Madagascar - Health Sector Improvement Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No: 20304-MAG IMPLEMENTATION COMPLETION REPORT (IDA-225 10) ON A CREDIT IN THE AMOUNT OF US$ SDRs 22.9 MILLION (US$ 31.0 MILLION EQUIVALENT) TO THE REPUBLIC OF MADAGASCAR FOR A HEALTH SECTOR IMPROVEMENT PROJECT June 21, 2000 Human Development 4 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 (Exchange Rate Effective June 2000) Currency Unit = Malagasy Franc (FMG) FMG 1.00 = US$ .00014 US$ 1.00 = FMG 7150.00 FISCAL YEAR January 1 -December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immuno Deficiency Syndrome HSP Health Sector Program CIR Country Implementation Review ICB International Competitive Bidding CPA Central Purchasing Agency IEC Information, Education, and Communicatioi CSP Projects Monitoring Unit (Cellule de Suivi des Projets) ILO International Labor Organization CSSP Primary Health Care Center ( Centre de Soins de Sante IUD Intra Uterine Device Primaires) DDDS Direction du Developpement des Districts Sanitaires NCB National Competitive Bidding DDT Dichloro-diethyl-trichlorotane (une pesticide) MCH Matenal and Child Health DEPP Studies, Planning and Programming Department MINSAN Ministere de la Sante (Direction des Etudes, de la Planification et de la Programmation) DGS Director General of Health (Directeur Ge6nral de la NGO Non-Governmental Organization Sante) DHS Demographic and Health Survey NPL National Population Law DIRDS Direction Inter Regionale du developpement sanitaire NPP National Population Policy DLMT Communicable Disease Control Department (Direction PHC Primary Health Care de Lutte contre les Maladies Transmissibles) DMC Curative Medicine Department (Direction de la PSC Project Steering Committee Medecine Curative) DMP Preventive Medicine Department (Direction de la ALAMA Central Drug Procurement Agency Medecine Preventive) DPL Pharmacy and Laboratories Department (Dirction de la STD Sexually Transmitted Disease Pharmacie et des Laboratoires) EEC European Economic Community TB Tuberculosis EPI Expanded Program on Immunization UNDP United Nations Development Programme FP Family Planning UNFPA United Nations Fund for Population Activities GDP Gross Domestic Product UNICEF United Nations Children's Fund GTZ Gernan Cooperative Agency USAID United States Agency for International Development HIV Human Immunodeficiency Virus WHO World Health Organization Vice President: Callisto E. Madavo Country Director: Hafez Ghanem Sector Manager: Arvil Van Adams Task Team Leader: Slaheddine Ben-Halima  FOR OFFICIAL USE ONLY CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 1 4. Achievement of Objective and Outputs 4 5. Major Factors Affecting Implementation and Outcome 8 6. Sustainability 9 7. Bank and Borrower Performance 10 8. Lessons Learned 13 9. Partner Comments 14 10. Additional Information Annex 1. Key Performance Indicators/Log Frame Matrix 16 Annex 2. Project Costs and Financing 18 Annex 3. Economic Costs and Benefits 20 Annex 4. Bank Inputs 21 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 24 Annex 6. Ratings of Bank and Borrower Performance 25 Annex 7. List of Supporting Documents 26 Annex 8. Borrower Contribution 27 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.   Project ID: P00 1520 IProject Name: Health Sector hnprovement Project Team Leader: Slaheddine Ben-Halirna TL Unit: AFTQK ICR Type: Core ICR Report Date: June 21, 2000 1. Project Data Name: Health Sector Improvement Project L/C/TF Number: IDA-225 10 Country/Department: MADAGASCAR Region: Africa Regional Office Sector/subsector: HB - Basic Health; HT - Targeted Health KEY DATES Original Revised/Actual PCD: 04/28/1987 Effective: 09/12/91 04/30/92 Appraisal: 00/00/0000 MTR: 06/30/94 10/03/95 Approval: 05/28/1991 Closing: 06/30/97 12/31/99 Borrower/lImplementing Agency: GOVERNMENT/GOVT. Other Partners: STAFF Current At Appraisal Vice President: Callisto E. Madavo Edward V. K. Jaycox Country Manager: Hafez M. H. Ghanem Francisco Aguirre-Sacasa Sector Manager: Arvil Van Adams Alain Colliou Team Leader at ICR: Slaheddine Ben-Halima. Edmond de Gaiffier ICR Primary Author: Paul Geli (consultant) and Nellie Sew Kwan Kan (Language Program Assistant) 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Sati3factory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability: L Institutional Development Impact: M Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: U Project at Risk at Any Time: Yes 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The project was designed to support the implementation of the Government's Health Sector Program (HSP) over the period 1992-96 with the objectives of: (a) reducing mortality and morbidity; (b) moderating fertility levels; and (c) improving the efficiency and sustainability of public expenditures for health, the sector policy framework and institutional coordination mechanisms. By accelerating the integration of  family planning services into the basic activities of the public health system, the project was also expected to contribute significantly to the implementation of the National Population Law adopted in 1991. The objectives were ambitious but appropriate at the time, in view of the health status of the population and the high rate of population growth, and in line with Government strategy for the sector and with the Bank's country assistance strategy for Madagascar. The health status of the population in Madagascar was poor, with indicators close to the averages for Sub-Saharan African countries. The reported leading causes of mortality and morbidity were malaria, perinatal health problems, diarrheal diseases and intestinal parasites, malnutrition, acute respiratory infections, tuberculosis (TB), and infectious diseases such as leprosy. During the last two decades, the health status of the population seemed to have stagnated, and there was some indication that diseases linked to poverty and unsanitary living conditions, notably TB, plague and water-borne diseases, might have been on ithe rise. The Government strategy for the development of the health sector was to focus on rehabilitating the public health system to enable it to deliver the basic services needed to meet the health needs of the population, with an emphasis on treating the most common endemic diseases and on improving the survival of infants, children and pregnant women. The HSP and the project were complex and demanding for the MOI-I and were, therefore, risky. The project's original objectives were clear, but the SAR and the legal documents did not include any indicator of success, quantitative or otherwise. Therefore, if the project had not been restructured, an assessment of the degree to which the original objectives have been achieved would have certainly been difficult. 3.2 Revised Objective: The revised project development objectives, as agreed with MOH during the mid-term review in 1995 and as formally revised in June 1996, were to: (a) achieve significant decreases in morbidity and mortality rates by helping the Borrower to strengthen priority disease control programs and epidemiological surveillance; (b) increase availability and affordability of essential drugs; (c) improve the quality of district health services and promote community-managed. cost recovery; and (d) strengthen the management and planning capacity of MOH. During the first three years of implementalion, the performance of the project was poor for a number of reasons related to the political situation as well as the design and management of the project. The project was rated as a problem project by the Bank in early 1994, and by the end of 1994, the Government started to implement an agreed action plan to improve project performance. The mid-term review, carried out jointly with MOH staff and donors in June and October 1995, led to proposals for partial restructuring of the project in the light of the sector reforms initiated by the MOH (decentralizing the health system and improving drug procurement and distribution) and support from other donors (for example, from USAID for family planning). Following an intense, one-year consultation process between Government, other donors, and the Bank, and using as a basis the Government health policy finalized in April 1996, the project objectives and activities were redefined. The project continued to have as an ultimate objective the reduction of mortality and morbidity rates. However, it no longer aimed at moderating fertility levels since this objective was already adequately pursued through other donors' financing. Instead, the project had a new objective of improving drug availability and affordability by supporting the newly established central drug procurement agency. The third objective of the original project, which was to improve the relevance and efficiency of public expenditures for health, the sector policy framework and institutional capacity, was redefined in line with the priority objectives of the new health pclicy. The focus of the project was now on: (i) strengthening - 2 -  primary health care at the district level, while promoting community-managed cost recovery; and (ii) developing an institutional capacity by focusing on priority management needs of the MOH, as defined in the new health policy. One could have argued that the project restructuring involved mainly changes in management, approach and focus, rather than changes in the substance of the development objectives. Nevertheless, the revisions of the project's objectives were reported to the executive directors and approved by them on a no-objection basis, as part of a restructuring package which also included changes in the projects activities and closing date. The Development Credit Agreement (DCA) was amended in May 1996. 3.3 Original Components. The project consisted of four components: (1) delivery of comprehensive communicable disease programs to control malaria, tuberculosis, leprosis, sexually transmitted diseases (including AIDS), and the plague, and the establishment of a communicable disease monitoring system (cost: US$ 16.5 million, excluding contingencies and taxes); (2) introduction/upgrading of family planning services as an integral component of maternal and child health care offered in at least 500 of MOH's clinics (cost: US$ 4.0 million, excluding contingencies and taxes); (3) improved delivery of primary health care services, including reasonable access to essential drugs in all MOH outpatient facilities (cost: US$ 9.0 million, excluding contingencies and taxes); and (4) the first phase of a long-term institutional development program to: (i) progressively restructure and strengthen the MOH's health delivery system to increase its efficiency and invite greater popular community/participation; (ii) strengthen MOHIs policy formulation and programming, monitoring and evaluation capacity; and (iii) broaden the financing base and improve the sustainability of public health expenditures (cost: US$ 4.9 million, excluding contingencies and taxes). 3.4 Revised Components: Based on the revised project objectives, the restructured project supported the following activities or components: Part A - Communicable disease control programs - US$ 18.6 million Part B - Improvement of drug availability and affordability - US$ 2.0 million Part C - Support to district health services and community-managed cost recovery - US$ 10.8 million Part D - Institutional development - US$ 5.0 million 3.5 Quality at Entry: In retrospect and with the wisdom of insight, the quality at entry seems to have been unsatisfactory, essentially because of a somewhat deficient project design for such a complex operation. On the positive side, as mentioned above, the project's objectives were consistent with the Bank CAS and government priorities at the time. According to the SAR, project preparation was well advanced, and irnplementation of the new activities could be started as soon as financing was available. Nevertheless, the performance of the project was very poor during the first three years. The mid-term review identified the main reasons for this poor performance, namely: (a) a lack of clear health policy and sectoral strategies, which has hindered implementation of the sector program (which became largely - 3 -  donor-driven); (b) too loose a definition of project objectives and a lack of well-defined targets with only very few output indicators that could be monitored; (c) poor project management performance; and (d) lack of donor coordination mechanisms, which was highly detrimental to project management and planning, because project implementation was based on donor coordination mechanisms (IDA was considered as the donor of last recourse, once MOH annual work programs and costs had been approved by all other donors). It is clear that the original project design hacd underestimated the risks associated with implementing such a complex operation, especially those linked to poor institutional capability and donor coordination. The design had paid insufficient attention to project implementation, organization and management issues, including procurement and accounting. The General Director of Health (DGS) was to be the project director, assisted by a Project Steering Committee (PSC) to be established with high level officials of the MOH as members and, for day to day project administration, by the existing Projects Monitoring Unit (CSP) of the MOH; no provision was made for the establishment of a project implementation or management unit. The intention, a most commendable one, which is periodically advocated by many in the Bank, must have been to ensure that all departments and services of MOH be fully involved in project implementation, with appropriate strengthening, if needed. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: At the same time that the project objectives were revised, performance indicators covering project output and outcome/impact were developed and began to be monitored. An effort was made to identify indicators that the country/MOH could collect and monitor. A summary of those indicators is shown in Annex 1, and more detailed information on those indicators is given in the borrower report (Annex 8). It should be noted that, for some of the outcome/impact indicators such as the reduction in mortality and morbidity, the achievements shown cannot be attributed so!lely to the IDA project and credit, but are also the results of investments and actions undertaken and/or financed by Government and other donors. Some of the targets were too optimistic and unrealistic. With those qualifications, the overall outcome of the project, compared to the revised objectives can be considered rather satisfactory. Another way to evaluate the success of the project is to rely on the judgement and opinion of the beneficiaries themselves. According to a beneficiary asssessment carried out in late 1999, 80 percent of the heads of the households surveyed were satisfied with the services offered by health centers. The percentage is about the same in urban areas (77 percent) and in rural areas (81 percent), but varies among the Provinces: 68 percent for Antsiranana and 87 percent for Toamasina. This perception is due to the belief that family health has improved (for 80 percent of households), but also to the way health providers managed their relations with patients (for 85 percent of households). Another factor was the competence of the medical personnel (for 92 percent of households). Moreover, a majority of households believed that drugs were available in sufficient quantities (ffrom 56 percent to 67 percent of households), and that the cost of health care was "acceptable" (from 55 percent to 72 percent of households). Among the households which were not satisfied, the main problems mentioned were the insufficient personnel in rural areas and the inadequate supply of drugs in urban areas. Regarding the impact of the project, 75 to 94 percent of households thought that the activities of the health centers have brought about an improvement in their living condition. Practically all the heads of households believed that their health status has improved, and a large majority also indicated an additional benefit as an increase in productivity and a reduction in absenteeism. Those findings are encouraging and augur well for a desirable improvement in the rate of utilization of health facilities, which remains low. - 4 -  (a) Regarding the objective of achieving significant decreases in mortality and morbidity associated with the main communicable diseases, the individual disease objectives have been partially achieved. (b) Regarding the objective of increasing the availability and affordability of essential drugp the central drug procurement agency (SALAMA) is operational, although some concerns remain about its role in the cost recovery scheme. Essential generic (EG) drugs are now widely available throughout the public health network. (c) The objective of improving the quality of district health services and promoting community - managed cost recovery has not been fully achieved. The support to the development of the district health system was limited to the strengthening of the central and provincial levels, although some investments were made to rehabilitate and equip a number of district facilities. A very significant achievement is the establishment and now successful operation of a nationwide cost recovery system. (d) The objective of strengthening the management and planning capacity of MOH was only partially achieved. 4.2 Outputs by components: As mentioned above, the overall assessment is satisfactory. By project components, the assessments are as follows: - (a) Communicable disease control programs. Although below the targets, the progress of the Malaria control program is the biggest plus of the whole project. The wide availability of anti-malarial drugs has certainly contributed to the countrywide lowering of malaria morbidity and mortality. Surveys of sentinel posts show a reduction of 19 percent in morbidity and 35 percent in mortality in the highlands, which no longer experienced the severe epidemics of 1987/1988; on the other hand, progress in the lowlands has been much more limited. Tuberculosis has successfully been brought under control despite problems encountered lately in the provision of TB drugs; the compliance with treatment (cure rate) increased from 60 percent to 67 percent. In spite of major improvements in the plague control, following the establishment of an exemplary organization, the strategy clearly showed its limitation when it is confined within the Health Sector (the plague lethality rate decreased from 21 percent to 19 percent, compared to the extremely ambitious and unrealistic target of 5 percent), and hence the necessity to deal also with hygiene and sanitation. Given the serious impact of schistosomiasis in many parts of the country, the project provided unforeseen support to the fight against this communicable disease, with promising positive results. Given the concomitant very low HIV prevalence (0.07 percent at project mid-term), with the rather high incidence of STDs, particularly syphilis, the strategy adequately focused on IEC and STDs treatment, as well as systematic testing for syphilis in pregnant women, and blood transfusion security. The latest figure (November 1999) shows a still low IRV prevalence rate of 0.14 percent. - (b) Improvement of drug availability and affordability. SALAMA, the central drug procurement agency, is one of the two best in Sub-Saharan Africa. It has united all donors, who wanted to have it. Equipped with an appropriate stock of essential drugs, SALAMA began to operate in 1998, and distributed drugs, with the previously allocated budget for drugs, to all health infrastructures. This drug allocation, based on the previous Central Pharmacy budget line (which used -5-  specialty drugs and/or expensive generic drugs), was used to purchase low cost generic drugs and, therefore, generated a'relative excess of drugs compared to the actual drug use rate. The drug budget line has continued to be used to purchase drugs directly (outside of SALAMA) for delivery to the health facilities. Due to the overstocking, drug management capacity under normal conditions could not be assessed. In conclusion, while SALAMA has operated as an efficient drug distribution agency, it has not yet started to fully play its expected role, including direct drug sales to the health facilities which should buy replacement drugs with the proceeds of their own sales within the cost-recovery system. For the future, it is important that SALAMA remain a private non-profit drug procurement and distribution agency. - (c) Support to district health services and community-managed cost recovery. The revised component included: (i) the establishment and operation of central and regional units of MOH in charge of strengthening management and planning capabilities of health districts and promoting community-managed cost recovery; (ii) implementation of annual development plans at the district level, based on eligibility criteria (including rehabilitation and equipment and support to the health, training and supervision activities); and (iii) supply of drugs to establish revolving funds for cost-recovery systems managed by communities. It seems that the implementation of this component suffered from differences of views between the MOH and the Bank on the manner in which it should be executed, particularly the role and staffing of the central (Service de Developpement des Districts - SDD) and provincial units (Cellules Regionales d'Appui aux Districts - CERAD) for support to health districts. The support provided by the project was finally limited to the strengthening of structures at central and provincial levels which helped 36 districts (that became eligible and selected because they had produced the best district development plans) to strengthen their planning capacity. The MOH district development department, the provincial directorates and the 36 eligible districts have been equipped with computers in 1999. In addition, 30 health facilities (not necessarily the same as the 36 "eligible" ones) were rehabilitated within the framework of this component. More facilities received equipment bought earlier in the course of the project. As most of the activities planned at the district level were not actually carried out, the output indicators focusing on the districts (indicators selected at the time of the mid-term review) are not considered relevant for this assessment. The utilization rate and the health personnel attended delivery rate were expected to attain respectively 70 percent and 45 percent at the end of the project in the eligible districts. Information available indicates that the utilization rate and the attended delivery rate were only 41 percent and 25 percent respectively, nationwide. These rates are indeed lower than the targets, but it is clear that the expectations had been unrealistically set too high. Cost-recovery involving local communities was established simultaneously nationwide in early 1998. This operation lacked preparation and a number of crucial management elements, including financial procedures and the definition of the roles and responsibilities of the various actors, hence some of the problems that occurred. While a recent audit showed a nasonably sound management of recovered funds, there are uncertainties as to how and for what purpose these funds should be used. - (d) Institutional development The revised component included: (i) formulation of a health sector investment program and updating of norms and standards for health services; (ii) irnprovement of human resource management, through computerization of personnel management, development of a plan to redeploy health staff and strengthening of the unit of MOH in charge of personnel management; (iii) upgrading of in-service training programs for -6 -  health personnel; (iv) strengthening of IEC activities; and (v) development of a management and information system at the district and central levels. - Health sector investment programs have been formulated. The norms and standards for health services have been upgraded. However, the work was done mostly by foreign consultants with limited involvement by MOH, so that the new norms and standards were not appropriate for Malagasy conditions and could not really be used. Revised norms and standards have been prepared, but have not yet been formalized. - Strengthening of the personnel management succeeded with regard to the regular updating of all the personnel files. However, due to some constraints on the side of the Administration and the poor performance of the consultant, the computerized system is not yet working adequately. A personnel policy memorandum has been adopted while waiting for a more comprehensive reform of the civil service status, currently under preparation. This memorandum contains MOH-specific rules for the management of health workers, particularly with regard to redeployment. The MOH did not implement a redeployment plan as such but started to correct the staffing discrepancies between urban/rural and central/periphery in a more progressive way, referring to the rules contained in the above-mentioned memorandum. Apart from projections about the health personnel to be retired during the next few years, no comprehensive human resource development plan taking into account the extension of the health facility network, the medical and paramedical school outputs, the attrition rate for other reasons than retirement, and the private sector needs has been elaborated. - The project training component, which intended to harmonize the content of 12 training modules for in-service training, finally resulted in reviewing the training curricula of the newly reopened paramedical schools -- although only one module (leprosy) was finalized by the end of the project. A total of 895 trainers were trained, as compared to the 180 which were initially planned. Regarding the training of district personnel, four modules on planning, management, monitoring, and evaluation have been finalized, though they are not yet routinely used. A national training policy and a training master plan have been formulated. - The IEC service functioned quite adequately during the last two years producing IEC messages in different formats (posters, leaflets, audio and video cassettes, TV spots, T-shirts, caps, bags, etc.) and in the six dialectic national languages, dealing with polio eradication, cost-recovery, mental health and blood donation. The service is also responsible for publishing a MOH biannual information and communication publication for the health personnel. The IEC service has correspondents in most other MOH departnents. - A computerized management information system was established at the central level in early 1998. It is operating quite well and produces valuable and very useful health and management statistics, since July 1998. 4.3 Net Present Value/Economic rate of return: The Staff Appraisal Report (SAR) did not include any economic analysis of the project. There are no data available to calculate a posteriori the economic rates of return or the cost effectiveness of the investnents and activities that were actually financed under the project. It should be noted, however, that both at the design stage and for the restructuring, a deliberate choice was made by the Bank to finance those areas of interventions which have a high, demonstrated cost effectiveness ratio, as identified in the document "Better Health for Africa" and the 1993 "World Development Report". -7 -  4.4 Financial rate of return: No financial rate of return was calculated for this project. 4.5 Institutional development impact: Based on the discussion above on the achievement of objectives and the output by component (particularly the institutional development component), the institutional development impact of the project can be assessed as modest. 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: During the first three years from 1991 to 1993, the project did not succeed in helping the Government initiate the key reforms which were spelled out in the HSP. This period was marked by profound political turmoil which led, after months of riots and disturbances, to the establishment of a new constitution in August 1992. The political situation remained highly uncertain thereafter, until the election of a new President and the formation of a new Govermment by the end of 1993. In this context, the credit took a year to become effective. The project has sought to address key sector issues during its first years of implementation, rather than before and during project preparation. As the project was designed in effect as a "sector program", the lack of implementation of key sector reforms has hindered implementation of other project activities. The MOH had to develop and implement emergency programs to mitigate the disastrous effects of cyclones, particularly the cyclone Geralda. 5.2 Factors generally subject to government control: - The project outcome was favorably affected by the fact that lessons learned from the poor performance of the first three years of project implementation were taken into account in project restructuring and the risks faced by the original project were dealt with through the restructuring. Project restructuring after the mid-term review made the project more responsive to the Government's new health policy and strategies for 1996-2000, which Government had defined in agreement with all partners in the sector and which constituted the framework for planning sector investment and donors' involvement, including that of IDA through the restructured project. A major factor which affected project implementation negatively was the 1997 crisis between the Govermnent and the Bank resulting from the nomination of a National Coordinator, whose qualifications and experience were not acceptable to the Bank. The crisis could have led to a suspension of disbursements and cancellation of the credit Actually, disbursements were defacto suspended during that period since nobody was authorized to sign checks. However, essential activities, such as anti-malaria activities, TB treatment, etc. continued to be carried out with Government and other donor funding (e.g., WHO, EU, German and French Cooperation). It took several months as well as a lot of effort and diplomacy to resolve this matter, and to reestablish good working relations based on mutual confidence and respect In the end, the cooperation between Government and the Bank has been excellent. The project management unit (UGP) was streamlined and performed very well, at a lower cost. One important feature of this project is the contribution made by international and bilateral agencies, not as - 8 -  cofinanciers, but as "contractors" or providers of technical assistance and training, such as: WHO and the Italian Cooperation for the anti-malaria control program; the French Cooperation for the anti-tuberculosis control program; the Pasteur Institute of Madagascar (IPM) for the anti-plague control program; and the German Agency for Technical Cooperation (GTZ) for the development of health districts. S. 3 Factors generally subject to implementing agency control: The project was too ambitious and complex to be implemented during the period of high political turmoil and uncertainty which prevailed at the beginning of the project. It was firmly grounded within a Health Sector Program (HSP), the implementation of which required strong institutional capacity and donor coordination, both of which were lacking in the early years of implementation. The project concept was indeed very innovative back in the late 1980s, as it was conceived in effect as a "sector investment program", to be refuied each year based on the previous year's performance. The MOH was to establish annual work prograrns and financing plans, agree with donors on their respective share of financing and finally present to IDA for review items to be financed under the credit (IDA being the financier of last resort). This process, which was to constitute the implementation mechanism for the project as described in the original credit agreement, was not followed in the early years of the project. The MOH prepared ad hoc annual work programs, neither framed by the HSP (which ceased to be a point of reference) nor discussed with donors. As a result, these annual work programs often claimed high levels of financing from the IDA credit, without clear strategies and consensus with other donors. It is only in the last few years that annual work programs were properly prepared and used as a basis for preparing procurement and disbursement plans; in the end, the system worked well. In addition to problems resulting from the complexity of the project and the poor institutional capacity of MOH in its early years, the project suffered from serious weaknesses in management, resulting in a wide range of problems from cases of misprocurement to unsatisfactory accounting and qualified audits. As all projects implemented by Ministries, the project had to be implemented within the context of the somewhat cumbersome procedures of the Malagasy administration. Some excellent decisions taken at the sector level were not always properly implemented because of lack of preparation. A case in point is the decision to simultaneously implement nationwide in early 1998, cost recovery involving local communities. Some problems occurred because the operation lacked preparation and a number of crucial management elements, including financial procedures and the definition of roles and responsibilities of all the actors involved. 5.4 Costs andfinancing: At the time of appraisal, the cost of the Project was estimated at US$ 42.5 million. IDA planned to provide financing of US$ 31.0 million, and the Government contribution was estimated at US$ 11.5 million. The actual cost, or latest estimate of the cost of the Project is US$ 34.36 million, which was financed by US$ 30.22 million from the IDA credit and only US$ 4.14 million from the Government. 6. Sustainability 6.1 Rationalefor sustainability rating: Sustainability is a complex question, particularly in the case of a project which was successful in dealing with many sectoral issues, and for which there is already a follow-on project that continues and expands most of the project activities. The overall macro-economic performance of the country is also an element of uncertainty. Generally, the existence of government commitment and a favorable policy environment as - 9-  well as local participation are factors that should contribute to the sustainability of the project. Regarding the individual components, malaria control is now a mature program; it has rationalized the method to control malaria, and will be sustainable at a relatively low cost. The same is true for the tuberculosis control program, which is an exemplary one. The very favorable cost effectiveness ratio of the strategy adopted for schistosomiasis control should make that program sustainable. On the other hand, the sustainability of the plague control program is more questionable, since it will still require a lot of interventions within and outside the health sector. The epidemiological surveillance system seems to be well established. As for drugs and cost recovery, there is no reason why SALAMA should not become financially viable, provided that it remains aE private non-profit drug procurement and distribution agency and provided that budgetary allocations for drugs do not jeopardize the functioning of the revolving fund system. It may be useful, however, to revisit the cost recovery system to put in place an institutional strengthening program while considering the questions of equity and access as well as the harmonization of the various donors' cost recovery schemes. The question of sustainability for the support to district health services does not arise since achievements have been minimal. Despite a number of uncertainties, the modest results of the institutional development component are by and large likely to be maintained. Somewhat related to the question of institutional development and sustainability, it is worth noting that the African Development Bank (AfDB) is using the project's management unit (Unite de Gestion du Projet - UGP) for the financing that it intends to provide to the sector. A very conservative assessment of sustainability would point towards a rating of "uncertain", an option which is not available, however. On balance, and after giving proper weight to the importance of the communicable disease control programs and to their impact, the sustainability of the project can be rated as "likely". 6.2 Transition arrangement to regular operations: Health care delivery is an on-going responsibility and activity of MOH and its raison d'etre. As mentioned above, activities carried out under the project are being continued by MOH, as part of its normal responsibilities, with Govermment financing and with the support of donors including a follow-on project financed by IDA. The same performance indicators used for this project (of which a summary is presented in Annex 1) could easily be monitored, since one of the achievements of the project is the establishment and operation of a satisfactory and well-performing management information system, including health statistics. 7. Bank and Borrower Performance Bank 7.1 Lending: As discussed above in the section on quality at entry, the performance of the Bank was unsatisfactory. Preparation and appraisal underestimated the risks associated with such a complex operation and paid insufficient attention to project implementation, organization and management issues. 7.2 Supervision; At the beginning of the project, there may not have been an appropriate skill mix in the Bank supervision team to help the Borrower in carrying out the process or sequence of activities: planning of actions or measures to be taken - procurement plan - procurement - disbursement - accounting and financial management. -10-  The mid-term review (MTR) for this project, carried out in June and October 1995, was probably one of the most comprehensive and thorough of all the reviews in which the Bank ever participated. The MTR was carried out jointly with MOH and WHO and other donors, with the support of a consulting firm. Bank staff were instrumental and deserve credit for ensuring that all the problems were thoroughly analyzed and that remedial measures (including a significant restructuring) were adopted. The role of the Bank may have been too overbearing, however, and may have inhibited more active participation of nationals in the restructuring exercise. After the restructuring, it seems that Bank staff displayed some bias in favor of an excessive use of foreign consultants and of structures parallel to the directorates and units of MOH, which became to some extent marginalized. In 1997 the Bank was right not to give its no-objection to the national coordinator proposed by MOH, and to try to find a compromise acceptable to the Borrower in order to resolve the crisis. It is not clear why this incident was allowed to happen and to last for so many months. Whether the Bank could have done more to prevent the occurrence of such a crisis or to solve it more expeditiously remains an open question. In any event, the Bank interventions in recent years have been more "low key", in its relations with both MOH and other donors (in effect, among donors the European Union took the lead over from the Bank). The quality of the Bank supervision improved considerably and would deserve a rating of satisfactory, or even highly satisfactory. In May 1999, the project was used as a case study at a workshop for the Africa supervision training course. The training group (mostly experienced TTLs) and the trainers, who compiled their ratings independently of each other, agreed on an overall assessment of 2. Although this was nothing like a thorough full QAG review, the consistency of the ratings strongly suggests a solidly satisfactory quality of supervision. 7.3 Overall Bank performance: Overall, the Bank performance can be rated as satisfactory. Borrower 7.4 Preparation: According to the SAR, the HSP was prepared by the MOH with the support of consultants. It is likely that at the time the MOH was influenced by and followed the lead provided by the Bank and other donors in project preparation. 7.5 Government implementation performance: The performance of the Borrower has varied during the eight-year implementation period of the project. From 1992 until 1994. Initially, the Health Sector Improvement Project (CRESAN) was a poor performer because of serious management weaknesses, and was rated a problem project in 1994. Moreover, it seems that there was a lack of political commitment on the part of MOH to address major sector issues, especially with regard to the chronic shortage of drugs at public health facilities and the need to decentralize health administration and to redeploy health personnel. In view of the management problems the Bank requested the establishment of a Project Management Unit (PMU). Project management improved as a consequence but was later jeopardized by problems with two - 11 -  awards of contracts following international competitive bidding (ICB) and unacceptable delays in the signing of contracts which had received the no-objection of the Bank. Furthermore, the management methods of the National Coordinator became questionable for both the MOH and the Bank. The project was managed in a non transparent way, both technically and financially. The National Coordinator was making decisions by himself, without consulting the MOH and the specific units in charge of project implementation. This further contributed lo undermining MOH's sense of ownership towards the project. Project financial management also became questionable, to the extent that the 1994 audit was qualified. From 1995 to 1996. In late 1994, policy dialogue between the Govemnment and the Bank proved successful, resulting in the implementation, in 1995, of an action plan with far reaching results: (i) the MOH initiated key sector reforns with regard to decentralization and drug procurement; (ii) donor coordination and project management were considerably strengthened (the procurement issues were solved to the satisfaction of the MOH and the Banlk, and project management was improved thanks to the replacement of the National Coordinator and the streamlining of management and financial procedures); and (iii) the project was restructured in 1995/1996 to help the MOH implement its new strategies. Since then, the project has been successful in supporting the MOH in implementing: (i) the decentralization of the health system by strengthening the newly established 111 health districts with the definition, in collaboration with all partners, of a minimum package of essential health services, norms, and standards as well as with the drafting of an acceptable policy on cost recovery; (ii) communicable disease control programs, which have registered significant results over the last ten years; (iii) the creation of a private non-profit drug procurement unit; and (iv) institutional strengthening through personnel management and in-service training, and the establishment of a health information and management system. In addition, the MOH elaborated its national health policy in April 1996, following a two-year participatory process which has involved all partners from the public and private sectors. From 1997 to 1999. A change in project management in April 1997 put this now successful project at risk. A new Minister of Health (appointed in March 1997) dismissed the current national coordinator (who, in the opinion of the Bank, was performing well) and, without Bank's approval, nominated a person whose qualifications and experience were not acceptable to the Bank; as a matter of fact, that person was the same person that had performed very poorly as project coordinator during the period 1992-1994 (the project was rated a problem project in 1994) and had to be replaced. The problem was finally solved with the recruitment of a new National Coordinator, and a leaner project management unit (Unite de Gestion du Projet - UGP) performed well, and at a lower cost. By focusing on the coordination of activities by the different directorates and units of MOH which imnplemented the program and facilitating the cooperation among donors, MOH and the UGP operated what was in effect a "sector investment program" the way it should be done. Government has not always complied with its undertaking to provide counterpart funds or has provided them with substantial delays. One of the unfortunate consequences has been that in a number of instances SALAMA took delivery of drugs with a very short remaining validity period, because MOH did not have the funds to pay the customs duties on those imported drugs. The various problems that have affected the project and the unfortunate incident regarding the appointment of a National Coordinator should not overshtadow the many achievements of MON, particularly in recent years, thanks to the dynamism and competence of the highest levels of the Ministry. Here are just a few examples of the very positive initiatives thai: have been taken in a great variety of areas: * MOH has taken charge of the coordination of donors, chairing twice a year donor roundtables which, in addition to being a forum for exchange of information, provided donors with an opportunity to - 12 -  express their interest in participating in the execution of the project. It was very appropriate for the MOH to put itself in the driver seat. * MOH has been quite open to the participation of donors in many activities, with no preserve or out-of bounds activity (pas de domaine reserve ou chasse gardee), if such openness could contribute to success. A case in point is the establishment of a well-performing computerized management information system (MIS), where the European Union contributed the software which is based on the experience of many African countries and which works very well. * MOH management made special efforts to remain in touch with the lowest levels of the health systems and to focus on "results on the ground", with the Minister chairing semi-annual meetings with the heads of all the 111 health districts and quarterly meetings with the provincial directors. * The simultaneous introduction of cost recovery, in the whole country, rather than phasing it in through pilot operations, was probably the right approach for such an essential, but politically sensitive and potentially controversial reform. One might regret, of course, that the preparatory work was not as complete and thorough as it should have been, but in the end cost recovery is now functioning nationwide. * In the preparation of a new health infrastructure development plan (carte sanitaire), MOH took into account the existence of private health practitioners and facilities. * MOH did not hesitate to rely on private contractors whenever they could provide a more efficient service than the Ministry itself (for example, contracting to NGOs the management of drugs in hospitals). * MOH introduced a scheme to provide incentives to about 700 medical doctors to set up a private practice in underserved areas. Generally, the MOITs good initiatives may have been more beneficial if they had been preceded by better preparatory work in a participatory manner among the Ministry staff as well as other donors. Donor coordination is definitely a responsibility and prerogative of Govenmuent However, in order for the project to benefit from the talents and experience of the intemational and national organizations that operate in the field, it is important that donors be appropriately consulted and informed about progress in project implementation so that they may cooperate in project execution (as has been the case with GTZ, WHO, UNICEF, and the Italian and French Cooperations). The same is true for all other stakeholders, including the Ministry staff which should participate fully in all stages of the project cycle. The whole project experience demonstrates that nationals can be trusted to manage and implement a project quite well. 7.6 Implementing Agency: 7.7 Overall Borrower performance: Overall, the Borrower performance can be rated as satisfactory. 8. Lessons Learned The lessons learned through the successful implementation of this project in Madagascar were already applied during the last few years of project implementation and were used in the preparation of the Second Health Sector Support Project (Cr. 3302-MAG). They are as follows: * The Government should, at an early stage, develop a comprehensive policy framework and sector strategy that form the basis for the intervention of all donors in the sector. * Officials of the Ministry or relevant Government Agency should always be completely involved and in - 13 -  charge of all stages of the project cycle. * For certain diseases linked to poverty and unsanitary conditions (such as the plague and cholera), a strategy confined within the health secotr has important limitations, and needs to be complemented by a multi sectoral approach (such as the implementation of measures to improve hygiene and sanitation). * It may be better to introduce major, politically sensitive, and potentially controversial reforms (such as cost recovery) all at once, nationwide rather than progressively, provided that the necessary preparatory work has been done. * Project design should include suitable arrangements for implementation by the Borrower, including eventually the establishment of a project coordination unit. * Project design should include a minimum of realistic performance indicators, both for project output and project outcome/impact, that the Borrower/implementing agency can collect and monitor, with detailed information on the relevant methodology and the means of measurement. 9. Partner Comments (a) Borrower/implementing agency: In 1991, the Health Sector Improvement Project was decided in partnership between the Government of the Republic of Madagascar and the International Development Association (IDA) in the presence of representatives of outside partners of the Ministry of Health (MINSAN/MOH), based on the objectives of the Health Sector Programme (HSP/PSS) for Primary Health Care (SSP). From 1992 to 1994, in its initial phase, the implementation encountered some difficulties highlighting the risks that the project implementation might be faced with: (1) socio-political context; (2) lack of collaboration between the project and the supervisory ministry; (3) technical problems inherent with the accounting system adopted by the Project Management Unit (PMU/UGP); and (4) differing views between the Borrower and IDA regarding the details of implementation and sustainability. In the second phase, from 1995 to 1996, there was a distinct improvement in disbursements after the restructuring. The extensive resort to sub-contracting with international consultants and various organizations (GTZ, OMS, IPM) and the creation of support units (Cellules d'Appui aux Districts - CERAD) at the level of the 6 provinces contributed to this improvement. However, this involved high cost in expenditure category 3 of the Project (Consultants, Studies, Training) that was increased by more than 100% of the initial amount allocated. Therefore, the reallocation of funds at mid-term review, rather decreased the amounts allocated to Works (category 1) and kept stationary the amounts for drug procurement (category 5). Concurrently, there was a noticeable slowing down in the national implementation of the Project. On the other hand, equipments (category 2) were purchased but were not directly utilized by the population. Personnel! qualifications improved through multiple training (category 3), but in view of the decay of infrastructures and the lack of renewal of technical equipment, these investments have not had noticeable effects on the quality of care provided to the population. In 1997, the differences of views between the Government and the Bank, regarding the orientation and the management of the Project, have been revised so that the population might get the maximum profit from the benefits of the Project, in spite of the constraints. Also, for its third and last phase, following changes in project officers on both sides, the Government's and the Bank's, the Project has been managed at lower cost and has given priority to national implementation. The resumption of the project operations has been oriented towards strategies clearly defined in the master plan of 1998-2000, that facilitate the cooperation between all partners and MINSAN/MOH. The implementation of the Project did proceed in a climate of open and real cooperation, and its contribution in refonning the sector has achieved concrete results, to the satisfaction of the Borrower and the Association. The most noticeable results are the development of a - 14 -  Health System based on District Health Services and the support to the implementation of a strategy of Financial Participation by the Users - Participation Financi6re des Usagers (PFU), the generalization of which was decided in early 1998. (b) Cofinanciers: (c) Other partners (NGOs/private sector): 10. Additional Information - 15 -  Annex 1. Key Performance Indicators/log Frame Matrix NOTE: The targets listed below have been set at about the time of the mid term review. Some of those were far too optimistic and unrealistic, so that even in cases where the targets have not been reached, some of the achievements may still be considered satisfactory. Kev Performance Indicators OUTCOME/IMPACT INDICATOR Baseline Target Actual Communicable diseases: * Malaria: (i) control malaria epidemics in the 41,940 173,271 highlands a) decrease morbidity, # of cases (% decrease) 213,985 (-70%/O) (19%) b) decrease mortality in the highlands, 4 of deaths 1,105 553 716 (%/odecrease) (-50%) (-35%) Communicable diseases: *Tuberculosis: (i) increase cure rate from 60% to 60% 70% 67% 70% (1998) Communicable diseases: * Plague Lethality rate 21% 5% 19% Communicable diseases: * HIV Prevalence Rate 0.07% 0.15% 0.14% Essential drugs: ensure drugs are supplied regularly to health facilities. no Yes yes Primary care: (i) utilization rate of health facilities na 70% 41% (ii) rates of attended deliveries na 45% 25% Institutional strengthening: (i) define a health policy, norms, standards and a 3- year rolling plan no Yes ves** *Unless indicated otherwise, the figures in the column "actual" are for 1999. ** Except for norms and standards: the work was done by foreign consultants with limited involvement by MOH, so that the new niorms and standards were not appropriate for Malagasy conditions and could not really be used - revised norms and standards have been prepared but have not yet been formalized. - 16 -  Output Indicators Baseline TargetLE Actual Malaria. i) OPID coverage population 1,544,471 2,500,000 2,529,5 ii) # of personel trained in case management 0 2,022 45 iii) mosquito nets dissemination in lowlands 0 75,000 1,400 17.360 Tuberculosis i) decrease in drop out rates 25% 18% 17% (1998) Plague. i) # of personel trained in case management 25 366 249 ii) # of HCs provided with adequate supplies 650 850 850 iii) # of HCs where DWague is controlled 161 425 288 HlIV/AIDSlSTIs i) # of personel trained in STIs syndromic 0 300 1.283 approach 0 31 12 ii) # of AV & Radio spots produced 0 8 5 iii) # of tvpe of posters & leaflets produced Surveillance system and Oper. Research i) # of sentinel stations 8 12 12 Primary Care i) strengthen capability of districts teams to 0 36 36 elaborate dev. Plans ii) support planning in 36 districts 0 36 0 iii) communities supported to establish committees. cost recovery 0 216 1.950 Essential Drugs i) Create private non profit drug procurement & Purchase 1st revolving drug fund na done done Institutional Strengthening i) strengthen personel management - update all personel files none done done - computerize data/management none done none ii) Strengthen in-service training - # of trainers trained 0 180 1,056 iii) Strengthen IEC staff capacity -1# trained (central, regional levels) 0 141 118 - 17 -  Annex 2. Project Costs and Financing 1. Comunicable Disease Control 19.43 18.60 16.53 85 89 Proaram__ 2. Maternal and Child Health 4.94 _ 0.19 care/Family Planning Program _ 3. Central Purchasing Agency -2.00 2.36 118 (CPA) _ 4. Other Primnary Health Care 10.73 10.80 6.29 59 58 (PHC) Programs//Support to district health services and community-managed cost recoverv _ 5. Institutional Strengthening 6.10 5.00 8.99 147 180 6. Taxes _ 1.30 _____ Total Proiect Cost 42.50 _ 36.40 34.36 81 94 Total Financing Reuired 42.50 36.40 46 8 4 * including contingencies Appraisal estimate of US$42.5 million excluded duties estimated at US$1.5 million, which were to be paid by direct budgetary transfer. Actual amounts (or latest estimates) for all components include taxes. Project Costs by Procurement Arrangements A ralsal Estimate (US$ million equivalent) |1. Works | 0.00 1.90 2 .40 0.00 4.30 } 0 ~~~~~~~~~(0.00) (1.40) 0 (.20) (0.00) (2.60) 2. Goods 19.10 0.70 6.10 0.00 25.90 (17.90) (0.50) (0.70) (0.00) (19.10) 3. Services 0.00 0.00 2.40 2.40 (technical assistance and (0.00) (0.00) (2.30) 0 (2.30) studies) ____|__. _.._ 4. Training 0.00 0.00 2.30 0.00 2.30 (0.00) 000) (2.30) (0.00) (2.30) 5. Stipends & Travel 0.00 0.00 2.20 2.20 (0.00) (0.00) (1.30) 0 (1.30) 6. Incremental Operating 0.00 0.00 4.10 4.10 Costs (0.00) (0.00) (3.40) Q (3.40) Total 19.10 2.60 19.50 0.00 41.20 _______________________ (17.90) (1.90) (11.20) (0.00) (31.00) Goods include Vehicles & Equipment Supplies, and Drugs and Technical Inputs.Total of US$41.2 million excludes taxes of US$1.3 million. -18-  Project Costs by Procurement Arran ements (Actual/Latest Estimate) (US$ million e uivalent) I Works 0.00 2.15 1.53 0.00 3.68 (0.00) (1.51) (1.10) (0.00) (2.61) 2 Goods 5.29 0.53 11.98 0.00 17.80 (4.41) (0.44) (11.66) (0.00) (16.51) 3. Services 0.00 0.68 8.46 0.00 9.14 (technical assistance and (0.00) (0.57) (7.88) (0.00) (8.45) studies) 4. Training 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 5. Stipends & Travel 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 6. Incremental Operating 0.00 0.00 3.74 0.00 3.74 Costs (0.00) (0.00) (2.65) (0.00) (2.65) Total 5.29 3.36 25.71 0.00 34.36 (4.41) (2.52) (23.29) (0.00) (30.22) Goods include Vehicles & Equipment Supplies, and Drugs and Technical Inputs. Figures in parenthesis are the amounts to be financed by the Bank Loan. All costs include contingencies. Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local govermnent units. roject Financing b Com onent (in US$ million e uivalent) s-.., -~ . ~ r~k.ot pprasa 1. Communicable Disease 14.63 4.80 16.22 0.31 110.9 6.5 0.0 Control Program 2. Maternal and Child 3.72 1.22 0.18 0.01 4.8 0.8 0.0 Health Care/Family Planning Program 3. Central Purchasing 0.00 0.00 2.15 0.21 0.0 0.0 0.0 Agency (CPA) 4. OtherPrimarylHealth 9.55 1.18 5.89 0.40 61.7 33.9 0.0 Care (PHC) Programs 5. Institutional 3.10 3.00 5.77 3.21 186.1 107.0 0.0 Strengthening Taxes 0.00 1.30 0.00 0.00 0.0 0.0 0.0 TOTAL 31.00 11.50 30.22 4.14 97.5 36.0 0.0 The appraisal estimate of US$11.5 million for government financing included taxes estimnated at US$1.3 million but excluded duties estimated at US$1.5 million equivalent, which were to be paid by direct budgetary transfer. Actual amounts (latest estimates) for all components include taxes. - 19 -  Annex 3: Economic Costs and Benefits The Staff Appraisal Report (SAR) did not include any economic analysis of the project. There are no data available to calculate a posteriori the economic r ates of return or the cost effectiveness of the investmnents and activities that were actually financed under the project. It should be noted, however, that both at the design stage and for the restructuring a deliberate choice was made by the Bank to finance those areas of interventions which have a high, demonstrated cost effectiveness ratio, as identified in the document "Better Health for Africa" and the 1993 World Development Report. -20 -  Annex 4. Bank Inputs a) Missions: Stage of Project Cycle No. of Persons and Specialty Performance Rating (e.g. 2 Economists, I FMS, etc.) Implementation Development MonthYear Count Specialty Progress Objective Identification/Preparation 11/1987 1 Economist/TTL I Nutrition Consultant I Health Financing Consultant 11/1989 1 Division Chief I Economist I Public Health Specialist 1 Nutrition Economist Health Economist (Consultant) 03/1990 2 Economist 3 Health Specialist I Health Specialist (Consultant) Appraisal/Negotiation 05/1990 l Economist I Health Specialist 2 Health Specialist (Consultant) I Architect/Urban Planner (Consultant) 10/1990 1 Architect/Urban Planner (Consultant) Supervision 07/1991 1 Economist (TTL) S S 2 Health Specialist I Health Specialist(consultant) 02/1992 1 Division Chief S S I Economist (TTL) I Public Health Specialist 07/1992 1 Public Health Specialist (TTL) S S 1 Population Health Specialist I Implementation Specialist 1 Economist I Information, Education and Communication Specialist I Financial Analyst Health Specialist (Consultant) -21 -  02/1993 1 Public Health Specialist (TEL) S S I Implementation Specialist 12/1993 1 Division Chief . U U I Public Health Specialist (TTL) 1 Information, Education and Cornmunication Specialist I Implementation Specialist 04/1994 1 Implementation Specialist U U 10/1994 1 Health Economist (TTL) U U 12/1994 1 Health Economist (TTL) U U I Pharmacist (Consultant) 06/1995 1 Health Economist (TTL) S S I Public Health Specialist I Information, Education and Corr-munication Specialist I Health Economist (Consultant) I Pharmacist (Consultant) 10/1995 1 Health Economist (TTL) S S I Public Health Specialist I Implementation Specialist 12/1995 1 Health Economist (TTL) S S 06/1996 1 Healhh Economist (TTL) S S I AIDS Specialist 12/1996 1 Health Economist (TTL) S S 1 AIDS Specialist 2 Nutrition Specialist (Consultant) 1 Publiz Health Specialist (Consultant) 01/1998 1 Public Health Specialist (TTL) S S I Public Health Specialist (Consultant) 05/1998 1 Public Health Specialist (TTL) S S I Operations/Implementation Specialist 10/1998 1 Operations/Implementation S S Specialtist (TTL) I Public Health Specialist I Public Health Specialist (Consultant) - 22 -  08/1999 1 Operations/Implementation S S Specialist (IT-L) I Public Health Specialist i Public Health Specialist (Consultant) 12/1999 1 Operations/Implementation S S Specialist (TTL) Public Health Specialist Public Health Specialist (Consultant) ICR 05/2000 1 Consultant I Language Program Assistant (b) Staff: Stage of Project Cycle ._____________ *No stff we*k us$ sO00 Identification/Preparation 119.5 286.1 Appraisal/Negotiation 84.1 226.9 Supervision 200.9 807.2 ICR 9.5 42.9 Total 414.0 1363.1 -23 -  Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating Macro policies O H OSUOM O N * NA FSector Policies O H *SUOM O N O NA Z Physical OH OSUOM ON ONA F Financial O H *SUOM O N O NA M Institutional Development 0 H O SU S M 0 N 0 NA Z Environmental O H OSUOM O N * NA Social Z Poverty Reduction O H OSU*M O N O NA Z Gender O H *SUOM O N O NA FM Other (Please specify) O H OSUOM ON * NA f Private sector development 0 H O SU O M 0 N 0 NA