Mozambique - Health and Nutrition Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 18103 IMPLEMENTATION COMPLETION REPORT MOZAMBIQUE HEALTH AN]D NUTRITION PROJECT (Credit 1989-MOZ) June 29, 1998 Africa Human Development Group 1 Eastern and Southern Arica Africa Region 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 Currency Unit = Metical (pl. Meticais) US$1 = 620.00 Meticais (at time of appraisal, June, 1988) US$1 = M 11,604.00 Meticais (at time of ICR, January, 1998) MEASURES Metric System 1 Meter (m) = 3.28 Feet I Square Meter (sq m) = 10.76 Square Feet FISCAL YEAR OF BORROWER January 1 -December 31 ABBREVIATIONS AND ACRONYMS AFDB African Development Bank BA Beneficiary Assessment BDM Banco de Mo9ambique CIR Country Implementation Review DCA Development Credit Agreement DNPC Direc,ao Nacional de Planificacao e Cooperagao DPCS Provincial Directorate of Commerce of Sofala EACB Empresa de Abastecimento a Cidade de Beira (Supply Company for the city of Beira) EACM Empresa de Abastecimento a Cidade de Maputo ERP Economic Rehabilitation Program GACOPI Gabinete de Coordinacao de Projectos de Investimento GOAM Organizational Secretariat for Supply in Maputo GOM Government of Mozambique GTZ German Technical Cooperation HMDP Health Manpower Development Plan HNP Health and Nutrition Project HSRP Health Sector Recovery Program ICB International Competitive Bidding ICR Implementation Completion Report MEDIMOC Parastatal Import/Export Enterprise for Medical Supplies MOC Ministry of Commerce MOH Ministry of Health mOPF Ministry of Planning and Finance NGO Non-Governmental Organization NHDP National Health Development Plan NPC National Planning Commission ODA Overseas Development Agency PAHO Pan-American Health Organization PIU Project Implementation Unit SAF Social Action Fund SAR Staff Appraisal Report SDR Special Drawing Rights SIP Sector Investment Program SOE Statement of Expenditure TA Technical Assistance UNICEF United Nations Children's Fund WFP World Food Program Managers and Staff Responsible Vice-President: Callisto E. Madavo Country Director: Phyllis R. Pomerantz Sector Manager: Ruth Kagia Task Team Leader: Kees Kostermnans L  FOR OFFICIAL USE ONLY TABLE OF CONTENTS Page No. PREFACE EVALUATION SUMMARY ............................................ i-vi PART I: PROJECT IMPLEMENTATION ASSESSMENT ............................................. 1 INTRODUCTION AND BACKGROUND ..............................................I PROJECT OBJECTIVES ..............................................I MAJOR FACTORS AFFECTING THE PROJECT ..............................................6 BANK PERFORMANCE ..............................................8 BORROWER PERFORMANCE ............................................. 8 ASSESSMENT OF PROJECT'S OUTCOME ..............................................:. 9 PROJECT SUSTAINABILITY AND FUTURE OPERATIONS ..............................................9 KEY LESSONS LEARNED ............................................. 10 PART II: STATISTICAL ANNEXES Table 1: Summary of Assessments ............................................. 13 Table 2: Related Bank Credits ............................................. 14 Table 3: Project Timetable ............................................. 14 Table 4: Credit Disbursements ............................................. 15 Table 5: Schedule of Activities in Project Implementation ............................................. 15 Table 6: Key Indicators in Project Operation ............................................. 20 Table 7: Major Studies Included in Project ............................................. 21 Table 8A: Project Costs ............................................. 23 Table 8B: Project Financing ............................................. 24 Table 9: Economic Costs and Benefits ............................................. 24 Table 10: Status of Legal Covenants ............................................. 25 Table 11: Compliance with Operational Manual Statements ............................................. 28 Table 12: Bank Resources: Staff Inputs ............................................. 28 Table 13: Bank Resources: Missions ............................................. 29 APPENDICES Appendix A: Mission's Aicle-Memoire Appendix B: Borrower's Comments on the ICR Appendix C: Map 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.  IMPLEMENTATION COMPLETION REPORT MOZAMBIQUE HEALTH ANqD NUTRITION PROJECT (Credit 1989-MOZ) PREFACE This is the Implementation Completion Report (ICR) for the Health And Nutrition Project in Mozambique, for which Credit number 1989-MOZ in the amount of SDR 21.0 million (US$ 27.0 million equivalent) was approved on March 14, 1989, and made effective on October 30, 1989. Soon after the project became effective, the DCA was amended, in March 1990, to introduce a new Component C to the project related to Social Dimensions of Adjustment (SDA) activities, with US$ 10.5 million in grant funding. The Credit was closed on June 30, 1997. The original closing date was December 31, 1994. At the time of project closing, the credit was over 99% disbursed, and the last disbursement took place on January 7, 1998. A balance of SDR 9617.0 was canceled. Cofinancing for the project was provided by the Govemment of Norway, the Government of Switzerland, UNICEF and WFP. Social Dimensions of Adjustment (SDA) activities were financed by the Governments of then-West Germany, the Netherlands, Switzerland and the United Kingdom. The ICR was prepared by K. Kostermans (Public Health Specialist); R. Silveira (Sr. Economist); S. Nellemann (Consultant); N. Moncada (AFTHI), and E. Boostrom (EDIHR), with the assistance of J. Murphy (Consultant). It was reviewed by R. Kagia (Sector Manager, AFTHI) and P. Pomerantz (Country Director). The document was also sent for review to the following people: N. Sirur (EDIHR); S. Agarwal (AFTS1); S. Bell (AFMMZ); D. Berk, 0. Pannenborg (AFTH4); D. Cotlear (LCSHD); E. Elmendorf (AFTH3); M. Sugar (LOAAF), and K. Uprety (LEGAF). The Borrower provided comments that are included as appendices to the ICR. This ICR was based on the findings of the Bank's final supervision/completion mission and on materials in the project files. The Borrower contributed to the preparation of the ICR by preparing completion summaries, contributing views reflected in the missions' aide memoire, and commenting on the draft ICR.  EVALUATION SUMMARY 1. Introduction. The Health and Nutrition Project (HNP) incorporated the first World Bank credit to the health sector in Mozambique. The project was conceived in the context of the Economic Rehabilitation Program (ERF') and the then-ongoing war which disrupted services in large parts of the country. The project was supposed to: (a) play a major role in helping to lay the foundation for continued provision of sustainable and efficient basic social services, (b) to assist in the development of measures that addlressed the uneven burden of adjustment and help offset the transitional costs that were borne disproportionately by the poorest segments of the population. 2. To help improve the health and nutrition status of the Mozambican people, the project had four objectives: (a) strengthening capacity in policy formulation and management on health and food security issues, with special attention to resource mobilization, institutional development, information systems, and planning and analysis; (b) improving efficiency, to enhance the impact of services within the tightly constrained budget; (c) improving service quality to enhance the provision of basic needs to the population; and (d) helping to mitigate some of the social costs of adjustment, to help sustain the ERP. In order to meet these objectives, the project had two main components: (i) policy formulation and management strengthening, and (ii) improving efficiency and quality of services. 3. The objective of the new Component C (SDA), added to the project shortly after effectiveness, was to strengthen the National Planning Commission's (NPC) capabilities for social planning for poverty reduction. The objective was to be achieved through: (i) carrying out social policy studies, (ii) data collection complementing then-current information on the poor and on the impact of interventions, and (iii) a Social Action Preparation Program. This program aimed at (1) preparing programs and policies geared to provide short-term poverty alleviation of vulnerable households through improvernent of their food security, increased access to basic services and other means to improve theiir economic welfare; (2) experimenting on a small-scale, with projects and programs proposed for poverty alleviation; and (3) financing the initial stages of large programs to increase progressively, allowing for learning-by-doing. 4. Evaluation of Project Objectives. Overall, the project has substantially achieved its major objectives. The objectives related to policy formulation provided very valuable support to the MOH at a time during which circumstances changed dramatically in Mozambique. Improving efficiency was and continues to be of extreme importance in the constrained Mozambican environment. However, the security situation at the beginning of the project made it impossible for these components to be implemented beyond the level of central hospitals. 5. Considering the institutional weaknesses surrounding the SDA component, it was unrealistic to expect that the enormous task of creating a poverty-conscious planning process could be tackled sufficiently within the project. The task of the SDA staff was made more difficult by the absence of clarity in the project's objectives. 6. During Negotiations, assurances were obtained for: (a) a joint Ministry of Health (MOH)-International Development Association (IDA) review of a cost recovery report and an action plan to implement the recommendations no later than April 30, 1990; (b) completion and review of a manpower development plan by October 31, 1990; (c) a MOH reorganization study  Evaluation Summary ii review by January 31, 1990; (d) a resettlement plan for families located on the site of a proposed pharmaceutical warehouse; (e) transfer of trucks to private retailers and to the Empresa de Abastecimento a Cidade de Beira (Supply Company for the city of Beira) (EACB) and the Empresa de Abastecimento a Cidade de Maputo (EACM); and (f) adequate housing for resident consultants employed under the project. The activities under covenants (a), (b), (c) and (e) were carried out or fulfilled, although with some delay. The resettlement plan was abandoned because of resistance by the involved population. Covenant (f) was re-negotiated since more attractive alternative housing arrangements became available. 7. Implementation Experience and Results: Achievement of Objectives. Project objectives were substantially achieved and some (e.g. National Health Manpower Development Plan) exceeded original aspirations. However, as a project designed to do what was achievable in the context of a protracted war --urban facility rehabilitation, improved planning, management and training-- its direct impact on overall health outcomes was not expected to be substantial or readily measurable, especially since the Project initially did not build capacity to monitor outcomes. The Project had positive impacts on: * Improving tertiary/quaternary health care facilities and their efficiency through rehabilitation and partial re-equipping of three urban hospitals, including efficiency-enhancing modifications, and through other technical assistance (TA) to improve efficiency. * Strengthening human resources planning and training in the health sector, through development and implementation of the National Health Manpower Development Plan (HMDP), rehabilitation and refurbishing of three training facilities, provision of training equipment and learning materials for all training facilities, training of training institutions' staff, long-term training of health workers, revision of job descriptions for health personnel, and provision of TA to strengthen curriculum development and training management. * Improving sector planning, management, information, and project implementation through the establishment and, later, strengthening of the MOH's investment project coordination unit [Gabinete de Coordina,co de Projectos de Investimento (GACOPI)], supporting MOH-led sectoral planning and donor coordination, and supporting health information system development and implementation. * Improving pharmaceutical supplies through participation in coordinated donor financing of essential drugs and supplies and through technical support for drug system planning, management and cost recovery. The Project strengthened the organization, management and logistics of central and provincial drug and supply distribution systems. 8. Implementation Record and Major Factors Affecting the Project. Given the difficult circumstances and deficient project preparation, project implementation has been satisfactory, with a high degree of MOH commitment from the start. Nevertheless, substantial accumulated delays in implementation resulted from: (a) poor performance of some consultants and construction firms, (b) Borrower's initial lack of knowledge of Bank procedures, particularly in procurement, (c) generally weak implementation capacity, and (d) insufficient responsiveness of the Bank in the early years. Although the performance of MOH and GACOPI improved, serious and unresolved problems in the Ministry of Planning and Finance (MOPF) and Banco de Mocambique (BDM) continued to cause serious delays. These delays were especially due to delays in contract approval and payments to contractors. Bank procurement staff provided much needed training and expedited the documentation clearance process. However, even after several Country Implementation Reviews and numerous specialized disbursement and procurement  Evaluation Summary iii missions, many of the problems at the MOPF and BDM have not been resolved. Initially, MOH delays in preparing documents such as terms of reference and procurement lists affected implementation. Implementation was further hampered by turnover of key high level staff and by several shifts in implementation priorities which occurred as a result of the rapid evolution of the political environment and the launching of the peace process. Subsequently, flexibility and prompt support from the Bank allowed project modifications, including necessary extensions. 9. Project Sustainability. The Project's achievements will be sustained through the successful implementation of the Health Sector Recovery Program (HSRP), which continues to finance and build upon actions initiated under the first credit. Long-term sustainability will be contingent on regular maintenance of infrastructure and equipment, incentive systems for personnel, availability of recurrent cost financing for the operations of service and training facilities, effective supervision and support, and further institutional development. Given the low level of Government finances available tD the sector, sustainability of the program will continue to largely depend on long-term commitmrent from external financiers. Working towards a sector- wide approach, all major external financiers of the sector have now shown such commitment. 10. Bank Performance. In accordance with GOM development strategy, efforts were made during identification and preparation to adapt project design to national realities, keeping in mind that this was a pioneering operation in the sector. However, both overall project preparation and appraisal were deficient (see Table 1). In retrospect, the rate of implementation of the project, as estimated in the Staff Appraisal Report (SAR), was overly ambitious. In addition, the SAR's lack of clear performance targets made it difficult to monitor implementation. Supervison of project implementation was satisfactory, both in terms of time spent on supervision and the close association that evolved between Bank, (GACOPI and MOH staff. Relationships of trust developed during the supervision years. Mission participants were generally well chosen, both for their technical ability and for their sensitivity and flexibility towards the Mozambican culture and reality. Increased involvement of the Bank's Resident Mission improved procedural issues with regard to procurement and disbursement. Relocation of a public health specialist to Maputo also improved implementation. II. Borrower Performance. During project identification and preparation, the Borrower's lack of knowledge of Bank guidelines and procedures and weak institutional capacity hampered performance. This improved during implementation, with the strengthening of the team at GACOPI responsible for procurement, financial management, monitoring of civil works, and by improving the support for coordination ofthe project. The team's knowledge of project execution has been invaluable in the implementation of other donor-supported projects and in the preparation and launching of the HSRP and the IDA credit supporting it. The project faced continuous obstacles caused by weak institutional capacity in other directorates of the MOH and by often-faulty processes in the central GOM apparatus. However, there is no doubt about strong MOH ownership of the project. 12. Future Operation. Based on some of the accomplishments achieved under the HNP, the HSRP continues to build upon actions initiated by MOH and several donors, including the Bank, helping to ensure successful operations and continued development in the sector. The HSRP is designed as a Sector Investment Program (SIP) and the Bank is supporting it through a credit from the International Development Association.  Evaluation Summary iv 13. Summary of Key Lessons Learned. The key lessons that emerge from the experiences associated with this credit are: * Project simplicity and realistic objectives are important factors in project success, especially in an environment of great uncertainty and recognized weak capacity such as prevailed in Mozambique in the late 1980s. Project design also needs to be flexible to accomodate evolving country conditions. * A Project Implementation Unit (PIU) within a ministry's Directorate of Planning can work effectively with other ministerial departments, central ministries, and donors, to coordinate and monitor donor-supported projects and programs; and help assure their mutual compatibility and coherence within national strategies, and support development of a sector wide program approach. However, such a PIU should remain a small administrative unit to facilitate communication with external financiers, and should not take over genuine functions of other departments in the ministry, or activities that can best be carried out by the private sector. One could therefore speak of a Project Administration Unit instead of a PIU. * Care needs to be taken when designing projects with more than one implementing sectoral ministry. Implementation is likely to become complicated; multiple implementing ministries should be avoided if feasible. * With the sectoral ministry clearly taking the lead in conceptualization and strategy development, donor coordination across the sector can be built around growing coordination in sub-sectors or sub-areas (e.g. human resources/training, pharmaceutical supply/financing, technical assistance, decentralization of financing). * To effectively monitor implementation, clear and monitorable performance targets need to be set at appraisal. * Continuity of technical assistance, often crucial to a project's success, can be achieved in the medium-term by ensuring repeated presence of the same advisors. This can also be achieved in the long-term with good communications access between visits. * E-mail communications between MOH/GACOPI and Washington-based Bank staff, which became available during implementation, greatly facilitated and sped up communication and decreased HNP communication costs.  PART I: PROJECT IMPLEMENTATION ASSESSMENT INTRODUCTION AND BACKGROUND I. Macroeconomic Setting. During the first half of the 1980s, Mozambique experienced a marked and continued decline in output and an aggravation of economic distortions and financial imbalances. These were the result of adverse exogenous factors and internal disruptions caused by widespread armed attacks and inappropriate economic policies. In 1987, GOM launched a far-reaching Economic Rehabilitation Program (ERP) with measures to increase reliance on market signals, improve economic incentives, and strengthen demand management through appropriate fiscal, monetary, exchange rate and external borrowing policies. By 1989, the ERP had begun to reverse the economic decline of previous years. It was well recognized that the ERP could have considerable short-term costs for vulnerable groups in the population. The project aimed to assist Government in mreeting these challenges in the areas of health and nutrition. 2. During implementation of the project, Mozambique made the transition from war to peace, and from a one-party state to a multi-party democracy: A peace agreement was signed in October, 1992, and general elections were held in 1994. Annual inflation tumbled from a three- digit to a one-digit level. These enormous changes meant that the project, with its limited objectives, acquired the image of being under-ambitious in scope, while being perhaps over- ambitious with regard to implementation capacity. 3. Bank's Role in the Sector. During the design of the project, many health facilities in the rural areas had been destroyed by the war, which targeted inter alia health infrastructure and health workers. Health services coverage, among the best in Africa before the war, had been on the decline, as were quality and efficiency at the secondary and tertiary levels of care. The project was designed to support activities that were feasible under the economic and security constraints. It was intended, as the first IDA investment in the sector, to selectively respond to immediate needs while assisting in developing a better knowledge of the health system requirements and a comprehensive sectcr strategy. IDA's involvement in the health sector began with a mission in mid-1987. Preliminary recommendations of a sector study (Report 7422-MOZ) led to the identification of the Project. PROJECT OBJECTIVES 4. The main original project objectives were three-fold: (a) to strengthen the Borrower's capacity in policy formulation and management of health and food security issues, (b) to improve quality and efficiency of services in health and food security sectors, and (c) to help the Borrower to mitigate some of the social costs of acljustment to help sustain the ERP. 5. Under objective (a) the project would: Strengthen policy formulation capacity by (i) facilitating the development of improved health policies in the areas of cost recovery, (ii) designing and implementing an action plan based on the recommendations of the said study, (iii) preparing and implementing a Health  Project Implementation Assessment 2 Manpower Development plan for MOH staff, and finally by (iv) strengthening the operational efficiency of MOH health facilities. * Strengthen the managerial and planning capabilities by: (i) conducting a study to analyze MOH's organizational structure and implement the recommendations of said study, (ii) conducting studies to prepare future projects in family planning, health and nutrition sectors, (iii) strengthening GACOPI within the Directorate of Planning and Cooperation, and finally (iv) strengthening MOH's financial management capacity by: (1) streamlining accounting and budgeting procedures and (2) developing a financial information system. * Improve the Ministry of Commerce (MOC) food security policies and information system by: (i) developing a food price policy by: (1) conducting a study of the Borrower's food needs, supply and access, (2) strengthening the capabilities to carry out policy analyses, acquisition of transport, and office equipment and supplies for MOC's Department of Food Security; and (ii) improving the information systems by: (1) integrating several food security information systems and (2) improving the provision of training for MOC staff in planning and utilization of food aid. In addition management capacity would be strengthened to coordinate and manage project activities and to carry out studies to plan for future projects in the area of food security. 6. Under objective (b) the project would: * Rehabilitate health facilities by (i) reconstructing or rehabilitating health posts, health centers, provincial and rural hospitals in the provinces of Manica, Tete and Sofala; (ii) financing the rehabilitation of hospitals at Maputo, Beira and Nampula in two phases; (iii) procuring priority hospital equipment and supplies, including spare-parts and pharmaceuticals. * Improve hospital efficiency through: (i) procuring administrative equipment and supplies; (ii) undertaking a reorganization of the hospitals at Maputo, Beira and Nampula; (iii) improving provision of assistance to and training for hospital staff in implementing procedures and systems to strengthen overall hospital management (including admissions and discharge procedures, cost accounting and control, clinical coding, materials and manpower productivity control). * Improve health facility maintenance by: (i) strengthening health facility and equipment maintenance centers at the central level in Maputo and provincial level in Beira and Nampula, (ii) improving inventory control, (iii) procuring and replenishing maintenance tool kits, and (iv) procuring vehicles and motor bikes for the involved centers. * Improve pharmaceutical supply by: (i) constructing, furnishing and equipping of central pharmaceuticals warehouse complex for MEDIMOC in Maputo; (ii) implementing a resettlement plan for the persons living in the sites assigned for the construction of the warehouse; (iii) developing drug management procedures; (iv) increasing on-the-job training for MEDIMOC staff; and (v) renovating, furnishing and equipping the MEDIMOC regional store in Beira. * Improve the efficiency and quality of pre-service medical, nurse and paramedical training through: (i) the Health Manpower Training program by: (1) upgrading physical facilities,  Project Implementation Assessment 3 including boarding and lodging facilities and acquisition of furniture for the ICS's at Maputo, Beira and Nampula; (2) strengthening curriculum development at the ICS's; (3) acquiring vehicles, office and teaching equipment, textbooks, teaching and learning materials for the ICS's; (4) launching teacher training for about 65 ICS teacher candidates; (5) launching refresher training for about 80 appointed trainers; (6) acquiring medical textbooks, equipment and supplies for the Faculty of Med.icine at Eduardo Mondlane University; and through (ii) the development of an in-service training program by: (1) designing the program and (2) revising, printing and disseminating job descriptions for MOH's health personnel. Improve efficiency and quality of services by supporting an urban food distribution system by: (i) strengthening the management of urban food supply systems in Maputo and Beira through: (1) strengthening of program management, data processing and analysis; (2) training for Organizational Secretariat for SUpply in Maputo (GOAM) and Provincial Directorate of Commerce of Sofala (DPCS) staff in management procedures and computer use; (ii) acquiring vehicles for food transport; (iii) strengthening school feeding programs; and (iv) conducting a pilot operation to improve the workers' canteen program by improvement of the facilities and acquisition of equipment. 7. The objectives of the project were in conformity with Mozambique's war situation and insecurity in the countryside. The project was overly complex if one takes into account that this was the first IDA investment operation iin the country's health sector and that implementation capacity was weak. The objectives of the project were clearly stated and consistent with IDA's country strategy at the time of appraisal, which emphasized assistance to safe areas of the country to minimize risk to infrastructure. Soon after the Project became effective, the DCA was amended in March, 1990, to introduce a new Component C to the project related to Social Dimensions of Adjustment (SDA) activiities -- the third objective of the project. 8. Under objective (c) for which then-West Germany, the Netherlands, Switzerland and the United Kingdom provided extra finances, the project would: * Carry out social policy studies to: (i) support development of options for policy measures and targeted interventions in the areas of(1) food security, (2) access to basic services, and (3) enhanced participation in the economic recovery of the absolutely poor; (ii) provide the necessary elements to allow ex-ante and ex-post social dimensions evaluation of major economic policy decisions and program interventions; and (iii) identify the size and composition of the absolutely poor and vulnerable and monitor the effects of institutional changes and macro-economic and sectoral policies, on specific groups of households; and (iv) support the Borrower's effort to integrate within the activities of its line ministries, and within the national budget, all activities presently dispersed under the areas of Rehabilitation, the Emergency Program, and Social Dimensions of Adjustment. * Carry out: (i) data collection complementing present information on the poor and on the impact of interventions, and (ii) a Social Action Preparation Program. This program aimed (1) to prepare programs and policies aimed to provide short-term poverty alleviation of vulnerable households through improvement of their food security, increased access to basic services and other means to improve their economic welfare; (2) to experiment on a small-  Project Implementation Assessment 4 scale with proposed policies and programs for poverty alleviation; and (3) to finance the initial stages of large programs to increase progressively, allowing for learning-by-doing. 9. The project was amended formally in May, 1993, and September, 1995, to better respond to changed political and economical Borrower circumstances and priorities. 10. Achievement of Project Objectives. Overall, the project has substantially achieved its major objectives. 11. The Strengthening Policy Formulation and Management component focused on institutional development. Assessments of organization and management needs by internationally-recognized consultants were used by the MOH in new organizational and policy papers. The Cost Recovery Study, the Health Manpower Development Plan and the Hospital Efficiency Studies were baseline studies for strengthening MOH operations during the project. Those three consultancies had positive and lasting results in terms of aligning policy measures and long term strategies. Results of those studies also were used later for the preparation of the new HSRP. 12. The Improving Efficiency and Quality of Services component was successful in: * The rehabilitation and extension of primary rural health facilities, under cofinancing of other donors and UNICEF, contributed to (i) the prompt stabilization of the population in secure areas during the war, (ii) the creation of social conditions and services for displaced people, and (iii) the resettlement after the war. The IDA credit's direct inputs were mainly focused on central-level strengthening and technical organization for planning and management of the initiatives and for donor coordination. * Improving the adequacy of the central hospitals. By default, these had become the most important health units during the war, both as referral facilities and because they were located in the most secure areas -- which tripled their populations during the conflict. The supervision of the civil works was far from adequate, and this has sometimes led to poor results. However, overall performance of the contractors was more or less satisfactory. * Achieving some of the initial objectives regarding maintenance, although the highest level of achievement was realized through the studies on hospital efficiency conducted for the central hospitals. These studies strengthened central hospitals' management in Maputo and Beira. The Central Hospital of Maputo, by far the largest facility in the country, particularly benefited from the TA. All services and functions in the hospital are now budgeted and information is computerized, except (unfortunately) for the financial flows with regard to the "Special Clinics". The studies also contributed to the improvement of the health information system, which now covers all tertiary and secondary levels of care, by providing inputs and pilot work for the design and testing of those aspects of the information system covering the hospital network. * Improving pharmaceutical supplies, through participation in an increasingly coordinated donor financing of essential drugs and supplies and through technical support for drug system planning, management and cost recovery. The project strengthened the organization, management and logistics of the central and some provincial drugs and supply distribution  Project Implementation Assessment 5 systems. Strengthening of the peripheral distribution system will continue with support from other donors under the HSRP. Implementation of the initial objectives for the rehabilitation of the pharmaceutical warehouse in Beira and construction of a new MEDIMOC central warehouse and offices in Maputo (see Table 5, point 4) had to be canceled under the Project, since the cofinancing donor withdrew support for it. This created a major inefficiency in the project, since the IDA credit had, at that time, already financed the construction of alternative housing for the population living on the location scheduled for the new MEDIMOC warehouse, while another cofinancing donor supported management improvement of MEDIMOC. Although the donor repeatedly confirmed to the Bank that it was still committed to financing the construction of the warehouse, this never materialized. The problem was partially due to lack of resolution of the resettlement question and the selection of the site that should have followed the resettlement study. Improving health manpower training through development and implementation of the HMDP was successful. The rehabilitation of three training facilities was completed, although with many delays and imperfections. Training equipment and learning materials for all training facilities was provided. Long, inte:rmediate, and short-term workshops and seminars for trainers and training management staff of all training centers were held. Long-term training of many cadres of health workers and revision of job descriptions for health personnel were carried out, as was the provision of TA to strengthen curriculum development and training management. 13. The Urban Food Distribution System sub-component was phased out in 1992, and canceled after the project was restructured. This was done under mutual agreement, as the initial objectives under this component were found to be unsuitable and inappropriately designed to address the actual needs. This was further supported by the 1990 Mozambique Food Security Study which recommended programs that were not included under this component (e.g. instead of a school feeding program, the study recommended programs on de-worming, iron supplementation and indirect targeting Df food products like yellow-maize). The provision of free trucks/vehicles was delayed, and finally implementation was halted after a number of donors, including the Bank and WFP, and the Government found it unsuitable to give away trucks/vehicles for free, particularly as the transport situation and availability of trucks was improving. Studies prepared under the aegis of the project had, and still have, a significant impact on the development of the sector strategy. In particular, background work on human resources development provided vital inputs in the preparation of the HSRP and the IDA credit now supporting it. 14. Finally, general project implementation capacity was significantly enhanced within the MOH through strengthening of GACOPI, including a team of local management professionals with expertise in financial management, procurement and civil works monitoring. This expertise has greatly increased over the life of the project. MOH staff were the main actors. The implementation unit, as part of the Planning Directorate, has a key role in the coordination of other donors, especially in the development and implementation of the MOH investment plan. 15. For the SDA component, considering the institutional weaknesses foreseen during appraisal of the project, it was unrealistiic to expect a newly-formed institution to tackle the enormous task of creating a poverty conscious planning process. A lack of reliable statistical  Project Implementation Assessment 6 data, the separation of economic and social planning, and the absence of institutional mechanisms to influence policy all acted to weaken the integration of social concerns into the economic and social planning process. Besides, the task of the SDA staff was made difficult by the absence of clarity in the project's objectives. The Social Action Fund (SAF) was handicapped by a lengthy sub-project appraisal and approval process. The lengthy process of recruiting technical staff, their lack of integration into existing functional departments, the absence of national counterparts for TA, and the high turnover of key project-related personnel in both the Government and World Bank seriously undermined the formulation and delivery of a coherent implementation strategy. 16. However, the SDA project component made a considerable contribution to the policy analysis area. It produced a poverty framework paper, studies on safety net for the poor, informal sector, minimum wage, national reconstruction plan, etc., although appropriate dissemination was often lacking. More importantly, the project created an enabling institutional environment to discuss and debate the issue of poverty in Mozambique. The Poverty Alleviation Unit in MOPF stands out as the single most important institutional by-product of this intersectoral dialogue which was nourished by the SDA project. 17. The Social Action Fund (SAF) was never intended to be a full-fledged targeted poverty program. It was conceived as a pilot program under which sub-projects would be tested. Because of the small size of the portfolio of projects and the lack of socio-economic data on individual projects, it is difficult to assess SAF's impact. However, the impression is that this impact was small. The limited scale of the subcomponent made it difficult to justify, on a cost basis, the minimum critical number of staff required to make the operation function. MAJOR FACTORS AFFECTING THE PROJECT 18. Although enormous delays were experienced during the project, the implementation record for the project should be rated satisfactory given the difficult war circumstances. The Government was highly committed to the project objectives from the start. When implementation issues were raised during project execution, they were discussed and addressed at the highest level of Government. As a result, a meaningful working relationship has been established between IDA and MOH staff. 19. Despite delays in most project activities, the project managed to fulfill virtually all objectives by its eventual closing date, with support from substantial Bank technical assistance from HQ and the Resident Mission. The following factors caused major delays in civil works and technical assistance: * A lack of knowledge of the standard and internationally accepted rules for project implementation activities, such as preparation of terms of reference and preparation of tender documents. * Tender documents prepared early in the project needed to be adapted to changing national realities. Similarly, changes in the content and circumstances of key consultancies already underway contributed to delays in their implementation and also required extension of their duration.  Project Implementation Assessment 7 * In civil works, consultants sometimes did not follow the agreed work programs and schedules. MOH also experienced problems with the low productivity of some contractors, while corrections of low quality work sometimes led to further delays. * Implementation was further hampered by turnover of key staff. All National Directors directly involved in the project, were replaced several times during preparation and implementation. The project was irnplemented under three different Ministers of Health. Turnover of key staff in the implementation agencies also limited the agencies' institutional capacity to carry out project-supported activities. 20. Implementing agencies' general level of understanding of the Bank rules and procedures was always weak. With rapid evolution of the political environment and the launching of the peace process, shifts in implementation priorities also slowed implementation and presented obstacles to the implementation of the initial targets and objectives. Subsequently, flexibility and prompt support from the Bank allowed project modifications which also justified the extensions that were needed. Problems with communications (i.e. telephones, mail services even within Maputo) and transport further complicated implementation problems, as well as MOH and Bank efforts to deal with them. Communications improved through e-mail and increase of Bank staff in Maputo. 21. Beneficiary Assessments. Formal beneficiary consultations at the design stage of the project, along with more extensive stakeholder consultations, might have helped establish a more realistic implementation timetable for a] l aspects of the project. However, the MOH staff and the Bank's implementation review team often made extensive field visits to consult on project progress and issues, thereby helping project implementation. For the SDA component, and certainly for the SAF, a client consultation (beneficiary assessment) would have been even more crucial, but this was not carried out in a systematic way. However, client consultations were not yet part and parcel of Bank operations at the time of project design, and it must be noted that the project has moved the discussion on systematic client consultations forward in Mozambique. 22. Costs and Financing Arrangements. Project costs and financing compared favorably with estimates at appraisal, as shown in Tables 8A and 8B, of the Statistical Annex. Total actual IDA financing amounted to US$30.2 million equivalent, compared to the original US$ 27.0 million. Actual Government contributions totalled US$3.9 million compared with the US$ 3.7 million estimated at appraisal. Disbursements, slow in the first years of the project, steadily improved over the life of the project. The amount of IDA credit funds available increased due to exchange rate fluctuations. 23. Actual financing of the SDA components totaled US$6.4 million equivalent as shown in Tables 8A and 8B, with contributions from Switzerland, the Netherlands, ODA (UK) and GTZ (then-West Germany). 24. The Project was audited annually as required in the DCA, and the general findings of the Audit Reports were favorable as to the procedures and practices of accounting within the project. However, in August, 1993, IDA suspended use of SOEs after the audit was nine months late. Auditors' remarks criticized the Special Account management and discrepancies in disbursements, problems which continued from year to year without adequate measures being  Project Implementation Assessment 8 taken by the Banco de Mocambique (BDM), the responsible Government agency. Only towards the very end of the project did BDM make a reconciliation of the accounts to allow for the final disbursements under the project. The audit reports for the SDA component were unqualified. Disbursements and procurement procedures were conducted in accordance with practices recommended by the Bank, except in cases when IDA provided a waiver. BANK PERFORMANCE 25. Bank support in project preparation and appraisal proved less than satisfactory by not recognizing enough the Borrower's low level of capacity. Bank support during supervision was satisfactory. The Bank was especially mindful during identification that project goals be set in accordance with Government's overall development strategies. Additional preparation of civil works components and efforts to keep this first project simple, especially in its first years, would have been warranted during project preparation. 26. The average time devoted to project supervision was about 20.6 staff weeks per year over the life of the project, although from 1993 onwards this was complemented by preparation and later supervision of HSRP. The composition of the missions was adequate to the needs of each particular visit. The Bank's response time on project related correspondence, such as no- objections, decreased significantly when the team began using e-mail. The SAR's lack of clear performance targets made it difficult to monitor implementation, and supervision missions in the project's early years could have taken a more proactive approach in seeking and -- with MOH -- confronting the causes of implementation delays and slow disbursement. 27. Despite several changes in task managers in the first two years of implementation, much less change took place among disbursement and legal staff connected to the project. The Bank team, certainly in later years, was generally considered flexible and pro-active in introducing changes when Government priorities changed or when processes were found to be lacking or inappropriate. 28. For the SDA initiative, Bank performance was less satisfactory. Frequently changing task managers caused shifts in thinking, and changes in priorities. The bureaucratic fund disbursement procedures seriously hampered the SAF implementation. BORROWER PERFORMANCE 29. Given the low capacity and the difficult circumstances in the country, Borrower performance was satisfactory. During project identification and preparation, the Borrower's lack of knowledge of Bank guidelines and procedures and weak institutional capacity hampered performance. This improved during implementation, with the strengthening of the team at GACOPI responsible for procurement, financial management, monitoring of civil works, and by improving the support for coordination of the project. A strong team was formed in the project implementation unit (GACOPI) which now excels in all crucial areas of project execution, including procurement, financial management, and monitoring of activities (principally civil works). Substantial experience during this project proved invaluable in the preparation of the HSRP and the IDA credit which supports it as a SIP. Despite substantial progress in the MOH, the project faced continuous obstacles imposed by faulty processes in the broad government apparatus. The most severe obstacles were disbursement-related ones at the BDM and contract  Project Implementation Assessment 9 approval impediments at the MOPF. UJnfortunately after several Country Implementation Reviews and countless specialized disbursement and procurement missions, the problems still were not resolved, especially in the case of contract approvals. High turnover of staff in MOH contributed to performance problems. However, in general, MOH authorities were eager to establish good working relationships with the Bank to address implementation issues as a team. 30. The SDA initiative was also pllagued by many staff changes on GOM side. Insufficient counterpart staff was provided to work: with foreign TA. However, the Poverty Alleviation Unit established itself very well within Government over the duration of the project. ASSESSMENVT OF PROJECT'S OUTCOME 31. Overall, the project has achieved good results against original goals, despite initial slowness in implementation. However, since this was a relatively small investment operation its direct impact on overall health outcomes is not expected to be substantial. Furthermore, since the project did not build capacity to monitor outcomes, its impact is not directly measurable. The project did support implementation of a health infornation system which directly contributes to that capacity, but in addition, validity of available data on health outcomes was low at the start and impossible to attain due to the war and later due to the low capacity of staff collecting the data. 32. Construction and rehabilitation work at hospitals and training institutes, which accounted for the bulk of the budgeted expenditures, was successfully carried out. Training of trainees and of health workers (initial and in-service) was also successfully implemented and will undoubtedly contribute to better service delivery if the appropriate incentive and salary structures are now put in place. The institutional development sub-components of the project, including the strengthening of the planning process of the MOH and of the implementation team within MOH were successfully carried out. Together with the TA and completed studies, these are considered to be extremely important activities and made the design of the HSRP possible. 33. The SDA component had limited impact as far as actual mini-projects under the SAF are concerned. The main impact of the project is that it created the possibility to mainstream poverty discussions into the general political debate. PROJECT SUSTAINABILITY AND FUTURE OPERATIONS 34. HNP's achievements will be sustained through the successful implementation of the HSRP. This sustainability is likely due to MOH's high commitment to the HSRP. Long-term sustainability will be contingent on regular maintenance of infrastructure and equipment, appropriate incentive systems for personnel, availability of sufficient recurrent cost financing for the operations of training facilities, effective supervision and support, and further institutional development. In the Government budget, allocations for maintenance have increased enormously in the last few years, and recently a new maintenance policy has been developed. Various institutional development activities uncler the project have led to positive changes in the operating procedures of the MOH. Since the projilect itself is fully integrated within the health services system and the sector as a whole, its sustainability depends on the sector's overall prospects.  Project Implementation Assessment 10 35. Given the present level of economic development of Mozambique, sustainability will also much depend on long-term commitment from bilateral and multilateral donor and cooperating agencies. A follow-on IDA credit in support of the HSRP, along with other donors' support, has ensured continuity of financing for all of the priority activities of the first project. Working towards a sector-wide approach, all major external financiers of the sector have now shown such long-term commitment. 36. As far as the SDA is concerned, the Poverty Alleviation Unit is now well established in MOPF and well integrated in the government's machinery, and it has good potential of influencing policies and coordinating actions aiming at ameliorating the conditions of the poor. The SAF has not yet grown into a full-fledged Social Action Program, as was intended. However, in the health sector a country-wide Health Development Fund is now providing funds for small health infrastructure. 37. Future Operations. As the first Bank operation in Mozambique Health, this project "opened a door" to the sector. The trusting relationship between the MOH and the Bank's team, together with the general trend towards more sector-wide approaches, made it possible to prepare the future IDA support to the sector as a SIP, providing broad, large and flexible support for the Ministry's HSRP. KEY LESSONS LEARNED 38. The key lessons that emerge from the experiences associated with this credit are: Design issues * Care needs to be taken when designing a project that involves more than one implementing sectoral ministry. This is likely to make implementation complicated and should be avoided whenever feasible. * Project simplicity, realistic objectives, and flexible design are important factors in project success, especially in an environment of great uncertainty and recognized weak capacity such as prevailed in Mozambique in the late 1980s. Planning, management and coordination issues * Effective planning and strategy development can be done on the basis of limited data, with adjustment and updating on the basis of new information and implementation experience. * With the sectoral ministry clearly taking the lead in conceptualization and strategy development, donor coordination across the sector can be built around growing coordination in sub-sectors or sub-areas (e.g. human resources/training, pharmaceutical supply/financing, technical assistance, decentralization of financing). * A Project Implementation Unit within a Ministry can work effectively with other ministerial departments, central ministries, and donors, to coordinate and monitor major donor-supported projects and programs, help ensure their mutual compatibility and coherence within national strategies, and support development of a sector program approach. However, such a PIU should remain a relatively small administrative unit and not start taking over genuine  Project Implementation Assessment 11 functions of other MOH departments. One could therefore speak of a Project Administration Unit instead of a PIU. * More thorough and detailed planning during project preparation could have avoided many major delays in project implementation and disbursement, especially with a Borrower and a sectoral ministry new to IDA procedures and requirements. * Close contact between the operational team and the disbursement staff is important to make sure that the decisions made by one of the teams are fully supported by the other. Implementation issues * To effectively monitor implementation, clear and monitorable performance targets need to be set at time of appraisal. * Project preparation and implementation planning need to consider carefully linkages within and among various subcomponent's activities. Such considerations are facilitated by the commitment of the ministry and of major donors to a sector-wide approach. Consideration of such linkages is also facilitated by the development and use of linkable relational databases and appropriate use of professional program planning and management tools (ZOPP, Microsoft Project) for sub-sector planning (WHO-developed models for projection of manpower availability and requirements, WHO/PAHO developed tools for pharmaceutical system planning and management), and tools for tracking and coordinating multi-source support for development efforts. Some of the tools mentioned have been used during implementation and for the preparation of the HSRP. * Greater involvement of beneficiaries, and participants could have helped in planning and achieving more realistic implementation rates for civil works, more relevant TA, or appropriate focus in training and continuing education, more appropriate relative emphasis in learning materials, and earlier detection of strong resistance to resettlement. * Government commitment to the project is fundamental in achieving objectives, but success is also highly dependent on the implenientation capacity of staff. * Good implementation is dependent not only on the quality and motivation of staff at the project implementation unit but also on the capacity and commitment in all departments in the sectoral ministry and central ministries. Strengthening those capacities is needed for the functioning of the overall system, rather then circumventing those departments or finding alternative temporary solutions. * Mozambique's centralized system of contract approvals and handling of project accounts requires the availability of specialized capacity in MOPF and the BDM. Such capacity remains weak and delays continue to occur in all projects, in spite of continuous supportive efforts by the Bank, MOH and others. Therefore, consideration should be given to giving more authority to sectoral ministries to approve contracts, with MOPF retaining audit and a posteriori monitoring of contract responsibilities.  Project Implementation Assessment 12 * Mid-term review and adaptation of a project can not only greatly improve implementation and disbursement, but also demonstrate IDA commitment and flexibility and effectively support development and implementation of a sector strategy by a sectoral ministry. It is hoped that recognition of this during HNP implementation will lead to the MOH's inclusion of pro-active, multi-donor annual reviews of the HSRP. * E-mail communications between GACOPI and Washington-based Bank staff, which became available during implementation, facilitated and sped up communication and decreased HNP communication costs. Internet-based worldwide networking, which has since become available to selected ministries through Mozambique's Eduardo Mondlane University, with Bank support, has been particularly used by GACOPI for file transfers and will increase in value as its use by other ministries and agencies working with Mozambique increases. External arrangements and technical assistance * "Twinning" and other institution or team focused technical assistance/support arrangements require careful selection and adequate counterpart involvement and management by the sectoral ministry. * Technical assistance effectiveness is heavily dependent upon both the quality/adaptabil ity/appropriateness of the TA and the "match" and the relationships between the technical advisors and key Borrower officials as counterparts. * Continuity of TA, often crucial to its success, is achievable through repeated medium-term presence of advisors (e.g. repeated 3 to 12 month periods of TA in Human Resources/ Training Development and, with good communications access between visits, repeated I to 3 weeks visits by an architect/planner) as well as through long term continuity. Sectoral issues * Increased payments to temporary trainers in the health training institutions helped resolve problems (e.g. serious delays in course completion) due to their originally-low motivation and irregular participation. These changes indirectly improved the working situation of full time trainers. * Slower than expected MOH/GOM salary growth has contributed to decreased morale and motivation. Inter alia, salary levels and available salary funding need to be considered in revising the NHDP and the HMDP.  Statistical Annexes 13 PART II- -STATISTICAL ANNEXES Table :1: Summary of Assessments B''?,fiij f '. .'bstan1iF - S -; : : A. Achievement of Objectives Macroeconomic policies X Sector policies X Financial objectives X Institutional development X Physical objectives X Gender concerns x Other social objectives X Environmental X Public sector management X Private sector management X Other X B. Project Sustainability . .. g.u0 .,: . . . . . C. Bank Performance Identification x Preparation x Appraisal X Supervision X D. Borrower Performance Preparation X Implementation X Covenant compliance X ig hly I Satisfa U -; --g- . SatisfEmctory _ _ __tcome X E. Assessment of Outcome X  Statistical Annexes 14 Table 2: Related Bank Loans/Credits I. Preceding .This was first operation in sector. Operations II. Following Operations Food Security 2487-MOZ 6.3 Strengthen national capacity to 1993 Ongoing confront and deter major causes of household poverty and food insecurity. Health Sector 2788-MOZ 98.7 Increase coverage and quality of health 1995 Ongoing Recovery care; strengthen institutions responsible for providing health care to the population; develop human resources in delivery of health care services. Table 3: Project Timetable Lete of. Prset p-Bfor DevlopA ; inDSg Helt Care August 1988 Identification (Executive Project Summary) January 1988 January 1988 |Preparation |April 1988 April 1988l |Appraisal lMay 1988 0 June 1988l |Letter of Prospects for Developing Health Care |August 1988l |Negotiations lNovember. 1988 Board Presentation December 1988 March 1989 Signing April 28, 1989 Effectiveness February 1989 October 30, 1989 Project Completion March 30, 1994 December, 1996 Credit Closing December 31, 1994 June 30, 1997  Statistical Annexes 15 Table 4: Credit Disbursements, Cumulative, Estimated and Actual (US$ thousands) . .- /v.t-S ; .- FY89 F90 F91 - - _ Appraisal 4,160 12,401 19,072 23,517 26,165 27,000 Estimate _ _ _ Actual 0 2,766 3,537 4,499 6,290 10,816 20,032 24,867 29,623 30,204 Actual as % of 0 9.8% 12.5% 16% 22% 38% 71% 88% 105% 107% Date of final disbursement: January 7, 1998 Table 5: Key Indicators for Project Implementation Key ImpIemientdatin1ndk tr4 fl fd"ii. A. Strengthening Policy Formulation and Management 1. Policy Studies and Implementation a. Cost recovery study - study completed mid 1989 Oct. 1989 - review with IDA end 1989 Nov. 1990 - implementation 1990-1994 1992-1995 b. Manpower development plan - study completed mid 1990 Dec. 1991 - review with IDA end 1990 1992 - implementation 1991-1994 on-going c. Development of cost control measures - study completed end 1990 on-going d. Strategic plan for health secltor computing - study completed end 1989 under revision 2. Strengthening of the MOH a. MOH reorganization - study completed March 1989 Sep. 1989 - review with IDA end 1989 Nov. 1990 - implementation end 1990 1991 b. Improving financial management and control - study completed end 1989 on-going - training completed mid 1990 on-going - implementation 1990-1994 1991-1995 3. Food security policies and programs a. Food pricing policy - study completed Feb. 1989 Sep. 1989 - TA completed mid 1991 End 1991 b. Food management information system - TA completion end 1990 End 1991 - implementation 1990-1994 1992  Statistical Annexes 16 Table 5: Key Indicators for Project Implementation (continued) B. Improvin d Efficiency and Service Quality . Health facilities reconstruction a. Maputo hospital - master plan completed end 1989 May 1992 - final design completed mid 1990 Nov. 1993 - tendering completed mid 1994 Aug. 1994 - civil works completed Dec. 1997 b. Beira hospital - master plan completed Sept. 1989 May 1992 - final design completed Mar. 1990 Nov. 1993 - tendering completed Sept. 1990 Aug. 1994 - civil works completed mid 1994 Dec. 1997 c. Nampula hospital - final design completed end 1989 Nov. 1993 - tendering completed mid 1990 Aug. 1994 - civil works completed mid 1993 Dec. 1997 d. Primary and secondaly facilities - Tete civil works completed end 1990 1992 - Manica civil works completed mid 1991 1992 - Sofala civil works completed mid 1992 1992  Statistical Annexes 17 Table 5: Key Indicators iFor Project Implementation (continued) Key Implementation Indicatoiri.eflcd 2. Hospital efficiency a. Hospital management operations - consultant employed Jan. 1989 mid 1992 - implementation 1989-1994 1993-95 b. Design new admission and discharge procedures - design completed End 1989 1993-94 - implementation completed mid-1994 1996 c. Hospital computerization - complete needs assessment mid-1990 1995 - complete installation and training End 1991 1996 d. Create demonstration site - complete establishment Sept. 1990 Maputo: - complete training mid 1992 1992 e. Improve clinical coding - complete preparation Early 1990 1996 - complete training mid 1991 1996 f. Improve laundry and food service - consultant employed Oct. 1989 mid 1992 - training completed End 1991 1996 g. Improve organization of laboratories - consultant employed Jan. 1990 mid 1992 - training completed End 1991 1996 h. Establish manpower productivity control system - consultant employed Oct. 1989 mid 1992 - training completed End 1991 1996 i. Reinforce management capability - consultant employed Oct. 1989 mid 1992 j. Improved cost control - consultant employed Jan. 1990 mid 1992 - equipment procured mid-1990 1994 - training completed End 1991 1996 k. Install design utilization review system - consultant employed Jan. 1990 mid 1992 - materials development cornpleted mid 1990 1992 - training completed End 1990 1996 1. Establish hospital discharge method - consultant employed Jan. 1990 mid 1992 - training completed mid 1990 1996 3. Health facility maintenance - maintenance kits procured Oct. 1988 mid 1992 - management expertise employed mid 1989 1993-94  Statistical Annexes 18 Table 5: Key Indicators for Project Implementation (continued) ~~ Key Implementation IndiCatoi~~~~~~~~~~~~~~~~pme 4. Pharmaceutical supply a. Maputo pharmaceutical store - final design completed mid 1989 Dec 1993 - tendering completed End 1989 Cancel - management expertise employed Jan. 1990 Aug 94 - construction completed b. Beira pharmaceuticals store - final design completed mid 1989 pending - tendering completed End 1989 pending - civil works completed mid 1990 pending  Statistical Annexes 19 Table 5: Key Indicators for Project Implementation (continued) Key ImplementationI ndicatoD it . _ 5. Health manpower and training a. Rehabilitation ICS Maputo - complete final design mid 1990 Nov. 1993 - complete tendering End 1990 Aug. 1994 - civil works completed Apr. 1992 June 1997 b. Rehabilitation ICS Beira - complete final design mid 1990 Nov. 1993 - complete tendering End 1990 Aug. 1994 - civil works completed Apr. 1992 June 1997 c. Rehabilitation ICS Nampula - complete final design March 1990 Nov. 1993 - complete tendering mid 1990 Aug. 1994 - civil works completed End 1990 June 1997 d. Other measures to improve pre-service training - procurement of didactic materials to ICS mid 1989 mid 1992 - training of trainers begins . mid 1989 Feb. 1990 - production of training materials completed mid 1991 - refresher training carried out 1990-1992 Mar. 1991 - procurement of textbooks for Faculties of Medicine mid 1989 e. Improvement of in-service training - functional analysis completed End 1989 - refresher training plan coimpleted Mar. 1990 - support to National Diractorate of Human Jan. 1990 Late 1992 Resources in place 6. Urban Food Distribution a. Ration program managemenil - installation of computers begins Jan. 1990 Apr. 1991 - training begins Sept. 1989 Early 1991 - consultant employed Sept. 1989 Aug. 1991 b. Easing urban transport shortage - procurement of vehicles and equipment mid-1989 Cancelled c. School-feeding program Cancelled - procurement of vehicles mid-1989 Cancelled - food supply 1989-1991 d. Workers' canteens Feb. 1991 - procurement of equipment Jan. 1990 Cancelled - civil works completed End 1990 Cancelled  Statistical Annexes 20 Table 6: Key Indicatoirs for Project Operation Orthopedicsqygg 1 1.1N A. Average length of stay (days) in Maputo hospital for selected categories of treatments Intemal medicine 6.8 NA Dermnatology 7.5 NA Plastic surgery 19.5 NA Orthopedics I 31.5 NA B. Average length of stay (days) in Nampula hospital for selected categories of treatments Medicine I 7.5 NA Surgery I 9.0 NA Obstetrics I 1.5 NA C. Average nenbth of stay (days) in Beira hospital for selected categories of treatments Medicine 12.0 NA Surgery 13.0 NA Chest 30.0 NA D. The number of lunches and dinners served in a hospital (N) should equal the number of patients (including mothers accompanying young children in pediatric wards) (P) and staff on duty (SD). Maputo hospital N/2(P+SD)=1 NA Nampula hospital N/2(P+SD)=1 NA Beira hospital N/s(P+SD)=l NA Note: The indicators have not been followed as the data were not available in the first years of project implementation. Afterwards, the limited character of the indicators and the lack of a strong correlation with the project outputs made following of the indicators inappropriate. Under the Health Sector Recovery Program the Ministry of Health will introduce an information system for the tertiary and quatemary level of care. For indicator D: In concordance with Hospital Management and MOH, the hospital efficiency sub-component did not address the issue of hospital feeding. It was thought that on a budget for food of less than US$ I per day, little efficiency gains could be made. The broader objectives of the Health and Nutrition Project are not measured by the above indicators. During the life of the project, major improvements were, however, achieved in making services available to the population in a more equitable manner. The project's support to policy formulation certainly contributed to this. The project's impact on training of health workers is shown for example by the following general MOH data: Average Numbers of Several Cadres of Health Workers per Level of Care llealth Post Small Health Center Large Heath Center Rural Hospital Level of Training 1990 1')5 1990 .>19 1990 1995 1990 1995 University 0 0 0 0.1 0 0.4 0.5 . Z.4 Mid-level 0 0.1 0.1 0$. 0.4 -2.2 3.2 7 - Basic 0.4 0.4A 2.1 2A. 9.2 8. 27.5 20.8 Elementary 0.4 0.6 1.5 L,i 5.8 .~2' 6.4 Average team 0.8 1 3.7 I..5 15.4 16$ 37.6 Data on health service utilization over the nineties show increasing equity. This is as much a result of the transition from war to peace, as an effect of the policies of MOH. Likely, the trends have reinforced each other.  Statistical Annexes 21 Table 7: Stiadies Included in Project Ud Purpose - *w | ; 1. Health Assessment of health referral Complete Not all recommendations could be implemented Referral systems in the three major cities: due to lack of funds. Some recommendations Maputo, Beira and Nampula. currently being implemented in Beira with AFDB funding. 2. Cost Identification of needed policy Complete Highly influential in defining the cost recovery Recovery modifications and institutional strategy currently being implemented under the requirements for effective Sector Investment Program (SIP) supported by a implementation. follow-up credit. 3. Manpower Development of realistic manpower Complete Became the basis for manpower planning in the Development plan for MOH relating manpower health sector. Plan needs by category of health worker to affordable training and employment scenarios. 4. Cost Development of appropriate cost Complete Incorporated in a more comprehensive expenditure Control containment measures for each level review of the sector which became the basis for Measures of facility, taking into account policy actions being implemented under the SIP. tradeoffs between coverage, equity, cost-effectiveness and quality of care. 5. Strategic Development of simple mechanisms Complete Plan for Health and procedures to increase /on-going Sector accountability and allow for routine Computing monitoring of cost containment effort. _ 6. MOH Identification of ways to improve Complete Internal discussion of study recommendations has Organizational functional efficiency of Ministry of led to defacto changes in MOH organization (not Structure Health. all of which have been formalized) which have had a positive impact on efficiency. 7. MOH Streamlining of existing accounting Complete Study recommendations currently being Financial and budgeting procedures within implemented under follow-up Health Sector Management MOH and development of simple Recovery Project. financial information system for use by MOH managers. 8. Food Development of appropriate food Complete Pricing Policy pricing policie- in the ration systern, taking into account issues such as the existing large differentials between producer and consumer prices, the suitability of current marketing margins and possibilities for adjusting pricing policies or designing other suitable interventions to ensure minimum food intake by the poorest families.  Statistical Annexes 22 Table 7: Studies Included in Project (continuation) ! iTPurpose .1t I , r 9. Food Security Developmenit of a food security Information The information system is now fully Information System information system which system was operational with support from the Food integrates information being initiated under the Security Capacity Building Project collected by the Ministry of SDA component Communications with the early warning system of the Ministry of Agriculture and the nutrition surveillance system of the MOH. 10. Health Facility Identification of priority needs for Cowplete Identified priority areas for investment Reconstruction reconstruction or rehabilitation of later incorporated in the SIP. Needs health sector facilities. 11. Hospital Development of a series of Complete Successfully computerized data and Efficiency measures to improve efficiency at trained staff in areas of personnel, finance the Maputo, Beira and Nampula and accounting, patient management, Central Hospitals in areas such as drug and supplies management, quality admissions and discharge control and information management. By procedures, cost accounting and end of project, however, still only scanty control, clinical coding and evidence that data being successfully used materials and manpower for policy purposes. productivity control. 12. Drug Development of effective Complete Successfully computerized stores Management procedures for inventory control management, commercial and financial and drug management at the central data, and stock management at central pharmaceuticals warehouse. level. By end of, roject. impact still weak or absent at orovincial and district levels. 13. Curriculum Development of improved Complete Output was unsatisfactory. Little impact. Development curriculum for pre-service training _ of health staff. 14. Functional Analysis of the present functions of Complete Objectives achieved. Analysis of Rural a selection of rural facilities and the Facilities suitability of staff skills to cope with expected workload; identification of training needs; and development of in-service training program. 15. Social Policy Development of options for policy Complete Poverty assessment and other studies had Studies measures and targeted interventions tremendous impact on thinking of policy in areas of (a) food security, (b) makers in country, leading to successful access to basic services, and (c) development of multi-sectoral approach enhanced participation in economic to poverty alleviation. recovery of the absolutely poor.  Statistical Annexes 23 Table 8A: Project Costs (US$ million) Project Component Apprabi1l3stiat iti Local Foreign Total Total costs Costs Costs Costs A. As defined in SAR 1. Civil works 2.2 9.2 11.4 14.0 2. Vehicles, equipment, furniture, supplies 1.1 18.1 19.2 20.8 3. Consultants' services, studies, audits 0.7 6.2 6.9 11.2 4. Training 0.2 0.1 0.3 1.3 5. Operating costs 1.8 2.1 3.9 2.7 6. Refund Project Preparation Advance 0.1 0.7 0.8 0.3 Subtotal 6.1 36.4 42.5 50.3 B. Social Dimensions of Adjustnent Activities 1. Goods N/A. 1.9 2. Consultants' services N/A. 2.5 3. Training N/A. 0.9 4. Operating costs N/A. 1.1 Subtotal 10.5 6.4 TOTAL 53.0 56.8  Statistical Annexes 24 Table 8b: Project Financing (US$ million) A. Original Project _ IDA 27.0 (SDR 2 1.0 m) 30.20 (SDR 20.99 m) Switzerland 5.3 (SF 7.2 m) 0.12 (SF 0. 19 m) Norway 0.2 (NK 10.6 m) I1.47 (NK 10.46 m) World Food Program* 4.4 4.4 UNICEF* 1.9 1.9 OPEC Fund* 8.5 Beneficiaries 0.2 0.0 Government of Mozambique 3.7 3.9 Sub-total 42.5 50.3 B. SDA Initiative Switzerland 3.1 (SF 4.75 m) 0.02 (SF 0.025 m) Netherlands 3.15 (G 6.0 m) 3.29 (G 5.69 m) ODA (UK) 1.35 (L 0.6 m) 0.92 (L 0.59 m) GTZ (Germany) 2.9 2.2 Sub-total 10.5 6.4 TOTAL 53.0 56.8 Note: Available information does not allow breakdown between local and foreign costs. * Parallel financing. All these projects expanded in time and scope during the implementation of HNP. Table 9: Economic Costs and Benefits Although no economic rate of return was calculated for this project at the time of appraisal, it is clear that the project focused on areas of prudent investment, i.e. health facilities in the relatively safe cities, spared by the war, and training institutes which would produce cadres of mid-level health workers, generally recognized as most needed for the efficient delivery of basic services. The project further focused on building institutional capacity, which is key for sector effectiveness.  Part III Statistical Annexes 25 Table 10: Status of Legal Covenants ecfiky..,'~9vnan6 rigina Autrtui ti Agreement.V Sec n venanteet fillet Fulfiment Descrip on o Covena t C