PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.

: AB3276 Project Name Region Sector Project ID Borrower(s) Implementing Agency PK Earthquake Disability SOUTH ASIA Other social services (60%);Health (40%) P099542 GOVERNMENT OF PAKISTAN Pakistan Poverty Alleviation Fund House No. 1, Street No. 20 Sector F-7/2 Islamabad Pakistan Tel: 2653304 Fax: 2652246 ppaf@isb.comsats.net.pk ISLAMIC REPUBLIC OF PAKISTAN Economic Affairs Division Government of Pakistan Pakistan Tel: +92 51 920 3815 Fax: +92 51 921 8976 [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) August 21, 2007 October 20, 2006 May 21, 2007

Environment Category Date PID Prepared Date of Appraisal Authorization Date of Board Approval

1. Country and Sector Background

The 7.6 magnitude earthquake that hit Pakistan on October 8, 2005 devastated one of the most remote mountainous parts of the world and one of the poorest parts of Pakistan. According to the joint ADBWorld Bank Needs Assessment, approximately 73,000 people died and more than 70,000 have been severely injured or disabled. Many injured had amputated limbs or severe spinal cord injuries that left them paralyzed. Preliminary estimates show a large population affected by physical or mental disorders and disabilities, including post-traumatic stress and trauma. Besides those newly disabled because of the earthquake, persons already disabled have sometimes lost their support systems and whatever services they were getting before the earthquake. People with disabilities will need external help geared to longterm rehabilitation. The magnitude of physical destruction, much bigger than first estimated, has focused the governments reconstruction efforts on housing with an aim to reconstruct most of the houses and secure shelter for the earthquake victims before winter. Housing reconstruction is stretching local capacities and causing other rehabilitation needs including those of the disabled people to remain largely unaddressed. The field visits and discussions with communities have indicated that many persons with disabilities (PWDs) still need medical help; many more need physical rehabilitation, and almost all who experienced the earthquake are in need of psycho-social assistance. These needs are placed against a severe lack of social services in the earthquake-affected areas.

In response to the earthquake, the government has adopted the National Strategy and Plan of Action for Vulnerable Populations in Earthquake-affected Areas, and the Earthquake Reconstruction and Rehabilitation Agency (ERRA) has recently prepared a social protection strategy. These documents formulate strategies and policies for assisting the vulnerable, including the PWDs, with community-based rehabilitation as key approach in an environment that faces an acute shortage of services and severely constrained resources. The proposed project is consistent with these strategy documents and would be implemented as part of the governments earthquake reconstruction efforts. The project would closely coordinate activities with ERRA and other actors operating in the affected areas to strengthen possible synergies and avoid duplication and overlap.

2. Objectives
The objective of the project is improve the quality of life of people with disabilities and their families in 34 Union Councils (UCs) affected by the October 8, 2005 earthquake, by ensuring better mobility, improved physical and mental health, increased participation in social and economic life, and strengthened empowerment. Specifically, the project aims to achieve the following outcomes in its target area of 34 UCs: 1. Improved quality of life of the targeted PWDs, as indicated by their better health, improved mobility, increased capacity to take care of themselves and participate in social and economic life. 2. Improved mental health of the targeted earthquake victims through easing and relieving their post-traumatic stress and disorders. 3. Improved and increased capacity of the community-based service providers, as well as that of specialized institutions, to provide good quality rehabilitation services to the PWDs. 4. More enabling environment and increased social mobilization of the PWDs, their families and communities to take action on disability. The project contributes to Pakistans long-term objective of reducing poverty and vulnerability and improving the welfare of its disadvantaged groups. Persons with disabilities (PWDs) are one of the most disadvantaged, vulnerable and marginalized segments of society. The project will test a model for community-based service delivery to and empowerment of this group. If successful, the model could be scaled up, integrating persons with disabilities better into social and economic life.

3. Rationale for Bank Involvement

1. The earthquake-affected population, including persons with disabilities has been assisted by the government, donors and non-governmental organizations. The general assistance package for the earthquake-affected households includes housing reconstruction grants, cash compensation for death/injury, and temporary cash transfers for income support and livelihood recovery. The World Bank has supported the governments relief, reconstruction and rehabilitation efforts since immediately after the earthquake through a range of activities and $840 million new lending and $30 million in reallocation. The new lending includes a $400 million Emergency Recovery Credit and a $100 million additional finance to the Pakistan Poverty Alleviation Fund, approved by the Board on December 15, 2005.

The PWDs in the earthquake-affected areas need medical care and specialized rehabilitation services in addition to the cash transfers and housing. The World Bank and the Japanese Government have approved two emergency JSDF projects for disability, which will help establish four Resource and Information Centers for community-based rehabilitation (through Handicap International), and four independent living centers (co-located in the Resource and Information Centers and operated by Milestone Society, a Disabled Peoples Organization) in the earthquake-affected areas. Also, a few services for people with disabilities have been provided through the health care system and other actors, although some of these services were on a relief basis and have now ceased. These services are well below the needs and not always of acceptable quality. There is also a lack of know-how of community-based rehabilitation and inclusion of persons with disabilities, calling for capacity building for the relevant actors. The proposed project will fill in some of the gaps in service provision to the PWDs in the earthquake districts. It will pilot a community-based approach to rehabilitation, offering a learning experience for the governments strategy that envisages community-based rehabilitation (CBR) as a core aspect of its disability policies. It will also contribute to building local capacity to address disability issues, applying state-of-the-art knowledge, techniques, and approaches. The proposed project is listed in the Country Assistance Strategy (CAS) and its objectives support the third CAS pillar of improving lives and protecting the vulnerable. The Pakistan Earthquake Disability Project, by supporting the establishment and improvements in delivery of services to persons with disabilities or mental health issues through community-based rehabilitation, is continuing a long-standing trend for the Bank in Pakistan to be a partner in disability with a special focus on launching innovative and catalytic initiatives.

4. Description
2. The project targets the PWDs in 34 earthquake-affected union councils; they are the UCs in which the Pakistan Poverty Alleviation Fund (PPAF), the executing agency for this project, is carrying out reconstruction and rehabilitation on behalf of the government. This project aims to reach all persons with disabilities and their families, regardless of type of disability and whether the disability was pre- or postearthquake. An initial census conducted by the PPAF revealed some 7,700 physically disabled in the 34project UCs (see Table 1 and appendix 4). Allowing for underreporting and mental health issues (not covered by PPAFs initial census), leads to an estimate of a target population of 15-20,000.
Table 1: Population and PWDs in project areas

Total population: Total number of houses/households: Casualties: Most vulnerable (widows, elderly, orphans, or disabled without support): Disabled (incidence of physical disabilities): Of which disabled adults: Disabled children Source: PPAF

471,254 86,945 7,842 4,902 7,742 4,398 3,344

The project has three components: (i) provision of services, mobilization and empowerment of people with disabilities and mental health issues and their families, (ii) capacity building for service providers and civil society organizations, and (iii) project management, monitoring, and evaluation. Component 1: Provision of services, mobilization, and empowerment (US$3.9 million) The objective of this component is to ensure delivery of a range of services addressing disability and mental health needs of PWDs and their families while at the same time mobilizing and empowering them to take action on disability. The component will ensure service delivery, mobilization and empowerment through a two-pronged strategy, comprising (a) community-based rehabilitation and (b) rehabilitation through a referral to specialized service providers (institutions). Community-based rehabilitation will target the PWDs, their families, and communities through social mobilization and other community-based activities aimed at raising awareness and knowledge regarding disability, and inducing and stimulating the demand for disability-focused services. This component will in particular aim at empowering the disabled to claim and identify ways of meeting their needs for rehabilitation and ensure participation in social and economic life. Besides enabling/empowerment/inclusion initiatives, the CBR approach aims at arranging for the provision of basic disability rehabilitative services at the community level provided by professionals, trained community organizers, and volunteers, including the PWDs themselves. The CBR activities under this project will be carried out by a network of already operating community mobilization teamsstrengthened by two disability community workers per union council and will feed into (and benefit from) the CBR activities emanating from the four planned Resource and Information Centers. These centers (envisaged to operate in Mansehra, Besham, Muzaffarabad, and Bagh) are planning a full menu of CBR activities; it is expected that after this project has closed, the CBR activities initiated by it will continue and remain anchored in these centers. Specialized institution-based rehabilitation services will be provided by specialized service providers/institutions by referring/bringing the PWDs to those institutions and/or through arranging for those institutions to deliver outreach services to the PWDs. To the extent possible, the services will be provided locally, relying on providers already active in the earthquake-affected areas. The services will include medical treatment, physical rehabilitation, provision of prosthetics and other aids, psycho-social counseling, and other specialized services. For example: Medical treatment (over and above the services offered by local clinics and practitioners) will be provided mostly by major hospitals inside and outside the area. Physical rehabilitation is expected to be mainly provided by the Pakistan Institute of Prosthetic and Orthotics Sciences (PIPOS), a government institution located in Peshawar. PIPOS runs five rehabilitation centers in the earthquake areas, each providing rehabilitation services such as production/fitting/maintenance of state of the art prosthetic and orthotics devices and physiotherapy, as well as psycho-social rehabilitation. Handicap International (HI) supports PIPOS with technical assistance, training, quality assurance, and management training. Mental health services are almost non-existent in the project areas and will therefore be procured specially by the project. Qualified providers will be invited to submit bids for such services, on a consultancy basis. The Operations Manual will specify the quality standards against which bids will be evaluated. Already, the Pakistan Institute of Medical Sciences (PIMS), Psychiatry Department, has indicated its interest in providing and training special teams of mental health counselors. In doing this, PIMS will be building on its experience acquired during the emergency

psycho-social relief it provided right after the earthquake. Assistance from the WHO will also be sought. Special and difficult cases that cannot be treated locally will be referred to relevant tertiary institutions, including among others the National Institute of the Handicapped (NIHd). Whenever possible, institutions that offer services provided free of charge would be preferred.

The key activities under this component will comprise: (i) Identification of people with disabilities and needs assessment. The starting point for the assessment will be initial data already collected by the PPAF on households with disabled members in the 34 union councils1. This data is incomplete, and a detailed identification and needs assessment is therefore required and will be carried out at the start of the project to complete (in coverage, scope, and detail) the initial data. A standard method for identification and needs assessment will be used (to be provided by the Handicap International). This information will be entered into the management information system (MIS) of the PPAF and partner organizations and will be used to track cases. The identification and needs assessment will be conducted by trained disability social workers in collaboration with specialized partners. (ii) Formulation and realization of individual rehabilitation plans for all PWDs in the project area. Based on the needs assessment, individual rehabilitation plans will be formulated by disability social workers and the PWDs, under the guidance and backing of professional staff from the HI and internationally recruited experts. These plans would comprise strategies for the provision of short- and long-term services for all types of disabilities and mental health needs such as health care, physical rehabilitation (for instance, basic physiotherapy, occupational therapy, provision of assistive devices), training in independent living, psycho-social counseling, and treatment of mental disorders. The priority will be given to activities that support, ease and enhance the capability of the PWDs to perform daily household chores and/or occupation-related tasks, thus improving the quality of life, welfare and livelihood of the disabled and their families. Workshops addressing specific needs, for instance those related to sensory impairment such as blindness and deafness can also be carried out. The services under the individual rehabilitation plans will be provided by specialized institutions (delivered preferably through outreach), and by trained community organizers, community-based organizations, trained volunteers, etc. As already mentioned, a special effort will be made to arrange for mental health services (see below). Taking into account the time frame and resources available to the project, individual cases will be prioritized for service delivery by urgency of need as assessed by trained professionals. (iii) Mapping and capacity assessment of service providers to receive referrals. A mapping and capacity assessment exercise will be undertaken by the PPAF with its disability specialized partners to identify institutions currently providing physical and mental rehabilitation that would have capacity to receive referrals of the targeted PWDs and provide good quality services. The capacity assessment would also serve: (a) as a basis for setting quality standards (see below); (b) for planning capacity enhancement and training of these services providers (see Component 2); and (c) in a few cases, to assist with procurement of essential drugs or equipment. (iv) Monitoring the quality of rehabilitation services. The PPAF, with inputs from specialized partners and international organizations, will define (in the Operations Manual) the standards for rehabilitation services for identified partners and service providers and ensure that services provided under the project

The data were collected as part of a housing damage assessment undertaken by PPAF. The assessment comprised all households in 34 UCs and was completed in June 2006.

are adequate and of high technical quality. PPAF will arrange third party assessments of the services and activities as needed. (v) Mobilization, social integration and empowerment through community-based information, education and communication (IEC). Community-based IEC would include a broad range of activities aimed at mobilizing and empowering the PWDs to organize themselves to take action on disability and improving their livelihood and integration into community life, for example: dissemination of information on disability, establishment of thematic/self-help groups; promotion of self-esteem or independent living; promotion of school enrollment of disabled children; awareness and anti-discrimination campaigns targeting schools, elders, womens groups, midwifes, and others. These activities would be supported through small grants awarded to community groups and NGOs against deliverables. Organizations would apply to PPAF for funding of projects that meet these objectives, and a large number of smaller organizations are expected to avail of this small grant facility. The key actors The PPAF, its partner organizations (POs), disability specialized partners (DSPs) and several communitybased service providers and activity organizers will be involved in implementing this component with the following responsibilities and roles: PPAF is the project executing agency and will ensure that the project is implemented successfully and its development objectives are accomplished. The PPAF will select the POs and DSPs that would carry out the project activities. The PPAF will perform supervision, monitoring, and evaluation. Partner Organizations (POs) will be selected based on the quality of their proposals as per PPAF guidelines. Their task will be to: (i) mobilize the communities in 34 UCs for action on disability issues through social mobilization teams (SMTs); (ii) recruit two disability social workers per UC (one female, one male) and provide for their training in disability issues in coordination with disability specialized partners; (iii) conduct the identification and needs assessment in collaboration with the DSPs; (iv) develop individual rehabilitation plans; (v) carry out disability-related awareness raising activities; (vi) ensure participation of community organizations, households and the PWDs in launching disability services and activities; and (vii) support, supervise, register and monitor the PWDs and their families participation in project activities. Disability Specialized PartnersDSPs (Handicap International, Pakistan Institute for Medical Science, and others to be identified) will: (i) carry out capacity and skills development of the POs and the PWDs and their families; (ii) assist the POs in planning and conducting the initial identification and needs assessment; (iii) assist the POs and their community organizers in developing individual rehabilitation plans and monitor their implementation from the technical view; (iv) map institutions for referral of the PWDs for treatment and rehabilitation; (v) provide, if required, capacity training to institutions mapped for service referrals; (vi) establish a mechanism for referral of the PWDs to the institutions including services which will be provided as community outreach services; (vii) help define the standards of services and ensure compliance; and (viii) support the supervision and monitoring of service delivery at community and specialized institutions level. Community-based service providers: Community-based groups and organizations will be essential in designing, organizing and carrying out rehabilitative services and mobilization, empowerment and social inclusion activities. Those organizations will be invited to submit their proposals to the PPAF. The PPAF would evaluate the proposals and award small grants against deliverables for those who qualify for financing. The skills, competences and awareness acquired by the PWDs, their families and communities

through active participation in rehabilitation activities would be essential in empowering the PWDs to be fully enjoying and contributing members of society. Component 2: Capacity building for disability rehabilitation (US$0.45 million) The objective of this component is to build the capacity of the PPAF, its partner organizations, as well as service providers and civil society organizations to ensure rehabilitation services to the PWDs and their families. Capacity building/skills development is required since neither the PPAF, nor its implementing POs have competences and previous experience in disability work. Training on all aspects of disability work will be delivered by Handicap International and others. Training will be tailored to meet the needs of the PWDs, their families and communities as identified in the needs assessment. Sensitization of Project and PO management: To ensure commitment and shared understanding of project objectives and design, the PPAFs general management, the PPAFs Reconstruction and Rehabilitation Unit staff, and the POs management will be provided with a half day disability sensitization course. In addition, a two weeks disability course for direct (operational) managers/core staff of the PPAF and its partners will be conducted at the project start. Training of disability social workers: A standard training course of two weeks in identification and needs assessment of all types of disabilities will be conducted at the project launch, targeting disability social workers who will be recruited to reinforce already operating social mobilization teams of the PPAFs POs. Following the needs assessment, a disability/CBR training course of three months will be provided over a period of 12 months, using interval training so as to allow project implementation to proceed. The training will be provided by Handicap International (through its technical advisors who will act as master trainers). Capacity building of specialized service providers (institutions): Handicap International will draw on internationally hired expertise to strengthen its ongoing collaboration with the Pakistan Institute of Prosthetic and Orthotics Sciences (PIPOS) in providing quality assurance training to the Institute and its five prosthetic centers established in the NWFP and AJK. The training would ensure that international best practice is followed in terms of comprehensive rehabilitation programs, including prosthetics adaptation, follow-up, physiotherapy training and psycho-social counseling. The Pakistan Institute for Medical Sciences (PIMS) supported by internationally hired specialists is expected to be the main partner responsible for training of the mental health service providers. Mental health capacity training will ensure that institutions and mobile teams have adequate competences in diagnosis of mental disorders including testing of adults and children for mental impairment and in service delivery in psycho-social counseling and treatment of mental disorders. PIMS already has experience with trauma relief services for the earthquake-affected population. For six months after the earthquake, PIMS provided counseling treatment to approximately 40,000 people in a project funded and technically supported by the WHO and the International Office of Migration. The project was ceased as funding ran out. Support to community-based organizations for proposal writing: The PPAF will offer support and training as needed for the POs, DSPs, and other community-based organizations to prepare grants proposals for the financing of disability-oriented initiatives in the communities.

Component 3: Project management, monitoring, and evaluation (US$0.4 million) This component will finance the project management and support functions undertaken by the PPAF. A small disability team would be established within the PPAF and would initially form part of the PPAFs Relief and Reconstruction Unit. The disability team would supervise all aspects of the projects implementation. It would also prepare an Operations Manual. The PPAF would also undertake its standard functions such as proposal reviews, activity supervision, procurement, financial management, and reporting. An elaborate Management Information System (MIS) has been developed for the PPAFs housing reconstruction. The data base captures key information on all 105,000 households in the 34 PPAF union councils. Data is entered at field level by the social mobilization teams (SMTs). Data is collated at regional, POs, and PPAF levels. The system affords the PPAF and the POs management real-time information on project progress, total and by subgroups. The database and data collection system can easily be amended to capture disability activities and would be utilized for this project. In order to ensure that beneficiaries themselves participate in project monitoring, two advisory councils (one in each of Azad Jammu Kashmir [AJK] and North West Frontier Province [NWFP]) comprising PWDs will be established. PPAF POs will hold quarterly meetings with these advisory councils to share progress update and seek advice for improvement. There will also be survey-based data collection. As a pilot project, aiming to assess the suitability of the project approach to eventually cover all of Pakistan, rigorous impact and process evaluation will be conducted with external technical assistance. It will have several elements: Overall impact on individuals and households: survey-based impact evaluation will be conducted at the end of the project focusing on the overall impact, comparing ex-post outcomes to the baseline data. Intervention-based evaluation will focus on specific interventions/treatments (such as psychosocial counseling, physical rehabilitation, or empowerment). Pilot replicability will also be assessed, focusing in particular on its organizational complexity, human resources requirements, affordability and sustainability.

5. Financing Source: Borrower Special Financing Total 6. Implementation

($m.) 0 5 5

The PPAF has well established criteria for selecting its POs, which will be followed by this project as well. The POs are identified and selected through transparent pre-selection criteria. The POs are expected to share the same values as the PPAF and to have the capacity to implement community projects. Under this project, the PPAF will enter into partnership with two groups of implementing partners: community partner organizations and specialized partner organizations. Government agencies cannot be POs of the PPAF under the terms described above. Instead, if a public organization (such as PIMS or any other public organization/institution) is chosen to deliver services under the project, it would be through a consultancy arrangement.

Six partner organizations have been tentatively identified as likely partners for this project, comprising of four existing POs (Islamic Relief, NRSP, SRSP, and Sungi) with whom the PPAF has on-going partnership agreements in the 34 targeted union councils and two disability and mental health specialized partners (Handicap International and PIMS). A tentative identification of partners has been conducted to assess capacity and interest in contributing to this project and to ensure rapid deployment of services once the project is effective. Partnership agreements with the pre-identified POs will be established based on desk reviews and field appraisals of proposals formulated by the POs themselves.

7. Sustainability
This project aims at securing sustainability through its partnership approach, exploiting synergies with the community mobilization and local development efforts. During the project implementation, the PPAF and its implementing POs will acquire considerable skills, knowledge, and awareness of disability and CBR which will enable disability mainstreaming into a range of development activities. For example, the PPAF will have competences in facilitating and advising potential partners on disability focused projects and in supporting their implementation. POs will have knowledge of social mobilization strategies on disability and how to stimulate and support disability initiatives at community level. Moreover, the project will widen the circle of service providers and organizations working on disability. All the involved organizations will be open to having PWDs as staff members. PWDs, their families and communities will have been empowered and will have knowledge about and enhanced coping strategies on disabilities. This being said, continuation of project activities once project financing has been used up will require new sources of financing to be identified, either domestic (philanthropic or government funds) or from foreign donors.

8. Lessons Learned from Past Operations in the Country/Sector 9. Safeguard Policies (including public consultation)
The safeguard Policy on Projects in Disputed Areas OP 7.60 will be triggered as the proposed project will be carried out in AJK, an area over which India and Pakistan have been in dispute since 1947. By financing the proposed grant, the World Bank does not intend to make any judgment as to the legal or other status of any disputed territory or to prejudice the final determination of the parties claims. Safeguard Policies Triggered by the Project Environmental Assessment (OP/BP 4.01) Natural Habitats (OP/BP 4.04) Pest Management (OP 4.09) Cultural Property (OPN 11.03, being revised as OP 4.11) Involuntary Resettlement (OP/BP 4.12) Indigenous Peoples (OP/BP 4.10) Forests (OP/BP 4.36) Safety of Dams (OP/BP 4.37) Projects in Disputed Areas (OP/BP 7.60)* Projects on International Waterways (OP/BP 7.50)
*

Yes [] [] [] [] [] [] [] [] [ x] []

No [x ] [ x] [ x] [ x] [ x] [ x] [ x] [ x] [] [ x]

By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas

10. List of Factual Technical Documents

ARTHQUAKE DISABILITY Bank Documents Back-to-Office Report: Social Protection Mission to Pakistan (November 22-December 8, 2005). Pakistan Earthquake Social Welfare/Disability (P099542) Statement of Mission Objectives (January17Febrauary 5, 2006). Back-to-Office Report: Social Protection Mission to Pakistan (January 17-February 5, 2006). Project Concept Note: PK Earthquake Social Welfare/Disability (P099542), May 17, 2006. Project Appraisal Document, PK Earthquake Social Welfare/Disability (P099542), May 22, 2006. Back-to-Office Report: Social Protection Mission to Pakistan Pre-appraisal Mission (June 2006). Back-to-Office Report: Social Protection Mission to Pakistan Appraisal Mission (July August 2006)

11. Contact point Contact: Rasmus Heltberg Title: Social Protection Economist Tel: (202) 473-5396 Fax: Email: rheltberg@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop