Morocco - Health Sector Investment Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 19394 IMPLEMENTATION COMPLETION REPORT KINGDOM OF MOROCCO HEALTH SECTOR INVESTMENT PROJECT (LOAN 3171-MOR) June 9, 1999 Human Development Group Middle East and North Africa Regional Office 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.  ii CURRENCY EQUIVALENTS Currency Unit: Moroccan Dirhams (MAD) 1990 US$1.00 = MAD 8.12 1991 US$1.00 = MAD 8.19 1992 US$1.00 =MAD 8.15 1993 US$1.00 = MAD 9.03 1994 US$1.00 = MAD 9.56 1995 US$1.00 =MAD 9.07 1996 US$1.00 = NMA4D 8.48 1997 US$1.00 = MAD 8.83 1998 US$1.00 = MAD 9.66 ABBREVIATIONS AND ACRONYMS ADB African Development Bank AIDS Acquired Immuno Deficiency Syndrome INAS National School of Administration (Institut National d Administration Sanitaire) BAJ Barnamaj Aoulaomiat Ijtimia - Social Priority Program DOTS Directly Observed Therapy Short Course FAD Afiican Development Fund (Fonds Africain de Developpement) HSIP/PRISS Health Sector Investment Project (Projet dI'nvestissement dans le Secteur de la Sante) ICR Implementation Completion Report HFMP Health Financing and Management Project MOH Ministry of Health PFGSS Health Financing and Management Project (Projet de Financement et de Gestion du Secteur de la Sant6) PMU Project Monitoring Unit SSN Basic Health (Soins de Sante de Base) STD Sexually Transmitted Diseases SEGMA Semi Autonomous Facilities (Service Etatique Gere de Maniere Autonome) USAID United States Agency for International Development UNFPA United Nations Population Fund UNICEF United Nations Children's Fund WHO World Health Organization FISCAL YEAR July 1 - June 30 Vice President: Kemal DerviE Country Director: Christian Delvoie Sector Director: Jacques Baudouy Sector Manager: George Schieber Task Team Leader: Mlaryse Pierre-Louis  FOR OFFICLAL USE ONLY IMPLEMENTATION COMPLETION REPORT KINGDOM OF MOROCCO HEALTH SECTOR INVESTMENT PROJECT TABLE OF CONTENTS Preface Summary of Assessment PART I - PROJECT IMPLEMENTATION ASSESSMENT ................................... 1 A. PROJECT DESCRIPTION .1 1. The project as initially designed. 1 2. Modification of the project design. 2 B. PROJECT EVALUATION. 3 1. Achievement of Project Objectives. 3 2. Main Achievements. 3 3. Major Factors Affecting the Project. 4. Project Sustainability. 6 5. Bank's Perforance. 7 6. Borrower's Performance. 8 7. Assessment of Project Outcome. 8 8. Future Operations. 9 9. Key Lessons Leamed .10 PART 11 - SUMMARY OF IMPLEMENTATION COMPLETION REPORT BY THE GOVERNMENT ........................................................................... 11 Introduction ..11 1. Background .11 2. Project Identification .12 3. Project Objectives .12 4. Project Execution .12 5. Project Results .13 5.1 Civil Works ..13 5.2 Health care coverag ..14 5.3 Health care progras ..14 5.4 Strengthening of infrastructure and facilities for diagnosis and treatment. 15 5.5 Training ..15 5.6 Technical assistance ..16 5.7 Sectoral refor ..16 5.8 Financial situation of the project ..18 6. Sustainability of Project Achievements .18 6.1 Technical sustainability ..18 6.2 Financial sustainability ..18 7. Lessons Leared .19 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.  iv PART III - STATISTICAL TABLES ............................. 21 Table 1: Summary of Assessments .......................................... 22 Table 2: Related Bank Loans ........................................... 24 Table 3: Project Timetable ........................................... 26 Table 4: Loan Disbursements: Cumulative Estimated and Actual ...... 27 Table 5: Key Indicators for Project Implementation ....................... 27 Table 6: Key Indicators for Project Operation .............................. 27 Table 7: Studies Included in Project ........................................ 27 Table 8A: Project Costs ........................................... 28 Table 8B: Project Financing ............................................ 28 Table 9: Economic Cost and Benefits ....................................... 29 Table 10: Status of Legal Covenants ......................................... 29 Table 11: Compliance with Operational Manual Statements ............. 30 Table 12: Bank Resources: Staff Inputs ..................................... 30 Table 13: Bank Resources: Missions ........................................ 31  v IMPLEMENTATION COMPLETION REPORT KINGDOM OF MOROCCO HEALTH SECTOR INVESTMENT PROJECT Loan 3171-MOR Preface This is the Implementation Completion Report (ICR) of the Health Sector Investment Project, for which a loan equivalent to US$104.0 million was approved by the Board on February 20, 1990 and became effective on September 11, 1990. The loan was closed on December 31, 1998, after two extensions. The original closing date was December 31, 1995. The last disbursement was made on April 7, 1999, with cancellation of the sum of US$10.032 million, bringing the amount of the loan down to US$93.96 million. The ICR was prepared by Maryse Pierre-Louis, Sr. Population and Health Specialist, of the Middle East and North Africa Human Development Group (MNSHD), and was reviewed by Jacques Baudouy, Director, MNSHD, George Schieber, Health Sector Manager for the Region, Marisa Femandez-Palacios, Maghreb Portfolio Manager, and Ms Thu-Ha Nguyen, of the Disbursements Division. The Borrower has submitted Part II of the ICR. Preparation of the ICR is based on information drawn from project files, discussions in the field with the persons in charge of the appraisal and supervision of the project, and information gathered by the Loan Closing Mission which took place from January 25 to February 12, 1999 and which comprised: Maryse Pierre-Louis (Senior Population and Health Specialist, Mission Leader), Christian Rey (Senior Portfolio Officer), Albert Sales (Public Health Specialist), Claude Ghouzi (Certified Public Accountant), and Rene Lecysyn (Architect). Ms. Eileen Sullivan contributed to this report which also benefited from comments from Ms. Claire Voltaire (MNSHD) and Jean-Jacques de St Antoine (LAC). Ms. Juliana Weissman (LAC) provided useful comments and valuable historic background on the project at the time of preparation and during the early phase of implementation. Ms. Claudine Kader provided the necessary support to the finalization of this report.  vi IMPLEMENTATION COMPLETION REPORT KINGDOM OF MOROCCO HEALTH SECTOR INVESTMENT LOAN Loan 3171-MOR Summary of Assessment Introduction The objectives of the Health Sector Investment Project (HSIP/PRISS) were to assist the Government in financing the first phase of a long-term effort to re-establish sustainable public health programs nationwide and to strengthen first-level referral services and the administration and management of health services in general. To accomplish these objectives, the project was subdivided into three components: restoration of basic health services; strengthening of emergency, diagnostic and referral services; and administrative and policy reforms in the health sector. The project built on pilot scale efforts financed under the Health Development Project (Ln. 2572-MOR), especially for primary health care activities. Summary of conclusions and key lessons learned The project objectives were consistent with the strategies of both the Government and the Bank at the time. However, they were very ambitious, and it is regrettable that steps were not taken during project preparation to ensure stricter prioritization of the many issues facing the Ministry of Health at that time. Overall, the project objectives were only partially accomplished. The project represented an important tool in reorienting health sector policy toward basic health care and vulnerable population groups and in building sector knowledge and capacity. However, there are marked differences to the extent to which the three types of targeted health programs were actually strengthened (public health programs, primary care and emergency services). In the area of public health programs, the project objectives were fully achieved. In terms of primary care, the results were somewhat uneven. Although there was a revival of activities in basic health facilities, it is difficult to assess the related project impact, given the persistence of serious problems affecting operations (for example, shortage of essential drugs) and the inadequacy of statistical data on quality of care. Lastly, the strengthening of emergency and first-level referral services was severely affected by the delays in completing the civil works. On the institutional side, the project supported studies on the organization of the Ministry of Health at the central level and peripheral levels, on health financing, hospital management and information systems, and the establishment of certain important training programs. However, the development of the sector's financing reforms is still underway. The key lessons to be learned from implementation of this project are: (i) a project's objectives must be realistic and geared to a selected few of the priorities identified in the sector strategy; (ii) a good balance must exist between project activities designed to achieve physical rehabilitation and those intended to improve operation of the services; (iii) investment projects must be linked to a well-defined sector strategy; (iv) the project management procedures must be well understood by the different stakeholders at both central and provincial levels, so that they can properly play their respective roles; (v) an efficient coordination and monitoring unit is an essential requirement for successful project implementation; (vi) with respect to civil works, it is essential to have a pre-established masterplan for each hospital and a program designed to minimize contingencies; (vii) the decentralization of responsibilities to the provincial level is a  vii key feature of successful project implementation; (viii) the definition, at the beginning of the project, of clear monitoring and evaluation indicators would have allowed a more systematic project assessment; (ix) strong support to the implementation of public health program is essential to their good performance and (x) more continuity in Bank supervision would have been beneficial. The Government will most likely continue to emphasize priority health programs and the improvement of basic health care, as confirmed by the loans and grants provided to the sector in the wake of this project. However, despite this favorable context, the project's sustainability is uncertain, since the share of the Government budget allocated to health has basically remained unchanged from 1987 to 1998 (which is insufficient) and since it is linked to key strategic factors (for some of which the Government has initiated or about to initiate considerable actions): (i) the deconcentration/decentralization policy for the sector; (ii) improvement of the sector's financing mechanisms, including a cost-recovery policy; (iii) the Government's capacity to maintain an adequate financial budget for priority health activities targeting vulnerable groups; (iv) implementation of efficient management systems at all levels, particularly in the hospital context; and (v) improvement of factors that are extemal to the health sector but affect the health conditions of the population (education, water supply, civil service reform).  1 IMPLEMENTATION COMPLETION REPORT KINGDOM OF MOROCCO HEALTH SECTOR INVESTMENT PROJECT Loan 3171-MOR PART I PROJECT IMPLEMENTATION ASSESSMENT A. PROJECT DESCRIPTION 1. The project as initially designed 1. Objectives. The objectives of the Health Sector Investment Project (HSIP/PRISS) were threefold: (i) reestablish sustainable health programs nationwide, reinforce priority health programs in primary care and at the first level of referral, and obtain maximum yield from past infrastructure investment; (ii) strengthen the administration and management of services provided by MOH in order to increase efficiency, control costs and facilitate the implementation of administrative reforms designed to decentralize the management of health services; and (iii) promote sector and policy reforms which address longer term issues related to the evolution and structure of the public and private sector health services delivery systems, financing mechanisms, and the mobilization of resources in support of the sector. The project built on pilot scale efforts financed by the Health Development Project (Ln. 2572-MOR) which has helped establish standards and institutional arrangements for the delivery of primary heath care. These objectives were clearly described in the January 1990 Appraisal Report. They were consistent with the Government's strategy (Five Year Plan 1988-1992) and directly addressed the major concerns of the Ministry of Health. They were also consistent with the Bank's country assistance strategy, particularly in terms of mitigating the negative impact of the structural adjustment period on the Ministry of Health's budget. 2. Components. The project had three components: * Restoration of basic health services (US$109.5 million) through: (i) the renovation and rehabilitation of rural hospitals, dispensaries and health centers; (ii) the provision of furniture, medical equipment, vehicles, essential drugs, materials and supply; and (iii) technical assistance for the development of technical manuals, architectural services for civil works, training of personnel and epidemiological studies and surveys. * Strengthening/rehabilitation of referral and emergency services (US$55 million) through: (i) the renovation of hospital emergency services; (ii) the renovation and equipment of maintenance centers in each of five regional hospitals; (iii) the equipment of 30 provincial hospitals; (iv) training in emergency medicine; and (v) international technical assistance for the development and implementation of national standards for emergency care; and * Administrative. Sector and Policy Reform (US$6.8 million) through: (i) equipment of provincial administrative units, construction of administrative buildings, (ii) training  2 in management and administration, information systems; and (iii) policy and program studies. 3. Inputs. The project provided for: (i) rehabilitation and equipment of rural hospitals, dispensaries, health centers, and construction of provincial administrative buildings; (ii) vehicles; (iii) consulting services for the development of technical manuals, architectural services; continuing education, development of national standards for emergency care and policy and program studies; and (iv) training of personnel. 4 Implementation Arrangements. From 1990 to 1994 the project was managed by a unit located within the Division of Planning, Statistics and Information Technology and from 1995 onward within the Directorate of Planning and Financial Resources, after the reorganization of the Ministry. The project coordination was done by the coordination committee which included the main directorates of the Ministry. The organization of the project unit remained the same during project implementation. 5. Cost and Financing. The project financing plan included an IBRD loan of US$104.0 million and a Government contribution of US$67.3 million. The project was to be completed by June 1995. 6. Agreements at Negotiations. At negotiations, the Government provided assurances that it would carry out a program in support of selected sector reforms in accordance with an implementation plan acceptable to the Bank. The plan included the following measures: (i) within twelve months after the rehabilitation of each hospital included in the project, the hospital would be authorized to retain all fees which it collects for services in order to apply such fees toward the coverage of its operating expenses; (ii) an improved fee collection system which is designed to ensure billing and facilitate collection of fees for all services rendered by the hospital would be developed and introduced by June 30, 1992; (iii) a study of the nature and extent of the provision by the private sector of health care services would be prepared and furnished to the Bank for its review and medium-term program to promote the development of private health care services would be developed; and (iv) a study to identify and recommend suitable ways to rationalize public and private sector health insurance systems, and to expand progressively the coverage of said system, would be carried out and a copy of the study would be provided to the Bank by December 21, 1991, after which views would be exchanged with the Bank on the results and recommendation of this study with a view to devising a suitable strategy for such rationalization and expansion over the medium-term. 2. Modification to the project design 7. During project implementation, the African Development Bank helped the Government with the construction of new community health centers (156). As a result, the proceeds of the PRISS were reallocated toward hospital emergency services'. The rehabilitation of provincial hospital emergency services increased from 14 (in the staff appraisal report) to 30. No amendments were made to the Loan Agreement itself, except to defer the loan closing dates. Reall'ation confirmed by the Bank by telex, dated June 22, 1994.  3 ACHIEVEMENT OF PROJECT OBJECTIVES 1. Objectives 8. The project objectives aimed at developing public health programs were substantially achieved. Good progress was also made to improve overall health sector policies and institution building. In the other areas, including the rehabilitation of physical infrastructure, and improvement of health services, the project objectives were only partially achieved. During the mid-term review, which took place between April 19 and May 4, 1994, the Bank and the Government agreed that the project objectives, as defined during the preparation phase, reflected the overall vision for the sector and did not require any further modification. Also, as 70 percent of the loan had already been committed by that time, it was assumed that the planned activities could still be carried out within the original timeframe. 9. The project objectives were probably over-ambitious, and it is regrettable that there was not stricter prioritization of the many issues facing the Ministry of Health at that time. Among other conditions, the project required the Government to implement, simultaneously and within a relatively short timeframe (and right during the structural adjustment period): (i) a major program to improve services at several levels nationwide; (ii) a major administrative reform of the Ministry of Health; and (iii) measures to prepare the sector's financial reform. The project was plagued by major implementation drawbacks (see para. 3 on major factors affecting the project) which could not be overcome despite a three-year extension. 2. Main Achievements - Sector policy. The project represented an important tool in reorienting sector policy toward primary health care services and the most vulnerable population groups. This policy has been reflected and strengthened by most of the development programs that have followed the PRISS, and its contribution in this area may be regarded as substantial. The project also helped finance major studies on health financing, hospital management and information systems. Towards the end of the project, some 40 hospitals became autonomous (SEGMA) with partial cost-recovery. * Institution building The project financed studies on the organization of the Ministry of Health at the central and peripheral levels, on the decentralization of human resources and the introduction of new information systems. The PRISS also made a substantial contribution to improving human resource management, thanks both to studies conducted on specific aspects and to the establishment of important training programs. Between 1991 and 1995, for example, an average of 5,500-6,000 health workers benefited from training each year under programs instituted by the project. At the same time, the project facilitated adoption of the strategy for decentralizing continuing education and the introduction of new approaches in this area. However, the overall objective to decentralize the management of health services, thanks to the implementation of administrative reforms has not yet been fully achieved. Overall, the institutional objectives have been partially achieved. * Physical activities. Substantial progress was made in the case of certain activities, such as the rehabilitation of primary health care centers, but the results were largely insufficient regarding the upgrading of emergency and first-level referral services. Overall, the project failed to achieve its physical objectives satisfactorily. The second component, originally designed to strengthen the emergency units of 14  4 hospitals, was reoriented in the second year of implementation to cover overall improvement of the hospital infrastructure in 30 provincial hospitals (see para. below related to emergency and first-level referral services; and page 2 para.7). The magnitude of this program was visibly beyond the planning and coordination capacities of the relevant central government departments. * Improvement of health services. The project objectives for the reinforcement of basic health services programs were only partially achieved. However, there are marked differences in the outcomes for the three principal types of service targeted: public health programs, primary care at the health center level, and first-level referral services, including emergency services. Public health programs. The project objectives were fully achieved. The quality and number of services delivered rose considerably and there was a marked decline in the health problems covered by those programs. A typical case was that of tuberculosis control; a program which benefited particularly from the HSIP, the tuberculosis control program showed substantial improvements in nearly all aspects: screening, treatment strategy, drug availability, training of health care personnel, etc. With over 90 percent rate of detection of infected cases and a 90 percent rate of successful treatment, this program is now considered by the World Health Organization as one of the most effective of its kind in the world. The tuberculosis control program is not an isolated case, and excellent progress was also made in most of the other programs: schistosomiasis control, malaria (eradication of both diseases is scheduled for 2004), leprosy (down to 80 new cases per year), AIDS and other sexually transmissible diseases (STDs), diseases of the eye, and the large-scale vaccination program.2 Primary care. The project has only partially achieved its objectives in terms of reinforcing basic health services at the health center level. The health centers located in the project's target areas seem to have experienced a marked increase in activity, a possible sign of improvement in the quality of care and enhanced credibility. There have been definite improvements in the infrastructure, and regional Ministry of Health officials also note some progress in terms of skilled personnel availability. However, it is difficult to judge the real impact of the project based on these factors. First of all, the relevant statistics are inadequate (not only with respect to the situation at the start of the project, but also in terms of the situation as it stands today). Next, the rehabilitation of the health centers is still recent and serious operational problems, such as frequent depletion of essential drug stocks and lack of motivation for workers in isolated rural areas, still persist. Under these circumstances, it is difficult to credit only the PRISS for the improvement of some indicators like the increase of the number of women who benefited from prenatal care (from 25% in 1992 to 42% in 1997) or the increase of the percentage of assisted deliveries (from 31% in 1992 to 43% in 1997)3. 2 The main programs supported by the project were: tuberculosis, STDs, malaria, leprosy, AIDS, hygiene and sanitation, ocular diseases, schistosomiasis, family planning, immunization, prenatal care. Unlike tuberculosis, these programs were also heavily supported by other development projects, so that their success may be only partially attributed to the PRISS. 3 These indicators are mentioned in the main text of the SAR. However, the breakdown shows significant urban/rural gaps in the increase of these indicators between 1992 and 1997: coverage of prenatal care increased from 61 to 69% in the urban areas (against 1S to 200/. in rural areas); likewise, the percentage of assisted deliveries increased from 64 to 70% in urban areas (against 13 to 20% in rural areas). Source: MOH statistics. Approximately 50% of the population live in rural areas.  5 Emergency and first-level referral services (rural hospitals). These services were so severely affected by the delays in civil works that it is almost impossible to assess the project outcome under this heading. Given the fact that the full implementation of these activities required, first, infrastructure rehabilitation, it is obviously not possible to assess the achievement of objectives until the health facilities concerned are fully operational. This is still not the case for most of the health facilities covered by the project. At the end of the project, only 10 (out of 30) emergency units were fully rehabilitated. Another serious constraint in the implementation of this component was the original lack of consensus concerning the role of emergency services in the overall health system, which seems to persist to date, despite the elaboration of a strategy on emergency services. Financing of health sector investments. Given that the project to a large extent aimed at boosting pre-project investments held up by the economic difficulties of the late eighties, the achievements under this heading must be considered unsatisfactory because the civil works were still not completed at a significant number of sites at the project's closing date (see para. above). 3. Major Factors Affecting the Project The project's implementation benefited from the Government's commitment to policy improvement and institution building in the health sector. Another positive factor was the progress made in upgrading the skills of a large number of senior Ministry of Health officials and the professionalism they displayed. On the negative side, the following major factors were identified4: Factors related to project design v the project's multiplicity of objectives and the vagueness of certain components; * failure to balance adequately, the physical rehabilitation activities and the supporting measures for improving health services management and operation. Factors beyond the Government's control * default on the part of the technical consultants and architectural firms responsible for supervising the infrastructure works; * default on the part of small contractors that were highly vulnerable to cash flow problems and obliged to stop work if they were not paid on time. Factors under the Government's control * weaknesses in management of the project itself, such as: - on the civil works side, a total lack of consistency between budget planning and the annual scheduling of allocations, undocumented delays in payment, and excessive centralization of the financial and technical management of project Partly due to the fact that some studies financed by the Health Development Project had not yet been completed at the time of project appraisal.  6 activities; delays in the implementation of the civil works was the main reason why the project was extended twice in an effort to achieve project development objectives aimed at strengthening emergency and first -level referral services; on the financial management side, the statements of account submitted by the project unit did not provide an adequate overall picture of the project's financial status, even at the end of the project; on the administrative management side, the coordination unit lacked the human and material resources necessary to its smooth operation and had no leverage over the other directorates. * weaknesses in the sector development strategy: the Government's commitment to reorient the health sector strategy was evident, but it seems that at the start of the PRISS, a "vision" of the future health system (for example, the respective roles of the different levels of care) was still not clearly defined. In addition, the decision to expand the primary health care network (through the construction of 156 health centers) did not correspond to the orientation agreed upon at the time of project preparation which was to place the emphasis on improvement of the functioning of the existing network and to expand it only when its full operating potential had been achieved and when financing policies had been developed; this further increased the imbalance between infrastructure development and the availability of operating resources. * weaknesses in sector management: the Ministry of Health reorganization mentioned above was a lengthy process, which clearly affected the project5; 4. Project Sustainability There is every reason to believe that the Government will maintain the sector strategy orientations introduced with the PRISS, a vital requirement for the project's sustainability. The decisions taken over the past few years to approve several development projects (for example, the BAJ, PFGSS and EU projects), which have pursued and reinforced the general objectives of the PRISS, is particularly welcome in this respect. There are also certain facts of a more technical nature which are very encouraging, such as the expected eradication, upon completion of the BAJ, of several diseases (leprosy, schistosomiasis) representing a serious public health problem at the start of the PRISS.6 In this favorable context, the sustainability of the PRISS remains uncertain since it is closely linked to activities and policies which have not been easy to implement so far (and which have been launched recently), including: * pursuing resource deconcentration and administrative decentralization of the sector; * strengthening of the management and quality of the health services, and of adequate support systems, particularly in the area of health personnel training and deployment, essential drug policy and management, and infrastructure repair and maintenance; 5 This was mainly due to tum over of staff. 6 The BAJ, approved in December 1996, has strengthened a number of the activities financed by the PRISS, and will make an enormous contribution to ensuring the latter's sustainability.  7 * putting in place an effective incentive system, designed to attract more skilled and motivated personnel at all levels, particularly in the disadvantaged rural areas; * more accurate targeting of the most vulnerable population groups - particularly the poor in rural areas and, within that group, women of childbearing age and young children;7 * improvement in sector financing and the Government's capacity to provide financing for those priority activities that will long remain its exclusive responsibility (for example, public health programs such as tuberculosis control, AIDS and other STDs etc., vaccination and family planning, and safe motherhood). In this context, it is worth stressing the fact that from 1989 to 1998, MOH budget, as a percentage of the Government budget, has essentially remained the same (from 4.9% in 1989 to 4.78% for the period 1998-99).8 The project's sustainability is also an issue in the particular case of infrastructure rehabilitation and development, since those actions have been expanded to include a large number of facilities, many more than originally planned, but with the same financing package. This could lead to maintenance problems over the short to medium term, and to the need to resume works that have been only partially completed by loan closure. Finally the project sustainability will depend greatly on the improvement of factors, outside the heath sector, which are known to have an impact on health status namely education, access to potable water, improvement of hygiene and poverty reduction. 5. Bank Performance The Bank's overall performance was unsatisfactory. Certain weaknesses may be identified at all phases of the project. The project represented an appropriate and timely response to the Government's needs, particularly in terms of rehabilitation of the health sector infrastructure, strengthening of the Ministry of Health's organizational framework, and sector policy reorientation. Nevertheless, it would have been better if the project had been less complex and had focussed on a smaller number of priority activities, particularly at the end of the structural adjustment period. This major weakness in the project design is particularly difficult to comprehend, since it was well known at the time of the appraisal that the Government might not have sufficient capacity to implement the project. Project preparation and appraisal have also been hampered by the failure to clearly define the activities to be financed by the project and to identify key indicators by which to evaluate these objectively. While it is true that a certain flexibility is desirable, several activities were still being discussed right up until the end of the project (for example, the emergency services' role in the care delivery system) while others were never clearly defined (for example, project activities to lay the groundwork for the sector's financial reform). The Bank's supervision missions were conducted regularly, and the skill mix of the supervision teams was adequate on the whole. However, there was some lack of 7 In this area, the sustainability of the PRISS will also depend directly on the improvement of factors that are external to the health sector but have a major impact on health conditions, such as education, access to water supply, satisfactory environmental hygiene, and gradual progress towards poverty alleviation. Between 1989 and 1998, GDP did not grow very significantly.  8 continuity in project management, due to the frequent changes of task managers, particularly during the first few years of implementation. Certain actions designed to improve project management performance were not taken in time. The mid-term review mission could have recommended the development of key indicators to improve monitoring and ensure more objective evaluation of the project upon its completion. 6. Borrower Performance Administrative and financial management Project coordination was the responsibility of a coordination committee which included all relevant departments of the Ministry of Health. The Project Monitoring Unit (PMU) was initially under the aegis of the Division of Planning and Health Infrastructure. In 1995, it was moved to the central Directorate of Planning and Financial Resources. The quality of administrative and financial management gradually improved during project implementation. However, as mentioned above, despite progress made, the coordination unit lacked sufficient material and human resources to enable it to post an optimum performance. With its location within one of the directorates of the Ministry, this unit did not have sufficient authority to fulfill its mandate. With respect to financial management, the quality and management of the data produced were such that it was not possible to have an overall financial statement at project completion. Accounts needed for management purposes were held in a number of different files and therefore not presented in a conducing manner to efficient and dynamic monitoring of the project or the reconstruction of its financial accounts. The Ministry was well aware of these weaknesses in project management, and consequently was able to make the necessary arrangements to improve management of the BAJ and PFGSS projects, based on lessons learned from the PRISS. Civil works management On the civil works, project implementation suffered from the insufficient coordination of a wide range of factors related to finances, human resources, and implementation deadlines and conditions, the result of a weak interactive relationship among the different levels concerned. The decision to delegate completion of the works to the provincial level, with the necessary budgetary allocations, came too late for the accumulated delays to be fully made up. Lastly, the fact that the loan amount originally allocated under the various categories were used to finance works whose scope considerably exceeded that of the original program means that certain reservations concerning the quality of the works should be expressed with the possibility that maintenance may become necessary over the medium-term. 7. Assessment of Project Outcome It is difficult to make an accurate and objective assessment of the outcome of the PRISS project because of two main reasons: (i) no monitoring and evaluation indicator was identified either at the time of appraisal or during implementation, and this failure could not easily be remedied (although the system's existing information system is in the process of being upgraded); based on project files, it was agreed at negotiations that the  9 Government would prepare a list of monitoring and evaluation indicators. There was no concrete follow-up to this action; however, as stated earlier, significant progress is being made to establish a solid health information system nationwide; (ii) the outcomes observed were generally the product of many factors and based on several development projects, and the specific contribution of the PRISS to those results cannot be determined. This is well illustrated by the Borrower's report, which focuses more on progress made in the sector since 1990 than on the specific outcomes of this particular project (see Part II, page 16, last para. of point 5.7). Overall (and on the basis of information available to date), the outcome of the PRISS cannot be judged as satisfactory, since the objectives aimed at reinforcing basic health services and strengthening emergency and referral services were not fully achieved. This overall conclusion is not shared by the Government which states in its report that the project outcome was satisfactory. However, three factors give the project a rather important place in the development of the sector in general: 1. Several activities were not carried out or completed until close to the end of the project's second extension, i.e. during the last few months. This was typical of major initiatives in the areas of health financing, management autonomy for a larger number of hospitals, etc., and also applied to the construction works at various sites. These activities represent steps in the right direction, and there is no reason to doubt their long-term impact on the sector's development, even though it is premature and difficult to assess that impact at the present time. 2. Several development projects were approved in the sector over the past few years, and some of these (for example, the PFGSS and the EU's projects) are just now in the initial phases of implementation. These projects generally strengthen the objectives of the PRISS and sometimes even try to remedy its deficiencies. Even though the PRISS does not seem to have produced any striking results, it has certainly played an important role as a catalyst in the sector's overall development. 3. The PRISS has also made an enormous contribution to the maturation process essential to the development of certain options and to the launching of reforms in the sector, such as administrative decentralization and the introduction of new methods of financing health care. 8. Future Operations Several development projects that directly strengthen the objectives of the PRISS have already been approved over the past few years and are still in progress. These projects include two Bank's projects: the BAJ (US$68 million, which addresses MCH issues and strengthens primary health care services and priority public health programs) and the Health Financing and Management Project (US$66 million) which addresses  10 health financing hospital reforms and decentralization issues as well as projects financed by ADB, USAID, and the EU9. 9. Key Lessons Learned The key lessons learned from the PRISS concern the importance: * of a gradual approach to the reform process and to projects with realistic and focused objectives that concentrate on a relatively limited number of priority areas or activities. This was taken into account in the design of both the Basic Health/BAJ and the Health Financing and Management Project s (HFMP). * of finding a good balance between activities geared to improving the sector's physical infrastructure and reducing problems of accessibility to services, and activities designed to improve operation of the services and such aspects as quality of care. The BAJ project includes activities aimed at improving the availability of drugs and of personnel in the selected provinces. The HFMP includes significant activities aimed at improving quality and management of health services in project hospitals. * of providing adequate support to priority public health programs. Such support was a major raison for their good performance during the period of project implementation. This support was strengthened under the Basic Health Project. In addition, the implementation of financing mechanisms under the HFMP will, in the long run, allow the Government to allocate more public resources to these programs. * of integrating investment projects into a well structured development strategy that clearly targets the most vulnerable population groups and the disadvantaged regions and gives priority to the most essential health services. In the interest of the preparation of the Health Financing and Management Project, a sound sector strategy was elaborated. * of decentralizing certain responsibilities to the regional and provincial levels. The implementation of civil works was decentralized to these levels, under the BAJ and the HFMP. * of involving the various stakeholders, at both the central and the provincial level, in project implementation. Under the BAJ, a systematic effort is made to involve provincial governors and medical officers in the project; likewise the new HFMP stresses mechanisms for ensuring consensus and coordination among key stakeholders on health financing strategies. * of establishing in advance a master plan for each construction site and a precise timetable for implementation of civil works. This is a pre-requisite to the rehabilitation of hospitals under the HEMP. * of having relevant monitoring and evaluation indicators at the start of the project. Detailed indicators for both the BAJ and the HEMP were agreed upon at negotiations. * of ensuring more continuity in Bank's supervision. This factor has been taken into account since the end of the PRISS. 9 ADB/FAD is currently financing a US$63,880.953 project on strengthening basic health care; USAID is currently implementing a US$52 million project on FP and child survival; The EU is financing two projects in the areas of maternal and child health, AIDS, family planning services, neonatal services (approx. ECU 4 million) and a new project on hospital reform, decentralization and organization of services (ECU 20 million)  11 Part Il Summary of The Implementation Completion Report of the HSIP by the Government Introduction This summary evaluation has been prepared by the Ministry of Health as a contribution to the Implementation Completion Report on the HSIP/PRISS project, which will be written by the World Bank. It is a summary of the more detailed accompanying report, which was prepared by an interdisciplinary team appointed by the Secretary General. This report includes a maximum of information obtained from all the sectors that participated in execution of the project. 1. Background At the identification stage of the project, the Ministry of Health had a number of strategic concerns: How to provide a balanced, efficient, and integrated health care system founded on two key components: hospital service and basic health care services. How to ensure equity between urban and rural areas, and among different regions. How to obtain more satisfactory results from the Safe Motherhood Program. How to control infectious diseases, the principal causes of infant and juvenile mortality. What type of health financing mechanisms to choose, how to implement them, and how to ensure their sustainability. These concerns stemmed from a national context characterized by: A very difficult economic situation, which had made it necessary for Morocco to adopt a structural adjustment program founded on economic austerity measures that were having a direct impact on the low-income population, despite a continuing modest growth rate. High illiteracy rates, especially in rural areas; approximately 13.1% of the population was classified as poor, with 75% of this group living in rural districts. A health system primarily oriented towards curative care, whereas epidemiological control required a preventive approach, which had actually been decided on in the late 1970s. A-public health sector viewed as inefficient in both management and quality-of-service terms, but expected to meet the health needs of more than 80% of the population, largely classified as indigent; the Ministry of Health budget, most of it allocated for payroll, represented barely 4% of the entire national budget.  12 2. Project Identification The HSIP/PRISS project (3171-MOR), approved by Decree No. 2.90.513 of Safar 6, 1411 (August 28, 1990), was the Bank's second health-sector lending operation in Morocco. Total project cost was estimated at US$171.0 million. The amount of the loan was US$104.0 million. The project became effective January 1, 1990 and, after two extensions, was closed on December 31, 1998. 3. Project Objectives The objectives, as defined in the Bank's Appraisal Report of January 1990, were to help the Government of Morocco: (i) in developing and strengthening basic health care services; (ii) in improving the administrative structure of the sector; and (iii) in developing sector policies aimed at increasing financial and economic efficiency. Explanation of objectives The 1988-1992 Development Plan emphasized not only basic health care services but also completion of the building of hospital facilities works on which had already been initiated during the previous Plans. In other words, project objectives and Ministry of Health priorities coincided, in respect of both basic health care services and hospital services. It was deemed necessary: to capitalize on what had already been done; to consolidate achievements to date in the basic health care programs; and to support a policy which, because it called for the rehabilitation of existing infrastructure facilities and not for the construction of new buildings, would not generate recurring costs. 4. Project Execution From 1990 to 1994, the project was coordinated by the Division of Planning, Statistics, and Information Technology, and from 1995 onward by the Directorate of Planning and Financial Resources. The Project Monitoring Unit was attached to each of these successively. The Project Coordinating Committee remained active throughout the project implementation period; its organization, composition and responsibilities were established from the very beginning. Execution of each project component was entrusted to the government department responsible for the specific area of activity involved. The fact that PRISS objectives were not rigid or inflexible meant that project activities could be reoriented to bring them more into line with the Ministry of Health general policy priorities. For instance, the physical rehabilitation program was modified in response to demographic pressures and the needs of rural districts. During the project execution period, the Ministry of Health was reorganized twice (in January 1990 and January 1995). Continuity of general policy and of project objectives was maintained. Nonetheless, the execution of certain activities, and the monitoring of this execution, were affected by personnel changes in both the executing entities and the Project Monitoring Unit.  13 5. Project Results 5.1 Civil Works A total of 153 basic health care clinics were selected for renovation and extension, a rehabilitation program that has now been completed. The necessary equipment for them, costing a total cost of DH 16.8 million, has also been installed. The project provided for renovation and extension of the eight rural hospitals. Works at four of them is completely finished, and is expected to be finished at the other four by March 2000 at the latest. Of the 30 provincial hospitals in which investments were to be made - after revision of the project - 10 are completely finished and 20 are nearing completion. It should be noted that delays in execution of the project civil works program have been of particular concern to the Ministry of Health. For this reason, a multidisciplinary commission set up to support the project executing entities was asked to provide an inventory of work sites, ascertain the underlying causes of the delays, propose practical solutions, and ensure that all decisions reached were implemented, so that the works not yet completed could be finished as soon as possible. The commission's first reports led to identification of some of the underlying causes of problems common to all the projects behind schedule.'