00 Price Contingencies 19.00 0.00 0.00 Total Project Costs 124.00 123.04 99.2% Project Preparation Fund 0.00 0.00 .00 Front-end fee IBRD 0.00 0.87 - Total Financing Required 124.00 123.91 99.9%

* including USD 6.35 million for the Avian Influenza Project.

(b) Financing

Source of Funds Type of Co financing

Appraisal Estimate

(USD millions)

Actual/Latest Estimate

(USD millions)

Percentage of Appraisal

Borrower 37.00 37.51 101.4% International Bank for Reconstruction and Development

87.00 86.40 99.3%

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Annex 2. Outputs by Component Component 1, or Part A - Sustained Access to and Qualitative Improvement of Health Care As revised, this component had two objectives. (1) First, improving the access to and quality of health care. Based on the implementation arrangements agreed with the Bank, the Center for Development of the Health Network (CDHN) of the Ministry designed three sub-components: 1(a) rehabilitation of health centers; 1(b) purchase of vehicles for health centers; and 1(c) provision of medical equipment for health centers. (2) Second, improving the quality of the EMS services in the country. This objective was to be achieved through the purchase of 500 ambulances and additional EMS equipment as well as some training activities (subcomponent 1d). Subcomponent 1(a): Rehabilitation of health centers Based on the experience of the previous project, a centralized approach would have been very difficult and inefficient for small and scattered works, given the large distances involved. Therefore, these activities were decentralized to the regions and implemented by the technical units of the universities. The rehabilitation of health centers was financed by the GOI funds and carried out by medical universities in four different phases, as follow:

Phase 1: about 32.30 billion IRRs were transferred to the universities and 228 centers were rehabilitated in 21 provinces.




In total, about IRRs 161.80 billion were transferred to the universities and close to 1,500 centers (588 urban health centers, 793 rural health centers and 81 rural health houses) in universities all over the country were rehabilitated at an average cost of about US$14,000 per center, but with wide variations between urban health centers, rural health centers and rural health houses. Approximately, 25 percent of existing urban or rural health centers was rehabilitated under the SPHCNP. The rehabilitation work was timely and complemented the Family Physician Initiative introduced in the rural parts of Iran. According to Mazandaran University of Medical Science, in the last year, the number of

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patient-visits in PHCs increased 2.5 times due to the successful synergy of the Family Physician Initiative and the physical rehabilitation of the PHCs. One local engineering consulting firm was hired for supervision of rehabilitation works. In addition, starting in 2007, the School of Public Health of the Tehran University of Medical Sciences (TUMS) carried out an environmental impact assessment study of rehabilitation projects. The Phase I report assessed about 112 primary health care centers in five different regions of the country. The Phase II report of the Environmental Management Plan (EMP) which includes an analysis of environmental issues by Primary Health Center and a section on mitigation measures has been completed in August 2008 and received by the Bank in December 2008. Subcomponent 1(b): Purchase of vehicles for health centers. The project purchased under ICB 1,080 4WD vehicles, which have been distributed to the medical universities. The technical specifications were prepared by the CDHN and the procurement of the vehicles was carried out centrally by the PIU. Subcomponent 1(c): provision of medical equipment for health centers. Nearly all of the health centers or rural health houses received some kind of medical equipment under the SPHCNP. The lists of equipment and the technical specifications were prepared by the CDHN and the procurement of the packages under ICB was carried out centrally by the PIU. All the items purchased have been distributed to the medical universities. In total, 2,507 urban health centers, 2,296 rural health centers and 11,821 rural health houses received upgraded equipment for improvements to patient care.

Package 1: Supply of Weighing Scales for Adults and Babies. Package 2: Supply of 8200 Stethoscopes and Manometers. Package 3: Supply of 4700 Laryngoscopes, 4700 Otoscopes and 1100 Diagnostic

Set. Package 4: Supply of 1100 Autoclaves and 1100 Disinfectors. Package 5: Supply of 1100 ECG Machines. Package 6: Supply of 1100 Suction Units. Package 7: Supply of 2200 Oxygen Cylinders. Package 8: Supply of 4700 Refrigerators for Vaccine. Package 9: Supply of 3600 Vaccine Carriers and 1200 Cold Box. Package 10: Supply of 35 Refrigerated Vehicles. Package 11: Supply of 5600 Air Conditioners. Package 12: Supply of 3600 Motorcycles. Package 14: Supply of 54 Micro Feeders. Package 15: Supply of 373,464 KG of Premix. Package 16: Supply of 600 Dental Units. Package 17: Supply of 2000 Blood Glucose Measuring Devices.

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Evaluation of sub-components 1(a), 1(b) and 1(c). In 2007, one independent local consulting firm ( eb & Tosei Salamat Institute) carried out an evaluation of the outcomes of sub-components 1(a), 1(b) and 1(c). The consulting firm interviewed members of village councils that are representative of the rural population, but also some women and health providers. The report shows very positive outcomes with increases in the level of client satisfaction with physical facilities, equipment and the referral system (transfer of patients to hospitals). MOHME is funding a study to assess the utilization rates of PHC centers measured by the average number of patient visits with general physicians. According to the terms of reference, the study will analyze what happened in 112 PHC centers that benefitted from the project, compared to a control group of another 112 PHC centers that were not major beneficiaries under the project. There have been delays in the start of the study and problems with the collection or retrieval of baseline data. Pending the results of the study, which are not likely to be available before September 2009, there is some anecdotal evidence that the number of visits increased and that the quality and accessibility of services (including the referral system) improved. Subcomponent 1(d): Purchase of ambulances and EMS equipment. The project purchased through LIB [it started as ICB, but the bids were not fully responsive to the bidding documents, so the bidding process was canceled and GOI started a new bidding process limited to the seven bidders that had submitted proposals] 500 ambulances financed by the Bank Loan, and through NCB some additional EMS equipment to be installed in the ambulances and financed by GOI counterpart funds (300 EMS backpacks, 260 wireless systems, 10 four-wheel drive vehicles, 60 DC shocks, and 17 mobile stations), which have been distributed to the medical universities. International training courses were included in the subcomponent (an Advanced Trauma License Support - ATLS - course was held in Qatar in 2007 for 18 staff of the Emergency Management Center (EMC)). According to MOHME, the project made a critical contribution to the establishment of EMS in the country. According to the PIU Status report of May 2008, the national response time average7 on rural roads was reduced significantly from 25 minutes in 2005 to 14 minutes in 2007. The response time in cities with a population of less than 500,000 was reduced from 15 minutes in 2005 to 7 minutes in 2007. It is estimated that the SPHCNP accounts for about one fourth of these improvements. However, although the number of emergency ambulance missions increased by about 21% (from 1.16 million in 2006 to 1.40 million in 2007), the mortality rates prior to hospital admission remained steady at around 3.2% to 3.6% between 2005 and 2007. According to the EMC in the MOHME, the project made a critical contribution to the establishment of EMS in the country. Through intersectoral efforts, GOI aims to further strengthen the capacity of the EMS sector and provide more timely responses to emergency cases. The GOI intends to increase the number of emergency stations from a current figure of 1,576 to 2,100 by the end of 2009.

7 The response time means the time required between the receipt of the call and the arrival of the ambulance.

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Component 2, or Part B – Improvement of the Nutritional Status of Children under three Years of Age and Lactating and Pregnant Women As revised, this component included two subcomponents: 2(a): nutrition education through nutrition graduate level training, technical assistance and on-the-job nutrition training for health care providers; and 2(b): micronutrient fortification. Subcomponent 2(a): Nutrition Education. This subcomponent included the design of long-term graduate programs for PhD and Masters Programs, graduate level and short-term programs overseas as well as workshops on child malnutrition and the management of child malnutrition in medical universities. The MOHME developed a three-year and ten-year nutrition strategy to strengthen human resource training in nutrition science and nutrition surveillance. The graduate level nutrition programs were designed under four contracts with the International Union for Nutritional Sciences (IUNS) and University of the Philippines in partnership with three Iranian universities, and are waiting for funding to be implemented in the three medical universities. A nutrition curriculum has been developed and needs to be integrated into the university program. Four PhD students completed their overseas training (three in Australia and one in the UK) in January 2009 (after project closing) and are expected to teach future nutrition programs in Iran. In addition, 65 nutritionists participated in the short-term international courses in Australia, Philippines, Thailand and The Netherlands, and 150 workshops on child nutrition and growth monitoring were conducted in the medical universities for 10,000 General Physicians and Pediatrics nationwide. A number of nutrition reports prepared in 2006 describe in some detail the results of the project-supported activities to build up the graduate programs in nutrition. They include: (i) the Final Report “Improving Graduate Education in Nutrition in Iran”; (ii) the supplemental report “Integrated Education Model”; (iii) the “Three-Year Start-Up Plan for Institution-Building Plans for MSc and PhD in Nutritional Epidemiology and Cellular and Molecular Nutrition”; and (iv) the “Ten-Year Plan for MSc and PhD in Nutritional Epidemiology and Cellular and Molecular Nutrition”. A qualitative evaluation of the effectiveness of the capacity development and training activities under the nutrition component to be carried out by an independent consultant was planned; it is not clear whether it will be done and when it might be completed. According to the TORs, the consultant’s report would include a discussion on project impact on the prevalence of child malnutrition and iron deficiency anemia among reproductive age women at the national level, and any lessons learned from the implementation of the nutrition capacity building subcomponent in the SPHCNP (success factors and challenges).

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In September 2007, the Nutrition Department was incorporated into the Population, Family and School Health Department (PFSHD) of the MOHME. The Government believes that this integration of nutrition into family health will reinforce recent achievements in nutrition and contribute to their sustainability. Subcomponent 2(b): Micronutrient fortification. This subcomponent included two sets of activities: (i) the design and development of a national plan of action for food fortification; and (ii) implementation of two pilot programs for micronutrient fortification. In 2005, MOHME signed an agreement with WHO for developing a National Plan on Iron Malnutrition and Flour/Food Fortification. The work included a technical consultation workshop in July 2005 and the constitution of working groups to review and assess micronutrient deficiencies, the milling industry, the regulatory framework, the inspection and control system, communication and advocacy, quality control and assurance, and institutional roles. A synthesis report was discussed at a first Technical Consultative meeting in October 2006 and a preliminary National Plan was discussed at a second Technical Consultative meeting in November 2006. The study confirmed that: (i) in Iran, bread is a staple food and wheat is a strategic product; (ii) iron fortification is feasible for the local flour industry; (iii) the existing national standards for wheat flour include specific provision for iron/folic acid fortification, and there is no barrier for implementing a mandatory wheat flour fortification (but, there is still no law to make it mandatory); and (iv) quality control of fortified flour is potentially available. In 2005, 18 provinces started flour fortification and 22 million people were consuming fortified flour. Since 2006, the national plan has been implemented, and the whole population of Iran (with the exception of Tehran proper) is now consuming fortified bread. All millers have been sensitized and have equipped their mills with micro feeders with their own resources. There is capacity for locally producing premix and micro feeders. The budget needed for implementing the national flour fortification plan (US$5.3 million) was allocated in May 2007, and the same amount was allocated for 2008. Under the subcomponent for micronutrient fortification, 54 micro feeders and 373 tons of premix were purchased and have been distributed to the medical universities. However, a local manufacturer produced micro feeders and sold them to private flour mills at a price lower than the cost of imported micro feeders, which have not been used up to now. Therefore, the success of the national micronutrient fortification cannot be attributed to the project. The first pilot flour fortification project was started in 2001 in Boushehr Province, after baseline data gathering. A mid-term evaluation in 2004 showed that the program has had only a beneficial effect on the prevalence of low ferritin levels for the intervention group in Boushehr Province against the control group in Fars province. An independent study was carried out in 2009 by the Academic Center for Education, Culture and Research and by the Institute for Health Sciences Research (IHSR) to evaluate the effectiveness of the flour fortification program on decreasing iron deficiency anemia among women of child

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bearing age in the Boushehr and Golestan provinces. The study found similar trends in the indicators of anemia/iron deficiency among the studied women in both Bushehr and Golestan provinces. The flour fortification program appears to have had beneficial effects on the ferritin levels (iron deficiency) in both provinces. The prevalence of iron deficiency in women of Bushehr province decreased from 22.2% in 2001 (before intervention) to 15.7% in 2009, while that in women of Golestan province decreased from 26.7% in 2007 (before intervention) to 14.6% in 2009. However, the prevalence of anemia (low hemoglobin) was significantly higher after intervention in women from both Bushehr and Golestan provinces. The lack of apparent beneficial effects of this program on the prevalence of anemia may be due to low bioavailability of the iron used for fortification, the inhibitory effect of dietary components (e.g. phytate) on iron absorption, the relatively low level iron content in the fortified flour, low consumption of other iron-containing foods (e.g. meat), and low consumption of fortified bread. Some of the important factors that diminish the beneficial effects of flour fortification on anemia in Iran include parasitic and infectious diseases, and other diseases prevalent in these areas (e.g. minor thalassemias). The relatively low availability of other micronutrients (e.g., vitamin A) should not be ignored. Studies have shown that the prevalence of anemia is high in developing countries affected by vitamin A deficiency, and improvement of vitamin A status has been shown to reduce anemia. Therefore, it seems that other interventions besides flour fortification with iron will be needed to substantially reduce the prevalence of anemia in Iran. In summary, the study has shown that the flour fortification program in Iran is a useful component of a public health strategy aimed at improving iron deficiency status. However, in areas where anemia is not due mainly to iron deficiency, an iron fortification program might decrease the prevalence of iron deficiency without affecting the prevalence of anemia. Component 3, or Part C – Capacity Building: As revised, this component includes the following five sub-components: Subcomponent 3(a) - Management Training; Subcomponent 3(b) - Improving the Quality of Vaccine Production; Subcomponent 3(c) - Health Sector Reform; Subcomponent 3(d) - PIU Management; and Subcomponent 3(e) – Avian Influenza project. Capacity building has been seen as a very positive aspect of the project by the Iranian authorities interviewed during the ICR mission, including the advisor to the Minister. The impacts from the capacity building component have led to a reorganization of services and departments within the MOHME and the Medical Universities in revisiting how health care and health care reform measures are being programmed and implemented. Subcomponent 3(a): Management Training. The quantitative data shows that the following numbers of health managers and staff have participated in the following training courses:

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English training courses (113 persons in IELTS and 87 persons in different

English courses) for all the persons nominated for Ph.D and Master courses to improve the ability of managers and experts of MOHME and medical universities to communicate better with other institutes around the world.

Ph.D courses in health informatics, clinical education, public health, health policy and management for 15 students (10 in Sweden, 2 in Australia, 1 in India, and 2 in UK) that completed their studies in December 2008.

Twenty one MSc students have completed their studies: 18 in Heidelberg University (Germany) from October 17, 2005 to October 13, 2006, one in Australia, one in the UK and one in Iran. As a result of this training, theses have been prepared which are actionable plans for health sector reform in Iran and there are health care management experts that now have the knowledge, skills and motivation to implement these plans. Student evaluations of the program ranked the program component as “good” to “excellent” with no evaluation falling below “satisfactory”.

Short-term training courses of two or three weeks on “restructuring in hospital management” and “health facility management” under three contracts with Karlsruhe University (Germany) were completed for 350 participants.

Short-term training courses on emergency medicine, hospital management, and project cycle management, etc. for 152 participants.

Fifty (50) persons participated in an emergency medicine leadership workshop in Tehran University by the George Washington University Medical Center for one week.

One hundred and fifty (150) managers of medical universities and MOHME participated in six local short-term courses at the NPMC center in Tabriz on Project Cycle Management and Human Resource Management that have been organized in collaboration with the International Labor Organization (ILO).

Seven training centers in Ahvaz, Bandar Abbas, Golestan, Ispahan, Shiraz, Tabriz and the University of Rehabilitation and Welfare Sciences have been strengthened to cover a wide range of health sector issues, with the goal that these become centers of excellence. Graduates and trainees have created “Teams of Health Mentors” who have organized the workshops and reviewed the training packages in order to identify their strengths and weak points and upgrade them with the latest findings in the relevant areas. Subcomponent 3(b): Improving the quality of vaccine production. WHO was contracted in May 2004 to manage the implementation of the subcomponent activities, which included a series of international and local training courses and workshops and international and local technical assistance interventions. This subcomponent was completed at the end of 2006. The project submitted an evaluation report in December 2006.

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The following activities have been carried out: a) Review and updating by one long-term consultant (11 months) of all the seven critical functions of WHO for assessment of the national authorities involved in the regulation of vaccines:

1. National regulatory system; 2. Marketing authorization (MA) and licensing activities; 3. Post-marketing activities including surveillance of adverse events following

immunization (AEFI); 4. NRA lot release; 5. Laboratory access; 6. Regulatory inspections; 7. Authorizations /approval of clinical trials.

b) Evaluation training courses in Iran and abroad for staff of MOHME and vaccine manufacturers. c) Preparation of all the documents needed for updating the system in all the seven critical function areas, including guidelines, standard operating procedures, checklists, etc. d) Purchase of books and of equipment for training and for improving the control on vaccines. The 2006 WHO assessment shows significant improvement in six out of seven critical functions from 2002 to 2006, with an increase in the overall score from 72% to 86%. A new WHO assessment was carried out in November 2007; the WHO formal report has not yet been received, but the team presentation showed a significant increase in scores and conditional passing for full functionality of the National Regulatory Authority (NRA) and National Control Laboratory (NCL). Subcomponent 3(c): Health Sector Reform (HSR). The objective of the subcomponent was to build capacity for better health policy through targeted health sector reform pilot projects. The subcomponent was designed to include a series of consultancies, training activities (fellowships, short courses, study tours, workshops and preparation of local training modules), provision of equipment and supplies, and publication of reports generated by the studies. According to the Aide memoire of the Bank Health Sector mission of June 2002, Health Sector Reform was the main objective of the Minister of Health and Medical Education. The Ministry set up a HSR committee with a secretariat reporting directly to the High Council of Health and the Minister. The HSR included various activities and studies that contributed to the establishment of the Family Physician Program (FPP) in Iran. Together with the rehabilitation of health facilities and physician houses and the provision of medical equipment and vehicles, HSR research and studies were part of the preliminary steps for the establishment of the FPP within the framework of the SPHCNP. The original plan was to have a Health Sector Reform Study by an international consulting firm implemented under the responsibility of the HSR Committee (HSRC).

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Actually, part of the subcomponent was implemented by WHO (under a contract signed in May 2004) under the guidance of the HSRC: it was completed in December 2006. WHO was a very good vehicle for implementation (particularly for consultant recruitment). However, since the subcomponent was experiencing difficulties, the WHO contract was downsized: a number of activities in the initial work plan were canceled and the procurement of equipment and supplies were transferred to the PIU. The subcomponent provided support for the establishment of the NHSRU and an information resource center, under the auspices of which a number of books and reports were published and/or translated into Farsi. The Health Sector Reform (HSR) sub-component assisted the government in implementing its reform objectives: (a) preparation of evidence-based models to improve the health system and improve data collection and analysis; (b) strengthening the capacity of the health system; (c) preparation of the reform package based on the Family Physician model; and (d) review of health reform initiatives. The results of the HSR sub-component is being used for the preparation of the government’s Fifth Five-Year Development Plan (2010-2015). The list of activities that were initiated and are still underway under the subcomponent is quite impressive. Some examples of these activities are listed below:

- In October/November 2002, a one-week study tour to the UK organized by the British Council to familiarize senior Iranian MOHME officials with the National Health Service.

- In 2003/2004, a series of workshops under the World Bank Institute (WBI)

Flagship Course on Health Sector Reform and Sustainable Financing were delivered by the American University of Beirut (AUB), including a senior policy seminar (Wise Men Seminar). Under a 12-month contract, it included the delivery of 8 courses: 1) Module on basic health economics; 2) Module on assessing health performance; 3) Module on financing health care; 4) Module on provider payment mechanisms; 5) Module on designing benefit packages and targeting public subsidies; 6) Module on reforming and managing health institutions; 7) Module on decentralizations; and 8) Module on quality and equity in health systems. The objective of the flagship program was to enable MOHME to: (i) develop a core team of Iranian trainers in the areas of health economics/finance; (ii) provide training in the area of health sector reform to key decision makers and managers; and (iii) help develop training capacity in the health sector. In sequel to the flagship course delivered by the AUB, the Lorestan University of Medical Sciences was contracted to develop and adapt the flagship courses for use in Iran.

- A total of 23 students have participated in short courses abroad, three post-

doctoral students have completed their studies abroad, 19 fellows participated in study tours, and 22 candidates participated in four local training modules of one week duration.

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- The HSR developed 29 sub-projects all over the country, with 23 research projects completed in the last two years. These projects dealt with improving leadership and governance functions, and health planning and management, and strengthening the health financing functions in MOHME.

- In December 2006, a two-day Senior Policy Seminar in Tehran, with experts from

MOHME, MPO and parliament and with the participation of the World Bank Institute (WBI). The topics covered financing, organization, regulation and payment systems for providers.

The MOHME is working toward three major goals: Healthy People, Equitable Access to Healthcare, and Sector Development to Improve Health Planning and Promote Equity. These goals are currently being implemented in four pilot provinces. In addition to these activities, the HSR is working on a health dictionary, and a policy paper on data collection, frequency and methods, as well as the establishment of a performing HMIS through increased automation, integration of HSR into the Health Policy Planning and Development of the MOHME, implementation of a clinical governance course at the Tehran Medical University, preparation of clinical and ethical guidelines for Family Physicians in rural areas, and the establishment of Health Policy Units in each university. The main achievements of the Health Sector Reform subcomponent are: (i) dissemination of the concepts of reform within and outside the health system; (ii) provision of a common language between policy makers, managers and experts in health system; (iii) capacity building in health system research areas at the National and Provincial levels; and (iv) provision of key information for policy making. Subcomponent 3(d): Project Implementation Unit (PIU) Management The PIU has been set up and maintained for the day-to-day coordination of all project activities implemented by the relevant MOHME Directorates. The PIU handled the project management functions such as financial management, procurement, scheduling, monitoring, controlling, evaluating and reporting. Despite the initial difficulties and problems, the project was successfully implemented with 99.3 % of the Loan disbursed. The key staff of PIU participated in the following short term courses: (a) Health Planning and Management/England; (b) Project Management / ILO-Italy; (c) Project Cycle Management/ILO-Italy; (d) PCM/ Monitoring and Evaluation/MDF-the Netherlands; (e) Procurement of the Consulting Services-ILO-Italy; (f) Financial Management-ILO-Italy; (g) Financial Management-AUB-Lebanon; (h)PCM/ILO-Italy; (i) Procurement of the health goods-ILO; (j) Special English courses; and (k) Computer courses. The technical services provided for the implementation of the components included the recruitment of two International consultants who successfully provided the required services: (i) a former senior Bank staff who was very experienced in procurement; and (ii) an international monitoring and evaluation (M&E) consultant who helped the PIU and subcomponent managers in developing and measuring indicators.

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Subcomponent 3(e): Avian Influenza (AI) project The objective of this supplemental project subcomponent was to assist the GOI in strengthening its preparedness for a potential outbreak of Highly Pathogenic Avian Influenza through strengthening its capacity to prevent, diagnose, and manage any suspected or confirmed human cases. The new subcomponent included five activities: (1) strengthening the surveillance system; (2) strengthening the health system response capacity; (3) communication and coordination; (4) capacity building and knowledge sharing; and (5) project management and monitoring and evaluation. This subcomponent was started in 2007 and implemented by the Center for Disease Control and Management – Iran (CDC-I). The project consisted of procurement of various equipment and items, training activities and workshops, and some consulting services. Of the capacity building activities that were carried out by CDC-I and the Medical Universities, 90% of the objectives were reached (221 seminars and 612 workshops were held, 545,696 pamphlets were distributed, 47,749 posters were developed, 264 radio and 206 TV spots were produced). Seminars and workshops improved the level of preparedness and knowledge on control and prevention of AI of health and veterinary professionals and poultry farmers, reaching more than 20,000 beneficiaries. For the organization of these workshops, about 71 contracts (for about US$500,000 in total) were signed between the PIU and medical universities all over the country. The CDC-I organized also a refresher course on Avian Influenza for health workers in the country. Post-test evaluation scores reflect an increased knowledge of AI. Following LIB, 250,000 doses of Influenza vaccine (Euro 798,000) were imported from France and delivered in November 2007. Other procurement through ICB included the purchase of 72 ventilators and 55,000 protection Kits. In addition, 72 ICU/CCU beds and 72 patient monitors, 72 Infusion pump, and 72 Syringe pumps were purchased through NCB. In term of consulting services, five (5) individual consultants were contracted to provide the technical services to the AI project: (i) a Senior Advisor (who had to be replaced for health reasons); (ii) a consultant to prepare an educational package for health community workers (HCWs – Behvarz or volunteers); (iii) a laboratory consultant to coordinate activities and upgrade the capacity of influenza sub national laboratories; (iv) a national consultant to prepare the National Pandemic Preparedness and Response Plan; and (v) an IEC consultant to prepare IEC materials. A National Preparedness Plan for Pandemic Influenza has been prepared and adopted, and Avian Influenza guidelines on surveillance have been updated and published. The ICR mission received the translated version of the Health Preparedness Plan (2nd revision). The plan details the actions to be taken through six different phases with respect to five domains: (i) planning and coordination; (ii) situation monitoring and

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assessment; (iii) prevention and containment; (iv) health system response; and (v) communication and education. The Center for Disease Control and Management-Iran (CDC-I) is now working on revising the comprehensive plan which includes all the key sectors and which will be validated by the President’s Office. Of the three simulation plans that were to be launched during 2008, only one was carried out in Tehran with the Veterinary organization and the CDC-I. In conclusion, the Avian Influenza activities have been successful; the Avian Influenza Subcomponent helped MOHME prepare the health sector for a possible pandemic of influenza: (a) health staff continue to be trained through a training of trainers approach; (b) hospitals have been designated for case management and isolation of possible human cases in each province; and (c) each hospital has dedicated rooms specially equipped to handle human cases. All the investments made to prepare the health sector for a pandemic of Avian Influenza may turn out to be very useful if Iran is affected by a pandemic of influenza. Health Sector Review In February 2005, the Bank proposed conducting a review of the health sector in collaboration with GOI. The objective of the review was to take a comprehensive look at the sector as a basis for identifying its relative strengths and weaknesses, and options for reform. The review was prepared in collaboration with key counterparts from the Government of the Islamic Republic of Iran. National experts prepared eight policy papers on the following subjects: (1) Primary Health Care (PHC); (2) Secondary Health Care (SHC); (3) Tertiary Health Care (THC); (4) Pharmaceuticals; (5) Human Resource Management; (6) Stewardship; (7) MIS; and (8) Health Financing. The process included among others a review of health financing and insurance, an update of the national health accounts, an assessment of the performance of the health system, and a review of the external environment of the health system. A well-attended and successful Forum on the Health Sector Review was held on November 24-25, 2007. The Forum included excellent presentations on Health Sector Reform (HSR) topics by key counterparts. It reviewed elements of the health sector (health service delivery, health financing, human resource, pharmaceutical sector) and provided a platform for an exchange of ideas and analysis on the challenges facing the sector, including cross-cutting issues related to governance and stewardship, monitoring and evaluation, and evidence-based policymaking.

The Health Sector Review Report (No. 39970-IR, dated June 2008) attempts to: (i) assess the strengths, challenges, and opportunities facing the current health system; (ii) offer analytic assessments of the health policies and plans; (iii) provide a framework for developing strategic options; and (iv) offer short- and medium-term recommendations and action plans to achieve the goals identified in the country’s Fourth Five-Year

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Development Plan. The health sector report has been translated into Farsi and will be published after approval by the Minister of Health.

Although originally not part of the SPHCNP, the Health Sector review that was carried out during the project implementation provided an opportunity for improved dialogue between the GOI and the Bank on sector issues. The contents of the report are being used for the preparation of Iran’s Fifth Five-Year Development Plan (2010-2015).The report is now on the WEB site of the MOHME.

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Actual Project Components and Costs

(US$ Million)

Components IBRD GOI Total Part A - Sustained Access to and Qualitative Improvement of Health Care

Rehabilitation of PHC 0.16 21.21 21.37 Vehicles 18.79 3.62 22.41 Equipment 17.20 3.82 21.02 EMS ambulances 27.00 2.23 29.23 Sub-total Part A 63.15 30.88 94.03 Part B – Improvement of the Nutritional Status of Children under Three Years of Age and Lactating and Pregnant Women

Capacity development 4.13 } 1.34 } …..

} 8.15 } .... Food fortification 2.68

Sub-total Part B 6.81 1.34 8.15 Part C – Capacity Building Management training 6.06 1.33 7.39 Quality of vaccine production 1.25 0.48 1.73 Health sector reform 2.30 0.67 2.97 PIU management 0.42 2.00 2.42 Avian Influenza (AI) Project 5.54 0.81 6.35 Sub-total Part C 15.57 5.29 20.86 Front-end fee IBRD 0.87 - 0.87 Grand Total 86.40 37.51 123.91

Source: Project Implementation Unit (PIU) – MOHME (January 2009)

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Annex 3. Economic and Financial Analysis (including assumptions in the analysis)

An annex of the Project Appraisal Document (PAD) presented the results of the economic analysis of the Project. The economic analysis provided: (i) justification for the program based on sector priorities; (ii) an analysis of alternatives, including the rationale for public sector involvement; (iii) assessments of the financial and fiscal impacts of the project; and (iv) a cost-effectiveness/cost-benefit analysis of project interventions. In light of the prevailing difficult economic circumstances, the project was designed to fulfill the most immediate health concerns of the population, while remaining cost-effective and keeping incremental recurrent costs to a minimum. Improving the health and nutritional status of children and pregnant and lactating women was viewed as a means by which to achieve long-term economic growth and stability. In addition, because the health facilities to be rehabilitated under this project were already in existence and had a maintenance budget, it was assumed that the incremental recurrent costs of maintaining them would be close to zero. In terms of improving the efficiency and effectiveness of the PHC system, the project was expected to result in potential savings through: (i) lower treatment costs due to a reduction in the cost of hospital admissions as a result of early detection and treatment; and (ii) lower cost for the provision of a service at a lower level of care. Those savings would offset, or at least reduce, the increased costs that would result from an increase in the utilization of hospitals (a better-functioning referral system could increase hospital utilization through the increased capacity to detect cases that require hospitalization). In addition, there would be external benefits to be gained from the project, which may include reductions in mortality and morbidity rates and increases in productivity for those benefiting from the project. Thus, overall it was expected that the potential benefits of the project would outweigh its costs. The cost savings due to the improved efficiency and effectiveness of the PHC system that were estimated at appraisal may have materialized; however, they are not documented since no economic analysis was carried out after project completion. The implementation arrangements allowed the Borrower to obtain good value for money. The rehabilitation of health centers financed by GOI funds was procured at competitive prices following national competitive bidding (NCB). The use of international competitive bidding (ICB) was also very cost effective since it enabled MOHME to obtain low prices for quality vehicles and ambulances financed by the Bank Loan.

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Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/

Specialty Lending Eva Jarawan Sr. Health Specialist MNSHD Task Team Leader Rekah Menon Economist MNSHD Health Economics Christian Rey Portfolio Manager MNSHD Implementation Claudia Rokx Nutrition Specialist MNSHD Nutrition

Iraj Talai Lead Financial Management Specialist

MNAFM Finance

Christine Wong Procurement Assistant MNSHD Procurement

Supervision/ICR Nicole Klingen Health Specialist MNSHD Task Team Leader George Schieber Health Sector Manager MNSHD Health Christian Rey Portfolio Manager MNSHD Implementation

Iraj Talai Lead Financial Management Specialist

MNAFM Finance

Claudia Rokx Nutrition Specialist MNSHD Nutrition Gail Richardson Sr. Health Specialist MNSHD Task Team Leader Mario Antonio Zelaya Consultant MNSHD Implementation Christine Wong Procurement Assistant MNSHD Procurement Frederick Yankey Financial Management Specialist MNAFM Finance Suha Rabah Program Assistant Thao Le Nguyen Senior Finance Officer LOAFC Disbursement Christopher Walker Lead Implementation Specialist AFTH1 Lead Specialist Dennis Streveler Lead HMIS Expert MNSHD HMIS Daniel Kress Sr. Health Economist MNSHD Task Team Leader

Nezam Motabar Sr. Financial Management Specialist

MNAFM Finance

Mahtab Zolghadri Sr. Procurement Specialist MNAPR Procurement Hadia Samaha-Karam Operations Officer MNSHD Operations Dominic Haazen Sr. Health Specialist MNSHD Health Alia Achsien Sr. Program Assistant MNSHD

Jean-Jacques Frere Senior Public Health Advisor MNSHD ICR Task Team Leader

Eileen Brainne Sullivan Operations Analyst MNSHD Operations Claudine Kader Sr. Program Assistant MNSHD John Langenbrunner Lead Economist, Health MNSHD Task Team Leader Miho Tanaka Health Specialist, consultant MNSHD Health Sylvia Robles Senior Public Health Specialist HDNHE Health

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Enis Baris Senior Public Health Specialist MNSHD Health Alaa Mahmoud Hamed Abdel-Hamid

Sr Health Specialist MNSHD Nutrition

Afifa Alia Achsien Senior Program Assistant MNSHD Robert Bou Jaoude Sr Financial Management Specialist MNAFM Finance Kelechi O. Ohiri Health Specialist HDNHE Health Sepehr Fotovat Procurement Specialist MNAPR Procurement Paul Geli Consultant MNSHD ICR

(b) Staff Time and Cost

Stage of Project Cycle Staff Time and Cost (Bank Budget Only)

No. of staff weeks USD Thousands (including travel and consultant costs)

Lending FY00 7 37.24 FY01 5 13.70 FY02 0.00 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00

Total: 12 50.94 Supervision/ICR

FY00 0.00 FY01 19 94.42 FY02 26 183.35 FY03 45 242.16 FY04 35 175.92 FY05 17 126.06 FY06 28 118.14 FY07 12 87.32

Total: 182 1027.37

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Annex 5. Beneficiary Survey Results (if any)

Client satisfaction with PHC services. In 2007, an independent local consulting firm carried out an evaluation of the satisfaction rates among the population (members of village councils that are representative of the rural population, but also some women) as well as health providers about physical facilities, equipment and referral system (transfer of patients to hospitals). The report shows very positive outcomes with increases in the level of client satisfaction. Some satisfaction rates are shown in the table below: Satisfaction rates of council members and women regarding:

Physical Environment

Equipment Referral system (transfer of patients to hospitals)

I. Village council members - before intervention 38% 15% 17% - after intervention 60% 52% 46% II. Women 60% 57% 48% Emergency Medical Services (EMS) According to MOHME, the project made a critical contribution to the establishment of EMS in the country: call volume increased, call response time decreased and patient satisfaction with EMS increased. According to the PIU Status report of May 2008, the national response time average on rural roads were significantly reduced from 25 minutes in 2005 to 14 minutes in 2007. The response time in cities with a population of less than 500,000 was reduced from 15 minutes in 2005 to 7 minutes in 2007. It is estimated that the SPHCNP accounts for about one fourth of these improvements. However, although the number of emergency ambulance missions increased by about 21% (from 1.16 million in 2006 to 1.40 million in 2007), the mortality rates prior to hospital admission remained steady at around 3.2% to 3.6% between 2005 and 2007.

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Annex 6. Stakeholder Workshop Report and Results (if any)

There was no stakeholder workshop.

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Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR

In The Name of God

Implementation Completion Report (ICR)

Second Primary Health Care and Nutrition Project (SPHCNP)

May 2009

Prepared by Project Implementation Unit (PIU) Ministry of Health and Medical Education (MOHME)

Islamic Republic of Iran

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Acronyms AIP Avian Influenza Project

APW Agreement for Performance of Work

AUB American University of Beirut

CDC Center for Disease Control

DMMDR Deputy Minister for Management Development and Resources

EMS Emergency Medical Services

FFCI Fairness in Financial Contribution Index

GOI Government of Iran

HMIS Health Management Information System

HSR Health Sector Reform

HTA Health Technology Assessment

ICR Implementation Completion Report

MOEAF Ministry of Economic Affairs and Finance

MOHME Ministry of Health and medical Education

MOU Memorandum of Understanding

MOWSS Ministry of Welfare and Social Security

MPO Management and Planning Organization

NCL National Control Laboratory

NHA National Health Account

NHSRU National Health Sector Reform Unit

NPMC National PHC Management Center

NRA National Regulatory Authority

OC Oversight Committee

PDO Project Development Objectives

PHCFPP Primary Health Care and Family Planning Project

PIU Project Implementation Unit

SPHCNP Second Primary Health Care and Nutrition Project

STC Short Term Consultant

TOT Training Of Trainers

WB World Bank

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Executive Summary This Implementation Completion Report (ICR) is prepared for the Second Primary Health Care and Nutrition Project (SPHCNP) and also covers the Avian Influenza Project (AIP) implemented in the framework of SPHCNP. The SPHCNP was a continuation of the Primary Health Care and Family planning Project (PHCFP) which was financed by the World Bank and terminated in Year 2001. Based on the agreement reached between MOEAF, World Bank and MOHME the overall agreement of the Bank for lending a second loan to Iran in the health sector was received on Year 1998. After such agreement several packages in the different fields of the health were designed by MOHME and were submitted to the Bank for approval. After long discussions between MOHME and World Bank during Year 1998, some of the projects such as EMS air ambulances and Hospital Waste Management and production of vaccine were rejected by the Bank due to the incompleteness of the project documents and other reasons related to the conditions and requirements of the Bank for approval of the project. Following that the SPHCNP, including some of the packages proposed by MOHME, was approved by the Bank in the beginning of Year 1999 and the Loan Agreement was signed on June 26, 2000. Based on the agreements reached, the Bank agreed to lend to Iran on the terms and conditions set forth in the Loan Agreement, an amount equivalent to eighty seven million U.S. Dollars (US$87,000,000). The objectives of the project were to assist the Government of Iran (GOI) in improving health conditions in rural and urban areas through: Sustaining access to and quality of primary health care; Improving the nutrition status of children under two and of pregnant and lactating

women; Capacity building in the health sector.

Due to the delay in signature of the Loan Agreement and problems on provision of local budget caused by the objection of MPO on the structure and initial design of the project, and other implementation problems, substantial delays occurred in starting of the project in the first two years. Delays in implementing the project were mainly related to the late effectiveness of the loan; lack of counterpart funds; insufficient experience of different departments of the MOHME involved in the implementation of the components with Bank Guidelines and procedures; inadequate capacity and the time spent for restructuring of the project and preparation of the new components. Because of the delays occurred in implementation of the project, based on the agreements reached with MPO by the end of Year 2001, the World Bank and GOI conducted an assessment of the project activities to define what could realistically be achieved by the project closing date. Based on this assessment, changes were made to the project subcomponents and the project restructured on Feb. 2002 maintaining the original objectives of the project. The components of the restructured project as agreed between MOHME, World Bank and MPO is shown in the following page;

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Part A- Improving Access to and Quality of the Health Services, including Emergency Services

A(1) - Rehabilitation of Health Facilities; A(2) - Purchase of vehicles; A(3) - Purchase of equipment A(4) - Purchase of Ambulances.

Part B- Improving Nutritional status

B(1) - Nutrition Education; and B(2) - Micronutrient Fortification.

Part C- Capacity Building

C(1) - Management Training; C(2) - Improving Quality of Vaccine Production; C(3) - Health Sector Reform; and C(4) - PIU Management.

However despite restructuring of the project on Year 2002, there was still very little progress on most subcomponents until early 2003. One of the problematic issues was financing rehabilitation of the health facilities in rural areas using loan through centralized payments from Special Account. The nature of the rehabilitation, the small amount and big numbers of the contracts and the scope of the works spread over all the country made the project impractical to be managed centrally by PIU and to be financed through loan. This matter and also the impossibility to reach a practical agreement between universities, PIU and the World Bank on the method and financing process of the activities prevented any progress in finalization of the agreements with the universities on the process of procurement and payments out of the loan created substantial delays in implementation of the rehabilitation component after restructuring. Moreover other implementation problems such as inadequate resources and institutional arrangements, full time project manager, and problems in identification and contracting of the international and local consultants of the complex components such as HMIS, HSR and Vaccine components delayed substantially the progress of the project after restructuring. In addition, purchasing the medical equipment and vehicles through ICB where the local regulations not allowed the importation of the medical equipment and vehicles slowed down the progress of the components 1(a) and 1(b) after restructuring. As the result the amount of funds utilized remained insignificant until end of 2003. However considering the commitment of then newly assigned administration in MOHME to overcome the delays in implementation of the project, substantial progress was made in a short span of time that included:

- Obtaining special permissions for importation of the vehicles and equipments; - Reaching an agreement with the World Bank and MPO to finance

rehabilitation totally from local funds;

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- Reaching agreements on specific issues such as assigning WHO as executing agency for implementation of Health Sector Reform and Quality of Vaccine Projects and

- Solving other problems hindering the progress of the components resulted in reaching a comprehensive agreement and signature of a Memorandum of Understanding (MOU) between MOHME, MOEAF and the World Bank in Feb. 2004 and applying the required changes to the Loan Agreement.

Based on such comprehensive agreements and MOU and due to the commitment and efforts made by different departments of MOHME especially then Deputy Minister for Management Development, component managers and PIU manager and experts, and also support, cooperation and assistance of the World Bank, MOEAF and MPO to implement the SPHCNP, by the end of loan closing date about 99.2% (More than 86 million USD) of the total amount of the loan (87 million USD) was disbursed and all the activities were implemented and the project achieved substantial part of it's objectives. The brief explanation about each component and the achievements are mentioned in the following paragraphs: Sub-component A(1): Rehabilitation of Rural Health Centers In the framework of this sub-component about 1400 selected Rural Health Centers in 41 medical universities all over the country, 588 Urban Health Centers, 793 Rural Health Centers and 81 rural health houses nationwide were rehabilitated. As the result in total approximately 25% of existing Urban or Rural Health Centers were rehabilitated under the SPHCNP. After restructuring of the SPHCNP based on the agreement reached on financing this component by GOI funds, the total amount spent for rehabilitation came to IRR 162 billion financed totally through local budget; Sub-component A(2): purchasing vehicles for the Health Centers In the framework of this sub-component 1080 four-wheel drive vehicles for rural health centers were purchased through ICB and delivered to the medical universities. The total amount spent for purchase of the vehicles was 18,790,000 USD financed out of the loan. Sub-component A(3): purchasing medical equipments In the framework of this sub-component 24 items of medical equipment for 2,507 Urban Health Centers, 2,296 Rural Health Centers and 11,821 Rural Health Houses were purchased through ICB and delivered to the medical universities. The initial estimated budget for the implementation of this sub-component was 20,630,000 USD, but the total amount actually spent for purchasing of the equipment was 17,921,000 USD financed out of the loan. This saving helped MOHME to implement Avian Influenza project as an additional and complementary initiative during Year 2006 and 2007 in the framework of SPHCNP. Evaluation of the outcomes of components A(1), (2) and (3) carried out by an independent consulting firm (Teb va Touseh institute) shows the following improvement and achievement in line with the objective of these components at the end of the project:

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1. About 60% of women and members of villages council expressed satisfaction with new environment of rehabilitated health centers

2. About 52.4% of members of village councils and 57.7% of women expressed satisfaction with the new equipment

3. About 46% of members of village councils and 48.5% of women expressed satisfaction with the transfer method of patient to hospital

4. Level of satisfaction of members of village councils from environment increased from 38.4% to 60.9%

5. Level of satisfaction of members of village councils from equipment increased from 14.6% to 52.4%

6. Level of satisfaction of members of village councils from the transfer method of patient to hospital increased from 16.5% to 46%

7. About 83% of the health providers and patients are satisfied with the health facilities. In line with the objective of the components A(1), A(2), A(3), the implementation of the activities has contributed to the improvement access to and Quality of the Health Care Services. The indicators shown in table 11 are evidence of such improvement in provision of Health Care Services since beginning of the project. Also in order to evaluate the outcome of these projects a survey was undertaken by an independent consulting firm. The final report of consultant "Evaluation of the Projects on Sustaining Access to and Improving the Quality of Primary Health Care" is attached to this report as Appendix 9 Sub-component A(4) - Improving Emergency Medical Services (EMS) In line with the objective of this component, since the old ambulances were outdated and not fully equipped and efficient, during the restructuring of the SPHCNP, the MOHME decided to use part of the loan for improving the EMS in the country and renewing the ambulance fleet. After long process and huge effort made by MOHME and cooperation of the World Bank, 500 ambulances were purchased through ICB and delivered to EMS department to be used all over the country. The estimated budget for the implementation of this sub-component was 25,910,000 USD, But finally 23,870,000 USD was paid out of the loan for procuring the ambulances. Moreover during the extension of the loan for AI project, due to the emergency need of the MOHME to improve the EMS services some equipment as mentioned in the Avian Influenza project section was purchased and delivered to the EMS department; The following indicators are evidences of improving the EMS situation after termination of the project: Despite increasing of the emergency missions from 1,159,887 in Year 2006 to 1,401,942 missions in Year 2007 which shows an increase of about 20.9% and increasing the level of EMS coverage from 35% in Year 2006 to 52% in Year 2007, the mortality rate due to the accidents had only decreased about 2.6% from 2004 to 2005, (from 7,213 in Year 2005 to 7,026 in Year 2006) showed a substantial reduction from 7,026 dead in Year 2006 to 6,552 dead in Year 2007 which show an average rate of 6.7% decrease of mortality rate due to the accidents.

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Response time of reaching to the accident place in the cities has decreased from 10 minutes in Year 2005 to 8.69 minutes in Year 2006 and to 7 minutes in Year 2007. The Response Time in roads is also decreased from 25 minutes in Year 2005 to 16.63 minutes in Year 2006 and to 10 minutes in Year 2007. The call volumes to the Emergency Stations in Tehran is increased from an average of 13,000 calls per day in Year 2005 to 14,000 calls in Year 2006 and to 15,500 calls in Year 2007. Sub-component B(1) : Developing Nutrition Capacity Based on the results of situation analysis which was conducted by an international consultant to assess the current situation of nutrition education curricula in Iran, the needs for capacity building in nutrition education in Iran was elaborated upon. Based on the results of this report ,it was decided that 4 programs, namely 1- Community Nutrition at the MSc level, 2- Food and Nutrition Policy, 3- Nutrition Epidemiology and 4- Cellular and Molecular Nutrition all 3 at PhD and MSc levels, be designed with the help and guidance of international consultants. After long procedure of selection of the consultant based on the World Bank guidelines, two consulting services contracts with the IUNS and another two contracts with University of the Philippines for the design of four graduate level nutrition training programs were signed in December 2004 and the Work Plan, Situation Analysis report and the Future Vision report and the 7 program packages (4 MSc and 3 PhD programs) were finalized and approved by MOHME. Due to the integrative nature of the project the local and international partners of the program have come to the conclusion to prepare a unified vision, start up and institution building plans and presents the programs as one single package containing 4 different programs to the Board of reviewers in the Deputy for Education, MOHME. Developing the nutrition knowledge and capacity of the physicians and health staff involved in the Nutrition related fields was a substantial effort carried out in the framework of the project. Six rounds of national workshops for master trainers were conducted for relevant sectors in the framework of this sub-component. The provincial workshops for, physicians and health staff have been conducted in the medical universities all over Iran. By the end of the project, about 15,000 physicians and health staff were successfully participated in workshops and were trained in public health approach to nutrition. There were also some other training activities carried out in the framework of the capacity development of the Nutrition Project mentioned in section 5.3.1 Sub-component B(2): Improving the Nutritional Status After restructuring of the SPHCNP, the Nutrition Project was also redesigned and the project was focused on fortification and capacity building. In line with the objectives of this sub-component different kinds of the activities were carried out. The activities were designed to support food fortification in country and build capacity in the related areas. As the result the project has contributed to implementation of flour fortification program which is initiated on Year 2006 all over the country. The main activities carried out in the framework of this sub-component are as follow:

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Design of National Plan for Food Fortification As the basic step for controlling of the food deficiencies and reducing malnutrition, design of National Plan for Food Fortification was an important initiative which was contracted with WHO for being carried out. The output of the contract with WHO was the National Plan for Food Fortification . The Plan was successfully designed under supervision of Nutrition Department and with contribution of international and local consultants recruited by WHO. Other consulting services and studies in relation of flour fortification that were carried out are: The project contributed to the flour fortification program in the country by financing purchase of premix and micro feeders, organizing the training workshops and printing of the books, manuals, posters and pamphlets. To assess the impact of the activities implemented in the framework of this sub-component (Nutrition workshops and other activities in line with the Capacity Development Part of Nutrition Project), the former director of the Nutrition Department of MOHME was selected by the MOHME as an individual consultant to carry out an evaluation study of this part of the project. At the time of finalization of the ICR this study was not started yet due to the administrative and institutional problem. Regarding the evaluation of outcomes of the Nutrition Project, the collected data shows a positive trend in the nutritional status of the population from Year 1998 which was considered as the base line until Year 2006 which was the date of termination of the project. Data analysis showed a positive trend for anemia indicators for the intervention group in Boushehr province against the control group in Fars province. In addition data were obtained from Anthropometry and Nutrition Indicator Survey (ANIS) carried out in Year 1998 and Year 2004 show the positive trend related to the child malnutrition rates for children under 5 years as shown in the following table; Category 1998 (ANIS 1) 2004 (ANIS 2) Stunting 15.4 4.7 Underweight 10.9 5.2 Wasting 4.9 3.7 Due to the importance of evaluation of the activities carried out in the framework of Food Fortification sub-component and the needs for evaluation of the results achieved to be used in the future interventions and sustainability of the flour fortification in the country, Research Center of Public Health Sciences was contracted on Oct. 2008. The study was started in November 2008 until May 2009. The final report of the consultant on the evaluation of flour fortification and assessment of the activities and outcome of this sub-component is attached to this report as Appendix 4.

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Sub-component C(1) : Management Capacity Building During the restructuring of the PHCNP, considering the importance of strengthening the management capacity of the health system, Management Training project was designed and proposed to the Bank. The project envisaged a comprehensive plan for the continuing in-service training of health managers. This was considered an intervention essential to build the capacity and bring efficiency to the health system. The project was approved by the Bank and was accepted as the first component of the Capacity Building section of the restructured PHCNP. Following objectives were laid down for the component: Undertaking the training of trainers; Developing up-to-date and tailor-made training packages; Undertaking the training of trainees; and Developing critical mass of trained personnel for sustaining the project's

intervention. The main activities undertaken in the framework of this component were as follow; Ph.D programs: In the framework of this activity 10 individuals selected by the Medical universities participated in the PhD programs in Karolinska Institute of Sweden (KI). Also 5 individual selected by the different departments of MOHME were participated in PhD courses in England, Australia, and India. The activity achieved its objective in term of output. However the evaluation of the outcome of this activity cannot take place at the time of preparation of ICR due to the uncompleted PhDs at this time. Master Degree Training: 18 persons from medical universities participated in master science in international health with a concentration in “health care management” program held in Heidelberg University of Germany from Oct. 17, 2005 through Oct. 13, 2006. One person participated in Master of Science in health services in York university of England In term of output, 18 Master Theses which are actionable plans for health sector reform in Iran and 18 health care management experts that now have the knowledge, skills and motivation to implement these plans are available to the health sector. Short Courses: In line with the objective of developing critical mass of trained personnel for sustaining the project's intervention and overall objective of the MOHME to improve the management capacity in the health sector about 32 MOHME's experts participated in the short term courses abroad. Also the following short term courses were organized; 50 persons participated in emergency medicine leadership work shop in Tehran

university by George Washington university medical center for 1 week.

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6 local short term courses in at the NPMC center in Tabriz for 150 managers of medical universities/ MOHME by ILO collaboration.

PCM ( project cycle management). HRM ( Human recourse management) Short-Term courses in Karlsruhe University. - Germany Restructuring in Hospital Management, 200 persons Facility Management, 50 Persons Health Management 100 Persons Other training activities and TOT courses were organized in the framework of this component which are mentioned in section 5.4.1 Sub-component C(2): Improving the Quality of Vaccine production Objective: Capacity building of National Regulatory Authority and National Control Laboratory for evaluation of Quality, Safety and Efficacy of the vaccines. After restructuring of the project in Year 2002 and including the vaccine project as an operational research sub-component of capacity building section of the SPHCNP, due to the implementation problems of this sub-component during Year 2003, the Bank and the MOHME reached final agreements regarding this sub-component. The Bank recommendation to assign WHO as an executing agency for implementation of this sub-component was find justified and a sound decision. Based on the negotiations between the World Bank, MOHME and WHO the agreements reached on the implementation issues and WHO was contracted for this purpose. . According to WHO assessment of National Regulatory Authority (NRA) and National Control Laboratory (NCL) it was identified that training and technical assistance are the principal needs of the MOHME to prepare the ground for ensuring full compliance with WHO standards, therefore the contract financed by the Bank focused only on technical assistance and training.

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Table 13 : Evaluation of Vaccine Project

Function

2002 Assessment By WHO team Before start of vaccine project

April 2006 assessment

By WHO team

% improveme

nt

2007 assessment

Internal audit

% improve

ment

National regulatory system

4.5/5 (90%) 6.5/7 (93%) (3%) 7/7 (100%) (10%)

Marketing authorization (MA) and licensing activities

11/14 (79%) 8/9 (89%) (10%) 8.5/9 (94%) (15%)

Post-marketing activities including surveillance of Adverse Events Following Immunization (AEFI)

7/9 (78%) 7.5/8 (94%) (16%) 7.5/8 (94%) (16%)

NRA Lot release 3.5/5 (70%) 4/4 (100%) (30%) 4/4 (100%) (30%)

Laboratory access 11/13 (85%) 7.5/12 (63%) (-12%) 11/12 (92%) (7%)

Regulatory inspections

6/10 (60%) 5/6 (83%) (23%) 5.5/6 (92%) (32%)

Authorization/Approval of Clinical Trials

2.5/6 (42%) 3.5/4 (88%) (46%) 3.5/4 (88%) (46%)

Sub-component C(3): Health Sector Reform Project

Objective : Capacity Building to manage and implement Health Sector Reform

In Year 2003 after overall agreement with MPO on the priorities of the MOHME and restructuring of the SPHCNP the Health Sector Reform project (HSR) was designed and submitted to the Bank to be funded in the framework of SPHCNP. The HSR project was submitted to the Bank as a part of restructuring process and the project was accepted to be financed by the WB as the Sub-component 3C of the SPHCNP. Due to the implementation problems such as resources, institutional arrangements, full time project manager, etc.. and also the complexity of the project in term of managing and contracting of about 25 international consultants and a great numbers of the local consultants, coordination and integration of the studies, etc.. and required technical capacity, as a part of overall agreement with the Bank, the WHO office in Tehran was selected as the executive agency for implementation of HSR project. The relevant contract was signed with WHO and project implementation was carried out starting May 2004 and was completed after one year delay at the end of 2006.

56

Main Achievement:

1. Disseminating the concepts of reform within and outside the health system.

2. Providing a common language between policy makers, managers and experts in the Health System of country.

3. Capacity building at National and Provincial levels.

4. Providing key information for policy making.

5. Devising some models for improving the key subsystems in health system.

6. Designing family physician system and referral path instruction and piloting it in

Bam district (Earth Quake affected 2003).

7. Putting some key articles in 4th national development plan (85,90,91,92,…).

8. Building an Intersect oral team.

9. International Collaboration with WHO and WB.

10. Preparing situation analysis in some parts of health system.

11. Working with international Short term Consultants.

12. Participating in fellowships, study tours and short term courses.

13. Increasing the capacity of the experts at national and provincial level in health system research areas.

Sub-component C(4): PIU Management and Staff Training Objective 3- Capacity Building to manage and implement the project An important element in the successful implementation of the SPHCNP was the management and implementation capacity of the PIU. This matter was considered since the preliminary steps and during the design of the PHCFP. As part of Capacity Building component of the project, the fourth sub-component designed with the objective of Strengthening the PIU implementation capacity through the provision of technical assistance, office equipment, training and capacity building. Based on the requirements of the World Bank, as executing agency, MOHME had to establish a PIU. While project implementation was the responsibility of the relevant MOHME departments, the project management functions (financial management, procurement, scheduling, monitoring, and coordination) should have been handled by the PIU. The established PIU consisted of PIU manager and the key staff handling the procurement, financial, and monitoring and evaluation tasks. Being responsible for the day-to-day coordination of the activities8 the important responsibility of successful implementation of the project was shared between PIU and the project managers. In accordance with the conditions of the World Bank and terms of the Loan Agreement the PIU which was established for implementation of the SPHCFP has been maintained

8 Section 4, Institutional and Implementation Arrangements, project Appraisal Document ( March 2000)

57

and strengthened by MOHME. After restructuring of the SPHCNP, due to the complexity of the sub-components which required very high capacity in terms of management, coordination, planning, procurement, financial, monitoring and administration matters the PIU had to be strengthened. Therefore the sub-component 3(d) were redesigned and strengthened with the objective of improving the management and implementation capacity. The sub-component consisted of training courses in Iran and abroad, workshops, technical assistances and consulting services and purchasing needed equipment.

58

Table 15 : Evaluation of Component 3(d)

Subcomponent: 3d. PIU Management Expected Results Indicators Actual Results and

Explanation of variance Outcome: Successful implementation of the project Outputs: - Professional specialized

in implementation, management, procurement, financial, planning, monitoring and evaluation capable to communicate and work in English language environment

- Technical services

provided for the implementation of the components

Level of the disbursement of the loan in % out of total amount of the loan Number of the PIU staff trained in specialized courses in local and courses abroad Number of International Consultants recruited

About 99% of the loan is disbursed The key staff of PIU participated in the following short term courses; Health Planning and Management / England Project Management / ILO – Italy Project Cycle Management / ILo – Italy PCM/ Monitoring and Evaluation / MDF-Netherland Procurement of the Consulting Services – ILO – Italy Financial Management – ILO –Italy Financial Management – AUB- Lebanon PCM/ ILO – Italy Procurement of the health goods – ILO Special English courses Computer courses MSP and Primavera course IELTS and Commercial English courses

- International Procurement Consultant is contracted and provided the required services successfully - International Monitoring and Evaluation Consultant is contracted and provided the required services successfully

59

Extension of the Loan and AI Project By the end of Year 2006 and approaching the closing date of the loan, the MOHME considering the remaining amount of the loan and emergency need for capacity building for controlling AI, expressed it's concern over the gaps in the Comprehensive Emergency Animal and Human Avian Influenza Preparedness and Surveillance Plan (AI Plan) and sought the Bank’s assistance in addressing such concerns. In line with the objective of getting the most benefit from the remaining amount of the loan estimated to be around 7 million USD, the MOHME explored whether the Bank would be able to provide any assistance in strengthening the AI Plan through an extension of the ongoing health project. Based on overall agreement of the Bank and emergency nature of the AI, the MOHME sent its official request to the MOEAF. The request presented the justification for the Bank’s consideration to extend the loan closing date by one more year and utilize the uncommitted loan proceeds to finance timely actions to complement the GOI efforts on the AI Plan. As the Bank also shared the concerns raised by the MOHME for addressing the urgent need to implement the AI Plan in anticipation of a future outbreak of the disease in the region and the fact that the Bank was cooperating with several countries in the region and neighboring regions on similar programs, agreed to extend the loan closing date until Dec. 31, 2007. The key areas agreed for possible cooperation were identified namely (i) improving laboratory capacity particularly to address surges resulting from increased sudden demands if there is an outbreak; (ii) strengthening the surveillance system capacity through building capacity at the lower tiers of health service delivery and integrating this at the PHC level; (iii) improving multi-sectored horizontal coordination to enable parallel AI surveillance and preparedness; (iv) improving communication through an assessment of how the information disseminated has contributed to any changes in attitudes or practices; (v) building capacity and knowledge sharing through study tours to learn from the experiences in other countries; and (vi) strengthening regional and cross-border cooperation. The AI project started beginning of Year 2007 and was managed by CDC. Due to the especial nature of the project and also lack of familiarity of the CDC with the Bank's procedures regarding the procurement of the goods and services the project remained incomplete by the end of Year 2007. Therefore MOHME expressed the importance of completion of the whole activities under AI project and requested additional time for completion of the project. Considering the status of the AI project and emergency nature of the activities, The World Bank agreed to extend the loan closing date for a limited time. Following this step the official request of MOHME was sent to MOEAF for extension of the loan closing date until 30, Sept 2008. Based on the justification provided to MOEAF, the official request of the latter was sent to the Bank and the World Bank agreed on the extension of the closing date of the loan until September 30, 2008. All of the AI project activities was terminated by the closing date of the loan and the project achieved the main part of it's objectives. By the closing date of the loan i.e. September 30, 2008, out of total amount of loan equal to 87 million USD, whole of the loan has been disbursed only very little amount of the

60

loan was cancelled. The original closing date of the loan was December 31, 2005. The loan was extended from Dec. 2005 till Dec. 2006 for completion of the remaining activities under SPHCNP. Following the first year extension of the loan closing date, due to the emergency needs of the Center for Disease Control (CDC) for strengthening of the system for prevention and control of Avian Influenza (AI) caused by the probability of risk of the outbreak of AI in the country, the MOHME decided to use the remaining amount of the Loan for such purpose and requested the Bank to extend the loan until Dec. 2007 for this purpose. Following such decision, the request of MOHME and the purpose was discussed with the Bank and after receiving the prior approval of the Bank, the request of MOHME was sent to the MOEAF and the Bank agreed on the extension of the loan for implementation of emergency Avian Influenza Project (AIP) for another 1 year from Dec. 2006 to Dec. 2007. Due to the complex nature of the AIP and also lack of implementation capacity in CDC, after request of CDC and MOHME, another extension of the loan from Dec. 2007 till Sept. 30, 2008 was granted by the Bank for completion of the remaining activities under AIP and also strengthening of Emergency Medical Services (EMS). This ICR is prepared by PIU using the material in the project file and discussions with Bank staff, who were involved in the project. It draws on the Monitoring and Evaluation reports prepared by M&E consultant, contracted by PIU and the evaluation report of the sub-components of the project carried out by the sub-components project managers assisted by the local private consulting firms and universities. The following indicators show the achievement of the project in term of outputs: Percentage of the hospitals staff trained in the workshops and training courses reached to 19.6 % The number of the hospitals staff trained is reached to 44,099 individuals The percentage of the provinces selected for simulation exercise is 10% The number of the provinces which the simulation exercise is carried out is 1 province The number of the reports received in Year 1386 ( 2007 ) is equal to 864 cases. (The number of the samples sent to National Influenza Laboratory from the hospitals and centers in the provinces) Capacity to conduct sequencing of H5N1 is in place The percentage of the poultry farms trained in term of personal protection and controlling of the farms against AI infection and transfer of disease is equal to 7.5%.

61

Annex 8. Comments of Co financiers and Other Partners/Stakeholders There are no cofinanciers and no comment from other partners / stakeholders.

62

Annex 9. List of Supporting Documents

a) Project Appraisal Document (PAD) for a Second Primary Health Care and Nutrition Project – Report No. 20202-IRN - April 3, 2000

b) Project Information Document (PID) – Report No. PID8574 – December 29, 1999 c) Loan Agreement – Loan Number 4550-IRN – June 26, 2000 d) Quality of Supervision Assessment (QSA5) – October 29, 2002 e) IRI – Management of HealthCare Waste Policy Note – Report No. 33286-IR –

October 17, 2005 f) Status Reports – IRI – Prepared by the Project Implementation Unit (PIU),

particularly the Status Report dated May 2008 g) Request for extension of closing date and amendment to the Loan Agreement –

Avian Influenza (AI) Plan – December 22, 2006 h) Food/Flour Fortification – Joint Project with World Bank – Nutrition Department

– MOH&ME - Undated i) Report of Management Training Project – July 3, 2007 j) Final report on Evaluation of Rehabilitation of Health Centers and Purchase of

Equipments and Vehicles – Primary Health Care and Nutrition Project - Component 1 – Sub-components 1(a), 1(b) and 1(c) – Teb & Tosei Salamat Institute (Medicine and Health Development Institute) – 2004-2007

k) Flour fortification with iron: a mid-term evaluation – Institute for Health Sciences Research – Tehran University of Medical Sciences – MOHME – 2007 – published in Public Health, journal of the Royal Institute of Public Health.

l) The effect of flour fortification with iron and folic acid on micronutrient status: baseline data from Golestan province, Iran – Institute for Health Sciences Research (IHSR), Academic center for Education, Culture and Research, and Ministry of Health and Medical Education – 2007

m) Iran – Health Sector Review – Report No.: 39970-IR - June 2008- Volume I: Main Report and Volume II: Background Sections.

n) Technical Support in Monitoring and Evaluation – April 6 to 23, 2005 – Final Mission Report, by Françoise Coupal.

o) Improving Graduate Education in Nutrition in Iran – Final Report (November 2006) and the supplemental Report Integrated Education Model (December 2006) – International Union of Nutritional Sciences (IUNS) and University of the Philippines Los Baños (UPLB).

p) Three-Year Start-Up Plan for Institution-Building Plans for MSc and PhD in Nutritional Epidemiology and Cellular and Molecular Nutrition.

q) Ten-Year Plan for MSc and PhD in Nutritional Epidemiology and Cellular and Molecular Nutrition.

r) WHO Final Report – December 2006 – Sub-component 3(b) – Improving the quality of vaccine production in the Islamic republic of Iran.

s) WHO Final Report – April 2007 – Sub-component 3© - Health Sector Reform Project.

t) I.R. Iran – National Preparedness Plan for Pandemic Influenza – Deputy of Health – Center for Disease Control Autumn 2007 (Revised in: 13/11/2007).

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u) Environmental Impact Assessment of Solid Waste and Wastewater and Environmental Management Plan for primary Health Care Centers of Iran – Volume 1 – August 2008 – Tehran University of Medical Sciences.

v) Draft Final Report – Program evaluation of flour fortification with iron and folic acid in Bushehr and Golestan Province – Iran

w) Trends and geographical inequalities of the main health indicators for rural Iran, by Mohammad Movahedi, Behzad Hajarizadeh, Azamdokht Rahimi, Masoumeh Arshinchi, Khadijeh Amirhosseini and Ali Akbar Haghdoost – MOHME – November 28, 2008.

Qolleh-yeQolleh-yeDamavand Damavand (5,671 m )(5,671 m )

S ISTAN VASISTAN VABALUCHESTANBALUCHESTAN

-- ---- --

F A R SF A R S--

BUSHEHRBUSHEHR--

Y A Z DY A Z D

E S F A H A NE S F A H A N--

HORMOZGANHORMOZGAN--

SEMNANSEMNAN--

K H O R A S A NK H O R A S A N----

K E R M A NK E R M A N--

MA

RKA

ZI

MA

RKA

ZI-- TEHRANTEHRAN--

QOMQOM

ZANJANZANJAN--

ILAMILAM----

ARDABILARDABIL --

GILANGILAN----

QAZVINQAZVIN

HA

MA

DA

NH

AM

AD

AN --

KORDESTANKORDESTAN--

KERMANSHAHKERMANSHAH-- --

LORESTANLORESTAN--

KHUZESTANKHUZESTAN----

MAZANDARANMAZANDARAN-- --

GOLESTANGOLESTAN--

KhvoyKhvoy

JaskJask--

--Bandar-eBandar-e

KanganKangan

BafqBafq--

-- --SirjanSirjan

-- --

IranshahrIranshahr----

MahabadMahabad-- --

KashanKashan-- --

BojnurdBojnurd--

SabzevarSabzevar--ShahrudShahrud-- --

TaybadTaybad-- --

GonabadGonabad-- --

ZabolZabol--

BamBam--

SarakhsSarakhs

RashtRasht

ZanjanZanjan--

TabrizTabriz--OrumiyehOrumiyeh----

KermanshahKermanshah-- --

HamadanHamadan--

SanandajSanandaj

IlamIlam-- --

KhorramabadKhorramabad----

ArakArak--

AhvazAhvaz--

Shahr-eShahr-eKordKord

YasujYasuj----

YazdYazd

ShirazShiraz-- --

BandarBandar'Abbas'Abbas

--

ZahedanZahedan----

KermanKerman--

MashhadMashhadSariSari----

SemnanSemnan--

ArdabilArdabil--

BirjandBirjand--

GorganGorgan

EsfahanEsfahan--

QazvinQazvin

Qom

TEHRANTEHRAN

Dasht-e-KavirDasht-e-Kavir(salt desert)(salt desert)

CHAHAR CHAHAR MAHALL VA-MAHALL VA-BAKHTIARIBAKHTIARI

--

KOHGILUYEH-VAKOHGILUYEH-VABUYER AHMADIBUYER AHMADI

--

AZARBAYJAN-EAZARBAYJAN-ESHARQISHARQI

--

AZARBAYJAN-EAZARBAYJAN-EGHARBIGHARBI

--

T U R K M E N I S T A N

I R A Q

S A U D IA R A B I A

AFGHANISTAN

PAKI

STA

N

UZBEKISTANAZERBAIJANARMENIA

TURK

EY

KUW

UNITED ARAB EMIR

ATES

OMAN

To Ankara

To Baghdad

To Unayzah

To Ad Dammam

To Baghdad

To Bela

To Quetta

To Delaram

To Herat

To Turkmenbashy

ToBela

S ISTAN VABALUCHESTAN

- -- -

F A R S-

BUSHEHR-

Y A Z D

E S F A H A N-

HORMOZGAN-

CHAHAR MAHALL VA-BAKHTIARI

-

KOHGILUYEH-VABUYER AHMADI

-

SEMNAN-

K H O R A S A N--

K E R M A N-

MA

RKA

ZI- TEHRAN-

QOM

ZANJAN-

ILAM--

ARDABIL -

GILAN--

QAZVIN

HA

MA

DA

N -

KORDESTAN-

KERMANSHAH- -

LORESTAN-

KHUZESTAN--

MAZANDARAN- -

GOLESTAN-

AZARBAYJAN-ESHARQI

-

AZARBAYJAN-EGHARBI

-

Khvoy

Jask-

Bandar-eLangeh

-Bandar-e

Kangan

Bafq-

- -Sirjan

Bushehr-

Chabahar- -

Iranshahr--

Mahabad- -

Kashan- -

Bojnurd-

Sabzevar-Shahrud- -

Taybad- -

Gonabad- -

Zabol-

Bam-

Sarakhs

Rasht

Zanjan-

Tabriz-Orumiyeh--

Kermanshah- -

Hamadan-

Sanandaj

Ilam- -

Khorramabad--

Arak-

Ahvaz-

Shahr-eKord

Yasuj--

Yazd

Shiraz- -

Bandar'Abbas

-

Zahedan--

Kerman-

MashhadSari--

Semnan-

Ardabil-

Birjand-

Gorgan

Esfahan-

Qazvin

Qom

TEHRAN

T U R K M E N I S T A N

I R A Q

S A U D IA R A B I A

AFGHANISTAN

PAKI

STA

N

UZBEKISTANAZERBAIJANARMENIA

TURK

EY

KUWAIT

QATAR

BAHRAIN

UNITED ARAB EMIR

ATES

OMAN

Helmand

Atrak

Atre

k

Aras

Tigris

E uphrates

CaspianSea

ArabianSea

Gulf of Oman

Dasht-e-Kavir(salt desert)

Kavir-eNamak

-

To Ankara

To Baghdad

To Unayzah

To Ad Dammam

To Baghdad

To Bela

To Quetta

To Delaram

To Herat

To Turkmenbashy

ToBela

Qolleh-yeDamavand (5,671 m )

40°N 40°N

35°N

30°N

25°N

35°N

30°N

25°N

50°E 55°E 60°E

50°E 55°E 60°E

ISLAMIC REP. OF IRAN

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other informationshown on this map do not imply, on the part of The World BankGroup, any judgment on the legal status of any territory, or anyendorsement or acceptance of such boundaries.

0 100

0 50 100 150 Miles

200 Kilometers

IBRD 33421

JANUARY 2005

ISLAMIC REPUBLIC OF IRAN

SELECTED CITIES AND TOWNS

PROVINCE (OSTAN) CAPITALS

NATIONAL CAPITAL

RIVERS

-MAIN ROADS

RAILROADS

PROVINCE (OSTAN) BOUNDARIES

INTERNATIONAL BOUNDARIES

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