Sri Lanka - Health and Family Planning Project

Document of The World Bank FiLE '' FOR OFFICIAL USE ONLY Report No. 7050-CE STAFF APPRAISAL REPORT SRI LANKA HEALTH AND FAMILY PLANNING PROJECT March 25, 1988 Population and Human Resources Division Country Department I Asia Regional Office 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 Sri Lanka Rupee (Rs) = 100 cents US$1.00 (at appraisal, September/October 1987) = Rs3O (Official Rates) = Rs (Free Market Rate) FISCAL YEAR January 1 - December 31 ABBREVIATIONS ABD - Asian Development Bank CMSD - Central Medical Supplies Department CPR - Contraceptive Prevalence Rate CDS - Community Development Services DDG - Deputy Director-General DHC - Divisional Health Center DHS - Demographic and Health Survey FHB - Family Health Bureau FP - Family Planning FPASL - Family Planning Association of Sri Lanka GHC - Gramodaya (village) Health Center HRM - Human Resources Management IEC - Information, Education and Communication IRDP - Integrated Rural Development Project IUD - Intra-uterine device MDPU - Management Development and Planning Unit MH - Ministry of Health MLGHC - Ministry of Local Government, Housing and Construction MOH - Medical Officer of Health MOPI - Ministry of Plan Implementation MWATH - Ministry of Women's Affairs and Teaching Hospitals NGO - Non-government Organization NHDA - National Housing Development Authority NIHS - National Institute of Health Sciences PHC - Primary Health Care PPF - Project Preparation Facility RDHS - Regional Directorate of Health Services SDHC - Sub-Divisional Health Center TFR - Total Fertility Rate UNFPA - United Nations Population Fund UNICEF - United Nations Children's Fund USAID - United States Agency for International Development WHO - World Health Organization  FOR OFFICIAL USE ONLY SRI LANKA HEALTH AND FAMILY PLANNING PROJECT Table of Contents Page No. CREDIT AND PROJECT SUMMARY .................. .................... . iii I. INTRODUCTION ........................ 1 II. SECTOR STATUS AND ISSUES ..............* .................... 1 A. Health and Population Conditions ......................... 1 B. Policies and Programs......... *........... . 2 C. Public Expenditure on Health .............................. 5 D. Sectoral Issues, Objectives and Strategy.................. 9 E. Role and Rationale for Association Involvement............ 14 III. THE PROJECT ........................ .... ................. *9............. 16 A. Objectives and Design .............. .0. ................. . 16 B. Summary Description ....... ........................... ...... . 17 C. Detailed Description .. . ........ ...........o.. . 18 Health Management Improvement ............ ............ ..... 18 Management Development. .. ............. ........... 18 Health Sector Policy Development.,.*.....*.*........ 22 Service Delivery ........... ..... ..... 23 Logistics*.*..#...e...... ................. .............. ...... 25 Drug and Supplies Management .................... ...... 27 Vehicle and Equipment Repair and Maintenance.......... 29 Family Planning .... 0.... ..................................... 30 Population Strategy Development ....................... 30 Service Delivery ..*..................... . ............O....* .... 31 Information, Education and Communication. ............. 32 This report is based on the findings of an appraisal mission to Sri Lanka from September 14-October 2, 1987. Mission members were: Messrs. J. Greene (Mission Leader), V. Kumar (Logistics Specialist), G. Sinclair (Architect), W.J. Smith (Economist), J. Herm (Family Planning, Consultant) and J. Satia (Health Management, Consultant). Ms. S. Patel assisted in preparing the report. 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.  - ii. - Page No. IV. PROJECT COSTS, FINANCING, PROCUREMENT, DISBURSEMENTS, ACCOUNTS AND AUDIT AND ENVIRONMENTAL IMPACT .............. 34 A. Costs . ........................................ 34 B. Financing .... 36 C. Procurement ........ ...................................... 37 D. Disbursements . . ................... 39 E. Accounts and Audit........................ . ... 39 V. PROJECT IMPLEMENTATION .. .... 40 A. Status of Project Preparation . . 40 B. Organization and Management . . ..40 C. Monitoring, Reporting and Evaluation .. . . 41 VI. PROJECT BENEFITS AND RISKS . ......... .. . 42 A. Benefits . ....................................... 42 B. Risks ...... .......................................... 43 VII. AGREEMENTS REACHED AND RECOMENDATION... 44 ANNEXES 1. Management Training Table . . ............... 46 2. Draft Terms of Reference for Health Strategy and Financing Study. .... . ........ . .52 3. Service Delivery Subcomponent Conceptsn . . 6 4. Yearly Project Costs by Year Component and Type of Expenditure . . .. 87 5. Estimated Schedule of Disbursements . . 89 6. Schedules of Key Actions by Components ............... 90 A. Management ....90 B. Logistics . . ........................................... 91 C. Family Planning ....93 7. Monitoring and Evaluation ....99 A. Management........ 99 B. Family Planning . . ..................................... 100 8. Selected Documents & Data Available in the Project File... 101 CHARTS 1. Organization for Primary Health Care ................ 103 A. Overall Structure . ........................... 103 B. Regional Service Delivery ..104 2. Organization Structure: Ministry of Health . ............. 105 3. Organization Structure: Ministry of Women's Affairs and Teaching Hospitals ................. .. . ........ 106  - 113 - 4. Organization of Management Development and Planning Units ................................. 6-00*0000000**4 107 5. Organization of Population Division, Ministry of Plan Implementation ................................. ......... 108 MAPS IBRD 19985 Sri Lanka - Health and Family Planning Project. IBRD 21017 Sri Lanka - Primary Health Care Complex Areas in Project.  I  - iv - SRI LANKA HEALTH AND FAMILY PLANNING PROJECT Credit and Project Summary Borrowert Democratic Socialist Republic of Sri Lanka Beneficiary: Ministries of Health, Women's Affairs and Teaching Hospitals and Plan Implementation Amount: SDR 12.9 million (US$17.5 million equivalent) Terms: Standard, with 40 years' maturity Project Description: The project would strengthen management in the Ministries of Health and Women's Affairs and Teaching Hospitals by assisting the establishment of Human Resource Management, Financial Management and Management development and Planning Units. It also would support: (a) health policy development through a health strategy and financing study and operational research and (b) improved service delivery in two health regions where management improvements would be tested and adapted for wider replication. In logistics, the project would improve storage facilities and management systems for drug and medical supplies distribution and would strengthen systems for vehicle and equipment maintenance and repair. In family planning, the project would assist strategic and service delivery planning and monitoring, as well as communications efforts to generate additional demand for spacing methods complementing a major service delivery effort financed by the United Nations Population Fund. The project would be carried out over five years. It provides funds for civil works; vehicles, furniture, equipment and supplies; training and consultant services; studies; special service delivery programs in two health regions; family planning grants to non-government organizations; production and dissemination of family planning messages through mass media, project coordination and incremental operating costs. The total project cost is estimated at US$21.39 million equivalent, with a foreign exchange component of US$5.74 million (27%). It includes US$260,000 in Project Preparation Facility financing and US$100,000 equivalent in retroactive financing, mainly for preparation of site plans and surveys, working drawings, fixtures and fitting lists for project-funded construction of drug storage  facilities and project coordination activities. A breakdown of costs and the financing plan appear in Schedule A. Amounts and methods of procurement and disbursement, anda disbursement schedule are shown in Schedule B. A timetable of key project processing events appears in Schedule C. Two maps and the Staff Appraisal Report, No. 7050-CE dated March 25, 1988, also are attached. Benefits and Risks: The project would develop increased capabilities for health management and planning; increased absorptive capacity in the sector; more cost-effective, efficient and equitable use of resources for health care, and reduced fertility. These changes would in turn lead to improved health status. Through reduced wastage and losses, the logistics component alone would produce annual savings estimated at Rs3O million or more from the third year of the project. Both individuals and society would benefit from reduced fertility. Fertile couples would enjoy reduced risk of infant and child mortality and morbidity. A 0.4 reduction in total fertility, to which the project would contribute, would enable Sri Lanka to reach replacement fertility five years earlier than currently anticipated. The project faces two main risks: possible faltering Government commitment to implementing management reform once the initial staffing effort is completed and possible Population Division difficulties in forging effective collaboration among concerned Government actors and voluntary agencies for integrated family planning services delivery and communications. To help counter the first risk, the project provides a combination of technical assistance and in-service training, for which details have been worked out, at all critical levels of the health management system. Annual training plans will be prepared and reviewed with IDA well in advance of execution. The establishment of Management Development and Planning Units in both health ministries also will help stabilize management processes and provide mechanisms to adjust them as required. Strengthening the Population Division's capacity for planning and implementation will enable it to coordinate more effectively with concerned agencies on population matters. The use of workshops as a principal mechanism to develop family planning and communications strategies will promote inter- agency consensus on goals and agency roles. Morevoer, the mid-term project review will serve as a vehicle to identify shortcomings in project assumptions and operations and make appropriate course corrections.  - vi - ProectCost: Local Foreign Total -------(US u