Document of

The World Bank

FOR OFFICLAL USiE ONLY

Report No.13136

PROJECT COMPLETION REPORT

RWANDA

FAMILY HEALTH PROJECT

(CREDIT 1678-RW)

JUNE 13, 1994

Population and Human Resources Operations DivisionSouth-Central and Indian Ocean DepartmentAfrica Regional Office

This document has a restricted distribution and may be used by recipients only in the performance oftheir official duties. Its contents may not otherwise be disclosed without World Bank authorization.

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

CURRENCY EQUIVALENTS(period average)

Currency Unit - Rwanda Franc (RwF)

1985: US$1.00 RwF 101.26

1986: US$1.00 = RwF 87.64

1987: US$1.00 = RwF 79.69

1988: US$1.00 = RwF 76.45

1989: US$1.00 RwF 79.98

1990: US$1.00 RwF 82.60

1991: US$1.00 RwF 125.14

1992: US$1.00 RwF 132.04

1993: US$1.00 RwF 143.24

FISCAL YEARJanuary 1 - December 31

GLOSSARY OF ABBREVIATIONS

DFCS - Direction de Financement et de Constructions ScolairesDHS - Demographic and Health SurveyFP - Family PlanningGTZ - Gesellschaft fur Technische Zusamnmenarbeit (German

Cooperation Agency)HC - Health Center(s)IEC - Information, Education and CommunicationMCH - Maternal and Child HealthMOHSA - Ministry of Health and Social Affairs

(in French: MINISAPASO)MINEPRISEC - Ministry of Primary and Secondary EducationMINIFIN - Ministry of FinanceMINISUPRES - Ministry of Higher Education and Scientific ResearchNC - Nutrition Center(s)ONAPO - Office National de la PopulationUSAID - United States Agency for International DevelopmentWHIO - World Health Organization

MEASURES

Metric British/US Equivalent

I meter 3.3 feet

I kilometer 0.62 mile

I square kilometer (km2) 0.39 square miles (sq.mi.)

FOR OFFICIAL USE ONLYTHE WORLD BANK

Washington, D.C. 20433U.S.A.

Office of Director-GeneralOperations Evaluation

June 13, 1994

MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT

SUBJECT: Project Completion Report on RwandaFamily Health Project (Credit 1678-RU)

Attached is the Project Completion Report on Rwanda-Family Health Project (Credit1678-RW) prepared by the Africa Regional Office. Part II was prepared by the Borrower.

This project aimed to improve the maternal and child health program by incorporating familyplanning and nutrition activities into primary health care, providing training to upgrade staff, andstrengthening the institutional capacity of the Ministry of Health and Social Affairs and the NationalOffice of Population. During the first several years, implementation was very slow, among otherreasons because of personnel problems, unfamiliarity with Bank procedures, reluctance to usetechnical assistance, and shortage of counterpart funds. These problems were eventually resolved andmost inputs completed by mid 1993, a year and a half later than planned.

Although the nutrition component was ignored and the population policy component wasunsatisfactory, the outcome of the project is rated as satisfactory because the mainobjective -improving maternal and child health and adding family planning services to the primaryhealth package -was achieved. However, its institutional development impact is rated as modest, andsustainability of results achieved as unlikely.

The PCR provides an adequate description of events but is weak on analysis.

No audit is planned at this time.

Attachment

This document has a restricted distribution and may be used by recipients only in the performance oftheir official duties. Its contents may not otherwise be disclosed without World Bank authorization.

FOR OFFICIAL USE ONLY

PROJECT COMPLETION REPORT

RWANDA

FAMILY HEALTH PROJECT

(CREDIT 1678-RW)

TABLE OF CONTENTS

Page No.

PREFACE ................................................ i

EVALUATION SUMMARY ................. ...................

PART I: PROJECT REVIEW FROM BANK'S PERSPECTIVE ............

A. PROJECT IDENTITY ..

B. BACKGROUND . .

C. PROJECT OBJECTIVES AND DESCRIPTION. 2Project Objectives.. 2Project Description. 2

D. PROJECT DESIGN AND ORGANIZATION. 3

E. PROJECT IMPLEMENTATION. 4Credit Effectiveness and Project Star-up. 4Implementation Schedule. 5Procurement. 7Project Costs.. 7Disbursements and Credit Allocation. 7

F. PROJECT RESULTS. 8Project Objectives and Physical Results.. 8Institutional Strengthening and Human Resources Development.. 8Population Policy. 9Impact of Project. 9

G. PROJECT SUSTAINABILITY. 9

H. BANK PERFORMANCE. 9

I. BORROWER PERFORMANCE .10

J. PROJECT RELATIONSHIP .11

This document has a restricted distibution and may be used by recipients only in the perfonnance of theirofficial duties. Its contents rnay not otherwise be disclosed without World Bank authorization.

TABLE OF CONTENTS(continued)

Page No.

K. CONSULTING SERVICES 11............................ 1

L. PROJECT DOCUMENTATION AND DATA 11................ 1

M. CONCLUSIONS AND LESSONS LEARNED 1................ 11

PART II: PROJECT REVIEW FROM BORROWER'S PERSPECTIVE .13

PART III: STATISTICAL INFORMATION .15

1. Related IDA Credits ................................. 15

2. Project Timetable .16

3. Credit Disbursements. 16

4. Project Implementation. 17

5. Project Costs and Financing. 18

6. Project Results. 19

7. Status of Covenants. 20

8. Use of Bank Resources. .............................. 22

PROJECT COMPLETION REPORT

RWANDA

FAMILY HEALTH PROJECT

(CREDIT 1678-RW)

PREFACE

This is the Project Completion Report (PCR) for the Family Health Project in Rwanda,for which Credit 1678-RW in the amount of SDR 9.8 million was approved on April 1, 1986 andsigned on May 23, 1986. The credit became effective on February 27, 1987 and was closed onDecember 31, 1993, about one and a half years behind schedule. The credit was fully disbursedat the closing date of December 31, 1993.

The PCR was prepared by the Population and Human Resources Operations Division ofthe South-Central and Indian Ocean Department (AF3PH). There was no completion mission.The Bank sent the Borrower Parts I and III with the request to prepare Part II which was receivedon December 21, 1993.

The PCR is based on the President's Report, the Staff Appraisal Report, the DevelopmentCredit Agreement, reports by and correspondence between the Bank and the Borrower, internalBank memoranda and interviews with Bank staff who have been associated with the project.

- 11 -

PROJECT COMPLETION REPORT

RWANDAFAMILY HEALTH PROJECT

(CREDIT 1678-RW)

EVALUATION SUMMARY

Objectives

i. The main objective of the Project was to improve maternal and child health withparticular emphasis on family planning within the national strategy for primary health care.Specific objectives were to: (a) make family planning services available in all health facilitiesas part of the maternal and child health program; (b) improve the quality and increase thecoverage of maternal and child health services; (c) target nutrition activities and integrate theminto maternal and child health services; (d) strengthen the institutional capacity of the Ministryof Health and Social Affairs (MOHSA) at the central and regional levels; (e) increase the outputand improve the quality of basic paramedical training programs; and (f) improve the NationalOffice of Population's (ONAPO) data base for population and policy formulation (paragraph 6).

Implementation Experience

ii. The overall implementation results of this project are good. The SAR was optimistic inits implementation plans and in forecasting project completion and the credit fully disbursed infive and a half years. This forecast did not take into consideration the fact that MOHSA was afirst time borrower unfamiliar with Bank procedures and the PHN disbursement profile of nineand a half years. The credit was disbursed in seven years which is considered good taking intoaccount the project's extremely slow-start up and the 1991-1993 civil war which delayed certainproject activities. During the first four years (1986-1990), Project implementation was sluggish.The slow start was mainly due to high turnover of project coordinators, weaknesses ininstitutional capabilities, slow decision making by MOHSA, cumbersome administrativeprocedures, unfamiliarity and/or poor compliance with Bank procedures, failure to followrecommendations of Bank supervision missions, and reluctance to resort to technical assistance.By mid-1990, only 25% of the credit had been disbursed. At the mid-term review, theGovernment and the Bank redefined the project's scope and priorities, and agreed upon a detailedimplementation plan and the staffing of an autonomous project unit. By that time, MOHSA washighly committed to speeding up project implementation, more familiar with Bank procedures,and a competent project coordinator was in place. The new coordinator understood the need touse technical assistance and recruited an international consulting firm to help DFCS preparebidding documents for civil works and equipment. MOHSA did a good job in implementing thetraining sub-components and its own institutional strengthening. However, it did not focus muchon the project's nutrition aspects. ONAPO's contribution to the implementation of the PopulationPolicy component has not been satisfactory. Regarding counterpart funding, only 30% of theagreed upon estimates were allocated to the project. This is in part due to the 1991-1993 civilwar which caused military expenditures to rise to 7% of GDP which had a negative impact on

- iii -

developmental expenditures. The project was completed in mid-1993 (paragraphs 11 to 20, and28).

Results

iii. The Project was successful in meeting its main objective to improve maternal and childhealth with particular emphasis on family planning. It contributed to the implementation of thenational strategy for primary health care by bringing about a better integration of family planningservices into the public health system. Most of the physical targets were exceeded. Thecontraceptive prevalence rate reached 13%, compared to an appraisal estimate of 10%. MOHSAwas strengthened. The training sub-component contributed to the training of 1,320 healthworkers (95 % of SAR estimate) and thus helped alleviate the acute shortage of paramedicalpersonnel. In summary, the Project had a significant impact on the quality and coverage ofMCH/FP services in Rwanda. Through this project, MOHSA acquired a better grasp andunderstanding of the importance of health financing and management issues. Finally, MOHSAlearned how to manage a Bank-financed project (paragraphs 21 to 25).

Sustainability

iv. Rwanda's health sector has always been heavily dependent on foreign assistance, evenfor recurrent expenditures. The project's institutional strengthening and the work on healthfinancing options which was developed during the project should, in the long-term, help MOHSAsustain its MCH/FP program efforts, it is likely that foreign assistance will continue to be neededto enable the Government to meet the increasing demand for MCH/FP services. This assistancewill in part be needed due to the current population growth at 3.1 % per year. The sustainabilityof this Project is therefore uncertain (Paragraphs 26 and 27).

Findings and Lessons Learned

v. Despite implementation delays and shortcomings of some project components, the FamilyHealth Project was successful. It had a positive impact on the delivery of MCH/FP services inRwanda. Both the Bank's and the Government's overall performance was satisfactory. Thelessons to be learned from the problems encountered during project implementation are: (a)project staff need to be highly competent and motivated; (b) the ministry concerned should notinterfere in the day-to-day management of the project; (c) technical assistance is necessary toassist in programming/monitoring until local expertise is developed; and (d) project personnelneed to be adequately trained in Bank procedures, mainly procurement. Since the MOHSA wasa first time borrower, the qualifications and number of persomel required should not have beenunderestimated. The Project also demonstrated that a lot of time is required to formulate realisticand meaningful proposals on additional sources of financing and resource mobilization in thesector. This increased knowledge of health financing will be instrumental in the preparation offuture operations (paragraphs 34 and 35).

PROJECT COMPLETION REPORT

RWANDA

FAMILY HEALTH PROJECT

(CREDIT 1678-RW)

PART I: PROJECT REVIEW FROM BANK'S PERSPECTIVE

A. PROJECT IDENTITY

Name Family Health ProjectCredit Number 1678-RWRVP Unit Africa RegionCountry RwandaSector Human ResourcesSub-Sector Health and Family Planning

B. BACKGROUND

1. Rwanda's salient characteristics include its small size; an annual population growth rateof 3.7% (ranking among the highest in Africa); a population density about 500 per square kmof arable land (ranking among the highest in the world); mountainous terrains and high averagealtitude; a landlocked position; lack of natural resources, including a serious shortage of arableland; underdeveloped physical and institutional infrastructure; and a very low level ofdevelopment.

2. At the time of project appraisal, social and economic indicators included per capitaincome of about US$270 (1983), among the lowest in the world, average life expectancy of47 years, adult literacy rate of 375, and an infant mortality rate of 115-125 per 1,000. As inmost sub-Saharan African countries, health conditions were poor. Mothers and young childrenaccounted for the bulk of Rwanda's morbidity and mortality cases. Many of the deaths couldhave been prevented with an effective MCH/FP/Nutrition program. Family planning serviceswere available on a very limited scale; according to the 1983 National Fertility Survey (NFS),contraceptive prevalence for modern methods was estimated at 0.9% of women ages 15-45 yearswho were in union, not pregnant and fertile.

3. The network of hospitals, Health Centers (HCs) and dispensaries was evenly distributedthroughout the country and health coverage was high by African standards (about 50% of thepopulation lived within 5 km of a health facility). A wide-scale expansion of the service networkwas therefore not required, but there was a need to upgrade health facilities in selected locations.There were shortages of staff, particularly for enrolled nurses and nurses aides, and of essentialdrugs. The effectiveness of the health care system was also affected by insufficient integrationof Maternal and Child Health (MCH) and Family Planning (FP) services, and of nutritionactivities.

- 2 -

4. Major population growth was inevitable, and the increasing pressure that it would bringon the country's social and economic systems made the need for large-scale efforts to reducefertility urgent. In order to increase the contraceptive prevalence rate and to meet the current andincreasing demand for FP services, the government adopted a strategy of integrated MCH andFP service delivery and of upgrading primary health care facilities. The government also tooksteps to strengthen the Ministry of Health and Social Affairs (MOHSA).

C. PROJECT OBJECTIVES AND DESCRIPITION

Project Objectives

5. The main objective of the Project was to improve maternal and child health withparticular emphasis on family planning within the national strategy for primary health care.Specific objectives were to: (a) make family planning services available in all health facilities aspart of the maternal and child health program; (b) improve the quality and increase the coverageof maternal and child health services; (c) integrate nutrition activities into regular MCH activitiesat the health center level and target nutrition programs towards "at risk" families; (d) strengthenthe institutional capacity of the Ministry of Health and Social Affairs (MOHSA) at the central andregional levels; (e) increase the output and improve the quality of basic paramedical trainingprograms; and (f) improve the National Office of Population's (ONAPO) data base for populationand policy formulation.

Project Description

6. The project consisted of the following components:

(a) Strengthening of Family Health Services. The Project was to support thedevelopment of a restructured MCH program which included nutrition activitiesand, most importantly, made FP services available nationwide. It was to achievethis through: (i) the implementation of a MCH/FP/Nutrition in-service trainingprogram for about 1,400 health center staff, including short and long-termforeign consultancies for curriculum development, training of trainers andoperating costs; (ii) the provision of medical supplies; and (iii) the upgrading andre-equipment of 30 health centers to strengthen the family health careinfrastructure.

(b) Institutional Strengthening of MOHSA. To implement effectively therestructured MCH program, MOHSA was to be strengthened, both at the centraland regional levels. At the central level, the MCH, Training, and Studies andEvaluation divisions were to be provided with equipment and logistical supportto better manage, evaluate and supervise field activities and with a long-termMCH/FP adviser. Improvements of the health information system throughtechnical assistance and equipment were to strengthen the planning capabilitiesof MOHSA. At the regional level, the decentralization process initiated byMOHSA was to be supported by: (i) training of regional teams to implement anin-service training program; (ii) strengthening the management and supervisioncapacity of the regional staff by providing vehicles, supplies, equipment,incremental operating costs and short-term foreign consultancies; and(iii) building eight MOHSA/ONAPO regional offices.

-3-

(c) Human Resources Development. Because paramedical personnel were scarce,the project was to: (i) provide pre-service training and deployment of about 200nurses aides (A4) to remedy the serious shortage of auxiliary staff in healthcenters; and (ii) finance the construction of two new A3-nursing schools with anestimated capacity of about 120 students each. The Ministry of Education wasto be responsible for staffing and managing the nursing schools. Technicalassistance was provided to improve teaching and curriculum development in theA3 schools.

(d) Population Policy. The Project provided direct support to ONAPO to strengthenits capacity to formulate and coordinate population policies by supporting twokey operational research studies. The studies were to focus on: (i) factorsinfluencing the acceptance and continuation of contraceptive use; and(ii) maternal and under-five mortality.

(e) Project Management. The Project was to strengthen MOHSA projectmanagement capability by financing 48 staff-months of consultant architecturalassistance for the project coordination office, incremental salaries for a projectcoordinator, an accountant and a support staff as well as equipment andincremental operating costs.

D. PROJECT DESIGN AND ORGANIZATION

7. The project was well prepared. The design of the project was the result of a successfulcooperative effort between the Government and the Bank which began during a population, healthand nutrition sector mission in June 1983. In November 1983, an agreement was reached on theoutline of the project and a PPF advance of US$440,000 was approved shortly thereafter. Twoyears elapsed between identification and appraisal because the MOHSA initially wanted to preparethe project without external technical assistance, but at that time lacked the technical expertisein certain areas. Project preparation accelerated when four international consultants wererecruited in the areas of family planning, architecture, nutrition, and management. At thetechnical level, the Government demonstrated ownership for the project as a local counterpartteam was created within MOHSA. The consultants and the MOHSA's team prepared a projectdocument. The document was extensively referred to during the appraisal and in the preparationof the SAR. It was occasionally referred to during project implementation. The delaysencountered during project preparation did have a positive impact on the project's overall scopeand objectives. The consulting team and Bank staff recognized the need to change the project'sscope from a "hardware" (rehabilitation, equipment purchases, etc.) to a "software" project thatwould focus on the delivery of comprehensive family health services. Regarding the familyplanning component, virtually no ownership was demonstrated, from ONAPO during projectpreparation. This situation had a negative impact on the implementation of the populationstudies.

8. In part as a result of this dialogue between Government and Bank staff during projectpreparation, the health sector was reorganized. This dialogue also resulted in the developmentof an overall strategy for implementing an integrated MCH/FP/Nutrition program responsive tothe country's needs which brought about the project's final orientation. The former Ministry ofSocial Affairs and Ministry of Health were merged to form the Ministry of Health and SocialAffairs (MOHSA). Three technical divisions were created within MOHSA's technicaldirectorate, namely: a MCH/FP division (including a family planning bureau and a nutrition

- 4 -

bureau), a Studies and Evaluation division, and a Training division (for basic and in-servicetraining). In addition, decentralization of health services management to the regional level wasinitiated, and with WHO's support, MOHSA started a comprehensive health financing study toanalyze trends in health expenditures, identify sources of financing and review opportunities foradditional resource mobilization in the sector. Finally, the merger of the Ministry of SocialAffairs (which included ONAPO) with the Ministry of Health brought under the umbrella ofMOHSA the strong cadre of ONAPO's specialist staff and managers who could now be used tomake a major contribution to the implementation of a national family planning program.ONAPO's mandate was to carry out educational and informational programs, research andevaluation, staff training, and program development in the areas of population and familyplanning. Actual delivery of FP services was to be undertaken by MOHSA field staff, actingunder the technical guidance of ONAPO's regional teams. Also the ONAPO teams were to carryout motivational programs designed by the ONAPO central office. All those government actionsset the stage for the implementation of the Family Health Project.

9. The Project was to be managed by three separate entities: MOHSA, ONAPO (which isadministratively under MOHSA's umbrella, but operates as a parastatal agency) and the DFCS(which is the architectural unit of the Ministry of Primary and Secondary Education). MOHSAwas responsible for implementing: (a) in-service training of paramedical personnel and nursingaides pre-service training (Training division); (b) PHC infrastructure rehabilitation program(Studies and Evaluation division); (c) integration of project activities with the ongoing MCHprogram, including FP and nutrition activities (MCH division); (d) overall regional institutionalstrengthening (Secretary General); and (e) monitoring overall project implementation and progress(Studies and Evaluation division). ONAPO was in charge of implementing two policy populationstudies as well as assisting in implementing FP activities, and DFCS was responsible for theconstruction of two new nursing schools and the training of teachers. A Project CoordinatingCommittee chaired by the MOHSA Secretary General, and consisting of ONAPO's director,along with officials from the Presidency and the Ministries of Finance, Planning and Primary andSecondary Education (DFCS), was responsible for overall project coordination. MOHSA'sproject management capability was to be strengthened by the appointment of a projectcoordinator, an accountant, an architect and support staff. The project coordinator would reportdirectly to the Minister of Health. It was agreed during negotiations that MOHSA would appointa MCH division chief and an additional training specialist in the Training division. A long-termMCH/FP expert would also be recruited under WHO contract to assist in the implementation ofthe Family Health program. Technical assistance would also be provided for pre-service and in-service training, and in health statistics.

E. PROJECT IMPLEMENTATION

Credit EffectivenDs and Project Start-up

10. The credit was approved on April 1, 1986, and signed on May 23, 1986. Additionalconditions of effectiveness included the appointments of key staff: a project coordinator, anaccountant and an architect, who were appointed in August 1985, June 1986 and November 1986,respectively. The recruitment of a procurement specialist even though necessary for a first timeborrower such as MOHSA was not recommended by the project preparation team. The absenceof this type of expertise contributed significantly to implementation delays for the civil works aswell as for equipment purchases. The Development Credit Agreement was approved bygovernment in September 12, 1986 and by the National Development Council in February 6,1987 and the law ratifying the agreement was signed on February 18, 1987 and published in the

Official Gazette on March 15, 1987. As a result, the Credit became effective only on February27, 1987, a delay of about five months from the originally planned date.

11. The delay in credit effectiveness, however, did not affect project start-up. Beforeeffectiveness, the Borrower took initial steps to implement the Project. It provided the locationsof the five unidentified health centers, signed a contract with the consulting firm for the civilworks, and started to define the training program and identify candidates for fellowships andstudy tours.

Implementation Schedule

12. The appraisal mission was optimistic when preparing the implementation plans andforecasting that the project would be fully disbursed and completed in five and a half years (theoriginal completion date was December 31, 1991). This forecast did not take into considerationthe PHN disbursement profile of nine and a half years and the fact that MOHSA was a first timeborrower. In addition, no recruitment of international technical assistance was envisaged to assistin project implementation. The project was fully disbursed in seven years which is considereda success taking into account the slow start-up period and the 1991-1993 war which also delayedcertain project activities (mainly the rehabilitation of health centers and nursing schools in thenorthem part of the country). Project implementation can clearly be divided into two phases,before and after the 1990 turnaround. Between 1986 and mid-1990, disbursements andimplementation were sluggish. Based on the SAR's forecasts, the health centers, regional offices,and nursing schools were scheduled to become operational between the end of 1988 and thebeginning of 1990. The implementation of other project elements (e.g. training, family planning,and nutrition) was supposed to be well advanced between the second and third year of projectimplementation with the final outputs materializing towards the end of the project. However, bythe end of 1989 (mid-term review), the project had accomplished very little, and only about 20%of the credit had been disbursed. The 1990 turnaround occurred, following a mid-term review(when only 25% of the credit had been disbursed compared to 77% forecasted in the SAR).During that time, the Government and the Bank redefined the project's priorities as well as thescope and orientation of the institutional strengthening component. It was decided, for instance,that the project would not focus on family planning activities as there was a free standing IDA-financed population project under preparation. An agreement was reached upon a detailedimplementation plan and the staffing of an autonomous project unit. The tumaround can alsobe attributed to Bank staff having spent 31.4 SW in FY90 for the supervision of this project.Also by 1990, a competent project coordinator was in place who understood the need to recruittechnical assistance to assist in the preparation of the bidding documents for the civil works andequipment. With the exception of a few items (mainly the completion of three health centers andone of the two nursing schools in the northern part of the country) which could not be completeddue to lack of fluxds when the war ended, the project was completed in mid-1993.

13. As a result of the mid-term review's recommendations, a project unit was created withinMOHSA to coordinate between ONAPO, DFCS, and the MOHSA divisions. This unit wasresponsible for all implementation related matters and reported to the Minister of Health. Thisunit was headed by a project coordinator who was assisted by a financial manager, an accountant,two architects (responsible for the civil works in five prefectures each) and a training specialist.The high turnover of project coordinators is one of the key factors responsible for the slow startof project activities. When the last one came on board in 1990, the unit proved to be effectivein speeding up project implementation as MOHSA had given it sufficient autonomy. Furthermore,the Minister had delegated the overall follow-up of the project to the Director General of Health.

- 6 -

He in turn also facilitated the implementation of this project and provided technical expertise onhealth related issues and was MOHSA's key interlocutor on health financing issues.

14. The performance of MOHSA and DFCS has been particularly bad for the implementationof the infrastructure part of the Project. Agreements had been reached at appraisal between theBank and Government on the nature of the upgrading/rehabilitation to be done for the healthcenters. However, during the preparation of detailed plans, MOHSA wanted to increase the sizeof those centers which, together with the addition of investments not previously considered forwater supply and electricity, resulted in a sizeable increase in costs. Government kept asking foradditional financing which was not available. MOHSA took advantage of the turnover of Bankstaff task managers (five in seven years) to keep pushing this request through. Finally, biddingfor the first two lots took place only at the end of 1988, and for the remaining lots in 1990. TheProject upgraded or rehabilitated 22 health centers (instead of 30 included in the projectdescription) and six regional offices (instead of eight). Due to the added features for the healthcenters, the thirteen housing units for MOHSA were dropped from the Project. Among the 22health centers, 19 were fully completed and three in the northern part of the country have onlybeen completed at 85% because of the war. Regarding water supply, only four health centersbenefited from the necessary investments. The remaining 18 will be equipped with financingprovided by Belgian aid. The construction of the two new nursing schools was also considerablydelayed. The school in Kaduha became operational in the Fall of 1992 and 180 students wereenrolled. The other school in Byumba is only 90% complete because of the war whichcontributed significantly to the construction delays. This school was also looted during the warperiod. The training of teachers by MINEPRISEC and MINISUPRES occurred in parallel withthe school construction.

15. MOHSA did a good job in implementing the training sub-components of the Project. Onthe basis of the newly defined MCF/FP strategy, curricula were developed and 100 trainers(10 per health region) were trained. Despite the delays in appointing additional trainingspecialists, the number of health center staff retrained was 1,320, compared to an appraisalestimate of 1400, and the number of additional A-4 nurses trained and deployed was 300,compared to an appraisal estimate of 200. Two hundred graduates are currently seekingemployment and 525 are currently enrolled in the training program. This training was part ofthe component for strengthening family health services. Nutrition activities, which were also partof that component, were not implemented. The five-year nutrition program which was finallydeveloped will be carried out under the Food Security and Social Action Project (Cr. 2388-RW).The component for the institutional strengthening of MOHSA was carried out, with the exceptionof the improvements of the health information system (HIS) (computers and training wereprovided for the HIS and a timetable for implementation is ready). Also, the number of regionaloffices was reduced from eight to six due to the fact that GTZ financed the remaining two.

16. Regarding the population policy, which was ONAPO's responsibility, very little was doneunder the Project. Field surveys were carried out in September/October 1989 for the study offactors influencing the acceptance and continuation of contraceptive use, but the results have onlybeen partially processed. During the last three supervision missions, the Bank asked the projectcoordinator to follow up to see if a draft of this study could be obtained. A report was receivedat the time of project closing (four-year delay) which is in part due to some problems thatONAPO was having with the Bank on managerial questions related to the on-going PopulationProject. The second study, on maternal and under-five mortality, was incorporated in theUSAID-funded Demographic and Health Survey (DHS) which was carried out in 1991. The

-7-

project staff were also not committed to this component as they did not perceive it as a toppriority.

Procurement

17. Poor knowledge of and/or compliance with Bank procurement procedures delayed projectimplementation, particularly for civil works, but there were also problems with the procurementof vehicles. In the absence of standard bidding documents to be given to MOHSA and DFCS,the preparation of bidding documents for specific works turned out to be a painful exercise.Consultant/architects participated in supervision missions. However, due to the changes inproject staff, procurement activities remained at a standstill between supervision missions. Aspreviously stated, the project had a design flaw as it did not forecast the need for the recruitmentof a procurement specialist that should have been recruited at the same time as other key projectstaff as a condition of credit effectiveness. Even in cases where Bank staff explained the Bankrequirements, as for the two nursing schools, the procurement process remained at a standstillbecause DFCS did not seem (or wish) to understand what was required to bring the documentsup to Bank standards. The DFCS was also in charge of school constructions for the ThirdEducation Project and the same types of problems were also occurring. One construction contractfor the health centers had to be cancelled because of poor performance by the contractor, whichmight have been avoided by a more careful assessment of this contractor's qualifications andcapabilities before contract award. Moreover, it seems that he had not been required to furnishany security for the advance payment that he received and it is not clear whether the Project wasable to recover that money from the performance security (bank guarantee).

Project Costs

18. Project accounts have been kept only by disbursement categories of the IDA credit withall expenditures summarized in a ledger. There is little information available in the files on theactual contribution by WHO and the Government. However, one of the progress reports refersto the fact that government counterpart funding has been about 33% of the amount estimated atappraisal. This is mainly a result of the three-year civil war which squeezed developmentexpenditures while military expenditures reached 7% of GDP by the end of projectimplementation. In any event, there is no informnation on the actual cost of each projectcomponent which could be compared with the estimate included in the Staff Appraisal Report(SAR). Regarding the IDA credit, variations between 1985 and 1993 in exchange rate betweenSDRs and US dollars in effect increased the available financing expressed in US dollars. Actualdisbursements amounted to US$13.5 million compared to an appraisal estimate of US$ 10.8million (a 25% increase). Assuming that the contribution by WHO and government has beenmuch less than the US$3.6 million estimated at appraisal, (say, of the order of US$1 milliononly), total project costs would be the same as the appraisal estimate of US$14.5 million, but fora somewhat reduced project.

Disbursements and Credit Allocation

19. The cumulative estimated and actual disbursements of Credit 1678 - RW are given intable 3 of Part III. The five and a half-year disbursement forecast of the SAR was unrealistictaking into account the fact that MOHSA was a first time borrower and that the Bank wide PHNdisbursement profile was nine and a half years. At the mid-term review, only about 20% of thecredit had been disbursed. Once the project execution gained momentum in 1990 (due to therecruitment of competent project staff, the high emphasis placed by the Bank on supervising the

-8-

project, and the willingness to resort to technical assistance for procurement issues) it wasconsidered prudent to increase the authorized allocation of the special account from US$ 600,000to US$ 1,000,000, and the additional deposit was made in February 1991. Disbursements thenincreased very rapidly, and by the closing date, because of an increase in the value of the SDRin dollars, actual disbursements in dollars represented 125% of the total amount estimated atappraisal. The allocation of the proceeds of the credit was amended twice to reflect the changesin financing requirements. Disbursements of the IDA credit were more than estimated atappraisal for civil works, and furniture, equipment, medical supplies and vehicles, and about thesame for the other categories. The original closing date was June 30, 1992, but the credit wasclosed on December 31, 1993 after two extensions. The credit was fully disbursed.

F. PROJECT RESULTS

Project Objectives and Physical Results

20. The Project was successful in meeting its main objective to improve maternal and childhealth with particular emphasis on family planning. The Project brought about a betterintegration of family planning services into the health system. However, the nutrition aspectswere neglected. As shown in Table 6 of Part III, most of the performance indicators in the SARwere exceeded. However, it should be noted that they were not systematically monitored duringproject supervision and were not included in the progress reports. Physical targets of the Projectwere exceeded. A recently undertaken Demographic and Health Survey (DHS) indicates aContraceptive Prevalence Rate of 13%, compared to an appraisal estimate of 10%. Importantgains were also made in child health monitoring, deliveries in health facilities, and prenatal care.MCH/FP services benefitted greatly from the training programs, medical supplies, the healthcenter standard manual, and supervision activities financed under the Project.

Institutional Strengthening and Human Resources Development

21. The project has been generally successful in its objective to strengthen MOHSA'sadministrative capacity to implement the MCH/FP program. Support provided under the projectwith regard to training, construction, equipment and logistics brought about improvements weremade at all levels - central, regional and field - despite the fact that MOHSA did not benefitas much as was expected from the services of a long-term MCH/FP adviser. However thedevelopment of a better health data base, which was expected to improve decision-making in keyareas of resource allocation and evaluation of program effectiveness, did not take place. One ofthe dated covenants was that MOHSA would submit, by December 31, 1987, a proposal toimprove its statistical health information system. Attempts were made to introduce an improvedsystem, on a pilot basis in a few regions, then nationwide, but they were not very successful(currently MOHSA is exploring other sources of financing). Regarding MOHSA's computerizedmanagement information system (MIS), in 1991, a consultant prepared a program and timetablein four phases for the installation of a MIS. This MIS could not be implemented under theproject due to lack of funds, because it entailed a large purchase of computer equipment andinternational technical assistance. It was agreed to implement the first phase of the MIS underthis project. However, some of the equipment is not being utilized to its fullest capacity withinMOHSA at present.

22. One of the expected benefits of the Project was that it would assist the government insolving one of the health system's most severe constraints - the shortage of paramedicalpersonnel. Despite the delays in the recruitment of additional training specialists, the output of

- 9 -

the paramedical in-service training was close to the appraisal estimate. This contributed toimproving the quality of medical staff nationwide. Many doctors and nurses in the field havecommented that the deployment of the newly trained A-4 auxiliary nurses have allowed them tospend more time on their normal tasks as doctors and nurses. It is too early to comment on theimpact of the nursing schools for A-3 nurses which are designed to train primary health carestaff.

Population Policy

23. The implementation of this component, which was intended to strengthen ONAPO'scapacity to formulate and coordinate population policies, has not been successful, because of theweakness of ONAPO's research unit. Two studies were supposed to be undertaken during thefirst and second years of the Project. However, ONAPO did not participate in the preparationof the component and therefore did not feel much ownership for the component's implementation.The first study was completed with a four-year delay (paragraph 17). The second study was notdone under the Project but as part of the USAID-financed DHS. In addition, it appeared that theworking relationships between ONAPO and MOH had been deteriorating over the past years.The relationship between ONAPO and the Bank significantly deteriorated during the past twoyears due to diverging views on managerial issues encountered while trying to launch activitiesfor the IDA-financed Population Project.

Impact of Project

24. Although some components had a slow start and were completed only recently, allindicators show that the Project already has had a significant impact on the quality and coverageof MCH/FP services to Rwanda's population. That impact is expected to increase in the futurewith the output of the nursing schools and the operational use of the technical guides and manualsprepared under the Project.

G. PROJECT SUSTAINABILITY

25. According to the Staff Appraisal Report, the Project's main recurrent cost was for salariesof the additional paramedical staff trained under the Project, and other incremental operating costsassociated with supervision, and in-service training. Under the most pessimistic scenario, thiscost was estimated at only 5 % of MOHSA operating budget, and was considered affordable. Itwas recognized, however, that Rwanda's health sector was heavily dependent on foreignassistance, not only for capital investment but also for recurrent expenditures.

26. During project implementation, while new budgetary positions were created toaccommodate the additional paramedical staff, the govermnent contribution was less thanestimated at appraisal. It is unlikely that significant additional financial resources could bemobilized for the sector any time soon. Although the institutional strengthening should helpMOHSA sustain its MCH/FP program efforts, foreign assistance will continue to be needed inorder to enable government to meet the increasing demand for MCH/FP services.

H. BANK PERFORMANCE

27. Generally, the Bank's performance has been satisfactory. Through the Family HealthProject, the Bank made a positive contribution to the integration of family planning into Rwanda'shealth system and to the institutional strengthening of MOHSA. Overall, the Bank did a good

- 10 -

job at the project preparation stage by recognizing the need to change the project's orientationand design from a "hardware" project (rehabilitation/construction, purchases of goods, etc.) toone focused on the delivery of comprehensive MCH/FP services. The Bank devoted adequateresources to supervision (Table 8). However, the staff turnover was high and there was excessivereliance on consultants. One of the task managers decided to go the "extra mile" to brief thecurrent project coordinator in detail on Bank procedures which made him more knowledgeableon how to go about implementing the project and more motivated. On the negative side, the taskof the Borrower has been made more difficult by the high turnover of Bank staff on the Project.The fact that five different architects, employed as outside consultants, worked on the Project atdifferent times is another clear illustration of the short sightedness of the Bank's decision severalyears ago that there was no need for architects in its operational divisions. This continuousproblem on the Bank's side in the last two years of project implementation was addressed throughthe use of short-term consultants. Project staff were not formally trained in Bank procurementprocedures; standard bidding documents were only provided at the time of the mid-term review.The health centers were originally overdesigned but were scaled down at appraisal. The Bankshould have been more assertive when, at the beginning of project implementation, MOHSA triedagain to get the Bank to finance over-designed health centers; a firm "NO" would have savedeverybody's time and money. This operation was instrumental in enabling the Bank to get aninsight on how the health sector operates and what are its key issues. This will be a contributingfactor in the design of better targeted future operations. The decision to bring to Washington in1990 for a period of two weeks the current Project Coordinator to brief him thoroughly on theway the Bank works, its procedures and what was expected of him turned out to be a criticalfactor to improve project implementation.

I. BORROWER PERFORMANCE

28. The Borrower should be given credit for the project's overall good results. Through thisproject, MOHSA learned how to properly manage a Bank project. MOHSA has done anexcellent job on training, and some of the tasks that have been considerably delayed, like theproduction of technical guides and manuals, had a positive capacity building impact because theyhave been carried out by Rwandese personnel. (an international expert assisted in the elaborationof the documents). Many of the favorable project results should have materialized earlier, butunfortunately the Project had a very slow start. This could have been overcome by morecommitment from high level staff within MOHSA, the appointment of a competent projectcoordinator, and a better timing for the recruitment of international technical assistance to assistin management and procurement issues. Implementation delays have resulted from the followingchronic problems: rapid turnover of project coordinators; weaknesses in institutional capabilities;slow decision making; cumbersome administrative procedures; poor knowledge and/or compliancewith Bank procedures, particularly procurement; failure to follow the recommendations of Bankmissions; and reluctance to resort to technical assistance. Government has also been remiss innot contributing its share of the financing. The deterioration in the political situation and the warhave also fueled implementation delays. Generally, ensuring proper coordination between theproject unit, MOHSA, ONAPO and DFCS turned out to be a difficult task.

29. More specifically, MOHSA did not do a good job on the implementation of the civilworks included in the Project. MOHSA's insistence in the early years of the Project on over-designed Health Centers was very unfortunate and later on the Project unit's architects interferedunnecessarily with the work of the consulting firm responsible for construction supervision.MOHSA did not take on its responsibilities on nutrition matters; its total lack of commitment inthis area is all the more regrettable given that Rwandese experts had the technical capacity to

- it -

prepare a reasonable program. The IDA-financed Rwanda Food Security and Social ActionProgram (FY92) will be tackling nutritional issues that were not addressed under this project.MOHSA's performance has been particularly poor on project accounts, which have not beenproperly maintained, and the auditor's and the Bank's recommendations went unheeded threeyears in a row. ONAPO's performance on the population studies has been unsatisfactory. Itscontribution to the project, the study of factors influencing the acceptance and continuation ofcontraceptive use was received at the time of project closing and could not be exploited under thisproject. Most covenants were complied with, but some with significant delays (Table 7).

J. PROJECT RELATIONSHIP

30. Bank relationship with MOHSA, ONAPO and DFCS on the Project has been good.However, considerable tension occurred during project appraisal as the Bank and the Governmentinitially held diverging views with regard to health center design.

K. CONSULTING SERVICES

31. The performance of the consulting firm to help with the civil works was good. The long-tern advisor on MCH/FP under contract with WHO was not available for the planned period andwas not therefore as productive as expected. The short-term technical assistance for the healthinformation system and the review of the MCH/FP training curricula was satisfactory. A long-term advisor was recruited during the last 15 months of project implementation who alsoperformed satisfactorily. However, the short-term technical assistance recruited under this projecthad virtually no opportunity to transfer any of their skills. The international consulting firmprepared the bidding documents for civil works and equipment but did not have a counterpart towhom it could transfer its knowledge. The above mentioned long-term advisor that was recruitedduring the last 15 months of project implementation was strongly suggested to the borrower asa means of speeding up project implementation. The project staff did not make use of hisexpertise to its full extent.

L. PROJECT DOCUMENTATION AND DATA

32. The Staff Appraisal Report, the President's Report and the Development CreditAgreement were not detailed enough for the implementation and supervision of the Project.Working papers were prepared prior to project appraisal, but due to the change in task managersthey were not systematically used during project supervision. MOHSA did not improve itsstatistical health information system. Audit reports were submitted in a timely manner duringthe last three years of project implementation. Prior to that time, audit reports were receivedwith a delay of up to five months. The fact that updated information on project costs bycomponent is not available did not facilitate the preparation of this PCR. The submission ofprogress reports was irregular until 1992. Since then, they have been submitted in a timelyfashion on a quarterly basis. Even though these reports were well prepared, the project teamperceived them as a Bank requirement and never used them as a management/monitoring tool forMOHSA.

M. CONCLUSIONS AND LESSONS LEARNED

33. Despite implementation delays and some shortcomings, the Family Health Project wasa good project. It has had a favorable impact on the delivery of MCH/FP services in Rwanda.Generally, the performance of the government and the Bank has been satisfactory.

- 12 -

34. According to the staff appraisal report, the main risk of the project was thatimplementation could be delayed because MOHSA had limited administrative capacity andvirtually no experience or appreciation of the managerial challenge inherent to implementing aBank-funded project. At the project appraisal and negotiations stages, the Bank tried to convinceMOHSA to recruit long-term technical assistance to assist in procurement and overall projectmanagement for the first three years of project implementation. However, MOHSA did not seethe need and made it clear that this was not a negotiable issue. The technical assistance couldhave helped get the project off to a good start. It would have transferred knowledge onprocurement and project management issues to the project staff and MOHSA so to enable themtake over for the latter part of the project. There was a flaw in the project design as therecruitment of a procurement specialist was not forecasted. It also appeared that during the firstfour years of project implementation, MOHSA was not very committed to the project. Had theseissues been addressed earlier, project implementation during the first four years would have beenquicker. At the time of the mid-term review in 1989, only 20% of the credit had been disbursed.By this time, MOHSA was extremely committed to making the project work. A project unit(staffed with competent persons) was created within MOHSA for the purpose of implementingthis project and was given complete autonomy for its day-to-day management. The project unitagreed to hire an international consulting firm to assist in the preparation of the biddingdocuments for civil works and equipment. During the mid-term review, it was also suggestedto hire a long-term international health manager to assist in project implementation, a suggestionwhich MOHSA also followed. On the accounting front, based on the recommendations of allaudit reports, the Bank suggested the computerization of the project accounting system as a wayof rectifying the problems linked to weak internal controls. The project unit staff did not takethis seriously, and after three years of efforts from the Bank's side, little was accomplished inthis domain. Supervision of the project by the Bank was quite intensive during some periods;in FY90 the Bank devoted 31.4 SW to the supervision of this project which was another reasonfor the project's turnaround. The skill mix during supervision missions was adequate. Duringthe last two years of project implementation, the project was mainly supervised by a financialanalyst; expertise on public health, nutrition, and architectural issues was sought numerous timesinformally from other Bank staff at headquarters or in the field preparing and/or supervising otherPHN operations at headquarters as well as in the field.

35. The first and most important lesson learned from this project was that when dealing witha first time borrower, the Bank should be more realistic when preparing implementation schedulesand disbursement forecasts. In terms of project management, the lessons learned are that: (a)project staff need to be highly competent, motivated and trained in Bank procedures; (b) MOHSAshould not be directly involved in the project's day-to-day management; and (c) technicalassistance is necessary for first time borrowers to assist in programming/monitoring andprocurement. The project also demonstrated that a lot of time is required to formulate realisticand meaningful proposals on additional sources of financing and resource mobilization in thesector. This knowledge of health financing and resource mobilization will be instrumental whenpreparing future operations in the sector. Overall, despite the delays and shortcomings of certainproject components, the Family Health Project's overall performance was good since it had apositive impact on the delivery of MCH/FP services in Rwanda.

- 13 -

PROJECT COMPLETION REPORTRWANDA

FAMILY HEALTH PROJECT(CREDIT 1678-RW)

PART II: PROJECT REVIEW FRONI BORROWER'S PERSPECTIVE

(TRANSLATION)

Rwandese Republic Kigali, December 21, 1993Ministry of Health No. 15/4283/PSF/93P.O. Box 84KigaliRWANDA

Family Health Project

Mr. David BerkDivision ChiefPopulation and Human ResourcesDivisionSouth Central and Indian OceanDepartmentAfrica Region

Dear Mr. Berk,

Reference made to your letter dated November 22, 1993 transmitting the ProjectCompletion Report for Credit 1678-RW, soliciting our comments and further clarifications, I ampleased to announce that we have found the report virtually complete. This facilitatedconsiderably our task. Please find some additional comments and the Government's opinion onthe above-mentioned report in the following paragraphs.

First of all, we familiarized ourselves with the report and then distributed it toall the concerned parties.

The various institutions and persons that worked on the project from projectidentification until closing reviewed and commented on the report. They are mainly the projectcoordination unit and the project's Interministerial Coordination Committee.

Comments were collected by the Family Health Project Coordination Unit andwere discussed during a meeting in which Mrs. Eileen Murray, task manager for the FamilyHealth Project on mission in Rwanda was present.

Comments and observations which were unanimously agreed upon wereincorporated into the draft Project Completion Report and the revised draft was made availableduring Mrs. Eileen Murray's mission.

- 14 -

Throughout this process and on the basis of the revised draft, we would like tostate the following:

- We confirm the data in Part III of the Project Completion Report;

- Our comments on Part I of the report were incorporated into the draft Project CompletionReport and this draft having been enriched reflects entirely our opinion;

- The Bank's performance was noted throughout all phases of the project. The key point wasthe numerous and pertinent supervision missions which were fielded at times where urgentproblem solving was necessary. Not only did these missions assist in problem solving, but theyalso helped in ensuring greater sustainability which was advantageous to all concerned.

- The Ministry of Health's performance was satisfactory after the initial trial and error perioddue to it being a first time borrower. The Ministry of Health became increasingly familiar withBank procedures which seems to indicate a good performance.

The clear management structure and the additional managerial autonomy granted to the projectteam were important factors which had a positive impact on project implementation.

We believe that in the future, the setting up or the revision of certain administrative proceduresand decision making levels will be necessary in order to minimize problems related toadministrative bottlenecks, even if this will only be beneficial for future projects.

- The relationship between the World Bank and the Ministry of Health was essentially frank andbased on mutual understanding. It is this type of relationship of a true partnership that inessence enabled the project to be completed.

Sincerely yours,

The Minister of Health

Dr. Casimir Bizimungu

cc: President of the RepublicPrime MinisterMinister of PlanMinister of Finance

- 15 -

PROJECT COMPLETION REPORT

RWANDA

FAMIILY HEALTH PROJECT

(CREDIT 1678-RW)

PART III: STATISTICAL INFORMATION

1. Related IDA Credits

Credit No./Project Purpose Year of Status CommentsTitle Approval

- Population To develop, on an 1982 Completed ONAPO was unable tocomponent of experimental basis, increase significantly theBGM II Rural community-based family number of contraceptiveDevelopment planning services in the acceptors. Major constraintProject prefecture of Kibungo. was lack of MOHSA(Cr. 1283-RW) Component to be involvement in FP services

implemented by provisions at health centerONAPO level.

- Second Education Establishment of one 1982 Completed Construction was of goodProject A-3 nursing school in quality.(Cr. 1263-RW) Gisenyi

- Population Project To support the 1991 Extremely ONAPO, which had been(Cr. 2272 - RW) implementation of the slow given the responsibility of

National Population progress coordinating thePolicy and to contribute because of implementation of thisto reducing the total manage- operation, has been unablefertility rate, improving ment to manage the projectmaternal and child problems properly. Responsibilityhealth, and integrating for the project has beenthe demographic transferred to MOHSA.dimension in cross-sectoral developmentactivities.

Food Security and To improve the food 1992 Credit Project is off to a goodSocial Action security and social effective start.Project welfare of the poorest 8/5/93(Cr. 2388 - RW) population groups, to

improve thegovernment's capabilityto monitor livingstandards of thepopulation, and toinitiate a long-termpoverty alleviationstrategy. .

16 -

2. Project Timetable

Item Original Date DateTimetable Revised Actual

- Identification 12/83 - 12/83(Initiating Project Brief)

- Preparation 4/85 - 4/85

- Appraisal Mission 7-8/85 - 7-/8/85

- Credit Negotiations 2/86 - 2/86

- Board Approval 4/1/86 - 4/1/86

- Credit Signature 5/23/86 - 5/23/86

- Credit Effectiveness 9/22/86 11/21/86 2/27/87

- Credit Closing 6/30/92 6/30/93 12/31/936/30/94

3. Credit Disbursements

Cumulative Estimated and Actual Disbursements|_____ ______ (USS million) l

Fiscal Year FY87 FY88 FY89 FY90 FY91 FY92 FY93 FY94

Appraisal 0.60 2.60 5.40 8.30 10.20 10.80 -

Estimate

Actual 1.07 1.61 1.87 2.73 3.68 7.65 12.63 13.51

Actual as % 178% 62% 35% 33% 36% 71% 117% 125%of Estimate

Note:Due to an increase in the value of the SDR in dollars, actual disbursements indollars have been greater than the amount estimated at appraisal.

- 17 -

4. Project Implementation

Appraisal Actual or PCRIndicators Estinates Estimates

A. Strengthening Family Health Services(a) Number of health center staff retrained 1,400 1,320(b) Number of additional A4 trained and 200 300

deployed(c) Number of peripheral health facilities 30 - 18 completed.

upgraded or rehabilitated - 4 completed at 60% only becauseof the war.

(d) Percentage of health centers delivering 100% 92%FP services

B. Institutional Strengthening(a) Training of MOHSA/ONAPO regional completed - completed

teams.(b) Fellowship and Study Tours completed - completed(c) Supply of vehicles & equipment completed - completed(d) Construction of regional offices 8 - 6(e) Health financing study completed - completed; because of complexity

of subject, additional studies wererequired.

(f) Health Information System Completed - Partially completed; first phase ofneeds assessment andrequirements finalized by aninternational consultant.

C. Human Resources Development(a) Construction of two A3 nursing schools completed - one completed.

- one completed at 90% onlybecause of the war.

(b) Training of teachers completed - not done

D. Population Policy(a) Study of factors influencing the completed - Completed.

acceptance and continuation ofcontraceptive use

(b) Study of maternal and under-five completed - completed (not under project, butmortality as part of USAID financed DHS

undertaken in 1991).

- 18 -

5. Project Costs and Financing

A. Project Costs (Appraisal Estimate)

Local I Foreign Total

------- US$ Thousand----

I. Strengthening Family Health 1,559 2,099 3,658Services

II. Institutional Strengthening 916 2,268 3,184

Ill. Human Resource Development 2,066 1,211 3,277

IV. Population Policy Studies 113 119 232

V. Project Management 368 555 923

VI. Refunding of PPF 176 264 440

Total Base Cost 5,199 6,517 11,715

ContingenciesPhysical 79 114 193Price 1,292 1,251 2,543

Total Project Cost 6,569 7,882 14,451(net of taxes and duties)

- 19 -

B. Project Financing Plan (Appraisal Estimnate)

Local Foreign I Total

-----US$ Thousand----

IDA Credit 3,740 7,063 10,803

World Health Organization 725 725

Government:Recurrent Budget 2,829 2,829Development Budget 93 I_93

6,569 7,882 14,451

Note: Because project accounts have been kept by expenditure category, there is noinformation on the actual cost of each project component which could be comparedwith the estimate included in the Staff Appraisal Report. Similarly and for the samereason, there is no information on the financing that has been actually provided bygovernment, IDA or WHO by project component.

6. Project Results

Indicators Appraisal Estimates PCR Estimates(As of, or for year ended (Most recent information

12/31/91) available)

I. Contraceptive 10% 13%prevalence

2. Child health 30% 85%monitoring

3. Deliveries in health 30% 30%facilities

4. Prenatal care 80% 95 %

Note: An evaluation of the economic impact or financial impact does not apply tothis project, and it is too early to assess the impact of the studies financed under theproject.

- 20 -

7. Status of Covenants

Section in Credit DeadlineAgreement Subject for Status

compliance

2.02 (b) Operation of Special N/A SatisfactoryAccount

3.01 Carrying out of project by N/A Not very satisfactory inMINISAPASO and the early years, since itMINEPRISEC was not with due

diligence and efficiency.

3.02 Procurement N/A Unsatisfactory butimproved towards the endof the project

3.03 Borrower to submit health 9/30 Not complied with by thesector investment program due date; generally,for following year, investment programsincluding proposed budget have been submittedfor project when published in

Official Gazette.

3.04 Borrower to submit study 4/30/87 Complexity of subjecton financing of public health required additionaland proposal for studies which were done,implementation. but no proposal for

implementation wassubmitted.

3.05(a) Borrower to appoint full- 9/30/86 complied with ontime chief for 10/29/86MINISAPASO's MCHDivision

3.05(b) Borrower to employ an 12/31/86 Not complied with byadditional training specialist due date, but in 1988for MINISAPASO's three additional trainingTraining Division specialists were assigned

to training division andproject unit.

3.06 Borrower to provide the 12/31/86 Complied with inlocations of the 5 September 1986.unidentified health centers

- 21 -

Section in Credit DeadlineAgreement Subject for Status

compliance

3.07(a) Borrower to submit proposal 12/31/87 Not complied with byto improve MINISAPASO's due date; consultantstatistical health information report submitted in 1991.system

3.07(b) Borrower to submit 12/31/87 Not complied with by theMINISAPASO's proposal due date. However, afor a career path for nurses MOHSA directive ofaides (level A4) March 1990 stated that

this personnel should berecognized as specializedworkers and providedwith the same benefits as"aides-infirmiers".Moreover, budgetarypositions were providedfor A4 nurses aides.

4.01(a) Borrower to maintain N/A Unsatisfactory; Borrowerproject accounts failed to remedy the

shortcomings identifiedby the auditor, despiteseveral reminders fromthe Bank.

4.01(b) Borrower to have project 6/30 1987: complied with inaccounts audited annually March 88

1988: complied with inOctober 89

1989: complied with inMay 90

1990: complied with inNovember 91

1991: complied with inAugust 92

1992: complied with inJune 93

- 22 -

Section in Credit DeadlineAgreement Subject for Status

compliance

Section of GeneralConditions

9.06 Progress Reports N/A Reports not submittedregularly during first fouryears. During the lastthree years, quarterlyprogress reports werereceived.

9.06 Completion report Not due yet

8. Use of Bank Resources

A. Staff Inputs (in staff-weeks)

Stage of Project Actual

Through Appraisal 95.9

Appraisal through board 45.4approval

Board approval through 4.3effectiveness

Supervision 128.3

Total 273.9

- 23 -

B. Missions

Stage of Month/Year Nurnber Days Specializations Performnance Types ofProject Cycle of in Represented Rating Problems

Persons Field (a) (b) (c)

ThroughAppraisal

Identification 11/83 3 15 PHS

Preparation 4/84 2 10 PHS

Preparation 9/84 2 7 PHS

Preparation 2/85 2 15 PHS

Pre-appraisal 4/85 4 14 PHS, AR

Appraisal 7-8/85 5 19 PHS, FA,AR, DEM

BoardApprovalthroughEffectiveness

supervision 1 5/86 1 5 PHS

supervision 2 8/86 4 8 PHS, AR, EC

Supervision

supervision 3 2-3/87 2 10 PHS, AR 2

supervision 4 9/87 2 7 PHS, AR

supervision 5 1-2/88 2 15 PHS, AR 2

supervision 6 10/88 3 10 PHS, AR, NS 2

supervision 7 2/89 1 12 PHS 2 PMF

supervision 8 4/89 1 6 AR 2 PRO

supervision 9 8/89 2 16 EC, PHS 2 PRO

supervision 10 11-12/89 2 13 AR 2 PRO

supervision 11 2/90 2 11 EC, PHS 2 PRO

- 24 -

B. Missions

Stage of Month/Year Number Days Specializations Performance Types ofProject Cycle of in Represented Rating Problems

l___________ Persons Field (a) (b) (c)

supervision 12 1-2/91 2 12 EC, AR 2 PMF

supervision 13 6-7/91 1 4 AR 2 PRO

supervision 14 10/91 2 14 PHS, AR 3 PMF

supervision 15 9-10/92 1 14 FA 2 SP

supervision 16 4-5/93 1 15 FA 2 SP

supervision 17 7/93 1 26 FA 1

a) Key to specialization:PHS = Public Health Specialist FA = Financial AnalystEC = Economist NS = Nutrition SpecialistAR = Architect DEM = Demographer

b) Key to performance rating:1 = Problem free 2 = Moderate problems 3 = Major problems

c) Key to types of problems:PMF = Project Management Performance PRO = Procurement SP = Studies Progress