Tanzania - Health Sector Development Program

 ICRR 11931 Report Number : ICRR11931 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 09/10/2004 PROJ ID : P058627 Appraisal Actual Project Name : Health Sector Development Project Costs 654.0 519.1 Program US$M ) (US$M) Country : Tanzania Loan/ Loan US$M ) 22.0 /Credit (US$M) 21.3 Sector (s): Board: HE - Health (82%), Cofinancing 245.4 345.5 Health insurance (11%), US$M ) (US$M) Central government administration (7%) L/C Number : C3380 Board Approval 00 FY) (FY) Partners involved : DANIDA, GTZ/KFW, IRISH Closing Date 12/31/2003 12/31/2003 AID, SWISS, DFID, NETHERLANDS Prepared by : Reviewed by : Group Manager : Group : Elaine Wee-Ling Ooi Fernando Manibog Alain A. Barbu OEDSG 2. Project Objectives and Components a. Objectives This project was the first of 3 Adaptable Program Loans (APL) in the Health Sector Development Program (HSDP) which will support Government of Tanzania's (GOT) health sector reform. Using a sector wide approach (SWAP), the HSDP aimed to improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, to maximize impacts on health outcomes, especially among the poor, women and children. Phase 1(2000-2003) would however accelerate the reforms and emphasize institutional capacity development . Specifically, it focused on a ) strengthening human resource capacity (particularly at local levels) to manage and adapt to changing roles and responsibilities; b ) developing and piloting systems to improve quality and delivery of services to improve health status; and iii ) improving resource mobilization and management through increased coordination and strengthening of support systems . b. Components The IDA credit financed a "slice" of Phase 1 of the HSDP. There were 4 components: i) Strengthening Service Delivery : decentralized district health services; reforms of the secondary and tertiary levels of hospital services; public /private mix of service delivery (520m); ii) MOH ) and Central Support Systems : enhance MOH in sector wide ii) Strengthening the Ministry of Health (MOH) management; health management information systems (HMIS), drugs/medical supplies and other central support systems; human resources development and management (100m); iii) iii ) Health Financing : National Health Insurance Fund, Community Health Funds and user fees (27m); iv ) National HIV /AIDS Fund : development of National AIDS Strategy; scaled up multisectoral public and private iv) efforts and community based AIDS programs (6.7m). c. Comments on Project Cost, Financing and Dates The above in (b) were planned costs for each component from the project appraisal document (PAD), as actual costs/component were not available from the ICR . Total project costs were $519.1m of which IDA expended $21.3m. Support from other donors were higher ($345.5m) than anticipated ($245.4m) at appraisal. The project closed as scheduled on 12/31/2003. 3. Achievement of Relevant Objectives: The overall impact of the program with respect to health outcomes will be measured at the end of the third phase in 2011, as per the matrix in page 29 of the PAD. As such, for this project (first phase) no outcome measurements were available at the writing of the ICR. Overall, this project achieved its objectives (which were institutional building in nature ) as follows: a) Strengthened institutional and human resource capacity -- The capability of MOH at the central level has vastly been enhanced with respect to its mandate as overall sector oversight and management body . MOH has grown very well into its current role; capably managed the HSDP reforms and coordinated all donor activities and financing within the medium term expenditure framework (MTEF) and the district funding baskets . (Health Sector is the only one with MTEF). MOH has demonstrated full commitment to and ownership of the SWAP . National technical guidelines and regulations concerning the Essential Package of Health, and Quality Standards & Criteria for District Health Services have been issued. At the local levels, training in planning, budgeting and financial management was provided to Council Health Management Teams, and zonal training centers were strengthened . 200 HIV/AIDS counselors were trained and counseling and testing centers set up in 170 facilities. More than 200 community based organizations now offer home based care for HIV /AIDS victims in 28 districts. Nonetheless human resources management/development within the sector, is comparatively one of the weaker elements in Phase 1. b) Developed systems to improve service delivery -- As part of the district health system, 113 Council Health Management Teams were established (appraisal target was only 1/3 of this number) and they have prepared comprehensive health plans against which they have received block grants . New resource allocation criteria were applied here, based on population size, poverty index, health status (under 5 mortality), and remoteness of the area. Procurement of supplies for several vertical programs were successfully integrated, and drug availability at facility level has improved considerably . User Satisfaction Surveys were introduced with initial good results but it is unclear if they have been consistently applied . A number of Accreditation and Quality Assurance programs (overseeing voluntary and private hospitals, drugs dispensing outlets, ante -natal care surveillance for HIV/AIDS at the district level, and private providers to the National Health Insurance Funds ) were initiated, but thus far, not all have been fully functional. c) Improved resource mobilization -- Joint financing mechanisms which aided in harmonizing implementation procedures and avoiding duplication and overlap were put in place . MTEF for the health sector was fully institutionalized, with almost 80% of donor funding reflected in the MTEF (exceeding the 50% planned). District Basket Funding (where donors pool all their resources together at the district level ) has also taken hold eventhough it fell short of the anticipated amounts at appraisal . (The mechanism was strongly supported by DANIDA which would like it continued into subsequent phases . In phase 2, IDA health funds are likely to go towards general budgetary support via the Poverty Reduction Support Credit (PRSC). It remains to be seen thus if the health sector will continue to receive sufficient resources from GOT .) The National Health Insurance Fund established shows promise and currently covers 245,000 civil servants; while the pre-payment health scheme under the Community Health Fund (envisioned for rural Tanzania ) has had mixed results. User fees were introduced by the National Muhimbili Medical Center, and secondary and tertiary hospitals will start contacting out non -professional functions to the private sector . A Private-Public Partnership Steering Group was formed (with private sector participation ) and has drafted a Standard Service Agreement between MOH and non -public hospitals (missionary and private, for profit ). All key performance measures and triggers for phase 2 were achieved as planned. 4. Significant Outcomes/Impacts: Firm adoption of the MTEF and other joint financing (district baskets) /implementation/monitoring procedures (annual public expenditure reviews (PER), annual joint reviews) by the majority of donors and MOH. Fully functioning district level health planning, delivery and financing mechanisms in place, where there is close engagement of district health teams and the Ministry of Regional Administration & Local Government . Institutionalization and adoption of many critical reforms for the sector, including establishment of the National Health Insurance Fund (which usually encounters strong opposition from stakeholders ) A fully committed and motivated MOH increasingly taking a strong lead in a sector with multiple donors . 5. Significant Shortcomings (including non-compliance with safeguard policies): Human Resources Management issues are still weak . An Independent Study on Human Resources in Health (2003) where Tanzania was a case study, reported the Tanzanian health civil workforce as grossly insufficient in quantity and quality. Attempts by project to revise the incentive and remuneration package for health manpower was rejected by Civil Service Department . Quality Assurance in a variety of areas (including use of HMIS) was not sufficiently strengthened as planned . Monitoring of achievement of these quality goals was not done systematically . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory Institutional Dev .: Substantial Substantial Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. NOTE: 7. Lessons of Broad Applicability: When there is a general move by IDA and other donors towards general budgetary support, as with a Poverty Reduction Strategy Credit (PRSC), certain sectors (health in this case) may become at risk of being "neglected"  by the government, ie the Ministry of Finance . It is important that Ministry and Health and donors (including IDA) continue to take action to ensure the required funding for health is not diminished . This tendency by MOF to neglect the health sector is already evident in this project where, with donor financing increasing in the sector, government spending (as a percentage of total sector spending ) has decreased - (applies only to 2004) Human resources issues in the health sector pertaining to incentives and improvement of service delivery, cannot be fully resolved without corresponding reform /action taken within the civil service as a whole . As reforms require new and diversified skills, investments in staff training have to be wholly integrated with the reform program with the appropriate resource allocation . 8. Assessment Recommended? Yes No Why? After the completion of the third phase in 2011 this program should be assessed . In this first phase good reforms and progress have been initiated and already demonstrating results in efficacy and efficiency . This has been a good SWAP experience with reasonably good donor coordination and harmonization of programs . Within Tanzania, the health sector is the first and only sector to have a MTEF . There are lessons to be extracted from this project. It will be also be interesting to see if the use of APL as a lending instrument gives the project added flexibility to adjust to the pace of reforms introduced . 9. Comments on Quality of ICR: ICR is satisfactory. However discussion/portrayal of project costs and cross referencing with PAD and PER FY 04 data are somewhat confusing, inconsistent and at times incorrect (increase in basket funds FY 03 to FY02 was 39% not 71%). ICR is commended for obtaining the comments from 4 co-financiers in addition to those of the Government. These comments provide us with a more comprehensive picture of project implementation and specifically its SWAP experience .