Malawi - Health Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 9258 PROJECT COMPLETION REPORT MALAWI HEALTH PROJECT (CREDIT 1351-MAI) DECEMBER 28, 1990 Population and Human Resources Operations Division Southern Africa Department Africa 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 Currency Unit = Malawi Kwacha (K) SDR 1.00 = US$1.08995 (Feb. 28, 1983) US$1.00 = K1.10 K1.OO = US$0.91 METRIC EQUIVALENTS 1 meter = 39.27 inches 1 kilometer = 0.62 miles 1 sq. kilometer = 0.39 sq. miles ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome CHSU Community Health Sciences Unit CMS Central Medical Stores MOH Ministry of Health MOWS Ministry of Works and Supplies PCR Project Completion Report PHC Primary Health Care UNICEF United Nations International Children's Education Fund UNDP United Nations Development Program WHO World Health Orga.iization FISCAL YEAR OF BORROWER April 1 - March 31 4  THE WORLD BANK Washington, D.C. 20433 U.S.A. Office of DiucGne-tual Opeqatean Ew,Iuatg December 28, 1990 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on Malawi Health Proiect (Credit 1351-MAI) Attached, for information, is a copy of a report entitled "Project Completion Report on Malawi: Health Project (Credit 1351- MAI)" prepared by the Africa Regional Office with Part II contributed by the Borrower. No audit of this project has been made by the Operations Evaluation Department at this time. Attachment of teir ffical dtie. .t co.en ma no otews_edslsdwtou ol akatoiai This document has a restricted distribution and may be used by recipients only In the peformance of their official duties. Its contentas may not otherwise be discksed without World Bankt autboriztion  MALAWI FOR OMCIAL USE ONLY PROJECT COMPLETION REPORT HEALTH PROJECT (Credit 1351-MAI) TABLE OF CONTENTS Page No. Preface l Su. .ary . . . . . . . . . . . . . . . . . . . . . . . . . . i Evaluation'Su'mmsr'y' ............... ii PART I PROJECT REVIEW FROM BANK'S PERSPECTIVE A. Project Identity . . . . ... . . . . . . . . 1 B. Project Background . . . . . . . . . . . . . . . . . . 1 C. Project Objectives and Description . . . . . . . . . . . . 2 D. Project Design and Organization . . . . . . . . . . . . 3 E. Project Implementation . . . . . . . . . . 4 F. Project Results . . . . . .... . . . . . . . . . 5 G. Project Sustainability ... . . . . . . . . . . .... 7 H . Bank Performance . . . . . . . . . . . . . 7 I. Borrower Performance ...... ......... .... 8 J. Consulting Services . . . . . . . . . . . . . . . . . 8 K. Project Documentation and Data . . . . . * . 8 PART II PROJECT REVIEW FROM BORROWER'S PERSPECTIVE A. Adequacy and Accuracy of Factual Information Contained in Part III .. ..... ............. .... 9 B. Comments on Analysis in Part I . . . . o . . . . . . . . . 10 C. Bank Performance.. . . . . . . .... . . . . . 10 D. Ministry Performance . . o . o . . . . . . . o . . . o. . 10 E. Project Relationship . . . . . . . . . . . .... . . . . 10 F. Relationship with Cofinanciers . . . . . . . . . . . . . . 10 PART III STATISTICAL INFORMATION A. Related Bank Loans andlor Credits . . . . . . . . . . . . . 11 B. Project Timetable . . . . . . . . . . . . . . . . . 12 C. Credit Disbursements ........... .......... 12 D. Project Implementation . . .. . . .. . . . . . ..... 13 E. Project Costs and Financing . . . . . . . . . . . . . . . . 14 F. Project Results . . . . . . .. . . . . . . . . . . . . 16 G. Status of Covenants . .. ................. 19 H. Use of Bank Resources . . . . . . . . . . . . . . . . . . . 21 ANNEX 1: Letter from Malawi Government (May 3, 1990) forwarding Part II of Project Completion Report - Health Project (Credit 1351-MAI) MAP IBRD 16734.R 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.  PROJECT COMPLETION REPORT MALAWI HEALTH PROJECT (CREDIT 1351-MAI) PREFACE This is the Project Completion Report (PCR) for the Health Project in Malawi, for which Credit 1351-MAI in the amount of SDR 6.3 million was approved on April 21, 1983. The credit was closed on December 31, 1988, four years behind schedule. The last disbursement was on July 31st, 1989 and the sum of SDR 37,823.59 was cancelled The PCR was prepared by the Population and Human Resources Operations Division of the Southern Africa Department (Preface, Evaluation Sunmmary, Parts I and III), and the Borrower (Part II). Preparation of this PCR was started during a mission in October, 1989, and is based, inter alia, on the Staff Appraisal Report; the Credit, Guarantee, and Project Agreements; supervision reports; correspondence between the Bank and the Borrower; and internal Bank memoranda.  - iil. - PROJECT COMPLETION REPORT MALAWI HEALTH PROJECT (CREDIT 1351-MAI) EVALUATION SUMMARY Obiectives 1. The project's objectives were co improve the effectiveness and efficiency of the health care system, through: strengthening of planning and administration, and preparation of a comprehensive new national health plan; development of Ministry of Health (MOH) capacity to perform epidemiological studies and evaluate health programs; expansion, on a selective basis, of primary health care facilities; expansion of training facilities; introduction of child spacing programs; and improvement of the pharmaceuticals supply system, especially in procurement and distribution. These objectives were timely and appropriate, and followed consistently from the findings of a Bank health sector review (by largely the same team) completed just prior to project preparation. In line with the objectives, the project provided for: training; renovation and upgrading of facilities; strengthening of support services for primary health care (e.g., equipment, vehicles, income generating activities); and studies and technical assistance. The project design and organization were basically sound and appropriate to the objectives, although more could have been done during preparation to avert the implementation problems noted below. Implementation Experience 2. The main variances between planned and actual implementation were: (a) the implementation period was lengthened from two to six years, through three extensions; (b) two of the components, pertaining to the Community Health Sciences Unit (CHSU) and the pharmaceuticals supply system, remained not yet fully operational at project completion, even with the extensions; and (c) lengthy delays were experienced in civil works. The factors contributing to these problems included: deficiencies in the architectural briefs prepared by the MOH for the Ministry of Works and Supplies (MOWS), and in the coordination between the two ministries; diversion of effort to the preparation of the national health plan, and to the development of the second and, later, the third projects; turnover and shortages of key MOH personnel and MOWS architects; MOH's dissatisfaction with the work done by the initial pharmaceutical consultants; problems in providing housing for CMS personnel; insufficient emphasis on supervision (especially regarding time in the field and mission composition); and the fact that a full-time project cocrdinator was not in place until 1987. Results 3. The project achieved virtually all of its objectives, except that the aims of the CHSU and pharmaceuticals components will be fully attained only when the remaining issues in those areas are resolved. The planning  - iv - and administration component was successful in producing a national health plan of good quality that formed the basis for the second project. This achievement was all the more impressive considering that after the consultants responsible for this work failed to complete the plan to MOH's satisfaction, the MOH decided to do it themselves without outside help. As an important side-product, the arduous process of developing the plan in- house served to markedly strengthen MOH's planning and evaluation capabilities. The child spacing component fully met its overall objective to introduce family planning programs in Malawi; this work %s completed ahead of time and the training program exceeded original targets. The PHC component, also completed ahead of schedule, was largely successful in developing the first phase of national primary health care program based on community involvement in LbO villages of the pilot districts. The CHSU and the pharmaceutical components, as noted above, were extensively delayed and have yet to achieve their full potential. Sustainability 4. Malawi is likely to derive important long-term benefits from the project as a result of its success in launching child spacing and primary health care in the country. In terms of the constructed and improved health and child spacing facilities. the benefits will probably be sustainable over the long term. -taer activities and programs will need to be sustained through wider refurms in health manpower development (expansion of posts, improvemer.ts in conditions of service) and continued Government and donor commitment to increased levels of recurrent spending - these are being supported in the Bar;;'s Second and Third Health Projects in Malawi. 5. Once operational, both the CHSU and the pharmaceutical components will also contribute significantly to project benefits. At appraisal, savings from the planned improvements in procurement and distribut_.on of pharmaceuticals were estimated to more than offset the incremental recurrent costs of the project. It is too early to confirm these calculations since neither the envisaged systems are in place nor are there any dependable, recurrent cost data available. Findings and Lessons Learned 6. With this project, the Bank started its positive contribution to Malawi's health and population sector, and built a constructive dialogue with the respective Malawian authorities. The Government and people of Malawi have benefited. On lessons learned, it is clear that the implementation period should from the outset have been set at more than two years, which was far too short for the work to be done and the challenges to be overcome. Second, the project might have gained from being simplified and scaled back even further than was done during preparation, considering that this was a first project and the sector had serious staff shortages. Third, further development of the CHSU and pharmaceuticals components before implementation would have helped. Fourth, more persistent effort to get a well-trained and experienced project coordinator in place early on could have aided the resolution of many problems. Fifth, supervision missions should have spent more time in the field and included more involvement by specialists in the areas experiencing difficulties, especially on civil works and pharmaceuticals.  PROJECT COMPLETION REPOkT MALAWI HEALri PROJECT (CREDIT 1351-MAI) PART I. PROJECT REVIEW FROM BANK'S PERSPECTIVE A. Project Identity - Name : Health Project - Credit Number t 1351-MAI - RVP Unit : Africa Regional Office - Country : Malawi - Sector : Population and Human Resources - Subsector : Health and Population B. Project Backgrouind 1. Sector Development Objectives. The principal objectives of the Government's health and population sector development over the long run were to improve the health status of the Malawi people and to address the country's population problems. The sector's immediate objectives were targeted to establishing a sound health services delivery system capable of promoting health, preventing and curing diseases, and increasing productivity. Since gaining independence in 1964, the Government has pursued these objectives by focusing on health manpower development in the 1960s and 1970s; and has sought to strengthen and expand the basic health services network while controlling communicable diseases. 2. Policy Context. The 1973-88 National Health Plan provided the basis for developing a network of facilities to substantially increase health coverage. The plan called for a comprehensive health care system to be developed comprising primary health centers, health sub-centers and health posts, together with the provision of health services at the community level. Financial constraints, however, largely prevented the development of such a system and contributed to staff shortages, inadequate training and transport difficulties. In response to these problems, the Government developed a primary health care program in 1978 to supplement its existing rural and MCH programs. At the same time the Government decided to permit properly trained health staff to offer child spacing services, including counselling and distribution of modern contraceptives. 3. Despite these initiatives, the Bank's health sector review in 1980 revealed that slow progress in health improvement was the result of inadequately defined and coordinated policies and strategies, poor sector planning, a bias towards hospital-based curative services, lack of criteria for guiding health sector investments, failure to adequately coordinate the private sector's extensive health activities with those of the Government, and deficiencies in the procurement and distribution of pharmaceuticals. The findings of the sector review, thus clearly showed the need for the development of an up-dated and financially viable national health plan and provided the basis for developing the Health Project.  C. Prolect Objectives and Description 4. Project Objectives. The mafn objective of the project was to improve the effectiveness and efficiency of Malawi's health delivery systems in responding to its health needs. Specifically, it was supposed to help the Government reach this objective over a two-year period by: (a) improving the MOH ability to plan, monitor and evaluate health programs and policies and develop a comprehensive national health plan; (b) strengthening the MOH's ability to carry out epidemiological studies with supporting laboratory services; (c) Instituting an efficient, cost effective pharmaceutical procurement and distribution system; (d) introducing the first phase of a national primary health care program; and (e) introducing a child spacing program. 5. Prolect Components. The project included five components: (a) Planning and Administration (i) technical assistance and training fellowships for MOH for producing a comprehensive national health plan (including a staff development plan), establishing a permanent planning, evaluation and monitoring capability, and improving the financial management, accounting and service statistics systems; (ii) support of studies on infant and child mortality and on possible linkages between traditional and modern health sectors; and (iii) technical assistance and on-the-job training for re-organizing the Central Medical Stores (CMS) into a commercial entity; (b) Community Health Sciences Unit (CHSU) Renovation and additions to an existing building in Lilongwe with the provision of housing, equipment and vehicles, training fellowships, and consultant assistance (funded, in part, by UNDP/WHO), to establish a unit to collect and analyze epidemiological data, including the necessary laboratory support services; (c) Pharmaceutical Procurement and Distribution Renovation of existing buildings in Blantyre, construction of new buildings in Lilongwe and Mzuzu, with housing equipment, vehicles, and consultant assistance to improve the procurement and management of the pharmaceutical system and its associated manufacturing capability,  -3- provide for the move of CMS from )lantyre to Lilongwe, as well as equipment for the training of pharmacy technicians; (d) Primary Health Care Development Training (with contributions from UNICEF and WHO), essential upgrading of rural facilities, equipment, vehicles and bicycles communications improvements, income generating activities and monitoring and evaluation activities, to develop a primary health care program based on community mobilization in three districts covering about 150 villages; and (e) Child Spacing Renovation of antenatal facilities at Zomba General Hospital and 15 selected district hospitals, furniture, equipment, training and a family formation study, to initiate a child spacing program in urban and rural areas. D. Prolect Desi_n and Organization 6. The Health Project derived its conceptual foundation from the discussions between the Bank and Government on the findings of the health sector review mission in September 1981. The Government accepted the findings of the review and felt that they would provide a good basis for developing this project. Initially, the Government had requested Bank assistance in a very broad scope. When it became apparent, however, that financial constraints would preclude the dimensions of such a project, the concept of the project was scaled down considerably. In retrospect, this decision was clearly correct. The project thus did not attempt to address all of the identified deficiencies of the sector, but focused on developing a national health plan and on redressing the most critical constrair . in the health care delivery system. Future health projects would then be designed to deal with some of the other problems. 7. Project preparation extended over a relatively short period of time. After the preliminary project discussions in September of 1981, the project was identified in January 1982, appraised in July 1982, and negotiated in March 1983. The preparation process benefitted from: drawing upon the results of a successful pilot program, in the case of the Primary Health Care Development component; thorough discussions with Government over an extended period of time, in the case of the Child Spacing component; and utilizing the findings of the health sector study. Two of the components (CHSU and pharmaceuticals) were not as well advarced as the others by the time of project effectiveness, and this was mirrored later in the project outcomes. 8. In both the preparatory and implementation phases of the project, it could not have been foreseen that the country would be beset during the project period by multiple economic problems (in incomes, employment, balance of payments, and then tightening of the budget) and the effects of the Mozambican war. These developments significantly exacerbated the constraints o01 easing staffing shortages and obtaining the building materials (especially cement) needed for civil works. 9. Overall responsibility for project implementation was to rest with the MOH, with each component managed by the head of the applicable section of the  - 4 - Ministry -- the Chief Health Planner for administration and planning, the Deputy Chief Medical Officer for CHSU, the Assistant Chief Medical Officer (MOH) for the Primary Health Care (PHC) program, and the Chief Pharmacist for the pharmaceutical procurement and distribution component. Responsibility for overall project coordination was assigned to the Principal Secretary of the Ministry. A coordinating committee, chaired by the Principal Secretary, was to have met quarterly to ensure the smooth progress of implementation. Soon after project implementation had started, it became apparent that neither the Principal Secretary nor his deputy was devoting sufficient time to adequately monitoring and coorGinating the project on a day-to-day basis. The Bank consequently already recommended the appointment of a full-time project coordinator in its first supervision mission. But it was not until January 1987 that a project coordinator arrivci in Malawi -- initially for the Second Family Health Project (Credit No. 1768-MAI) but later, by default, for the (first) Health Project as well. 10. How the design, preparation, and organizational/institutional features of the project contributed to its outcome is, as always, difficult to sort out from the influences of other factors on outcome, such as implementation performance. Nevertheless, it seems likely, for the reasons indicated in the following sections, that the design and preparation work could have been more effective in preventing difficulties that arose during implementation, particularly in regard to the CHSU and pharmaceuticals components and the delay in project completion. The design should have provided for longer than a two-year implementation period, which was far too short for the work that was to be done and the challenges the Government faced. It might also have been advisable to simplify and scale back the project even further than was done during preparation, given that this was a first project and the sector had serious staff shortages. In addition, further development of the CHSU and pharmaceuticals components before implementation would have been desirable, although oth r factors from the implementation period also weighed heavily on the progress of these components and could not have been entirely foreseen at the outset. E. Project Implementation 11. The main vAriances between planned and actual implementation were: (a) the implementation period was lengthened from two to six y ars, through three extensions; (b) two of the components (CHSU and pharmaceuticals) remained not yet fully operational at project completion, even with the extensions; and (c) lengthy delays were experienced in civil works. The slower than anticipated progress of the CHSU and pharmaceuticals components has delayed efforts to build local capability to carry out epidemiological work, medical research and publiz health laboratory work (for example, imported goods cannot be tested for zontamination in Malawi at the present time). In addition, the anticipated benefits from the pla-ned improvements of the pharmaceutical component have not yet been fully realized, since some aspects (including the manufacturing plant in Lilongwe, and the establishment of appropriate distribution and inventory systems and procedures and the required computer support) are still not entirely operational. 12. Factors common to most of the civil works delays include (a) the preparation by MOH of inaccurate and/or incomplete architectural briefs for the Ministry of Works and Supplies (MOWS); (b) poor coordination between MOH  and MOWS; (c) during first couple of project years focus diverted to resolving massive problems relating to the preparation of Natior.al Health Plan; (d) to an increasing degree beginning from May 1984, focus by all concerned parties on preparation of a second health project; (el lack of proper synchronization between training of personnel and construction schedules; (f) unexpected transfers of senior MOH personnel; (g) shortage of architects at MOWS due to transfer of personnel and death of two key architects; and (h) shortage of building materials due to delays in issuance of foreign exchange permits for importation. 13. Also, the completion of CHSU was delayed becauses (a) Several candidates to head CHSU were not accepted by foreign universities; and (b) tLe epidemiologist desigaated te head the unit after completion of training was transferred to head the Acquired Immune Deficiency Syndrome (AIDS) program. Additional reasons for the delay of the pharmaceutical component included: (a) MOH's dissatisfaction with the work by the initial pharmaceutical consultants caused about a two year project delay; (b) housing in Lilongwe built for CMS, but occupied by non-project personnel effectively preventing start-up of the pharmaceutical component; (c) protracted disputes between contractors and MOWS over designs of some buildings; and (d) failure to create the staff posts in a timely fashion. 14. While some of these factors could hardly be anticipated during project preparation or avoided by more astute supervision, staff shortages at almost all levels of the project and the difficulties at MOWS should probably have required more conservative projections with regard to the expected implementation period at the design stage and more aggressive .ccention and follow-up during the supervision of the project. Based on the very positive experience and impact on the project progress once the project coordinator was on board, efforts on the part of the borrower and the Bank should have been more intensive to fill this position much sooner. Furthermore, forward planning and synchronization between civil works schedules, training and assignment of personnel, and availability of equipment and materials could have expedited the implementation period -- for example, through evacuating staff houses in time so that project personnel at CMS Lilongwe could start operation of the facilities; training lab technicians to avoid that manufacturing of pharmaceuticals in Blantyre is done without any quality control of material input or production output; readying computer and inventory systems so enable the completed drug depots in Lilongwe and Mzuzu to assume their regictal distribution role and to allow the transfer of the CMS from Blantyre to Lilongwe; and assigning the required staff to operate the three completed and totally underutilized PHC training units. F. Prolect Results 15. The project achieved virtually all of its objectives, except that the aims of the CHSU and pharmaceuticals components will be fully attained only when the problems noted above are resolved. 16. One of the primary goals of the project was to produce a comprehensive ten year national health plan for 1985-95 and to improve the planning and evaluation capability of MOH. While the plan was expected to be completed by December 31, 1984, serious problems developed relating to the performance of the consultant group, which ultimately led to a mutually agreed, premature  -6- termination of the contr ct. As a consequence, MOH planning staff decided to take on the job themselves and, with the assistance of senior MOH management and some consultant advice, worked hard to complete the wotk. The final product, completed in December 1985, printed in Summer of 1986 and issued in early 1987, was of good quality and received high acclaim from the National Health Planning Committee. The plan also formed the basis for the development of the Second Family Health Project. As an important side-product, the arduous process of developing the national health plan in-house served to markedly strengthen MOH's planning and evaluation capabilities. 17. The child spacing component fully met its overall objectives to introduce family planning programs in Malawi. The component was completed ahead of time and the training program exceeded original targets. According to latest statistics, child spacing services are offered in 106 of the 364 MOH and Private Hospital Association of Malawi (PHAM) facilities. Unfortunately, the initial momentum in the selected pilot districts -- Dowa, Mzimba and Mzuzu -- has not continued to date. Other districts have now exceeded by far the Mwanza and Dowa districts in terms of acceptors. Contributing to this slowdown has been the grave shortage of nurses qualified in child spacing service delivery, and the lack of in-service training and infrequent health inspections. In addition, after most of the construction of the antenatal units was completed and operational, integration of child spacing with MCH activities was introduced rendering most of the existing antenatal facilities too small and no longer space efficient, despite the fact that about ten facilities are currently being upgraded with funds from project cost savings. 18. The PHC component also almost fully met its objective to develop the first phase of national primary health care program based on community involvement in 150 villages of the pilot districts. The component was also completed ahead of schedule. Mainly due to severe financial constraints and staff shortages, the PHC program now has difficulty to sustain its early momentum. For example, the national coordinator of the National PHC Committee is the only person in MOH attending to PHC matters. He has no support staff, no funds for field visits, no vehicles, and no funds to effectively stimulate community-based programs. On the civil work side, the construction and upgrading of six rural health centers was successful despite some continuing water supply problems. Unfortunately, the three PHC training centers were never used for the intended purpose, as all PHC training had been completed when the construction was ready for occupancy. In addition, Government correctly decided that additional PHC training would in the future better be carried out in the communities rather than in classrooms. As a result, the training units are neither properly staffed, supplied and maintained, and remain grossly underutilized. 19. The problems with the CHSU and the pharmaceutical components have been described. It must be emphasized that when and if the current constraints and deficiencies are eliminated, both components should also meet their original objectives. With respect to CHSU this would primarily mean the creation of posts for and the recruitment of a senior epidemiologist, a microbiologist and laboratory technicians. With respect to the pharmaceutical component, this would mean the return of staff houses to project staff, the possible redesign and reconstruction of the drug manufacturing plant in Lilongwe, the development of appropriate computer, inventory and distribution systems, and the recruitment of qualified personnel.  -7- G. Project Sustainability 20. Malawi is likely to derive long-term benefits in the social sectors from the project as a result of its success in launching child spacing and primary health care in the country. In terms of the constructed and improved health and Maternal and Chield Health (MCH)/Child Spacing facilities, the benefits should be sustainable over the long term. Other activities and programs will need to be kept alive through persistence, search for new initiatives, and continued funding. Once operational, both CHSU and the pharmaceutical components should also contribute significantly to project benefits. 21. At appraisal, savings from the planned improvements in procurement and distribution of pharmaceuticals were estimated to more than offset the incremental recurrent costs of the project. It is clearly too early to confirm these calculations since neither the envisaged systems are in place nor are there any dependable, recurrent cost data available. If the savings do eventually outweigh the costs, that is likely to take longer -- given the delays in project implementation -- than the originally expected "ten years or sooner" from project effectiveness. H. Bank Performance 22. With the Health Project, the Bank started its positive contribution to Nalawi9s health and population sector. During the full implementation period, the Bank's dialogue with the respective Malawian authorities was constructive. In hindsight, it appears that the Bank's supervision activity was overshadowed by efforts to prepare and supervise a second project and later prepare a third project. In light of the serious problems encountered throughout implementation, more field time during the 14 supervision missions for the first project could probably have identified difficulties earlier. Considering that a large number of problems, especially in the later years, stemmed from the civil works part of the project, it is unfortunate that there was no consistency in the use of implementation specialists and that in four missions no such specialization was represented. Similarly, a pharmaceutical specialist participated in only three of the first five missions, but not in any of the following nine missions. As indicated, the pharmaceutical component is still not operational and has yet to overcome some very difficult problems. With a more forceful and persistent approach, the Bank could likely have contributed to earlier solution of problems such as the occupation of staff housing by non-project personnel, the assignment of a project coordinator, the submission of timely audit and progress reports, or the establishment of an appropriate project cost monitoring system. 23. For future projects the following lessons learned from the Health Project may be of value: (a) Priority of supervision of projects must remain high within the work program of the Bank and within Government. Sufficient staff, consultant, and budgetary resources must be allocated to supervision. (b) Project performance must be rated accurately to receive the appropriate attention from management.  -8- (c) Sufficient time has to be allotted during supervision missions to visit project sites and facilities. A plan should be set up for each project to ensure that over a certain number of supervision missions, say a cycle of four missions or about two years, all such sites and facilities have been inspected. As supervision must not cease after closing date of a loan/credit if earlier difficulties in the project have not been fully resolved (OD 13.05), budgetary resources should in these cases continue to be available. (d) A well-trained and experienced project coordinator who on a full-time basis facilitates and properly monitors project implementation, and liaises between government agencies and cofinanciers, is a key element to successful projects. I. Borrower Performance 24. MOH's performance especially during the early stages of the project was affected by the departure of senior staff and by the lack of an experienced, full-time project coordinator. During the first couple of years, MOH's main focus was on overcoming problems arising from consultants who had been retained to prepare the ten year national health plan and to prepare the pharmaceutical components. In this context, MOH is highly commended for taking on the final preparation of the ten year national health plan primarily through its own resources when the consultant group failed to produce an acceptable document. By enormous effort, it completed work of excellent quality. During this difficult period, MOH could probably have benefitted by consulting more closely with the Bank in order to solicit the Bank's advice and support. 25. The borrower's compliance with the Credit Agreement is detailed in Par- III, Table 7. The review shows that the main problems relate to (a) substantial implementation delays; (b) poor record keeping of project activities, costs and financing; (c) non-project related occupation of staff housing an the child spacing hostel; (d) failure to provide personnel for the operation of CHSU, CMS and the PHC training units; and (e) substantial delays in preparation of audits and submission of progress reports. J, Consulting Services 26. As indicated, MOH experienced major problems with the consulting group retained for the development of the national health plan. Because was MOH wus dissatisfied with the performance of some of the consultants in the field and their frequent personnel changes, the contract was terminated by mutual agreement at the end of 1984. MOH was not satisfied with the consultants initially retained for the preparation of the pharmaceutical component and MOH hired additional consultants to complete the work in this area. Following this experience, MOH became exceedingly cautious in their recruitment practices regarding external technical assistance. K. Project Documentation and Data 27. In spite of repeated comments by early supervision missions, a proper project monitoring and information system wag never put in place. As a  -9- consequence, there is little institutional memory regarding this project in MOH as many of the persons involved in the early stages have left the ministry. Especially grave is the lack of essential project data, such as project investment and recurrent costs (beyond IDA disbursement data), foreign exchange content, the Government's own contribution to the project, and assistance provided by cofinanciers. In its last progress report dated June 30, 1989, MOH reports that it has not been possible to locate in the MOH Registries documentation on several aspects of project implementation including reports of supervision missions. The available documentation conveys the impression that regular monitoring of project activities at both MOH and IDA has not had high priority. Preparation of PCRs under such circumstances become an exceedingly difficult undertaking. PART II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE A. Adequacy and accuracy of factual information contained in Part III 28. The Ministry is in general agreement with the information presented subject to the following: (a) Project Costs (5) Information on project costs are not available in the required format, and are therefore estimates derived from disbursements under the credit and Malawi Kwacha expenditures. (b) Project Financing (5) Activities by other agencies except in respect of the CHSU have been completed as part -f their country programmes and it has been found difficult to extract expenditures in respect of project items. (c) Project Results - A. Direct Benefits The following need to be noted: (i) All officers of disease control programmes were posted to the CHSU during December, 1989. The Unit is functional. (ii) Regional and district PHC coordinators were appointed effective 22 August, 1989 and the momentum of the work is being accelerated. (iii) The PHC Training Centers are being utilized for training activities including PHC with first priority to MOH. (d) Projects Results - B. Studies Although the study at (5) was not done, a pilot survey to develop indicators for the measurement of progress for Health for All 2000 has been completed and will be revised annually.  - 10 - (e) Status of Comments (7) In regard to item 4.01 (c), it may be noted that the audit report for the period April, 1988 to March, 1989 was submitted to IDA on 20 February, 1990. B. Commen:s on Analysis in Part I 29. The Ministry is in general agreement with the analysis in Part I. However, it is necessary that the following are noted: (a) The number of static MOH facilities offering child spacing services as at 31 December, 1989 stood at 171. (b) The deployment of only the National PHC Coordinator at the center should not be considered a down grading of the PHC effort. PHC pervades the entire spectrum of MOH activities especially the preventive services and are supported by programme personnel. (c) Comments at para. 19, in regard to the CHSU and the pharmaceutical component of the project, need to be viewed in the context of recent intensified efforts by MOH to overcome the stated problems. C. Bank Performance 30. The Bank inputs during preparation, appraisal and implementation were most critical in this first health project. Greater focus on major issues during supervision and efforts at their resolution may have facilitated satisfactory progress. D. Ministry Performance 31. Unforseen problems and additional tasks detailed in Part I, placed heavy burden on the limited resources available to Government resulting in implementation delays. One important lesson arising from the implementation record is the need to treat parts of each component as a whole and to ensure their implementation in a systematic and synchronized manner, enabling avoidance of some of the problems experienced in this project. E. Proiect Relationship 32. Bank relationship with Government during the evaluation and implementation phases of the project has been good. F. Relationship with Cofinanciers 33. Activities cofinanced were implemented in parallel as part of country programmes of UNICEF and UNFPA. The only component not implemented was UNDP technical assistance to CHSU. This was due to delayed completion of facilities. The relationship with all agencies was good.  - 11 - PART III. STATISTICAL INFORMATION A. Related Bank Loans and/or Credits Table 1: IDA CREDIT RELEVANT TO THE PROJECT Loan/Credit Year of Purpose of Status Comments Title Approval Project Credit 1768-MAI 1987 Improve family Under Implementation of Second Family health, child- implemen- civil works Health Project spacing services tation processing well; and MOH capacity software compo- to deliver nents are affected health services by chronic shortage of personnel  - 12 - B. Proiect Timetable Table 2: PLANNED, REVISED AND ACTUAL DATES OF PROJECT TIMETABLES Item Planned Date Revised Date Actual Date Health Sector Mission 10/1980 Identification Mission 09/1981 (Initial project discussion with IDA) Preparation Mission 09/21/81 09/21/81 09/21/81 Appraisal Mission 07/07/82 07/07/82 07/07/82 Credit Negotiations 03/15/83 03/15/83 03/15/83 Board Approval 04/26/83 04/26/83 04/26/83 Credit Signature 05/20/83 05/20/83 05/20/83 Credit Effectiveness 07/01/83 08/22/83 08/22/83 Project Completion 06/30/85 06/30/88 Credit Closing 12/31/85 12/31/86 12/31/88 12/31/87 34. Comments on Timetable. The originally projected date of project completion, less than two years after Credit Effectiveness, was unrealistic. The Credit Closing was formally extended three times. Construction of major works on Central Medical Stores in Lilongwe, the Regional Medical Stores at Mzuzu and the Community Health Sciences Unit started in July/August 1986, i.e., well after the initial Credit Closing date. C. Credit Disbursements Table 3: CUMULATIVE ESTIMATED AND ACTUAL DISBURSEMENTS (SDR '000) Bank FY: 1984 1986 1986 1987 1988 1989 1990 Appraisal Estimate 1,650 4,8006,360 - - - - Actual 119 1,914 2,446 2,780 3,810 5,916 6,262 Actual as X of Est. 7 40 s9 44 60 94 99 Date of Final Disb. a/ */ As of July 31, 1989, SDR 37,823.69 was cancelled. Last application: No. 167 for K 621,892.4 dated July 31, 1989  - 13 - D. Project Implementation Table 4: PLANNED AND ACTUAL COMPLETION DATES OF CIVIL WORKS COMPONENTS Planned Actual Months Component Completion Completion of Delay Community Health Sciences Unit (CHSU) 12/85 09/87 31 Pharmaceutical Procurement and Distribution 05/85 09/89 52 Health Centers 06/85 01/86 7 Child Spacing 01/85 08/85 7 10/89 5 35. Comments on Proiect Implementation The civil works program that had been agreed before Board presentation was overly optimistic. Design work was to be done by MOWS staff with no private architects being involved. As it soon turned out, staff shortages in MOWS prevented timely preparation of designs and tender documents. Tendering itself did not seem to have presented difficulties or delays, probably because no international competitive bidding was required. After construction had started, problems and major delays occurred in connection with importation of building materials, seriously delaying, e.g., completion of buildings for the Central Medical Store in Lilongwe. Completion of store buildings for the regional medical store in Mzuzu was badly delayed because of the need, after construction had started, to re-design the roof structure, which caused a protracted dispute between the contractor and MOWS engineers. In retrospect as indicated in Part I, paragraph 16, the appointment of a project coordinator would have minimized the implementation delay.  - 14 - E. Prolect Costs and Financing Table 6: PROJECT COSTS (USs '000) Appraisal Estimate Actual Local Foreign Total Local Foreign Total Category Costs Costs Costs Coats Costs Costs I. INVESTMENT COSTS Pharmacout,cal Supply and Distribution 2,260.2 676.6 2,826.8 N/A N/A 2,669.8 Community Health Sciences 416.8 808.6 1,224.8 N/A N/A 108.3 Planninga and Administration 98.9 832.1 981.0 N/A N/A 1,268.8 Primary Health Care 1,678.2 667.4 2,346.6 N/A N/A 2,351.4 Child Spacing 470.0 696.0 1,065.0 N/A N/A 497.4 Total Invest. Costs 4,914.1 3,478.1 8,392.2 N/A N/A 6,886.7 II. RECURRENT COSTS 211.6 109.5 321.0 N/A N/A N/A III. TOTAL PROJECT COSTS 6,126.6 3,687.6 8,713.2 N/A N/A N/A 36. Comments Actual project costs are based on estimates since the borrower did not keep complete records of its own contribution to the project cost. Due to Kwacha devaluations, Bank agreed to finance certain expenditures which were envisaged under the Second Family Health Project (Credit 1768-MAI) from QECH; 35 additional vehicles). Thus, total estimated investment costs for the Health Project amounted to only US$6.9 million.  - 15 - Table 6: PROJECT FINANCING (US$ million) Planned Actual IDA 6.8 6.2 Domestic 1.3 0.7 a/ Sub-Total 8.1 6.9 UN Cofinancing Institutions 0.6 Not available TOTAL COSTS 8.7 37. Comments on Prolect Financing As the cofinancing amounts were relatively small, no formal cofinancing arrangements were made. UnZortunately, no accurate records as to the type of support provided by the cofinanciers or the value of this support was maintained over the project period by the borrower. Likewise, since only IDA disbursement records were kept, Government's own contribution to the project cannot be quantified with any precision. The given estimate is based solely on the Credit Agreement percentages for foreign exchange and local exchange (Schedule 1). The Government's contribution, however, was most likely higher since not all expenditures incurred for the project were submitted to IDA for reimbursement.  - 16 - F. Prolect Results Table 7: Direct Benefits Esttmated at: Indicators Appraisal Closing Date Full Dovelopment Proparation of Planned period 198U-1995 Hoelth N/A Revised Natlonal 1986-1996. Plan issued In Health Plan. 1987. Establish CHSU to Epidemiological Construction Operation not undertake opTd- work to start completed, not yet likely to start miological studies January 1986; operational due to before 1991/2 and laboratory Microbiology to lack of managing unless T.A. services (public start middle of personnel, received to manage health 1985; Biochemistry CHSU. laboratory). to start middle of 1986; Lab, tech- nology to start January, 1986. Transfer Central Move to take place Construction Transfer in 1990 Medical Stores In Spring of 1986. virtually only possible If from Blontyr- to completed, but problems of staff Lilongwe. lack of housing, computer procedures, and stock-keeping computer software, procedures can be shortage of staff resolved. and unauthorized use of staff housing prevent imp lamentation. Improve drug manu- Production to Major construction Production start- facturing In start by Spring of design deficion- up at Lilongwe Blantyre and add 1986. cios and housing will depend on facilities In shortage continue expert review of Mzuzu and to cause plant. Full pro- Lilongwe. substantial delays duction cannot be in start-up of envisaged before Lilongwe plant. 1991. Quality Mzuzu drug manu- control needed. facturing facility was cancolled. Improve drug Depots and Construction of Computer and pro- distribution In improved system to depots completed cedure specialist Malawi including be ready by the but not yot needed to establishmnt of middle of 1985. occupied. Little eliminate major two regional work done on problems. depots. system and procedure Improve- ments. Major computing problems.  - 17 - Develop PHC Pilot program About 1201,00 Service coverage PTrogr" Ea-sd on covering 120,000 persons initially oxtended by the community persons. Full- affected by project. The sub- mobilization In time PHC Project. Shortage *equent project Uwange, Dows and coordinatoro to be of staff and is supporting PHL Mzimba districts, appointed. PHC funds. No full- activit-s. committee time PHC structure at coordinators village, area, assigned; health district and inspectors carry region to be out PHC tasks in established. addition to their regular work. Selection, 800 PHC workers to 300 trained within Pilot scheme was training/ be trained/re- original project successfully retraining of trained, implementation *xtended to a community workers period (two large number of (TEAS and health years). However, other districts. are workers), after 1982 review, National core PHC worker system group to train was replaced by district -alth Health Service management team. Assistance. Upgrading of 6 units. 6 units completed; 6 units. facilities in Dows one unit under and Uzimba to construction health sub-centers (Nalunga). and add staff housing. Construction of a training Construction Training centers PHC training centers. completed only to be used for centers in Mwanza, after PHC training district$s non PHC Dows and Uzimba had taken place health training districts. and after program n-eds and other change calling for ministries. all PHC training to be performed in the communities themselves. Due to staff shortage, centers are mostly unused. Provision of child First project CS available at N/A !prcinJ (CS) at year; CS at _ ill central and central hospitals, central hospitals district hospitals all district and 22 district and in a large hospitals and at hospitals; second number of rural rural heoith project year: CS health centers. c-nters. at one rural health center in each district. Upgrading of Upgrading of Zomba hospital and Duo to savings, antenatal antenatal care at 12 units additional facilities to Zomba hospital and completed, improvements at 10 permit CS 15 of 21 district hospitals services. hospitals. initiated before Credit Closing date. Orientation of 2,000 during Partly alone. CS training health staff in initial project continues. CS. period. g.  - 18 - Technical CS I1a. 116. N/A trainin7g of hospital staff. Establishent of Throe centers to Centers are N/A technical training be established, operational. conters for CS at Lilongws, Zomba and Blantyre hospitals. 38. Comments on Prolect Results Due to the originally anticipated brevity of Project implementation (two years), it was felt at Appraisal that project impact could primarily be measured by process indicators, rather than by direct results on health status improvements. Furthermore, this Project was meant to a large degree to prepare the basis for future health projects. Table 8: PROJECT STUDIES Purpose as Defined at Impact of Appraisal Status Study 1. Infant and Analysis of 1977 Not done. See under Study Child census data to However, Family No. 8. Mortality provide Formation Study information on addressed Infant infant and child and child mortality by mortality Issues. district. 2. Role of Obtain objective Not done. But WHO Impact of WHO Traditional Information to consultant did supported study Medical determine linkages some work In this not known. Practi- between modern and area In 1988. tioners traditional health sectors. S. Review PHAM Review ways of Not done. On Utilization of Improving the low financial side, PHAM facilities level of however, a lot of remains low. utilization of work has been PHAM facilities done. and need for financial assistance. 4. Medical Determine Completed by WHO Provided basis for School Study financial and consultant Covernment feasibility of consortium. decision to pursue developing medical development plans. school in Malawi.  - 19 - 6. Boo-line To measure PHC Focus clightly N/A Epidemi- program's Impact changed. Primary ological over time. focus In PHC given Study to troining. In 1987, MOH, NHO, UNICEF, etc. carried out PHC roview. To determine Conducted In 1984 Survey updated 6. Family future priorities by the National demographic Formation In programs for Statistical Office Indicators Survey mothers ond with MON particularly on children. participation. fortility and mortality and gathered baseline data on KAP regarding child spacing. G. Status of Covenants Table 9: COMPLIANCE WITH CREDIT AGREEMENT Section/Covenant Status of Compliance 3.01(a) The Borrower shall carry out the In compliance, with the exception of (i) Project in conformity with substantial implementation delays; (ii) appropriate practices. poor record keeping relating to Project activities and financing; (Ili) due to severe housing shortage, staff housing and child spacing hostel built under Project have been occupied by non- project related personnel; and (iv) necessary staff positions for some project components (CHSU; pharmaceutical distribution; PHC training centers) have neither been created nor filled due to budgetary problems, but this Issue is now being resolved. 8.02(a) The Borrower shall employ In full compliance. *peci.lists In accordance with World Bank guidelines. The Borrower shall employ not later Covenantod personnel has been employed than September 80, 1988, a health at differont times but not during full planner, an epidemiology, a project period. Epidemiologist has bee finanlial analyst, a manpower trained; but was recently appointed to planning expert and two lead AIDS Program. pharmaceutical consultants. (b) Designate a Malawian counter-part to In light of severe staff shortages, work with each consultant so counterpart personnel has been made employed, available whenever possible.  - 20 - 3. e The Borrower shall cause all goods Houses built under Project for staff to and services under the Credit to be operate CHSU and Central Medical Stores used exclusively for the purpose of in Lilongwe have been or upied by non- the project until Its completion. project personnel causing substantial delays In the start-up of these facilities. Also, Child Spacils Training Hostel (old nurses home) cannot be used for Intended purpose due to non- project use. The COM Is in the process of releasing these houses to the designated institution. 3.04(a) The Borrower shall furnish to IDA In compliance. certain project documents. (b) The Borrower shall maintain records Record keeping regarding Project on project progress, permit IDA activities, Project costs and Project mission visits and provido at benefits have been insufficient to regular intervals certain adequotely monitor progress of the information. Project. Progress reports were submitted to Bank only very sporadically, although quartorly reporting was stipulated. Between 1987 and 1989 only two progress reports were received. (c) The Borrower shall prepare a PCR not Although Bank had requested basic iater than six months aftor closing information requirod for PCR date. preparatlcn, such Information was not received du. ing the covenanted period. Some important data (Project costs, co- financlngi tupport, namely non-IDA costs) have stltl nmot been furnished. 8.05 The Borrower shall acquire land In compl irncrj. rights as neoded for Project. 4.01(s) The Borrower shall maintain Project In compllnic* only in so far as IDA accounts. disbura.enlt accounts are concerned. No accounts mnAn.arned for Government's and co-financie-n' contribution to Project's investment an*d recurrent costs. (b) The Borrower shall maintain separate In compliancQ accounts for statements of expenditures. (c) Audit roports shall be submitted Reports were dnliAquent for every fiscal within six months after the end of year during Froject period. Due to each fiscal year. these delays, *udits for two yeare had to be combined. Only two audit reports were received, covering period: April 1984 - March 1988 and April 1986 - March 1988. Latest audit report for period April 1988 to March 1989 not yet received. Audit ropfrto only covered IDA portion of Project. 4.02 The Borrower shall produce a revises National Health Plan for 1988 - 1996 was National Health Plan for the period issued in 1987 after an about two year 1986 - 1995 by December 31, 1984. delay. T pZ  - 21 - 4.08 The Borrower shall Introduce a scalo Revisod scale of foes was Introduced In of fees for health services by April 1994. 1, 1984. 4.04 The Borrower shall operate the Not fully complied with. Central Contral Medical Stores as a district Medical Stores now operated as Treasury self accounting undertaking not Fund Activity within MOH, providing later than April 1, 1984. advan.e foreign exchange funding for purchase of pharmaceuticals and medical equipment; but with lose autonomy than a district self-accounting undertaking would have provided. 4.06 The Borrower shall ensure review of Review not undertaken. NOOs by PHC core group of MOH to ensure bettor coordination between them and public health providers. 4.08 In order to improve the staffing of In compliance as health centers under the health centers in Its primary Project are concerned. Staffing posts health care program, certain for the thre training units In Mzimba, staffing levels at health centers, Mwanza and Mponola have not been PHC t-aining units and districts created, and consequently units are not should be achieved, staffed. H. Use of Bank Resources Table 10: STAFF INPUTS AS OF DECEMBER 18, 1989 Stage of Project Cycle FY82 FY83 FY84 FY85 FY88 FY87 FY88 FY89 FY90 Total Preparation 66.0 66.0 Appraisal 49.8 49.8 Negotiations 7.7 7.7 Supervision 0.4 81.1 19.2 8.9 13.1 11.4 6.8 89.4 Other (PCR) 0.7 0.1 8.4 9.2 TOTAL 65.0 67.4 81.1 19.2 8.9 18.1 12.1 6.4 8.4 208.6 39. Comments on Staff Inputs Staff input for project preparation through negotiations amounted to 112 staff-weeks, which is about the average for Bank projects overall. However, supervision input exceeded the originally expected time substantially because the implementation period was estimated at two years but actually extended over six years. The total annual staff time allocated to supervision appears to have been adequate, an average of 14 staff-weeks per annum. While supervision carried out in the field amounted to 18 staff-weeks during the first year of project implementation (FY84), the average amount of time spent in the field during the following five years amounted to only about 5 staff- weeks or about 2.3 staff-weeks per mission.  - 22 - Table 11: MISSION DATA Performance Month/ No. of Staff Weeks Status by Mission Year Persons a/ in Field Activity b/ Health Sector Mission 10/80 Appraisal 07/82 F M DI OS a/ Supervision I 09/83 2(A,PH) 2 1 1 - 1 Supervision II 12/83 2(A,A) 2 1 1 - 1 Supervision III 02/84 4(E,M,P,PH) 7 1 2 1 2 Supervision IV 06/84 4(A,H,P,PH) 7 1 1 1 2 Supervision V 10/84 4(HP,M,P,PH) 4 c/ 1 1 1 2 Supervision VI 04/85 3(A,HP,PH) 3 c/ 1 1 1 2 Supervision VII 06/86 4(A,E,MS,PH) 2 c/ 1 1 1 2 Supervision VIII 09/86 3(A,E,MS) 4 c/ 1 1 1 2 Supervision IX 04/87 2(A,E) 2 c/ 1 1 1 2 Supervision X 08/87 1(E) 1 c/ 1 1 1 2 dl Supervision XI 11/87 3(A,E,PH) 2 1 1 1 2 Supervision XII 03/88 3(A,E,PH) 2 c/ 1 1 1 1 Supervision XIII 10/88 3(A,E,PH) 1.5 c/ 1 1 1 1 Supervision XIV 03/89 3(A,E,PH) 1.5 c/ 1 1 1 1 TOTAL 45.0 Proj. Completion 11/89 2(A,E) 4 - - - - a/ A=Architect; E=Economist; H=Health Advisor; HP=Health Planning Specialist; M=MCH/FP Specialist; MS=Management Specialist; P=Pharmaceutic Specialist; PH=Public Health Specialist b/ F=Available Funds; M=Project Management; DI=Development Impact; OS=Overall Status c/ The Health Project was supervised together with the preparation/super- vision of the Second Family Health Project. d/ No Form 590 on record. 39. Comments The performance ratings of the project do not seem to reflect the serious difficulties described in the supervisions reports. In light of the staffing shortages, management problems and underutilization of project facilities, the project management, development impact and overall status seem overrated. Over the six year project implementation period, three different taks managers/project officers were responsible for the project's supervision providing a considerable degree of lack of continuity. Also, regarding public  - 23 - health specialization, there has been remarkable consistency in Bank personnel. However, with respect to architects, seven different specialists (staff or consultants) participated in ten full supervision missions. No architect/ implementation specialist was represented in four missions. Moreover, in light of the difficulties in the pharmaceutical component, a specialist in this area may have been able to identify some of the design, construction, and procedural problems at an earlier stage and assisted Government in taking the appropriate remedial actions. Pharmaceutical specialists were used in only three early supervision missions. Record of Project Progress Reports Submitted by Govenrment (a) As of October 22, 1985. (b) For period ending December 31, 1988, submitted on March 9, 1989. (c) For period ending June 30, 1989, submitted on October 27, 1989.  ANNEX 1 -25- Page I of 2 I.n reply please quore No. AJ)M1 /14/87 Tdeann: Mma , Ulo tu MINISRY OF HEALTH Telepbons: LUlog 730099 P.O. BOX 30377 cuuuao ibeu be aid'mu ge CAPITAL CITY Tb. S.awb,7 for Healtb LILONGWE 3 EsEa1t ^t-1*sX MALAWI 3rd May, 1990 Mrs. N. Shields, AF6PH The World Bank, Population and Human Resources Division, 1818 H. Street, N.W. WASHINGTON, D.C. 20433, U.S.A. Dear Mrs. Shields, MALAWI: HEALTH PROJECT (CREDIT 1351 MAI) PROJECT COMPLETION REPORT Thank you for your letter of 2 April, 1990 forwarding the Project Completion Report (PCR) on the above project. I have studied the report with interest and have noted the areas for follow-up. The Ministry has taken several steps to strengthen its performance. Specifically, action is being taken to strengthen the Planning Division and the Project Implementation Unit. Already, an appointment has been made to the post of Principal Health Planning Officer and the Project Implementation Unit has been staffed with a Project Architect and additional accounting staff. We are also pursuing the establishment of a Manpower Development Unit as part of the Planning Division and renewed efforts are being made to ensure improved co- ordination not only in project work, but in all Ministry activities at central and lower levels. Important aspects of this project which need continued attention will be closely followed up and IDA will be kept informed of progress. This will be particularly relevant to the Pharmaceutical Supply and Distribution activities and the Community Health Sciences Unit. DOate Lo,g /p5/~ Recd. / No. Foa-Actbn: cc: c _ _ 2/... ITo ____- 5I-e (cJ .i  - 26 - ANNEX 1 Page 2 of 2 The project review from the Government's perspective for inclusion as Part II of the report is forwarded herewith. I have forwarded copies of my letter to the Secretary to the Treasury and the Principal Secretary, Ministry of Works for their information. Yours sincerely, R. P. Dzanjalimodzi SECRETARY FOR HEALTH  I B R D 16734R jj>, <tARONGA;AAM \ woD~ ~ ~ ~~~~~~~~~~~~~~~~~~~~.1 ORV , g d W,AMAINIO \ '>' XCh-we~~~to ;t ' ~ o e il NGS CSTON I A5 . ,. \i; PAlr I~~~~~~~~~~~~~~~~~M~ -( / j koooo 9 Y ;gc~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~55. 3 / H+ NKHATA .j RELIEF 1 A r IiNGS0N A below 915 / \ htw rz*SAY t 16 Roods~ ~ ~~;i~ \\ 1