Turkey - First Health Project (FHP)

 ICRR 10486 Report Number : ICRR10486 ICR Review Operations Evaluation Department 1. Project Data : OEDID: OEDID : L3057 Project ID : P009030 Project Name : First Health Project (FHP) Country : Turkey Sector : Basic Health L/C Number : L3057-TU Partners involved : Prepared by : Roy A. Jacobstein, M.D., Consultant, OEDST Reviewed by : Timothy A. Johnston Group Manager : Gregory K. Ingram Date Posted : 08/18/1999 2. Project Objectives, Financing, Costs and Components : The goal of this project was to develop a more efficient and partly self-financing public health system that provided higher quality services. It was expected to lay the foundation for further Bank-supported work, and to stimulate health sector reform. It had three objectives: 1) improve health status in 8 underserved provinces; 2) improve service quality and efficiency, and financial sustainability; and, 3) strengthen the management capacity of the MOH. These objectives were to be met via facility construction and/or upgrading, training and better utilization of MOH personnel, implementation of preventive/primary care MCH programs, and development of a health MIS. Total project costs were estimated at $US146 million at appraisal (IBRD share $US75 million) and $208 million at project close (IBRD share $71.16 million). The project closed on December 31, 1998, one year behind schedule. Final disbursement took place on June 11, 1999. A balance of $3.84 million was cancelled as of June 30, 1999. 3. Achievement of Relevant Objectives : The objective to reorganize and strengthen provincial health services was partially met. A large number of facilities of various types were constructed and most were staffed and operational. The objective to strengthen the capacity and capability of the MOH was met via the training of a large number of staff, and the installation of a health management information system (MIS) that is in widespread use throughout Turkey. Policy reform objectives were not achieved, in large part because of lack of Parliamentary support for reform proposals. 4. Significant Achievements : Two hospitals, 35 health centers, 98 health posts, and 2 training centers were built in the 8 underserved provinces; others were upgraded. Thus it is reasonable to assume that access to health services increased. Relevant skills training was provided for 13,000 MOH staff; it is likewise reasonable to assume that quality and management of service delivery therefore improved. A health MIS has been installed nationwide. Besides being of intrinsic value, it may serve to stimulate future health system reform, since individual hospitals can now use their data for funding and other management decisionmaking. 5. Significant Shortcomings : Hospital construction encountered major cost overruns, and counterpart funding was insufficient, and sometimes untimely. Only 2 of 5 planned hospitals were complete by project close. Baseline data had not been collected, so actual improvements in health status of project beneficiaries could not be documented. Difficulties in recruiting and retaining staff were a major problem; for example, 5 of 35 health centers built under FHP were non-operational due to staffing shortages. The need for facility construction of the nature and extent supported under FHP was unclear. Necessary policy analysis in support of GOT health sector reform and increased financial commitments for health failed due to the unfavorable political environment. The Project Coordination Unit, established to compensate for lack of sufficient MOH capacity, became a rival to the MOH and hindered project achievement. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Marginally Satisfactory The ICR rates the project as partially sucessful in achieving objectives, which is consistent with the OED rating. Institutional Dev .: Partial Modest Sustainability : Uncertain Uncertain Bank Performance : Deficient Unsatisfactory ICR rated Bank performance as Satisfactory in appraisal, but deficient in identification and implementation (OED does not give 'marginal' ratings for Bank or borrower perfomance). Borrower Perf .: Satisfactory Unsatisfactory ICR rates borrower performance as deficient in preparation and covenant compliance, but sat. in implementation. Despite achievements, lack of progress in policy reforms and significant cost overruns in infrastructure suggest an unsat. rating overall. Quality of ICR : Satisfactory 7. Lessons of Broad Applicability : Baseline situational data is crucial for project design, management and evaluation, if the Bank is to be able to document the outcome and impact of its health sector interventions. The implicit paradigm that construction of more health facilities, especially hospitals, will lead to better health outcomes is open to serious question. Solving system problems such as staffing shortages, and deployment and remuneration policies, is at least as important. Likewise, a strong policy dialogue for health sector reform, linked to the provision of resources, would enhance effectiveness considerably. The establishment of an external management unit parallel to the beneficiary agency has the potential to become quite problematic. Training components must have provision for documenting the effect of such training (on outcomes such as service delivery). A staff member in the resident mission dedicated to support of health projects can be of great benefit in these situations (project complex, new; policy dialogue needed). 8. Audit Recommended? Yes No 9. Comments on Quality of ICR : Competent, concise, high-quality. There are no overall ratings, however, for Bank and Borrower Performance, and the overall rating of Satisfactory for Project Outcome is unjustified, and in fact is belied by the admirably frank and incisive commentary about project shortcomings.