Tanzania - Health & Nutrition

 ICRR 10595 Report Number : ICRR10595 ICR Review Operations Evaluation Department 1. Project Data : Date Posted : 05/01/2000 PROJ ID : OEDID : C2098 P002774 OEDID: Appraisal Actual Project Name : Health & Nutrition US$M ) Project Costs (US$M) 70 51.77 Country : Tanzania Loan /Credit (US$M) Loan/ US$M ) 47.6 47.6 Sector, Major Sect .: Basic Health , US$M ) Cofinancing (US$M) 15 N.A. Population Health & Nutrition L/C Number : C2098 FY ) Board Approval (FY) 90 Partners involved : Gov't of Belgium, Closing Date 06/30/1996 06/30/1999 ODA/DfID, Danida, UNFPA, SDC Prepared by : Reviewed by : Group Manager : Group : Timothy A. Johnston Roy Gilbert Gregory K. Ingram OEDST 2. Project Objectives and Components a. Objectives The project sought to raise the quality, coverage, and effectiveness of family planning, nutrition and basic health services through provision of support to critical and strategic elements of the HNP sector . b. Components Project components included: (i) institutional capacity strengthening for health planning and policy formation; (ii) manpower development and training in the health sector; (iii) sustainable provision and financing of pharmaceuticals and medical supplies; (iv) control of micronutrient deficiency; (v) implementation of the national population policy; (vi) enhance rural primary health care through a trial implementation of a revised PHC strategy; and (vii) strengthened urban primary health care in Dar es Salaam . c. Comments on Project Cost, Financing and Dates The project was approved in March 1990. The project closing date was extended twice, first in June 1996 to accommodate delays the first three years of project effectiveness, and the second in April 1998 to allow pretest alternative financing schemes and support preparation of broader sector reform initiatives . 3. Achievement of Relevant Objectives : Most of the relevant objectives were achieved, although with significant delays . (i) The Strengthening National HNP Systems component achieved most of its objectives . Project-sponsored TA and training strengthened planning and technical capacity at both district and national level . Project conditions contributed to several key policy reforms, including increased budget allocations to health (from 7 percent in the late 1980s to 12 percent in 1998/99); introduction of cost-sharing in government facilities; and autonomization of the Central Medical Stores. Pharmaceutical reforms and direct project support for drug procurement improved drug availability, particularly in districts with revolving drug funds . The Micronutrient Deficiency Control component appeared to have only mixed impact, however, and the National Population Policy component was unsuccessful . (ii) Strengthening Rural Primary Health Care : This component had modest success in increasing community involvement, but participation focused on rehabilitating health facilities rather than nutritional activities . Facility rehabilitation and equipment have improved facility quality in rural clinics and district hospitals, but the impact on utilization was lower than expected . (iii) Dar Es Salaam Urban Health Project: This component was fully satisfactory, and helped rehabilitate 60 urban facilities, establish local health boards, introduce cost -sharing, and establish a preventive maintenance program . 4. Significant Outcomes /Impacts : The project eventually contributed to important sector reforms and policy changes, particularly for health financing and the pharmaceutical sector . The project supported autonomization, recapitalization, and managerial strengthening for the state Medical Stores Department, which has strengthened its financial viability and reduced stock-outs at the central level. To improve drug supplies at the end -user level, the project helped establish facility-level revolving drug funds in 23 districts (out of 114), and piloted Community Health Funds (CHF) in 10 districts. A 1999 survey found that drug availability had improved significantly in CHF facilities, compared to 1996. Project conditionality contributed to a doubling of the percentage budget allocation to the health sector . These measures should contribute to the financial sustainability of the sector . The project also contributed to improved basic infrastructure in Dar es Salaam and 10 of the poorest districts, and piloted an innovative maintenance scheme for urban health centers, which could be more widely replicated, particularly at district level . Training provided through the project has helped increase capacity at both central and district levels . The project help lay the groundwork for the current multi-donor Health Sector Reform Program, which should help alleviate the severe fragmentation that has characterized previous donor support to the Tanzania health sector . 5. Significant Shortcomings (including non -compliance with safeguard policies ): The project suffered from inadequate quality at entry, because of overly complex design involving multiple implementing ministries; inadequate ownership and stakeholder involvement; and poorly designed cross-conditionalities, which resulted in little disbursement for the first three years . A mid-term review in 1993 led to project restructuring in 1996, and subsequent improvements in Bank and borrower implementation performance . Shortages of counterpart funds further delayed implementation in the mid -1990s, but the situation improved following an improved macroeconomic situation in the late -1990s. Drug stock-outs remain a problem in districts or facilities that have not yet implemented revolving drug funds . Bank performance in initial project design and supervision was unsatisfactory, and supervision was disrupted by the transfer of the Tanzania portfolio from the southern Africa region to East Africa in the late 1980s. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory Substantial progress in final years compensates for unsatisfactory quality at entry. Institutional Dev .: Partial Substantial Progress on difficult pharmaceutical and financial reforms merit a rating of "substantial" Sustainability : Uncertain Uncertain Given Tanzania's heavy reliance on donor funds for sector financing, sustainability remains a challenge. Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : Relevant lessons include: Complex policy reforms are better pursued as project outcomes rather than up -front conditionalities; The involvement of multiple agency /ministries must be weighed carefully -- the potential benefits can be undermined by the difficulties of intersectoral coordination; Project components should consist of closely -related activities; otherwise supervision becomes extremely difficult Macroeconomic analysis and policy work should be closely coordinated with sector dialogue, and can be mutually enhancing Baseline data and clear performance targets are essential for effective project supervision and impact evaluation 8. Audit Recommended? Yes No 9. Comments on Quality of ICR : ICR was well-written, but included little data on outcomes at the end -user level. Incorporation of findings from an independent impact evaluation conducted in early 2000 would have strengthened the ICR . The stakeholder ICR workshop (summarized in Appendix B) is a "good practice" example that could be more widely replicated .