Uganda - First Health Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 16259 IMPLEMENTATION COMPLETION REPORT UGANDA FIRST HEALTH PROJECT (CREDIT 1934-UG) January 28, 1997 Human Development Eastern and Southern Africa Africa Region 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 l  UGANDA FIRST HEALTH PROJECT CURRENCY EQUIVALENTS At the time of Project Appraisal Uganda Shillings 60 = US$ I At the time of project completion mission Uganda Shillings 1000 =US$ 1 WEIGHTS AND MEASURES Metric System FISCAL YEAR OF BORROWER July 1-June 30 ABBREVIATIONS AND ACRONYMS AMREF Africa Medical Research Foundation AIDS Acquired Immune Deficiency Syndrome CMS Central Medical Stores DANIDA Danish International Development Agency DHSP District Health Services Pilot and Demonstration Project FHP First Health Project ICR Implementation Completion Report IDA International Development Agency KAP Knowledge, Attitudes and Practices KCC Kampala City Council MOH Ministry of Health NGOS Non Governmental Organizations NRM National Resistance Movement ODA Overseas Development Agency (United Kingdom) PIU Project Implementation Unit SIDA Swedish International Development Agency SDR Special Drawing Rights STI Sexually Transmitted Infections Vice President Callisto E. Madavo Director James W. Adams Technical Manager Ruth Kagia Task Manager Mary T. Mulusa  FOR OFFICIAL USE ONLY Table of Contents Preface EVALUATION SUMMARY ..................................... ........................... i-v PART I: IMPLEMENTATION ASSESSMENT Introduction .................................................................1 Project Objectives ................................................................. 2 Achievement of Project Objectives ................................................................ 2 Major Factors Affecting the Project ................................................................ 6 Project Sustainability ................................................................ 7 Borrower's Performance .................... ............................................ 8 Bank's Performance ................................................................. 9 Assessment of Outcome ................................................................ 9 Future Operations ................................................................ 10 Key Lessons Learned ................................................................ 11 Part II: STATISTICAL ANNEXES Table I a - Summary of Assessments: Rehabilitation of Health Facilities. Table lb - Summary of Assessments: Health Education and Community Activities. Table Ic - Summary of Assessments: Strengthening the Delivery of Health Care Table 2 Related Bank Credits Table 3 Project Timetable Table 4 Credit Disbursements, Estimated and Actual Table 5 Key Indicators for Project Implementation Table 6 Key Indicators for Project Operation Table 7 Studies Included in Project Table 8 Project Costs Table 9 Project Financing Table 10 Status of Legal Covenants Table 11 Compliance with Operational Manual Statements Table 12 Bank Resources: Staff Inputs Table 13 Bank Resources: Missions Appendices Appendix A Mission Aide-Memoire Appendix B Borrower Contribution to the ICR Appendix C Civil Works Costs Appendix D Utilization of Rehabilitated Hospitals Appendix E Ministry of Health Budget Appendix F Map of Uganda. No. IBRD 25052R 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 authority.   IMPLEMENTATION COMPLETION REPORT UGANDA FIRST HEALTH PROJECT (Cr. 1934-UG) PREFACE This is the Implementation Completion Report (ICR) for the First Health Project in Uganda, for which Credit 1934-UG in the amount of SDR 30.8 million (US$ 42.5 million at the prevailing exchange rate) was approved on June 23, 1988, and made effective on January 11, 1989. The credit was closed on March 31, 1996 (the original closing date). The last disbursement took place on September 25, 1996', and an undisbursed balance of SDR 1.9 million (US$ 2.76 million, at the prevailing exchange rate) was canceled on the same date. Co-financing for the project was provided by the Swedish International Development Agency (US$ 6.5 million) and the Government of Austria (IJS$ 10.0 million). The ICR was prepared by Ms. Mary Mulusa, Human Development Unit, Eastern and Southern Africa and reviewed by Mrs. Ruth Kagia, Technical Manager, AFTHI, and Mr. James Adams, Country Director for Uganda. The Borrower reviewed the draft report before it was finalized. Preparation of this ICR was started in February, 1996, during the Bank's final supervision mission. An ICR mission comprising Ms. Mary M. Mulusa (Team Leader), Ms. B. Helbling (Operations Officer), Mr. F. Walker (Architect), Ms. H. Nannyonjo (Operations Officer), and Dr. K. Grant (Physician, ODA), was undertaken between August 12-23, 1996. This report is based on material in the project files and information collected during the Bank's final project completion mission. The Borrower contributed to this ICR by preparing its own evaluation of the project's preparation and implementation experience (Appendix B). July 31, 1996 was the final date for payments under the credit - an allowance of four months following project closing (March 31, 1996) was approved by IDA. An exception was made to allow for one last payment on a civil works contract for work completed by the project closing date.   IMPLEMENTATION COMPLETION REPORT UGANDA FIRST HEALTH PROJECT (Cr. 1934-UG) EVALUATION SUMMARY Introduction 1. The First Health Project (FHP) became effective on January 11, 1989 and closed on March 31, 1996. It is the first IDA credit in the health sector in Uganda. The World Bank has been involved in the social sectors in Uganda through the implementation of five education sector credits. Four of these credits are closed, while the Fifth Education project is currently under implementation. The Program for Alleviation of Poverty and Social Costs of Adjustment Project (PAPSCA) 2 which was approved in 1990 and closed on September 30, 1995, provided support to some health activities targeting vulnerable groups. Two health sector projects, the Sexually Transmitted Infections Project (Credit 2603-UG) and the District Health Services Pilot and Demonstration (Credit 2679-UG) are being implemented as a follow-up to the FHP and became effective on July 22, 1994, and July 17, 1995, respectively. Project Objectives 2. The objectives of the FHP were: to carry out urgent rehabilitation and equipping of selected health care facilities; to build a hospital in Rakai District; to strengthen preventive health programs through health education and community activities; and to improve the long-term effectiveness of the health care system through institutional development and improved internal efficiency. The project was later modified to provide urgent support to mitigate the effects of the AIDS epidemic, to take account of changes in the scope of physical rehabilitation, and to prepare for the projects mentioned above. 3. Evaluation of Project Objectives. The objectives of the FHP were consistent with the needs of the sector and the country at that time. It was the first major project in the health sector following two decades of civil strife in Uganda. It was necessary to restore a critical number of health facilities to support a minimum level of service provision and to begin the process of developing a sustainable health delivery system. The project design was appropriate and responded to these two needs. Changes made to the project objectives were appropriate as it was necessary to review priorities based on the implementation experience and the improved data that became available over time and to prepare for the future health sector reforms. 2 Credit 2008-UG.  Evaluation Summarv Page ii of v Covenants and Agreements Expected to Promote Achievement of Project Objectives 4. A number of key covenants were incorporated into the project. The Ministry of Health (MOH) undertook to provide adequate funds for health services including the development of cost recovery schemes and involvement of the community in financing local health facilities. The MOH would also carry out a number of studies: a manpower and management study (to establish staffing standards for the rehabilitated facilities as well as for the whole public health system); a study of the health information system; a study on the efficiency and effectiveness of the health system; and, a study on the community-based distribution system for drugs, supplies and condoms. The MOH also agreed to establish management committees for each hospital and health center and a Health Education Coordination Committee to oversee the implementation of the preventive health education program. The covenants were comprehensive and appropriate for achieving project objectives. Most of them were accomplished though this took longer than originally anticipated. Implementation Experience and Results 5. Achievement of Objectives. Overall, the project was satisfactory. Objectives were substantially achieved for the components on physical rehabilitation and for strengthening health services delivery. The component on health education and community activities achieved some of its objectives but it was less successful than the other two components. 6. Physical Rehabilitation and Equipping of Health Facilities. The objectives of this component were substantially achieved; key areas of the main teaching and referral hospital (Mulago), eight district hospitals, forty health centers and a research center were rehabilitated, a new health center was built in Rakai district and equipment was provided to most of these facilities. There is marked improvement in the condition of the facilities that were rehabilitated. While the civil works were fully completed, major problems were experienced during project implementation. Higher than expected costs (the mid-term review noted that civil works costs were 77% above estimates), delays in construction, and shortfalls and delays in the release of counterpart funds were issues during implementation. The MOH adjusted the scope of works in response to the higher costs. Our review indicates that appropriate adjustments were made and that the central problem was that the original cost estimates were based on insufficient site inspection and inadequate data. Implementation of this component also suffered from complicated inter- governmental clearance procedures and an initially weak Project Implementation Unit (PIU). The persistent shortfalls in counterpart funds were largely part of the overall fiscal constraint faced by the Government. The restored facilities reinstated services in areas that had been most adversely affected by the civil strife. Utilization rates have increased for most of the facilities. In a few cases, however, facilities are underutilized due to low population density and inadequate operational budgets. 7. Health Education and Community Activities. The objectives of strengthening preventive health programs through health education and community activities were only  Evaluation Summary Page iii Qfv partially achieved. Activities to increase the number of people reached with health messages through newspapers and the radio were implemented. Training was provided to journalists and educators to enhance the quality of health messages in the newspapers, television and radio. A coordination mechanism between the Ministry of Information and Broadcasting and the Ministry of Health was established and a number of NGO health activities were supported. However, several planned activities under this component were not carried out: the purchase of equipment to boost transmission by public radio stations; a number of innovative ideas for carrying health messages; and development of a community based distribution system for drugs and supplies including renovation of the Central Medical Stores. The main reason for failure to carry out these activities was the inability of different government agencies to agree on procurement procedures and evaluation of bids received (the procurement of radio transmitters was, for example, eventually not carried out). 8. Strengthening the Delivery of Health Care Services. The objectives of this component were substantially achieved. Planning, monitoring and evaluation in the MOH were strengthened through technical assistance and training. With support from the project, the MOH prepared "The White Paper on Health Policy" in 1993 and a "Three- Year Health Plan Frame" (1993/94-1995/96). The process of strengthening district capacity for health services management (planning, budgeting, and accounting) was initiated and health plans were prepared for all districts in Uganda. Facility-level management was enhanced through the establishment of management committees with community participation. A quality assurance unit was established to oversee the quality of health services. However, other aspects of the component fell below expectations: the health information system was not fully developed though some work on it was started and health care financing schemes, especially user charges, were not developed as expected. This has been largely due to political and economic constraints. A framework for working with NGOs was not developed until the last years of the project. 9. Disbursements. The credit was signed on July 11, 1988 and became effective on January 11, 1989. It was completed on March 31, 1996 instead of June 30, 1995. The credit closed on March 31, 1996, as originally scheduled but an additional 4 months was allowed for payment of existing commitments for a number of civil works contracts. The credit disbursed a total of SDR 28.9 million (US$ 40.48 million) and an amount of SDR 1.9 million (2.76 million) was canceled. The SIDA grant of US$ 6.5 million and the Austrian grant of US$ 10 million were fully disbursed. The Government contribution amounted to only US$ 3.5 million out of the planned US$ 6.5 million and this slowed down implementation especially in the first three years of the project. The counterpart funding problem was not unique to the First Health Project as the Government was facing severe resource constraints. 10. Performance of the Borrower. The Government was committed to the project and took most of the necessary policy decisions, however, project implementation faced considerable constraints during the first two years. Implementing agencies were not adequately consulted during preparation and ownership of the project was centered on  Evaluation Summarv Page iv of v the PIU. This contributed to the inability to reach consensus on a number of issues especially procurement of critical inputs for the project. In addition, the PIU was weak, release of counterpart funds was often delayed and the amounts insufficient to fully fund project components. Audit qualifications took long periods to resolve. The mid-term review proposed useful suggestions for addressing problems that had arisen during the first four years of implementation. Following the mid-term review, the Government took steps to address these problems. Qualified staff were hired in the PIU. Technical assistance and training was provided for the PIU and the MOH management. Counterpart funds were provided and actions were taken to address audit qualifications. Overall, there was a notable improvement in performance in the latter half of the project. 11. Performance of the Bank. During project appraisal, the Bank recognized implementation risks that included: inadequate capacity at the MOH; uncertainty over the feasibility of developing alternative financing mechanisms for the sector; and low motivation of underpaid Government staff. In addition, costs were not easy to determine given the paucity of data during project preparation. However, the Bank did not pay sufficient attention to the ability of the Government to provide counterpart funds. The Bank also did not involve all the implementing agencies in the design of the project. A number of major problems particularly on civil works (proposed Rakai hospital) and procurement (e.g. radio transmitters) took a long time to resolve. The Bank could have been more proactive in assisting the Government to come to closure on the issues in a shorter time than it took. The above notwithstanding, the Bank was responsive to implementation constraints and assisted the Government to restructure the activities in line with changing priorities. The Bank also later encouraged collaboration among the different implementing agencies during the course of project implementation. 12. Plansforfuture project operations and sustainability. A number of actions are already being undertaken to sustain project investments. Project activities are being supported through the regular MOH budget that has been increased in the last few years. Guidelines have been issued to facilities to set aside a portion of their revenues from user charges (20%) for maintenance needs. However, despite the above actions, budgeted funds are not adequate to meet the minimum levels of maintenance and operational needs for the rehabilitated facilities. Health education activities are being strengthened through improved communication between the health education department and the technical departments. In addition, two IDA-funded projects were prepared as a follow-up to the FHP project. Both projects carry forward the health sector reform process in addition to their specific focus. Institutional capacity building is also being strengthened through the The STI project objectives are: (i) to prevent sexual transmission of HIV; (ii) to mitigate the personal impact of AIDS; (iii) to support institutional development to manage HIV prevention and AIDS care. The DHSP project objectives are: (i) to pilot test new sector policies and strategies which will facilitate implementation of essential health services; (ii) to strengthen management and planning capacity at district levels to provide essential health services, and (iii) to restructure the Ministry of Health so as to build its capacity to provide health policy leadership and to support the Government's decentralization policy.  Evaluation Summary Page v of v Government's implementation of the civil service reform, the decentralization policy and the health sector reform. A sector strategy for the next five years is being developed by the MOH to identify priorities for new investment. It will be important for the strategy to also address the sustainability of investments being undertaken in the sector. Key Lessons Learned 13. Key lessons learned are summarized below: (1) Government commitment to the project was critical to its success. As imp!ementation proceeded the increased commitment was reflected in improved implementation performance. In addition, the Uganda Government took many of the necessary policy decisions that included the articulation of the health sector policy in the "White Paper" and the development of a three-year plan. (2) The health sector in Uganda requires additional resources from the Government budget as well as through the development of alternative sources of financing. Development of alternative sources of financing for the health sector involves a wider range of reforms in the sector. More attention should also be given to ensuring adequate counterpart funding for projects. (3) The support provided to the sector under the First Health Project was of an emergency nature and while it has contributed to improving health services, much more still needs to be done to get the health system to a functional level. The Government cannot possibly address the needs of the sector by itself and it will be critical to identify ways in which all resources, public, private (including NGOs) and from donors, can be brought together to address the needs of the sector. Hence, it is critical for the Government to shift away from narrowly defined projects to a sector wide approach. (4) For project implementation, all stakeholders should be consulted during project design. Implementation agencies should be involved as well and responsibilities for implementation clearly defined. Procurement procedures should be agreed upon and included in an implementation manual. Detailed procurement plans and documentation should be prepared during project appraisal.  I  PART I: Implementation Assessement Page I of 13 IMPLEMENTATION COMPLETION REPORT UGANDA FIRST HEALTH PROJECT CREDIT 1934-UG PART 1: PROJECT IMPLEMENTATION ASSESSMENT Project Identity Name: Uganda, First Health Project Credit No. 1934-UG Credit Amount US$ 42.5 million RVP Unit Human Development 1, Africa Region (AFTH1) Sector Human Development Introduction 1 . Uganda went through two decades of civil strife beginning in the early 1970s. During this time, the health system virtually collapsed. Health facilities were destroyed and equipment and supplies looted. Staff went unpaid for long periods of time and drug supplies were insufficient. The health status of Ugandans deteriorated dramatically. The immediate challenge for the Government in 1986, was to put in place a health system to address the most urgent problems including a resurgence of diseases such as measles and malaria. In addition, the new Government was faced with a growing AIDS epidemic. The Government established a Health Policy Review Commission in 1986 to make recommendations on how to restore health services. The report of the commission provided a framework for the development of a national health policy, "The White Paper on Health Policy". It was also decided to prepare a national health plan that would identify priority areas in the health sector. The Government sought assistance to support its efforts. The First Health Project was a "fast track" response to this need. The project was prepared and appraised between January - February, 1988 and became effective on January 11, 1989. It was closed on March 31, 1996 as scheduled. An amount of SDR 28.9 million was disbursed out of the IDA credit of SDR 30.8 million, SDR 1.9 million was canceled. The SIDA grant of US$ 6.5 million and the Austrian grant of US$ 10 million were fully disbursed. The disbursement record is particularly commendable given the difficulties encountered in the course of implementing the project.  PART I: Implementation Assessement Page 2 of 13 Project Objectives 2. The project's main objectives were to carry out urgent physical rehabilitation of selected health care facilities; construct a hospital in Rakai district (which was hardest hit by the AIDS epidemic); strengthen preventive health programs; and improve internal efficiency and long-term sustainability of health care delivery. To achieve these objectives the project provided funds to: (a) rehabilitate key areas of Mulago Hospital, re- equip the Blood Transfusion Center, rehabilitate eight district hospitals and thirty rural health centers and construct a hospital in Rakai district; (b) promote health status by creating awareness through health education programs, develop a community-based distribution system for drugs and supplies and develop a program for counseling and patient management for people infected with AIDS; (c) strengthen the Health Planning Unit, the management capability in the Ministry of Health (MOH), hospitals and rural health facilities, and develop alternative ways of ensuring adequate financing of the health sector. 3. The Development Credit Agreement was amended on October 23, 1994, to reallocate funds among project components and to provide funds for piloting sector reforms. The amendment allowed for construction of a new health center, rehabilitation of five health centers and an office for the District Medical Officer instead of the proposed construction of a 1 00-bed hospital in Rakai district. The amendment was appropriate and in line with evolving needs. 4. The project objectives were clearly defined and responsive to the country's needs for immediately re-establishing health services and beginning the process of developing a sustainable health system. The project comprised a wide range of activities that posed varying challenges during implementation. The project was demanding for a Government that was constituted after a long troubled period. Reliable data for project preparation was not available as information systems had broken down. The following risks were identified: weak institutional capacity, demoralized and underpaid Government staff, and the uncertainty of introducing user fees and other alternative health care financing options. During implementation, these issues presented significant problems but most were adequately addressed. Changes made to the project objectives were appropriate as it was necessary to review priorities based on the implementation experience especially with respect to cost overruns on the physical works; to select more cost-effective alternatives as was the case in reducing the size of new health facility for Rakai district, and to look ahead by beginning to test some of the envisaged reforms in the sector. Achievement of Project Objectives 5. Overall, the project was satisfactory. Two components of the project in particular, rehabilitation of facilities and strengthening of delivery of health services achieved most of their objectives. The third component on health education and community activities achieved some of its objectives but was less successful than the other two components. Details of achievements of each project component are presented below:  PARTII: Implementation Assessement Page 3 of 13 6. Rehabilitation, Construction and Equipment of Health Facilities: Physical Rehabilitation and Equipping of Health Facilities accounted for the major part of the project. The objectives of this component were substantially achieved. The civil works program as originally proposed during project appraisal was implemented with some changes. Rehabilitation included key areas of Mulago hospital (elevators, kitchen, laundry, Central Sterile Supplies Department, workshops and living quarters), eight district hospitals, forty health centers and critical extensions to the Joint Clinical Research Center4. The most significant change in the civil works was the rehabilitation of five health centers and the construction of a District Medical Office in Rakai in place of the proposed 1 00-bed district hospital. A number of planned rehabilitation works were taken over by other financing agencies. The African Development Bank undertook some of the works originally included in the project at the Mulago hospital. Three health centers were rehabilitated by AMREF, World Vision and the German Volunteer Service. On the whole, the quality of civil works was satisfactory. Most of the original rehabilitation was completed by the end of 1992. There was an average of seven months delay in execution of civil works contracts. Other works resulting from restructuring of the project: Rakai Health facilities (new health center and rehabilitation of five health centers); the Joint Clinical Research Center outpatient's department; and smaller works at Mulago were completed by the project closing date. Site inspections indicated that satisfactory construction techniques and standards were used. Attention was paid to the need for cost- effectiveness in the selection of areas to be rehabilitated within each facility. Designs were reviewed to ensure that only the most essential work was carried out and excess capacity was not created. There is a marked improvement in the condition of the facilities that were rehabilitated. Utilization rates for most of them has increased though it is not uniform. In most cases, and especially for highly populated areas, facilities have high occupation rates. In a few cases, facilities are underutilized and this is partly due to low population density and incomplete equipping and low budgets for operation (see Appendix A). Health centers and parts of Mulago hospital (except for the Rakai health center) visited by the mission had full occupancy rates. The Mulago student hostel occupancy rate has increased from 35% in 1988 to 100% as a result of the rehabilitation. 7. The Austrian Government provided equipment to project facilities through a grant of US$ 10 million. The rest of the equipment was provided under the IDA credit. The rehabilitation and equipment restored a significant level of capacity that had fallen out of use over a long period at the selected facilities. The credit also successfully provided drugs and supplies and supported training of hospital maintenance workers. While this project was not specifically designed as a poverty reduction intervention, the rehabilitation of hospitals and health centers in rural areas has significantly increased access of the poor to quality health services. In Kampala, where the only alternative hospitals are managed by NGOs charging full costs, the refurbishment of Mulago has provided access to good quality services to the urban poor as has the rehabilitation of Naguru, Kiswa and Kisenyi health centers. The financial objectives have not been fully achieved as resources for See Appendix D.  PART I: Implementation Assessement Page 4 of 13 maintenance have not been fully provided. The satisfactory maintenance of buildings is a matter of concern. Except for some minor maintenance being undertaken by the equipment workshop at Mulago, visits to sites revealed that no remedial maintenance was being carried out on the newly completed or rehabilitated buildings. This is mainly because increases in public funding to health have not been as high as expected5. Most of the health facilities are raising up to 10% of their non-wage recurrent expenses through user fees. An effort has been made to set aside 20% of fees collected for maintenance of facilities. However, the cost sharing scheme has not been implemented as well as was expected due, largely, to political constraints and, in any case, amounts collected through user fees are not substantial relative to needs. 8. Health Education and Community Activities: A number of important activities under this component of the project were carried out. Support in the form of subsidized newsprint was given to two newspapers to increase circulation: the "New Vision" an English daily newspaper which has the widest circulation in the country, carries health messages regularly, while "Munno" a local language newspaper carried messages before it closed down due to financial problems. Vehicles, equipment and training were provided to strengthen health education activities. Support to development of radio programs was provided through the establishment of a liaison office in the Ministry of Information and Broadcasting. Health messages for AIDS prevention were developed. However, a number of innovative ideas (comic books, school exercise books, public transport stickers and posters and lottery tickets) for carrying health messages were not implemented because of an inability to resolve procurement and administrative problems among the different government agencies involved. They were later considered low priority items and dropped from the project. Some of these activities were later picked up by other donors and NGOs. Equipment to boost transmission by public radio stations was not purchased due to failure to agree on specifications and complete the procurement. The community- based drugs distribution program that included renovation of the Central Medical Stores (CMS) was not carried out. However, DANIDA later rehabilitated the CMS as part of its assistance to the essential drugs program. A positive outcome of this component is the impetus it provided for support to health education activities by other agencies. More broadly it is extremely difficult to assess the impact of this component since a number of the original activities were not carried out. A Knowledge, Attitude and Practices (KAP) study carried out in three pilot districts in 1991/92 but was not repeated as recommended in the mid-term review. This is unfortunate as it would have assisted in assessing the project impact. Institutional capacity building was not very successful as collaboration among implementing departments was not effective. Physical objectives were only partially achieved, as important equipment to boost public radio transmission was not purchased. Support to the private sector was partially successful with respect to the newspapers but was less so for the other "innovative" ideas for carrying health messages that were not implemented. See Appendix F.  PART I: Implementation Assessement Page 5 of 13 9. Strengthening the delivery of health care. The MOH Planning Unit was strengthened through technical assistance and training. With support from the project, the Planning Unit developed the "White Paper on Health Policy" in 1993 and the Three-Year Health Plan (1993/94). Sectoral policies were substantially achieved with the development of the health sector policy and the three year plan. Institutional capacity building was achieved through support to the Planning Unit. The Planning Unit is coordinating the MOH's implementation of the Government's decentralization policy. The unit is providing technical support to the districts in building capacity for planning, implementation, financial management, monitoring and evaluation of health services. The districts are now in their second year of producing annual work plans as a basis for resource allocation. 10. Institutional capacity building for district and facility level management was improved. District Health Management Teams have been constituted while management committees have been established for hospitals and health centers. These committees, which include representatives of health services, the local administration and community leaders, are responsible for administration and financial management including resource generation. The project has also supported the development of a Quality Assurance Unit. This unit is still small but it is already conducting training and supervisory visits for improving the technical quality of the decentralized health services. A start has been made on development of a health information system but this is still a long way from generating information for use by health care providers to improve health services. Activities involving NGOs (except support to Safe Motherhood Initiatives, physical rehabilitation and equipment) were not carried out as modalities for working with NGOs had not been fully developed until late in the project implementation period. 11. The financial objectives were partially achieved. Budget frames have been introduced as part of the annual planning process, allowing the MOH to monitor trends in health expenditure. The planning unit now produces reports of trends in health expenditures that show the break-down between primary care and hospital care. Total Government recurrent expenditure on health has risen from 19.5 billion shillings in 1992/3 to 44.7 billion shillings in 1995/6. Expenditure on primary health care has risen from 25% to 32% while that spent on hospitals has declined from 70% to 58% during the same period. However, the proportion spent on management has risen from 5% to 10% and donor funding still accounts for the most significant share (72% in 1995/96) of primary health care spending. 12. Progress on developing alternative schemes for health care financing fell below expectations. This was mainly due to the political difficulties in introducing user charges in a situation in which the Government has traditionally guaranteed free medical treatment financed through the central budget. The recent constitutional change decentralizing management and financial responsibility to districts has led to some progress in introduction of user charges. While still in its early stages, the ground work has been laid and support is continuing through the District Health Services Pilot and Demonstration Project (DHSP). Many hospitals and health units are raising up to 10% of their non-staff  PART I: Implementation Assessement Page 6 of l3 budget through cost sharing and funds are retained at the local level. No other financing mechanisms were considered under the First Health Project, but local health insurance schemes will be piloted under the DHSP. 13. Poverty reduction objectives were not explicitly identified in this project but policy decisions have had to take them into account. The Government's caution in introducing cost sharing is due to its concern regarding the impact of the policy on the poor and their access to health services. The decision to decentralize public services including those in the health sector and to increase community participation in the management of service delivery are driven by the intention to improve service to the public, the greatest proportion of whom are poor. 14. The Government has articulated the policy of developing collaboration with the private sector especially NGOs which provide a large share of health services. However, development of collaboration mechanisms was achieved to a very limited extent under the First Health Project. This is now being undertaken with the assistance of the DHSP project. Major Factors Affecting the Project 15. Factors not generally subject to government control: The Government faced resource constraints during the reconstruction period following the civil strife. Furthermore, coffee prices also dropped in 1987/88 and this resulted in lower government revenues for the following three years. This partly accounts for the inadequate allocations of counterpart funding to the project (this applied to other Government projects as well). In addition, at the time of project appraisal, information on the status of the selected facilities was inadequate and adjustments had to be made to the scope of works for a number of the facilities as implementation proceeded. There were also delays in completing a number of the construction activities resulting in extensions of contracts and related costs partly due to shortage of materials and qualified contractors. 16. Factors generally subject to government control. The project suffered major setbacks due to shortage of counterpart funds. Even though the Government faced constraints in revenue collection, the health sector share in the Government budget was low. Counterpart funds amounted to only about 6% (US$ 3.5 million) of total project costs instead of the planned 10% (US$ 6.5 million). In the early part of project implementation, release of funds from the Treasury was often delayed and the amounts were below budgeted levels. This led to significant shortfalls in those expenditure categories that depended heavily on counterpart funds (civil works, in-country workshops and seminars, incremental operating costs of the PIU and key departments of the MOH: planning and health education). There were also bottlenecks arising out of complicated inter-governmental clearance procedures and a weak PIU: the PIU was inadequately staffed and the staff had very limited experience in implementing similar projects. After the mid-term review in 1992, these problems were gradually overcome with the strengthening of the PIU and improved communications between different government  PARTI: Implementation Assessement Page 7 of 13 agencies. A number of qualifications in the audits of the project remained unresolved for a long time. Most of these were resolved except for the construction of Buhozi clinic which was completed much later than envisaged. A report is still due from the Government on the final outcome of its investigation of the rehabilitation of the clinic (refer to ICR mission aide-memoire para 16, Appendix A). 17. Factors subject to the control of the project implementation unit. Difficulties experienced at the beginning of the project are largely because very little time was devoted to preparing implementing agencies for the substantial task ahead with the initial project in a sector. Furthermore, there was very little coordination among the agencies and the PIU. These problems were subsequently addressed over time: more competent staff were hired and trained. Technical assistance was also provided to the PIU. This resulted in major improvements in implementation during the latter half of the project. Project Sustainability. 18. Mulago hospital is the main health services provider in Kampala and the surrounding districts and was one of the beneficiaries of the First Health Project. Even more critical, Mulago hospital accounts for a large share of the Ministry of Health resources (16% of total health budget in 1995/96). Addressing sustainability of project investments is closely linked to sustainability of Mulago hospital services - in its own right as well as due to its relationship to other levels of service delivery. The workload at Mulago increased over the last four years (from 66,101 admissions in 1992 to 72,105 in 1995). Though data was not readily available, according to the MOH, increases in outpatient services have been higher than inpatient attendance. The rehabilitation program has contributed to this increase. Mulago is still faced with serious shortages of drugs and supplies and funds for maintenance activities (preventive in particular) are in:,ufficient. It will become increasingly difficult for the central government to provide adequately for the hospital while reallocating more funds from secondary and tertiary level facilities to primary health care. 19. Reacting to the issue, the Government commissioned a study which was funded by ODA to make recommendations for addressing the future of Mulago hospital. The study has made a number of recommendations for consideration by the Government which include, the need to: clarify the roles of Mulago hospital, the Kampala City Council (KCC) and NGO hospitals in services provision for Kampala city; s parate management of training schools for nurses and paramedical staff from Mulago hospital management; delineate -esponsibilities and financing of shared facilities between Mulago hospital and the Makerere University, and grant autonomy including revenue generation to Mulago hospital. The Government is seriously considering the recommendations from the study and has proposed to grant autonomy to Mulago by the 1998/99 fiscal year. These actions are expected to improve the efficiency of Mulago hospital and reduce its demands on the national budget as well as shift some of the work to lower level hospitals and health centers which are less expensive.  PARTI: Implementation Assessement Page8of/3 20. Rehabilitated hospitals and health centers are handling more patients as compared to similar facilities which have not undergone any rehabilitation. The improved physical environment has contributed to staff recruitment and retention. Experience has shown that the physical and functional rehabilitation of facilities has also enhanced the ability to raise revenues through user fees due to restored confidence of users. This will increase the financial sustainability of the hospitals and clinics in the long run. In the meantime, many facilities are setting aside a portion of the cost sharing revenues (usually in the order of 20%) for maintenance. However, these funds are not adequate to meet the maintenance needs of the facilities. Efforts are still needed to provide more funds for maintenance. As mentioned earlier, the districts now have the mandate for resource mobilization and allocation and are exercising it with varying degrees of success. The Government should continue to assist them in strengthening this capacity. The support of the Quality Assurance and Planning units is expected to contribute to a more efficient and effective service delivery system. Funding for health facilities will still continue to be largely public and as identified during the appraisal of the project, there is need to increase public funding for the health sector. The Ministry of Health recurrent budget has increased from Ug shs. 45 billion in 1992/93 to Ug shs. 85 billion in 1995/96, an increase in real terms of 44% over this period. The share of the health sector in Government spending is still low (2% of GDP) compared to other countries in the region. 21. The Government is pursuing the implementation of its sector policy objectives in the two projects prepared as a follow-up to the First Health Project: the Sexually Transmitted Infections (STI) Project and the District Health Services Pilot and Demonstration Project (DHSP). Both projects are carrying forward reforms and activities initiated under the First Health Project. A larger effort is being undertaken, through the STI project, to control the spread of HIV infection while alleviating the suffering of those already afflicted with AIDS. This project is supporting health education, drugs and supplies for opportunistic infection and capacity building for implementation. The DHSP support includes continued pilot testing of reforms; strengthening institutional capacity of districts; further rehabilitation of district level health facilities; developing collaboration with NGOs and the private sector; testing autonomy for Government units including Mulago; new funding mechanisms; and, restructuring of the Ministry of Health. These projects emerged directly from the First Health Project and take up the key issues facing the health sector in Uganda. There are other donor-funded projects supplementing the Government's efforts in the above areas. Borrower Performance 22. The Government was highly committed to implementation of the project but the project suffered setbacks in the first two years of implementation. The staff in the PIU were relatively inexperienced and had no prior knowledge of World Bank procedures. In addition, since the capacity building and implementation of the project was largely concentrated in the PIU, other key participants in the sector were not fully involved. This created a problem for collaboration with other departments and accounted for the fact that some departments (Health Education in particular) were not aware of their  PART I: Implementation Assessement Page 9 of 13 responsibility in the implementation process. As a result a number of activities were either not carried out or financed by other donors. Covenant compliance was partially satisfactory, the most significant weakness being consistent delays and qualifications in audit reports. Counterpart funds were inadequate and often delayed. There were also delays in procurement of goods and services and weak contract administration. After the mid-term review in 1992, the MOH made an effort to address these problems. More qualified and competent staff were hired for the PIU. Technical assistance was brought in to strengthen the PIU and the MOH, and staff were trained in World Bank procurement, financial and disbursement procedures. Efforts were also made to enhance coordination among implementing departments in the MOH and other ministries. These actions greatly contributed to speeding up implementation. Bank Performance 23. The Bank provided a fairly thorough analysis of the health sector given the limited data available at the time of project appraisal. Three main risks were identified: (a) lack of implementation capacity in MOH; (b) uncertainty over the feasibility of developing alternate methods of financing; and (c) lack of motivation at all levels of the civil service mainly due to low levels of remuneration. With the benefit of hindsight, the accuracy of these risks can be confirmed. Costing and timing of such a large project was a challenge given the inadequate data. One risk which was not taken into account was the ability of the Government to raise adequate counterpart funds given the difficult economic conditions at the time. The Bank did not also involve all key implementing agencies in project design. This was particularly evident in the case of a number of agencies responsible for implementation of the health education component. As a result of poor communication and failure to resolve problems some activities in the component were canceled. The project could have benefited from more World Bank staff supervision time. This would have enabled corrective actions to be taken more regularly instead of awaiting the major mid-course restructuring. This may have reduced the delays experienced especially with respect to resolving impasses between Government agencies on the evaluation of bids for radio transmitters and in reaching agreement between the Government and the Bank on the size of facility to be constructed in Rakai. In addition, a practical implementation manual would have been useful for implementing agencies. Apart from the cases cited above, the Bank was responsive in addressing problems which arose in the course of implementation and assisted the Government to restructure the project in line with changing priorities. Assessment of Outcome 24. Overall, the project outcome was satisfactory. The project greatly improved facilities at Mulago and at the 8 district hospitals and 40 health centers and provided equipment and a more conducive working and living atmosphere for staff. It is difficult to measure the impact of the rehabilitation and equipping of the facilities on the quality of service delivery. Visits to facilities and discussions with staff yielded different responses, though overall the perception was that there was a major improvement from the conditions  PART I: Implementation Assessement Page 10 of 13 prevailing at the time of project appraisal. Though the rehabilitation barely scratched the surface of rehabilitation needs in Uganda (e.g. 8 district hospitals out of 71 district hospitals - 11%), important inroads have been made in improving facilities especially of areas most adversely affected by the civil strife. The greatest achievements of the project have been in institutional capacity building for implementing health sector policy (both at the central and district levels) and initiating the process of reform. Though some activities were carried out for preventive health programs, this was the least successful part of the project. It is difficult to draw a link between the general health status in a country and a specific project such as the First Health Project. However, it is worth noting that there have been improvements in some health indicators. According to the Demographic and Health Survey, 1995, the infant mortality rate has fallen from 119 per 1000 births in 1988/89 to 97 per 1000 births in 1995 while the proportion of children aged 12-23 months who are fully immunized has increased from 31% to 49% during the same period. Future Operations 25. The Government health policy clearly stresses the importance of maintenance of existing infrastructure. Guidelines have been provided to institutions requiring them to provide funds for maintenance needs. The MOH will continue sensitizing managers of health facilities on the importance of maintenance of buildings and equipment. Training for maintenance will also continue to be provided. The Health Education Department will work closely with other departments to ensure that health education messages are consistent. This is particularly important as there are many different programs all contributing to the education of the public on better health practices. As for institutional strengthening, the Government is continuing with the process of decentralization of services. Additional work is already underway on delegating more responsibility to districts and individual facilities. The structure of the Ministry of Health is being reviewed further in line with decentralization needs. The planning function is also being strengthened especially in light of the need to enhance the capacity of the districts to take on a more central role of service provision. The Government is committed to providing additional budgetary resources to the health sector. At the same time initiatives are also underway to develop alternative schemes for health care financing. Another key element of improving delivery of health services is the realization that all care providers (public, private and NGOs) have to be taken into account. The Government has already initiated action to work out mechanisms for collaboration. Two IDA-funded projects are supporting the actions presented above: the DHSP project is providing support for health sector reforms and the STI project focuses on preventing the transmission of HIV and supporting AIDS patients. Other donors active in the sector are also supporting the Ministry of Health's reform efforts. 6 Different estimates of infant mortality have been made based on the 1988/89 Demographic and Health Survey. The level of 19 is adjusted for sample coverage and reporting errors.  PARTI: Implementation Assessement Page 11 of 13 26. It is a challenge for the Government to maintain rehabilitated facilities and provide competent and motivated health care staff, drugs and supplies to enable them function effectively. At the same time, more public health facilities require rehabilitation. Resources for meeting all these needs are limited. The Government should prepare a sector-wide investment strategy for the future. The strategy should aim for improvement of health services delivery including: improving competence of staff, provisions of adequate funds for operations, maintenance of existing infrastructure, rehabilitation of selected high priority facilities. The strategy should pay particular attention to ways of improving the quality of services. This will call for mobilization of additional resources from both Government budgets and from users of health services through the development of appropriate health financing mechanisms. However, even more important is the need for creating an environment where different players (public sector, private sector, NGOs and donors) can contribute to the improvement of health services in the country. Key Lessons Learned 27. A number of lessons can be drawn from the experience of implementing the First Health Project. a. Sectoral Issues. i. Government commitment to the project is central to implementation success. The Uganda government was committed to addressing the problems in the health sector and took the necessary policy decisions which included the articulation of the health sector policy in the "White Paper" and the development of a three year plan. ii. Incremental support provided by individual projects must be fully embedded within an overall sector strategy. The First Health Project was an emergency response to re-establishing health services but more importantly it also provided assistance to the Government's development of a sector strategy. iii. The success of new health services funding mechanisms requires the involvement of all stakeholders: policy makers, care providers and consumers of health services. It is also critical to address the efficient use of resources in addition to the provision of additional resources. iv. Development of alternative financing schemes involves other reforms in the health sector. Technical assistance will be required for such new areas. v. More attention needs to be given to the development of a Health Information System which can be easily managed by health care givers especially at district and health facility level. This will be facilitated by  PARTI: Implementation Assessement Page 12 of 13 the involvement of health care givers in the design of the system especially if they see the system as a tool they need for their work. vi. Health education will continue to be important for preventive and promotion of good health practices. However, more work needs to be done on the best way of improving health education with an emphasis on the roles of different players. vii. With the increasing needs in the sector, it is timely to shift from narrowly defined projects to a sector-wide program approach taking into account the necessary reforms such as health care financing and the involvement of all players (public, private and NGOs). b. Implementation Issues viii. Project design should allow for a substantial degree of flexibility. The health sector is subject not only to changes in the disease burden (for example the AIDS epidemic) but also in its need to respond to major policy decisions such as decentralization. The tasks facing it cannot always be predicted years ahead and major projects must be responsive to changing priorities ix. There should be greater involvement of all stakeholders in the design of the projects. This greatly facilitates implementation. x. Agencies expected to be responsible for implementing specific activities in project design and supervision should be fully involved in project design and consulted regularly during implementation. This helps to build ownership. Responsibilities for implementation should be clearly explained during project design and attention should be paid to this during implementation. A detailed practical implementation manual should be prepared as part of project appraisal as a reference document for implementation. xi. Efforts should be made during implementation to ensure availability of counterpart funds and recurrent support to proposed investment. It may even be necessary to build in conditionality for counterpart contributions.  PARTI.: Implementation Assessement Page 13 of 13 xii. Capacity building is important for institutional strengthening; capacity constraints should be identified for implementation as well as for technical areas. Particular attention should be paid to clarifying IDA and Government rules for procurement and disbursement. Lack of adequate knowledge in these areas slows down implementation considerably. Clear guidelines on project implementation procedures (including procurement and disbursement) are crucial. Procurement plans and bid documents should be finalized during project appraisal.  14 PART II Table la Uganda First Health Project Table la: Summary of Assessments: Rehabilitation and Construction of Health Facilities Component Substantial Partial Negrgible Not applicable A. Achievement of objectives macro policies XX sector policies XX financial objectives _ XX institutional development _ XX physical objectives XX poverty reduction XX gender issues XX other social objectives XX environmental objectives XX public sector management XX private sector development XX X X _ _ _ Likely Unlikely Uncertain |B. Project sustainability XX Highly Highly satisfactory Satisfactory Deficient unsatisfactory IC. Bank performance _ ______= ___=___ identification XX preparation assistance XX appraisal XX supervision xx D. Borrower performance preparation XX _ implementation __ X_XX_=_______ _ ___ covenant compliance XX operation XX E. Assessment of outcome XX  15 PAR r II Table lb Uganda First Health Project Table 1 b: Summary of Assessments: Health Education and Community Activities Component Substantial Partial Negligible Not applicable A. Achievement of objectives macro policies XX sector policies XX _ - financial objectives XX __ institutional development XX physical objectives XX poverty reduction xx gender issues XX other social objectives XX environmental objectives XX public sector management XX e private sector development XX Likely Unlikely Uncertain B. Project sustainability XX Highly Satisfactory Deficient Highly satisfactory unsatisfactory C. Bank performance identification XX preparation assistance XX appraisal XX supervision XX D. Borrower performance preparation XX implementation XX covenant compliance xx operation XX E. Assessment of outcome XX  PART II 16 Table Ic Uganda First Health Project Table 1 c: Summary of Assessments: Strengthening the Delivery of Health Care Component Substantial Partial Negligible Not applicable A. Achievement of objectives macro policies XX _ sector policies XX financial objectives XX institutional development XX . physical objectives XX poverty reduction XX gender issues XX other social objectives XX environmental objectives XX public sector management XX private sector development XX Likely 1Unlikely Uncertain B. Project sustainability XX Ilaigaty Satisf actory Deficient Highly satisfactory . . . . . . unsatisfactory C. Bank performance identification XX preparation assistance XX appraisal XX supervision XX D. Borrower performance preparation XX implementation XX ,covenant compliance XX operation XX _ E. Assessment of outcome XX  17 PART 11 Table 2 Uganda First Health Project Table 2: Related Bank Credits Credit Purpose Year of Status _ Appro_al Parallel Operations 1. Program for Alleviation of Poverty The project objectives were to address urgent 1990 Closed, and Social Costs of Adjustment Project. social needs of Uganda's most vulnerable September (Cr. 2008-UG) groups through collaboration of communities, 1995 NGOs and the Government and strengthening of Government capacity to identify and implement interventions. Following Operations 1. Sexually Transmitted Infections The project is assisting: the prevention of 1994 Ongoing, Project. (Cr. 2603-UG) sexual transmission of HIV; the mitigation of closing personal impact of AIDS; and, institutional December development for managing HIV prevention and 31, 2000. AIDS care. 2. District Health Services Pilot and The project is assisting: pilot testing delivery of 1995 Ongoing, Demonstration Project. (Cr. 2679-UG) a package of essential services at the district; closing strengthening management and planning December capacity of districts for service delivery; and, 31, 2002. restructuring and capacity building of the Ministry of Health. Planned Operations The project will assist the development of Planned, 2000 3. Health Sector Reform Project Public Health Programs, Health Care Financing and alternative health care delivery options.  18 PART II Table 3 Uganda First Health Project Table 3: Project Timetable Steps in Project cvcle Date Planned Date Actual Identification December, 1987 Preparation/Appraisal January - February, 1988. January - February, 1988 egotiations May, 1988 May 12-18, 1988 Board Presentation July, 1988 June 23, 1988 Signing July, 1988 July 11, 1988 Effectiveness September, 1988 January 11, 1989 Mid-Term Review December 31, 1990 August 3-16, 1992 Project Completion June 30, 1995 March 31, 1996 Loan Closing March 31, 1996 March 31, 1996  19 PART II Table 4 Uganda First Health Project Table 4: Credit Disbursements, Estimated and Actual Actual cutminul. SAR Estimates Actual as % of credit Yr/Quarta r Quarterly Cummul. Quarterly Cummnul. Credit n:SS n illionx) (USS nhilli.liq.) FY89 Ql 1.20 0.00 0.00 0.00 Q2 2.20 3.40 3.39 3.39 0.08 Q3 3.00 6.40 0.00 3.39 0.08 Q4 4.20 10.60 0.00 3.39 0.08 FY90 Ql 3.00 13.60 0.00 3.39 0.08 Q2 2.60 16.20 0.03 3.42 0.08 Q3 2.90 19.10 1.53 4.95 0.12 Q4 3.00 22.10 1.73 6.68 0.17 FY91 Ql 2.60 24.70 1.41 8.09 0.20 Q2 2.60 27.30 0.27 8.36 0.21 Q3 1.60 28.90 1.84 10.20 0.25 Q4 1.60 30.50 1.20 11.40 0.28 FY92 Ql 2.60 33.10 0.07 11.47 0.28 Q2 2.20 35.30 3.86 15.33 0.38 Q3 0.80 36.10 3.07 18.40 0.45 Q4 1.30 37.40 2.88 21.28 0.53 FY93 Ql 0.40 37.80 3.85 25.13 0.62 Q2 0.40 38.20 0.72 25.84 0.64 Q3 0.50 38.70 1.97 27.81 0.69 Q4 0.40 39.10 0.00 27.81 0.69 FY94 Ql 0.30 39.40 0.53 28.34 0.70 Q2 0.30 39.70 1.83 30.18 0.75 Q3 0.30 40.00 0.93 31.11 0.77 Q4 0.50 40.50 0.85 31.96 0.79 FY95 Ql 0.50 41.00 0.76 32.72 0.81 Q2 0.50 41.50 2.48 35.20 0.87 Q3 0.50 42.00 1.19 36.39 0.90 Q4 0.50 42.50 0.97 37.36 0.92 FY96 Q1 0.00 37.36 0.92 Q2 1.34 38.69 0.96 Q3 0.93 39.62 0.98 Q4 0.84 40.47  Quarterly Credit Disbursements, Estimated vs. Actual 4.50 :. iE; . E wE i i i. ~~~~~~. . . .. .. ^...:. : ::::< :) i: : 4~ ~ ~ ~ ~~~~~~~~~~~~~~. .. .. .. . .. .... . .: .. . . .. :- .. -gz. ... .. . .:; . ; . . ....: . .. .. . . .. .. ... . 4.00r........... 3.50 . . ... ..-.... .... . . . . .. ... 0 SAR Estimates 3.00 . . . ......... . .._ . ................ Actual .. .. . . .. . . ..: . . . . en . ~ ~ ~~~~~~~~~~~ . ... ... .. .. . .. : A : . : :i ,o 2.50 . .. . - . .... ........ ..... . . 2.200 ____L__1__1 t .E..L LH;: - 2 .0 - - --- -- - _._ . .. .. . ... ........................... ... ... .. .. .... .. ... .. .. ... .. .. . .................. _,...._...t 0 0 | * 1.50 . _ .. . _ . . 1.00 - CL 0.50 0.00 m C) C"I ~ ~~~~~~~~~~ CO) LO1)( CD m 0 0) a) )0 LL ~~ ~ ~~~Li. IL L LiL IL IL IL Quarterly  Uganda First Health Project Table 5: Key indicators of Project Implementation1 Item Unit FEstiniated Actual Comment A. Rehabilitation and Construction of Health Facilities 1. Mulago Hospital Rehabilitation 90% The following selected areas were completed: elevators, officers houses, nurses hostels, doctors mess, kitchens, laundry, maintenance workshop, central sterile supplies department. Equipment, drugs and supplies were also provided. Due to cost overruns the scope of work was reduced: water and sewerage works, a number of staff houses, hospital roads, fencing and paving. 2. Equipment of Blood Transfusion Center % 100% All expected equipment was provided by end of 1990. Rehabilitation of the center was supported by the European Development Fund. 3. Rehabilitation of District Hospitals number 8 8 All works were carried out though there were delays in expected completion times. 4. Rehabilitation of Health Centers number 30 40 More health centers were rehabilitated as a result of savings due to reduced ________ I__________ scope of work on the proposed Rakai hospital. 5. Construction of 100 bed hospital in Rakai District number I I Reduced to a 32-bed health center. 6. Construction of Maintenance Workshops number 2 2 One workshop for Mulago hospital and one for district hospitals. B. Health Education (9) Mass Media 1. Provision of subsidized newsprint to New Vision tons 400 400 Completed. newspaper 2. Equipment of national radio service n.a Some equipment was provided but the main equipment consisting of transmitters was not provided due to inability to carry out the procurement. 3. Development of training materials n.a. Completed. 4. Training Carried out for joumalists and health educators. 5. Construction of lean-to-shelters number 30 ---- Intended to be used as billboards for health messages at rehabilitated health centers. Considered of low priority and was later canceled. I No performance indicators were provided in the Staff Appraisal Report or the President's report. These indicators have been developed from the staff appraisal report. iV  Table 5: Key indicators of Project Implementation (continued) Item Unit Estimated [ Actual Comment (it) Community Based Distribution Programfor drugs and information 1. Renovate central medical stores in Entebbe n.a. - Not lone. Activity later undertaken by DANIDA as part of the essential l________ _____ drugs program. 2. Construct and equip regional medical stores number 4 1 3. Establish distribution system for community n.a. - distribution of drugs and health information l (iii) Counseling and Patient Managenentfor people with AIDS Workshops n.a Completed. Training Materials n.a. Completed. Training for care givers n.a. Completed. C. Strengthening Health Care Delivery 1. Technical Assistance n.a Both short-term and long-term technical assistance was provided for project management, Ministry of Health Management, development of 10 year plan and health care financing. 2. Training n.a. Training including study tours provided for journalists (health education), planning and management staff. 3. Studies n.a. A number of studies carried out (refer to table 10 - Status of legal covenants). 4. Workshops n.a National and district level workshops carried out for: preparation of the health plan, health care financing, project management, health educators, village level health workers etc. 5. Establishing drug revolving funds for Mulago, n.a. Not established as policy on cost sharing was not fully implemented. district hospitals and communities 6. Establishment of Management Committees for n.a. Completed. hospitals and health centers. 0i  Uganda First Health Project Table 6: Key Indicators for Project Operation 1v Project Impac to be maintained Follow-up actions being Issues Ouitstanding |lanned Actions taken__ _ _ _ _ _ _ _ _ _ _ _ 1. Maintenance of rehabilitated facilities and Training continues to be Inadequate provision in budgets Increase budget allocations for equipment. provided for staff in for maintenance funds for both maintenance. Sensitization of maintenance of equipment. equipment and buildings. In the managers of hospitals and health case of maintenance of buildings centers on the need to develop no systematic procedures are in maintenance systems. place for maintenance. 2. Dissemination of health education The New Vision newspaper Refining messages and ensuring The Health Education messages. continues to carry regular health consistency of health education department will play a more education messages. Other messages developed by different central role in quality control media TV and Radio are also agencies. and supervision. The STI and actively disseminating messages. DHSP projects are supporting health education. 3. Strengthen management capability of The Government policy of Next steps in devolving powers Another review of the Ministry MOH, Hospitals and rural health facilities. decentralization has enhanced to districts and individual of Health structure will be the role of management by facilities especially hospitals. undertaken - relinquishing more devolving more powers to Training to enhance skills of authority from the central level districts. The MOH was managers will be necessary. which will remain in a restructured under the Civil supervisory and policy setting Service Reform. role while districts and individual health facilities take on direct management responsibility. > :  Table 6: Key Indicators for Project Operation (continued). Project Impact to be maintained Follow-up actions being Issues Outstanding Planned Actions 4. Increase public resources to the health The Government is increasing (i) Further increase in public The Government will continue sector and develop alternative schemes for budget allocations to the allocations to the Ministry of to develop and pilot schemes for financing health care. Ministry of Health. User charges Health. (ii) Continued health care financing under the are being implemented at health development of user charges DHSP project. facility level through the and other alternative financing constitutional mandate of local schemes. (iii) Shifting more authorities to raise revenues. A resources to primary health. few community financing schemes are being piloted. 5. Continue reforms in the health sector. Two credits were prepared as a Implementation of reforms in the The Government intends to follow-up to the First Health health sector including those continue implementing reforms Project. Both projects support mentioned above. using support from STI and ongoing reforms. The STI DHSP projects. The project focuses on reducing the Government is also preparing its spread of HIV infection and health sector strategy for the supporting care to AIDS patients next five years. The strategy while the DHSP project is will be the basis for developing a supporting piloting of policy sector-wide investment program. reforms for implementation of essential health services. 1/ Indicators were not provided in the SAR or in the President's reports. The above indicators have been developed from the SAR. Abbreviations: STI Sexually Transmitted Infections Project (Cr. 2603-UG) DHSP District Health Services Pilot and Demonstration Project (Cr. 2679-UG) -q kV  UGANDA FIRST HEALTH PROJECT Table 7: STUDIES CONDUCTED Study/Purpose of Study Consultants Slat us i in pact of Study 1. Study on Human Resources for the Health Sector (1991) External and Local Completed The study was used to identify training and management requirements for Ministry of Health To review available data and assess the manpower working in the public staff. health system; suggest measures for establishing technically and administratively feasible norms for managing health units including hospitals; and, identify opportunities and constraints to health personnel development and retention. 2. Study on prevalence of AIDS Extemal Completed The information was used in the preparation and appraisal of the Sexually Transmitted Infections To review the impact of AIDS in Uganda and suggest components for Project (Cr. 2603-UG). inclusion in a new project. 3. Knowledge. Attitude. Practices Study Local Completed The study was completed in 1992 after a long delay. It provided useful information on public To determine the impact of health education programs. awareness and practices in regard to their health. The mid-term review recommended that another KAP study be done before the end of the project to assess the impact of health education programs but this was not carried out. 4. Study on Decentralization of Health Services in Uganda. July, 1993. External and Local Completed This report was used in the formulation of health policy reforms; the establishment of the policy To review the roles of the Ministry of Health and Ministry of Local for district level organizations; preparing Government in a decentralized system of service delivery; to identify the guidelines for management committees for options and the process for the decentralization of health services; to hospitals/health units; and for integrating vertical recommend an action plan for the management of district services; and to programs at the district level. advise on the roles of the committees functioning at different levels of the system during decentralization. -4-  Table 7: STUDIES CONDUCTED (continued) Study/Purpore of Siudy Contulrunii Ditatilq hlup:arl or Study 5. Study to assess the economic benefit and feasibility of moving the Local Completed The study recommended the relocation of the Ministry of Health headquarters from Entebbe to Kam=ala 1994. Ministry of Health headquarters to Kampala. The report was used in the preparation of the District Health Services Pilot and Demonstration Project which is supporting the transfer of the __________________ _________________ ________ ________ ______ __________ ____ hheadquarters 6. Study on Manpower Development and Training requirements. 1991, Extemal and Local Completed The reports are being used for capacity building 1993. being undertaken by the Ministry of Health. To develop a system for upgrading the skills of staff through training. 7. Improving Management Systems in the Ministry of Local Government. External Completed The report was used in the re-organization of 1994. health service delivery for services falling under local authorities. To recommend an organizational structure and a computerization process for the management information system in the Ministry of Local Government under the decentralized framework for delivery of services. 8. Development of the Sexually Transmitted Infections Project. 1994 External and Local Completed The project report was used in the appraisal of the Sexually Transmitted Infections Project. To prepare a project addressing the AIDS pandemic and related sexually transmitted diseases. q e 0r  Table 7: STUDIES CONDUCTED (continued) .S.:.. 5.:.:.:.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~........ .... ...~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.* . . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ..... ....* ... . .*..~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... 11. Studies on Ouality Assurance development in Uganda (1 994) External and Local Continuing The small unit which was the nucleus for these studies is now being developed into a quality To make recommendations for establishing a Quality Assurance process in assurance unit of the Ministry of Health. It is the delivery of health services. focal point for training and supervision of staff in improving the quality of health services especially under the decentralized system. | 12. Beneficiary Assessment Study (I 994)) External and Local Completed The report was used in the preparation of the District Health Services Pilot and Demonstration To assess the impact of programs and services on beneficiaries. Project. eD -3 _  Uganda First Health Project Table 8. Project Costs - Staff Appraisal Report Estimates and Actual Expenditures (US $ Millions) SAR Eistimates Acttal Ixppeniliture category (ov't Austria 1/ lltA/SlDA Tlaal Gov't Austria llDA IDl)A 'rotol 1. Civil Works 2.40 22.50 24.90 0.90 - 0.80 23.10 24.80 2. Vehicles, furniture, materials, supplies and equipment 1.50 10.00 15.70 27.20 10.30 0.13 8.99 19.42 3. Technical Assistance and Consultancy 3.50 3.50 0.44 3.43 3.87 4. Local and External Traini 0.60 0.90 1.50 2.99 1.50 4.49 oo 5. Monitoring, Research and Incremental Recurrent Expenditures 2.00 0.00 6.40 8.40 2.60 0.10 2.14 2.92 7.76 6. Piloting Health Reforns 2/ 0.54 0.54 Total project costs l 6.50 10.00 49.00 65.50 3.50 10.40 6.50 40.48 60.88 11 Cofinancing from the Austrian Government was confirmed after appraisal. 2/ The Development Credit Agreement was amended in July, 1995 to allow piloting of health sector reforms in preparation for the next IDA financed health projects. 5 x  29 PART II Table 9 Uganda First Health Project Table 9: Project Financing Appraisal Actual Source F-Istimates Expenditures _ __ ((tSS M) W((SS ND IBRD/IDA 42.50 40.48 SIDA 6.50 6.50 Austria 10.00 10.40 Domestic Contribution 6.50 3.50 TOTAL 65.50 60.88  Uganda Table 10: Status of Legal Covenants DCA : ::: :; e rptl on::o:en ::: ::: C :an :1.rsn ::rgina . Ate:al . F: ::: : Comtns :RC(erenc..;; ,;.: . typle staes. ::.::.: :Com..n.ent t *::: cc.>::.:...: C V. ... - .~~~~~~~~~~~........... Article III The Borrower shall, carry out the project through MOH 1 2 CP N/A, The Govemment was fully committed to implementation of the project but para. 3.01(a) with due diligence and efficiency and in conformity with many problems were experienced, notable among which were the appropriate administrative, financial, engineering and public persistent delays and shortfalls in counterpart funding exper' nced. The health practices, and shall provide, promptly as needed, the situation improved in the latter half of the project. The Govemment made funds, facilities, services and other resources require for the efforts to provide a conducive environment for implementation and project. addressed problems as they arose. Article HI The Borrower shall with the assistance of a suitably 12 CD 12/31/88 3/1991 A 10-year plan was prepared with assistance of a consultant in 1991. The para. 3.03 (a) qualified expert, prepare a national health plan. current three-year plan (1993-1996) was developed from it in 1992. ._________ __ District plans for implementation are now prepared annually. Article III The Borrower shall submit a detailed action plan for the 12 CD 12/31/88 1991- A draft paper on restructuring the Ministry of Health (MOH) was prepared para. 3.03 (b) implementation of refomis of the organization and 1993 in 1993 as part of the Civil Service Reform. Later more work on management of the health system. restructurind was carried out as part of the preparation for the District Health Services Pilot and Demonstration Project which is now under implementation. Article III The Borrower shall submit a proposal satisfactory to IDA 12 CD 12/31/89 1993 This was addressed in the White Paper on Health Policy issued in 1993. It w para. 3.04 (a) for the development and implementation of a referral was developed further by the Decentralization Task Force as part of the system. Govemment's preparation for decentralization. Article III (i) The Borrower shall submit to IDA a review of existing 12 CD 12/31/89 1991, A manpower study was carried out in 1991. More work on staffing in the para. 3.04 (b) manpower in the health sector, including an optimal staffing 1993 health sector was done in the National Health Personnel Study in 1993. and implementation plan for the sector. Action was taken as part of the Civil Service Reform as well as through the (ii) To the extent practicable, transfer excess staff to Govemment's decentralization policy implementation (1994-1995). understaffed categories of the sector and provide training as appropriate. 10- Article 1II The Bonrower shall submit evidence to IDA that the co-financing CP Cofinancing amounting to US$ 6.5 million was secured from SIDA and para. 3.05 Borrower has secured the equivalent of not less than US$ 10 million from the Austrian Government, $6,500,000 for financing the project. 0g  Table 10: Status of Legal Covenants contl *:CA Descrription of Covenant Covenant tyale Present Originil .1ual ConinenitN Reretenee . stiutus dale dim Article IV parn 4.01 (a) (a) Maintain or cause to be maintained records and accounts 1 CD N/A. N/A. Accounts were maintained but audit reports tended to be adequate to reflect, in accordance with sound accounting delayed and a number of qualifications remained unresolved practices, the operations, resources and expenditures, in for a long time. Audits were carried out for FY 1989/90; respect of the project, of the departments or agencies of the 1991/92; 1992/93; 1993/94 and 1994/95. The report for Borrower responsible for carrying out the project or any part 1995/96 is due. It is noteworthy that actions to address the thereof. qualifications have been taken up more actively in the last two years. (b) The Borrower shall; (i) have the records and accounts referred to in paragraph (a) of this Section, including those for the Special Account and the Trust Fund for each fiscal year, audited in accordance with appropriate auditing principles consistently applied by independent auditors acceptable to the Association; (ii) furnish to the Association, as soon as available, but in any case not later than six months after the end of each year a certified copy of the report of such audit by said auditors, of such scope and in such detail as the Association shall have reasonably requested; and (iii) furnish to the Association such other information conceming said records, accounts and the audit thereof as the Association shall from time to time reasonably request - c) For all expenditures with respect to which withdrawals from the Credit Account were made on the basis of statements of expenditure, the Borrower shall: (i) maintain or cause to be maintained, in accordance with paragraph (a) of this Section, records and accounts reflecting such expenditures; (ii) retain, until at least one year after the Association has teceived the audit for the fiscal year in which the last withdrawal from the Credit Account was made, all records (contract, orders, invoices, bills, receipts and other documents) as evidence of such expenditures; (iii) enable the Association's representatives to examine such records; and (iv) ensure that such records and accounts are included in the annual audit referred to in paragraph (b) of this Section and that the report of such audit contains a separate opinion by said auditors as to whether the statements of expenditute submitted during such fiscal year, together with the procedures and internal controls involved in their preparation, can be relied upon to support the related withdrawals. Cs  Table 10: Status of Legal Covenants contJ D)(A Descripliul. uf Coveniant Cuvenasil type Present Original Actual Cu(imlniits lteference statuis fute date Schedule 4 The Borrower shall coordinate the implementation of the 5 C N/A. N/A. The Project Coordination Committee was established and met para.l Project through a Project Coordination Committee with the regularly until early 1991. Since then the Permanent Secretary Permanent Secretary as Chairmnan, and comprising senior has supervised the project and met regularly with his staff of MOH; representatives of the Ministries of Local counterparts for purposed of coordination. Government, Justice, Finance, Planning and Economic Development, and Housing and Urban Development. A project coordinator was appointed in late 1988. In 1991 the Schedule 4 The Project Implementation Unit (PIU) shall carry out day- 5 C N/A. N/A. Project Coordinator was changed with the concurrence of IDA. para. 2 to-day implementation of the Project and monitoring the A further change was made in 1994, due to the unfortumate activities of the health Education Unit, the organization, demise of the coordinator. The staffing of the PIU was administration and management training programs and the reviewed in 1991 and in the course of implementation and progress of civil works. PIU shall be headed by a Project changes made to improve the strength of the unit. Coordinator whose qualifications are satisfactory to IDA. Schedule 4 PIU shall prepare and submit to the Association, semiannual para 3. reports on the progress of implementation of Project 5 C N/A. N/A. Progress reports and work plans were prepared and submitted to activities with effect from December 31, 1988 IDA every year starting in 1989. Schedule 4 MOH shall carry out a comprehensive review of progress CP 12/31/1990 8/1992 A Mid-term review of the project was carried out in August, para. 4 made in the implementation of the Project and provide IDA 1992. A review of the PIU was carried out in 1991 and a D with: Financial Review of the project in 1992. (a) details, on the financing of the health sector, including 11 A financial review was carried out in early 1992. A proposal recurrent costs, to ensure that adequate funds are made for cost-sharing was prepared by the MOH and submitted to the available to sustain health services; Government. The Govemment deferred its implementation as the environment was not conducive for its implementation. (b) financial plans, with details on altemative schemes for the 2 Cost sharing was then introduced on a limited scale but was generation of resources, including cost recovery at the later enhanced when the constitution allowed revenue facilities to be rehabilitated under the Project, to ensure that generation by local authorities following the decentralization such schemes are properly established; and appropriately policy. Govemment has remained committed to diversifying implemented. financing of the sector. This has been clearly articulated in the White Paper on Health Policy, 1993 and in the Letter of Sector Policy drafted in June 1994 for the District Health Services Pilot l________________ _________ and Demonstration Project Schedule 4 The Borrower shall finalize an action plan for completion of 5 C 1988 The condition was satisfied in 1988. Documents for para. 5 the full set of documentation, drawings, site plans, rehabilitation and civil works have subsequently been specifications and bills of quantities for all rehabilitation revised/prepared as needed. works. C.  Table 10: Status of Legal Covenants cont./ DCA Desaription of CoveantC ntp -a uA 1 -.CommDents Referenc . ... ...... Schedule 4 In order to improve the management and manpower .......... ........ .....A Health Manpower Study was completed in 1991. para. 6 standards of the facilities to be rehabilitated under the Retrenchment was carried out beginning in July. 1992. Project, the Borrower shall: (a) during rehabilitation carry our a manpower analysis and C management study of each facility. 5 (b) submit staffing plans 5 CD 6/30/1989 Staffing for rehabilitated facilities was carried out by the (i) for each facility to be rehabilitated technical assistance provided by the Austrian Government. CD 12/31/1989 (ii) for the new electrical and mechanical workshop Carried by Austrian consultants. O establish staffing standards, eliminate redundant positions 12 CD The organization and staff rationalization has since been and workers and finalize redeployment of staff by date of reviewed through the restructuring of the MOH in line with completion of physical works. dentralization and the civil service reformn. Schedule 4 The Borrower shall appoint a Health Education Coordination 5 C 12/31/1988 12/1988 The Committee was established in 1988 and met regularly para. 7 Committee, to bc chaired by MOH's Director of Medical under the chairmanship of the PS/DMS. Services, and comprising representatives of other divisions of MOH, representatives of the Ministries of education, Information and Broadcasting and the New Vision and Munno newspapers. Schedule 4 The Borrower shall carry out studies (one each year) and 9/30/89 para.8 submit a copy of cach study to IDA within six months of completion: Studies: 1991 (i) Two Health Manpower Studies were carried out in 1991 and (i) to identify the corrcct staffing of MOH facilities at all 12 CD 1993 1993. levels and to identify training and retraining needs; (ii) A Management Information Study was carried out in 1993 (ii) to develop health information and management systems for the MOH and the Ministry of Local Govemment. (iii) on the efficiency and effectiveness of the health system (iii) The efficiency and effectiveness of the health system was (iv) on the establishment of community-based distribution reviewed as part of the study on decentralization of health systems for drugs and supplies, including condoms. services. (iv) The drugs supply system was reviewed with DANIDA .d assistance. A new Drugs Policy was adopted in 1994. co  Table 10: Status of Legal Covenants cont./ DCA Descripfionjof Covenant. :. ;..:... Covenant Prt ntt'Origina cAct.a. : :um n .t: Reference .t ......:....e. . . Reference~. . .:.. .;. : :;. : . .. .... ........ ..... . ........ . .. ..... esL.; Scebdule 4 (a) Establish management committees for each hospital and 12 C 12/31/1989 N/A. This conditions was met gradually. Management commnittees were para. 9 health center, with functions including overseeing of each introduced following a voluntary approach based on MOH guidelines. facility, generating additional funding through introduction Individual facilities are charging increasingly for health services. The of alternative financing schemes, including cost sharing upon constitution allows local authorities to raise revenues for their services. completion of rehabilitation works. Additional work on health financing is being undertaken by the Health (b) Membership of management committee shall be chaired Planning Unit of the MOH. by the local resistance committee chairman and include representatives of Ministry of Local Government, the administration of the facility and prominent community leaders Schedule 4 To encourage community participation in financing of local 2, 11 CP 6/30/1989 Community participation was achieved through the Government's para. 10 health facilities, the Borrower shall ensure that funds decentralization policy. District Health Management Teams were established generated through commnunity and health-related financing under the chairmanship of the RC5. Cost sharing continued to be activities, including cost-recovery on drugs are re-channeled implemented informally. The constitution has now given the mandate to to the respective facility. districts to raise revenues and cost sharing is being implemented in most health facilities. I Schedule 4 The Borrower shall provide funds to: l NC NA NA Drug revolving funds were not given to Mulago and to district hospitals due para. 11 (a) Mulago hospital to launch revolving drug funds to revenue shortfalls and also because of the absence of a policy on cost- (b) district hospitals and health centers to launch revolving sharing. Funds are largely provided through the govermnent budget Now funds and finance activities required to generate funds with cost-sharing picking up, some health unit have started to provide drug revolving funds. Schedule 4 The borrower shall submit proposals for income-generating 2,3 NC Viable activities were not identified. par. 12 activities based on community participation, which shall include accounting mechanisms. Schedule 4 The Borrower shall ensure that funds generated from the sale 3 C NA NA Funds from this account supported activities of a number of NGOs: Safe pars. 13 of newsprint to he provided to the New Vision newspaper are Motherhood Initiative; Primary Health Care activities for the Uganda used to establish a health revolving account to support Council of Women; UWESO and the North Ankole Project Modalities for mother-and-child health care programs of NGOs through further work with NGOs are being developed under the District Health MOH. Services Pilot and Demonstration Project. cr CL  Table 10: Status of Legal Covenants contJ DCA I)eslripliun of Coveuant Covenint lPreseit i Originail Aclial Comiments IReferelice type status date date Schedule 4 In order to define the role and relationship of NGOs in 5,12 NC NA NA A mechanism for working with NGOs was not established and most of the para. 14 providing complementary support to MOI's health services activities were subsequently not carried out the Borrower shall: (i) conduct a national workshop with the assistance of a duly qualified expert; (ii) strengthen the coordination of activities of such organizations with MOH; (iii) provide finds for new initiatives of Ugandan NGOs, especially for development of women's groups. Covenant types: Present status: I = Accounts/audits 8 = Indigenous people C = covenant complied with 2 = Financial performance/revenue 9 = Monitoring, review, and reporting CD = complied with after delay generation from beneficiaries 10 = Project Implementation not covered CP = complied with partially 3 = Flow and utilization of project funds by categories 1-10 NC = Not Complied 4 = Counterpart funding 11= Sectoral or cross sectoral budgetary 5 = Management aspects of the or other resource allocation Project or executing agency 12 = Sectoral of cross-sectoral policy/ 6 = Environmental covenants regulatory/institutional action 7 = Involuntary resettlement 13 = Other o ms 8  36 Uganda PART II First Health Project Table 11 Table 11: Compliance with Operational Manual Statements Statement Commen th Number and Title OD 10.60 The Bank requires appropriate accounting policies to ensure accountability for all funds of the Accounting, borrower and submissions of audited financial statements for each fiscal year from the date agreed at Financial negotiations. Reporting, and Auditing Accounts have been maintained for the project. OD 13.10 The Bank requires Borrower compliance with audit reporting and details the scope of coverage by the Borrower audits. Compliance with Audit Audits were submitted for all the years though they tended to be delayed (submitted after the due Covenants date). OD 6.30 The Bank expects the Borrower to demonstrate commitment to the project by contributing 10% Local Cost minimum (net of taxes and duties) to the project. Financing and Cost Sharing The Borrower's contribution amounted to 6% percent of total project cost as compared to the projected level of 10% projected at appraisal. OD 13.25 The Bank allows, on an exceptional basis, some or all of the project savings to be used to fnance use of project additional project activities not included in the original project description, provided that Cost Savings implementation of the project is satisfactory (including substantial compliance with the Agreements), the activities proposed have high priority and are consistent with project objectives, and that they have been fully appraised by bank staff, and financing these activities does not violate country limits on cost sharing. The project realized some savings from activities not carried out under the health education component (purchase of radio transmitters) and reduced scope of civil works. The savings were used to finance additional rehabilitation at the Joint Clinical Research Center and Mulago hospital and to pilot policy reforms in preparation for the follow-on projects. OD 13.30 The Bank may approve for selected disbursements covering only part of a project to permit (a) Extension of implementation of some mutually agreed, high priority contracts; (b) the extension of the validity of closing dates letters of credit covered by a special commitment or (c) provision for retention payments, when the conditions for release (e.g. completion of performance tests or expiration of a warranty period) are met after the closing date. The Bank allowed 4 months after the project closing date for disbursements retention payments for a number of civil works contracts. OD 13.55 The borrower prepares and makes available to the Bank its own evaluation on the project's execution and initial operation, cost and benefits, the Bank's and borrower's performance of their respective ICR preparation obligations under the loan agreement, and the extent to which the purposes of the loan were achieved, adopts a plan for the operational phase of the project and assists the Bank in ICR preparation. The Ministry of Health prepared its own evaluation of the project's achievements (the summary of the report is attached to the ICR) and participated in the ICR preparation with the Bank team.  37 PART II Table 12 Uganda First Health Project Table 12: Bank Resources: Actual Staff Inputs 1/ S-'ag *,r l'rnjmcl Cycile ' Strff WeeLk Co%ts tirl'Irni'ec { iS'IDO Preparation to Appraisal 77.4 179.3 Negotiations through Board Approval 14.0 33.9 Supervision 154.5 421.9 Completion 2/ 6.1 31.0 Total 252.0 666.1 1/ Source: MIS - World Bank 2/ Resources for Completion are provided for the period upto January 1, 1997. Memo: The MIS shows planned resources data for only two years FY 1996 and FY 1997.  Uganda First Health Project Table 13: Bank Resources: Missions Stage of project Month/ Number Davs Specializtd staff skills Inplefnent D Develop- Types of rrohlems Cycle year of in field reprewenled -atinn nent e yr persons status 1lImip:oc _ Preparation to Appraisal 2/1988 14 21 Public Health Specialists, IEC Specialist, Operations Officers, Management Specialists, Architect Board to Effectiveness 9/1988 10 14 Public Health Specialists, IEC Specialists, Critical PIU staff not yet appointed. Work programs NGO Specialist, Architect, Management not developed. Delays in opening special account Specialist, Medical Equipment Expert and signing agreements with SIDA. Lack of I coordination among implementing agencies. Supervision 2-3/1989 4 12 Operations Officers, Public Health HS HS PIU still weak. Work programs not yet developed. Specialists, [EC Consultant, Architect, Project Coordination Committee not yet in place. ___ __ Management Specialist __w 11 00 Supervision 4/1990 7 Public Health Specialist, Economist, IEC HS HS Delays in plumbing and electrical works at Mulago. Specialist, Architect, Medical Equipment Delays in release of special account funds. ________ _______~ ~~ ExpertI Supervision 8/1990 4 5 Public Health Specialist, TEC Specialist, HS HS Delays in procurement of radio transmitters and in Architect, Operations Officer preparing the design for Rakai hospital. A number of health education items found not viable and dropped from project Supervision 2/1991 3 12 Public Health Specialist, Architect, HS HS Major problem - design of Rakai hospital found to be _ _______ ________ Operations Officer unacceptable and audits overdue. Supervision 9/1991 3 12 Public Health Specialist, Architect, US S Project management unsatisfactory, project Operations Officer coordinator to be replaced. Actions from previous mission not addressed. Audit report incomplete and qualified. TA not effectively used. - a-  Table 13. continued. Stage ofproject Month/ Number llays Speeialized staffskills linplement D)evelop- Tyles of lroblems Cycle year of in field represented -ation meet - . persons status Impact Supervision 3/1992 3 12 Public Health Specialist, Architect, S HS Major cost overruns on civil works as a result a Operations Officer, Management number of institutional houses at Mulago and for the Specialist PIU to be dropped. Supetvision 2-3, 1993 3 24 Public Health Specialist, Architect, US S Shortfall in counterpart funds. Need to reduce scope Operations Offtcer of work at Rakai and Mulago. Delay on Borrower action on radio transmitters. Supervision 4/1993 1 4 Public Health Specialist S S Rakai and Mulago civil works - scaling down. .____________________ ____________ Procurement of radio transmitters still unresolved. Supervision 6/1994 3 14 Public Health Specialist, Management S S Rakai and Mulago civil works - scaling down. Specialist, Implementation Specialist, Procurement of radio transmitters still unresolved. Supervision 2/1995 2 3 Projects Officer, Operations Officer S S Quality of construction at Buhozi clinic unsatisfactory - works scaled down, audits qualified, inadequate maintenance of rehabilitated facilities. Supervision 10/1995 5 10 Public Health Specialist, Architect, S S Procurement delays - Joint Clinical Research Center. Operations Officer, Management Qualified Audits. Earlier counterpart funding Specialist shortfall unlikely to be met. Supervision 2/1996 2 7 Architect, Operations Officer S HS Counterpart funds backlog not settled. Some audit qualifications not yet addressed. Some civil works on Rakai and JCRC not yet completed. Completion 8/1996 5 4 Operations Officer, Clinical Specialist, S S Project activities completed. Architect - - - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~  40 APPENDIXA Page 1 of 9 UGANDA FIRST HEALTH PROJECT IMPLEMENTA TION COMPLETION REPOR T MISSION AIDE-MEMOIRE AUGUST23, 1996 1. An IDA team visited Uganda, August 12-23, 1996, to prepare the Implementation Completion Report (ICR) for the First Health Project. The team comprised Ms. Mary Mulusa (Task Team Leader); Ms. Beatrice Helbling (Operations Officer); Ms. Harriet Nannyonjo (Operations Officer); Mr. Frederick Walker (Consultant Architect) and Dr. Kenneth Grant (ODA Consultant). The ICR is based on a review of project documents and reports; discussions with implementing agencies; and visits to rehabilitated health facilities. We were unable to visit all rehabilitated facilities as they are widely dispersed geographically. However, almost all the facilities have been visited by previous World Bank supervision missions. 2. This aide-memoire summarizes the team's findings: 3. We would like to congratulate the Ministry of Health for preparing a Project Completion Report that represents the Government's own evaluation of the project. Our work was greatly facilitated by this report. Ministry of Health staff and NGOs met during the field visits and keenly discussed the achievements and shortcomings of the project. They offered suggestions for improving health sector projects. 4. The team also met with the Honorable Dr. Crispus Kiyonga, Minister for Health. He summarized the achievements of the First Health Project and commended his staff for preparing a thorough evaluation of the project. The Minister raised a number of critical issues which need to be addressed in the health sector. He acknowledged that the project has supported substantial physical improvements at the Mulago hospital, at eight district hospitals and at forty health centers. However, he pointed out that the project has only scratched the surface as many more health facilities remain in deplorable condition. There is need for rehabilitation of more hospitals and health centers, to bring the facilities to an appropriate and acceptable standard. This is especially critical for reviving the referral system and making it operate effectively. 5. The Minister restated the Government's commitment to: (a) increasing resources to the Health Sector (including exploring alternative sources of financing such as user fees and health insurance schemes); (b) increasing resources to preventive and promotive health programs with particular attention to health education; (c) strengthening collaboration with other health providers such as NGOs (e.g. by seconding Government staff to NGO health units); (d) building capacity for improved resource allocation based on work plans at both central and district levels; (e) strengthening decentralization of health service provision to the districts. Evidently, the time has come for the Government to consider a sector-wide approach to health sector investment. It was agreed that the  41 APPENDIX A Page 2 of 9 MOH should develop a longer term strategy (e.g. through the five-year plan) for the sector which can be used as a basis for preparing a sector-wide program for support by donors. The World Bank is prepared to provide the necessary technical support. Achievement of Objectives 6. The main objectives of the project were to carry out urgent physical rehabilitation of selected health care facilities; construct a hospital in Rakai district; strengthen preventive health programs; and, improve the internal efficiency and long-term effectiveness of health care delivery. To achieve these objectives the project provided funds to: (a) rehabilitate key areas of Mulago Hospital, re-equip the Blood Transfusion Center, rehabilitate eight district hospitals and thirty rural health centers and construct a hospital in Rakai district; (b) promote health status by creating awareness through health education programs for all levels of the population, develop a community-based distribution system for drugs and supplies and develop a program for counseling and patient management for people infected with AIDS; (c) strengthen the Health Planning Unit, the management capability in the MOH, hospitals and rural health facilities and develop alternative ways of ensuring adequate financing of the health sector. 7. Overall, project objectives were substantially achieved. The project was implemented within the original schedule and it closed on March 31, 1996. An additional period of four months was allowed by IDA to accommodate final payments. Details of achievements of each project component are as follows: 8. Physical Rehabilitation and equipment of Health facilities. Objectives of this component were substantially achieved. All the civil works were completed by March 31, 1996. Rehabilitation included: key areas of Mulago hospital (elevators, kitchen, laundry, Central Sterile Supplies Department, workshops and living quarters) eight district hospitals, forty health centers and critical extensions to the Joint Clinical Research Center. At the time of project appraisal, information on the status of the selected facilities was inadequate and adjustments had to be made to the scope of works of a number of the facilities as implementation proceeded. In addition, other agencies took over a number of the activities. At Mulago Hospital, the African Development Bank rehabilitated some of the areas originally included in the IDA project. Three health centers were rehabilitated by AMREF, World Vision and German Volunteer Service. The most significant change in the civil works was the rehabilitation of five health centers and a District Medical Office in Rakai instead of the construction of a new 1 00-bed district hospital. This decision was based on the findings of the "Health Personnel Study" that highlighted the need for health facilities to be based on anticipated demand rather than arbitrarily set standards for districts. On the whole, the quality of civil works was satisfactory. The Austrian Government provided equipment through a grant of US$ 10 million. The rest of the equipment was provided under the credit. The rehabilitation and equipment gave a major face-lift to the selected facilities and reinstated capacity that had  42 APPENDIXA Page 3 of 9 fallen out of use over a long period.1 The credit also successfully provided drugs and supplies and supported training of hospital maintenance workers. All this has contributed to enhanced health services. Apart from problems discussed above, the project experienced delays during the construction period and a number of contracts had to be extended (see Annex 1). This was largely due to complicated inter-governmental clearance procedures and a weak Project Implementation Unit (PIU). These problems were gradually overcome with the strengthening of the PIU and improved communications between different government agencies. 9. Health Education and Community Activities. A number of the planned activities for this component were implemented. The "New Vision" that had the widest circulation was supported through subsidized newsprint to increase its circulation. The paper has continued to carry health messages regularly. Support was provided to "Munno" a local language newspaper that carried messages for a while before it closed down due to financial problems. Four mobile cinema vans were purchased to strengthen regional health education activities. Regions, districts and the army were also provided with equipment and training materials. Training for journalists and health education officers in newspaper, radio and television techniques was carried out. Support to development of radio programs was provided through the establishment of a liaison office in the Ministry of Information and Broadcasting. Health messages for AIDS prevention were developed. However, a number of innovative ideas (comic books, school exercise books, public transport stickers and posters and lottery tickets) for carrying health messages were not implemented because of an inability to resolve procurement and administrative problems. Some of these activities were later picked up by other donors and NGOs whose procedures were less cumbersome. Equipment to boost transmission by public radio stations was not purchased due to failure to define requirements and carry out the procurement. The community-based drugs distribution program which included renovation of the Central Medical Stores (CMS) was not carried out. DANIDA later rehabilitated the CMS as part of its assistance to the essential drugs program. It is extremely difficult to assess the impact of this component since a number of the activities were not carried out. A Knowledge, Attitude and Practices study carried out in three pilot districts in the early years of the project was not repeated as recommended in the mid- term review. However, a positive outcome of this component is that it provided an impetus for support of health education activities by other agencies. In a number of cases it proved easier for the Health Education Unit to deliver planned activities with funding from other donor programs instead of the First Health Project. Overall, the objectives of the component were partially achieved. 10. Strengthening the delivery of health care. Objectives for strengthening the delivery of health care were substantially achieved. Planning, monitoring and evaluation in the MOH was strengthened through technical assistance and training. With support For example, the Mulago hospital hostels for students are now operating at full capacity as compared to between 30-40% capacity before the rehabilitation.  43 APPENDIXA Page 4 of 9 from the project, the Planning Unit developed the health sector policy, the "White Paper" in 1993 and the Three-Year Health Plan (1993/94). Through decentralization, the Government policy on management of health services has changed from a top-down approach to one of delegating responsibility for planning and service delivery to districts. With guidance of the Planning Unit, the districts are now in their second year of producing annual health work plans as a basis for resource allocation. Districts have also been supported in developing capacity for implementation and financial accounting. Management of health services delivery has been enhanced with the establishment of management committees for hospitals and health centers. These committees which include representatives of health services, the local administration and community leaders, are responsible for administration and financial management including resource generation. The project has supported the development of a Quality Assurance Unit responsible for overseeing the quality of the decentralized health services. A start has been made on development of a health information system but this is still a long way from generating information for use by managers to improve health services. Development of health care financing alternatives has fallen below expectations (see below). Activities involving NGOs (except support to Safe Motherhood Initiatives, physical rehabilitation and equipment) were not carried out as modalities for working with NGOs were not fully developed. 11. Achievement of Financial objectives: Financial objectives have been partially achieved. Annual budget frames have been introduced as part of the annual planning process. These allow the MOH to monitor trends in health expenditure. The planning unit now produces reports of trends in health expenditures which show the break-down between primary care and hospital care. Total Government expenditure on health has risen from 19.5 billion shillings in 1992/3 to 44.7 billion shillings in 1995/6. Expenditure on primary health care has risen from 25% to 32% while that spent on hospitals has declined from 70% to 58% during the same period. The proportion spent on management has risen from 5% to 10%. Donor funding still accounts for the most significant share (72% in 1995/96) of primary health care spending. Progress on developing alternative schemes for health care financing has fallen far below expectations. This was almost certainly due to the very real political difficulties in introducing user charges in a situation in which the Government has traditionally guaranteed free medical treatment financed through the central budget. Delegation of management and financial responsibility to districts has led to some progress in developing alternative financing mechanisms, notably cost sharing through user charges. This is still in its early stages but the ground work has been laid and support is continuing through the District Health Services Pilot and Demonstration Project (DHSP). Many hospitals and health units are raising up to 10% of their non-staff budget through cost sharing and funds are retained at the local level. No other financing mechanisms were considered under the First Health Project, but local health insurance schemes are being piloted under the DHSP. 12. Institutional development. Objectives for institutional development have been substantially achieved. Two key units assisting the decentralization process have been strengthened. As mentioned above, the project has supported capacity building of the  44 APPENDIX.A Page 5 of 9 MOH Planning Unit. The unit is providing guidance to districts in planning, implementation and financial management as well as monitoring and evaluation. In addition, a Quality Assurance unit has been established to oversee the technical aspects of health service delivery. This unit in particular, plays a critical role in coordinating and monitoring the different processes of decentralization at the district level. The establishment of management committees for each health facility has contributed to enhancing local involvement in planning and management of health services and has been a major contribution to the development of cost sharing. 13. Poverty reduction objectives. This project was not specifically designed as a poverty reduction intervention. However, because the poor live predominantly in rural areas, the rehabilitation of hospitals and health centers in rural areas has significantly increased access of the poor to quality health services. In Kampala where the only alternative hospitals are managed by NGOs charging full cost recovery, the refurbishment of Mulago has provided access to good quality services to the urban poor as has the rehabilitation of Naguru, Kiswa and Kisenyi health centers. 14. Implementation Record. This project responded to an emergency in post-war Uganda and was therefore prepared in less time than is normally allocated for preparation of this type of project. Disbursement data show that after a start-up delay of six months, the project picked up and most activities were completed by the project closing date of March 31, 1996. An amount of US$ 41.9 million dollars was disbursed out of the IDA credit of US$ 42.5 million2. However the appreciation of the SDR against the dollar will result in a balance of $ 2.5 million to be canceled. The SIDA grant of US$ 6.5 million and the Austrian grant of US$ 10 million were fully disbursed. The disbursement record is commendable given the difficulties encountered in the course of implementing the project. Difficulties experienced at the beginning of the project are largely due to the fact that very little time was devoted to preparing implementing agencies for the task ahead. There was no implementation manual prepared and no project launch workshop was held. 15. Counterpart funds. The project suffered major setbacks due to shortage of counterpart funds. Counterpart funds amounted to only US$ 3.5 million instead of the planned US$ 6.5 million. This resulted in a Government contribution of 6% of total project costs instead of the planned 10%. In the early part of project implementation, release of funds from the Treasury was often delayed and the amounts were below budgeted levels. This led to significant shortfalls in those expenditure categories that depended heavily on counterpart funds (in-country workshops and seminars, incremental operating costs of the PIU and key departments of the MOH: planning and health education). We do acknowledge that shortage of counterpart funds was common to all 2 The original credit amount was US$ 52.5 million. The Governrment received an Austrian grant of US$ 10 million and as a consequence the IDA credit was scaled down by the same amount.  45 APPENDIXA Page 6 of 9 IDA/GOU projects. Despite these problems, the First Health Project has one of the best disbursement records for projects in Uganda. 16. Audits. A number of qualifications in the audits of the project remained unresolved for a long time. Most of these were resolved with the exception of Buhozi clinic which was completed much later than envisaged. IDA awaits the final report on the clinic in view of this qualification which was under investigation by the Government. 17. Efficiency, Effectiveness and Sustainability. At Mulago hospital, there is evidence of an increase in workload of most departments over the last four years (from 66,101 admissions in 1992 to 72,105 in 1995). The rehabilitation program has contributed to this increase as Mulago provides much better services than other facilities in Kampala. However, the hospital is still plagued with serious shortages of drugs and supplies and funds for maintenance activities (preventive in particular) are insufficient. It will become increasingly difficult for the central government to provide adequately for the hospital while reallocating more funds from secondary and tertiary level facilities to primary health care. To address this issue, the Government commissioned a study on ways to make the hospital autonomous. The study was funded by ODA and it has made the recommendations summarized below: a) Roles of Mulago and the Kampala City Council in health services provision should be urgently defined; b) KCC should strengthen its services at district and health center level; c) KCC should explore the possibility of commissioning more secondary care from mission hospitals; d) Discussions should also cover the possibility of KCC compensating Mulago under a service agreement, for the primary care services carried out at Mulago; e) An independent management board (with powers to hire and fire its own staff and raise revenues including setting appropriate fee levels) should be considered for Mulago hospital; f) The training schools for nurses and paramedical staff should be separated from Mulago Hospital and placed under separate management; g) There should be a Memorandum of Understanding between Mulago and the University setting out responsibilities and financial obligations for each institution; h) Mulago should further develop its outreach services.  46 APPEND1X A Page 7 of 9 18. The Government is committed to implement the necessary changes and it is proposed that Mulago hospital will be autonomous by the 1998/9 financial year. This move will pave the way for addressing long-term sustainability for Mulago. 19. The rehabilitated hospitals and health centers have experienced increased activity when compared with similar facilities which have not been rehabilitated. The improved physical environment has contributed positively to staff morale and made it possible to recruit and retain more staff. Experience has shown that the face-lift of rehabilitated facilities restores confidence of users and enhances the ability to raise revenues through user fees. This will increase the financial sustainability of the hospitals and clinics in the long run. In the meantime, many facilities are setting aside a portion of the cost sharing revenue usually in the order of 20% for maintenance. However, these funds are not adequate to meet the maintenance needs of the facilities. Efforts are still needed to provide more funds for maintenance. As mentioned earlier, the districts now have the mandate for resource mobilization and allocation and are exercising it with varying degrees of success. The Government should continue to assist them in strengthening this capacity. The support of the Quality Assurance and Planning units is expected to contribute to a more efficient and effective service delivery system. Borrower performance 20. The Government was highly committed to implementation of the project but the project suffered setbacks in the first two years of implementation. The staff in the PIU were relatively inexperienced and had no prior knowledge of World Bank procedures. In addition, since the capacity building and implementation of the project was largely concentrated in the PIU, ownership was confined to the PIU. This created a problem for collaboration with other departments and accounted for the fact that some departments (Health Education in particular) were not aware of their responsibility in the implementation process nor could they get through the "red tape". As a result, a number of activities were either not carried out or financed by other donors. Covenant compliance was only partially satisfactory, the most significant weakness being consistent delays and qualifications in audit reports. Counterpart funds were inadequate and often delayed. There were also delays in procurement of goods and services and weak contract administration. The MOH recognized these problems and made efforts to address them. More qualified and competent staff were hired for the PIU. Technical assistance was brought in to strengthen the PIU and the MOH, and staff were trained in World Bank procurement, financial and disbursement procedures. Efforts were also made to enhance coordination among implementing departments in the MOH and other ministries. These actions greatly contributed to speeding up implementation. Bank Performance 21. The 1988 Staff Appraisal Report provides a fairly thorough analysis of the health sector given the limited data available at the time. Three main risks were identified: (a)  APPENDIXA Page 8 of 9 lack of implementation capacity in MOH 3(b) uncertainty over the feasibility of developing alternate methods of financing; and (c) lack of motivation at all levels of the civil service mainly due to low levels of remuneration. With the benefit of hindsight, the accuracy of these risks can be confirmed. In addition, costing and timing of such a large project was a challenge given limitations in data availability. This meant that changes in design, modifications in objectives and timing were to be expected. Nonetheless, the project could have benefited from more World Bank staff supervision time. This would have enabled corrective actions to be taken more regularly instead of awaiting the major mid-course restructuring. Given the magnitude of civil works and the inherent problem of insufficient maintenance funds, far greater emphasis should have been placed on enhancing the administrative and financial ability of the MOH to sustain the rehabilitation efforts. It is therefore hoped the following projects (Sexually Transmitted Infections project and the DHSP project) will address some of the shortcomings of the First Health Project. Key Lessons Learned 21. Lessons learned from the project are: a) More effort is required in assessing likely counterpart funding and recurTent support to proposed investment. b) The implementation experience demonstrates the value of capacity building for institutional strengthening. c) There should be greater involvement of all MOH departments, other ministries, NGOs and to the extent possible the private sector in project design. This helps to build ownership among all agencies implementing project activities. Each implementing body should be aware of its responsibilities. The selection procedures and contractual agreements with NGOs and other implementing agencies should also be worked out before implementation starts. d) Clear guidelines on project implementation procedures (including procurement and disbursement) are crucial. Procurement plans should be drawn up during appraisal. e) Project design should allow for a substantial degree of flexibility. The health sector is fairly volatile not just in terms of the disease burden e.g. the AIDS epidemic, but also in terms of the policy environment such as the recent decision to Mainly due to under-staffing and serious financial and managerial problems.  48 APPENDIX A Page 9 of 9 decentralize provision of services. The tasks facing it cannot always be predicted years ahead and major projects must be responsive to changing priorities. f) With the increasing needs in the sector, it is timely to shift from narrowly defined projects to a sector wide program approach with an appropriate financing plan that takes into account both investment and recurrent expenditures. append-a doc/c/fr  49 Annex 1 IMPLEMENTA TION COMPLETION REPORT MISSION UGANDA FIRSTHEALTH PROJECT (CR. NO. 1934-UG) 18-25 AUGUST, 1996 CIVIL WORKS COMPONENT Site Visits: Masindi District Hospital and 4 Health Centers (08/19/96): Contractor: Messrs. Concorp International Consultant: Messrs. C & Q Associates Tender Price: US$ 2,049,790 Final Price: US$ 2,191,673 Consultant Fee: US$ 109,206 Start on Site: April, 1991 Completion: September, 1992 1. The contract included some new construction and rehabilitation of existing structures. The site is fenced and located in the center of Masindi Town with plenty of space for future development. Individual buildings for each activity are spread over the site and include: national medical equipment office, private patient ward (4 beds), new X ray building, 20 bed maternity ward (200 visits and 5 deliveries per day), 26 bed pediatric ward, operating theater, MCH (100 per day)/ante-natal (150 per day)/FP clinic (20 per day), 46 bed general ward, mortuary, new central kitchen, outpatients (30-40 per day), night duty house, tailoring, 6 bed isolation ward, medical stores, physiotherapy, administration and 8 staff houses and 19 staff quarters. 2. Water from a borehole to the storage tank is available on site, mains electrical power can be intermittent. A new generator is on site but there are insufficient funds to install this at present. The hospital has only one old vehicle and new ones are urgently required. In general the hospital is well equipped, however, new delivery tables were defective, no incubators were available, some sterilizers were not operating, and some beds were broken and unrepaired. 3. Major defects included: no ceiling to the male general ward as this had been eaten by termites, evidence of termite penetration in most areas of the hospital, floor cracking and crazing evident in most blocks, some doors rotten and eaten away, and paint of corrugated iron roofing sheets had worn away. The overall appearance of buildings was good and there were no signs of severe deterioration, however, the buildings have  50 received no maintenance since September 1992 and it is advised that some areas will need a coat of paint over the next year. 4. The hospital prepares a quarterly budget which goes to the District for approval. This budget is shared with Kirandongo Hospital on a 3/5 to 2/5 split basis. The total budget request for the last quarter was Ush. 340 million or Ush. 204 million for Masindi alone. Requests for maintenance funds are regularly included, however, the budget is substantially cut at District level and no essential maintenance is carried out. 5. Comment: The District Administrative Secretary must be advised that the hospital should receive a regular and sufficient supply offunds to undertake essential maintenance and repairs. The current problems occurring with termite penetration will escalate and severe deterioration to structures will occur causing the hospital to slip back to its broken-down state as at the time of appraisal. The preliminary eradication of termites would cost only US$ 2, 000, which is a very small amount when considering the damage that the termites will exact over the next twelve months. Pakanyi Health Center (08/19/96): 6. Situated 10 kilometers from Masindi on the Masindi-Gulu road. Well located fenced site at side of road with area for future expansion. New buildings consist of a health center which includes store, injection room, consulting/treatment room, dispensary, 4 bed general ward, and delivery/maternity room. Other buildings include a covered waiting shed, patient lavatories, placenta pit, 2 new staff quarters and another quarter located in the old clinic building are also available. Solar power provides electricity and water is available from a nearby borehole and 2 rain water storage tanks. 7. The Health Center receives approximately 30 patients a day and undertakes 3-5 deliveries per week. The center is staffed with 4 nurses/midwives who receive their salaries direct from the DMO's office. The center also receives Ush. 187,000 every quarter as operating costs. 8. Comment: The buildings were in good condition despite having had no maintenance since their completion in 1992. Some minor defects ofpaint deterioration to walls and the roof were apparent, however, buildings generally were very sound and well constructed. Joint Clinical Research Center (JCRC) (08/20/96) Contractor: Messrs. Roko Construction Consultant: Messrs. Norman and Dawbarn/Plan Systems Tender Price: US$ 698,000 Final Price: US$ 823,236 Consultant Fee: US$ 114,888 Start on Site: October, 1995 2  51 Completion: 30 August, 1996 9. The JCRC buildings are 99% complete. Both the General Ward block and Outpatients are complete, however, some putty glazing still needs to harden, some site clearance and cleaning is required, contractors huts need to be removed from site, and the car parking area needs final compacting and applying with tarmac. The General Ward includes: 2x8 bed wards, 2 sluice, 4 patient lavatory areas, 2 assisted baths, cleaners room, nurse station and store, store, staff lavatory and counseling room. Outpatients include: waiting room, reception/records, registration/records, tea kitchen, dispensary, patient lavatories, x-ray, dark room, 3 counseling rooms, staff lavatories, casualty room, treatment, sluice, blood sampling room, lecture room, and 3 consulting rooms. 10. The buildings are constructed with concrete block plastered walls, IT4 corrugated roof sheeting and granolithic floor finishes are very well constructed and finished. Outstanding works, including painting putty glazing and finishing the car park are advised for final completion by August 30,1996, ready for hand-over to JCRC. A final payment request of US$ 196,000 is with IDA and still requires settlement. MOH have received a retention bond from the main contractor covering the amount to be settled during the six months maintenance period. 11. Comment: The quality of workmanship is very good, however, it would seem that the buildings will remain unusedfor some time as equipment andfurniture have still to be purchased. It is a matter of concern that equipment is notyet available when this contract has been running for nearly one year. Mulago Hospital (08/20/96): Kitchen, Laundry and Living Quarters Contractor: Messrs. Spencon Services (Quarters) & Messrs. Roko Construction Consultant: Messrs. Gauff Consulting Engineers Tender Price: US$ 3,681,805 Final Price: US$ 3,681,805 Consultant Fee: US$ 900,787 Start on Site: 13 October, 1993 Completion: 28 February, 1995 Nakasero Nurses Quarters (10 units plus 2 staff quarters) 12. Buildings occupied in May, 1995. Minor defects apparent, however, quality of workmanship satisfactory. Student Nurses and Trained Nurses Hostels and Doctors Mess 13. Buildings occupied in March, 1995. Each building shows great improvement in quality of workmanship. The inspection revealed that the buildings were still in sound condition except for some minor defects such as: hand wash basins coming away from 3  52 wall, some power points blanked off and defective, external paint defects from pipe leakage, leak in laundry ducting, flushing handles to lavatories missing, electrical systems unsafe in one area, and some floor cracking apparent. Of concern is the lack of kitchen equipment in the main hostel kitchen area. The MOH needs to address this without further delay. Also, sani-bins need replacing in nurse lavatories. The warden stated that maintenance was carried out by workshop staff on either personal request or the submission of a service requisition form, however, some delays could be experienced in getting these requests solved. The mission was advised that Mulago receives a yearly allocation for maintenance of Ush. 800 million. Doctors Quarters (72) 14. Occupied mid-1995. Some buildings are now showing external paint defects and the access road to this area is very bad. However, construction and finishes still remain satisfactory. Laundry 15. Area generally satisfactory. Steam leakage to pipes require repair, this had been reported to the maintenance workshop but action is yet to be taken. Further leakage also continues to occur from overhead main feeder pipes. Bottom of machines going rusty and these need raising above ground level on pads. A leak was apparent on the roller press and one Universal Press needs correction as its automatic lifting above the working level was too fierce. Hospital needs to investigate the possibility of a regular servicing contract. Kitchen 16. Area generally satisfactory. Extractor hood over cooking equipment defective resulting in bad staining and fungus growing on ceilings. Fan extract needs increasing and extent of canopy needs enlarging. Mulago: Medical Equipment Workshop Contractor: Messrs. Concorp International Consultant: Envirotec Consult Tender Price: US$ 216,421 Final Price: US$ 216,421 Consultant Fee: 106,180 Start on Site: September, 1993 Completion: August, 1994 17. Area generally satisfactory, however, central courtyard appears to be dumping site for broken beds. 4  53 The mission was advised that the bio-medical equipment maintenance checking system has now been expanded to include some building maintenance items and that a services requisition form exists for the use of departments for reporting defects. Regular servicing contracts exist for lifts and x-ray equipment. Major maintenance works which cannot be carried out by the workshop are contracted out directly by the hospital. Rakai District Health Centers - Rakai, Mutukula, Lyantonde, Kachera and Kalisizo DMO Office Contractor: Messrs. Concorp International Consultant: Messrs. Sentoogo & Partners Tender Price: US$ 2,800,000 Final Price: US$ 3,149,061 Consultant Fee: US$ 153,644 Start on Site: April. 1995 Completion: 31 March, 1996 Rakai Health Center (08/21/96) 18. Works include: Outpatients Deparent: Waiting, examination, dressing, injection, 2 medical assistant rooms, doctors office, pharmacy, store, and registration. MCH and Ante Natal: 2 waiting rooms, ante natal room, vaccination, examination, counseling, x-ray, laboratory, dental clinic, and store. Operating Theater: Anesthetic, recovery ward, major operating theater (a/c provided), scrub up, 2 sluice, sterilization and preparation area, 2 sterile stores, minor operating theater, 2 staff changing, doctors office, store, and day ward. Mateity/Delivery: waiting, assisted bath, examination, linen store, duty room, premature babies room, sluice, 2 delivery rooms, and shower area. Matemity Ward: 2x8 bed wards, 2 nurse stations, 2 examination rooms, sluice, linen store and outside bathrooms. Male and Pediatric Wards: 2x8 bed wards, 2 nurse station, 2 examination rooms, sluice, linen store and outside bathrooms. Kitchen Shed. 6 Staff Quarters with separate ablution blocks and kitchens. Generator House. 19. Water is not yet available on site but piping and storage tanks are installed and ready for connection to the DANIDA water scheme, which is expected to be completed later this year. Electricity is also to be supplied later this year. Water is currently being obtained from rain water storage tanks at each of the buildings. The site to the main hospital buildings is fenced and the area is well landscaped with flowering shrubs, grassed areas and small trees. The state of construction of the buildings is good with no visible signs of deterioration and cracking. 20. Currently there are few staff on site, they include: I dental surgeon, 1 medical assistant, 1 registered nurse, 1 enrolled mid-wife, 1 enrolled nurse, 4 nursing aides, 1 dental assistant and 2 watchmen. Daily through put to the outpatients is 20-25. An ample supply of essential drugs was reported. The clinic has received equipment, much of which was still in their original boxes. X-ray equipment was available but a 3  54 radiographer and technician had still to be posted. The dental clinic was only able to do extracts and the dental chair had no gas, compressed air or water attachments. 21. Comment: The new clinic is currently underutilized and understaffed People in the District refer to this unit as the 'Rakai Hospital' and it is the intention of the DMO and District personnel to run it as such. However, the District does not have the funds to undertake this and discussions have taken place with local government and MOHfor the necessary funds to be providedfrom the central government budget. The mission was assured at the final meeting with MOH on 23 August 1996 that the Government was taking up the matter offunding and staffing the Health Center and that the unit would be fully operational in the very near future. DMOs Office 22. The DMOs office block was substantially completed and handed over in November 1995. The building includes offices for the district medical officer, district health visitor, district health inspector, education officer, TB and leprosy officer, assistant inspector of drugs, records and a store and office for drug distribution to the district. The site also includes a 26,000 liter rainwater storage tank, solar pump and generator house. The overall standard of construction was satisfactory and the contractor was on site taking care of the final defects and repairs under the six months maintenance period. Kalisizo Health Center 23. The contract included the addition and rehabilitation of an Outpatient Block, MCH Unit, Operating Theater, Administration, Generator, Incinerator, 20,000 liter Water Tank and an Ablution Block. Mains water and electricity are available. The buildings were handed over to the DMO on January 31, 1996 and were equipped and occupied in March 1996. The main contractor was currently on site repairing minor defects under the maintenance contract. The overall standard of construction was of an acceptable standard. 24. Kalisizo is a 45-50 bed hospital which is currently running at 220% capacity with over 100 in-patient residents in the buildings (80% of them have AIDs). The new administration block has yet to be used as an office and is currently occupied by approximately 30 pediatric patients because of the acute overcrowding elsewhere. Staff include: 2 medical officers, 1 nursing officer, 4 enrolled mid-wives, 8 enrolled nurses, 1 dental assistant, 1 dental surgeon, 1 laboratory assistant and 1 attendant, 12 nursing aides, 1 electrician, 4 watchmen, 1 mortuary attendant, 1 pharmacist, 1 anesthetic, 1 secretary and 1 driver. The hospital is fully equipped except for an x-ray machine, it also has 1 new vehicle. 25. Comment: Many of the new and rehabilitated buildings have still to become fully occupied and operationaL Assurances were given that this would be a gradual process and that within the next three months all buildings would be fully utilized and effective.  55 Remedy for Correcting the Maintenance Problems Evident in all Buildings 26. It is apparent from the visits to the completed buildings, except Mulago, that little or no maintenance is being carried out at any facility. This being due to a number of factors which include: lack of funds at the districts, lack of understanding by hospital staff to remedy defects arising, inability of hospital administrators to push hard for the necessary funds, and no regular inspection of premises to identify problems and deal with them in a timely manner. At Mulago, it was also apparent that hostel wardens and service department heads need some instruction on how maintenance needs can be assured. The MOH are advised that this situation needs to be corrected immediately and that districts need to be advised of the urgency for this. 27. It is recommended that a workshop be held to raise awareness of the maintenance problem. It should be attended by district hospital medical superintendents, DMOs, administrators and a representative from the districts; unit heads from Mulago could also be included. The workshop would focus on: what to look for, carrying out regular maintenance inspections on buildings and equipment, record-keeping and preparation of report forms, access to remedies (hospital handyman, equipment workshop or local tendering), awareness of procedures for applying for maintenance funds, how to carry out the physical inspection of a building and equipment where no maintenance has occurred, and how to advise hospital staff to report when defects become apparent. Resident Mission - Uganda A:DOC2.DOC 08/23/96 4:06 PM 7  56 APPENDIX B PrQiect Completion Report - First Health Project (Cr. 1924-UG) Summary Page I IMPLEMENTATION COMPLETION REPORT GOVERNMENT OF UGANDA FIRST HEALTH PROJECT - IDA CREDIT 1934-UG Project Implementation - Executive Summary Preamble This is a summary of the Implementation Completion Report for the First Health Project, IDA Credit number 1934-UG. The full report finalized on 9th August, 1996, has appended to it, the full cost tables and other details of implementation. Background and Project Description 1.0 Political turmoil through two decades till the mid-80's left most of Uganda's health infrastructure in a state of disrepair. Rising death rates, break-down of the health system, resurgence of infectious diseases previously under control (such as measles and malaria), rapidly growing AIDS epidemic - all amounted to a health crisis in Uganda. The First Health Project responded to meet the needs of minimal rehabilitation as an emergency post-war intervention and to pave the way for future sector operations. The project objectives were: 1.1 Physical rehabilitation of selected health care facilities to make them operational and to build a hospital in Rakai district. 1.2 Strengthening preventive health programs. 1.3. Improving the internal efficiency and effectiveness of health care delivery. 2.0 The project, in three parts, aimed: 2.1. To rehabilitate and construct health facilities (in Part A) by: 2.1.1 Rehabilitation of key areas of Mulago Teaching Hospital through re-establishment of the water supply and installation and refurbishment of the sewage system; rehabilitation of hospital elevators and living quarters of health staff; renovation and equipping of hospital kitchens and the central sterile supplies department; construction and equipping of a new electrical and mechanical workshop for the hospital; construction of security fencing and repair of roads and paving within the hospital; supply of drugs and consumable supplies; and training of hospital maintenance workers.  57 APPENDIX B PrQiect Completion Report - First Health Project (Cr. 1934-UG) Summarv Page 2 2.1.2 Rehabilitation of the Blood Transfusion Center in Kampala, including the acquisition of blood typing and screening equipment, cold storage facilities and vehicles. 2.1.3. Rehabilitation of the essential services of eight district hospitals, including the acquisition of equipment and the refurbishing of water supply and sewage systems. 2.1.4 Rehabilitation of thirty rural health centers and the acquisition of equipment and vehicles. 2.1.5. Construction of a new hospital of about 100 beds in Rakai district including the acquisition of equipment and supplies. 2.2. To promote, (in Part B), health awareness through health education programs by increasing use of the mass media, training of journalists and health education officers in newspaper, radio and television techniques; production of health education materials for use by National Resistance Army (NRA); acquisition of program support equipment for Health Education Division; construction of lean-to-shelters; studies; Community activities by developing a community-based program for distribution of drugs and supplies, including condoms; a program of counseling and patient management to AIDS-infected patients, including assistance to their families, and a health and hygiene education program. 2.3. To improve (in Part C), the delivery of health care by strengthening: the planning unit and management capacity of the MOH; hospitals and rural health facilities through management training; the financial performance of the system through improved planning and budgeting and alternative schemes for financing health services including cost sharing with beneficiaries; support for programs of Non-Governmental Organizations; project management; and, preparation of a follow-on project. 3. The Development Credit Agreement was amended on 13th October, 1994, restructuring the project in order to: avoid duplications with other programs, adjust for cost overruns in civil works and to allow for follow-on projects by: 3.1 Excluding from the project objectives: (i) The construction of security fencing and repairing of roads and paving at Mulago hospital. (ii) The construction of a hospital in the Rakai district. (iii) The construction of lean-to-shelters; and community activities in the second component of part B of the project.  58 APPEND1X2B Project Completion Report - First Health Pro]ect (Cr. 1934-UG) Summarv Page 3 3.2 Included among the project objectives were: (i) Rehabilitation of selected health centers in the Rakai district, including the acquisition of equipment and supplies. (ii) Development and piloting of policy reforms in selected districts. 4. Most of the project activities were completed by December, 1993. On July 31, 1996, expenditure figures in US$ million were: Source Amount of Credit World Bank US $ 40.48 out of 42.5. Due to change in SDR a balance of US$ 2.5 million may be canceled. The absorption rate will be 95%. SIDA US$ 6.5 million was fully disbursed. Austria US$ 10 million was fully disbursed. GOU US$ 3.5 million as against a commitment of US$ 6.5 million (54%). 5. The project was simple in design, 67% of which was for procurement of civil works, equipment, material and supplies. It was well within the capacity of MOH to implement with some external technical assistance. The Government of Uganda (GOU) was modest in its request for assistance; IDA was responsive to the urgency of the situation and to adjusting the project to changing circumstances during implementation. 6. The following sector policy objectives were achieved: (i) Preparation of a national health plan which included actions for the implementation of reforms involving the organization and management of the health system (DCA article III, sections 3,03). (ii) Proposing a referral system while rationalizing staff distribution (DCA article III, section 3.04). (iii) Specific management studies were undertaken to guide development plans (SAR part I para. 1.46). 7. The financial objective was achieved in the civil works component. The cost overruns on civil works contracts were largely within expected limits. A revolving fund using counterpart shillings from the sale of newsprint to "New Vision" supported NGO activities with a focus on maternal and child health programs. The institutional  59 APPEND1X B Project Completion Report - First Health Prolect (Cr. 1934-UG) Summary Page 4 development objective was achieved by increasing the number of staff trained in preventive orientation to health care and upgrading the professional capacity of staff. A health education division for Information, Education and Communication (IEC) was established, complete with a set of health educators to support districts. 8. Major Factors Affecting the Project. The project was implemented during a period when Uganda was embarking upon a recovery process following two decades of civil strife. Economic performance of the country had deteriorated significantly. In addition, the country was faced with the 1987/88 drop in coffee prices, this had a negative impact on Government revenues as taxes on coffee exports dropped from 4.6% of GDP in 1985/86 to only 0.1% of GDP in 1991/92. Government revenues increased slowly during this period from 5.7% of GDP in 1987/88 to 8.2% of GDP in 1993/94. These factors were largely out of the control of the Government and had adverse impacts on counterpart funding for the project. Counterpart funds were often inadequate and were released late. With a low overall national per capita spending on health, coverage was limited. The morale of poorly paid health workers was low; supervision was inadequate and the management information system and audits were inadequate to meet the commitments. Further, at the early stage of institutional development, the interaction between separate departments needed improvement. The Project Implementation Unit's ability to coordinate with other departments of the Ministry ( as well as other ministries in the GOU), and gamer support was therefore limited, it initially had a weak capacity for contract management, thus leading to delays in procurement, among other factors. Finally, the collaboration with NGOs was initiated without prior preparation of administrative and contractual framework. This had to be developed much later. 9. Performance Indicators. The Staff Appraisal Report did not provide performance indicators. Hence a list of performance indicators was derived for the civil works component, (Part I1I, Table 5). The civil works were satisfactorily executed while delays in procurement pushed some works beyond the target date. 10. Disbursement. After a start-up delay of two quarters, most civil works activities were completed by end of December, 1993, earlier than anticipated (Part III, Table 4). Total funds disbursed out of the IDA credit and out of local financing are shown in para 4 (see part III, Appendix C, Table 2). 11. The Government of Uganda allocations in the budget vote for the project amounted to 83%, but, the amount released (equivalent of US$ 3.8 million) fell below the level needed (US$ 6.5 million). In the initial years even these releases were sporadic and delayed, leading to shortfalls in funding of: civil works contracts, in-country workshops, seminars, incremental operating costs, and key departments of the MOH (planning and health education) which depended heavily on counterpart funding.  60 APPENDIX B Project Completion Report - First Health Project (Cr. 1934-UG) Summarv Page 5 12. Part A: Civil Works. The selection and procurement of civil works for 8 rural hospitals and 27 health centers (excluding those in Rakai districts) and for the rehabilitation of the Blood Transfusion Center in Kampala, costing US$ 15.51 million, were all implemented early in the project - with cost overruns. This led to delays while the project was being re-structured. Later, the procurement of works for Mulago hospital, two equipment workshops, five health centers in the Rakai district, were taken up at a cost of US$ 10.51 million - totaling US$ 26 million (about 61% of the credit). 13. Equipment Maintenance. The project aimed to strengthen the medical equipment maintenance capacity through the construction of Mulago hospital medical equipment maintenance workshop; the construction of Wabigalo central medical equipment maintenance workshop and training of equipment maintenance workers. In summary, IDA funds were applied to construction while SIDA funds facilitated training; funds from the Austrian government (a parallel credit later converted to a grant) were applied to procurement and installation of equipment. 14. The unstable market and economic environment resulted in unexpected cost overruns in the initial civil works. The external works, and parts of the sewage and water works at Mulago hospital, as well as the construction of a hospital in Rakai were therefore, dropped. The outcome of dropping the hospital construction at Rakai turned out to be a cost-effective action with greater public benefits from increased access to primary health services. 15. Part B: Health Education Component. There were two sub-components: health education and community activities. Health Education. (i) The expanded use of the mass media: radio, television and newspapers; (ii) workshops for health educators and training of village health workers; (iii) material support to the Health Education Division of the Ministry of Health; (iv) training of health education personnel; (v) studies (vi) assistance of the Public Health Department of the National Resistance Army. In the print mass media, the project supported the New Vision newspaper by providing 400 metric tons of newsprint over two years to increase circulation of the newspaper. These funds were paid back by the newspaper from its revenues; and were later made available to NGOs through a Maternal Child Health revolving fund account used to support NGOs initiating PHC activities with an income generating aspect. Even after the end of this component, the newspaper still carries a special weekly publication of the population health page. The project procured equipment and spare parts for Radio Uganda and Uganda Television to enable them to increase airing of health messages. These messages have proved popular and are being sponsored by the Ministry of Information and Broadcasting (MOIB). The procurement of radio transmitters for MOIB was not completed. The procurement process had to be discontinued despite repeated attempts. After it was finally agreed to engage an independent consultant to help prepare, evaluate and supervise the new procurement  61 APPENDIX B Project Completion Report - First Health Project (Cr. 1934- UG) Summara Page 6 package whose specifications would be agreed upon by both the Government and the World Bank. The package was prepared too late to be financed by the credit and now MOIB will have to procure it from other sources. The project trained two journalists in New Delhi who are now back working with the MOIB. 16. Workshops for health educators and training of village level workers were conducted in three districts. The program was very successful in increasing awareness of the AIDS epidemic. Material support to Health Education Division comprised the procurement of vehicles (including 4 cinema vans) , stationery, office equipment and furniture and training for the division. Regional health education offices were strengthened with transport and office equipment. The project trained 4 officers at Diploma level in Health Education, two at Masters degree level and two graphic artists. This was in addition to support for international workshops and study tours. The other element of this sub-component was to conduct studies and to support the Public Health Department of the National Resistance Army (NRA). Studies on Knowledge, Attitude and Practices (KAP) were conducted in three districts. The studies revealed 85% increased awareness of the community to AIDS. The project also assisted the NRA health department by providing vehicles, office equipment, news gathering machines, training abroad and facilitated senior officers to participate in international workshops and seminars. 17. The second sub-component comprising community activities was phased out of the project (see para. 5). 18. In part C of the project, the preparation of a White Paper on Health Policy (1993) and the National Three Year Health Plan Frame 1993/94 -1995/96 were supported. The White Paper was adopted by the Government and the National Plan Frame was launched at a workshop for local community leaders and relevant officials, organized in Kampala on 25th October, 1993, for all districts. The project further supported the preparation (by local district health authorities) of strategic Three Year Health Plans covering the a period 1993-96, for all districts of Uganda. The plans were presented to the local legislative councils and approved in all cases. The District Health Planning and Annual Work plan exercises were supervised by the Planning Unit with active participation of the Ministry of Local Government. Support to the Planning Unit also included training in health planning and health economics. Finally, the project supported a senior economist to strengthen the Health Planning Unit. 19. In the component for strengthening management capabilities of MOH, the project provided a Management Advisor who worked closely with the Permanent Secretary, Director of Medical Services and the Minister for Health. The advisor was involved in the following: preparation of the Health Policy White Paper; the Task Force on decentralization of Health Services in Uganda; the district planning exercise; the preparation of the STD/AIDS project and the District Health Services Project;  62 APPENDIX-B Prqiect Completion Report - First Health Project (Cr. 1934-UG) Summarv Page 7 development of alternate health financing approaches including cost recovery initiatives; and, development of administrative arrangements for management of health facilities e.g. formation of management committees. The project supported training in management, local and international workshops, seminars and conferences related to policy process and health development programs. 20. Support was provided for NGOs as indicated below: (i) Safe Motherhood Initiatives - community based activities and training of TBAs. (ii) Kihihi Health Center Project - construction. (iii) Women International Maternity Association (WIMA) - rehabilitation of Nagulu, Kisenyi and Kiswa clinics. (iv) Busanza Community Health Project - community based activities, training and construction of Buhozi clinic. (v) Joint Clinical Research Center - medical wards extension. (vi) UWESO. (vii) North Ankole Project - construction of Rushere Health Center. (viii) World Vision International. (ix) Baale County Community Based Organization for Health - community based activities, training and construction at Baale, Galiraya, Wabuwoko, and Kayonza health centers. (x) Ruhinda Development Association - community based activities, training and construction of health center at Ruhinda. (xi) Bunyaruguru Development Association - construction of Kyavula/Kichwamba and Katerera Health centers. The decentralization policy has enhanced the use of NGOs for the provision of health services at community level. 21. The project facilitated the MOH to review the National Health Policy and to acquire a national health plan frame for purposes of guiding future investments in health. The policy focuses upon sustainability by limiting interventions to a cost-effective primary health care approach and on developing administrative arrangements at local level  63 APPENDIX B Project Completion Report - First Health Project (Cr. 1934-UG) Summarv Page 8 for management. To ensure durability of medical equipment, maintenance workshops were established and personnel were trained in the maintenance of equipment. 22. Studies. Twelve topics for investigation were selected for study, most having been identified at appraisal. Both local and external consultants were contracted (Part III, Table 7). The studies combined a process of information gathering, (to fill the information gap created by prolonged neglect during the years of civil strife), analysis of the situation, and recommendations on the options and goals for the future. The studies also provided an input to the Three Year National Health Plan and prepared the way for two follow-on health projects of a more extensive scale. 23. A special initiative was the testing and piloting of new policy reforms in the health sector as part of preparation for a follow-on project. The specific objectives of the pilot activities were; (a) to undertake a trial at the district level of a sustainable model for delivery of minimum essential health service package; (b) to act as a test bed for capacity building activities at the district and central level of health care management; and (c) to initiate the testing of new policy reform based upon building capacity to assess cost- effectiveness of interventions, using the burden of disease analysis. Activities were undertaken by the MOH with technical assistance from SIDA for establishing supervision for the three pilot districts. The pilot supported specific preparations for delivering essential elements of primary health care that were identified as cost-effective. The project further supported management training needs assessment in the pilot districts and initiated management training in the field. Finally, the pilot initiated the building of a capacity for cost-effectiveness assessments using data from the three districts. The outcome of these initiatives fed into the preparation of the District Health Services Pilot and Demonstration Project and its initiation following its effectiveness. Performance of Key Players. 24. Government of Uganda. At the start of project implementation, the MOH was weak in management and the PIU took over the implementation of the project. In respect of project implementation, the Project Implementation Unit (PIU) staff had no prior experience with IDA/World Bank procedures. There was no implementation manual in place at the beginning of the project. The Government's compliance with covenants was frequently delayed and partial (details on the status of each covenant are presented in Part III, Table 9). Apart from the Health Planning Unit, other departments of the Ministry were too weak to assume the responsibility for preparing departmental work plans to assist with the district planning exercise. For future operations, the Ministry is already taking steps to build capacity at the central level and further strengthen the effort at the district level. Overall, the GOU only managed too attain 54% of its financial obligation for counterpart funding. This financial constraint adversely affected the GOU performance.  64 APPENDIX B Project Comipletin Report - First Health PrQiect (C. 1934- UG) Summary Page 9 25. IDAlWorld Bank. Identification of the post-war critical areas in which intervention was necessary was successful. While IDA took risks, preparation did not proceed swiftly enough to reflect the urgency of the situation. However, IDA kept the project design flexibly simple and focused largely on civil works. Appraisal over- estimated the capacity of the GOU to contribute counterpart funds at 10%. IDA also underestimated the recurrent cost implications of the project. In supervision, IDA was responsive to the changing priorities and needs of the project, paid attention to recurrent funding constraints, and facilitated the MOH/PIU to manage initial maintenance requirements for the rehabilitated health units. Assessment of Outcome 26. Overall, the project outcome was satisfactory. The momentum of the Government's health sector rehabilitation efforts was boosted. The project put the sector on a path to recovery. The dilapidated health units were rehabilitated and their utilization increased. Supplies for health care delivery began to flow, thus partially raising the morale of health workers. In the north and the north-east of the country where civil strife persisted, the effects were less noticeable. 27. A department of health education has been established in the MOH and all districts enabled to establish a capacity to prepare and execute information, education and communication (IEC) programs. The institutional capacity of the Ministry has been strengthened in addition to capacity at the district level to prepare strategic and annual plans of operation. Pre-investment studies had a positive impact. The project fulfilled the objective of preparing for more investments in the sector (STI and DHSP). It also provided valuable information for the review of the government's White Paper on health Policy and the Three-Year Health Plan Frame. Key Lessons Learned 28. The following lessons can be drawn from the experience of implementing the First Health Project: 28.1 More attention should be paid to assessing the capacity for likely counterpart funding and recurrent support for the proposed investment. Key performance indicators need to be specified during project preparation. Inadequate counterpart funding leads to delays in project implementation and the need to restructure the project. In addition, project sustainability is compromised by poor assessment of necessary recurrent support. 28.2 Continued underfunding of the health sector will perpetuate low health services coverage and constrain the application of cost-effective interventions by limiting the scope of financial reforms required to shift funds to those interventions.  65 APPENDIXJB Project Completion Report - First Health Project (Cr. 1934-UG) Summary Page 10 28.3 The implementation experience demonstrates the value of capacity building for institutional strengthening. The MOH management and the capacity of the Health Planning Unit greatly benefited from the experience and productivity improved. 28.4 Greater involvement of MOH departments in supervision of health care management and delivery is reqaired, especially for developing standards and procedural manuals to sustain the investment in the sector. 28.5 Decentralization and more autonomy for district implementation management will require close supervision. Local involvement by users in the sustainability of health services should also be enhanced. 28.6 Continuous training in procurement (especially contract management) and disbursements enhances the performance of the PIU. 28.7 Formal arrangements prior to collaboration with NGOs are required to ensure both compliance and facilitate monitoring. 28.8 Late financial audits need to be avoided. Continuous audits would be necessary especially for decentralized operations. Dr. Patrick Y. Kadama Project Coordinator Ministry of Health, Kampala August 20, 1996  66 Appendix C. Uganda First Health Project Details of Civil Works Costs i/ Activity SAR Estimnates 1 Actual Costs, 1SS '000 (includes July 1996 contigency) ______00__ A. Government Health Facilities 1. Medical Stores 2/ 314.00 00 2. Rehabilitation of Mulago Hospital including 11,015.66 6451.15 medical equipment workshop 3/ 3. Rakai Health Centers 4/ 4,830.20 3303.10 4. Eight District Hospitals and Thirty Health 6,699.80 15,332.00 Centers 5/ 5. Renovation of Project Implementation Unit 417.50 176.00 Buildings 6. Wabigalo Medical Equipment Workshop 575.00 777.80 rotal (overnment Facilities 23,852.16 26,040.05 B. Non-Governmental Organizations Health Facilities 1. Joint Clinical Research Center: Outpatient dept ---- 938.10 (OPD) and general ward. 2. Women International Maternity AID (WIMA). ---- 264.70 Nagulu, Kisenyi and Kiswa clinics in Kampala. 3. Kihihi Health Center (construction of OPD, matenity ---- 220.00 ward and staff quarters). 4. Rujumbura Development Foundation Clinic ---- 150.50 5. Bunyaruguru Development Association ---- 48.00 (construction of Kyavula/Kichwamba and Katerera Health Centers). 6. Baale County Community Based Organization ---- 220.00 for Health. (Baale, Kayonza, Kitimbwa/Wabuwoko and Galirava health centers)._ Total NGO Facilities 1841.30 Source: Ministry of Health, Uganda 1/ Costs as of July 30, 1996. 2/ Medical Stores were dropped during project restructuring - work later carried with support from DANIDA.  67 Appendix C. Details of Civil Works. continued! 3/ Mulago Works included: Lifts; Electrical works; Living quarters (nurses hostels and doctors housing); Kitchen; Laundry and Central Sterile Supplies Department; Mulago medical equipment workshop. 4/ In place of the planned new hospital in Rakai District a new health center and office for the District Medical Officer were constructed and four health facilities rehabilitated: Mutukula dispensary, Lyantonde, Kachera and kalisizo health centers. 5/ Rehabilitation of District Hospitals and health centers as follows: (i) Iganga Hospital and two health centers: Mayuge and Narnungalwe. (ii) Kayunga Hospital and nine health centers: Nakawuka, Buwama, Kanoni, Zirobwe, Nyimbe, Mpenja, Butoolo and Wakyato. (iii) Pallisa Hospital and two health centers;Kamoge and Budaka. (iv) Lira Hospital and three health centers: Anyeke, Teboke and Aboke. (v) Masindi Hospital and four health centers: Bwijanga, Buliisa, Kakumiro and Pakanyi. (vi) Kambuga Hospital (vii) Kabale Hospital (viii) Kiboga Hospital and four health centers: Kiganda, Kasambya, Mwera and Kabasanda. (ix) Health centers in Eastern Uganda; Kiyunga, Masafu and Nagongera  68 Appendix D. Uganda First Health Project Utilisation of Rehabilitated Hospitals Table 1. Outpatient Department New Cases (1992 - 1995) Ilosiiital 1992 199 1994 1995 Kayunga 22,509 24,367 21,402 31,124 Lira 8,630 9,216 8,894 10,644 Kabale 20,641 20,893 24,996 28,964 Kamibuga 31,150 28,004 33,240 36,244 Iganga 27,406 26,454 24,970 37,720 Pallisa 14,661 16,434 20,974 21,634 Kiboga 11,544 12,950 12,611 13,860 Masindi 10,574 11,642 10,934 13,795 Source: Ministry of Health, Uganda. Table 2. In-patient Admissions (1993 - 1995) lHospital 1993 1994 1995 Kayunga 1,299 1,184 1,516 Lira 1,692 1,825 1,904 Kabale 2,340 2,613 2,692 Kambuga 922 864 1,175 Iganga 4,135 4,300 4,216 Pallisa 1,535 1,846 1,924 Kiboga 969 1,032 1,260 Masindi 1,294 1,108 1,426 Source: Ministry of Health, Uganda.  69 Appendix E Ministry of Health Recurrent Expenditure A. Government 92/93 93194 94195 95/96 PHC 4,885 7,054 4,118 14,396 Hospitals 13,590 23,832 29,474 26,072 Management 1064 2,490 4,008 4,200 Total 19,539 33,376 37,600 44,668 B. Donor PHC 18,289 19,488 13,883 37,796 Hospitals 6,345 2,731 1,403 2,920 Management 844 1,844 1,187 97 Total 25,478 24,063 16,473 40,813 C. Total: Government and Donor PHC 23,174 26,542 18,001 52,192 Hospitals 19,935 26,563 30,877 28,992 Management 1,908 4,334 5,195 4,297 Total 45,017 57,439 54,073 85,481 Ministry of Health Capital Expenditure 92/93 93194 94/95 95/96 A. Government PHC 103 133 93 101 Hospitals 709 642 1,375 502 Management 1964 2,491 5,865 2,554 Total 2,776 3,266 7,333 3,157 B. Donor PHC 3,146 5,046 4,278 9,024 Hospitals 29,021 8,515 3,674 10,707 Management 9,561 3,099 12,640 8,570 Total 41,728 16,660 20,592 28,301 C. Total: Government and Donor PHC 3,249 5,179 4,371 9,125 Hospitals 29,730 9,157 5,049 11,209 Management 11,525 5,590 18,505 11,124 Total 44,504 19,926 27,925 31,458  70 Appendix E (continued) Ministry of Health Total Expenditures Government and Donor 92/93 93/94 94/95 95/96 A. Government PHC 4,988 7,187 4,211 14,497 Hospitals 14,299 24,474 30,849 26,574 Management 3,028 4,981 9,873 6,754 Total 22,315 36,642 44,933 47,825 B. Donor 92/93 93/94 94/95 95/96 PHC 21,435 24,534 18,161 46,820 Hospitals 35,366 11,246 5,077 13,627 Management 10,405 4,943 13,827 8,667 Total 67,206 40,723 37,065 69,114 C. Total: Government and Donor 92/93 93/94 94/95 95/96 PHC 26,423 31,721 22,372 61,317 Hospitals 49,665 35,720 35,926 40,201 Management 13,433 9,924 23,700 15,421 Total - 89,521 77,365 81,998 116,939  71 Appendix D. Uganda First Health Project Details of Civil Works Costs 1i/ Activitv SAR Estimates Actual Costs, IISS '000 (includes July 1996 contigency) .SS'00I A. Government Health Facilities 1. Medical Stores 2/ 314.00 00 2. Rehabilitation of Mulago Hospital including 11,015.66 6451.15 medical equipment workshop 3/ 3. Rakai Health Centers 4/ 4,830.20 3303.10 4. Eight District Hospitals and Thirty Health 6,699.80 15,332.00 Centers 5/ 5. Renovation of Project Implementation Unit 417.50 176.00 Buildings 6. Wabigalo Medical Equipment Workshop 575.00 777.80 'oftal (Covernment Facilities 23,852.16 26,040.05 B. Non-Governmental Organizations Health Facilities 1. Joint Clinical Research Center: Outpatient dept ---- 938.10 (OPD) and general ward. 2. Women International Maternity AID (WIMA). ---- 264.70 Nagulu, Kisenyi and Kiswa clinics in Kampala. 3. Kihihi Health Center (construction of OPD, matenity ---- 220.00 ward and staff quarters). 4. Rujumbura Development Foundation Clinic ---- 150.50 5. Bunyaruguru Development Association ---- 48.00 (construction of KyavulalKichwamba and Katerera Health Centers). 6. Baale County Community Based Organization ---- 220.00 for Health. (Baale, Kayonza, Kitimbwa/Wabuwoko and Galirava health centers). Total NGO Facilities 1841.30 Source: Ministry of Health, Uganda 1/ Costs as of July 30, 1996. 2/ Medical Stores were dropped during project restructuring - work later carried with support from DANIDA.  72 Appendix D. Details of Civil Works. continued/ 3/ Mulago Works included: Lifts; Electrical works; Living quarters (nurses hostels and doctors housing); Kitchen; Laundry and Central Sterile Supplies Department; Mulago medical equipment workshop. 4/ In place of the planned new hospital in Rakai District a new health center and office for the District Medical Officer were constructed and four health facilities rehabilitated: Mutukula dispensary, Lyantonde, Kachera and kalisizo health centers. 5/ Rehabilitation of District Hospitals and health centers as follows: (i) Iganga Hospital and two health centers: Mayuge and Namungalwe. (ii) Kayunga Hospital and nine health centers: Nakawuka, Buwama, Kanoni, Zirobwe, Nyimbe, Mpenja, Butoolo and Wakyato. (iii) Pallisa Hospital and two health centers;Kamoge and Budaka. (iv) Lira Hospital and three health centers: Anyeke, Teboke and Aboke. (v) Masindi Hospital and four health centers: Bwijanga, Buliisa, Kakumniro and Pakanyi. (vi) Kambuga Hospital (vii) Kabale Hospital (viii) Kiboga Hospital and four health centers: Kiganda, Kasambya, Mwera and Kabasanda. (ix) Health centers in Eastern Uganda; Kiyunga, Masafu and Nagongera  73 Appendix E. Uganda First Health Project Utilisation of Rehabilitated Hospitals Table 1. Outpatient Department New Cases (1992 - 1995) Hospital 1992| 1993 1994 1995 Kayunga 22,509 24,367 21,402 31,124 Lira 8,630 9,216 8,894 10,644 Kabale 20,641 20,893 24,996 28,964 Kambuga 31,150 28,004 33,240 36,244 Iganga 27,406 26,454 24,970 37,720 Pallisa 14,661 16,434 20,974 21,634 Kiboga 11,544 12,950 12,611 13,860 Masindi 10,574 11,642 10,934 13,795 Source: Ministry of Health, Uganda. Table 2. In-patient Admissions (1993 - 1995) Hospital 1993 1994 1995 Kayunga 1,299 1,184 1,516 Lira 1,692 1,825 1,904 Kabale 2,340 2,613 2,692 Kambuga 922 864 1,175 Iganga 4,135 4,300 4,216 Pallisa 1,535 1,846 1,924 Kiboga 969 1,032 1,260 Masindi 1,294 1,108 1,426 Source: Ministry of Health, Uganda.  74 Appendix F Ministry of Health Recurrent Expenditure A. Government 92/93 93(94 94/95 95/96 PHC 4,885 7,054 4,118 14,396 Hospitals 13,590 23,832 29,474 26,072 Management 1064 2,490 4,008 4,200 Total 19,539 33,376 37,600 44,668 B. Donor PHC 18,289 19,488 13,883 37,796 Hospitals 6,345 2,731 1,403 2,920 Management 844 1,844 1,187 97 Total 25,478 24,063 16,473 40,813 C. Total: Government and Donor PHC 23,174 26,542 18,001 52,192 Hospitals 19,935 26,563 30,877 28,992 Management 1,908 4,334 5,195 4,297 Total 45,017 57,439 54,073 85,481 Ministry of Health Capital Expenditure 92/93 93/94 94/95 95(96 A. Government PHC 103 133 93 101 Hospitals 709 642 1,375 502 Management 1964 2,491 5,865 2,554 Total 2,776 3,266 7,333 3,157 B. Donor PHC 3,146 5,046 4,278 9,024 Hospitals 29,021 8,515 3,674 10,707 Management 9,561 3,099 12,640 8,570 Total 41,728 16,660 20,592 28,301 C. Total: Government and Donor PHC 3,249 5,179 4,371 9,125 Hospitals 29,730 9,157 5,049 11,209 Management 11,525 5,590 18,505 11,124 Total 44,504 19,926 27,925 31,458  75 Appendix F (continued) Ministry of Health Total Expenditures Government and Donor 92/93 93194 94/95 95196 A. Governmmnt PHC 4,988 7,187 4,211 14,497 Hospitals 14,299 24,474 30,849 26,574 Management 3,028 4,981 9,873 6,754 Total 22,315 36,642 44,933 47,825 B. Donor 92/93 93/94 94/95 95/96 PHC 21,435 24,534 18,161 46,820 Hospitals 35,366 11,246 5,077 13,627 Management 10,405 4,943 13,827 8,667 Total 67,206 40,723 37,065 69,114 C. Total: Government and Donor 92/93 93/94 94/95 95196 PHC 26,423 31,721 22,372 61,317 Hospitals 49,665 35,720 35,926 40,201 Management 13,433 9,924 23,700 15,421 Total 89,521 77,365 81,998 116,939   MAP SECTION  I  IBRD 25052R 30' g 32' 34'/ 35' '