Turkey - Second Health Project : Essential Health Services and Management Development in Eastern and Southeastern Anatolia

/ V' :Ifco2 --7 d' Document of The World Bank Report No. 12765-TU STAFF APPRAISAL REPORT REPUBLIC OF TURKEY SECOND HEALTH PROJECT: ESSENTIAL HEALTH SERVICES AND MANAGEMENT DEVELOPMENT IN EASTERN AND SOUTHEASTERN ANATOLIA AUGUST 25, 1994 MICR(OGRAPHICS Report No: 12765 TU Type: SAP Human Resources Sector Operations Division Central and Southern Europe Departments Europe and Central Asia Region  CURRENCY EOUIVALENTS Currency Unit - Turkish Lira (TL) AVERAGE EXCHANGE RATES (Turkish Lira per USS) Currency Unit CY1989 CY1990 CY1991 CY19" CY1993 CY1994 August US$1.00 = TL 2,122 2,629 5,200 8,000 13,000 31,180 WEIGHTS AND MEASURES Metric System FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS CY - Calendar Year DC - Direct Contracting Fp - Family Planning FY - Fiscal Year Fyp - Five-Year-Plan GD - General Directorate GDP - Gross Domestic Product GNP - Gross National Product HDI - Human Development Index ICB - International Competitive Bidding IHCR - Integrated Health Care Reform ILO - International Labor Organization IS - International Shopping LCB - Local Competitive Bidding MCH - Maternal and Child Health MIS - Management Information System KOH - Ministry of Health NHS - National Health Service OECD - Organization for Economic Cooperation and Development OP - Operational Policies PCC - Project Coordination Committee PCU - Project Coordination Unit PEC - Primary Health Care PIP - Project Implementation Plan POX - Project Operations Manual PP - Priority Provinces PPP - Purchase Power Parity RPCC - Research, Planning and Coordination Council SPO - State Planning Organization SSX - Social Security Institution TA - Technical Assistance TL - Turkish Lira TOR - Terms of Reference UNDP - United Nations Development Programme UNHCR - United Nations High Commission for Refugees UNICEF United Nations Children Fund WHO - World Health Organization YOK - Higher Education Council  REPUBLIC OF TURKER SECOND HEALTH PROJECT: ESSENTIAL HEALTH SERVICES AND MANAGEMENT DEVELOPMENT iN EASTERN AND SOUTHEASTBkN ANATOLIA STAFF APPRAISAL REPORT TABLE OF CONTENTS Pace No. Loan and Project Summary . . . . . . . . . . . . . . . . . . . . . . i X. THE HEALTH OF THE TURKISH POPULATION . . . . . . . . . . . . . . . . 1 A. General/Sector Background. .................. ... . . .......... . 2 B. Key Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 C. Government Health Sector Strategy . . . . . .. . .... . 7 D. Past World Bank Involvement in the Health Sector . . . . . . . . 8 B. Rationale for Continued World Bank Involvement . . . . . . . . . 9 F. Role of International Donor Community . . . . . . . . . . . . 10 tII THE5 PROJECT . . . . . . . . . . . . . . . . . . . . . . 0. . ............... il A. Project Objectives .......... .......... . . .4.11 B. Project Description. ..4 ..........4. . 11 C. Environm3ntal Impact . . . . . . . . . . . . . . . . . . . . . . 14 III. PROJECT COSTS. FINANCING, MANAGEMENT AN IMPLEMENTATION . . . . . . . 15 A. Introduction . . . . . . . . . . . . . . .15 B. Project Cost . . . . . . . . . . . . . . . . . . . . . . . . . .15 C. Project Financing. . . . . . * 4 4 * * . . . . . . . . .15 D. Project Management and Implementation . . . . . . . . . . . . . . 16 S. Project Procurement Arrangements . . . . . . . . . . . . . . . .17 F. Disbursements. . . . . . . . . . . . . . . . . . . . . . . . . .17 a. Project Audit Reporting and Evaluation . . . . . . . . . . . . . 17 H. Status of Preparation . . . . . . . . . . . . . . . . . . . . . . 18 IV. BENEFITS AND RISKS . . . . . . . . . . . . . . . . . . . . . . . 19 V. AGR1M5 ENTREACHEDANDRECOMMNDA TI ON ............. ... 20 This report fs based on the findngs of an aWraisal mission Which visited Turkey in Janumry 1994. The appraistl mission comprised Alexander S. Preker (Mission Leader, Senior Health Economist, ECI HR), Wm. Bradford Herbert (Senior Operations Officer, EC1/21R)4 Carlos Ferreira (Chief, Information Technology, EMTDR), CraiS R. Neal (Policy Officer, COPPE), Virginia H. Jackson (Operations Officer, EC1/2NR), Efd K. Dib U -plementatien Specialist, SA2PH), JulSan Lob-Levyt (Public Health Specialist. Consultant), Carol Collado (Clinical Training Specialist, Consultant), PhiLip Berman (Health Services Manageent Training Specialist, Consultant) and Nathias Kalina (Acute Care Specialist, Consultant). Dale Hill (Senior Economist, RMTur) Joined the mission for some of its meetings. Ross Pavis, Sabrina Huffman and Toni Koleva (EC1/2HR) provided assistance with text processing and copy editing. Task Nanaaer: Alexander S. Preker (ECI/2HR); fl.vlial Ch.S: Ralph W. Harbison (EC1I2R); Director: Michael Wiehen CECIOR); Poor RevSewers: Guy Ellena (MN1PH); Monica Fong (MN2AG); and Jose-Luis Bobadilla. Mary E-Ning Young (PHU).  REPUBLIC OF TURREY SECOND HEALTH PROJECT: ESSENTIAL HEALTH SERVICES ANp MANAGEMENT DEVELOPMENT IN EASTERN AND SOUTHEASTERN ANATOLIA STAP? APPRAISAL REPORT TABLE Or CONTENTS (continued) Pace No. ANNE^E Annex 1: Project Implementation P&an .... ............... 21 Annex 2: Detailed Cost Estimates ....... .................. .. . .. 63 Annex 3: Detailed Implementation Schedule .............. . -......... 481 Annex 4: Monitoring and Evaluation Indicators ......................... 93 Annex 5s Status Report of First Health Project .......... 121 statistical Tables and Figures.. ... .* * *. * * * * *... * * * *.. ....... ..... .. .129 Glossary of Terms .............. * *............ ............. .# .... 149 Bibliography of Materials in the Project Files ....................... 153 Map ls Demographic Regions- IBRD 25580 Map 2: Socioeconomic Regions- IBRD 25581 Map 3: 23 Project Provinces- IBRD 25582 Map 4s Turkey- IBRD 24903-R  REPUBLIC OF TURXEY SECOND HEALTH PROJECTs ESSENTIAL HEALTH SERVICES AND MANAGEMENT DEVELOPMENT IN EASTERN AND SOUTHEASTERN ANATOEIA L.oun and Project 8ummary BORROWERs Republic of Turkey BENEFrCrARIESa Min$stry of Health (MOH) departments, provincial health directorates, health care units in the project provinces, pilot hospitals and selected universities. LOAN AMOUNTs US$150.0 million equivalent. TERWSt Seventeen years, including a five-year grace period, at the IBRD standard variable interest rate. PROJECT OBJkCTIVEs The primary goal of the Second Health Project is to red4ce the burden of disease due to avoidable illness and disability in Turkey. To achieve this goal, the specific objectives of the Project are to: (a) improve equity of access tq essential health services in 23 eastern, low- income, priority provinces; and (b) improve the quality of health care management in selected institutions. PRQ= DESCRIPTION: The proposed Prcject will provide fellowships, training, technical assistance, studies, health programs, computer hardware and software, medical and office furniture, equipment, vehicles, teaching materials, civil works and non-salary incremental recurrent costs. The Project, which covers 16 percent of Turkey's total population (11.8 million people in 1993) and 29 percent of its surface area, will be implemented over seven and a half years through the following two components (US$200.0 million total cost): The Primary Health Care Cogponent (US$155.6 million total cost) will improve equity in access to essential health services by: (a) upgrading the traiiing of primary health care personnel; (b) expanding basic health care interventions known to be cost-effective; and (c) strengthening the network of health care facilities to support the above activities. This component forms the centerpiece of the Second Health Project. It sets priorities based on the leading causes of mortality and morbidity, and it will keep these at the forefront of debates on reforms in the health care system. The Health Policy and Wanaaement Component (US$44.4 million total cost) will improve the quality of health care management in selected institutions bys (a) upgrading the training of staff in policymaking, planning, management,  - ii - monitoring and evaluation; (b) decentralizing and restructuring management responsibility in six pilot hospitalsl (c) introducing basic management support systems in Provincial Health Directorates and selected hospitals in the project provinces, as well as evaluating a more comprehensive management information system in one urban pilot hospital in western Turkey; and (d) conlucting pre- investment studies to support broader reforms in the health sector. Activities supported under (b) and (c) are explicitly designed as trial runs for future countrywide implementation. BENEFITS: The Project's major benefit will be to reduce the number of avoidable deaths and disability in the project provinces, especially among women and childr-n. Targeted investments in training and facilities will lead to better staffed and equipped essential health services in these provinces. Such interventions are well known to be cost-effective and a precondition for improving maternal and child survival. A second benefit of the Project will be to obtain better value for money spent on health services. Staff in the project provinces will be trained in health services management and provided with management support systems. This will allow them to improve the quality of scrvices provided and avoid wasting scarce resources. RI8R8S A major risk faced by the Project is that it may become difficult to implement and supervise activities in a number of the project provinces which currently have accessibility problems. Contingency plans are included to allow: (a) out- of-province training where necessary; (b) pro-selection of only urban facilities for new civil works to ensure t1e possibility of an adequate supervision, staffing and supply of equipment; (c) province-by-province costing to allow flexibility under a phased implementation plan; and (d) use of a professional engineering firm to oversee the construction programs. A second risk is the limited institutional capacity of MOH departments, especially in the area of training. This risk will be mitigated by: (a) appropriate deployment of staff trained through fellowships financed under the First Health Project; (b) technical assistance, including management contracts for logistic support in coordinating training activities; (c) decentralization of training efforts to provincial teams; (d) modular distance-based education; (e) improved coordination of the different General Directorates in an integrated approach to training activities; and (f) collaboration with universities as co-participants in the implementation of training programs.  - iii - REPUBLIC OF TURKEY SECOND HEALTH PkOJEC? ESSENTIAL HEALTH SERVICES AND MANAGEMENT DEVELOPMENT IN EASTERN AND SOUTHEASTERN ANATOLIA Estimated costs and Financina Plan (US$ Million)3t