Rwanda - Family Health Project

Document of The World Bank FOR OFFICLAL USiE ONLY Report No.13136 PROJECT COMPLETION REPORT RWANDA FAMILY HEALTH PROJECT (CREDIT 1678-RW) JUNE 13, 1994 Population and Human Resources Operations Division South-Central and Indian Ocean 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 (period average) Currency Unit - Rwanda Franc (RwF) 1985: US$1.00 RwF 101.26 1986: US$1.00 = RwF 87.64 1987: US$1.00 = RwF 79.69 1988: US$1.00 = RwF 76.45 1989: US$1.00 RwF 79.98 1990: US$1.00 RwF 82.60 1991: US$1.00 RwF 125.14 1992: US$1.00 RwF 132.04 1993: US$1.00 RwF 143.24 FISCAL YEAR January 1 - December 31 GLOSSARY OF ABBREVIATIONS DFCS - Direction de Financement et de Constructions Scolaires DHS - Demographic and Health Survey FP - Family Planning GTZ - Gesellschaft fur Technische Zusamnmenarbeit (German Cooperation Agency) HC - Health Center(s) IEC - Information, Education and Communication MCH - Maternal and Child Health MOHSA - Ministry of Health and Social Affairs (in French: MINISAPASO) MINEPRISEC - Ministry of Primary and Secondary Education MINIFIN - Ministry of Finance MINISUPRES - Ministry of Higher Education and Scientific Research NC - Nutrition Center(s) ONAPO - Office National de la Population USAID - United States Agency for International Development WHIO - World Health Organization MEASURES Metric British/US Equivalent I meter 3.3 feet I kilometer 0.62 mile I square kilometer (km2) 0.39 square miles (sq.mi.)  FOR OFFICIAL USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A. Office of Director-General Operations Evaluation June 13, 1994 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on Rwanda Family Health Project (Credit 1678-RU) Attached is the Project Completion Report on Rwanda-Family Health Project (Credit 1678-RW) prepared by the Africa Regional Office. Part II was prepared by the Borrower. This project aimed to improve the maternal and child health program by incorporating family planning and nutrition activities into primary health care, providing training to upgrade staff, and strengthening the institutional capacity of the Ministry of Health and Social Affairs and the National Office of Population. During the first several years, implementation was very slow, among other reasons because of personnel problems, unfamiliarity with Bank procedures, reluctance to use technical assistance, and shortage of counterpart funds. These problems were eventually resolved and most inputs completed by mid 1993, a year and a half later than planned. Although the nutrition component was ignored and the population policy component was unsatisfactory, the outcome of the project is rated as satisfactory because the main objective -improving maternal and child health and adding family planning services to the primary health package -was achieved. However, its institutional development impact is rated as modest, and sustainability of results achieved as unlikely. The PCR provides an adequate description of events but is weak on analysis. No audit is planned at this time. Attachment 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.   FOR OFFICIAL USE ONLY PROJECT COMPLETION REPORT RWANDA FAMILY HEALTH PROJECT (CREDIT 1678-RW) TABLE OF CONTENTS Page No. PREFACE ................................................ i EVALUATION SUMMARY ................. ................... PART I: PROJECT REVIEW FROM BANK'S PERSPECTIVE ............ A. PROJECT IDENTITY .. B. BACKGROUND . . C. PROJECT OBJECTIVES AND DESCRIPTION. 2 Project Objectives.. 2 Project Description. 2 D. PROJECT DESIGN AND ORGANIZATION. 3 E. PROJECT IMPLEMENTATION. 4 Credit Effectiveness and Project Star-up. 4 Implementation Schedule. 5 Procurement. 7 Project Costs.. 7 Disbursements and Credit Allocation. 7 F. PROJECT RESULTS. 8 Project Objectives and Physical Results.. 8 Institutional Strengthening and Human Resources Development.. 8 Population Policy. 9 Impact of Project. 9 G. PROJECT SUSTAINABILITY. 9 H. BANK PERFORMANCE. 9 I. BORROWER PERFORMANCE .10 J. PROJECT RELATIONSHIP .11 This document has a restricted distibution and may be used by recipients only in the perfonnance of their official duties. Its contents rnay not otherwise be disclosed without World Bank authorization.  TABLE OF CONTENTS (continued) Page No. K. CONSULTING SERVICES 11............................ 1 L. PROJECT DOCUMENTATION AND DATA 11................ 1 M. CONCLUSIONS AND LESSONS LEARNED 1................ 11 PART II: PROJECT REVIEW FROM BORROWER'S PERSPECTIVE .13 PART III: STATISTICAL INFORMATION .15 1. Related IDA Credits ................................. 15 2. Project Timetable .16 3. Credit Disbursements. 16 4. Project Implementation. 17 5. Project Costs and Financing. 18 6. Project Results. 19 7. Status of Covenants. 20 8. Use of Bank Resources. .............................. 22  PROJECT COMPLETION REPORT RWANDA FAMILY HEALTH PROJECT (CREDIT 1678-RW) PREFACE This is the Project Completion Report (PCR) for the Family Health Project in Rwanda, for which Credit 1678-RW in the amount of SDR 9.8 million was approved on April 1, 1986 and signed on May 23, 1986. The credit became effective on February 27, 1987 and was closed on December 31, 1993, about one and a half years behind schedule. The credit was fully disbursed at the closing date of December 31, 1993. The PCR was prepared by the Population and Human Resources Operations Division of the South-Central and Indian Ocean Department (AF3PH). There was no completion mission. The Bank sent the Borrower Parts I and III with the request to prepare Part II which was received on December 21, 1993. The PCR is based on the President's Report, the Staff Appraisal Report, the Development Credit Agreement, reports by and correspondence between the Bank and the Borrower, internal Bank memoranda and interviews with Bank staff who have been associated with the project.   - 11 - PROJECT COMPLETION REPORT RWANDA FAMILY HEALTH PROJECT (CREDIT 1678-RW) EVALUATION SUMMARY Objectives i. The main objective of the Project was to improve maternal and child health with particular emphasis on family planning within the national strategy for primary health care. Specific objectives were to: (a) make family planning services available in all health facilities as part of the maternal and child health program; (b) improve the quality and increase the coverage of maternal and child health services; (c) target nutrition activities and integrate them into maternal and child health services; (d) strengthen the institutional capacity of the Ministry of Health and Social Affairs (MOHSA) at the central and regional levels; (e) increase the output and improve the quality of basic paramedical training programs; and (f) improve the National Office of Population's (ONAPO) data base for population and policy formulation (paragraph 6). Implementation Experience ii. The overall implementation results of this project are good. The SAR was optimistic in its implementation plans and in forecasting project completion and the credit fully disbursed in five and a half years. This forecast did not take into consideration the fact that MOHSA was a first time borrower unfamiliar with Bank procedures and the PHN disbursement profile of nine and a half years. The credit was disbursed in seven years which is considered good taking into account the project's extremely slow-start up and the 1991-1993 civil war which delayed certain project activities. During the first four years (1986-1990), Project implementation was sluggish. The slow start was mainly due to high turnover of project coordinators, weaknesses in institutional capabilities, slow decision making by MOHSA, cumbersome administrative procedures, unfamiliarity and/or poor compliance with Bank procedures, failure to follow recommendations of Bank supervision missions, and reluctance to resort to technical assistance. By mid-1990, only 25% of the credit had been disbursed. At the mid-term review, the Government and the Bank redefined the project's scope and priorities, and agreed upon a detailed implementation plan and the staffing of an autonomous project unit. By that time, MOHSA was highly committed to speeding up project implementation, more familiar with Bank procedures, and a competent project coordinator was in place. The new coordinator understood the need to use technical assistance and recruited an international consulting firm to help DFCS prepare bidding documents for civil works and equipment. MOHSA did a good job in implementing the training sub-components and its own institutional strengthening. However, it did not focus much on the project's nutrition aspects. ONAPO's contribution to the implementation of the Population Policy component has not been satisfactory. Regarding counterpart funding, only 30% of the agreed upon estimates were allocated to the project. This is in part due to the 1991-1993 civil war which caused military expenditures to rise to 7% of GDP which had a negative impact on  - iii - developmental expenditures. The project was completed in mid-1993 (paragraphs 11 to 20, and 28). Results iii. The Project was successful in meeting its main objective to improve maternal and child health with particular emphasis on family planning. It contributed to the implementation of the national strategy for primary health care by bringing about a better integration of family planning services into the public health system. Most of the physical targets were exceeded. The contraceptive prevalence rate reached 13%, compared to an appraisal estimate of 10%. MOHSA was strengthened. The training sub-component contributed to the training of 1,320 health workers (95 % of SAR estimate) and thus helped alleviate the acute shortage of paramedical personnel. In summary, the Project had a significant impact on the quality and coverage of MCH/FP services in Rwanda. Through this project, MOHSA acquired a better grasp and understanding of the importance of health financing and management issues. Finally, MOHSA learned how to manage a Bank-financed project (paragraphs 21 to 25). Sustainability iv. Rwanda's health sector has always been heavily dependent on foreign assistance, even for recurrent expenditures. The project's institutional strengthening and the work on health financing options which was developed during the project should, in the long-term, help MOHSA sustain its MCH/FP program efforts, it is likely that foreign assistance will continue to be needed to enable the Government to meet the increasing demand for MCH/FP services. This assistance will in part be needed due to the current population growth at 3.1 % per year. The sustainability of this Project is therefore uncertain (Paragraphs 26 and 27). Findings and Lessons Learned v. Despite implementation delays and shortcomings of some project components, the Family Health Project was successful. It had a positive impact on the delivery of MCH/FP services in Rwanda. Both the Bank's and the Government's overall performance was satisfactory. The lessons to be learned from the problems encountered during project implementation are: (a) project staff need to be highly competent and motivated; (b) the ministry concerned should not interfere in the day-to-day management of the project; (c) technical assistance is necessary to assist in programming/monitoring until local expertise is developed; and (d) project personnel need to be adequately trained in Bank procedures, mainly procurement. Since the MOHSA was a first time borrower, the qualifications and number of persomel required should not have been underestimated. The Project also demonstrated that a lot of time is required to formulate realistic and meaningful proposals on additional sources of financing and resource mobilization in the sector. This increased knowledge of health financing will be instrumental in the preparation of future operations (paragraphs 34 and 35).  PROJECT COMPLETION REPORT RWANDA FAMILY HEALTH PROJECT (CREDIT 1678-RW) PART I: PROJECT REVIEW FROM BANK'S PERSPECTIVE A. PROJECT IDENTITY Name Family Health Project Credit Number 1678-RW RVP Unit Africa Region Country Rwanda Sector Human Resources Sub-Sector Health and Family Planning B. BACKGROUND 1. Rwanda's salient characteristics include its small size; an annual population growth rate of 3.7% (ranking among the highest in Africa); a population density about 500 per square km of arable land (ranking among the highest in the world); mountainous terrains and high average altitude; a landlocked position; lack of natural resources, including a serious shortage of arable land; underdeveloped physical and institutional infrastructure; and a very low level of development. 2. At the time of project appraisal, social and economic indicators included per capita income of about US$270 (1983), among the lowest in the world, average life expectancy of 47 years, adult literacy rate of 375, and an infant mortality rate of 115-125 per 1,000. As in most sub-Saharan African countries, health conditions were poor. Mothers and young children accounted for the bulk of Rwanda's morbidity and mortality cases. Many of the deaths could have been prevented with an effective MCH/FP/Nutrition program. Family planning services were available on a very limited scale; according to the 1983 National Fertility Survey (NFS), contraceptive prevalence for modern methods was estimated at 0.9% of women ages 15-45 years who were in union, not pregnant and fertile. 3. The network of hospitals, Health Centers (HCs) and dispensaries was evenly distributed throughout the country and health coverage was high by African standards (about 50% of the population lived within 5 km of a health facility). A wide-scale expansion of the service network was therefore not required, but there was a need to upgrade health facilities in selected locations. There were shortages of staff, particularly for enrolled nurses and nurses aides, and of essential drugs. The effectiveness of the health care system was also affected by insufficient integration of Maternal and Child Health (MCH) and Family Planning (FP) services, and of nutrition activities.  - 2 - 4. Major population growth was inevitable, and the increasing pressure that it would bring on the country's social and economic systems made the need for large-scale efforts to reduce fertility urgent. In order to increase the contraceptive prevalence rate and to meet the current and increasing demand for FP services, the government adopted a strategy of integrated MCH and FP service delivery and of upgrading primary health care facilities. The government also took steps to strengthen the Ministry of Health and Social Affairs (MOHSA). C. PROJECT OBJECTIVES AND DESCRIPITION Project Objectives 5. The main objective of the Project was to improve maternal and child health with particular emphasis on family planning within the national strategy for primary health care. Specific objectives were to: (a) make family planning services available in all health facilities as part of the maternal and child health program; (b) improve the quality and increase the coverage of maternal and child health services; (c) integrate nutrition activities into regular MCH activities at the health center level and target nutrition programs towards "at risk" families; (d) strengthen the institutional capacity of the Ministry of Health and Social Affairs (MOHSA) at the central and regional levels; (e) increase the output and improve the quality of basic paramedical training programs; and (f) improve the National Office of Population's (ONAPO) data base for population and policy formulation. Project Description 6. The project consisted of the following components: (a) Strengthening of Family Health Services. The Project was to support the development of a restructured MCH program which included nutrition activities and, most importantly, made FP services available nationwide. It was to achieve this through: (i) the implementation of a MCH/FP/Nutrition in-service training program for about 1,400 health center staff, including short and long-term foreign consultancies for curriculum development, training of trainers and operating costs; (ii) the provision of medical supplies; and (iii) the upgrading and re-equipment of 30 health centers to strengthen the family health care infrastructure. (b) Institutional Strengthening of MOHSA. To implement effectively the restructured MCH program, MOHSA was to be strengthened, both at the central and regional levels. At the central level, the MCH, Training, and Studies and Evaluation divisions were to be provided with equipment and logistical support to better manage, evaluate and supervise field activities and with a long-term MCH/FP adviser. Improvements of the health information system through technical assistance and equipment were to strengthen the planning capabilities of MOHSA. At the regional level, the decentralization process initiated by MOHSA was to be supported by: (i) training of regional teams to implement an in-service training program; (ii) strengthening the management and supervision capacity of the regional staff by providing vehicles, supplies, equipment, incremental operating costs and short-term foreign consultancies; and (iii) building eight MOHSA/ONAPO regional offices.  -3- (c) Human Resources Development. Because paramedical personnel were scarce, the project was to: (i) provide pre-service training and deployment of about 200 nurses aides (A4) to remedy the serious shortage of auxiliary staff in health centers; and (ii) finance the construction of two new A3-nursing schools with an estimated capacity of about 120 students each. The Ministry of Education was to be responsible for staffing and managing the nursing schools. Technical assistance was provided to improve teaching and curriculum development in the A3 schools. (d) Population Policy. The Project provided direct support to ONAPO to strengthen its capacity to formulate and coordinate population policies by supporting two key operational research studies. The studies were to focus on: (i) factors influencing the acceptance and continuation of contraceptive use; and (ii) maternal and under-five mortality. (e) Project Management. The Project was to strengthen MOHSA project management capability by financing 48 staff-months of consultant architectural assistance for the project coordination office, incremental salaries for a project coordinator, an accountant and a support staff as well as equipment and incremental operating costs. D. PROJECT DESIGN AND ORGANIZATION 7. The project was well prepared. The design of the project was the result of a successful cooperative effort between the Government and the Bank which began during a population, health and nutrition sector mission in June 1983. In November 1983, an agreement was reached on the outline of the project and a PPF advance of US$440,000 was approved shortly thereafter. Two years elapsed between identification and appraisal because the MOHSA initially wanted to prepare the project without external technical assistance, but at that time lacked the technical expertise in certain areas. Project preparation accelerated when four international consultants were recruited in the areas of family planning, architecture, nutrition, and management. At the technical level, the Government demonstrated ownership for the project as a local counterpart team was created within MOHSA. The consultants and the MOHSA's team prepared a project document. The document was extensively referred to during the appraisal and in the preparation of the SAR. It was occasionally referred to during project implementation. The delays encountered during project preparation did have a positive impact on the project's overall scope and objectives. The consulting team and Bank staff recognized the need to change the project's scope from a "hardware" (rehabilitation, equipment purchases, etc.) to a "software" project that would focus on the delivery of comprehensive family health services. Regarding the family planning component, virtually no ownership was demonstrated, from ONAPO during project preparation. This situation had a negative impact on the implementation of the population studies. 8. In part as a result of this dialogue between Government and Bank staff during project preparation, the health sector was reorganized. This dialogue also resulted in the development of an overall strategy for implementing an integrated MCH/FP/Nutrition program responsive to the country's needs which brought about the project's final orientation. The former Ministry of Social Affairs and Ministry of Health were merged to form the Ministry of Health and Social Affairs (MOHSA). Three technical divisions were created within MOHSA's technical directorate, namely: a MCH/FP division (including a family planning bureau and a nutrition  - 4 - bureau), a Studies and Evaluation division, and a Training division (for basic and in-service training). In addition, decentralization of health services management to the regional level was initiated, and with WHO's support, MOHSA started a comprehensive health financing study to analyze trends in health expenditures, identify sources of financing and review opportunities for additional resource mobilization in the sector. Finally, the merger of the Ministry of Social Affairs (which included ONAPO) with the Ministry of Health brought under the umbrella of MOHSA the strong cadre of ONAPO's specialist staff and managers who could now be used to make a major contribution to the implementation of a national family planning program. ONAPO's mandate was to carry out educational and informational programs, research and evaluation, staff training, and program development in the areas of population and family planning. Actual delivery of FP services was to be undertaken by MOHSA field staff, acting under the technical guidance of ONAPO's regional teams. Also the ONAPO teams were to carry out motivational programs designed by the ONAPO central office. All those government actions set the stage for the implementation of the Family Health Project. 9. The Project was to be managed by three separate entities: MOHSA, ONAPO (which is administratively under MOHSA's umbrella, but operates as a parastatal agency) and the DFCS (which is the architectural unit of the Ministry of Primary and Secondary Education). MOHSA was responsible for implementing: (a) in-service training of paramedical personnel and nursing aides pre-service training (Training division); (b) PHC infrastructure rehabilitation program (Studies and Evaluation division); (c) integration of project activities with the ongoing MCH program, including FP and nutrition activities (MCH division); (d) overall regional institutional strengthening (Secretary General); and (e) monitoring overall project implementation and progress (Studies and Evaluation division). ONAPO was in charge of implementing two policy population studies as well as assisting in implementing FP activities, and DFCS was responsible for the construction of two new nursing schools and the training of teachers. A Project Coordinating Committee chaired by the MOHSA Secretary General, and consisting of ONAPO's director, along with officials from the Presidency and the Ministries of Finance, Planning and Primary and Secondary Education (DFCS), was responsible for overall project coordination. MOHSA's project management capability was to be strengthened by the appointment of a project coordinator, an accountant, an architect and support staff. The project coordinator would report directly to the Minister of Health. It was agreed during negotiations that MOHSA would appoint a MCH division chief and an additional training specialist in the Training division. A long-term MCH/FP expert would also be recruited under WHO contract to assist in the implementation of the Family Health program. Technical assistance would also be provided for pre-service and in- service training, and in health statistics. E. PROJECT IMPLEMENTATION Credit EffectivenDs and Project Start-up 10. The credit was approved on April 1, 1986, and signed on May 23, 1986. Additional conditions of effectiveness included the appointments of key staff: a project coordinator, an accountant and an architect, who were appointed in August 1985, June 1986 and November 1986, respectively. The recruitment of a procurement specialist even though necessary for a first time borrower such as MOHSA was not recommended by the project preparation team. The absence of this type of expertise contributed significantly to implementation delays for the civil works as well as for equipment purchases. The Development Credit Agreement was approved by government in September 12, 1986 and by the National Development Council in February 6, 1987 and the law ratifying the agreement was signed on February 18, 1987 and published in the  Official Gazette on March 15, 1987. As a result, the Credit became effective only on February 27, 1987, a delay of about five months from the originally planned date. 11. The delay in credit effectiveness, however, did not affect project start-up. Before effectiveness, the Borrower took initial steps to implement the Project. It provided the locations of the five unidentified health centers, signed a contract with the consulting firm for the civil works, and started to define the training program and identify candidates for fellowships and study tours. Implementation Schedule 12. The appraisal mission was optimistic when preparing the implementation plans and forecasting that the project would be fully disbursed and completed in five and a half years (the original completion date was December 31, 1991). This forecast did not take into consideration the PHN disbursement profile of nine and a half years and the fact that MOHSA was a first time borrower. In addition, no recruitment of international technical assistance was envisaged to assist in project implementation. The project was fully disbursed in seven years which is considered a success taking into account the slow start-up period and the 1991-1993 war which also delayed certain project activities (mainly the rehabilitation of health centers and nursing schools in the northem part of the country). Project implementation can clearly be divided into two phases, before and after the 1990 turnaround. Between 1986 and mid-1990, disbursements and implementation were sluggish. Based on the SAR's forecasts, the health centers, regional offices, and nursing schools were scheduled to become operational between the end of 1988 and the beginning of 1990. The implementation of other project elements (e.g. training, family planning, and nutrition) was supposed to be well advanced between the second and third year of project implementation with the final outputs materializing towards the end of the project. However, by the end of 1989 (mid-term review), the project had accomplished very little, and only about 20% of the credit had been disbursed. The 1990 turnaround occurred, following a mid-term review (when only 25% of the credit had been disbursed compared to 77% forecasted in the SAR). During that time, the Government and the Bank redefined the project's priorities as well as the scope and orientation of the institutional strengthening component. It was decided, for instance, that the project would not focus on family planning activities as there was a free standing IDA- financed population project under preparation. An agreement was reached upon a detailed implementation plan and the staffing of an autonomous project unit. The tumaround can also be attributed to Bank staff having spent 31.4 SW in FY90 for the supervision of this project. Also by 1990, a competent project coordinator was in place who understood the need to recruit technical assistance to assist in the preparation of the bidding documents for the civil works and equipment. With the exception of a few items (mainly the completion of three health centers and one of the two nursing schools in the northern part of the country) which could not be completed due to lack of fluxds when the war ended, the project was completed in mid-1993. 13. As a result of the mid-term review's recommendations, a project unit was created within MOHSA to coordinate between ONAPO, DFCS, and the MOHSA divisions. This unit was responsible for all implementation related matters and reported to the Minister of Health. This unit was headed by a project coordinator who was assisted by a financial manager, an accountant, two architects (responsible for the civil works in five prefectures each) and a training specialist. The high turnover of project coordinators is one of the key factors responsible for the slow start of project activities. When the last one came on board in 1990, the unit proved to be effective in speeding up project implementation as MOHSA had given it sufficient autonomy. Furthermore, the Minister had delegated the overall follow-up of the project to the Director General of Health.  - 6 - He in turn also facilitated the implementation of this project and provided technical expertise on health related issues and was MOHSA's key interlocutor on health financing issues. 14. The performance of MOHSA and DFCS has been particularly bad for the implementation of the infrastructure part of the Project. Agreements had been reached at appraisal between the Bank and Government on the nature of the upgrading/rehabilitation to be done for the health centers. However, during the preparation of detailed plans, MOHSA wanted to increase the size of those centers which, together with the addition of investments not previously considered for water supply and electricity, resulted in a sizeable increase in costs. Government kept asking for additional financing which was not available. MOHSA took advantage of the turnover of Bank staff task managers (five in seven years) to keep pushing this request through. Finally, bidding for the first two lots took place only at the end of 1988, and for the remaining lots in 1990. The Project upgraded or rehabilitated 22 health centers (instead of 30 included in the project description) and six regional offices (instead of eight). Due to the added features for the health centers, the thirteen housing units for MOHSA were dropped from the Project. Among the 22 health centers, 19 were fully completed and three in the northern part of the country have only been completed at 85% because of the war. Regarding water supply, only four health centers benefited from the necessary investments. The remaining 18 will be equipped with financing provided by Belgian aid. The construction of the two new nursing schools was also considerably delayed. The school in Kaduha became operational in the Fall of 1992 and 180 students were enrolled. The other school in Byumba is only 90% complete because of the war which contributed significantly to the construction delays. This school was also looted during the war period. The training of teachers by MINEPRISEC and MINISUPRES occurred in parallel with the school construction. 15. MOHSA did a good job in implementing the training sub-components of the Project. On the basis of the newly defined MCF/FP strategy, curricula were developed and 100 trainers (10 per health region) were trained. Despite the delays in appointing additional training specialists, the number of health center staff retrained was 1,320, compared to an appraisal estimate of 1400, and the number of additional A-4 nurses trained and deployed was 300, compared to an appraisal estimate of 200. Two hundred graduates are currently seeking employment and 525 are currently enrolled in the training program. This training was part of the component for strengthening family health services. Nutrition activities, which were also part of that component, were not implemented. The five-year nutrition program which was finally developed will be carried out under the Food Security and Social Action Project (Cr. 2388-RW). The component for the institutional strengthening of MOHSA was carried out, with the exception of the improvements of the health information system (HIS) (computers and training were provided for the HIS and a timetable for implementation is ready). Also, the number of regional offices was reduced from eight to six due to the fact that GTZ financed the remaining two. 16. Regarding the population policy, which was ONAPO's responsibility, very little was done under the Project. Field surveys were carried out in September/October 1989 for the study of factors influencing the acceptance and continuation of contraceptive use, but the results have only been partially processed. During the last three supervision missions, the Bank asked the project coordinator to follow up to see if a draft of this study could be obtained. A report was received at the time of project closing (four-year delay) which is in part due to some problems that ONAPO was having with the Bank on managerial questions related to the on-going Population Project. The second study, on maternal and under-five mortality, was incorporated in the USAID-funded Demographic and Health Survey (DHS) which was carried out in 1991. The  -7- project staff were also not committed to this component as they did not perceive it as a top priority. Procurement 17. Poor knowledge of and/or compliance with Bank procurement procedures delayed project implementation, particularly for civil works, but there were also problems with the procurement of vehicles. In the absence of standard bidding documents to be given to MOHSA and DFCS, the preparation of bidding documents for specific works turned out to be a painful exercise. Consultant/architects participated in supervision missions. However, due to the changes in project staff, procurement activities remained at a standstill between supervision missions. As previously stated, the project had a design flaw as it did not forecast the need for the recruitment of a procurement specialist that should have been recruited at the same time as other key project staff as a condition of credit effectiveness. Even in cases where Bank staff explained the Bank requirements, as for the two nursing schools, the procurement process remained at a standstill because DFCS did not seem (or wish) to understand what was required to bring the documents up to Bank standards. The DFCS was also in charge of school constructions for the Third Education Project and the same types of problems were also occurring. One construction contract for the health centers had to be cancelled because of poor performance by the contractor, which might have been avoided by a more careful assessment of this contractor's qualifications and capabilities before contract award. Moreover, it seems that he had not been required to furnish any security for the advance payment that he received and it is not clear whether the Project was able to recover that money from the performance security (bank guarantee). Project Costs 18. Project accounts have been kept only by disbursement categories of the IDA credit with all expenditures summarized in a ledger. There is little information available in the files on the actual contribution by WHO and the Government. However, one of the progress reports refers to the fact that government counterpart funding has been about 33% of the amount estimated at appraisal. This is mainly a result of the three-year civil war which squeezed development expenditures while military expenditures reached 7% of GDP by the end of project implementation. In any event, there is no informnation on the actual cost of each project component which could be compared with the estimate included in the Staff Appraisal Report (SAR). Regarding the IDA credit, variations between 1985 and 1993 in exchange rate between SDRs and US dollars in effect increased the available financing expressed in US dollars. Actual disbursements amounted to US$13.5 million compared to an appraisal estimate of US$ 10.8 million (a 25% increase). Assuming that the contribution by WHO and government has been much less than the US$3.6 million estimated at appraisal, (say, of the order of US$1 million only), total project costs would be the same as the appraisal estimate of US$14.5 million, but for a somewhat reduced project. Disbursements and Credit Allocation 19. The cumulative estimated and actual disbursements of Credit 1678 - RW are given in table 3 of Part III. The five and a half-year disbursement forecast of the SAR was unrealistic taking into account the fact that MOHSA was a first time borrower and that the Bank wide PHN disbursement profile was nine and a half years. At the mid-term review, only about 20% of the credit had been disbursed. Once the project execution gained momentum in 1990 (due to the recruitment of competent project staff, the high emphasis placed by the Bank on supervising the  -8- project, and the willingness to resort to technical assistance for procurement issues) it was considered prudent to increase the authorized allocation of the special account from US$ 600,000 to US$ 1,000,000, and the additional deposit was made in February 1991. Disbursements then increased very rapidly, and by the closing date, because of an increase in the value of the SDR in dollars, actual disbursements in dollars represented 125% of the total amount estimated at appraisal. The allocation of the proceeds of the credit was amended twice to reflect the changes in financing requirements. Disbursements of the IDA credit were more than estimated at appraisal for civil works, and furniture, equipment, medical supplies and vehicles, and about the same for the other categories. The original closing date was June 30, 1992, but the credit was closed on December 31, 1993 after two extensions. The credit was fully disbursed. F. PROJECT RESULTS Project Objectives and Physical Results 20. The Project was successful in meeting its main objective to improve maternal and child health with particular emphasis on family planning. The Project brought about a better integration of family planning services into the health system. However, the nutrition aspects were neglected. As shown in Table 6 of Part III, most of the performance indicators in the SAR were exceeded. However, it should be noted that they were not systematically monitored during project supervision and were not included in the progress reports. Physical targets of the Project were exceeded. A recently undertaken Demographic and Health Survey (DHS) indicates a Contraceptive Prevalence Rate of 13%, compared to an appraisal estimate of 10%. Important gains were also made in child health monitoring, deliveries in health facilities, and prenatal care. MCH/FP services benefitted greatly from the training programs, medical supplies, the health center standard manual, and supervision activities financed under the Project. Institutional Strengthening and Human Resources Development 21. The project has been generally successful in its objective to strengthen MOHSA's administrative capacity to implement the MCH/FP program. Support provided under the project with regard to training, construction, equipment and logistics brought about improvements were made at all levels - central, regional and field - despite the fact that MOHSA did not benefit as much as was expected from the services of a long-term MCH/FP adviser. However the development of a better health data base, which was expected to improve decision-making in key areas of resource allocation and evaluation of program effectiveness, did not take place. One of the dated covenants was that MOHSA would submit, by December 31, 1987, a proposal to improve its statistical health information system. Attempts were made to introduce an improved system, on a pilot basis in a few regions, then nationwide, but they were not very successful (currently MOHSA is exploring other sources of financing). Regarding MOHSA's computerized management information system (MIS), in 1991, a consultant prepared a program and timetable in four phases for the installation of a MIS. This MIS could not be implemented under the project due to lack of funds, because it entailed a large purchase of computer equipment and international technical assistance. It was agreed to implement the first phase of the MIS under this project. However, some of the equipment is not being utilized to its fullest capacity within MOHSA at present. 22. One of the expected benefits of the Project was that it would assist the government in solving one of the health system's most severe constraints - the shortage of paramedical personnel. Despite the delays in the recruitment of additional training specialists, the output of  - 9 - the paramedical in-service training was close to the appraisal estimate. This contributed to improving the quality of medical staff nationwide. Many doctors and nurses in the field have commented that the deployment of the newly trained A-4 auxiliary nurses have allowed them to spend more time on their normal tasks as doctors and nurses. It is too early to comment on the impact of the nursing schools for A-3 nurses which are designed to train primary health care staff. Population Policy 23. The implementation of this component, which was intended to strengthen ONAPO's capacity to formulate and coordinate population policies, has not been successful, because of the weakness of ONAPO's research unit. Two studies were supposed to be undertaken during the first and second years of the Project. However, ONAPO did not participate in the preparation of the component and therefore did not feel much ownership for the component's implementation. The first study was completed with a four-year delay (paragraph 17). The second study was not done under the Project but as part of the USAID-financed DHS. In addition, it appeared that the working relationships between ONAPO and MOH had been deteriorating over the past years. The relationship between ONAPO and the Bank significantly deteriorated during the past two years due to diverging views on managerial issues encountered while trying to launch activities for the IDA-financed Population Project. Impact of Project 24. Although some components had a slow start and were completed only recently, all indicators show that the Project already has had a significant impact on the quality and coverage of MCH/FP services to Rwanda's population. That impact is expected to increase in the future with the output of the nursing schools and the operational use of the technical guides and manuals prepared under the Project. G. PROJECT SUSTAINABILITY 25. According to the Staff Appraisal Report, the Project's main recurrent cost was for salaries of the additional paramedical staff trained under the Project, and other incremental operating costs associated with supervision, and in-service training. Under the most pessimistic scenario, this cost was estimated at only 5 % of MOHSA operating budget, and was considered affordable. It was recognized, however, that Rwanda's health sector was heavily dependent on foreign assistance, not only for capital investment but also for recurrent expenditures. 26. During project implementation, while new budgetary positions were created to accommodate the additional paramedical staff, the govermnent contribution was less than estimated at appraisal. It is unlikely that significant additional financial resources could be mobilized for the sector any time soon. Although the institutional strengthening should help MOHSA sustain its MCH/FP program efforts, foreign assistance will continue to be needed in order to enable government to meet the increasing demand for MCH/FP services. H. BANK PERFORMANCE 27. Generally, the Bank's performance has been satisfactory. Through the Family Health Project, the Bank made a positive contribution to the integration of family planning into Rwanda's health system and to the institutional strengthening of MOHSA. Overall, the Bank did a good  - 10 - job at the project preparation stage by recognizing the need to change the project's orientation and design from a "hardware" project (rehabilitation/construction, purchases of goods, etc.) to one focused on the delivery of comprehensive MCH/FP services. The Bank devoted adequate resources to supervision (Table 8). However, the staff turnover was high and there was excessive reliance on consultants. One of the task managers decided to go the "extra mile" to brief the current project coordinator in detail on Bank procedures which made him more knowledgeable on how to go about implementing the project and more motivated. On the negative side, the task of the Borrower has been made more difficult by the high turnover of Bank staff on the Project. The fact that five different architects, employed as outside consultants, worked on the Project at different times is another clear illustration of the short sightedness of the Bank's decision several years ago that there was no need for architects in its operational divisions. This continuous problem on the Bank's side in the last two years of project implementation was addressed through the use of short-term consultants. Project staff were not formally trained in Bank procurement procedures; standard bidding documents were only provided at the time of the mid-term review. The health centers were originally overdesigned but were scaled down at appraisal. The Bank should have been more assertive when, at the beginning of project implementation, MOHSA tried again to get the Bank to finance over-designed health centers; a firm "NO" would have saved everybody's time and money. This operation was instrumental in enabling the Bank to get an insight on how the health sector operates and what are its key issues. This will be a contributing factor in the design of better targeted future operations. The decision to bring to Washington in 1990 for a period of two weeks the current Project Coordinator to brief him thoroughly on the way the Bank works, its procedures and what was expected of him turned out to be a critical factor to improve project implementation. I. BORROWER PERFORMANCE 28. The Borrower should be given credit for the project's overall good results. Through this project, MOHSA learned how to properly manage a Bank project. MOHSA has done an excellent job on training, and some of the tasks that have been considerably delayed, like the production of technical guides and manuals, had a positive capacity building impact because they have been carried out by Rwandese personnel. (an international expert assisted in the elaboration of the documents). Many of the favorable project results should have materialized earlier, but unfortunately the Project had a very slow start. This could have been overcome by more commitment from high level staff within MOHSA, the appointment of a competent project coordinator, and a better timing for the recruitment of international technical assistance to assist in management and procurement issues. Implementation delays have resulted from the following chronic problems: rapid turnover of project coordinators; weaknesses in institutional capabilities; slow decision making; cumbersome administrative procedures; poor knowledge and/or compliance with Bank procedures, particularly procurement; failure to follow the recommendations of Bank missions; and reluctance to resort to technical assistance. Government has also been remiss in not contributing its share of the financing. The deterioration in the political situation and the war have also fueled implementation delays. Generally, ensuring proper coordination between the project unit, MOHSA, ONAPO and DFCS turned out to be a difficult task. 29. More specifically, MOHSA did not do a good job on the implementation of the civil works included in the Project. MOHSA's insistence in the early years of the Project on over- designed Health Centers was very unfortunate and later on the Project unit's architects interfered unnecessarily with the work of the consulting firm responsible for construction supervision. MOHSA did not take on its responsibilities on nutrition matters; its total lack of commitment in this area is all the more regrettable given that Rwandese experts had the technical capacity to  - it - prepare a reasonable program. The IDA-financed Rwanda Food Security and Social Action Program (FY92) will be tackling nutritional issues that were not addressed under this project. MOHSA's performance has been particularly poor on project accounts, which have not been properly maintained, and the auditor's and the Bank's recommendations went unheeded three years in a row. ONAPO's performance on the population studies has been unsatisfactory. Its contribution to the project, the study of factors influencing the acceptance and continuation of contraceptive use was received at the time of project closing and could not be exploited under this project. Most covenants were complied with, but some with significant delays (Table 7). J. PROJECT RELATIONSHIP 30. Bank relationship with MOHSA, ONAPO and DFCS on the Project has been good. However, considerable tension occurred during project appraisal as the Bank and the Government initially held diverging views with regard to health center design. K. CONSULTING SERVICES 31. The performance of the consulting firm to help with the civil works was good. The long- tern advisor on MCH/FP under contract with WHO was not available for the planned period and was not therefore as productive as expected. The short-term technical assistance for the health information system and the review of the MCH/FP training curricula was satisfactory. A long- term advisor was recruited during the last 15 months of project implementation who also performed satisfactorily. However, the short-term technical assistance recruited under this project had virtually no opportunity to transfer any of their skills. The international consulting firm prepared the bidding documents for civil works and equipment but did not have a counterpart to whom it could transfer its knowledge. The above mentioned long-term advisor that was recruited during the last 15 months of project implementation was strongly suggested to the borrower as a means of speeding up project implementation. The project staff did not make use of his expertise to its full extent. L. PROJECT DOCUMENTATION AND DATA 32. The Staff Appraisal Report, the President's Report and the Development Credit Agreement were not detailed enough for the implementation and supervision of the Project. Working papers were prepared prior to project appraisal, but due to the change in task managers they were not systematically used during project supervision. MOHSA did not improve its statistical health information system. Audit reports were submitted in a timely manner during the last three years of project implementation. Prior to that time, audit reports were received with a delay of up to five months. The fact that updated information on project costs by component is not available did not facilitate the preparation of this PCR. The submission of progress reports was irregular until 1992. Since then, they have been submitted in a timely fashion on a quarterly basis. Even though these reports were well prepared, the project team perceived them as a Bank requirement and never used them as a management/monitoring tool for MOHSA. M. CONCLUSIONS AND LESSONS LEARNED 33. Despite implementation delays and some shortcomings, the Family Health Project was a good project. It has had a favorable impact on the delivery of MCH/FP services in Rwanda. Generally, the performance of the government and the Bank has been satisfactory.  - 12 - 34. According to the staff appraisal report, the main risk of the project was that implementation could be delayed because MOHSA had limited administrative capacity and virtually no experience or appreciation of the managerial challenge inherent to implementing a Bank-funded project. At the project appraisal and negotiations stages, the Bank tried to convince MOHSA to recruit long-term technical assistance to assist in procurement and overall project management for the first three years of project implementation. However, MOHSA did not see the need and made it clear that this was not a negotiable issue. The technical assistance could have helped get the project off to a good start. It would have transferred knowledge on procurement and project management issues to the project staff and MOHSA so to enable them take over for the latter part of the project. There was a flaw in the project design as the recruitment of a procurement specialist was not forecasted. It also appeared that during the first four years of project implementation, MOHSA was not very committed to the project. Had these issues been addressed earlier, project implementation during the first four years would have been quicker. At the time of the mid-term review in 1989, only 20% of the credit had been disbursed. By this time, MOHSA was extremely committed to making the project work. A project unit (staffed with competent persons) was created within MOHSA for the purpose of implementing this project and was given complete autonomy for its day-to-day management. The project unit agreed to hire an international consulting firm to assist in the preparation of the bidding documents for civil works and equipment. During the mid-term review, it was also suggested to hire a long-term international health manager to assist in project implementation, a suggestion which MOHSA also followed. On the accounting front, based on the recommendations of all audit reports, the Bank suggested the computerization of the project accounting system as a way of rectifying the problems linked to weak internal controls. The project unit staff did not take this seriously, and after three years of efforts from the Bank's side, little was accomplished in this domain. Supervision of the project by the Bank was quite intensive during some periods; in FY90 the Bank devoted 31.4 SW to the supervision of this project which was another reason for the project's turnaround. The skill mix during supervision missions was adequate. During the last two years of project implementation, the project was mainly supervised by a financial analyst; expertise on public health, nutrition, and architectural issues was sought numerous times informally from other Bank staff at headquarters or in the field preparing and/or supervising other PHN operations at headquarters as well as in the field. 35. The first and most important lesson learned from this project was that when dealing with a first time borrower, the Bank should be more realistic when preparing implementation schedules and disbursement forecasts. In terms of project management, the lessons learned are that: (a) project staff need to be highly competent, motivated and trained in Bank procedures; (b) MOHSA should not be directly involved in the project's day-to-day management; and (c) technical assistance is necessary for first time borrowers to assist in programming/monitoring and procurement. The project also demonstrated that a lot of time is required to formulate realistic and meaningful proposals on additional sources of financing and resource mobilization in the sector. This knowledge of health financing and resource mobilization will be instrumental when preparing future operations in the sector. Overall, despite the delays and shortcomings of certain project components, the Family Health Project's overall performance was good since it had a positive impact on the delivery of MCH/FP services in Rwanda.  - 13 - PROJECT COMPLETION REPORT RWANDA FAMILY HEALTH PROJECT (CREDIT 1678-RW) PART II: PROJECT REVIEW FRONI BORROWER'S PERSPECTIVE (TRANSLATION) Rwandese Republic Kigali, December 21, 1993 Ministry of Health No. 15/4283/PSF/93 P.O. Box 84 Kigali RWANDA Family Health Project Mr. David Berk Division Chief Population and Human Resources Division South Central and Indian Ocean Department Africa Region Dear Mr. Berk, Reference made to your letter dated November 22, 1993 transmitting the Project Completion Report for Credit 1678-RW, soliciting our comments and further clarifications, I am pleased to announce that we have found the report virtually complete. This facilitated considerably our task. Please find some additional comments and the Government's opinion on the above-mentioned report in the following paragraphs. First of all, we familiarized ourselves with the report and then distributed it to all the concerned parties. The various institutions and persons that worked on the project from project identification until closing reviewed and commented on the report. They are mainly the project coordination unit and the project's Interministerial Coordination Committee. Comments were collected by the Family Health Project Coordination Unit and were discussed during a meeting in which Mrs. Eileen Murray, task manager for the Family Health Project on mission in Rwanda was present. Comments and observations which were unanimously agreed upon were incorporated into the draft Project Completion Report and the revised draft was made available during Mrs. Eileen Murray's mission.  - 14 - Throughout this process and on the basis of the revised draft, we would like to state the following: - We confirm the data in Part III of the Project Completion Report; - Our comments on Part I of the report were incorporated into the draft Project Completion Report and this draft having been enriched reflects entirely our opinion; - The Bank's performance was noted throughout all phases of the project. The key point was the numerous and pertinent supervision missions which were fielded at times where urgent problem solving was necessary. Not only did these missions assist in problem solving, but they also helped in ensuring greater sustainability which was advantageous to all concerned. - The Ministry of Health's performance was satisfactory after the initial trial and error period due to it being a first time borrower. The Ministry of Health became increasingly familiar with Bank procedures which seems to indicate a good performance. The clear management structure and the additional managerial autonomy granted to the project team were important factors which had a positive impact on project implementation. We believe that in the future, the setting up or the revision of certain administrative procedures and decision making levels will be necessary in order to minimize problems related to administrative bottlenecks, even if this will only be beneficial for future projects. - The relationship between the World Bank and the Ministry of Health was essentially frank and based on mutual understanding. It is this type of relationship of a true partnership that in essence enabled the project to be completed. Sincerely yours, The Minister of Health Dr. Casimir Bizimungu cc: President of the Republic Prime Minister Minister of Plan Minister of Finance  - 15 - PROJECT COMPLETION REPORT RWANDA FAMIILY HEALTH PROJECT (CREDIT 1678-RW) PART III: STATISTICAL INFORMATION 1. Related IDA Credits Credit No./Project Purpose Year of Status Comments Title Approval - Population To develop, on an 1982 Completed ONAPO was unable to component of experimental basis, increase significantly the BGM II Rural community-based family number of contraceptive Development planning services in the acceptors. Major constraint Project prefecture of Kibungo. was lack of MOHSA (Cr. 1283-RW) Component to be involvement in FP services implemented by provisions at health center ONAPO level. - Second Education Establishment of one 1982 Completed Construction was of good Project A-3 nursing school in quality. (Cr. 1263-RW) Gisenyi - Population Project To support the 1991 Extremely ONAPO, which had been (Cr. 2272 - RW) implementation of the slow given the responsibility of National Population progress coordinating the Policy and to contribute because of implementation of this to reducing the total manage- operation, has been unable fertility rate, improving ment to manage the project maternal and child problems properly. Responsibility health, and integrating for the project has been the demographic transferred to MOHSA. dimension in cross- sectoral development activities. Food Security and To improve the food 1992 Credit Project is off to a good Social Action security and social effective start. Project welfare of the poorest 8/5/93 (Cr. 2388 - RW) population groups, to improve the government's capability to monitor living standards of the population, and to initiate a long-term poverty alleviation strategy. .  16 - 2. Project Timetable Item Original Date Date Timetable Revised Actual - Identification 12/83 - 12/83 (Initiating Project Brief) - Preparation 4/85 - 4/85 - Appraisal Mission 7-8/85 - 7-/8/85 - Credit Negotiations 2/86 - 2/86 - Board Approval 4/1/86 - 4/1/86 - Credit Signature 5/23/86 - 5/23/86 - Credit Effectiveness 9/22/86 11/21/86 2/27/87 - Credit Closing 6/30/92 6/30/93 12/31/93 6/30/94 3. Credit Disbursements Cumulative Estimated and Actual Disbursements |_____ ______ (USS million) l Fiscal Year FY87 FY88 FY89 FY90 FY91 FY92 FY93 FY94 Appraisal 0.60 2.60 5.40 8.30 10.20 10.80 - Estimate Actual 1.07 1.61 1.87 2.73 3.68 7.65 12.63 13.51 Actual as % 178% 62% 35% 33% 36% 71% 117% 125% of Estimate Note: Due to an increase in the value of the SDR in dollars, actual disbursements in dollars have been greater than the amount estimated at appraisal.  - 17 - 4. Project Implementation Appraisal Actual or PCR Indicators Estinates Estimates A. Strengthening Family Health Services (a) Number of health center staff retrained 1,400 1,320 (b) Number of additional A4 trained and 200 300 deployed (c) Number of peripheral health facilities 30 - 18 completed. upgraded or rehabilitated - 4 completed at 60% only because of the war. (d) Percentage of health centers delivering 100% 92% FP services B. Institutional Strengthening (a) Training of MOHSA/ONAPO regional completed - completed teams. (b) Fellowship and Study Tours completed - completed (c) Supply of vehicles & equipment completed - completed (d) Construction of regional offices 8 - 6 (e) Health financing study completed - completed; because of complexity of subject, additional studies were required. (f) Health Information System Completed - Partially completed; first phase of needs assessment and requirements finalized by an international consultant. C. Human Resources Development (a) Construction of two A3 nursing schools completed - one completed. - one completed at 90% only because of the war. (b) Training of teachers completed - not done D. Population Policy (a) Study of factors influencing the completed - Completed. acceptance and continuation of contraceptive use (b) Study of maternal and under-five completed - completed (not under project, but mortality as part of USAID financed DHS undertaken in 1991).  - 18 - 5. Project Costs and Financing A. Project Costs (Appraisal Estimate) Local I Foreign Total -------US$ Thousand---- I. Strengthening Family Health 1,559 2,099 3,658 Services II. Institutional Strengthening 916 2,268 3,184 Ill. Human Resource Development 2,066 1,211 3,277 IV. Population Policy Studies 113 119 232 V. Project Management 368 555 923 VI. Refunding of PPF 176 264 440 Total Base Cost 5,199 6,517 11,715 Contingencies Physical 79 114 193 Price 1,292 1,251 2,543 Total Project Cost 6,569 7,882 14,451 (net of taxes and duties)  - 19 - B. Project Financing Plan (Appraisal Estimnate) Local Foreign I Total -----US$ Thousand---- IDA Credit 3,740 7,063 10,803 World Health Organization 725 725 Government: Recurrent Budget 2,829 2,829 Development Budget 93 I_93 6,569 7,882 14,451 Note: Because project accounts have been kept by expenditure category, there is no information on the actual cost of each project component which could be compared with the estimate included in the Staff Appraisal Report. Similarly and for the same reason, there is no information on the financing that has been actually provided by government, IDA or WHO by project component. 6. Project Results Indicators Appraisal Estimates PCR Estimates (As of, or for year ended (Most recent information 12/31/91) available) I. Contraceptive 10% 13% prevalence 2. Child health 30% 85% monitoring 3. Deliveries in health 30% 30% facilities 4. Prenatal care 80% 95 % Note: An evaluation of the economic impact or financial impact does not apply to this project, and it is too early to assess the impact of the studies financed under the project.  - 20 - 7. Status of Covenants Section in Credit Deadline Agreement Subject for Status compliance 2.02 (b) Operation of Special N/A Satisfactory Account 3.01 Carrying out of project by N/A Not very satisfactory in MINISAPASO and the early years, since it MINEPRISEC was not with due diligence and efficiency. 3.02 Procurement N/A Unsatisfactory but improved towards the end of the project 3.03 Borrower to submit health 9/30 Not complied with by the sector investment program due date; generally, for following year, investment programs including proposed budget have been submitted for project when published in Official Gazette. 3.04 Borrower to submit study 4/30/87 Complexity of subject on financing of public health required additional and proposal for studies which were done, implementation. but no proposal for implementation was submitted. 3.05(a) Borrower to appoint full- 9/30/86 complied with on time chief for 10/29/86 MINISAPASO's MCH Division 3.05(b) Borrower to employ an 12/31/86 Not complied with by additional training specialist due date, but in 1988 for MINISAPASO's three additional training Training Division specialists were assigned to training division and project unit. 3.06 Borrower to provide the 12/31/86 Complied with in locations of the 5 September 1986. unidentified health centers  - 21 - Section in Credit Deadline Agreement Subject for Status compliance 3.07(a) Borrower to submit proposal 12/31/87 Not complied with by to improve MINISAPASO's due date; consultant statistical health information report submitted in 1991. system 3.07(b) Borrower to submit 12/31/87 Not complied with by the MINISAPASO's proposal due date. However, a for a career path for nurses MOHSA directive of aides (level A4) March 1990 stated that this personnel should be recognized as specialized workers and provided with the same benefits as "aides-infirmiers". Moreover, budgetary positions were provided for A4 nurses aides. 4.01(a) Borrower to maintain N/A Unsatisfactory; Borrower project accounts failed to remedy the shortcomings identified by the auditor, despite several reminders from the Bank. 4.01(b) Borrower to have project 6/30 1987: complied with in accounts audited annually March 88 1988: complied with in October 89 1989: complied with in May 90 1990: complied with in November 91 1991: complied with in August 92 1992: complied with in June 93  - 22 - Section in Credit Deadline Agreement Subject for Status compliance Section of General Conditions 9.06 Progress Reports N/A Reports not submitted regularly during first four years. During the last three years, quarterly progress reports were received. 9.06 Completion report Not due yet 8. Use of Bank Resources A. Staff Inputs (in staff-weeks) Stage of Project Actual Through Appraisal 95.9 Appraisal through board 45.4 approval Board approval through 4.3 effectiveness Supervision 128.3 Total 273.9  - 23 - B. Missions Stage of Month/Year Nurnber Days Specializations Performnance Types of Project Cycle of in Represented Rating Problems Persons Field (a) (b) (c) Through Appraisal Identification 11/83 3 15 PHS Preparation 4/84 2 10 PHS Preparation 9/84 2 7 PHS Preparation 2/85 2 15 PHS Pre-appraisal 4/85 4 14 PHS, AR Appraisal 7-8/85 5 19 PHS, FA, AR, DEM Board Approval through Effectiveness supervision 1 5/86 1 5 PHS supervision 2 8/86 4 8 PHS, AR, EC Supervision supervision 3 2-3/87 2 10 PHS, AR 2 supervision 4 9/87 2 7 PHS, AR supervision 5 1-2/88 2 15 PHS, AR 2 supervision 6 10/88 3 10 PHS, AR, NS 2 supervision 7 2/89 1 12 PHS 2 PMF supervision 8 4/89 1 6 AR 2 PRO supervision 9 8/89 2 16 EC, PHS 2 PRO supervision 10 11-12/89 2 13 AR 2 PRO supervision 11 2/90 2 11 EC, PHS 2 PRO  - 24 - B. Missions Stage of Month/Year Number Days Specializations Performance Types of Project Cycle of in Represented Rating Problems l___________ Persons Field (a) (b) (c) supervision 12 1-2/91 2 12 EC, AR 2 PMF supervision 13 6-7/91 1 4 AR 2 PRO supervision 14 10/91 2 14 PHS, AR 3 PMF supervision 15 9-10/92 1 14 FA 2 SP supervision 16 4-5/93 1 15 FA 2 SP supervision 17 7/93 1 26 FA 1 a) Key to specialization: PHS = Public Health Specialist FA = Financial Analyst EC = Economist NS = Nutrition Specialist AR = Architect DEM = Demographer b) Key to performance rating: 1 = Problem free 2 = Moderate problems 3 = Major problems c) Key to types of problems: PMF = Project Management Performance PRO = Procurement SP = Studies Progress