World Bank Documentdocuments.worldbank.org/curated/en/655391468098973705/... · 2016. 8. 29. · SOKOTO HEALTH PROJECT (LOAN 2503-UNI) EVALUATION SUMMARY Introduction 1. Loan 2503-UNI

Document of

The World Bank

FOR OMCLAL USE ONLY

Repot No. 13730

PROJECT COMPLETION REPORT

NIGERIA

SOKOTO HEALTH PROJECT(LOAN 2503-UNI)

NOVEMBER 29, 1994

Population and Human Resources DivisionCentral-Western Africa 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.

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CURRENCY EOUIVALENTS

Currency Unit = = Naira (N)

1983 US$1 = = Naira 0.711986 US$1 == Naira 1.751987 US$1 = = Naira 4.021988 US$1 = = Naira 4.541989 US$1 = = Naira 7.371990 US$1 = = Naira 8.041991 US$1 == Naira 9.901992 US$1 == Naira 17.31993 US$1 == Naira 24.0

ABBREVIATIONS

EPI Expanded Program on ImmunizationFGN Federal Government of NigeriaFMOH Federal Ministry of HealthFMHSS Federal Ministry of Health and Social ServicesFP Family PlanningLGA Local Government AuthorityMCH Maternal and Child HealthPHC Primary Health CarePEC Project Executive CommitteePMU Project Management UnitSHT School of Health TechnologySMOF State Ministry of FinanceSMOH State Ministry of HealthSSG Sokoto State GovernmentTBA Traditional Birth AttendantTRC Training Resource CenterZHO Zonal Health Offices

FISCAL YEAR

January I - December 31

FOR OFFICIAL USE ONLY

THE WORLD BANKWashington, D.C. 20433

U.S.A.Office of Director-GeneralOperafions Evaluation

November 29, 1994

MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT

SUBJECT: Project Completion Report on NigeriaSokoto Health Project (Loan 2503-UNI)

Attached is the Project Completion Report on Nigeria -Sokoto Health Project (Loan 2503-UNI) prepared by the Africa Regional Office. Part II was prepared by the Borrower.

This project assisted in expanding and improving delivery of primary health care in one stateof Nigeria and in strengthening the Federal Ministry of Health.

Implementation problems were severe. Initiation was delayed, the project had to berestructured just after becoming effective, counterpart funds were insufficient, the state was dividedinto two during the course of the project, project management and institutional capacity (to handleprocurement, and monitoring and evaluation, among other things) was weak. Nevertheless, with anextension of 2-1/2 years, the project accomplished most of its specific targets and its outcome is ratedas marginally satisfactory. Institutional development is rated as modest and sustainability as uncertain(in large part because of continuing financial problems of the states involved).

The Project Completion Report is of acceptable quality. An audit is planned.

Attachment

This document has a restricted distribution and may be used by recipients only in the performance of theirofficial duties. Its contents may not otherwise be disclosed without World B1ank authorization.

FOR OFFICIAL USE ONLY


NIGERIA


TABLE OF CONTENTS

PREFACE . .........................................EVALUATION SUMMARY .............................

iiiPART I: PROJECT REVIEW FROM THE BANK'S PERSPECTIVE

1. Project Identity .................................2. Background . ..................................

I3. Project Objectives, Description, Design and Organization ...... 24. Project Implementation ........................... 45. Project Results ................................ 56. Project Sustainability ............................ 77. Bank Performance .............................. 88. Borrower Performance ........................... 99. Project Relationship .............................

1010. Consulting Services ............ .. .............. 1011. Findings and Lessons ...... ..................... 1012. Project Documentation and Data .................... 11PART II: PROJECT REVIEW FROM THE BORROWER'S PERSPECTIVE

1. By Sokoto State Ministry of Health ................... 122. By Kebbi State Ministry of Health .163. By Federal Ministry of Health and Social Services .... ...... 18

PART II: STATISTICAL INFORMATION

Table 1: Related Bank Loans ......................... 31Table 2: Project Timetables .......................... 33Table 3: Loan Disbursements - Cumulative andActual Disbursements .. .............. .............. 34Table 4: Project Costs and Financing .................... 35Table 5: Status of Covenants ............. I ........... 36Table 6: Project Results ............................

38Table 7: Use of Bank Resources ....................... 39Table 8: Mission Data by Stages of Project ... I ............ 40

This document has a restncted distribution and may be used by recipients only in the performanc of ther official duties. Its contents may not otherwise be disclosed without World Bank authorization. l

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NIGERIA


PREFACE

This is a Project Completion Report (PCR) for the Sokoto Health Project in Nigeria,for which Loan 2503-UNI was approved in the amount of US$34.0 million equivalent. TheLoan was appraised on October 19, 1982, approved by the Board on March 14, 1985, anddeclared effective on January 15, 1986. It was closed on May 31, 1993 (against the originalclosing date of December 31, 1990). An amount of US$3.0 million was canceled from theloan in December 1992, and the final disbursements amounted to US$26.2 million or 77% ofthe original loan amount. On November 8, 1993, an undisbursed amount ofUS$4,761,370.48 was also canceled.

This PCR has been jointly prepared by the Population and Human Resources Divisionof the Western Africa Department (Preface, Evaluation Summary, Parts I and III), and theBorrower (Parts II and III).

Preparation of this PCR was started during the Bank's final supervision mission of theproject in February 1993, and is based, inter alia, on the Staff Appraisal Report; the Loan andProject Agreements; supervision reports; correspondence between the Bank and the Borrower;internal Bank memoranda; information in the project files; and Borrower submissions. Bankstaff also conducted field visits during the preparation of the PCR. Part II of this PCR hasbeen prepared by the Sokoto State Ministry of Health, Kebbi State Ministry of Health, andFederal Ministry of Health and Social Services.

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PROJiECT COMPLETION REPORT

NIGERIA


EVALUATION SUMMARY

Introduction

1. Loan 2503-UNI was signed with the Federal Government of Nigeria (FGN) on May17, 1985 for financing a Sokoto Health Project. This health project was the first in Nigeria tohave been prepared by a state government within the framework of primary health care (PHC)policies. It attempted to implement these policies and address priority issues in a manner thatwas adapted to local needs and consistent with local resource availability.

Obiectives

2. The main objectives of the project were to assist in expanding and improving deliveryof primary health care in Sokoto Statel/ and strengthening the technical advisory capacity ofthe Federal Ministry of Health (FMOH)2/ on health sector planning and programming.

ImDlementation Experience

3. The project was originally scheduled to be completed by July 1990, but most of theproject activities were only completed by May 1993, or a delay of almost three years. It wasonly during the last 18 months of the project life that implementation picked up considerably.At the time the loan was closed, $7.8 million was canceled (of which $3.0 million had beencanceled earlier in December 1992), and the total disbursement was $26.2 million.

4. To address the changing priority needs of the health sector in Sokoto State and theavailable financial resources of the Borrower, the project was restructured in May 1986 toinclude the provision of essential drugs, the establishment of a cost recovery mechanism, andthe mobilization of the community to participate in planning and implementing PHC services.In June 1989, in light of the increasing difficulties the government faced in financing

I/ In 1992 Sokoto State was divided into two states: Kebbi State and Sokoto State. The legalagreements were amended to reflect this change.

2/ The name was later changed to the Federal Ministry of Health and Social Services(FMHSS).

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recurrent expenditures, the project was recosted, and the civil works component scaled downand refocussed from new construction to rehabilitation of existing health facilities.

5. Project implementation was jeopardized by (a) insufficient counterpart funds; (b)unstable political and economic conditions, including the division of Sokoto State into twostates; (c) insufficient capacity to handle procurement; and (d) weak project management andinstitutional capacity.

Results

6. The project did not meet all of its specific appraised targets, but it has yielded benefitsand has made important contributions towards the development of PHC in the project states.It laid the foundation for a strengthened PHC system by expanding the provision of maternaland child health (MCH) and, to a limited degree, family planning (FP) services and, throughprovision of essential drugs, medical equipment, and staff training, improved the quality ofservices provided, although not consistently in all project health facilities. It also helpedincrease the immunization coverage from 10% in 1982 to 60% in 1992 (albeit short of the70% targeted at appraisal). The full impact of this service expansion and qualityimprovement will not be known for some time, but limited data from clinics and first-handobservations by State Ministries of Health (SMOH) indicate improved services and usage insome facilities. The project also contributed to the preparation of a National Essential DrugsProject and a National Population Project which were subsequently financed by the Bank, and

the development of a national health insurance scheme and a national population policy.

7. What was not fully achieved was the development of: (a) a larger cadre of trainedfemale health workers to provide MCH/FP services, (b) a system for coordinating andmonitoring and evaluating health programs, and (c) the FMOH's technical advisory capacityfor sector planning and programming.

Findinas and Lessons Learned

8. The main lessons from the project are as follows:

(a) Changes in the health sector can occur rapidly and call for flexibility inimplementing health projects. Adjustments in project design proved to bevery time consuming and required intensive efforts fiom both the Borrowerand the Bank;

(b) Establishing a separate Project Management Unit (PMU) resulted in thecreation of parallel programs, activities and structures which was wasteful. Itdiscouraged the commitment and ownership by the SMOH to the project. TheBank also underestimated the difficulties in assimilating the ProjectManagement Unit into the mainstream functions of the SMOH;

(c) Appointment of key personnel within the PMU was seriously delayed andconsequently affected project activities at the early stage.

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NIGERIA


PART I: PROJECT REVIEW FROM THE BANK'S PERSPECTIVE

1. Project Identity

Name: Sokoto Health Project3/Loan Number: 2503-UNIRegional Unit: Africa Region - Western Africa DepartmentCountry: NigeriaSector: Health

2. Backeround

2.01 At the time the project was designed and prepared, the economic environment in thecountry and in Sokoto State was favorable, although government revenues had started to dropdue to the softening of the oil market. The rate of economic growth was about 7% p.a. andaverage GNP per capita was estimated at $760 (compared to $340 in 1991). The growth inoil revenues in the seventies enabled the government to embark on massive investmentprograms in basic infrastructure.

2.02 The health sector benefitted, albeit slightly, from increased budgetary resources.Drugs were generally available at government health facilities; the primary health levelnetwork had been expanded; and the number of health workers had been substantiallyincreased. In spite of these improvements, a significant proportion of the population still didnot have reasonable access to health care. Where the primary health system was accessible,maternal and child health services, immunization, and family planning - essential to reducemortality and morbidity - were often not available. Although great emphasis had been placedon increasing the number of health workers, there was a need to improve the quality of theirservices to increase their impact on health conditions which were poor by internationalstandards. Nigeria's mortality and morbidity from preventable and infectious diseasesremained high. The approach to family planning remained cautious and the government did

3/ The project name was changed to Kebbi State and Sokoto State Health Project in 1992when the Sokoto State was divided into two states.

not have a population policy nor a family planning program aimed to lower the country's high

fertility rate.

2.03 Recognizing these unsolved health issues, the government refocused its efforts by

shifting from its costly Basic Health Services Scheme - the centerpiece of the 1975-80 Plan

when the economy was at its peak - to a primary health care program, which gave more

emphasis to basic health care provided at the dispensary level. Furthermore, it decentralized

the responsibility of implementing PHC to the state governments and increased the active

involvement of local governments that operated most of the PHC facilities, in the sector

planning process. Among the states, Sokoto State - the home of the President of Nigeria at

that time - was the first state to rise to that challenge by preparing a health program within the

framework of PHC policies for external funding.

2.04 The project was the first Bank-financed health project in Nigeria. The Bank's

dialogue on this project began in 1978 during the preparation of a health component for the

Sokoto Agricultural Development Project (SADP) (Loan 2185-UNI) which subsequently led to

a joint decision to upgrade the health component to a free-standing health project. Preparation

of this project was completed by an expatriate consulting firm.

3. Project Objectives, Description. Desien and Organization

3.01 Project Objectives: The project had two major objectives: Part A was to assist

Sokoto State Government (SSG) in its efforts to reduce mortality and morbidity from

preventable and infectious diseases by focusing on PHC which was to be provided through the

dispensary system of the Local Government Authorities (LGA) in Sokoto State. The project

sought to increase access to and improve the quality of primary health care by expanding the

health network; strengthening MCH service delivery; expanding the program of immunization

(EPI) against childhood diseases; and developing regular technical supervision and in-service

training programs. The project also was to support the development of institutional

mechanisms for the Sokoto State Ministries of Health (SMOH) to provide LGAs with

technical support and to better coordinate public sector health activities. Technical support to

LGAs was designed to strengthen training and supervision of health care programs. Part B of

the project aimed at strengthening FMOH's technical advisory capacity for sector planning,

programming, and developing a lasting capability for the replication and promotion of state

health activities for PHC. The project was to assist the FMOH in its preparation of future

health projects and to create within the FMOH an institutional capacity to provide technical

and financial assistance for projects meeting federal guidelines and standards. Part B included

a study on health finance and increased cost recovery in the health system.

3.02 Project Description: The following is the composition of Part A:

a) primary health services development - to expand health network through the

construction of health clinics and provision of equipment/staff, to develop MCH and Family

Planning services at the primary level through the construction of MCH annexes and

provision of equipment/staff;

b) expanded program on immunization - to provide vaccines, equipment, vehicles,

technical assistance, training expenses and funds to cover incremental operating costs;

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c) training and supervision - to train female community health aides/femalecommunity health assistants, to train Traditional Birth Attendants (TBAs), to establish regularin-service training programs, and to strengthen the existing primary health worker supervisionsystem;

d) institutional development, monitoring, and evaluation - to establish a zonalmanagement system and to develop a health project/program monitoring and evaluationsystem.

3.03 Part B was primarily to provide technical assistance, equipment, vehicles, andfellowships to the FMOH. The project was also to provide funds to FMOH for helping thestates prepare future health projects and a strategy for creating within FMOH an institutionalcapacity to provide technical and financial assistance for projects meeting federal guidelinesand standards.

3.04 Project Design: The project's original design was based on the country's existingsector and macro policy objectives, and the existing approach agreed by the Bank and theBorrower in developing and financing state-level projects. By the time the project waspresented to the Board, however, some important events had occurred that affected theoriginal strategy. The economic and political conditions in the country had deteriorated withplummeting oil prices, the overthrow of the government, and the devaluation of the Naira,which in turn, led to a further and deepening deterioration of the health system. Drugs wereno longer available in most government facilities; equipment were not functioning; and therewere inadequate funds for recurrent expenditures. The state and local governments wereparticularly financially distressed.

3.05 In light of these developments, the project design was changed in May 1986. Thesechanges included the provision of essential drugs, introduction of appropriate cost recoverymeasures, scaling down the number of new health clinics to be established, undertaking ahealth financing study, and the mobilization of the community to participate in the planningand implementation of PHC services. During a mid-term review in June 1989, the projectwas recosted and refocussed towards improving the quality of rather than improving theaccess to health services, in view of the increasing difficulties of the government, particularlythe LGAs in meeting recurrent costs. Thus, construction of new health centers was givenlower priority over rehabilitation of existing facilities. These changes have generally been ofa positive nature and were more congruent with the priority needs of the health sector andwith the government's available financial resources for recurrent expenditures.

3.06 Or2anization: Part A of the project was implemented by the Sokoto State Ministry ofHealth (later adding Kebbi State Ministry of Health) and Part B by FMOH. Under Part A, ahigh level, policy-making Project Executive Committee (PEC) was established whichcoordinated project activities, reviewed project implementation and approved annual actionplans, budgets, and large contracts, and appointed senior project staff. A ProjectManagement Unit (PMU), designed to be integrated into the SMOH's structure and workingthrough four Zonal Health Offices (ZHO), was established to manage the project. ThePermanent Secretary of FMOH had overall responsibility for implementing Part B, with theNational Health Planning Directorate and the Primary Health Care Coordination Unitresponsible for preparing detailed budgets and work programs. The format of the projectorganization was copied from the Bank-assisted Sokoto Agriculture Development Project.

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4. Project Implementation

4.01 Loan Effectiveness and Project Start-up: The loan of $34 million was approved by

the Board on March 14, 1985 and became effective on January 15, 1986, eight months after

loan signing. The main reasons for the delay were difficulties in: (i) restructuring the project

to reflect the changes mentioned in paragraphs 3.05 and 3.06, and (ii) difficulties in meeting

the conditions of effectiveness. The adjustments were agreed upon prior to Board approval

and effectiveness. However, extensive resources were diverted toward modifying the Project

Agreements. It was only in June 1986 that the Amendment to the Loan and Project

Agreements were signed, and in August 1986 that the Memorandum of Understanding

Regarding the Adjustments in the Sokoto Health Project was agreed upon. Serious delays in

recruiting key PMU technical staff hampered operations.

4.02 Progress of Implementation: The project was originally scheduled to be completed by

July 1990, but most of the project activities were only completed by May 1993, or a delay of

almost three years. It was only during the last 18 months of the project life that

implementation considerably picked up.

4.03 The four factors which were principally responsible for delays in project

implementation were: (a) lack of counterpart funds; (b) unstable political and economic

conditions, including the division of Sokoto State into two states; (c) insufficient capacity to

handle procurement; and (d) weak project management and institutional capacity.

4.04 The FMOH provided its counterpart contribution at the start of implementation.

The counterpart funding arrangements for this project were similar to the SADP project in

which the federal government was obligated to provide counterpart funding. However, the

continuing devaluation of the Naira and the increasing demand for additional resources for

PHC from other states made it politically impossible for FMOH to continue providing the

counterpart funding. FMOH's contribution of $10.9 million was equivalent to only about

N7.7 million in 1985, but increased to N213 million in 1992 as a result of the devaluation of

the Naira. Thus, FMOH was unable to provide counterpart funding, especially towards the

latter part of the project life, in spite of the fact that the Bank, in 1989, increased its share of

financing from 66% to 84%, and decreased the FMOH's share from 20% to 9% (or N29.1

million), SMOH from 6% to 3% (or N8.7 million), and the LGAs from 8% to 4% (or N11.7

million). The LGAs also had serious problems in meeting their counterpart contributions,

which were initially expected to be modest in the form of dispensary staff salaries. Due to

the subsequent changes in the federal revenue allocations (in which federal funds were directly

given to LGAs, instead of through the state governments), it was agreed that LGAs would

carry a higher share of the project cost to include cash contributions. But even at the reduced

proportion, the LGAs were not able to provide the required counterpart funding. On the

other hand, Sokoto State contributed its statutory counterpart funding consistent with their

obligations in the legal document. In light of the experience from this project and of that of

another Bank-financed project (Imo Health), FMOH has stopped providing counterpart

funding to Bank-financed state-level health projects.

4.05 The political instability in Nigeria made it difficult to implement the project on

schedule. The changes in government (from civilian government to military government and

reverse) and the consequent frequent replacement of health commissioners seriously hindered

the steady implementation of project activities. A civil disturbance in Sokoto State destroyed

the SMOH headquarters, equipment, vehicles, and project files. This was followed by a

strike of nurses, and shortly before project completion, a strike of civil servants. The divisionof Sokoto State into two states (Kebbi State and Sokoto State) also slowed downimplementation. Project assets and liabilities had to be reallocated; Legal Agreements had tobe amended; and Kebbi State needed time to establish its own Project Management Unit.

4.06 The project continuously had problems in procurement. Internal procedures withinthe SMOH concerning procurement clearances were cumbersome and time consuming, yet,neither the SMOH nor the PMU were willing to build its capacity for procurement, other thanhiring initially local procurement agents, the practice of which was later abandoned because ofthe high costs of the fees charged. SMOH never hired a qualified procurement officer for theproject during the entire life of the project. Thus, there was no adequate procurementplanning, preparation of bidding documents and bid evaluation reports took a long time, andconsiderable amount of Bank staff-time was spent on checking on procurement just so mis-procurement did not occur. Part of the problem was also due to the Project ExecutiveCommittee (PEC) which at times rejected the recommendations for contract awards by thetechnical committee, and often reviewed the procurement contracts regardless of the amounts.There were as well long delays in reviewing consultant contracts by the State Ministry ofJustice, and the delays in the placement of key technical staff from the State Ministry ofWorks resulted in significant slippage in the execution of the civil works component.

4.07 The PMU was not adequately staffed: it took about 10 months to appoint the firstproject manager, and 19 months to find his replacement after his contract was not renewed;the project also did not have a qualified financial controller for a long time. Other vacanciescould not be filled up immediately by competent and qualified people in view of thereluctance of SMOH to appoint people outside the State when no qualified candidate could befound locally. From the technical side, the SMOH had serious manpower constraints and wascomplicated by the frequent turnover of the health commissioners (para. 4.05).

4.08 Project Costs: The estimated project cost at appraisal was about $53 million. Fromthe appraisal in 1983 until project closing in May 1993, the Naira depreciated by 1371 % (inUS$ terms). At project closing, total project cost was estimated to be $31.6 million.

4.09 Disbursements: Given the revisions of the project and the three-year delay, it makeslittle sense to attempt a detailed comparison between the appraisal and actual schedules. Atthe time of the original completion date, 29.6% of the loan had been disbursed. Before theloan was closed on May 31, 1993, after two extensions, there was an $3.0 millioncancellation from the project. Total disbursement was $26.2 million. Disbursements againstcommitments were made until November 8, 1993, and an undisbursed amount of $4.8 millionwas canceled.

5. Project Results

5.01 The project did not meet all its specific appraised targets, but it has yielded benefitsand made important contributions towards the development of PHC in the project states. Itincreased both the quality and the coverage of health services, albeit short of the appraisedtargets, particularly in rural areas which had been previously neglected. The full impact ofthis service expansion and quality improvement will not be known for some time, but limiteddata from clinics and first-hand observations by SMOH from both states indicate improvedservices and usage, although not consistently in all project facilities.

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5.02 Specifically, the following physical achievements were made:(a) upgraded and constructed 70 health facilities which represented 117% of appraisal

target (1000% of revised target of mid-term review); renovated 135 health centres (135% ofappraisal target, and 68% of revised target of mid-term review); constructed 4 Zonal HealthOffices; constructed 148 boreholes; a Central Medical Store was constructed in both Kebbiand Sokoto States;

(b) procured vehicles, furniture, office equipment for PMUs, clinics and dispensaries;provided vehicles, furniture, equipment for the State EPI program; provided vaccines,vehicles, furniture, equipment for the State Central Medical Stores; provided vehicles, officeequipment, teaching aids for the development of state health planning and managementcapacity;

(c) increased the supply of essential drugs, medical equipment and supplies;(d) increased the coverage of immunization from 10% to 60% (short of the 70%

target);(e) trained or retrained about 4560 traditional birth attendants (TBAs) (182% of target)

and institutionalized their role in health care delivery; and(f) trained around 300 community health extension workers (compared to the 300

target), trained 36 Senior Health Tutors on clinical instructions, trained 620 LGA healthpersonnel on drug revolving fund scheme, trained 60 senior community health extensionworkers on clinic management, provided overseas training for 15 senior health personnel, andabout 148 LGA supervisors were trained (compared to appraisal target of 60, and mid-termreview target of 5). (See Table 6 in Part III.)

5.03 The project also introduced the concepts of cost recovery and cost containment;encouraged the community to actively participate in planning and implementing PHC services;introduced a technical supervision and in-service training program; and developed amechanism for the SMOH to provide LGAs with technical support through a zonalmanagement system (four zonal offices were established for the purpose for monitoring andevaluation of LGA health activities). Furthermore, it contributed to the preparation of theNational Essential Drugs Project and the National Population Project, which weresubsequently funded by the Bank, and to the development of a national health insurancescheme and a national population policy.

5.04 The project was particularly active in community mobilization. Together with theState Ministry of Health, the project involved the rural communities and helped theirparticipation and increased their general awareness of health related activities and issues.SMOH and the project procured and distributed TBA stocked kits to over 29 LGAs, andprovided financial support to the State Women Commission for conducting a workshop onmobilization strategies. The project also established an additional 44 village healthcommittees (VHCs). These committees still exist and have continued to monitor the progressof their various facilities. The importance and usefulness of the VHCs has been recognizedby the SMOH who now uses some of the same instruments to assist them with health relatedcommunity matters. The project contributed to the increased participation in training and thedevelopment of training manuals. Women in Health activities were also developed under thisproject. There were 29 committees of women in health established by the SHP following anationwide initiative launched by FMOH. These activities encouraged greater participation ofwomen in health, including instituting infant weaning and child feeding activities, andnutrition and income generation programs. The project was instrumental at helping breakdown some of the cultural and religious barriers to training female workers. Although fewer

than the estimated number were trained, there is a positive indication that more communitieswould in the future be willing to allow their young women be trained.

5.05 The availability of upgraded health facilities, trained staff, and drugs has led to anincrease in the utilization of the cliniics with tangible results. A comparison of clinic registersfor this year and previous years as well as reports from clinic staff and patients indicate thattwice the number of people are using the clinics than previously, and currently there areapproximately 200 patients a month. The clinic staff of the facilities visited by Bank staffreport that there has been a marked decrease in child mortality due to epidemics since thestart of the immunization programmes. Whooping cough and in some areas tuberculosiswhich were responsible for the death of many children are now rare. Where maternal andchild health annexes had been constructed, there were reports of an increase of usage bypatients by approximately 40% in comparison to mother having their babies at home as waspreviously done.

5.06 What was not fully achieved was the development of (a) a larger cadre of trainedfemale health workers, (b) a comprehensive health program monitoring and evaluation systemat the States, and (c) FMOH's technical advisory capacity for sector planning andprogramming and a lasting capability for the replication and promotion of state healthactivities for PHC, although some important beginnings have been introduced. The HealthCare Financing - Cost and Utilization Study produced a "Draft Final Report". The finalsection of the study was only 75% completed.

6. Project Sustainability

6.01 The State Governments of Sokoto and Kebbi can build on the project achievements toensure the sustainability of the PHC programs. The concept of cost containment and costrecovery mechanisms which the project introduced, if continuously pursued, will help inimproving the financing of the health sector. Additional training is necessary to improve theunderstanding of drug revolving funds. The promotion of efficient ways of procuring drugs,and the use of generic instead of brand-name drugs, coupled with the drug cost recoveryprogram will ensure that the population will have a sustainable and reliable supply of safedrugs at affordable prices, provided the basic principles of the essential drugs programdeveloped under the project, are continuously adhered to.

6.02 Following the handing over of the projects facilities to the LGAs around the time theproject was closed, it will be very important that links be established between the PHCdepartment in the SMOH and the LGA facilities and that the SMOH improve supervision andmonitoring, as well as provide technical support. The facilities that were upgraded and/orconstructed can undoubtedly be used for a long period of time, but they will revert to theirpre-project condition, unless there is adequate maintenance. Local building/maintenancegroups need to be established within the LGAs and continued use of existing village healthcommittees should be encouraged. The village health committees have an important role toplay in ensuring that the facilities are adequately maintained and that people are made awareof their value.

6.03 Various training have been undertaken including the unprecedented training and re-training of over 4500 TBAs, but unless follow-up training is undertaken, their effort will be

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diluted over time. The use of trained TBAs to complement the work of salaried health

workers will ensure that basic services are provided at a minimum cost.

7. Bank Performance

7.01 The Bank made a positive contribution by providing the technical and financial

support to the development of PHC in the project areas. It showed flexibility in its approach

on a number of occasions. The first instance was the restructuring of the project shortly after

negotiations to reflect changes in circumstances since appraisal. The second instance was

during the mid-term review when the Bank responded to the local communities' request that

PHC services in some facilities requiring maintenance, regardless of ownership, would be

resuscitated by the project through the provision of equipment, drugs and trained staff.

7.02 However, in retrospect, there were some obvious shortfalls in the Bank performance.

At the design stage, the Bank should have read better the signals of a deteriorating economy

and its implications for the priority needs of the health sector, and should have designed

accordingly a project which was more calibrated to the capacity of the Borrower. By doing

so, time would have not been wasted in restructuring the project even before it started.

7.03 The arrangement of counterpart funding from the federal government was patterned

after a practice in the agriculture sector for Bank-assisted, state-level projects. It created a

precedent that was hard to live up to and eventually had to be abandoned. The Bank, in this

regard, contributed to the development of a situation that eventually became untenable in

political terms since FMOH could not put most of its PHC budget into counterpart funding

for Sokoto and Kebbi States, as well as for Imo State (another Bank-assisted state-level health

project).

7.04 The decision to establish a separate Project Management Unit, also patterned after the

Bank-assisted SADP, resulted in the creation of parallel programs, activities and structures

which was wasteful. It also explains the lack of commitment and ownership by the SMOH to

the project and the dilution of project impact on institutional development. The Bank also

underestimated the difficulties in assimilating the PMU into the mainstream functions of the

SMOH. Attempts to correct this mistake were needed in early May 1986 but it was not until

mid 1988 that the Sokoto PMU was finally assimilated to the mainstream functions of the

SMOH.

7.05 The main responsibility for preparing the project was given to an expatriate consulting

firm, with the state government playing a passive role, which explains the lack of government

commitment and ownership. While this was the current practice at that time particularly for

preparing state-level projects because of the lack of local capacity, the Bank, in retrospect,

should have been more forceful in ensuring a much more active government involvement.

7.06 In terms of staff-time spent on supervision, the Bank spent a total of 182 staff-weeks

of supervision between 1986 and 1993, i.e. 22.8 weeks per year. The Bank sent three

missions in 1985 and five missions in 1986, and thereafter, twice a year. Staff from the Bank

Resident Mission also visited the Sokoto to follow-up on agreements reached during the

regular missions. The Bank's extensive and above-average supervision did not necessarily

correlate with improved performance. Nor was it able to help resolve the start-up problems

in spite of the frequency of the Bank missions in 1985-1986; nevertheless, it should be noted

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that the supervision in the earlier years was difficult, as it involved a major projectrestructuring. In terms of the nature of assistance at implementation, in retrospect, the Bankshould have given more timely technical assistance on procurement.

8. Borrower Performance

8.01 During project preparation and appraisal, Sokoto State provided all the supportneeded, including financing the full cost of project preparation. Despite slow progress, thestate governments deserve credit for the turn-around in project implementation during the lastyear and half of the project period.

8.02 As mentioned earlier, the Borrower's performance contributed to the delays in projectimplementation, namely inadequate support by the federal government, lack ofcommunications between Nigerian officials, frequent changes in health commissioners and keyPMU staff, lack of counterpart funds, misuse of project funds for expenses not related to theproject, and lack of general supervision by FMOH and SMOH.

8.03 The federal government was not able to support the project actively. A series ofchanges in the appointment of state health commissioners and senior PMU staff disrupted thecontinuity of project management. After the departure of the first Project Manager, the PMUhad no manager for about 18 months. The PMU also functioned poorly during the earlystages of project life because it did not have a qualified financial controller for a long time.Communication between Nigerian officials was inadequate. No regular meetings werescheduled among FMOH, SMOH, LGAs and project officers. Financial contributions fromthe federal government and the LGAs were not met fully. A few government officialsmistakenly thought that they were free to spend project funds and consequently misspentfunds. The misspent funds were returned to the project account only after a long period oftime and repeated demands for reimbursement made by the Bank. General supervision byFMOH and SMOH on the quality and quantity of services provided under the project was notcarried out frequently.

8.04 This performance, however, when compared to subsequent Bank-financed healthprojects both within and outside Nigeria, is not unusual, considering the following factors: (a)it was the first Bank-financed health project in the country; (b) the serious constraints inmanpower, especially in management and technical skills in Sokoto; and (c) the difficultpolitical and economic environment within which the project was implemented. But outsidethese factors, additional problems associated with the performance of the borrower included:lack of communication among the FMOH, SMOH, the LGAs, and the PMU; cumbersomeprocurement procedures; reluctance of the state government to hire competent and qualifiedpeople outside the state; PEC's involvement in routine procurement decisions; and failure tocarry through some of the agreed arrangements for implementing the project (such as focusingon rehabilitation instead of construction of new facilities, expanding the agreed simplearchitectural design for health centers, appointment of a procurement officer, providingadequate staffing of the upgraded health centers with trained personnel).

8.05 The main lessons that can be learnt by the Borrower from the experience from theproject are: (a) the implementing agency should have the primary responsibility in the design,preparation and implementation of projects; (b) improved communication and coordinationamong the FMOH, SMOH, and the LGAs, and more involvement of the LGAs and the

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community in designing, planning and implementing health programs would have facilitatedproject implementation and would have resulted in more project benefits.

9. Project Relationship

9.01 In general, there had been regular dialogue between the Bank and the Borrower.Although a Project Manager was once replaced and the Project Executive Committee wasabolished without prior consultation with the Bank, the Bank and the Borrower were able toset up regular communications and establish a good working relationship through directdiscussions and frequent meetings.

9.02 The relationship between the FMOH and the State was unsatisfactory. There was notadequate communication and coordination between the two parties. One of the reasons wasthe long distance between Lagos and Sokoto State. The other reason was the difficulties incommunications. FMOH officials were displeased with state officials because they were notinvited to PEC meetings nor given sufficient notice of meetings. Sokoto State wasdisappointed at FMOH for not providing advice and funding for the project as agreedpreviously.

9.03 Frequent changes in health commissioners and the Project Managers often led to apoor relationship between the SMOH and the PMU. New officials did not always agree withthe priorities set in the project. For a while, serious internal conflict within the PMU causeda severe breakdown in project management. From interviewing the Borrower, it was notedthat LGAs were ill-informed about project objectives. LGAs would probably appreciate theproject more if they were more aware of its benefits to them.

10. Consulting Services

10.01 The performance of consultants, contractors and suppliers in the project was mixed.T'he continuing devaluation of Naira made it difficult for some small-time contractors tocomplete their construction contracts. The performance of the UN agencies who were used asconsultants (e.g. WHO, UNICEF, and UNIDO) was, in general, satisfactory.

11. Findings and Lessons

11.01 The health financing structure at the time of project design differed from its structureduring implementation. At the time of project appraisal, major investments were taking placein the infrastructure of the PHCs. However, after the project had been approved, difficultiesoccurred with regard to the Borrower's financial capacity to provide counterpart funds andfinance recurrent costs. Project activities for PHC were originally to be carried out by thestate governments for the LGAs. The proposed structure discouraged LGAs from taking thelead in implementing the project. When the project was implemented, the federal governmentshifted overall management responsibilities for PHC to LGAs. However, the LGAs did nothave the capacity to effectively implement PHC programs.

11.02 Although the Borrower and the Bank agreed on major adjustments prior topresentation to the Board, legal documents had not been finalized until long after project

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effectiveness. Drafting the documents after Board approval delayed implementation of the

project.

11.03 The decision to establish a separate Project Management Unit resulted in the creation

of parallel programs, activities and structures (such as EPI and MCH/FP) which was wasteful.

It also explains the lack of commitment and ownership by the SMOH to the project and

dilution of project impact on institutional development. The Bank also underestimated the

difficulties in assimilating the Project Management Unit to the mainstream functions of the

SMOH.

11.04 One of the conditions of effectiveness was the Borrower to have appointed the Project

Manager, the Deputy Project Manager and the Financial Controller. Sokoto State failed to

identify a suitable candidate for PM months after Board approval. After a long search, an

expatriate was hired by Sokoto State through Bank assistance. However, his appointment

proved to be counterproductive as it made coordination between the PMU and SMOH difficult

and created morale problems among local staff.

11.05 The lack of active involvement in the careful preparation of the project by the

government, relying fully on expatriate consultants, led to a lack of ownership and

commitment by the government to the project which are essential factors to the success of the

project.

12. Project Documentation and Data

12.01 The quality of project reports was very good at the beginning of project

implementation, but it deteriorated over the years, including the regularity of submission.

The last time regular progress reports were prepared and submitted to the Bank was in March

1992. Project files were burned down during the civil disturbances in 1991 resulting in

incomplete project documentation at the States.

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FEDERAL REPUBLIC OF NIGERIA

SOKOTO HEALTH PROIECT(LOAN 2503-UNI)

PART II: PROJ.ECT REVIEW FROM THE BORROWER'S PERSPECTIVE

A. BY SOKOTO STATE MINISTRY OF HEALTH

I. a) The Sokoto Health Project was designed to provide ways of improving thedeteriorating state of health care delivery system in the State. It is against this backgroundthat the Local, State and Federal Governments and the World Bank decided in 1985 tofinancially support the establishment of the project towards the improvement of the primaryhealth care delivery system.

b) Sokoto Health Project became officially effective on January 15th, 1986 andwas billed to close on 31st December 1990. It was however extended for 2 years to end on3 1st December 1992. At the end of 1992, it was further extended to 31st May 1993 tocomplete certain key activities that would enhance the overall performance level of theproject.

2. The main objectives of the project were:

a) Improving the dispensary system by renovating 224 and upgrading 120dilapidated dispensaries, staffing and equipping them with medical equipment, furniture andboreholes;

b) Expansion of EPI/ORT program through Maternal Child Health and FamilyPlanning support services;

c) Establishing Community Mobilization System through health education;

d) Training of primary health care staff;

e) Establishment of an Essential Drug Programme;

f) Establishment of Zonal Health Offices for the State and provision ofinfrastructure and other impetus necessary to make the health supervisory system efficient.

3. The responsibility of achieving the overall objectives rest on the Project ManagementUnit which has the following departments:

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Construction (civil works)ProcurementTraining and Manpower DevelopmentMaternal Child Health and Family PlanningCommunity Mobilization/Health EducationZonal Health OfficesFinance

a) Construction (Civil Works)i) 70 dispensaries were upgraded to clinicsii) 135 dispensaries were renovatediii) 2 Zonal Health Offices constructed at Wurno and Gusauiv) 148 Bore-hole constructedv) Central pharmaceutical stores constructed to serve the total needs of

the state.

b) Procurementi) Procured vehicles, furniture and office equipment for Project

Management Unit over the life of the project that have helped toimprove the efficiency of the PMU;

ii) Procured furniture for all clinics and dispensaries;iii) Provided vehicles, furniture and equipment for the State EPI

programme;iv) Provided vaccines, vehicles, furniture and equipment to the state

medical stores to enhance the drug revolving fund scheme;v) The health planning and management capacity development strategy

of the state was given a boost with provision of vehicles, officeequipment and teaching aids;

vi) Procurement of drugs and medical equipment and supplies.

c) Community Mobilization/Health Educationi) 235 Village Health Committees were established;ii) 40 Voluntary Village Health Workers were trained;iii) 1,072 villages were enumerated on household survey. Interviews

were also conducted covering each household;iv) Seminars were conducted for traditional rulers on Community

Mobilization and EPI/ORT Programme;v) Various seminars were organized for the members of the Village

Health Committees;vi) Support to Health Education Unit of State Ministry of Health with

health education materials;vii) Printed home-based record card and distributed to all Local

Government Areas;viii) Printed posters of various types for the purpose of public enlightment;ix) Procurement of 700 kits for Voluntary Village Health Workers;x) Procurement of Community Mobilization Equipment and Materials;xi) Drugs for Voluntary Village Health Workers' Kits were also

procured;xii) Home based record cards were printed.

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d) Maternal Child Health and Family Planning and Women in Healthi) 1020 Traditional Birth Attendants were trained;ii) 1300 re-trained Traditional Birth Attendants, these include others

earlier trained by Ministry of Health;iii) 29 Committees of Women in Health were established in the 29 Local

Government Areas of Sokoto State;iv) Series of workshops and seminars were conducted for Community

Health Extension Workers in MCH/FP and Women in HealthActivities;

v) Family planning materials were procured and distributed to all clinics;vi) Printed and distributed MCH/FP posters;vii) Purchased and distributed 1,600 TBA, stocked kits to 29 Local

Government Areas in Sokoto State;viii) TBA certificates and ID cards were printed and issued to trained

TBAs in the State;ix) TBA training materials were purchased and distributed to all Local

Government Areas in Sokoto State;x) ORT/Food demonstration materials were purchased and distributed to

13 functional clinics with MCH/FP programmes in the State;xi) Procured two grinding machines for women in health activities for

Wurno and Gusau Zones.

e) Training/Management Developmenti) Trained 300 Female Community Health Extension Workers for 29

LGAs in the State;ii) Trained 36, Senior Health Tutors on clinical instruction;iii) Trained 620 Local Government Areas health personnel on Drug

Revolving Fund scheme;iv) Trained 60 Senior Community Health Extension Workers on clinic

management;v) Provided overseas training for 15 Senior Health Personnel;vi) Trained 29 LGAs PHC Directors on supervision checklist;vii) Supported the new School of Health Technology, Gwadabawa with

bedding materials, library books, lab equipment, and other teachingaids;

viii) Supported School of Nursing Midwifery with library books;ix) Supported Specialist Hospital, Sokoto with renovation of its library

and provision of books;x) Vital science equipment were procured and distributed to LGAs;xi) Printing of posters and temperature charts: printed 10,000 copies of

BD and Hourly TPR and printed 4,000 copies of posters to be used inthe clinics and for public enlightenment on PHC in the communities.

4. Finance

Total amount loaned by the International Bank for Reconstruction and Development(IBRD) to the Federal Government of Nigeria is US$34.0 million. US$31.3 is on lent toSokoto and Kebbi State Governments. Sokoto Health Project has utilized US13,721,584.50 at

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the end of all transactions.41 Counterpart contribution is thus: Federal Government -N6,870,720.0; Sokoto State Government - N5,238,000.0; and Local Governments -N9,567,692.4. The World Bank has successfully recovered its initial advance under theSpecial Account arrangement. All audit reports have shown proper management of accountsof the project.

5. Performance of IBRD

a) Positive:i) On the whole, the Bank performed credibly. Whatever achievement

we have today in the Primary Health Care delivery system owes a lotto the Bank.

ii) We note with appreciation the extension of closing date of the projectlife span on two occasions which together extended the project life by2 years five months to end of 31st May 1993.

iii) We also note the tremendous effort put to see to the approval andexecution of the shopping list in November 1992.

b) Negative:i) One of the major problems encountered in project implementation is

delays in seeking and getting World Bank approvals for virtuallyevery activity. We do appreciate that what we consider cumbersomeprocedure put up by the World Bank is the international standard,nonetheless our socio-economic pack of development suggests that wegive less time to such procedures and more to execution. A generalprocedural framework should be agreed upon and certain activitiesfalling within should not require further Bank's approval.

ii) The performance of international staff especially the Project Managerwas quite poor. The Bank should encourage local staffing wheneverfeasible.

6. Performance of Project Management Unit

a) Positivei) The PMU has also performed fairly satisfactorily.ii) It was able to work within the Bank's guidelines and acceptable limits

throughout the project lifespan.iii) It executed all activities that from the success story of Sokoto Health

Project.

b) Negativei) Had a poor procurement department that was not able to handle the

procurement of drugs and medical equipment and supplies. Changesin mid 1992 that saw to the termination of the ProcurementCoordinator and taking over of procurement functions by the financedepartment save the situation.

ii) Delays in payment of contractors due to cashflow problems.

4/ This figure was adjusted due to splitting of the States (see Table 4 on page 35).

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iii) Poor communication and other logistics.iv) Save for the tail end of the project's lifespan, the PMU has not been

aggressive, because of the bureaucratic set up of the Ministry ofHealth, the project wasn't allowed to implement activities (routine)without making reference to Ministry which caused delays.

7. Performance of the Government

a) PositiveThe Government has since inception given the project all forms ofsupport to enhance achievement of objectives.

b) Negativei) There were occasional changes in project key personnel due to

changes in Government.ii) Decisions were taken faster by the Health Commissioner in the

absence of the Project Executive Committee who have demonstrateddelays in taking decisions.

iii) Poor payment of counterpart funding by the Federal Government.iv) Policy changes in national health structure.v) Inflationary trends and continued Naira devaluation led to non-

performance of many suppliers.vi) The creation of States brought about delays that affected the

performance of the project. Kebbi State was created out of SokotoState on 27th August 1993 and this led to the splitting of formerSokoto Health Project into Sokoto and Kebbi Health Projects. Thesplitting practically took effect from 1st July 1992 after the WorldBank mission of June 1992 agreed on the modalities.

B. BY KEBBI STATE MINISTRY OF HEALTH

1. INTRODUCTION

Creation of states: The creation of Kebbi State out of former Sokoto State on the 27th,August 1991 led to the splitting of the former Sokoto Health Project into Kebbi and SokotoState Projects on June 2, 1992. Under the new arrangement, both Kebbi and Sokoto Stateswere merely to complete those scheduled components of the former Sokoto State that then fellunder their purview. In the light of that, Kebbi Health Project (KHP) developed its objectivesand targets.

2. PLAN AND IMPLEMENTATION AND COST

The targets set by Kebbi Health Project after the split were met up to about 95%.Implementation of the Kebbi plan cost a total of N270 million, which includes a total ofUS$12.3 million drawdown by KHP, 5/ plus N5.47 million from State and N1.l millionfunding from LGAs.

5/ This figure was adjusted due to splitting of the States (see Table 4 on page 35).

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3. PROBLEMS AND EXPERIENCES IN IMPLEMENTATION

a) World Banki) World Bank's performance has been very professional. The

professionalism was even carried to a fault. The control procedureswere too involved. They could have been made simpler withoutlosing control and competition in procurement, either initially atnegotiations or by amendments during implementation.

ii) Secondly, the Bank's supervision missions were insufficient,infrequent for effective control in terms recognition of problems andmodifying rules to accommodate them.

iii) Frequently, the Bank took long to give replies to requests. This wasprobably because the Bank did not have professionals to look at theissues, but rather it had to use consultants.

iv) The Bank's attitude to loan negotiation, agreement, andimplementation was apparently incentive to local problems. Provisionshould be made for the Bank to take local factors into consideration toaid speed in project implementation as long as quality and efficiencyand effectiveness are not compromised.

v) Bank's report on drawdown, commitments, and charges were too farin between to be useful, such that anytime there was any charge ingovernment and/or management, it was difficult to know these itemsoff hand.

b) Federal Governmenti) The main problem with the Federal Government has been that she

was not paying her part of the counterpart funding regularly or ingood amounts. To date she has performed only up to about 30%.

ii) Being the Borrower and closer to the project states than the Bank, theFederal Government should establish an effective supervisionmachinery to keep track on project implementation.

c) State Governmenti) The State Government has been prompt in payment of contribution.ii) The major problem has been interferences in project management

from upper levels of government sometimes stifling projectimplementation.

iii) Related to the above, were frequent changes of government andcorresponding changes in top management of the project.

d) Local GovernmentsThe LGAs were not clear about their role in the project until late.And when informed, they did seem keen about their own contributionto the project, and what the project would do for them.

e) Managementi) A health project like this should have an indigenous health

professional right from the beginning instead of an expatriate andnon-health-professional one. This would have helped localunderstanding and appreciation of the issues and speedierimplementation of the project from its early years.

ii) There seemed to be an initial lack of complete understanding of theprocurement sections of the agreements on the part of the earlier

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project and task managers of the project. This led to issues that didnot need to go to the Bank for approval and wasting valuable time.

iii) A major lesson is that all heads of departments of this kind of projectshould have efficient and effective professionals in their fields, andthat, professional or not, once project staff begin to show signs ofincompetence, they should be replaced.

f) Termination of ProjectBy the closing date of the project on May 31st 1993, the project stillhad an outstanding liability of well over N1O million, and acommitment of about Nl million. The states also had all the LCsopened in respect of all the ICBs to be executed by variouscompanies (which together would cost the project N2 millionincluding Sokoto's portion), to be cleared and to be distributed.Hence, the project only stopped engaging fresh activities, disengagedmost staff, but continued to pay off liabilities and applying forreimbursement from the Bank hoping to finish by about end of July.

C. BY THE FEDERAL MINISTRY OF HEALTH AND SOCIAL SERVICES

1. The Sokoto Health Project was designed with the primary aim of reducing mortalityand morbidity from preventable and infectious disease, improving the quality of primary careby supporting a number of innovative initiatives and to provide means of improving thedeplorable state of health care delivery system in Sokoto State within the concept of PrimaryHealth Care strategy. It is in light of this that the Federal Government, the State, the SokotoState Local Government Areas and the World Bank agreed in 1985 to financially andtechnically support the project towards the achievements of its noble objectives. Theobjectives included the following:

i) Provision of effective MCH services;ii) Family Planning;iii) Manpower development;iv) Community mobilization through efficient Health Education;v) Provision of drugs and equipments;vi) EDP/ORT support services;vii) Provision of infrastructure;viii) Other services necessary to improve health services delivery in the

entire State.

2. These objectives were not completely achieved by the project due to numerousunavoidable constraints encountered during the course of implementation. However, it isnoteworthy that the impact of the project was appreciated not only by the indigenous ofSokoto State but all the people who were somehow associated with the project.

General Background

3. In 1970, the World Bank gave loans to Sokoto and Kaduna States for the developmentof an agricultural project. Later it was discovered that progress of development could beenhanced if health components were included to take care of the rural community involved.A health project component was conceived to be attached to the agricultural project. Thehealth project was formulated and cashed for inclusion in agricultural project. Because of

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time lag between the two projects, integration in execution was not possible. The healthproject was separately planned to be added onto the agricultural project. The health projectformulated was based on primary health care approach - "Sokoto Health Project".

Project Objectives

4. The health project was the first in Nigeria to have been prepared by a stategovernment within the new framework of Primary Health Care policies. It was to seek theimplementation of these policies and addressed priority issues in a manner that was adapted tolocal needs and consistent with local resource availability. The Sokoto Health Projectconsisted of Parts A and B.

Part A4.01 This part aimed to assist Sokoto State Government in its efforts to reduce mortalityand morbidity from preventable and infectious diseases by focusing on the first level of healthcare provided through the dispensary system of the Local Government Area (LGA) in SokotoState. In particular, it aimed to increase access to and improve the quality of Primary HealthCare by supporting:

a) the expansion of the health network;b) the strengthening of Maternal and Child Health (MCH) service delivery

including family planning;c) expansion of the immunization programme against childhood diseases;d) the development of regular technical supervision and in-service training

programmes; ande) through the establishment of a zonal management system, the project would

support the development of institution mechanisms for Sokoto Ministry ofHealth (SMOH) to provide LGAs with technical support and coordinatedbetter the public sector health activities.

Part B4.02 This project portion aimed at strengthening Federal Ministry of Health's (FMOH)technical advisory capability for the replication and promotion of state health activities forPrimary Health Care (PHC).

5. The project was expected to be implemented within a period of five years. While PartA of the project was implemented by Sokoto State Ministry of Health, Part B wasimplemented by the Federal Ministry of Health. The project was designed in such a way thatthe FMOH activities (Part B) would complement and helped replicate the experience gainedunder Part A of the project, thereby strengthening institutional linkages in the health sector.

Organization and Management of the Proiect

6. Sokoto State Ministry of Health had overall responsibility for the implementation ofPart A of the project. However, operation of the project health facilities was to be carried outby the LGAs under the supervision of the Sokoto State Ministry of Local Government inorder to ensure proper coordination, establishment of an effective mechanism for policyguidance, and implementation monitoring, Sokoto State Government established a high levelProject Executive Committee (PEC) to oversee the project implementation.

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7. FMOH was represented on PEC by the Director of Primary Health Care and Directorof National Health Planning Departments. Other members included Director Generals (DGs)of the Sokoto Ministry of Finance (SMOF), Sokoto Ministry of Local Government, SMOH,Sokoto Ministry of Planning (SMOP) with the Commissioner of Health as the Chairman.

The Project Executive Committee (PEC) is responsible for:a) determining operational policies;b) coordinating relevant activities;c) reviewing project implementation;d) approving annual action plan and budgets;e) approving contracts exceeding N100,000.00;t) approving senior project staffs.

8. Under Part B, formerly Permanent Secretary and later the Hon. Minister of Healthimplemented the technical assistance component. He was responsible for the following:

a) approving the budgets and work programme;b) overseeing implementation and approving the award of all contracts;c) operating the subproject account into which the Federal Military Government

(FMG) contribution and loan disbursement.

Proiect Implementation

9. The Sokoto State Ministry of Health (SMOH) and later Kebbi State Ministry of Health(KSMOH) had the major responsibility for implementation of Part A of the project withSokoto, Kebbi LGAs assisting while the Federal Ministry of Health was responsible for thePart B.

10. The implementation of Part B was done expeditiously, but same could not be said ofPart A because of multifarious constraints encountered during implementation. It is on recordthat more than 66% of the project objectives were achieved. The Part B of the project wasimplemented according to the agreed concept in the project document and by mid-term reviewPart B was about ninety five percent completed. Part B focused mainly on the following:

- training and other technical assistance which geared towards strengthening themanagerial process and nascent health planning and statistical units in StateMinistries of Health;

- supported State and LGAs' five year health planning;- supported various studies;- provided project preparation funds for at least three health and population projects.

Proiect Cost and Finance

11. The whole issue of Sokoto Health Project including the cost of the project and themethod of sharing cost were discussed at inter ministerial meetings consisting FMF, FMNP,FMA, WB and FMOH. The total cost of the project for 5 years after several review andadjustments was put at US$53.00 million. It is assumed that about 66% of the project

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objectives were met utilizing about US$48 million out of the project cost. The exact cost ofthe project will be available at a later date.6/

12. Financing plan was that the bank loan of US$34.00 million would finance 66% of thetotal project cost net of duties and taxes. It covered full foreign exchange component of theproject and about US$13.3 million equivalent of 41 % of local costs.

13. The proposed Bank loan of US$34 million was made to the Federal MilitaryGovernment (FMG) in 1985 out of which US$31.1 million was on-lent by FMG to the SokotoState Govermnent, and FMOH was supposed to utilize US$2.9 million. The US$34.00million was payable over 20 years including five (5) years of grace at the standard variableinterest rate. The local project accounts were opened in 1985. Part A account in Sokotowhich was operated by the SMOH Commissioner and Part B account at the Central Bankwhich was operated by the FMOH. As per the Federal Executive Conclusion on the projectthe Federal Military Government was to contribute the sum of N8.4 million spread from1985-1900 as follows: 1985-N1.4 million, 1986-NI.3 mil., 1987-N1.4 mil., 1988-N1.8 mil.,1989-NI.2 mil., 1990-N1.2 mil.

14. According to the World Bank agreement, the FMG local currency contribution to theproject was to be shared as follows: 86% Sokoto State project Part A account maintained inSokoto, 13.8% to Federal Ministry of Health account for Part B maintained at the CentralBank, SSMO-LGA also sent her yearly contribution to the Part A account in Sokoto.

15. By January 1989, the Federal Government had contributed N5.98 million,7/representing 94.92% of total contribution (N6.30 million) expected of her for the projectwhose date of expiration was 31st July, 1990. However, during the mid-term review whichwas May 1989, the life of the project was extended till July 31, 1992, and the project costwas reviewed and later the life was extended till December 31, 1990. The total revised costPart A of the project was US$37.1 million of which $31.3 million was financed by the WorldBank. This represented an increase from 66% to 84% of the World Bank share of the cost offinancing the total project. The remaining 16% of US$5.8 million (N49.5 million) of thetotal cost of Part A increased accordingly. The FMOH contribution was up to N29.1 million,Sokoto State MOH to N8.7 million and Sokoto LGAs to Nl 1 .7 million.

Project Achievement

16. Although the project was manned with myriads of constraints the achievements fromFebruary 1986 to 31st December 1992 can be clearly enumerated as follows:

a) Construction (Civil Works)70 dispensaries were upgraded to clinics;135 dispensaries were renovated;2 Health Zonal Offices constructed at Wurno and Gusau;

6/ The exact project cost was never given to the Bank by the Federal Ministry of Health andSocial Services.

7/ This figure differs from that of the figures the Bank had gathered (see page 4. paragraph4.04).

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66 Boreholes Tank.8/

b) Community Mobilization- 235 Village Health Workers- 40 Voluntary Village Health Workers- 1072 villages were enumerated on household, survey and interviews were

conducted to each household;- seminar were conducted for Traditional Ruler on Community Mobilization

EPI/ORT Programme, Phase I District Heads, Phase II VillageHeads; various seminars were organized for the members of theVillage Health Committee costing N369,000.00;

- support to Health Education Unit of State Ministry of Health (HealthEducation Materials) costing N1,000,000.00);

- printed home base record card at the cost of N760,000.00 and distributed toall Local Government Areas;

- printed posters of various types at the cost N250,000.00 for the purpose ofenl ightment.

c) Maternal Child Health and Family Planning and Women in Health DepartmentThe Department had to date achieved the following:- 1020 TBA were trained;- 1300 retrained TBA;- 29 committees of women in health were established in the 29 Local

Government Areas - Sokoto State;- various workshop and seminars were conducted for Community Health

Extension Workers in MCH/FP and Women in Health Activitiescosting N22,999.00;

- family planning commodities were distributed costing N322,299.00;- printed posters MCH/FP costing N50,000.00;- purchased and distributed over 2,500 TBA kits to 29 Local Government

Areas in Sokoto State;- TBA Certificate and ID Card were printed at the cost of N42,000.00 and

giving qualified TBA for Sokoto and Kebbi State;- Procured various and equipments for EPI/DRF support;- 82,796 deliveries were handled and recorded by the TBAs;- TBA training materials to 27 Local Government Areas in Sokoto State were

purchased and distributed;- ORT food demonstration materials to 13 functional clinics with MCH/FP

programmes were purchased and distributed to 27 Local GovernmentAreas in Sokoto State.

d) Training/Manpower Development Department- trained 484 Female Community Health Extension Workers for both Seniors

and Juniors for Kebbi and Sokoto State;9/- trained 36 Senior Health Tutors on clinical instruction;

8/ Figure contradicts with that of Sokoto's: Sokoto's calculation was 148 (page 13).

9/ Figure contradicts with that of Sokoto's: Sokoto's calculation was 300 (page 14).

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- trained 620 Local Government Areas Health Personnel on Drugs RevolvingFund Scheme;

- trained 60 Senior Community Health Extension Workers on clinicsmanagement;

- trained 15 Senior Health Personnel on various disciplines overseas;- 29 PHC Directors on supervision checklist;- supported School of Health Technology Jega with library books, bedding

materials and has equipment;- supported new School of Health Technology Gwandabawa with bedding

materials and library books;- supported Specialist Hospital Sokoto with renovating of its library and

provision of books;- supported School of nursing/midwifery with library books;- trained 20 Senior Personnel of Health Planning and Management.

Performance Assessment of Staffs

a) SSMOH & SSLGs

17. The project part of which was implemented by SSMOH & SSLGAs was not evenlyhandled throughout the life of the project. The staff strength in most cases throughout the lifeof the project was grossly deficient. Also the quick changes of the key staff did not allow forcontinuity of the project implementation. The foreigners occupying key positions in theproject served as a major set back during implementation. The foreigners usually spent overhalf of their time learning the culture and the new environment which made little or no impacton the project implementation. The project launching which would have served as a means ofinforming and enlightening the generality of the people did not take place.

b) The World Bank

18. The project was designed in such a way that the FMOH had no authority whatsoeverover the implementation procedures of the project. Sokoto State was given all authorities andwas the World Bank as the only institution that could offer assistance, provided guidance andguidelines. The recruitment of foreigners and foreign consultants for the project was basedmainly on the advice of the World Bank and this did not help the project. Local experts fromother part of the country could have been allowed to compete for the jobs on the project. TheFMOH technical support to the project is very crucial. For the success of the ongoing andfuture projects under the World Bank support, Washington should formulate strategy ofsharing authority, supervisory and responsibility with the FMOH. This would stimulate theFederal officials to offer the needed technical guidelines and technical support required by theproject from the Federal level.

c) Federal Ministry of Health

19. While a number of health agencies at all levels of Government partake in theimplementation of the project, responsibility for overall project co-ordination, guidance andtechnical supports which was supposed to be with FMOH was not allowed to be there. Hencethe supposedly official ultimately responsible for the project, the Federal Ministry of Healthwas totally out of the picture. Though the Directors of PHC&PRS were members of PEC,SHP officials ensured that notification for meetings never reached Lagos in good time to

- 24 -

allow for their full participation at such meetings. Decisions were reached about theimplementation of the project with very little or no input at all from the Federal level.Mechanism for the FMOH to enforce authority was not there. It was realized that thosecorrective activities which FMOH could have put in to the implementation constraints werenot there. In conclusion, the FMOH was rendered as mere observer in the implementation ofa project into which she was heavily financially committed and this should be corrected nowand in all such future projects.

Problems Encountered in Project Mobilization and Execution

20. Although Sokoto Health Project (SHP) became legally effective on 15th January 1986,the Project Management Team was not recruited and a number of essential pre-startupactivities was not undertaken immediately. Notably the "Project Launch Workshop", a meansof informing the public and all participating levels of Government about project objectives andstrategies in order to obtain advance understanding and commitment, were not put in. Thisplace was indeed a crucial opportunity missed, as resistance to the original Loan in manyinformed quarters of the State was significant. It was felt by many, who criticized that such asignificant amount of foreign exchange should never have been borrowed for a "soft" (i.e.non-capital investment return) project.

21. The key project management nucleus was not effectively in place to undertake fullscale mobilization until 1st April 1986. Expectedly, it was discovered by World Bankofficials that the very premise of public sector financial capability and growth, upon which thejustification for the project was based, was entirely in question. Rather than a situation ofavailable financial resources, the fall in world oil prices and the attendant Naira value crisis,brought into serious question the ability of the LGAs to sustain the incremental health servicerecurrent costs occasioned by project implementation. While the domestic and internationalcrisis of financial confidence started well before Loan effectiveness, it was not consideredsufficient reason to suspend or retard activation of the Loan and commencement of multi-component project activities. Instead, an entire restructuring exercise was commenced prior toLoan effectiveness, which was not crystallized until be end of April 1986. The following five(5) months were spend in negotiations with the State Government regarding massiverestructuring exercise, and the ensuing Cabinet deliberations, during which very little physicalprogress was achieved. One of the key elements of the restructuring package was a majorhealth care financing consultancy study, the results of which were, in effect, to indicate theState's ability to pay for the Sokoto Health Project. This is clearly information which shouldhave been obtained prior to full loan effectiveness and multi-component implementation.

22. These unique constraints served as a serious physical and psychological retardant tothe State authorities and project personal responsible for initial project mobilization, and set atone of implementation uncertainty that took and long time to overcome.

23. From the beginning, it was clear that participating state agencies and, indeed, theProject Executive Committee (Board) were insufficiently aware of the true nature and scope ofthe project, and the unique pre-conditions to effective implementation of externally-financedproject within an existing government framework. A number of key project initiatives weredesigned with inextricable link to the existing bureaucracy, thereby virtually institutionalizingimplementation impediments as a natural result of the orientational dichotomy betweenpermanent and limited - life organizations. Typical of the impediments to effective

- 25 -

implementation were the following environmental and institutional factors: endemicbureaucratic delays:

24. Countless hours of management time were consumed in completing certain routine,policy and legal formalities, such as:

- change in the authorized state signatures from the Ministry of Finance to theMinistry of Health/Sokoto Health Project sixteen (16) months to effect;

- establishment of the required N500,000.00 overdraft facility took twelve (12)months;

- amendment to authorize the dollar-denominated Special Account andsubsequently activate the account took sixteen (16) months to complete;

- execution of the Legal Amendment to the Loan Agreement was not done intime;

- payment of Statutory Federal Financial Subventions on quarterly basis tookconsiderable efforts and time;

- lack of understanding of mutual roles in the interministerial vetting andapproval process created numerous unnecessary delays and fosteredunwarranted feelings of competitiveness or lack of highly requiredcooperation.

b) World Bank Conditionalities and Implementation Experience:

25. Sokoto State Government experience with World Bank projects was limited to theagricultural sector when the Sokoto Health Project was mounted under a different divisionwithin the Bank. Although the Rules and Regulations are theoretically the same, conditions ofapplication and interpretation varied widely. While it was true to say that the Ministry ofHealth did not fully understand the loan and implementation conditionalities, it was equallytrue that the Bank only slowly came to appreciate the unique situation of the Borrower.

26. Early communications, implementation and understanding hampered the closecooperation which characterized the relationship since the appointment of an experiencedclient-sensitive project officers. This mutual lack of understanding which continued duringthe initial year of implementation, served as a temporary retardant to early progress.

27. While the World Bank funds were in every sense a loan to the State, they weredisbursed only in satisfaction of certain strenuous conditionalities which should be observed ifdefault was to be avoided. This often meant that the most pragmatic or locally efficient andauditable means to achievement could not be utilized. Though not always fully appreciated bythe State Government, and most certainly not by local businessman or the Loan repayingpublic, it was essential that strict conditionalities be observed. Any form of deviationreceived Bank's approbation, and cancellation of proportionate amounts from the Loan fund.

c) Professional Management Personnel Recruitment:

28. When a number of posts to be internationally recruited were negotiated out of theproject agreement, provision was not made for their effective replacement with nationally-recruited contract or limited consultancy personnel.

29. The recognition of these posts as essentially senior in nature was thereby lost, andmanagement capability vacuum created. This situation was exacerbated by the project

- 26 -

restructuring exercise which established a number of major components without provision for

their exceptional managerial requirements. The uniqueness of the interventions planned under

the project and the commensurate requirement for specialized and exceptional managementskills was never adequately addressed by the Project Executive Committee, to the detriment of

project implementation.

30. Compounding the problems was the fact that vacant posts requiring highly specializedindividuals were filled with seconded personals whose main qualifications were availabilityand willingness to serve.

d) State Ministry of Works as Consultants:

31. The initial positioning of the SMOW&T as construction planning and implementationconsultant to the project was an experiment which even in concept had little chance for

success. Its efforts to the contrary, the SMOW&T had proved incapable of providing the

overall hands-on engineering and construction management services required of a State widemulti-site building programme. The unfortunate miscasting of an essentia! sister services into

a role for which it was not institutionally equipped or disposed resulted in major area ofimplementation disappointment and created considerable mutual frustration in the twoparticipating organizations. Litany of non-responsiveness was chronicle from the inception of

the consultancy, after five(5) months of inter-ministerial contract negotiations, which couldnever have occurred with or been tolerated of an external engineering constructionconsultancy organization. This unique experiment in public sector consultative services

clearly failed.

e) Delay of Cancellation of Essential Consultancies:

32. The unpopularity of consultancies associated with externally funded projects,particularly as they had come to be associated with large percentages of foreign exchange loan

funds, redundancy of data collection and compilation efforts by foreign experts, andaccumulation of unused data upon Ministry shelves, had been visited upon the Sokoto Health

Project. Unfortunately, the design of this project was a landmark and was to be utilized as apilot effort within the country and as a model for implementation elsewhere. Thus many ofthe components in the design could have been unique not only to Sokoto State by to theFederal Republic. This meant that the theoretical knowledge and experiential skillsprerequisite to implementation of number of these components did not in fact locally exist. In

addition, the scope of these components was such that master implementation on a large scaleturnkey basis was required. Therefore, the inevitability of major consultancies, many of

which were embodied in the restructuring exercise or otherwise agreed with the Bank, had

been well established. Due to an essential misunderstanding of this situation both on the part

of the SOSG and the PEC commissioning of essential consultancies in health care financingand drug revolving fund implementation was retarded for almost two years. Lack orrecognition of the scale and impact of the management and supervisory systems component,not fully understood, resulted in a two years' implementation delay in this component,

characterized by stopgap measures, after the cancellation of the implementation consultancywhich required a year of work to develop. The same situation developed with respect to theoverall community mobilization/health education implementation consultancy designed to plan

and guide overall institution of the statewide community health awareness programme. Manymonths of pre-approved work was wasted, and excellent framework abandoned when the

required technical assistance was disapproved.

- 27 -

f) Others were:

33. - inefficient procurement specialist- lack of continuity of project key personnel- delay from PEC in taking decisions- state creation and the splitting of the project as a political factor

34. The above highlights some of the major constraints to effective implementation of theSokoto Health Project, which may be representative of the impediments generally encounteredin the realization of externally-funded public section undertakings. In any event these andother factors have served to severally constrain the Sokoto Health Project. Notwithstanding,significant strides were made, and the pace of project momentum and physical achievementincreased considerably. Still, it is clear that significantly more could have been achieved hadthe requisite freedom to act, the main requirement for effective implementation and the onecharacteristic which most distinguishes project-type management from the traditional publicsector management approach was allowed from the onset.

Solutions That Should Have Been Proposed at Mid Term Review

35. In the specific instance of the Sokoto Health Project, the solutions are directlysuggested from the exposure of the problems. After seven years of life, the measuresnecessary to have increased pace and effectiveness of implementation can be summarized as:

1) streamnlining of the vetting and approvals cycle through such measures asappointment of an independent legal council or a specific senior SMOJ Attorney to becomeexpert in SHP-related matters, increasing PEC contracts approval threshold, etc.;

2) removing SHP from the recruitment constraints imposed by adherence to the publicservice grading/sa!ary system totally unsuited to the essentially limited employment periodsinherent in project work, and maintaining secondments to an absolute minimum other than incounterpart development roles;

3) retaining the SMOW&T within its traditional capability as monitoring andevaluation agent for the SG and evaluation agent for the SG and employing the professionalservices of nationally recognized firm of engineering/construction consultants, coupled withdirect recruitment of construction field management personnel;

4) adopting a large-scale statewide construction strategy more suited to the operationaland supervisory realities than myriad small contracts with multiple contractors of widelyvarying capabilities;

5) adoption of internationally competitive bidding to those consultancies agreed withthe IBRD to be essential to the proper implementation of the specialty components;

6) reorganization of the management functional responsibility with the project, withnational recruitment for all positions clearly requiring particular expertise unavailable withinthe State, couple with a distinct counterpart relationship to ensure the most efficient transferof expertise.

Lessons Learnt

36. 1) Recruitment of project staff and consultancies could have been within the countryexcept resources are not available;

2) Supervisory authority could have been shared by the World Bank and FMOH;3) Recruitment of staff, consultant to the project should have been national and not

restricted to the project state only;

- 28 -

4) FMOH should be encouraged and empowered to play leading role in theimplementation of state project whose land was guaranteed by Federal Government ofNigeria;

5) Encourage the use of local experts except where not available within the country;6) Related federal ministry should be a controlling authority to implementation or

should be given authority to act when there are problems, since the FMOH and the stateconcerned would be financially committed;

7) The FMOH should have the knowledge of decisions on all concerned projectsbefore forwarding them to the Bank;

8) Both FMOH and the World Bank should have "no objection" power over theappointment of project staff, consultants and award of contract over US$5,000.00;

9) While the Project Executive Committee is chaired by SMOH Commissioner,FMOH representative (DPHC&DC) should be his Vice and hold the chair when theCommissioner would not be around;

10) Project staff should be properly remunerated and not restricted to Governmentgrade level;

11) FMOH project officer representing the DPHC&DC should be made to handle theproject on a full time basis and report adequately to DPHC&DC;

12) There should be policy endorsement to ensure that project fund be used only forwhat is meant for and project procedures should be carefully followed;

13) Future project should be costed in US dollars;14) In project implementation, World Bank should not undermine the authority of

FMOH but rather enhance it, and strategy to foster such should be formulated.

Recommendations

37. 1) The use of foreign experts should be discouraged as this would not enhance thecontinuity of the project at the expiration of their contract. Local experts could be readilyavailable at a reduced cost;

2) FMOH that would be financially committed in the project should be given authorityto act when problems arisen;

3) In all procedures, FMOH should have a knowledge of decisions on the projectbefore forwarding such to the Bank;

4) There should be supportive powers from both FMOH and World Bank over theappointment of project staff, consultants and award of contract over US$5,000.00;

5) Project staff recruitment should be on national level, and not restricted to theproject state;

6) FMOH should be adequately represented in the Project Executive Committee whilethe committee is chairmaned by CMOH, (Commissioner) and the Vice should be therepresentative of FMOH (DPHC&DC);

7) That project staff must be properly remunerated and not restricted to governmentgrade level;

8) Policy for the implementation of future projects must ensure that project fund beused only for what it is meant for; and that the procedures of the project implementation befollowed carefully;

9) The use of foreign currency in the cost of the project is highly recommended;10) World Bank and FMOH should work one accord and formulate strategies to foster

the proper implementation of future projects.

- 29 -

Conclusions

38. Sokoto Health Project is a very important project in the sense that it is the first of itskind in Nigeria to be prepared and implemented within the context of Primary Health Careapproach. However, it might be argued that is was unfair to Sokoto State to have tried such avery important pilot project of its complexes in that State without adequate back up provisionsin terms of sufficient project policy. Both the World Bank and FMOH would have madeenough provisional guidelines to enhance institutional capacity required of a project of suchcomplexity, innovation, commitment, experience and dedications.

39. Today, both Sokoto/Kebbi States indigenous have benefitted tremendously from theproject and its impact on the health services delivery is in no small measure appreciable. Thefact that over 60% of the stated objectives were met on 31st December 1992 made it a highlyrewarding and beneficial project to the country. However, all the World Bank supported on-going and future health project should carefully study Sokoto Health Project implementationand procedural problems, achievements, and constraints. This will be of a tremendousadvantage towards their successful implementation.

40. One problem that stood out against Sokoto Health Project was the inability of theproject to recruit an experienced and well qualified procurement officer. This madeprocurement extremely difficult for the project and it gave the picture as if the World Bankposed difficulty in issuing the required no objection. With an efficient and experiencedprocurement officer the problems of the World Bank assisted projects would be considerablyreduced.

41. As part of the success of Sokoto Health Project (SHP) is the development of FMOH'srole in the preparation, evaluation and replication of state health programme for PHC. TodayPHC is a success all over the nation and so far SHP assisted in the development of ImoHealth and Population Project, Essential Drugs Project, and Health System Fund Project.Also the technical assistance under Sokoto Part B to the FMOH greatly strengthened itscapabilities in the areas of health sector planning and programming, evaluation and replicationof similar projects.

42. This eventually helped in accelerating the development and operation of PHCprograms nation-wide. The development of the institutional capabilities at FMOH level todevelop affordable, widely accessible and efficient system to deliver Primary Health Careservices which in real terms brings about the improvements in the health status of thepopulation in general terms is another justification for the success of SHP.

43. The fear of the risk of insufficient counterpart funding right from onset is justified.Despite the fact that SHP was scaled down and reviewed with the objective of cost-minimization which confirmed earlier that the financial requirements of the project on SokotoState Government and the LGAs were considered affordable, all the three levels ofGovernment including FMOH found it extremely difficult to meet the much needed financialobligations. This was due to the rate of Naira devaluation which was one US$ to one Nairawhen the project turned effective and rose as high as to one US$ to thirty five Naira duringthe life of the project.

- 30 -

44. However, the advancement of technical know-how already developed at the federallevel makes the condition of SHP replicable in other states of the Federation veryencouraging.

45. Sokoto/Kebbi Health Project with all the attendant constraints was a successful projectin which both the World Bank and FMOH tried very hard to enable the general populace inboth States benefitted tremendously.

- 31 -


FEDERAL REPUBLIC OF NIGERIA


PART III: STATISTICAL INFORMATION

TABLE 1: RELATED BANK LOANS(Page I of 2)

Year ofLoan Purpose Approval Status Comments

First (Bauchi) Lay foundation 1979 Closed PCR/PPARUrban Development for both a national completed.Project low-cost housing(Ln 1767-UNI) program and a

broader futureurban lendingeffort; seek todemonstrate theapplicability ofthe sites & servicesand upgradingapproaches forlow-income shelterprovision.

Anambra Water Enhance living 1981 Closed PCRSupply and conditions in completed.Sanitation Project Anambra State(Ln 2036-UNI) by improving

water supply,solid wastecollection anddisposal, urbaninfrastructure& health education

- 32 -

(Page 2 of 2)

Year ofLoan Purpose Approval Status Comments

Imo Health and Improve health of 1989 On-going Weak projectPopulation Project the people of Imo management,(Ln 3034-UNI) State and provide non-compliance

voluntary family with legalplanning services. covenants,

mid-termreview plannedearly 1994.

National Essential Ensure public has 1989 On-going Project isDrugs Project access to sustainable generally on(Ln 3125-UNI) supply of safe, track. Drug

effective, affordable procurementdrugs. remains a big

problem.

National Population Strengthen institu- 1991 On-going Project isProject tional framework, on track and(Ln 2238-UNI) expand on experimental implementation

basis intersectoral expected tonational population be improved.program.

Health System Fund Improve state health 1991 On-going FMOH/PFIs'Project systems by utilizing performance(Ln. 3326-UNI) PFIs to implement, unsatisfactory.

and assist states in Mid-termimproving health review wassystem investment completed inplanning. Nov.1993.

- 33 -

TABLE 2: PROJECT TIMETABLE

Item Original Date Actual Date

Identification April 1980October 1980

Preparation July 1981October 1981

Initial Project Brief October 5, 1982

Appraisal September 1982 October 19, 1982

Issues Paper December 27, 1982

Appraisal Follow-up October 1982 May 12, 1983

Loan Negotiations July 29, 1983 November 28, 1983

Board Approval */ July 1984 March 14, 1985

Loan Signature May 17, 1985

Loan Effectiveness August 15, 1985 January 15, 1986

Loan Closing December 31, 1990 May 31, 1993

Date of Last Disbursement November 8, 1993

#/ The project was not presented to the Board as scheduled because the FederalMilitary Government decided to review its entire external borrowing program beforeapproving any of the already negotiated project.

- 34 -

TABLE 3: LOAN DISBURSEMENTSCUMULATIVE AND ACTUAL DISBURSEMENTS

(US$ Thousand)

Estimated Revised Actuali. ActuallYear Amount Amount Amount as % of

…------- Cumulative -- ---- Estimate

1986 1,200.00 227.09 0.71987 5,100.00 2,260.56 7.31988 10,200.00 5,111.30 16.51989 17,700.00 12,500.00 8,475.97 27.31990 27,200.00 23,700.00 9,202.04 29.71991 34,000.00 30,000.00 11,205.82 36.11992 34,000.00 16,650.37 53.71993 26,238.63 84.6

Loan DisbursementCumulative Estimated and Actual Disburasmanta

(US$ Thousend)

35,000.00 T30,000.00

25,000.00

20,000.00

15,000.00

10,000.00

5,000.00

0.00to oN 0 c, o - Xco 0 go co 0 0) CD CD

| * ~Estimated - - - Revised Actual0) 0) 0) 0) 0) 0) 0) 0)~~~~~~~~~~~~~~~~~~~~~~~~~~~

- 35 -

TABLE 4: PROJECT COSTS AND FINANCING

A. Prnioct Costs(Thousands of Naira and US$)

(tam N~~~~~~~lrg :y~~~~~~~~ . N1~~~~*.~~~~ ~ ~ VS 4:. ~~~~~~~~:.....j:.... ...

Category 1 10,843.0 18,258.4 87.37e.0 10,086.2 6,224.0 5,795.2 31145.8 519e.3ICivil Works)

Cateaory 2 2,908.8 4,361.0 139,875.6 1 e,541.9 1,314.4 791.1 8618.3 7970.3(FunitureNehicles/Suppliesl

Category 3 1,558.8 2,337.0 1 8,e20.1 2,384.3 617.4 309.0(Intl.Consultants/Trainingl

Cateoory 4 2,700.0 2,579.7(Part B: ConsuttantesVehicles)

Cateoory 5 9,131.1 13,e89.8 37,777.0 4,593.5 14,138.0 1,eO7.1 15283.8 1393.0(Lcl.Training/Optg CostsaPMU/ZHOs) __ __ ___ __PMU.......... .... .................... ..................... ............ ........................ ....... ... . ...... .. . ...

Total 24,441.7 39,344.2 281,648.7 33,585.9 21,878.4 8,810.8 53,027.9 14,858.8 _ 2,579.7

B. Proiect Financing(Millions of Naira and US$)

Sotwc. of F~~~~~~~~~...... . .. . ........ .. . ........

World 8ank 31.1 2.9 31.3 2.9 2e.2

FMOH 9.4 1.5 4.0 1.5 6.9

State Ministries of Health 2.8 0.9Sokoto Stats 5.2Kebbi State 5.5

LGAs from both States,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.,. 3.7 1.3 10.7 __-

TOTAL 47.0 4.4 37.5 4.4 28.3 2e.2

-36 -

TABLE 5: STATUS OF COVENANTS

(Page I of 2)

Section Covenant Status of Compliance.... ..... - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ - -

Loan Agreement3.01 (a)(b)(c)(d) Commitment of the Borrower to cause Complied.

SSG pursue and execute the objectivesof the Loan as set forth in Schedule2 of the Agreement, relend proceedsand protect Borrower's and Bank'sinterest

3.02 (a) Borrower shall open an account for Complied.Part B

3.02 (b) Borrower shall make adequate budgetary Revised FMOHprovisions for the purpose of its contribution to SHPcontribution to Part A had not been met.

3.03 (a)(b) Appoint consultants for Part B and complete Preliminary ReportHealth Care Financing Study completed.

3.04 (a)(b) Insure imported goods and commit them Complied.to the purpose of the Project

3.05 (a)(b) Seek prior clearance on procurement plans Mostly complied,and maintain records for such procurement, limited cases onmonitor and advise on cost and benefit proceedinganalysis procurement process

with prior clearancefrom Bank.

4.02 (a)(b)(c) Maintain good accounting and procedures Audit report wereand have audited report for each fiscal usually late andyear sent to the Bank a few were not

satisfactory.

Project Agreement SSG's commitment to the project objectives PEC was established2.01 (a)(b)(c)(d) and establishing the PEC, PMU, and the but abolished withoutfour ZHOs prior consultation

with Bank, PMU setup but key staffmissing for someperiod of time,

- 37 -(Page 2 of 2)

Section Covenant Status of Compliance

2 ZHOs upgraded and2 ZHOs constructed.

2.02 (a)(b)(c) SSG to open special account and project Complied.account and ensure payments of itscontribution to the project

2.03 Recruitment consultants/experts/specialists Complied.to assist SSG to carry out Part A

2.04 All procurement to be financed from the Complied.Loan have to be made in accordance withSchedule I of the Agreement

2.05 (a)(b) Insure goods imported and use the goods Complied.and services for the purpose of the Project

2.06 (a)(b) SSG to cause SHP in furnishing the Bank Complied.with all procurement plans, maintainingrecords, monitoring the progress, andproviding information on costs/benefitsconcerning Part A

2.07 SSG to perform all its obligations under Complied.the subsidiary loan agreement

2.08 (a) SSG to exchange views with Bank on Complied.progress and performance of Part A

2.09 SSG agrees that the relend proceeds Complied.be deducted from the Federation Accountand the Borrower pays any such deductiondirectly into project account

2.10 SSG to cause to acquire land and its Complied.rights necessary for executing PartA of the Agreement

3. 01 (a) SSG to cause PMU to maintain all Complied.records on its accounting procedure

3.02 (a)(b) SSG to cause PMU to audit its accounts Complied, butand financial statements and furnish often late.to the Bank not later than six monthsafter each fiscal year.

7 5 * r i } | l [| 6 L t ' e 1 |- --1 -E R- - - - - - i - -

ii Ii I _EI I I I I 1_I*I ; za

I I I I a I

° ° °° EE° o E

I a N &P P I P P I

I - N ~~~~~~~~~~11- --- I

N o o o No

g o | o g , k

*…======== = ==== == ====================== I: …=N *

;_________________-_----_-----------------------

O O O e §_"8

afi Z o ; I N

* o a g a o S Y | 8 i i C

| wo S_ ^ M g * f000 n

i~ ~ ~ ~~~ I !i| O _ | t g -g g 0 9 w~~~~~~~ I s

S I-~~~~~~~~~~~~~~~~~o I I

| O > w s ¢ U ! q o | w a i u U § S b O , E a r

*i o - lii Ii g <S I5I I i * - I U== = = == = = = == = = = = == = = = == = = = = == = = = =

-~~~~~~~~~I 8t

- 39 -

TABLE 7: USE OF BANK RESOURCES

Staff Inputs

Stage of Original Revised ActualProject Cycle Plan Plan Staff Wks

Preparation, Preappraisal - - 53.1

Appraisal - - 38.7

Negotiation - - 18.3

Supervision 89 117.5 182

TOTAL 89 117.5 292.1

- 41 -

(Page 2 of 2)

Stage of Month/ No. of Total PerformanceProject Cycle Year Persons 1/ Staff Wks Ratings

PM2/ OS3/

9/1988 1 HQ 0.4 n.a.

12/1988 2 HQ 1.6 2 2

5,6/1989 4 HQ, 2L, IC 12.0 3 3

11/1989 IL 0.2 n.a.

5,6/1990 2HQ, IL 3.5 3 3

9/1990 IL 0.3 n.a.

11/1990 3 HQ, IL 2.0 3 3

11/1991 3 HQ 2.5 3 3

6/1992 3 HQ, 2L 5.6 no ratings

3/1993 3 HQ 2.5 4 4

Subtotal 31 46.5

TOTAL 44 58.7

Note: 1/ HQ - Headquarters Staff; L - Local Staff, C - Consultant.2/ PM - Project Management.3/ OS - Overall Status.

- 40 -

TABLE 8: MISSION DATA BY STAGES OF PROJECT

(Page 1 of 2)

Stage of Month/ No. of Total PerformanceProject Cycle Year Persons 1/ Staff Wks Ratings

PM2/_OS3/

Preparation - 5/1983 6 HQ 6.0Appraisal

11/1984 2 HQ 0.8 - -

Subtotal 8 6.8

Board Approval - 4/1985 1 HQ, 1L 0.6 -

Effectiveness7/1985 2 HQ, IL 1.2 2 2

11/1985 2HQ, 1L 3.6 1 1

Subtotal 5 5.4

Effectiveness - 4/1986 2 HQ, 1L 3.6 1 1

6/1986 1 HQ 0.4 1 2

7,8/1986 I HQ 3.0 2 2

10/1986 1 HQ, 1L, 1C 3.0 2 2

4/1987 1 HQ, IL 3.0 3 2

7/1987 1 HQ, 1L 1.0 2 2

11/1987 1 HQ 0.1 n.a.

11/1987 2 HQ 0.9 n.a.

6/1988 IC 0.9 n.a.

- 41 -

(Page 2 of 2)

Stage of Month/ No. of Total PerformnanceProject Cycle Year Persons 1/ StaffWks Ratings

PM2/ OS3/

9/1988 1 HQ 0.4 n.a.

12/1988 2 HQ 1.6 2 2

5,6/1989 4 HQ, 2L, IC 12.0 3 3

11/1989 IL 0.2 n.a.

5,6/1990 2HQ, 1L 3.5 3 3

9/1990 IL 0.3 n.a.

11/1990 3 HQ, IL 2.0 3 3

11/1991 3HQ 2.5 3 3

6/1992 3 HQ, 2L 5.6 no ratings

3/1993 3HQ 2.5 4 4

Subtotal 31 46.5

TOTAL 44 58.7

Note: 1/ HQ - Headquwten Staff; L - Local Staff; C - Consultant.2/ PM - Project Management.3/ OS - Overal Status.

Documents

World Bank Documentdocuments.worldbank.org/curated/en/655391468098973705/... · 2016. 8. 29. · SOKOTO HEALTH PROJECT (LOAN 2503-UNI) EVALUATION SUMMARY Introduction 1. Loan 2503-UNI