– Final Report to the Government of Belgium –

1. Project Title: Contribution to the reconstruction of the health system destroyed by the December 2003 earthquake in Bam

2. Country: Iran Beneficiary Population:

230 000 people in Bam district

3. Start date of project: 01/02/2005 End date of project: 30/04/2006

4. Project Duration (Period of Implementation):

15 months Project extension: –

5. Amount (Euro): 1 250 000 Amount (US$): 1 696 060

6. Contact desk in HQ: Ms Cintia Diaz-Herrera Technical Officer Donor Relations 20 Avenue Appia 1211 Geneva 27, Switzerland Tel: + 4122 791 1629 Fax: + 4122 791 4844 E-mail: diazherrerac@who.int

WHO Country Office: Dr. Mubashar Riaz Sheikh, WHO Representative Iran Tel.: +9821-8363979-81 Fax: +9821-8364100 E-mail: whoteh@ira.emro.who.int

7. Objective: • Contribute to the re-establishment and rehabilitation of primary health care services

in Bam through re-equipment of urban health centers being built in coordination with international NGO's and the private sector;

• Training of the health care staff, NGO's and the private sector;

• Strengthening of the referral system at different levels of the health care system; and

• Reinforcing health sector coordination through the establishment of a framework for collaboration on different activities regarding restoration of health services in Bam including reconstruction.

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Final Report

Contribution to

Reconstruction of the Health Care System

destroyed by the December 2003

Earthquake in Bam, Islamic Republic of Iran

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Table of contents

I. Acronyms…………………………………………………………………………. 4 II. Summary .................................................................................................... 5 III. Activities and achievements......................................................................... 5 IV. Significant challenges of the project............................................................. 13 V. Strengths of the project................................................................................ 14 VI. Lessons learnt ............................................................................................. 16 VII. Recommendations for future humanitarian aid policy and practice.............. 16 VIII. Annexes ...................................................................................................... 18 • Annex 1: List of equipment purchased against Belgian fund • Annex 2: Measures for Safer Food (Poster) • Annex 3: Progress of Reconstruction of UHFs

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I. Abbreviations/Acronyms ADRA Adventist Development & Relief Agency International APW Agreement for Performance of Work ARI Acute Respiratory Infections BDHN &C Bam District Health Network and Center CBI Community-Based Initiative CBO Community-Based Organization CHV Community Health Volunteer CMT Country Management Team CTC Cholera treatment center DC Disease Control DFID Department of Foreign International Development ECO European Commission Organization EHA Emergency Humanitarian Assistance EMRO Eastern Mediterranean Regional Office EQ Earthquake EPR Emergency Preparedness and Response EWARS Early Warning Sand Alert Response System GP General Practitioner HCP Healthy City Project HF Health Facility IEC Information, Education and Communication INGO International Non-Governmental Organization IFRC International Federation of the Red Cross and Red Crescent IRCS Iranian Red Crescent Society IT Information Technology KUMS Kerman University of Medical Sciences LSP Logistics Support to Country Programs MH Mental Health MOH/ME Ministry of Health and Medical Education MW Midwife NGO Non-Governmental Organization OCHA UN Office for the Coordination of Humanitarian Affairs OPD Outpatient Department PHC Primary Health Care POA Plan of Action PIN People in Need QA Quality Assurance SCI Spinal Cord Injury SHRMD Secretariat of Health for Risk Management in Disasters PSC Program Support Cost TNA Training Needs Assessment TOR Terms of Reference TOT Training of Trainers TDH Terre des Hommes TF Task Force UN United Nations UHC Urban Health Center UNICEF United Nations Children Fund UNDP United Nations Development Program WHO World Health Organization WHV Women Health Volunteers WR World Health Representative WV World Vision

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II. Project Description The project supported by the Government of Belgium was implemented in coordination with the Ministry of Health and Medical Education (MOHME) and aimed at providing primary and higher level services in a working environment adequate to user's requirements and safer for patients and workers. It entailed strengthening of health sector coordination through the establishment of a framework for collaboration on different activities related to the restoration of health services in Bam. The main activities included reconstruction and re-equipment of health facilities, capacity building and training of staff, support of partners in health, health care systems development and direct service delivery. While detailing this project, WHO took into consideration all existing commitments between MOHME and other partners, including other Ministries, UN agencies, NGOs and the private sector.

III. Activities 1. Re-equipment of Urban Health Centres in Bam Provision of the necessary equipment (both medical and general equipment) for the two polyclinics, the training centre for community health workers (Behvarzes) and the administrative buildings for the offices for the Bam District Health Network and Centre. 2. Capacity building Training of health care staff, NGO's and the private sector in health on emergency situations, promotion of mitigation and preparedness, nutrition and food safety strategies in emergencies, First Aid for school children and teachers and establishment of a community development fund. 3. Awareness raising, health promotion and strengthening of the referral system at different health care system levels 4. Reinforcement of health sector coordination and disease surveillance A joint cooperation with partners as well as a framework for different activities has to be enhanced. Workshops will be organized as well as health partner meetings chaired by WHO. 5. Monitoring the reconstruction of urban health facilities (UHFs) Monitoring the reconstruction of urban health facilities will be addressed through a close collaboration with health partners including local partners, NGOs and the Government of the Islamic Republic of Iran. 6. Strengthening WHO presence in the field Health needs are increasing on the ground and WHO will strengthen its presence by recruiting additional staff, including international and local officers. A review workshop on office performance will be organized to address this issue.

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IV. Results

1. Re-equipment of Urban Health Centres in Bam

WHO procured the necessary equipment (both medical and general equipment) for the two polyclinics, the training centre for community health workers (Behvarzes) and the administrative buildings for the offices for the Bam District Health Network and Centre. A list of the equipment is presented in Annex 1. A standardized and comprehensive list of basic medical and general equipment was agreed upon with the MOHME. The complete list of equipment has been procured and delivered to Bam and kept in the district health network (DHN) storehouse at Bam. Equipment was delivered to each urban health centre (UHC) only upon completion of the reconstruction and under joint supervision of the WHO sub-officer staff and the designated officer of the DHN. For the effective use of the equipment, WHO applied a tracking and labelling system to register all equipment and accordingly, an inventory list was formed for each urban health facility (UHF). WHO hired a procurement officer to facilitate effective purchase and ensure proper and timely delivery of the equipment to the destination. A distribution plan was developed and shared with Bam DHN as reference for distribution and appropriate monitoring.

2. Capacity building

2.1. Training of health care staff, NGO's and the private sector on health in emergency situations In preparation for an effective training program, WHO – in collaboration with the MOHME and KUMS – assisted the Bam DHN to conduct a training needs assessment (TNA) in order to set priorities, identify target groups of health workers to be trained, and develop a curriculum for training. Subsequently, a series of training sessions was organized, mostly on priority health issues identified by the TNA for the health staff and volunteers in Bam in March-May

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2005. These trainings were carried out with the support of other extrabudgetary contributions. A skill-based training program was completed in two rounds. The first round was organized in Bam DHN in September-December 2005 and included a total of 34 workshops that benefited 911 health workers. They were trained in areas of disease surveillance and emergency medical care (including emergency in primary health care services, oral health and cardio-pulmonary resuscitation (CPR)). The details are provided in the table and graphic 1 below.

Table 1. Status of first round of skill-based Training in Bam (September-November 2005)

Category (Subject) Courses

planned Total Target

Courses organized

Target achieved

Kardans (OH) 3 80 3 65 (81.25%) Medical staff (GCPR) 8 200 8 198 (99%) Behvarzes (OH) 6 160 6 146 (91.25%) High-risk groups’ leaders (TOT)

1 30 1 20 (66%)

Experts (PHC M&E) 1 30 1 29 (96.6%) General physicians (PHC M&S)

1 20 1 11 (55%)

Kardans (PHC M&S) 1 30 1 29 (93%) Medical staff (NCPR) 3 96 3 100 (104%) Training of Trainers (SBT) 1 25 1 30 (120%) Kardans (SBT/DS) 3 80 3 84 (105%) Behvarzes (SBT/DS) 6 160 6 143 (89.3%) Total 34 911 34 855 (93.85%) OH: oral health; GCPR: general cardio-pulmonary resuscitation; TOT: training of trainers; PHC M&S: primary health care monitoring and supervision; NCPR: neonatal cardio-pulmonary resuscitation; SBT/DS: skill-based training on disease surveillance

Graph 1. Status of the first round of the skill-based training in Bam

(September-November 2005)

02040

6080

100120

140160180200

Kardans

Medical staff( G

CPR

)

Behvarzes

(OH

)

High riskgroup

Experts (PH

CM

&S)

GPs

Kardans

(PHC

M&

S)

Medical Staff( N

CPR

)

ToT (SBT)

Kardans (SB

T)

Behvarzes (

SBT)

Target

Trained

The second round was organized in Zarand in February-March 2006 for health workers and volunteers from Zarand and Ravar DHNs. A total of 13 courses benefiting 270 participants (145 from Zarand and 25 from Ravar DHNs) were successfully implemented (Table and graph 2).

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To facilitate supportive supervision and timely reporting, WHO provided 27 motorbikes for the supervisors and Behvazes in remote areas of Zarand and Ravar. The Districl TGovernor of Zarqnd and high government officials from Kerman and Zarand participated in the handing-over of the motorbikes to the staff in a ceremony attended by a WHO delegation headed by the WR.

Category/Subject Courses planned

Total Target

Zarand/Ravar

Courses Organized

Target achieved

(Zarand/Ravar)

Health Experts (PHC M&S)

2

42 ( 35+7) 2 49 (116%), (42+7)

Kardans (SBT) 2 42 (33+9)

2 41 (97.6%), (37+4)

Behvarzes (SBT) 5 128 (103+25) 5 112 (87.4%), (103+9)

GPs (PHC M&S) 1 32 ( 21+11) 1 15 (46.6%) Kardans (PHC M&S) 2 42 ( 33+9) 2 41 (97.6%), ( 37+4) Behvarzes (General CPR

1 23 ( 21+2) 1 12 (52.1%)

Total 13 309 ( 246+63) 13 270 (87.3%); (145+25)

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Table 2. Status of the second round of skill-based training in Zarand and Ravar, (February-March 2006)

PHC: Primary Health Care; M&E: Monitoring & Supervision; Kardans: Health Technicians; Behvarzes: Community Health workers running health houses; Behyar: Assistant Nurse; SBT: Skill-based training; GP: General Practitioner; CPR: Cardio-pulmonary resuscitation

Graph 2: Status of the second round of skill-based Training

2.2. Promotion of mitigation and preparedness To promote the concept of mitigation and preparedness among district, local health managers and the vulnerable population in the communities at high risk of disaster, WHO supported KUMS to organize a training of trainers (TOT) for representatives of five districts from Kerman province. Thirty-four participants from the districts of Kerman, Jiroft, Bam, Ravar and Zarand attended the TOT which focused on preparedness and mitigation issues with emphases on earthquakes and road traffic accidents. Subsequently, the trainers from each of the five districts organized four-day workshops targeting a total of 269 participants in the five districts. Participants included community health workers (Behvarzes), health experts, representatives of trade unions (labour and business associations), organized forces, staff and volunteers of IRCS and staff of the governors’ offices. Furthermore, the participants of the district workshops organized 165 periphery workshops designed to benefit a total of 4125 people at village level. The outbreak of Cholera which affected several areas of the country in August 2005 did not affect Bam; however, efforts of WHO, the Bam DHN and partners in health were directed for preparedness and prevention measures in contemplation case of a potential outbreak. 2.3. Nutrition and Food safety in Emergencies In collaboration with MOHME and KUMS, WHO supported the organization of a training of trainers' workshop (TOT) for 60 participants from different districts of Kerman province on nutrition and food safety during emergencies. The function aimed at enhancing and maintaining healthy behaviour and adequate food hygiene during emergencies.

0

20

40

60

80

100

120

140

Experts (PH

C M

&S)

Kardans (SB

T)

Behvarzes(SB

T)

GPs ( PH

CM

&S)

Kardans (

PHC

M&

S0

Behyars (G

CPR

)

Target

Trained

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2.4. Training on First Aid for school children and teachers in Bam To promote preparedness and appropriate response by the communities, in coordination with KUMS and MO Education in Bam, WHO supported training on first aid for school children and teachers in Bam. Fifty-seven teachers were trained (29 from secondary schools, 20 from elementary schools, 2 experts and 6 members of the health committees) to further train pupils in their schools. A total of 991 pupils of different grades benefited from the training (451 Grade 1, 53 Grade 2 and 487 Grade 3). 2.5. Establishment of community development fund WHO extended the support directed to the Bam Healthy City project (HCP) to enhance better livelihood of high-risk groups (women heading households and orphan girls). Following the skill-based training, a group of thirty women representing women health volunteers (WHVs) were identified as core for establishment of a community development fund in Bam. They received loans to support them to run small businesses in their identified areas of expertise. Repaid loans will be directed to other beneficiaries to sustain functionality of the development fund controlled under supervision of the Bam Health Council and Municipality of Bam conforming to government rules. 3. Awareness raising, health promotion and strengthening of the referral system at different health care system levels Ten thousand posters (Annex 2) on five basic messages for hygienic and safe food were designed, produced and disseminated in Kerman and five other disaster-prone areas (Hormozghan, Boshehr, Yazd and Sistan-Baluchestan provinces). Five ambulances were delivered to Bam in July 2005. Four additional ambulances were purchased through other donor contributions. They facilitate transportation of injured and critically ill patients from remote rural areas to the two main hospitals in Bam and for referral of severe cases for tertiary health care services in Kerman.

The Ambulances 4. Reinforcement of health sector coordination and disease surveillance. To enhance the efforts of the Bam DHN, WHO supported the DHN regarding the regular collection of health facilities’ statistics, data entry and weekly reporting of the disease situation in Bam. The staff of the Disease Control Unit (DCU) of Bam DHN was trained to maintain effective disease surveillance measures.

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A framework was developed for collaboration on different activities regarding the restoration of health services in Bam including reconstruction (Figure 1). Regular meetings with different agencies including UN, NGOs and the Government of Bam helped in solving many of the problems and addressing jointly the needs of the health sector. Monthly situation reports, notes for the record as well as regular updates both at field level and in the country office document the coordination activities. The disease surveillance system put in place in the aftermath of the earthquake topped up with the skill-based training gradually became a health information system. Instead of the secondary data that were used to feed the system, the surveillance system is now building up to have first hand data collected according to well defined case definitions.

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Figure 1: The WHO Coordination framework

1. WHO as core member of the UN coordination group regularly monitored the security situation, assessed progress of the humanitarian assistance in the area, shared information on agencies’ specific programs/plans, identified gaps in humanitarian services and proposed solutions.

2. WHO chaired the weekly health cluster meetings where all health sector partners (UN, local and INGOs and MOHME) convened to assess the progress of different partners’ projects, highlighted constraints and discussed with MOHME authorities and other health-related agencies ways and means to promote implementation of health projects.

3. WHO regularly participated in the bi-weekly meeting on water and environmental sanitation (WATSAN). Coordination efforts were also materialized by an experience-sharing workshop described below. WHO and KUMS conducted an overview exercise on the joint support provided for the response operations in Bam and Zarand earthquakes. The three-day workshop meant to draw lessons for better and effective performance in the future. Sixty-three participants from 9 provinces (Ghazveen, Qom, Tehran, Lorestan, Bandar Abbas, Kerman, Semnan, Mazanderan and Shiraz) and representatives from UNDP, IRCS, Basij and Sepah attended the workshop.

The Chancellor of KUMS, the Deputy Governor General (GG) of Kerman province and the WR addressed the workshop. Presentations on different humanitarian

Task Force

WHO NGOs

UN

MOH

Communities

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response efforts by partners in Bam and Zarand were shared and followed by active discussions. Participants highlighted the lessons learnt from the joint response efforts for emergencies in order to be used for better performance in future disaster management efforts.

The material and documents related to the joint programs implemented during various phases of the response and the documents shared in the workshops were compiled in a CD shared with partners. Joint cooperation with partners was strengthened specially regarding the need for an accessible and effective mental health program for the people affected by the earthquake. WHO prepared and shared a proposal, which was accepted by the Swiss Development Agency (SAD) and later became operational to include KUMS. The joint project entailed conduction of a field survey in Bam to explore the root causes underlining mental health problems and to serve as a basis for a comprehensive mental health services program.

In the joint project, WHO supported capacity building of the local staff representing Bam DHN, researchers from SAD and KUMS to conduct the survey. The qualitative data has already been collected and is currently in the process of analysis. Jointly with Caritas Italy, WHO supported the TOT for 25 participants representing the Association of Spinal Cord Injuries (SCI) cases in Bam. The TOT focused on knowledge and life skills for home-based management of common health problems of this group (including self-insertion of urinary catheters, wound dressing, prevention and home management of bed sores, etc). Trainers were further supported by Caritas Italy to conduct training sessions for an additional 210 chronic SCI cases in Bam. The mechanism for effective coordination included:

• Regular meetings with partners and national counterparts which created the interface between NGOs and MOHME;

• Regular visits to reconstruction sites, camps and partners’ projects; • Progress reports and dissemination of information; • Data collection, surveys and joint assessments; • Monitoring and supervisory trips to the field in Bam to ensure effective

implementation of activities. At the same time, WHO had its internal support mechanisms to ensure adequate delivery of the tasks such as:

• Regular weekly teleconferences with the regional office to obtain timely and necessary advice and support;

• Regular coordination meetings in the country office at Tehran; • Weekly reports, notes for the records, monthly situation report on the

project; • Frequent coordination meetings with the MOHME officials at national level.

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5. Monitoring the reconstruction of urban health facilities (UHFs) In collaboration with MOHME and partner agencies, WHO closely monitored and facilitated the reconstruction of 22 urban health facilities (UHFs) (details are presented below in graph 3). With the Belgian support, WHO equipped two polyclinics, one Behvarzes training centre and the administrative buildings of the Bam District Health Network and Centre. The facilitation role of WHO encompassed the coordination with various partners involved, the expedition of land allocations for reconstruction of health facilities and the approval for construction plans. Reconstruction of the UHFs was sponsored by various partners including local NGOs (Bahman), INGOs (The Czech People In Need, ADRA Germany, World Vision Australia and New Zealand and IFRC), the private sector (Ayatollah Sistani of Iraq), business corporations (Kish Free Zone targeting Malek Ashtar UHC) and the Government of the Islamic Republic of Iran. To date, seven (7) of the UHFs targeted for equipment have been completed (Annex 3).

Graph 3: Status of Reconstruction of Urban Health Facilities in Bam Comparative progress, July 2005-July 2006

0%

20%

40%

60%

80%

100%

120%

22 Bahm

an

Seied Taheredin

Behvarz training center

Mrs. Ziya

Muslim

Aid

Ayatolah Sistani

Emam

Polyclinic

Polyclinic#2

Razm

andegan

Malek A

shtar

Ghasem

zadeh

Bagh K

han

Baravat N

orth

Baravat South

Bam

DH

N

Bam

DH

C

Emam

Laboratory

July 2005

July 2006

Other UHFs supported by partners in health included: Mehdieh Maternity Hospital built by Mercy Corps and equipped by SC UK, Imam Emergency Outpatient Department built by Mercy Corps, Health Network laboratory sponsored by the German ASB and 96-bed Pasteur general hospital built by the Government and equipped by the French Government. An additional UHC at Razmandeghan was later identified by the Government as priority health facility for reconstruction. Caritas Italy officially accepted undertaking the reconstruction. Active rebuilding of the UHC will start in September 2006 pending completion of the official agreement with the Government.

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The Government of the Islamic Republic of Iran also sponsored the reconstruction of the Behvarzes training Centre, the two Polyclinics and the two administrative buildings of the Bam DHN and Centre. These health facilities still face a series of delays due to constraints, mostly related to Government’s budget allocation. The deadline set for finalization of the reconstruction of these facilities is estimated by end of the current Iranian year (March 2007).

6. Strengthening WHO presence in the field WHO expanded its presence in Bam to meet the increasing and diversified needs on the ground. Two international staff, a national EHA technical officer, one training associate, one procurement officer and a driver were recruited to facilitate WHO's response. This enabled WHO to effectively manage the program. Consequently, WHO was able to timely mobilize a response team to Zarand District in Kerman province immediately after the earthquake of 22 February 2005. The Bam experience contributed to a more organized and efficient response to the relief operations in Zarand where, within the first 24 hours, WHO jointly with MOHME conducted an assessment to identify gaps including health facilities affected by the earthquake and environmental health concerns. Further to this, WHO launched a successful response operation providing essential drugs, establishing seven fully equipped emergency health facilities, training health workers on health in emergency situations and mental health and establishing an early warning system (EWARS). The WHO country office organized its first review workshop from 4-6 May 2006 at the Azadi hotel, Ramsar city, Mazandaran province. All WRO staff members (30 technical and support staff members) participated at the review aiming to improve office performance, discuss and finalize pending salient issues of the WHO country office. The review reached consensus on directions for effective office management and means for achieving the articulated objectives. Participants commended the benefits of the review and experiences gained, namely improved staff relationships and working environment.

V. Lessons learnt The lessons learnt regarding project implementation are:

- Despite timely procurement and placement of the equipment in Bam, delay in the process of reconstruction of the UHFs deprived the needy population of Bam from access to quality health services. WHO played a vital facilitation role and expedited the process of reconstruction. Funded by other extrabudgetary contributions, a WHO-supported unit was established in the MOHME to address disaster management, effective coordination of the health sector and corporate response operations.

- Staffing problems remain a great challenge for delivery of essential health

services despite the fact that MOHME provided some technical health staff and physicians to the temporary urban and rural health facilities. All newly completed and delivered UHCs remained understaffed. This is due to inadequate motivation, inappropriate living conditions and lack of appropriate accommodation in Bam.

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- Impact evaluation on the humanitarian assistance including training activities

and performance of health staff on quality of health services is of outmost importance

- Lessons learnt from the planning and implementation of this project will feed into local and provincial plans emphasizing preparedness, mitigation and capacity building activities for both WHO and MOHME staff. The lessons learnt concerning partnership coordination are:

- Regarding the situation of humanitarian support in Bam by the end of 2005, the majority of the INGOs left the Region and only few stayed to look after unfinished projects (WV, ASB, STL, Caritas Italy and Cord Aid). Since June 2006, only Caritas Italy and STL remain in the area. However, UN agencies (WHO, UNICEF and UNDP), with the remaining INGOs and the Government focused on better coordination to address priority unmet needs of the population, especially the vulnerable groups. The areas of collaboration were to ascertain the gaps in order to avoid duplication and optimize the use of resources.

- The main strength of the project was its effective and practical coordination framework among partners in health in Bam. The coordination involved various partners (Task Force, MOH, NGOs and CBOs) at all levels in Bam, Kerman and Tehran. The joint frameworks with Caritas Italy in support of SCI cases, SAD and KUMS on mental health are examples of successful and effective partnerships.

- The coordination and harmonization mechanisms, promoted by WHO under the leadership of the MOHME, enabled the resolution of most difficulties faced by NGOs and others partners and thus enabled the start of the process of health service reconstruction. Nevertheless limited initial coordination among health reconstruction partners and actors – including health authorities at different levels – as well as bureaucratic challenges complicated and delayed key decisions related to the design and functions of different health facilities and therefore the health reconstruction efforts.

- The understanding and experience gained by WHO in Iran regarding humanitarian response was significant in the areas of training, needs assessment, coordination and support for emergency health services. Despite concerted humanitarian efforts addressing prevalent gaps in health services, the living situation of the population in temporary shelters was jeopardized by various health risks. Environmental health, mental health, children’s health, health of special groups (e.g. SCI cases) and women's health remain of great concern. Long term rehabilitation programs were acknowledged and WHO addressed the situation through joint cooperation projects with concerned partners.

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Lessons learnt as regards adjustments needed/made in the strategies, target o key outcomes and outputs:

- Training should also focus on project cycle management, resource mobilization, health information, communication and logistics in emergencies.

- For sustainability of the project activities, mid and long term plans on disaster management to be addressed by WHO and partners should focus on preparedness and mitigation. Warrant the use of the training material and procedures, developed for Bam and Zarand, in other regions while focusing on preparedness and mitigation activities.

- Water and environmental health conditions remain unsatisfactory in the temporary accommodations. Inadequate amounts of safe drinking water and poor quality, lack of proper sanitation and waste disposal, and continuous threat of possible disease outbreaks have added a larger burden on the health care services. The need for an adequate supply of safe water through proper waste and sewage disposal in absorptive wells, food safety regulations and monitoring, as well as proper slaughter houses were acknowledged earlier and constituted the main components of the WHO-supported community-based program "Rehabilitation of Bam as a Healthy City".

- Poor environmental sanitation favoured increased incidence of cutaneous Leishmaniasis observed since the end of 2004 and which reached an outbreak level by mid 2005. The outbreak affected both urban and rural Bam especially among school children and young people in particular those residing in temporary shelters.

- The training program aimed at improving health services and motivating health workers to provide better care to the public. It considered the actual training needs of the health workers at Bam (covering public and private health providers) and how to respond to post-disaster needs, albeit with a look at disaster preparedness and mitigation. The training program extended beyond Bam to benefit Zarand and Ravar districts of Kerman province.

- WHO's presence at field level proved to be crucial for the successful implementation of the planned activities. Technical and administrative staff including international experts with the required public health skills were deployed at Bam and Tehran. Technical support for local authorities at district level enhancing supervision and monitoring of project activities was highly appreciated (a good example is shown by the active participation of local health officials in all meetings held by WHO in the field).

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VI. Future work plan

- Preparedness and mitigation: National authorities and humanitarian partners should highlight preparedness and mitigation related activities in the areas of capacity building, awareness raising, promulgation and reinforcement of codes and rules, etc.

- Advocacy: WHO, UN agencies and donor communities should emphasize advocacy as a tool to promote better contribution of the national partners to influence decision makers, legislators, CBOs and the private sector in favour of appropriate budget allocations for preparedness and mitigation.

- Sustainability: humanitarian agencies that contributed to the response in Bam have to work out an appropriate exit strategy for their programs and projects to ensure sustainability of the activities undertaken. Long-term, sustainable community-based initiatives have to be considered for a smooth transition – such as joint cooperation programs with district and provincial partners (like the joint cooperation between WHO and KUMS).

- Implementation flexibility: donors and executing agencies should consider flexibility in implementation of projects designed for emergency situations. Accommodating the use of the funds for priority needs and gaps emerging during the implementation period would minimize the bureaucracy which might impede timely implementation.

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VII. Annexes

Annex 1: List of Equipment purchased against the Belgian contribution

1. General Equipment

NO. Item Description Quantity Unit cost USD

Total cost per item USD

1 Student chair 20 20 400 2 Ceiling fan 4 49 196 3 Video 1 110 110 4 Typing desk 1 61 61 5 Desk stationeries 3 22 66

6 Reception and copier desks 2 61 122

7 Desk chair 2 60 120 8 Paper shelf 2 9 18 9 Multi-row shelf 2 26 52 10 Heater 2 20 40 11 Trash can 2 7 14

12 Paper cutting devices, ruler, scissors 1 129 129

13 Bed for students (one for each) 20 89 1,780

14 Blankets (2 per student) 40 16 640

15 Pillow (1 per student) 20 4 80

16 Sheet and pillow sheets for each student

40 8 320

17 Bed cover for each student 40 8 320

18 Mattress for each student 20 22 440

19 Small bed table for each student 20 26 520

20 Vacuum cleaner 1 230 230 21 Iron 1 34 34 22 Iron board 1 14 14

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23 Sewing machine 1 90 90

24 Scissors- measurement tape, needles and string

1 10 10

25 Heater 25 8 200 26 Wall mirror 10 38 380 27 Washing machine 1 235 235 28 Radio 1 7 7 29 TV set and desk 1 345 345

30 Desk and chair for study 20 68 1,360

31 Desk lamp 20 12 240 32 Machine woven carpet 3 139 417 33 Shoes shelves 2 38 76 34 Sign boards 1 33 33 35 Pump for sink sewage 2 22 44 36 Slippers 20 4 80 37 Trash can with cap 1 7 7 38 Book shelves 11 57 627

39 Emergency lighting system 2 94 188

40 Large refrigerator or freezer 2 490 980

41 Gas stove 1 176 176 42 Meat grinder 1 89 89

43 Lunch table for 12 and chairs 2 265 530

44 Tea flax 4 28 112 45 Pot and kettle 4 4 16 46 Food spoon and fork 40 5 200 47 Large knife 4 6 24 48 Large tray 6 9 54 49 Pots in different sizes 10 18 180 50 Pan 3 16 48

51 Water pitcher and glasses 3 18 54

52 Different types of plates and small plates

40 19 760

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53 Food serving tray 4 9 36 54 Electric Samovar 1 31 31 55 Large and small bowl 2 4 8 56 Ladle 2 4 8 57 Bread basket 3 4 12

58 Fruit forks and knives 40 1.5 60

59 Cube dish 3 1 3 60 Salt shaker 6 1 6

61 Cupboard with large shelves 20 35 700

62 Dish basket 4 4 16 63 Cup and saucer 30 3 90

64 Pick nick portable cooking gas 1 14 14

65 Waste Bin 2 11 22

66 Machine woven carpet (3 X 4) 3 235 705

67 Wall mirror 1 39 39 68 Cloths wardrobe 2 29 58 69 Bed 1 41 41 70 Mattress and pillow 1 26 26 71 Blanket 2 29 58

72 Water and soap water dish 15 5 75

73 Small wooden catcher (spoon) 100 1 100

74 Small, tea and food spoons 4 3 12

75 Glasses 2 2 4 76 Cups 2 2 4 77 Scaled dish 2 3 6 78 Soap and soap case 1 5 5 79 Bed sheet 1 9 9 80 Telephone set 1 19 19

81 Small table with two chairs 1 84 84

82 Table cloth 1 8 8 83 Heating equipment 1 34 34 84 Cool water dispenser 5 480 2,400 85 Ring clock 1 14 14

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86 Pillow sheet and bed sheet 2 11 22

87 Report book 1 3 3

88 Curtain and curtain bar 70 14 980

89 Desk with chair and Stationeries 6 258 1,548

90 Book shelves 3 21 63 91 Cooler or fan 2 56 112

92 Calendar, punch and stapler 3 7 21

93 Telephone set 2 17 34 94 Conference table 1 96 96 95 Waste Bin 1 3 3 96 Mirror 1 4 4 97 Wall Clock 75 14 1,050

98 Cooler ( Air-conditioner ) 50 565 28,250

99 Fire Extinguisher Capsule 50 49 2,450

100 Television 24 Inches 6 300 1,800

101 pc with extra accessories 26 705 18,330

102 Shelf for cassettes ( audio & video ) 1 35 35

103 Executive office desk with chair 2 529 1,058

104 Conference table (6 person) with chair 2 352 704

105 Clerk desk with chair 40 100 4,000

106 metal shelf 20 35 700 107 Computer desk 6 117 702

108 Computer chair 6 70 420

109 Trash can with cap 25 24 600

110 Desk stationeries (material and equipment)

94 105 9,870

111 Desktop tray 40 11 440

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112 Calculator 26 16 416 113 Large calculator 4 44 176

114 White board Medium size 58 45 2,610

115 Telephone set (Two lines) 94 38 3,572

116 Television 5 290 1,450 117 Video Player 2 100 200 118 Refrigerator 5 212 1,060 119 Fan with stand 10 58 580 120 Safe box 2 176 352 121 Store room shelves 120 5 600 122 PC with accessories 40 705 28,200

123 Emergency power generator 1 3529 3,529

124 Samovar 2 35 70 125 Cups and glasses 2 8 16 126 Large pot 2 4 8 127 Steel pitcher 4 9 36 128 Steel tray 4 11 44 129 Gas stove 1 370 370 130 Gas capsule 3 24 72 131 Trash can 35 4 140 132 Cloths stand 98 25 2,450 133 Mirror 57 16 912

134 Picture wooden frame (30 cm X 50 cm) 67 18 1,206

135 Cooler 62 565 35,030 136 Clerk desk with chair 54 102 5,508 137 Desktop tray 54 9 486

138 Executive office desk with chair 1 529 529

139 Conference table (9 person) with chair 1 824 824

140 Mirror 1 14 14 141 Library cabinet 3 82 246

142 Rotator filing cabinet with files 10 376 3,760

143 Mirror 8 6 48 144 White board, large size 22 62 1,364 145 Desk and chair 1 102 102

24

146 File drawer 119 69 8,211 147 Trash can 3 2 6 148 Storage shelves 100 18 1,800 149 Drug shelves 160 18 2,880 150 Carpet (2 X 3 meter) 3 117 351

151 Prayer Soil Block Shelf 2 29 58

152 Waste Bin 22 4 88 153 Chair 12 41 492

154 Books & Journals cabinet 2 41 82

155 Suggestions Box 1 12 12 156 Books Shelves 50 24 1,200 157 Study Table 5 35 175 158 Chair 180 30 5,400 159 warmer 1 9 9 160 Office Desk 1 70 70

161 Chair of Library In-charge 1 29 29

162 Chair 50 29 1,450 163 Video CD 2 100 200 164 Microphone & stand 1 23 23

165 Pager System 1 58 58 166 Radio & recorder 1 35 35

167 Office Desk, chair with stationeries 3 259 777

168 Examination desk 1 35 35 169 Chair 1 47 47

170 Waste Bin (Infected material) 2 6 12

171 Partition 1 35 35

172 Water Heater with accessory items 1 176 176

173 Shaver 1 12 12 174 Dressing Trolley 1 71 71 175 Eye Protection Glass 2 4 8

176 Protection Coat ( apron ) 1 7 7

177 Television 14 Inches 1 212 212 178 Sleeping Bed 1 110 110

25

179 2 doors locker (wardrobe ) 2 118 236

180 Video CD 2 176 352 181 Radio & Recorder 2 23 46

182 Microphones ( different types : with wire & wireless )

4 117 468

183 Shelf for cassettes ( audio & video ) 1 35 35

184 Staff chair 8 60 480 185 Staff desk 6 105 630

186 Secretary chair with wheels 8 64 512

187 Cooler (Air conditioner) 10 823 8,230

188 Fire extinguisher 56 64 3,584 189 Stationeries 20 141 2,820 190 Shelf 4 43 172 191 Glass shelf 20 62 1,240

192 Waste bin with Pedal & cap 30 35 1,050

193 Wall Clock 34 14 476

194 Cleaning equipment 4 23 92

195 Examination room chair 12 176 2,112

196 Reception chair 24 31 744 197 Medical files shelf 4 70 280 198 Desk calendar 4 11 44 199 Paper case 4 6 24 200 Punch machine 4 8 32

201 Telephone (Receiver) 4 34 136

202 Stamp 4 1 4

203 Wooden wardrobe with glass door 4 141 564

204 Trash can 4 35 140 205 Refrigerator 26 164 4,264 206 Kettle 4 3 12 207 Sheets and blanket 4 47 188 208 File cabinet 8 235 1,880

26

209 Cloths bin 4 12 48

Total cost 242,276 2. Medical Equipment

No. Item Description Quantity Item cost USD

Total Cost per items

USD 1 Anoscope 4 329 1,316

2 Gynecology bed 4 741 2,964

3 Speculum vaginal 10 34 340 4 ECG machine 2 1,300 2,600

5 Infants weight measuring scale 2 81 162

6 Infants warmer 2 329 658

7 Stethoscope 4 50 200

8 Electrical cutter 2 4,000 8,000

9 Suction machine 2 2,573 5,146

10 Surgical set 4 2,941 11,764

11 Suture set 10 206 2,060

12 Operation table 2 5,879 11,758

13 Operation theater cyanotic lamp 2 16,471 32,942

14 Surgical instrument table 2 94 188

15 Resuscitation set 6 453 2,718

16 Plain mercury sphygmomanometer 2 24 48

17 Stretcher 2 353 706 18 Bending stretcher 1 21 21 19 Pulse oximeter 2 1,300 2,600

20 Plaster cast electrical saw 2 529 1,058

21 Dressing set 20 141 2,820

27

22 Examination bed 8 53 424

23 examination trolley 10 118 1,180

24 Cotton alcohol jug 6 2 12

25 Infusion stand 4 24 96

26 Straight receiver 4 12 48

27 Kidney receiver 4 12 48

28 Portable operation lamp 3 1,656 4,968

29 Medium size gauze bix 8 6 48

30 Chettle forceps 5 33 165

31 Chettle jug 4 6 24

32 Stainless steel basin 4 18 72 33 Oxygen cylinder 4 94 376 34 Air way set 4 6 24 35 Autoclave 4 5,879 23,516 36 laundry machine 4 2,941 11,764

37 Drying machine 4 1,624 6,496

38 Ironing machine 4 1,647 6,588 39 Cloths basket trolley 2 12 24 40 Examination tray 2 59 118 41 Reflex hammer 2 4 8

42 Otoscope and ophthalmoscope set 3 176 528

43 Oxygen cynlinder 4 179 716

44 Bed-side Partition 5 22 110

45 Negatoscope ( x-ray view box) 2 24 48

46 Adults blood pressure apparatus 2 71 142

47 child blood pressure apparatus 2 71 142

48 Combined blood pressure set (Adult & Child)

1 165 165

28

49 physical examination torch Light 7 12 84

50 AMBU bag set 1 53 53

51 Oxygen Mask 1 14 14

52 Air-way set 1 5 5 53 Tongue retractor dish 2 2 4

54 Height Measurement stand 2 24 48

55 Physician chair 2 47 94

56 Wheeled physical chair 4 80 320

57 Alcohol cotton dish 2 2 4

58 weight measuring scale 2 47 94

59 ordinary Flash light 2 10 20 60 Small Bix 2 15 30 61 Medium Bix 2 20 40 62 Large Bix 1 25 25 63 Kocher curve forceps 2 38 76

64 Straight haemostatic forceps 2 26 52

65 Sharp tip right scissors 2 29 58

66 Flat tip right scissors 2 29 58

67 Straight haemostatic forceps 4 26 104

68 Curve homeostasis forceps 4 26 104

69 Curved scissors 2 29 58

70 Straight needle holder forceps 2 24 48

71 Scalpel handle 4 8 32 72 Anatomy model 1 353 353 73 Anatomy model 1 294 294 74 Medicine shelf 2 58 116 75 Cloth Sheet (bedpan) 6 3 18 76 Plastic sheet (bedpan) 4 7 28 77 Chronometer 1 8 8

29

78 Hot water bag 2 9 18 79 Ice bag 2 12 24 80 Steel tray 4 10 40 81 Steel pan 1 7 7

82 Small towel 4 4 16

83 Capped dish 2 12 24 84 Medium receiver 4 9 36 85 plastic suitcase 1 15 15

86 Adults BP apparatus with stethoscope 2 35 70

87 Tourniquet 2 1 2 88 Oil lamp 2 3 6

89 Anatomy model of eye, ear, heart and kidney 1 1,000 1,000

90 Anatomy model of viscera and full human skeleton

1 985 985

91 Small manual rubber suction 1 3 3

92 Large manual rubber suction 1 5 5

93 Long forceps holder 1 10 10 94 Ordinary scissors 2 5 10 95 Curved scissors 2 9 18 96 Long forceps 2 7 14 97 Kocher forceps 1 29 29 98 Galley pot 1 9 9 99 Toothed forceps 4 7 28

100 Tiny forceps 2 29 58 101 Oral thermometer 4 3 12 102 Anal thermometer 4 3 12 103 Thermometer dish 4 2 8

104 Capped enamelled covet 2 2 4

105 Sterilizing furnace 1 1,100 1,100

106 Scissors (different types) 3 26 78

30

107

Complete set (Audiometery, Tympanometery and acoustic room)

1 18,822 18,822

Total cost 172,624 3. Radiology Equipment

No. Description Quantity Item cost USD

Total cost USD

1 Radiology machine 800 ml. amp with fluoroscopy 2 63,000 126,000

2 X-RAY developer & processor machine 2 6,118 12,236

3 Sonography 2 39,000 78,000 Total cost 216,236 4. Information technology (IT) equipments

NO. Description Quantity Item cost USD

Total cost USD

1 Overhead 1 300 300 2 Slide projector 4 500 2,000 3 Computer and printer 1 1,350 1,350 4 Overhead projector 3 235 705 5 Opaque 3 235 705 6 Video projector 2 2,600 5,200 7 Digital Camera 3 516 1,548 8 Printer 53 300 15,900 9 Copier 5 2,160 10,800 10 Fax machine 2 221 442 11 Scanner 1 165 165 12 High speed scanner 1 501 501

13 Central Telephone System 1 4,890 4,890

31

14 Entry & Exit Computer Clock 1 800 800

15 Video Camera 2 1,000 2,000 Total cost 47,306

5. Laboratory equipments

NO. Description Quantity Item cost USD

Total cost USD

1 Cell counter 2 15,882 31,764 2 Hood 6 518 3,108 3 UV lamp 2 70 140 4 Centrifuge 4 939 3,756 5 Microscope 6 1,124 6,744 6 Photometer 2 4,118 8,236 7 Refractometer 2 2,941 5,882 8 Centrifuge 2 2,353 4,706

9 Water bath (Ban Mary) 37 4 400 1,600

10 Haematocrite centrifuge 2 729 1,458 11 Refrigerator 10 165 1,650 12 Chronometer 6 75 450

13 Blood sample bench and chair 4 79 316

14 Examination bed 2 41 82 15 Partition 6 34 204 16 Pipetter (Sampler) 4 850 3,400 17 Autoclave 2 2,941 5,882

18 Full computer set with related program 4 898 3,592

Total cost 82,970

32

Annex 2: Measures for Safer Food (Poster)

33

Annex 3: Urban Health Facilities in Bam, update of reconstruction July 2006

No. Facility Name Sponsoring Agency

Equipped by progress Construction

Remarks

1 Ghassem Zadeh UHC

World Vision WHO-UK DFID

100% Operational

2 Abdollahi UHC Ayatollah Sistani

WHO-UK DFID

100% Operational

3 22 Bahman UHC People in Need (PIN)

WHO-UK DFID

100% Operational

4 Beasat UHC Muslim Aid WHO-UK DFID

65%

5 Bagh-e-Khan UHC ADRA WHO-UK DFID

100% Operational

6 Mrs Zia UHC IFRC WHO-UK DFID

100% Operational

7 Malek-e-Ashtar UHC Kish Island Free Zone

WHO-UK DFID

20%

8 Seyyed Tahereddin UHC

Bahman NGO

WHO-UK DFID

5%

9 Barawat North UHC

World Vision WHO-UK DFID

100% Operational

10 Barawat South UHC

World Vision WHO-UK DFID

100% Operational

11 General Polyclinic 1

Ministry of Housing

WHO- Belgium

75% Expected March 2007

12 General Polyclinic 2

Ministry of Housing

WHO-Belgium 70% Expected March 2007

13 Health Network Laboratory

ASB-Germany

Merlin-UK 100% Operational

14 District Health Network Office

Ministry of Housing

WHO-Belgium 70% Expected March 2007

15 District Health Center Office

Ministry of Housing

WHO-Belgium 70% Expected March 2007

16 Behvarzes Training Center

Ministry of Housing

WHO-Belgium 77%

17 Mehdieh Maternity Hospital

Mercy Corps Save the Children NGO

100% Operational

18 Imam Emergency OPD Center

Mercy Corps Ministry of Health

100% Operational

34

No. Facility Name Sponsoring Agency

Equipped by progress Construction

Remarks

19 Pasteur 96-Bed Hospital

Ministry of Housing

French Government

100% Operational

20 115 Ambulance Station

VIHA-Germany based Iranian NGO

Government 100%

Operational

21 Razmandegan-UHC Caritas-Italy WHO-Belgium 5% Agreement signed

22 Youssef Zadeh-UHC Housing Foundation

WHO-Belgium 0% For rehabilitation