Niger - Health Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 15818 IMPLEMENTATION COMPLETION REPORT REPUBLIC OF NIGER HEALTH PROJECT (Credit 1668-NIR) June 25, 1996 Population and Human Resources Operations Division West Central Africa Department 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.  CURRENCY EQUIVALENTS (June 1995) Currency Unit = CFA franc (CFAF) US$ = 500 CFA franc CFAF I million= US$2,000 SDR I = US$1.496 WEIGHTS AND MEASURES Metric System FISCAL YEAR OF BORROWER October 1 - September 30 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARIEP Antennes Regionales de l'Education pour la Sante (Regional Satellites for Health Education) BDRN Banque de Developpement de la Republique du Niger (Niger Development Bank) CNAT Centre National Anti-Tuberculeux (Anti-Tuberculosis National Center) DCA Development Credit Agreement DEP Direction des Etudes et de la Programmation (Directorate of Studies and Programming) DPhL Direction des Pharmacies et Laboratoires (Directorate of Pharmaceuticals and Laboratories) EPI Expanded Program of Immunization EPS Education pour la sante (Health Education) FAC Fonds d'Aide et de Cooperation (French Bilateral Aid Agency) FP Family Planning FED European Development Fund HIV Human Immuno-deficiency Virus MCH Maternal and Child Health MOPH Ministry of Public Health MOPHSA Ministry of Public Health and Social Affairs NGO Non-governmental Organization ONPPC Office National des Produits Pharmaceutiques et Chimiques (National Chemical and Pharmaceutical Products Bureau) PMI Protection maternelle et infantile (Mother and Child Health) PMU Project Management Unit SDR Special Drawing Rights STD Sexually Transmitted Disease WHO World Health Organization UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development The CFA franc is tied to the French franc (FF) at a ratio of FFI to CFA franc 100 following the January 12, 1994 devaluation of the CFA franc from a ratio of FF I to CFA franc 50. The French franc is currently floating.  FOR OFFICIAL USE ONLY TABLE OF CONTENTS PREFACE EVALUATION SUMMARY ..............................................................i PART I: PROJECT IMPLEMENTATION ASSESSMENT ..................................................1 I. INTRODUCTION .I A. Macroeconomic Setting .1 B. Bank's Role in the Sector .1 II. PROJECT OBJECTIVES .. A. Original Project Objectives .1 B. Project Components .2 C. Credit Covenants and Special Agreements .2 D. Evaluation of Project Objectives .3 III. IMPLEMENTATION EXPERIENCE AND RESULTS .3 A. Assessment of Project's Success and Sustainability .3 B. Summary of Costs .5 C. Financing Arrangements .5 D. Implementation Schedule .5 E. Analysis of Key Factors Affecting Implementation .5 F. Assessment of the Bank and the Borrower's Perfornance .6 G. Assessment of Project's Outcome .7 IV. SUMMARY OF FINDINGS, FUTURE OPERATIONS AND KEY LESSONS LEARNED .............................................................8 A. Findings of Project Implementation Experience ......................................................8 B. Future Operations and Sustainability ....................... ...............................9 C. Lessons for Future Projects in the Sector in Niger ...................................................9 PART II: STATISTICAL TABLES ................. ........................................... 11 APPENDICES: A. Mission's Aide-M6moire B. Borrower's Contribution to the ICR C. Map IBRD 19460R This docunent his a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed wiLhout World Bank authorization.  1
 IMPLEMENTATION COMPLETION REPORT REPUBLIC OF NIGER HEALTH PROJECT (Credit 1668-NIR) PREFACE This is the Implementation Completion Report (ICR) for the Health Project in Niger, for which Credit 1668-NIR was approved on March 20, 1986, in the amount of SDR 25.1 million (US$27.8 million equivalent). The Credit became effective on November 3, 1986. Due to various factors, including the January 1994 devaluation, which had an impact on various components of the project, the project was closed on June 30, 1995, 24 months behind its scheduled closing date of June 30, 1993. Of the total negotiated credit of SDR 25.1 million, SDR 24.8 million (US$37.1 equivalent in 1995) has been disbursed and SDR 0.32 million has been canceled, of which SDR 0.3 million due to misprocurement; and SDR 0.02 million due to unused credit funds at closing. The ICR was prepared by a team led by Ms. Denise Vaillancourt (Task Manager, AF4PH) of the Africa Region and composed of several members of the completion mission: Ms. Johanne Angers (Operations Analyst, AF4PH), Ms. Regina Amadi (Consultant), and Mr. Aboubacar Magassouba (Consultant). The ICR was reviewed by Messrs. I. Porter, Division Chief (AF4PH), S. Singh, Acting Operations Adviser (AF4DR), and A. Cisse, Country Economist (AF4CO). The Borrower submitted its input to the ICR in a report dated May 16, 1996 (Appendices). The Borrower's acceptance of the ICR was received in April 1996 during an appraisal mission of the Second Health Project which is recorded in the mission's aide-memoire. Preparation of this ICR was started during the Bank's completion mission in June/July 1995. It is based on the Staff Appraisal Report (SAR), the Development Credit Agreement (DCA), the Borrower's Progress reports, Bank's supervision reports, correspondence between the Bank and the Borrower, relevant records, workshops with the various stakeholders and beneficiaries, and discussions with key Government officials, stakeholders and Bank staff. The Borrower participated in the preparation of the ICR by contributing views reflected in the mission's Aide-Memoire, by organizing and supporting a series of evaluations of the project's preparation and implementation stages, which reflected a spectrum of perspectives, including those of communities, service providers, MOPH technical and managerial staff at the central and departmental levels, the unions, and an independent evaluator. During the Bank's completion mission, the Government also organized an evaluation workshop, at which the various perspectives were presented and discussed. In addition, the Government reviewed and commented on the draft ICR.   IMPLEMENTATION COMPLETION REPORT REPUBLIC OF NIGER HEALTH PROJECT (Credit 1668-NIR) EVALUATION SUMMARY BANK'S ROLE IN THE COUNTRY AND SECTOR 1. Niger, a large land-locked country, is one of the poorest countries in the world, with social indicators which are among the lowest in the Sahelian countries. It had a population of about 8.7 million in 1994, about half of which is less than 15 years old, and which is growing at about 3.3 percent annually. Subsistence agriculture has traditionally dominated the economy, with livestock also providing an important source of income and export receipts. During the uranium boom of the late 1970s, Niger went through a period of rapid growth, during which the public sector assumed an important role in the economy. In 1981, however, uranium prices plummeted and Niger's production decreased. Moreover, poor economic policies pursued by the Government in the boom era left in their wake structural deficiencies in the economy. With assistance from the Bank, in FY86 the Government prepared a structural adjustment program aimed at restoring and subsequently maintaining minimum acceptable growth in the medium and longer term. (paras 1. 1-1.2). 2. The health project (Credit 1668-NIR) marked the beginning of the Bank's involvement in Niger's health sector and was designed to support the Government's structural adjustment objectives at the sectoral level: (a) more efficient use of resources; (b) mobilization of resources through cost recovery; and (c) policy reform to improve overall efficiency and effectiveness of the health sector (para. 1.3). PROJECT OBJECTIVES AND COMPONENTS 3. Original Project Objective. The objective of the project was to assist the Borrower to improve the performance of its public health sector through: (a) adoption of appropriate mechanisms for investment planning and recovery of costs; (b) design and implementation of policies in the fields of population, nutrition, maternal and child health care, and control of communicable diseases including, inter alia, malaria and diarrhea; and (c) implementation of training programs for health personnel (para. 2.1). 4. Project Components. Part A of the project supported health sector adjustment aimed at strengthening financial and operational management, improving basic health services, increasing cost recovery, improving essential drugs availability and developing population and nutrition policies. Part B supported improvements in basic health and family planning services through activities to: (a) improve facilities and strengthen priority programs; (b) develop health education and community initiatives in health and nutrition; and (c) develop health manpower (para. 2.2). 5. Credit Covenants and Special Agreements. Conditions of effectiveness were as follows: (a) through the intermediary of the National Chemical and Pharmaceutical Products Bureau (ONPPC), establish an account in a commercial bank to operate a revolving fund for the replenishment of chloroquine for the anti-malaria program; (b) establish and adequately staff a Project Management Unit (PMU) and set up an appropriate project accounting system; and (c) establish a local advance account and deposit an initial amount of CFA franc 30 million. All conditions of effectiveness were complied  ii with and the project was declared effective on November 3, 1986 (para. 2.3). Special covenants or agreements were included to help promote achievement of project objectives (Table 10). Two amendments were made to the Development Credit Agreement (DCA). In October 1987, at the Government's request, the DCA was amended to assist in the financing of a population census. An allocation of 750 million CFA franc equivalent was made available in two tranches deposited in a special account (Special Account B) managed by the Ministry of Plan. Another amendment was made in December 1993 to provide for 100 percent IDA financing of the Project Management Unit's (PMU) operating costs (para. 2.5). 6. In April 1994 in view of the limited financial resources remaining in the credit, agreement was reached on the transfer of activities foreseen under this project to the ongoing population project (Cr. 2630-NIR). Activities transferred to the population project supported the following programs: (a) nutrition; (b) health education; (c) social development support; (d) expanded program of immunization (EPI) and social mobilization; (e) mother and child health; and (f) family planning (para. 2.4). 7. Evaluation of Project Objective. The project's objective was consistent with Niger's strategy for economic recovery and development, which was based on adoption of a structural adjustment program, and was responsive to Niger's priority health problems. However, the objectives were ambitious, covering a wide range of sector issues simultaneously at the different levels of the health sector (policy, design and delivery of services, manpower development, infrastructure, etc.) in a country with very little management and institutional capacity and in which the Bank had little or no sector operational experience. Nevertheless, the objectives were, on the whole, well targeted to produce the desired results i.e., policy reform and its application and implementation nationwide, and improvements in priority services. IMPLEMENTATION EXPERIENCE AND RESULTS 8. Assessment of Project's Success and Sustainability. The objective of assisting the Government in introducing policy reform in the health sector within the overall framework of its structural adjustment program was substantially achieved. Studies aimed at improving sector policy were carried out and were instrumental in the development and implementation of key reform measures, including: according hospitals greater financial and managerial autonomy and prompting improvements in resource mobilization and hospital management; adoption of a law in June 1995 on cost recovery for the non-hospital sector; increased participation of communities in financing and management of health services; development of a sector plan, which espouses the district (decentralized) health approach. Most program objectives were also substantially met. Project investments contributed to improvements in the quality and coverage of basic health services. Program objectives for vaccination coverage and training were not, however, fully achieved (paras. 3.1-3.4). 9. Prospects for the sustainability of project interventions are good, thanks both to its success in building management capacity and to its success in demonstrating the potential for mobilizing resources through cost recovery. The experience of designing and carrying out studies and operational research and of the design and implementation of policy reform emanating from these studies and research contributed to significant improvements in the Ministry of Public Health (MOPH) capacity for sector strategic management. Capacity was also strengthened through long-term training provided under the project in planning, management, and public health and through the creation of directorates responsible for health sector planning and pharmaceutical policy reform (para. 3.5). 10. Summary of Costs and Financing Arrangements. At appraisal, the total cost of the project (Table 7A) was estimated at US$29.3 million equivalent (net of taxes and duties). IDA's contribution at appraisal was estimated at US$27.8 million and the Government's participation at US$1.5 million. Total  iii credit amount disbursed at ICR preparation (US$37.1 million) was higher than anticipated at appraisal due to changes in the US dollar/SDR exchange rate (Table 4). The Government's contribution of US$1.6 million equivalent, was higher than anticipated at appraisal. USAID contributed the equivalent of US$1.2 million under a Health Sector Grant to finance five studies planned under Part A of the project. In May 1994 the Kingdom of the Netherlands granted the equivalent of US$770,000 to provide budgetary support to the project (paras. 3.6-3.8). 11. Implementation Schedule. Project preparation was fairly long: five years elapsed between the first reconnaissance mission (May 1980) and the appraisal mission (June 1985) (Table 3). Project effectiveness was delayed from July 14, 1986 to November 3, 1986 due to some delays in meeting conditions of effectiveness. The original closing date was June 30, 1993, but the Credit was not closed until June 30, 1995, after two extensions. An outstanding balance of SDR 0.02 million (about US$0.03 million equivalent) was canceled effective November 14, 1995 (para. 3.9). 12. Key Factors Affecting Implementation. Three categories of factors affected the Government's capacity to implement the project: political events; financial constraints; and organizational/managerial constraints. The political events, which occurred during the life of the project, caused activities in all sectors to slow down and even to come to a standstill. The high turnover of Health Ministers during the life of the project (eight Ministers in nine years) caused numerous delays, as each new Minister revisited and questioned project objectives and implementation progress. From project launch through 1991 the PMU was plagued with serious management and financial problems, and with a high turnover of project coordinators, both of which caused considerable delays in project implementation. Financial constraints included lack of counterpart funds and cash flow problems. These constraints were mitigated through an amendment of the DCA that allowed 100 percent financing of operating costs of the PMU and through a Dutch Grant used to finance local costs. The recruitment in 1992 of a new project coordinator and a technical assistant for the PMU enhanced project implementation and accelerated achievement of project objectives (paras. 3.10-3.12). Management/organizational capacity to implement a project of this magnitude and complexity was inadequate. The highly centralized structure of the MOPH, heavy bureaucratic and administrative procedures and the vertical structure of health programs left decentralized administration and services with, at best, a very passive role in project implementation. 13. Assessment of the Bank's and the Borrower's Performance. The Bank adopted a comprehensive approach by placing the project in the context of Niger's health reform, which, in turn, was part of the overall structural adjustment program of the country. Project identification, appraisal, design, and supervision were satisfactory. However, institutional capacity to carry out a project of this nature was underestimated. The Bank did not devote adequate resources to field supervision, both in terms of quantity and in terms of adequate skills mix to address and resolve the several key issues to project implementation, particularly those concerning financial management (para. 3.13). The Government of Niger's performance in project preparation was satisfactory. The Government's commitment to reform in general, and to the project in particular, was largely responsible for the successes/impacts recorded in spite of Niger's limited management and institutional capacity, and financial resources. Overall rating of the project implementation fluctuated between 2 and 3 (paras. 3.14- 3.15). 14. Assessment of the Project Outcome. Significant advances were made with project assistance, particularly with regard to its contributions to policy formulation and reform and to the strengthening of capacity in planning and service delivery (paras. 3.16-3.18). Among the most noteworthy of project outcomes are: the production of a coherent and strategic National Sector Development Plan, hospital reform, adoption of a cost recovery law, and, in selected areas, improved quality of curative and preventive services, increased capacity for receiving and treating patients, intensification of health  iv information education and communication activities and increased involvement of communities in health sector activities. Lack of baseline data and weak monitoring and evaluation did not permit an assessment of the project's impact on health status in areas receiving project assistance. IMPORTANT FINDINGS OF PROJECT IMPLEMENTATION EXPERIENCE 15. Investments in service quality improvements (infrastructure, program development, and training) were not fully exploited or consolidated due to a lack of technical support and follow-up that should have been provided through the implementation of a well-designed supervision program. Likewise, a lack of follow-up and evaluation of training investments left MOPH incapable of ensuring optimal utilization of newly acquired skills. The lack of a clear policy on preventive activities and on health education caused them to receive low attention and priority under the project, despite the importance attributed to them in project design and documentation. Greater emphasis on all of these--supervision, training evaluation, policy on prevention and promotion--would have contributed to enhanced service quality (paras. 4.1- 4.2). FUTURE OPERATIONS 16. The application of lessons learned in future sector investments were extensively discussed with the Government and various other stakeholders as these were an important focus of the participatory evaluation process. It is encouraging to note that these lessons are reflected, both by the Government and by the Bank, into their strategies for the development and implementation of future health operations in Niger. The Health Sector Development Plan for the period 1994-2000 captures the essence of a number of key lessons learned, including: (a) the need to decentralize sector management and administration and integrate more fully programs and services through the creation and support of health districts; (b) the need to strengthen capacity in strategic management and management of resources; and (c) the need to identify and utilize more fully the existing (often untapped) potential of the various stakeholders and contributors to health sector performance. Project achievements in capacity building and in the mobilization of resources will contribute to ensuring the sustainability of this and future interventions (paras. 4.5-4.7). LESSONS FOR FUTURE PROJECTS IN THE SECTOR IN NIGER 17. . Three main lessons are learned from this project. First, Project objectives should be sufficiently modest and based on a sound knowledge of the existing situation. Clear targets and indicators should be set at the outset. A rolling planning process would accommodate both more rigor and more flexibility during project implementation. 18. Second, inadequate management/institutional capacity is found to be more constraining of good sector performance than resource availability. More effort must be devoted to develop capacity in management of resources and in decentralized strategic sector management in order to improve sector effectiveness. In addition, decentralization and integration of programs and services and a clarification and complementarity of roles and responsibilities at all levels of the health system (including those of stakholders outside of the public health system) are also crucial to sector effectiveness. Implementation experience also revealed the importance of integrating and "mainstreaming" project activities more fully into MOPH operations, both at central and decentralized levels. 19. Third, financial participation of the communities has caused them to be more involved in, and more demanding of, health service delivery, prompting the public service to strive to be more client- oriented. This process should be nurtured and supported in future operations (paras. 4.3-4.4).  IMPLEMENTATION COMPLETION REPORT REPUBLIC OF NIGER HEALTH PROJECT (Credit 1668-NIR) PART I: PROJECT IMPLEMENTATION ASSESSMENT I. INTRODUCTION A. Macroeconomic Setting 1.1 Niger, a large land-locked country covering an area of 1.27 million km2 and 600 km away from the closest seashore, is one of the poorest countries in the world. It had a population of about 8.7 million in 1994, about half of which is less than 15 years old, and which is growing at about 3.3 percent annually. The country's social indicators are among the lowest in the Sahelian countries. Subsistence agriculture has traditionally dominated the economy with millet and sorghum taking up to 80 percent of the cultivated area. Livestock also provides an important source of income and export receipts. Except for the Sahelian drought periods, the country has been self-sufficient in staple food production. 1.2 The discovery of large uranium deposits in the late 1960s triggered the development of an important mining sector which expanded rapidly under highly favored conditions in the world market during the late 1970s. At that time, uranium became the country's principal foreign exchange earner amounting to 70 percent of exports and a major source of Government revenues (around 12 percent). As a result, Niger went through a period of rapid growth during which the public sector assumed an important role in its economy. Unfortunately the uranium boom ended in 1981, when prices plummeted and Niger's production decreased. Poor economic policies pursued by the Government in the boom era left in their wake structural deficiencies in the economy. Financing constraints, exacerbated by overspending during the uranium boom, highlighted the urgent need to address the underlying structural issues of the economy. The Government, with assistance from the Bank, prepared a structural adjustment program (FY86) aimed at restoring and subsequently maintaining minimum acceptable growth in the medium and longer term. The program included policy reforms to increase the efficiency of existing investments, improve resource allocation and develop the resource base of the country. B. Bank's Role in the Sector 1.3 The Health Project (Credit 1668-NIR) marked the beginning of the Bank's involvement in Niger's health sector and was designed to support the Government's structural adjustment objectives at the sectoral level: (a) more efficient use of resources; (b) mobilization of resources through cost recovery; and (c) policy reform to improve overall efficiency and effectiveness in the health sector. Prior to its effectiveness date of November 3, 1986, 28 IDA credits had been approved for Niger for a total amount of US$363.7 million equivalent, including a structural adjustment credit in the amount of US$60 million equivalent. II. PROJECT OBJECTIVES A. Original Project Objective 2.1 The objective of the project was to assist the Borrower in improving the performance of its public health sector through: (a) adoption of appropriate mechanisms for investment planning and  2 recovery of costs; (b) design and implementation of policies in the fields of population, nutrition, maternal and child health care, and control of communicable diseases including, inter alia, malaria and diarrhea; and (c) implementation of training programs for health personnel. B. Project Description and Components 2.2 Part A of the project supported health sector adjustment through: (a) the financing of studies aimed at strengthening financial and operational management, improving basic health services, increasing cost recovery, improving essential drugs availability and developing population and nutrition policies; and (b) the funding of proposals for implementing policies emanating from the above- mentioned studies or operational experience. Part B supported improvements in basic health and family planning services through activities to: (a) improve facilities and strengthen priority programs; (b) develop health education and community initiatives in health and nutrition; and (c) develop health manpower. C. Credit Covenants and Special Agreements 2.3 Special covenants or agreements were included to help promote achievement of project objectives (Table 10). Conditions of effectiveness were as follows: (a) through the intermediary of the National Chemical and Pharmaceutical Products Bureau (ONPPC), establish an account in a commercial bank to operate a revolving fund for the replenishment of chloroquine for the anti-malaria program; (b) establish and adequately staff a PMU and set up an appropriate project accounting system; and (c) establish a local advance account and deposit an initial amount of CFA franc 30 million. All conditions of effectiveness were complied with and the project was declared effective on November 3, 1986. Conditions of disbursement were as follows: (a) disbursement against implementation of proposed activities, based on study results or operational experience derived from the project, were conditioned upon IDA's approval of plans of action prepared by the Government in collaboration with IDA and supported by a feasibility study; and (b) disbursement against purchases of vaccines were conditioned on IDA's approval of the proposed target coverage for the following year's immunization campaign. 2.4 Agreed Changes. In April 1994 in view of the limited financial resources remaining in the Credit, agreement was reached that certain activities foreseen under the project would be undertaken by the ongoing population project (Cr. 2630-NIR), since these activities were also programmed. The activities programmed under the health project and transferred to the population project were as follows: (a) nutrition program, specifically, training of professional staff, literacy, and dissemination of the national policy; (b) health education program; (c) social development support program; (d) EPI and social mobilization program; (e) mother and child health program; and (f) family planning program. Five of the six studies planned under Part A of the project were ultimately financed under a USAID Health Sector Grant but remained an integral part of project activities. Responsibility for the management and execution of policies studies was given to the Ministry of Public Health and Social Affairs (MOPHSA) rather than the Ministry of Plan (MOP), as originally planned. A number of other program activities were ultimately supported under the project including: activities related to HIV/AIDS, purchase of anti- tuberculosis drugs, a survey on youth, and the population census. The project's closing date was extended in 1993 and 1994. 2.5 Amendments. Only two amendments were made to the Development Credit Agremment (DCA). In October 1987, at the Government's request, the DCA was amended to assist in the financing of a population census. An allocation of 750 million CFA franc equivalent was made available in two tranches deposited in a special account (Special Account B) managed by the Ministry of Plan (MOP).  3 Another amendment was made in December 1993 to provide for 100 percent IDA financing of the PMU's operating costs. D. Evaluation of Project Objectives 2.6 The project's objectives were consistent with the Bank's and Niger's strategy for economic recovery and development, which was based on adoption of a structural adjustment program; and the objectives were responsive to pressing needs of the sector. However, the objectives--and the consequent project design--were ambitious, covering a wide range of sector issues simultaneously at the different levels of the health sector (policy, design and delivery of services, manpower development, infrastructure, etc.) in a country with very little management and institutional capacity and in which the Bank had little or no sector operational experience (Table 2). Objectives were neither sufficiently specific nor clearly understood by those responsible for their realization. Considering that the project was the Bank's first health investment in Niger, preparation, especially objective setting, could have benefited from (a) a better assessment of the Borrower's capacity to implement the project; (b) more specific performance criterialindicators for monitoring achievement of project objectives and implementation, which should have been established jointly with Ministry of Public Health (MOPH) staff; (c) better baseline data for setting realistic objectives and indicators; and (d) a more serious consideration of other donors' interventions in the sector (USAID, UNFPA, WHO, UNICEF, FAC). This would have enhanced donor coordination in the health sector in Niger. Nevertheless, the objectives were, on the whole, well targeted to produce the desired results i.e., policy reform and its application and implementation nationwide, and improvements in priority services. Furthermore, project design (particularly for Part A of the project) was flexible, allowing for lessons to be drawn and immediately applied during the life of the project. 1II. IMPLEMENTATION EXPERIENCE AND RESULTS A. Assessment of Project's Success and Sustainability 3.1 Sector Policy Objectives. The objective of assisting the Government in introducing policy reform in the health sector within the overall framework of its structural adjustment program was substantially achieved. Studies aimed at improving sector policy were carried out and were instrumental in the development and implementation of key reform measures (Table 6). National hospitals were transformed into etablissements publics a caractere administratif and, as such, were accorded greater financial autonomy. This reform has prompted improvements both in resource mobilization and in hospital management practices. In June 1995 the National Assembly adopted a law on cost recovery for the non-hospital (primary health care) sector, which encourages resource mobilization for primary health care and improved management of resources and services. Pilot studies have already demonstrated, as is the case in other countries, that community participation in the financing of health services and in the management of collected revenues provides communities with some leverage in their demand for quality services and incites the health system to be more client oriented and thus improve that quality. Studies and operational research carried out under this component contributed to an improved appreciation of the strengths and weaknesses of the current health system and to the development of policies on nutrition, drug supply, malaria control and diarrheal disease control. These contributions are fully reflected in the Government's national health sector development plan for the period 1994-2000, which provides a coherent framework for sector reform, and which has been instrumental in attracting and effectively coordinating external assistance to the sector. 3.2 Program Objectives. Project investments to upgrade the technical skills of service providers and to strengthen infrastructure and technical equipment of selected health facilities contributed to  4 improvements in the quality and coverage of basic health services. In addition, a number of priority health programs and services were strengthened both through improved strategic management and through direct support to implementation activities. Notable achievements in this regard include: the creation of an interministerial committee for malaria control; the definition of a national, multisectoral nutrition policy; the creation of a national program on diarrheal disease, strengthening of the health education program at the central and departmental levels; the initiation and successful implementation of community participation in health and nutrition activities. Among the quantifiable results of these interventions (presented in detail in Table 5) are: greater awareness and action on the part of communities for understanding and taking charge of their own health issues and problems; an increase in immunization rates and in prenatal consultations; and improvements in maternal health indicators. 3.3 Not all program objectives were fully met, however. Training achievements fell short of targets (Table 5). A supervision plan was developed, but never implemented, with funds from Part A of the project, as had been envisaged. While departmental level health directorates received equipment and material for health education activities, these are not being effectively used. No meetings of donors was held throughout the life of this project in an effort to coordinate aid to the sector as was provided for in the DCA. The revolving fund for chloroquine never functioned properly. 3.4 Physical Objectives. The project has been particularly successful in rehabilitating the number of health facilities planned at appraisal. Of the 113 health facilities slated for rehabilitation under the project, 110 were rehabilitated and equipped in the seven departments covered by the project (Agadez, Diffa, Dosso, Maradi, Tahoua, and Zinger, and in the metropolitan area of Niamey). The civil works program suffered a slow start when many factors causing delays in the implementation of the program were encountered. These factors were delays in the planning of the implementation of the civil works program, in carrying out key studies and launching the bidding process, in starting up works activities for some contractors due to their weak financial and/or technical capacities, the lack of understanding of the World Bank's procurement procedures, and the lack of supervision and monitoring. The collapse of the Niger Development Bank (BDRN) in 1991/1992 was also a factor in some of the delays in construction due to a freeze of accounts held by a few contractors. Fortunately, the program gained momentum during the second phase of project implementation (from 1992). A civil works engineer was recruited as a technical assistant to the PMU to ensure coordination and supervision of the activities. The breakdown of the 110 health facilities supported by the project is as follows: 51 rural dispensaries, 23 maternities, four medical posts, three medical centers, and 29 sanitaries blocks were rehabilitated and equipped. Furthermore, many other types of facilities essential to activities related to the health sector have received support from the credit, including: 20 houses for medical staff, two warehouses for ONPPC, 12 fences for health facilities, six sub-regional satellites for health education (EPS), 45 EPI shelters, two nutrition centers, and the National Institute of Public Health of Zinder. Table 5 gives details on physical and logistical inputs provided under the project. 3.5 Institutional Development Objectives and Project Sustainability. Prospects for the sustainabiliby of project interventions are good, thanks both to its success in building management capacity and to its success in demonstrating the potential for mobilizing resources through cost recovery. The experience of designing and carrying out studies and operational research, and of the design and implementation of policy reform emanating from these studies and research, contributed to significant improvements in MOPH capacity for sector strategic management. Capacity was also strengthened through long-term training provided under the project in planning, management, and public health. Under this project the MOPH structure was strengthened through the creation of the Directorate of Studies and Programming (DEP) and the Directorate of Pharmacies and Laboratories (DPhL), which play a key role in, respectively, health sector planning, and pharmaceutical policy reform. An important indicator of the enhanced capacity of MOPH is the quality of the Government's Health Sector Development Strategy.  5 Developed with very little intervention from external sources, both the diagnosis of health sector status and issues and proposals for effectively addressing them are extremely well done, reflect lessons of experience gained through the implementation of this and other projects and provide the basis for strategic and well coordinated sector interventions. The granting of financial and managerial autonomy to hospitals is yet another significant achievement in institutional development. B. Summary of Costs 3.6 At appraisal, the total cost of the project (Tables 7A and 7B) was estimated at US$29.3 million equivalent (net of taxes and duties) with a foreign exchange component of US$18.2 million (62 percent). Base cost estimates were in June 1985 prices. The breakdown of the project's costs in local and foreign currencies is given in Table 7A. 3.7 Several factors contributed to the changes in cost from the time of the appraisal (June 1985) to project closing (June 1995): (a) a five-year delay in project start-up and a two-year extension of the project closing date; (b) the impact of the 1994 devaluation on the cost of construction and equipment; and (c) project support to activities not foreseen at appraisal, such as the strengthening of the DEP, DPhL, ONPPC, STD/AIDS program and the partial financing of the 1988 population census. C. Financing Arrangements 3.8 IDA's contribution at appraisal was estimated at US$27.8 million equivalent (February 1986 exchange rate with SDR) and the Government's participation at US$1.5 million equivalent. Total credit amount disbursed at ICR preparation (US$37.1 million equivalent) was higher than anticipated at appraisal due to changes in the US dollar/SDR exchange rate (Table 4). The Government's actual contribution of US$1.6 million equivalent (reflected in the audit report of December 31, 1995) was higher than anticipated at appraisal. USAID contributed the equivalent of US$1.2 million under a Health Sector Grant to finance five studies planned under Part A of the project. The January 1994 devaluation of the CFA franc prompted additional donor assistance which significantly eased the constraint of counterpart funds. In May 1994 the Kingdom of the Netherlands granted the equivalent of US$770,000 to provide for budgetary support to the project. It is significant to note that, at the time of project closing, the Government decided to use the balance of the funds in the project account (about 300 million CFA franc) to finance the rehabilitation of two warehouses at the ONPPC for the stocking of drugs as well as the purchase of 500,000 doses of anti-meningitis vaccines. D. Implementation Schedule 3.9 Project preparation was long: five years elapsed between the first reconnaissance mission (May 1980) and the appraisal mission (June 1985) (Table 3). Project effectiveness was delayed from July 14, 1986 to November 3, 1986 due to some delays in meeting conditions for effectiveness, particularly in relation to lengthy administrative procedures for hiring the project accountant. The original closing date was June 30, 1993, but the Credit was not closed until June 30, 1995, after two extensions. Disbursements against commitments were made until November 14, 1995. An outstanding balance of SDR 0.02 million (about US$0.03 million equivalent) was canceled effective November 14, 1995. E. Analysis of Key Factors Affecting Implementation 3.10 Three categories of factors affected the Government's capacity to implement the project: political events; financial constraints; and organizational/managerial constraints. The democratization process, which occurred during the life of the project caused activities in all sectors to slow down and  6 even come to a standstill during the various crises inherent in the process. In addition, and more specifically, the high turnover of Health Ministers during the life of the project (eight Ministers in nine years) caused numerous delays, as each new Minister revisited and questioned project objectives and implementation progress. Causes of financial constraints are numerous and varied. Propelled by the economic crisis, lack of counterpart funds delayed implementation of certain activities and severely constrained the operation of the PMU. There were times during the life of the project that the Government was unable to pay salaries for periods of up to six months at a time. Cash flow problems were further exacerbated by the collapse of the BDRN, whose assets (including the project's special accounts) were frozen. These constraints were mitigated through an amendment of the DCA that allowed 100 percent financing of operating costs of the PMU and through a Dutch Grant used to finance local costs. 3.11 Management/organizational capacity to implement a project of this magnitude and complexity was inadequate. The highly centralized structure of the MOPH, combined with heavy bureaucratic and administrative procedures, left administrators and service managers in the periphery with, at best, a very passive role in project implementation. Furthermore, the vertical structure of health programs within MOPH unnecessarily complicated service delivery and constrained efforts to integrate service delivery. As at the political (Ministerial) level, heavy turnover of heads of key technical programs (average of once a year per program), combined with high mobility of service delivery personnel, further exacerbated efforts to improve health program effectiveness and service delivery. 3.12 From the project launch through 1991, the PMU was plagued with serious management and financial problems, and with a high turnover of project coordinators, both of which caused considerable delays in project implementation. Financial mismanagement was evident in inadequate accounting of project funds and delays in submission of audit reports. The use of IDA special account to finance the Government's counterpart expenditures led to a de facto suspension of the special account by the Bank in January 1992. PMU capacity for project management, supervision, and procurement was also lacking. The recruitment in 1992 of a new project manager, along with the long overdue hiring of a technical assistant for the PMU enhanced project implementation and accelerated achievement of project objectives. F. Assessment of the Bank and the Borrower's Performance 3.13 Identification of the project was satisfactory in that it was consistent with Niger's strategy for economic recovery and development and with the Bank's country strategy, which depended on the adoption of a structural adjustment program. The amount of time and resources devoted to project preparation and appraisal is indicative of the fact that dialogue was at times difficult and that the Bank exercised considerable caution in entering the health sector in Niger. The Bank adopted a comprehensive approach by placing the project in the context of Niger's health reform, which, in turn, was part of the overall structural adjustment program of the country. Project appraisal and design were satisfactory. The project design addressed the need for policy reform in a pragmatic and flexible manner thus supporting a learning approach that was quite innovative for its time. However, institutional capacity to carry out a project of this nature was underestimated. Project supervision was deficient. Despite the fact that the project represented the Bank's first intervention in the health sector in Niger, the Bank did not devote adequate resources to field supervision, both in terms of quantity and in terms of adequate skills mix to address and resolve the several key issues to project implementation repeatedly raised in Aide-Memoires, particularly those concerning financial management. 3.14 The Government of Niger's performance in project preparation was satisfactory. The Government's commitment to reform in general, and to the project in particular, was largely responsible  7 for the successes/impacts recorded in spite of Niger's limited management and institutional capacity, and financial resources. It worked closely with the Bank in project identification and preparation. 3.15 On the whole, Borrower performance on project implementation is satisfactory. A review of 590s and BTOs indicate that the Borrower's performance can be assessed on three levels: (a) technical: the Borrower performed above average in implementing the health action programs, thereby achieving, in great part, the project's development objective. As a result, the project had, and continues to have, a good development impact as the project has assumed a prominent role in providing support for critical health sector activities; (b) management and institutional: the Borrower's performance was mediocre because of the weak management ability of PMU and fragile institutional capacity of collaborating government agencies; (c) Government commitment and provision of resources: the Government's commitment which was very high at project onset fluctuated during implementation due to frequent ministerial reshuffles, weak commitment on the part of senior government officials and the Borrower's inability, in the earlier stages of the project, to provide counterpart funds on a timely and reliable basis. The appointment of a dynamic and capable project coordinator (manager) in 1992 permitted considerably accelerated activity during the last months or years of the project during which time this allowed the project to correct and significantly improve past performance and achieve a successful outcome. G. Assessment of the Project's Outcome 3.16 Despite the very difficult political and economic climate during its implementation and despite a high turnover of project staff, program coordinators and ministers, this project culminated in a number of notable accomplishments. While not all objectives were fully met, significant advances were made with project assistance, particularly with regard to its contributions to policy formulation and reform and to the strengthening of capacity in planning and service delivery. MOPH institutional capacity was strengthened through the creation of the Directorates for Studies and Programming, and for Pharmacies and Laboratories, which play crucial roles in sector planning and the formulation and oversight of pharmaceutical policy. Studies and planning activities financed under the project, combined with skills development in planning, management, and public health, contributed to improved appreciation of sector strengths and weaknesses and were instrumental in the production of the National Sector Development Plan, which provides a coherent framework for sector development. Study results also provided the basis for hospital reform and the recent adoption of a law on cost recovery. 3.17 Various assessments of project performance encompassing the views of, respectively, beneficiairies, the Ministry of Health and an external evaluator, note improvement in the quality and coverage of service delivery. Investments in infrastructure, program development and technical skills development of service delivery staff resulted in improved coverage and quality of service delivery. These are evident in improved quality of curative and preventive services, increased capacity for receiving and treating patients, intensification of health information, education and communication activities, and increased involvement of communities in health sector activities. 3.18 Not all project objectives were fully achieved, however. The project fell short of its targets for immunization coverage (55 percent achieved) and for specialized training for technical staff (48 percent achieved). In addition, no aid coordination meeting was held during the life of the project, nor was the supervision program, developed during the project, implemented. The revolving fund for chloroquine never functioned successfully. Lack of baseline data and inadequate monitoring and evaluation of activity did not permit an assessment of the project's impact on health status in areas receiving direct project assistance. It must be noted, however, that national health indicators for Niger remain abysmally  8 low, posing a formidable challenge to the Government and all of its partners to continue, and in fact, intensify efforts to improve health status. IV. SUMMARY OF FINDINGS, FUTURE OPERATIONS AND KEY LESSONS LEARNED A. Findings of Project Implementation Experience 4.1 Experience gained through the implementation of this project highlighted a number of weaknesses and challenges for improving service coverage and quality, management and organization of sector activity. This experience will be reflected in the design and development of future interventions in the sector. 4.2 Services. The importance of supervision of health personnel cannot be overemphasized. While the Government did prepare a detailed plan of action for the supervision of health field staff, as required under the DCA, this program was never implemented, despite its eligibility for financing under Part A of the project. As a result, investments in service quality improvements (infrastructure, program development, and training) were not fully exploited or consolidated due to a lack of technical support and follow-up through supervision. Likewise, a lack of follow-up and evaluation of training investments left MOPH incapable of ensuring optimal utilization of newly acquired skills and specilizations and of assessing utility of training to guide future investments in human resources development. The lack of a clear policy on preventive activities and on health education in essence caused them to receive low attention and priority under the project, despite the importance attributed to them in project design and documentation. 4.3 Sector Management/Organization. Even more constraining to good sector performance than resource availability is the management of resources: human, financial and physical (particularly maintenance). Mobility, low motivation and inequitable distribution of health and administrative personnel, lack of capacity and heavy and overcentralized mechanisms for accounting and financial management and neglect of maintenance all compromised project (and program) effectiveness. More effort must be devoted to develop capacity in management of resources and in decentralized strategic sector management (planning, programming, aid coordination, monitoring, evaluation) in order to improve sector effectiveness. In addition, deficiencies in MOPH organization also compromised project effectiveness and must be corrected. The project was conceived in a vertical and centralized fashion responding to MOPH organization at the time. Sector effectiveness calls for the decentralization and integration of programs and services and a clarification and complementarity of roles and responsibilities at each level of the health system. Greater attention should be paid to institutional development and management capacity building in future interventions. 4.4 Participation. Through the pilot testing of cost recovery schemes experience was gained in eliciting the financial participation of the population in sector activities. This experience also demonstrated that because of its financial participation, the population becomes more demanding of service quality and more interested in participating in the management of resources and in the planning, implementation, and management of sector activities. As a result of this phenomenon, the health system is more conscious of the need to be more client oriented--a significant and positive evolution, indeed. Future investments should include assistance in this regard. Because demands of population are intersectoral (major health problems are due to lack of access to clean water), this new orientation will also require a much more holistic approach to health with greater effort to achieve intersectoral coordination and partnerships with other development agencies (NGOs) at all levels of the system. While participation has evolved significantly over the life of the project, participation of women is still very limited, due primarily to cultural factors.  9 B. Future Operations and Sustainability 4.5 The application of lessons learned in future sector investments were extensively discussed with the Government and various other stakeholders as these were an important focus of the participatory evaluation process. It is encouraging to note that these lessons are reflected, both by the Government and by the Bank, into their strategies for the development and implementation of future health operations in Niger, respectively: the National Health Sector Development Plan for the period 1994-2000, and the Bank's Sector Investment Program approach. The design of a proposed Health II project, which was appraised in April 1996 and negotiated in June 1996, has already benefited significantly from this accumulated experience. 4.6 The Health Sector Development Plan for the period 1994-2000 provides the basis for the proposed IDA intervention in the health sector. A very solid document, it captures the essence of a number of key lessons learned from the first IDA operation, including: (a) the need to decentralize sector management and administration and integrate more fully programs and services through the creation and support of health districts; (b) the need to strengthen capacity in strategic management and management of resources; and (c) the need to identify and utilize more fully the existing (often untapped) potential of the various stakeholders and contributors to health sector performance. The plan states very well "what to do", but the challenge remains to define "how to do it". Discussions during the ICR mission highlight how lessons learned could be further exploited to improve this plan, including: setting of more realistic objectives; prioritization of interventions; introduction of a rolling planning process that would be reviewed and revised annually; and the estimation (and minimization) of investment and recurrent costs. 4.7 Key features of the new sector approach, which are guiding the design and implementation of the proposed IDA intervention include: a coherent sectoral framework that would provide the basis for eliciting and coordinating the various contributions of donors; Government initiation and ownership of sector activity and increased partnership among the various stakeholders in the planning, execution and evaluation of sector activity; a deliberate and systemic approach to capacity building, management strengthening and institutional development, which would encompass the (often untapped) potential roles of all partners in sector development; a better appreciation of client perspectives and more efforts to respond to the needs and demands of clients; choice of indicators that would emphasize performance of the system and impact of interventions; the adoption of a learning approach, which would be pragmatic, rather than theoretical, and which would be subject to ongoing evaluation and refinement in light of experience; economic and financial viability, encompassing the importance of establishing priorities, cost-effectiveness of interventions; a full appreciation of recurrent cost implications and cost containment; and the importance of forging better links and partnerships with central and other ministries at all levels of the system to understand opportunities and constraints of decentralization, public finance, civil service reform, etc. (i.e. macroeconomic linkages) and to improve intersectoral coordination and collaboration to achieve better health. This approach has been thoroughly discussed and well received by the Government and donors alike. C. Lessons for Future Projects in the Sector in Niger 4.8 Lessons of Project Design and Development. Project objectives should be sufficiently modest and based, to the extent possible, on a sound knowledge of the existing situation. The compilation of reliable baseline data is very important in this regard. Objectives should also be commensurate with the resources placed at the disposal of project/program staff. Clear targets and indicators should be set at the outset. Key stakeholders, including the beneficiaries, service providers, local authorities, NGOs and key donors involved in the sector, should be identified at the outset and involved in all stages of project  10 design and development: needs assessment, design, setting of targets and indicators, implementation, management and evaluation. A least cost approach should drive the project design and costing exercise, with a particular emphasis on fully accounting for and minimizing the recurrent cost implications of project/program investments. A rolling planning process should be incorporated into the project design, which would accommodate both more rigor and more flexibility during project implementation to take into account and manage opportunities and constraints emerging from experience. A more holistic and rigorous assessment of institutional capacity would have modified project design and introduced interventions to strengthen that capacity. 4.9 Lessons of Project Management. Analysis of a number of weaknesses in project management have revealed important lessons that should be applied to future operations. The most important of these lessons are: the need to provide project staff with sufficient training in procurement and in other Bank procedures and requirements; the need for improved mechanisms for coordination of project activities and communication among the various responsible program managers; the need to minimize turnover of program management and service delivery staff. Implementation experience revealed the importance of integrating and "mainstreaming" project activities more fully into MOPH operations, both at the central and decentralized levels. Among other things this would provide for more objectivity and transparency in setting priorities within the context of the project and accord line responsibility for program management and implementation to those normally responsible within MOPH structure. Opportunities should be more fully exploited to address and quickly resolve project implementation issues. The mid- term review process could have been more fully exploited in this regard. Furthermore, issues raised in Aide-Memoires of supervision missions should be rigorously addressed and resolved. Routine (quarterly or semi-annual) reporting on project execution, which was not done under this project, could also be instrumental in identifyipg and resolving implementation issues effectively and efficiently. Adequate resources to field supervision, both in terms of quantity and in terms of adequate skills mix, should be devoted to address and resolve the several key issues to project implementation, particularly those conceming financial management.  IMPLEMENTATION COMPLETION REPORT REPUBLIC OF NIGER HEALTH PROJECT (Credit 1668-NIR) PART II: STATISTICAL TABLES Table 1: Summary of Assessments Table 2: Related Bank Loans/Credits Table 3: Project Timetable Table 4: Credit Disbursements: Cumulative Estimated and Actual Table 5: Key Indicators for Project Implementation and Operation Table 6: Studies Included in Project Table 7A: Project Costs Table 7B: Project Financing Table 8: Economic Costs and Benefits Table 9: Status of Legal Covenants Table 10: Compliance with Operational Manual Statements Table 1 1: Bank Resources: Staff Inputs Table 12A: Bank Resources: Missions Table 12B: Bank Resources: Supervision Missions   I1 Table 1: Summary of Assessments A. Achievement of Objectives Substantial Partial Negligible Not applicable Macroeconomic Policies 0 0 0 IX Sector Policies 1S 0 0 0 Financial Objectives 0 9 0 0 Institutional Development 0 1810 0 Physical Objectives 15 0 0 0 Poverty Reduction 0 0 0 0 Gender Issues 0 Q 0 0 Other Social Objectives 0 0 0 Environmental Objectives 0 0 0 Public Sector Management 0 15 0 0 Private Sector Development 0 fZ0 0 Training and Technology 0 0 0 Other (Specify) 0 0 0 0 B. Proiect Sustainabilitv LiklY Unlikely Uncertain U 0 0 C. Bank Performance satisfactorv Satisfactory Deficient Identification 0 15 0 Preparation Assistance 0 0 Appraisal 0 0 Supervision 0 0 HighLy D. Borrower Performance satisfactoa Satisfactory Deficient Preparation 0 19 0 Implementation 0 U 0 Covenant Compliance 0 0a 0 Highly Highly E. Assessment of Outcome satisfict Satisfactoly Unsatisfactory unsatisfactora 0 O 0 0  12 Table 2: Related Bank Credits Credit title Purpose Year of approval Status Preceding operations Not Applicable Following operations Population Project The Project aims at assisting the Government in 1992 Supervision implementing an effective national population (Cr. 2360) program, with the primaiy objective of accelerating the onset of fertility decline by increasing the contraceptive prevalence rate as rapidly as possible, reducing matemal mortality, promoting attitudes favoring a reduction in family size norms, and enhancing the capacity of women to effectively participate in socio-economic development. Health II Project The Project envisages at supporting the Ministry Expected June 1996 Appraisal of Public Health in its implementation of the "Plan de D&veloppement Sanitaire". It will seek to: (a) reduce morbidity and mortality through improvements to the quality and coverage of basic health services with a particular focus on establishing and supporting the health district system; (b) improve the availability and affordability of essential generic drugs to all of Niger's population through the restructuring and strengthening of the pharmaceutical sector, effectiveness and efficiency of which will be addressed through interventions to strengthen and decentralize strategic sector management and management of resources; and (c) expand and exploit sector capacity through efforts to appreciate and more effectively utilize the capacity of various partners active in the health sector, starting at the peripheral levels.  13 Table 3: Project Timetable Identification (Project Brief) 01/81 02/82 Preparation 06/81 02/83 Appraisal 11/84 06/85 Negotiations 11/85 02/86 Board Presentation 01/86 03/86 Signing 04/86 04/86 Effectiveness 07/86 11/86 Project Completion 12/92 06/95 Credit Closing 06/93 06/95 Table 4: Credit Disbursements: Cumulative Estimated and Actual (US$ million) Bank Fiscal Year Appraisal Estimate Actual Actual as % of and Quarter Estimate 1987 2.5 1.35 54 1988 6.4 5.18 81 1989 11.4 8.08 71 1990 17.2 12.89 75 1991 22.0 16.01 73 1992 25.6 19.04 74 1993 27.8'/ 24.05 87 1994 25.68 n/a 1995 34.90 n/a 1996 37.10 n/a Date of final disbursement: November 14, 1995 (the above data are taken from the loan database of November 28, 1995). '/ A total of US$0.44 million was cancelled from the negotiated amount equivalent to US$27.8 million, of which USS0.41 million due to misprocurement and US$0.03 million due to unused credit funds.  Table 5: Key Indicators for Project Implementation and Operation SAR Planned Actual Part A. Health Sector Adjustment 1. Studies: (a) Hospital Fee System I (b) Cost effectiveness of university hospitalfacilities l (c) Cost effectiveness of basic health services and operations 1 (d) MSP's financial management, includinghospital management plan I (e) Cost recovery of basic heatlh services at the local level I (f) Improvement of the distribution of essential drugs I I 2. Sub-projects (implementation of recommendations resulting from studies above and n.d. 8 some key activities agreed between Government and IDA) (a) Directorate of Studies and Programming (DEP) (b) Directorate of Health Protection and Sanitation 4- (c) Directorate of Pharmacies and Labs (DPHL) (d) ONPPC (e) National Tuberculosis Control Center (CNAT) (f) Survey of Aspirations of Youth in Niger (g) STD/AIDS Program (h) 1988 General Census of the Population 3. Support to Government's Initiatives in (a) development of cost recovery measures for basic halth services 0 l 4. Sector Management (a) organizing annual meetings of all aid agencies participating in the financing of health I/year ad hoc sector activities in Niger a/ These studies have been combined into one. Note: Details on indicators can be found in separate tables by components and sub-components in AISC.  Table 5 (continued) Planned Actual Planned Actual Part B. Basic Health and Family Planning Services (iii) staff training and fellowships: 1. Strengthening and extension of health care services: (a) Upgrading, rehabililaion and equipping ofhealthfaciUlies: 113 126 * laboratory assistants 6 3