Tunisia - Health and Population Project

Document of The Wor!d Bank FOR OFFICIAL USE ONLY Report No. 9054 PROJECT COMPLETION REPORT TUNISIA HEALTH AND POPULATION PROJECT (LOAN 2005-TUN) OCTOBER 11, 1990 Population and Human Resources Operations Division Country Department II Europe, Middle East and North 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.  GOVKRNIENT OF THE REPUILIC OF TDRISIA Currency Unit Dinar At Appraisal US$1.00 - D.T. 0.4 At Completion US$1.00 - D.T. 0.886 FISCAL M&6 January 1st to December 31st BHS Basic Health Services CNI National Computer Center (Centre National d'Informatique) cRFP Center for Pedagogical Research and Training (Centre de Recherche et de Formation Pedagogique) DBHS Directorate of Basic Health Services FP Family Planning HPN Health, Population and Nutrition INE National Institute of Child Health (Institut National pour l'Enfant) INNTA National Institute of Nutrition and Food Technology (Institut National de Nutrition et Technologie Alimentaire) HAS Ministry of Social Affairs (Minist6re des Affaires Sociales) MCH Mother and Child Health MFPV Ministry of the Family and Protection of Vomen MIS Management Information System MOPH Mtnistry of Public Health ONFP National Office of Population and Family Planning PCU Project Coordination Unit TYR Total Fertility Rate UNFPA United Nations Fund for Population Activities USAID US Agency for International Development  FOR OFFIAL U ONLY THE WORLD SANK Washington, DC 20433 USA Offic. of Doivc.Cmwal Op,wwwo EvWImitnA October 11, 1990 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on Republic of Tunisia Health and Population Project (Loan 2005-TUN) Attached, for information, is a copy of a report entitled "Project Completion Report on Republic of Tunisia Health and Population Project (Loan 2005-TUN)", prepared by the Europs, Middle East and North Africa Regional Office. No audit of this project has been made by the Operations Evaluation Department at this time. Attachment This document has a retrctd distribution and may be used by recipients only in the performance of their olilcial duties. Its contents may not otherwise be disclosed without World Dnk authoriation  FOR OFFICAL USE ONLY PROJECT COMPLETION REPORT TUNISIA FIRST HEALTH AND POPULATION PROJECT (LOAN 2005-TUN) TABLE OF CONTENTS PREFACE . ............... EVALUATION SNAY ............... ii PART I PROJECT REVIEW FROM RBANS PsrECTsIV . . . . . . . . . . . . . .1 Project Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Project Background . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Project Objectives and Description . . . . . . . . . . . . . . . . . . . . 2 Project Design and Organization . . . . . . . . . . . . . . . . . . . . . 2 Project Implementation . . . . . . . . . . . . . . . . . . . . . . . . . a Project Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Project Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . 15 Bank Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Borrower Performance . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Project Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Consulting Services . . . . . . . . . . . . . . . . . . . . . . . . . . . is Project Documentation and Data . . . . . . . . . . . . . . . . . . . . . 18 PART II PROJECT REVIEW FROM BoRaoRw's PEPZCTIVE . . . . . . . . . . . . 21 PART III STATISTICAL INFORKMZION . . . . . . . . . . . . . . . . . . . . . 25 Table 1: Related Bank Loans . . . . . . . . . . . . . . . . . . . . . 25 Table 2: Project Timetable . . . . . . . . . . . . . . . . . . . . . 26 Table 3: Loan Disbursesents A. Cumulative Estimated and Actual Disbursements . . . . . . . 27 Table 4: Project Implementation . . . . . . . . . . . . . . . . . . . . 28 Table 5: Project Costs and Financing A. Project Costs . . . . . . . . . . . . . . . . . . . . . . . 29 B. Project Financing . . . . . . . . . . . . . . . . . . . . . 30 Table 6: Project Results A. Direct Benefits . . . . . . . . . . . . . . . . . . . . . . 31 B. Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 7: Status of Covenants . . . . . . . . . . . . . . . . . . . . . 31 Table 8: Use of Bank Resources A. Staff Input . . . . . . . . . . . . . . . . . . . . . . . . 32 B. Mlssions . . . . . . . . . . . . . . . . . . . . . . . . . 32 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 TUNISIA HEALTH AND POPULATION PROJECT (LOAN 2005-TUN) PREFACE This is the Project Completion Report (PCR' for the Health and Population Project in Tunisia, for which Loan 2005-TUN in the amount of US$12.5 million was approved on May 28, 1981. The Loan was closed on December 31, 1988, two years behind schedule. The Loan Account was kept open until September 30, 1989, at which time, total disbursements were 8.3 million. The Borrower requested a three month extension of the grace period, which the Bank approved. Parts I and III of the PCR were prepared by the Population and Human Resources Operations Division of the Europe, Middle East & North Africa Regional Office. The Borrower's comments are included as Part II. Preparation of this PCR was started during the Bank's final supervision of the project in October, 1988, and is based, inter alia, on the Staff Appraisal Report; the Loan Agreement; supervision reports; correspondence between the Bank and Borrower; internal Bank memoranda; and interviews with Bank staff.  - iii - PROJECT COMPLETION REPORT TUNISIA HEALTH AND POPULATION PROJECT (LOAN 2005-TUN) EVALUATION SUMMARY A. Proiect Obiectives 1. The purpose of the project was to (i) integrate family planning services with preventive and curative care, nutrition, health education and sanitation, to establish a basic health delivery system in eight underserved governorates; and (ii) support the government's plans to extend basic health services gradually to the entire Tunisian population by 1990. B. mlDIementation Exoerience 2. Despite rapid and promising initiation of major components, significant factors impeded project implementation including: (a) Institutional rivalry between the NOPH and ONFP, which prevented the planned integraz.ion of basic health services with family planning; (b) Ministerial turnover at MOPH in 1984, accompanied by criticism and reassessment of project goals and BHS policy, caused profound delays in implementation and a one-year cessation of supervision; (c) A combination of project complexity, scale, and inadequate preparation, affected achievement of the MIS, health education, and studies and applied research components; (d) Borrower reluctance to use technical assistance funds, affected training programs, civil works supervision, and use of consultants; (e) Overestimated Borrower capability, as well as cumbersome bidding and evaluation procedures, delayed procurement; and (f) Chronic tardiness in gowernorates' submission of documentation supporting expenditures, caused slow pace of disbursements. C. Results 3. The project was a qualified success, achieving several of its objectives, including: (i) strengthened BHS capability and orientation of MOPH; (11) establishment, staffing and equipping of major health infrastructure in 8 governorates; and (iii) improved health training system. 4. Other objectives may be achieved longer-term, if the MOPH maintains its commitment to the BHS program.  - iv - D. Sustainability 5. In view of progress in laying the groundwork for a national BHS system, sustainability is especially vital. The major issues are: (a) Adequate recurrent funding for BHS; (b) Maintenance of structures and equipment; (c) Renewed efforts to integrate family planning in BHS; (d) Training and motivation of health service personnel; (e) Establishing of monitoring and evaluation and a focussed research program; and (f) Further effort to build institutional capacity and coordination. E. Findinas and Lessons Learned 6. The project experience provides the following lessons: (a) Preparation should have included a thorough analysis of the existing health system, the government's goals, and plans for achieving them; (b) Institutional antagonism over integration might have been avoided by better collaborative arrangements, and a designed integration process with timetable; (c) Projects seeking major change need careful lobb-ing for their concept and objectives; (d) A series of simpler, phased projects is preferable to projects of massive scope and scale; (e) Project supervision is a mutual obligation whose deliberate interruption should not go unchallenged; (f) Better supervision might have rescued the studies, applied research and health education components; and (g) Undue reliance was placed on technical assistance to mitigate project risks, in a country known for its resistance to borrowing for this purpose.  TUNISIA HEMITN AND POPULATION PROJICT (LOAN 2005-TUN) PROJECT COMPLETION REPORT PART Is PROJECT REVIEW FROH BANK'S PERSPECTIM A. Proiect Ildentit Project Name Health and Population Project Loan No. 2005-TUN RVP Unit ENENA. Department 2, Population and Human Resources Division Country Tunisia Sector Population and Human Resources Subsector Health B hsksrBa d 2.01. The reduction of social inequalities has been a goal of the Tunisian Government since independence. Up to the mid 1970s, the Government's development efforts in the health sector emphasized expansion of physical infrastructure, and of hospital-based and curative services, principally in urban areas. Institutional deficiencies and slow progress towards integration and decentralization had perpetuated Inappropriate and costly patterns of health, family planning and nutrition services. This strategy had (a) not satisfied the basic health needs of a majority of the people, including 50X of the rural poor; and (b) neglected the organization, management and maintenance requirements of the rapidly expanding physical infrastructure. 2.02. Thus, inadequate health service coverage and nutrition outreach, poor sanitation and limited access to safe water were perpetuating high infant and child mortality, persistent high fertility and malnutrition. These, in turn, contributed to impaired learning and productive capacity, the latter one of the major impediments to economic development affecting particularly the agricultural sector. 2.03. While family planning (FP) and fertility reduction programs, since their inception in 1964, had made remarkable progress, due to well over a decade of successful promotion which had garnered widespread popular support, many problems remained. These included logistical and financial constraints on extending rural coverage, shortages of specialized personnel, and inadequate supervision and monitoring of field activities. The GOT had established demographic objectives designed to keep population growth in line with economic development and thus it was necessary to expand FP services, which in any case, tended to lag demad. Experience had shown that to increase the use of existing * services and generate further demand for FP, it had to be offered in conjunction vith maternal and child care. 2.04. Government awareness of these deficiencies resulted in a radical shift of emphasis in the mid 1970s, reflected in the Fifth Development Plan (1977-81) which stressed, for the first time, basic health services (3BH) and preventive nedleine, delivered through an integrated, decentralized and more cost-effective system. The Bank's contribution to establishing macroeconomic linkages betweom health, family planning and e*one c dewelopmnt was colal  in implementing the Government's new BHS strategy and, therefore, the project came to represent the definition of that strategy. C. Project Oblectives and DescriDtion 3.01. Proiect Obiectives : The overall purpose of the project was to (a) integrate family planning services with preventive and curative care, nutrition, health education, and sanitation, to establish a basic health delivery system in eight underserved governorates; and (b) support the Government's plans to extend basic health services gradually to the entire Tunisian population by 1990. Specific objectives of the project- were to reduce infant mortality, morbidity from common diseases, and fertility, and ensure more eq.litable distribution of, and access to basic health services. These objectives were to be achieved over a five-year period, once the project had become fully operational. Targeted beneficiaries would include 86,000 infants, 280,000 children from 1 to 5, and 300,000 married women of reproductive age, and coverage was to be extended from 50% to 90% of the project area population, which totalled 2.3 million at appraisal. 3.02. Proiect DescriRtion The project comprised the following components: (a) strengthen the management capability of the Ministry of Public Health (MOPH) through the provision of supporting staff and services; (b) improve and expand the basic health care delivery system and infrastructure in eight governorates through: (i) the construction and/or remodelling, equipping and furnishing of about 140 health posts, 325 dispensaries, 90 staff houses, 2 regional health education centers, 6 paramedical schools, and 8 vehicle maintenance workshops; and (ii) provision of additional equipment for 21 district hospitals, and appropriate transportation; (c) improve and expand the scope, content and effectiveness of national edaucation and communication programs in health, population and nutrition; (d) improve the training system and its infrastructure, and train, upgrade and redeploy health personnel in the project area; and (e) provide technical assistance in support of all components. D. Prolect Desitn and Organization 4.01. ConceRtual Basis and Desien : Despite an average 16% per year of GDP being spent on social programs from 1970-1978, of which public health took the second largest share, the health sector at the time of project preparation was still dominated by patterns of care appropriate to industrialized countries, supported by an entrenched medical lobby, with infrastructure concentrated in urban areas and the emphasis still, despite official pronouncements, on hospitals and sophisticated, curative care. However, the existence of a group of young, highly motivated, public health-oriented physicians convinced the Bank that  - 3 - Tunisia had the human as well as technological and financial resources to make ambitious changes to the system. 4.02. Project design sought to accommodate the lessons derived from five previous schemes (Bank and bilateral aid), including the USAID/WHO-supported Medjez-el-Bab pilot primary health care project, and the IDA Population I Project (Cr. 238-TUN), implemented by the National Office of Family Planning (ONFP) and the MOPH. 4.03. The Bank's mandate was sweeping and thus the scope and scale of the project reflected its ambitiois objectiveLs'. A sophisticated, comprehensive approach was adopted which relied heavily upon political and economic continuity and a well-informed, broad-based constituency which understood and supported project goals. The record indicates, however, that the integration concept itself eluded understandinig or consensus within the Government, did not permeate the he. -h hierarchy even within MOPH, and that its structural, administrative, financial and political implications evoked insecurity and resistance. Much depended upon the Minister and his enthusiastic team being able to integrate services using the resources of the project, without clear evidence that other key players in the system including the ONFP, the medical fraternity, and political groups at the certral and regional levels, were on board. 4.04. Proiect Pregaration : Preparation was initiated in 1977 following intensive efforts by the Bank's Population Division to strengthen its pipeline in the health sector and persuade a reluctant Tunisian Government to continue to include social sector projects in its borrowing agenda. 4.05. Project preparation was thorough and eve.ry effort was made to accommodate the lessons of pilot projects, and initiate measures to correct institutional deficiencies well in advance of project effectiveness. Much was achieved to establish training programs. effect the necessary administrative reorganization and decentralization of MOPH, and modernize its management and budgeting systems. Nevertheless, a number of issues complicated and delayed preparation including: (a) The project was seen, initially, to focus on family planning and maternal and child health, and thus its preparation was entrusted to the ONFP. However, inexperience with project preparation and lack of the requisite technical expertise, combined with reluctance to collaborate with the MOPH, meant virtually nothing occurred in the first year. (b) The complexity, sophistication and scope of the project increased greatly from 1978 when the MOPH, Ministry of Planning and Bank agreed The ambitious objectives are better understood in light of the Government's own enthusiasm for comprehensive changes and the fact that this was one of the earliest Bank health projects. The epidemiological objectives were sought by Management and final figures represented a compromise with what Project staff thought achieavable under optimal circumstances.  - 4 - that it was to become the model for the HOPH's new system and thus had to address a broad range of activities essential to a fully integrated approach, if it was to succeed. This, in turn, placed heavy demands ott the MOPH and ONFP not only to design the detailed elements of a new health system, but to do it within the Bank's preparation schedule. The record reflects Tunislan appeals for assistance beyond the Bank's usual advisory role, as well as serious GOT concern over the funding requirements for complex preparation needs. (c) Modification of the project outline stemming from the shift in emphasis from family planning to health integration signalled profound changes in the structure, role and function of the ONFP, and its relationship to the MOPH, but these issues were not addressed by the Government. Early proposals tended, not surprisingly, to stress civil works construction and skirted the definition of project organization, administration and financing. The Bank actively sought detailed proposals of the HOPH's integration and decentralization processes, and a timetable for bringing about full service integration, but there is no evidence these were ever provided. id) Repeated Cabinet-level changes destabilized the preparation process by causing discontinuity of implementation policies and disorienciiion of resource use and planning. (e) Preparation lacked formal coordination until the late stages, when the lOPH set up a task force comprising working and consultative groups2, wnich achinved major progress in important areas. However, task force members were unable to coordinate their efforts and tended to work in isolation, which did not bode well for the planning or implementation of an integrated system. 4.06. Proiect Organization : Project success rested on the introduction of basic institutional reforms in the sector and bot.h Bank and Borrower put great effort into setting up organizational and administrative arrangements that would ensure the speedy introduction of the integrated basic health services policy and effective centrol and coordination of project implementation. The SAR sets out clearly the responsibilities of the MOPH and other involved agencies. A number of important steps were taken, including: (a) The MOPH was reorganized in 1980, and ministerial decrees delegated authority to 20 medical regions corresponding to the 20 governorates, each headed by a Regional Director of Health with wide executive and administrative powers. 2 Working groups headed by HOPH Planning Director, and Consultative groups made up of MOPH divisions and other Government agencies involved in rural social services development, including Ministry of Plannir, Ministry of Social Affairs (MAS), ONPP, etc.  -5- (b) A new Directorate of Basic Health Services was established within MOPH to strengthen public health care delivery, and importantly, to supervise the activities of the ONFP and the National Institute of Nutrition and Food Technology (INNTA)3, which would retain responsibility for policy formation, research and training but no longer be in charge of service delivery, now to be provided by the DBHS through its regional agents4. (c) A Project Coordination Unit, responsible for project administration and implementation, was established in 1981. (d) A Basic Health Advisory Committee chaired by the MOPH and including heads of the ONFP, INNTA and the National Institute of Child Health (TNE) was formed to study and advise the Government on policies and procedures for to effect the integration of health, FP and nutrition services. 4.07. Effects on Implementation : The project called for collaboration and coordination between a number of powerful national agencies whose willingness to integrate their activities was declared, but not guaranteed. The Bank's expectation, for example, that the ONFP and INNTA "will divest themselves of their field activities"5, and "ensure that their field staffs and activities in the project area are integrated with those of the MOPH" , was unrealistic, given the high degree of autctomy, visibility and influence to which they had become accustomed. 3 A semi-autonomous organization under MOPH, created in 1969. With broad-based internal assistance, main activities were food research, nutritional assessment and regional food supply analysis, aimed at setting agricultural production targets. Like ONFP, a vertical program with limited scope in rural areas. Integrated BHS was to include INNTA's applied nutrition program, to be delivered by MOPH personnel, and for which nutrition training programs were already in place. 4 ONFP was encouraged in the 1970s by AID and others to develop its own FP service delivery system (principally due to lack of MOPH capacity, and dilution of service) and was given generous funding to do so. The rationale was to improve the quantity and quality of services. The resulting system, while successful, was somewhat duplicative, high cost, and still had insufficient coverage in rural areas. 5 SSAR, para. 2.09. 6 SAR, para. 5.03.  4.0 This is not to say that the Bank was unaware of the implications of project requirements. Early on, the new approach was foreseen having major ramifications for the ONFP in particular and its relationship to the MOPH. The project was expected to add momentum to that process. The Bank realized that sustained GOT effort would be required to secure their wholehearted cooperation in the integrated delivery of services which were being provided separately. 4.08. However, the leverage that would have been provided by a designed, phased action plan for integration based on a thorough analysis of the existing institutional framework was absent, and the ONFP felt no incentive to take the initiative given that it believed, genuinely, that its work and existence were at stake. Therefore, relations between the MOPH and ONFP deteriorated progressively in the first 18 months of implementation, with adverse operational effects. 4.9. The sustained technical and logistical support needed by the DBHS from the ONFP to reinforce the former's ability to provide family planning services within the basic health services framework did not materialize. Bank supervision staff sought without success to stimulate a more systematic and dynamic collaboration between the two agencies on training, data collection and analysis, as well as joint programming of field activities. At the core of the matter were (a) perceived differences in operational objectives based on their respective public health and demographic mandates; and (b) a complex set of institutional, political and personality considerations, the latter precluding discussion of the former. The Bank and donor organizations became embroiled and despite best intentions managed to antagonize both parties through their respective perceptions of the problem. 4.10. Population aspects of the project increasingly lost focus as it seemed the goal of integration would not be met and resolution through the project ceased to be pushed. Donor agencies, in fact, urged the Bank to leave the ONFP alone in order for the organizational and managerial implications of integration to be studied. The ONFP was subsequently absorbed by the newly created Ministry of the Family in 1986, then reabsorbed by MOPH in 1987, with much the same original form, function, influence and tensions. 4.11. The record reveals little about the effectiveness of the PCU or Health Advisory Committee. The former was intended to report directly to the Chef de Cabinet of the MOPH, who was nominated Project Coordinator. In the early years of implementation, the Project Coordinator held, simultaneously, the positions of Director of Basic Health Services and Chef de Cabinet, which proved useful for implementation, especially for strengthening public health structures within the MOPH. However, this usefulness did not extend to the resolution of the dispute with the ONFP, and relations with the governorates were uneasy because of an element of central authoritarianism and the inconsistency of some of the directives issued by the DBHS with existing MOPH administrative directives. 4.12. The PCU was also unable to expedite or effectively coordinate procurement which became the single greatest practical obstacle to project implementation, a key factor in -the diminishing effectiveness of Bank supervision, and largely responsible for the two one-year extensions of the  closing date. Implementation benefitted in the last three years from the continuous services of a capable, steady coordinator who tried to keep things moving despite lack of staff or real authority. The Project Coordinator's summary report of the project mentions inherent management problems at the MOPH impeding smooth progress, as well as a tendency for the PCU to concentrate its coordination at the internal, departmental level and chiefly on financial matters pertaining to the project, to the detriment of a more "intersectoral" approach (perhaps alluding to a greater role in coordinating efforts with the ONFP). 4.13. Little can be said of the Health Advisory Committee, charged with ensuring prompt integration of health, FP, and nutrition services. The ongoing institutional controversy, the fading of the project's FP connection, and the inability of the MOPH until the last months of the project to implement the MIS component (see para 5.08) , resulting in a serious lack of data on which to judge the extent of regional health service outreach, integration or effectiveness, suggests that the Health Advisory Committee was not the catalyst for change envisaged. 4.14. An Assessment : The Bank was challenged with designing a new system through a single project and was undoubtedly aware of the risks. But this awareness did not translate into measures to reduce the potential for institutional controversy. For example: (a) Undue faith was placed in the ability of the Minister and his departmental directors and advisors to effect needed changes, particularly in budgetary allocations. The Minister's private assurances to this eifect were not followed by actual changes in the budget. (b) The Bank's understanding that there was widespread popular demand for the proposed system caused potential institutional arnd political obstacles to be downplayed. Thorough analysis of the relationship between project components and the existing health system and the obstacles to integration of health and FP services might have laid the groundwork for a better working relationship between the MOPH and ONFP. As it was, integration appeared to be imposed for political reasons and aroused the ONFP's implacable opposition as a result. (c) Whilst the extension of the successful pilot scheme to the national level would seem logical, the institutional and organizational environment of a national program was quite different. Medjez-el- Bab's success derived fror its manageable size, the wholehearted commitment of project staff working at the micro level in a community where communication was simpler, goals more modest, and political and institutional stresses insignificant compared to those which were present at the national level.  -8- E. Prolect Implementation 5.01. Implementation commenced well in advance of effectiveness, with promising progress in the first years following rapid initiation of civil works, procurement, plans for and development of the MIS, and execution of the fellowship and training programs. However, progress from 1984 was impeded by a number of significant factors including the following: 5.02. Institutional Im'.)ediments : The Minister of Health was replaced twice in three months from October 1983 to January 1984, with attendant turnover in the Director of Basic Health Services, Project Coordinator, and dissolution of the original HOPH team. The new Minister expressed serious reservations about the project7 and deferred project-related commitments pending reassessment of the overall direction of the BHS policy and project objectives. This position was encouraged by the new health team which, despite limited public health experience, was critical of project performance and achievement under the nascent BHS policy. 5.03. At the same time, the efforts of the new Director of BHS to involve his team in furthering the BHS strategy were impeded by their lack of familiarity with the history and objectives of the BHS program. Paralysis set in as a result of conflicting pressures from the Ministry of Planning to hasten project disbursements and, from traditional sources (political and medical communities) to build more hospitals, despite the worsening financial position of the Ministry, and austerity measures affecting BHS outreach programs. 5.04. Bank supervision staff noted in 1984 that technical discussions were soured by personal, conceptual, and ideological issues, and that the MOPH clearly preferred to defer extension of the BHS program than delay hospital construction, despite the lower capital and recurrent costs of the former (and implicit requirement of the project that hospital construction be curtailed). 5.05. A 1984 Bank Public Expenditure Review stated that, despite the project, health care financing was still poorly structured with expenditures skewed towards tertiary care and considerable scope remaining for improved efficiency. The GOT appeared to have disregarded the Bank's policy recommendations under the ongoing project, reflected in negligible improvement in regional resource allocations, management performance or the health referral system. The provisions of the Sixth Development Plan (1982-86) had, in fact, already demonstrated the absence of political will on integrated basic health care. 5.06. From early 1984 until April 1985, the Minister of Health communicated only rarely with the Bank and was reluctant to receive supervision missions (in technical violation of the Loan Agreement), apparently due to the lack of a Project Coordinator and concerns about project design. Service delivery suffered (especially health education and MIS development), audits were two years overdue, 7 Criticism focussed inter alia, on perceived rapid expansion of the physical network, without commensurate human resources availability or training.  -9- the construction program faltered, procurement encountered inordinate delays and price escalation due to lengthy MOPH review processes, and the research and studies programs remained stalled in their infancy. 5.07. In addition, the integration of family planning into the BHS system, already affected by the unresolved institutional dispute, sut5ered further through the Government's failure to specify arrangements for providing FP services, after transferring the ONFP to the new Ministry of the Family, an agency with only minimal budget or agenda. Yet another casualty of this period was the proposed Second Health and Population Project, already at the post appraisal stage, which was blocked by the-Minister due to concerns about the first project, the costs and sustainability of the new BHS system and escalating appraisal costs at a time of austerity. 5.08. Component ExRerience : Following the appointment in late 1985 of a new Project Coordinator, implementation improved generally, but remained problematic in the following respects: (a) MIS: 5.09. This component was strikingly difficult to implement, and achieved virtually nothing until the last months of the project period. It represented an ambitious and perhaps, idealized vision of a sophisticated, responsive system able to provide systematic and timely data, and "promote the speedy identification and correction of problems"8. The original MIS concept was prepared at a time of rapid technological change, computers were seen as the necessary catalysts to modernization and efficiency, and the MOPH leadership wanted the best. The CNI proposal for the implementation of the MIS was far- reaching and overly complex and thus set aside by the new Minister during the 1984-85 hiatus described earlier. Other problems including: (a) inadequate understanding of the role and functions of an MIS; (b) technical issues such as equipment compatibility; (c) relative cost effectiveness of alternative systems; (d) the CNI's responsibilities with respect to the system; and (e) procurement delays, foiled introduction of the envisaged working system by project's end. 5.10. Nevertheless, in the last months of the project, a total of 30 computers were acquired, of which about half were being used within MOPH, most notably to process data collected from an inventory of health services. Others were in use for (i) patient registration at a major hospital; (ii) on a test basis in the DBHS in Jendouba Governorate; (iii) within the planning and epidemiology units of MOPH; and (iv) at the Center for Pedagogical Research and Training (CRFP). 5.11. The lack of a functioning system meant that baseline project indicators were never updated as planned and the project monitoring data base was poor, making determinations of health service outreach and attainment of specific project goals difficult to measure. 8 SAR, para. 5.15.  - 10 - (b) Studies and Applied Research 5.12. This component achieved minimal success. The SAR (paras. 3.13 and 7.03) called for the design of a research program, in consultation with the Bank, before December 1981. The Loan Agreement, however, makes no reference to this undertaking and it was, apparently, not carried out. The DBHS, following weak response to its solicitation of research proposals, did attempt to develop a program but little was accomplished. The limited success of the research component may be attributed to (i) inadequate perception of the critical link between research and planning; (ii) the lack of a specific research agenda set down as part of project preparation; (iii) the existence of other indigenous research agencies with ongoing programs which perhaps reduced pressure on the Borrower to execute this component. 5.13. Several studies were executed successfully, on infant mortality, vaccination coverage and hepatitis. A study on health financing became a matter of urgency with the fiscal crisis of 1984, but was deferred because of the Ministerial turnover. Interest in financing issues was revived in the fall of 1988 after the appointment of a new minister, and a review of health financing is now being carried out by the MOPH and the Bank as sector work. The "Carte Sanitaire" inventory showing the distribution of sector resources, took much time to execute, but is now beginning to produce a body of data for analysis. (c) Construction Program 5.14. The project called for the building of about 225 health structures. Their successful completion with delays of about a year, and to generally commendable standards of architecture and construction, was a major achievement, especially given the constraints which included (a) the heavy supervision burden created by the simultaneous start-up of the program in all eight governorates; (b) the PCU's inability to assign sufficient staff to that task; and (c) the inadequacy of travel allowances for supervisors. The project had allocated funds for this purpose under technical assistance, but the issue was a question of Tunisian law, and the comparative benefits assigned other Ministries for similar purposes. The Bank was unable to convince GOT to release the funds. (d) Technical Assistance 5.15. The funds allocated for technical assistance were largely unused throughout the project. While the Borrower's draft report cites overestimated allocation as the main reason, in fact. Tunisia, like many countries, has been reluctant to borrow for this purpose, preferring to obtain such assistance free of charge from WHO, UNICEF, USAID, etc. The project had little effect on this attitude and the Borrower paid for consultants, overseas training, and travelling allowances for supervisors (paras 5.13, 5.15).  - 11 - (e) Training 5.16. Project funds for training were chiefly to bolster training infrastructure in the form of remodelling and equipping paramedical schools, vehicles, curriculum development, consultant services to prepare programs and seminars, and travel expenses for MOPH personnel engaged in training, project management and evaluation. The latter suffered from the same Borrower reluctance to use project funds for travelling expenses as the technical assistance component. 5.17. However, while the project did-not directly fund hands-on training, it did stimulate much activity especially in the early years. Collaboration between the CRFP, the DBHS, and regional health directors was especially fruitful in retraining full-time paraiaedical school teachers, arranging seminars, preparing teaching materials (in addition to USAID-developed materials used under the project), and training instructors. Numbers of fellowships abroad for health educators and planners exceeded expectations. (f) Provision of Basic Health Services 5.18. By mid 1985, the MOPH had taken most of the measures necessary to decentralize the organization of BHS, about 50% of project-financed dispensaries were operating, and the training program was implemented. However, while the development of BHS Was well-conceived and supported by heneficiaries, it encountered the following difficulties: - Health education was of uneven quality and most health posts were without basic educational materials; - Supervision and monitoring of health care quality was generally insufficient; - Many centers were underutilized and overstaffed, primarily with nurses who had no FP training, while midwives were present as little as once a week in many facilities; - As a consequence, by late 1987, only 60% of project facilities were offering FP services, despite the integration policy, and responsibility for FP education and services was still widely viewed as the exclusive domain of the midwife and specialized physician; Bureaucratic inefficiency caused long delays in the payment of staff salaries with attendant loss of morale; Despite years of MOPH effort, and changes in medical curricula, the shortage of physicians willing to serve in rural areas remained acute; The equipping of health posts was very slow due to budgetary restrictions and procurement problems; and  - 12 - General deterioration of the health sector because of a lack of attention to maintenance affected the overall quantity and quality of health service delivery. (g) Procurement 5.19. Procurement became, progressively, the single greatest practlcal impediment to project implementation, the principal reason for two extensions of the closing date, and an inordinate drain on supervision time. 5.20. The Bank overestimated the procurement capacity of the MOPH and did not work carefully enough on establishing acceptable bidding and evaluation procedures or documentation at the outset. The change of Minister in 1984 further protracted procurement schedules when a review of MOPH procurement and standardization policies resulted in dates for validity of offers having to be extended, price escalation, and lengthy review processes within MOPH, which delayed contract awards on vital computer and X-Ray equipment. (h) Disbursements 5.21. Disbursements were exceedingly slow from the beginning and the schedule was adjusted repeatedly. The reasons for this were: - Regional authorities were receiving funds from the Center to pay contractors and others through the regular budget and thus had no incentive to submit documentation to the Center in support of expenditures for civil works; - HOPH was reluctant to use project funds earmarked for technical assistance (see paras 5.13 - 5.15); - Chronic delays in awarding contracts for goods; and - Dramatic appreciation of the U.S. dollar. 5.22. Disbursements as of the December 31, 1988 Closing Date were US$5.60 million. The Loan Account was held open until June 30, 1989 to permit further drawdown of the Loan at which time disbursements were US$8.3 million. The Borrower requested a 3-month extension of the grace period, which the Bank approved. Most of the factors causing disbursement delay were beyond the Bank's control. The slow submission of project documentation has been fairly typical of Bank-financed projects in Tunisia. 5.23. An Assessment of Imglementation : The SAR identified major project risks as being (i) scale and design roo difficult for effective MOPH coordination and implementation; (ii) resistance from the medical establishment to the shift of emphasis to rural areas and preventive care; and (iii) the traditional difficulty of recruiting Tunisian physicians to serve in rural areas. This assessment proved correct, despite actions taken or suggested to countervail their occurrence, for the following reasons:  - 13 - (a) The reorganized MOPH still fell far short of the managerial and organizational efficiency required to implement the new system; (b) The project did not, in fact, pay adequate attention to the existing health system (SAR, 1:29) which would have provided a better understanding of the processes necessary to transform that system in a less controversial manner; (c) The Medjez-el-Bab experience proved the feasibility of project activities at the pilot level, but its application to a national system represented a different magnitude of activity with many added complications (some of which could have been foreseen). (d) The ONFP has successfully resisted integration, importantly because the government effort required to ensure its cooperation with the MOPH (SAR 6.04), presumed the Government's own wholehearted commitment to the concept; (e) While decentralization of MOPH administration was effected in large measure, continued changes at the ministerial level and perpetuation of a bipartite health system in which hospital construction remained an unassailable element meant the medical establishment could continue to resist change. Again, reorganization of the MOPH meant little in this situation. It faced with fatalism, the inevitability of financial decline from trying to run two systems; and, (f) Motivating physicians to serve in rural areas requires a complex blend of incentives. It was evident at project's end, that despite all the measures taken to change their orientation, almost any job was preferable to a public health post in a rural area. The absence of salary incentives, shortage of adequate housing, lack of other amenities, and cost of traveling to see family in other parts of the country, plus the social problems for single female health professionals all continue to act as strong disincentives to rural service. F. Prolect Results 6.01. Achievement of Oblectives : The project achieved several of its objectives and others may be achieved in the longer term if the MOPH maintains its commitment to the BHS program. 6.02. The project strengthened the BHS capability and orientation of the MOPH through internal reorganization including the establishment of the DBHS, a comparatively vital body whose functions were, in turn, decentralized in an effective manner to the Governorates. The MOPH was, however, unable to achieve the envisaged integration of BHS and over time the ONFP settled back into its  - 14 - traditional, vertical posture on FP9. The seeds of this situation may be found in project preparation, assumptions about institutional behavior and commitment, and in the unique status of the ONFP. 6.03. The project established, staffed and equipped major health infrastructure in 8 governorates, a commendable and important achievement given existing constraints. The quality and distribution of care, however, still needs major attention. National HPN education and communication programs remain embryonic. 6.04. An improved health training system was implemented but needs further work in (i) gaining acceptance for FP training in nursing and medical curricula; (ii) ensuring that all midwives and nurses have such training, since many still do not; and, (iii) training a new generation of physicians who accept the philosophical as well as practical implications of rural public health service. 6.05. Population objectives of the project were more implied than actual, and limited support was offered the ONFP in the form of equipment. By the end of 1988, the ONFP appeared to a great extent, to have defined the parameters of integration, with MOPH concurrence. A 1988 USAID mid-term evaluation of one of its own FP projects states, "joint planning of family planning activities is not yet a reality between ONPF, MOPH and Ministry of Social Affairs (HAS)", (although it is reported that coordination is now better at the regional level). 6.06. Proiect ImRact : Only limited judgments can be made about project impact at this stage. The project challenged Government to adopt and sustain a health care policy based on equity and pragmatic, long-term national considerations. An extensive infrastructure now exists, which has raised public awareness of certain obligations of Government to deliver services, and much has already been achieved to train the requisite staff. The project funded a large quantity of medical equipment in support of service delivery, and, in the last stages of the project, some 30 computers. The latter was a promising breakthrough whose next stage, information systems development, merits encouragement. 6.07. Little data is yet available on specific project objectives relating inter alia, to reductions in fertil_ty and morbidity from common diseases. The Borrower reports a 50% de:line in infant mortality and a doubling of the rate of medical consultations from 15 to 30% across the project area. Project staff report a current T"s (total fertility rate) of 4.3, and a significant increase in contraceptive prevalence, to 51%. With the exception of medical consultations, it is unlikely that these figures can be attributed solely to project intervention, but they are encouraging. 9 The ONFP claims it could not release its service delivery function to MOPH until it was sure of MOPH capacity. Donor agencies supported this position. However, the ONFP began to intrude on the MOPH mandate, taking on more medical functions and using specialized physicians for even simple services, chiefly because it needed the support of the medical community to justify the continuation of a vertical planning program.  - 15 - G. Project Suatainabilitt 7.01. The project made sufficient progress in laying the groundwork for a national BHS system, that the issue of sustainability becomes especially vital. The post-Bourguiba period has been characterized by efforts to get health sector planning back on course, perhaps through less ambitious but more soundly-based initiatives that look, inter alia, at financing, maintenance, training and health education. 7.02. The key issues of sustainability are the following: - Adequate recurrent funding for health and FP services, which presumes real commitment to the concept of BHS and the will to contain the cost of hospital services and the cost-efficiency of retaining parallel delivery systems for MCH and FP; - A systematic and well-funded maintenance program for structures and equipment, which will, in turn, require specialized training programs; - Training and motivation of health service personnel including quality control supervisors, and renewed efforts to increase the capacity of BHS to provide MCH/FP; - New initiatives to establish systematic monitoring and evaluation, and a focussed research program with a strong planning orientation; - Concerted effort to build institutional capacity and coordination, since health and population invariably involve multiple agencies. H. Bank Performance 8.01. The Bank put great effort and vision (and with hindsight, excessive optimism) into designing a project which would establish a new system reflecting the Government's policy shift to national basic health care, which the Bank supported wholeheartedly and believed was feasible. Components were designed to cover most major requirements of such a system including the reorganization of the principal Ministry well in advance of project effectiveness. As anticipated, implementation was not smooth, due to a combination of events of varying predictability. However, regular supervision, except for the 1984-85 hiatus previously described (para 5.06), sought to maintain momentum and iron out problems, even though at times the internal logic of the Tunisian bureaucracy proved impervious to creative solutions. A major failing of the preparation process was not to understand the interests at stake in the ONFP/MOPH "integration" discussions, and then to assume away the potential implementation difficulties. 8.02. Conclusions: A number of conclusions can be reached from a review of the project experience, and these might usefully guide the preparation of future projects in the sector:  - 16 - Despite extensive preparatory analysis of the public health problems, the political and organizational inertia of the existing health system did not receive sufficient attention. A more comprehensive analysis should have included definition of the government's long term policy goals and the process envisaged for achieving them; Integration of health and FP services required greater emphasis on rational, mutually agreed collaborative arrangements, a designed process with timetable to avoid the antagonism that arose from the perception that integration was being imposed, attention to differing priorities and the authority to take remedial measures; - Project preparation should include, as a matter of course, careful lobbying for its concept and objectives, especially where major changes are contemplated which intrude upon vested interests, responsibilities and prerogatives. Care must be taken to ensure (as far as possible) that all relevant parties are on board; - Projects of massive scope and scale seeking to attain complex objectives simultaneously, should be avoided in preference to a series of simpler, phased'efforts which address logical steps in a longer-term program. This is especially true where institutional capacity is weak and vulnerable to political pressures; - Project supervision is a mutual obligation, and its deliberate interruption by the Borrower should not go unchallenged; - Acknowledging the difficulty of reversing the direction of components if preparation was weak, nevertheless, more intense supervision might have rescued the studies, applied research and health education components, which were important for project success and sustainability. The fate of these components further emphasizes the need for simpler projects that inter alia permit more focussed supervision; - Undue faith was placed in the ability of the technical assistance component to mitigate acknowledged project risks, in a country well known for its resistance to the use of borrowed funds for this purpose. I. Borrower Performance 9.01. The principal factors affecting Borrower performance throughout the project cycle were the MOPH's fluctuating level of influence in the system and managerial shortcomings, unsteady commitment to the central project concept, political pressures, and deteriorating economic conditions which adversely affected social spending. 9.02. Preparation was prolonged by the escalating demands of project design, the Borrower's inexperience, and the challenge of defining the more complex aspects of BUS organization, management and finance. While the management capabilities of the MOPH were undoubtedly enhanced by the project,  - 17 - it remains a bureaucracy prone to political pressure, leadership turnover and consequent lack of clear direction. 9.03. The Project Coordination Unit lacked adequate staff or power and was entirely out of commission for almost two years, with serious effects on project implementation and management. However, within its limitations and given the scope of the project, the PCU performed well, especially after 1985. The extensive and successful construction program deserves special note. The Borrower's system for transmitting funds to the Governorates for timely payment of contractors worked well, (though the governorates submission of documentation in support of expenditures was chronically tardy), and a major effort was made to maintain the momentum of a program covering 8 governorates simultaneously, despite lack of supervision staff and funding. 9.04. The Borrower resisted hiring the long-term consultants required by covenant, especially on the MIS, because, as previously stated, it did not want to use project technical assistance funds allocated for this purpose. Thus it argued successfully for alternative, in-house and short-term arrangements (CNI) that cost less, but may have had adverse effects on the quality and timely execution of certain components. 9.05. Conclusions : The Borrower might usefully derive the following lessons from the project experience: - Clear health policy goals and a consensus on the means to their achievement, are prerequisites for good project design; - The Borrower should be ready, in the spirit of the Loan Agreement and its own development priorities, to intervene more directly in inter-agency disputes that threaten project implementation; - The 3orrower shuuld understand its obligation to permit regular Bank supervision, and to facilitate the activities of organizations established specifically, to promote project management and implementation; - Greater appreciation is needed of the critical value to policy planning, of information systems for data collection and analysis, and a focussed research program. J. Proiect Relationshios 10.01. The Bank's relationship with the principal project agencies and their relationship with each other, were not always smooth and had prejudicial effects on project implementation. Relations with the MOPH deteriorated rapidly after January, 1984 due to political, philosophical and financial differences of opinion over the project, and Bank supervision missions were postponed repeatedly. This disagreement must be seen against the backdrop of the uncertain economic and fiscal situation in Tunisia at the time, putting constraints on  - 18 - health sector financing and casting doubt on the sustainability of project abjectives. 10.02. Relations with the ONFP were poor from the beginning, partly a leftover from the experience with the First Population Project, but more importantly because, as earlier described, it felt its existence, mission and prerogatives threatened by the project. The Bank could have been more sensitive to ONFP concerns in project preparation, and tried harder to create a more broadly-based dialogue about integration of FP and the new BHS policy. On the other hand, the ONFP's reaction could more accurately and simply be seen as the natural desire of a prominent, well-funded-and connected, autonomous agency to stay that way, largely free of controls or oversight. Its present status and the failure of integration to date, presents the same challenge as in 1981, to be addressed in creative new ways that maintain the high priority of population/FP programs, and reduce the level of mistrust, since "integration" of FP remains the best course of action to improve service reach and efficiency. 10.03. The MOPH relied heavily on ONFP cooperation for the effectiveness of the new DBHS and its regional representatives, in establishing the integratec BHS, but was unable to promote a working dialogue free of personal and political rancor. The relationship normalized to some extent in the later stages but this was after integration had faded from prominence in project implementation, and the ONFP had largely reasserted its independence. K. Consulting Services 11.01. The project called for consultant services for the applied research program, the organization of training and the supervision of civil works. The MOPH decided against employing long-term specialists for the MIS, health planning and management, in favor of in-house efforts supplemented by short-term consultants. As previously described, neither the applied research nor MIS components were fully implemented. Consultants retained to oversee designs and supervise civil works construction performed vell. L. Proiect Documentation and Data 12.01. Legal Agreements : The Loan Agreement was a sound and useful document whose only reported weakness was its procurement provisions, which staff described as inflexible, especially in the distribution of categories of procurement. 12.02. Staff Apgraisal Report : The SAR provided a comprehensive and useful framework for project implementation although it (i) describes a project which was over-reaching in key respects; (ii) tended to put difficult objectives in the best possible light, glossing over the seriousness of acknowledged risks; and (iii) referred repeatedly to family planning as if it were a material element of the project, which it was not, while ignoring the importance of FP to population objectives which go beyond "health". 12.03. The project had specific family planning targets, but these were to be &r. implied resilt of establishing the integrated BHS system. No direct aid was Siven to the ONPP throughout the project until 1987, when some equipment was  - 19 - purchased, and the ongoing FP dialogue between the Bank, ONFP and MOPH was limited, because of the atmosphere of distrust created by the integration issue. 12.04. Project Data Base : No progress was made until the very end in establishing the MIS, thus the record lacks a consistent, evolving data base. As originally designed, the MIS component vas overly ambitious and its implementation problematic. Baseline project indicators were not revised, .-s originally planned. 12.05. The Project Implementation Index File proved of only limited usefulness, chiefly because the accessible data did not reflect the lists of documents, including the Borrower's annual progress reports, presumed to have been forwarded to it. This report recommends more consistent use of the P.I.I.F. and a follow-up system to ensure the receipt and storage of key project papers.  - 21 - PART II: REVIEW FROM BORROWER'S PERSPECTIVE (A) Accuracy of Part III: No comments received from Borrower (B) Comments on Part I: (i) The report mentions the "institutional rivalry" between the Ministry of Health and the ONFP (National Family Planning Office). Since each has a well-defined role in the structure of the government, this term is inappropriate. It would be more accurate to speak of a lack of good coordination between the two. (ii) It is suggested that remarks concerning delays in project preparation caused by the ONFP's lack of experience in project preparation be replaced by a statement that because the MOH had more technical expertise available, project preparation was delegated to that institution. (iii) An observation in the report to the effect that repeated changes at tne cabinet level in the MOH destabilized the project preparation process and created discontinuity in project execution be replaced by a statement to the effect that because of some -onstraints in the MOH, the project's preparation and execution were subjct to some disconitinuity and changes in the allocation of resources. (iv) A statement in the report to the effect that too tmach confidence was placed in the capacity of the MOH and advisors to carry out the necessary reform was countered by a MOH suggestion that the project underestimated the refonms required, in partic.:lar with respect to the allocation of resources, which slowed project ':.iplementation. (v) The PCR describes the MOH reorganizati. in 1980 which delegated some authority to the governorates. Certain detalls of the delegation of authority, to the regional health directors, an' rLot to the basic health services, were clarified by the MOH in their coitmients. This clarification does not alter the conclusions of the PCR. (vi) The PCR comments on the failure of the Government to make more progress in the integration of health and family planning services were considered to be centered too much on the negative attitude of the ONFP and its efforts to maintain its autonomy, while the lack of a clearly defined strategy for integration and the lack of training of MOH personnel in family planning were omitted from the PCR. In fact, the PCR mentions specifically that the failure to develop a strategy or training activities were two of the side effects of the institutional rivalry between the MOH and the ONFP. (vii) The MOH comments conclude with remarks to the effect that in spite of the delays experienced during the course of the project, the integration of health and family planning services is now proceeding -well, and as of 1990, 74% of health services offer some family planning services. There  - 22 - are, however, persistent problems related to the provision of sufficient quantities of medicines, health personnel, equipment, transportation and supervision. (C) Evaluation of Bank Performance during project preparation and implementation, particularly in terms of lessons to be learned for the future. The Bank's role lay primarily in providing technical assistance for project preparation and implementation. The supervision missions, which were conducted regularly, ensured that there was fairly regular monitoring of the execution of the various project components and the recommendations made at the end of each mission were designed to help project officials ensure that the activities planned were being properly carried out and that optimal use was being made of project funds. However, this assistance was rather limited in the case of certain components, in particular studies and research and health information and education. Although efforts were made, Bank assistance failed to result in feasible programs in research and health education or even in the formulation of a strategy in these areas. In future, greater emphasis must be placed, starting with project preparation, on the programming of research, information and education activities, as was done in the case of the infrastructure component. There should have been more dovetailing between the infrastructure, on the one hand, and the health activities (health care, research, training, education), on the other. The Bank's financial assistance should also have been adapted to possibilities for using the funds, in light of current procedures in Tunisia. The technical assistance component, which was to cover travel and personnel supervision costs, among others, was overestimated. (D) Self-evaluation during project preparation and implementation Although the overall objectives of the project were achieved in general, there were still certain areas of project implementation where certain activities could not be completed successfully and several difficulties inherent in the management system hindered the smooth implementation of the project. The setting up of a project coordination unit enabled the Ministry to undertake and ensure fairly satisfactory monitoring of activities. Coordination was, more often than not, however, limited to work at the departmental level and to aspects relating to financial management, when it really should have been focused more on other aspects and included intersectoral activities.  - 23 - Stren2ths (1) Allocating the credits to the gouvernorats made it possible to complete the new construction as planned. Despite some delays, the rate of progress was fairly good, considering the fact that the component involved 225 rural health structures and construction had been contracted out to a large number of local companies. (2) The contribution of the two assistant engineers who aided the Regional Infrastructure Directorates was decisive monitoring of the work sites. (3) Purchase of vehicles, motorcycles and equipment for the health centers had made it possible to upgrade primary health care. (4) Despite budgetary constraints, the Ministry was able to assign the necessary staff to the centers built under the project and efforts were made to improve training programs. Weaknesses (1) Allocating the credits had drawbacks in terms of the disbursement of funds by IBRD, since the regions tended to be late in sending the project unit the expenditure records, which then had to be forwarded to the Bank. (2) Since 225 buildings had been scheduled for simultaneous construction, it was extremely difficult to monitor the sites properly, particularly as the Project Coordination Unit was understaffed. (3) The travel allowance rates and the inability of supervisors and instructors to assume these costs in many cases handicapped certain activities and the monitoring of the works. (4) Procurement was slowed down by the red tape (in addition to currency fluctuations and import licenses which delay government contracts), entailing waits for equipment. (5) Public accounting procedures were not compatible with the management of programs receiving external financing. For each activity the project unit had to obtain prior approval from the World Bank, the go-ahead from the control authorities (expenditure control, procurement commission, etc.) and the project unit was audited each year by Ministry of Finance auditors, as required by the loan agreement. (6) The late availability of allocations and lengthy disbursement procedures meant that the regions did not receive the funds in time to execute certain works in the course of the year. In addition, the cancellation at the end of each year of the amounts made available but not spent seriously hampered the execution of investments planned because the same formalities had to be repeated at the start of the new fiscal year.  - 24 - (7) Although the Ministry of Health succeeded in computerizing personnel management, it had proved impossible to develop the management information system in the proper manner (inventory control and processing of statistical and epidemiological data) because the necessary computer equipment was not acquired. With reference to the disbursements under the construction component, care must be taken in future to devise a more efficient system for this component. It should be possible to make disbursements on the basis of a contract figure plus 15% for inflation as soon as the reimbursable portion has been established; the following system should be adopted: for center X, whose total cost would be D 100,000, the reimbursable portion would be 40% of D 115,000, i.e. D43,000. The reimbursable amount would thus be established and the Bank would disburse 30% as soon as the contract is approved, the remaining 70Z being paid when the center is completed, following certification by a Tunisian consultant. This would thus avoid all the problems involved in obtaining expenditure records, cost breakdowns, etc. The equipment component experienced several delays, particularly at the bid examination stage and with the conclusion of certain contracts. In light of this, steps should be taken in future to ensure better identification of equipment when the work program (plan d'operation) is prepared and a provision included in the loan agreement to allow the use of UNICEF or WHO for the procurement of certain equipment.  - 25 _ PART THR: STATISTICAL IUP4ORAfIC Related N-nk Loom andior Credits Loan/Credit Year of Title Puropose Approval Status Coasnnts Cr. 238-TUN U.S.S4.6 M Credit to 1971 Completed and closed, Positive impact on FP support the Tunisian Decembor 31. 1981 Service delivery. MH and national FP program other important benefits through a population However, institutional and project implemented by program goals not achieved the ONFP and MOPH. due to preoccupation with construction problems and fivefold escalation in total cost. (a) A Second Health and Population Project was identified in 1983 and appraised in 1984. seeking to extend the BHS concept nationwide and resolve institutional problems evident under Loan 2005-TUN. Project was blocked by new Minister in 1984. due to concerra about the achievements and recurrent cost implications of the BBS policy. (b) A third project was identified in 1987 but was aet aside by the Minister of Planning, in favor of health sector work emphasizing services and finance. A dialoguo bat now opened on a new Population Project, once again reviving the issue of tho respective roles and attitudes to 35S on the part of MDPH and ONFP.  - 26 - 2. Prolect Timetable Date Date Date Planned Revised Actual -- Identification 1977 n.a. June 1977 - Preparation Sept. 1977 n.a. March 4, 1978 - Appraisal mission n.a. n.a. June 1979 (pre-appraisal) Oct. 1979 (pre-appraisal) Nov. 1979 (Ist stage appr.) May 1980 (2nd stage appr.) Sept. 1980 (post-appraisal) - Loan Negotiations n.a. n.a. April 27, 1981 - Board Approval FY1979 n.a. May 28, 1981 - Loan Signature n.a. n.a. July 15, 1981 - Loan Effectiveness Oct. 15, 1981 Jan. 29, 1982 March 23, 1982 Apr. 30, 1982 - Loan Closing1/ Dec. 31, 1986 Dec. 31, 1987 Dec. 31, 1988 Dec. 31, 1988 - Loan Completion2! Dec. 31, 1986 n.a. September 30, 1989 t Loan Closing date was extended twoco from original of Docmber 31, 1985. principally to complete procurement of computers for the MIS, and X-Ray equipment. 2 Loan Account hold open to complete disbursements.  - 27 - Cmulative Estimated nd Acturl Dieburante (U S. 8 000) F8 FY8 rm Un Wi" FYU r!n Ff Appraisal Estimate 0.9 3.8 7.9 10.6 12.5 8.5 6.6 Actual - 0.08 1.44 1.97 2.77 3.79 6.U4 6.09 6.6 Actual I of Estimate: 2.1 18.2 18.6 22.0 44.6 69.8 71.6 97.6 Date of Final Disbursement: (RN1t: Not known at time of PCR proparation. Loan Account to remain open until Septeber 30. 1989)2/. Source: Preaident'a Report and Statement of Loen. 1 U.S.$4.0 million of Loan cancelled in March 1987, due to drmtic appreciation of US dollar and other causes. Loan Cloeing date extended twice, fro Dceber 31, 1986 to Dscebor 31. 1988. 2 Figure for total actual disburcsemts prered on June 19, 1989 and includes US8121,000 of unprocessed Borrower claim for reisura_ment. Total disbursemnts at Loan Cloa4n date were uss5.60 mIlliun.  - 28 - 4. Project Imolementation Appraisal Indicators Estimate Actual CONSTRUCTION (units)1/ - health posts 76 (81) 66 - rural dispensaries 82 (80) 81 - urban dispensaries 11 (16) 15 - staff houses 88 (69) 55 - vehicle maintenance workshops 8 6 - health education centres 2 2 VEHICLES (units)2/ - minibus (tra iing) 6 6 - audio-visual vans 6 n.a. - ambulances 19 19 - 4-wheel drive 31 29 - small sedans 53 58 - mopeds 100 550 EOUIPMENT (U.S.$'000)3/ - MIS 250 160 - Training 160 n.a. - I.E.C. 680 n.a. - basic health services 2,662 n.a. - project administration 10 n.a. TRAINING (units) - mid-level managers and statisticians 40 n.a. - full time teachers 45 n.a. - physicians, public health 80 n.a. - paramedicals 1,060 n.a. - fellowships abroad for health planners 6 13 - fellowships abroad for health educators 8 9 1 eRvised by MDPH in December, 1981. with Bank approval following rt-assesament of noeds. Revised figures in brackets. No data available on audio-visual vans; two 7 tonne trucks also purchased. 3 About 30 computers purchased; total cost of equipment Including vehicles was U.S.S5.94 million.  - 29 - 5. Project Costs and Flnaneina A. Project Costs (U.S.$) Loan Revised Loan Categorv Allocation Allocationh/ Actual Costs2' Foreign Exchange Local Total Costs Costs Costs I Civil works - by contract 1,900,000 900,000 - by force account 1.600.000 1.600,000 2.170,0003/ 4,658,000 6.828.000 II Equipment. furniture vehicles & materials 5,700,000 4,380,000 5,780,000 6,325,500 12,105,500 II Computer Services 800,000 800,000 160,000 204,680 364,680 IV Technical Assistance 1,500,000 500,000 390,000 312,000 702,000 V Training4/ 200,000 200,000 n.a. n.a. - VI Increm. Cost of 4/ Internal Travel for project staff 100,000 20,000 n.a. n.a. VII Unallocated 700,000 100,000 n.a. n.a. - TOTAL 12,500,000 8,500,000 8,500,000 11.500,180 20,000,180 1/ U.S.S4.0 million cancelled, March 1987 and the total Loan reduced to U.S.S8.5 million at the request of the Tunisian Government. By February, 1987, project costs mounted to only 65Z of estimated dollar cost du- to exchange rate changes since appraisal. The dollar exchange rate fluctuated from 0.400 DT at appraisal, to 0.840 by February, 1987. The Government estimated and the Bank confirmed, that only US$8.5 million of the Loan would be needed. 2/ Local costs in Tunisian Dinars. converted at 1.026, exchange rate at June 16, 1989. 3/ Includes contract and force account. 4 Included under technical assistance component.  - 30 - B. Project FinancMn& Source Planned 2 Revised1'/ Final22 (USS M) (USS M) (USS M) IBPD 12.5 30.0 8.5 23.0 8.3 41.4 Domestic 28.5 70.0 28.5 77.0 11.' S881 TOTAL: 41.0 lU00 37-0 100.0 19lo 1 US$4.0 million cancelled in March 1987 principally due to dramatic appreciation of US dollar. Based on MOPN data showing total local cost of TD 11.8 million, converted at June 16, 1989 exchange rate of 1.026.  ^ 31 _ 6 PrmoWimot A. Direct Banafita No data yet available from Borrower on results for specific project indicators including fertility. infant mortality, or morbidity froe coon and coamnicablo diseases. Borrower still in process of compiling this data with new computer capability end has notified intention to forward it. B Studies Purpos as Defined at Impact of AMUriAL Status SAUdz_ 1. Infant Mortality n.a. Completed n.a. 2. Vaccination n.a. Completed n.a. 3. Hepatitis na. Completed n.a. 4. Carte Sanitairea Detailed study Data collected end n.a. Health Resource for extension of under nalysis as Inventory integrated BUS at June. 1909 nationwide. The Loan Agreement required the preparation of studies (and applied research) to Ci) identify improved ways and means of meeting basic health needa in rural areas and to determine the cost and impact of health services; and (ii) a detailed study for oxtention of an integrated health delivery systm throughout Tunisia which becme known as the Cartte Snitaire. A study on health services costs and tinancing was sought by the Bank. but never executed. 7. Status of Covaamto Section of Loan DOadline for Agreement omliance Sta 3.02 (a) MOPH to set up and suitably staff na. Condition mt initially. the Project Coordination Unit (PCU) Project Coordinator then left KPB in Jan. 1984 and replacment not ned until 1985. 3.02 (b) PCU to prepare a mid-term evaluation 01/31/S4 Was done ia Nov. 1983 but new Minister of Health requested a new evaluation. Bank agreed to a review. Condition mt. 3.03 (a) HDPH to recruit: Ui) 1 architect/coaultant and 06/30/82 Condition met. 2 construction supervisors (ii) (A) a managment informtion 03/31/82 HOPS decided not to recruit long term systi expert specialists for (A) and (B) as planned (B) a health planner/manager 03/31/82 originally. Decided to propare MIS in-house and aupplemet own staff with short-term consultants. (C) a curriculum developuent expert 03/31/82 Due to progress made after project appraisal. Bank agreed full tim expart not needed and could be replaced by short-term specialized consultants. 3.06 (a) All sites to be acquired for urban 12/31/81 Condition met. facilities to be constructed under the Project. 3.07 (b) Completion of all arraments for 03/31/82 Condition met. computer services to be made available by the National Computer Centre. 4.03 13P1 to establish a Health Advisory 03/31/82 Condition mt. Comittee. 5.01 .DII to appoint the Director of Condition of Loan Condition mt. Basic Health Services. Effectiveness.  - 32 - A. Staf Inputs (Staffweeks) Stage of To ?r-iect cycle F Y7 9 FY8Y2 EFY8 EXi eM FM E8 E M7 EU Ei I Preparation 75.7 18.2 .1 940 Appraisal 81.2 60.3 141.5 Negotiations 5.3 513 ?rocessing time .7 7.0 25.3 37.0 Sub-total 80.4 106.4 90.9 277.7 Adinilstration 2.0 .6 .9 1.3 3.4 1.0 1.4 n. na. 10.7 Supervision 2.5 14.4 24.3 15.2 14.6 20.4 19.6 10,4 5.5 127.1 S..b-total 4.5 15 0 25.2 16.5 18.2 21.4 21.0 10.4 5.5 137.8 .__ ___ ____ _~~~~~~~-- - _ _ ..... ----- _ ---- _ _ --_____-__ 160.6 212.8 190.9 30 .0 50.4 33.0 36.4 42.6 42.0 20.6 11.0 831.1 a. Hiam Stage of No. of Days Speeisaiti Perform.' T,ypaa of YrO1. CYB1e Month/'Lear Por