Guinea - Health Services Development Project

 Health services development project Report No: ; Type: Report/Evaluation Memorandum ; Country: Guinea; Region: Africa; Sector: Other Population Health & Nutrition; Major Sector: Health Nutrition & Population; ProjectID: P001054 The Republic of Guinea Health Services Development project, supported by Credit 1837-GUI for SDR15.1 million (US$19.7 million equivalent), was approved in FY88. The credit closed on June 30, 1995 after an 18-month extension, and a small balance was canceled. The Africa Regional Office prepared the Implementation Completion Report (ICR). The borrower’s ICR and comments are included as appendixes. The objectives of the project were to improve the quality and efficiency of basic health services by strengthening the Ministry of Health and Social Affairs (MSAS), introducing policy and administrative reforms, and, in Middle-Guinea, strengthening the financial and operational management of basic health services, restoring facilities, and introducing cost recovery. The project financed vehicles, equipment, materials and drugs; technical assistance, training, fellowships and studies; and incremental operating costs. Despite difficulties and delays, the project was implemented largely according to plan and achieved most of its physical and institutional objectives, including making a start on community-based management of health facilities. It strengthened the MSAS and priority technical programs, improved staff skills, and improved the quality of the ministry’s surveys, studies and dissemination activities. Basic health services in Middle-Guinea also improved substantially under the project, especially community- based management of health facilities and cost recovery for both drugs and services in health centers and hospitals. The project also made a start on improving the situation of women by providing training in mother and child care, hygiene, disease prevention and family planning. These positive results were due to strong commitment from government, staff and beneficiary interest in most activities, and the success of cost recovery in generating funds. Implementation problems included poor road conditions over long distances, remote sites, delayed local funding, weak management of procurement and financial aspects, contractual issues, poor maintenance of building and equipment, limited technical expertise, and weak political support in Middle-Guinea for family planning. The project did have some disappointing outcomes. Family planning efforts had little impact, and health centers are not being used to capacity. The project’s impact on health status was not assessed. With respect to future operation of the project, the ICR notes that a follow-up health sector project is under way and that a Population and Reproductive Health project is being prepared, but it does not address the operation and maintenance (O&M) of the newly improved health facilities. The Operations Evaluation Department (OED) lowers the ICR rating for project outcome from satisfactory to marginally satisfactory. The project achieved its stated intermediate objectives but did not address the impact of these investments on rates of use of health facilities or the health of the targeted vulnerable groups. OED agrees with the ICR rating of institutional development as substantial, sustainability as likely and Bank performance as satisfactory. Management capacity was strengthened, performance of technical programs improved substantially, the administrative structure of MSAS was changed, staff were redeployed, and planning and budgeting were improved. Sustainability prospects are enhanced by all project activities having been included in regular government operations, and by provisions in a follow-up sector credit to address cost recovery and health sector budget allocations. However, project objectives and design focused too closely on intermediate outputs and physical aspects at the expense of the developmental objective of improving the health of vulnerable groups.  The ICR is satisfactory, but would have been improved by giving greater attention to the future operation of project facilities and the financial sustainability of health facilities, which was a concern at appraisal. It lists some familiar lessons, including the need to assess the impact of cost recovery on the poor, to raise low utilization rates of health facilities and to foster political support for family planning programs. The overriding lesson, however, is that in framing objectives and designing such health sector operations, projects need to give more attention to the overall development objective of improving health standards and to monitoring changes. An audit is planned.