Mozambique - Health and Nutrition

 ICRR 10181 Report Number : ICRR10181 ICR Review Operations Evaluation Department 1. Project Data : OEDID : OEDID: C1989 Project ID : P001787 Project Name : Health and Nutrition Country : Mozambique Sector : Other Population Health & Nutrition L/C Number : C1899 Partners involved : Prepared by : Charles Derek Poate, OEDST Reviewed by : Susan A. Stout Group Manager : Roger H. Slade Date Posted : 08/18/1998 2. Project Objectives, Financing, Costs and Components : Objectives : (i) strengthen capacity in policy formulation and management of health and food security issues; (ii) improve efficiency to enhance the impact of health services within the tightly constrained budget; (iii) improve service quality to enhance the provision of basic needs; (iv) help mitigate some of the social costs of adjustment. (v) After project effectiveness an objective to address the social dimensions of adjustment (SDA) was added to: strengthen the capability of the National Planning Commission for social planning to address poverty reduction. Components : (i) policy formulation and management strengthening; (ii) improving efficiency and quality of services; (iii) social policy studies and data collection to complement information on the poor and on the impact of interventions; and, (iv) a social action preparation program to prepare appropriate programs and policies, test proposals for poverty alleviation and financing the initial stages of large programs. Costs and financing : The total project costs were US$ 56.8 million (US$ 53 million at appraisal) of which the Bank financed US$ 30.2 million (US$ 27 million at appraisal). Co-financing was provided by Norway, Switzerland, West Germany, the Netherlands and the United Kingdom. Parallel financing through the expansion of existing projects was provided by UNICEF, WFP and the OPEC Fund. The Bank credit was approved on March 14, 1989 and was made effective on October 30, 1989. The loan was closed on June 30, 1997, thirty months after the original closing date, at which time the credit was over 99% disbursed. The final disbursement took place on January 7, 1998, when a balance of SDR 9617 was canceled. 3. Achievement of Relevant Objectives : The project substantially achieved its major objectives and provided valuable support to the MOH at a time when national circumstances changed dramatically. The project had positive impacts on: (i) improving tertiary/quaternary health care facilities and their efficiency through rehabilitation and partial re-equiping three urban hospitals and efficiency improvements; (ii) strengthening human resources planning and training through development and implementation of a National Health Manpower Development Plan, rehabilitation of training facilities and improvements in training curricula;(iii) improving sector planning, management, information and project implementation through the strengthening the Ministry of Health's (MOH) investment project coordination unit and initiation improvements in the health information systems , and; (iv) improving pharmaceutical supplies by facilitating coordination in donor financing for essential drugs and supplies and technical support for drug system planning, management and cost recovery. The project established basic capacity for sectoral planning and reform which is being furthered through the design and implementation of a multi-donor sector investment program. 4. Significant Achievements : Despite being designed to do what was achievable in the context of a protracted war, the achievement of some objectives by the project (for example, the National Health manpower Development Plan) exceeded original aspirations. 5. Significant Shortcomings : Since the project was designed in the context of a protracted war -- facility rehabilitation, improved planning, management and training, its direct impact on overall health outcomes was (as expected at appraisal) not expected to be substantial or measurable. Serious and unresolved problems in the Ministry of Finance and the Bank of Mozambique caused substantial implementation delays. Implementation was further hampered by turnover of key staff, the lack of clear performance targets at appraisal and by shifts in implementation priorities which occurred as a result of shifts in the political environment and the launching of the peace process. 6. Ratings : ICR OED Review Reason for Disagreement /Comments  Outcome : Satisfactory Satisfactory Institutional Dev .: Substantial Substantial Sustainability : Likely Uncertain Although MOH is committed to the project, and to efforts to build on its accomplishments are underway through sector reform, limited government resources cast doubt on the ministry's ability to maintain the infrastructure and equipment, provide appropriate incentives for staff, and make available sufficient recurrent finance. Sector financing will require significant external assistance for the foreseeable future. OED therefore rates sustainability as "Uncertain". Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : (i) Since implementation is likely to be complicated with more than one implementing sectoral ministry, multiple implementing ministries should be avoided in countries with limited co-ordination capacity;(ii) Continuity of technical assistance should be ensured by the repeated presence of the same advisors; Project simplicity and realistic objectives are especially relevant in an environment of great uncertainity; Posting a public health specialist in the Resident Mission facilitate project supervision and the establishment of email connections between the MOH and the Bank greatly facilitated supervision and support for the project. 8. Audit Recommended? Yes No 9. Comments on Quality of ICR : The ICR is satisfactory and presents clearly the issues involved in a complex and long-running project implemented under difficult circumstances.