Document of The World Bank

Report No: 32159

IMPLEMENTATION COMPLETION REPORT(IDA-26740)

ON A

CREDIT

IN THE AMOUNT OF US$19.2 MILLION

TO THE

LAO PEOPLE'S DEMOCRATIC REPUBLIC

FOR THE

HEALTH SYSTEM REFORM AND MALARIA CONTROL PROJECT

June 30, 2005

Human Development Sector UnitEast Asia and Pacific Region

CURRENCY EQUIVALENTS

(Exchange Rate Effective March 23, 2005)

Currency Unit = Kip 1 Kip = US$ 0.0009US$ 1 = 10050 Kip

FISCAL YEAROctober 1 September 30

ABBREVIATIONS AND ACRONYMS

ADB Asian Development BankBHS Basic Health ServicesBTC Belgian Technical CooperationCPR Contraceptive Prevalence Rate DCA Development Credit AgreementHE Health EducationIBN Impregnanted Bed NetICHC Integrated Community Health CenterIDA International Development AssociationIEC Information, Education and CommunicationIHE Institute of Health EducationIMR Infant Mortality RateMMR Maternal Mortality RateMOH Ministry of HealthPCU Project Coordination UnitPSR Project Status ReportSAR Staff Appraisal ReportSDR Special Drawing RightsTFR Total Fertility RateTTL Task Team Leader

Vice President: Jemal-ud-din KassumCountry Director Ian PorterSector Manager Fadia Saadah

Task Team Leader/Task Manager: Hope C. Phillips

LAO PEOPLE'S DEMOCRATIC REPUBLICHealth System Reform and Malaria Control Project

CONTENTS

Page No.1. Project Data 12. Principal Performance Ratings 13. Assessment of Development Objective and Design, and of Quality at Entry 24. Achievement of Objective and Outputs 35. Major Factors Affecting Implementation and Outcome 66. Sustainability 77. Bank and Borrower Performance 88. Lessons Learned 109. Partner Comments 1110. Additional Information 13Annex 1. Key Performance Indicators/Log Frame Matrix 14Annex 2. Project Costs and Financing 16Annex 3. Economic Costs and Benefits 18Annex 4. Bank Inputs 19Annex 5. Ratings for Achievement of Objectives/Outputs of Components 21Annex 6. Ratings of Bank and Borrower Performance 22Annex 7. List of Supporting Documents 23

Project ID: P004200 Project Name: Health System Reform and Malaria Control Project

Team Leader: Hope C. Phillips TL Unit: EASHDICR Type: Core ICR Report Date: June 28, 2005

1. Project DataName: Health System Reform and Malaria Control

ProjectL/C/TF Number: IDA-26740

Country/Department: LAO PEOPLE'S DEMOCRATIC REPUBLIC Region: East Asia and Pacific Region

Sector/subsector: Health (91%); Central government administration (9%)Theme: Health system performance (P); Rural services and infrastructure (P);

Child health (S); Other communicable diseases (S); Population and reproductive health (S)

KEY DATES Original Revised/ActualPCD: 02/02/1989 Effective: 05/05/1995 06/30/1995

Appraisal: 08/23/1993 MTR: 06/30/1998 08/27/1998Approval: 01/05/1995 Closing: 12/31/2001 12/31/2004

Borrower/Implementing Agency: LAO PDR/MOHOther Partners: Government of Belgium

STAFF Current At AppraisalVice President: Jemal-ud-din Kassum Gautam KajiCountry Director: Ian C. Porter Callisto E. MadavoSector Manager: Fadia Saadah Jayasankar ShivakumarTeam Leader at ICR: Hope C. Phillips Willy de GeyndtICR Primary Author: Hope C. Phillips

2. Principal Performance Ratings

(HS=Highly Satisfactory, S=Satisfactory, 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: UN

Institutional Development Impact: M

Bank Performance: U

Borrower Performance: S

QAG (if available) ICRQuality 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 overall objective as stated in the Staff Appraisal Report (SAR) for this International Development Association (IDA) Credit is to improve the health status of the Lao population, and to reduce morbidity and mortality rates in selected parts of the country. Its specific objectives would be to: (a) improve the quality of basic health care, particularly for infants, children and women through health system reform for priority health programs, including family planning; (b) strengthen the malaria control program in the country; (c) improve health awareness and health behavior in the population by strengthening the MOH (Ministry of Health) Institute of Health Education (IHE) to develop health education messages; and (d) build the capability of the MOH and of participating health systems to implement project activities. The first Form 590 paraphrases the objective and notes that: "The Project aims at improving the health status of the Lao people in selected parts of the country focusing on women and children who are the most vulnerable members of the population. It will reduce morbidity and mortality by increasing accessibility to basic health care services in two provinces and two zones, and by strengthening the national malaria control program in eight provinces. It will give the country the ability to conduct effective health education programs to improve health awareness in the population".

The objectives were clear, realistic and in line with Government priorities as well as the Bank’s strategy. The Project had one parallel bi-lateral financier, and an expectation of support from the private and public sectors. On the basis of its being the first Bank Project support to the country’s health sector, as well as the geographic dispersion and the number of institutions involved, the Project should be considered demanding, complex and risky.

3.2 Revised Objective:The objectives were not revised.

3.3 Original Components:In support of the objectives, the Project had four components: (a) Basic Health Services (BHS), covering the Provinces of Savannakhet and Sekong, and a pilot in the Special Zone of Saysomboune and an area on the Boloven plateau in the Province of Champassak; (b) Malaria Control, covering eight Provinces; (c) Health Education (HE); and (d) Project Management. The components were relatively well related to achieving the objectives, and simplifications and adjustments in the details during implementation improved the relevance of these components in support of the development objectives. The first component of the Project was to be implemented by the respective Provincial Health Departments. The Institute of Malariology, Parisitology and Entomology would be responsible for implementing the second component, and the IHE would be responsible for implementing the third component. Overall Project implementation would be the responsibility of a Project Coordination Unit (PCU) which was yet to be established in the MOH. The design of the fourth component recognized that, in view of the Project being the first Bank support to the health sector, as well as the limited in-country capacity, there would be a need for capacity enhancement. The Project was designed on the basis of sector work (Report No. 8181-Lao, November 30, 1990), Government’s priorities and policies, as well as prevailing country circumstances. In recognition of the capacity constraints, it was agreed that the PCU would support both this Project and a Project funded by the Asian Development Bank (ADB). However, there was over optimism with respect to the administrative (including procurement), and financial management capacity which would be required for successful implementation, as well as the number of staff necessary to support this first Bank intervention in the health sector.

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3.4 Revised Components:The Project Status Report (PSR) for June 2000 indicates that the Credit was restructured on December 18, 1998. The restructuring consisted of: (a) phasing out of the HE component, with IEC activities for the BHS and Malaria Control being moved to their respective components, and (b) limiting the support under the BHS for health centers to a fewer number, notwithstanding their having received training and equipment, given the challenges associated with making these operational.

3.5 Quality at Entry:The Project was never subjected to a review for Quality at Entry, however, findings from a Quality Assessment Group review (FY00-01) of problem projects noted that the Project was not ready for implementation. The operation was prepared over a five year period, with health service delivery and malaria control being included in all the permutations, however, the HE component was only included from 1993. Although the Project was consistent with Government priorities as well as the Country Assistance Strategy, it was too complex as a first intervention in the health sector, especially as institutional capacity was acknowledged as fragile: the design included the involvement of a number of different agencies, and the coverage of each component was different. In total there were six amendments to the DCA, four of which were not related to extension of the closing date; some changed the aggregates for procurement, and in one instance to specific include revised activities. The Project had a “C” rating for the environment, which was consistent with the policy prevailing at the time. This six year Project completed the software aspects in eight years, but closed after nine years to allow for the completion of hardware aspects. In terms of issues and focus, the project aimed to address key priorities, but was clearly too complex for the country. It had not built in enough risk mitigation measures, and could not be implemented as planned; simplifications and adjustments were needed in order to improve Project performance. Hence, despite the correct technical focus, this project is considered Unsatisfactory in terms of quality at entry.

4. Achievement of Objective and Outputs

4.1 Outcome/achievement of objective:Impact indicators were provided for each component in the SAR, and it was expected that these would be measured at the beginning, midpoint, and end of project. The SAR notes that the outcome indicators for the Basic Health Programs were: (i) changes in contraceptive prevalence rate (CPR), total fertility rate (TFR), and cases of tetanus; (ii) decrease in maternal mortality rate (MMR) and perinatal mortality rate by cause of death; and (iii) decrease in acute and moderate malnutrition rates. For the Malaria component, the indicators included (i) % of malaria positive slides; (ii) % of hospitalized cases of malaria; and (iii) malaria mortality rates. For the HE component, outcome indicators were: (i) increase in knowledge among the target population after two and four years; and (ii) required behavioral changes adopted by the target population after two and four years. The mid-term review PSR notes that the following would be the outcome indicators: (i) CPR; (ii) MMR; (iii) infant mortality rate (IMR); (iv) malaria mortality rate; (v) malaria positive tests; and (vi) increase in health practices knowledge. The PSRs did not report on the indicators during the supervision of the project. The SAR indicated that in 1990 the IMR was 106 per 1,000 live births, at the end of the Project the 2000 National Health Survey reported the IMR to be 83. The SAR did not provide information on the CPR for 1995, but as there had been no systematic efforts in family planning, the usage is believed to have been quite low at that time; the 2000 National Health Survey indicates that the national average is currently 32.2%. The MMR, as reported in 1995 was 656 per 100,000 and the 2000 National Health Survey reports that the rate was 530 per 100,000 in 2000. For malaria control indicators, the data presented is for Provinces supported by the Project. With respect to malaria positive tests, the slide positivity rate in 2003 was 8.1%, compared to 16.4% in 1996; this is a 50% decrease. The malaria mortality rate was 22.2 per 100,000 in 1996, and fell to 3.1 per 100,000 in 2003;

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this compares favorably with the national figures which were reported to be 4.0 in 2003. The HE component was phased out after the Mid Term Review, and IEC activities subsumed under the BHS and Malaria Control components, and the only specific information available relates to malaria control. Findings from a Knowledge, Attitude and Practice Survey covering two Provinces (360 persons) in 2001 reports that for causes of malaria, 98.1% of respondents identified mosquito bites, 99.4% indicated not sleeping under a net, 98.9% reported lack of hygiene, 71.7% sited drinking unboiled water, and 32.8% attributed the disease to evil spirits. Although it is not possible to soley attribute all of the improved indicators to the Project, access to basic health care was improved in selected Districts, the malaria control program was strengthened and there was a marked drop in mortality in the Districts supported by the Project, the health promotion under the HE component was subsumed under the first two components and knowledge on causes of malaria has improved, and the capacity to implement project activities was strengthened over the life of the Project. The outcome of the Project is rated Satisfactory.

4.2 Outputs by components:It needs to be recognized that the design of the components and their outputs were appropriate for achieving the development objectives in a different country context. However, the country context was not as sufficiently addressed in the design, and the mitigation measures were inadequate. The SAR expected 31 indicators to be tracked for structure (physical, financial and staffing inputs and refer to the related organizational arrangements), and process (measuring how the inputs are being used) indicators. Having so many indicators to be tracked is unwieldy and could have contributed to the poor reporting of these indicators in the PSRs.

Information available from the BHS component indicate that 42 health centers, 7 District and Inter-District Hospitals, 4 Provincial and Regional Hospitals, 8 Provincial malaria stations, 6 District malaria stations and 2 Severe Acute Respiratory Syndrome facilities were constructed or rehabilitated. Vehicles (cars, motorcycles and bicycles), drugs, medical equipment and furniture for health centers and hospitals were procured. At least 3,618 staff were trained, with 1,307 of these being village health volunteers, and 183 being traditional birth attendants. Although not envisaged at design phase, in line with the Government’s Primary Health Care Policy, and in support of the health services reform process, the Project supported an Integrated Community Health Center (ICHC) model, designed with Belgian Technical Cooperation (BTC) inputs, which was piloted in 29 health zones. This model, which has a transparent mechanism for providing information on charges to patients, and involves the community in identifying the poor for exemption from paying for health center services, has been adopted by MOH for country-wide expansion. The Project also supported the establishment of the Village Drug Revolving Kits in locales where access to health care delivery was limited; these have been established in 476 villages, covering 148,449 people in 27 Districts in the 7 southern Provinces. In spite of the fact that some of the specific support was not envisaged at design phase, the support to ICHCs improved the quality of services provided to those living in more remote areas. Although no specific indicators for the ICHCs are available, it appears that the approach led to an increase in access by those in the ICHC’s catchment area.

Under the Malaria Control component, the success of the coverage in the original 8 Provinces, and increased demand, resulted in the coverage being expanded to 10 Provinces in 1999. In total, approximately 1.4 million people (59% of the total population living in the Project area, although the expectation was 100% coverage) were covered by the integrated bed net (IBN) program. The Malaria Facility Network increased from 595 in 1998/99 to 2,716 in 2002/2003, while an additional 4,304 staff were trained over the same period. New or rehabilitated malaria stations were funded in eight Provinces, including lab equipment, as well as vehicles, motorcycles, bicycles, and boats. Approximately 350,000 bed nets were distributed, and more than 3,000 villages provided with anti-malarial drugs. Technical manuals, as well as IEC tools and campaigns were supported by the Project. These activities helped strengthen the

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malaria control program in the country.

Prior to the redistribution of activities under the HE component in February 1999, the Center of Information and Education for Health was rehabilitated and equipped, two vehicles were provided, as well as audio-visual equipment. Around 600 people received training under this component, and a number of workshops were held in 1999 attended by approximately 100 people; over 50% of the expenditures under this component were for training and consulting services. After February 1999, the information, education and communication (IEC) activities were subsumed under the BHS and Malaria Control components. Since its curtailment after midterm, the original indicators were obviously not met. However, the integration of HE into programs, as opposed to having a vertical program as originally designed, was deemed to have helped improve health awareness for malaria control, since this was evaluated. Findings from a survey indicate awareness in the sample of above 98% on causes for malaria.

The Project Development Objective did not expect to have an impact on macroeconomic policies, but did expect to have an impact on health sector policies through health system reform for priority health programs, including family planning. Notwithstanding the difficulty of attribution, on the basis of the outcomes and outputs described above, and on the future direction of the health sector (in particular with respect to ICHCs, training of village health volunteers in minority communities, and revolving drug funds) the impact on health sector policies is rated Modest. With respect to the anticipated physical objectives, the completion of a number of referral facilities, the successful piloting of ICHCs, the provision of transportation, as well as laboratory needs for the malaria component merit a rating of Substantial for the Project Provinces. The objectives did not specifically include financial or environmental objectives so these are not rated, and the institutional development objectives are discussed in 4.5 below. There were no private sector development objectives, so this is not rated. The Project strengthened the Health Sector’s management, through capacity building to the Provinces and Districts within which it operated. On the basis of the support provided to the referral system, and the piloting at the health center level of ICHCs, the rating for Health Sector management is rated Modest.

In evaluating this Project’s impact on poverty, it should be noted that the Provinces selected for inclusion in the BHS component included the most populous Province (Savannakhet) and the newest and poorest Province (Sekong). Due to capacity constraints, the Malaria Control component was limited to 8 of the then 17 Provinces, selected on the basis of the disease prevalence, ease of communication, security, transport, organizational capacity, and support from other agencies. It was eventually expanded to cover 10 Provinces on the basis of its success and the demand for this type of support. The HE component was national, and was expected to increase health knowledge, adjust attitudes and behaviors in regard to basic health, malaria control, among others, however this support, after the mid-term review, was subsumed under the components; with respect to HE, the only specific information available relates to malaria. Since malaria was the worst single threat to child health, and, in some communities, accounted for 80% of morbidity, and on the basis of the indicators reported elsewhere, support from the HE component contributed to the achievement of positive outcomes. Province specific indicators (except for malaria) were not collected for the Project, so it is difficult to quantify Province specific improvements, let alone be able to attribute these to the Project. Therefore the rating for poverty reduction is Modest.

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4.3 Net Present Value/Economic rate of return:Not calculated at appraisal.

4.4 Financial rate of return:Not calculated at appraisal.

4.5 Institutional development impact:The SAR indicates that in order to accomplish the objectives, the Project would comprise a number of components and sub-components, including specifically “institutional development” which consisted, among other things, of (i) IEC programs to improve health awareness and health behavior in the population; (ii) training to upgrade staff clinical and management skills; (iii) technical assistance; and (iv) support to MOH in project management. With respect to IEC, the HE component was phased out after the Mid Term Review due to its failure thus far to improve health awareness and/or health behavior in the population; its activities were subsumed under the BHS and Malaria Control components. Substantial technical assistance to the Project was provided by BTC in the form of advisors. It also supported a number of trainees in areas such as epidemiology of tropical diseases; public health; biostatistics; health system reform and sustainable health care financing; health care planning; drug management; IAPSO and World Bank procurement, equity fund, and health insurance system. The Bank supported training costs for hospital management and health system reform and sustainable health care financing. Other sources of funding covered topics such as primary health care program, and health system management. It is reported that knowledge and skills were increased as illustrated by improvements in setting, monitoring and adjusting monthly action plans and regular reporting on project implementation, however, it is not possible to quantify the extent to which staff’s clinical and management skills were upgraded. While IDA financed the PCU, approximately 85% of the parallel financing provided through the BTC was for technical assistance to support the PCU, and the Center of Malaria, among others. The official integration of the Procurement Unit under the PCU into the MOH’s Centre for Medical Equipment and Supplies under the guidance of the PCU provided an opportunity to build MOH’s capacity for procurement. Although the project provided important contributions in terms of institutional development, the project did not address some of the key constraints in terms of public sector management issues as that was beyond its objectives; some of these reforms are being addressed through other initiatives in the country. On the basis of its achievements described above, the institutional development impact is rated as Modest.

5. Major Factors Affecting Implementation and Outcome

5.1 Factors outside the control of government or implementing agency:The implementation of the Project was not affected by factors outside the control of either Government or the implementing agency.

5.2 Factors generally subject to government control:Government administrative procedures relating to procurement and disbursement contributed substantially to delays experienced during implementation, since each step in the clearance often required approximately 30 days. A second factor subject to Government’s control was the appointment of the Project Coordinator; having a Coordinator with less operational experience contributed to delays during implementation. With the designation of a more operationally oriented Project Coordinator there was a substantial improvement in the pace of implementation. All in all, the most serious delay in implementation arose as a result of a contractual dispute over the quality of hospital construction; without Government intervention it took more than two years to resolve, placing a drain on the time and money of the MOH and the PCU, as well as the Bank.

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5.3 Factors generally subject to implementing agency control:The inability of the implementing agency to resolve the contractual issues described above substantially affected the implementation. While Government administrative procedures were cited as bottlenecks, in one instance it appeared that the implementing agency itself was requiring more clearances than either the MOH or the Ministry of Finance. Failure, for more than a year, to transfer vehicles to two of the Provinces partially affected activities in those Provinces. Documentation available on hand indicates substantial delays in procurement, from drugs to staffing of PCU, which resulted in an implementation schedule which differed significantlyfrom the original plan.

5.4 Costs and financing:The 12.9 million Special Drawing Rights (SDR) Project was equivalent to US$19.2 million at the time of negotiation, with US$2.5 million as contingencies. The Project was designed to be completed in 6 years, but as of the original closing date only 44.45% of the Credit had been disbursed, and 2 extensions were granted resulting in 9 years of implementation. The HE component activities were reduced right after the Mid-Term Review, and this component only disbursed around US$0.5 million, or 26.55%, against an original estimate of US$2.0 million. Savings from this went to finance activities in the BHS component, whose actuals amounted to US$15.3 million, versus the original estimate of US$9.6 million. The actuals for the Malaria Control program were 76.4% of the original estimate, and expenditures for project management were 43.2% of the original estimate. Government’s cash contribution to the Project amounted to US$0.5 million, against an original estimate of US$2.4 million; it is understood from the Government that while estimates appear to indicate that there was a shortfall of around US$0.4 million for civil works and goods, indeed the contractors were paid. The anticipated US$0.4 million from the private sector for drugs in Savannakhet never materialized, however, another private entity donated US$0.03 million for bed net impregnation. Support from the BTC, in the form of technical assistance, was originally to be co-financing. However, since the support was tied, this assistance was provided in parallel to the Project implementation. By the time this support concluded, an equivalent of US$4.35 million had been provided (around 85% for technical assistance and 15% for goods), as opposed to the original estimate of US$2 million, mainly due to the extension of project implementation.

Unfamiliarity with World Bank procurement procedures, as well as the lack of dedicated TTLs during the first part of the Project affected the pace of implementation, as did a contractual dispute relating to civil works which delayed activities by almost two years. Delays in responding by the Bank on issues relating to procurement, experienced during the first part of the Project, were ameliorated once support activities were decentralized to the field. The technical support provided by the BTC was invaluable, and their presence in-country went a long way towards ensuring that activities were less off-track than they could have been.

6. Sustainability

6.1 Rationale for sustainability rating:It will take some time for the health system to be sustainable at a level that can provide basic health services purely through Government resources. The Government is working with other donors, including the Bank, towards a longer term plan to direct more resources towards basic health services. The sustainability rating has been provided on the basis of on-going and/or expected support which will be provided to the Lao PDR health sector. The experiences gained from piloting the ICHC model under the BHS component has resulted in a decision to expand the approach in order to build upon the perceived positive outcomes from local participation. This approach will be supported in the eight Southern and Central Provinces by a proposed IDA Credit/Grant, as well as ongoing BTC support. The current ADB support to the health sector covers the Provinces which the proposed Bank support will not cover. With funding being provided by the Global Fund Program for malaria (which includes early diagnosis and

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appropriate treatment, IBNs, surveillance, social marketing of re-treatment tablets, and support for IEC), the foundation laid by the Project for Malaria Control is expected not only to remain, but will be expanded to cover 100% of the people at risk by 2007. While Government is interested in continuing to explore mechanisms for providing health care to the poor in a sustainable manner, it is currently not able to do so without external support. As a consequence the sustainability of the Project activities is expected to be Unlikely unless donor support continues.

6.2 Transition arrangement to regular operations:As noted in the sustainability section, support for many of the activities funded through this Project will be continued either through World Bank, other funding or Government support. The design of the follow-on Bank support has been collaborative so as to ensure maximum compatibility, and avoid duplication. The experiences from the pilot ICHCs show that communities are willing to become involved in the operation and maintenance of health centers, and that they are willing to select poor families who should receive an exemption from paying fees. With the attendant improvement in the quality of services at health center and community level (through training of Village Health Volunteers and Traditional Birth Attendants), the population is expected to be more inclined to avail themselves of these services, thereby generating fees to contribute to the ICHCs operation and maintenance. The follow-on Project will be tracking a number of the indicators such as specific immunization rates, and births attended by skilled personnel. A HMIS which collects data at the Health Center level has been piloted and will be supported under the proposed Bank Project down to the village level where ICHCs are providing services; the system is manual, although it is amenable to computerization. In addition, there are a number of existing surveys which have the capability of providing information on the indicators, although in some instances only to the Provincial level. All of these mechanisms will provide information on the health status of the population. Since it will take time before the Government will be able to fund the provision of health services without donor support, the transition in the medium-term will require donor support.

7. Bank and Borrower Performance

Bank7.1 Lending:The Project was in line with the Government’s interest in focusing on maternal and child health, as well the Country Assistance Strategy (Report No. 15284, dated January 18, 1996), whose stated goal was poverty reduction by, among others, creating necessary social and physical infrastructure to enable the poor to respond to opportunities, and target vulnerable groups and regions; reference to a 1993 CAS in this report indicated that support for the health sector would include improving the quality and coverage of basic health. The areas which this Project would focus on evolved over time from the first mission, which was undertaken in March of 1988. In December of 1990 a Grant of Yen 28 million was approved for the preparation of the Project which the Bank would execute; at that time there was an expectation that appraisal would take place in January of 1993, however the signing of the Grant was delayed by a year. Unfamiliarity with the Bank contributed to delays in the design, but eventually resulted in a more participatory preparation process by the Country. Most missions included representatives from other key partners such as the World Health Organization, and United Nations Children Fund. The appraisal took place in September of 1993, and a second Japanese Grant of Yen 72.3 million, also executed by the Bank, became effective on January 24, 1994. The appraisal focused mainly on technical issues, with less attention paid to procurement and financial management. Confirmation was received from the Government of Belgium that it would provide the equivalent of US$2 million for technical assistance, however this support was provided in parallel since the Bank could not manage tied funds. A last minute request by the Government, just prior to negotiations, for inclusion of two additional areas for support under the BHS

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component, was accommodated by the Bank; as a consequence this support had not been prepared or appraised. The support for these areas was designated as a pilot, and conditions of disbursement associated with its acceptable design was included in the DCA. Key agreements during negotiations included supporting incentives at various levels such as the retention of funds for the sale of drugs and services at the point of collection, and that selective salary increases would be allowed if linked to superior performance of functions and if paid out of the Government’s budget earmarked for higher salaries in hardship areas. With respect to safeguards, the Project was classified as a C for environmental purposes, which was consistent with the practice at the time.

Although the lending instrument was appropriate, the Project design, covering different Provinces for different components, was complex, particularly since this was the first health Project that the Bank had supported in Lao PDR. The SAR indicates that the country’s institutional capacity may delay implementation (especially in areas of procurement, accounting and auditing systems), and approximately 20% of the Project costs, which included a Grant from the Government of Belgium, was earmarked for technical assistance. It was expected that training in fiduciary aspects would take place prior to Project effectiveness, although there is no record that this occurred. The files indicate that a Project Performance Plan, giving outputs and impact indicators, was prepared in March of 1995, after the appraisal, negotiations, and Board approval.

While the design team made a significant effort to ensure participatory preparation and addressed key sectoral issues that would produce important results, there were a number of weaknesses. These include: (a) complexity of design in a sector which had no previous experience in executing Bank Projects (b) inadequate attention to fudiciary aspects of the project, especially at appraisal; and (c) inadequate measures to address the risk associated with the capacity to implement the Project. A Quality Assurance Group’s review of the Quality of Supervision of Risky Projects (FY00-01) judged that the project was not ready for implementation at approval. On the basis of the foregoing, the Lending is judged to be marginally Unsatisfactory.

7.2 Supervision:The supervision of this Project got off to a weak start, with staff assigned for short periods of time, resulting in less attention being paid to the fledgling Project, or to the Project management capacity constraints. Not withstanding this lack of stability in TTLs, some continuity was provided through team members who worked on the Project across TTLs. The combination of frequent staff changes, and initially only focusing on technical issues, at the expense of fiduciary aspects, resulted in the delays to flag problems or obtain needed support for implementation. Just prior to the Mid-Term Review, the first of two more long lasting TTLs (covering around 70% in the second half) was assigned. This more permanent arrangement made a difference to the implementation, as changes and adjustments were made in response to problems and constraints faced during the first half of Project implementation. As noted above, this Project was subject to a Quality Assurance Group review of the Quality of Supervision of Risky Projects (FY00-01), which found the supervision to be satisfactory. While the review noted the insufficient budget being provided for this risky Project, the supervision team did not let lack of supervision budgets affect their responsibilities. When resources provided were insufficient, the team would overrun its budgets in order to provide the needed support. There was good cooperation with donors, as evidenced by the sharing of a PCU with ADB, and the parallel financing provided by BTC. Perhaps more could have been done to link this support to other programs that would address systemic issues, in order to maximize the possibility of improving results, such as civil service incentives. However, this Project was drawing to a close while other relevant Bank support was being designed. Even though the initial supervision of the Project was weak, the efforts of the Bank during the latter part of the Project merit an overall rating of Satisfactory.

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7.3 Overall Bank performance:Notwithstanding the successful completion of the Project, and the improvement in supervision from just before the mid-term review onwards, the Bank's overall performance is rated marginally Unsatisfactory. This rating is given on the basis of the marginally unsatisfactory Lending rating, and the failure during the first part of Project to focus sufficient attention on implementation issues.

Borrower7.4 Preparation:This Project, the first of its kind in support of the health sector in Lao PDR, involved quite a bit of dialogue both within Government, as well as with various stakeholders, including other donor partners as well as non-governmental organizations. Although initially Government took a more hands-off approach, the participatory nature of the preparation, once it was clear that this was a Government project, is written up as an example of participatory approaches in the World Bank Participation Sourcebook. Indications from the files point to a great deal of internal Government discussion about the objectives of the Project, as well as its scope (which included highly populated as well as areas with lagging health outcomes). The deliberations relating to the latter are evidenced by Government’s desire, just prior to negotiations, to include on a pilot basis, two areas targeting the more vulnerable. On the basis of the foregoing, the preparation is rated Satisfactory.

7.5 Government implementation performance:Government’s support to the Project is evidenced by having put in place a Steering Committee to direct and supervise not only this Project, but the ADB support as well. The composition of the Committee included representation from the Ministry of Health, as well as key Vive Governors of relevant areas, as well as the Ministry of Finance; the Director of the PCU served as the secretary to the Committee. While counterpart funding was identified as a potential risk during preparation, and a problem periodically during implementation, it does not appear to have affected the pace of implementation. In recognition of the capacity constraints in-country, the PCU supporting this Project also served as the management unit for an ADB project in health. The PCU was identified as a bottleneck at one stage, and the Government eventually replaced the Coordinator. With the designation of a new Coordinator in February 2001, there was considerable improvement in the pace of implementation. While Government procedures negatively affected the pace of implementation, the Project did close on a positive note, with positive outcome indicators, although it is not possible to entirely attribute these to the Project. Notwithstanding the initial delays, Government’s eventual intervention had a positive effect on the pace of implementation, and for this its performance is rated Satisfactory.

7.6 Implementing Agency:

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The Project was executed by a PCU, which was shared with an ADB supported health project, on behalf of the MOH. In the beginning, Project implementation was negatively impacted by the failure to ensure that the PCU was adequately staffed. As noted above, there was a contractual dispute which delayed completion of one activity by almost two years; the Ministry could probably have been more proactive in ensuring that the impasse was resolved in a more expeditious manner. Many of the shortcomings for implementation (procurement, unresolved contractual disputes, requiring additional clearances) were ultimately resolved with the designation of a more operational Coordinator in 2001. With this appointment, the Unit commenced the task of resolving the contractual dispute, and put in place the necessary staff to facilitate the implementation. Notwithstanding the initial slow pace of implementation, activities moved forward, which resulted in the Project ending on a positive note. For this improvement, the overall performance of the implementing agency is rated Satisfactory.

7.7 Overall Borrower performance:Based on the above, the overall Borrower performance is rated Satisfactory.

8. Lessons Learned

On the basis of the challenges faced by the Project during implementation of the first health sector lintervention, to improve the likelihood of satisfactory performance, the design of a project needs to be simple in countries where (a) the sector has had no prior experience in working with the Bank, and (b) there are capacity constraints. Τhe positive experiences associated with collaboration between IDA and the BTC shows that good lcooperation among donors can lead to a win-win situation for a sector and Country.Experiences with sharing a PCU with ADB affirm that in capacity constrained environments, lharmonization and collaboration among donors are important, so as not to tax the system on the ground. However, it is important to ensure that the Unit is fully and appropriately staffed in order to ensure timely implementation.Implementation during the first part of Project reaffirm that not only do appropriate mitigation lmeasures need to be included in the design of Projects where both human and financial resources are constrained, they need to be implemented as well.In view of the implementation delays experienced during the initial stages of the Project, it is clear that lthere is a need to maximize continuity in the leadership of the Bank task team. In these circumstances there is a need to focus on developing Project management skills of our borrowers. The Project also demonstrates that good supervision can turn projects around and give satisfactory loutcomes.On the basis of the sheer volume of indicators selected, it is more useful to both the Bank and the lBorrower to select indicators which are: (a) strategic, (b) meaningful, and (c) trackable.Opportunities should be sought to increase the chance of better outcomes at the macro level. Therefore llinking sector support to other programs that address systemic issues could produce synergies that might increase the chance of better results.

9. Partner Comments

(a) Borrower/implementing agency:This Report was shared with the Borrower, who provided the following comments: ".......we have reported your ICR to the MoH Steering Committee which includes representatives from Ministry of Finance and Ministry of Foreign Affairs. We very much appreciated your report. It is not too long but including everything especially the strong point and weak point. From your

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report we can draw some lessons and pay more attention to the Second Health Project such as 1. coordination with all donors who are implementing health projects in Laos 2. regarding project staffing 3. monitor project's indicators and put in project report and so on. The other thing we should pay more attention is training on Procurement and Financial Management. Implementation of District Allocation for the second health project is a big challenge for us due to it covers 60 districts. Regarding your assessments and ratings we think it is reasonable."

Government's Executive Summary from their Implementation Completion Report follows: EXECUTIVE SUMMARYof Government's Implementation Completion Report

The Health System Reform and Malaria Control Project jointly financed by GOL, IDA credit and Belgian Technical Cooperation has been implemented since 1995 to December 2004. It was the first loan project of the Ministry of Health, covering 10 provinces of Lao PDR. Though there were many problems faced during the implementation of the project, a large number of significant results was produced and summarized below.

First, the basic health care services have been improved through the strengthening health infrastructure in project provinces. Health facilities, such as hospitals at provincial and district hospitals and health centers have been rehabilitated or built new. In total there are 42 health centers, 7 district or inter-district hospital, 4 provincial and regional hospitals, 2 SARS facilities, and 8 provincial malaria stations renovated or built new. In line with this, it is the supply of additional and more appropriate types of medical equipment, including 2 CT-Scanner machines for 2 regional hospitals. About 7 million USD has been invested in civil works and more than 6.4 million USD has been invested in the procurement of basic and modern medical equipment for a better quality of health care. This is evidenced by a substantial increase in the number of in-patient and out-patient caseloads.

Concerning capacity building, in order to sustain the health care services, the project has focused on up-grading technical, clinical, and managerial skills of staff at the central, provincial, district and health center levels. More than 600 health personnel have been trained in health education campaigns, more than 3000 people trained on different topics of the basic health services, and more than 7000 people trained in malaria control, with giving high priority to health center workers and village volunteers living in rural areas, especially in under-served ethnic minorities areas, as they have direct impact to local people.

For the Basic Health Services Component, its objectives were found too ambitious and unlikely to be achieved during the Mid-Term review, therefore the project with the direct assistance of the Belgian consultants has redirected its goals with more concentration on the development of the so-called "Pilot Health Zones" which are to be used as the models for expansion in 5 project provinces. So far, twenty nine "pilot health centers" have been effectively developed. Those health centers are meant to be “ integrated community centers". “Integrated” means that different activities such as curative, preventive and promotional are integrated, and that collaboration with other sectors (education, agriculture,..) is also committed. “Community” means that health center belongs to the local community or administrative level, and that health care and promotion activities are jointly planned and executed. The community gets involved in managing and monitoring the health centers including its accounting. This model has been proved to be successful and is planned to be expanded in the 2nd phase.

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So far, the project has tried to create a sense of project ownership amongst provincial, district and health center personnel as well as the community. The piloting of the "Integrated Community Health Center" has tremendously involved people at each level in the planning, implementing, monitoring and evaluating of key project inputs. Regular quarterly meetings with the assistance of Belgian TA have improved the capabilities of the staff working at district and health center level. The pilot health centers have also strengthened community support and involved them in health problem solving process.

To fill the gap of inaccessibility to health care services, a village drug kit system has been introduced to be applied. The project has successfully provided drug kits to 476 remote villages so far. About 140,000 people living in the target rural and remote areas have been able to access and receive the most minimal health care. When transportation is improved, health facilities reach these people and private pharmacies are locally available, the drugs kit system will be removed and replaced by a more sustainable and effective health care system.

The most significant outcome of the Project is the accomplishment in reducing morbidity and mortality rates due to malaria through the programs of Impregnated Bed Nets (IBN), the Early Diagnosis & Adequate Treatment and the Heath Education campaigns. In the last 3 years, it should be noted that there has been no outbreak of malaria. The malaria control component has been implemented in 10 out of 18 provinces of Lao PDR. This is a new initiative of practicing IBN program through the sufficient supply of nets, insecticides and dipping materials, and the establishment of IBN Fund to sustain the malaria control activities. Regarding the people's knowledge on malaria, the 2000 KAP survey showed that there was a significant increase in their knowledge related to the causes of malaria and their health care behavior: 98 % reported that malaria was caused by mosquito bites; and 90 % reported that they went to see trained health personnel when sick.

The project was facing with a lot of problems, especially at the beginning of the project, due to a poor design of project management at central and local levels resulting in a number of problems in the domain of civil works and procurement of goods. There was no unit of civil work at the PCU to manage the related activities. However, the situation has been gradually improved later by the establishment of necessary PCU units, such as procurement of goods, civil works, basic health services and malaria control. The malaria control has been directly managed by the Center for Malaria, Parasitology and Entomology (CMPE). Since Mid-term review, the Project has been better coordinated with concerned departments of the Ministry of Health, and had a closer supervision from the Central and Provincial Steering Committees.

However, this transition has not yet fully built the capacity of government staff, because the majority of PCU staff, who work for procurement of goods, civil works and accountants are private consultants. Even though the MOH has tried to shift the responsibility to its related departments. For example, the procurement of goods of the project has been incorporated in and under the responsibility of the Center for Drugs and Medical Equipment Supply; while civil works are under direct supervision of the Department of Planning & Budgeting, but their roles and responsibilities are still limited.

Even though a large number of provincial and district hospital staff have received clinical, nursing and management training and refresher training, but the training plan has not yet been well coordinated between vertical programs such MCH, health education, malaria, drug kit system or other basic health services. Some provinces have been able to create a core group to take the role of trainers, but they still lack regular technical assistance and teaching materials.

For the new project to be financed by IDA credit, it is strongly commended the emphasis be given

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on project management at each level. The project should be lead by a strong team of qualified and experienced personnel. The project design including its indicators should be clearly defined and appropriate to the Lao context. The project activities and responsibilities should be gradually integrated to concerned MOH departments by building the personnel's capacities related to the project management, planning and financing. At the same time, there should be a plan to transfer technical knowledge and skills from contractual staff to government staff.

A more systematic approach in personnel training should be developed for each level. Special attention should be given to the following topics: (1) improving the quality of care and increasing accessibility to under-served areas, (2) PHC services through the development of ICHC and of minimum package of activities such as basic curative care, emergency, preventive services, health education, maternal and child health, immunization, nutrition supplementary program, surveillance for communicable diseases and health management information system; (3) improvement of delivery system; and (4) management of revolving drug funds to make health activities more sustainable.

A more systematic, equity and sustainable health care financing should be initiated and piloted. The exempting fee for the poor, transparent accounting system, cost recovery, equity funds and community-based health insurance should be taken into account.

Last but not least, a system to motivate staff should be created and applied, because it can be considered as a key factor to the success of project. Importantly, incentives should be first given to the staff who work hard in rural and difficult areas.

(b) Cofinanciers:A copy of the Report was shared with Belgian Technical Cooperation, parallel financiers of the Project, who advised that they had no comments.

(c) Other partners (NGOs/private sector):

10. Additional Information

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Annex 1. Key Performance Indicators/Log Frame Matrix

Outcome / Impact Indicators:

Indicator/Matrix

Projected in last PSR1

Actual/Latest Estimate

1. Contraceptive Prevalence Rate No data provided 32.2% (contraceptives only introduced in 1998)

2. Maternal Mortality Rate No data provided 530 per 100,000; 1995: 656 per 100,0003. Infant Mortality Rate No data provided 83 per 1,000; 1995: 117 per 1,0004. Malaria Mortality Rate SAR: reduce by 50% by end of project 3.1 per 100,000; 1995: 22.2 per 100,0005. Malaria Positive Tests No data provided 8.1%6. Increase in Healthy Practices Knowledge No data provided For malaria, 90% of surveyed people (360)

have knowledge of malaria symptoms and prevention, and practice malaria prevention

Output Indicators:

Indicator/Matrix

Projected in last PSR1

Actual/Latest Estimate

# of facilities repaired, expanded, built new and # of square meters for each, by cost center

53 Rural Health Centers, 4 District Hospitals, 3 Inter-District Hospitals

40 Rural Health Centers (Savannaket 5, Champassack 5, Xaysomboune Special Zone 2, Vientiane 2); 5 District Hospitals (Phoune, Longsane, Xonebuly, Paksong and Thateng); 2 Inter-District Hospitals (Champhone, Sepone); 2 Proincial Hospitals (Sekong, Xaysomboune Special Zone); 2 Regional Hospitals (Savannakhet, Champassack); 1 Center of Malaria; 1 Center of Health Education; 8 Provincial Malaria Stations, 5 District Malaria Stations; and 2 SARS facilities.

# of workers trained by type of worker and type of training

SAR anticipated 2 overseas training, 78 in-service training, 2 anesthesiology, 58 in-service laboratory, 2 radiology, 115 nursing, 23 midwifery, 400 Village Health Workers (p. 47)

15 people trained overseas (5 in health system reform and sustainable health care financing, 10 (co-financed) in hospital management; 3618 staff trained locally: 282 Provincial Health Office level, 278 provincial hospital staff, 800 District Health Officer level, 668 health center level, 1307 Village Health Volunteers and 183 traditional birth attendants.

Value of pharmaceuticals and contraceptives procured and distributed

No data provided US$0.8 million pharmaceuticals procured; US$1.5 million of insecticides, bed nets and net dipping.

# of mothers trained in growth monitoring, recognizing symptoms of pneumonia, and using ORS

No data provided IEC provided to mothers by trained VHVs and TBAs; number trained unknown

# of children immunized, # of ORS packages used, # of complicated pregnancies referred, # of IUDs inserted, by level of care

No data provided The National Health Survey of 2000 indicates that 32.4% of children received the 6 recommended vaccinations during the first 12 months of life. 95.5% of children under 5 who had diarrhea received recommended home treatment, including ORS; no data available on referral of complicated pregnancies or IUDs inserted.

Frequency of clinical and management supervisions at village, health center and at district levels, activities of the DHMT and the PHMT in managing the care delivery

No data provided Once a month for each type of activity; main activities include monitoring of drug kit system, MCH care, vaccinations, IBN redipping and administrative activities

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# of children being monitored for growth and weight, # of children and pregnant and lactating mothers receiving food supplements

No data provided 1,347 children undeer 5 were monitored for growth and weight: 15.4% were moderately or severely wasted, 40.7% stunted, and 40% underweight; 1209 children aged 6-59 months received Vitamin A supplement; 4% of women who recently gave birth received Vitamin A supplement and 13.6% took iron tables during their pregnancy.

Families protected with mosquito nets SAR p. 64: 15% by year 3, 40% by year 4, 80% by year 5 and 100% by EOP

58.9% of villages covered with malaria control program in 2002.

% of villages covered with early diagnosis and treatment facilities for malaria

SAR: 100% by EOP 58.9% of villages covered with malaria control program in 2002.

# of persons trained in the following categories: village health communicators, village broadcast operators, school teachers, Lao Women Union members, and monks by place and length of training

No data provided 94 village health communicators trained in Nambak District; 64 primary school teachers from districts trained on IEC; District Health Communicators were trained as follows: 36 in LBP, 28 in Sekon and 35 in SVK; 28 from 10 villages of Xaysomboune District, 30 from 10 villages of Longsane District, and 28 from 18 villages of Muang Phoune District were trained as health communicators. Data on length of training unavailable.

# of radio broadcasts per village per month No data provided IEC radio programs are broadcast at central and provincial level and on national television every Saturday.

1 End of projectThe output indicators above are a selection of those provided in the SAR.

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Annex 2. Project Costs and Financing

Project Cost by Component (in US$ million equivalent)AppraisalEstimate

Actual/Latest Estimate

Percentage of Appraisal

Component US$ million US$ millionA. Basic Health Services Savannakhet & Sekong 9.60 15.34 159.78B. Malaria Control 5.90 4.51 76.42C. Inforomation, Education, Communication 2.00 0.53 26.55D. Project Management 4.00 1.73 43.25

Total Baseline Cost 21.50 22.11 Physical Contingencies 0.70 Price Contingencies 1.80

Total Project Costs 24.00 22.11Total Financing Required 24.00 22.11

Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent)

Expenditure Category ICBProcurement

NCB Method

1

Other2 N.B.F. Total Cost

1. Works 3.90 0.80 0.00 0.40 5.10(3.90) (0.80) (0.00) (0.00) (4.70)

2. Goods 7.70 0.70 0.80 0.90 10.10(7.70) (0.70) (0.00) (0.00) (8.40)

3. Services 0.00 0.00 3.30 2.00 5.30(0.00) (0.00) (3.30) (0.00) (3.30)

4. Miscellaneous 0.00 0.00 3.50 0.00 3.50(0.00) (0.00) (2.80) (0.00) (2.80)

Total 11.60 1.50 7.60 3.30 24.00(11.60) (1.50) (6.10) (0.00) (19.20)

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Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million equivalent)

Expenditure Category ICBProcurement

NCB Method

1

Other2 N.B.F. Total Cost

1. Works 5.52 1.00 0.40 0.00 6.92(5.34) (0.90) (0.30) (0.00) (6.54)

2. Goods 4.90 0.07 2.39 0.65 8.01(4.90) (0.07) (2.34) (0.00) (7.31)

3. Services 0.00 0.00 2.50 3.70 6.20(0.00) (0.00) (2.50) (0.00) (2.50)

4. Miscellaneous 0.00 0.00 0.98 0.00 0.98(0.00) (0.00) (0.86) (0.00) (0.86)

Total 10.42 1.07 6.27 4.35 22.11(10.24) (0.97) (6.00) (0.00) (17.21)

1/ Figures in parenthesis are the amounts to be financed by the IDA Credit. All costs include contingencies.2/ 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 managing the project.

Project Financing by Category (in US$ million equivalent)

Category Appraisal Estimate Actual/Latest EstimatePercentage of Appraisal

IDA Govt. CoF. IDA Govt. CoF. IDA Govt. CoF.1. Civil Works 4.70 0.40 6.54 0.38 0.00 139.1 95.02. Goods 8.60 1.70 7.31 0.02 0.68 85.0 1.23. Consultant services, training, auditing

2.80 2.40 2.50 0.00 3.70 89.3 154.2

4. Incremental operational and maintenance costs

3.10 0.40 0.86 0.12 0.00 27.7 30.0

IDA categories given per the Development Credit Agreement. The amounts in appraisal cofinancing are US$2.0 million parallel financing from the Government of Belgian, and US$0.4 million expected from private sources for drugs.

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Annex 3. Economic Costs and Benefits

None was calculated at preparation.

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Annex 4. Bank Inputs

(a) Missions:Stage of Project Cycle Performance Rating No. of Persons and Specialty

(e.g. 2 Economists, 1 FMS, etc.)Month/Year Count Specialty

ImplementationProgress

DevelopmentObjective

Identification/Preparation02/89

Appraisal/Negotiation08/1993

Supervision

09/30/1995 3 TTL (1); PUBLIC HEALTH SPEC. (1); HEALTH EDUCATION AND IEC (1)

HS HS

06/08/1996 5 HEALTH EDUC & IEC SPEC (1); PUBLIC HELATH SPEC. (1); IMPLEMENTATION SPEC (1); PUBLIC HEALTH SPEC (1); HEALTH PLANNER (1)

S S

12/18/1996 3 IMPLEMENTATION (1); TASK MANAGER (1); HEALTH EDUCATION & IEC (1)

S S

05/31/1997 5 IMPLEMENTATION (1); TASK MANAGER (1); HEALTH PLANNING; (1); IMPLEMENTAT (1); HEALTH EDUCATION & IEC (1)

S S

11/22/1997 3 TASK MANAGER (1); HEALTH EDUCATION & IEC (1); PLANNING & IMPLEMENTAT (1)

S S

9/16/98 4 TTL (1); PUBLIC HEALTH SP. (1); IMPLEMENTATION SP. (1); HEALTH SYSTEMS SP. (1)

S S

02/17/1999 24 HEALTH ECONOMIST (1); ARCHITECT (1)

S S

10/20/1999 4 PRJECT ANALYST (1); PUBLIC HEALTH SP. (1); CIVIL WORKS SP. (1); TEAM LEADER (1)

S S

05/13/2000 2 TEAM LEADER (1); CIVIL WORKS/PROCUR. SP (1)

U S

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10/31/2000 4 TEAM LEADER (1); PUBLIC HEALTH SP. (1); OPERATIONS ANALYST (1); HEALTH SYSTEM SP. (1)

U S

06/04/2001 1 TEAM LEADER (1) S S

09/21/2001 3 TEAM LEADER (1); PUBLIC HEALTH SP. (1); ARCHITECT (1)

S S

03/02/2002 4 TTL (1); PUBLIC HEALTH SP. (2); PROCUREMENT SP. (1)

S S

11/24/2002 3 TTL (1); PUBLIC HEALTH SP.. (1); ARCHITECT (1)

S S

04/15/2003 4 TTL (1); PROCUREMENT SPEC. (1); PUBLIC HEALTH & PHARM. SP.. (1); ARCHITECHT (1)

S S

11/15/2003 3 TTL (1); PROCUREMENT SP. (1); ARCHITECHT (1)

S S

ICR

(b) Staff:

Stage of Project Cycle Actual/Latest EstimateNo. Staff weeks US$ ('000)

Identification/PreparationAppraisal/Negotiation 940Supervision 920ICRTotal 1,860

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Annex 5. Ratings for Achievement of Objectives/Outputs of Components(H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable)

RatingMacro policies H SU M N NASector Policies H SU M N NAPhysical H SU M N NAFinancial H SU M N NAInstitutional Development H SU M N NAEnvironmental H SU M N NA

SocialPoverty Reduction H SU M N NAGender H SU M N NAOther (Please specify) H SU M N NA

Private sector development H SU M N NAPublic sector management H SU M N NAOther (Please specify) H SU M N NA

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Annex 6. Ratings of Bank and Borrower Performance

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory)

6.1 Bank performance Rating

Lending HS S U HUSupervision HS S U HUOverall HS S U HU

6.2 Borrower performance Rating

Preparation HS S U HUGovernment implementation performance HS S U HUImplementation agency performance HS S U HUOverall HS S U HU

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Annex 7. List of Supporting Documents

Documents consulted included the following:

Project Status Reports, aide memoires and back-to-office reportsProject filesGovernment's Implementation Completion Report.

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