Morocco - Health Development Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 14675 PROJECT COMPLETION REPORT MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) JUNE 26, 1995 Human Resources Division Country Department I 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.  CURRENCY EQUIVALENTS At appraisal: US$1 = Dirham (DH) 9.47 DH1 = US$0.106 1986-1994 Period Average US$ 1 = DH 8.4 DH 1 = US$ 0.120 FISCAL YEAR OF BORROWER January 1 - December 31 ABBREVIATIONS AND ACRONYMS ADB African Development Bank FP Family Planning IEC information, Education and Communication GDP Gross Domestic Product MCH Maternal and Child Health MOPH Ministry of Public Health PPF Project Preparation Facility SIAAP Service d'Infrastructure des Actions Ambulatoires Provinciales (Division in charge of ambulatory services at provincial level) UAM Unite d'Approvisionnement en Medicaments (Drug Supply Unit)  FOR OFFICIAL USE ONLY The World Bank Washington, D C 20433 U.S.A Office of the Director-General Operations Evaluation June 26, 1995 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECT: Project Completion Report on Morocco Health Development Project (Loan 2572-MOR) Attaclhed is the Project Completion Report (PCR) on the Morocco Health Development project (Loan 2572-MOR, approved in FY85) prepared by the Middle East and North Africa Regional Office. Part 1I was prepared by the Borrower. The main objective of the project was to accelerate the transition from an urban based and hospital-oriented health system to a more cost-effective system of primary care services emphasizing outreach in rural areas. To achieve this objective the project was to (a) strengthen primary health care delivery, including family planning, in three provinces; (b) strengthen the capacity of the Ministry of Public Health (MOPH) in planning, training, research, evaluation and health service administration; and (c) improve the supply, distribution and control of drugs. Implementation of primiary health care activities in the three pilot provinces was successful as demonstrated by improvements in the accessibility of services and service utilization. Efforts to strengthen the support system were less successful partly because the MOPH was reorganized several times during project implementation. Moreover, the training and health education activities included in the original project design were absorbed into projects financed by other donors and were not evaluated in the PCR. Studies of hospital management and health financing were delayed, but eventually proved useful to the borrower. The drug supply component was a source of considerable discussion throughout project implementation, and resulted in little apparent impact on drug policy. The outcome of the project is rated as satisfactory. Improvements in the approach to primary health care delivery piloted under the project are being extended to non-project provinces. However, the financial sustainability of the primary health care approach established by the project is uncertain, and is the subject of a continuing dialogue with the borrower. Sustainability is therefore rated as uncertain. Institutional development is rated as modest as systems for assuring local adaptation of service delivery models remain dependent on continued prodding from the central administration rather than on improved organization and better incentives in regional and local administrations. The PCR provides an adequate account of project implementation. An audit is planned. Attachment <T 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 TABLE OF CONTENTS Preface.. Evaluation Summary .......................................... PART I. Project Review from Bank's Perspective ...... .................. 1 - Background ..........................................1 - Project Objectives and Description ...........1..................... I - Project Design .......................................... 4 - Project Implementation ........................................ 5 - Project Results and Outcome ..................................... 5 - Project Sustainability and Future Operation ............................ 8 - Bank Performance ......................................... 9 - Borrower Performance ........................................ 10 - Key Lessons Learned ........................................ 10 PART lI. Project Review from Borrower's Perspective ....... . . . . . . . . . . . . . 13 PART III. Statistical Information ................. ... .... ... .... . . 19 - Table 1: Related Bank Loans/Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 - Table 2: Project Timetable .20 - Table 3: Loan/Credit Disbursements .21 - Table 4: Selected Monitoring and Impact Indicator in the Project Area .21 - Table 5: Studies Included in Project .22 - Table 6A: Project Costs .............................. 23 - Table 6B: Project Financing . .............................. 23 - Table 7: Status of Legal Covenants ............................ . 24 - Table 8: Bank Resources: Staff Inputs ........................... . 25 - Table 9: Bank Resources: Missions .............................. 26 This documnent 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.   - i - PROJECT COMPLETION REPORT MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) Preface This is the Project Completion Report (PCR) for the Health Project in the Kingdom of Morocco, for which loan 2572-MOR in the amount of US$28.4 million equivalent was approved on June 6, 1985 and made effective on July 29, 1986. The loan was closed on December 31, 1993 after two extensions from its original closing date of December 31, 1991. Final disbursement took place on April 12, 1994, at which time a balance of US$ 2.6 million was canceled. The PCR was prepared by Claire Voltaire, MN1HR of the MENA region and reviewed by Roslyn G. Hees, Division Chief, MN1HR, and Rene Vaurs, Acting Project Adviser, MN1DR. Preparation of this PCR was begun during the Bank's final completion mission in May 1994. It is based on material in the project file, on the Borrower's financial completion report and on its impact evaluation of the basic health component which was carried out by the three pilot provinces and the Institut National d'Administration Sanitaire. (See Annex).   - iii - MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) Evaluation Summary Project Obiectives and Description 1. The project aimed at accelerating the shift from an urban-based hospital-oriented health system to a more cost-effective system of primary care emphasizing outreach activities in the rural areas. To that end, the project included four components which aimed at improving: (i) primary care delivery in three pilot provinces by strengthening the infrastructure and equipment as well as the logistics and monitoring of the programs delivery, and the training of medical staff; (ii) the management capacity of the Ministry of Public Health (MOPH) at both central and provincial levels, in terms of planning, training, research and evaluation, and health service administration; (iii) training and IEC programs; and (iv) the supply of basic drugs by establishing a coordinated system for the procurement, storage, formulation, packaging, distribution and control of drugs for the public system. Summary of Findings 2. The project has mixed results. Two of the four components were completed: a. The Primary Health Care component was fully implemented in its physical and "software" aspects though a large share of the new facilities only became functional at the veiy end of the project; to date 29 health facilities out of the 126 (more than 20%) built remain closed due to insufficient staff to man them. In contrast, reorganization of service delivery, planning, supervision and monitoring methods were put in place at the start of the project and are well assimilated by staff in all three provinces. The project has indeed permitted to improve population coverage. b. It is difficult to measure the extent to which the project has strengthened MOPH management capacity as the ministry underwent several reorganizations during project implementation. While management of civil works certainly improved, procurement, program budgeting and resource allocation remain serious issues for the MOPH. The outcome of the two studies on the financing of the health sector and on hospital management which were carried out is uneven: (i) the health financing study was of good quality and served as a basis to the discussions on health financing reforms which have culminated with the preparation by the Government, with Bank support, of a health insurance reform proposal; (ii) the Hospital Management Study output is more difficult to assess as its diagnostic phase was never followed by the prospective one that was intended to specify and test the options for reform. c. Training and IEC Component: Only 25% of the funds allocated to this component were disbursed, due to the availability of bilateral funds to finance training activities. d. Improvement in the supplv of basic drugs: This component remains incomplete. Equipment for the drug Unit built under the project has yet to be purchased and, despite some improvements, the Central Pharmacy organization, procedures for the procurement and distribution of drugs remain an issue for the MOPH.  - iv - 4. Several factors adversely affected project implementation. In particular: (i) the lack of counterpart funds as a result of the economic situation, delays in allocation and release of funds and the weak capacity of MOPH to manage commitments and disbursements; (ii) frequent organizational and staff changes in the MOPH which resulted in a lack of continuity of the dialogue; and (iii) the relative passivity of the Bank contribution in its comments to studies and progress reports and in proposing remedial actions. The main findings of this post-evaluation are the following: a. The financial sustainability of the system needs to be addressed without delay. The MOPH has already integrated this lesson in its dialogue and indicated its intention to proceed with new investments only when the sustainability of the sector has been addressed i.e, when adequate investment and more importantly recurrent resources can be secured. To that end, the preparation of the proposed FY96 Health Management and Financing Project has been halted. If project does not proceed, the health sector sustainability should be addressed through the FY96 Social Priorities Project. b. The overall organization of the pharmaceutical sector and the provision of drugs to the public sector need to be reviewed. A thorough review of the pharmaceutical sector and the development of a drugs policy for the public sector should be carried out prior to any further financing of drugs in a project. c. The policies and proiect activities cannot be divorced from their implementation structure: The current organization of the MOPH and of the medical provinces is ill- adapted to the objectives pursued by the MOPH and discourage efficiency and accountability. While MOPH is fully aware of this issue and has prepared a new organizational chart more in line with its objectives, it has not yet been implemented. Implementation arrangements for future projects should be an integral part of their design and should take into account the overall organizational structure of the Ministry, or should not proceed without addressing needed changes. d. The impact of the strategies deployed to deliver basic services (fixed facilities outreach techniques and better organization) should be assessed carefully to facilitate the development of a cost-efficient approach, adaptable to the specificities of each region. e. The Bank should have a more pro-active attitude in its comments and proposals for remedial actions (ie. restructuring of the project, increasing the supervision of "pilot/demonstrative" aspects of the project). The preparation of new projects should not start before the results of the previous project can be built on, and lessons learned so as to be integrated into the new design. 5. Overall assessment. The project results are partly satisfactory. The improved approach to the delivery of primary health care is being adopted in non-project provinces, although the financial sustainability of the approach remains uncertain and is being examined as part of the Bank's dialogue in the country.  PROJECT COMPLETION REPORT MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) PART I. PROJECT REVIEW FROM BANK'S PERSPECTIVE BACKGROUND 1. In the late 1970s, Morocco faced major economic and financial difficulties. While the population was increasing rapidly, GDP growth slowed down, fiscal and external imbalances reached peak levels, in particular after the 1979 drought and unemployment increased, varying between 22 to 30 percent. In 1980, with Bank and IMF support, the Government adopted an ambitious plan for recovery aimed at liberalizing the economy and redressing fiscal imbalances. The prospect of a period of financial constraints resulting from these reforms induced the Government to examine the possible impact of dwindling average family income and food availability on the population health status. At the time, Maternal and Child Health (MCH), Family Planning (FP) and nutrition programs reached less than one-third of the target population, transportation costs for outreach activities were soaring and budgetary allocations for drugs were grossly insufficient. The MOPH endeavored to review its strategy, placing emphasis on the expansion of primary health to the entire population. Such strategic thinking was integrated in the 1981-85 National Economic Plan. 2. The Government's medium- and long-term objectives for the population, health and nutrition sectors, which project objectives derived from, included: a. in population, to control demographic growth so as to limit size to 30 million or less by 2000 by stepping up population activities and raising contraceptive prevalence; b. in health and nutrition, to minimize the impact of the economic crisis on the health of the population, to improve MOPH's management and hospital performance, and identify cost-effective alternatives to the current health and nutrition programs. Because of its heavy dependance on external funds, the Government's long-term objectives were to secure an adequate financing scheme for health care activities and eliminate pockets of malnutrition by raising domestic food production. PROJECT OBJECTIVES AND DESCRIPTION 3. The project objectives, as defined in the Staff Appraisal Report, were to assist the Ministry of Public Health (MOPH) in strengthening and accelerating its on-going shift from an urban-based hospital-oriented health system to a more cost-effective system of primary care emphasizing outreach activities in the rural areas. 4. The project consisted of four components which aimed at:  2 a. strengthening primary health care in three provinces as a means to test a new delivery scheme before its implementation countrywide. Special attention was given to six core programs: immunization, FP, MCH, nutrition, front-line curative care and basic sanitation. The organization of the system was conceived to deliver these programs through polyvalent purpose staff, according to several types of strategies adapted to local conditions (terrain, population density..) by using a different mix of types of facilities, outreach techniques and staff. To achieve this objective, the following activities were to be implemented: upgrading and expanding the physical infrastructure; providing equipment; training of health staff; improving logistics and monitoring implementation to allow continuous adjustments. To that end, the project financed construction and rehabilitation of buildings, equipment, drugs, per-diems and vehicles; b. strengthening the management capacity of MOPH at central and provincial levels. The objectives were to improve capacities in terms of health sector planning, staff training, research and evaluation, and public health service administration, as a necessary condition for a large scale extension of the health care delivery experience to the rest of the country. Specifically, this component was to: (i) strengthen the planning capacity of the MOPH Infrastructure and Planning Department, in which the Project Unit was based; (ii) improve MOPH administration in particular in the areas of program budgeting and resource allocation, procurement and bidding procedures, civil works and maintenance, and management of personnel; and (iii) support the implementation of a health services monitoring and evaluation system and the realization of two studies on the financing of the health sector and hospital management. To that end, the project financed technical assistance and expert services, training and equipment; c. strengthening training and IEC programs; specifically this component was to: (i) strengthen the capacity to train paramedical personnel by completing the pedagogic equipment of a college of public health which had been financed under the Bank Third Education Project; and (ii) increase the capacity of the MOPH Health Education unit to produce IEC materials by providing audio- visual, printing and graphic equipment as well as technical assistance and fellowships for the production and dissemination of IEC materials; and d. improving the supply of basic drugs by (i) improving procedures and establishing a coordinated system for the procurement, storage, formulation', packaging, distribution and control of drugs for the public health system; and /f Formulation is the fuial stage of drug production, from intermediate ingredients to final or finished form. It consists of simple mechanical operations such as mixing, solving or dispersing and fragmentation into dosage forms.  - 3 - (ii) redefining the respective roles of the Pharmacie Centrale, the National Drug Control Laboratory and the Drug Supply Unit (UAM) to be created under the project. Disbursements on this component were conditioned upon the creation of the structure in charge of managing this unit. To this end, the project was to finance the construction of storage, packing and shipment space, a packaging unit and a small formulation laboratory as well as the related equipment, training and technical assistance. 5. Clarity of Objectives. Overall, the project objectives were well defined and were an integral part of the Government objectives which were also supported by other donors and international organizations involved in Morocco (UNICEF, USAID, WHO). They were consistent with the Bank assistance strategy in the social sectors which included improving basic social services in rural areas and encouraging a shift from capital and foreign exchange intensive hospitals to expanding basic health services. 6. The degree of Government commitment to the project varied between components: a. The extensive preparation work carried out by the MOPH over the period 1979-1984 for the Primary Health component with the support of a project preparation facility (PPF), ensured a good understanding of the concepts and a strong ownership especially at provincial levels; b. The second component -- Management -- responded to the perceived needs of the MOPH and was meant to support its on-going structural reorganization. With regards to the studies, addressing sector financing and hospital management issues was rightly perceived by the Borrower as a means to develop a sustainable system in the medium and long term. C. The third component --Training and IEC-- aimed at completing activities started in the Third Education Project (Loan 1220T-MOR), and as such its objectives were not reassessed and its implementation not expected to be problematic. d. While the objectives of the last component -- the improvement of the supply of basic drugs - were shared by all involved, the means to achieve them seem to have been ambiguous from the on-set of the project. There has been no doubt that the creation of the drug unit and the reorganization of the drug supply system were fully justified from a public health perspective. However, the scope of this component and the private pharmaceutical sector seem to have evolved early in the project, increasing doubts as the economic viablility of the approach adopted.  -4 - PROJECT DESIGN 7. This first Bank project in the health sector in Morocco initially included two components: basic health services and management capacity. Its design aimed mainly at creating a replicable model of basic health care while at the same time, strengthening the MOPH management capacity. It was also aimed at building a knowledge base, in particular in the areas of sector financing and hospital management which would have helped increase sector sustainability and would have permitted to build on initial achievements. The IEC and drugs supply components were added at a later stage of preparation, and their integration in the main concept of the project was not as strong. 8. The design of the project aimed successfully at improving the technical aspects of basic health care delivery, as well as the management of programs. The health planning activity which took place was a bottom-up effort in which each provincial unit defined its problems, goals, management modes and monitoring tools. However, the functional links between this unit (Service d'infrastructure des actions ambulatoires provinciales, SIAAP) in charge of ambulatory care and inter alia of the six core programs supported by the project, the medical province and the different departments at the central level were not redefined to ensure the coherence of the project with the overall organizational structure of the system . This may be explained by the fact that the MOPH was, at the time of appraisal, under-going a structural reorganization to eliminate the existing dichotomy between the administrative and technical functions. As a result the provinces had to concentrate their efforts in implementing as best as they could, directives from the central level, sometimes to the detriment of the more pro-active approach promoted by the project, in which they defined their objectives and strategies according to local priorities. 9. In the early 1990s, the MOPH underwent another reorganization which increased the number of departments at central level and provided them with increased autonomy. The provinces found themselves faced with an even greater number of interlocutors. Basic core programs were rightly being delivered by the same multi-purpose medical staff, and their supervision, monitoring and evaluation done by the same persons at provincial level. Nevertheless, at central level, program guidelines, training, monitoring and financing remained vertical, creating some overlaps and/or conflicting messages which made integration and coordination at the provincial level more difficult and cumbersome. The transfer of the Project Unit from the Direction des Affaires Techniques (Division de la Planification), to the Direction de la Prevention et de l'Encadrement Sanitaire created an additional discrepancy between functions and structure. 10. Finally, with regard to the drug supply component, the project design foresaw the need for a close collaboration with the pharmaceutical private sector. However, it failed to set in place the mechanisms which would have ensured its collaboration.  -5- PROJECT IMPLEMENTATION 11. All project components were completed with the exception of the Drug Supply Unit and of the Training and IEC component which were executed only partially. Several factors influenced project implementation, causing significant delays: a. Lack of counterpart funds: Insufficient budgetary allocations as a result of the economic situation, delays in allocation and release of funds, political resistance to favor these provinces over others, and weak capacity of MOPH to manage commitments and disbursements, resulted in important delays from the project inception. In particular, the initial lag between Board presentation (June 1985), loan effectiveness (July 1986) and the first disbursements (March 1987), which was due to the lack of budgetary allocation, was never caught up. As a result, the loan closing date had to be extended twice (from December 31, 1991 to December 31, 1993). b. Frequent changes in the MOPH and in the Bank: Both institutions encountered several structural reorganizations and changes in individual responsibility. This resulted in additional delays as new mechanisms had to be designed and new managers had to become familiar with the project before taking action. This loss of momentum affected the levels of funds allocated to the project, as "lobbying" for the project was weaker. The transfer of responsibility for civil works from the MOPH to the Ministry of Public Works also caused delays in the construction of facilities. C. Relative passivity in the Bank's contribution: The frequent changes in task management described above and the conflicting priorities due to the simultaneous preparation and implementation of the Health Sector Investment Project (Loan 3171) led to a relative passivity of the Bank. It was slow or even silent in commenting on the two studies (Health Financing and Hospital Management) carried out by the Borrower, or on the project mid-term review prepared by the MOPH. The persistent misunderstanding in the realization of the last component -- improvement of the supply of drugs, which remains incomplete is another example, as explained in paragraph 19. PROJECT RESULTS AND OUTCOME 12. Primary Health Care. This component was fully implemented in its physical as well as its "software" aspects though a large share of the new facilities only became functional at the very end of the project; to date 29 health facilities out of the 126 (more than 20%) built, remain closed due to insufficient staff to man them. In contrast, reorganization of service delivery, planning, supervision and monitoring methods, were put in place at the start of the project and are well assimilated by staff in all three provinces. As illustrated by the MOPH  - 6 - mid-term review and final evaluation of the component, progress has also been achieved by the provinces in evaluation of outputs and outcomes. 13. The global management and planning methods put in place during the project have enabled the efficient deployment of staff which in turn permitted an improved population coverage in the three provinces. The Health service monitoring system put in place as part of the project has facilitated the decision process and provided a number of monitoring and impact indicators. However, as illustrated by the MOPH evaluation report (see examples in Table 4 in Annex to this PCR) the selection of these indicators does not always permit to link coverage and impact. 14. As shown in the table below, access to a health facility has been greatly improved. The ratio of population to health facility has evolved greatly during the project period from one basic center for 75,000 in 1985 to one for 44,000. While the number of general practitioners allocated to the project area doubled during the 1985-92 period (from 33 to 61), the number of para-medical staff only progressed for the same period from 717 to 841. Percentage of Population with access to a health facility in the project area 1985 1988 1990 1992 < 3Km 28 31 33 38 3 to 6 Km 14 15 17 14 6 to 10 Km 22 23 22 23 > 10 Km 36 31 28 25 15. Before being fully assessed, the deployment strategies for basic health care delivery developed in the project were generalized to all provinces, with external support from: (i) the Bank through the Health Sector Investment Project (Loan 3171-MOR), though with an evolution of the six core programs supported and, (ii) since 1992, the African Development Bank (ADB) in ten provinces. Considering the importance of the investments realized, in particular with regards to the construction of new centers, the achievements of the project have to be assessed in the context of their cost efficiency. This analysis should: (i) distinguish the earlier phase of the project during which improvements in service coverage were registered, though the new centers had not yet been constructed, suggesting that the reorganization of the provinces alone contributed to a large extent to the results obtained; and (ii) the cost-efficiency of the centers constructed cannot be assessed over the period of the project alone.  - 7 - 16. Strengthening of MOPH Manaeement Capacity. The MOPH underwent several reorganizations during project implementation which did not always seem to be technically motivated. The project design did not take into account the then upcoming reorganization. Under these conditions, it is difficult to measure the extent to which the project improved central management as it was intended (see para. 4.b). While management of civil works certainly improved, procurement, program budgeting and resource allocation remain serious issues for the MOPH. This is compounded by the "balkanisation" of the MOPH Departments characterized by overlapping and scattered responsibilities which prevent measuring output and efficiency, and promoting accountability. 17. The health service monitoring system was put in place in the provinces, as described in para 13 above. The outcome of the two studies on the financing of the health sector and on hospital management which were carried out, is uneven: a. The health financing study was of good quality, considering the lack of information available at the time. It resulted in a thorough data collection and analysis. The study served as a basis to the discussions on health financing reforms which have culminated with the preparation by the Government, with Bank support, of a health insurance reform proposal. This study has however not yet translated into concrete results in the financing of the system. An indirect benefit of the study was a transfer of know-how between the foreign firm and the teams of local consultants, jointly in charge of its realization. This fruitful association led to the emergence of a group of young Moroccan experts who has since then contributed significantly to the debate on health issues. This study also led to the creation, within MOPH, of a Health Economics Unit. b. The Hospital Management Study output is more difficult to assess. The diagnostic phase to which each hospital included in the study actively participated, was never followed by the prospective one that was intended to specify and test the options for reform. Also, due to a lack of counterpart capacity or a shift in MOPH priorities, the results of the initial phase were insufficiently discussed. 18. The results of the Training and IEC component are less clear. Only 25 percent of the funds initially allocated were actually disbursed. Half of this amount financed the equipment of the College of Public Health and the balance financed the production and dissemination of IEC materials. The lack of disbursements on this component is due to the availability of bilateral funds to finance the training activities. Though no formal amendment to the loan agreement was made, this component seems to have been dropped and was therefore not supervised.  - 8- 19. There is a discrepancy between the initial design of the last component - Improvement of the drug supply - described in paragraph 4.d, and its actual implementation, which remains unexplained by existing documentation and is probably at the origin of the misunderstanding between Bank and the MOPH. This was compounded by the fact that, until recently, the Bank's position with regard to drug sector policy was unclear. The UAM was built, though with three years delay, and with a design which does not correspond to its initial more modest concept. However the equipment remains to be purchased and, more importantly, the legal structure of UAM and the terms of its relationship with the private pharmnaceuticals sector are still undefined. Despite some improvements, the Central Pharmacy organization, procedures for the procurement, distribution and control of drugs still need to be improved. PROJECT SUSTAIN4ABILITY AND FUTURE OPERATION 20. Technical Sustainability. The global management methods and deployment strategies developed in the project to deliver the six core health programs have become an integral part of planning practice and are unlikely to disappear. However, some of the key features of this strategy, such as the travelling nurse who greatly contributed to the increase in population coverage, are being put in question as this category of staff who is more likely to accept this function has been eliminated in favor of more qualified nurses. It may therefore prove more difficult, especially in the mountainous provinces with dispersed population, to attract new candidates. Signs of low morale are already evident in this category of staff, whose working conditions have deteriorated (lack of maintenance of motorcycles, delays in payment of per diem,..). Similarly, unless drugs and contraceptives, and means of transportation for the mobile teams remain regularly available, it is unlikely that the provinces will be able to maintain their coverage level. This situation is the more problematic that the population expectations have risen with the educational level and the previous availability of services. 21. Financial Sustainability. The operating budgets of the provinces had a line item specific to the project. However, no provision has been made to ensure an appropriate level of operating budget after project closing to continue financing the drugs, per diems, and other consumable items necessary to ensure the functioning of the programs. It is therefore expected that the project investments will not be preserved and that the achievements realized in terms of population coverage will not be sustained, unless a sufficient allocation for recurrent costs is maintained. 22. Both the Bank's on-going Health Sector Investment Project and the ADB recent Basic Health Project which finance operating costs, have equally failed to integrate mechanisms to ensure the progressive sustainability of the health system which would reflect the priority given to basic health services by the Government. On the contrary, the inclusion in the Health Sector investment Project (Loan 3171 -MOR) of a significant component for the provision of drugs was an imnplicit acceptance that the financing of these operating costs would continue to depend on external financing.  - 9 - 23. The low level of national resources available in the public health sector and the related heavy reliance on external funds to finance not only investments but, increasingly, operating expenditures, considerably limit the MOPH capacity to articulate its operational priorities and control allocation of resources. All resources are already pre-allocated and pre-spent and the margin of maneuver is limited. BANK PERFORMANCE 24. During the 15-year period between project identification and loan closing, the Bank performance can be characterized by its irregularity, in terms of (i) the frequency of its missions and exchanges with the Borrower, and (ii) the quality and emphasis of its contribution and of the high turnover of its project managers, compounded by its organizational changes. Two phases can be distinguished: a. The first phase (preparation - early implementation) from 1979 to 1987, during which the project was handled by a specialized non-regional PHN Department. Field visits and correspondence, although infrequent, were very focussed and led to a systematic and thorough review of each of the project components, a broad discussion of all issues and agreement on the remedial actions and next steps. b. The post-Bank's reorganization phase, which scattered available health specialist resources. During this period, and even more after the start of the Health Sector Development Project (Loan 3171-MOR) which overshadowed the first project, supervision became less systematic, of shorter duration, concentrating on a limited number of themes -- mainly disbursement procedures and budgetary allocations -- which were rightly perceived as obstacles to timely implementation. As a result, difficulties in the realization of some of the components remained unseen or unaddressed for a long time. Bank documentation reflects this situation and progress and difficulties on some of the components remained unreported. Overall, Bank's attitude during the supervision period was rather passive and resulted in a number of missed opportunities to deepen the dialogue with the Borrower as illustrated by the following examples: The Borrower's mid-term review report of the project was received but not commented on. Similarly, it is only after the strong insistence of the MOPH that the Bank commented on the study of health financing and there is no record on any written comment made to the MOPH on the hospital management study. The implementation of the component aiming at improving the supply of drugs is another case in point. While the appraisal documentation clearly defines the drug Supply unit as a "procurement, packaging, distribution and limited formulation unit, with a close collaboration  - 10 - with the private sector", this unit seems to have evolved -- at least in its building design --into a full production unit. This evolution which is not documented in the files, has resulted in a misunderstanding between the MOPH and the Bank. Despite its skepticism that a public production unit was economically justified considering the rapid evolution of the Moroccan private pharmaceutical industry, the Bank failed to clearly state its position or to provide the necessary support to: (i) undertake a full assessment of the economic feasibility of this unit; and (ii) develop a coherent drug policy. At the same time, the Bank sent opposite signals that the component could proceed by giving non- objection to the procurement documents for the construction and equipment of the UAM, and providing informal advice on its status. BORROWER PERFORMANCE 25. Overall, Borrower's performance was excellent with regards to analyzing issues and conceptualizing strategies. However, the project suffered from difficulties in operationalizing the policies defined and the implementation capacity of the MOPH remains weak as a result of its structural organization. During the second half of implementation, the project seems to have been put on "automatic pilot" and activities were being carried out -- though at a slow pace-- without a thorough review of their impact. This is the more surprising that this pilot experience was meant to lay the ground work for broader reforms countrywide, and that the technical aspects of service delivery were indeed generalized. 26. With regards to the realization of the health financing study, the Borrower's performance was commendable. The report was produced, discussed extensively within the health sector (through workshops, seminars...) and more generally in the Government. The MOPH was very successful in mobilizing external support (USAID, WHO..) on the topic, and translating the study's recommendations and implications into operational activities, such as the health insurance proposal. 27. Although difficult to assess in the absence of records, the Borrower's performance on the Hospital Management Study was not as good. Counterparts do not seem to have reviewed the study's findings with the consulting firm and very few discussions of the report took place. It is only with the preparation of the Hospital Management Project that the dialogue with the Bank on that subject was renewed. KEY LESSONS LEARNED 28. Both the Bank and the MOPH should make more systematic use of the findings of this project to build on their future operations. Though a good opportunity was missed with the on-going Health Sector Investment Project (Loan 3171-MOR), since it started before the lessons of the previous one could be fully drawn, its implementation has permitted a better understanding of the issues which should be addressed. The areas of focus of future operations should be:  - 11 - a. The financial sustainability of the health system needs to be addressed without delay. The MOPH has already integrated this lesson in its dialogue and has indicated its intention to proceed with new investments only when the sustainability of the sector as a whole has been addressed ie. when adequate investment and more importantly recurrent resources (staff salaries, drugs... ) can be secured. To that end, the preparation of the proposed FY96 Health Management and Financing Project has been halted although it attempted to support health financing and hospital management reforms identified through the two studies supported by the project. If the Health Management project does not proceed, the health sector sustainability should be addressed through the FY96 Social Priorities Project. b. The overall organization of the pharmaceutical sector and the provision of drugs to the public sector need to be reviewed. The continued financing of drugs through external funds has been a disincentive to exploring more cost- effective alternatives and to rationalizing the procurement of drugs. This has been ultimately detrimental to the development of a fair and transparent competition within the private sector and very costly for the Government, as the prices of drugs produced in Morocco are high and foreign exchange is mobilized to finance what should be local costs. A thorough review of the pharmaceutical sector and the development of a drugs policy for the public sector should be carried out prior to any further financing of drugs in a project. c. The policies and project activities cannot be divorced from their implementation structure: The current organization of the MOPH and of the medical provinces is ill-adapted to the objectives pursued by the MOPH and discourage efficiency and accountability. While MOPH is fully aware of this issue and has prepared a new organizational chart more in line with its objectives, it has not yet been implemented. Irnplementation arrangements for future projects should be an integral part of their design and should take into account the overall organizational structure of the Ministry. or should not proceed without addressing needed changes. d. The relative impact of the strategies deployed to deliver basic services (fixed facilities, outreach techniques and better organization) should be assessed carefully to facilitate the development of a cost-efficient approach, adaptable to the specifications of each region. e. The Bank should ensure that appropriate mechanisms are included in the project design or, whenever possible, implemented prior to effectiveness to meet intended objectives. While the project design clearly stated that UAM should collaborate with the private sector, this failed to happen. The Bank should also have a more pro-active attitude in its comments and proposals for remedial actions (ie. restructuring of the project, increasing the supervision of "pilot/demonstrative" aspects of the project) The preparation of new projects should not start before the results of the previous project can be built on, and lessons learned so as to be integrated to the new design.   - 13 - PROJECT COMPLETION REPORT MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) PART II. PROJECT REVIEW FROM BORROWER'S PERSPECTIVE EXECUTIVE SUMMARY INAS' mandate is to evaluate the Health Development Project in three provinces: Agadir, Taroudant and Settat. This project was implemented in these provinces in 1986 and comprises 4 main components: 1. Development of health services at the provincial level; 2. Management, research and evaluation at the level of the Ministry of Public Health; 3. Health training/education at the national level; and 4. Basic drug supply at the national level. The project covers 2 million inhabitants and includes all levels of the system. Our evaluation mainly concerns the first component of the project: The development of basic health services. This evaluation was carried out by INAS, UGP and teams from the three provinces. There has been no foreign technical assistance. Funds were allotted for the purpose of this evaluation from INAS' general budget and was about DH 50,000. This amount financed three three-day workshops in Rabat for a dozen participants. The evaluation was delayed from original schedule for logistical and human reasons (change of directors and staff responsible for health services in the provinces, weak research capacity of provinces). An implementation progress report was attached to this evaluation to inform managers at central level on the dysfunctions identified during this crucial phase of the project, and in particular the status of implementation of the infrastructure and equipment components and, the ending of the project budgetary allocation. The proposed corrective measures are forwarded to all central managers. The principal limitation of this evaluation is the time frame 1985-1992. In 1992, the newly built infrastructure was not quite functional. We therefore expect an under-estimated view of the level of health coverage in terms of access, availability and use. To validate this evaluation, it is recommended to update this data through a second evaluation in 1996. The main point of this evaluation is that local teams have been trained and involved in all stages, specific training on research methodology was taught to some participants.  - 14 - The province presently has a detailed data base by sector and district which will serve for the planning of health services and the management of programs at the local level. Evaluation of the Resources put in place. Infrastructure: Infrastructure in the project area increased from 137 to 192 basic health services facilities. Architecture is satisfactory and well received by staff and population. Facilities are large, but nurses quarters are found small. Completion time of a random sample of 51 health facilities shows that 50% were built with within one year (3 months in Settat and 4 years in Taroudant). Equipment: All facilities are sufficiently equipped and equipment remains in stock in provincial storage pending the opening of the recently completed facilities. In Settat, there is equipment in stock for peripheral laboratories that should be redeployed for the national level. The quality of equipment is adequate and appreciated by professionals. The Radiology units suffer serious problems with the relationship user-supplier (breakdown, absence of corrective maintenance and installation problems). - Budget: Public works and equipment used 60% of the budget allotted to the project. In 1992, the project represented between 81 % and 18% of the operating budget depending on line items. This budget covered transportation expenses, office supplies, hygienic products, gas, drugs. The portion allotted to rural areas is important for all provinces. The project management unit produced a financial evaluation report on the project.  - 15 - - Human resources: In the three provinces, a total of 134 nurses were assigned between 1985-1992. The ratio nurses/health services facilities (all categories) reached 4.44% in 1992 compared to 5.25% in 1985. Staff assignments do not correspond in parallel to the needs of the 50 new completed facilities which started operations in 1992. The situation will be worse if the other completed facilities are open (another twenty centers). Process Evaluation: Project Implementation mechanisms represented an experiment for the Ministry of Public Health. Management structures were implemented and terms of reference were identified and set at all levels (central and provincial). However, the following problems were identified: lack of coordination, lack of synchronization central/peripheral, set up of the various project components and mobility of operational and supervisory staff. All project components under consideration were set up according to a plan which differs from one province to the other (see documents from provinces). Due to project size and requirements, the management component has become a priority over research. The study of this process is a lesson for everyone planning a similar project. This study on the process is documented in each province's specific report. Impact Evaluation: There has been a marked improvement of all priority health programs. In 1992, the immunization completion rate was 82%. The rate of recruitment of women in obstetrics reached 38%. Childbirth in supervised environments reached 35% (of which 45% in ambulatory environment). There is improvement in tuberculosis screening and a decrease of the 5 target diseases in the 3 provinces. Indicators in these provinces are slightly above national averages. According to the Ministry of Health's Office of Information and Statistics, infant mortality has significantly decreased between 1985 and 1992 for the 3 overall provinces. This decrease is similar to that of the national level.  - 16 - RESULTS Service Delivery: - Access: The 1992 situation showed that, on average, every citizen, may find a clinic within 14 km. This distance varies depending on the province. Population located farther than 10 km from a clinic dropped from 40 to 28% (extremes vary between 23 and 37%). 40% of inhabitants have access to a basic health center (35 % minimum, 48 % maximum). - Availability: Basic health services (CPN, immunizations, PF, corrective, etc.) are available in most of the basic health services facilities. Delivery Strategy: 60% of population was covered by the urban and rural fixed site (1992): 12% by outreach teams. 19% by outreach personnel by contact point. 5% by house visits. It is expected that the fixed site strategy will predominate over other delivery after the opening of about 20 centers. The outreach strategy is hampered by difficulties at : viability, logistics, management and efficiency. Integration: In all newly completed health facilities, a model of integration of health services has been developed, particularly for the SMI/PF/Childbirth. The same polyvalent staff ensures the care of beneficiaries in its entirety in the same space and for different needs. This experiment has every chances of being successful. It will be interesting to study it after a while. Efficiency: In the fixed strategy, the improvement of diagnostic tools, technology, allocation of essential drugs were accompanied by an improvement of care.  - 17 - Use of health services: All health facilities are under-utilized. In some centers, it is way beneath all acceptable norms despite availability of required resources. The rate average occupation rate of certain childbirth units varies between 22% in Settat and 42% in Agadir. This is quite low. OTHER ISSUES: 1. Traditional midwives: The experience is positive and replicable. Its limits reside in the difficulty of maintaining motivation and ensuring continuity of supervision by the health team. 2. In-service training: The in-service training program is presently solid at the level of these provinces. Skills and attitudes are improved for overall personnel, particularly technical personnel of SIAAP. The decentralization of the training process started at the level of these provinces to extend to the national level. The managers of these provinces designed the training modules on the management process and participated in the revision of health programs structures at the national level. 3. Peripheral laboratories: There is a wide gap (as to performance and output) among laboratories. The problem of these laboratories is supervision and management of these units. Staff and population are satisfied with this technology. 4. Community participation: The population, through local authorities and groups, has been informed and solicited to participate in the design phase of the project. The actual role of the population could not be assessed in this study. It remains that its contribution is punctual and consists of mainly the allocation of required resources (land, fuel, etc.) and not the decision-making process. The project did not identify one preferable approach on which professionals could build on. S. Competence of management personnel There is improvement in the managerial and programming capacity of all higher level staff of SIAAP and health districts. This situation may deteriorate if it does not resist the changes in the local political and administrative environment (partitioning, change of responsibilities, mobility of staff, lack of motivation).  - 18 - RECOMMENDATIONS 1. A second evaluation covering 1993 and 1994 is required to confirm the trend observed. 2. The achievements of the project must be sustained by local authorities. 3. The dysfunctions observed and reported to the central authorities will need to be considered for this and future projects. 4. The after-project financing needs must be assessed so that inadequate budget be provided in order to prevent the rapid degradation of the project's assets. 5. Any project must be preceded by a strategic evaluation. Decisions should remain subject to modifications during the life of the project and design should not be considered as immutable. 6. It is important to ensure the stability of key-personnel of the project at least until the end of the implementation phase. 7. The Health Development Project was a good vehicle for increased exchanges of views, communications, challenges between and with the local and central team. It spread the philosophy of basic health services which all teams adhered to and defended. What are the alternatives to create today in its place? Provincial teams are already discussing the "funeral of the project".  - 19 - PROJECT COMPLETION REPORT MOROCCO HEALTH DEVELOPMENT PROJECT (LOAN 2572-MOR) PART III. STATISTICAL INFORMATION TABLE 1: RELATED BANK LOANS Loan Title Purpose Year of Status I I Approval Preceding Operations This loan was the first Bank loan in the sector in Morocco. Prior to this loan, Bank involvement in the health sector was limited to a schistosomiasis component in the agriculture development Doukkala I Project (Loan 1201-MOR) and to a health manpower training component in the Third Education Project (Loan 1220T-MOR) which consisted in the construction, furnishing and equipping of a college of Public Health in Rabat, a school of medical technicians in Casablanca and three nursing schools in Oujda, Fes and Agadir. Following Operations Health Sector Investment To support the Government strategy to reinforce (a) basic health; FY90 Under supervision. 21% Project (Ln 3171-MOR) (b) referral, emergency and diagnostic services provided at regional disbursed. Closing date: and provincial hospitals, and building and biomedical equipment December 31, 1996 maintenance capabilities; (c) administration and management of (likely to be posponed). services provided by the MOPH in order to increase efficiency, and facilitate the implementation of administrative reforms designed to decentralize the management of health services; and (d) sector and policy reforms which address longer term issues related to the evolution and structure of the public and private sector health services delivery systems, financing mechanisms, and the mobilization of resources in support of the sector. Social Priorities Project The proposed project would assist the Government in the Planned implementation of its social strategy to help the least advantaged FY96 Under Preparation groups of Moroccan society play a full role in the country's economy, thus contributing both to increased productivity and enhanced equity. The basic health and nutrition component of this project would support the implementation of the medium-term action plan aiming at improving access of the target rural population to a package of essential services. To that end it would implement a number of intertwined actions: (a) rehabilitating/expanding the health infrastructure, while providing the necessary material, drugs (including contraceptives) and equipment; (b) promoting outreach and demand promotion strategies for the delivery of essential clinical and preventive services in remote areas; (c) strengthening and expanding FP services, and stimulating further demand for FP services (e.g. IEC programs); (d) improving the nutritional status of high risk groups and implementing programs to reduce the prevalence of micronutrient deficiencies; and (e) supporting actions aimed at redeploying and retraining the medical and paramedical personnel, in particular in the area of supervision and monitoring at the provincial level. Health Management The project would support Government efforts to (i) address major Planned Project hospital intemal efficiency issues to contain costs while improving Fy 96 Under preparation quality of services; and (ii) introduce new health financing reforms, able to increase the level of resources available and promote equity. Borrower asked to delay The proposed project would include the following components: (a) project preparation until development of hospital management capacities; (b) improvement sector ftnancing issues of service quality; and (c) development and implementation of new have been addressed at financing mechanisms and institutional development. the Govenmmental level.  - 20 - TABLE 2: PROJECT TIMETABLE Steps in Project Cycle Date Planned* | Date Actual Identification n/a September 1979 Project Preparation Facility (PPF) June 83 Preparation n/a April 1980, June 1981 Appraisal n/a October 1984 Negotiations n/a April 1985 Board Presentation n/a June 6, 1985 Signing Before October 1985 January 17, 1986 Effectiveness October 1985 July 27, 1986 Midterm review carried out by the Borrower December 1987 November 89 Project completion June 30, 1990 Loan closing December 31, 1991 December 31, 1993 As provided in Project Brief for processing steps up to Board Presentation, and in the Staff Appraisal Report (SAR) for steps occurring after Board Presentation. **AIl components were completed by June 1993 with the exception of the Drugs supply unit which remains incomplete to date. (see para. 19) and the IEC component which was dropped.  - 21 - TABLE 3: LOAN DISBURSEMENTS: CUMULATIVE ESTIMATED AND ACTUAL (US$ million) FY86 FY87 I FY88 [ FY89 | FY90 I FY91 [FY92 I FY93 | FY94 Appraisal Estimate 1 3 5 0 10 4 16.4 22 4 26.9 28 4 = Actual 0 0.13 1.13 3.54 7.93 13.98 19.33 23.52 25.84 Actual as % of estimate 0 002 0.1 0.21 0.35 0.52 0.68 0.82 0.90 Date of final disbursement April 1994 TABLE 4: SELECTED MONITORING AND IMPACT INDICATOR IN THE PROJECT AREA 1985 1988 1990 1992 IMMUNIZATION - Vaccinal Coverage (BCG) (Recruitement rate of children less than one year old) 66% 83% 84% 92% - Incidence of declared cases * Whooping-cough 393 11 10 14 * Measles 149 120 46 537 * Polio 4 0 0 0 FAMILY PLANNING * Rate of new acceptors (pills) 7% 9% 14% 13% * Rate of new acceptors (IUD) 0.25% 0.56% 0.65% 1.7% * Contraceptive prevalence rate* NA NA NA NA BASIC HEALTH SERVICES * Drop-out rate for tubercolosis treament 26% 16% 7% 4% MCH * % of assisted deliveries 21% 24% 28% 35% * % of assisted deliveries occurring in BHC 22% 26% 32% 45% * Infant Mortality** NA 57%o 52%o 48%o * Nimber of neonatal tetanus cases 23 15 2 0 SANITATION * % Water points treated 75% 71% 81% 87% * Incidence of Typhoid 37 15 12 9 Source: MOPH Project Evaluation Report (August 1994). * The 1992 DHS estimates the national prevalence rate at 41.5%. Only new acceptors and recruitment rates were monitored at province level ** Estimates, for two of the 3 provinces.  - 22 - TABLE 5: STUDIES INCLUDED IN PROJECT Study Purpose Status Impact of Study 1. Health Service MOPH was to implement A service monitoring Data collection remains Monitoring a comprehensive system was put in place in oriented towards services monitoring and evaluation the provinces which has provided by the centers system for the present facilitated the decision and is not often related project, including family process and permitted the to the total population. planning programs as a mid-term review and post- It is unclear whether first step toward evaluation of this project. these statistics, which monitoring the progress of represent a heavy the Health Development administrative burden for Plan as a whole. Data the staff are fully utilized collected by health in decision making. facilities was to be processed and complemented by operational or evaluative research. 2. Study on the Its purpose was to analyze Study completed in The study's Financing of the the availability and October 90. Was followed recomnmendations are Health Sector allocation of funds, and by several seminars and being implemented, and the efficiency and equity workshops to mobilize have resulted in of the present and external support and led to particular in the alternative financing the creation of a Health development of a health schemes. Economics Unit within insurance scheme. MOPH. 3. Study on Since hospitals absorb Diagnostic completed in While the diagnostic Hospital 72% of MOPH's operating June 89. The assessment phase was carried out Management budget, the study focused focussed on 5 areas: and provided insight on on hospital performance, Structural and physical hospital management the cost containment and characteristics of the prospective phase possible methods of cost hospital sector within intended to specify and recovery, in accordance MOPH, human resources, test options for reform with the alternatives of the financial resources and was not carried out. study on financing. organizational structure. This phase is however expected to be developed as part of the Health Management project preparation.  - 23 - TABLE 6A: PROJECT COSTS Appraisal Estimate (US$M) Actual/latest estimate (US$M) 1/ Local | Foreign | Total Local | Foreign Total Item costs costs costs 2/ costs 2/ Development of basic health services 12.5 10.7 23.2 20.7 17.6 38.3 3/ Strengthening of MOPH Management 0.8 0.9 1.7 0.7 0.9 1.6 Strengthening of training and EIC Capacity 0.5 1.1 1.6 0.1 0.3 0.4 Improvement of drug supply system 2.4 4.4 6.8 4.7 8.2 12.94/ Total Baseline Costs 16.2 17.1 33.3 26.2 27.0 53.2 Contingencies 7.1 7.2 14.3 PPF 0.06 Total Project Costs 23.3 24.3 47.6 26.2 27.0 53.3 5/ 1/ Exchange rate used corresponds to 1986 - 1993 average (US$ I = DH 8.4) 2/ Share of foreign costs in total calculated on the basis of appraisal estimates. 3/ Increase in cost of this component is due to the cumulative effects of: (i) an increase in the number of centers built; (ii) delays in implementation; and (iii) increase in the square footage of the center following the adoption of modular plan. 4/ Estimated cost of completing component. Expended to date : US$ 4.8M. 5/ Estimated cost of completing the project. Expended to date: US$ 41.9M. TABLE 6B: PROJECT FINANCING 1/ Appraisal Estimate (US$M) Actual/latest estimate (US$M) Local Foreign | Total Local 1 Foreign | Total Source costs J costs costs j costs IBRD 4.1 24.3 28.4 1.5 24.0 25.5 Government 19.2 - 19.2 16.4 - 16.4 Total 23.3 24.3 47.6 17.9 24.0 41.9 1/ This table reflects the financing arrangements for expenses already occurred. Financing source to complete the project (US$ 11.4M) has not yet been determined.  - 24 - TABLE 7: STATUS OF LEGAL COVENANTS Ori*Ina Revised Coven. Present FuWl fulfill. Description of covenant Agree./Sect. Type Status date date Cornuents 3.02 (a) 7 CP Establish & maintain a drug supply unit to Only construction was completed. undenatke Tesponsibility for the carrying out of The legal status of the unit remainsl the drug supply program included in Part D of to be defned and equipment to be project. ordered. 3.02 (b) 4 CP Each FY Each fiscal year DSU is provided, through Counterparts funds were separate annual budgetary allocations, with funds insufficient for timely suWficient to enable it to meet the estimated implementation. expenditures required for the carrying out of such a program. Sc. 5.la 5 C Maintain & continue to operate PIU. Sc. 5.la 5 C DIPC continues to carry its operations with assistance of qualified staff in adequate numbers. Sc. 5. ]a 5 CP - DSU is vested with responsibility for drug supply operation. Sc. 5.2a 5 C 12/31/86 Fumish to Bank proposed action plans for strengthening MOPH management. Sc. 5.2b 7 C Thereafter carry out such plans. Implemented 1990. Sc. 5.3a 8 C 12/31/85 Establish & maintain theteafter an interministerial committee to coordinate study on health sector financing (part B.3b) & review results of the study. Sc. 5.3b 7 C 12/31/86 Fumish to Bank detailed report on progress in Report completed October 1990. carrying out study. Sc. 5.4a 5 C 12/31/87 Fumish to Bank detailed report on progress in Delayed by delay in project carrying out study on hospital management (part effectiveness. Report received ________ _________ ~~B.3 6130/89. Sc. 5.5a 7 C 12/31/87 Fumish to Bank detailed report on progress implementation of project, including findigs and recommendations of health program study (pan B.3b). Sc. 5.6a 7 NC by 12/31 dropped Furnish to Bank detailed program of production This project component has been of each and dissemination of IEC material during the year dropped because of the availability year following calendar year of health education of concessional funding for health materials (part C.2). education programs. Sc. 5.6b 7 NC Thereafter carry out such a program. See above. Sc. 5.7a 7 NC Fumish to Bank for approval proposed programs See above. of fellowship training (parts B, C. D) and lists of proposed candidates for training. Sc. 5.7b 7 NC Thereafter carry out such programs. See above. Status 1. Account/audit C - Complied with 2. Financial Performance/generate revenue from beneficiaries NC - Not complied with 3. Flow and utilization of Projects funds CP - Complied with Partially 4. Counterpart funding 5. Management aspects of the Project or of its executing agency 6. Monitoring review and reporting 7. Implementation 8. Sectoral or cross-sectoral budgetary or other resource allocation 9. Sectoral or cross-sectoral budgetary/institutional action 10. Other  - 25 - TABLE 8: BANK RESOLTRCES: STAFF INPUTS Planned Actual Stage of project cycle Weeks 1 US$ Weeks ( USS Through appraisal n/a 85.6 Appraisal - Board n/a 79.6 Board - Effectiveness n/a n/a" Supervision n/a3' 110.8 Completion n/a 7V TOTAL 283 i/ Period Board & effectiveness cumulated with supervision. 2/ Estimate 3/ Data on planned staffweeks only exist for the period 89-94 and correspond to 85.5 sw (or average of 14.2 per year) which compare to an actual time of 76.2 sw for that period (or 12.7 average per year).  - 26 - TABLE 9: BANK RESOURCES: MISSIONS A. PREPARATION M/Y | No. Days in Skills | Comments persons Field j - March 1979 (Identification) 5 11 PH Specialist 11 Loan Officer 11 Education Specialist 11 PH Specialist 11 PH Specialist tlNFDA - September 79 Preparation 4 10 RH Specialist 10 Education Sp. 10 Loan Officer 10 PH Specialist - April 80 Preparation 4 11 PH Specialist 11 Economist 11 Loan Officer 11 PH Sp. Consultant - June 81 Preparation 5 Economist - June 83 5 5 Economist Iw 10 Architect 2w 5 PH Specialist 1w 5 PH Specialist 1w 5 Imp. Specialist 1w - October 24 - Nov. 5, 83 2 12 PH. Specialist 8 PH. Specialist March 84 1 20 PH. Specialist July 84 (Pre.appraisal) 1 3 PH. Specialist Sept. 84 Appraisal 9 20 PH. Specialist 20 Health Economist 20 Economist 20 Architect 20 PF. Consultant 20 Pharmac. Syst. Consultant Research 20 Assistant ? Division Chief ? Loan Officer March 85 I 7 PH. Specialist Review of project timetable and its budgetary implications  - 27 - TABLE 9 CONTINUED B. SUPERVISION M/Y No. Days in Skills Project Problems persons Field Rating Overall Dev. rating rating - June 86 (29 to 9) 3 12 PH. Specialist 12 PH. Specialist 15 Economist April 87 3 12 PH. Specialist Reviewed new 12 Operations Assistant organizational Structure 12 Health Economist of MOP & IEC component slow to start - February 88 1 ? I/ Disbursement Officer Discussions on opening of Special Account - August 88 2/ 3 8 Health Specialist 2 1 - Lack of operating 8 PH. Physician resources 8 Architect - Restructuration of tuberculosis program - January 89 4 8 PH. Specialist 2 1 8 PH. Physician 8 Pop. Specialist 8 Hospital Ad. Sp. - October 89 2/ 4 5 Health Specialist 2 1 - Mid-term review 5 PH. Physician carried out by MOPH 5 Architect 5 Education/Training Sp. - June 90 2/ 3 5 Health Specialist 2 1 - Delays in payments to 5 Financial Analyst contractors; funds to be 5 Architect delegated to provinces - Bids for UAM to high - November 90 2/ 2 9 Health Specialist 2 1 - Slow implementation 9 Financial Analyst - Projects costs to be updated - February 91 2/ 1 9 Financial Analyst -Health Financing repor received - New bid document for UAM reviewed - May 91 2/ 3 9 Health Specialist 2 1 -Discussion on 9 Financial Analyst feasibility of UAM 9 Architect I/ Multi purpose missions. Share of time allocated to project not available. 2/ Starting August 1988, all missions covered both the Health Development Project and the Health Sector Investment Project. Mission time has been apportioned equally to each project which is likely to overestimate time actually spent on the first project.  - 28 - TABLE 9 CONTINUED B. SUPERVISION (LTD) M/Y No. Days in Skills Projec Problems persons Field Rating Overall Dev. rating rating October 91 4 8 Sr. PHN Specialist 2 1 - Disbursement Issues 8 PH. MD - lack of counterpart 8 Hospital Administ. Sp- funds 8 Architect - Request for postponement of closing date - May 92 2 5 Financial Analyst 2 1 - Limited budget 5 Implementation Specialist allocations - November 92 3 9 Financial Analyst 2 1 - Some centers ready 9 Implementation Specialist but not staffed 9 Health Specialist - Status of UAM to be defined - MOPH Negotiating with the Pharmaceutical private sector - April 93 2 3 Project Officer 2 I UAM equipment and 3 PH Specialist status - May 94 (PCR) 1 6 Project Officer - -   IMAGING Report N o: 14675s TYpe: FCP