Malawi - Second Family Health Project

Docmmknt of The World Bank FOR OmCIAL USE ONLY Report No. 13508 PROJECT COMPLETION REPORT MALAWI SECOND FAMILY HEALTH PROJECT (CREDIT 1768-MAI) SEPTEMBER 8, 1994 Population and Human Resources Operations Division Southern Africa Department Africa Regional Office This document bas a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed witbout World Bank authorization.  CURRENCY EQUIVALENTS (February 26, 1987) Currency Unit Malawi Kwacha (MK) SDRI.00 = US$1.27 US$1.00 = MK2.00 (September 10, 1993) US$1.00 = MK3.96 FISCAL YEAR OF BORROWER April 1-March 31 LIST OF ABBREVIATIONS AND ACRONYMS CDA Community Development Assistants CHW Community Health Workers CPHS Controller for Preventive Health Services CS Child spacing DCMO Deputy Chief Medical Officer DDC District Development Committee DPMT Department of Personnel Management Training EDF Economic Development Fund EEC European Economic Community EN Enrolled Nurse EP&D Department of Economic Planning and Development EPI Expanded Program of Immunization GOM Government of Malawi IDA International Development Association IEC Information, Education, and Communication KCH Kamuzu Central Hospital KFW Kreditanstalt fur Wiederaufbau MA Medical Assistant MCH Maternal and Child Health MIM Malawi Institute of Management MOCS Ministry of Community Services MOH Ministry of Health MOWS Ministry of Works and Supplies MYP Malawi Young Pioneers NFWC National Family Welfare Council PHAM Private Hospital Association of Malawi PHC Primary Health Care PHN Population Health and Nutrition PIU Project Implementation Unit QECH Queen Elizabeth Central Hospital RHC Rural Health Centers TB Tuberculosis TBA Traditional Birth Attendants UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USAID United States Agency for International Development VHC Village Health Committee WHO World Health Organization ZGH Zomba General Hospital  FOR OFFICIAL USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A Office of Director-General Operations Evaluation September 8, 1994 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on Malawi Second Family Health Project (Credit 1768-MAL) Attached is the Project Completion Report on Malawi -Second Family Health Project (Credit 1768-MAL) prepared by the Africa Regional Office. Part I was prepared by the Borrower. This project continued the efforts of the first to expand and strengthen the existing health system, increased the availability of child spacing services, and strengthened the management capabilities of the Ministry of Health. In addition, it supported design and implementation of a multisectoral family health program through other government agencies. Most of these purposes were achieved to some degree-sufficiently so to rate the project outcome as satisfactory, the benefits as likely to be sustainable, and the institutional development impact as modest. The PCR is of adequate quality. Part I is useful in giving more details and explanations for some events. An audit of this project, together with the first health project, is planned. Attachment This document has a restricted distribution and may be used by recipients only In the performance of their official dutlies. Its contents may not otherwise be disclosed without World Bank authorizatlon.   FOR OFFICIAL USE ONLY PROJECT COMPLETION REPORT MALAWI SECOND FAMILY HEALTH PROJECT (Credit 1768-MAI) TABLE OF CONTENTS Page No. Preface Evaluation Summary ............. i-ii PART I. PROJECT REVIEW FROM BANK'S PERSPECTIVE ....................... I A. Project Identity ............................................... I B. Project Background ............................................ 1. C. Project Objectives and Description ........... ......................... 2 D. Project Design and Organization . .................................... 3 E. Project Implementation . .......................................... 3 F. Project Results ............................................... 6 G. Project Sustainability ............................................. 6 H. Bank Performance .............................................. 6 1. Borrower Performance . .......................................... 7 J. Consulting Services ............................................. 8 K. Project Documentation and Data . .................................... 8 PART II PROJECT REVIEW FROM BORROWER'S PERSPECTIVE ................... 9 A. Adequacy and Accuracy of Part III ........... ......................... 9 B. Comments on Analysis in Part I . .................................... 9 C. Bank Performance ............................................. 12 D. Performance of Borrower . ........................................ 12 E. Effectiveness of Relationship between Bank and the Borrower .................. 14 F. Performnance of Co-Financiers............................... 14 PART III STATISTICAL INFORMATION .15 A. Related Bank Loans..................................... 15 B. Project Timetable .15 C. Loan Disbursements..................................... 16 D. Project Project Implementation.16 E. Total Project Costs and Financing .18 F. Statu Status of Loan Covenants.22 G. Use of Staff Resources .24 ANNEX 1: Names of Officials Met during the PCR mission . 26 ANNEX 2: Project Implementation Summary ........... 28 ANNEX 3: Rural Health Centers Completed ....... 30 This document has a restricted distribution and may be used by recipients only in the perfornance of their official duties. Its contents rnay not otherwise be disclosed without World Banlc authorization.l   PROJECT COMPLETION REPORT MALAWI SECOND FAMILY HEALTH PROJECT (Credit 1768-MAI) PREFACE This Project Completion Report (PCR) is for the Second Family Health Project in Malawi, for which Credit 1768-MAI in the amount of SDR 8.7 million was approved on 24 March, 1987. The Project closed as scheduled on 30 June, 1993. The last disbursement was on 19 November, 1993. There was an undisbursed balance of SDR 2,232.62, which was cancelled. The PCR was prepared by the Population and Human Resources Division of the Southern Africa Department (Preface, Evaluation Summary, Parts I and III), and the Borrower (Part 11). Preparation of this PCR is based, inter alia, on the Staff Appraisal Report; the Development Credit Agreement, supervision reports, progress reports, correspondence between the Bank and the Borrower, the findings of a completion mission which visited Malawi during August and September 1993, and interviews with Government of Malawi officials.   PROJECT COMPLETION REPORT MALAWI SECOND FAMILY HEALTH PROJECT (CREDIT 1768-MAI) EVALUATION SUMMARY Objectives 1. The main objectives of the Project were to: (a) improve health status of families, particularly of mothers and children, through expanding and strengthening existing health programs; (b) increase availability and accessibility of child spacing (CS) services within the Ministry of Health (MOH) maternal and child health (MCH) program; (c) strengthen MOH's capacity to plan, manage and evaluate health services in the framework of a decentralized health system; and (d) design and implement a multi-sectoral family health program through other government agencies. These objectives were in line with the long term objectives of the Government of Malawi (GOM) in the health and population sector and the 1986-95 National Health Plan, and were generally achieved through: expanding primary health care (PHC) services; strengthening management, manpower and support systems; integrating CS with MCH services; providing support to the functional literacy, youth and information, education and communication (IEC) programs. Imlnementation Experience 2. The overall Project implementation was satisfactory. The Project continued the process of institutional development, further developing the human resources and support systems initiated under the first IDA health project and now continuing under the Population Health & Nutrition (PHN) Sector Credit (Cr. 2220-MAI). Major problems experienced during implementation were related to increases in construction costs, inadequate supervision of civil works, vacancies in the Project Implementation Unit (PIU), lack of a proper accounting system, and delays or non-compliance with some conditionalities. Furthermore, planning in general, and manpower planning in particular, remained weak during the life of the Project, thereby adversely affecting implementation. Difficulties were experienced within and between the two parts of the Project because the coordinating committees met less frequently than anticipated, and the overall coordinating committee never met. Results 3. The Project expanded PHC services, and integrated some CS activities with MCH services, although the multisectoral portion of the Project appears to have continued in a linear fashion. Quantifying Project impact is not possible because no baseline data was available to compare with; the lack of clearly identified monitoring indicators in the Project documents also contribute to quantifying difficulties. One of the positive results of the Project was the recognition that support for decentralization would need to continue beyond the Project, and a number of activities continue to be funded under the PHN Sector Credit. The most important results of the Project has been the carrying forward of lessons into the implementation efforts of the ongoing Sector Credit.  ii Sustainability 4. The project is likely to be sustainable in the long-term since the physical facilities constructed are a one-off investment and the GOM is conmmitted to providing manpower and other recurrent costs, while decentralized planning and management are areas which GOM continues to work on in a changing environment. GOM continues to be committed to the strengthened institutionis and the expanded PHC activities, focussed on the rural population, who will, in the long-term, continue to benefit from the physical facilities, improved coverage and greater access to MCH and CS services. The sustainability of the planning capacity within MOH will continue to be determined by the constrained decision making environment that persists in the Malawi civil service. It is therefore not conceivable that MOH will be able to make and take decisions which impact on the long-term sustainability of activities unless this climate changes. Implementation of the multisectoral program under this Project experienced difficulties. Findings and Lessons Learned 5. Unforeseen problems, such as the increase in costs of civil works and the shortage of funds from parallel financiers were solved with a high degree of flexibility and continuous dialogue with the Government. Although overall supervision was good, shortcomings related to poor accounting, weak donor coordination, delays or non-compliance with some covenants and inadequate supervision of civil works by GOM still occurred. Following are some of the lessons which should be considered for future projects: (a) Government ownership is necessary; (b) uncertainties associated with parallel financing should be recognized; (c) key positions need to be filled; (e) an effective monitoring system is needed; (d) a project launch workshop should be held; (f) detailed documentation on project implementation should be maintainied; and (g) mid-termli reviews should be undertaken.  PROJECT COMIPLETION REPORT MALAWI SECOND FAMILY HEALTH PROJECT (CREDIT 1768-MAI) PART I. PROJECT REVIEW FROM BANK PERSPECTIVE A. Project Identity Project Name Second Family Health Project Credit Number 1768-MAI RVP Unit : Africa Regional Office Country : Malawi Sector : Population and Human Resources B. Project Background 1.I Sector Development Obiectives. At the time of the identification of the Second Family Health Project, measles, malaria, acute respiratory infections, diarrhoea and malnutrition were the most common causes of morbidity and mortality, and the infant mortality rate in Malawi was significantly higher than in neighboring countries. The annual population growth rate was 3.2 percent and GOM was aware of the negative consequenices of high population growth on socioeconomic development. The long-tern objectives of GOM, in the health and population sector, were to decrease morbidity, mortality, malnutritioni and fertility. The medium term objectives were to strengthen the capacity of MOH in manpower development, planning, monitoring and evaluation, improve management of health services, expand the health care delivery system, strengthen cost-effective programs, and integrate CS in MCH services. 1.2 Policy Context. While the first Health Plan (1965-69) was devoted primarily to curative services and development of nursing manpower, the 1973-88 Health Plan focused on development of basic health services, control of communicable diseases, manpower development, construction of new and rehabilitation of existing hospitals, expansion of MCH services, introduction of PHC on a pilot basis, and reorganization of MOH. Implementation of the Plan was hampered by a lack of adequate financial resources, scarcity of trained manpower and inexperienced health administrators. 1.3 Recognizing the limitations of the second Health Plan, in 1983 MOH prepared the 1986-95 Health Plan through IDA's First Family Health Project (Cr. 1351-MAI), with medium term goals of achieving a drop in early childhood mortality of 33.3 percent over a 5 year period, achieving an improvement in maternal health, and having an impact on the major causes of morbidity through the PHC approach and/or core health services. Specific objectives were to improve: access to health services, child survival and health status, and support to management of the health care delivery system (by strengthening relevant programs); nutritional status of mothers and children: and mechanisms for health manpower development and deployment. Due to budgetary cons, raints, cost recovery and cost effectiveness, consolidation of existing services, and expansion of priority health programs (which had low recurrent or manpower implications) were emphasized. Majo;r obstacles to achieving these objectives were: access to health services, shortage of drug supplies, MOH's management capability, over-centralization of the decision making process (with unclear roles at the region and district levels), and poor financial planning, budgeting and manpower managemiient. The need to address these problems was one of the bases for the Project.  2 C. Proiect Objectives and Description 1.4 Project Objectives. The Project was an integral part of the first three years of the 1986-95 National Health Plan and a follow-up to the First Family Health Project. The main objectives were to (a) improve health status of families, particularly mothers and children, through expanding and strengthening existing health programs; (b) increase the availability and accessibility of CS services within MOH's MCH program; (c) strengthen MOH's capacity to plan, manage and evaluate health services in the framework of a decentralized health system; and (d) design and implement a multisectoral family health program through other government agencies. 1.5 Proiect Components. The Project was composed of two parts, with Part A implemented by MOH, and Part B implemented by various government agencies coordinated by the Department of Economic Planning and Development (EP&D). 1.6 Part A included: (a) Expanding PHC from 9 to 15 districts through training; provision of equipment and supplies for village health committees (VHCs); constructing, furnishing and equipping 17 new RHCs; upgrading 6 existing health sub-centers; and replacing I district hospital. (b) Strengthening Management. Manpower and Support Systems through technical assistance, workshops and training; providing MOH and major hospitals with computers for budget management; replacement of an existing enrolled nurses school; constructing, furnishing and equipping three regional level training facilities; constructing pharmaceutical depots at eight district hospitals; equipping a quality control laboratory; conducting a baseline survey, evaluation studies, and a study on the potential of health insurance. (c) Family Health and MCH Program Support through technical assistance, training, provision of vehicles, equipment and IEC materials; CS support through orientation of health staff and training 900 service providers; construction of surgical contraception units at 8 district hospitals, as well as 3 new urban health centers and replacement of a family health unit in Lilongwe; and expansion of nutrition activities through technical assistance, training, and developing IEC materials. (d) Proiect Manapement for Part A which included establishment of a PIU, salary support for a project coordinator, technical advisor, clerk of works, procurement officer, accountant and support staff, as well as provision of office equipment and supplies. 1.7 Part B included: (a) Functional Literacy, Nutrition and Women's Programs under MOCS, to introduce family health topics into ongoing functional literacy and women's programs and expand these programs to the Northern Region; construct, furnish and equip a regional training center, produce IEC materials, support overseas and local training; introduce nutrition activities in MOCS, train women's groups and community development assistants, strengthen nutrition-related activities through growth monitoring, nutrition education, and construction of fish ponds.  3 (b) Youth Programs, under the Department of Youth, to introduce family health messages aimed at young audiences through training, educational programs, equipment, and IEC materials. (c) IEC to develop nationwide programs by the Information Department, through overseas training, surveys, production of materials, and evaluation activities. D. Project Design and Organization 1.8 The Project derived its conceptual foundation from the first phase of the 1986-95 National Health Plan, the First Family Health Project, and the World Bank Population Sector Review (Report No. 5648, 1986). Following approval of this Plan, MOH prepared a comprehensive implementation program for the period 1986-90, which was appraised by IDA in December 1985. It was agreed with GOM that the US$24.9 million Project would be financed with: US$11 million from IDA, and US$1.9 million from GOM; parallel financing of US$2.6 million by UNICEF, US$3.5 million by the Economic Development Fund (EDF), US$4.1 million by Kreditanstalt fur Wiederaufbau (KfW), and US$0.9 million each by the Government of the Netherlands and UNFPA. The Project was identified in June 1985, appraised in December 1985, negotiated in February 1987, approved by the Board on March 24, 1987, and declared effective on June 15, 1987. Reasons for the lag between appraisal and negotiations were attributed to the temporary unavailability of the task manager due to ill-health. 1.9 The Project continued the process of institutional development, further developing the human resources and support systems initiated under the first IDA health project, introducing multisectoral population activities, and supporting on-going activities implemented by MOH and other ministries. According to the design of the Project, implementation of Part A was the responsibility of the Principal Secretary (PS) of MOH. Coordination of activities under Part B was the responsibility of EP&D. The PS of MOCS had overall responsibility for monitoring Part B. The Secretary for Youth and Malawi Young Pioneers (MYP) was responsible for youth programs and the Chief Information Officer was responsible for IEC. The PS of Ministry of Works and Supplies (MOWS) was responsible for the implementation of civil works, and the Planning Unit of MOH was responsible for procurement of furniture, equipment and supplies, and for recruitment of consultants. The coordinating committees for Part A and Part B were supposed to meet monthly. In addition, an overall coordinating committee was expected to meet quarterly to review overall progress. E. Project Implementation 1.10 In general, Project implementation was good. The PIU, which became the coordinating unit for the implementation of all donor-funded projects, promoted good interaction and rapport between IDA and GOM, and developed mechanisms with enough flexibility to reorient the Project when the need to change or exclude activities was identified. Staffing difficulties' in the PIU contributed to some of the problems experienced in implementation. In addition, difficulties were experienced within and between Parts A and B because the coordinating committees met less frequently than expected, and the overall coordination committee never met. Greater detail on component implementation is given in Annex 2. The procurement officer was never appointed; the accountant position was vacant for two years; and the architect's post was only filled for a total of 26 months.  4 1.11 PHC. The aim to expand PHC from 9 to 15 districts was generally achieved. Civil works were completed, and the cost overruns experienced were the result of the general increase in construction costs, and the increased cost required to enlarge the Mzimba District Hospital so that it could fulfill its role. All of the upgraded RHCs were equipped; IDA provided the equipment when UNICEF was unable to equip all of the RHCs as originally envisaged. While the upgraded RHCs are operational, 3 of the 17 new RHCs are not operational, 3 do not have Medical Assistants and 12 are experiencing water problems2 (see Annex 3). Regional and District PHC coordinators were appointed as part of the decentralization process, and the PHC program was evaluated and a report produced. A report on urban PHC was also produced and its proposals were considered in the preparation of the PHN Sector Credit. Management. Manpower, and Support Systeiins 1.12 Management. As part of the effort to improve management of health services, the Complement and Grading Review Committee reviewed MOH's structure, staffing patterns, department and unit functions, and career structures; developed job descriptions for various cadres: and proposed a structure which would be more responsive to the needs of the health sector. The report was approved, the new structure adopted, some key positions filled and some recommendations were implemented in phases. Unfortunately, high staff turnover, study leaves and increased activities to be covered have over-stretched the capacity of the newly created Planning Unit. As a result of restructuring of MOH, the decentralization process was begun with the establishment of Regional Health Teams to provide back-up and supervisory support to health activities in the region. In addition, a plan to introduce cost reduction measures at MOH and the hospitals was developed. Lack of additional personnel at the periphery and concern over loss of control by headquarters slowed down the pace of decentralization. With regard to cost reduction measures, the committee established to monitor implementation met irregularly and consequently only a portion of the activities were undertaken. 1.13 Manpower. Implementation of this sub-component, to strengthen MOH capacity to train enrolled nurses, establish in-service training and plan and analyze manpower issues, was partially completed. The Zomba School of Nursing was completed, and a Manpower Development Unit was created. Cost overruns precluded the building of the regional in-service training centers, and manpower planning analysis was hampered by sketchy information on the number, type, physical location and function of the various health cadres employed by MOH. 1.14 Support Systems. This sub-componient, to strengthen moilitoring and evaluation capacity at MOH and improve efficiency in pharmaceuticals, was satisfactorily implemented. A number of studies were carried out (see Part III Table 9), the pharmacy at KCH, as well as the pharmaceutical depots and the planned support services at six district hospitals were completed. 1.15 Some of the partially implemented activities under this component (manpower development, the study on health insurance and cost reduction measures), are included in the PHN Sector Credit currently under implementation. 1.16 MCH. This sub-component was satisfactorily implemented, although not all activities were carried out. Vehicles required for supervision and mobile services were purchased with savings under the First Family Health Project; this enabled the purchase of an ambulance, as well as the 2 Water supply prohlems were due to lack of coordination with the Water Department of MOWS.  5 construction and furnishing of a new Paediatric Ward at KCH, originally to be funded by KfW. IEC and training materials for MCH were produced, MCH Centers and antenatal clinics were supplied with drugs. An MCH integrated services workshop was held, but the MCH manual for use by health workers was not produced. 1.17 Child Spacing. The Project assisted in the expansion of CS services. In-country study tours were organized to visit facilities where CS was successfully integrated with MCH services; UNFPA sponsored a tour to observe management of community based distribution programs of contraceptives and integration of CS activities. This led to the establishment of NFWC, and a committee in MOH to plan and monitor progress in CS integration. Integration was slow due to a shortage of staff,3 and the sensitive nature of CS. Periodically logistics problems led to shortages of commodities, but the availability of contraceptives improved with the assistance of UNFPA and USAID. The construction of surgical contraceptive units in hospitals did not take place due to non-availability of parallel funds from KfW. Financing problems precluded the building of the urban health units and this activity has been shifted to the PHN Sector Credit currently under implementation. 1.18 Nutrition. This sub-component was carried out satisfactorily. The promotion of nutrition education and growth monitoring at health clinics, the development and production of flip charts, posters and booklets were undertaken as part of the UNICEF country program. 1.19 Functional Literacy, Nutrition and Women's Programs. Funding for this component, initially expected to be provided by EDF and IDA, was provided solely by EDF, with the exception of constructing and equipping of Mzuzu Regional Training Center. Studies on target food subsidies and household food security were carried out under this component and were used as preparation for the PHN Sector Credit. Introduction of CS in adult literacy programs was only partially achieved, due to constraints referred to above, and the difficulty in implementing multisectorally when coordination is weak. 1.20 Youth Programs. This component was mostly successfully implemented. MYP A Family Life Education Resource Book was produced. An information booklet on Youth Life Experiences, flip charts, leaflets and posters on family health topics were developed in draft form. Six health shelters were built, and one has been destroyed by wind. All of the sewing machines were delivered, and used for training in income generation activities. Of the three fish ponds built, with technical advice from the Fishery Department, only two are functional. 1.21 IEC. Implementation of this component was satisfactory. Under this component family health messages were published in a free publication with an estimated audience of 80,000. Two Information Department staff were sent overseas to be trained in graphics, audio visual and communication techniques. Family health messages for billboards and match box labels, radio programs and films on family health were produced after the content was reviewed by MOH. Short-term technical assistance to revise training in CS, and the production of training amterials in order to reorient and train health staff, TBAs and VHCs in CS and IEC did not take place.  6 F. Project Results 1.22 On the whole, the Project expanded PHC services, and integrated some CS activities with MCH services, all of which are more accessible than in the past. The multisectoral portion of the Project appears to have continued in a linear fashion, as opposed to an integrated manner. Therefore. it is only possible to say that most of the planned activities were carried out. It is not possible to quantify the impact of the Project because no surveys were carried out before the start, or at the end. of the Project. Difficulty in quantifying results can also be ascribed to the lack of clearly identified monitoring indicators in the Project documents, lack of institutional memory, and reports which appear to conflict with evidence in the field. One of the results of the Project was the recognition that support for decentralization would need to continue beyond the Project, and, as a consequence, a number of activities initiated under this Project continue to be funded under the PHN Sector Credit. One of the most important results of the Project has been the carrying forward of lessons into the implementation efforts of the ongoing Sector Credit. G. Project Sustainability 1.23 The Project is likely to be sustainable in the long-term since the physical facilities constructed are a one-off investment and the GOM is committed to the provision of manpower and other recurrent costs, while decentralized planning and management are areas which GOM continues to work on in a changing environment. The Project strengthened institution building and expanded PHC activities to the rural population, who will, in the long-term, continue to benefit from the physical facilities, improved coverage and greater access to MCH and CS services. The sustainability of the planning capacity within MOH will continue to be determined by the constrained decision making environment that persists in the Malawi civil service. This has lead to uncertainty about their authority among decision makers who become demoralized and leave. The current political climate does not create the conducive conditions for a long-term, sustainable planning capability to be developed, retained and fully utilized. It is therefore not conceivable that the Ministry will be able to make and take decisions which impact on the long-term sustainability of activities unless this climate changes.4 As mentioned above, implementation of the multisectoral program under this Project experienced difficulties, many of them a result of the complexity of trying to get more than one ministry, each with different reporting and performance evaluating structures, to work together. This made the multisectoral program implementation unsustainable. H. Bank Perforrnance 1.24 There were 13 supervision missions with architects, public health specialists and economists present in most missions. Notwithstanding the frequent turnover of Bank staff responsible for supervision, Bank staff contributed to the success of the Project through supportive supervision and technical advice. Flexibility in modifying Project activities and prompt actions, in consultation with the GOM, helped solve some of the unforeseen problems, such as the increase in costs of civil works and the shortage of funds from parallel financiers. Combined supervision of this Project and preparation of the PHN Sector Credit helped link the two projects, and allowed the shifting ol activities (i.e., management, decentralization and cost reduction measures) which were not cotnplcylj under the Project. Overall supervision was good; dialogue with GOM and executing agencies 'Aas The passage of a referendum establishing a multiparty system in Malawi. and the electionis held on May 17, 1994. appear to have brought about an environment which should assist in fostering an atmosphere which could he conducive to sustainability of activities which have client ownership.  7 constructive, and modifications were always fully discussed and agreed with the GOM. However, some of the shortcomings include: (a) failure to strongly voice concerns relating to audits and accounts so that the need for corrective action was taken seriously; (b) failure to ensure compliance with covenants, or carry out a mid-term review to restructure if warranted; (c) inclusion of unconfirmed financing in project design; and (d) supervision reports with differing formats made it difficult to follow the implementation history of Project components. The Bank's culture, at the time of the design and implementation of this Project, of placing more importance on lending rather than implementation, as reflected in the design and supervision of this project, could have contributed to the significance of the shortcomings noted. 1.25 Lessons learned. The lessons learned from the project can be divided into those in line with the Wapenhans Report, standard practices and specific project-related lessons: Wapenhans Report lessons: (a) Government ownership is necessary, as was the case with this project, to ensure the commitment required to carry out and sustain the activities; (b) realism is needed when reviewing implementation capacity during planning and when supervising the project so as to avoid creating false expectations on either part; and (c) key positions, necessary for implementation, have to be identified as early as possible and filled at project start-up to avoid adversely affecting implementation. Standard practices lessons: (a) a project launch workshop (which includes all line managers) should be held in order to define responsibilities and bring managers on board; if line managers are unclear about project objectives, and their role in achieving them, it will be more difficult for them to be motivated to carry out activities; (b) more assistance is needed to enhance Government's experience in procurement, disbursement, accounting, monitoring and evaluation; (c) an effective monitoring system needs to be put in place to ensure that potential problems are identified and solutions sought in a timely manner to avoid delays in implementation (the system should be one which both lender and borrower can use); (c) institutional memory (i.e., consistent, standardized supervision reports, and detailed documentation on project implementation) should be maintained to allow for follow-up of project implementation; and (e) mid-term reviews should be undertaken to allow for adjustment, if necessary. Specific lessons: (a) project objectives and activities should be stated as clearly as possible to enable monitoring and evaluation; (b) targets and monitorable indicators should be clearly defined so that a determination can be made of the success or failure of the activities undertaken; (c) coordination and interaction mechanisms between activities of the donors need to be clearly defined during project preparation, as well as the impact of possible non-availability of funds for key activities; and (d) a well defined training plan is needed to ensure that no "temporary" vacancies exist and that training is appropriate for the job to be performed. I. Borrower Performance 1.26 GOM should be commended for successfully completing the Project within the closing date. Most of the covenants were complied with, and counterpart funds were adequate and timely. As mentioned above, civil works were implemented in a timely manner; however, inadequacies relating to civil works consisted of a roof at Zomba, and windows at KCH which leaked, and problems with placement of buildings at Mzimba, as well as lack of water and staff at some of the RHCs rendering  8 them inoperational. The overall coordination committee never met and this adversely affected the implementation of the multisectoral component of the Project. The accounting and audit reports were not always timely or up to standard. Identification and appointment of PIU staff were delayed and this affected the pace of implementation. J. Consulting Services 1.27 The anticipated technical assistance was utilized. The PIU utilized technical assistance in the form of a Project Coordinator (foreign), a Technical Adviser (local), Project Accountant (local) and two Project Architects (the first foreign and the second local). Civil works were implemented by MOWS, and consultants were recruited by the PIU in MOH's Planning Unit. A Complement and Grading Review Study was carried out, in lieu of a job analysis and development of training curricula for national and district levels, under the Management, Manpower and Support Systems component; this was carried out jointly with the Department of Personnel, Management and Training (DPMT). As a follow-up, a training needs assessment was undertaken in collaboration with MIM. Technical assistance for the project management of Part A, a long-term advisor for the pharmaceutical program (WHO/The Netherlands), and a training advisor (EEC) for the functional literacy program were funded by the Project. An urban PHC consultancy was completed in June 1989. Overall GOM was satisfied with the work of the various consultants. K. Project Documentation and Data 1.28 As mentioned above, the lack of uniformity in Project supervision reports made tracking of components more cumbersome than necessary. A lack of financial records, and the absence of a central repository for records on GOM's side made it difficult to thoroughly review the accounts. During the life of the Project only eight out of 24 progress reports were forwarded to IDA. The records kept by parallel financiers were not in a format which coincided with IDA categories, resulting in an inability to separate costs for different categories, or designate between local and foreign expenditures.  9 PART II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE A. Adequacy and Accuracy of Part III 2. 1 The information presented in Part III covers the major aspects of project implementation and is adequate for the purposes of the report. 2.2 The report reflects the position of project activities at time of project completion and is generally accurate. B. Comments on Analysis in Part 1 Part 1 - A to D: The Project 2.3 The information on project background, objectives, project design and organization is descriptive. However, it may be noted that although the MOH Project Monitoring Commnittee did not meet monthly, it held regular meetings, considered issues regarding project programs and was very useful in ensuring expeditious implementation of activities. 2.4 While it is correct that the overall coordinating committee under EP&D never met, it may be noted that this, at least partly, was due to its coordinating role on population and related issues not being firmly established at the time. However, after the institution of the Population Advisory Committee, a sub-committee on IEC functioned at EP&D and helped in the coordination of Part B activities of the project. 2.5 In retrospect, it should be stated that activities under Part B of the project related to IEC through organizations outside MOH, were aimed at promotion of child spacing and could have been coordinated by MOH. The IEC strategy in the PHN Sector Project has reverted to the strengthening of the MOH IEC Unit and its coordinating role. Part 1 - E: Project Implementation 2.6 Unavailability of funds was the reason for major variations between planned activities and actual outputs. In areas such as manpower development, changes in planned activities were agreed upon due to changes in priorities. For example, it was decided that rather than proceeding on the consultancy on development of unit and job descriptions, the Ministry would proceed with the complement and grading study in collaboration with DPMT. This study was designed to review the MOH establishment in regard to numbers of personnel, their grades and staffing patterns; career structures of all cadres and to propose functions for its departments and units including job descriptions. The scope of the study was thus broader and later programs of manpower development and management improvement were considerably influenced by the recommendations of the review which received Government approval. 2.7 The activities were, therefore, modified taking into consideration linkages with related activities and their possible impact. Although, such changes may appear to delay the achievement of agreed objectives, steady progress has been made in the correct directions. The incorporation of these activities in the PHN Sector Project ensures attention to their further development.  10 2.8 A fully staffed PIU may have helped overcome some of the operational problems experienced in project implementation. Two specific areas were financial management and supervision of field activities. 2.9 The supply of water to health centers has presented problems. MOW at the commencement of the project provided the Water Department with information on health center sites and requested location and construction of boreholes. However, this work was delayed in some cases and construction work was allowed to proceed. This has in some instances caused serious problems. MOW having recognized the problem has issued instructions to all Ministries in March 1993 that prior to commencement of any construction project, a water supply feasibility report, reviewing the likelihood of acceptable water supply, likely source and practical methods of delivery should be obtained from the Controller of Water Services in addition to other information. This requirement should help to eliminate problems experienced at health centers under the project. 2.10 It should also be noted that the accelerated manpower training programs under the PHN Sector Project would ensure the a-ailability of MAs and ENMs at health centers constructed under the project. In fact, the LSHS will graduate 63 MAs in November and CHAM5 14, making a total of 77 MAs. Although the expanded training program at ZSN has not commenced due to delay in rehabilitation of buildings, the output of ENMs from CHAM Schools of Nursing should help in overcoming the shortage of trained nurses. 2.11 In the implementation of the child spacing component, issues relating to work on needs assessment, logistics and availability of contraceptives was supported by other donors especially US AID. The multisectoral IEC program in support of child spacing was not fully effective and this experience has led to focus of activities under the PHN Sector and PHICS' projects to strengthening the MOH IEC Unit at central, regional, district and community levels. 2.12 The revised organization structure of MOH was implemented in 1987. The Complement and Grading Study reviewed the MOH structure and recommended several improvements designed to strengthen its effectiveness. The upgrading of the Planning Unit to the status of a Division under the Controller of Planning was recommended in this study. The Planning Division has not benefitted from this as critical posts have remained vacant. This matter is receiving urgent consideration. Part 1 - F: Project Results 2.13 The expansion of PHC activities from 9 to 15 districts involved not only civil works in the construction and upgrading of rural health facilities, but importantly the training of VHCs, TBAs and health staff. It is noted that regional and district PHC Coordinators were appointed. The Malawi concept of PHC emphasized its multisectoral nature and all personnel in health and health related agencies were oriented in PHC, in addition to the DDCs. 2.14 In the area of management, the project initiated the process of decentralization with the establishment of regional teams and the assignment of accounting personnel to regions, major Christian Hospital Associaiion of Malawi. previously known as Private lIospital Association of Malawi, INB. Footnote added by IDA 1 USAID-funded project. INB. Footnote added by IDA.]  11 institutions and district hospitals. The Complement and Grading Review and the later work by MIM have helped strengthen the process which will be continued under the Sector Project. 2.15 Results achieved in the implementation of cost reduction measures were not adequate. The program was based on recommendations of several studies carried out by the Planning Unit during 1985-86. The major problem in the implementation of the proposed measures was the pre-occupation of hospital managements in day to day administration. This did not permit the hospital teams to focus on issues and plan programs to achieve results. Some improvements were effected in transport systems at the major hospitals; the boiler system at QECH and the laundry at KCH. This program is continued under the PHN project and needs renewed commitment for its successful implementation. 2.16 In manpower development, the activities initiated under the project with the appointment of the Training Officer for the improvement of MOH capability to undertake manpower planning and analysis was further strengthened with the establishment of the Manpower Development Unit (MDU) with USAID assistance. The MDU initially experienced staffing problems but these have been overcome and the unit is fully functional. Manpower data for the preparation of a Manpower Development Plan were collected and the draft plan is to be completed by December this year. Activities of the MDU are further supported under the PHN Sector Project including the establishment of a Personnel Information System (PIS) scheduled to be fully operational by September, 1994. 2.17 Project activities in family health, benefitted from several donor inputs within the project and outside. Overall considerable improvements have been recorded in MCH activities including CS as evidenced by the results of the DHS. Recent initiatives of Government in the preparation of the population strategy and the establishment of the NFWC are important steps in meeting the development challenges confronting the country. 2.18 Problems experienced in the determination of specifications of the boats required for lake- shore MCH services delayed their purchase. With increased costs of construction and other constraints, this delay resulted in its abandonment. However, the boats are needed for lake-shore services and efforts are being made to identify funding for this purchase. Part 1 - G: Proiect Sustainabilitv 2.19 Issues in regard to manpower, water supply, housing and supplies including drugs are receiving priority attention. The RHCs are expected to be fully operational by December, 1993. The continuing support for several after critical programs under the PHN Sector Project would ensure increasing attention to the attainment of objectives of these programs. 2.20 MOH is aware of the need for increased availability of drugs at health facilities. The initiatives in regard to rationalization of services among major service providers and improved efficiencies in service utilization should assist in overcoming some of the present problems. The emphasis placed on rational use of drugs and improvements to the pharmaceutical supply and distribution system should contribute to these efforts.  12 Part 1 - K: Project Documentation and Data 2.21 Some of the problems relating to lack of documentation arise from the implementation of parts of the project funded by different donors as separate programs not always concurrently with other programs. Several units were, therefore, involved in implementation and collection of data was difficult. To this was added the problems of the post of Project Accountant being vacant for a long period. C. Bank Performance 2.22 The Bank played a positive role during the evolution and implementation of the project. The close relationship established during the implementation of the First Family Health Project which culminated in the formulation of the National Health Plan 1986-1995, was further strengthened in the development of this project. 2.23 Some items listed under Part I as lessons learnt from the experience of implementation of the project have in fact been incorporated into PHN Sector Project activities. 2.24 From the GOM perspective, lessons learnt from Bank performance include the following: (a) Firm commitments need to be secured from co-financiers or parallel financiers of project components by their increased involvement in project preparation and appraisal and other appropriate means; (b) Increased attention by GOM to development of design briefs for infrastructule development through wide consultations should be encouraged; (c) Infrastructure development should be balanced adequately with other resource requirements in project formulation; (d) Increased attention should be given to provision of specialist advice in such areas as procurement and project accounting where such needs are established with borrowers. D. Performance of Borrower 2.25 On the whole, the project was implemented a schedule and results achieved are significant. The main factors that contributed to this satisfactory performance are given below: (a) The positive approach of the Bank in supporting project programs and constructive advice of supervision missions on the project; (b) The Project Coordinating Committee under the chairmanship of the PS was able to create adequate interest and understanding of project activities among heads of divisions and units in the MOH and to generate a reasonable degree of enthusiasm in project implementation. (c) Close consultation with MOW helped ensure expeditious completion of the civil works program of the project.  13 (d) Regular interactions with Program Managers by the PIU helped in the follow-up of individual programs especially during the initial period of project implementation. (e) The establishment of the PIU within the Planning Division with specific responsibility for the civil works, procurement and disbursement aspects of the project and its role in actively supporting heads of divisions/units and Program Managers in the implementation of individuals project programs helped accelerate pace of project implementation. 2.26 As previously noted, several problems were experienced during project implementation. These could be presented as lessons learnt during project implementation which would be useful in current and future projects. These include the following: (a) Successful operation of coordinating mechanismiis is essential in the implementation of projects with several components; (b) Responsibility for the implementation of programs should be vested with specific officers who should be given the resources and support to carry out project activities; (c) Care should be taken to ensure that project programs are integrated to the greatest extent possible with relevant national programs; (d) Project Implementation Unit (PIU) is a useful mechanism for project implementation. Its principal mandate in addition to the specialist functions, should be to support programs managers in the implementation of project programs and in the enhancement of the overall implementation capacity of the Ministry; (e) Delays in appointments to key positions in the organization have serious effects on project implementation and should be avoided; (f) MOH should devote increased attention to development of briefs for physical facilities in order to avoid problems during project implementation; (g) In project formulationi adequate attention should be given to availability of relevant resources such as manpower; (h) Attention should be given to improved coordination in ensuring availability of water supply to health facilities in the rural sector; (i) The standard lists of equipment and furniture for district hospitals and rural health centers should be revised taking into consideration current needs and advances in technology; (j) The design of borehole water supply systems at RHCs should be reviewed in consultation with MOW and the Water Department in regard to water supply needs, specifications of equipment and methods of delivery as adequate supplies are not assured under existing schemes; (k) The financial management aspects of project implementation should be improved;  14 (I) Increased attention should be given to field supervision of construction work by the PIU. E. Effectiveness of Relationship between Bank and the Borrower 2.27 The mutual understanding and appreciation of problems that developed between the MOH and the Bank during project development and the first years of its implementation helped overcome the major problems of project implementation and enabled effective use of project resources. Supervision missions provided opportunity for exhaustive and in depth review of project activities which provided constructive guidance. Although there were several changes of Task Manager for the project, these changes did not disturb the Bank GOM relationship and the pace of project implementation was maintained. 2.28 Preparations for the PHN Sector Project commenced during the last years of this project. This provided the opportunity to review project programs and to understand the major constraints within which project programs have to be implemented. Several activities not completed due to changing needs and priorities and difficulties in respect of particular activities would benefit from the implementation experiences of this project. F. Performance of CoFinanciers 2.29 As noted elsewhere, problems were experienced in financing of project activities. Some, especially the programs of international agencies such as UNICEF and UNFPA commenced prior to the approval of the IDA credit and were continued thereafter. Others such as the EC components were approved later with changes in the content of some programs. Some of the anticipated funds were not available at all. 2.30 As a result of the above, difficulties were experienced in project implementation and some of the anticipated benefits may have been affected. The activities in PHC may be a good example which could have benefitted more from cumulative effects of all activities such as community orientations, training, provision of supplies, transport and health facilities had these been implemented as a package. In spite of such problems, the project activities have made a significant impact on the health status of the population. 2.31 The several co-financiers of the project have different modalities of project implementation. This gave rise to specific problems of coordination and record keeping. As previously noted, firm arrangements in regard to financing of project programs and methods of implementation during project preparation would help to minimize such problems.  15 PART III. STATISTICAL INFORMATION A. Related Bank Loans 3.1 The Project followed on the First Family Health Project which was approved on April 21, 1983 and closed on December 31, 1988. Although the first project was extended three times, some components were still not fully operational by project completion. The first Project provided for training, renovation and upgrading of facilities, strengthening of support services for PHC, studies and technical assistance. It also improved the access and the quality of PHC facilities, expanded training and introduced CS services, and enabled the production of the 1986-95 National Health Plan that formed one of the bases of this Project. B. Project Timetable TABLE 1: PLANNED AND ACTUAL DATES OF PROJECT TIME TABLE STEP PLANNED DATE | ACTUAL DATES Identification 6/22-29/8S 6/22-29/85 Preparation 9/19-30/85 9/19-30/85 Appraisal 1/86 12/2-20/85 Post Appraisal 6/9-17/86 6/9-17/86 Negotiations 9/86 2/2-6/87 Board Approval 11/86 3/24/87 Signing Date 5/7/87 5/7/87 Credit Effectiveness 6/15/87 6/15/87 Completion Date 12/31/93 12/31/93 Closing Date 6/30/93 6/30/93 3.2 Comments on timetable. Because of the complexity of the Project, the number of parallel financiers involved, and the absence of a firm financial plan, a post-appraisal mission was needed. This permitted the firming up of donors' financing plans, and gave GOM more time to undertake several activities to ensure a prompt and smooth start of the Project. However, KfW decided not to fund those activities which they had initially expressed an interest in. While most of the project's components were completed and the project closed on time, a number of activities were shifted to the PHN Sector Credit.  16 C. Loan Disbursements TABLE 2: CUMULATIVE AND ACTUAL DISBURSEMENT (US$ MILLION) BANK FY 1988 1989 1990 1991 1992 1993 Cumulative estimate at appraisal 0.66 2 97 6 05 8.69 10.45 11.02 Estimate as '7 ot the loan I1 27 55 79 95 1() Cumulative actual 1.528 5.053 7 577 10.315 I 1.104 1 1.595 Actual as % ot- thel loan 13 44 65 89 96 1) 3.3 Comments on Loan Disbursement. The projected schedule of disbursement was realistic and well planned, as indicated by the high disbursement level (only SDR 2,232.62 was cancelled). The difference between the planned and actual disbursement is a result of currency fluctuations. D. Proiect ImDlementation TABLE 3: PLANNED AND ACTUAL COMPLETION DATES OF CIVIL WORKS COMPONENTS PLANNED MIONTHS COMPONENT COMPLETION ACTUAL COMPLETION OF DELAY (PHC) 19 New and 6 upgraded 7 RliCs in 1987. Construction completed heixeen 12 RHCs, all provided withl 9 in 1988 and 9 1989 and 1990. IDA funded 17 water; 3 staff houses tor in 1989 |new II'DI tunded 2) and all each new and I tor each upgrades. 3 RIlCs are still renovated RHC. closed due to lack of water and/or stalf and many have ,kater problems. Hospital at Mzimba with July, 1990 August. 1992 25 20 staff houses. School for enrolled November. 1989 Novemher. 1989 0 nurses and hostel at Zomba. Three Regional Training Not Applicable Deleted due to increase in Not applicable Centers construction costs  17 PLANNED MONTHS CONIPONENT CONIPLETION ACTUAL COMPLETION OF DELAY (Management. Manpower & Support System) Pharmaceutical Not given. 3 districts hospitals Unknown depots at 8 district provided with depots in hospitals. 1988 and 3 district hospitals provided with depots in 1990. 1 pharmacy completed at KCH in 1990. (Family Health) Regional Rural Not given The center at Mzuzu was Unknown Training Center at completed in June 1989. Mzuzu. The fish ponds were not 150 Fish ponds. implemented. 7 fish ponds and 10 Not given 3 fish ponds and 6 health Unknown shelters attached to shelters were completed dispensaries. Surgical Not given Deleted due to Not contraceptive units unavailability of funds from applicable at 7 district KFW. hospitals; I urban family health unit in Lilongwe; 3 new health centers and upgrading two existing ones in Blantyre and Not given Lilongwe Completed in January 1990 Not applicable Paediatric Ward at KCH, Lilongwe 3.4 Comments on Proiect Implementation. Although construction was generally completed on time, the three regional training centers were not constructed, and design problems were experienced at some facilities which required corrective interventions. At Mzimba Hospital the water pressure was insufficient, the pharmacy was too small, the number of examining rooms for outpatients were too few, the mortuary had to be relocated, and the TB and psychiatric patients are still located in the old hospital due to a shortage of appropriate space. The windows at the paediatric ward of KCH were poorly designed causing problems during the rainy season, and the Zomba School of Nursing had a leaky roof.  18 E. TOTAL PROJECT COSTS AND FINANCING (including contingencies) TABLE 4: TOTAL PROJECT COSTS (US$ '000) APPRAISAL ACTUAL CATEGORY LOCAL I FOREIGN TOTAL LOCA [FOREIGN | TOTAL Civil works 6,752.5 4,780.4 11,532.9 N.A. N.A. 14,971.7 Furniture, materials, equipment, and vehicles. 1,703.8 4,974.6 6,678.4 N.A. N.A. 4,833.4 Technical assistance, N.A. N.A. 5,338.2 design fees, monitoring, research, evaluation. 4,866.0 1,863.7 6,729.7 activities, training (including overseas) and salaries. TOTAL 13,322.3 11,618.7 24,941.0 N.A. NA. 25,143.3* N.A. = Not Available * Does not include the training costs supported by UNICEF: EEC contribution in ECU was transformed into USS applying the exchange rate of August 1993. TABLE 5: PROJECT FINANCING (US$ MILLION) | SOURCE ! PLANNED [ ACTUAL IDA 11.0 11.6 UNICEF 2.6 1.8 EDF 3.5 6.3 |KfW 4.1 0 Government of the Netherlands 0.9 1.7 UNFPA 0.9 1.9 Government of Malawi 1.9 1.8| TOTAL 24.9 25.1  19 3.5 Comments on Project Financing. Several changes in the original financing plan took place during the first two years of project implementation. KfW decided not to participate in the Project, and those costs (salaries of staff, vehicle operating and maintenance costs) were picked up by IDA. After the EEC appraisal, several activities to be financed by EDF were modified: (a) some RHCs and housing units, to be financed by EDF, were financed by IDA; (b) the EDF credit included provision for the New Mulanje District Hospital; and (c) the functional literacy component, which was originally to be financed jointly by IDA and EDF, was funded totally by EDF, with the exception of the Mzuzu Regional Training Center. This allowed the release of US$1.3 million of IDA funds for other activities. Vehicles were purchased utilizing savings under Credit 1351-MAI, and the amount saved was utilized for the construction and furnishing of the Paediatric Ward at KCH. Provision for drug production decreased from US$1.6 to 0.9 million, and provision for project management was reduced from US$1.6 to 0.7 million. At project closing GOM's contribution was 1.8 million equivalent. TABLE 6: ALLOCATION OF LOAN PROCEEDS (US $'000) CATEGORY ORIGINAL ACTUAL DISBURSEMENT ALLOCATION Local Foreign Total Civil works 6,152.4 3,882.8 4,447.1 8,329.9 Furniture, material, equipment and vehicles 2,562.6 69.1 1,936.5 2,005.6 Technical Assistance, design fees, monitoring, research, evaluation, activities and training (including overseas). 2,305.7 155.1 1,104.4 1,259.5 TOTAL 11,020.7 4,107.0 7,488.0 11,595.0 3.6 Comments on Proiect Costs. Civil works increased to US$8.3 million, due to a general increase in construction costs, and an increase in the size of Mzimba Hospital. The Paediatric Ward at KCH, which KfW was supposed to fund, was financed by IDA using savings made available by required vehicles being purchased under the first IDA health project. The absence of a monitoring system of expenses did not allow forecasting of cost overruns. This increase was met through reallocating from Category 2 (vehicles, equipment) and unallocated funds.  20 TABLE 7: DIRECT BENEFITS OF THE PROJECT COMPONENT ESTIMATED AT BENEFITS AT EXPECTED BENEFITS APPRAISAI CLOSING DATE AT FULL DEVELOPMENT Management, Continue (he inlstitutioIn There is a llet MOII Better planninlg and Manpower and huilding initiated by the structure, managemietn ot ofhealth Support Systems First Famils llealth The neu enirolled nurses se ices. Better staftinlg Project. school. completed in le els Imlproved quality Better planninig and Zomba, should increase of sers ices, cost-effective maniagement ot the h ealth manpower outputs. use ol scarce resources. services. Better Regional llealth Teams I)ecrease morbidity and Loordiinationi and have beenl establi shed mortality impiplcmenltatioul ot licalth D)ecentralization ot tfinance programs. More rational and accouniting has been use of manpower. introduced. The I)ecentralization of' plharmaceutical systemn has accountinig and effective been strenigthened. drug distribution system. Expand PHC from Replacement of' I existinig Holspital is operational All B3etter access to healti 9 to 15 districts district hospital, RIICs have been services in rural areas. construction of 19 new completed, some are fully RHCs and upgrading ot 6 staffed and have water. health sub-centers; provision of equipnietlt aiid supplies tfor VIICs. Expand family' Provision of transport to Imnproved supervision and Increased coverage of health activities MCII services; training; mohile services. antenlatal and delivery expansion of CS; Availability ol care. continuation of nutrition contraceptives has Eetter access to CS, activities; production of implroved inlcreIase in coIltraceptive IE-C materials, coverage anid decrease in tertility' rates. D)ecrcase inl maternial and inifant mortality. Improvement in nutritional status tirough prolonged birth interval. Functional Family health introduced 'the Regional Trainlinig B3etter health through literacy; through functional literacy Ceinter in the Northerin improved awareness and Youth Program; and youth programs Region was built. The health practices. and [EC. traininig curriculum and tht traininlg work plan in functional literacy waS developed. IEC materials produced.  21 TABLE 8: PROJECT STUDIES PURPOSE l A FIELD OF STUDY AS DEFINED STATUS INPACT OF STUDY AT APPRAISA1I,l Baseline healthl status Support MO}l's effoits Baseline survey combined Monitoring and and utilization study in to strengtlheni its withi a study on health evaluation capacity xear I: tfollovX -up in moniitorinig and indicators for Health for strengthened. year 3. evaluationi capability. All bv the Year 2000 completed February 1989; no other study undertaken. PIIC evaluation completed Surveys and evaluation and report issued June studies of specific 1987; EPI evaluation programs (e.g. PIIC. completed August 1988 EPI, Tuberculosis (TB1) and report issued control of diarrhoeal September 1989: TB diseases, malaria prevalence survey was not onchocerciasis. ) done; malaria and diarrhoeal diseases control programs evaluation completed June 1989: Onchocerciasis Control Program reviewed April 1989. Targeted tood subsidies Conducted in 1991. study and evaluation of area-based househlold food security projects. E'valuation otf cost Assess the feasibility Not done Not applicable reduction measures and advantage ot cost implemenlted bs MOH. reductioni measures. Study of impact ot tees on tac ility utilization and potential otf hIealtli inisurance. Complemenit and Improve structure, Completed October 1988; Reorganization of MOH Grading Study organization and recommendations of the under implementation, managenmenit of MOII study were accepted and new organization chart are being implemented. adopted, development of job descriptions and unit functions done. Training needs Not detined. Study completed April Training needs are still assessment, includinig 1991. under evaluation due to the developmelit of a ongoing discussions model training program related to for regional and district decentralization. health teams.  22 F. STATUS OF LOAN COVENANTS TABLE 9: COMPLIANCE WITH LOAN COVENANTS CREDIT | COVENANT STATUS AGREEMENT l l _l Section 3.01 (a) The borrower to execute the project with efficiency In compliance and in conformity with accepted procedures and ensure resources availability. Section 4.01 (a) The borrower to maintain financial records and Absence of accountant accounts, in accordance with sound accounting made it difficult to practices. maintain proper records. Section 4.01 (b) Ensure, for each fiscal year, auditing of project Audit reports were not accounts, including those for the Special Account. always timely or up to Provide audit reports to IDA, not later than 6 standard. months after the end of each fiscal year. Furnish to IDA any other accounting information as requested. Section 4.01 (c) The Borrower to mainitain records and account of expenditures; retain all records of expenditures for at least one year after the completion of the audit; enable the Association's representatives to examine such records; ensure that such records and accounts are included in the annual audit. Schedule 4, para I Establish Project Coordination Committee at EP&D The Coordination for Parts A and B not later than October 1, 1987. Committee never met. Carry out mid-term review not later than December Mid-term review not 31, 1988. done. Submit annual implementation plans tour months The annual before the beginning of the Borrower's fiscal year. implementation plans were not submitted. Schedule 4. para 2 MOH to appoint a hill time project coordinator for In compliance. Part A. Schedule 4. para 3 Establish withiii MOH a coordinating committee for At most, MOH Part A to meet once a month. coordinating committee met quarterly. Schedule 4, para 4 (a) MOH to appoint a clerk of works by October 1, An architect was and (b) 1987 and a procurement officer by October 1, 1988. appointed in place of a clerk of works. The procurement officer was not appointed. Schedule 4, para 5 MOH to ensure supervision of project components In compliance. by designated officials.  23 CREDIT COVENANT STATUS AGREEMENT Schedule 4, para 6 MOH to conduct the following studies and submit the results to IDA for review and comments: (a) a mid-term evaluation of the PHC Program by (a) A PHC review was December 31, 1988; conducted in June 1987. (b) annual plan assessment and review workshops; (b) Only carried out in 1988 (c) a study on the impact of the revised fee (c) Not done. schedules on the utilization of services and on the potential for health insurance by December 31, 1987; (d) Substituted with a (d) a baseline health status and utilization survey by survey of indicators on December 31, 1987; Health For All By The Year 2000, completed in February 1989. (e) One study done. (e) annual impact studies of various programs; (f) In compliance. (f) a special evaluation of the EPI program by September 30, 1989; (g) Not done. (g) a TB prevalence survey by December 31, 1989. Schedule 4, para 7 The Borrower to ensure staffing of the new or 9 RHCs have staff, but upgraded RHCs with at least one medical assistant not the requisite I medical and two enrolled nurses per facility. assistant and 2 enrolled nurses, and 3 have neither category of staff. Schedule 4, para 8 (a); The borrower to submit to IDA a revised In compliance. and (b) organization chart for MOH by September 1, 1987 and formally adopt it by October 1, 1987; establish and make appointments to the positions of Controllers for Clinical Services, Family Health Services, Community Health Services and Health Technical Support, three regional health officers and three regional nursing officers by October 1, 1987. Schedule 4, para 9 (a) The Borrower to establish within MOH a committee The committee was with Deputy Secretary of MOH as chairman and formed but met representatives of Queen Elizabeth Central Hospital irregularly. (QECH), KCH and Zomba General Hospital (ZGH), to monitor the implementation of cost reduction measures, before July 31, 1987 Schedule 4, para 9 (b) Establish positions of expenditure control accountant Accountants in post. at MOH, three regional accountants and one accountant at each of the three major hospitals before October 1, 1987. Schedule 4, para 9 (c) Establish a position of assistant accountant at each of Posts established. the 21 district hospitals before August 31, 1988.  24 CREDIT COVENANT STATUS AG REEMENT Schledule 4 para 9 <dl) Implement cost reduction measures at N(I)I anrd Soime niiasures QEICFI hy Decembber 31. 1987. inIplcIllented Schedule 4. para 9 (el Suhmit to IDA an evaluationi ot cost reducti(ni Not dotie. measures iiplciplemited by N1OII by NMarch 31 1988. Scledule 4. para 9 (1) I)ecentralize tifianice and accounitinig functions of the Fuiictionii deceitiralizei. thirce miajor hospitals helore April 3), 1988. Schedule 4. para 9 (Ig Implemieint cost reduction nicasures at KCII atid siilie measures ZGII by April 3(, 1988 implemented. Schtedule 4. para 9 (hb Im pleme1cnt cost reductioi n easures at all district Not itIplemenint. hospitals by l)ecember 31. 1988. Schedule 4, para 10 (a) Appoinit a traitiing otticer to coordinate in-service Offlice appoilntedl trai imug programs in MNI(I helore Septembiher 1 NlanipoAer l)eDelopntemit 1987. t.nit created. Schedule 4. para 1() (b) Suhblit to IDA betore December 31. 1987 in scrs ice Not imipleiciieted. traininig programi tfor the following fiical Ncar and annually thereafter. Schedule 4. para 11 Appoint 6 cliitical otticers and 16 etnrolled nurses to Activity cancelled. urban Cilinics after their comilpletioni. Schedule 4. para 12 N1OCS to be responsible tor ttmomtitorilng II coitipliance iniipleititietationi of actisities of Part 3. Schledule 4. para 13 B tahlish. the lIcalth. Itiloriiatioti, Education anid Not doone. Comimiuniicationi Colitiiittee by Sept itihcr 1I 1987. G. USE OF STAFF RESOURCES TABLE 10: STAFF INPUTS BY STAGE OF PROJECT CYCLE (In staff weeks) .STAGE OF ACTUAL ACTlUAL AC TlUtAI | PROJECT Pt.ANNEI) REV ISEI) IIQ FIEI.I) TOTA( I. Through appraisal N. A. N. A. 88.7 12.6 1()1.3 Appraisal to board N. A N. A. 15.6 22 8 3 8.4 Board to N A. N. A. N. A. N A N.A. eftectiven'ess Supervision 57.8 83.6- 50.2 27.6 77.8 N.A Not A%ailable From FY 89 onAards  25 TABLE 11: MISSION DATA BY STAGE OF PROJECT MISSION TIME PARTICIPANT STAFF S WEEKS I PERFORMANCE STATUS 2/ Identification | 6/85 2 (Ph. E) 2.3 Preparation 8/85 6 (Phi Pop, F. 10.3 IEC, Arc, Denmo) Appraisal 12/85 6 (2 Ph, E, Arc. 15 IEC, Res) Post Appraisal 6/86 5 (Ph, Arc. IEC. 3.2 E, Res) Implemenitatiol 11/86 3 (IEC. Arc, E) 3 Mission Launch 4/87 2 (Arc. E) 1.6 G P M F Spi1 1 11/87 3 (E. Ph. Arc) 2.1 1 2 2 nr Spn 2 3188 3 (E', Ph, Arc) 1.8 2 2 1 nr Spn 3 10/88 3 (E. Ph, Impl) 2.1 2 2 1 nr Spn 4 3/89 3 (E, Ph. Arc) 2.8 1 1 1 1 Spio 5 10/89 2 (Plh, Arc) 1.1 I 1 2 1 Spn 6 3/90 2(Ph, E) 2 1 1 1 1 Spoi 7 6/90 2 (Arc, E1) 2.8 1 2 1 1 Spni 8 1W/90 2(E, Arc) 2 1 1 1 1 Spn 9 3/91 2(E, Ph) 1.6 1 2 1 1 Spin 10 6/91 3 (E, Ph, Imp) 3.2 1 1 1 1 Spn II 12/91 2(E, Ph) 2.6 1 1 2 Spn 12 6/92 2 (Ph, Pop) 2.8 2 3 2 2 Spn 13 3/93 2 (Ph, Pop) 0.7 2 3 2 2 Notes I/ Arc = Architect; Demo = Demographer; E Economist; [EC = Information Education and Communication specialist: Imp = Implementation Specialist: Ph = Public Health Specialist; Pop = Population Specialist; Res = Research Assistant. 2/ G = General Status: P = Procurement: M = Management; F = availability of local funds; nr = not rated.  26 ANNEX 1 NAMES OF OFFICIALS MET DURING PCR MISSION MOH Mr. Mizere, Principal Secretary Mr. Muva, Deputy Secretary Mr. Mvula, Under Secretary Dr. Chimimba, Chief of Health Services Dr. Khosa, Acting Controller of Preventive Services Professor Khonje, Controller of Technical Support Services Dr. Chaziya, Deputy Controller of Clinical Services Dr. Mukiwa, Principal LSHS Ms. Mahaka, Principal Zomba School of Nursing Dr. Mbvundula, Technical Advisor Ms Kasonda, Head, Family Health Division Ms. Makoza, Chief Nursing Officer Mr. Perera, Project Coordinator Mr. Chidyaonga, Project Architect Mr. Kambalematore, Project Quantity Surveyor Mr. Hara, Administrative Officer, PIU Mr. Mwanza, Procurement Officer, PIU Mr. Kalanje, Principal Manpower Development Officer Mr. Madise, Senior Health Planning Officer Mr. Limbane, Principal Personnel Officer Ms. Gunde, Senior Personnel Officer Mr. Chidamba, Public Health Officer Mr. Mtika, Planning Officer Ms. Ghambi, Senior Administrative Officer (Planning) Ms. Kasondi, Rural Housing Advisor MINISTRY OF WOMEN. CHILDRENS AFFAIRS AND COMMUNITY SERVICES Ns. Kalyati. Principal Secretary Nis ILaatunen, Long Term Consultant Ms. Chirambo, Project Coordinator Ms. Shawa. Nutritionist MTENTHELA MATERNITY HEALTH CENTER Mr. Sendezera, Medical Assistant MCHINJI HOSPITAL C. Chidongo, Chief Clinical Officer H.H.D. Masuku, District Environmental Health Officer M. Mpekansambo. Acting Matron MZIMBA HOSPITAL Dr. Huggett, District Health Officer Dr. Pape, Govemment Medical Officer Dr. Bettels, Peace Corps Doctor Mr. Gondwe, Assistant Hospital Secretary Mr. Sani, District Health Inspeclor Mr. Malata, Acting Matron Ms. Thole, Registered Community Health Nurse REGIONAL HEALTH MANAGEMENT TEAM (NORTHERN REGION) Dr. Khosa, Regional Health Officer Mr. Mwamanyeta, Accountant Ms. Katambo, Regional Nursing Officer Ms. Muyengembe, Regional Public Health Nurse Mr. Daudi, PHC Coordinator Mr. Matela, Executive Officer Ms. Mphande, Public Health Nurse  27 REGIONAL HEALTH MANAGEMENT TEAM (SOUTHERN REGION) Mr. Antila, Senior Accountant Mr. Jumula, Principal Environmental Health Officer REGIONAL PHARMACEUTICAL DEPOT, MZUZU Ms. Coats, Pharmacist in Charge MZUZU TRAINING CENTER Mr. Singini, Principal MZOKOTO HEALTH CENTER Ms. Chirwa, Enrolled Nurse Midwife MINISTRY OF FINANCE Dr. Chayenda, Deputy Secretary Mr. Mphonda, World Bank Desk Officer Mr. Sibande, Senior Assistant Secretary on WorLd Bank Desk EP&D Mr. Kandaya, EP&D Ms. Ayodaye, Family Nutrition Unit/Ministry of Agriculture Mr. Chapakusa, Family Nutrition Unit/Ministry of Agriculture OECH Mr. Mtende, Principal Accountant Mr. Nyirenda, Hospital Secretary KCH Ms. Kanjere, Hospital Secretary Mr. Chikhosi, Hospital Administrator Mr. Banda, Senior Assistant Hospital Secretary Mr. Kaunda, Senior Accountant MAKHANGA RURAL HEALTH CENTER Mr. Benson Mtemula, MA DONORS Ms. Benbow-Ross, UNFPA Dr. Graaff, WHO Mr. Lovasz, EEC Ms. Hahn, UNICEF  28 ANNEX 2 PROJECT IMPLEMENTATION SUMMARY (as of 30 June, 1993) PROJECT CONIPON(ENTI| STATUS AT THE END OF THE PROJECT (a) Expansion of PHC program iront 9 to 15 districts, includinig training ot healti statt ( Copleted of MOH, DDCs and V13Cs provision ot equipment, supplies. motorcycles and bicycles. C onipleted (b) Constructing, turnishing anid equipping about 19 new RIICs andl related housing facilities and upgrading 6 subcenters to RIICs Completed (c) Constructing, furnishing and equipping a district hospital anid eclated housing facilities at Mzimba. MANAGEMENT, MANPOWER and SUPPORT SY S1l EMS (a) Strengthening rnalagemiitt at nationial, regionial atid district lcI tli iough . MOI)I ieorganited regioiial healtlh teatils establishied, (i) reorganizing MOII s structure; planning capability (ii) establishing regional health teams; improved (iii) operating annual workshops in hospital maniagemlent atid administratiotn; Matiagetment strecngtiening (iv) improving planning capability at cenitral and district lesels: anid continues unider Cr. 2220- tv) supporting the accounting sections of MOHi thte regioial teamils, the three MAI. major hospitals and thte 21 district hospitals. i[icluditig pro iding computers to MOII and the three major hospitals. (b) Strengthening MOH 's nraipo%er developimient capability through Nursing school completed: (i) constructing, furnishing and equippinlg a nursing schlool atid irlated Manrpower l)evelopmient facilities at Zomba; Unitt established: trainintg (ii) constructing, furnishinig and equipping three regiotial tramnitig tacilities tol olficer appointed health workers; and (iii) supporting MOI( 's nianpower planiting atid analysis capahility (c) Improvement of MOII s support systetms through: Substantially a1CCo,plisheJd (i) increasing MOII s monitoring and evaluation capabilities, howe er. oni six depots (ii) constructing, turnishing and equipping pharmaccutical depots at eight completed at district district hospitals, including provision of vehicles and supplies: hospitals. (iii) establishing a quality control lahoratory (iv) training pharmacists, pharmacy techlinicians and assistants; and (v) reviewing and decentralizing the plharmaceutical systen.  29 PROJECT COMPONENT STATUS AT THE END OF THE PROJECT (D) FAMILY HEALTH (a) Support of the MCH program through: Vehicles provided and drugs (i) providing vehicles and boats for health services' delivery; distributed. (ii) developing an integrated family health course for about 200 health workers annually; (iii) in-service training for about 900 health workers in priority diseases; and (iv) preparing and distributing drugs annually for about 1,100 MCH centers and about 640 prenatal clinics. (b) Expansion and reinforcement of CS program through: Manuals and information (i) constructing, furnishing and equipping surgical contraception units at seven materials prepared. district hospitals; (ii) constructing, furnishing and equipping an urban family health unit in Lilongwe, three health centers in Blantyre and Lilongwe, and upgrading two existing health centers in Blantyre and Lilongwe; (iii) reviewing training plans for surgical contraception and development of a system of quality control; (iv) training all health staff involved in the CS program; and (v) preparing and distributing manuals and information materials. (c) Establishment of nutrition activities in MOH. No new nutrition activities initiated. MULTISECTORAL FAMILY HEALTH ACTIVITIES (a) Introducing family health topics in MOCS's functional literacy and women Training center completed; programs through: some training carried out (i) constructing and equipping a training center for the Northern Region; and some informational (ii) training MOCS staff in health topics; materials prepared and (iii) preparing and distributing informational materials; distributed. (iv) training women's groups in nutritional subjects; and (v) constructing and operating fish ponds. (b) Introduction of family health education activities in the MYP program through: Instructors trained; some (i) training instructors; informational materials and (ii) providing informational materials and equipment; and equipment provided; and (iii) constructing fish ponds. some fish ponds constructed. (c) Development and implementation of nationwide IEC programs dealing with family health subjects through: Not done. (i) preparing and distributing informational materials; and (ii) training Information Department staff.  ANNEX 3 Rural Health Centers Completed Date Equipment Water StafHmg Staff Poptlation District Name of RHC Takeover Delivery Supply Houses C overageo Remarks Houses Coveragel _ _I__ _ _ _ _ _ _ _ _ M E H _ Karonga Njala ya Nkhunda 5/90 5/90 Water system needs 1 I 1 5 3 14,000 New. maintenance. In operation. Rumphi Chitimba 6/90 6/90 Borehole functioning. - 2 1 6 3 12,000 New. In operation. Mzokoto 10/89 5/90 Piped water from - 2 1 4 3 11,000 Upgrade. Phwezi Water Scheme. Mzimba Choma 4/90 6/90 Water tank needs I - 4 3 10,000 New. cornection to borehole. In operation. Khosolo 5/90 10/91 Operational. I 4 3 13,000 Upgrade. Bula 5/91 5/91 Borehole needs 1 2 1 3 3 11,000 New. Nkhatabay connection to the tank. In operation. Chitheka 5/92 6/92 Borehole needs - - - 1 3 12,000 Not operational. connection to the tank. Kamboni 5/90 12/90 Borehole not cornected 1 1 1 7 3 15,600 New. Kasungu 5/91 to the tank. In operation. 5/92 Kawanba 6/89 11/89 Water pipes not 1 I 1 3 3 25,625 Upgrade. connected to the reservoir tank. Nkhota Kota Nsenjere 1/92 7/90 Borehole poorly 1 2 1 8 3 7,366 Upgrade. 8/90 connected to the tantk. 5/91 Dowa Chakhaza 5/90 10/90 Borehole not connected 1 2 1 3 3 34,285 New. to the tank. I In operation. Kayembe 5/90 10/90 Borehole not connected 2 - 4 3 59,112 New. to the tank. In operation.  Date Equipment WaterStfigsaf Ppdio District Name of RHC Takeover Delivery supply ltaff |Coverage |io Houses Cvrg eak M E H 0 Nthondo 10/92 12/92 Operational. 1 2 - 4 3 81,000 New, Lilongwe In operation. Kangoma 11/91 12/92 Operational. l 2 7 3 35,800 New. In operation. Kalulu 4/90 6/90 Borehole not connected - - 1 3 12,000 New. Dedza to the tank. Not operational. Kaphuka 8/90 6/90 Borehole not connected 1 2 1 7 3 22,000 Upgrade. to the tank. Functions as Rural Hospital. Ntcheu Ositini 10/88 5/91 Operational. Rural 1 2 - 8 3 12,880 New. piped water from In operation. Mpina-Balaka water supply. Mangochi Lungwena 6/90 11/90 Works well. 1 2 1 4 3 12,000 New. Functions as field practice unit for Medical School. Chiradzulu Mauwa 5/90 8/91 Borehole not connected - 2 1 4 3 14,000 New. to the tank. I In operation. Chitera 5/90 5/91 Borehole not connected l 2 1 5 3 12,000 New. to the tank. In operation. Chikwawa Kumaniza 7/89 10/89 Operational. Solar I I 1 6 3 68,032 New. pump installed. In operation. Chabvala 6/90 8/91 Borehole not connected 1 3 17,000 New. to the tank. Not operational. Mulanje Nkhulambe 6/90 7/90 Borehole not connected I 1 1 7 3 24,959 Upgrade. 12/90 to the tank. In operation. M = Medical Assistant E = Enrolled Nurse Midwife H = Health Assistant 0 = Others