Sri Lanka - Health Services Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. P-6858-CE MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 13.0 MILLION TO THE DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA FOR A HEALTH SERVICES PROJECT November 21, 1996 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Currency Unit = Rupees (LKR) LKRI.00 = US$.018 US$1.00 = LKR55.6 (October 11, 1996) FISCAL YEAR January 1 - December 31 PRINCIPAL ACRONYMS USED ADB Asian Development Bank AIDS Acquired Immunodeficiency Syndrome HIV Human Immunodeficiency Virus IDA International Development Association MOH Ministry of Health NCD Non-Communicable Disease NGO Non-Governmental Organization PMU Project Management Unit STD Sexually Transmitted Disease WHO World Health Organization Vice President Mr. D. Joseph Wood Director Ms. Mieko Nishimizu Division Chief/Manager Ms. Barbara Herz Task Manager Ms. Frances Plunkett FOR OFFICIAL USE ONLY DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA HEALTH SERVICES PROJECT Credit and Project Summary Borrower: Democratic Socialist Republic of Sri Lanka Implementing Agency: Ministry of Health, Highways and Social Services Beneficiary: Not applicable Poverty: Not applicable Amount: SDR 13.0 million (US$18.8 million equivalent) Terms: Standard, with 40 years maturity Commitment Fee: Standard (a variable rate between 0 and 0.5% of the undisbursed credit balance set annually by the Executive Directors of IDA) Onlending Terms: Not applicable Financing Plan: See Schedule A Net Present Value: Not applicable Staff Appraisal Report: 15466-CE Map: IBRD 28019 Project Identification Number: LK-PA-10526 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 wihout World Bank authorization.  MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA FOR A HEALTH SERVICES PROJECT 1. I submit for your approval the following memorandum and recommendation on a proposed development credit to the Democratic Socialist Republic of Sri Lanka for SDR 13.0 million (US$18.8 million equivalent), on standard IDA terms, with a maturity of 40 years, to help finance a project to strengthen Health Services. 2. Country/Sector Background. Sri Lanka has made progress in reducing the incidence of poverty, reflected in improvements in development indicators as well as in consumption. This progress is due to a combination of factors including: (i) public provision of basic preventive and curative health as well as education services, which have achieved excellent results; (ii) income transfer programs that have enabled higher consumption by the poor; and (iii) a relatively good long- term growth performance, with real per capita GDP growth of about 2.5% per year on average for the period 1950-93. 3. However, Sri Lanka is still a low-income economy. Although its long-term growth rate in per capita terms compares favorably with most of the developing world, it falls well short of the growth rate achieved in the last three decades by the high-performing East Asian economies. The main reason for this lag is that Sri Lanka's policies have been less supportive of economic growth. Problems with macroeconomic management have constrained domestic saving and investment and fueled inflation; export growth has been constrained by inward looking trade policies, interventions in the labor market and at times in the past, exchange rate overvaluation; and the agriculture sector's performance has been constrained by pervasive controls on land ownership, use, marketing and pricing. Civil strife in the northern and eastern regions has also constrained economic growth. 4. Sri Lanka has done very well in terms of education, demographic and health indicators. By 1990, literacy rates were 93% for males and 83% for females. The demographic transition is now virtually complete: mortality levels are similar to those in developed countries (life expectancy at birth of over 72 years in 1995), and fertility has declined to replacement level (total fertility rate of about 2.2 in 1995). The population growth rate is less than 1% per annum and falling, and the current population of about 18 million is expected to stabilize at approximately 25 million in about 2025. Through good implementation of immunization programs and an effective primary health care system, outstanding progress in the prevention and control of communicable diseases has been achieved. 5. However, a number of serious public health problems remain. Malaria was virtually eliminated in the 1960s, but there have been several serious resurgences in recent years. About a third of young children are malnourished, and almost 20% of births are low birth weight. To prevent epidemic spread of HIV, measures to ensure that transmission will be contained must be strengthened. Additionally, the aging of the population is resulting in major changes in the disease pattern of the population as non-communicable disease of adults (cardiovascular disease, stroke, cancers, diabetes) come to dominate the disease profile (the epidemiological transition). -2- 6. Rationale for IDA Involvement. The project is fully consistent with the Country Assistance Strategy (CAS) for Sri Lanka, discussed by the Board on June 13, 1996, which indicates that IDA expects to respond to Government requests for assistance in addressing key public health issues through the project. The project is also intended as a step in expanding a policy dialogue in the Health sector. The program of policy-related studies and pilot implementation, linked to an ongoing dialogue with the Ministry of Health (MOH) through an annual review process, will be used to develop mutual trust. 7. IDA's comparative advantage in the health sector is based on the ability to bring to bear relevant cross-country experience in the health sector, particularly in the areas of helping Government to assess priorities within the sector, develop more cost-effective ways of providing health care, and explore issues relating to sustainability and non-government options for delivering health care. These issues must now be given priority in view of the well-advanced epidemiological transition in Sri Lanka as well as increasing pressures on scarce public resources. 8. Drawing on experience gained from the IDA-assisted Health & Family Planning Project, which closed in September 1995, IDA is well positioned to assist Government in coordination of donor assistance and as the lender of last resort. There is no other major source of external financing available for the project. The UN and bilateral agencies concerned with the health, population and nutrition sectors--principally WHO, UNFPA, and UNICEF--have cooperated fully in project preparation. The Asian Development Bank, the other potential lender, is currently supporting a health project that concentrates on secondary health care. 9. Project Objectives. The objectives of the project are to strengthen Government's ability to address (i) remaining major public health problems (malaria, STD/AIDS, and malnutrition); (ii) new challenges raised by the epidemiological transition and the increasing importance of non- communicable diseases of adults; and (iii) key health policy and financing issues. 10. Project Description. To achieve these objectives, the project will support cost-effective approaches to the prevention and/or control of malaria, HIV/AIDS, and malnutrition; a pilot effort for prevention and treatment of non-communicable diseases; and three program support components, for development of health policy, management information systems, and health education. Pilot initiatives will be developed in areas of agreed high priority, including generation of additional resources for tertiary health care and achievement of an appropriate public-private mix in the sector. 11. The malaria component (17% of project base costs) will support expanded implementation of WHO's revised, more cost-effective malaria strategy, which since its introduction has been largely responsible for substantial declines in malaria cases while reducing insecticide spraying by 65%. The STD/AIDS component (39% of project base costs) will support the national STD/AIDS control program which, with the substantial involvement of NGOs, has moved promptly to take the medical and behavioral steps necessary to contain the spread of HIV; the chances are reasonable that if Sri Lanka takes additional steps now, epidemic spread of HIV can be avoided. The nutrition component (14% of project base costs) will support the reorientation of the Health Ministry's existing growth monitoring program to a growth promotion program based on a cost-effective education/communication approach that is proving successful in the IDA-assisted Poverty Alleviation project (Cr. 2231-CE); micronutrient concerns will also be addressed. The pilot non- communicable diseases component (2% of project base costs) will support a pilot effort to identify -3- the dimensions of non-communicable diseases and develop cost-effective strategies for prevention and treatment. Three program support components (26% of project base costs) will provide essential support to the planning, management and implementation of the Ministry's programs: a health policy development component will support an agreed program of studies and pilot initiatives in key areas of health policy and financing, linked to an ongoing policy dialogue through annual reviews; and management information systems and health education capacities will be strengthened. Project management accounts for the remaining 1% of base costs. The project is planned for five years and is expected to be completed by December 31, 2001; the credit is scheduled to close on June 30, 2002. 12. Project Costs and Financing Plan. The total cost of the project is estimated at about US$22.6 million equivalent, including contingencies. The estimated IDA contribution will be US$18.8 million; the Government will finance the remaining US$3.8 million. A breakdown of costs and the financing plan are shown in Schedule A. The amount and methods of procurement and the disbursement schedule are shown in Schedule B. A timetable of key project processing events and the status of Bank Group operations in Sri Lanka are given in Schedules C and D respectively. The Staff Appraisal Report, No. 15466-CE, is being distributed separately. 13. Project Implementation. The lead implementing agency will be the MOH. The provincial Health Departments, which now have responsibility for most health facilities and services, will be involved in all components. Overall project coordination will be provided by a Project Management Unit (PMU), which will be responsible for project procurement, disbursements, monitoring and reporting. The PMU will carry over from the IDA-supported Health & Family Project, which closed in September 1995, providing valuable experience and continuity. The malaria, STD/AIDS and nutrition components will be implemented by the units in the Ministry currently responsible for these programs. To strengthen implementation of the nutrition component, a senior nutrition post will be created in the MOH. The pilot non-communicable diseases (NCD) health policy, and management information systems (MIS) components will be implemented by the Research & Training Unit, the Management Development & Planning Unit, and the Planning & Management Information (PMI) Unit of the Ministry, respectively. NGOs will have significant roles in the implementation of the nutrition and STD/AIDS components. 14. Project Monitoring and Reporting. The PMU will submit to IDA semi-annual reports reviewing project progress and problems for the period under review and cumulatively. One month prior to the beginning of the project year, the Government will submit to IDA annual action plans for the coming year covering each component for comment and approval by IDA. By June 30, 1999, the Government and IDA will carry out a joint mid-term review of the project, and following the review Government will implement agreed recommendations. Within six months of the completion of the project, the Borrower will submit a project completion report to IDA. 15. Project Sustainability. Successive governments in Sri Lanka have been fully and firmly committed to support of public sector health services. Continued priority support for the programs that address major public health problems--malaria, STD/AIDS, malnutrition--can be expected. The incremental recurrent cost implications of the project, reaching about 1.8% of the projected recurrent budget for Health by the final project year, are modest. Of the incremental recurrent costs, the project will finance only drugs, medical supplies and laboratory supplies. For the malaria and nutrition components, with the completion of project-assisted intensive phases of these programs it can be anticipated that after completion of the project the resources required to sustain progress will be -4- significantly lower than the level of project inputs. Requirements for the STD/AIDS program, however, are likely to continue to increase for the foreseeable future. Altogether, it is estimated that in the first post-project year project-related recurrent costs will decline to about 1.6% of the projected recurrent budget for Health, a necessary and sustainable public health outlay. 16. Lessons from IDA Experience in the Sector. The only IDA-assisted social sector project that has been completed in Sri Lanka, the Health & Family Planning Project (Cr. 1903-CE), closed on September 30, 1995. This project experienced major difficulties in its early phases, due primarily to lack of "ownership" by the implementing ministry and poor project management. However, after a very critical mid-term review by the Borrower, project management was modified and implementation improved substantially. On the basis of this and other country experience, the following lessons can be drawn: (i) the politically sensitive nature of many aspects of health policy in Sri Lanka, given the widely held view that the state has a moral obligation to provide free health and education services to all citizens; (ii) the importance of "ownership" of a project by the ministry primarily responsible for implementation, given the difficulties of inter-ministerial cooperation; (iii) the need to ensure that senior national and provincial managers understand and support the strategies underlying project assistance to specific programs; (iv) the crucial role of project management in coordinating project activities and monitoring progress at both national and provincial levels; (v) the useful role that a thorough mid-term review carried out by the Borrower can play; (vi) the need to ensure that IDA practices and procedures are understood by those responsible for project management by the time the project becomes effective; and (vii) the importance of drawing on regional and international experience to strengthen project and program design. The preparation team drew on experience in other countries to help the Government identify cost-effective strategies in the nutrition and STD/AIDS areas, and the pilot NCD effort is expected to make extensive use of developed country experience in developing NCD options. 17. Actions Agreed. The Government has provided assurances that (a) it has title to the site designated for the headquarters facility of the National STD/AIDS Control Program in Colombo and that plans for the facility have been approved by an architect acceptable to the Association; (b) a post of Director Nutrition (MOH) has been created; (c) the post of Director Information & Management (MOH) has been filled; (d) the Government has title to the site designated for the Health Education Bureau hostel in Colombo and that the plans for the building have been approved by an architect acceptable to IDA; (e) acceptable sample bidding documents for International Competitive Bidding (ICB) and National Competitive Bidding (NCB) are available; (f) by December 31, 1997, private blood banks will be required to follow MOH standards for the safety of the blood supply; (g) by June 30, 1998, the MOH will carry out, under terms of reference satisfactory to IDA, an evaluation of the impact of the thriposha supplementary food program and will furnish to the Association the findings and recommendations of the evaluation, and that the MOH will carry out agreed recommendations of the study; (h) by March 31, 1997 a candidate whose qualifications and experience are acceptable to IDA will be appointed to the post of Director Nutrition (MOH); (i) under the general guidance of health workers, trained community volunteers will be allowed to carry out growth monitoring and other growth promotion activities; (j) by June 30, 1997 an operational plan for a pilot diabetes prevention and treatment program acceptable to IDA will be prepared and furnished to IDA for its concurrence and that the plan will be carried out taking into account IDA's comments; and (k) under terms of reference and in accordance with a time schedule agreed with IDA, a program of policy-related studies will be carried out; that the results and findings of the studies will be reviewed annually with IDA and that the recommendations will be timely implemented taking into account -5- IDA's comments. A Letter of Health Development Policy acceptable to IDA has been received from Government. 18. Poverty Impact. For the nutrition component, there is evidence that the proportion of malnourished children under 5 years of age increases as per capita household consumption decreases. Hence, it can be expected that the proportion of children targeted by the nutrition program supported by the project will be largest among poverty households. For malaria and STDs, however, the benefits of program interventions are likely to be more evenly distributed among all income groups. 19. Environmental Considerations. No adverse impact on the environment is expected from the project, which has been determined to be in screening Category C. A positive environmental impact is expected to result from the revised malaria strategy that the project will support, since the amount of insecticide used for spraying has been reduced by 65%. Additionally, 20% of the insecticide now used is environmentally more acceptable than the malathion which was previously used exclusively. The only insecticide being supported by IDA is the environmentally acceptable form used for impregnation of bed-nets. 20. Benefits. For the strengthened malaria and nutrition programs, expected project impact can be estimated. The annual incidence of malaria cases in the six high-prevalence districts is expected to fall from more than 40 detected cases per thousand population in 1994 to less than 10 per thousand by 2001 The percentage of underweight infants and young children below age five, which was about one third, or more than 500,000 infants and children, in 1993, is expected to be reduced by about half by 2001. The percentage of low-weight births, which was about 20%, or roughly 80,000 newborns, in 1993, is expected to be reduced to less than 15% by 2001. Iodine deficiency is expected to be virtually eliminated and iron-deficiency anemia significantly reduced by 2001. The goal of the STD/AIDS program is ensure that Sri Lanka remains a low HIV-prevalence country. 21. Economic Justification. There is clear economic justification for public sector involvement in the areas supported by the project. There are positive externalities from the early detection and prompt treatment of malaria cases, which reduces transmission; moreover, malaria vector control is in the nature of a public good. Interventions to prevent and treat STDs and to prevent the spread of HIV also have positive externalities. The nutrition component will address lack of knowledge that leads to inadequate maternal nutrition and inappropriate breast-feeding and weaning of young children; such information deficiencies cannot be addressed through market mechanisms, since there is no effective demand for this type of service. Similarly, the health education component will strengthen the public sector's ability to convey important health-related information to households on a wide variety of topics. And health policy development is of course an important public sector function. For non-communicable diseases, the case for prevention through health education is clear, and related policy measures such as taxation might also be considered. Since the public sector is currently providing most of the care for these diseases, cost-effective improvements in prevention and treatment can be justified in the shorter term and in the longer term will benefit private sector development as well. 22. Cost-Effectiveness. The project will support expanded implementation of the revised WHO malaria strategy introduced in 1993. Since adoption of the revised strategy, the number of malaria cases has declined significantly and program costs have been reduced. The program for prevention of epidemic spread of HIV/AIDS was developed with technical inputs from WHO and -6- other donors and draws on accumulated international experience to identify the most technically appropriate as well as cost-effective strategies. For nutrition, the present, expensive supplementary feeding program has not been effective. The project will support a much less costly community-based information/education approach that appears to be achieving good results in the IDA-supported Poverty Alleviation project. 23. Risks. There are three major implementation risks. First, the unsatisfactory experience of the first half of the IDA-assisted Health & Family Planning project raises questions about the implementation capacity of the MOH. To address this risk, in developing the project care has been taken to avoid earlier lack of "ownership" and project management problems. The Ministry has taken the lead in project development, thus enhancing ownership by those responsible for implementation. Care has been taken to strengthen the PMU and to provide technical assistance for project-supported programs, in order to ensure that adequate support for both project management and program implementation will be available. Good performance in the second half of the Health & Family Planning project provides grounds for believing that previous difficulties have been overcome. Second, provincialization of the health services raises the possibility that financial support for services will not be maintained. It is not yet possible to assess this risk fully, because decentralization is an ongoing process and the central MOH still provides most funds. Thus far, the quality of services does not appear to have suffered, and some examples of excellent provincial initiatives can be cited. Third, the nutrition and the STD/AIDS components depend to a significant extent on the involvement of NGOs. Although the NGO sector in Sri Lanka has substantial capacity, the MOH's record of cooperation with NGOs has not been strong. For the STD/AIDS program, this issue has been and will continue to be addressed by external agencies other than IDA channeling assistance to NGOs directly. For the nutrition program, the focus will be on organizing cooperation between the health system and available NGO resources at the divisional and community levels to achieve common health and nutrition objectives. Additionally, IDA's health policy dialogue must contend generally with lack of a constituency for health policy reform in the Health Ministry, and specifically with the Government's reluctance to consider wide-scale introduction of politically sensitive cost-recovery measures. These difficulties will be addressed through an ongoing dialogue linked to an agreed program of policy- related studies and pilot initiatives under the project. 24. Recommendation. I am satisfied that the proposed Credit will comply with the Articles of Agreement of IDA and recommend that the Executive Directors approve it. James D. Wolfensohn President by Gautam Kaji Attachments Washington, D.C. November 21, 1996 Schedule A Page 1 of 1 SRI LANKA HEALTH SERVICES PROJECT Estimated Project and Program Costs* (1996/97 - 2000/01) (LKR Million) (US$ Million) % % Total Foreign Base Local Foreign Total Local Foreign Total Exchange Costs A. Malaria 110.31 49.22 159.53 1.95 0.87 2.81 31 14 B. STD/HIV/AIDS 267.86 213.05 480.92 4.72 3.76 8.48 44 42 C. Nutrition 90.82 38.43 129.25 1.60 0.68 2.28 30 11 D. Non-Communicable Diseases 20.25 25.17 45.41 0.36 0.44 0.80 55 4 E. Program Support Health Policy Development 44.24 37.38 81.61 0.78 0.66 1.44 46 7 Management Information Systems 62.34 26.74 89.07 1.10 0.47 1.57 30 8 Health Education Bureau 90.41 65.15 155.56 1.59 1.15 2.74 42 13 Subtotal Program Support 196.98 129.26 326.24 3.47 2.28 5.75 40 28 F. Project Management 9.28 3.13 12.41 0.16 0.06 0.22 25 1 Total BASELINE COSTS 695.50 458.26 1,153.76 12.27 8.08 20.35 40 100 Physical Contingencies 36.18 32.04 68.22 0.64 0.57 1.20 47 6 Price Contingencies 150.32 86.41 236.15 0.70 0.43 1.13 38 6 Total PROJECT COSTS 882.01 576.71 1,458.71 13.61 9.07 22.68 40 111 *Includes an estimated US$2.0 million of taxes and duties. Program Financing Plan (US$ million) Local/Foreign/Taxes by Financiers (US$ million) IDA Government Total Amount % Amount % Amount % I. Foreign 8.23 100.0 0.0 0.0 8.23 36.4 II. Local (Excl. Taxes) 10.52 85.2 1.83 14.8 12.35 56.6 Ill. Taxes - - 2.02 100.0 2.02 8.9 Total Project 18.76 83.0 3.84 17.0 22.60 100.0 Schedule B Page 1 of 3 SRI LANKA HEALTH SERVICES PROJECT Summary of Proposed Proc urement Arrangements (US$ milliodi equivalent) Procurement Method International National Competitive Competitive Other N.I.F. Total Bidding Bidding A. Works AIDS/STD Complex 0.86 - - - 0.86 (0.80) (0.80) Hostel Construction - 0.28 - - 0.28 (0.26) (0.26) Minor Civil Works (diff. locations) - 1.47 - - 1.47 (1.37) (1.37) B. Goods Furniture - - 0.131 0.13 (0.10) (0.10) Computer Hard- and Software 0.64 - 0.11 - 0.75 (0.51) (0.09 (0.60) Misc. Equipment and Materials 0.92 0.30 0.32- - 1.54 (0.74) (0.28) (0.29) (1.31) Lab/Med Equipment/Consumables 0.45 - - - 0.45 (0.36) (0.36) Medical Supplies, Drugs and Contraceptives 4.00 - 0.38- 4.38 (3.80) (0.36) (4.16) C. Vehicles 2.55 - - - 2.55 (1.91) - (1.91) D. Consultancies International TA - - 0.39 - 0.39 (0.39) (0.39) National TA - - 0.88 - 0.88 (0.84) (0.84) E. Training National Training - - 1.40 - 1.40 (1.33) (1.33) Fellowships & Study Tours - - 0.47 - 0.47 (0.47) (0.47) F. Miscellaneous RM & E - - 1.97 - 1.97 (1.88) (1.88) Health Education Programs - - 1.83 - 1.83 (1.74) (1.74) Incremental Salaries - - - 0.22 0.22 Operation & Maintenance - - 1.355 1.65 3.00 (1.24) - (1.24) Total 9.42 2.05 9.25 1.87 22.60 (8.12) (1.91) (8.73) - (18.76) Note: Figures in parenthesis are the respective amounts financed by IDA. N.I.F. - Non-IDA financed I / Furniture will be procured through NS; small computer items and special supplies will be procured through NS. 2 / Small ofice equipment and other items (US$0.24 million), except for condom vending machines, vill be procured through NS; condom vending machines (US$0.08 million) will be procured through UNFPA. / Small amounts of drugs and medical supplies (US$0.10 million) will be procured through NS. Condoms and contraceptives (US$0.28 million) will be procured through UNFPA. 4 / TA for Health Policy Development (US$0.35 million) is expected to be contracted to an academic institute: MIS Development and Architectural Design (USSO 42 million) are expected to be contracted to firms; the remaining TA is expected to be contracted to individuals. / Spare parts and small maintenance equipment for vehicles, medical lab equipment, and computer hardware. Schedule B Page 2 of 3 Allocation and Disbursement of the Proposed IDA Credit (Million) Amount of the Credit Allocated % of (Expressed in Expenditures Category SDR Equivalent) to be Financed (1) Civil Works 1,450,000 85% (2) Goods 5, 680,000 100% of foreign expenditures, 100% of local expenditures (ex-factory cost) and 85% of local expenditures for other items procured locally (3) Consultants' services 2,080,000 100% and training (4) (a) HNE (Health and 970,000 100% Nutrition Education) activities (b) HNE materials 210,000 100% of foreign expenditures, 100% of local expenditures (ex-factory cost) and 85% of local expenditures for other items procured locally (5) RME (Research, Monitoring 1,250,000 100% and Education) activities (6) Unallocated 1,360,000 TOTAL 13,000,000 Schedule B Page 3 of 3 Estimated Schedule of Disbursements (US$ million) IDA Fiscal Year Amount per Cumulative Disbursement and Semester Semester Amount % Profile 1997 January - June 1997 2 1.51 1.51 8.0 0 1998 July - December 1997 1 1.52 3.03 16.2 10 January - June 1998 2 3.03 6.06 32.2 18 129 July - December 1998 1 2.15 8.21 43.7 26 January - June 1999 2 2.15 10.36 55.2 34 2000 July - December 1999 1 1.87 12.23 65.2 46 January - June 2000 2 1.87 14.10 75.2 58 2001 July - December 2000 1 1.26 15.36 81.9 66 January - June 2001 2 1.26 16.62 88.6 78 July - December 2001 1 1.07 17.69 94.2 82 January - June 2002 2 1.07 18.76 100.0 90 1 94 2 96 2004 1 98 2 100 Schedule C Page 1 of I SRI LANKA HEALTH SERVICES PROJECT Timetable of Key Processing Events (a) Time taken to prepare: 21 months (Identification through Appraisal) (b) Prepared by: Government of Sri Lanka benefiting from Japanese Policy and Human Resources Development Fund, with the assistance of IDA (c) First IDA mission: February 1994 (d) Appraisal mission: October 1995 (e) Negotiations: October 1996 (f) Planned date of effectiveness: February 1997 (g) List of relevant PCRs: Indonesia PCR 1994 Second Health Manpower Project; Bangladesh PCR 1993 Third Population and Family Health Project; Bangladesh PCR 1989 Second Population and Health Project; Indonesia PCR 1990 Provincial Health Project Project documents prepared by: Ms. Frances Plunkett (Task Manager); Mr. Chris Walker (Senior Public Health Specialist, EXCQA); Mr. Peter Heywood (Nutrition Specialist, HDD); Mr. James Herm (IEC Specialist, Consultant); Mr. Bruce Geisert (MIS Specialist, Consultant); Mr. Jay Satia (Management Specialist, Consultant); and Mr. Mark Spohr (Health Specialist, Consultant). Peer reviewers for the project were Ms. Judith McGuire (Nutrition Specialist, HDD); Mr. Michael Porter (Public Health Specialist, Consultant); and Mr. Jeffrey Hammer (Economist, PRDPE). Mission support was provided by Ms. Homira Nassery and production of the report was supported by Ms. Lydia Maningas. Mr. Paul Blay (Principal Operations Officer, SAIPH) assisted with processing; Ms. Mieko Nishimizu (Director, SAIDR) and Ms. Barbara Herz (Chief, SAIPH) have endorsed the Project. MOP Schedule D Page 1 of 2 Status of Bank Group Operations in SRI LANKA IBRD Loans and IDA Credits in the Operations Portfolio (As of September 30, 1996) Difference between Original amount in US$ millions expected Project Loan or Fiscal and actual ID Credit No. Year Borrower Purpose IBRD IDA Cancellations Undisbursed disbursements' Number of Closed Loans/Credits: 66 Active Loans LK-PA-10276 C17760 1987 GOSL AGRIC. RESEARCH 18.60 3.22 1.73 2.28 LK-PA-10308 Cl9090 1988 GOP SMALLHOLDER RUBBER 23.50 5.18 6.63 8.69 LK-PA-10332 C20430 1989 GOSL FORESTRY 1l 19.90 6.51 4.85 9.75 LK-PA-10343 C20720 1990 GOSL GENERAL EDUCATION 49.00 6.86 -0.59 LK-PA-10363 C21830 1991 GOSL 3RD ROADS 42.50 20.83 12.90 LK-PA-10368 C22310 1991 GOSL POVERTY ALLEVIATION 57.50 32.56 31.12 LK-PA-10373 C22490 1991 GOSL/CEB TELECOMS 11 57.00 37.02 36.34 LK-PA-10374 C22500 1991 GOSL SMI IV 45.00 5.63 2.76 LK-PA-10378 C22600 1991 GOSL IRRIG. REHAB. 29.60 23.90 14.09 LK-PA-I0386 C22970 1992 GOSL POWER DISTRIBUTION 50.00 43.01 32.77 LK-PA-10398 C23800 1992 GOSL 2ND AGR. EXTENSION 14.34 10.84 2.14 LK-PA-10409 C24420 1993 GOSL COMMUNITY WATER SUPP 24.30 15.17 4.47 LK-PA-10419 C24840 1993 GOSL PRIVATE FINANCE DEV. 60.00 15.97 -3.01 LK-PA-10420 C24950 1993 GOSL COLOMBO URB. TRANSP. 20.00 12.47 4.62 LK-PA-10467 C27570 1995 GOSL COL. ENVIRON. IMPROVE. 39.00 33.31 2.22 LK-PA-10517 C28800 1996 GOSL PVT. SECTOR INFRAS. DEV 77.00 76.35 LK-PA-42263 C28370 1996 GOSL TELECOM REG. & PUBL. 15.00 14.41 1.46 LK-PA-42266 C28810 1996 GOSL TEACH ED& DEPLOYMENT 64.10 63.50 0.28 TOTAL 0.00 706.34 14.91 425.04 162.29 Active Loans Closed Loans Total Total disbursed (IBRD and IDA) 291.95 1293.82 1585.77 Oflwhich repaid 0.00 154.27 154.27 Total now held by IBRD and IDA 691.42 1100.16 1791.58 Amount sold 0.00 3.59 3.59 Ofwhich repaid 0.00 3.59 3.59 Total undisbursed 425.05 1.63 426.68 a. Intended disbursements to date minus actual disbursements to date as projected at appraisal. Note: Disbursement data are updated at the end of the first week of the month. MOP Schedule D Page 2 of 2 Sri Lanka - Statement of IFC Investments Committed and Disbursed Portfolio As of September 30, 1996 (In US Dollar Millions) Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 1980/84/96 Lanka Orix 10.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1981 Lanka Hotels 0.00 0.64 0.00 0.00 0.00 0.64 0.00 0.00 1985 Lanka Orix 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1988/95 Union Assurance 0.00 0.98 0.00 0.00 0.00 0.98 0.00 0.00 1992 CKN Fund Mgmt. 0.00 0.06 0.00 0.00 0.00 0.06 0.00 0.00 1992 Pyramid Trust 0.00 0.25 0.00 0.00 0.00 0.25 0.00 0.00 1993/94 Lanka Cellular 0.00 2.03 0.00 0.00 0.00 2.03 0.00 0.00 Total Portfolio: 10.00 3.96 0.00 0.00 0.00 3.96 0.00 0.00 Approvals Pending Commitment Loan Equity Quasi Partic 1996 ASIA POWER 0.00 0.00 0.00 0.00 Total Pending Commitment: 0.00 0.00 0.00 0.00 Schedule E Sri Lanka at a glance POVERTY and SOCIAL Sri South Low. Lanka Asia Income Development diamond* Population mid-1994 (millions) 17.9 1,220 3,176 Life expectancy GNP per capita 1994 (US$) 640 320 390 GNP 1994 (billions US$) 11.4 390 1,239 Average annual growth, 1990-94 Population (%) 1.3 1.9 1.8 Labor force (%) 1.6 2.0 1.8 GNP Gross per primary Most recent estimate (latest year available since 1989) capit enrollmen Poverty: headcount index (% of population) 22 .. a Urban population (% of total population) 22 25 26 Life expectancy at birth (years) 72 61 65 Infant mortality (per 1,000 live births) 18 73 53 Child mainutrition (% of children under5) 38 62 38 Access to safe water Access to safe water (% of population) 60 70 67 Illiteracy (% of population age 15+) 12 54 41 Gross primary enrollment (% of school-age population) 106 100 106 - Sri Lanka Male 106 111 112 --Low-income group Female 105 90 100 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1975 1985 1994 1995 conomic ratios GDP (billions USS) 3.8 6.1 11.7 12.8 Gross domestic investment/GDP 15.6 23.4 27.0 25.9 Openness of economy Exports of goods and non-factor services/GDP 27.5 25.6 33.7 33.6 Gross domestic savings/GDP 8.1 11.7 15.0 14.4 Gross national savings/GDP 7.4 14.0 19.0 18.0 Current account balance/GDP -4.9 -9.8 -8.0 -7.9 Savings I Investment Interest payments/GDP 0.5 1.9 1.9 2.1 Total debt/GDP 21.5 58.2 76.0 78.8 Total debt service/exports 26.1 16.5 11.1 11.6 Present value of debt/GDP .. .. 41.5 Present value of debt/exports .. .. 101.6 Indebtedness 1975-84 1985-95 1994 1995 1996-04 (average annual growth) - Si Lanka GDP 5.7 4.3 5.1 5.5 4.9 - Low-income group GNP per capita 3.7 3.1 4.0 3.9 3.7 Exports of goods and nfs 4.0 7.3 8.4 6.7 7.3 1 STRUCTURE of the ECONOMY 1975 1985 1994 1995 (6 of GDP) Growth rates of output and investment (%) Agriculture 30.4 27.7 24.0 23.3 5 Industry 26.4 26.2 24.7 24.7 10 Manufacturing 20.1 14.7 15.6 15.6 5 Services 43.2 46.1 51.4 52.1 o -5 9 91 92 93 94 9S Private consumption 82.6 78.3 75.6 75.7 -10 General government consumption 9.3 10.1 9.4 10.0 Imports of goods and non-factor services 35.0 37.3 45.7 45.2 -GI -o-GDP 1975-84 1985-95 1994 1995 (average annual growth) Growth rates of exports and imports (%) Agriculture 4.3 1.8 3.3 2.0 20 Industry 5.3 6.2 8 1 5.0 5 Manufacturing 4.1 6.9 3.0 5.0 Services 6.7 4.7 74 6.4 Private consumption 7.0 3.8 5.5 4.7 0 General government consumption 3.0 2.3 7.4 11.0 90 91 2 93 94 Gross domestic investment 13.4 4.3 8.9 0.9 -10 Imports of goods and non-factor services 11.1 5.0 11.6 3.4 Gross national product 5.4 4.4 5.5 5.1 -Eports Imports Note: 1995 data are preliminary estimates. The diamonds show four key indicators in the country (in bold) compared with its income-group average. If data are missing, the diamond will be incomplete. Schedule E Sr Lank PRICES and GOVERNMENT FINANCE 1975 1985 1994 1995 Inflation (%) Domestic prices (% change) 25 Consumer prices 6.6 1.5 9.7 10.4 20 Implicit GDP deflator 4.9 2.8 9.7 9.5 15 10 Government finance s (% of GDP) a - - - Current revenue . 22.0 18.9 20.4 92 93 94 95 Current budget balance .. 2.2 -3.0 -2.1 Overall surplus/deficit .. -11.5 -10.5 -10.4 TRADE (millions US$} 1975 1985 1994 1995 Export and import levels (mill. US$) Total exports (fob) .. 1,333 3,189 3,472 6,000 Tea . 442 420 383 sX0 Other agricultural goods .. 94 278 295 Manufactures . 233 2,131 2,440 4,00D Total imports (cif) .. 1,948 4,768 5.145 3 ,000 Food .. 217 589 631 2000 Fuel and energy .. 404 296 321 Capital goods .. 382 1,358 1,430 Export price index (1987=100) . 96 119 121 89 90 91 92 93 94 95 Import price index (1987=100) .. 86 148 155 Terms of trade (1987=100) .. 111 80 78 iDExports eaimports BALANCE of PAYMENTS 1975 1985 1994 1995 (millions US$) Curren account balance to GDP ratio (%) Exports of goods and non-factor services 632 1,561 3,944 4,308 o Imports of goods and non-factor services 804 2,296 5,343 5,773 - D 1 92 93 95 Resource balance -172 -734 -1,399 -1,464 2 Net factor income -18 -127 -161 -225 Net current transfers 3 266 627 679 Current account balance, - before official transfers -187 -596 -933 -1,010 Financing items (net) 161 481 1,282 918 Changes in net reserves 26 115 -349 92 ,I Memo: Reserves including gold (mill. US$) 57 472 2,035 1,910 Conversion rate (local/JS$) 7.0 27.2 494 52.1 EXTERNAL DEBT and RESOURCE FLOWS 1975 1985 1993 1994 (millions USS) Total debt outstanding and disbursed 815 3,540 6,793 7,811 IBRD 36 61 58 54 IDA 39 397 1,222 1,339 GA Total debt service 169 320 418 405 F 50754 B IBRD 6 9 15 13 547 1339 IDA 0 3 15 16 C Composition of net resource flows 17 Official grants 56 151 197 160 Official creditors 61 297 265 289 D Private creditors -22 44 -85 -66 E 1260 Foreign direct investment 0 26 195 166 3487 Portfolio equity 0 0 0 112 World Bank program Commitments 30 137 86 0 A - IBRD E - Bilateral Disbursements 19 79 130 78 B - IDA D - Other multilateral F - Private Principal repayments 3 5 15 15 C - IMF G - Short-term Netflows 16 74 115 63 Interest payments 3 8 15 15 Net transfers 14 66 100 48 International Economics Department 3/5/96  г о � � ш и а а �  IBRD 28019 80° 81° 82° SRI LANKA HEALTH SERVICES PROJECT o SELECTED CITIES @ PROVINCE CAPITALS K honochch~ nO NATIONAL CAPITAL ulittivu MAIN ROADS RAILROADS DISTRICT BOUNDARIES PROVINCE BOUNDARIES 9o- -9 \Manner Vavuniya0 1 2 3 4 5 6 KILOMETERS OTrincomalee Anuradhopura Nochchiyagan a Talawa' TambuHegamq 0cc Eppawala. PuftalamnQ, Gaineoo i8. 8 Weikonda Sidhdhapuro 0PalonnarawKck\ i Galki,agama Mnompitiya ORandiyonu ara Äralageinwila aau atte'Satticaloa Dehite-9 Kan ya Kurunegola® Motale Girandurukolte Kandy,. ahlyangane Ampar mpaha adulla 7 Nuwara Eliya'- COLOMBOW' b Monaragala Rotnopuro Kalutara The houndries, colors, bilipitiya denominations ond any t l other 'nformation shown on ths map do not ml,on the paoo The Worl Bank Group ony judgmnt on the läga status of any territory Hambontota or ony endorsement or cceptance of such -°boundones Gl ° 6' 6- 80 Matora 81° 82° MAY 1996   I MAGI NG Report No: P- 6858 CE Type: MOP