Morocco - Health Development Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 15798 PERFORMANCE AUDIT REPORT MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) June 26, 1996 Operations Evaluation Department This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Currency Equivalents' Currency Unit Dirhams US$ SDR 1984 8.811 9.362 1985 10.062 10.568 1986 9.104 10.656 1987 8.359 11.066 1988 8.209 11.049 1989 8.488 10.673 1990 8.242 11.442 1991 8.707 11.658 1992 8.538 12.442 1993 9.299 13.257 1994 9.203 13.080 1995 8.482 12.589 Abbreviations and Acronyms CP Central Pharmacy (Pharmacie Centrale) DAT Direction des Affaires Techniques (Technical Department of MOPH) GOM Government of Morocco TEC Information, Education and Communication INAS Institut National d'Administration Sanitaire IUD Intra-uterine Device MOE Ministry of Equipment MOF Ministry of Finance MOPH Ministry of Public Health OED Operations Evaluation Department PAR Performance Audit Report PCR Project Completion Report PDSS Projet de D6veloppement des Services de Sant6 (Health Development Project) PIU Project Implementation Unit PRISS Project d'Investissement dans le Secteur de la Sant6 (Health Sector Investment Project) SAR Staff Appraisal Report UAM Unit6 d'Approvisionnement en M6dicaments (Drug Supply Unit) UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organization Fiscal Year Government: January 1-December 31 1. Source: International Financial Statistics Yearbook, various issues. Prepared by IMF Statistics Department. FOR OFFICIAL USE ONLY The World Bank Washington, D.C. 20433 U.S.A. Office of the Dlrector-General Operations Evaluation June 26, 1996 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Performance Audit Report on Morocco Health Development Project (Loan 2572-MOR) Attached is the Performance Audit Report on the Morocco Health Development Project prepared by the Operations Evaluation Department (OED). The Loan for US$28.4 million equivalent was approved in June 1985. The project was closed in December 1993 after two extensions, and an undisbursed balance of US$2.56 million equivalent was canceled following final disbursement in April 1994. The project's objectives were to strengthen primary health care delivery in three provinces and to improve the capacity of the Ministry of Public Health (MOPH) at the central and provincial levels as a precondition for extending the health care delivery system to the rest of the country. The project had four components: (a) to improve and expand care to rural areas by piloting a new health care delivery system and upgrading and extending the physical infrastructure (70 percent of total project costs); (b) to strengthen the management and policymaking capabilities of the MOPH (5 percent); (c) to support training and information, education, and communication (IEC) programs (5 percent); and (d) to improve the supply of basic drugs (20 percent). Despite construction delays and slow release of counterpart funds, the project successfully constructed and equipped 148 health facilities, thus greatly improving access to basic health services in rural areas. The new health care delivery system developed under the project has since been expanded nationwide. The outcome of the attempt to strengthen the institutional capacity of the MOPH is difficult to measure, as the MOPH underwent several reorganizations during project implementation. Institutional impact was greater in the provinces than at the central level. The government's research group undertook a good evaluation of the project, albeit very late. Data were not available to monitor the basic health care component during implementation, but evaluation data do provide an excellent account of project accomplishments. Bilateral grants became available to finance IEC activities, thus only 25 percent of funds allocated to this component were disbursed. The drug supply component had little apparent impact on drug policy and failed to achieve its objective of improving the drug supply. The delay in this component was in a large measure the reason for the two extensions of the project. A new drug supply unit for storage, distribution, and formulation (the final stage of drug production from intermediate ingredients to a final form, such as tablets) was constructed under the project but was not operational at the time the project was closed, The storage and distribution unit has since become operational, but the formulation unit has not. It is doubtful if the government will ever recoup its investment in this unit (estimated to be US$13 million). This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. 2 OED, in agreement with the PCR, rates the project as satisfactory, institutional development as modest, and Bank and borrower performance as satisfactory. The audit upgrades the sustainability rating from uncertain to likely, for two reasons: all health facilities are now operational (many were not at the time of the PCR), and despite financial and technical constraints, provincial authorities are committed to the continued operation of the health facilities and maintenance of the gains made under the project. Important lessons from this project are that monitoring and evaluation systems need to be available from the beginning of the implementation period if they are to be used to influence outcomes; that clear communication and continuous dialogue between the Bank and the implementing agency are essential to avoid misunderstandings; and that design of new projects should not detract from the supervision of an ongoing project. Attachment FOR OFFICIAL USE ONLY Contents Preface ........................................................................................................... 3 Basic Data Sheet .......................................................................................................... 5 Evaluation Summary ........................................................................................................... 7 1. Sector Background ..................................................................................................... 11 Background ...................1.... ................11 Bank Activities in the Sector ........................... ..... 11 2. Project Objectives and Content ................................................................................. 14 Project Objectives and Components ....................... ..... 14 Project Design..................I5........ ...............15 Relevance.................. .................... ..... 16 3. Implementation and Results ..................................................................................... 17 Overall Implementation ................7..... ..............17 Primary Health Services ................................... 18 Enhanced MOPH Management Capacity ................... ..... 20 Training and IEC........................................21 Drug Supply...........................................22 4. R atings ............................................................................................................................. 23 Outcome ...................... ............... 23 Sustainability ............................................... 23 Institutional Impact ....................................... 24 Borrower Performance ............................. ....... 24 Bank Performance ............................... ........ 24 5. Issues and Lessons ..................................................................................................... 26 Drug Supply Component ................................... 26 Monitoring and Evaluation of Basic Health Component ...............28 Lessons ....................................... ....... 29 Figure 1.1: Morocco Health Sector Activities Timeline............................ 13 Table 3.1: Change Over Time in Access Indicators in Three Provinces.......... ................. 20 Annex: Statistical Tables 1. Distribution of the Population by Kilometric Radius-Agadir............................. 31 2. Results of the PDSS System Implementation-Agadir ............... .........31 3. Distribution of the Population by Method of Coverage-Agadir .......... ........31 4. Evolution of the Availability of Services-Agadir ...........................31 This report was prepared by Ms. Laura Raney (Health Economist) guided by Mr. Robert van der Lugt (Task Manager), who audited the project in December 1995. Ms. Diana Qualls and Ms. Sophie Lefebvre provided administrative assistance. The report was issued by the Agriculture and Human Development Division (Roger Slade, Chief) of the Operations Evaluation Department (Francisco Aguirre-Sacasa, Director). This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed wiLhout World Bank authorization. 5. Distribution of the Population by Kilometric Radius-Taroudant ........... ........ 32 6. Results of the PDSS System Implementation-Taroudant .................... .....32 7. Distribution of the Population by Method of Coverage-Taroudant........ ........... 32 8. Evolution of the Availability of Services- Taroudant.................................... 32 9. Distribution of the Population by Kilometric Radius-Settat............................33 10. Results of the PDSS System Implementation-Settat ..................... ......33 11. Distribution of the Population by Method of Coverage-Settat ........... .........33 12. Evolution of the Availability of Services-Settat ..................... ......... 33 Annex 2: Borrower Comments ............................................................................................ 34 Map: IBRD 18651 IBRD 18652 IBRD 18653 3 Preface This is a Performance Audit Report (PAR) for the Morocco Health Development Project, for which a loan in the amount of US$28.40 million equivalentI was approved on June 6, 1985 (Loan 2572-MOR). The project was closed December 31, 1993 after two extensions from its original closing date of December 31, 1991. An undisbursed balance of US$2.56 million (nine percent of the total loan) was canceled following final disbursement on April 12, 1994. The PAR is based on the Project Completion Report (PCR),2 the President's Report,3 the Staff Appraisal Report (SAR),4 review of Bank files, sector and economic reports, and discussions with Bank staff. An OED mission visited Morocco in December 1995, discussed project experience and outcomes with Government officials, and visited several project sites in the provinces of Taroudant, Agadir and Settat. Evaluations of the basic health component carried out by the health authorities in the three pilot provinces and the Institute National d'Administration Sanitaire (INAS) were also used in the preparation of this report. The PCR was completed in July 1995 and provides an excellent account of the implementation of the project and important lessons learned. The borrower's perspective on the project is included in Part 2. The PAR confirms the major findings of the PCR but examines in more detail several of these findings as well as some issues not fully covered in the PCR. In particular, it focuses on the issue of pharmaceuticals and monitoring and evaluation. It also examines the outcome of the project in the context of Bank lending for the sector as a whole. The findings of the PAR will be a building block for OED's forthcoming study of experience with health lending. In accordance with normal OED procedures, copies of the draft PAR were sent to the Government of Morocco for comments. Numerous comments were received reflecting the importance government authorities attach to this project. These comments have been included in Annex 2 with appropriate cross references and annotations. 1. All references to the Loan amount in the text and tables of this report are US$ equivalent. 2. Project Completion Report: Morocco, Health Development Project (Loan 2572-MOR), Report no. 14675, June 26, 1995. 3. President's Report: Kingdom of Morocco Health Development Project (Ln. 2572-MOR), Report no. P-4079-MOR, May 15, 1985. 4. Staff Appraisal Report, Kingdom of Morocco Health Development Project (Ln. 2572-MOR), Report no. 5440- MOR, May 15, 1985.  5 Basic Data Sheet MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) Key Project Data (amounts in US$ million) Appraisal Actual or Current Actual as % of Estimate Estimate Appraisal Estimate Item Total Total Total project costs 47.6 53.3 112% Loan amount 28.4 25.8 91% Cofinancing - - - Cancellation - 2.6 na Date physical components completed 06/90 06/93 (06/96)' Economic rate of return na na na Institutional performance: Moderate a. Most of the project investments were completed in 1993; the pharmaceutical component is expected to be completed in 1996. Cumulative Estimated and Actual Disbursements (amounts in US$ million) FY86 FY87 FY88 FY89 FY90 FY91 FY92 FY93 FY94 Appraisal Estimate 1.3 5.0 10.4 16.4 22.4 26.9 28.4 - Actual 0 0.13 1.13 3.54 7.93 13.98 19.33 23.52 25.84 Actual as%of Appraisal 0 0.02 0.1 0.21 0.35 0.52 0.68 0.82 0.90 Date of final disbursement: April 1994 Project Dates Date Planned' Date Actual Identification n/a March 1979 Project Preparation Facility (PPF) June 1983 April 1982 Preparation n/a Sept. 1979, April 1980, & June 1981 Pre-appraisal n/a July 1984 Appraisal n/a September 1984 Negotiations n/a April 1985 Board Presentation n/a June 6, 1985 Signing Before October 1985 January 17, 1986 Effectiveness October 1985 July 27, 1986 Midterm review carried out by the Borrower December 1987 November 1989 Project Completion June 30, 1990 June 30, 1993b Loan Closing December 31, 1991 December 31, 1993 a. As provided in Project Brief for processing steps up to Board Presentation, and in the Staff Appraisal Report (SAR) for steps occurring after Board Presentation. b. All components were completed by June 1993 with the exception of the Drugs supply unit which remains incomplete to date (see para. 19 PCR) and the IEC component which was dropped. Staff Inputs (staff weeks) Stage of Project Cycle FY84 FY85 FY86-93 FY94 Total Preappraisal 85.6 85.6 Appraisal 79.6 79.6 Negotiationse na Supervision 110.8 110.8 PCR 7 7 Total 283 a. Included in Appraisal Figures. 6 Mission Data Month/ No. of Staff Specialization' Project Project Types of Year Persons Days Rating Rating Problems (Overall) (Dev) Identification 03/79 5 55 A/ Z/C/A/D Preparation 09/79 4 40 E/C/Z/A Preparation 04/80 4 44 A/F/Z/G Preparation 06/81 1 5 F 06/83 5 30 F/H/A/A/I 10/83 2 20 A/A 03/84 I 20 A Pre-appraisal 07/84 I 3 A Appraisal 09/84 9 140? A/J/F/H/K/L/M/N/Z Post Appraisal 03/85 I 7 A Review of project timetable and its budgetary implications Supervision I 06/86 3 39 A/A/F Supervision 2 04/87 3 36 A/O/J Reviewed new organizational structure of MOP & IEC component slow to start. Supervision 3 02/88 1 ?c P Discussions on opening of Special Account. Supervision 4 08/88b 3 24 Q/R/H 2 1 -Lack of operating resources -Restructuration of tuberculosis program Supervision 5 01/89 4 32 A/A/SIT 2 1 Supervision 6 10/89b 4 20 Q/R/H/U 2 1 -Mid-term review carried out by MOPH Supervision 7 06/90b 3 15 Q/V/H 2 1 -Delays in payments to contractors; funds to be delegated to provinces -Bids for UAM too high Supervision 8 1/90b 2 18 Q/V 2 1 -Slow implementation -Projects costs to be updated Supervision 9 02/91b 1 9 V -Health Financing report received -New bid document for UAM reviewed Supervision 10 05/91b 3 27 QN/H 2 1 -Discussion on feasibility of UAM Supervision II 10/91 4 32 W/X/T/H 2 1 -Disbursement Issues -Lack of counterpart funds -Request for postpone- ment of closing date Supervision 12 05/92 2 10 V/1 2 1 -Limited budget allocations Supervision 13 11/92 3 27 V/I/Q 2 1 -Some centers ready but not staffed -Status of UAM to be defined -MOPH negotiating with the pharmaceutical private sector Supervision 14 04/93 2 6 Y/A 2 1 -UAM equipment not procured and status remaines undefined Completion 05/94 1 6 Y - ------------- a. Specialization: A=PH Specialist; B=Loan Specialist; C=Education Specialist; D=PH Specialist UNFDA; E=RH Specialist; F=Economist; G=PH Sp. Consultant; H=Architect; I=Implementation Specialist; J=Health Economist; K=PF Consultant; L=Pharmac. Syst. Consultant Research; M=Assistant; N=Division Chief; O=Operations Assistant; P=Disbursement Officer; Q=Health Specialist; R=PH Physician; S=Pop. Specialist; T=Hosp. Ad. Sp.; U=Education/Training Sp.; V=Financial Analyst; W=Sr. PHN Specialist; X=PH MD; Y=Project Officer; Z=Loan Officer b. Starting August 1988, all missions covered both the Health Development Project and the Health Sector Investment Project. Mission time has been apportioned equally to each project which is likely to overestimate time actually spent on the first project. c. Multi-purpose missions. Share of time allocated to project not available. 7 Evaluation Summary Introduction 1. The Morocco Health Development Project was the first World Bank Group operation in the health sector of Morocco. It assisted the Moroccan Ministry of Public Health (MOPH) to strengthen and accelerate its policy shift away from an urban-based, hospital-oriented health care system to a more cost-effective system of primary care emphasizing outreach activities in the rural areas which was outlined in the 1981-1985 Development Plan, and in accordance with the principles spelled out in the 1978 Alma Ata conference "Health for All by the Year 2000." Project Design 2. The project objectives were to strengthen primary health care delivery including family planning in three provinces, and to improve the capacity of the MOPH at the central and provincial levels as a necessary precondition for extending the health care delivery system to the rest of the country. The project had four components: (a) to improve and expand care to rural areas by piloting a new health care delivery system in three provinces (Agadir, Taroudant and Settat), through upgrading and extending the physical infrastructure, providing equipment, support for training, and improvement in logistics; (b) to strengthen the management capabilities of the MOPH and strengthen its role as policymaker for the health sector; (c) to support training and information, education and communication (IEC) programs; and (d) to improve the supply of basic drugs. Implementation 3. Implementation proceeded slowly. The project became effective in July 1986, 6 months after it was signed and more than 20 months after it was appraised. The first disbursement was made in March 1987. Limited availability and slow release of counterpart funds by the Ministry of Finance (MOF) was a major cause of delays. Serious construction delays occurred and are attributed to several factors, including cumbersome government accounting procedures, the borrower's difficulties in adapting to Bank procurement and disbursement procedures, and the transfer of responsibilities for civil works from the MOPH to the Ministry of Equipment during project implementation. The project was closed after two one-year extensions. An amount of US$2.56 million was canceled at that time. 4. Once built, a number of the health facilities (20 percent in 1994) remained closed because of lack of budget and staff. The staffing problem is generic in the health sector, not specific to the project. However, all project facilities were operational at the time of the audit though some were not operating at full capacity due to lack of staff. As noted in the PCR, the MOPH underwent several reorganizations during project implementation which resulted in the "balkanization" of the various departments, characterized by overlapping and scattered responsibilities. The institutional impact of the project was therefore limited. However, project evaluation was completed as was a very good (albeit late) effort, and studies were completed on financing the health sector and hospital management. Only 25 percent of the IEC component was implemented under the project, because of the availability of other donor grant funding to finance such activities. The component to improve the supply of basic drugs was substantially delayed and is still not fully completed. Ambiguities about its function continue today, despite 8 the careful planning prior to appraisal and apparent agreements reached among the Government of Morocco (GOM), the Bank and the private sector. Results 5. Two years after the closing of the Health Development Project, there is no doubt that the major component, to improve and expand basic health care to rural areas, was a success. Over 134 rural health facilities were constructed and equipped. The ratio of population to health facility improved from one basic center per 75,000 people in 1985 to one for 44,000 people in 1994, and the number of general practitioners in the project area more than doubled. The new health care delivery system developed under the project (reorganization of service delivery, planning, supervision and monitoring methods) was successfully integrated by staff and has been generalized from the three provinces to the rest of the country. This delivery system continues to be supported under follow-up Bank projects and by other donors. 6. The outcome of the drug component (21 percent of total estimated project costs) was not as favorable as the basic health component. The drug supply unit was constructed after a three year delay and is much larger than the initial modest design. The unit, which was to provide storage and distribution of drugs for the public health sector as well as formulate a small number of basic drugs in close collaboration with the private sector, was not operational at the time of project closure. The equipment for the formulation unit was not procured under the project, nor was the legal status or terms of its management and relationship with the private sector defined prior to closing. Delays in the construction of the drug supply unit meant that its storage and distribution function did not become operational until two years after closing. The stocks of medicines were transferred from the Central Pharmacy to the new unit in December 1995 at the time of the audit, and although the equipment for the formulation unit had been procured and paid for by the government, it was not installed. A delay of at least six more months was estimated before the formulation unit would become operational. In the meantime, the legal status of the unit remains to be defined, and the government still has not reached agreement with the private sector as to its operation. Thus the management and operation of this formulation unit remains in question. It is doubtful if the government will ever recover its investment in this unit (estimated to be US$13 million). 7. Taking into account the relative merits of the various objectives and components, project outcome is rated as satisfactory. Sustainability was rated as uncertain in the PCR, as many facilities had not yet become operational because of staffing shortages and lack of funds. However, at the time of the audit, all facilities (except the drug supply unit) were operational and providing basic health services. While questions about quality of service and efficiency remain, the provinces are committed to the new service delivery approach, which has also been replicated nationwide. The study on the financing of the health sector which was completed in 1990 was followed by several seminars and workshops and led to the creation of a health economics unit within the MOPH. Health sector financing is currently the subject of an intense policy dialogue between Morocco and the Bank (under an ongoing project as well as a forthcoming project). Therefore, the audit rates project sustainability as likely. 1. Formulation is the final stage of drug production, from intermediate ingredients to final or finished form. It consists of simple operations such as mixing, solving or dispersing, and fragmentation into dosage forms (tablets, capsules, tubes, etc.) 9 8. The results of the component to strengthen the MOPH are less clear given the host of changes that took place during the eight years of the project, including reorganizations in 1985, 1989 and 1994, and the appointment of new Ministers of Health in 1987 and 1992 (see project timeline, Figure 1.1). As the PCR states, on balance, the management of civil works improved, however procurement, program budgeting, and resource allocation remain serious issues for the MOPH. As in the PCR, the audit rates institutional impact as modest. Overall, the audit agrees with the satisfactory ratings given by the PCR for borrower and Bank performance, although selected aspects of both were weak. Lessons 9. The lessons from this project are as follows:2 (a) Projects should retain a degree offlexibility to adjust their "blueprint" to changing needs. Both beneficiaries and provincial health authorities were involved in project design, but the detailed blueprint specified in the implementation volume did not promote continuation of this participatory element through project implementation. Field staff complained to the audit mission about the rigidities of project design and Bank procedures. The answer must not be less thoroughness during design, but more openness during implementation. Long gaps in Bank missions between appraisal and supervision and between supervisions are certainly not helpful in this respect. (b) Monitoring and evaluation systems need to be available from the beginning of the implementation period if they are to influence outcomes. In this project, a good evaluation was completed and provided a wealth of data. However, these data were produced too late to be useful for project implementation or the design of the follow-on project. (c) Clear communication and continuous dialogue between the Bank and the implementing agency are essential to avoid misunderstandings. Despite the extensive preparation of the pharmaceutical component, serious misunderstandings arose that negatively affected the outcome of this component. It is unclear if these misunderstanding were caused by a lack of agreement during project's initial stages, a lack of consistency in Bank messages, and/or frequent staff changes in both the Bank and the MOPH. The end result was a lingering bitterness on the part of the MOPH and embarrassment on the part of the Bank that continue to affect the current health sectordialogue. (d) New projects should not detract from the supervision of an ongoing project. In the case of this project, preparation for the follow-on project began almost immediately (with the third supervision mission). The focus on preparing the follow-up project resulted in inadequate supervision of this project. 2. INAS adds that another important lesson is that continuity in staffing and motivation of staff are necessary to maintain project momentum. 10 (e) Borrowers prefer grant funding for training and technical assistance activities. This preference can be accommodated with improved donor coordination and flexibility in the design and implementation of such components. 11 1. Sector Background Background 1.1 During the first 15 years after independence (1956), a conservative approach to economic policy predominated in Morocco, and GDP increased at an average rate of 4 percent a year. During the mid-1970s, economic policy became more ambitious, and the rate of growth between 1973-1977 was 7.5 percent per year. But, like many other developing countries, Morocco experienced an economic crisis beginning in 1978 lasting through the early 1980s. The Moroccan Government adopted a stabilization program in 1978 in order to redress the rapidly deteriorating financial situation. Since then, the Bank has helped Morocco through an intense reform program, with loans, policy advice, and economic and sector work (the effectiveness of this Bank program is the topic of a special OED study). With a per capita GNP of $1,150 (1994), Morocco remains a relatively poor country at the lower end of the group of lower- middle-income countries. 1.2 Today, Morocco is in the midst of demographic and epidemiological transition. Since the 1960s, the mortality rate has declined from 19 per 1,000 to 7.3 per 1,000 in 1992, and the crude birth rate has fallen from 50 per 1,000 to 28 per 1,000. Infant mortality has declined from 119 per 1,000 to 57 per 1,000, and life expectancy at birth has increased from 45 to 65 years. The contraceptive prevalence rate for modern methods is estimated at 43 percent in 1994, compared with about 13 percent in 1984. The total fertility rate has decreased from 5.8 in 1980 to 3.6 in 1994. The annual population growth rate has slowed from 2.8 percent for 1955-1960 to 2.1 percent in 1992-1994. But despite these significant achievements, the performance of key indicators remains poor. The maternal mortality rate is among the highest in Africa, averaging 232 per 100,000 as compared to 50 in Tunisia and 140 in Algeria. Only 40 percent of all births take place in a medical setting. Early neonatal deaths still account for one-half of the infant mortality rate. Potentially controllable infectious diseases remain a leading cause of mortality and morbidity in children aged 1-5. Communicable diseases and maternal and child health problems have been brought under better control through health programs and improved lifestyles but still represent an important challenge particularly in the rural areas. 1.3 At the time of the project, the organization and management of the health sector faced several constraints: an ineffective system of health care delivery that was biased toward urban and curative care; the absence of policymaking in the MOPH and consequent lack of coordination among different health providers; weak internal planning and management within the MOPH; the hospital subsector's inefficient use of resources; insufficient overall financing for the sector; and the MOPH's disorganized and complex pharmaceutical supply system that resulted in severe shortages of basic drugs and threatened the credibility of the entire primary health system. 1. An OED country assistance review is presently under preparation. 12 Bank Activities in the Sector 1.4 The Health Development Project (PDSS)2 was the first major Bank project in the health sector in Morocco. Prior Bank involvement in the sector included a bilharzia (schistosomiasis) control component in the Doukkala Irrigation Project (Loan 1201-MOR) and a health worker training component in the Third Education Project (Loan 1220-MOR). The objectives of the PDSS were to (a) strengthen primary health care delivery in three provinces (including family planning), and (b) enhance the capacity of the MOPH at the central and provincial levels in planning for the health sector, training of staff, research and evaluation, and administration of the public health service as a necessary precondition for extending the health care delivery system to the rest of the country. A loan of US$28.3 million contributed to the expected total project cost of US$45.5 million. The project was implemented in 1985-1994. 1.5 The Bank is continuing its support to the health sector with the 1990 Health Sector Investment Project (PRISS, Loan 3171-MOR for US$104 million), which built on the 1985 Health Development Project.3 This follow-on project focused on (a) reinforcing essential basic health services, (b) strengthening the administration of management of health services, and (c) promoting sector and policy reforms that address long-term issues related to the evolution and structure of the public and private sector health services delivery systems, financing mechanisms, and the mobilization of resources in support of the sector. The project is expected to be completed by December 1997, and project implementation thus far has been rated as satisfactory.4 Continued support for basic health is planned with the 1996 Basic Health Project (Social Priorities Program) and a Health Management and Financing Project scheduled for 5 FY97 (see Figure 1.1) 1.6 Bank support has been and remains focused on strengthening basic health care delivery, increasingly in poorer, rural areas. In addition, assistance has been provided for the managing and administrating of health services, and policy reform (including the pharmaceutical sector, health financing and hospital management). 2. Projet de D6veloppement des Services de Sant6. 3. Projet d'Investissement dans le secteur de ]a Santd. See Staff Appraisal Report, Kingdom of Morocco Health Sector Investment Project (Loan 3171-MOR), Report No. 8108-MOR, January 8, 1990. 4. Supervision Report, July 1995. 5. The project would complement USAID, UNFPA and UNICEF interventions in the sector and would consist of three components: (a) improving access to essential curative and preventive health care in 20 targeted provinces; (b) strengthening the emergency, diagnostic, and referral services; and (c) promoting administrative and policy reforms. For more details see the SAR, Morocco: Basic Health Project (Social Priorities Program), Report No. 15073-MOR. Erterior Changes Structural Adjustment and f Economic Policy Reform 1983-1990 March 1995 Appointment of Mrh19 MOP]I undergoing new MOPH Appointment of structural Appointment of new MOPIl reorganizing at time Another MOPi I new MOPH e) of appraisal reorganization 1985 86 1987 1988 1989 190 1991 1992 1993 1994 1995 1996 1997 198 Illl86ll 1991 PDSS 1993 PDSS End April 1994 PRISS End Date E mayDisbursement #1 Original End PDSS Final December 1997 :- Health Date Disbursement ib Development July 1986 2572 (PDSS) 1990 Health Sector investment 19PDS C Loan Project LN3171 (PRISS) Original PRISS End Date December 1995 1996 Basic Health Project (Social Priorities Bank Activities in the Health Sector Program) Project preparation for Health Management and Financing Project, FY97 14 2. Project Objectives and Content 2.1 Following the Alma Ata "Health for All by the Year 2000" conference in 1978, Morocco began to revamp its existing health system, which had been focused on urban hospitals. Morocco's Third Development Plan (1977-80) included ambitious investments in large hospitals that resulted in insufficient operating budgets for basic health services. The overall allocation of funds remained low: in 1982 sectoral financing totaled US$8.35 per capita.6 The Fourth Development Plan (1981-85) marked a sharp departure from the previous policy and gave priority to basic health services. This plan called for decentralizing programming, improving management information systems, upgrading training of personnel, and remedying severe shortages of basic drugs. The Fifth Development Plan (1988-92) health objectives emphasized primary care, basic health services, and cost-effectiveness, in addition to continued attention to the drug supply system. Project Objectives and Components 2.2 The project aimed at accelerating the shift from an urban-based, hospital-oriented health system to a more cost-effective system of primary care emphasizing outreach activities in the rural areas. The project objectives were to strengthen primary health care delivery (including family planning) in three provinces, and to improve the MOPH's capacity at both the central and provincial levels as a necessary precondition for extending the health care delivery system to the rest of the country. The project had four components: (a) Primary Health Services ($23 million-70 percent of total project costs). The primary health care system envisaged in the 1981-85 Fourth Development Plan was to be fully implemented in three provinces-Agadir, Settat, Taroudant-with a view to extending the project to the rest of the country. The project would provide investment in additional buildings, equipment and vehicles. Project implementation would be closely monitored and accompanied by operational research to allow for continuous adjustments. It was hoped that the project would result in a viable alternative to the then prevailing health care delivery system. (b) Management ($1.7 million-5 percent of total project costs). The project was to improve the management capability of the MOPH and strengthen its role as policymaker for the health sector by strengthening the ministry's planning capacity, establishing a capacity to carry out evaluation studies, and improving administrative procedures. The project would provide equipment, supplies, vehicles, technical assistance for local and foreign consultants, and fellowships for overseas training. (c) Training and Information, Education and Communication (IEC) ($1.6 million- 5 percent of total project costs). The project would strengthen the capacity to train paramedical personnel and produce IEC materials by providing equipment for a training center constructed under the Third Education Project. It would also 6. Compared with Algeria at US$22.0 and Tunisia at US$31.0. 15 provide equipment, vehicles, and technical assistance for the production and dissemination of IEC materials. (d) Supply ofBasic Drugs ($6.8 million-20 percent of total project costs). The project would create a new drug supply unit (Unit6 d'Approvisionnement en M6dicaments, or UAM) to establish a coordinated system for the procurement, storage, formulation, packaging, distribution, and control of drugs for the public health system. The project was also to finance the construction of storage, packing and shipment space, a packaging unit and a small formulation laboratory, and the equipment, training, and technical assistance needed to operate this unit. Project Design 2.3 More than a decade of activity preceded the appraisal of this first health project. A brief desk review of Morocco's demographic situation was conducted in 1973. Despite the Bank's policy against direct lending for health at that time, a mission was nevertheless undertaken in FY77 to review the population and health delivery system. At the same time, it was decided in 1977 not to pursue a nutritional project. A health sector report was prepared in 1978 in which the Bank recognized the potential contribution of a maternal health/family planning services project based on an approach being implemented with support from USAID. 2.4 A reconnaissance mission in 1978 noted that Morocco's family planning program was fully integrated within the health structure, and a second mission in that same year found that the 7 government, contrary to its earlier views, was willing to discuss population issues . Building on this dialogue, a Bank mission in 1979 identified an integrated population, health, and nutrition project and recommended that this project be followed by a second one in FY84. Further preparation took place during 1979-84, with Bank inputs and technical assistance by WHO, USAID and UNICEF. A $75,000 project preparation facility was approved in 1982. The Bank finally pre-appraised and appraised the project in 1984. 2.5 Preparation of the Primary Health Services component-the major project component- included a study of the sociocultural determinants of hygiene and sanitation in peri-urban and rural areas. Carried out by the MOPH and the Institut Agronomique Hassan II with UNICEF support, the study identified suitable community-based interventions for implementation under the project. These interventions-maternal and child health programs, immunizations, nutrition and basic sanitation-involved little innovation and were based on extensive experience in Morocco. The primary care service delivery strategy was developed on the basis of precise mapping of population, topography, access, existing physical and human resources, and with the close involvement of communities and provincial health officials. 2.6 Health planning in the three pilot provinces was a bottom-up effort. Localities identified their own problems and established program goals. Each province aggregated the local plans into a provincial plan. The MOPH provided assistance to this decentralized effort. 7. The integrated family planning program was in stark contrast with the vertical family planning program at the time in Tunisia. 16 2.7 The drug component was designed to reorganize the entire public sector drug supply system. The aging facilities of the Central Pharmacy (CP) were to be replaced and a new drug supply unit (UAM) established. 2.8 Within the Bank, a note to the files praised the project appraisal as being one of the most comprehensive, informative, and interesting in the health sector, and stated that the wealth of information and analysis it contained reflected extensive preparation for a small but complex project and a deep understanding of a difficult sector. However, another note to the files expressed concern that the project appeared too complex, questioned whether local institutions were capable of carrying it out effectively, and suggested that intensive project supervision would be necessary. 2.9 Other components, such as management and IEC, had also carefully been researched with technical assistance from (among others) UNICEF, USAID, and WHO. As a result the project's technical quality at entry was very high.8 Relevance 2.10 The project addressed the government's goals for the sector as laid out in the Fourth Development Plan (1981-1985) which set precise objectives for basic health in the areas of MCH, family planning, immunization, health education and basic sanitation. The Plan also gave priority to improving the management of basic health services by decentralizing programming, improving the management information system, and upgrading the training of personnel. The project was based on the internationally accepted Alma Ata principles of "Health for All by the Year 2000" and was also consistent with the Bank's health strategy at the time which encouraged the shift from capital and foreign exchange intensive hospitals to expanding basic health services in order to improve access and affordability to low-income groups. The project was to test an alternative to the existing health system and set the basis for its countrywide implementation. It incorporated the development of a cost-effective health care delivery system with emphasis on primary care and family planning. The project is therefore judged as relevant. 8. Internal Bank memoranda dated February 13, 1985 and April 10, 1995. 17 3. Implementation and Results Overall Implementation 3.1 Project Management. A project implementation unit (PIU) was established in 1984 under the Direction des Affaires Techniques (DAT) in the MOPH. The PIU was given overall responsibility for conducting all project-related procurement, disbursement, and accounting operations and was staffed by a project coordinator and five professionals (an administrator, a medical doctor, an economist, and two chief supervisors of health services), all of whom had actively participated in project preparation. Later, an experienced architect and four secretarial and support staff were added, and a drug supply unit (UAM) interim director was designated by the Minister of Health. In the provinces, the project was implemented by the provincial Medical Directorates. Civil works were to be supervised by the MOPH's construction units in Taroudant, Agadir, and Settat under the overall responsibility of the PIU architect and in consultation with the Ministry of Equipment (MOE). However, the MOE was responsible for civil works, and the MOPH was not directly involved with their execution. 3.2 Funding. Prior to appraisal in October 1984 and even after negotiations in April 1985, the Bank expressed concerns about the government's financial constraints. Slow release of the 1985 investment budget for the MOPH delayed the signing of the loan for nine months. Even after the loan was signed in January 1986, problems with authorization of the 1986 budget delayed the effective date of the loan until July 1986. Insufficient funds and administrative complications continued to be limiting factors throughout the life of the project. 3.3 To address the funding problems, the Bank suggested the creation of a revolving fund or special account. However, Moroccan law at the time prevented the establishment of such funds in foreign currency. After further discussions, it was agreed in 1988 to establish a revolving fund in local currency in a commercial bank. 3.4 Disbursements were lower than anticipated during the first years of project implementation because of the failure of the Ministry of Finance (MOF) and the MOPH to allocate adequate counterpart resources. In response, during the fourth year of implementation the government reached agreement with the Bank on a simplified disbursement schedule, and the MOF simplified and delegated payment procedures to civil works contractors. As a result, disbursements accelerated sharply in 1991. In 1986-1990, only $8 million (28 percent) of the loan was disbursed. In the first six months of 1991, $5.9 million or 20 percent of the loan was disbursed. 3.5 The concentration of resources in the three pilot provinces, while justified from a technical standpoint, also created understandable resistance from other provinces and complicated the annual allocation of the investment budget. This problem was resolved gradually with the successful execution of major elements of the project, the growing recognition that the long-term benefits of the project extend beyond the three pilot provinces, and the replication of similar project activities in other provinces under the follow-up project. Primary Health Services 3.6 Civil Works. The development of primary health services was the major component of the project and consisted of the construction of basic health clinics, five rural hospitals, five peripheral 18 laboratories, and four radiology units. Construction was delayed by (a) the project's late start; (b) difficulties in identifying contractors willing to deal with such small and widely dispersed construction; (c) the general financial crisis in Morocco in 1987,that led the MOF to curtail payments for ten months; and (d) cumbersome government payment procedures that caused a ten-month delay in paying contractors, who in turn suspended construction pending receipt of payment. Only 30 percent of the civil works planned for 1987 were underway by the end of that year. 3.7 Responsibility for civil works was transferred from the MOPH to the Ministry of Equipment (MOE) during implementation. However, progress on civil works remained slow throughout the life of the project. The absence of a full-time project director at the central level made it difficult to overcome these delays. The project's relatively loose organization was regarded by Bank staff as the bottleneck in efforts to solve administrative problems. Several key provincial officials told the audit mission they felt more or less abandoned by the central administration during this time. 3.8 Overall, 134 basic health facilities (not including the five rural hospitals) were constructed in rural areas under the project. The National Institute of Health Management (Institut National d'Administration Sanitaire-INAS) conducted an evaluation of the primary health care component in each of the three provinces. The INAS evaluation examined construction timetables for a random sample of project health facilities in the three provinces.9 The findings show that 50 percent of the facilities were completed within one year of start of construction, though construction times varied from three months in Settat to four years in Taroudant. Upon project completion, approximately 20 percent of new facilities remained closed because of staffing shortages. In Taroudant, the audit team was told that certain facilities remained closed from 18 months to 2 years. All health facilities were operational at the time of the audit, though provincial authorities pointed out that some facilities are not fully operational because of a lack of staff. For example, the rural hospital in Ighrem in the province of Taroudant lacked laboratory and radiology technicians and was operating as a health center rather than a hospital. In Agadir the audit mission was told that some health facilities function with a reduced number of personnel, below the required norm: health centers function as rural dispensaries; rural dispensaries operate as basic rural dispensaries; and the nurses at the delivery houses, already at reduced numbers, also perform deliveries, undertake MCH activities, and take part in outreach activities in rural areas. The staffing shortages were said to be a general problem in the sector, not specific to the project. 3.9 Participation by local communities was substantial. They were involved in the selection of the sites, and many communities contributed land for construction. Communities in the province of Agadir, for example, donated 23 plots of land for new construction. 1o In total, communities contributed 67 plots of land in all three provinces. Other forms of participation included renovation and general maintenance of structures, provision of electricity, transport (for emergency evacuations), and supplies (such as fuel and disinfectant for water points). 3.10 Results. The primary health care component was fully implemented and had a significant impact on access to health care. In all, 134 new basic health facilities were constructed in previously under- or unserved rural areas: 31 health centers, 16 rural dispensaries, 45 health posts, and 42 delivery houses. This construction represents a doubling of the number of existing facilities in the three provinces, from 136 in 1985 to 270 in 1994. In the province of Agadir, which benefited the most 9. "Evaluation du Projet de Ddveloppement des Services de Santd dans les Provinces d'Agadir, Taroudant et Settat, P6riode 1985-1992," Royaume du Maroc, Minstre de la Santd Publique, Institut National d'Administration Sanitaire, Evaluations Equipes de la D616gation des Trois Provinces, INAS et VOP, d6cembre 1994. 10. Provincial authorities in Agadir noted that not all planned health facilities were constructed on the donated land. 19 from new construction under the project, the number of basic health facilities increased by 85 percent. This new construction greatly improved access to basic health care in the three provinces. The ratio of population to health facility improved from one basic center per 75,000 people in 1985 to one for 44,000 people in 1994, and the number of general practitioners in the project area more than doubled. 3.11 In addition to the improved infrastructure, the other major achievement of the primary health services component was the organization and mobilization of the central and provincial teams, and decentralized planning in support of primary health care. The project established sound standards and flexible institutional arrangements for the delivery of primary health care services. These standards and arrangement were replicated in other provinces beginning in July 1988 and have since been expanded nationwide. This new service delivery system has become an integral part of Morocco's system of decentralized administration of health services. Most Moroccan officials indicated to the audit mission that the spirit of PDSS was very much still alive today in the provinces, especially the decentralized planning and management, service delivery mechanisms, and teamwork fostered under the project. 3.12 The findings of the INAS evaluation of the primary health care component in each of the three provinces cover the period 1985-1992, and thus exclude the last two years of the project. 11The study therefore probably underestimates the level of health coverage in terms of access, availability, and use. The results of the project in terms of physical access and availability of services are documented in Annex Tables 1-12 and are summarized below in Table 3.1. 11. These data are from the following provincial evaluation reports: "Evaluation du Projet de Ddveloppement des Services de Santd dans la Province de Taroudant Pdriode 1985-1992," Avril 1994, Royaume du Maroc, Ministre de la Sant6 Publique, Dd16gation de la Province de Taroudant, INAS, et UGP, "Evaluation du Project de D6veloppement des Services de Sant6 dans la Province d'Agadir P6riode 1985-1992," Avril 1994, Royaume du Maroc, Minist re de la Sant6 Publique, Ddidgation de la Province d'Agadir, INAS, et UGP, and "Evaluation du Project de D6veloppement des Services de Sant6 dans la Province de Settat P6riode 1985-1992," Avril 1994, Royaume du Maroc, Minist6re de la Sant6 Publique, D6Igation de la Province de Settat, INAS, et UGP. 12. INAS recommended an update of the report in 1996, but no funding has been made available. However, the audit agrees that it would be a good idea to do a follow-up impact type evaluation which would include issues of patient satisfaction or quality of care (para. 5.9). - 13. It is unlikely that all of the improvements over time can be attributed solely to this project as various other factors most likely also had an impact. 20 Table 3.1: Change Over Time in Access Indicators in the Three Provinces Agadir Taroudant Settat Percentage population more than 10 km away from a health facility 1985 41 43 28 1992 (1993)a 22 31 19 Percentage population served by fixed facility 1985 36 38 16 1992 (1993) 49 46 57b Percentage facilities visited regularly by doctors 1985 9 8 24 1992(1995) 22 12 36 a. In brackets, year of observation in Settat. b. In 1995 it had reached 72 percent. 3.13 The INAS evaluation also reported improvement in health indicators in the three provinces: * the immunization rate increased from 66 percent in 1985 to 92 percent in 1992; * assisted deliveries rose from 21 percent in 1985 to 35 percent in 1992; * the rate of new acceptors (pills) almost doubled between 1985 and 1992-from 7 percent to 13 percent; * infant mortality was estimated to have declined from 57 per 1,000 in 1988 to 48 per 1,000 in 1995, mirroring a national decline; and * the incidence of declared cases of whooping cough and polio declined. 3.14 Nevertheless, as reported to the audit mission by other donors, there are still problems that need to be overcome in the health sector. For example, the mix of family planning services provided in health facilities is still inadequate. Some 70 percent of women use the pill; IUDs require a number of visits, and this inconvenience discourages their use. Outreach services do not always address all women's concerns: the itinerant nurse is male. Though the inter-disciplinary mobile teams are supposed to have a female nurse, there is still a shortage of female staff in rural areas. Other concerns expressed relate to the difficulties of maintaining an adequate supply of contraceptives, the irregularity of visits from itinerant nurses, and the fact that the outreach program is conducted by the less qualified staff. There are still not enough midwives, and those that exist are concentrated in urban areas and in the private sector. Improving the quality of care and the efficiency of service delivery are challenges that remain in the health sector. Enhanced MOPH Management Capacity 3.15 Despite the positive outcomes at the provincial level, the achievements of the project's component to enhance the management capacity of the MOPH are less certain. There is little evidence that the ministry's planning capacity has been strengthened, and numerous structural changes within the MOPH during project implementation-two reorganizations, the appointment of two new ministers, and other changes in senior staff and project management-hindered plans to address the organization of services, streamlining of procedures, retraining of staff, and modernization of office technology. These changes interrupted project momentum and undermined political commitment at various times (see Figure 1.1 for the timeline of events). One of the more immediate impacts of these various changes on project management was the creation of a number of technical departments, instead of one. As a result, technical expertise was scattered organizationally, and responsibilities overlapped, forcing project managers to communicate with several departments rather than one. 21 3.16 As the PCR notes, under these circumstances it is difficult to measure the extent tothat the project improved central management. Management of civil works did improve. In addition, the project did have success in developing a program of studies designed to support the planning and management process (monitoring and evaluation, financing the health sector and hospital management) as noted below. However, other aspects of management capacity, including program budgeting, resource allocation, and procurement, remain serious concerns. Institutional impact in the provinces was more pronounced (para. 3.11). 3.17 Monitoring and Evaluation. Project evaluation was completed and was a very good (albeit late) effort. Data were not available to assist in monitoring the basic health care component during implementation but did provide an excellent account of the accomplishments of the project in terms of accessibility and indicators of project impact (see Table 3.1). Unfortunately, these data were not available at the time the follow-on project was being planned; thus, lessons learned were not incorporated. 3.18 Studies. The health financing and hospital management studies were completed under this component. For both, however, there were start-up delays and subsequent lengthy contracting arrangements for selection of consulting firms. The health financing study was completed in October 1990 and was followed by several seminars, including a national seminar on health financing reforms, and workshops to mobilize external support. The study also led to the creation of a health economics unit within the MOPH. Study findings were also useful in to the MOPH in the preparation, with Bank support, of a health insurance reform proposal. The forthcoming Health Management and Financing Project contains a health financing component that builds upon this study. 3.19 The hospital management study was completed in June 1989. It focused on the structural and physical characteristics of the hospital sector within the MOPH, human resources, and financial resources. This study, which was to constitute the program's diagnostic phase, provided insight on hospital management, but the prospective phase intended to specify and test options for reform was not carried out because of the delay in completing the study and the reorganization of the MOPH in 1990,that left no one in charge of hospitals. The MOPH and the Bank never formally discussed the study. The second phase is, however, expected to be developed as part of the Health Management and Financing Project currently under preparation. Training and IEC 3.20 Because bilateral funds unexpectedly became available to finance IEC activities after the project was appraised, only 25 percent of the funds allocated to the training and IEC component were disbursed. Of this amount, about 50 percent was used to buy equipment for the College of Public Health and the other half to produce and disseminate IEC materials. This component was thus dropped, although no formal amendment to the loan agreement was ever made, but the component's development goals were achieved with support from other donors-a better solution from Morocco's perspective. The government remains reluctant to use Bank funding for training and technical assistance activities when other grant funding is available. It is unclear why the availability of grant funds was not considered during project preparation. Drug Supply 3.21 The drug supply component was a source of considerable discussion during the project but had little apparent impact on drug policy. The delay in this component was in a large measure the reason for the two extensions of the project. The objectives of the component were to create a new entity, the UAM, that would have full responsibility for the managerial, administrative, and technical 22 functions of drug supply that had been scattered among various departments in the MOPH. In addition to strengthening the central capacity to manage the drug supply system, the component would construct a new facility for the UAM that would include (a) an area for the storage and handling of drugs, (b) a packaging unit for primary care drugs, and (c) a small formulation unit with a control laboratory. 3.22 Construction of the UAM building began only in 1991 after numerous delays. The original construction bids in 1990 were found to be too high, so the entire project had to be rebid. But it is unclear from the files why it took four years to begin with this component. The building was completed in 1993 but was not operational at the time of project closure; medicine stocks had not been transferred from the Central Pharmacy, the formulation equipment had not been purchased and, more importantly, the legal structure of the UAM and the terms of its relationship with the private pharmaceuticals sector remained to be defined. Thus, this component failed to achieve its objective of improving the drug supply. In addition, a further issue is the fact that the design of the UAM as constructed does not resemble the modest design approved during appraisal. While the files indicate that the drawings for the new design of the UAM were approved, existing documentation does not explain how this new design evolved from the original. 3.23 A major issue during project implementation was the shift in the Bank's position in regard to this drug component. Toward the end of the project, the Bank abruptly withdrew its support for the concept of the formulation unit. An aide-m6moire dated December 1992 stated that formulation was not the most cost-effective method for supplying basic drugs. Because purchasing them in bulk and repackaging them was cheaper, the Bank deemed it preferable to make the UAM a packaging, computerized stock management and distribution center for primary care drugs. Again, the files contain no information that explains the Bank's decision, which had a major impact on relations between the Bank and government. The government remained committed to the formulation unit, and construction, that was already underway, continued. 3.24 At the time of audit, the building for the UAM had been separated into two parts corresponding to its dual functions (storage and distribution, and the formulation and packaging of basic medicines). The storage and distribution function of the UAM became operational in December 1995, more than 18 months after project closure, when the drug stocks were transferred from the dilapidated Central Pharmacy. Considerable progress had been made since project closure in organizing the pharmaceutical warehouse and developing procedures for the procurement, distribution and control of drugs, but the formulation unit was not operational. Although the government-supplied equipment had arrived, it had not been installed. Separate offices had been built for the administration of the formulation unit, formalizing the unit as a separate entity. However, no progress had been made on either the legal operating status of the formulation unit or the management of the unit, which was to involve the private sector. 23 4. Ratings 4.1 The PCR rated the project outcome as satisfactory, sustainability as uncertain, and institutional development as moderate; these rating were confirmed by OED during PCR review. The audit also confirms these ratings but upgrades the sustainability rating to likely. Borrower and Bank performance are rated as satisfactory. Outcome 4.2 The project's major contribution was the basic health component,that accounted for 70 percent of total project costs. The new health care delivery system (reorganization of service delivery, planning, supervision and monitoring methods) was successfully implemented in the three provinces, and based on its success, has been expanded to the rest of the country. The number of basic health facilities in the three provinces doubled as a result of the project, significantly improving access to basic health services in rural areas. Despite the substantial benefits, however, the working conditions of staff and the availability of drugs and supplies remain problematic. The component to enhance the MOPH's management capacity, that was meant to support the ministry's ongoing structural reorganization, did not succeed, largely because of the many changes that took place in the ministry during the project. The project's institutional impact was more pronounced in the provinces than at the national level. The monitoring and evaluation system and two studies envisioned under this component were successfully completed. The training and IEC component was only partially disbursed due to the availability of grant funding. The drug supply component failed to achieve its objectives. However, the objective of strengthening primary health care delivery (including family planning) in the three provinces was achieved, and project outcome is rated as satisfactory. Sustainability 4.3 Technical. To deliver services, the project envisioned using several types of strategies adapted to local conditions (such as terrain and population density), staff trained to perform a variety of tasks, and different mixes of facilities and outreach techniques. This new delivery scheme has become an integral part of planning and practice and has been extended nationwide. As the PCR states, however, concerns remain the quality of care and the efficiency of service delivery. Working conditions for the traveling nurses, who have contributed greatly to the increased coverage health services provide, have deteriorated as motorcycles are not maintained and per diem payments are often late. Problems ensuring regular supplies of drugs and contraceptives and transportation for the mobile teams will also require continued attention. Staffing is also a problem, since the lowest grade staff (those more likely to accept positions as traveling nurses) was eliminated, and it may be difficult to attract the newer, more qualified staff to the poor mountainous areas. 4.4 Financial. Appropriate budgetary resources are required to finance the drugs, travel allowances, er diems, and other consumables necessary to keep the program's project facilities functioning. In general, the level of resources allocated to the health sector is low, part of the wider public finance prioritization issue. Continued heavy reliance on external funds to finance 14. Staff are paid directly from the central MOPH. 24 both health investments and operating costs limit the MOPH's capacity to articulate its operational priorities and control allocation of resources.15 4.5 Overall. All facilities are now operational, although as provincial authorities noted, some facilities are not fully operational because of a lack of staff. Despite financial and technical constraints, provincial authorities are committed to their continued operation. Hence, the audit rates the project achievements as sustainable. Also, there are two follow-up projects that are continuing the efforts in basic health care, 1990 Health Sector Investment Project (PRISS), and the 1996 Basic Health Project (Social Priorities Program). Utilization and quality of services are among the remaining issues for Morocco which hopefully these projects will address as improvement of access has not led to a proportional increase in utilization. Institutional Impact 4.6 Institutional impact is rated as moderate. At the central level it was limited, but at the provincial level it was substantial. In addition, the project unit became efficient in civil works procurement, and INAS and the provinces undertook a very valuable evaluation of the projects. Some of these institutional achievements have already been replicated; others could be. Borrower Performance 4.7 The audit agrees with the PCR that borrower performance was excellent with regard to analyzing issues and conceptualizing strategies. However, making the strategies operational was much more difficult. Implementation capacity in the MOPH remains weak and was substantially affected by the frequent restructurings and reassignments during the project implementation period. Project implementation was slow, and there was little monitoring and assessment of impact-a significant weakness in what was supposed to be a pilot operation. However, the approach to basic health services delivery was generalized throughout the country and is being implemented, partly in the framework of the other follow-on Bank-supported projects. Also, the 16 borrower generally met the project's legal conditions. Borrower performance is therefore rated as satisfactory. Bank Performance 4.8 The Bank spent substantial resources and time (see paras. 2.3-2.4) on the identification, preparation, and appraisal of this project and thus developed, as the SAR shows, a well-designed project. Regretfully, the Bank ultimately accepted the government's request to include a drug supply component in the project. In retrospect, this component turned out to be a mistake. In- depth analytical work was done to find the optimum design for this component, and Bank performance during this design period was exemplary. 4.9 However, Bank supervision was not as thorough or intense as its effort during preparation and appraisal. Concern had been expressed, more than once, that the complexity of the project and the weakness of local institutions would require intensive supervision. Supervision was not adequate, however. The first project supervision took place one year after 15. Note the comments by INAS. It is their opinion that lack of strategic planning in the MOPH is the cause of this allocation problem. 16. As detailed in PCR Table 7. 25 Board approval (almost two years after appraisal). Ten months passed between the Bank's first and second supervision missions (in June 1986 and April 1987), and a year between the second and the third (in August 1988). 17 The quality of supervision also appears to have been a problem, particularly in regard to the drug supply component. Supervision tended to focus on issues related to disbursement, procurement, and budget allocations. Although these issues were rightly perceived as hindering effective implementation, this focus came at the expense of attention to technical details. Moroccan officials indicated to the audit mission that they regretted the fact that Bank technical experts did not spend more time in the field sharing insights and advice with their Moroccan colleagues. This feeling was especially pronounced in Settat, where the drug component was to be implemented, where officials felt short changed. As they told the audit mission, Bank missions visited them only for the day and spent more time in Agadir and Taroudant. Furthermore, missions switched their attention from project implementation to the design of the follow-on Health Sector Investment Project beginning with the third supervision mission in August 1988. Hence, as recognized in the PCR, the lack of adequate Bank supervision meant that problematic aspects of some components remained unresolved or were not addressed for a long time (para. 3.22). 4.10 Bank performance during preparation and appraisal was highly satisfactory but unsatisfactory during supervision. On balance, the combined rating by the audit mission is satisfactory. Despite shortcomings, the relationship continued and perseverance ultimately paid off in terms of continued, and now improved, sector dialogue. 17. For details see Basic Data Sheet. The supervision mission in February 1988 is not counted as it was only a mission by the disbursement officer to discuss the revolving fund. Important as this was, it can hardly be regarded as a substitute for full Bank supervision. 26 5. Issues and Lessons 5.1 This audit raised a number of issues, but this section focuses on two deemed the most important-the drug supply component and the monitoring and evaluation of the project. Drug Supply Component 5.2 The drug supply component has been a continual source of confusion and misunderstanding. While the formulation concept was carefully analyzed, and the formulation unit was designed to focus on the relatively small number of basic drugs the health sector required, the formulation unit constructed bears no resemblance to the original design. Instead of the modest formulation unit of 800 square meters envisioned in the SAR, the actual unit is about 5,000 square meters. The files give no indication of how the new design originated or why it was approved. It is unclear why such a large unit was needed, given the relatively small volume of basic drugs the pubic sector consumes (about 2 percent of national consumption) and their low monetary value (basic drugs are the least expensive). 5.3 The PCR states that part of the problem may have been the fact that, until recently, the Bank did not have an overall policy on drugs. The decision to construct a formulation unit was backed up by two in-depth economic analyses which concluded that the MOPH could formulate and package drugs for its primary health care program more cheaply than it could procure them 18 from either the private sector or UNICEF. The audit disagrees with the PCR, which states that the Bank failed to (a) clearly state its position, (b) to provide the necessary support to undertake a full assessment of the economic feasibility of this unit, or (c) to develop a coherent drug policy. While the Bank did not pursue an overall drug policy, it did expand the scope of the component beyond the MOPH's original request only to modernize the production unit.19 All aspects of public sector drug supply, storage, and distribution became part of the project, making the Bank's involvement more policy oriented. 5.4 The questions regarding this component that remain originated during its implementation. While there is scant evidence that Bank staff expressed skepticism regarding this component early in the project cycle, the files show that beginning in 1992, six years after the project became effective and a year after construction began, the Bank withdrew its support for such a unit. This turnaround appears to have been fueled by concerns about delays in procuring equipment, the availability of technical assistance, the uncertain legal status of the unit, and more importantly, the lack of agreement with the private sector concerning management of the new unit. The question of why this action was undertaken so late in the project cycle remains unanswered. There is little in the files to offer an explanation, but the history of this component points to some answers. 5.5 The drug supply component was added relatively late in the design phase. The MOPH originally proposed that its formulation unit, which prepared 46 basic drugs for the primary care 18. The Bank undertook another economic analysis of the component in 1987 which confirmed the findings of the earlier studies. 19. This matter is currently being pursued in the 1996 Basic Health Project (Social Priorities Program). 27 system, be modernized under the project. Both the MOPH (with assistance from WHO and UNICEF) and the Bank undertook extensive economic analysis of procurement, management, and distribution procedures for and the production of basic drugs. 5.6 The Bank expended substantial resources on the design of this component and analyzed all possible alternatives. The Bank contracted an international technical expert in basic drug production and distribution to study Morocco's pharmaceutical system. His report suggested improvements to the government's original plan. He also had numerous discussions with the private sector, which indicated its support and agreed to cooperate with the government's plan for a formulation unit. The Bank became convinced that a reorganization of the drug supply system (including formulation) was necessary. Final design for the formulation unit was based on discussions with the MOPH officials and representatives of the pharmaceutical industry, backed up by the MOPH's technical studies. The final design was also predicated on the assumption that (based on the earlier discussion) there would be some form of cooperation between the government and the private sector regarding drug formulation. However, such cooperation did not take place, and this issue remained unresolved at the time of the audit. In retrospect, this assumption-that the two parties would reach some agreement-seems to have been flawed, as nothing was ever agreed to. The incentives for the private sector to cooperate were not fully examined, and the MOPH had its own agenda, namely to replace its dilapidated formulation unit. 5.7 The drug supply component costs were estimated in the PCR to reach US$13 million equivalent, twice the amount estimated at appraisal. At the time of the audit, the formulation unit was still not operational and many obstacles remain, not the least of which is lack of agreement as to the legal status of the formulation unit and private sector management. A major concern is that despite its technical merits (the design of the formulation unit is very good), its financial and economic merits are doubtful given its large size and the fact that the public sector consumes less than 2 percent of all drugs in the country. The lack of clarity in the government's position with regard to (a) the unit's overall potential capacity; (b) the unit's potential market (internal private market, internal public market, and/or exports); and (c) its cost-recovery policy have resulted in the private sector's lack of interest in managing and operating this unit. 5.8 It is puzzling that the Bank agreed to local formulation, then dodged confronting the issue as it loomed ever larger. It is clear that the Bank was at fault for not paying closer attention to the issue of the formulation unit and addressing the potential problems earlier. This mistake may be attributed to the Bank's lack of experience in the pharmaceutical sector. Supervision of this component was reported to be difficult as there were no pharmaceutical specialists in the Bank and both the roster of international consultants as well funds for supervision were limited. However, since the Bank agreed to finance this component, it should have provided technical expertise during implementation, as it did during the design phase. The Bank's withdrawal of support for this formulation unit, which occurred so late into the project, resulted in resentment and bitterness on the part of the MOPH. Bank staff report that the issue has become somewhat of a sore point and carries over into current dialogue. 20. To substantiate its case, the MOPH reassured the Bank (a) that procuring these drugs in the international market was much too expensive in foreign currency and that the finished forms would not fit the needs of primary care; (b) that the local industry had consistently shown little interest in bidding for the formulation of these low-cost, generic drugs, which required that capital and production capacity be immobilized to produce even minimum benefits; and (c) that its economic analysis of two alternatives-formulation by the MOPH and procurement in bulk on the international and local markets-indicated potential savings through formulation by the MOPH. 28 Monitoring and Evaluation of Basic Health Component 5.9 The design of basic health care delivery system developed under the project was based on a detailed study of patient consultations at health facilities in Agadir and Settat carried out during project preparation. This study provided the MOPH with a precise profile of current demand and a good insight into major flaws in the existing delivery system. As a result of the study, the following objectives were set for health centers: (a) Hospitality: improve the reception of patients, change working hours to meet patient's needs, decrease waiting times, and improve access to nurses and physicians. (b) Quality of care: improve laboratory and x-ray services, provide transportation for emergencies, make easier hospital referrals and admissions, improve medical records, and provide basic emergency dental care. (c) Dispensing of basic drugs: improve the supply of appropriate drugs, fill prescriptions correctly, and make distribution more efficient. The SAR stated that progress in these areas would guarantee the continued participation of communities in the public health program. A timetable for improvement was set and progress was to be closely monitored. However, INAS' evaluation of the basic health care component did not address the issues of patient satisfaction or quality of care.21 5.10 The INAS evaluation pointed to the fact that basic health facilities in all three provinces were underutilized. However, the evaluation neither quantifies this observation nor documents the reasons why. On the basis of limited interviews, the audit mission was able to identify the following reasons for underutilization: the centers were too distant and took too much time to reach, patients believed the services were of poor quality, waiting times were too long, drugs were in short supply, and not enough referrals were provided. It was also mentioned that private facilities were not very expensive, had shorter waiting times, better service (that is, more pleasant staff and more time with physicians). 5.11 The government should undertake a patient survey to assess satisfaction with the quality of care. INAS noted to the audit mission its interest in undertaking such research and indicated that resources would be available but recognized that assistance from a specialist would be needed. The audit recommends that patient surveys and quality of care studies be included in the follow-on projects. 5.12 As noted above, the monitoring and evaluation was not timely, taking place at the end of the project rather than midway as planned, and detailed provincial reports were not provided to 22 the Bank. Nevertheless, the evaluation, which included all three provinces, was a significant undertaking, was very well done, and resulted in a wealth of data not available for the other provinces. While the follow-on projects are based on similar principles, provincial project 21. INAS responded that the Bank could have provided the necessary additional resources for the evaluation of the project. In that case, the report by INAS could have been more exhaustive and focused on the impact of the project. 22. There is some disagreement on this point, with the borrower claiming they were provided and Bank staff claiming they were not officially submitted, only informally given. 29 officials expressed a sense of frustration that they had not been sufficiently consulted regarding lessons learned, and that the experience gained from the project-in terms of implementation, measurement, and administrative evaluation for instance-was insufficiently mined. They felt that the follow-on projects had, to a large extent, reinvented the wheel. As the PCR notes, the Bank missed the opportunity to incorporate lessons in follow-on projects. 5.13 A monitoring and evaluation base has been established that can easily be widened (to other provinces) and deepened to include evaluation of impacts (initially in the three project provinces). Since INAS has shown its capabilities in this respect, the audit suggests that the Bank consider supporting it to do a similar evaluation of PRISS (Health Sector Investment Project, Loan 3171 -MOR). Lessons 5.14 The lessons from this project are as follows:23 (a) Projects should retain a degree offlexibility to adjust their "blueprint" to changing needs. Both beneficiaries and provincial health authorities were involved in project design, but the detailed blueprint specified in the implementation volume did not promote continuation of this participatory element through project implementation. Field staff complained to the audit mission about the rigidities of project design and Bank procedures. The answer must not be less thoroughness during design, but more openness during implementation. Long gaps in Bank missions between appraisal and supervision and between supervisions are certainly not helpful in this respect. (b) Monitoring and evaluation systems need to be available from the beginning of the implementation period if they are to influence outcomes. In this project, a good evaluation was completed and provided a wealth of data. However, these data were produced too late to be useful for project implementation or to assist in the design of the follow-on project by providing lessons learned. (c) Clear communication and continuous dialogue between the Bank and the implementing agency are essential to avoid misunderstandings. Despite the extensive preparation that went into the pharmaceutical component, serious misunderstandings arose that negatively affected the outcome of this component. It is unclear if these misunderstandings were caused by a lack of agreement during the project's initial stages, a lack of consistency in Bank messages, and/or 23. INAS adds that another important lesson is that continuity in staffing and motivation of staff are necessary to maintain project momentum. 30 frequent staff changes in both the Bank and the MOPH. The end result was a lingering bitterness on the part of the MOPH and embarrassment on the part of the Bank that continue to affect the current health sector dialogue. (d) New projects should not detract from the supervision of an on-going project. In the case of this project, preparation for the follow-on project began almost immediately (with the third supervision mission). The focus on preparing the follow-up project resulted in inadequate supervision of this project. (e) Borrowers prefer grant funding for training and technical assistance activities. This preference can be accommodated with improved donor coordination and flexibility in the design and implementation of such components. 31 Annex 1 Annex Tables Table 1: Distribution of the Population by Kilometric Radius-Agadir Year Less than 3 to 5 km 6 to 10 km More than 3 km 10 km 1985 22 13 24 41 1992 36 20 22 22 Table 2: Results of the PDSS System Implementation-Agadir Evolution of Health Coverage Health Facilities 1985 1992 Number Number Urban Health Center 2 10 Urban Dispensary 8 0 Rural Health Center -7 11 Rural Dispensary - 13 16 Basic Rural Dispensary 15 24 Urban Delivery Houses 1 2 Rural Delivery Houses 2 11 Peripheral Laboratory 0 5 Radiology 1 5 Rural Hospital 0 1 Table 3: Distribution of the Population by Method of Coverage-Agadir Year Fixed Facilities Meeting Point Mobile Teams Not Covered 1985 36 15 3 46 1992 49 29 22 Table 4: Availability of Services at Health Facilities-Agadir (Percent of all facilities offering various services) Year Regular Deliveries Pre and Family Planning Family Vaccinations Peripheral Visits by a % Post Natal (Oral Planning % Laboratory Physician Care % Contraceptives) (IUD) % % 1985 9 3 23 45 2 45 0 1992 22 11 37 62 22 62 5 Increase 144 267 61 38 1000 38 400 Annex 1 32 Table 5: Distribution of the Population by Kilometric Radius-Taroudant Year Less than 3 to 5 km 6 to 10 km More than 3 km 10 km 1985 26 14 17 43 1992 31 17 20 31 Table 6: Results of the PDSS System Implementation-Taroudant Evolution of Health Coverage Health Facilities 1985 1992 Number Number Urban Health Center 1 2 Urban Dispensary I I Rural Health Center 5 8 Rural Dispensary 23 30 Basic Rural Dispensary 20 22 Urban Delivery Houses 1 0 Rural Delivery Houses 0 2 Rural Maternity 0 2 Peripheral Laboratory 2 2 Radiology 0 0 Birthing Houses 1 2 Zone Hospital 1 0 Rural Hospital 0 3 Table 7: Distribution of the Population by Method of Coverage-Taroudant Year Fixed Facilities Meeting Point Mobile Teams Not Covered 1985 38 6 4 52 1992 46 16 16 22 Table 8: Availability of Services at Health Facilities-Taroudant (Percent of all facilities offering various services) Year Regular Deliveries Pre and Family Planning Family Vaccinations Peripheral Visits by a % Post Natal (Oral Planning % Laboratory Physician Care % Contraceptives) (IUD) % % 1985 8 14 24 47 7 38 2 1992 12 27 57 64 11 64 2 Increase 50 93 137 36 57 68 0 33 Annex 1 Table 9: Distribution of the Population by Kilometric Radius-Settat Year Less than 3 to 5 km 6 to 10 km More than 3 km 10 km 1985 32% 15% 25% 28% 1993 41% 23% 17% 19% Table 10: Results of the PDSS System Implementation-Settat Evolution of Health Coverage Health Facilities 1985 1994 Number Number Urban Health Center 3 13 Urban Dispensary 3 0 Rural Health Center 6 11 Rural Dispensary 30 36 Basic Rural Dispensary 3 37 Urban Delivery Houses 0 0 Rural Delivery Houses 2 15 Rural Maternity 2 15 Peripheral Laboratory I I Radiology 0 0 Zone Hospital 0 2 Rural Hospital 0 1 Table 11: Distribution of the Population by Method of Coverage-Settat Year Fixed Facilities Meeting Point Home Visits Mobile Teams Not Covered 1985 16% 0% 58% 4% 28% 1993 57% 22% 13% 8% - Table 12: Availability of Services at Health Facilities-Settat (Percent of all facilities offering various services) Year Regular Deliveries Pre and Post Pre and post Family Planning Family Vaccinations Peripheral Visits by % Natal Care Natal care (Oral Planning % Laborator a (with Doctor) % (with nurse) % Contraceptives) (IUD) % % Physician % 1985 24 23 71 66 86 35 82 0 1995 36 67 93 76 100 84 100 4 Increase 50 191 31 15 16 140 22 400 34 UNOFFICIAL TRANSLATION Annex 2 Royaume du Maroc Prime Minister Minister in Charge of the Population C.N.E.P No. 25/224/S.G Rabat, May 22, 1996 Fax to the attention of Mr. Roger Slade, Chief, Agriculture and Human Development Division, Operations Evaluation Department World Bank (Fax 202 47 76 391) From: Mr. Mohamed Bijaad, General Secretary of the Minister in charge of Population Text: Thank you for your letter dated from April 29, 1996, concerning the project audit report on the Health Development Project (Credit 2572-MOR). In answer, please find enclosed some observations regarding the report. Sincerely, Mohamed Bijaad General Secretary of the Minister in Charge of the Population Annex 2 35 SOME OBSERVATIONS CONCERNING THE PROJECT AUDIT REPORT ON THE HEALTH DEVELOPMENT PROJECT a. Comments on the form: -The project audit report refers to the Moroccan plan as being plans of Text adjusted arrangement and not as being plans of economic and social development; accordingly -The report refers also to the development plans of 1980-85 and 1985- Text adjusted 90. The authors probably referred to the plans of 1981-85 and 1988-1992. gy b. In depth comments: -The evaluation focused a lot more on the implementation aspects and This OED Performance Audit the results obtained on the project. But the report does not give enough Report was not indications on the effects and the impact of the project on the concerned meant to be an provincial beneficiaries, on the efficacy of the new system compared to the old impact evaluation. The issues one, and on the quality of care provided. It would have been more appropriate mentioned are best to give some indications on the effectiveness of the usage, which is made of addressed in an impact evaluation project's physical results and to show how the new system was able to improve which provides the wait time in the sanitary establishment, the access of the medical and evidence of paramedical personnel and the attitude of the beneficiaries regarding the quality development impact, five to ten of the care given. years after project completion. OED is interested in the possibility of conducting an impact evaluation of the project in the future. In addition OED recommends that future, evaluations of Bank financed projects in the health sector in Morocco address utilization of basic health services, satisfaction with quality of care and the efficiency of the service delivery. 36 UNOFFICIAL TRANSLATION Annex 2 Royaume du Maroc Prime Minister Minister of the Incitement of the Economy THE MINISTER DELEGATE OF THE FIRST MINISTER IN CHARGE OF THE INCITEMENT OF THE ECONOMY MR. ROGER SLADE CHIEF, AGRICULTURAL AND HUMAN DEVELOPMENT DIVISION OPERATIONS EVALUATION DEPARTMENT WORLD BANK FAX Subject: Project Audit Report of the Health Development Project (Credit 2572-MOR) Reference: Your letter of April 29, 1996 Dear Sir, Following your letter, concerning the project audit report of the above project, I have the privilege to inform you that the preliminary version of the report does not raise any observations on the part of the Moroccan authorities. Sincerely, Monkid Mestassi In charge of Mission for the Prime Minister UNOFFICIAL TRANSLATION 37 Annex 2 Royaume du Maroc Ministry of Public Health INSTITUT NATIONAL D'ADMINISTRATION SANITAIRE (I.N.A.S.) No: 288/INAS Mr. Roger Slade, Chief Agriculture and Human Development Division, Operations Evaluation Department World Bank 1818 H Street N.W. Washington, D.C. 20433 - U.S.A Subject: Analysis of the Evaluation Report of the Health Development Project (PDSS) We reviewed the report on the evaluation of the PDSS with a lot of interest. In addition, we sent a copy of the report to each of our three concerned provinces: Agadir, Taroudant and Settat. Through this letter, we would like to present our feed-back, which is a synthesis of our comments: those of Dr. M. Lardi and those of the three teams of the above provinces. As a general matter, the contents of the report relates to the contribution, the efforts, and the difficulties of expertise of the PPS project. However, we sense a redundancy in some of the paragraphs. Our main comments are as follows: The report of the INAS could have been more exhaustive and focused on the Opinion added in impact of the project if the World Bank had put at our disposal the budget and footnote 21 the specialized manpower. "Organization Plan" to be replaced by "Five Year Plan 1981-1985." Text adjusted accordingly "creation of an economic unit of health (and not a service)." Text adjusted accordingly Collage de Sant6, km 4,5 - Route de Casablanca, Rabat - TI. : (07) 69.10.82 - T61ex : 36616 335, avenue Mohamed V - Rabat - Tl.: (07) 76.11.21 - Fax: (07) 76.38.95 - T61ex: 362.37 M 38 Annex 2 It is necessary to define what we mean by "viability" because the mobile strategy, for example, would not be followed at the same pace if there is a reduction in gas resources. Page 9. line 3: What is the meaning of "the implementation volume for the project"? Page 9. Paragraph (e): The restructuring of the MSP and the departure of the director of the project left an empty space. The problem of coordination increased; the pile-driving of the project became almost absent at a given moment of the life of the project. The changes affected the Minister, as well as the general secretary, the directors, the provinces' delegates, and the chief doctors of the Regional Office in Charge of Ambulatory Service (SIAAP) in these provinces. Page 11. Paragraph 1.2: The population of Morocco, according to the census of September 1994, is estimated at 26,023412 inhabitants and 50181 foreigners. Text adjusted 2.06-the demographic increase (census 1994) accordingly Page 11. Paragraph 1.3. line 3: Text adjusted The health system targeted the curative and urban contributions. accordingly Page 15: We agree that the project is characterized by its large complexity which caused problems for us with the coordination, the follow-up and the evaluation. Page 14: b) The World Bank did not provide the help necessary for the evaluation of the ono added in project. Page 17: Para. 3.1: The structure of the administration of the project is detailed in the document of The information on the evaluation of the project, directed by the INAS and the three provinces. We the administrative structure was taken think that it is necessary to correct this part. directly from the projectfiles. Page 19:a [para. 3.11] The extension of the project was done at the national level, for example: the peripheral laboratory, the formation component, extension of the sanitary cover, the structure of the program of basic health care. etc.... Pagze 19. line 4: Text adjusted in "the results obtained........physical access (and not material)." para. 3.12 In the table 3.1: Text adjusted in We are propose that you add "statistic of the zone." Table 3.1 Annex 2 39 Page 23. para. 4.4: Opinion noted in We think that the absence of the strategic planning and the incoherence in the footnote 15 p.litics of health thwart the capacity of the MOPH to organize its operational priority in a coherent manner and master the allocation of the resources. Page 24: The INAS can be a partner in the administration of the health projects if the government desires it. We share your opinion on the unity of supply of medicine. Page 28. para. 5.9: We don't provide hospitalization in the health centers. Translation error corrected Page 28. para. 5.12: Divergence of We have made all the documents of the evaluations available for the disposal of opinion on this the World Bank point as explained in footnote 22 Page 30: Yes, for the conclusions, as a whole, except for the point (e); it is difficult to understand the meaning of this sentence. The project needs the stability of the key persons in the administration of the projects. The retention of these persons in their position requires a serious motivation. Statistical data Finally, we are attaching to the present document a copy of faxes coming from were taken from the provinces concerning this topic, as well as the written corrections of the the final INAS statistical data on pages 50-52. evaluation reports provincial reports) We hope we have met your expectations. dated April 1994 as well as updates Sincerely, provided to the audit mission in the field. The written corrections of the statistical The Director of the INAS data conflict with the INAS Pr. N. Fikri Benbrahim. eauto eot evaluation reports, and without further justification, it is difficult to adjust official reports. 40 UNOFFICIAL TRANSLATION Annex 2 Royaume du Maroc Ministry of Public Health Taroudant, 05/28/96 PROVINCE OF TAROUDANT The Delegate of M.S.P in the Province of TAROUDANT The Director of the INAS. RABAT Subjit The Evaluation Report - the Health Development Project (PDSS) I have the honor to transmit to you our comments regarding the reading of the Evaluation Report of the PDSS. 1. Concerning the form: the report is, in our opinion, a little narrative, probably unintentionally, generating repetitions which could sometimes bother the reader. 2. Concerning the content: 2.1- The report emphasizes the "failure" of the drug supply unit component without being convincing about the cause of this failure. Nevertheless, the report has the merit to recognize the incompetence of the World Bank in the realm of pharmaceuticals. 2.2- As far as the health indicators are concerned (p. 14), figures given See notice above by the provinces would be desirable. Also, we have to factor in the interaction of on statistical data the other programs in the realization of the performance, even though it is Text ad usted in difficult to judge the real impact of the project on its evolution. 2.3- The denomination of "health post" (p. 19, last line) would Text adjusted in correspond to the basic health dispensary? para. 3.10 2.4- The report does not point out the weakness of the implementation of the IEC component at the provincial level, and that the provinces did not really benefit from the resources in that way. 2.5- The report does not signal the "disappointment" of the provincial managers expressed during the meetings, concerning the absence of incentives for internships and workshops in foreign countries. Ville nouvelle M'haita, Taroudant - T6l. : (08) 85.22.71 / 85.20.32 - Fax: 85.20.91 - T6lex : 81974 Annex 2 41 Royaume du Maroc Ministry of Public Health PROVINCE OF TAROUDANT (following) 2.6- The report underestimates, in our opinion, the efforts used within the central administration of the Ministry of Public Health, in the matter of organization (flow chart) and the administrative procedure. 2.7-Civil Engineering: the report does not draw attention to the reticence expressed concerning the conception of the buildings, in particular the narrowness of the nurses' lodgings and the technical installation of the rural hospitals (radiology, lab...). Conclusion: As a general matter, the evaluation report took back the worries expressed by the provincial delegates responsible concerning the lasting impacts of the project PDSS. We notice some objectivity in the analysis of some failures in the different stages of the project. Finally, we hope that the recommendations from this evaluation will help the central delegates responsible avoid the "burial of the project" and preserve the spirit of the PDSS and of its achievements. The Provincial delegate (Taroudant) Ville nouvelle M'haita, Taroudant - Tl. : (08) 85.22.71 / 85.20.32 - Fax : 85.20.91 - Tdex: 81974 42 UNOFFICIAL TRANSLATION Annex 2 Settat, May 24, 1996 The Delegate of the Ministry of the Public Health for the Province of Settat to Mr. the Director of the INAS Subject: Comments concerning the evaluation report of the Health Development Project (PDSS) I have the privilege to address our comments and suggestions to you, after reviewing the evaluation report: See paras. 3.12, -The report does not refer to the studies nor to mid and final evaluations. and 3.18-3.19 n aWhile this comment -Some aspects were not studied in depth: is true, these items were included in - Community participation. the report. -~ See para. 3.9 - Intersectorial collaboration. - Qualitative evaluation of the utilization of the health services. See para. 5.10 - Impact of the health interventions implemented. See para. 5.13 - Evaluation of the mobile strategy. - Evaluation of work conditions. See paras. 4.2 and - Problems due to the development of the infrastructure, especially the lack of paras. 3.8and human resources. 3.14. - Impact of the project on the quality of the administration of the health The audit did not services, on the quality of the care, and on the state of the health of the set out to be an population. impact study, though OED is interested in the Also, we agree with the conclusions of the evaluators in that the project cannot possibility of be considered a pilot experiment since there are a large number of other health conducting an factors which complemented the development of the health programs. fpact e eto the future. Dr. Rhazzal Hassan UNOFFICIAL TRANSLATION 43 Annex 2 ROYAUME DU MAROC MINISTRY OF PUBLIC HEALTH INSTITUT NATIONAL D'ADMINISTRATION SANITAIRE (I.N.A.S) Collige de Santi Publique Km 5, Route de Casablanca Rabat - Maroc TO : 69 16 26 Fax: 69.96.34/69.16.26 From: Pr. N. Fikri Benbrahim Director of the National Institute of Health Administration (INAS) Fax: 00-212-7-69 16 26 To: Mr. Roger Slade Chief, Agriculture and Human Development Division, Operations Evaluation Department World Bank. Washington DC 20433 - USA Date 06/03/1996 Message: Following your letter seeking feedback on your document on the evaluation of the PDSS, here are the comments of the team of Agadir. Sincerely, The Director of INAS Pr. N. Fikri Benbrahim 44 Annex 2 Agadir, May 27, 1996 ROYAUME DU MAROC MINISTRY OF PUBLIC HEALTH DELEGATION TO THE WILAYA OF AGADIR AND PREFECTUR OF AGADIR IDA OUTANANE No. 1889/SIAAP/SSB. The Prefectoral Delegate To The Director of INAS RABAT T_picL Evaluation of the Health Development Project (PDSS) Reference: Your correspondence No. 244 of May 14, 1996 Following your correspondence, named above, I have the honor of presenting our comments: * Page 7, Para. 4 and Page 18: Text adjusted in - The health facilities built during the PDSS and considered in the paras. 4, 3.8 and document of evaluation as operational, function in reality with a reduced number 4.5 of personnel which does not correspond with the norm required. For example: - some health centers function as rural dispensaries. - some rural dispensaries function as basic rural dispensaries with the absence of nurses. - the nurses of the delivery houses, already at reduced numbers, are also doing: * the deliveries * the MCH activities * and take part into the outreach activities of the mobile team in the field. Those facilities were opened due to the pressure of the population and the local authority. Page and 16: - read organization plan 1981-1985 instead of 1980-85. Text adjusted *Page 14: accordingly - read organization plan 1988-92 instead of 1985-90 Text adjusted accordingly Annex 2 45 Page 17: The civil engineering part was given to the Delegation of the Text adjusted in Ministry of Equipment. The Ministry of Public Health was not directly involved paras. 3.1 and 3.7 with the execution of the construction works. Its involvement was limited to being present during the opening of the sealed orders and during the provisory reception of the constructions. General comments: The evaluation document did not highlight the problem of Text adjusted in planned health facilities that were not realized and for which the population gave footnote to up some parcels of land for their construction.  IBRD 18651 10o0 9°30 9°00' MOROCCO ro -- R¥ b, HEALTH DEVELOPMENT ESSAOUIR A PROJECT I AGADIR PROVINCE na EXISTING PROPOSED Health Focilities:t --- • Basic Dispensories T. C~ " oDispensories ......* Health Centers "o AoHospitals 0 lp 20M Tamri Extension of a Hospital KILOMETERS r ,, h.,~ ~ou er kla ou T anane ''d '''ie "rth ''' ATLAS Physical Features Elevations in meters: 2000 ed - 1500 Askrud1000 Sidi Boushub 3°0 0 30°30' Tomraght Anza Izdar Rivers Agodir SLSSVLEY SOUJSS VALLEY|| Urban Area T kig0ne Main Roads InezganA 0 DAdSecondary Roads Ait MeTloul Provincial Boundaries A t / a -- International Boundaries International Boundary ougra (approximate) Indicates the Territory of the n Former Spanish Sahara Ait Am'rø (Western Sahara) Inchaden SPAIN Ait Bak HAG Atlantic 30Ocean ERbAt 0 Had-ait-Belfaa 30°00' -QSETTAT 30°00' M.Gae Ait Quad M AGADIRW~9 4 .------ TAROLDANT j **-Ta--- ALGERIA T. r;-n;t, TlZNIT - MAURITANIA 1000 9°30' 900 FEBRUARY 1985  MOROCCO HEALTH DEVELOPMENT PROJECT I MARRAKECH sTAROUDANT PROVINCE S p- Hah F C. : - se } s--l-r F--. 3 1 '.. R-ad, 3 __ S. SaR..d. L ? A --- - In5ern,atioa Boundoa,, - i5996~099 B-d-JO, -I _,,ø.ao~~h s - -Sp--n .. h ENN AGADIR " ALGERIA TIZNTT A T AU ''TIZ N IT AURITANIA roo'ALI o  IBRD 18653 ¯", 730- aMOROCCO HEALTH DEVELOPMENT PROJECT I A ri jc n tic c éc n Casablanca SETTAT PROVINCE •Basic Dispensories . .C S BL AN AB E N • • Dispensaries 3330' CA-SABLANCA Health Centers x s-S L l M A N E mopia g \ Hospital Transformation of a Hospital du S.hel T tg Ou .d Sebbah 1 ( TElevations in meters: Berrch.d El G.oro Urban Areo Sidiel- Main Roods - Secondary Roods U.l.d Abbom -hn---- Provincial Boundaries International Boundaries -- International Boundary (approximate) S----- Indicates the Territory af the Former Spanish Sahara Tle Oulad (Western Sohara) Khemis Gdan..R.e Houzzao to 20 30 S H KLOMETERS HdMz~.r Tl u.dYr TI. Oul F. ø8 røfl t7 ø,~h,øyp~~ Rm-O Gui-,15ý,rd F~SPAIN Tnine TOuadel de, Ould B~i MOROCCO AGADIR : - c-nøy Is, AROJDAN.T •B E N l ALGERIA ,1~~ ~ El Borou13ø0 -32'30' 32°30 EL KELAA DES SRARHNA • MELLAL MLI mAURITANIA 800- 730' FESRuARY 1985   IMAGING Report No: 15798 Type: PPAR