Colombia - Health Services Integration Project

Document of The World Bank FOR OFICLAL USE ONLY Report No. 13574 PROJECT COMPLETION REPORT COLOMBIA HEALTH SERVICES INTEGRATION PROJECT (LOAN 2611-CO) SEPTEMBER 30, 1994 Human Resources Operations Division Country Department III Latin America and the Caribbean Regional Office This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  GLOSSARY AT-PAS Asistencia Tecnica-Plan de Ajuste Sectorial (Technical Assistance-Sector Adjustment Plan) CGR Contralorfa General de la Republica (General Colombian Comptrollership) DNP Departamento Nacional de Planeaci6n (National Planning Department) FNH Fondo Nacional Hospitalario (National Hospital Fund) GOC Government of Colombia ICBF Instituto Colombiano de Bienestar Familiar (Colombian Institute of Family Wellbeing) INS Instituto Nacional de Salud (National Institute of Health) ISS Instituto de Seguros Sociales (Social Security Institute) LA Loan Agreement MOF Ministry of Finance MOH Ministry of Health PCR Project Completion Report PHC Primary Health Care PMU Project Management Unit PNR Plan Nacional de Rehabilitaci6n (National Rehabilitation Plan) SAR Staff Appraisal Report SENA Servicio Nacional de Aprendizaje (National Vocational Training Service)  FOR OFFICIAL USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A. Office of Director-General Operations Evaluation September 30, 1994 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on Colombia Health Services Integration Project (Loan 2611-CO! Attached is the Project Completion Report on Colombia - Health Services Integration Project (Loan 2611-CO) prepared by the Latin America and the Caribbean Regional Office. Part II was prepared by the Borrower. The project aimed to expand primary health care coverage, increase efficiency, and strengthen sector management. Changes in Government water policy, a decision to decentralize health delivery, and lack of implementation capacity resulted in reprogramming and substantially down-sizing the project. The revised project focussed mainly on technical assistance to support the decentralization program. Implementation was fraught with difficulties, some stemming from internal security problems; but in addition, both borrower and Bank performance was inadequate. While in the end some useful assistance for the decentralization program in the form of local technical assistance and training was provided, the project outcome was unsatisfactory and sustainability is unlikely. Institutional development was quite modest. The PCR is of good quality. No audit is planned. Robert Picciotto by H. Eberhard Kopp Attachment This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.   FOR OFFICIAL USE ONLY COLOMBIA PROJECT COMtPLETION REPORT HEALTH SERVICES INTEGRATION PROJECT (Loan 2611-CO) TABLE OF CONTENTS Pagye No, PREFACE .................... i EVALUATION SUMMARY .................... ii I. PROJECT REVIEW FROM BANK'S PERSPECTIVE. 1 Project Identity .......... I Background .1 Sector Development Objectives . Policy Context . Linkages Between Project, Sector and Macro Policy Objectives .2 Project Objectives and Description. 2 Project Objectives .2 Project Componentes .3 Project Design and Organization. 4 Project Implementation .5 Project Results .7 Project Sustainability .8 Bank Performance .8 Borrower Performance ......... ........................ 10 Project Relationship .................................. 11 Consulting Services ................................... 11 Project Documentation and Data ........................... 12 II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE ... ...... 12 EII. PROJECT PROFILE AT TIME OF COMPLETION .... .......... 19 ANNEX 1 - PEOPLE CONTRIBUTING AND/OR iTTERVIEWED ...... 29 This document has a restricted distribution and may be used by recipients only in the perfonnance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.   COLOMBIA HEALTH SERVICES INTEGRATION PROJECT (Loan 2611-CO) PROJECT COMPLETION REPORT PREFACE This is the Project Completion Report (PCR) for the Health Services Integration Project in Colombia, for which Loan 261 1-CO in the amount of US$36,500,000 was approved on July 30, 1985. The Government of Colombia (GOC) requested cancellation of sections of the loan on three occasions for a total reduction of US$18.95 million. The closing date was postponed to June 30, 1993, a twelve-month extension from the original closing date. Ninety-six (96.6) percent of the rescheduled loan was disbursed and the last disbursement was on September 16, 1993. The PCR was jointly prepared by the Human Resources Division of the Latin America and Caribbean Regional Office, Department III (Preface, Evaluation Summary, Parts I and III), and the Borrower (Part II). Part I is based, inter alia, on the Staff Appraisal Report (SAR); the Loan Agreement (LA) and its amendments; supervision reports; a consultant's report on the completion of physical facilities, and the Bank's correspondence files. Part II was prepared by the staff of the Project Management Unit (PMU) before it was partially disbanded in July 1993, and officially submitted by the GOC on November 16, 1993.   EVALUATION SUNIMARY Project Objectives and Content 1. This first health sector project in Colombia proposed to support sector development through expanding Primary Health Care (PHC) coverage, increasing efficiency, and strengthening sector management. The project objectives aimed at: (1) strengthening 19 of the 107 health regions through improved management, infrastructure, trained staff and greater community participation in areas with minimal access; (2) expanding rural water supply; (3) increasing service delivery efficiency through improved cooperation between the Social Security Institute (ISS), the Ministry of Health (MOH), the Colombian Institute of Family Wellbeing (ICBF), the National Institute of Health (INS) and other institutions; (4) improving the maintenance of plant and equipment; (5) developing information systems to support planning and control functions; (6) reinforcing the national laboratory network; and (7) conducting research studies relevant to operational problem solving and policy issues. Changes in the government's water policy, a mid-term evaluation in 1989, a new health law emphasizing decentralization, and lack of implementation capacity, resulted in a reprogramming of activities in 1987, and a downsizing of the project in 1990 and 1991. The 1990 reformulation of the project refocussed the objectives to: (1) offer technical assistance to strengthen the administration capacity of the health system in order to improve health service delivery, mainly in relation to the proposed decentralization, institutional reorganization, and municipal autonomy established by Law 10 of 1990; (2) support the process of development through a plan of human resources training which would provide national and international opportunities in specific knowledge areas, and through the dissemination and training at the departmental and municipal levels to prepare them for the introduction of the institutional reorganization of the sector; and (3) provide technical assistance for small water supply projects through the Technical Assistance-Sector Adjustment Plan (AT- PAS) of Loan 2916-CO (Water Supply and Sewerage). Implementation Expenence 2. The project encountered a time of extreme changes both in organization and policy in the Borrower country and in the Bank. In Colombia, weak implementation capacity, delays in obtaining counterpart funds, lack of adequate staffing at the start of the project, high turnover of key personnel (12 Ministers of Health and seven Project Coordinators from preparation to project completion), and problems of coordination affected, in some phases of project implementation, the country's ability to execute activities. An overseer committee formed with members of the National Planning Department (DNP), the MOH, the INS, the National Hospital Fund (FNH), and the Bank Resident Mission met sporadically, with the purpose of exchanging ideas about improvements in project execution, but with little effective results; over the years it was dismantled. The project was not adopted by successive MOH personnel in its original spirit or design; it was caught in a transition period of policy and institutional changes in the health and water sectors; and failed to integrate itself into the MOH. The Bank, as well, was undergoing an important reorganization (1987), with implications for personnel tumover, incomplete files, and policy changes in project design, more oriented towards the prioritization  iii of innovative responses to sector issues. All of the initial staff had left the project before the second year of implementation was completed, resulting in certain lack of continuity. The technical expertise to assist the country in problem solving, such as assistance in identified auditing and accounting difficulties, was not always available during the transitional times and for reasons of political turmoil in the country. 3. In 1987 the Government of Colombia (GOC) was launching a special effort to address socio-economic problems in the most disadvantaged regions of the country. These neglected rural areas were targetted for assistance through two development programs--National Rehabilitation Plan (PNR), and the Poverty Eradication Plan. At the same time, the Administration was implementing its newly adopted decentralization policies that have delegated water sector responsibilities from the MOH to the Ministry of Public Works. Consequently, the Government requested the Bank to redirect the funds of the project earmarked for the rural water works to health care delivery activities in the PNR areas. The amendment to the Loan Agreement (LA) of September 1987 enlarged the geographical coverage of the project from 19 Health Regions to 22 Departments; and the water works were included in a Water Sector Loan. A mid-term evaluation carried out in 1989 which demonstrated difficulties in implementation, and the passing of a new Health Law (Law 10 of 1990) emphasizing municipal instead of regional responsibilities for health, brought about a request from the MOH and DNP to reformulate the project, cuting down non-priority activities and focusing in technical assistance to prepare the normative and procedural modifications of the system and the strengthening of the managerial capacity for the implementation of Law 10; and earmarking an amount for the preparation of a new project. As a result of the reformulation, cancellations of US$7.7 million, US$4.75 million, and US$6.5 million took place in March 1990, July 1990, and August 1991 respectively. In total, US$18.95 million were cancelled, reducing the total project loan to US$17.5 million. Also, in 1991 at the insistence of one Minister of Health, US$400,000 from this loan were made available for technical assistance activities in the area of small water supply and sewerage works managed by the Technical Assistance-Sector Adjustment Plan (AT-PAS) project (Loan 2916-CO). 4. The FNH was in charge of the procurement of medical equipment for the national laboratory network, financed by the loan, as well as of the procurement of medical equipment, vehicles, computers and software, and equipment for basic environmental services to be financed by export credits. Despite a strong effort from the Bank to help in the preparation of bidding documents, delays of up to four years occurred before the bidding process was started. This, coupled with cumbersome public sector procedures for the approval of contracts, resulted in delays in the reception and installation of the equipment, cancellation of the orders for vehicles due to price increases and the closing of the project, and complaints of the MOH that the computers ordered with specifications prepared in 1987 were obsolete when received in 1993. 5. The FNH was also responsible for the execution of civil works for the component Attention to People, and the INS was in charge of the civil works for the component Attention to the Environment. The latter legally ceased to execute activities in January 1989, and the unfinished works were cancelled during the reformulation of the project. The FNH performed  iv a very weak supervision of the works, allegedly because of lack of staff, and despite the availability of funds from the loan for hiring consultants. The MOH sent counterpart funds to the regions, sometimes without a clear indication of its specific use. In some regions, the money was simply kept in their bank because of lack of implementation capacity; and the supervision reports prepared by the Regional Coordinators, and the accounting books of the regions did not match. It is clear that flows of funds were not well defined in the project design. Extremely limited budget allocations continues to hinder the maintenance of infrastructure and equipment. The Government's perception that the creation of maintenance workshops for hospitals has not been effectively implemented resulted in the discontinuation of the National Vocational Training Service (SENA) involvement in training maintenance technicians in the early years of project implementation. Successive qualified opinions in audit reports failed to be taken into consideration by the Borrower until the last years of project implementation. However, corrective measures were taken after pressure from the Bank and at the initiative of the last project coordinator. Project Results 6. The initial, ambitious objectives were partially effected, especially civil works for PHC with the construction of 14 new health centers and 77 new health posts. Fifteen regional and 34 local hospitals, and eight maintenance workshops were remodelled, with 36 health centers and 55 health posts upgraded. In total, civil works for service delivery were completed in 86% for new and 53% for remodelled establishments, notwithstanding the difficulties posed for implementation and monitoring by the security situation. The public health laboratories at the regional and departmental levels were re-equipped. During the first five years of the project, the upgrading of skills of 5,617 persons in PHC areas was realized with an additional 4,000 community leaders having participated in the training exercises oriented towards stimulating community participation in health. Technical assistance and research supported by the project paved the way for the elaboration of the new law. This legislation revolutionized the health sector in Colombia by decentralizing the responsibility for the operation of health services delivery to the municipal authorities. Approximately 10,000 persons were trained during project implementation and 150 meetings were held at municipal and departmental levels to sensitize personnel for the application of the new Health Law. Development of regulations for the new law, and the strengthening of hospital management through technical assistance from universities, as well as the preparation of the Municipal Health Services Project approved on June 8, 1993 (Ln 3615-CO) were supported by the loan. The training activities and the technical assistance provided in the last years of the project facilitated a strengthening of the local level and their preparedness for assumption of responsibilities under the municipalization of health. There were severe limitations posed for both national and Bank supervision when certain regions of the project were inaccessible due to security problems. Supervision from the Bank was limited by travel regulations. The project closed after a 12 month extension, having disbursed 46.3% of the original loan, or 96.6% after restructuring it.  V Project Sustainability 7. This project was instrumental in supporting the process of providing the legal framework for restructuring health care services in Colombia, and as such becomes part of a long-term strategy. Its ambitious design was appropriately scaled down to make it more manageable and to respond to the new policy framework. The intended institutional building capacity at the central level did not materialize as expected due to the high turnover of Ministers during the life of the project which impeded a positive integration of the project into the MOH, and the lack of clarity in the initial design on the nature of each component. Technical assistance and training efforts were beneficial to advance the decentralization of health services and the readiness of the participants to assume their roles in the restructured system. Findings and Lessons Learned 8. The major lessons learned during project implementation which are common to the Bank and the Borrower are summarized as follows: (a) Project design should not be overambitious. Furthermore, should a loan need to be adapted to changing circumstances in the policy and institutional setting of the sector, flexibility in reformulating project design and implementation arrangements to accomodate the new reality should be the answer. (b) Implementation agencies should be kept to a minimum to facilitate clarity of responsibilities. Greater attention should be paid to institutional arrangements for project implementation, especially if the project is broad-based in scope. (c) Detailed implementation plans should be defined in a Project Implementation Manual, including detailed terms of reference for all technical assistance and training activities; and working drawings for civil works. This would guide project implementation, counteract personnel turnover, and facilitate availability of counterpart funds. (d) Auditing responsibilities solely in the hands of the General Colombian Comptrollership (CGR), tend to be slow in completion, and subject to intra-agency conflicts and political interference. Private auditing, could facilitate timely submission of reports. In addition, lessons of particular interest to the Borrower are as follows: (a) Ownership and continuity could be increased by assuring participation of MOH operational level personnel during preparation, appraisal, and implementation stages of the project. Also, mechanisms which would allow the strengthening of existing capacity within the system should be introduced to sustain the planned development.  vi (b) Enlarging the geographical area of the project with evidenced management problems should be weighed against the political importance given these areas. Additional lessons learned for the Bank are as follows: (a) Difficulties with coordination of supervision activities between sectoral divisions in the Bank fosters confusion at the managerial level in the country. (b) When security problems force the use of alternative supervision mechanisms, the interaction with the Borrower suffers.   COLOMBIA HEALTH SERVICES INTEGRATION PROJECT (Loan 2611-CO) PROJECT COMPLETION REPORT PART I. PROJECT REVIEW FROM BANK'S PERSPECTIVE 1. Pro2ject Identity Project Name: Health Services Integration Project Loan Number: 2611-CO RVP Unit: Latin America and the Caribbean Region. Country Department m Country: Colombia Sector: Health Subsector: Primary Health Care Services 2. Background 2.01 Sector Development Objectives. (at time of project appraisal). In 1985, the Government of Colombia (GOC) had assumed various initiatives to increase Primary Health Care (PHC) coverage and improve child and infant health and nutrition, environmental conditions, and reduce high mortality and morbidity. The GOC's demonstrated concern for increasing coverage, and effectiveness, accompanied by the development of efficient management practices was reflected in the Health Plan of 1983-86. Several previous Bank loans in Nutrition and Rural Development had supported infrastructure development at the PHC level. To support the extension of these goals, this project was formulated to develop a comprehensive approach to improving sector efficiency and to strengthen management while extending access to services to those most in need. 2.02 Policy Context. In 1982, the GOC selected the Pacific Coast and border areas as priority zones for accelerated multisectorial economic and social development. The World Bank's Health Sector Review (Report No.4141-CO) of 1982, with which the GOC concurred, identified equity, efficiency and effectiveness in health care delivery as salient issues. A 1984 presidential commission had created a technical committee for coordination between the Social Security Institute (ISS) and the Ministry of Health (MOH) identifying geographical areas for implementation. The National Institute of Health (INS) and MOH had, in 1984, clear responsibilities for water and sanitation services in the rural areas, and the National Hospital Fund (FNH), as the procurement arm of the MOH, was to be strengthened to assume fiscal  2 management responsibilities in addition to those of hospital maintenance and equipment. While decentralization of health services was discussed, the creation of regional bodies, mentioned in the 1983-86 Health Plan was not yet implemented, and decisions continued to be centralized. 2.03 Linkages Between Project. Sector and Macro Policy Objectives. The Ministry of Finance (MOF), the National Planning Department (DNP), the ISS, the MOH, through its service and human resources representatives and its semi-autonomous institutions, and even members of Parliament, all participated actively in the design phase of the project. As identified above, the structure for implementing an integrated approach in PHC for targeted priority populations was in place. Colombia was experiencing, however, a time of great transition in the organization and orientation of the government. Decentralization of state responsibilities was being developed, the drafting of the new Colombian constitution was in progress, and change was a constant. For example, in the health sector, the passage of the decentralization law (Law 10 of 1990), facilitated by information from studies supported by this project, also clearly demonstrated the need to reorient some activities originally included in the project design. Additional modifications became necessary due to reorganizational efforts which separated water and environmental concems from the MOH. 3. Project Objectives and Description' 3.01 Project Objectives. (1) strengthen 19 of the 107 health regions through improved management, infrastructure, trained staff and greater community participation in areas with minimal access to PHC; (2) expand rural water supply; (3) increase service delivery efficiency through improved cooperation between ISS, MOH, INS, the Colombian Institute of Family Wellbeing (ICBF), the National Vocational Training Service (SENA), and others; (4) improve the maintenance of plant and equipment; (5) develop information systems to support planning and control functions; (6) reinforce the national laboratory network; and (7) conduct research studies relevant to operational problem solving and policy issues. These objectives were to change several times during the life of the project. The first amendment to the LA of September 1987 responded to changes in the mandate of the MOH and INS for rural water supply, which was transferred to the Ministry of Works, and to the GOC's interest in supporting the zones included in the National Rehabilitation Plan (PNR), designed to address socio-economic problems in the most disadvantaged regions of the country. As a consequence, the GOC's requested to expand the scope of the project to 22 departments. The project was restructured, with the funds previously allocated to rural water works being redistributed to the newly incorporated regions for civil works and training for health. After a mid-term evaluation (September 1989) which demonstrated difficulties in implementation, and the passing of a new Health Law (Law 10 of 1990) emphasizing municipal instead of regional responsibilities for health services delivery, the GOC requested cancellations of US$7.7 million in March 1990 and I The statement of the objectives and components in the original project documents (Staff Appraisal Report (SAR) and Loan Agreement (LA) vary somewhat, although the scope remains the same. Those included have been chosen to illustrate the complex elements of the project.  3 US$4.75 million in July 1990. The project was reduced again with an additional cancellation of US$6.5 million in August 1991. Reorientation of the project focussed on providing technical assistance and training during a transitional period while preparation of a new project, more in line with the new country policies and goals in health funded by the loan was underway. The revised objectives of the revision were to: (1) offer technical assistance to the Health Care System to strengthen its capacity for the delivery of health services and in relation to the proposed decentralization, institutional reorganization, functional integrity and municipal autonomy as established by the new law; (2) support the process of development through a plan of training human resources which would provide national and international opportunities in specific knowledge areas and in dissemination and training for institutional reorganization in the sector; and (3) provide technical assistance for small water supply projects through the Technical Assistance-Sector Adjustment Plan (AT-PAS) of Loan 2916-CO. The arrangement with the AT- PAS program was in the interest of maintaining consistency within Bank loans to the GOC in matters of rural water projects. 3.02 Project Components. The project had four components: (1) the organization and delivery of low-cost basic health care services; (2) the organization and delivery of basic environmental health services; (3) strengthening the capacity of the INS laboratory network and (4) institutional development. Within the first component the following were considered: (a) construction and equipping of three local hospitals, seven health centers, and 53 health posts; remodelling and upgrading of eight regional hospitals, 29 local hospitals, 27 health centers, and 53 health posts; (b) strengthening the maintenance capacity of regional and local hospitals by remodeling and upgrading 19 maintenance workshops, and training maintenance technicians; (c) carrying out training programs for professional staff including, inter alias (i) management training for regional managers, physicians and supervisors, (ii) upgrading of professional skills, mainly at the auxiliary nurse and health promotor levels, and (iii) in-service training for other health workers; and (d) acquisition of vehicles for utilization in health care services delivery and supervision. The second component contemplated: (a) installation, expansion or rehabilitation of piped water supply systems and school sanitary units in about 250 rural communities, including acquisition of equipment; (b) a program to strengthen INS capabilities for implementing the basic rural sanitation program, including technical assistance, training of INS personnel, and acquisition and utilization of vehicles and equipment; (c) developing a national rural water supply development plan; (d) acquisition and utilization of vehicles and equipment for supervision and vector control; and (e) training programs for sanitary engineers and sanitation promoters. The third component proposed to: (a) carry out training programs for operational and maintenance personnel of INS laboratories; (b) prepare and adopt preventive maintenance manuals; and (c) acquire and utilize laboratory equipment for the INS central laboratory and the MOH's sectional and regional laboratories in the project area. The fourth component, institutional development, focussed on strengthening the capabilities of the health sector institutions by: (a) developing planning and control systems (strategic, management, financial control, cost containment, monitoring and evaluation); (b) improving the quality of information supporting decision making by: (i) reviewing and revising the information systems network, (ii) carrying out training programs for data input operators, programmers and systems analysts, and (iii) acquisition and utilization of equipment for MOH at the national level and its sectional and regional levels in the project area;  4 (c) carrying out training programs for health sector institution's personnel in the project area and in about six other regional health units; (d) carrying out studies as required to foster the objectives of the project; and (e) operating a unit assisting the MOH's Secretary General in the management of the project. During the project lifetime, changes were made which affected all of the components. The civil works were increased to support the PNR zones, anticipating the additional construction of one regional and two local hospitals, eight health centers, and 36 health posts. In the remodeling and upgrading aspects, 11 regional hospitals, 31 local hospitals, 38 health centers, and 71 health posts were added. Maintenance workshops were incorporated into the remodeled or newly constructed regional hospitals. The aspects related to INS rural water supply, training of sanitary engineers and technicians and the INS central laboratory were deleted, although the MOH's sectional and regional laboratories were retained. Eventually, with the restructuring of 1991, the project evolved into the provision of technical assistance and training for a transitional period. 4. Project Design and Organization 4.01 As can be identified from the variety of objectives, number of participating agencies, and different levels of implementation activities (national, regional, departmental, and local), the project envisioned a complete, integral system, consistent with Colombian policy and the World Health Organization recommendations emanating from the "Health for All by the Year 2000" declaration of which Colombia was a signatory. The design followed this framework, proposed to concentrate on some of the lesser developed areas, increase equity in health and achieve these goals through a collaborative process among different providers. As such, it provided an attractive and innovative alternative to existing inequity and fragmentation, albeit within a model which tended to rely on the more centrally oriented decision making in place at the time. 4.02 The MOH had assembled a highly motivated and competent team for project development. It is doubtful, however, that they were experienced in the fiscal management of such an investment plan, nor were they or the Bank able to estimate with accuracy the demands that such an ambitious program would place on an already inefficient system. They did provide detailed information on each of the participating departments including health care delivery, community services, population information, sanitation and infrastructure needs, all complete with computer models. Other agencies, already mentioned, participated in the design, although in retrospect, it is possible that the full magnitude and scope of the implications for local deployment of resources- personnel, financial, and material- may not have been understood due to a lack of a detailed implementation plan with specific roles and responsibilities for each. For instance, the role of ICBF was unclear from the SAR; consequently it is not mentioned in the LA. GOC changes and the high rate of turnover of key persons responsible for project activities (12 Ministers of Health and seven Project Coordinators) left the project without a core group which had participated in and understood its purpose. This was particularly damaging at the critical start-up phase. 4.03 Although the Health Sector Review Report of 1982 and the preparatory work recognized management and human resources areas as weaknesses, project design did not take into  5 consideration this fact and was overly ambitious. When the expansion of project areas was required to include those judged as priorities in the PNR, a project difficult to implement, became even more so. The Bank, however, accepted the proposed amendment. Not only did the geographical scope and the number of civil works increase, but the number of departments involved, each with its own priorities and autonomous civil governments with which to deal during project implementation increased. Whereas originally nine departmental level governments had been involved, the number became 22. Because of the decentralization brought about by Law 10 of 1990, at the end of the project, 105 separate entities, not all at the same level, were involved. An additional factor which was to hamper efforts was the consideration of Colombia as a more homogeneously functioning country than it was. Overconfidence in the quality of human resources available for local implementation resulted in the absence of critical management support provisions, especially at regional and operative levels. The project's focus on underprivileged areas required additional resources, strategies, incentives and other inputs to stimulate development at the local levels which were not included, perhaps because the design was developed basically on a conceptual basis by national consultants and central level functionaries, without extensive discussion with the implementation level personnel as to feasibility of implementation. 4.04 The SAR identified the risks inherent in the need for cooperation between several agencies that provide health, population and nutrition services, water supply, construction services, and equipment maintenance. This risk was meant to be minimized through the strengthening of the regional management capacity, through technical cooperation by more developed to less developed health regions and by interagency cooperation agreements. The project area was divided into five regions headed by zonal coordinators, each in charge of a manageable number of departments, to assist in the interagency coordination and day to day decisions. They were dismissed after the reformulation of the project in 1991. Detailed monitoring and evaluation criteria were not available at appraisal for the components, even though their absence had been noted and their elaboration requested. 5. Project Implementation 5.01 The project was downsized from an initial US$36.5 million to US$17.5 million; 96.6% of the lower amount was disbursed. A start-up setback of four months was experienced due to delays of the GOC in meeting conditions of effectiveness (setting up project accounts and signing agreements among implementing agencies). The initial design called for an implementation period of six years with an additional 12 months for loan closing. The GOC requested a six- month extension of the closing date, which was amended to one year by Bank recommendation and mutual consent in order to facilitate full disbursement for commitments entered into during fiscal year 1991 and technical assistance activities taking place in calendar years 1992/93 (mainly the preparation of a new project). 5.02 The FNH was in charge of the procurement of medical equipment for the national laboratory network, financed by the loan, as well as of the procurement of medical equipment, vehicles, computers and software, and equipment for basic environmental services to be financed  6 by export credits. Despite a strong effort from the Bank to help in the preparation of bidding documents, FNH's insistence on continuing with previously established work patterns caused a four-year delay before the bidding process was started. This, coupled with cumbersome public sector procedures for the approval of contracts, resulted in delays in the reception and installation of the equipment, and cancellation of the orders for vehicles due to price increases and the closing of the project. It also resulted in procurement of items that were considered obsolete by the time of reception. For example, computers to be bought with export credit funds, were contracted in 1990 with 1987 specifications, and delivered in 1993. 5.03 The FNH was also responsible for the execution of civil works for the component Attention to People, while the INS was responsible for the civil works of the component Attention to the Environment. INS legally ceased to execute these activities in January 1989, and the unfinished works were cancelled during the reformulation of the project. The FNH perforned a very weak supervision of the works, allegedly because of lack of personnel and counterpart funds. The MOH advanced own resources to the regions, sometimes without a clear indication of the purpose; and some regions just kept the money in their bank because of lack of implementation capacity. In some cases, moneys were used for purposes different from the project, but the facts were detected by the auditors and reported in qualified opinions in the audit reports. The Regional Coordinators, however, failed to follow-up on the matter. In later years, and after pressure from the Bank and the initiative of a new Project Coordinator, corrective measures were introduced. Supervision of civil works by Bank staff was made difficult by security issues due to political unrest and drug trafficking activities. Institutionalization of maintenance as a routine activity through FNH was limited, principally due to insufficient national budget allocations, leaving this necessary activity deficient, and investments unprotected. The hability to organize the reception of goods with the finalization of construction work was not always good, and the result is that some equipment bought with project funds was unable to be installed due to lack of infrastructure, technical capacity of personnel, or training available on its use. The training of maintenance technicians by SENA was phased out once the project was reformulated in 1990. 5.04 Although the initial project design included strategies to address the perceived risks, the proposed actions were insufficient. The magnitude of managing the different components, each of which could have been developed as a separate project, and the efforts required to consolidate the different entities in cooperative actions, proved to be unsurmountable, given the political context of decisions within the country. The non-compliance of GOC to follow through on commitments, such as the timely availability of counterpart funds, added to the bureaucratic delays. The flows of funds were not well defined in the project design. Complicated approval procedures internal to the govemment also impeded progress. The physical isolation of the PMU offices, intemal differences among participating agencies and the lack of integration of the project into the MOH structure gave rise to claims of a parallel organization, competitive with the MOH. Management from the PMU was made difficult since many of the implementing agencies made their own technical judgments, and the project activities did not appear to be seen as integral to their overall plan by rotating decision makers. The reliance on consultants rather _ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - -------  7 than line personnel to staff the PMU left them without the necessary weight within the system to negotiate these difficulties. 5.05 The recommendations resultant from the mid-term evaluation (1989) stipulated in the LA, Section 3.01 (j), established clearly the need to restructure the project, which was supported by the GOC and Bank staff and was followed by three different cancellation requests and a reorientation of activities. These modifications to the LA accompanied the changes in the health sector and reflected Bank practice of scaling down those components poorly managed or no longer considered a priority. Following the last reformulation in 1991, the project focussed on a well-defined set of tasks. Only when the project focussed on managerial training at hospital levels and deployed heavy technical assistance to the regions at the level of the municipalities to strengthen their capabilities to manage and deliver health care services, it attained clearly its objectives. 6. Project Results 6.01 In spite of difficulties, the following results have been important. The studies completed in 1988/89 contributed useful information for the development of Law 10, the municipalization of health services, which provides a new structure for the delivery of health care services in Colombia. The studies were organized in three groups: (1) financing, social security, and nutrition; (2) diagnosis of the health sector, infrastructure, and basic health; and (3) research, human resources, and decision-making processes. They were published in two volumes and made available to the public. During the first five years of the project, the upgrading of skills of 5,617 persons in the PHC areas was provided, with an additional 4,000 community leaders having participated in training exercises oriented towards stimulating community participation in health. During the latter years, 150 events were sponsored to encourage dialogue, questions and preparation for the implementation of the new health law. These training activities and the technical assistance provided in the last several years of the project facilitated a strengthening of the local level and their preparedness for assumption of responsibilities under the municipalization of health. With respect to the strengthening of hospital management, five nucleus composed of universities, health services and university hospitals were created in the Costa, Antioquia, Bogota, Valle and Santander regions, each one under the supervision of a manager. Each nucleus contained an average of 8-10 hospitals. Technical assistance was provided to them through three universities. National and international scholarships on a variety of subjects took place in the latter years of project implementation. 6.02 Of the 110 new constructions and 268 remodelling or upgrading works planned in the amended project, 95 (86%) of the new and 140 (53%) of the remodelled were completed. Of the remodelling group, only 44% of the health posts were completed, while 57% of local hospitals, and 55% and 79% of health centers and regional hospitals were completed, appearing to demonstrate a bias towards new construction and larger civil works (see Part HI, Tables 7 and 8). The regional and departmental laboratory network was re-equipped, including physical upgrading in one case. Eight maintenance workshops were remodelled. Very few vehicles were bought at the beginning of project implementation for health services delivery and civil works  8 supervision. The larger order to be procured with export credits was cancelled due to bureaucratic delays in contract signing and price increases. Rural water supply and environment were supported by technical assistance channelled through the AT-PAS program (Ln 2916-CO). Support was provided for the preparation of the Municipal Health Services Project (Ln 3615- CO). The strengthening of the MOH's existing central level capacity was quite limited, due to the many changes in structure and personnel as well as the lack of integration of the project into MOH. 7. Project Sustainability 7.01 The initial project design proved difficult to implement and therefore was redimensioned to make it more manageable and to respond to the new policy framework. Institutional-building capacity was not achieved in any of the project areas as envisioned under the original design, partially due to excessive changes in the MOH structure of responsibilities for health care delivery, the failure of the original regional authorities to become part of the system, personnel turnover, lack of management involvement of local level personnel, lack of clarity in the initial design on the nature of each component, and heavy reliance on consultants. Technical assistance and training efforts were beneficial to advance the decentralization of health services and the readiness of the participants to assume their roles in the restructured system. 8. Bank Performance 8.01 An over optimism would seem to have prevailed at the time of design due to the presence of a highly competent national team and the knowledge of resources generally available in the country. This however did not reflect the situation in the local implementation areas, leading to serious implementation problems. For a first project in the sector, the inclusion of numerous agencies, complex financing and local disbursement schemes with cost recovery, community participation, and suppliers credits, may have been inappropriate or too ambitious. The enormity of the management of so many participating agencies was not fully appreciated, neither by the local authorities nor by the Bank. Within the Bank, differences of opinion between the different divisions responsible for health and water supply as to the advisability of including the rural water supply component in a health project resulted in extensive discussions, and joint supervision materialized only once, with decreasing priority being given to this component. 8.02 Lack of a detailed implementation plan and working drawings for civil works caused delays and confusion in some activities, especially since institutional memory was a problem due to staff tumover. At appraisal, progress indicators were established for the majority of components. It was not possible to ascertain that these were ever used as monitoring criteria, either in Colombia or within the Bank. The turnover of local personnel proved to be very demanding on Bank staff time, as correspondence on procedures had to be restarted frequently. The review of bidding documents took over two years due to the Borrower's reluctance to adopt the standard bidding documents of the Bank, and the whole bidding process took four years. It had proven difficult to counteract individual requests for hiring consultants when the information submitted to the Bank was not reflecting actual capacity of the incumbent. After  9 the reformulation of the project, annual reviews of programmed activities were introduced to monitor the scope of work, taking into consideration the weak implementation capacity demonstrated in the early years of project execution. Security questions posed great difficulties for project supervision, as Bank regulations often limited travel to the provinces. As an altemative, in the beginning of the project, the zonal coordinators were brought to BogotA for discussion; therefore, only secondary information was available on the participating departments. This aspect also influenced the availability of consultants to assist in the supervision activities, especially in the civil works area. Reliance on in-country supervision by the regional coordinators was used for some of the civil works and health care activities, but even they were unable to visit some places. In June 1993, a consultant architect visited Colombia to review the civil works component on a random basis to provide information for the PCR. In the last phase of implementation, almost all the activities were supervised through reports and discussions in Washington, during visits by Government officials involved in the preparation of the Municipal Health Services Project, which included the Project Coordinator. 8.03 Several audit reports demonstrated irregularities in project implementation, and there is documentation for project monies being used for activities not contemplated by the LA. Corrective action, however, was limited to deadline extensions or threats to interrupt acceptance by the Bank of disbursement requests based on statement of expenditures. In this respect, the Bank was slow to respond to identified difficulties. For example, in 1991, after three years without country contact by the Principal Financial Management Specialist of the Technical Department, and several qualified audit reports, his first visit was for only five days to discuss with the Comptroller General of the Republic four different Bank projects with identified difficulties. No feedback was given, nor meetings held, with the corresponding MOH entities. Intra-divisional recommendations from that report for a Colombian portfolio review appear to have been delayed.2 In 1992, after repeated problematic CGR reports, a promised visit from the Principal Financial Analyst never materialized. 8.04 The lessons learned for the Bank are as follows: (a) Project design should not be overambitious. Under changing circumstances in the policy and institutional setting of the sector, flexibility to redirect the project to accomodate the new reality should be adopted. (b) Implementation agencies should be kept to a minimum to facilitate clarity of responsibilities. Greater attention should be paid to institutional arrangements for project implementation, especially if the project is broad-based in scope. 2 At the time of the preparation of this report, a new draft document, Suggested Plan of Action for the Improvement of Implementation of Bank Funded Projects in Colombia is under review.  10 (c) Detailed implementation plans should be defined in a Project Implementation Manual, including detailed terms of reference for all technical assistance and training activities; and working drawings for civil works. (d) Difficulties with coordination of supervision activities between sectoral divisions in the Bank fosters confusion at the managerial level in the country. (e) Auditing mechanisms other than CGR should be considered to meet the deadlines for submission of audit reports. The Bank should have used its rights to request audit reports from other independent auditors in order to meet deadlines. Also, clearer guidelines for Bank staff about the follow-up on audits with qualified opinions should be established. (f) When security problems force the use of alternative supervision mechanisms, the interaction with the Borrower suffers. 9. Borrower Performance 9.01 Although an apparently highly skilled and motivated team participated in the preparation process, this project was plagued with difficulties from the beginning. There were start-up delays and implementation proved problematic. Failure to develop management, financial, and procedural aspects to meet deadlines, the complex co-financing required for procurement, frequent turnover of key policy and implementation personnel, bureaucratic delays, lack of willingness or resources on the part of involved parties to participate in, or authorize activities, limited management capacity, confusion in interpretation of project components, and staffing deficits, all appeared early in the process. Cumbersome public sector procedures resulted in delays in the signing of contracts; and resultant cost increases at purchase time caused cancellation of orders. Lack of timely counterpart funds was a serious problem, either because they had not been considered in the MOH budget, or due to complicated approval procedures which could take up to six months. Failure by the Bank to enforce its rights, permitted that audit reports be performed by the CGR which created delays in the submission of reports to the Bank, and opportunities for the project to become a pawn in political battles. 9.02 The MOH delegated management responsibilities to the PMU, while reporting to the Secretary General and the Minister of Health. The result was a lack of integration of project activities in the MOH that gave rise to claims of a parallel organization. The intersectoral committee which was to exercise overseer responsibilities met on an irregular basis, and did not influence project activities or organization. Supervision of some aspects, like civil works, was very weak, despite the availability of funds from the loan to hire consultants for that purpose due to the non-availability of FNH personnel. Programming and reporting was made on a haphazard basis in the early years of project implementation, and improved in later years. National consultants were used extensively, mainly to provide technical assistance in the implementation of the new health law and for the improvement of hospital management. Although this did  I1 contribute to the strengthening of local capabilities, it did not promote the development of increased technical competency within the MOH's central level. 9.04 The lessons for the Borrower are as follows: (a) Project design should not be overambitious. When77 changes in the policy and institutional setting of the sector so requires, a reformulation of the project becomes necessary to focus on the new priorities. (b) Implementation agencies should be kept to a minimum to facilitate clarity of responsibilities. (c) Ownership and continuity could be increased by assuring participation of MOH operational level personnel during preparation, negotiations, and implementation stages of the project. Also, mechanisms which would allow the strengthening of existing capacity within the system should be introduced to sustain the planned development. (d) The establishment, at the design stage, of a system to preserve institutional memory, as well as detailed plans with defined roles and responsibilities for, and flow of funds with respect to, each implementation agency, would assist in facilitating continuity of activities despite personnel turnover. (e) Enlarging the geographical area of the project with evidenced management problems should be weighed against the political importance given these areas. (f) Auditing responsibilities solely in the hands of the CGR, as initially required by the Colombian Constitution, tend to be slow in completion, and subject to intra-agency conflicts and political interference. 10. Proiject Relationship 10.01 The main strength of the Bank/Borrower relationship was the ability to examine implementation difficulties and restructure. There has been continued interest in addressing the weaknesses in the sector. Main interlocutors were MOH, FNH, DNP, and INS; and SENA in a lesser extent because it was phased out in 1990. Even if the participation of ICBF is mentioned in the SAR, they were never active in the project, and its participation was not enforced by including it in the LA. After the Bank's reorganization of 1987, the continuity of Bank staff during the supervision of the project counteracted the Borrower's lack of institutional memory due to frequent turnover of govemment officials and Project Coordinators. 11. Consulting Services 11.01 National consultants played a significant role in the development of project activities, during project preparation, conducting research, assisting in the implementation of the new  12 health law, and staffing the PMU. In the latter, they were involved in training and supervision activities, management and accounting functions. While this contributed to completion of activities, it did inhibit the development of institutional capacity, as the work was usually realized without line personnel from the Ministry accompanying it. Removal of delays in consultant contracting was attempted through utilization of the services of the United Nations Development Programme and the Organization of Ibero-American States administrative services, although these agreements were not without its own problems, i.e. excessive delays hampering execution and payments. 12. Project Documentation and Data 12.01 The LA of August 21, 1985, and its amendment of September 1987; the memoranda on cancellations of 1990 and 1991; and the SAR were adequate for purposes of project execution and supervision. There is a lack of information about the execution of physical facilities and monitoring indicators. A good deal of detailed information was lost in the Bank during the reorganization of 1987, and in the country during frequent changes of Project Coordinators. 12.02 Progress reports were submitted, although, in the beginning years, they were not always timely. This improved in the last three years of the project. In-country files and accounting information were not always structured nor available for auditing purposes, and especially at the regional and local levels, separate files for the project were often unavailable. Information on the training activities found in Bank files and progress reports was limited in scope, making it impossible to know either the total number of persons trained (when information was given in numbers of events) or the impact or contribution that some of the individual scholarships would have. 12.03 Part II of this PCR was developed by the PMU before the closing date (June 30, 1993), taking into consideration MOH's decision to disband it, and the lack of institutional memory in MOH to undertake this requirement. Part II was officially submitted by GOC to the Bank in November 1993. In order to include in this report activities that were to take place during the closing of the accounting (July 1 to October 31, 1993), Parts I and H1 of the PCR were prepared by the Bank after the receipt of Part II. The final PCR was sent to GOC in April 1994 and its comments were incorporated. PART II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE I. Introduction It is a convention of the World Bank that the Project Completion Reports (PCRs) for Bank-financed projects be prepared in three parts. The first part, drafted by the World Bank itself and sent to the borrower six months before closing, sets out the basic parameters from which the borrower may then prepare its part of the report. The Bank then initiates the third and final stage, thus completing the report.  13 In the case of the Health Services Integration Project, this sequence of events has not been followed. It was agreed with the Bank that Part II of the PCR, based on the Bank's official Guidelines, would be delivered by the Project Coordination Unit by closing. The content of this part, prepared by the Colombian Government, is based partly on an analysis of existing project-related documentation and of the experience gained during the most recent project coordination activities, but mainly on interviews with the ex-ministers and ex- coordinators whose departments were responsible for management of the project. Those interviews were backed up by a targeted survey designed to elicit information on the following points: (a) Principal strengths and weaknesses in project design and development. (b) Role of government agencies in relation to the project (Ministry of Health, DNP, Ministry of Finance). (c) Role of the Bank in project design and development. (d) Evaluation of relationship between the Bank and the Government. (e) Evaluation of the Project Coordination Unit. (f) Suggestions for future projects. These core aspects are elaborated on below, not necessarily in the above order. II. Role of the Colombian Government in project design and development 1. The project was badly designed. The objective was to establish an integrated health services system. Since there were insufficient data from which to project the system's future, half of the implementation time was taken up in adjustments, reassignments and reorientations, involving inter alia changes in the key components of the National Health System. 2. The program was disorganized and unfocused. Although this was a loan from the World Bank, with the normal characteristics of that institution, the program was designed to create 19 operational units with a view to achieving integration of the centralized national health system. At project end, it was found that each new Minister of Health has seen fit to create additional capacities, and that the number of operational units to be disbanded totaled 105. Probably the regions needed those services, but the project objectives, target population and aims suffered as a result.  14 There is no doubt that the Colombian entities that should have supervised the project, such as the DNP, and the World Bank itself, were lax in their relationship with those agencies that kept wanting to alter the project's strategies and objectives. 3. The program was never institutionalized at the Ministry of Health. At the initiative of the project designers, and in the absence of clear guidelines from the different Health Ministers, the project implementation mechanism was left in the hands of an operating group parallel to the Ministry, which led to mistrust, critical relationships and inconsistencies. 4. The program was unable to extricate itself from the weaknesses of the Ministry of Health. One of the most serious problems arising during project implementation was that of the unnecessary and wasteful administrative formalities then plaguing the Ministry of Health, involving lengthy and inconclusive bid proceedings, here again without regard to the linkages between Government procedures and those of the World Bank. This was evident in the negotiation of the bidding documents, a situation that was only solved by the streamlining of the Ministry's administrative procedures in 1991/92. 5. The annual plan of program activities was constantly being renegotiated. The annual activities planning mechanism, intended to serve as a basis for the ongoing organization and structuring of project implementation, turned out to be ineffectual, with the result that the balances to be disbursed by the World Bank then had to be negotiated; the success or otherwise of implementation depended on the capacities of the current Ministers of Health and Project Coordinators, while effective reprogramming depended on their negotiating skills vis-a-vis the World Bank. In general, the loan funds were seen as short-term resources and not as long-term financing, as provided in the Loan Agreement. 6. Unstable program management led to errors in project execution. Since the start of project activities at the Ministry of Health there has been a total of 12 Ministers and 7 General Program Coordinators. This rapid tumover led to changes in the project objectives and a broadening of their scope, as well as an intensification of the administrative weaknesses noted at different stages of the project. The dichotomy of having a program that was managed autonomously and at the same time dependent on the administrative efficiency of each administration led to instability and various incidents of inefficiency and ineffectiveness throughout the entire project. It seems essential to ensure that the Project Coordination Units have the necessary autonomy and independence, and also that members of the Ministry staff be included in tasks related to project implementation. To this end, they would be assigned to their respective area of expertise, but no extra work would be involved. In addition, the Ministry's guidelines should make clear provision for vigilance and monitoring. 7. Lack of a monitoring and evaluation system. The program design did not make any provision for the use of specific instruments, variables or indicators to be used in monitoring and evaluating the project and assessing its benefits to the Government, in particular to the health  15 sector. Only in the last stage, when actions were focusing on Law 10 and its implementation, were a few monitoring and evaluation instruments available, both for the various project processes and for the expected results. 8. The program led to the establishment of better and more extensive relations between the central and regional government authorities. The fact of having established more flexible transfers than those coming from the national budget, and of having access to technical assistance provided by the project through private consultants to the executing agencies, led to various changes, but without an objective system of application. One example of such changes is that of the incorporation of continuing training plans for promoters into certain executing agencies, using the approach offered by the project, while in other, perhaps the most significant, cases steps were taken to incorporate the model and instruments designed by the project for the health decentralization process. 9. The program stimulated investment needs in the regions. As a result of the investments carried out by the project in the areas of civil works and procurement of goods, a 1992 project study revealed that over 40% of the municipalities receiving funding for construction from the loan and local counterpart funds sometimes financed over 50% of the total cost of the works out of their own resources. There is no doubt that in some cases this was politically motivated, but in the end it helped to improve the health conditions of the local communities, and ensured that the political and health authorities made an effort in sectors to which priority had not previously been assigned. 10. The program found a path more suited to the 1989 redefinition of its objectives. During the tenure of Health Minister Eduardo Diaz Uribe, the large number of objectives was trimmed down, and the focus placed on formulation of the new decentralized health system. Under Law 10 of 1990, a certain 'organic and orderly structure' was achieved. There is no doubt that this streamlining, and to some extent the more focused format, resulted in greater consistency and cohesion in the area of technical and financial programming, although this was rather a long way from the original project. By maintaining the project's new focus and ensuring that all its actions were oriented toward the strengthening of both conceptual and practical aspects and toward the technical assistance provided by the project for the local government agencies, Minister Camilo Gonzalez Posso also helped improve the project's efficiency and effectiveness. The results of this process were unequivocal: the integration program - Loan 2611, took the lead in health decentralization right from the time of formulation of the Law and its regulations, particularly in the provision of technical assistance and advice to the local government agencies, designed instruments for use by the departments and municipalities in the decentralization process, supported the Ministers in the formulation and negotiation with Congress of the pertinent legislation, designed the first monitoring and evaluation system for the decentralization process, and established a relationship and dialogue with National Government  16 agencies in order to link the decentralization efforts of the municipalities and departments with those that bodies such as the DNP and the Presidency of the Republic, among others, were making vis-a-vis the same local agencies. This revealed more clearly the need for the Ministry of Health to have a department in charge of orienting and coordinating all actions related to the decentralization process. 11. The National Government provided no assistance for the project. The above paragraphs point clearly to the absence of monitoring, vigilance and ownership on the part of the Ministry vis-a-vis the project. Except for the remarks on implementation provided by the Controller General's office for 1991, there was no action on the part of national government agencies related directly or indirectly to project implementation, in the area either of financial supervision (Ministry of Finance) or of support for planning, supervision and control of the activities (DNP). 12. From the financial standpoint the country did not need the loan. The loan required US$36 million counterpart funding from the Colombian Government. Because the original amount to be disbursed by the World Bank was trimmed on three occasions, the country received only US$17.5 million from the Bank, while the original counterpart level was maintained. In the end, the original US$72 million was reduced to only US$53 million, and of that the country itself provided US$35.5 million. LII. World Bank's role 1. The World Bank's role fluctuated between that of technical assistant and supervisor. The Bank's failure to provide the ongoing technical assistance required for this type of project only served to intensify the project's instabilities and weaknesses. At a given moment it appeared that the Bank only stepped in when financial aspects were involved, for example when implementation fell behind schedule. 2. The levels of the Bank's demands fluctuated widely. The Bank was inconsistent in its requests both for annual orderly and coherent plans of activities and for technical and financial progress reports; and when the project made the effort to submit these, the Bank did not even respond, giving the impression that it did not even read them. Where the hiring of consultants (firms or individuals) was concerned, the Bank was also lax, in that it allowed the Ministry to appoint and hire consultants without any attention to the profiles required for the project. This was even more evident when the appointments were made by the Ministry's senior officers (Minister, Vice-Minister, Secretary General). The Bank was also lax in accepting changes to and additions of units without sufficient justification, for example when it allowed agencies not to participate when they had actually been assigned project implementation responsibilities in the legal agreements (e.g. ICBF, Sena, ISS). Over the past two years, when there was a marked change in these aspects, the benefit of maintaining a closer technical Bank/Govemment technical relationship became apparent.  17 Significant changes also took place in levels of implementation, in the quality of the actions planned, in monitoring, in the rigorous performance and accomplishment of the actions planned, and in the monitoring processes adopted. 3. The Bank's system of project monitoring and control was not apparent. The existing mission reports do not reflect the presence of a monitoring and control system designed to properly correct or solve existing problems or reaffirm the project's positive aspects or strengths. m. [sic] General recommendations for other projects Based on the analysis submitted, regarding both the role of the Colombian Government and that of the Bank vis-a-vis the project, there are certain recommendations that both parties should consider right from the start of the project cycle. These are: 1. The project design should be kept simple and uncomplicated. As a step in this direction, the number of executing agencies should be minimized. 2. At the project preparation stage, there should be a clear view of the political and legislative circumstances that could affect or alter future project development, so that no project is exposed to such risks. 3. The projects should be somewhat more focused in their operation. 4. Right from the design stage, a project should identify the system to be used to monitor and evaluate both its development process and its impact. 5. The operating framework for the projects should be provided by a Coordination Unit, autonomously managed but fully institutionalized, without the need to create bodies parallel to the ministries. 6. A project should start out with some sort of formal event or launching, designed both to provide the project staff with training in the respective procedures and to ensure that the World Bank's procedures are compatible with those of the Colombian Government. 7. A strategy needs to be sought to protect both the project objectives and goals and the Coordination Units from the effects of changes at Minister level. 8. The Colombian government agencies, such as DNP and the Ministry of Finance, need to be assigned a clear technical assistance mandate for projects in their particular areas of expertise; such technical assistance would not supplant the capacities of the [other] ministries, but nor would it simply wait on the sidelines until pressed into service when problems have escalated and become difficult to handle.  18 9. The World Bank should play a more visible role in the area of technical assistance, following a plan to be drawn up in liaison with the Government. 10. The Bank should endeavor to systematize its monitoring and supervision procedures and to ensure their constant application. 11. The Bank should be more strict in requiring compliance with the rules governing the various project procedures (hiring, competitive bidding, reports, disbursements, etc.). 12. It would be helpful to standardize certain project-related requirements such as the format for technical and financial reports, so that these can be as helpful as possible, and the format for evaluating potential consultants and consultant performance. 13. The Bank, supported by the Colombian Government, should promote an exchange of experiences among Bank-financed projects in this country, initially within the same sector, in this case the social sector, and subsequently including the other sectors concerned.  19 PART III: PROJECT PROFILE AT THE TIME OF COMPLETION Table 1: RELATED BANK LOANS l | ~~~~~~Year of|l Loan Title | Purdose | Approv |i Status c onnmenots 1487-CO Support an Integrated 1977 Completed June Adverse economic Integrated Nutrition program of nutntuon, 1985 conditions, project Improvement health, nural water supply, complexity and lessening sanitation, and technical support by a now assistanco government in 1982 hindered implementation. However, a major indirect outcome of the project was its contribution to general policy formulation for health end nutrition 2961-CO Water Rehabilitation and 1988 Under Loan provided health Supply & Sewerage expansion of water supply, Implementation services and water supply sewerage systems and at the municipal level solid waste services and through the AT-PAS to improve sector program (Technical efficiency and provide Assistance-Sectoral sector-wide training Adjustment Plan) 3201-CO Expand ongoing home 1990 Under Assessment of the Community Child child care prognm, Implementation effectiveness of training Development systematic training and and home upgrading is in upgrading of homes of process as port of the child care providers, annual review improve the management information system and monitoring and evaluation techniques 3615-CO Strengthen public health 1993 Under Loan will be effective Municipal Health system to provide curative Implementation shortly Services and preventative health services through local municipal sub-projects Comments: Health components were also included in two rural development projects (Ln. 1352-CO and Ln 2174-CO) which introduced, consolidated or expanded primary health care in rural areas. These projects served as a catalyst between the Ministry of Health and individual departments.in providing basic health services. The projects also made a major contribution in expanding infrastructure in rural areas and those with limited services.  20 Table 2: PROJECT TIMETABLE ITEM DATE PLANNED | DATE REVISED ACTUAL DATE Identification Oct 83 Initial Project Brief Nov 83 Preparation Nov 83 - Jan 84 Nov 83 - Jan 84 Pre-Aopraisal Apr. 84 Apr 84 Appraisal Mission June 84 Aug-84 June - July 84 Post Appraisal Oct 84 Negotiations Dec. 84 Feb. 85 May 85 Board Approval Feb. 85 Apr. 85 Julv 85 Signature Aug. 85 Aug 85 Effectiveness Nov. 85 Nov 85 Project Completion June 91 June 92 June 93 Closing Date June 92 June 93 June 93 Comment: Based on progress made during project preparation and in agreement with the Government to reduce the number of components (including the scope of the water supply component) and size lof geographic area, conditions were favorable for appraisal by the originally planned date. However, a post-appraisal mission was necessary to explore ways to further simplify the project due to the limited capacity of the Ministry of Health and fiscal constraints within the country. In order to complete all draft agreements between the Ministry of Health and other agencies and to resolve problems in setting up a Special Account under existing Colombian laws, negotiations were delayed five months.  21 Table 3A: CUMULATIVE ESTIMATED AND ACTUAL DIS8URSEMENTS (US$ MILLIONI FY8el FY87 FY98 FY89 FY90 FY91 FY921 FY93 FY94 'APPRAISAL ESTIMATE 2.0 5.3 10.4 17,5 25.7 32.7 36.5 FORMALLY REVISED 5/90 2.1 2.1 5.9 8.1 9.4 13.5 17.6 17.6 17.6 ACTUAL 2.1 5.9 5.9 8.1 10.3 13.5 14.2 16.6 17.0 ACTUAL AS % OF FORMAL REV. 100.0% 287.3% 100.0% 100.0% 110.3% 100.0% 80.7% 94.4% 96.6% DATE OF FINAL DISBURSEMENT AND 8ALANCE OF US$601,015.58 CANCELLED 09J16193 Table 38: Disbursements Planned. Revised. Actual tIN Uss mILLIONa) 40 10 < _ 5, - - II- - 1986 1987 1988 1989 1900 1991 1992 1993 1994 - APPRA1SAL EST. - FORMAL REV. (8/90h ' REVISED (2/91) - REV18ED (2/92) ACTUAL Date are Bank Fisoal Yera  22 Tab6. 4: STATUS OF LEGAL COVENANTS SECTION OfGNAL REV