Equatorial Guinea - Health improvement project

 ICRR 10537 Report Number : ICRR10537 ICR Review Operations Evaluation Department 1. Project Data : Date Posted : 03/27/2000 PROJ ID : P000649 OEDID: OEDID : C2348 Appraisal Actual Project Name : Health improvement US$M ) Project Costs (US$M) 6 4.67 project Country : Equatorial Guinea Loan /Credit (US$M) Loan/ US$M ) 5.5 4.47 Sector, Major Sect .: Basic Health , US$M ) Cofinancing (US$M) 0.5 0.2 Population Health & Nutrition L/C Number : C2348 FY ) Board Approval (FY) 92 Partners involved : the Government Closing Date 12/31/1996 08/31/1999 Prepared by : Reviewed by : Group Manager : Group : Chorching Goh Andres Liebenthal Gregory K. Ingram OEDST 2. Project Objectives and Components a. Objectives To strengthen the capacity of the Ministry of Health to plan, coordinate, and monitor health sector activities, by establishing a coherent sector policy and strategy . To build up a credible Ministry of Health (MOH) management system and team, strengthen MOH's organization and staff capabilities, and promote regular consultations with the donors active in health and the beneficiaries of health care To help the government improve the quality of its field services and increase its capacity for service delivery in primary health care, mother and child health, family planning, major diseases control, and essential drug supply. b. Components 1. To strengthen health sector management capacity (at the central level and hospital administration ) by establishing management units respectively at the Ministry of Health, Malabo Hospital and Bata Hospital . 2. Establish a Health Information Management System to improve MOH's health strategy development and implementation planning capacity. 3. Train Staff at all levels of the Health System . 4. Strengthen Priority Health Programs through a. Malaria Control b. Mother Child Health/Family Planning c. Sexually Transmitted Disease (STD] control d. Pilot Program for Essential Drugs c. Comments on Project Cost, Financing and Dates The project took 10 years between identification and completion, and closing date was delayed for 3 more years. The Government had great difficulty meeting counterpart funding, and provided only 9% of its expected co-funding. At appraisal, the project cost US$ 5.5 million; at completion, it cost US$4.47 million. 3. Achievement of Relevant Objectives : The project's objectives were generally not achieved except for a partial fulfillment of staff training . Some training took place for nurses, birth attendants, and hospital administrators, but anecdotal evidence suggested that the trained personnel were no longer in the same communities . Tangible project achievements were limited to the construction of four health centers, the extension of the health school in Bata, and the rehabilitation of MOH buildings and drug warehouses, but all of these were found to be under-utilized and deteriorating. 4. Significant Outcomes /Impacts : The project funded the preparation and publication of a useful booklet on treatment of Sexually Transmitted Disease (STD), and copies were seen in clinics during ICR mission . 5. Significant Shortcomings (including non -compliance with safeguard policies ): No monitoring indicators or quantified outputs were reported to demonstrate the progress of the Project . There was no recorded inventory of procurement (e.g., 13 vehicles, 1000 mattresses, essential drugs ) under the project. The status of studies (e.g., prevalence of malaria, a review of hospital finances and operations, hospitals' action plans, an inventory of health facilities, and assessment of rehabilitation needs ) funded by the project is unknown. Management capacity was not strengthened; various units (e.g., Managing Committee and Planning Unit at MOH) set up by the project were not operational . Health Information Management System was never operational . Service delivery for the Priority Health Programs did not improve : 1. Endemic malaria persisted in Bioko Island where the Malaria Control program was to be piloted. 2. Four newly constructed health centers, meant to improve Mother Child Health/Family Planning, were under-utilized, and physically deteriorating . 3. The National STD control center, which the Project funded, was no longer in operation . 4. There was a shortage of essential drugs in the entire public health system that was started with US$ 0.65 million of the project's funding. 5. Despite the costly rehabilitation of drug warehouses, they were practically empty (Malabo and Bata), and their physical conditions were deplorable (Malabo). The lack of reaction by Bank management to the lapses in project supervision indicates an institutional weakness of the Bank. Problems remained even though all (but one) of the ten supervision missions had reported violation in legal and financial covenants . There were also serious breaches of Bank procedures where several oral agreements between the Borrower and the Task Manager were never formally incorporated into the Loan Agreement . The Borrower became resentful when these promises were eventually null, and had insisted that the Bank was responsible for various aspects of the project's failure . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Unsatisfactory Unsatisfactory Institutional Dev .: Negligible Negligible Sustainability : Unlikely Unlikely Bank Performance : Deficient Highly Unsatisfactory Borrower Perf .: Deficient Highly Unsatisfactory Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : Projects in countries with poor institutional capacity should be simpler . Quantifiable indicators/outcomes, tangible targets or concrete products must be included to monitor and evaluate projects' activities . Counterpart funding should be realistic : the Borrower's inability to fulfill its obligation then results in disbursement suspension that impedes the project's progress . Increasing the physical capacity of health centers will not result in better service delivery if fundamental problems related to institutional capacity, skills of health professionals, quality of services, and accessibility are not addressed. Given that the Borrower's capacity for management and implementation is so weak, appropriate institutional support and systematic technical assistance should have been provided . Equally important, the Bank's technical assistance must transfer necessary skills to qualified and committed national counterparts . A core team of implementing staff (at the borrower-country) should preferably be maintained from preparation till completion to ensure ownership of and commitment to the project . 8. Audit Recommended? Yes No Why? The Borrower's views differ drastically from the Bank's regarding how and why the project has failed. This project also raises questions about how the Bank supervises and manages difficult and problematic projects. 9. Comments on Quality of ICR : The ICR did an objective and conscientious job in describing the project's outcomes and weaknesses .