Sri Lanka - Health and Family Planning Project

Docurient of The World Bank FOR OFFICIAL USE ONLY Report No. 15763 IMPLEMENTATION COMPLETION REPORT DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA HEALTH AND FAMILY PLANNINC PROJECT (CREDIT 1903-CE) JUNE 20, 1996 Population and Human Resources Operations Division Country Department I South Asia Regional Office . ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1 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 Name of Currency Unit = Sri Lanka Rupee (Rs) Appraisal Year Average $US I = Rs. 30 Completion Year Average $US 1 = Rs. 50 WEIGHTS AND MEASURES I meter (m) = 3.28 feet (ft) I kilometer (kim) = 0.62 miles (mi) SRI LANKA FISCAL YEAR: JANUARY I-DECEMBER 31 ABBREVIATIONS AND ACRONYMS AMC - Anti-Malaria Campaign ARTI - Agrarian Research and Training Center DDG - Deputy Director-General DDHS - Divisional Director of Health Services GHC - Gramodava (Village) Health Center HRD - Humani Resources Development HRIS - Hluman Resources Information System IDA - Internationial Development Association IEC - Informationi, Education and Communication MCH - Maternal-Child Health MDPU - Managemenit Development and Planning Unit MOII - Ministry ot Health NGO - Non-Governlmenit Organization PHC - Primary Health Care PHM - Public Health Midwife PHN - Population. Health and Nutrition PPF - Project Preparation Facility SAR - Staff Appraisal Report SDHC - Sub-Divisional Health Center TFR - Total Fertility Rate UNFPA - United Nations Population Fund WHO - World Health Organization  FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT SRI LANKA HEALTH AND FAMILY PLANNING PROJECT (Credit 1903-CE) Table of Contents Pane No. Preface .......................................................... Evaluation Summarv ...... ........................................ii Part 1: Project Implementation Assessment ............................... Background ....... ............... .. ........................ Statement/Evaluation of Project Objectives ............ ..1............ Achievement of Project Objectives ...... .................... . 2 Implementation Record and Major Factors Affecting the Project .......... . 4 Project Sustainability ......................... 9 IDA Performance ............................................ 10 Borrower Performance ..................... .................... 11 Assessment of Outcome ........ ........... .. ................... 12 Future Operation ...................... ...................... 12 Key Lessons Learned ..................... .................... 13 Part II: Statistical Annexes ........................................... 14 Table 1: Summary of Assessments .......................... ... 15 Table 2: Related Bank Credits .............................. ... 17 Table 3: Project Timetable .................................. .. 18 Table 4: Credit Disbursements: Cumulative Estimated and Actual ........ 19 Table 5: Key Indicators for Project Implementation .................. 20 Table 6: Key Indicators for Project Operation ...................... 21 Table 7 Studies Included in Project .......................... ... 25 Table 8A: Project Costs .................................... ... 27 Table 8B: Project Financing ................................ ... 27 Table 9: Economic Costs and Benefits ................. ... ........ N.A. Table 10: Status of Legal Covenants . .. . .. ............. 28 Table 11: Compliance with Operational Manual Statements .............. N.A. Table 12: Bank Resources: Staff Inputs ........................... 29 Table 13: Bank Resources: Missions ........................... ... 30 This document has a restricted distribution and may be used by recipients only in the performnance of their ofricial duties. Its contents may not otherwise be disclosed without World Bank authorization. l  Appendixes: A. Post-Project Management Letter .......................... 31 B. Borrower's Summary and Evaluation ........... ...... 33 C. Cofinancier Contribution to the ICR ....................... N.A. D. Miscellaneous Appendixes 1. Fertility and Family Planning: 1987; 1983 ................ 37 2. Summary of Technical Assistance for Management .... ...... 38 3. Summary of the Recommendations of the Health Strategy and Financing Study .................... 41 Map: IBRD No. IBRD 28020  IMPLEMENTATION COMPLETION REPORT SRI LANKA HEALTH AND FAMILY PLANNING PROJECT (CREDIT 1903-CE) Preface This is the Implementation Completion Report (ICR) for the Health and Family Planning Project in Sri Lanka. for whichi Credit 1903-CE in the amount of SDR 12.9 (US$17.5 million equivalent) million was approved oni July 13, 1988 and made effective on April 4, 1989. The Credit was closed on September 30, 1995 compared with the original Closing Date of September 30, 1994. The undisbursed balance of SDR 1,362,535.03 was canceled effective February 16, 1996, the date on which the final transaction, a refund of US$467,616.13, took place. The ICR was prepared by Frances Plunkett, SAIPH, of the South Asia Region and reviewed by Barbara Herz, Chief. SAIPH, and Fakhruddin Ahmed, Project Advisor, SAIDR. The Borrower provided comments that are included as Appendix B of the ICR. Preparation of this ICR was begun during the Bank's final supervision mission in October 1995. It is based on material in the project file. The Borrower contributed to preparation of the ICR by preparation of a project completion report, a summary of the project completion report, and comments on a draft of the ICR that have been incorporated into the final report.   - ii - IMPLEMENTATION COMPLETION REPORT SRI LANKA HEALTH AND FAMILY PLANNING PROJECT (Credit 1903-CE) Evaluation Summary Introduction 1. The project was the first project in the Population, Health and Nutrition (PHN) sectors to be assisted by the International Development Association in Sri Lanka. There were no co- financiers. Project Objectives 2. Objectives. The Staff Appraisal Report states three project objectives, to (i) strengthen management of the government health system; (ii) increase the efficiency and cost-effectiveness of the health logistics system; and (iii) promote lower fertility and improved matemal and child health through increased and more effective use of contraception. These objectives were to be achieved through three major components: Health Management Improvement, Logistics, and Family Planning. Additionally, in support of service delivery objectives, three special programs, to reduce the prevalence of malnutrition, malaria, and gastro-intestinal infections, were assisted. These objectives reflected Bank health sector priorities for Sri Lanka and were consistent with the Bank's country assistance strategy. However, the effort to cover such a broad range of management, policy and service delivery objectives resulted in a complex project whose objectives were inconsistent with the priorities of the implementing Ministrv of Health, which focused on service delivery. 3. Achievement of Obiectives Project service delivery objectives (objective (iii), a part of objective (i) and the special programs) were generally achieved; management and policy achievements (objectives (i) and (ii)) were limited. Under the Health Management Improvement component. a Management Development & Planning Unit (MDPU) established in the Ministry of Health (MOH) contributed to strengthened management of the health system, particularly in the areas of prospective planning and management training. A Health Strategy and Financing Study was completed and provided important inputs for a follow-on project. In three divisional (sub- district) areas, strengthening of primary health care infrastructure was linked with improved matemal-child health coverage and increased use of modem contraceptives. For Family Planning. survey data for 1987 and 1993 indicate an increase in contraceptive prevalence from 61.7% to 66.1% and a corresponding decline in the total fertility rate from 2.8 to 2.3, suggesting that replacement fertility of approximately 2.1 will be achieved well before the government's target date of 2005. Use of temporary contraceptive methods rose by 5.7 points. Under Special Programs. the malaria progran achieved substantial reductions in numbers of detected cases in four high- prevalence districts. The gastro-intestinal diseases program was effective in improving knowledge and practice related to their prevention. However, neither human resources, financial, nor logistics  - iii - management objectives were achieved. A pilot for a nutrition program achieved no significant impact and was canceled. Implementation Experience and Results 4. Major Factors Affecting the Proiect. Civil conflict in many parts of the Island in 1988- 90 disrupted public institutions, including medical facilities and training institutions, some of which were closed for varying periods. Consequent training and staffing delays were resolved, however, by project-end. Additionally, the long-standing civil conflict in the northem and eastern regions continued through the entire project. Although there was little direct impact on project implementation outside the affected areas, there was a major decentralization of governmental authority, including the health services, to the provinces in 1989. In consequence, a long overdue reorganization of primary health care was carried out, and project support was adapted to the new system. However desirable in principle, the changes in what had previously been a highly centralized system created confusion and uncertainty, and their administrative and financial implications are still being worked out. The provision of health services appears to have been maintained adequately. 5. Implementation Record. The project was planned as a five-year operation. It became effective in April 1989 and was implemented by the Ministry of Health. Prior to the mid-term review (December 1992), project management was poor and there were major implementation difficulties; however, following a subsequent mutually agreed revision of the project that eliminated most management improvement activities and expanded service delivery support, and a change in project management, implementation improved dramatically. The project was never formally restructured, although almost 40% of the credit was canceled in 1994. A one-year extension of the Credit Closing Date, to September 30, 1995, permitted achievement of many of the project's physical targets. In local currency terms, project expenditures were about 94% of the original estimate. 6. The Health Manaaement Improvement component was not fully implemented. Neither personnel nor financial management in MOH was reorganized, the data base for a Human Resources Infonnation System (HRIS) was not completed. and delayed completion of a Health Strategy and Financing Study prevented policy-related follow up. However, the MDPU was established and contributed to strengthened management of the health system through management training and prospective planning activities. Technical assistance tasks in support of improved management were largely completed, but utilization was limited. Civil works and training activities of the service delivery subcomponent to strengthen primary health care in three selected divisional (sub-district) areas were completed and achieved their goals. Under the Logistics component drug stores and vehicle maintenance facilities were constructed, but a unified management system was not accomplished. The Family Planning component successfully implemented a package of infrastructure, training and communications inputs. Of the three Special Programs the introduction of a revised malaria control strategy achieved substantial results. The gastro-intestinal diseases program combined training of health staff and community members supported by a communications prograrn to improve prevention and treatment of these diseases. However. a pilot for a nutrition program achieved no significant impact and was cancelled.  - iv - 7. Sustainabilitv. Sustainability of project investments should be assessed in the context of public health services in Sri Lanka, which have achieved impressive results and have been considered a priority by successive governments. One indication of government commitment is that incremental recurrent costs, with the exception of those for the special programs, were borne by Government throughout the project. The unanticipated provincialization of the health services, which gave the provincial governments responsibility for staffing and maintenance of most of the facilities constructed with project assistance, has given rise to questions about the sustainability of the decentralized health services generally. The provincial governments are known to operate under serious resource constraints, and in particular maintenance of small facilities in scattered areas is likely to be a problem. Nevertheless, since provincialization the health system has continued to provide the good quality health services for which Sri Lanka is well known and, given the importance of these services in Sri Lanka, can be expected to continue to do so. 8. IDA Performance. IDA played an active role in project preparation, including provision of a project preparation facility which supported national consultancies and subsequent for development of project components. It is difficult to justify the complex management-oriented project recommended by the appraisal mission, given the known risk of relying on the Ministry of Health to implement management reforms. After effectiveness the project foundered on lack of "ownership" by the implementing MOH and the management aspects were largely unimplemented. Given the risks, it would have been more realistic to have limited the number of reform activities rather than attempt to accomplish such a complex reform package in a single project. An IDA effort to develop a pilot Nutrition program despite lack of Ministry support also failed. Particularly in the first half of the project, IDA supervision was technically strong, with good continuity. However, while management letters in the early stages reflected IDA's concem about poor implementation, no concrete actions were taken prior to the mid-term review. 9. Borrower Performance. Borrower performance during project preparation and the first half of the project was poor, including failure of the Ministries of Finance and Health to coordinate their approaches, lack of commitment to the project by the implementing Health Ministry, and seriously deficient project management. Relations between the project coordinator and many MOH officers were strained, and there were major delays in procurement of equipment, furmiture, supplies and utilities. However, MOH organized a thorough mid-term review and took steps to ensure improvements in the light of an extremely critical report. IDA and MOH jointly revised the project, eliminating unrealistic management objectives and expanding service delivery support. Additionally, a new project coordinator was appointed, and implementation improved dramatically. MOH also prepared a very useful project completion report. 10. Management of project accounts and submission of disbursement applications were satisfactory. However, procurement activities suffered from lack of adequate understanding by project staff conceming IDA procurement requirements and procedures. The Borrower was not in compliance with covenants relating to staffing for most of the project, but when the Credit closed only two covenants relating to health financing and policy remained unmet. These areas are expected to be covered in a follow-on project. 11. Assessment of Rroiect outcome. This project is difficult to categorize as generally "satisfactory" or "unsatisfactory" because its results were so mixed. The original complex project quickly proved to be unrealistic and unimplementable, although after a mid-term revision  -v - implementation was excellent. Despite the many handicaps, the project accomplished significant service delivery, institutional development, and research goals. However, important aspects of project appraisal, implementation and supervision were clearly unsatisfactory. Given these problems, as well as failure to achieve many of the project's objectives. on balance the project is rated "unsatisfactory." Summary of Findings, Future Operations, and Key Lessons Learned 12. Future Operation. An IDA mission in October 1995 discussed with Govemment project sustainabilitv issues and continuation of project-supported activities. Project-supported primary health care and family planning service delivery and IEC activities were implemented as part of ongoing programs and will continue to be supported, as will management training of Divisional Directors of Health Services. Government is aware of operational and maintenance issues arising from provincialization of the health services: however, Govermment is considering additional decentralization measures and provision for support of operation and maintenance responsibilities is not yet clear. The proposed follow-on Health Services Project, which is expected to become effective in the second half of 1996, would continue support to the Anti-Malaria Campaign, the MDPU, and the HRIS and would begin the effort to address health policy and financing issues incorporating the recommendations of the Health Policy and Financing Study. 13. Findings and Kev Lessons Learned. The key lessons to be learned from project experience relate to the importance of "ownership" by the implementing ministry. Failure by IDA to take adequate account of the priorities of the implementing ministry and to ensure that senior managers in the ministry understood and supported project assistance strategies seriously compromised implementation, a situation that was exacerbated by the complexity of the project. Additionally, the importance of effective project management and the need for greater familiarity by project staff with IDA procurement guidelines and procedures were apparent. The frank mid-term assessment of project status carried out by the implementing ministry provided a framework for revision of the project that facilitated successful implementation in the project's second half These lessons were carefully taken into account in the design and development of the follow-on project as well as orientation of project staff.  - I - IMPLEMENTATION COMPLETION REPORT SRI LANKA HEALTH & FAMILY PLANNING PROJECT (Credit 1903-CE) Project Identity Name: Health & Family Planning Project Credit: 1903-CE RVP Unit: South Asia Country: Sri Lanka Sector: Population, Health & Nutrition Background 1. The Health & Family Planning Project was the first project in the Population, Health and Nutrition (PHN) sectors in Sri Lanka to be assisted by the International Development Association (IDA). There were no co-financiers. Statement/Evaluation of Project Objectives 2. The Staff Appraisal Report states three project objectives: to (i) strengthen management of the government health system; (ii) increase the efficiency and cost-effectiveness of the health logistics system; and (iii) promote lower fertility and improved maternal and child health through increased and more effective use of contraception. Management objectives included improvements in the areas of human resources management, financial management, planning capacity and service delivery, as well as a major health strategy and financing study to provide the basis for identification of needed health policy and financing initiatives. Additionally, in support of service delivery objectives, three special programs, to reduce the prevalence of malnutrition. malaria and gastro-intestinal infections, were assisted. 3. Project objectives reflected Bank health sector priorities for Sri Lanka, which are consistent with the Bank's country assistance strategy: to sustain and improve the health services, which have achieved excellent results in terms of demographic and mortality indicators but face a shift in disease patterns from communicable to non-communicable diseases as the population ages; and to address key health policy and financing issues concerning the efficiency and effectiveness of public services and the role of the private sector in circumstances of increasingly constrained resources. However, the effort to cover all of the objectives noted above resulted in a complex project, and the emphasis on management improvements and policy changes proved to be inconsistent with the priorities of the implementing ministry, which focused on service delivery. In the early part of the project it became clear that most of the project's management objectives were unrealistic and unimplementable.  -2 - Achievement of Project Objectives Summary of Project Implementation and Achievements 1. Health Management Improvement Human Resources Management reorganization and reorientation of existing DDG (Admin) unit not implemented; data base for a Human Resources Information System partially established Financial Management & not implemented; canceled Budget Control Management Development & established; in-service management training Planning Unit and prospective planning supported Health Sector Policy Development delayed completion of study deferred utilization of findings to follow-on project Service Delivery DDHS system and in-service training in selected project districts supported; MCH improvements achieved 2. Logistics unified system not implemented Drug & Supplies Management implementation limited to civil works Vehicle & Equipment Maintenance implementation limited to civil works 3. Family Planning improvement of services and fertility reduction objectives achieved Special Programs Nutrition canceled after unsuccessful implementation Malaria implementation of revised malaria control strategy in four high-prevalence districts supported; significant reduction in number of cases achieved Gastro-intestinal infections improvement in related knowledge and practice in selected project districts achieved  - 3 - 4. Project achievements are summarized in the table above. Consistent with the priorities of the implementing Ministry of Health, project service delivery objectives (the service delivery subcomponent of component 1, component 3, and the special programs in the table above) were generally achieved, with the notable exception of the special program for nutrition: management and policy objectives (components I and 2 in the table above) were not. The following paragraphs review the achievements of the individual components and subcomponents. 5. Health Management Improvement. A Management Development & Planning Unit (MDPU) established under a new Deputy Director General Planning in the Ministry of Health contributed to strengthened management of the health system, particularly in the areas of in-service management training and prospective planning (para. 21). 6. A planned Health Strategy and Financing Study was completed. However, since results were not available until almost the end of the project, health sector policy development linked to study results was deferred to a follow-on project (para. 23). 7. In three divisional (sub-district) areas, strengthening of primary health care infrastructure was clearly linked with improved maternal-child health (MCH) coverage, including increases in early registration of pregnant women, post-natal visits, use of modern contraceptives methods, and decreases in deliveries by untrained persons (para. 24). A baseline survey was carried out too late in the project to provide a basis for impact assessment. 8. Neither reorganization and reorientation of the Health Ministry's unit for personnel management nor reorganization and rationalization of financial management and budget control in the Ministry was achieved. Implementation of a Human Resources Information System was begun, but the system was not yet functioning when the project ended (paras. 18-20). 9. Logistics. Completion of planned civil works supported drug and supplies management as well as vehicle and equipment maintenance activities. However, a unified system intended to achieve improvements in the effectiveness and efficiency of the Ministry's logistics arrangements was not implemented (paras. 26-28). 10. Family Planning. Survey data for 1987 and 1993 (Appendix D. 1) indicate an increase in contraceptive prevalence (the proportion of couples with wife of reproductive age practicing contraception) from 61.7 % to 66.1 %, and a corresponding decline in the total fertility rate, from 2.8 to 2.3. These data suggest that replacement fertility of approximately 2.1 will be achieved well before the Government's target date of 2005. Overall prevalence of modern contraception increased by 3.1 percentage points, from 40.6% to 43.7%; sterilization fell by 2.6 points but use of temporary contraceptive methods, a specific project objective, rose by 5.7 points. It is reasonable to conclude that major project support for the family planning program contributed significantly to the increase in contraceptive prevalence and therefore to fertility decline (para. 29). 11. Special Programs. The malaria project supported a revised WHO malaria control strategy in four high-prevalence districts that achieved substantial reductions in the numbers of detected cases following its introduction in 1993. Over the period 1993-95, the number of detected cases in the four districts declined to between one fourth and one third of previous levels. While it is probable that weather conditions and the natural malaria cycle played a part in these reductions, the revised malaria  - 4 - control program was considered to be the major factor responsible (para. 32). Pre- and post- intervention surveys indicated that the gastro-intestinal diseases program was effective in improving knowledge and practice related to prevention of these diseases (para. 33). However. lack of a baseline precluded an epidemiological assessment. A pilot for a nutrition program achieved no significant impact and was canceled (para. 31). Implementation Record and Major Factors Affecting the Project 12. At the time the project was appraised in 1987, two ministries were responsible for the health sector, the Ministry of Health and the Ministry of Women's Affairs & Teaching Hospitals, while the Population Division of the Ministry of Plan Implementation was the focal point for most population activities. In 1990, the two health ministries were combined and the Population Division was shifted to the Ministry of Health. The reconstituted ministry was known as the Ministry of Health & Women's Affairs. After a change of government in 1994, the Ministry of Health was reorganized as the Ministry of Health, Highways and Social Services. / 13. Project development began with discussions among IDA and the ministries concerned with the health and population sectors, including the Ministry of Finance. A number of key management issues considered essential to expansion of the capacities of the then health ministries as well as aspects of the health services requiring operational support were identified. Local consultancies to develop proposals in these areas were funded through a project preparation facility. Workshops covering the major topics were held; participants included a wide range of stake holders from the medical profession and academic and research institutions as well as Government. The project that emerged, with the apparent support of the major stake holders, was complex and ambitious. In addition to support for family planning and primary health care programs, it called for major innovations in the health ministries: reorganization and reorientation of personnel functions (human resources management); revamping of financial management and budget control; creation of a new DDG unit for the unfamiliar areas of health planning and management; a major health strategy and financing study leading to initiatives in controversial areas of health policy: and development of a unified logistics system dealing with the always contentious area of pharmaceuticals. 14. The project was planned as a five-year project. It became effective in April 1989, approximately 11 months after approval by the Board and 18 months after appraisal. After 1990 it was implemented solely by the Ministry of Health (MOH). Prior to the mid-term review carried out in December 1992, there were major implementation difficulties, and the project was listed as a problem project. After the mid-term review, an effective project coordinator was appointed and the project was revised by mutual agreement between IDA and the Ministry of Health: the management and policy activities were largely eliminated or deferred and the service delivery activities expanded. Project management and implementation improved dramatically. The project was never formally restructured, although almost 40% of the credit was canceled in 1994. A one-year extension of the Credit Closing Date, to September 30, 1995, permitted achievement of many of the project's physical targets. In local currency terms, actual project expenditures were about 94% of the original estimated total project cost (Table 8A). Project expenditures reflected the mid-term revision: expenditures on 1/ For convenience, the "Ministry of Health" is referred to throughout.  I- D - civil works and goods were 82% and 26% higher than original estimates, respectively, while other categories were lower (Table 8A). 15. Several factors affected project implementation at the outset. First, rivalry between the two health ministries complicated initial implementation and increased the resistance of the Ministry of Health to management improvements. Second, civil conflict in many parts of the Island in 1988-90 disrupted public institutions, including medical facilities, some of which were closed for varying periods. Training of doctors and other medical staff was interrupted, which delayed staffing of medical facilities supported by the project. This difficulty was resolved by the time the project ended. 16. Third, the long-standing civil conflict in the northern and eastern regions of Sri Lanka continued throughout the entire project period, making implementation of activities in these areas impossible, although there was little direct effect on the project otherwise. However, in response to civil and ethnic conflict, there was a major decentralization of governmental authority to the provinces in 1989, which included the health services, and further decentralization to the divisional level was introduced in 1993. As part of provincialization, a long overdue reorganization of primary health care was carried out. Project support for delivery of primary health care in three project areas was adapted to the new system (paras. 24-25). However desirable in principle, the changes in what had previously been a highly centralized system created confusion and uncertainty, and their administrative and financial implications are still being worked out. The provision of health services appears to have been maintained adequately, and several examples of encouraging local and provincial initiatives can be cited. 17. The project's implementation experience reflected the priorities and strengths of the implementing Ministry of Health. Those components and subcomponents concerned with service delivery--family planning, primary health care, malaria, gastro-intestinal infections--were by and large successfully implemented. However, as noted above, with the major exception of the Management Planning & Development Unit (para. 21), the Ministry of Health never implemented the management aspects of the project. The following paragraphs summarize the implementation record of the individual project components and subcomponents. 18. Health Manazement Improvement - Human Resource Development. The project called for the creation of a human resources development (HRD) unit in the Ministry of Health through reorientation of the existing unit under the Deputy Director General (Admin), to be redesignated DDG (HRD), and the incorporation of all HRD functions carried out in the Ministry into the HRD unit. The reorientation did not take place, agreed incremental staff was not recruited, and the unit continued to do traditional establishment work. Of seven proposed studies, only two with a direct bearing on establishment matters were carried out (Table 7). 19. The development of a computerized Human Resources Information system (HRIS) was undertaken to improve personnel records, procedures, and management. With consultant assistance, considerable progress was made in designing the system, obtaining data from health facilities, and establishing a database. However, at the end of the project the data base for the system had not been completed and provision of additional data required from central and provincial facilities was uncertain. HRIS was as not functioning as a system and will not become sustainable unless input and updating of records are linked to a larger human resources development effort and specifically to  - 6 - promotions and transfers. The post of Director (HRIS) was created only late in the project and by project-end had not been filled. 20. Health Management Improvement - Financial & Budgetarv Control. The objective of this subcomponent was to strengthen health management at central and peripheral levels by designing and implementing financial management and budget control systems and streamlining operational procedures. The systems were to cover budgeting, resource allocation, financial and management accounting, and evaluation of financial performance as related to program outputs. Nothing was done to implement these activities: agreed incremental staff was not appointed, no in-service training was done, and no consultant services tor the design of new systems were utilized. The mid-term review mission therefore recommended that the sub-component be canceled. 21. Health Management Improvement - Management and Planning. The project supported the creation of a Management Development and Planning Unit (MDPU) in the Ministry of Health headed by a Deputy Director General Planning and staffed by four Directors for planning, management training, organizational development and management information. Although all director posts were initially staffed, due to subsequent turnover at no time during the project were all of them filled. The concept of management development was new to the Ministry and was not understood by some of those staffing the MDPU, let alone the rest of the Ministry. Only about half of agreed supporting and administrative positions were filled, and information systems development was not undertaken. Nevertheless, by project-end the MDPU was functioning. Available study tours and training programs for staff were utilized. The MDPU carried out a number of planned activities, including in- service management training for DDHSs and other health staff (Table 6), needs assessment and curriculum development for nursing officers, a ten-year Perspective Plan for Health, annual development plans for the Ministry, and other studies (Table 7). Given the well-known difficulties of establishing new institutional units as well as the staffing difficulties encountered, the accomplishments of the MDPU were considerable. Measures to expand understanding of the role and function of the MDPU in the Ministry would have helped the Unit to become better established. A consultant report on the organization and functioning of the Unit was completed in 1994 but not utilized. 22. Health Management Improvement - Technical Assistance. The project supported a major international technical assistance consultancy for management support covering financial and administrative manuals, HRIS, a health planning data base, hospital management, health management training, staffing and organization of the MDPU, and health manpower requirements; total cost was US$1.0 million. The consultancy tasks were linked to the management improvement components, so that although most expected activities and products were completed (Appendix D.2), effectiveness was uneven. In those cases where there was genuine interest on the part of MOH (e.g. hospital management, health management training), accomplishments were substantial. Where Ministry commitment was lacking, however, utilization and follow up are uncertain or unlikely (e.g. HRIS, health manpower analysis). In the case of administrative manuals, it became clear that detailed knowledge of existing procedures was required and the task was turned over to national consultants. The limited impact of the technical assistance was a reflection of the lack of commitment on the part of MOH which constrained implementation of the management improvement component generally. In retrospect, given the outlook of the Ministry and the project implementation difficulties which became evident early in the project, IDA approval of an expensive, multi-task international technical assistance contract seems questionable. A more carefully focused approach, taking account of MOH  capacities and utilizing national expertise wherever possible, would have been less costly and probably more effective. 23. Health Management Improvement - Health Sector Policy Development. This sub-component supported a Health Strategy and Financing Study whose objectives were to: (i) compile a comprehensive data base on availability of health services, including utilization and costs, (ii) analyze the causes of current problems of the health care system, including health care financing; and (iii) examine various policy options in terms of improving efficiency and equity of services. The study was to be prepared by an expert consultant and completed by 1992, agreed recommendations were to be implemented by the Ministry, and the findings were to provide the basis for further health policy research. In fact, the study did not begin until 1992 and was completed in 1995, near the end of the project. Total cost was approximately $500,000. A workshop to review preliminary results was held in June 1994. Although a subsequent workshop planned to discuss the results and recommendations of the final report never took place, study findings were utilized in the preparation of the health policy component of the follow-on project (para. 47). The study's recommendations are summarized in Appendix D.3. 24. Health Management Improvement - Service Delivery. The goals of the service delivery sub- component of the management component were to strengthen the primary health care (PHC) infrastructure and to provide in-service training. The project supported a PHC model previously adopted by Government which called for a three-tiered structure of village health centers (GHCs), subdivisional health centers (SDHCs) and divisional health centers (DHCs). After the health services were decentralized in 1989 and reorganized on a divisional basis under the newly created post of Divisional Director of Health Services (DDHS), project support was adapted to the new system and infrastructure was strengthened in a pilot division in each of three project districts. By the time of the mid-term review, about 80% of planned works had been completed and all vehicles had been procured. Following the mid-term review, it was agreed that the project would further support the new DDHS system through assistance for DDHS offices and quarters as well as mini-labs and emergency treatment units in peripheral hospitals in the project districts, and additional assistance along these lines was included in the extension year. Once the provincial health services were fairly well established, responsibility for implementing the service delivery aspects of the project, particularly civil works, was given to the provincial health departments, with the project coordinator monitoring provincial activities through regular field visits and review meetings. This approach provided good results. 25. Although delays in provision of equipment, furniture, electricity and water, and in appointment of sufficient numbers of staff, were experienced, the position by the end of the project was satisfactory. It was observed that virtually all GHCs, which combine living quarters and clinic space, were occupied by the public health midwives (PHMs) for whom they were intended and that local residence by PHMs significantly expanded the scope of their activities, especially household visits and provision of MCH services. Increases in early registration of pregnant women, post-natal visits, use of modern contraceptive methods, and decreases in deliveries by untrained personnel were all noted. However, the subdivisional centers appeared to be underutilized. In-service training programs were carried out, including management training for DDHSs and team training of staff responsible for preventive and curative services (Table 6), although in two of the three districts the team training was done only in the final year of the project. The only part of the DDHS package that was not implemented was the development of information systems to support local-level planning.  - 8 - 26. Logistics. The logistics component was intended to support improvements in two areas: drugs and supplies management, and vehicle and equipment maintenance and repair. Implementation of the component was unsatisfactory. The mid-term review recommended cancellation of the component; however, Government took measures to ensure that the remaining civil works were completed (Table 6). 27. Civil works for the storage and accommodation of drugs were largely completed within two years of the start of the project, and vehicles were procured. However, completed buildings could not be made operational for periods ranging from six months to two years because of delays in the procurement of equipment and supplies. While the additional storage space for drugs and supplies undoubtedly eased previous storage problems, the drugs stores are reported to have been poorly designed and in need of modifications. Garages and service bays for repair of vehicles were also constructed. The garages are now the responsibility of the provincial governments; two of them are functional, but the provincial councils must allocate resources for staff before the other seven become operational. Since it appears to be difficult for the provincial governments to operate these facilities, the provincial health departments should consider leasing them to the private sector and obtaining needed repair services on a contract basis. 28. The project contributed to the completion of a study of regional morbidity patterns to obtain better data on drug needs for primary health care, and lists of essential drugs were prepared and published. With this exception, however, the technical and management aspects of the component were almost entirely neglected. The underlying objective of the component was the development of a unified logistics system, and tO this end provision for technical assistance, staff, and equipment for a computerized system was made. This assistance went virtually unutilized. Only a preliminary investigation was undertaken, and planned technical assistance in specialized areas (equipment maintenance, pharmaceutical logistics and clinical pharmacology), as well as associated baseline studies, were not carried out. 29. Family Planning. At the time of the mid-term review, the family planning component was the one component of the project that had made good progress. As planned, population strategy was developed in a series of workshops, and a Demographic & Health Survey comparable to an earlier survey in 1987 was conducted (Appendix D. 1). Service delivery was strengthened through renovation of family planning clinics and improvement of sterilization facilities; in addition, traditional (ayurvedic) practitioners were trained. Information. Education and Communication (IEC) strategies were developed as part of the population strategy workshops. Communication capacities were strengthened through republication of existing effective family planning materials, development of new materials, and training of government and NGO staff in communication methods. Mass media efforts for family planning were also carried out. A program to train family planning volunteers in the Mahaveli area was canceled when a survey indicated that family planning knowledge and practice in the area was satisfactory and replaced by programs to improve the family planning counseling skills of staff nurses and to train auxiliary health workers for two high-fertility districts. Funds were made available to the Family Planning Association of Sri Lanka and the Sri Lanka Association for Voluntary Surgical Contraception for the training of health auxiliaries and nursing officers of base hospitals in family planning counseling. The effective implementation of the project-assisted package of support for the family planning program, including infrastructure, training, and IEC, can be considered one of the factors responsible for the continued decline of fertility in Sri Lanka.  - 9 - 30. Special Programs. Provision was made for special programs to address major causes of morbidity in three project districts. The programs were to be identified on the basis of epidemiological analysis carried out in the first year of the project. However, this was not done, and malaria, gastro-intestinal infections, and malnutrition were selected as the problems to be addressed on the basis of existing information. 31. The first special program developed was a pilot nutrition program incorporating on-site supplemental feeding for pregnant and lactating women and malnourished children ages 6-35 months. The program had difficulties from the outset. The area selected for the pilot lacked a medical officer and a public health nurse in post, and 6 or 11 public health midwife posts were vacant. A planned baseline survey was not carried out. Since the Family Health Bureau did not have an appropriate officer, responsibility for the program was contracted to the Agrarian Research and Training Institute (ARTI). About 120 volunteers were trained and some 60 feeding centers were opened. However, the intended approach, a community-based program incorporating growth promotion, supplementary feeding and communication to effect behavioral change, was not fully understood or implemented. Local health staff were not involved in planning the program and relations between them and ARTI program staff were not good. A core technical group to support skills training, supervisory and monitoring systems and beneficiary assessment never developed. The mid-term review mission therefore recommended that the program be canceled. 32. Assistance for malaria control was used to support the introduction of the revised WHO malaria control strategy adopted in 1993 to improve the technical capacity and effectiveness of the Anti-Malaria Campaign of the Health Ministry after resurgences of malaria in 1987 and again in 1991. The revised strategy emphasized early diagnosis and prompt treatment, using mobile clinics in high-prevalence areas, and sustainable control measures including selective (rather than blanket) spraying for vector control, introduction of additional insecticides in order to prevent development of resistance through rotation, and use of insecticide-impregnated bed nets. Support for the revised strategy was begun in two high-prevalence districts in 1993 and extended to two additional high- prevalence districts in 1994. Effective implementation resulted in substantial improvements in case detection and treatment through mobile clinics, good acceptance and use of impregnated bed nets, and a major reduction in the amount of insecticide used for house spraying. The introduction of the revised strategy is credited with a significant role in recent declines in the prevalence of malaria. 33. On the basis of a study which indicated substantial lack of information and/or misinformation about the causes and prevention of yastro-intestinal infections, a educational program was undertaken that included public health inspectors, medical officers, school teachers and children, and food handlers (Table 6). IEC equipment was provided to health facilities. Survey evidence indicated that the program was able to improve knowledge and practice related to prevention of these diseases, although an epidemiological assessment was not possible because of lack of a baseline. However, the program seems to have been planned without any links to basic sanitation and water supply efforts, which probably limited its potential effectiveness. Project Sustainability 34. In the context of the public health services in Sri Lanka, which have achieved impressive results and have been considered a priority by successive governments, project investments can be judged as likely to be sustainable. One indication of government commitment is that incremental  - 10 - recurrent costs, with the exception of those for the special programs, were borne by Government throughout the project. Of the special programs, only the malaria program involved modest post- project incremental costs, which will be further reduced by the end of the follow-on project, when they can be expected to be absorbed by the program. By the end of the project, the Management Development and Planning Unit, the only major project investment in institutional development, was functioning and appeared to be well on the way to institutionalization; its further development will be supported by the follow-on project. Implementation of the Human Resources Information System was incomplete, but since it will also be supported by the follow-on project its ultimate sustainability will not be tested for some time (para. 47). 35. The unanticipated provincialization of the health services, which among other consequences gave the provincial governments responsibility for staffing and maintenance of most of the facilities constructed with project assistance, has given rise to questions about the sustainability of the decentralized health services generally. The provincial governments are known to operate under serious resource constraints, and in particular maintenance of small facilities in scattered areas is likely to be a problem. Nevertheless, since provincialization the health system has continued to provide the good quality health services for which Sri Lanka is well known and, given the importance of these services in the country, can be expected to continue to do so. The provincial governments are now responsible for staffing the vehicle repair and maintenance facilities that have been constructed with project support but have not yet done so in seven of nine cases. Since it appears to be difficult for the provincial governments to operate these facilities, the provincial health departments need to consider alternatives for obtaining vehicle repair services (para. 27). IDA Performance 36. IDA played an active role in proiect development and preparation, including provision of a project preparation facility which supported national consultancies and subsequent workshops for development of project components. What emerged was a complex and ambitious project, the management aspects of which went largely unimplemented. It is difficult to justify the complex project recommended by the appraisal mission, which was technically strong but took inadequate account of the known risk of relying on the Ministry of Health to implement management reforms-- lack of commitment to management reform is one of the project risks mentioned in the SAR. In retrospect, IDA's conscientious effort to involve a broad group of stake holders in project development did not suffice to guarantee effective ownership. In the event, it was the views of a small group of key managers in the Ministry of Health whose views and priorities proved to be crucial. It would have been more realistic had the project design reduced the implementation risk by limiting the number of reform activities rather than attempting to accomplish such a complex reform package in a single project. 37. IDA's failure to take adequate account of the views of the Ministry of Health was the major cause of the unsuccessful effort to implement a pilot nutrition program. IDA carried out Nutrition sector work and made the development of a special nutrition program a priority early in the project. However, since the Ministry clearly did not welcome the effort and did not support it in the field, its subsequent failure was predictable. 38. In some respects, IDA supervision of the project was effective. Particularly in the first half of the project, supervision was technically strong, and three members of the project preparation team  - 11 - also participated in the mid-term review mission, thereby providing substantial continuity. The mid- term review mission utilized the recommendations of the review to reach agreement with Government on a revision of the project that identified what could realistically be accomplished in the remainder of the project, thus providing the basis for successful completion of the project. 39. However, early supervision of the project did not deal effectively with emerging difficulties; while management letters reflected IDA's concerns, no concrete steps were taken. When it became apparent in the early stages that project management was unsatisfactory and that implementation of management reforms was unlikely, it would have been appropriate for IDA to have made a special assessment of the situation and discussed the options, including restructuring of the project and cancellation of some or all of the project, with Government. In view of IDA's failure to address implementation issues in the first half of the project, the supervision record must be judged less than satisfactory. Borrower Performance 40. The Ministry of Finance and both of the then Health Ministries played major roles in project development and preparation, and the standard of Borrower technical preparation was excellent. However, the priorities of the ministries involved proved to be quite different. The Ministry of Finance supported the inclusion of major management reforms and a health policy study in the project. After the project became effective, it became apparent that the Ministry of Health was not actually prepared to support implementation of management innovations and reforms and that there was little interest, in some cases hostility, among senior managers in the Ministry. As a result, the management aspects of the project suffered from a lack of "ownership" on the part of the Ministry responsible for their implementation. 41. In the first half of the project, serious project management and implementation difficulties were experienced. At the beginning of the project, a full-time project coordinator was appointed and a project coordination office was set up. All senior managers in the Health Ministry and other ministries who were involved with project implementation were appointed members of a Steering Committee, which was chaired by the Secretary of Health and convened by the project coordinator. Since the Steering Committee was unable to devote detailed attention to project matters, the results were not satisfactory. Some senior managers had neither any commitment to the project nor any understanding of its objectives and did not contribute to its progress. Relations between the project coordinator and many MOH officers were poor, so that the coordinator was unable to fill the gap. Additionally, there were major delays in procurement of equipment, furniture, supplies and utilities, resulting in corresponding delays in making facilities functional after completion of construction. 42. The Ministry of Health organized a thorough mid-term review of the project carried out by a well-qualified consultant team. The report of the review team was extremely critical of the performance of the Ministry of Health; the Ministry and IDA jointly revised the project and the Ministry took steps to ensure improvements in project management, which became evident rapidly. Subsequent to the mid-term review, implementation of the revised project was excellent. The Ministry made a systematic and very useful final review of the project after the credit closed (Appendix B). Thus, the project's implementation record was inconsistent, comprising both effective implementation of service delivery components and almost total failure to implement most  - 12 - management reforms, while project management went from deficient in the first half to quite competent in the second half of the project. 43. Submission of disbursement applications was satisfactory. However, for the anticipated follow-on project, the project unit needs to upgrade its accounting and record-keeping procedures. Procurement activities suffered from lack of adequate understanding by project staff concerning IDA procurement requirements and procedures. The Borrower was not in compliance with covenants relating to staffing until almost the end of the project period, but when the Credit closed only two covenants relating to health financing and policy remained unmet, due to delayed completion of the Health Strategy and Financing Study. These areas are expected to be covered in the follow-on project (para. 47). Assessment of Outcome 44. This project is difficult to categorize as clearly "satisfactory" or "unsatisfactory" because its results were so mixed. Important aspects of project appraisal, implementation and supervision were clearly unsatisfactory. The IDA appraisal mission did not take adequate account of known risks and recommended an overly complex management-oriented project; subsequently, IDA did not take action when the project quickly proved impossible to implement in its original form. For their part, the Borrower's policy and implementing ministries involved did not coordinate their approaches, with the result that the implementing ministry did not take "ownership" of major aspects of the project. Additionally, project management in the first half of the project was deficient. 45. It should be noted that despite the many handicaps, the project accomplished significant service delivery, institutional development, and research goals. However, given serious problems in all aspects of the project and failure to achieve many of the project's objectives, on balance the project is rated "unsatisfactory. Future Operation 46. An IDA mission in October 1995 discussed with Government project sustainability concerns and continuation of project-supported activities (Appendix A). Project-supported primary health care and family planning service delivery and IEC activities were implemented as part of ongoing programs and will continue to be supported. Management training of DDHSs will be continued. Government gave assurances that needed modifications to the drug storage facilities supported by the project would be made (para. 27). Government is aware of operational and maintenance issues arising from provincialization of the health services; however, at the time of writing Government is considering additional decentralization measures and provision for support of operational and maintenance responsibilities is not yet clear. 47. The proposed follow-on Health Services Project, which is expected to become effective in the second half of 1996, would continue support to the Anti-Malaria Campaign, the MDPU, and the HRIS and, drawing on the results of the Health Strategy and Financing Study, would begin to address major health policy issues. The revised malaria strategy would be extended to additional high- prevalence districts, and the Anti-Malaria Campaign would undertake important surveillance and research activities as well. The MDPU would obtain support for two project objectives that were not achieved: access to health policy and financing expertise, and development of management  - 13 - information systems. The HRIS would obtain continued support for data collection and entry and would have additional time in which to become institutionalized. Key Lessons Learned 48. The following lessons concerning project design, management and implementation can be drawn from the project. a. In project development, failure by IDA to understand fully and take adequate account of the priorities of the implementing Ministry led to lack of "ownership" of the project on the part of that Ministry, which seriously compromised implementation (para. 36); b. In project development, failure by IDA to ensure that senior managers understood and supported project strategies for assistance to specific programs resulted in consequent failure to utilize assistance for those programs (para. 36); c. Project ownership and implementation difficulties were further exacerbated by the complexity of the project (para. 36); d. Lack of effective project management in the early stages of the project was a key factor in implementation difficulties (para. 41); e. Better familiarization of project staff with IDA procurement guidelines and procedures would have helped to avoid delays in the procurement of equipment, furniture and supplies (paras. 41; 43); f. The frank mid-term assessment of project status carried out by the implementing ministry played a key role in the mid-term revision of the project that led to greatly improved implementation in the latter part of the project (para. 42). 49. These points were carefully taken into account in the design and development of the follow-on Health Services Project as well as orientation of project staff.  - 14 - Part II: Statistical Annexes  - 15 - IMPLEMIENTATION COMPLETION REPORT SRI LANKA HEALTH AND FAMILY PLANNING PROJECT (CREDIT 1903-CE) Table 1: Summary of Assessments A. Achievement of obiectives Substantial Partial Nliot avolicable Macro policies D D D Sector policies D D D Financial objectives D D D Institutional development D D D Physical objectives D D D Poverty reduction D Gender issues D D D Other social objectives D D D Environmental objectives D D D Public sector rnanagement D D D Private sector development D D D Other (specify) I a o n (Continued)  - 16 - Table 1: Summary of Assessments (continued) B. Proiect sustainability Likelv Unlikely Uncertain (T/ (') (/) HijzIy C. Bank performance satisfactory Satisfactory Deficient Identification DI0 Preparation assistance D D Appraisal D D Supervision D 0 W HiszhIv D. Borrower verformance satisfactorE Satisfactorv Deficient () (* () Preparation D D Implementation D D Covenant compliance D W D Operation (if applicable) D D D Hi2bJv Hi ghl v E. Assessment of outcome satisfactory Satisfactorv Unsatisfactorv unsatisfactorv (T(/) (1 *) O O. D  - 17 - IMPLEMENTATION COMPLETION REPORT SRI LANKA HEALTH AND FAMILY PLANNING PROJECT (Credit 1903-CE) Table 2: Related Bank Loans or Credits Year of Loan/Credit Title Purpose Approval Status Poverty Alleviation Project To reorient and expand the 04/1991 Credit under existing institutional capacity implementation to serve the poor, and to create additional capacity; to develop credit and other services: to expand productive wage employment for the poor; to development programs for nutritional interventions for malnourished children and pregnant mothers; to create policy research and program formulation capacity to take greater account of issues of poverty and employment in overall growth policies and public investment projects.  - 1i - Table 3: Project Timetable Step in project cycle Date planned Date actual/latest estimate Identification August 1986 August 1986 Preparation Feb. - March 1987 Feb. - March 1987 Appraisal September 1987 September 1987 Negotiations March 1988 March 1988 Board Presentation May 5, 1988 May 31, 1988 Signing July 8, 1988 July, 1988 Effectiveness September 1988 April 4, 1989 Midterm review January 1991 January 1993 Project completion June 30, 1994 Sept. 30, 1995 Credit closing Sept. 30, 1994 Sept. 30, 1995  - 19 - Table 4: Credit Disbursements: Cumulative Estimated and Actual (US$ millions) FY89 FY90 FY91 FY92 FY93 FY94 FY95 FY96 Appraisal Estimate 2.00 7.10 11.90 14.40 16.30 17.30 17.50 - Actual 0.20 0.83 1.00 2.23 5.66 7.56 10.56 11.49 Actual as % of Estimate 10% 12% 8% 15% 35% 44% 60% 66% Date of final disburement 2/16/96 NB: US$4.7 million equivalent was canceled in August 1994. The Credit Closing Date was extended by one year, from September 30, 1994 to September 30, 1995.  - 20 - Table 5: Key Indicators for Project Implementation Expected Outcome Achievement HEALTH MANAGEMENT IMPROVEMENT COMPONENT Rationalization of DDG (Admin.) unit in MCH Not accomplished Rationalization of financial management and Not accomplished budget control in MOH Creation of health planning and management Accomplished through establishment of capacity in MOH MDPU Adoption of policies to improve efficiency and Not accomplished equity of health system Rationalization of health facilities and staffing Accomplished outside project through provincialization of health services Expansion and improvement of PHC services in Accomplished selected districts Reduction of facility by-passing Not accomplished LOGISTICS COMPONENT Establishment of unified system for management Not accomplished of drugs & supplies and vehicle & equipment maintenance FAMILY PLANNING COMPONENT Development and implementation of annual Accomplished strategies Improvements in coverage and quality of service Accomplished delivery Improvements in coverage and quality of IEC; Accomplished inclusion of additional media; strengthening of staff interpersonal communication skills Increase in contraceptive prevalence, especially Accomplished use of reversible contraceptive methods  - 21 - Table 6: Key Indicators for Project Operation A: Civil Works Facilities Target Achievement Service Delivery * DHCs 3 3 * SDHCs 8 8 * GHCs 105 105 * DDHS offices 20 20 . DDHS quarters 19 17 Logistics . Construction of Divisional 9 9 Drug Stores . Renovation of Divisional Drug 9 9 Stores * Rehabilitation of Main Drug I I Store in Colombo * Construction of new Drug 5 5 Stores in Teaching Hospital * Construction of Model 3 3 Pharmacies with Facilities for Repackaging * Construction of Garages and 9 9 Service Bays e Construction of Generator 9 '9 Rooms