Niger - Health Project

 Health project Report No: ; Type: Report/Evaluation Memorandum ; Country: Niger; Region: Africa; Sector: Other Population Health & Nutrition; Major Sector: Health Nutrition & Population; ProjectID: P001965 The Niger Health project, supported by Credit 1668-NIR for SDR 25.1 million (US$27.8 million), was approved in FY86. It was the first Bank operation in the health sector in Niger. Following two one-year extensions, the credit was closed in June 1995. The dollar value of the credit amount disbursed (US$37.1 million) was higher than anticipated at appraisal due to changes in the US$/SDR exchange rate. SDR 0.32 (US$0.33) million was canceled. Additional financial assistance was provided by the United States Agency for International Development (USAID) (US$1.2 million) and the Government of the Netherlands (US$0.77 million). The Implementation Completion Report (ICR) was prepared by the Africa Regional Office. Annex B contains the borrower’s contribution to the ICR. The Dutch, UNICEF, and USAID participated in the ICR mission but did not provide written comment. The project objective was to assist the government to improve the performance of the public health sector. The project had two parts: Part A to support policy reform and Part B to strengthen basic health and family planning services. Despite an ambitious design and limited management, institutional capacity, and financial resources, the project made substantial achievements in both its policy reform and investment activities. This success was due in large part to the government’s commitment to reform in general and the project in particular. A series of studies and planning activities, financed under Part A, contributed to policy formulation and reform, including (i) greater financial and managerial autonomy for hospitals and improved resource mobilization and hospital management; (ii) pilot studies of cost recovery for basic health services and the subsequent passage of a national law on cost recovery for the non-hospital sector; and (iii) adoption of a health sector plan with a district (decentralized) approach that provides a coherent framework for sector development. The government also developed its National Health Sector Development Plan for the period 1994–2000 identifying the reform needs in the sector. Additional activities took place which were unforeseen at appraisal: a population census, a survey of youth health issues, purchase of anti-tuberculosis drugs, and activities related to HIV/AIDS. However, towards the end of the project, a number of activities were transferred to the on-going population project (Cr. 2360) which planned to finance the same set of basic health activities: nutrition, maternal and child health, family planning, immunization, and health education. Achievements under Part B were substantial. Despite delays in planning and funding, 110 of 113 health facilities were upgraded. Substantial achievements were made in training, although these fell short of targets. These investments increased capacity of the health system to receive and treat patients and improved the quality and coverage of care. In addition, a number of priority health programs and services were strengthened through management interventions, including: creation of an interministerial committee for malaria control; definition of a national, multisectoral nutrition policy; creation of a national program on diarrheal disease; strengthening health education programs at the central and departmental levels; and successful introduction of community participation in financing and managing health and nutrition activities. The vaccination and training subcomponents were successfully implemented, but they reached only a portion of those intended. Lack of baseline data and weak monitoring and evaluation prevented an assessment of project impact on health status in areas receiving project assistance. The Operations Evaluation Department agrees with the ratings presented by the ICR. Outcome is rated as satisfactory because the project achieved its main objectives. Sustainability is rated as likely since the borrower is taking appropriate steps to mobilize recourses for the recurrent costs of the sector, including activities initiated through this project. Institutional development is rated as modest because of the positive intent of many proposed reforms but lack of action (e.g., reforming the planning and budgeting system) to ensure they take effect. Bank performance is rated as satisfactory. The lessons identified by the ICR suggest: (i) the need for modest project objectives based on a sound knowledge of the existing situation; (ii) the need to define performance indicators by project appraisal to enable the borrower and the Bank to objectively assess project achievements and impacts; (iii) the importance of integrating and mainstreaming project activities more fully into the Ministry of Public Health’s operations, both at the central and decentralized levels; and (iv) that financial participation of the communities increases their involvement in, and demand for, health services, in turn prompting the public service to be more client-oriented. The ICR is satisfactory despite the absence of a plan for future operation. An audit is planned because the project achieved ambitious objectives under difficult circumstances, and the experience is valuable.