Mozambique - Health Sector Recovery

 ICRR 11777 Report Number : ICRR11777 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 06/24/2004 PROJ ID : P001792 Appraisal Actual Project Name : Health Sec Recovery Project Costs 355.7 344.5 US$M ) (US$M) Country : Mozambique Loan /Credit (US$M) Loan/ US$M ) 98.7 79.9 Sector (s): Board: HE - Health (88%), Cofinancing 140.5 NA Central government US$M ) (US$M) administration (12%) L/C Number : C2788 Board Approval 96 FY ) (FY) Partners involved : UNDP, ADB, DANIDA, Closing Date 06/30/2001 08/31/2003 DFID, EU, FINIDA, Italy, Netherlands, NORAD, OPEC, SDC, SIDA, USAID, WHO, UNICEF, WFP, UNFPA Prepared by : Reviewed by : Group Manager : Group : Elaine Wee-Ling Ooi Ridley Nelson Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives The overall Health Sector Recovery Program (HSRP) objective, as reported in the SAR, was to support the Mozambican National Health Strategy (MHS) in the improvement of the health status of the population in general, and aimed at a decrease in infant and child mortality, in particular . This would be achieved via an increase in health coverage of the population from 40% to 60%, with better quality services provided . While not a full fledged SWAP, the program was a move towards it, providing for joint planning and annual reviews by Ministry of Health (MOH) and all donors, and the consolidation of all health budgets into one operational framework . b. Components The IDA credit financed a " time slice" of the HSRP/MHS that included three components : Health Services Delivery - targeted rural /underserved areas with maintaining /upgrading facilities, stabilizing provision of food/medical / laboratory supplies, and supporting provincial level operations ($256.2m); Institutional Support - aimed at strengthening sector management, financial and administrative capacity (central/provincial levels), health system improvements, sector policy development, establishing policies, procedures and a health management information system ($63.6m); Human Resources Development - supported implementation of the 10-year Health Manpower Development Plan, improved national training capacity, restructured in -service training, and provided key support to Faculty of Medicine ($35.9m). c. Comments on Project Cost, Financing and Dates Project preparation was prolonged (PCD to approval took 6 years) due to change of design from a simple investment project to a more integrated approach, to bring coherence to the sector which had previously more than 120 separate donor projects. Total project costs at SAR were $ 355.7m, with $98.7m commitment from IDA, and $116.5m from government. Actual costs were $344.5m with $79.9m from IDA. Government and other donor expenditures were not indicated in the ICR. The project closed two years later than scheduled on 08/31/2003. 3. Achievement of Relevant Objectives: The program achieved its objective of supporting the MHS in improving the population's health and, specifically, in the reduction of infant and child mortality . During the implementation of the HSRP, IMR fell from 162 to 101 and CMR from 282 to 197, exceeding program targets. Intra-hospital MMR declined more slowly to 164 from 234 (achieving 61% ). No monitoring system was in place to adequately track the intended health coverage of 60%, but indications are the overall coverage has improved significantly . Vaccination coverage (DPT) and antenatal care were 82% and 97% respectively also exceeding targets, while institutional deliveries increased to 48% from 29%. A caveat to this assessment with respect to attribution are the potentially significant contributions of (i) other health projects (albeit of smaller scope) running in parallel to the HSRP and (ii) the significant number of private providers (NGOs and other charities) active in Mozambique in health provision and improvement . Program targets were generally met in upgrading /construction of rural health centers /hospitals which were staffed and equipped adequately. Population covered per health center decreased from 84,000 to 42,000 indicating a better spatial/equitable distribution of facilities . With the increased access and training provided to high numbers of medium- and basic- level health workers, it is reasonable to expect that quality of services have and can continue to be improved. Client satisfaction surveys however recorded only 52 % were satisfied against a targeted 75%. 4. Significant Outcomes/Impacts: Project had good baseline data and monitoring indicators defined at the start which enabled the program to track its most important achievements in health outcomes as well as targeted outputs in service delivery, quality and training. Progress in health system development, program management and the good use /collection of data/information, facilitated the capacity building /mobilization of central/provincial/local governments/entities, in achieving and exceeding program targets. This was in spite of the institutional weaknesses of the country, its emergence from protracted civil war, external economic shocks and the horrific floods of 2000. Project was able to accomplish its far reaching goals in civil works and institutional support . A new health sector policy for 2000-2010 was developed; and inputs provided to the Public Expenditure Review and the Medium Term Expenditure Framework. A system is in place enabling greater predictability and adequacy of pharmaceuticals and medical supplies . A common drug fund of $15-20 million annually (8 donors/MOH) has rationalized drug procurement and achieved economy of scale. Implementation of health manpower development plan was on track . Improved health facilities, skills development and other incentives indicate (anecdotal evidence presented only ) improved morale, productivity of MOH staff and greater inclination to work in remote areas . 5. Significant Shortcomings (including non-compliance with safeguard policies): Stronger emphasis should have been placed on HIV /AIDS given that it was pandemic in the region . HIV prevalence rate in patients with sexually transmitted infections was increasing rapidly (2.6% in 1995 to 12.2% in 1997). A planned study/policy paper on HIV/AIDS was also not carried out. Comments by Finnish donor coordinator for the program emphasizing the need for greater donor harmonization, suggests some weakness in harmonization despite the intended sector wide approach . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Satisfactory Institutional Dev .: Substantial Substantial Sustainability : Likely Likely Fiscal sustainability is of some concern . While institutional conditions and political commitment appear very favorable, there is less evidence of financial resilience (cost recovery and recurrent counterpart funding) to sustain the substantial achievements of the program. 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: In post conflict situations, additional time and resources may be necessary for project preparation to elicit full government ownership and donor support, and to prevent fragmentation of the recovery program . Broader sector wide approaches require new M&E tools . Care should be given to ensuring the inclusion of the right indicators and having baselines; good balance between routine data collection and periodic surveys . Having a good M&E system (as in this project) facilitates assessment of project achievements . Location of the task team leader within the country to monitor and supervise can be a key element to project implementation and success. 8. Assessment Recommended? Yes No Why? While this was not a SWAP, it was an innovative, integrated program that has been successful . Lessons to be extracted in how the program responded to the considerable challenges of the sector . 9. Comments on Quality of ICR: ICR quality is satisfactory overall but its coverage of issues should have been more comprehensive and indepth . There needed to be greater evidence linking overall health outcomes and program contributions, for example pre-project trends in indicators and what could reasonably be attributed to the program . Further, discussion had centered on those activities / inputs financed by IDA when it was important to have the assessment of the larger HRSP program. Government expenditures and the results of cost sharing and recovery, necessary for our understanding of the fiscal situation /sustainability of the sector were not provided . There was inconsistency in maternal mortality figures provided by SAR (pg 94) and ICR (pg 8 and 23), and between the IMR achievements described under Borrower comments (ICR pg 10) and under Bank discussion (pg 8).