China - Rural Health & Preventative Medicine

 ICRR 10363 Report Number : ICRR10363 ICR Review Operations Evaluation Department 1. Project Data : OEDID: OEDID : C1713 Project ID : P003446 Project Name : Rural Health & Preventative Medicine Country : China Sector : Basic Health L/C Number : C1713; L2723 Partners involved : GTZ, Dutch Development Assistance, Rotary International Prepared by : Roy A. Jacobstein, OEDST Reviewed by : Timothy A. Johnston Group Manager : Gregory K. Ingram Date Posted : 08/19/1999 2. Project Objectives, Financing, Costs and Components : The project was designed to assist the MOH to improve the quality and coverage of its rural health and preventive medicine services. The project had four components: 1) Rural Health––constructing new facilities, training service providers in the poorer counties of five provinces, and improving disease monitoring, immunization delivery, and management of other preventive health programs; 2) Vaccine Production––construction and rehabilitation of three national centers for the production of essential vaccines meeting international standards; 3) improved Drug Quality Control; and, 4) the conduct of relevant Operational Research in disease surveillance and approaches to rural health insurance. At appraisal, total project costs were estimated at $177.4 million; actual total project cost was $248.1 million, due to cost overruns of $100 million in the Vaccine Production component. The funding shortfall was met via reallocated project funds, GOC funds ($44 million), a Rotary International Grant ($15 million), and Dutch Development Assistance ($4.5 million). The project was officially closed in June 1996, four years behind schedule; the vaccine production facilities were finally completed in 1998. 3. Achievement of Relevant Objectives : The rural health, drug quality control, and operational research components appeared to have met most of their specific objectives, although the absence of monitoring and evaluation data makes it difficult to assess impact. The vaccine production facilities were finally completed, but with substantial delays and significant cost overruns. The facilities are still not producing vaccines, although they recently passed the international "facility acceptance" test. 4. Significant Achievements : The rural health component improved geographical access to basic health services in the five target provinces, and the delivery of preventive services was apparently strengthened through training financed by the project, as was disease control and monitoring. The Drug Quality Control Component provided training and equipment for drug efficacy and quality testing, and contributed to the revision of the Chinese pharmacopoiea in 1995. The Operational Research component helped the Chinese Academy of Preventive Medicine to broaden its mission and to attract additional government and other support. Studies on health education campaigns and rural health insurance experiment were considered particularly valuable. Finally, regarding the Vaccine Production component, all five vaccines are projected to be in licensed production by the end of 1999 or early 2000. 5. Significant Shortcomings : The major project shortcoming was the substantial delays and cost overruns with the Vaccine Production component, resulting in costs exceeding 350% of planned levels. Several years were lost initially because of poor performance by the international contractor chosen to construct the facilities. Production costs will likely be significantly higher than appraisal estimates, undermining the original justification that domestic production will result in net savings from vaccine imports. In retrospect, the original decision to proceed with an industrial project based in the health sector is questionable. The absence of monitoring data on the other components makes it difficult to judge whether the project resulted in the expected impacts -- whether in terms of health outcomes, service utilization, or the impact of staff training. Inadequacy of recurrent cost coverage by the GOC--despite strong economic performance--may have reduced the impact of new facilities. Finally, the Drug Quality Control component did not give sufficient attention to key policy dimensions; despite improved training and equipment, the national control authority did not have enhanced regulatory enforcement capability. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Marginally The rural health, drug, and research Unsatisfactory components merit satisfactory ratings, but are outweighed by the significant inefficiencies of the vaccine component, which constituted a majority of project costs. Institutional Dev .: Substantial Substantial The ICR reports that even the vaccine component resulted in significant learning and technology transfer to the borrower . Sustainability : Uncertain Uncertain The long-term economic viability of the vaccine centers is still in doubt . Bank Performance : Satisfactory Satisfactory Project identification and design were clearly deficient, but the Bank deserves credit for attempting to rectify problems during supervision Borrower Perf .: Satisfactory Satisfactory Similar comments apply as for Bank performance. Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : A number of key lessons can be drawn from this project: 1) Project components that are industrial in nature should be appraised as such (including rate of return assessments), and not supervised primarily by health specialists; 2) Project monitoring and evaluation frameworks and indicators of intended outcome must be identified in the project formulation stage and then must inform project implementation and supervision. 3) In expanding health infrastructure, retention and adequate remuneration of properly trained staff are critical, yet are often overlooked. Training components should include plans to assessing the outcome of such training on outcome. 4) A critical policy aspect of “strengthening