Independent Oversight and Advisory Commi ee for the WHO Health Emergencies Programme

22‐24March2017ByprofessorWalidAmmarandDrMikeRyan

T h e h u m a n i t a r i a n e m e r g e n c y i n I r a q r e m a i n s o n e o f t h e

l a r g e s t a n d m o s t v o l a t i l e i n t h e w o r l d .

IOAC Iraq mission report, 22-24 March 2017

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1 . I N T RO D UC T I O N

1.1 Background

The humanitarian emergency in Iraq remains one of the largest and most volatile in the world. More people are vulnerable now than at any time in the past and the situation is expected to worsen. Iraqi civilians in conflict areas (e.g. Mosul) are in extreme danger.

Over 11 million people are vulnerable and in need of essential health services, with 3.5 million internally displaced people (IDPs) living amongst host communities and in 92 IDP camps (29 associated with the Mosul operation alone). The health system is struggling to cope with the management of trauma cases as well as provision of prevention services, primary health care, and chronic disease management.

IOAC Iraq mission report, 22-24 March 2017

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1.2 Mission objectives and activities carried out (see Annex 1 for detailed programme)

The objective of the IOAC Mission was to review the implementation of the WHO Health Emergencies (WHE) Programme in Iraq by:

Meeting with WHO staff to review WHO’s structure, human resources, funding, emergency business processes, partnerships, implementation of projects and service provision, as well as staff wellbeing and security.

Meeting with Government (MoH Baghdad and Kurdistan), UN Partners (HC, OCHA, UNICEF, UNFPA), implementing partners (INGOs/NGOs/private sector) and key donors (ECHO, OFDA/DART), health cluster partners, and coordinators to review how WHO’s services, performance and approach to partnership are perceived.

Examining to what extent the WHO Country Office (CO) and partners on the ground are aware of and benefitting from the WHE programme roll-out and “WHAT WHO” they want to see in future.

Carrying out targeted site visits to see WHO’s work on the ground in the service of affected. populations and with implementing partners and government. The IOAC team visited Emergency Hospital Erbil, Adhbah Field Hospital (10 km from Mosul) and Primary Health Care centre at Haman al-Allil-1 IDP camp (10 km from Mosul).

1.3 Specific findings

WHO in Iraq is delivering a wide range of essential services utilising the skills and commitment of 74 national staff, 18 international staff, seven secondees, and six surge staff from Regional Office (EMRO) and Headquarters (HQ) (as of 24 March). The programme’s planned budget was US$107 million for 2016/17, of which $97 million has been raised (97% from voluntary contributions) and $80 million (83%) has been spent. Funds were mobilised as part of Iraq’s Humanitarian Response Plans for 2016 (HRP 2016) and 2017 (HRP 2017), for which the total two-year funding requirements for the health sector amounted to $193.3 million.

The CO has been successful in leveraging strong operational coordination and partnerships with the Government, UN and a wide range of other national and international implementing partners. In addition, the partnerships with nine donors have deepened and the CO has been successful in accessing the United Nations Central Emergency Response Fund (CERF) and OCHA pooled funds.

IOAC Iraq mission report, 22-24 March 2017

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WHO core emergency service provision covers:

Coordination (including health cluster coordination)

Technical support/assistance to partners

Information management (collection, analysis and dissemination)

Surveillance, early warning and response (e.g. EWARN, polio)

Polio eradication and essential immunization

Operational and financial support/contracting for primary and secondary health care

Procurement and management of critical supplies (e.g. drugs, medical supplies and vaccines)

Trauma pathway management and coordination, including trauma stabilization points (PSTs) and field hospitals (EMT type 1, 2 and 3).

THE HUMANITARIAN EMERGENCY IN IRAQ REMAINS ONE OF THE LARGEST AND MOST VOLATILE IN THE WORLD.

IOAC Iraq mission report, 22-24 March 2017

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2 . C O UN T R Y O F F I C E S T RUC T U RE A ND H UMA N RE S O URC ES

Specific findings

The WHO programme in Iraq is distributed across six offices, with 74 national and 18 international staff (see Table 1). In addition, there were seven secondees from international response networks such as the EU Civil Protection Mechanism (EU/CPM) and EMTs and six surge staff from HQ and RO at the time of the IOAC mission. The organigram is complex, with many staff covering functions in more than one office and spending significant time between offices. Reporting lines within Iraq are clear but coordination and communication pathways to RO and HQ not so clear.

The overall impression of the IOAC mission was that many staff are overworked and have been doing long hours on an ongoing basis since the onset of the most recent humanitarian emergency in 2014. It is also evident that technical staff are constantly in the field, with very little “back office” support. This requires these staff to carry out their managerial and administrative functions late in the evenings and at weekends, further adding to long-term fatigue and burnout.

A number of critical positions remain vacant, including those of Deputy WR, programme/technical manager, and security officer positions. The CO identified the need for 10–12 new positions and this request has been communicated to management at RO and HQ levels. Approval has now been granted, and the process of recruitment to fill out these positions has been initiated.

Very few staff are fully aware of the detail of the new WHE Programme and it was clear to the IOAC Mission that much of the success of the CO is attributable to the competence and commitment of the WR and his staff and not necessarily attributable to the impact of the new WHE Programme.

IOAC Iraq mission report, 22-24 March 2017

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3 . B UD GE T I NG A N D F I N A NC I N G

Specific findings

WHO Iraq has a budget ceiling of $120 million, with a planned cost of $107 million and $97 million available (97% from voluntary contributions). Of available funds, $80 million has already been spent, which represents 83% implementation against available funds after 58% of the implementation period (2016/17 [24 months]). This increased implementation rate is due to increased demands on WHO due to the deteriorating country situation.

The CO is spending funds across its core areas of service provision, with major areas of expenditures in trauma pathway management, polio eradication and procurement of drugs and medical supplies/equipment. Staff costs represent 10% of overall expenditure (Table 2).

IOAC Iraq mission report, 22-24 March 2017

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A significant proportion of overall spending (approximately 75% of all funds distributed to the Iraq programme in 2016/17 thus far) is accounted for by tendering and contracting with associated business processes that are complex and time-consuming (Figure 1).

The CO has been effective at accessing CERF funds ($13 million) and OCHA pooled funds. It is increasingly effective in successful fundraising with in-country donors, especially ECHO and OFDA. However the CO is not accessing WHO contingency funds and has no access to advance funding against pledges or pipeline funds. The current financial horizon is 3–4 months without further funding being secured. Worryingly, financing is not available to replace the ageing vehicle fleet operated by WHO in-country.

THE COUNTRY OFFICE IS SPENDING FUNDS FOR TRAUMA PATHWAY MANAGEMENT, POLIO ERADICATION AND PROCUREMENT OF DRUGS.

IOAC Iraq mission report, 22-24 March 2017

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4 . EME RG E N C Y B US I N ES S P RO C E S S ES

Specific findings

The WHO CO is managing a wide range of business and procurement processes including human resources and procurement of medical goods and supplies, and is contracting with local and international organizations for provision of critical services.

In general, WHO staff, as well as local and international service providers, were satisfied with the efforts of the WHO team to make these processes as efficient as possible, although frustration was expressed regarding the often long delays in implementation of the processes. For example, it takes an average of 87 days from initiation of a new position to having that staff member at the duty station—a process that involves multiple organization levels. Similar delays were noted regarding the 32 separate Letters of Agreement (LOAs) generated thus far in 2016–17. It takes an average of 57 days for the initiation, approval and payment of an implementing partner under the LOA process (involving at least 24 separate administrative steps at multiple WHO organizational levels) (Figure 2).

Delays in LOAs for implementing partners, deployment of staff/consultants and procurement of goods were the single most consistently raised issue by WHO-Iraq and by the funding and implementing partners.

On examination of this process, it was noted that there are a number of factors that are possibly driving these delays:

Lack of clear policies and/or organizational resistance

Mind-set and culture has not moved to an emergency concept of operations

Inadequate delegation of authority

Complex administrative processes (e.g. offline GSM, E-workflow, GSM)

Many levels of the organization involved

Lack of awareness or knowledge of implementation of emergency SOPs

Lack of a pre-qualification process

“No regrets” policy is spoken but not supported

IOAC Iraq mission report, 22-24 March 2017

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The lack of improvement in the area of business processes would indicate that the WHE Programme reforms and efforts in this area have still not reached the CO and are not as yet affecting the efficiency of doing business in this priority emergency country.

Figure 2: Schematic illustration of administrative steps associated with LOA process

IOAC Iraq mission report, 22-24 March 2017

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5 . P A RT N E RS H I P S

Specific findings

Examination of this area of WHO’s performance in-country was an extremely positive aspect of the IOAC mission. The feedback from partners was overwhelmingly positive about WHO’s engagement with partners and regarding the technical support and other services being provided.

WHO has proven itself to be a reliable and highly competent partner to:

Government HC and all UN partners Health cluster partners Implementing partners (NGO, INGOs, private sector) Donor partners

WHO has established a welcome and supported coordination and leadership role in health that:

Is proactive and transparent Consults, communicates and coordinates effectively Provides financial, technical, information and operational support in a comprehensive fashion Focuses on delivery and delivers what it says it will Works hard to fix problems Absorbs criticism and input in a constructive fashion

THE FEEDBACK FROM PARTNERS WAS POSITIVE ABOUT W.H.O.’S ENGAGEMENT WITH PARTNERS.

IOAC Iraq mission report, 22-24 March 2017

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6 . S T A F F W EL L B E I N G A ND S EC URI T Y

Specific findings

The IOAC mission observed excellent staff morale given the difficult working conditions and heavy demands. However, it was noted that some staff are overstretched, with field work during the day and then having to return to the office to carry out administrative and other duties in the evening.

It was reported that WHO receives a very good service from UNDSS on security planning and support. However, there is only one WHO Field Security Officer in place, with one new staff member just joined. This level of security support is inadequate given the number of WHO staff, the distribution of WHO Offices and sub-offices and the heavy demands of field missions and deployments.

Frustration was expressed by many staff over R&R rules and procedures which are quite restrictive and inflexible and are especially difficult for staff who have long distances to travel to see family etc.

Staff health care was reported to be well organized and accessible and staff accommodation is satisfactory overall, with some restrictions in Baghdad.

THE IOAC MISSION OBSERVED EXCELLENT STAFF MORALE GIVEN THE DIFFICULT WORKING CONDITIONS AND HEAVY DEMANDS.

IOAC Iraq mission report, 22-24 March 2017

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7 . C O N C L US I O N S

WHO is perceived to be delivering well in Iraq. It has dynamic and experienced leadership with committed, competent and hardworking staff.

The partners on the ground believe it is doing the “right things” and welcome its coordination and leadership role. Its role and performance are not only appreciated by partners but seen as game-changing and vital.

However, the WHE Programme is being placed under huge demands to do more. Its current staffing levels, budgets and funding availability are not aligned to these demands. Its administrative support systems and business process are outdated, over-complicated, and disabling rather than enabling performance.

Professor Walid Ammar and Dr Michael Ryan stop to wear bullet proof jackets before proceeding to Athbaa field hospital in Mosul area. March 2017

Credit: WHO Iraq/P. Ajello

IOAC Iraq mission report, 22-24 March 2017

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The IOAC mission concluded that the overall excellent performance of the country programme in emergencies is attributable in large part to the competence, skill and tireless commitment of the WR and his staff. This highlights the critical role that WRs and key staff play in both the actual and perceived performance at of WHE at country level.

The IOAC mission also concluded that there is evidence that the WHE Programme at Regional Office and Headquarters levels has become more responsive to CO needs, particularly in the area of technical assistance and deployment of surge and deployment of specified expertise when needed. However, the issues identified with finance, human resources and emergency business processes indicate that the reforms being implemented by WHE have not yet reached the COs and remain a major barrier to efficiency and programme effectiveness.

It is important that these issues are addressed urgently if the WHE Programme in-country is to maintain and sustain its high level of performance.

WORLD HEALTH ORGANIZATION IS PERCEIVED TO BE DELIVERING WELL IN IRAQ.

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Annex: Programme of the field visits in Iraq by the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme (IOAC)

22–24 March 2017

IOAC Mission team: Professor Walid Ammar and Dr Mike Ryan

Wednesday 22 March 2017

Time Agenda item description and issues Venue 15:00–16:00 Dr Ryan to join weekly meeting of Trauma

Working Group WHO Office

16:00–19:30 Meeting with WHO Representative and senior staff (general overview including SC briefing)

WHO Office

Thursday 23 March 2017

Time Agenda item description and issues Venue 08:00–09:00 Visit Emergency Hospital Erbil and meeting

with NGO Emergency (Italian) Emergency Hospital in Erbil

09:30–10:30 Meeting with WHO Iraq team to discuss a series of topics (workforce, finance, partnerships, WHE structure and incident management)

Dedeman Hotel

10:30–11:15 Meeting with Health Cluster members Dedeman Hotel 11:30–12:30 Meeting with H.E. Minister of Health, KRG MOH–KRG 13:00–13:30 Meeting with UNICEF Representative UNICEF Office (ERO) 13:30–14:15 Discussion with USAID/OFDA TC with link to Emily Dakin

(OFDA DART Team leader, USAID, Baghdad )

14:15–15:00 Discussion with DSRSG/ HC/RC – Ms Lise Grande

Skype call in WHO Erbil Office, meeting room (Ms Lise Grande joining the call from New York, USA)

15:00–15:30 Trauma Coordination Team WHO office 15:30–16:00 Break 16:00–17:00 Meeting with OCHA HOC office 17:30–18:30 Meeting with Senior Deputy Health Minister-

MOH IRAQ, Dr. Hazem Al-Jumaily and his team

Dedeman Hotel

19:30–21:00 Working dinner with WR and senior staff to advance discussions on CO capacities to respond to emergencies

De Fermo Turkish restaurant

21:00–22:30 Meeting with Health Cluster Coordinators Dedeman Hotel

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Friday 24 March 2017

Time Agenda item description and issues Venue 07:30–16:00 Field visit to Adhbah Field Hospital.

Field visit to WHO supported primary health care centre in Hamam al-Alil. Field visit to IDP camp in Hamman al-Alil.

Different sites in Mosul area

18:30–20:30 Wrap up meeting with WR and WHO team WHO office