Sri Lanka - Health and Family Planning Project

 Health and family planning project Report No: ; Type: Report/Evaluation Memorandum ; Country: Sri Lanka; Region: South Asia; Sector: Basic Health; Major Sector: Health Nutrition & Population; ProjectID: P010307 The Sri Lanka Health and Family Planning project, supported by Credit 1903-CE for US$17.5 million equivalent, was approved in FY89. The credit was closed on September 30, 1995 after a one-year extension. A total of US$6.7 million equivalent was canceled because of project restructuring in 1994. The South Asia Regional Office prepared the Implementation Completion Report (ICR), to which a summary of the borrower’s report is appended. The project’s objective was to (i) strengthen the government health system at the central and regional levels by improving staffing and financial management, planning capacity and service delivery, and policy formulation capabilities; (ii) increase the efficiency and cost-effectiveness of the distribution system for pharmaceutical and medical supplies; and (iii) reduce fertility and improve maternal and child health through more effective use of contraception. The project had three components: health management improvement (44 percent of total project base cost), health logistics system (30 percent) and family planning (26 percent). Three special programs on malaria control, malnutrition and gastrointestinal infections complemented the service delivery objectives. While project service delivery objectives were generally met, health management improvements and policy reforms were largely not realized. The original project design was complex and relied an achieving sustained consensus between the Ministry of Finance’s, whose original priorities were on achieving management and policy reform in the sector and the Ministry of Health’s (MOH) priorities, which were to improve health service delivery. This consensus was not achieved. As a partial consequence, most of the original management improvement activities were dropped and service delivery support was expanded when the project was revised after the 1993 midterm review. Civil works and training activities improved health service delivery in some areas, but baseline data collection was carried out too late to allow impact to be assessed. The distribution of pharmaceuticals and management of medical supplies did not improve despite the completion of civil works and provision of vehicles and relevant equipment. Family planning services improved and the total fertility rate fell from 2.8 to 2.3 between 1987 and 1993. However, the government health care system was decentralized in 1989, and it is difficult to distinguish the project’s impact from effects of this and other policy changes. Of the three special programs, only that which supported the MOH’s new Anti-Malaria Campaign, designed to follow the revised WHO malaria control strategy, was effectively implemented. The Operations Evaluation Department (OED) agrees with the ICR in rating project outcome as unsatisfactory, institutional development as modest, and sustainability of the improved health infrastructure as likely. OED rates IDA performance as unsatisfactory because IDA did not adequately assess the implementation risks of focusing on the priorities of the Ministry of Finance when these design objectives did not reflect the priorities or support of the Ministry of Health, the core implementing agency. The main lesson from the project is that IDA must carefully assess borrower commitment to sector reforms at the design phase to ensure that project objectives are consistent with the government’s sectoral priorities, recognizing that government views are not monolithic. Particularly in settings where major policy and financial reforms are being considered, consensus on the priority for, and directions of, key policy changes among financial and line agencies of government is essential. A follow-on project adopts a more modest set of objectives, which are clearly owned by the Ministry of Health. The new project takes an incremental approach to health policy reforms, aiming to achieve consensus among concerned parties, while at the same time continuing to strengthen the public health services. The ICR is of satisfactory quality and effectively conveys the negative consequences of the ownership problems inherent in the project’s original design. No audit is planned.