Morocco - Health Sector Investment Project (HSIP)

 ICRR 10510 Report Number : ICRR10510 ICR Review Operations Evaluation Department 1. Project Data : OEDID: OEDID : L3171 Project ID : P005440 Project Name : Health Sector Investment Project (HSIP) Country : Morocco Sector : Basic Health L/C Number : LN3171-MOR Partners involved : Prepared by : Roy A. Jacobstein, M.D., Consultant, OEDST Reviewed by : Timothy A. Johnston Group Manager : Gregory K. Ingram Date Posted : 08/18/1999 2. Project Objectives, Financing, Costs and Components : The Project's objectives were to help the GOM to: 1) develop and strengthen basic public and primary health care services nationwide, and to "obtain maximum yield from past infrastructure investments"; 2) strengthen administration and management of MOH services; and, 3) promote sector and policy reforms to increase financial efficiency and resource mobilization. The Project had three components: 1) Restoration of Basic Health Services; 2) Strengthening of Emergency, Diagnostic and Referral Services; and, 3) Administrative and Policy Reforms. Total Project cost at appraisal was US$ 171.3 million, of which US$ 104.0 million was an IBRD loan. After two extensions, the loan was closed on December 31, 1998, three years after originally planned. US$ 10 million of the loan was cancelled, and the final project cost was US$ 161.6 million. The last disbursement was made on April 7, 1999. 3. Achievement of Relevant Objectives : The project contributed to expanding preventive health care coverage and disease control programs, and strengthening sector policies. Infrastructure components were more problematic, experiencing significant delays and cost overruns. The Project funded renovation and extension of existing facilities, including 153 basic health care clinics, 8 rural hospitals (4 completed, 4 anticipated finished by 3/'00), and 30 provincial hospitals (10 finished, 20 "nearing completion"). The project provided much technical, management and skills training, but the impact of two reorganizations of the MOH was mixed. An average of 5,500-6,000 health professionals received training each year (but the impact was not evaluated). Cost recovery at hospitals has increased, and 40 hospitals became autonomous near the end of the project. 4. Significant Achievements : The Project proved to be an important tool in reorienting sector policy toward primary health care services -- a notable achievement. A number of key sector indicators improved, including infant mortality, child malnutrition, vaccination rates, and the prevalence of several infectious diseases targeted by the project decreased. The national TB program was classified by WHO as "very effective." These improvements cannot be attributed to this Project alone, but it seems likely that it made a contribution. 5. Significant Shortcomings : The Project, though relevant, was somewhat vague in its expected outcomes, and did not rely on data for planning or monitoring and evaluation purposes. Centralized management of the infrastructure component contributed to weak supervision, and non-payment of contractors by the ministry of finance was a major factor in delays. GOM allocations to the health sector have not increased, and inadequate counterpart funding is a persistant problem. Because of construction delays and other problems, emergency and first-level referral services were not strengthened to the extent anticipated. The commendable emphasis in this Project on renovation rather than new construction is somewhat artificial, given the extensive new construction of over 150 health clinics carried out by the GOM with ADB funds, which may have further contributed to recurrent cost constraints. Although contributing to improved access, whether or not any of these new or renovated facilities are adequately staffed and actually providing services is not documented. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Unsatisfactory Marginally Despite some progress in preventive Unsatisfactory health services and disease control, there were significant implementation problems. Institutional Dev .: Partial Modest Sustainability : Uncertain Uncertain Bank Performance : Deficient Unsatisfactory The ICR notes deficiencies at every stage of the Bank's project cycle . Borrower Perf .: Deficient Unsatisfactory Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : Baseline situational data and relevant, agreed-upon indicators, as well as specific planned benchmarks and targets for output, outcome and impact are necessary for optimal project design, management and evaluation. An advance master plan and precise timetable for implementation of civil works is desirable. Realistic and focused objectives that concentrate on a limited number of priority areas or activities are preferable, particularly in the context of sector reform. Efforts to improve quality of care and other aspects of management of services may be more important in improving service utilization than expanding or renovating infrastructure. The impact of training inputs needs to be documented; this is more meaningful than simply listing the numbers of people trained. 8. Audit Recommended? Yes No 9. Comments on Quality of ICR : The Bank's ICR was admirably frank about project shortcomings, and did not try to attribute improvements in sector indicators to the project. The ICR could have been more succinct and systematic in its presentation of the project, and better placed the project evaluation within the sectoral and macroeconomic context. Despite a lack of project specific data, it might have made greater use of available data presented to buttress conclusions. The borrower's ICR gives a much more positive evaluation of the project; the Bank's ICR should have commented on the reasons for the differences.