Nepal - Population & Health

 ICRR 11022 Report Number : ICRR11022 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 08/06/2001 PROJ ID : P010460 Appraisal Actual Project Name : Population & Health Project Costs 39 37.6 US$M ) (US$M) Country : Nepal Loan /Credit (US$M) Loan/ US$M ) 26.7 23.87 Sector (s): Board: HE - Health (92%), Cofinancing none Central government US$M ) (US$M) administration (8%) L/C Number : C2600 Board Approval FY ) (FY) Partners involved : Closing Date 12/31/2000 12/31/2000 Prepared by : Reviewed by : Group Manager : Group : Roy A. Jacobstein Timothy A. Johnston Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives The Project’s main objective was to support the Government’s National Family Planning and Maternal and Child Health (FP/MCH) Program in increasing the contraceptive prevalence rate (CPR) and decreasing the total fertility rate (TFR). The three specific objectives were to (a) increase the coverage, quality, and utilization of FP/MCH services; (b) to improve the functioning of grass-roots health facilities; and (c) enhance the government's institutional and managerial capacity for MCH/FP. b. Components Four discrete project components were identified: 1. Outreach Service Delivery ($32.1 million), focused on: training and deploying female MCH workers at the Sub-Post Level; construction and/or renovation and equipping of Health Posts (HPs) and Primary Health Centers (PHCs); and field operations support for staff mobility, and monitoring and supervision. 2. FP/MCH Clinical Units ($1.8 million), to supplement other donor funding by establishing five (of 35) units for surgical contraception and MCH care in rural district hospitals. 3. Logistics and Supplies ($1.3 million), consisting of construction and renovation of warehouses for essential drugs, vaccines and contraceptives, transportation of supplies, and support for logistics management field operations. 4. Institutional Development ($3.8 million), to: enhance capacity and sustainability by supporting an integrated MIS for FP/MCH; create seven clinical training centers in existing hospitals; build maintenance capacity for infrastructure and equipment; support a Project Implementation Unit (PIU) for Project management. c. Comments on Project Cost, Financing and Dates Total project costs at appraisal were $39 million, with an IDA credit of $26.7 million and Government of Nepal (GON) contribution of $12.3 million. Latest estimates at closing were a total project cost of US$37.6 million, with a credit of $US23.87, GON contribution of $13.73 million, and unused credit of $2.83 million. Less than 8% of the credit was disbursed before Mid-Term Review (9/16/97). This was the first IDA-supported Project in the health sector in Nepal. 3. Achievement of Relevant Objectives: The Project substantially achieved its output and outcome objectives, with coverage and utilization of MCH/FP services documented to have increased significantly, and targets for the deployment of female MCH workers achieved. The Project’s development objectives, couched in population-level terms, also were met. For example, the CPR rose from 21.3% in 1994/95 to 34.5% in 1999/2000. The TFR fell from 5.5 in 1991 to 4.6 in 1996 and an estimated 4.0 in 1999/2000. Maternal mortality ratios (per 100, 000 live births) fell from 850 in 1991 to 540 in 1996 to an estimated 400 in 1999/2000. Infant mortality rates also fell, from 107 per 1000 live births in 1991 to 75 in 1997 to an estimated 50 in 1999/2000. The extent to which these improvements are due to the Project is uncertain, but it seems reasonable to attribute some of the nationwide improvement in MCH/FP status to the Project, given its substantial achievement of output and outcome targets, particularly after MTR in late 1997. 4. Significant Outcomes/Impacts: The Project provided timely, cost-controlled infrastructure support to approximately 550 health facilities, including 60% of Nepal’s Health Posts (HPs) and Primary Health Care Centers, with construction of 133 new HPs and renovation of 35 more; these 168 are now fully functional. In addition, staffing of facilities was augmented. A new cadre of village-based female MCH workers was established, with over 3000 deployed in sub-health posts in all 75 districts of Nepal. Logistics for contraceptives, vaccines and essential drugs was improved, including construction of 11 warehouses (versus the planning target of 7) and expansion of storage capability by over 40%. About 9600 staff received training for logistics, financial management, and integrated supervision. These investments in infrastructure, training and deployment led to increased utilization and improved outcomes. Outpatient visits in outreach health facilities increased from 4.5 million per year in 1994/95 to over 7 million in 1999/2000. Antenatal visits more than doubled by the end of the Project (15.5% to 35%), attended deliveries more than quadrupled (from 3.1% to 13.5%), and the number of FP users increased steadily. 5. Significant Shortcomings (including non-compliance with safeguard policies): For various reasons, including the inevitable learning curve for project personnel in new sectors, the Project only began proceeding well after the Mid-Term Review, with only 8% of the credit being used prior to MTR. There were 11 changes in government from 1991-2000 and turnover at the MOH and the PIU was high in the early years, which slowed implementation. The PIU’s ability to implement the Project was impeded by tensions in its institutional relationship with the Department of Health Services (the main implementing unit of the MOH), since the management structure of the Project sidelined the DOHS. Lack of donor coordination proved problematic throughout the project. The Field Operations Support component encountered constrictive rules and inadequate daily allowances for field staff, which constrained fieldworker and supervisor mobility and limited progress in this area. Finally, sustainability is unlikely, due to inadequate Government budgetary support. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory Institutional Dev .: Modest Modest Sustainability : Unlikely Unlikely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE: NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. 7. Lessons of Broad Applicability: Clarification of the role of the PIU vis-à-vis a MOH’s implementation unit is important at the time of Project design as well as implementation, to reduce bureaucratic ambiguity and potential rivalry. Synergistic development of infrastructure and service/logistics capability can result in demonstrable improvements in coverage and utilization, even in very poor countries. In community-based interventions, early and steady involvement of community leaders and end-users results in better ownership, support, and use of facilities. In the absence of government commitment to donor coordination, the Bank should take the lead in advocating and advancing such coordination. 8. Assessment Recommended? Yes No 9. Comments on Quality of ICR: In general the ICR was well written and internally consistent, and its judgments were well supported by the text. There was good attention to quantitative indicators of achievement, at the output, outcome and impact levels. The lessons learned section had a wealth of observations (though some of the observations were, strictly speaking, findings, rather than lessons learned.)