Mexico - Basic Health Care

 Basic Health Care Report No: ; Type: Report/Evaluation Memorandum ; Country: Mexico; Region: Latin America And Caribbean; Sector: Basic Health; Major Sector: Health Nutrition & Population; ProjectID: P007655 Mexico—Basic Health Care Project (Loan 3272-ME) The Basic Health Care project in Mexico, supported by Loan 3272-ME for US$180 million, was approved in FY90 and closed on December 31, 1996, three months later than planned. In October 1995, the Bank canceled US$40 million from the loan in response to a request from the borrower in view of the 1995 economic crisis in Mexico. Final disbursement took place on May 14, 1997, at which time a balance of US$3.8 million was canceled. At closing, the total loan amount was thus reduced to US$136.2 million. There were no cofinanciers. The Implementation Completion Report (ICR) was prepared by the Latin America and the Caribbean Regional Office. Comments from the borrower are included as an appendix to the ICR. The project’s objectives were to (i) improve and extend the delivery of basic health care and nutrition to about 13 million uninsured people in four states and in marginal areas of the federal district; and (ii) support institutional improvements at state and federal levels to decentralize budget management and operations and strengthen management. To accomplish these objectives, the project included components to (i) upgrade and expand the health services network, including a maintenance plan for facilities and equipment, furniture, materials, vehicles, and basic medical supplies; hiring or reassigning and regrading staff; and improving training and supervision; and (ii) institutional development, designed to support decentralization of health services at national and state levels, operational research to improve service delivery, evaluation, and policy studies, and the development of a management information system (MIS). At the mid-term review in 1993, a more equitable allocation of resources was made to strengthen achievement of objectives, and the share for the federal district was decreased, while that for the four poorer states was increased from 64 percent to 80 percent of the funds. In addition, new construction and rehabilitation of health centers was scaled back. The project accomplished many of its objectives, despite its complexity. The project provided a flexible vehicle for improving health care in the targeted states. In addition to the expansion of the health network, the project successfully demonstrated the challenges inherent in devolving procurement responsibilities to the state level and the use of private contractors for specialized maintenance. The project did not succeed in achieving legal decentralization of health services, but it did lay the groundwork for formal decentralization of the health sector. A national evaluation survey suggests that project- supported facilities benefited poor communities and increased the accessibility of services. Despite exceeding its ambitious training targets, the project did not address the incentives which influence staff location and was unsuccessful in motivating staff to work in the targeted districts. Staff shortages in rural and poor areas continue to impair service provision. Also, health facilities continue to face shortfalls in the supply of basic medicines reflecting continuing budget constraints and logistical problems. The project supported a flexible program of research, appropriately targeted at responding to state-level needs for policy analysis. Unfortunately, the activity did not receive sufficient technical guidance and supervision, and the quality of resulting studies was uneven and inadequately disseminated, and few recommendations were followed up by decisionmakers. A planned improvement in management information systems designed to provide state managers with better tools for the administration of health services was only partially implemented. Nonetheless, mobile health units, increased specialized medical services, and training benefited the remote areas, and hospital services improved with the provision of new equipment. As is typical of health sector investments, no ERR or IRR was calculated at appraisal, and no economic or financial assessment was included in the ICR. The ICR rates project outcome as satisfactory, sustainability as likely, and Bank performance as satisfactory. Although OED concurs with the ICR rating of the Bank’s performance, it rates the outcome of the project as marginally satisfactory because of the limited accomplishment of institutional objectives. OED rates project sustainability as uncertain, rather than likely, because increases in recurrent costs caused by the project may cause long-term problems, the regular budget of the Ministry of Health has declined in the project area, and the sector continues to face serious fiscal constraints. The key lessons learned are that (i) even with a strong commitment by the borrower, implementation problems are likely to arise if line agencies do not share project ownership; (ii) mechanisms for planning, budgeting, and transferring funds to the local level need to be simple, transparent, and easily applicable to ensure timely project implementation—these are rarely features of national implementing agencies with rigid and often inappropriate rules and procedures; and (iii) project flexibility is essential to accommodate revisions in project design and priorities, as well as changes in the political environment. The quality of the ICR is satisfactory. A more complete discussion of the results of the evaluation survey, particularly concerning the utilization of project-financed services would have added to the report’s quality. An audit is planned.