World Health Organization the Islamic Republic of Iran Project Proposal Rehabilitation of the Health System in the Earthquake-affected areas of Lorestan Province, the Islamic Republic of Iran 2006 1
I. BACKGROUND On 31 March 2006, a series of earthquakes nearing 6 on the Richter scale shook many parts of Lorestan province, particularly the rural areas of Dorud and Boroujerd Districts. Fortunately the tremors served as an early warning system and the people left their homes in time to prevent a large scale human disaster. According to government statistics, 72 people died, and 1418 were injured, while 320 villages were damaged (10-100%). Sixty villages were completely destroyed. Nearly 15 000 buildings suffered damages of more than 50% in eight affected cities of Lorestan. Some 33 000 units were destroyed or severely damaged in the affected villages. It is estimated that around 12 000 domestic animals, the key source of people s livelihood, were killed. The majority of the population in the affected villages are farmers or nomad animal breeders of low socioeconomic status with low hygienic and environmental sanitation standards. (WHO assessment for damaged health facilities - Annex 1) The health system was seriously affected by the earthquake. Fifty-three different types of health facilities serving a total population of over 70 000 people in 138 villages were affected (38 villages with a total population of over 15 000 in Dorud and 100 villages hosting over 57 000 in Boroujerd). The damage to the two main hospitals in Boroujerd, with a total bed capacity of over 200 (100-beds each), paralysed the health authorities and required evacuation of most of the injured victims to the nearby cities and provinces. The destruction caused by the earthquake rendered the majority of the water sources in the affected villages non-functional increasing conditions for potential outbreaks of water-borne diseases such as cholera and hepatitis, previously experienced in the area, and complicating the situation for prevalent endemic disease such as brucellosis in the region. II. RESPONSE Despite the devastation caused by the disaster, the response of and cooperation between the Iranian authorities, Iranian Red Crescent Society (IRCS) and organized forces were swift and exemplary. Various government agencies including the Ministry of Interior, Ministry of Health, the Army, Mobilization Forces (Basij) and the IRCS contributed to the rescue and relief operation. Likewise, the UN dispatched a joint rapid assessment team (RAT) to assess the degree of damage and recommend appropriate emergency support. The UN Country Team, UN agencies, the International Federation of Red Cross (IRFC), the Iranian Red Crescent Society (IRCS) and some NGOs active in the country mobilized quantities of relief items including tents and blankets as well as technical support. One day after the earthquake, tents were pitched in the yard of the destroyed 2
and totally evacuated Imam General hospital in Boroujerd to help the local health workers provide services to the critically injured people. On the second day of the event, the Basij Forces succeeded in establishing a sixty-bed capacity field hospital, vis-à-vis to Imam Hospital, which could cater for traumatized cases. Although the other hospital in Boroujerd (Chamran) was left with serious cracks rendering the facility insecure for both health workers and patients, the hospital continued providing services in the casualty section. In Dorud, the hospital was not affected and could manage the small number of injured accessing the facility. The possibility of using mobile hospitals was also explored by different local and national authorities, however due to time constraints and lack of adequate financial resources, this was not pursued. WHO immediate response As part of the UN RAT, on the second day of the earthquake WHO dispatched an emergency field officer to the affected area for assessment of the situation. The WHO field team based in Bam reinforced WHO presence in the quake-affected areas to ensure effective coordination of the health cluster response and to monitor the operations on the ground. Immediately after the preliminary assessment, WHO mobilized two New Emergency Health Kits (NEHK) sufficient to cover the health and medical needs of 20 000 people for three months, placed in Dorud and Boroujerd. As an urgent support to restore health services, WHO dispatched two connexes to replace the destroyed health houses in Azna and Pahlavankal villages in Doroud and secured emergency funds necessary for purchase and installation of four, fully equipped, emergency health centers placed in the most affected villages of Azna and Safid-kal in Dorud; and Shirvan and Darehgorg in Borujerd. Assessing the needs in the quake-affected areas: WHO, in coordination with the district health networks (DHN) in Doroud and Boroujerd and Lorestan University for Medical Science (LUMS), conducted a series of assessments to identify gaps in different health services. Water and environmental sanitation (WATSAN) were top priorities. The need for latrines and showers was and is still prevalent now. Guided by the initial assessment of the local health authorities, a joint team comprising WHO, representatives of the DHN of Dorud and Boroujerd and the Housing Foundation conducted assessment for: 3
Sixty-two primary health care (PHC) facilities reported as affected by the earthquake (53 health houses (HHs) and 9 rural health centres (RHCs)) in both districts (19 in Dorud and 43 in Boroujerd) and two main hospitals in Boroujerd The assessment meant to identify the physical destruction for the buildings and equipments (see annexes). In Dorud, 1 rural health center and 2 health houses fully destroyed in need of reconstruction while 11 HHs with variable degrees of damage are targeted for rehabilitation. In Boroujerd district, 39 primary health care facilities are affected. Two RHCs and 4 HHs need full reconstruction; 6 RHCs and 27 HHs need rehabilitation. The government catered for rehabilitation of Chamran hospital and allocated a plot for reconstruction of a new 200 bed hospital to replace the completely damaged Imam General hospital in Boroujerd for which WHO has prepared a separate proposal for reconstruction. III. THE WHO IN THE ISLAMIC REPUBLIC OF IRAN IN BRIEF WHO has six core functions built on its mandate: Providing leadership on matters critical to health and engaging in partnerships where joint action is needed. Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge. Setting norms and standards, and promoting and monitoring their implementation. Articulating ethical and evidence-based policy options. Providing technical support, catalysing change, and building sustainable institutional capacity. Monitoring the health situation and assessing health needs. The Country Cooperation Strategy (CCS) for the Islamic Republic of Iran was developed in June 2004. It is an analytical framework and agreed statement for WHO s cooperation with the national authorities highlighting WHO's actions in the short to medium term and how it will operate to achieve its intended objectives. Six directions have been determined by the CCS for collaborative assistance: Promoting health as central to sustainable human and economic development; Enhancing leadership capacities for reforming the health system; 4
Applying risk management approaches to effectively deal with behaviour-related disorders and conditions; Addressing the unfinished and emerging agenda for communicable diseases; Promoting a culture of research and technological development; and Strengthening institutional mechanisms for effective emergency and humanitarian action for health. The programmes and activities supported by WHO include: - A capacity building component, such as fellowships and trainings, for eligible Iranian professionals working in the health sector to pursue diploma courses and/or participate in national and international workshops - Fielding experts/consultants to provide technical assistance in specific areas - Funding research, particularly operational research - Exchanging information WHO works with other players including other UN agencies, donors, nongovernmental organizations, WHO collaborating centres, private sector and communities to promote the health and quality of life of the entire population. WHO priority programmes 1. Emergency and Humanitarian Assistance: The devastating earthquake that hit the city of Bam 26 December 2003 claimed almost 30 000 lives and left more than 23 000 injured and more homeless. As the lead UN agency in health, WHO in Iran was among the very first international organizations to engage actively in the urgent humanitarian response efforts and also in the long-term recovery and rehabilitation process in Bam. The WHO flash appeal succeeded to attract international donors contributions to support the response operations during the relief and subsequent recovery and rehabilitation phases. During the early period, assistance was provided for ensuring adequate preventive and curative services, securing safe water supply, improving the environmental sanitation conditions and food safety, establishing a disease surveillance system to protect the community against outbreak, and ensuring timely rehabilitation of the healthcare delivery system focusing on the establishment of temporary health centres. WHO also responded to the other areas affected by disasters e.g. Zarand and Lorestan as well as extending technical assistance to the earthquake-affected population in Pakistan. 2. Development of Health Systems: Given the epidemiological and demographic transitions in the country, radical changes are needed to enhance the performance of the Iranian health system. WHO, on behalf of the Ministry of Health, is executing a Health Sector Reform 5
Project supported by the World Bank. The interventions not only focus on health care delivery, but also on governance and health financing. In this regard, work is in progress to design and test various modalities, particularly the expansion of health insurance aiming to provide universal coverage to the rural areas and more vulnerable sections of the society. Micronutrient deficiencies are one of the most common nutritional problems in Iran. Based on a successful flour fortification pilot study implemented from 2001 (in Boshehr province) showing an improvement in haemoglobin and serum ferritin among the target population, a national plan for flour fortification is being developed as a joint project with World Bank. The Islamic Republic of Iran produces most of the vaccine requirements for the expanded program for immunization. To assure the quality of vaccine products, the MOH&ME developed a project financed through a World Bank loan with WHO acting as the executing agency to enhance the capacity of the National Regulatory Authority (NRA). The project is developing guidelines and standard operating procedures and training of staff from the NRA, the Food and Drug Control Laboratory, and manufacturers. 3. Disease Control and Health Promotion: WHO supported the health authorities to establish a functioning epidemiological surveillance system. The quality of the system and its high sensitivity to detect outbreaks provided a critical and effective tool to monitor and control outbreaks like cholera and avian influenza. Measles vaccination coverage is generally very high and the Ministry of Health aims at eliminating the disease. To this end, a national mass campaign for measles elimination was conducted and more than 30 million 5-25 year-olds were vaccinated during late 2003 and early 2004. WHO extended its support through provision of supplies and equipment for evaluation of the measles immunization effectiveness. The country faces a serious problem of substance abuse with around 3.7 million abusers and opium dependants. Among injecting drug users, 90% are male and 10% females and the average age of users is 35 years. A national strategy against substance abuse has been devised based on supply reduction including an abstinence-based approach. Methadone-based treatment is being adopted, which has led to a reduction in the number of users and in violence. An outreach HIV/AIDS system using mobile clinics is also designed for street drug users. The annual consumption of tobacco is estimated at 54 billion cigarettes of which about 12 billion are produced by the national tobacco industry and the remaining are imported through illegal channels. To launch a nationwide program to reverse the current trend, WHO worked closely with the Iranian Parliament in many 6
sessions and meetings in the process of ratifying the Framework Convention on Tobacco Control. WHO, in collaboration with the MOH&ME, the School of Public health and Tehran University of Medical Sciences, is supporting International Diploma Courses on Malaria Program Planning and Management in the areas of epidemiology, case management, malaria drug policy, entomology, and vector control, planning, and management. Participants from Eastern Mediterranean Region Member States and other regions are benefiting from this training. 4. Health for Sustainable Development: WHO advocates and supports the Community-Based Initiatives (CBIs) which aim at improving the health and quality of life of local communities through their involvement in different health, poverty alleviation and socioeconomic development activities. The CBIs include Basic Development Needs (BDN), Healthy City Program (HCP), Healthy Village Program (HVP), and Women in Health and Development (WHD). By the end of 2005, the total coverage of CBI in Iran was 19 healthy cities with a population of 5 036 488; 43 healthy villages with 78 856; and 17 BDN areas with a 27 730 population. WHO is facilitating the role and participation of the Islamic Republic of Iran in the newly established Commission on Social Determinants of Health (SDH) and for developing a national strategy for providing a solid evidence base for action on the SDH, and facilitating further work in reducing the health inequities. 5. Research and Governing Bodies: Health system research is one of WHO s priority areas. Through WHO support, the country has undertaken a national health research system analysis to identify the weaknesses and strengths of the health research system and make recommendations for future national policy and direction. WHO is further supporting nine research centres in collaboration with the Ministry of Health in order to design participatory empowerment plans and communitybased research in population research stations. WHO has been assigned as the Chair of the UN Theme Group on the Islamic Republic of Iran's Capacity Strengthening on Millennium Development Goals (MDGs), Human Rights, and Good Governance. Major achievements include: Increased public awareness and advocacy activities on MDGs roundtables with media, preparation for producing TV programs on MDGs with the state radio and TV, MDG posters publication and exhibitions. 7
Strengthening the national statistical system to include gender and regionally disaggregated data collection, analysis, dissemination, and utilization for monitoring the MDGs. WHO is fully engaged in preparing advocacy materials and celebrating the Health Day, Population Day, Zoonoses Day, No Tobacco Day, Asthma Day, Blood Donors Day, Tuberculosis Day, Mental Health Day, Older Person Day, Suicide Day, and World AIDS Day. 6. The Library and Information Centre These facilities have been fully operational since April 2005 and are providing regular services to governmental agencies, academia, civil society organizations and general public. The library collection consists of more than 8000 printed titles; subscriptions to 40 international journals and a collection of WHO posters and non-print materials. WHO produces a series of advocacy and documentation materials that highlight the main activities and events. These include quarterly newsletter, annual and biennial reports and other publications like WHO Response to the Earthquake in Bam and Zarand. The publications are widely distributed within the government sectors, universities and research institutes, diplomatic missions and UN agencies in the country, WHO country offices within the Eastern Mediterranean Region, the Regional Office and Headquarters. 7. Developing Effective Partnerships: The WHO country office has established effective partnerships with various organizations, academic institutes and government sectors and signed memorandum of understanding or joint plans of action in this regard (UNIDO, UNICEF, Ministry of Welfare and Social Security, Imam Khomeini Relief Foundation, Kerman University of Medical Sciences, etc). The agreements established a framework for mutual cooperation for the development and implementation of joint endeavours aiming at promoting the health and wellbeing of the people. IV. PROJECT OBJECTIVE To contribute to the rehabilitation of the health system in the areas affected by the 31 March earthquake in Lorestan province. V. STRATEGY 1. Coordinate the response operations with the government, UN agencies, local and international non-governmental organizations (INGO) and the community to optimize resources utilization and avoid duplication of efforts 2. Advocate for international support for timely recovery and rehabilitation of the health system by national government, donor agencies and governments 8
3. Enhance and promote the local capacity of health workers and communities for better preparedness and effective management of the response operations, and monitor the health situation of the people in the affected areas 4. Promote the concept and importance of mitigation to local authorities, affected communities and concerned sectors (construction engineers, health staff and community leaders, etc) through training, provision of technical guidelines and financial support for priority public facilities 5. Coordinate with Kerman UMS for appropriate knowledge transfer and sharing of experience in different aspects of disaster management (DM) with Lorestan. VI. SPECIFIC OBJECTIVE 1. To support the Ministry of Health to organize 13 training courses for 425 health workers, active in the health facilities in the affected area, on disease control and surveillance 2. To support the Ministry of Health to organize 10 training sessions to train 350 health workers on mental health 3. To provide support for rehabilitation of 53 PHC facilities with full equipment and furniture 4. To provide training for 60 experts and managers in disaster management 5. To support organization of training for 360 community representatives of the nine districts of Lorestan on preparedness 6. To monitor the public health and disease situation in the earthquake affected areas. VII. PROJECT SUMMARY The devastating earthquake that hit Dorud and Boroujerd compounded prevalent poverty and inadequate funding for the health system, to further decrease accessibility and quality of health services in the affected areas of Lorestan. A well coordinated health cluster will ensure corporate and effective response efforts by all partners to ensure effective response operations. Destruction of water and environmental sanitation facilities, and a previous history of infectious disease outbreaks such as cholera, call for urgent prevention and control measures against impending outbreaks. This implies emergency training for the health staff and community volunteers as well as effective surveillance measures to safeguard the community. Efforts to render health facilities earthquake-resistant to serve as safe heavens for the local residents will have positive psychological effects as well as ensure provision of quality health service during emergencies. The local authorities have already agreed on areas for reconstruction of new health facilities and detailed needs for rehabilitation of the rest of the health facilities identified and agreed upon. Hence, for commencement of the 9
rehabilitation process no constraints are foreseen. Upon confirmation of the donation to WHO HQ, the WHO country office will immediately proceed with MOH and partners to draw necessary action plans for different project components. The expected project duration is around one full year. WHO will ensure generation of additional resources from other potential local/international donors including the national government and other private local donors to fill gaps in the health system. Details of the project implementation and the work plan will be submitted once finalized with the government and Ministry of Health in particular. (Annex 2. Project plan of action). VIII. PROJECT COST Outcome Estimated cost US$ Health cluster coordinated and basic needs for health assessed 7,500 & identified Rehabilitation of heath system ensured and access to services 160,000 improved Potential risk for Health Facilities addressed 150,000 Measures for prevention and control of diseases taken 52,593 Mental Health of the EQ-affected people supported 29,356 Priority WATSAN needs addressed 400,000 Building capacity of the local health staff and Behvarzes 45,638 Effective WHO field operations ensured. 110,000 Total 955,087 Remarks The total estimated cost is US $ 955,087. XI. PROJECT DURATION Duration of the project is suggested to be one year following receipt of the necessary project funds. IX. MONITORING AND EVALUATION A continuous monitoring system will be implemented as part of project activities. Mid-term financial and narrative report will be submitted after nine months following initiation of the project. Final narrative and financial report will be submitted within 3 months after closure of the project. Monitoring and evaluation reports will be shared with donors, as well as with central, provincial and district 10
health authorities. Upon completion of the project, an evaluation will be undertaken jointly with local health authorities and beneficiary communities. XII. CONCLUSION Support for this humanitarian endeavour will not only satisfy the basic needs of the earthquake-affected people of Lorestan, but will substantially contribute to the well-being of the entire population of the region. 11
Annex 1: Result of the joint assessment of the physical infra-structure of the health facilities Health facilities affected by the earthquake in Lorestan: District Health Facilities Urban Health Centers Rural Health Centers Health Houses Total Assessed Total Assessed Total Assessed Dorud 8 0 7 2 65 17 Boroujerd 14 0 14 7 85 36 Total 22 0 21 9 150 53 Percentage of damage to the Health Facilities assessed: District Degree of damage 0-30% 30-60% 60-100% Total Dorud 14 1 2 Boroujerd 28 4 4 > 30% for reconstruction, but priority for 60-100% Total 42 5 6 Health facilities by type of rehabilitation needed District Type of health facility Total Hospital Rural Health Health Houses Centers Repair Re- Repair Re- Repair Re- Construction construction construction Dorud 0 0 0 1 11 2 14 Boroujerd 0 2 6 2 27 4 39 Total 0 1 * 6 3 38 6 53* * Hospitals not included, separate proposal prepared for Imam Hospital In Dorud, one RHC as well as two HHs were destroyed which need complete reconstruction, eleven HHs require rehabilitation/repair. In Boroujerd district, two RHCs as well as thirty-one HHs need full reconstruction. Two city hospitals in Boroujerd (Imam and Chamran) need complete reconstruction (submitted in a separate proposal). 12
Annex 2: Proposed project s plan of action Expected Result Main activities Responsible Estimated Cost US$ Health cluster coordinated and basic needs for health assessed Assess the needs for WATSAN in the affected area Assess the gaps in PHC services (equipment & staff) in the affected areas Assess the basic needs of Ministry of Health Ministry of HME WHO/FAO/ Lorestan UMS Remarks 1,500 A consultant will be hired WHO/ MOH 3,000 WHO team MOH/partner agencies Sub-total 7,500 Rehabilitation of 53 health facilities and provide basic equipments Rehabilitation of health system ensured and access to services improved Support 50 temporary staff to run Urban Health Centers and mobile teams in the affected areas for six month (50x300 US$ x 6 months) 3,000 Detailed POA on process WHO 70,000 Target facilities identified and assessed Ministry of Health /WHO Sub-total 160,000 Potential Risks for Support mitigation for risk-prone WHO/Housing Health Facilities addressed communities and health facilities Foundation & MOH Sub-total 150,000 Train 425 health workers on disease surveillance in 13 courses Measures for prevention and control of diseases taken 90,000 Staff will work under supervision of Lorestan UMS; WHO monitoring 150,000 Physical structures of HFs will be enforced against EQs WHO/MOH 38,693 Skill-based training for staff & volunteers on health in emergency issues Provide training equipment WHO 3,900 Lorestan UMS Hire a consultant for Training on Disaster Management Support Disease Control unit to enter and analyse data Provide and share weekly bulletin on Early Warning System (EWARS) on disease situation WHO 4,000 Will work under joint WHO/MOH supervision Ministry of Health /WHO 2,000 Sub-total 52,593 4,000 Regular bulletins to be produced & distributed at local and national levels 13
Expected Result Main activities Responsible Estimated Cost US$ Mental Health of the EQ-affected people supported Training of 350 Ministry of Health staff and Behvarzes on MH and disease surveillance WHO/ Ministry of Health Sub-total 29,356 Priority WATSAN needs addressed Hire an expert to assist Ministry of Health for assessment of WATSAN Ministry of Health /WHO Provide chlorine (300,000) tablets for water disinfections Provide and distribute 4,000 hygiene kits Remarks 29,356 Health workers will obtain adequate knowledge for mental health and early warning concepts in emergencies 2,500 Will work under WHO supervision WHO/MOH 30,000 proper training will be provided on use of chlorine tablets to be followed by distribution by volunteers for families WHO/MOH & partners Purchase of 300 family latrines WHO/Partners 7,500 Purchase and installation of 50 communal showers Two-month training of ten experts on water safety. Basic equipment for WATSAN for EQaffected areas 40,000 Distribution for 4,000 affected families WHO/Partners 56,000 Will be placed in 50 identified locations WHO/MOH/Unive rsities for MS 4,000 Lorestan and KUM WHO 260,000 To be distributed for affected villages Sub-total 400,000 The capacity of the Support training of 60 Managers of local health staff Lorestan UMS in the area of disaster and Behvarzes built management in one two-day course Training 75 GP on Disaster Management and surveillance and WATSAN in three courses 3,300 University will run the training and WHO will technically contribute to the training course WHO 9,338 LUMS will organize the training & WHO will provide technical & financial support Support organizing TOT on preparedness for representatives of the communities in 9 districts of Lorestan WHO 5,400 University will run the training and WHO will 14
Expected Result Main activities Responsible Estimated Cost US$ province Support training of communities (360 participants) in 9 districts of Lorestan province on preparedness for representatives Support organization of experiencesharing workshop to draw lessons of the response operations following the EQ Remarks technically contribute to the training course WHO 20,600 University will run the training and WHO will technically contribute to the training WHO/Lorestan University of Medical Sciences 7,000 Sub-total 45,638 Effective WHO field Provide technical support for program 110,000 operations ensured. management and monitoring Total budget 955,087 course 15
Annex 3: Basic equipments for the Health facilities Equipments for Health Houses (HH) No Description Qtn Specification Comment 1 Bin (with door) 40 With lid, 12 small and 28 big size for garbage collection 2 Alcoholic heater 2 3 Torch light 40 4 White bed sheet 40 Provided by the DHN 5 Bed plastic layer 40 Provided by the DHN 6 Furnace 1 7 Hand bag 40 For Behvarzes These are the items that do not exist in the HHs, are non functional or old and recommended for renewal 8 Child scale 35 9 Portable scale 25 10 Stethoscope 40 Adult 11 sphygmomanometer 25 Child 12 sphygmomanometer 40 13 Speculum (ear) 40 Tipped 14 forceps(toothed) 38 15 Kocher forceps 30 16 Haemostatic forceps 35 17 Round tipped forceps 35 18 Curved scissors 40 19 Straight scissors 40 20 Steel forceps dish 40 21 Long forceps 40 22 Needle holder forceps 40 23 Agraf forceps 40 16
24 Scalpel handle 40 25 Air way 40 26 Suture set 40 27 Serum trophy set 38 28 Small pour 40 29 Large pour 40 Thermometer(mouth & 30 Rectal) 35 Steel thermometer 31 holder 40 32 Fan (replacement of water cooler) 28 12 ceiling fans and 26 bench top 17
Equipment for the Health Centres (HC) No Description Qtn Specification Comment Othoscope & 1 ophthalmoscope 8 2 Laryngoscope 8 3 Autoclave 8 4 Patient bed 8 5 Dressing & suturing 10 6 Generator (electric) 8 7 Gas stove 8 8 CNG gas cylinder 8 9 CD shock with ECG 8 10 Pillow 6 These are the items that do not exist in centres, are non functional or old and are recommended to be renewed World Health Organization Country Office- the Islamic Republic of Iran Address: Building of the Ministry of Health and Medical Education; Simaya-e- Iran Street, Phase 5, Shahrak-e-Qods. Tehran, the Islamic Republic of Iran. Telephone: +9821-88363979-80-18 Fax: +9821-88364100 P.O. Box: 14665-1565 E-mail: whoteh@ira.emro.who.int 18