Tanzania - Health Sector Development Program Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No: 29517 IMPLEMENTATION COMPLETION REPORT (PPFI-Q1720 PPFI-Q1721 TF-25923 IDA-33800) ON A CREDIT IN THE AMOUNT OF US$ 16.2 MILLION TO THE GOVERNMENT OF TANZANIA FOR A HEALTH SECTOR DEVELOPMENT PROGRAM June 28, 2004 Human Development 1 Country Department 4 Africa Region 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.  CURRENCY EQUIVALENTS (Exchange Rate Effective 30 June 2004) Currency Unit = TSh TSh 1 = US$ 0.00090 US$ 1 = T.Sh1107.5 SDR 1=US$1.47 FISCAL YEAR July 1 June 30 ABBREVIATIONS AND ACRONYMS APL Adaptable Program Loan MCH Maternal and Child Health CHF Community Health Fund MMC Muhimbili Medical Center CMS Central Medical Store MoF Ministry of Finance CHMT Council Health Management Team MoH Ministry of Health DANIDA Danish Agency for Development Assistance MOU Memorandum of Understanding DFID Department for International Development MSD Medical Stores Department DHMT District Health Management Team MTEF Medium-term Expenditure Framework DHS Demographic and Health Survey NBC National Competitive Bidding DRF Drug Revolving Fund NHIF National Health Insurance Fund EHP Essential Health Package NGO Non-Governmental Organization FY Fiscal year PER Public Expenditure Review GFAMT Global Fund against AIDS, Malaria, and PoW Program of Work TB Tuberculosis PORALG President's Office Regional and Local Government GoT Government of Tanzania PRS Poverty Reduction Strategy HIPC Highly Indebted Poor Countries PSR Project Supervision Report HMIS Health Management Information System QAG Quality Assessment Group HRH Human Resources for Health QA Quality Assurance HSDP Health Sector Development Program RBM Roll-back Malaria ICB International Competitive Bidding RHST Regional Health Support Team KCMC Kilimanjaro Christian Medical Center RS Regional Secretariat LGA Local Government Authority SWAp Sector-wide Approach TB Tuberculosis Vice President: Calisto E. Madavo Country Director Judy M. O'Connor Sector Manager Dzingai Mutumbuka Task Team Leader/Task Manager: Emmanuel Malangalila  TANZANIA Health Sector Development Program CONTENTS Page No. 1. Project Data 2 2. Principal Performance Ratings 2 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 3 5. Major Factors Affecting Implementation and Outcome 23 6. Sustainability 26 7. Bank and Borrower Performance 27 8. Lessons Learned 29 9. Partner Comments 30 10. Additional Information 35 Annex 1. Key Performance Indicators/Log Frame Matrix 38 Annex 2. Project Costs and Financing 40 Annex 3. Economic Costs and Benefits 41 Annex 4. Bank Inputs 42 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 45 Annex 6. Ratings of Bank and Borrower Performance 46 Annex 7. List of Supporting Documents 47  Project ID: P058627 Project Name: Health Sector Development Program Team Leader: Emmanuel G. Malangalila TL Unit: AFTH1 ICR Type: Core ICR Report Date: June 30, 2004 1. Project Data Name: Health Sector Development Program L/C/TF Number: PPFI-Q1720; PPFI-Q1721; TF-25923; IDA-33800 Country/Department: TANZANIA Region: Africa Regional Office Sector/subsector: Health (82%); Compulsory health finance (11%); Central government administration (7%) Theme: Health system performance (P); HIV/AIDS (P); Gender (S); Decentralization (S); Rural services and infrastructure (S) KEY DATES Original Revised/Actual PCD: 04/17/1998 Effective: 07/01/2000 09/29/2000 Appraisal: 03/15/1999 MTR: 03/01/2002 Approval: 06/15/2000 Closing: 12/31/2003 12/31/2003 Borrower/Implementing Agency: UNITED REPUBLIC OF TANZANIA/MINISTRY OF HEALTH & MIN. OF REGIONAL ADMIN. AND LOCAL GOVT Other Partners: Governments of Denmark, Ireland, Germany, the Netherlands, Switzerland and the United Kingdom STAFF Current At Appraisal Vice President: Callisto E. Madavo Callisto E. Madavo Country Director: Judy M. O'Connor James W. Adams Sector Manager: Dzingai B. Mutumbuka Dzingai B. Mutumbuka Team Leader at ICR: Emmanuel Malangalila Phillip Gowers ICR Primary Author: Wacuka W. Ikua; Jean-Pierre Manshande 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability: L Institutional Development Impact: SU Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: S S Project at Risk at Any Time: No  3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: In support of the Government of Tanzania's health sector reforms, IDA approved a three-phase Adaptable Program Loan (APL) to support the Health Sector Development Program (HSDP) over the period 2000-2011. HSDP's overall purpose was "to improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, and to maximize the impacts on health outcomes, especially among the poor, women, and children". This ICR addresses Phase 1 of the Program which covered the period from September 28, 2000 to December 31, 2003 with a Credit amount of SDR 16.2 million (US$22 million equivalent). Its specific objective was to accelerate the reforms and emphasize institutional capacity development. It focused on: (i) strengthening human resource capacity (particularly at local levels) to manage and adapt to the changing roles and responsibilities; (ii) developing and piloting systems to improve quality and delivery of services which in turn would improve the health status; and (iii) improving resource mobilization and management through increased coordination, and strengthening of the support systems. Progression to Phase 2 was triggered by: (i) the integration of health sector financing, with at least 50% of donor resources for the sector reflected in the MTEF; (ii) the testing and implementation of district block grants, linking inputs to outputs, outcomes and performance, in at least 30% of the 113 districts; and (iii) the establishment of effective national guidelines for an Essential Health Package for use by district management teams to ensure the quality of services. All triggers were determined to have been achieved by May, 2003. 3.2 Revised Objective: Improve resource management and quality of health services through sector reforms and institutional capacity building. The objectives were not revised The Development Credit Agreement (DCA) was amended (on March 6, 2001) to establish two new Special Accounts; in addition to the original Special Account (SA-A, used for activities outside the Basket), the DCA created the US Dollar Holding Account (SA-B to fund Basket activities) and the multi-sectoral HIV/AIDS component (SA-C). 3.3 Original Components: The Program's four components and six sub-components were: 1. Strengthening Service Delivery, comprising: i. District Health Services; ii. Level 2 and 3 Hospitals; and iii. Public/Private mix 2. Strengthening the MoH & Central Support Systems, comprising: i. the Role of Central MoH & Sector-wide Management; ii. Central Support Systems; and iii. Human Resource Development & Management; 3. Health Financing; and 4. the National HIV/AIDS Fund. 3.4 Revised Components: N/A - 2 -  3.5 Quality at Entry: Overall, the project quality at entry was rated satisfactory in June, 2000 by QAG. Per the reviewers, the team showed a broad mastery of the sector and its issues and also an ability to build borrower ownership for the project (the project was actually presented to the PAD decision meeting by the Tanzanian Minister of Health). There was a strong indication of donor support for a coordinated sector strategy managed by the government and well-formulated, long-term objectives of improving the access, utilization, quality and financing of health services so as to maximize impacts over the long term on health outcomes especially among the poor, women and children. The project employed innovative financing instrumentation, enabling joint programmatic donor support in addition to traditional parallel financing of elements of the sector development program. On the other hand, the reviewers found that the task team did not provide sufficient clarity about what would be monitored overtime. Given that this operation was prepared over a long time period, with considerable investment of staff and budgetary resources, it was felt monitoring should have been more developed. There were also understated risks, especially regarding (i) the likelihood that the donors would maintain discipline overtime, (ii) the weak capacity of the Tanzanian institutions as well as in the low level of community participation in project development, and (iii) the potential for conflict among stakeholder groups. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Given Phase 1's emphasis on capacity building and systems development to improve MoH's capacity to manage the sector and the regions/districts' ability to implement the activities, HSDP achievement of Development Objectives (Dos) is rated as satisfactory. As a SWAp, IDA's contribution to these achievements has been assessed on the basis of GoT's attainment of the PoW's 1999-2003 objectives and targets. Annex 1 summarizes the key performance measures. Program successes were obvious in many areas: (i) annual PERs and annual reviews of rolling three-year MTEFs have been fully established in the sector; (ii) basket funding functions smoothly; (iii) district-based health planning and management system and its financing through block grants have been expanded; (iv) immunization coverage has increased; and (v) zonal training centers have been strengthened. While HSDP resulted in the scale-up of several key reforms, it did not fully implement some important accompanying measures. In particular, it was less successful in: (i) setting up a functional quality assurance system; (ii) finding solutions to the insufficient and unbalanced mix of human resources; and (iii) persuading the Civil Service Department to accept propositions for revision of remuneration and incentive package for health manpower. Also, although the MoH has made progress in establishing indicators of sector performance (as presented in the Public Health Sector Performance Profile), the HMIS is currently unable to provide the kind of information and evidence required to report upon these indicators, and there has been no progress on strengthening the HMIS in the last year. The 1999 Tanzanian Reproductive and Child Health Survey and the 2002 census (results of IMR and U5M) not yet released) should provide enough evidence to measure the program's impact during Phase 1; these will be augmented by a Demographic and Health Survey (DHS), which is planned in August - 3 -  2004. 4.2 Outputs by components: 1. Strengthening Service Delivery The table in Annex 1b summarizes the current status of HSDP's efforts to develop systems to improve the quality and delivery of services and presents considerations for Phase II. (Total cost: US$520.00million; IDA: US$ 12.90 million) comprising: (a) District Health Services; (b) Level 2 and 3 Hospitals; and (c) Public/Private Mix (a) District Health Services Health systems development: As of July 2003, the MoH had devolved authority for managing the district hospitals, health centers and dispensaries to all 113 Council Health Management Teams (CHMT), thereby exceeding the initial target of 30% of the districts. In addition, managerial capacity has been strengthened in a number of important areas: