Senegal - First Human Resources Development Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No: 17097 IMPLEMENTATION COMPLETION REPORT REPUBLIC OF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT I (Credit 2255-SN) September 30, 1997 Human Development CGroup II AFTH2 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 Currency Unit Franc CFA - FCFA US$1 (1991) = 303 FCFA US$1 (1992) = 265 FCFA US$1 (1994) = 500 FCFA US$1 (1993) = 297 FCFA US$1 (1997) = 500 FCFA WEIGHTS AND MEASURES Metric System ABBREVIATIONS AND ACRONYMS AGETIP - Agence d'execution des Travaux d'interet Public contre le sous-emploi AIDS - Acquired Immune Deficiency Syndrome ASBEF - Association Senegalaise pour le bien-etre Familial CEDEPS - Centre departemental d'Education populaire et sportive CHO - Community Health Organization CONAPOP - National Population Commission CONGAD - Conseil des ONG d'Appui au Developpement CPR - Contraceptive Prevalence Rate CS - Coniite de Sante CSU - Component Support Unit DAEB - Direction d'Alphabetisation et de L'Education de Base DHDP - District Health Development Plan DHR - Division of Human Resources DHS - Demographic and Health Survey DMO - District Medical Officer EU - European Union FLE - Family Life Education FP - Family Planning GEEP - Groupe d'Etudes en Population IDA - International Development Association IEC - Information, Education and Communication IPM - Institut de Prevoyance des Maladies MCH - Maternal and Child Health MFEF - Ministry of Women, Children and the Family MEFP - Ministry of Economy, Finance and Planning MASA - Ministry of Health and Social Affairs MOI - Ministry of the Interior MTS - Ministry of Youth and Sports NGO - Non-Governmental Organization PAIP - Priority Action and Investment Program PCU - Project Coordination Unit PHC - Primary Health Care PHRD I - Human Resources Development Project 1 PNA - Pharmacie Nationale d'Approvisionnement PNDS - National Development Plan for Health PRA - Pharmacie Regionale d'Approvisionnement PSFP - Projet Sante Familiale et Population (U.S.A.I.D) RHDP - Regional Health Development Plan RMO - Regional Medical Officer RNI - Rate of Natural Increase SANFAM - Sante de la Famille SIP - Sector Investment Program for Health SNEPS - Service National d'Education en Population et Sante STD - Sexually Transmitted Disease TA - Technical Assistance UNDP - United Nations Development Programme UNFPA - United Nations Fund for Population Activities U.S.A.I.D. - U.S. Agency for International Development WHO - World Health Organization WID - Women in Development FISCAL YEAR Calendar YearVice President Jean-Louis Sarbib Country Director Mahlmood A. Ayub Technical Manager Ok Pannenborg Contact Staff Member Alassane Diawara  FOR OFFICIAL USE ONLY I[PLEMENTATION COMPLETION REPORT REPUBLIC OF SENEGAL HIJMAN RESOURCES DEVELOPMENT PROJECT I (Credit 2255-SN) TABLE OF CONTENTS PREFACE ...............................................i EVALUATION SUMMARY ...............................................ii PART 1: PRCIJECT IMPLEMENTATION ASSESSEMENT ...............................1 A. Introduction . B. Project Background .1 C. Project Objectives and Description .2 D. Achievement of Project Objectives .3 E. Implementation Record and Major Factors Affecting the Project .4 F. Project Sustainability .5 G. Bank Performance .7 H. Borrower Performance .8 I. Assessment of Outcome .9 J. Future Operations .9 K. Lessons Learned .10 PART II: STATISTICAL ANNEXES Table 1: Summary of Assessments .12 Table 2: Related Bank Loans/Credits .13 Table 3: Projiect Timetable .13 Table 4: Loan/Credit Disbursements: Cumulative Estimated and Actual .14 Table 5: Key Indicators for Project I mnpementation .14 Table 6: Key Indicators for Project Operation .15 Table 7: Studfies Included in Project .15 Table 8A: Project Costs ............................ 16 Table 8B: Project Financing ............................ 16 Table 9: Ecomomic Costs and Benefits ................................................................... 16 Table 10: Status of Legal Covenants ............................ 17 Table 11: Conipliance with Operational Manual Statements ..................................... 20 Table 12: Bank Resources: Staff Inputs .......................................... 20 Table 13: Bank Resources: Missions ...................................................................... 21 APPENDICES Annex I: Mission's Aide-memoire ......................... 23 Annex II: ]Borrower contribution to the ICR ......................... 30 Annex III: Map ......................... 37 This document has a restricted distribution and may be used by recipients only in the performance of their officiial duties. Its contents may not otherwise be disclosed without World Bank authorization,   i IMPLEMENTATION COMPLETION REPORT REPUBLIC OF SENEGAL HUM,AN RESOURCES DEVELOPMENT PROJECT I (Credit 2255-SN) PREFACE This is the Implementation Completion Report (ICR) for the Human Resources Development Project [ in Senegal, for which Credit 2255-SN in the amount of SDR 25.4 million (US$35.0 million equivalent) was approved on May 30, 1991 and made effective on January 17, 1992. The credit was closed 15 months after the original closing date. Final disbursement took place on September 29, 1997. A balance of about SDR 1.5 million will be cancelled. Preparation of this ICR was begun during the Bank's final completion mission of February 1997, and it iis based on material in the project file, data provided by the Ministries of Health, Mlinistry of Economy, Finance and Plan, Ministry of Youth and Sport, Ministry of Women, Children and Family, and discussions with Ministry officials. The borrower contributed to preparation of the ICR by preparing a separate evaluation of the project and commenting on the draft ICR. The ICR was prepared by a team composed of Alassane Diawara (Task Manager, AFTH2), Anwar Bach-Baouab (Task Team Leader, AFTH2) and Alice Morton (Social Anthropologist, Consultant). It was reviewed by Ok Pannenborg, Technical Manager, AFTH2, and Peter HalTold, Acting Country Director, AFC 14. The borrower provided comments that are included as appendixes to the ICR.   ii IMIPLEMENTATION COMPLETION REPORT REPUBLIC OF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT I (Credit 2255-SN) EVALUATION SUMMARY Credit Number: Cr. 2255-SN Credit Amount: US$25.4 million Beneficiary: Ministry of Health, Ministry of Economy, Finance and Plan, Ministry of Youth and Sport, Ministry of Women, Children and Family Date effective: January 17, 1992 Date Closed: March 31, 1997 Introduction 1. PHRD I was prepared during 1989-1990, appraised in 1990 and negotiated in 1991. It was the first of a series of operations to be developed under the umbrella of a comprehensive human resources development program supporting key elements of Senegal's medium-term social and economic development plan. This project focused on the population and health sectors. PHRD II, appraised later, focused on education and training.. Two additional IDA-financed social sector projects--functional literacy and community nutrition--complement those PHRD I activities that are oriented toward women and youth. At the time PHRD I was appraised, an earlier IDA-financed health sector project had been completed, which allowed for a certain continuity in implementation within the Ministry of Health and Social Affairs (MASA). That project, however, had no significant population component, so that PHRD I represented IDA's first effort to support the Government's new comprehensive National Population Policy Declaration (1988). 2. In 1991, Senegal was characterized by an accelerating population growth rate of 3.2% per year, a low level of life expectancy compared with other poor countries (48 years), very low contraceptive prevalence for modem methods (4.8% in 1990), and very high infant and matemnal mortality (still 510/100,000 deliveries in 1996). There was evidence of demand for contraceptive services despite cultural constraints, as well as a need to focus population and health services increasingly on youth, who already constituted nearly 50%,f0 of the population in 1990. At Project appraisal, Senegal also had a high morbidity rate due in part to a high incidence of preventable and treatable diseases. Diarrhea, respiratory iinfections and malaria, compounded by poor nutrition, were the  iii leading causes of morbidity and mortality. Sexually transmitted diseases (STDs), including AIDS also contributed to poor health status. Despite progress made during the 1980s as a result of a clear policy shift toward a minimum package approach in primary health care, the public health system continued to suffer from inadequacy and inequities in sector financing, and low efficiency in the use of resources by public health facilities. The institutional base for health care management was weak, and private sector and NGO involvement in public health was minimal. Project Objectives 3. PHRDI's objectives were to support Government's efforts to: (i) control fertility and reduce the rate of population growth, through implementation of the National Population Program, and (ii) restructure the health sector to enable it to provide basic health services of improved quality and wider accessibility, through implementation of the National Health Policy. Key policy reform measures included in this investment operation were: (i) liberalization of regulations on contraceptive distribution and use; (ii) measures in support of the district health system, including adoption of organizational norms for the district; ensuring sufficient budgetary allocations; personnel redeployment; adoption of organizational and procedural guidelines for community health organizations, and (iii) measures to restructure the health sector toward the promotion of essential drugs. 4. To meet its objectives, the project design took a comprehensive, multi-sectoral approach, addressing as many determinants of fertility behavior as possible, while working on increasing both the demand for and the supply of services, and targeting the needs of key groups and levels of intended beneficiaries--health care providers, clients of the health care system, private sector firms and their employees, private and public sector pharmacists. It also placed special emphasis on women and youth as ultimate beneficiaries of services as well as promoters of demand. In retrospect, the objectives as stated were extremely ambitious given the 3 years length of the project as designed. Implementation, Experience and Results (i) Achievement of Objectives and Sustainability 5. Given the 15 month extension of the initial project completion date, the project's development objectives have been largely achieved. This is true despite the fact that the objectives are broad and ambitious, and the project design complex and innovative. Regarding the first objective, contraceptive prevalence for modem methods had risen to 9% by 1994, and results of the second Demographic and Health Survey, anticipated for September 1997 may show increased prevalence, although it is unlikely that the original target of 14% by project completion will have been attained. Project activities in support of this objective, involved four ministries, five organizational levels from the capital to the community, four NGOs, studies and policy work by a variety of institutions, as well as training by five entities at several levels, and of eight categories of personnel and ultimate beneficiaries. 6. Coverage and quality of FP services in the public and private sectors have been considerably enhanced, through training of 720 nurses who are heads of health posts, provision of  iv materials on maternal-child health and on nutrition to health posts, and reproductive health curriculum reform for all health schools, accompanied by development of better teaching materials. Women's groups, youth associations and local health committees have been sensitized through various IEC programs, and are thus likely to demand higher quality of care as well as more accessible services since they are now involved in managing the funds generated through cost recovery. For the private sector, FP services and IEC have been enhanced in private and para- public companies, as well as in pharmacies, through training of clerks, pharmaceutical warehouse managers and pharmacists, as well as the health personnel of private finns. 7. The second objective--restructuring the health sector to ensure better quality, better managed and rnore accessible health services-- has also been achieved. The health component ($25 mill:ion) included sector-wide reforms and institutional strengthening sub- components as well aLs sub-components that would be piloted or completely supported in three health regions--.-Dakar, Thies and Diourbel. Decentralization of management and funding to the regional, district and community levels, including the formation of regional health teams and development of regional and district-level health plans; training in management for regional and district general practitioners and health post nurses; construction of and equipment for 60 health posts, development of a decentralized personnel deployment plan, successful introduction of essential drugs in the context of the Bamako Initiative, including provision of initial stocks, and introduction of generic drugs in both the private and public sectors accompanying the complete overhaul of the national pharmacy and its management systems, have contributed significantly to attainment of this objective. Anticipated deployment of two GPs to each district has been only partially achieved, despite MASA efforts to implement its staff redeployment policy. This was due to the lack of progress at the time of implementation in decentralization of human resources in the country as a whole. All sector-wide policy reforms have been achieved including those related to annual increases to the overall proportion of the national budget allocated to the healtlh sector. Summary of Findings, Future Operation and Key Lessons Learned (i) Findings 8. The project indicates that reforms can be started and generalized under an investment operation without conditionalities and budget support, given government commitment and good project design. But it has been noted that, where project success depends on significant redeployment of civil servants concrete human resources management measures should be included in conditions of effectiveness, and should be taken up in dialogue on civil service reform under other projects and programs. (Relevant wherever administrative reform and public sector modernization interventions are also being supported by bilateral or multilateral agencies, including the IMF). Also including project funding for expatriate technical assistance is less viable in projects than was previously the case. If government technicians can do work "en regis", they will; if not, they will contract for local TA. Only if IDA supervision proves that results have not been obtained using this approach will expatriate TA funds then be spent (now increasingly relevant in AFR and other regions as well). Finally if demand is accurately assessed and accountability measures introduced and monitored, cost recovery rates for services can increase very quickly. Within five years, decentralized health care centers and their health committees are recovering an  v average of 120-130% of recurrent costs apart from salaries of state employees and amortization of infrastructure. (ii) Future Operations 9. The major proportion of project activities will be replicated in other regions of the country with support from the SIP which, in turn, will be co-financed by a group of multilateral and bilateral donors. The donor consultative group meeting for this SIP was held in May 1997, in response to the Government's new National Development Plan for Health (PNDS). IDA has worked very closely with the European Union to mobilize donor consultation and collaboration. Appraisal of IDA's participation in the program was made in May 1997. The project has been negotiated with the Government in July 1997, and is schedule to be presented to the Board on September 4, 1997. 10. The remaining activities initiated or expanded under PHRD 1, including the women's sub- component and the youth sub-component, are already receiving some parallel funding. In the former case, African Development Bank Project (five regions), and in the latter case UNFPA, has made funding available. UNFPA is also supporting policy related studies and dialogue to assist in the preparation of the second Population Priority Investment Action Plan. Meanwhile, UNICEF, UNFPA, various Nordic bilaterals, the Dutch and the Japanese are potential sources of support to these and related initiatives in the context of a proposed donor consultative group meeting for the Government's social development program. This meeting would be centered around the Women's Action Plan, the Youth Action Plan, the Poverty Alleviation Action Plan, as well as an overall Human Development Action Plan which is currently being developed. IDA has indicated that if approached by the GOS to provide funding for a multi-sectoral social development and poverty alleviation intervention, it would consider such a request favorably in the context of the forthcoming Country Assistance Strategy. (iii) Key Lessons Learned 11. Significant lessons for future project work and policy reform can be learned from studies and surveys funded under an investment operation. This speeds up preparation and appraisal of the next sector credit and enhances the policy dialogue during the implementation of that investment operation. 12. Intensive Resident Mission and HQ supervision can support implementation of complex, multi-sectoral projects that also involve decentralization, but this commitment should be made at the outset. 13. A well-tailored role for NGOs under government contract can prove very effective and may be both less expensive and more participatory than direct govermment implementation. 14. Including a gender focus in IEC for FP and reproductive health in a multi-sectoral project is effective, especially when supported by local-level income-generating and literacy activities. If possible, this should also include targeting a certain proportion of women members of other local- level committees, such as district or sub-district health committees.  vi 15. Multi-donor geographical division of multi-sectoral activities, unless coordinated from the preparation phase on, is likely to complicate rather than to simplify implementation, as differences in technical content, procedures and component funding levels are introduced. 16. Addressing key beneficiary groups with demand-driven IEC and service delivery programs, including counseling, can be extremely effective in environments where cultural prohibitions are prorninent. Outreach dimensions of these same programs can also help to change attitudes and behavior of non-targeted beneficiaries. (True in multi-ethnic and multi-cultural environments, as well as in those where religious or political factors constitute a risk for project objective attainment or sustainability).  I  IMPLEMENTATION COMPLETION REPORT REPUBLIC OF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT I (Credit 2255-SN) PART I: PROJECT IMPLEMENTATION ASSESSMENT A. Introduction 1. This Implementation Completion Report (ICR) is the product of a completion mission which took place in late February and early Marchl 1997, a month before the Project closing date. The mission met with staff of all five project coordination and support units, with senior officials in each ministry concerned, and carried out visits to field sites in two regions of the country. Visits included interviews with beneficiaries at all levels of the decentralized structures involved in project implementation, including the community level. A joint meeting was held with the three NGOs that. had been involved in the family planning IEC component, under the auspices of CONGAD, the national NGO association. Project completion reports from each component unit and from the central coordination unit were reviewed and revised. An aide-memoire was prepared by the mission team, reviewed at the technical level with the component coordinators, and discussed at a wrap-up meeting with ministry officials (see Appendix 1). 2. Meetings were also held with staff of other donor agencies--U.S.A.I.D., UNICEF, UNFPA, EU-- that had financed parallel or related projects during the five years of PHRD I implementation. Their views were sought concerning the context surroumding the PHRD I implementation process and its evolution over time, project strengths and weaknesses, and potential for consolidating outcomes through Bank and other donor funding. These discussions were also oriented. toward future donor collaboration in the context of the Government's new National Development Plan for Health (PNDS) and the proposed Health Sector Investment Program (SIP), as well as a possible poverty-oriented multi-sector development plan. B. Project Backgroumd 3. PHRD I was prepared during 1989-1990, appraised in 1990 and negotiated in 1991. It was the first of a series of operations to be developed under the umbrella of a comprehensive human resources development program supporting key elements of Senegal's medium-term social and economic development plan. This project focused on the population and health sectors. PHRD II, appraised later, focused on education and training. Two additional IDA-financed social sector projects--functional literacy and community nutrition--complement those PHRD I activities that are oriented toward women and youth. At the time PHRD I was appraised, an earlier IDA-financed health sector project had been completed, which allowed for a certain continuity in implementation within the Ministry of Health and Social Affairs (MASA). That project, however, had no significant population component, so that PHRD I represented IDA's first effort to support the Government's new comprehensive National Population Policy Declaration (1988). 4. In 1991, Senegal was characterized by an accelerating population growth rate of 3.2% per year, a low level of life expectancy compared with other poor countries (48 years), very low contraceptive prevalence for modem methods (4.8% in 1990), and very high infant and maternal mortality (still 510/100,000 deliveries in 1996). There was evidence of demand for contraceptive services despite cultural constraints, as well as a need to  2 focus population and health services increasingly on youth, who already constituted nearly 50% of the population in 1990. At Project appraisal, Senegal also had a high morbidity rate due in part to a high incidence of preventable and treatable diseases. Diarrhea, respiratory infections and malaria, compounded by poor nutrition, were the leading causes of morbidity and mortality. Sexually transmitted diseases (STDs), including AIDS also contributed to poor health status. Despite progress made during the 1980s as a result of a clear policy shift toward a minimum package approach in primary health care, the public health system continued to suffer from inadequacy and inequities in sector financing, and low efficiency in the use of resources by public health facilities. The institutional base for health care management was weak, and private sector and NGO involvement in public health was minimal. 5. These inter-related problems dictated a project design that allowed for collaboration among a number of MASA entities, both at the center and the periphery. A separate sub-component was required to resuscitate the moribund MASA pharmaceutical system (PNA), linked to putting in place an essential and generic drugs policy. The cross-sectoral population component supported integration of family planning into decentralized public sector primary health care, as well as training and IEC activities through private sector pharmacies, youth associations, and women's groups. A key design element to facilitate implementation of this multi-sectoral and multi- component project was the inclusion of a series of studies, policy papers and related dissemination activities that would support the on-going policy and institutional reform process over the proposed three years of project implementation. C. Project Objectives and Description 6. PHRD l's objectives were to support Government efforts to: (i) control fertility and reduce the rate of population growth, through implementation of the National Population Program, and (ii) restructure the health sector to enable it to provide basic health services of improved quality and wider accessibility, through implementation of the National Health Policy. Key policy reform measures included in this investment operation were: (i) liberalization of regulations on contraceptive distribution and use; (ii) measures in support of the district health system, including adoption of organizational norms for the district; ensuring sufficient budgetary allocations; personnel redeployment; adoption of organizational and procedural guidelines for community health organizations, and (iii) measures to restructure the health sector toward the promotion of essential drugs. 7. Designed as a three-year transition effort, the Project had very ambitious objectives, the attainment of which was not completely within the manageable interest of the Project or of IDA. Other donors, such as U.S.A.I.D. and UNICEF had already taken the lead to support the development of population policy, and in the areas of contraceptive service delivery, family planning IEC, and in certain vertical programs such as vaccinations, while the EU and France were assisting the pharmaceutical agency. However, continued reform of the primary health care system, and further activities to support changes in fertility behavior were critical to the Association's country strategy and ultimate success of other sector operations and directly supported the Government's national policies and programs. To meet its objectives, the project design took a comprehensive, multi-sectoral approach, addressing as many determinants of fertility behavior as possible, while working on increasing both the demand for and the supply of services, and targeting the needs of key groups and levels of intended beneficiaries--health care providers, clients of the health care system, private sector firms and their employees, private and public sector pharmacists. It also placed special emphasis on women and youth as ultimate beneficiaries of services as well as promoters of demand. In retrospect, the objectives as stated were extremely ambitious given the length of the project as designed.  3 D. Achievement of Project Objectives 8. Given the 15 month extension of the initial project completion date, these development objectives have been largely achieved. This is true despite the fact that the objectives are broad and ambitious, and the project design complex and innovative. Regarding the first objective, contraceptive prevalence for modem methods had risen to 9% by 1994, and results of the second Demographic and Health Survey, anticipated for April 1997 may show increased prevalence, although it is unlikely that the original target of 14% by project completion will have been attained (see Table 1 - health and population indicators). Project activities in support of this objective, (approximately one-third of the $39 million project funding level), involved four ministries (Finance, Economy and Plan; Health and Social AfEfairs; Women, Children and the Family; and Youth and Sports), five organizational levels from the capital to the community, three NGOs, studies and policy work by a variety of institutions, as well as training by five entities at several levels, and of eight categories of personnel and ultimate beneficiaries. 9. Coverage and quality of FP services in the public and private sectors have been considerably enhanced, tirough training of 720 nurses' who are heads of health posts, provision of materials on maternal-child health and on nutrition to health posts, and reproductive health curriculum reform for all health schools, accompanied by development of better teaching materials. Women's groups, youth associations and local health committees have been sensitized through various IEC programs, and are thus likely to demand higher quality of care as well as more accessible services since they are now involved in managing the funds generated through cost recovery. For the private sector, FP services and IEC have been enhanced in private and para-public companies, as well as in pharmacies, through training of clerks, pharmaceutical warehouse managers and pharmacists, as well as the health personnel of private firms. Institutional support to the MASA's national education and health promotion service (SNEPS), has been a further factor in the improved coverage and quality. The high level of success in the training component and IEC for FP in support of the PNFP, is in part related to the work of three NGOS, ASBEF, SANFAM for private sector firms and pharmacies, and GEEP for in-school IEC programs. Nine youth centers and two sub-centers have been built, and equipment provided for these and additional ones not originally included in the project area, while more than 73 youth associations have received training in a variety of areas, including FP IEC. Members of 223 wonmen's groups have received functional literacy training, FP IEC. Over three thousand women have received literacy and numeracy training in local languages, and, when the management training cycle is finished and all supplementary equipment delivered, they will be operating labor-saving technologies to generate income, and will now also manage 30 women's centers on a cost-recovery basis. 10. The second objective--:restructuring the health sector to ensure better quality, better managed and more accessible health services-- has also been achieved. The health component ($25 million) included sector-wide reforms and institutional strengthening sub-components as well as sub-components that would be piloted or completely supported in three health regions---Dakar, Thies and Diourbel. Four other regions were included in a U.S.A.I.D.-funded program with similar elements. This component also included six studies to help assess particular problem and policy areas that facilitated preparation of the SIP, scheduled for FY 1997. Decentralization of management and funding to the regional, district and community levels, including the formation of regional health teams and development of regional and district-level health plans; training in management for regional and district general practitioners and health post nurses; construction of and equipment for 60 health posts, development of a decentralized personnel deployment plan, successful introduction of essential drugs in the context of the Bamako Initiative, including provision of initial stocks, and introduction of generic drugs in both the private and public sectors accompanying the complete overhaul of the national pharmacy and its management systems, have contributed significantly to attainment of this objective. Anticipated deployment of two GPs to each district has been only partially achieved, despite MASA efforts to implement its staff redeployment policy. This was due to the lack of progress at the time of implementation in decentralization of human resources in the country as a whole. Appointment of the second GP to the district level is now beginning to take place however. The short-term training of GPs in emergency surgery, designed to allow them to perform simple life-saving operations under emergency conditions without risking lives through lack of emergency transportation facilities, was blocked by the academic medical community despite early positive negotiations  4 during project appraisal. As an interim measure, surgeons are being made available on an emergency basis from the nearest hospital to the decentralized treatment facilities. All sector-wide policy reforms have been achieved including those related to annual increases to the overall proportion of the national budget allocated to the health sector. Success in this reform area was achieved despite overall budget cuts and wage ceilings introduced in the context of structural adjustment, administrative reform and decentralization. In fact, public expenditures for health have actually tended to stagnate, despite overall increases in budget allocation to the sector and great success in cost recovery for basic services and essential drugs. Despite the devaluation of the CFA Franc, prices for essential drugs were maintained at pre-devaluation levels, ensuring affordability and the integrity of the cost- recovery system. Overall, the success of reforms included in this investment operation without SECAL-type conditionalities and IDA budget support is remarkable. E. Implementation Record and Major Factors Affecting the Project 11. Outside Government Manaeeable Interest. At the time PHRD I was negotiated and became effective, a manual of operations and a procurement plan were not conditions of effectiveness. Therefore, the first year of effectiveness resulted in little implementation although the component support units and the central coordination unit were set up and staffed, and some activities under the health and women's components were undertaken. Given the fact that the health component represented 75% of project funding, the health component unit had a separate special account. While this facilitated progress in procurement under that component, it also resulted in the other three ministry-based component managers and technicians often questioning the requirement that their activities be funded through the second special account, managed by central coordination unit which. This dual level of management and oversight did, indeed, lead to implementation and disbursement delays, and resulting inter-agency and interpersonal conflicts also contributed to lack of anticipated collaboration, coordination and synergy. Once momentum had been achieved, the threshold for special account replenishment required support units to prepare replenishment requests for both accounts, more often than unit staff had anticipated. In some cases, in order to speed up payment for key activity implementation, IDA agreed to direct payments below the usual threshold. Health has been one of the pilot sectors in which all budgets are being decentralized. PHRD I fostered this process, but was to some extent constrained by the fact that IDA discourages sub-accounts, since these may encourage borrower governments to fail to take appropriate budgetary measures to accompany decentralization moves. The fact that under the latest GOH policy budgets are being completely decentralized will resolve this problem in the future. 12. The existence of parallel and sometimes conflicting other donor's projects and budget support posed some problems for the PHRD I implementation and disbursement, especially under the population component. The fact that PHRD was "managed" at the Cabinet level of the Ministry of Economy, Finance and Plan, while the related FNUAP projects were with the Population and Human Resources Direction caused failures in communication and coordination. Similarly, the fact that U.S.A.I.D. and FNUAP worked at the National Population Program level while PHRD I worked at the MCH/FP Direction level led to failures in communication and coordination among projects, especially in terms of training and IEC materials production. Finally, the devaluation of the CFA Franc in early 1994 caused a disbursement delay of seven months, while the Government developed standards and procedures for re-evaluating project costs, contracts, counterpart contributions and related procurement issues. 13. Within Government Manageable Interest. Government commitment to sector reforms was generally good for health care, population, improvement of the situation of women, and diversification in the activities of youth associations. There were changes in population policy following the Intermational Population Conference in Cairo in 1994, shifting to a reproductive health-oriented policy from a family planning-oriented one. These changes were facilitated by studies and policy discussions financed by the project under the Institutional Strengthening component. The key reform area affecting project implementation was the development and implementation of overall decentralization policy, following the initial steps in decentralization of the health sector. Decentralization became effective in January 1997, and fortunately, the PHRD I design was actually in advance of this significant and formal policy reform. Timely provision of counterpart funds proved to be a problem; the  5 75%/ 25% split initially established for IDA and counterpart funds, respectively, proved inoperable due to persistent delays in availability of counterpart funds. Resulting delays in procurement and in other areas were such that IDA agreed to 100% financing for certain activities. 14. Although the Government quickly appointed key staff to the various project coordination units, steps were not taken to replace those of them who proved to be ineffective. This caused a two-year delay in implementation of the youth component, and problems in institutional strengthening of the National Health Education Service (SNEPS), and its support to otlher project components. 15. Within Control of Imiplementinf Azengv, PHRDI was implemented by the Ministry of Economy, Finance and Plan, and was attached to the Minister's Cabinet. Oversight was supposed to have been exercised by an Intenninisterial Committee (IC), with the central coordination unit (UCP) as its secretariat. Since the IC did not meet, the UCP began to play a strong an oversight and management role, rather than the coordination role originally anticipated. Repeated requests by that unit for meetings of the Committee were not honored, and over five years of implementation, the Committee met only twice. Meanwhile, some ministries refused to conform to procedures developed by the coordination unit, for example making their own procurement arrangements, some of which were then disallowed. Others persisted in trying to manage civil works even when the decision had been taken to contract with AGETIP to ensure faster construction and equipment of physical structures. Some units were loath to decentralize management of training or other activities to the district level, and there were no sanctions available to encourage them to do so. The anticipated use of local and expatriate experts did not materialize in some cases, and in others, was postponed until errors had already been made. 16. On the positive side, the UCP developed an operations manual and a variety of procedures and implementation and monitoring tools, and carried out a strict monitoring schedule. Despite the delays and difficulties with counterpart funds, difficulties in managing international bidding, and problems with the special account, the UCP achieved a perfect audit track record, which is remarkable for a project of this complexity and scope. By the end of February, 1997 one month before the completion date, 95% of funds had been disbursed, despite more than two years of implementation delays and the seven month devaluation-related disbursement hiatus. Credit should also be given to the Health coordination unit (USC/Sante) for effective management of the second special account. The head of the Youth coordination unit (USC/Jeunes) was able to achieve nearly all sub- component objectives in little more than one year of implementation, while the women's coordination unit (USC/Femmes) effectively managed an innovative, multi-faceted women's program in five regions, with minimal funding for local-level staff. This component got started earlier than some others, although it too experienced serious delays in civil works, anrd in payment of para-professional literacy trainers and auxiliaries. F. Project Sustainability 17. Policy Environment. ]n large part due to policy reform measures supported by PHRD I and other IDA credits, the policy environment in Senegal is now extremely favorable for sustainability of most actions initiated under the Project. This is especially true for the continued decentralization of management and service provision in primary health care, including reproductive health and essential drugs. The cost recovery program managed by local committees has proved so successful that decentralized, elected officials and ministry staff will together have to ensure that sufficient funds are reinvested in health and essential drugs related activities specifically, while fees for service do not become inflated and the array of "minimum packages" maximized. Cost recovery through health committees amounted to 2 billion FCFA by the last months of Project implementation, and many decentralized health centers were recovering 100-130% of their recurrent costs except for ministry staff salaries and amortization of infrastructure. In addition, some committees were able to pay for additional staff (secretaries, drivers, auxiliaries), no longer included under current central ministry funding guidelines. Others are moving to renovate or build "cases de sante"--sub-district level health centers--and then hire health agents or nurses to run them, and procure essential drugs from the regional or district-level pharmacy. this shows that if demand is accurately assessed, and accountability measures introduced and monitored, cost recovery rates for  6 services can increase very quickly. Best practice examples are already being replicated by other donors, such as the adolescent advice centers with "hot-lines" already included in the Project's regions and funded by UNFPA and ASBEF. For reproductive health and population/FP specifically, there remain some issues of de-medicalization of service delivery, availability of contraceptives at the local level as well as women's health issues in general. These matters will be pursued in policy dialogue in connection with the new Sector Investment Program for Health. 18. Government Commitment. The Government is now highly committed to promoting functional literacy and numeracy among women and youth, in part due to successes under the women's and youth components of this Project. There is now a Literacy Ministry, whose main target is women. The GOS has provided a small amount of funding to consolidate activities funded under PHRD 1, and in conjunction with its Women's Action Plan, is seeking donor funding to extend these and related activities throughout the country. For youth, the situation is less clear. PHRD 1 was the first major project to include the Ministry of Youth and Sports MJS). Under the Project, emphasis for youth association activities shifted radically from an all-male, sports program orientation, to development and dissemination of an education for family life program, also supported by UNFPA. Employment generation activities were not included for youth, but the rising rate of unemployment for urban and rural adolescents and young adults (both included as "youth" under Senegal's legal definition, which extends to include those 15-35), is a potentially explosive political issue that the GOS is very much interested in addressing. However, it is unclear at this juncture that without bridging donor support, the MJS will be able to assimilate and generalize all the lessons learned from the IDA and UNFPA supported initiatives. These initiatives together have had a definite and measurable positive impact on knowledge, attitudes and behavioral changes regarding contraception, sexual behavior and protection against STDs, including AIDS as demonstrated by the second Knowldged Attitude Practice (KAP) Study conducted in January 1997. The sample for KAP II was 1,029 youth between the ages of 15 and 25 participating in non-school activities, who had benefited from the project component in Dakar, Thies, Kaolack and Saint-Louis. This compares with a sample of 680 covered in the first KAP study. The study used both focus groups and quantitative survey methods, and focused on attitudinal and behavioral change resulting from IEC and the EFL program specifically. Highlights of KAP II results are that 81% of those interviewed stated that they had changed their behavior and attitudes regarding sexual activity, fertility, delinquency and their relations with their environment, including their parents, and that these changes were positive. All those interviewed, regardless of region, know both modem and traditional contraceptive methods. Of modern methods, the condom is the best known (94.3% of respondents), followed by the pill (92.6%) and the IUD (77.3%/6). Boys responded slightly more positively on condoms than girls, responses of boys and girls were equal for pills, and those of girls exceeded those of boys for the IUD by about half. 87% of those sampled seemed very favorable about contraception, saying that it was necessary to space births, to avoid early pregnancy, and to be able to better support children. 19. Institutional! Mana2ement Effectiveness. The move toward decentralization of all social development activities, as well as financial resource generation to the regional and district levels will radically alter the institutional and management context for activities initiated and strengthened under PHRD 1. In some instances, further support for institutional strengthening at these decentralized levels, and at the sub-district level, will be necessary. In the PHC domain, however, PHRD 1 has already accomplished a great deal. There is evidence to suggest that in Senegal, as elsewhere, management that is closest to beneficiaries is likely to be more effective than that which is more centralized and more distant. The span of authority of elected officials will continue to increase, while the power of civil servants is likely to diminish, and self-managed programs in health, women's affairs, youth affairs, as well as in infrastructure development and maintenance are the wave of the future. Decentralized activities piloted under PHRD 1, and attempts at lateral coordination at the regional and district levels fostered under the Project within the health sector, and across health and the other sectors, can provide best practice examples for replication in other regions, as well as providing lessons about what works less well. 20. Local Participation and Social Impact. More than any other facet of the PHRD 1 initiatives and interventions, it is the emphasis on increased local participation and empowerment of community health committees, women's groups and youth associations in the context of decentralization and cost recovery programs  7 that makes their sustainability extremely likely. Some concem is expressed at the central level that if supervision by civil servants from the center and the periphery diminishes, political pressure by local elites to capture benefits may substantially increase. Nevertheless, the intensity of continued supervision desired by many ministry staff involved in the Project seems more representative of the old heavy "encadrement" system than of the new orientation toward decentralization and participation. For PHC, there is still a need to improve quality of care and health education througlh participatory management of health services. As local health committees see that they are indeed empowered, can generate (and withhold) significant funds, and are required by law to pay for lower-level health personnel, they are likely to demand better quality care and more participation in management of health posts and other health infrastructure. As youth associations see what women's groups can do with income generating activities initially supported under the Project, they too will begin to innovate, as has already been the case in some conmmunities. Still, the genuine withdrawal of the state bureaucracy from local-level affairs, and ensuring benefit delivery to the poorer and more remote communities or peri-urban areas at affordable prices should be reinforced and monitored. This will be done in part by the beneficiaries themselves, perhaps if local committees join in regional lederations that can then elect members of a national, apex organization. This will also be supported by the Health Sector Investment Program and a possible Poverty Alleviation Project, the PAGD and the Community Nutrition Project as well as interventions by other donors. G. Bank Performance 21. Identification of PHRD I, as the first of a series of social development projects following on a health sector investment project, turns out to have been extremely unsightful. Many of the reforms and investment activities funded under the Project, such as the decentralized health district approach, the promotion of cost recovery mechanisms at the community level, and participation by community members and beneficiaries themselves in PHC management, as well as women's income generation and management training in addition to literacy and numeracy training, have been in the vanguard, and have had a very positive impact on the generalization of good policies and best practices to other interventions, including those of other donors. Another innovative facet of the project that has been successful in implementation is the inclusion of policy and programmatic studies and dissemination activities that have led to and advanced execution of reforms without requiring conditionality or budget support. This, combined with the cross-sectoral approach, and a variety of self- sustaining activities including those fostered by Government contracting with NGOs, are particularly noteworthy. Preparation and appraisal proceeded relatively smoothly, in part because the Project supported key elements of the Government's own economic and social development policy and strategy. Given the multiplicity of Government and non-government actors, negotiations for particularly delicate aspects of project design, such as emergency surgery training for GPs; redeployment of MASA staff to the regional and district levels; steps necessary to introduce the minimum package approach to PHC, as well as the essential and generic drug initiatives, were well staffed out during preparation and appraisal. The appraisal team, together with other donors, paid careful attention to measures needed to bring the national pharmacy from bankruptcy to profitable status, and to ensure appropriate management of inventory, especially for essential drugs, proved crucial to the ultimate successes achieved in the pharmaceutical domain. Nevertheless, the lack of conditions of effectiveness relating to the preparation of a procuremeni and an operations manual upstream of project effectiveness, led to very significant delays in project start-up. (these were not required at the time the Project was appraised). 22. The Association also contributed to project success in intensive supervision. The joint supervision model, in which task management is shared between the Resident Mission and HQ has proved indispensable to ensure that project complexity did not lead to project failure. Continuity of IDA staff involvement since project launch has also been extremely impcrtant. The Project provided considerable training in procurement and disbursement to Senegalese project staff, tc help ensure smooth implementation. IDA also worked hard to ensure that there was increased coordination among donors with parallel interventions, although official co-financing did not take place. When it emerged during implementation that there were some overlaps in funding with other donor programs and projects, such as for contraceptive procurement, IDA worked with the Government to program available credit funds accordingly. Recognizing after the mid-term review that delays had been such that the completion date  8 should be revised, IDA moved quickly, agreeing on an action plan to ensure that all project activities would be completed and all funds disbursed by the new completion date. As part of this mid-course correction, IDA introduced further involvement of AGETIP for civil works and other interventions. H. Borrower Performance 23. Government of Senegal participation in project preparation was particularly good at the policy reform level. The Project corresponded to support for several key objectives of the Government's newly prepared National Population Policy, and its later National Family Planning Policy, as well as initial moves toward decentralization and implementation of the Bamnako Initiative in primary health care PHC. The Government participated intensively in identification and preparation, presenting its national population policy in draft to the Bank at HQ, and then working through a Government committee for nearly two years to prepare the project. After effectiveness, despite some initial changes in the institutional location of the coordination unit and the identification of the central Coordinator, the Government quickly named staff to project support units (PSUs/UCPs), which then began-in consultation with the Bank-to put in place necessary procurement and other procedures. Aside from those in the Health Component Support Unit (UCP/Sante), none of these staff were familiar with Bank Group project implementation, however. Therefore, training was provided in Bank procurement and disbursement procedures, as well as project planning and management. Not all coordination unit staff who were anticipated beneficiaries chose to participate in this training, however. 24. Since the IC which was supposed to oversee and manage the Project, only met once in 1992, and again in 1995, despite repeated requests addressed to the Minister of Finance, Economy and Plan by the UCP, other coordination mechanisms were designed by project staff, including an Inter-component Technical Coordination Group, in order to facilitate exchanges among various support units responsible for particular components, and to foster inter-component synergies and collaboration. Though this group met monthly, it was boycotted by staff of certain ministries. In part as a result of the failure of these implementation arrangements, and the inability or unwillingness of the MEFP to either reinforce or change them, the central coordination unit (UCP), took over additional oversight and management responsibilities. This, in turn, aggravated claims by other units that the central unit was trying to subordinate them without authorization. Meanwhile, within components, similar claims were made by technical units that were already directorates or services of major ministries, and thus did not accept the authority of Project component support units to intervene in their affairs. These inherent structural problems, combined with personality conflicts, exacerbated implementation delays throughout the implementation period. 25. Within the health component at the regional and district levels, coordination and collaboration were significantly better, and the establishment of regional-level teams proved relatively successful despite some staffing shortages. Collaboration among components was also generally better at these levels, in part because there were real benefits for all stakeholders if they collaborated, and in part because--coincidentally--those assigned to some of the project regions from different ministries had already worked well together in other contexts. In Thies, a formal protocol for collaboration was drawn up in February 1996, calling for collaborative planning, formation and resource sharing and monthly meetings. This protocol was sent to other project regions as an example, but was not always replicated, in part because appropriate signals did not come from above through the respective line ministries. This continued to be the case despite a structured program of field monitoring and evaluation visits observed by the UCP and the CSUs. 26. Following the mid-term review in October 1994, the IC met for the second and last time, and project staff were instructed to abide by the context of the Credit Agreement. Meanwhile, certain key unit leaders were replaced, and implementation activities in youth, health and IEC moved forward much more quickly. Construction and equipping of civil works, however, continued to lag because individual ministries did not want to contract out to AGETIP even if this would speed up implementation and relieve them of considerable management burdens. Timely provision of counterpart funds proved a problem; those line items where a 75%-25% split was established for IDA and counterpart funds, respectively, proved particularly hard to implement due to persistent  9 unavailability of counterpart funds. This was a genuine problem due to the country's economic circumstances in 1993-94. Others delays were such that para-professional staff went unpaid for six months at a time, while some NGO contractors have been waiting for final payments for over seven months. 27. Overall, the Project made little use of technical assistance personnel whether Senegalese or expatriate except in the reform of the F'NA and for specific policy studies under the population institutional strengthening and health components. In the former case, long-term technical assistance was provided by other donors. Project funds originally included for TA were eventually programmed but had transparent decisions about the use of these funds been made earlier by the Borrower, they could have been progranumed sooner, leading to earlier and more significant impact. Those contractors who were used performed adequately. Despite training and careful supervision by the Task Managers, many bidding documents had to be revised, sometimes more han once, with the result that procurement was frequently significantly delayed. In addition, there were key differences of opinion among technical and support unit staff regarding almost all procurement actions; support unit staff who were in charge of carrying out the procurement actions according to technical specifications provided by the other technicians in some cases lacked sufficient understanding of these specifications. This, too, resulted in delays and in instances in which the equipment ultimately delivered was inappropriate or incomplete. 28. Thus, Borrower performance was mixed. In some areas, such as policy reform and implementation, it was highly satisfactory. In others, such as institutional strengthening and day to day management, it was marginally satisfactory, and in terms of anticipated synergies, it was unsatisfactory. Nonetheless, all activities are being achieved, and all funds disbursed, with a clean audit record despite all of the problems and weaknesses. The result is highly positive even though the process was in many ways extremely management and supervision intensive, and less than satisfactory. L Assessment of Outcome 29. The outcomes of PHRD I are satisfactory. It has achieved almost all its development objectives, with the probable exception of the targeted increase in contraceptive prevalence. The very positive evolution of the PNA structure and systems is a bonus derived from the Project's essential drugs activity. Sustainability at the district and sub-district levels is virtually assured, in large part because of the decentralized and participatory nature of interventions and activities. Those elements which are both exemplary and most innovative, such as self-managed income generating activities for women's groups, and the education for family life activities of youth associations, perhaps require some additional interim support to become completely institutionalized. This support is likely to be forthcoming from a combination of donor-funded efforts and Government support to be provided through decentralized resource mobilization, including cost recovery. J. Future Operations 30. The major proportion of project activities will be replicated in other regions of the country with support from the SIP which, in turn, will be co-financed by a group of multilateral and bilateral donors. The donor consultative group meeting for this SIP Is was held in mid-April 1997, in response to the Govemment's new and revised National Development Plan for Health (PNDS). IDA has worked very closely with the European Union to mobilize donor consultation and collaboration. Appraisal of IDA's participation in the program was made in May 1997. The project has been negotiated with the Government in June 1997, and is schedule to the Board on September 4, 1997. 31. The remaining activities initiated or expanded under PHRD I, including the women's sub-component and the youth sub-component, are already receiving some parallel funding. In the former case, African Development Bank Project (five regions), and in the latter case UNFPA, has made funding available. UNFPA is also supporting policy related studies and dialogue to assist in the preparation of the second Priority Investment Action Plan. Meanwhile, UNICEF, UNFE'A, various Nordic bilaterals, the Dutch and the Japanese are potential sources of  10 support to these and related initiatives in the context of a proposed donor consultative group meeting for the Government's social development program was held in May 1997. This meeting was centered around the Women's Action Plan. IDA has indicated that if approached by the GOS to provide funding for a multi-sectoral social development and poverty alleviation intervention, it would consider such a request favorably in the context of the forthcoming Country Assistance Strategy. K. Lessons Learned 32. The project indicates that reforms can be started and generalized under an investment operation without conditionalities and budget support, given government commitment and good project design. 33. Significant lessons for future project work and policy reform can be learned from studies and surveys funded under an investment operation. This speeds up preparation and appraisal of the next sector credit and enhances the policy dialogue during the implementation of that investment operation. (Relevant for a variety of sectoral and multi-sectoral investrnent operations, especially where it is known that government and donors are going to shift from a project to a program approach). 34. Intensive Resident Mission and HQ supervision can support implementation of complex, multi-sectoral projects that also involve decentralization, but this commnitment should be made at the outset. (Relevant for an increasing number of operations in Africa and LAC as well as other regions). 35. A well-tailored role for NGOs under government contract can prove very effective and may be both less expensive and more participatory than direct government implementation. (Especially relevant in the context of decentralization and deconcentration of service delivery and state disengagement from service provision and infrastructure management). 36. Weakness in project design, with no conditions of effectiveness requiring early arrangements for procurement plans and implementation procedures make subsequent implementation difficult despite earlier appearances of consensus on key collaborative elements. 37. Where project success depends on significant redeployment of civil servants concrete human resources management measures should be included in conditions of effectiveness, and should be taken up in dialogue on civil service reform under other projects and programs. (Relevant wherever administrative reform and public sector modernization interventions are also being supported by bilateral or multilateral agencies, including the IMF). 38. Including a gender focus in IEC for FP and reproductive health in a multi-sectoral project is effective, especially when supported by local-level income-generating and literacy activities. If possible, this should also include targeting a certain proportion of women members of other local-level committees, such as district or sub- district health commnittees. (Relevant for most projects where significant behavior change is required to achieve project objectives whether or not these are specifically gender oriented). 39. Central coordination units in central (non-technical) ministries may be sources of delay and rivalry rather than--as intended--facilitative of collaboration and increased implementation and disbursement efficiency. The same may be true of centralized technical support services located in one of several project technical ministries. Further, when the project ends, PCU management or technical capacity is dispersed, leading to little gain in institutional capacity or sustainability. Such units are not sustainable and decrease institutionalization of aid management capacity.  I1 40. Multi-donor geographical division of multi-sectoral activities, unless coordinated from the preparation phase on, is likely to complicate rather than to simplify implementation, as differences in technical content, procedures and component funding levels are introduced. 41. Including project finding for expatriate technical assistance is less viable in projects than was previously the case. If government technicians can do work "en regis", they will; if not, they will contract for local TA. Only if IDA supervision proves that results have not been obtained using this approach will expatriate TA funds then be spent. (Now increasingly relevant in AFR and other regions as well). 42. Separate special accounts for different project components may be effective, but do not encourage coordination. Where there is a central coordination unit with sign-off or clearance authority, even a separate special account may not lead to quicker disbursement. (Generally true in AFR and elsewhere). 43. If demand is accurately assessed and accountability measures introduced and monitored, cost recovery rates for services can increase very quickly. Within five years, decentralized health care centers and their health committees are recovering an average of 120-130% of recurrent costs apart from salaries of state employees and amortization of infrastructure. 44. Addressing key beneficiary groups with demand-driven IEC and service delivery programs, including counseling, can be extremely effective in environments where cultural prohibitions are prominent. Outreach dimensions of these same programs can also help to change attitudes and behavior of non-targeted beneficiaries. (True in multi-ethnic and multi-cultural environments, as well as in those where religious or political factors constitute a risk for project objective attainment or sustainability).  I  12 PART II: STATISTICAL ANNEXES Table 1: Summary of Assessment .......................................................................... ..................................................................................................... ........................................................ A. Achievement of Obiectives Substantial Partial Negligible Not applicable ........................... ................. ............................................................................................................................................................. ........... Macro Policies i 0 0 G ...................................................... ............ ........................................................................................................................................ . ........ Sector Policies B 03 0 0 ............................................. ........... ............................................................................................................................................................ Financial Objectives 0 n 0 0 Institutional Development i0 0 0 Physical Objectives i 0 0 0 Poverty Reduction . 0 0 0 i....................................................... ............ ....................................................................................................................................... ........... Gender Issues B 0 Ander Is es 0~~~~~~~~....... .................. ................... .. no;............................................................. Other Social Objectives 0 0 0 0 Enviromental Objectives 00 O Public Sector Management 0 0 0 B Private Sector Development 03 0 0 B r -- --- --- -- --- -- - - ---------------------------- ---------------------- -- ...................................................... Other (specify) 03 0 0 0 ~~~~~~~~~~~~~~~~~~~~............................................................................................................. ..................................... B. Project Sustainabiliti Likely Unlikel Uncertain I B 0: ................................................................................................. ..................................................................................................... .................................................................................... C. Bank Performance satisfacto Satisfactory Deficient i i ~~~~~(/) (/) (/)i ................................................................ ................................................................................................. Identification 0 0 Preparation Assistance 0 . 0 r................................................................................... ................................................................................ Appraisal 0 B 0 ...................................................................................................................................................................................................................................... Supervision 0 B 0 .................................................... .................................................................................... D. Borrower Performance satisfactorv Satisfactory Deficient (/) (/) (/) 3.............................................................. .................................................................................................................................................... Preparation 0 O 0 ;........................................................................................................................................................................................................................... ........... Implementation 0 B 03 Covenant Compliance 0 B 03 Operation (if applicable) 0' 0 ........................... ............................................................................................................................................................................................... EE. Assessment of Outcome ig satisfactor Satisfactor Unsatisfactov unsatisfactorE . ................................................................................... . .................................................................................... ........................................................................................................  13 Table 2: Related Bank Loans/Credits (US$ thousands) Loan/credit title Purpose Year of approval Status Preceding operations 1.Rural Health Project (CR. Provide technical, logistical and 1982 completed 1310 SE) managerial support for Senegal Primary Health Care Following operations 1. Endemic Diseases Control Support Government in its efforts to 1997 Starting Project alleviate the burden of endemic and epidemic diseases on Senegalese's populations with, in particular, a reduction of the burden of malaria, schistomiasis and onchocerciasis. 2. Integrated Health Sector Support the Government's health plan and 1998 Appraised Development Project- SIP- five year investment program for period !N PE-2369 1997-2001. Building on analytical work, SN-PE-2369 policy and institutional reforms initiated under this completed project, it will help(i) expanding access and use of health services(ii) increasing the overall efficiency of the health care system in mobilization and use of services. Table 3: Project Timetable Steps in Project Cycle Date Planned Date Actual/ I J Latest Estimate Identification (Executive Project Sumnmary) February 1989 November 1989 Preparation Appraisal April 1990 June 1990 Negotiations September 1990 February 1991 Letter of Development Policy (if applicable) November 1989 Board Presentation May 1991 Signing January 1992 Effectiveness October 91 January 92 First Tranche Release (if applicable) 1989 Midterm review (if applicable) December 1990 March 1995 Second (and Third) Tranche Release (if applicable) March 91 Project Completion June 1995 March 1997 Loan Closing December 1995 March 1997  14 Table 4: Loan/Credit Disbursements: Cumulative, Estimated and Actual FY92 FY93 FY94 FY95 FY96 FY 97 Appraisal Estimate 8,500 21,100 2,700 35,000 Actual 4,797 11,297 18,190 26,480 31,600 Actual as % of Estimate 56 53.5 55.6 75.6 Date of Final Disbursement September 29, 1997 Table 5: Key Indicators for Project Implementation 1. Key Implementation Indicators in SARW President's Report Estimated Actual 1. HPNS trained in FP service delivery 360 720 2. Social agents trained in FO/IlED 384 364 3. Women trained in fimctional literacy 2000 3000 4. "Case-foyers" constructed 30 30 5. Women's groups receiving equipment 225 223 6. Demographic and Health survey 1 1 7. HPNs trained in HP services management 360 360 8. DMO2s trained in emnergency surgery 12 0 9. DMOs trained in practical training zones 10 0 10. New Hps constructed 60 60 11. MCH centers transformed into HPs 4 4 12. Hpsd receiving an initial stock of drugs 360 600 13. Nombre d'associations de jounes partenaires 73 73 au projet 14. Nombre de comites de Sante renouveles 800 800  15 Table 6: Key Indicators for Project Operation 1. Extension du partenariat avec les ONGs 2. Processus de d6centralisation des services sanitaires 3. Consolidation de I'accessibilite aux Medicaments essentiels 4. Activites pour augmenter le taux de prevalance Contraceptive 5. Poursuite des activites d'alphabetisation des femmes. 6. Appui des groupements feminins pour les activites d'allegement des travaux. 7. Activitbs d'education a la vie familliale avec les Associations de Jeunes Table 7: Studies Included in Project Purpose as Defined Study at Appraisal/Redefined Status Impact of Study 1. Politique Broaden the supply and completed The private sector imports generic pharmaceutique a long distribution of essential drugs essential drugs, and the government tenne through the private sector. will aimed establishes pharmaceutical norms covering both public and private sectors. 2. Etude de r6organisation Reorganisation of the PNA into completed The statute is in process of being de la PNA an autonomous public entity. changed. 3. Etudes sur les besoins Management of Human completed Provide information needed to en personnel. prepare the PND and the SIP 4. Etude sur les besoins en Management of Human completed Provided infor to prepare a Human formation. Resources Plan 5. Etude du Secteur Reform of the hospital system completed Provide information permitting the hospitalier. restructuration of the hopital system 6. Etude sur le Development of a sector completed Projection of financing needs for the financement du secteur de financing plan next 5 years. la Sante 7. Etude sur le schema Restructure the budgetary completed budg6taire system. 8. Etude sur la Establish a maintenance policy completed Provided a cost analysis on various maintenance des levels of the health pyramid. equipements hospitaliers 9. Etude sur les normes Establish standards to improve completed hospitalieres et les services planning mechanisms for health specialis6s facilities.  16 Table 8A: Project Costs Appraisal Esfimate (US$M) Actual/Latest Estimate(US$M) Local Foreign Total Local Foreign Total Item Costs Costs Costs Costs 1.Civil works 9.4 9.9 2. Vehicules, Equipment and materials 7.0 6.8 3.Furniture 0.8 0.6 4. Drugs 2.8 4.5 5. Consultants 4.4 2.7 6. Training 2.2 2.6 7. Incremental operating costs 2.6 2.4 8. Refimding of PPF 0.8 0.6 9. Unallocated 5.0 0.0 TOTAL 35.0 30 Table 8B: Project Financing Appraisal Estimate (US$M) Actual/Latest Estimate(US$M) Local Foreign Total Local Foreign Total Source Costs Costs Costs Costs BRD/IDA 10.5 24.5 35 Cofinancing Insl;itution none Other External Sources none Domestic Contribution 2.9 - 2.9 TOTAL 13.4 24.5 37.9 Table 9: Economic Costs and Benefits During Project Preparation, no economic rate of return (ERR) or net present value of the project was prepared. Therefore there is no baseline with which to compare actual estimates.  Table 10: Status of Legal Covenants REPUBLIC OF SENEGAL Human Resources Development Project I( Credit 2255 SE) Agreement Section Covenant Present Original Revised Description of Comments type status fulfillment fulfillment covenant date date Dev. Credit 3.01 (a) 5 C 1992 The Borrower declares it commitment to the Overall the Goverment was committed to the Agreernent objectives of the project as set forth in schedule 2 to objectives of the project and has taken all actions and this agreemnent and, to this end, shall carry out the measures required for its imnplementation project with diligence and efficiency 3.01(b) 5 C during the The borrower shall carry out the project in Work program and budgets for each year have been project life accordance with the implementation program set prepared in accordance with implementation program forth in schedule 4 to this agreement. 3.02 5 C during the Procurement of the goods, works and Procurement plans for the civil works, goods and project life consultants'services required for the project and to be services have been implemented in conformance with financed out of the proceeds of the credit shall be schedule 3. governed by the provisions of schedule 3 to this agreement 4.01 1 C during the Maintained records and accounts adequate to reflect Accounting procedures have been established and project life in accordance with sound accounting practices have worked well 4.01(b) I C Have records and accounts referred to the paragraph independent auditor selected (A) of this section in accordance with appropriate auditing principles consistently applied, by independent auditors acceptable to the Association 4.01 (i) I C 6 month after Furnish 6 months after the end of each year a MOHSA budget presentation was revised accordingly the end of certified copy of the report of such audit by said each fiscal auditors year  Table 10: Status of Legal Covenants REPUBLIC OF SENEGAL Human Resources Development Project I( Credit 2255 SE) Agreement Section Covenant Present Original Revised Description of Comments type status fulfillment fulfillment covenant date date 4.01 (ii) I C Project Life Furnish to the association such other information concerning said records, accounts and the audit thereof as the association shall form time to time reasonably request 4.01 (iii) 2 project life For all expenditures with respect to which withdrawals from the credit account were made on the basis of statement of expenditures, the Borrower shall: 4.01C 2 Project Life maintain or cause to be maintained records and accounts reflecting such expenditures; 4.01 C(i) 2 retain, until at least one year after the Association has received the audit report for the fiscal year in which the last withdrawal form was made, all records evidencing such expenditures; 4.01 C(ii) 2 Project life Enable the Association representative to examine such records, and 4.01 C(iii) I every six Ensure that every six months said auditors furnish to months the Association an opinion as to whether the SOE submitted during such period can be relied upon to support the related withdrawals. The Borrower shall take all necessary measures 4.02 Every Year To increase MOHSA's percentage share of the Goverunent's recurrent budget to 5.25% during FY91-92, to 5.75% during FY93, to 6.25% during FY 94, to 6.75% during FY95 and 7.25% during FY96;  Table 10: Status of Legal Covenants REPUBLIC OF SENEGAL Human Resources Development Project I( Credit 2255 SE) Agreement Section Covenant Present Original Revised Description of Comments type status fulfillment fulfillment covenant date date 4.02 (ii) 2 1992 To revise the presentational form of MOHSA's budget to clearly delineate drug and material allocations for the 45 districts of Senegal starting with the budget law for FY 91-92 4.02 (iii) 5 To ensure that total drugs and material allocations to the 45 districts shall be at least 1.5 million FCAF in FY91-92, 1.1 million FCFA in FY93, subsequently, such allocation shall increase annually by at least 10% in real terms through FY96. Covenant types: 1. = Accounts/audits 8. = Indigenous people 2. = Financial performance/revenue generation from beneficiaries 9. = Monitoring, review, and reporting 3. = Flow and utilization of project fimds 10. = Project implementation not covered by categories 1-9 4. = Counterpart funding 11. = Sectoral or cross-sectoral budgetary or other resource allocation 5. = Management aspects of the project or executing agency 12. = Sectoral or cross-sectoral policy/ regulatory/institutional action 6. = Enviromnental covenants 13. = Other 7. = Involuntary resettlement 8. Present Status: CP = complied with partially C = covenant complied with NC = not complied with CD complied with after delay  20 Table 11: Compliance with Operational Manual Statements BORROWER COMPLIED WIH ALL OPERATIONAL MANUAL STATEMENTS. Table 12: Bank Resources: Staff Inputs Stage of Planned Revised Actual Project Cycle _ l _ Weeks US$ Weeks US$ Weeks US$ Preparation to Appraisal N/A N/A N/A N/A 148.7 309.9 Appraisal-Board N/A N/A N/A N/A 64.1 138.2 Negotiations through Board Approval N/A N/A N/A N/A 19-9 44.5 Supervision 46.5 46.8 159.8 293.7 Completion 22 10 10.0 31.4 TOTAL 402.5  21 Table 13: Bank Resources: Missions Performance Rating Number Specialized Implem- Devpt Types of Stage of Month/ of Days in Staff Skills entation Objectives Problems Project Cycle Year Persons Field Represented Status Through 05/88 2 7 PS,PHS _ _ Appraisal 12/88 3 5 OS,E,A 02/89 4 20 E, ED 07189 N/A N/A N/A 12/89 8 18 C, E, N, PS, PF Appraisal 07/90 20 PF, AF, PF, AF, - - - through Board A, SP Approval Supervision 02/92 3 PHS, PrS 2 1 10/92 3 PHS, PS 2 1 06/93 4 PS, PHS, E, HS 3 1 11/93 1 PS 3 2 06/94 5 CS, HS, PS, E 3 S 10-94 2 HS, PS S S 02-95 3 HS, PS, PHS S S 10/95 3 HS, PrS, S S 06/96 2 HS, PS, AC, HS S S Completion 02/97 5 PrS, HS, PS, HS, - - _ SA PS; population specialist - PrS; Procurement Specialist - CS; Communities Specialist - HS; Health Specialist- PHS; Public Health Specialist - E; Economist - AC; Audit Coordinator; SA- Socio- Antropologist, C - Coordinateur, A-Architecte, CS - Consultant, N-Nutritioniste, PF - Promotion des femmes, AF -Alphab6tisation Fonctionelle, Al- Aspects Institutionels, PF - Plannification Familiale, SP - Sante Publique.  22 ANNEX I Page 1 of 8 Republique du S&ndgal Pirojet de Developpement des Ressources Humaines I Population et SantW Aide m6moire Mission de Supervision 12 fWvrier au 06 mars 1997 1. Introduction 1.1 M. Anwar Bach-Baouab, charge du Projet de Developpement des Ressources Humaines (PDHR I), Mme Alice Morton, Messieurs Alassane Diawara et Abdou Salam Drabo ont effectue une mission de supervision dudit projet du 12 fevrier au 6 mars 1997. M. Bernard Abeille s'est joint a la mission pour participer a ses travaux sur les procedures de gestion. La mission a eu des seances de travail avec les responsables des differents volets du projet et a 6te recue en audience par Son excellence Mme Aminara Mbengue Ndiaye - Ministre de la Femme, de l'Enfant et de la Famille, Son excellence Me Ousmane Ngom - Ministre de la Sante Publique et de l'Action Sociale, M., Ousmane Ndiaye, Directeur de Cabinet du Ministre de la Jeunesse et des Sports, et par M. Lamine Diouf, Conseiller aupres de M4. le Ministre de l'Economie, des Finances et du Plan. La mission a .galement rencontre IA. Moustapha Ka, Vice-President de l'Assemblee Nationale avec lequel elle s'est entretenue de la prochaine tenue a Dakar du colloque des parlementaires de la sous-region et les representants des organisations multilat6rales et bilaterales pour un tour d'horizon sur le developpement du secteur de la Sante. La liste des personnes rencontr6es figure en annexe. 1.2 La mission presente ses vifs remerciements a l'ensemble des personnes rencontrees pour la chaleur de leur accueil et la cooperation apportee au deroulement de la mission. Le present aide-memoire resume les conclusions et recommandations de la mission. Son contenu sera confirme par la representation residente a Dakar de la Banque mondiale 2. Objectifs de la mission Les objectifs de la mission etaient de (i) faire le point sur l'execution du PDRH I; (ii) d'identifier les actions residuelles qui pourraient aboutir avant la cl6ture du projet; et (iii) faire avancer le processus de preparation du rapport d'achevement du projet. La mission a saisi l'opportunite de sa presence a Dakar pour faire egalement le point de 1'etat d'avancement du Plan National de Developpement Sanitaire (PNDS) et du Programme d'Investissement Sectoriel (PIS).  23 ANNEX I Page 2 of 8 3. Contexte General de la Mission 3.1 Cette mission constitue la derniere mission de supervision du projet avant sa cl8ture prevue pour le 31 mars 1997, apres deux prolongations successives d'une annee et de trois mois portant sur la periode du lerjanvier 1996 au 31 mars 1997. Ces prolongations reposaient essentiellement sur le fait que de nombreuses activites etaient tres avancees et qu'il etait necessaire de les parachever et de mettre en place des actions pour en consolider les resultats positifs. La mission a porte egalement sur l'examen des rapports provisoires d'evaluation prepar6s par la partie sen6galaise et l'elaboration du rapport d'achevement du PDRH I. L'examen des documents provisoires du PDNS et du Programme PIS ainsi que l'etat d'avancement des actions preparatoires a la prochaine mission d'evaluation de ce dernier ont fait l'objet d'entretiens separes tout en mettant en exergue les enseignements a tirer de l'execution du PDRH I. 4. Etat d'avancement du PDRH I 4.1 D'une maniere generale, la mission estime que le PDRH I a atteint ses objectifs de developpement malgre les contraintes qui sont apparues durant la premiere annee de sa mise en oeuvre. Les activites et les resultats tres positifs des quatre principales composantes du projet ont et passees en revue au cours des seances de travail avec les responsables des cellules de coordination et de suivi du projet. Leur synthese et les enseignements tirbs de leur execution feront l'objet d'un rapport d'achevement conjoint du projet. Dans le cadre de ces rencontres, la mission a souligne que des mesures particulieres d'accompagnement devront 8tre prises pour assurer la perennite des actions du projet. La mission a note avec beaucoup de satisfaction le meme souci aupres des autorites s6negalaises. En raison de la cl6ture prochaine du projet, la mission a egalement insiste pour que l'ensemble des activites residuelles puissent 8tre achev6es avant le 31 mars 1997. Elle a clairement indique que la date du 31 mars fait reference a l'execution des activites et non a l'engagement des depenses et a encourage l'administration du projet a veiller a ce que cette contrainte soit bien prise en compte, a l'exception d'un personnel restreint, charg6 d'expedier les affaires courantes et d'assurer les paiements dans les trois mois qui suivent la date de cloture. 4.2 Enfin, au cours des rencontres avec les differents participants au PDRH I la mission a pu noter un interet marque pour la poursuite d'une cooperation avec la Banque dans le domaine du d6veloppement humain. A ce propos il a ete convenu de poursuivre la reflexion pour arr8ter une vision et definir le cadre de cette cooperation a la lumiere des actions que le gouvernement envisage d'entreprendre dans le cadre du plan de lutte contre la pauvrete, des plans d'actions de developpement de la femme et des jeunes et du Programme d'Actions Prioritaires en matiere de Population (PAIP) en cours d'elaboration.  24 ANNEX I Page 3 of 8 4.3 Composante Sante Malgr6 des delais comsiderables, a part deux volets cibles, toutes les interventions on tete achev6es a 100% y inclus la construction ou la refection de 60 postes de sante et des 4 centres de sante, la constitution de stock initial de medicaments pour les districts sanitaires menant une meilleur disponibilite en medicaments et produits essentiels apres la reorganisation de la PNA, le renforcement des comites de sante, et le recouvrement des couts. En moyenne, les 60 postes de sante recouvrent entre 100% et 130% de leurs frais recurrents a part les d6penses d'infrastructures et les salaires des agents de l'Etat. Des conventions ont 6te signees avec trois ONGs pour appuyer le volet IEC/PH. En matiere de formation en PF des chefs de postes, des superviseurs et des formateurs en nutrition, les cibles ont meme ete depassees. Seul le programme de formation en chirurgie d'urgence et l'affectation de deux medecins par centre de sante n'ont pas ete effectifs. Meme si le taux de prevalence contraceptive par rapport aux methodes modernes n'est passe qu'a 9% en 1995 au lieu de 14% e scompte, le changement en termes de couverture est appreciable, et l'acces, l'utilisation et la qualite des services sont notables, et permettent d'apprecier 1'existence d une integration des activites du paquet minimum devolu au poste de sante. 4.4 Composante Population 4.4.1 Sous composante "Promotion du Statut de la Femme" Cette sous-composante est basee sur des etudes du milieu qui ont permis la selection des 223 groupements feminins beneficiaires de l'appui du projet, qui ont exprimes leurs besoins en matiere de formation et d'appui en equipements d'allegement des travaux. Pour le volet "Alphabetisation fonctionnelle", apres la conception de manuels et la formation des 446 alphabetisatrices choisies parmi les groupements, 50 monitrices, plus de 3.000 femmes maltrisent la lecture, 1'ecriture et le calcul dans les 4 langues nationales. Pour le volet technologies appropriees pour I'allegement du travail des femmes, et la generation de revenus pour les groupements, 225 moulins, batteuses et autres equipements de transformation de produits agricoles ont ete fournis aux groupements, et le beneficiaires ont recu une formation technique et en gestion. Les comptes bancaires ont et ouverts par les groupements. En plus., les groupements ont beneficie de formation des auxiliaires en LEC, et les causeries en IEC se font sur le terrain bases sur 26 themes relatifs a la SMI, PF, 1'environnement et A la legislation. Un film sur les grossesses rapprochees, et des spots entre autres materiaux multi-mediatiques ont ete concus. Apres un retard significatif, la construction de 30 cases-foyers par l'AGETIP a ete r6alis6e, et le materiel et equipement sont en voie de livraison. Dans la meme convention avec l'AGETIP, les fonds pour la post-alphabetisation et le financement des projets d'accompagnements pour les activites a but lucratif sont assures et detailles dans le rapport d'achevement.  25 ANNEX I Page 4 of 8 4.4.2 Sous composante "Promotion des Jeunes" Pour atteindre les objectifs d'informer, de sensibiliser et d'eduquer les membres de 73 associations de jeunes selectionnes dans les localites urbaines et peri-urbaines en matiere de sante reproductive et PF, l'USC jeunes a elabore, en collaboration avec tous ses partenaires un programme d'IEC en PF, et plus gen6ralement un programme d'education a la vie familiale (EVF) utiisant plusieurs medias et approches, et base sur une etude CAT. En plus, le programme a soutenu les activites participatives des associations et ONGs menant des actions sinilaires, et la rehabilitation des CDEPS et des foyers de jeunes. La formation en IEC, EVF, gestion, formulation de projets, communication avec les adolescents, manipulation d'appareils audiovisuels, et l'approche MASRP pour definir les besoins ont et octroyees aux agents du MJS et au 146 "jeunes relais". Des equipements audiovisuels ont et fournis au CDEPS et foyers choisis et 2 foyers et 9 CDEPS ont et rehabilit6s. Apres la revue a mi-parcours, certaines activites du programme ont ete elargies pour inclure d'autres associations en milieu rural, et les 73 associations prealables ont elargi leurs activites pour encourager des associations dans d'autres quartiers. L'experience des centres-conseils avec "hot lines"(ecoute au telephone) est a suivre de tres pres, ainsi que l'appropriation des activites soutenues par le projet avec les associations impliquees. L'analyse de la deuxieme etude CAO devrait faciliter la consolidation des acquis de cette sous- composante par le MJS et les associations. 4.4.3 Sous composante "Renforcement Institutionnel du Programme National de Population" Les activites de cette sous-composante sont centrees sur deux axes. Des etudes et recherches en matiere de population, et le suivi et 'e6valuation de la mise en oeuvre de la politique nationale de population. Trois etudes ont e achevees sur differents themes, ciblant l'impact du milieu familial sur le comportement des adolescents, l'impact des groupements feminins dans le processus migratoire du bassin arichidier, et des centres de decision dans divers groupes ethniques en matiere de PF entre autres. APAP/Senegal mene une etude sur l'impact des perspectives alternatives de la mise en oeuvre des politiques et programmes de population. L'axe suivi et l'evaluation du PNP a inclus une etude evaluative du PNP en 1995, et a contribue a l'elaboration du deuxieme PAIP. Plusieurs seminaires inter-regionaux ont ete animes pour sensibiliser des cadres et des autorites administratives. D'autres seminaires a l'intention des parlementaires, des joumalistes et des leaders religieux ont abouti a l'emergence de reseaux en population et developpement qui contribuent a la promotion de la politique de population. 4.5 Activites de l'UCP L'UCP a eu pour charge principale: - d'assurer le secretariat du Comite Interministeriel  26 ANNEX I Page 5 of 8 - de g6rer le compte special A - de cordonner la production des documents d'ensemble du projet - de superviser et de coordonner les activites de suivi - d'assurer la liaison avec les bailleurs de fonds. Au plan de l'organisation et de l'integration des activites, les realisations ci-dessous ont ete faites pour combler certains vides constates dans la structuration du projet: - la signature d'un arret6 interministeriel fixant les relations entre l'UCP et les USC et creant en meme ternps le groupe technique intercomposante - l'institutionnalisation de cellules regionales inter-composante pour garantir la synergie des equipes sur le terrain - l'institutionnalisation de tournees annuelles intersectorielles dans les regions pour le suivi en commun des activites du projet - la mise en place d'un comite technique de coordination des activites IEXC. En ce qui conceme la gestion administrative, des instruments servant d'appui a la gestion administrative et financi6re du projet ont ete mis au point. II s'agit d'un manuel de proc6dures regissant le projet, d'une instruction sur la decentralisation financiere de la composante sante, de la mise en place d'un systeme comptable et d'un logiciel de suivi budgetaire, et enfin de la signature d'un marche d'audit des comptes du projet et de conventions de maitrise d'ouvrage d6legue pour la realisation du volet genie civil des sous-composantes "jeunes" et "femmes" apres leur accord pour confier a l'AGETIP cette operation. 4.6 Coordination du Projet Etant donne la nature multisectorielle des objectifs et interventions du projet, une structure de coordination assez lourde a ete mise en place pour rapprocher les programmes executes par les quatre ministeres impliques, et aussi pour faciliter le volet gestion financiere et de passation de marches. Les trois sous-prograrnmes d'IEC en population ont aussi ete orient6s vers le SNEP pour une meilleure coordination et rapidite de production de supports apres une experience prealable de separation par secteur. Les intervenants, sous le guide d'un comite interministeriel qui n'a presque pas fonctionne ont cree un groupe technique inter-composante pour appuyer les actions de l'unite de coordination du projet (I'UCP) au MEFP. Malgre la volonte de coordonner et d'harmoniser les actions des composantes a travers les unites de soutien de coordination (USC) de chaque ministere cette coordination s'est averee tres difficile.  27 ANNEX I Page 6 of 8 La passation de marches, la gestion des comptes speciaux, les volets de genie civile, ont tous pos6s problemes tout au long de l'execution du projet comme il ressort dans les rapports d'evaluation de l'UCP. La collaboration entre les USC et l'UCP n'a pas toujours evolue dans le sens souhaite, et la collaboration sur le terrain n'a pas toujours eu lieu, malgre le programme assez intensif de suivi et d'evaluation poursuivi par les unites de coordination, y inclus l'UCP. Malgre ces contraintes et problemes, les objectifs et les activites cibles par le projet sont acheves en grande partie et les activites residuelles s'executeront d'ici la cldture du credit. De bonnes reactions des responsables apres la revue a mi-parcours, soutenus par une supervision intensive et collaborative de l'IDA au niveau de la Mission residente et du Siege ont permis d'atteindre ces performances. 5. Le PNDS et le PIS 5.1 La mission a pu constater des avancees significatives dans l'elaboration des documents du PNDS et du PIS. La formulation des dix strategies de developpement socio-sanitaires retenues dans le document provisoire du PNDS est claire, toutefois la mission estime qu'il y a lieu d'ameliorer la couverture dans ce document des actions qui devront etre prises pour le renforcement institutionnel a tous les niveaux et la r.organisation du ministere dans le cadre de la politique de decentralisation. A ce propos, la mission a insiste aupres des autorites pour qu'elles privilegient la qualite des documents par rapport a l'urgence qui parait souhaitee de tenir au plus vite une reunion des bailleurs de fonds. 5.2 La mission a participe a la reunion des bailleurs de fonds organisee par le MSPAS pour une lecture commune des documents provisoires du PNDS et du PIS. Elle a pris note avec satisfaction de la decision de faire en sorte que les observations et les commentaires des bailleurs de fonds fassent l'objet d'une correspondance conjointe coordonnee par la Delegation de l'Union Europeenne. La mnission a pris note egalement de la disposition favorable des bailleurs de fonds d'harmoniser autant que possible, leurs mecanismes d'appui au budget de fonctionnement des structures decentralisees du MSPAS. 5.3 La mission estime que la date de la premiere semaine d'avril 1997, pressentie par le MSPAS pour reunir une consultation des bailleurs de fonds pourrait etre maintenue. Cela necessite toutefois que les documents finalises du PNDS et du PIS ainsi que la lettre de politique sectorielle soient distribues au plus tard a la mi-mars 1997. L'objet de cette reunion de consultation formelle avec les bailleurs de fonds partenaires est d'obtenir un consensus et un engagement des partenaires le plus large possible.  28 ANNEX I Page 7 of 8 5.4 Les procedures de gestion du PIS La mission a reitere l'urgence de proceder prealablement a la prochaine mission d'evaluation, la preparation d'un projet de manuel des procedures, d'un programme et d'un budget detaille des activites pour les trois premieres annees d'activites, d'un projet de plan de passation des niarches, et d'une proposition de plan de financement pour les deux premieres annees du PIS, conformement aux recommandations de la mission de pre- evaluation et a la note technique annexee a l'aide-memoire de cette m8me mission. Ces dossiers devront etre prepar6s a la lumiire de la nomenclature interne de budget fonctionnel du MSPAS. Dans cette perspective le MSPAS s'est engage a: (i) recruter le consultant choisi pour 1'6laboration du projet de manuel de procedures avant la mi-mars 1997; (ii) finaliser un projet de plan de passation des marches des deux premieres annees avant la fin du mois d'avril 1997; (iii) proposer un organigramme des structures de suivi, d'evaluation et de gestion du PIS avant la fin du mois d'avril 1997; (iv) mettre au point une banque de donnees de specifications techniques des fournitures standards et equipements; (v) finaliser les normes des infrastructures et les presenter dans des tableaux separes pour chaque niveau de soins, y compris pour les hopitaux. (vi) Affiner la strategie de maintenance suivant les recommandations de la mission de pre-evaluation (voir annexe de l'aide memoire) 5.5 Participation des ONG et des Communautes a la politique de sante et d'action sociale La mission a eu plusieurs rencontres avec le CONGAD, le collectif des ONG au Senegal, les representants des agences de cooperation bilat6rale et multilaterale partenaire, le Ministere de la Sante Publique et de I'Action sociale dans l'esprit de la concertation continue et la recherche du consensus qui a toujours caracterise l'approche dans la preparation du Programme d'Investissement sectoriel (PIS),. La mission se rejouit de la creation du Reseau Sant&SIDA/Population compose d'ONG membres et non membres du CONGAD. Ce reseau est le lien entre les ONG partenaires A la mise en oeuvre du PJS et aura un r6le tres important dans la consolidation du Partenariat entre le MSPAS et les ONG au Senegal. La mission a, enregistre avec satisfaction le courant d'echanges qui s'etablit deji entre le Reseau et le Secretariat permanent du PNDS.  29 ANNEX I Page 8of8 v agences de cooperation bilaterale et multilat6rale de soutenir le processus * de partenariat entre le MSPAS et les ONG. La mission constate neanmoins qu'il reste beaucoup a faire quant a la creation de la structure de coordination et la formulation des modalites pratiques de la participation des ONG a la mise en oeuvre du PIS.  30 ANNEX 11 Page 1 of 7 IM'LEMENTATION COMPLETION REPORT REPUBLIC DU SENEGAL CREDIT 2255-SN Borrower Contribution to the ICR 1. Project Coordination and Management The difficulties encowuered during the project implementation were linked to the project's historic context or to the lengthy nature of government and World Bank procedures. This has represented a considerable constaint during the first two years of the project's life, hampering both the Population and Health comnponents and the work of the PCU itself. This difficulties comprised: the one year's delay in project startup noted as an obvious constraint right back at the time of the project launching workshop, in March 1992. Delays were also anticipated as a result of the lengthy process of international bidding to procure the capital goods required for the project activities. According to the procurement plans, normally prepared upstream prior to credit effectiveness, but which had only just started by the date of the above-mentioned seminar, the bid proceedings were expected to last at least a year,; * the time taken to install the PCU and the CSUs for the Population component and to hire staff for example, by Jume 1992, the PCU responsible for project coordination still had no official address; * the delays in fudfliing the conditionalities for funding the special accounts (no funding until June 1992); * certain unforeseen circumstances which delayed completion of the procurement plans (rejection by the CNCA, etc.;); * suspension of credit withdrawals durng the first years of project implementation, but not directly related to the PDRH1; * the devaluation of the CFAF, which in 1994 paralyzed contract performance for seven months, and therefore the withdrawals, with the delayed publication of the circular on the principles of contract updating. This picture is compounded by the problems caused by the allocative key whereby 75% of opering expenses were to be covered out of the IDA credit and 25% out of Senegalese counterpart funds. This key was a factor in holding up procurement. Because of delays in payment of the 25% portion of the invoices certrin suppliers and service providers refused outright to have anythiig to do with the project.  31 ANNEX II Page2 of 7 Another problem was the low level of the cap on special account A, CFAF 75,000,000 before devaluation, when four units were drawing from it. This low cap had an adverse effect on the pace of withdrawal and on the size of the expenses that could be handled by the special account. the difficulties of mobilizing counterpart finding, and inadequacy of that funding. The principal constraint encountered by the PCU in performing its role as coordinator was the rejection of the institutional fiamework and the resultant continuing disputes. This problem, which dates from the PDRH1 appraisal missions and the IDA negotiations, resurficed during the project launhing workshops despite signature of the Credit Agre,ment, when certain CSUs demanded the right to autonomous management of their component. This was the motivation for the Intenninisterial Committee meeting, chaired by the Prime Minister, in June 1992, and during the five pilot years represented a constant stumbling block for the PCU, since its authority was constantly being disputed. The Prime Minister had given firm instructions concerning compliance with the Credit Agreement. At this level, one of the PCU's difficulties involved relations with the CSUs, noncompliance with certain working principles, such as the meeting of deadlines for the filing of mission reports, submission of requests, budgets, activities programs, contract documents, and other elements requested by the Bank in its aide-memoires and whose availability on time was important because of procedural constraints involving the participation of other actors. This led to constant deviations from the mutually agreed programming. Nonperformance of various roles in the procurement process was also a problem on occasion. The quarterly withdrawal plans suggested by the Bank to enable the PCU to prepare estimated cash budgets were no longer drawn up. Finally, to ensure the sustainability of decision making authority and of operation of the programs, it was recommended that each CSU would have an Assistant Director appointed by ministerial decree. This was not the case in any of the units. Organization of World Bank Supervision Relations with the Bank were good and very constructive on the whole. Especially appreciated were the openness and availability of the supervisor in Dakar and the project officer in Washington, who throughout the project were very objective listeners and made valuable suggestions that helped to ward off stunbling blocks and resolve problems. However, three difficulties should be highlighted: * As stated during the mid-term review, the need for IDA non objection for specific activities, when detailed work programs and budgets were prepared and approved each year, was a factor contributing to credit withdrawal delays; * The PCU had some difficulty in playing its role as coordinator. Contacts between the Bank and the CSUs were often direct, bypassing the PCU and undermining its role of serving as liaison between the parties;  32 ANNEX II Page 3 of 7 With respect to the health component, the PCU sometimes received IDA non-objection concernng activilies on which the CSU had never ciscussed and coordinated with the PCU in advance; The Bank mission of June 1996 refused to deal with problems of micro-management and authorized greater flexibility in the non objection requirement, for exaffple by leaving it to the project to decide dir-ecdy on IEC contracts and certain other small contracts. 2. Project Performance The health CSU had no supporting institutional structure. Moreover, the skills levels available were inadequate given the importance of the work it was called upon to do. Its workload was managed by two key individuals, the technical director and the civil engineer. Health Component 1. The PDHR1 has resulted in restructuring and rationalization of the health systemn and in the design and implementation of reforms necessary to the development of the health sector. 2. The development of a pharmaceutical policy and the promotion of essential drugs have come about thanks to the project's support. 3. Technical upgrading of the health posts (HPs) and health centers (HICs) has led to improved service delivery. 4. Community participation has speeded up thanks to the project, which supported the reform of the rules governing the health committees, trained the members of those committees, and developed IEC at all levels. 5. Decentralized plarnng (with preparation of the PDDSIPDRDS) became a reality tanks to the project. 6. Health coverage in the urban areas has improved considerably, particularly in Dakar, Thies and Diourbel, tianks to the civil engineering program. Dakar, home to 30% of the country's population, was practically without any health posts or first-level reference centers, so that bottleneck situations frequenty occurred at the hospitals. 7. The contraceptive prevalence rate has improved, particularly in the rural area, with extension of FP planning activities to over 500 health posts in the country's ten regions. 8. FP contracts signed with NGOs showed good performance, and their contributions to execution of the NFPP are very significant. 9. Thanks to its refonn, PNA is becoming a vital institution once again.  33 ANNEX II Page 4 of 7 10. The MRs and health districts, supported by the HRDP, have stepped up their efforts in the area of training of district and regional framework teams [equipes cadres]. 11. Budgetary reform, including a new nomenclature, has enabled the districts to inprove their budgets considerably, thanks to increases of 0.50/o, and the share of the health budget in the national budget and an increase in the districts' equipment. 12. Thanks to studies financed by the HRDP, MOHSA will be able to consolidate its reforms over the short or medium term. Population Component Promoting the Status of Women Performance may be assessed at three levels: At the level of activities Dlannins. irenaration and imnlementation, we can note that the human resources provided by the Government have been utilized optimally, and that they have an in depth knowledge of the environment and solid experience in the inplementation of similar projects. The specialists have been used whenever needed and the experience gained from other projects and programs in the sector has been capitalized. Anew approach has been developed through a preliminary environmental survey. A new action strategy for literacy campaigns has been implemente, which results n the first-time organization of a single-level training cycle of less than 18 months and the development of women's skills to enable them to become millers or mechanics. Regarding the involvement and responsibility of women in imnlementation of the component. We can count a total of 3,000 women with responsible positions on the management committees, 446 village literacy teachers and 446 IEC auxiliaries. This represents a hard core (17 persons/women's group [GPF]) capable of sustaining and developing the project's achievements. Among other aspects we note a substantial financial and material contributions from women: CFAF 50 million for shelter construction, the signature of memoranda of agreement between the CSU and GPFs clearly spelling out the relationships arnong all institutions involved and the involvemnent of women in the construction of cases-foyers. The last level is the percentage of completion of project activities. Over 90% of the planned activities have been completed and all physical investments have taken place, as well as the major part of the training program for supervisors and beneficiaries. Reaching Young Men and Women In relation with this component, we noted a considerable improvement in opcration of the associations, thanks to the training and equipment received. This improvement has resulted in  34 ANNEX II Page 5 of 7 more efficient administrative and financial management and a diversification of activities. The credilitiy of the Association has been enhanced in enhanced credibility of the associations in the eyes of the Govemment, the NGOs, the authorities, and the parents, who are consequently paying greater attention to the associations' activilies, particularly in the area of Family Life Education (FLE). With respect to Ministry of Youth and Sports (MYS) workers and institutions, the project has strengthened the workers' capacities for effective action and also resulted increased attendance at, and greater involvement by, the CDEPS and young people's centers Voyers desjeunes]. Thanks to the tniung received, MYS personnel have acquired skills in managemet, planing, and monitoring of FLE/'IEC programs. The results thus obtained have encouraged the MYS to include FLE/IEC training modules in its leadership training programs. RLPNP While few in number, the studies carried out have brought to light interesting facts concerning the detemining factors of population growth from the anthropological and cultural viewpoints (Dimbas study), and information on adolescent concerns about fertility. At the political level, expansion of the partners to include the h;lan and Populaton Network (RIP), the research institutes, and universities, with the setting up of the Consultative Committee on Research, and the sensitization campaigns directed at the COREPORHs and basic organizations to increase their awareness of population-related phenomna, should also be emphasized. Lastly, the evaluation of population policy and programs contained in the APAP/SENEGAL and DIAGNEISARRISECK studies provides very useful analyses that can serve as a guide for future actions. 3. Overall Project Coordination Two basic objectives of the PCU in its day-to-day activities were to give the CSUs the necessary operating resources and to perform its management role, keeping an eye on the need to comply with both government and Bank procedures while ensuring transparency and a good percentage of credit withdrawal. With respect to the first of those two basic objectives, the PCU has largely achieved its goal, if we look at the project's beneficiary population and impact at the national and regional level. Illustrations are provided by the CSUs' own reports. For example, the Promotion of Women's Status CSU notes on page 21 of its evaluation report that "90 percent of the results expected from the component, despite the innovative approach, the project's complexity, and ithe time taken, have been achieved," adding that "all material investments have been made or are in process of being made, as is the case with most of the training program for supervisors and the target female audience."  35 ANNEX II Page 6 of 7 On page 29 of the report of the Young Men and Women's CSU, we find: "Given the results of the evaluation, it is true to say that the project objectives have to a certain extent been broadly achieved." Reports given by target groups, regional authorities, local elected officials, and political authorities both at the evaluation workshops and to the press also bear witness to the project's success. With respect to the second basic objective, the percentage of withdrawal of the credit proceeds was over 90 percent. Shortfills in certain categories were compensated through reallocations. Project audits were generally submitted on time, and to date the project accounts have been regularly certified without reservation by the auditors. The report of the Inspection Genirale d'Etat on administraive and financial management of the project has not given rise to any major problems. Having acquired the necessary skills in the accounting and budgetary software, the project accountants are now able to keep up to the minute checks on all the project accounts. In addition, the special field trips [tourn6es] and CRDs have considerably expanded the project's target audience and popularity. At certain times during the life of the project, when various programs had fallen so far behind that the Bank was considering restructuring their appropriations, the PCU was able to intervene vigorously, helping restore equilibrium and bringing the activities back on track. For example, it helped to reactivate the Young Men and Women's CSU regional teams and get the support of group's activities going again, after it was tom apart by internal disorders between 1992 and 1994. Another aspect reactivated by the PCU was EEC, long one of the project's weak points; this helped reestablish the linkage between the Population and Health comnponents and to complete the agremnt that were to be signed with the media. Currently, with the assignment of a new EPS Director, productions and broadcasts are progressing normally. This has is now opened the way for active intgration of FP/IEC, something that the project is successfully working on, and which has always been a problem at the multisectoral level. With respect to sectoral inter-team synergy at the regional level, a successful outcomes are clearly discenible and visiting missions have noted effective integration at that target levels, particularly in the area of FP/1EC. CONCLUSIONS AND RECOMMENDATIONS Regardless of the constraints that have ansen, the project's success and popularity and the achievement of its objectives are acknowledged by all. Its very real impact on the target groups may be gauged by the positive behavioral changes already noted in the female population and in young men and women, by the improvement in health coverage indicators, thanks to a strengthening of the health infiastructure network, availability of drugs, and technical upgrading of  36 ANNEX II Page 7 of 7 regional health facilities as well as m the conmunity participation m the health effort; and the introduction of decentralized planning. The following nrconunendations should also be reviewed: The first recommendation was made by all parties, including target groups, regional authonties, local elected officials, and field workers, on the occasion of the evaluation seminars, field trips [toumees] and CRDs, namely that the project be reinserted into the fiamnework of its original objectives and be expanded to include all the regions; Another unanimous recommendation was to ensure consolidation of the project gains at all levels including, literacy and IEC for women; deepening of FLE traimning of young men and women and extension of this aspect within the rural populations, taking into account young people's socioeconomic needs; and improving health coverage and continuation of efforts to control maternal and infant/child mortality, etc. The issue of the institutional famnework has to be dealt with by the political authorities, and given the problems it has caused during this pilot phase, it will need to be assessed in light ofthe choices made.   SENEGAL MAURITANIA SENEGAL ai}at'a HUMAN RESOURCES DEVELOPMENT PROJECT Rivers P ROJET DE DEVELOPPEMENT DES RESSOURCES HUMAINES ~ C onic dre a nne ( f ,. / .......... /o ,/4 Xha , ,/ ................. / ^ ^/ ff / '/ /" / D " / * rt H-ealth Can-t- Kaborear /-zz s 7/ ; / / / s />n--SidaC--[t . . A;RCntre do Scal ATLAtNTIC ,,, ,,/, +A R Mu:.,,' ,,/./,/,,''.,,w ,'',/.', '/.* cak GAXA5 j Th D2RBE *kf / . ., , , . x i . . / ; Na~~~)ortml" Capisai R- "/ 4'< ...I. d...-ii - t .,RA O~~~ClaNMbu ;lgie / ,,,, . . ',,/ /,. /////m'/'/////Ks)s//O/y// J ) ( 2>> iaIe pSoine BSzndwiu AMAOUD /-) .. d -r.+ 0 aa a,~~~~~ on otm 'KPI/ O-oOJr ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~P.- rg cy/S,.,/- I f ATUWTlt ) MAURITANIA l S.v pr ATLANTIC 5 SENEGAL< 2 t *% innmeS6hO U<-\-a H t MALI~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~L i)GAMBIA_t / : OCEAN GUINEA ,I on ma in~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~AHC UD    IMAGING Report No. 17097 Type: ICR