Docurient of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 15763

IMPLEMENTATION COMPLETION REPORT

DEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA

HEALTH AND FAMILY PLANNINC PROJECT(CREDIT 1903-CE)

JUNE 20, 1996

Population and Human Resources Operations DivisionCountry Department ISouth Asia Regional Office

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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 EQUIVALENTS

Name of Currency Unit = Sri Lanka Rupee (Rs)

Appraisal Year Average $US I = Rs. 30Completion Year Average $US 1 = Rs. 50

WEIGHTS AND MEASURES

I meter (m) = 3.28 feet (ft)I kilometer (kim) = 0.62 miles (mi)

SRI LANKA FISCAL YEAR: JANUARY I-DECEMBER 31

ABBREVIATIONS AND ACRONYMS

AMC - Anti-Malaria CampaignARTI - Agrarian Research and Training CenterDDG - Deputy Director-GeneralDDHS - Divisional Director of Health ServicesGHC - Gramodava (Village) Health CenterHRD - Humani Resources DevelopmentHRIS - Hluman Resources Information SystemIDA - Internationial Development AssociationIEC - Informationi, Education and CommunicationMCH - Maternal-Child HealthMDPU - Managemenit Development and Planning UnitMOII - Ministry ot HealthNGO - Non-Governlmenit OrganizationPHC - Primary Health CarePHM - Public Health MidwifePHN - Population. Health and NutritionPPF - Project Preparation FacilitySAR - Staff Appraisal ReportSDHC - Sub-Divisional Health CenterTFR - Total Fertility RateUNFPA - United Nations Population FundWHO - World Health Organization

FOR OFFICIAL USE ONLY

IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Table of Contents

Pane No.

Preface ..........................................................

Evaluation Summarv ...... ........................................ ii

Part 1: Project Implementation Assessment ...............................

Background ....... ............... .. ........................Statement/Evaluation of Project Objectives ............ .. 1............ Achievement of Project Objectives ...... .................... . 2Implementation Record and Major Factors Affecting the Project .......... . 4Project Sustainability ......................... 9IDA Performance ............................................ 10Borrower Performance ..................... .................... 11Assessment of Outcome ........ ........... .. ................... 12Future Operation ...................... ...................... 12Key Lessons Learned ..................... .................... 13

Part II: Statistical Annexes ........................................... 14

Table 1: Summary of Assessments .......................... ... 15Table 2: Related Bank Credits .............................. ... 17Table 3: Project Timetable .................................. .. 18Table 4: Credit Disbursements: Cumulative Estimated and Actual ........ 19Table 5: Key Indicators for Project Implementation .................. 20Table 6: Key Indicators for Project Operation ...................... 21Table 7 Studies Included in Project .......................... ... 25Table 8A: Project Costs .................................... ... 27Table 8B: Project Financing ................................ ... 27Table 9: Economic Costs and Benefits ................. ... ........ N.A.Table 10: Status of Legal Covenants . .. . .. ............. 28Table 11: Compliance with Operational Manual Statements .............. N.A.Table 12: Bank Resources: Staff Inputs ........................... 29Table 13: Bank Resources: Missions ........................... ... 30

This document has a restricted distribution and may be used by recipients only in the performnance of theirofricial duties. Its contents may not otherwise be disclosed without World Bank authorization. l

Appendixes: A. Post-Project Management Letter .......................... 31B. Borrower's Summary and Evaluation ........... ...... 33C. Cofinancier Contribution to the ICR ....................... N.A.

D. Miscellaneous Appendixes1. Fertility and Family Planning: 1987; 1983 ................ 372. Summary of Technical Assistance for Management .... ...... 383. Summary of the Recommendations of the

Health Strategy and Financing Study .................... 41

Map: IBRD No. IBRD 28020

IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT (CREDIT 1903-CE)

Preface

This is the Implementation Completion Report (ICR) for the Health and FamilyPlanning Project in Sri Lanka. for whichi Credit 1903-CE in the amount of SDR 12.9 (US$17.5million equivalent) million was approved oni July 13, 1988 and made effective on April 4, 1989.

The Credit was closed on September 30, 1995 compared with the original Closing Dateof September 30, 1994. The undisbursed balance of SDR 1,362,535.03 was canceled effectiveFebruary 16, 1996, the date on which the final transaction, a refund of US$467,616.13, took place.

The ICR was prepared by Frances Plunkett, SAIPH, of the South Asia Region andreviewed by Barbara Herz, Chief. SAIPH, and Fakhruddin Ahmed, Project Advisor, SAIDR. TheBorrower provided comments that are included as Appendix B of the ICR.

Preparation of this ICR was begun during the Bank's final supervision mission inOctober 1995. It is based on material in the project file. The Borrower contributed to preparationof the ICR by preparation of a project completion report, a summary of the project completionreport, and comments on a draft of the ICR that have been incorporated into the final report.

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IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Evaluation Summary

Introduction

1. The project was the first project in the Population, Health and Nutrition (PHN) sectorsto be assisted by the International Development Association in Sri Lanka. There were no co-financiers.

Project Objectives

2. Objectives. The Staff Appraisal Report states three project objectives, to (i) strengthenmanagement of the government health system; (ii) increase the efficiency and cost-effectiveness ofthe health logistics system; and (iii) promote lower fertility and improved matemal and child healththrough increased and more effective use of contraception. These objectives were to be achievedthrough three major components: Health Management Improvement, Logistics, and FamilyPlanning. Additionally, in support of service delivery objectives, three special programs, to reducethe prevalence of malnutrition, malaria, and gastro-intestinal infections, were assisted. Theseobjectives reflected Bank health sector priorities for Sri Lanka and were consistent with the Bank'scountry assistance strategy. However, the effort to cover such a broad range of management, policyand service delivery objectives resulted in a complex project whose objectives were inconsistentwith the priorities of the implementing Ministrv of Health, which focused on service delivery.

3. Achievement of Obiectives Project service delivery objectives (objective (iii), a partof objective (i) and the special programs) were generally achieved; management and policyachievements (objectives (i) and (ii)) were limited. Under the Health Management Improvementcomponent. a Management Development & Planning Unit (MDPU) established in the Ministry ofHealth (MOH) contributed to strengthened management of the health system, particularly in theareas of prospective planning and management training. A Health Strategy and Financing Studywas completed and provided important inputs for a follow-on project. In three divisional (sub-district) areas, strengthening of primary health care infrastructure was linked with improvedmatemal-child health coverage and increased use of modem contraceptives. For Family Planning.survey data for 1987 and 1993 indicate an increase in contraceptive prevalence from 61.7% to66.1% and a corresponding decline in the total fertility rate from 2.8 to 2.3, suggesting thatreplacement fertility of approximately 2.1 will be achieved well before the government's target dateof 2005. Use of temporary contraceptive methods rose by 5.7 points. Under Special Programs. themalaria progran achieved substantial reductions in numbers of detected cases in four high-prevalence districts. The gastro-intestinal diseases program was effective in improving knowledgeand practice related to their prevention. However, neither human resources, financial, nor logistics

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management objectives were achieved. A pilot for a nutrition program achieved no significantimpact and was canceled.

Implementation Experience and Results

4. Major Factors Affecting the Proiect. Civil conflict in many parts of the Island in 1988-90 disrupted public institutions, including medical facilities and training institutions, some of whichwere closed for varying periods. Consequent training and staffing delays were resolved, however,by project-end. Additionally, the long-standing civil conflict in the northem and eastern regionscontinued through the entire project. Although there was little direct impact on projectimplementation outside the affected areas, there was a major decentralization of governmentalauthority, including the health services, to the provinces in 1989. In consequence, a long overduereorganization of primary health care was carried out, and project support was adapted to the newsystem. However desirable in principle, the changes in what had previously been a highlycentralized system created confusion and uncertainty, and their administrative and financialimplications are still being worked out. The provision of health services appears to have beenmaintained adequately.

5. Implementation Record. The project was planned as a five-year operation. It becameeffective in April 1989 and was implemented by the Ministry of Health. Prior to the mid-termreview (December 1992), project management was poor and there were major implementationdifficulties; however, following a subsequent mutually agreed revision of the project that eliminatedmost management improvement activities and expanded service delivery support, and a change inproject management, implementation improved dramatically. The project was never formallyrestructured, although almost 40% of the credit was canceled in 1994. A one-year extension of theCredit Closing Date, to September 30, 1995, permitted achievement of many of the project'sphysical targets. In local currency terms, project expenditures were about 94% of the originalestimate.

6. The Health Manaaement Improvement component was not fully implemented. Neitherpersonnel nor financial management in MOH was reorganized, the data base for a Human ResourcesInfonnation System (HRIS) was not completed. and delayed completion of a Health Strategy andFinancing Study prevented policy-related follow up. However, the MDPU was established andcontributed to strengthened management of the health system through management training andprospective planning activities. Technical assistance tasks in support of improved management werelargely completed, but utilization was limited. Civil works and training activities of the servicedelivery subcomponent to strengthen primary health care in three selected divisional (sub-district)areas were completed and achieved their goals. Under the Logistics component drug stores andvehicle maintenance facilities were constructed, but a unified management system was notaccomplished. The Family Planning component successfully implemented a package ofinfrastructure, training and communications inputs. Of the three Special Programs the introductionof a revised malaria control strategy achieved substantial results. The gastro-intestinal diseasesprogram combined training of health staff and community members supported by a communicationsprograrn to improve prevention and treatment of these diseases. However. a pilot for a nutritionprogram achieved no significant impact and was cancelled.

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7. Sustainabilitv. Sustainability of project investments should be assessed in the contextof public health services in Sri Lanka, which have achieved impressive results and have beenconsidered a priority by successive governments. One indication of government commitment is thatincremental recurrent costs, with the exception of those for the special programs, were borne byGovernment throughout the project. The unanticipated provincialization of the health services,which gave the provincial governments responsibility for staffing and maintenance of most of thefacilities constructed with project assistance, has given rise to questions about the sustainability ofthe decentralized health services generally. The provincial governments are known to operate underserious resource constraints, and in particular maintenance of small facilities in scattered areas islikely to be a problem. Nevertheless, since provincialization the health system has continued toprovide the good quality health services for which Sri Lanka is well known and, given theimportance of these services in Sri Lanka, can be expected to continue to do so.

8. IDA Performance. IDA played an active role in project preparation, includingprovision of a project preparation facility which supported national consultancies and subsequent fordevelopment of project components. It is difficult to justify the complex management-orientedproject recommended by the appraisal mission, given the known risk of relying on the Ministry ofHealth to implement management reforms. After effectiveness the project foundered on lack of"ownership" by the implementing MOH and the management aspects were largely unimplemented.Given the risks, it would have been more realistic to have limited the number of reform activitiesrather than attempt to accomplish such a complex reform package in a single project. An IDAeffort to develop a pilot Nutrition program despite lack of Ministry support also failed. Particularlyin the first half of the project, IDA supervision was technically strong, with good continuity.However, while management letters in the early stages reflected IDA's concem about poorimplementation, no concrete actions were taken prior to the mid-term review.

9. Borrower Performance. Borrower performance during project preparation and the firsthalf of the project was poor, including failure of the Ministries of Finance and Health to coordinatetheir approaches, lack of commitment to the project by the implementing Health Ministry, andseriously deficient project management. Relations between the project coordinator and many MOHofficers were strained, and there were major delays in procurement of equipment, furmiture, suppliesand utilities. However, MOH organized a thorough mid-term review and took steps to ensureimprovements in the light of an extremely critical report. IDA and MOH jointly revised the project,eliminating unrealistic management objectives and expanding service delivery support. Additionally,a new project coordinator was appointed, and implementation improved dramatically. MOH alsoprepared a very useful project completion report.

10. Management of project accounts and submission of disbursement applications weresatisfactory. However, procurement activities suffered from lack of adequate understanding byproject staff conceming IDA procurement requirements and procedures. The Borrower was not incompliance with covenants relating to staffing for most of the project, but when the Credit closedonly two covenants relating to health financing and policy remained unmet. These areas areexpected to be covered in a follow-on project.

11. Assessment of Rroiect outcome. This project is difficult to categorize as generally"satisfactory" or "unsatisfactory" because its results were so mixed. The original complex projectquickly proved to be unrealistic and unimplementable, although after a mid-term revision

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implementation was excellent. Despite the many handicaps, the project accomplished significantservice delivery, institutional development, and research goals. However, important aspects ofproject appraisal, implementation and supervision were clearly unsatisfactory. Given theseproblems, as well as failure to achieve many of the project's objectives. on balance the project israted "unsatisfactory."

Summary of Findings, Future Operations, and Key Lessons Learned

12. Future Operation. An IDA mission in October 1995 discussed with Govemmentproject sustainabilitv issues and continuation of project-supported activities. Project-supportedprimary health care and family planning service delivery and IEC activities were implemented aspart of ongoing programs and will continue to be supported, as will management training ofDivisional Directors of Health Services. Government is aware of operational and maintenanceissues arising from provincialization of the health services: however, Govermment is consideringadditional decentralization measures and provision for support of operation and maintenanceresponsibilities is not yet clear. The proposed follow-on Health Services Project, which is expectedto become effective in the second half of 1996, would continue support to the Anti-MalariaCampaign, the MDPU, and the HRIS and would begin the effort to address health policy andfinancing issues incorporating the recommendations of the Health Policy and Financing Study.

13. Findings and Kev Lessons Learned. The key lessons to be learned from projectexperience relate to the importance of "ownership" by the implementing ministry. Failure by IDAto take adequate account of the priorities of the implementing ministry and to ensure that seniormanagers in the ministry understood and supported project assistance strategies seriouslycompromised implementation, a situation that was exacerbated by the complexity of the project.Additionally, the importance of effective project management and the need for greater familiarity byproject staff with IDA procurement guidelines and procedures were apparent. The frank mid-termassessment of project status carried out by the implementing ministry provided a framework forrevision of the project that facilitated successful implementation in the project's second half Theselessons were carefully taken into account in the design and development of the follow-on project aswell as orientation of project staff.

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IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH & FAMILY PLANNING PROJECT(Credit 1903-CE)

Project Identity

Name: Health & Family Planning ProjectCredit: 1903-CERVP Unit: South AsiaCountry: Sri LankaSector: Population, Health & Nutrition

Background

1. The Health & Family Planning Project was the first project in the Population, Health andNutrition (PHN) sectors in Sri Lanka to be assisted by the International Development Association(IDA). There were no co-financiers.

Statement/Evaluation of Project Objectives

2. The Staff Appraisal Report states three project objectives: to (i) strengthen management ofthe government health system; (ii) increase the efficiency and cost-effectiveness of the health logisticssystem; and (iii) promote lower fertility and improved maternal and child health through increasedand more effective use of contraception. Management objectives included improvements in the areasof human resources management, financial management, planning capacity and service delivery, aswell as a major health strategy and financing study to provide the basis for identification of neededhealth policy and financing initiatives. Additionally, in support of service delivery objectives, threespecial programs, to reduce the prevalence of malnutrition. malaria and gastro-intestinal infections,were assisted.

3. Project objectives reflected Bank health sector priorities for Sri Lanka, which are consistentwith the Bank's country assistance strategy: to sustain and improve the health services, which haveachieved excellent results in terms of demographic and mortality indicators but face a shift in diseasepatterns from communicable to non-communicable diseases as the population ages; and to address keyhealth policy and financing issues concerning the efficiency and effectiveness of public services andthe role of the private sector in circumstances of increasingly constrained resources. However, theeffort to cover all of the objectives noted above resulted in a complex project, and the emphasis onmanagement improvements and policy changes proved to be inconsistent with the priorities of theimplementing ministry, which focused on service delivery. In the early part of the project it becameclear that most of the project's management objectives were unrealistic and unimplementable.

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Achievement of Project Objectives

Summary of Project Implementation and Achievements

1. Health Management ImprovementHuman Resources Management reorganization and reorientation of existing

DDG (Admin) unit not implemented; data basefor a Human Resources Information Systempartially established

Financial Management & not implemented; canceledBudget Control

Management Development & established; in-service management trainingPlanning Unit and prospective planning supported

Health Sector Policy Development delayed completion of study deferredutilization of findings to follow-on project

Service Delivery DDHS system and in-service training inselected project districts supported; MCHimprovements achieved

2. Logistics unified system not implementedDrug & Supplies Management implementation limited to civil works

Vehicle & Equipment Maintenance implementation limited to civil works

3. Family Planning improvement of services and fertility reductionobjectives achieved

Special ProgramsNutrition canceled after unsuccessful

implementation

Malaria implementation of revised malaria controlstrategy in four high-prevalence districtssupported; significant reduction in number ofcases achieved

Gastro-intestinal infections improvement in related knowledge and practicein selected project districts achieved

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4. Project achievements are summarized in the table above. Consistent with the priorities of theimplementing Ministry of Health, project service delivery objectives (the service deliverysubcomponent of component 1, component 3, and the special programs in the table above) weregenerally achieved, with the notable exception of the special program for nutrition: management andpolicy objectives (components I and 2 in the table above) were not. The following paragraphs reviewthe achievements of the individual components and subcomponents.

5. Health Management Improvement. A Management Development & Planning Unit (MDPU)established under a new Deputy Director General Planning in the Ministry of Health contributed tostrengthened management of the health system, particularly in the areas of in-service managementtraining and prospective planning (para. 21).

6. A planned Health Strategy and Financing Study was completed. However, since results werenot available until almost the end of the project, health sector policy development linked to studyresults was deferred to a follow-on project (para. 23).

7. In three divisional (sub-district) areas, strengthening of primary health care infrastructure wasclearly linked with improved maternal-child health (MCH) coverage, including increases in earlyregistration of pregnant women, post-natal visits, use of modern contraceptives methods, anddecreases in deliveries by untrained persons (para. 24). A baseline survey was carried out too late inthe project to provide a basis for impact assessment.

8. Neither reorganization and reorientation of the Health Ministry's unit for personnelmanagement nor reorganization and rationalization of financial management and budget control in theMinistry was achieved. Implementation of a Human Resources Information System was begun, butthe system was not yet functioning when the project ended (paras. 18-20).

9. Logistics. Completion of planned civil works supported drug and supplies management aswell as vehicle and equipment maintenance activities. However, a unified system intended to achieveimprovements in the effectiveness and efficiency of the Ministry's logistics arrangements was notimplemented (paras. 26-28).

10. Family Planning. Survey data for 1987 and 1993 (Appendix D. 1) indicate an increase incontraceptive prevalence (the proportion of couples with wife of reproductive age practicingcontraception) from 61.7 % to 66.1 %, and a corresponding decline in the total fertility rate, from 2.8to 2.3. These data suggest that replacement fertility of approximately 2.1 will be achieved wellbefore the Government's target date of 2005. Overall prevalence of modern contraception increasedby 3.1 percentage points, from 40.6% to 43.7%; sterilization fell by 2.6 points but use of temporarycontraceptive methods, a specific project objective, rose by 5.7 points. It is reasonable to concludethat major project support for the family planning program contributed significantly to the increase incontraceptive prevalence and therefore to fertility decline (para. 29).

11. Special Programs. The malaria project supported a revised WHO malaria control strategy infour high-prevalence districts that achieved substantial reductions in the numbers of detected casesfollowing its introduction in 1993. Over the period 1993-95, the number of detected cases in the fourdistricts declined to between one fourth and one third of previous levels. While it is probable thatweather conditions and the natural malaria cycle played a part in these reductions, the revised malaria

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control program was considered to be the major factor responsible (para. 32). Pre- and post-intervention surveys indicated that the gastro-intestinal diseases program was effective in improvingknowledge and practice related to prevention of these diseases (para. 33). However. lack of abaseline precluded an epidemiological assessment. A pilot for a nutrition program achieved nosignificant impact and was canceled (para. 31).

Implementation Record and Major Factors Affecting the Project

12. At the time the project was appraised in 1987, two ministries were responsible for the healthsector, the Ministry of Health and the Ministry of Women's Affairs & Teaching Hospitals, while thePopulation Division of the Ministry of Plan Implementation was the focal point for most populationactivities. In 1990, the two health ministries were combined and the Population Division was shiftedto the Ministry of Health. The reconstituted ministry was known as the Ministry of Health &Women's Affairs. After a change of government in 1994, the Ministry of Health was reorganized asthe Ministry of Health, Highways and Social Services. /

13. Project development began with discussions among IDA and the ministries concerned with thehealth and population sectors, including the Ministry of Finance. A number of key managementissues considered essential to expansion of the capacities of the then health ministries as well asaspects of the health services requiring operational support were identified. Local consultancies todevelop proposals in these areas were funded through a project preparation facility. Workshopscovering the major topics were held; participants included a wide range of stake holders from themedical profession and academic and research institutions as well as Government. The project thatemerged, with the apparent support of the major stake holders, was complex and ambitious. Inaddition to support for family planning and primary health care programs, it called for majorinnovations in the health ministries: reorganization and reorientation of personnel functions (humanresources management); revamping of financial management and budget control; creation of a newDDG unit for the unfamiliar areas of health planning and management; a major health strategy andfinancing study leading to initiatives in controversial areas of health policy: and development of aunified logistics system dealing with the always contentious area of pharmaceuticals.

14. The project was planned as a five-year project. It became effective in April 1989,approximately 11 months after approval by the Board and 18 months after appraisal. After 1990 itwas implemented solely by the Ministry of Health (MOH). Prior to the mid-term review carried outin December 1992, there were major implementation difficulties, and the project was listed as aproblem project. After the mid-term review, an effective project coordinator was appointed and theproject was revised by mutual agreement between IDA and the Ministry of Health: the managementand policy activities were largely eliminated or deferred and the service delivery activities expanded.Project management and implementation improved dramatically. The project was never formallyrestructured, although almost 40% of the credit was canceled in 1994. A one-year extension of theCredit Closing Date, to September 30, 1995, permitted achievement of many of the project's physicaltargets. In local currency terms, actual project expenditures were about 94% of the original estimatedtotal project cost (Table 8A). Project expenditures reflected the mid-term revision: expenditures on

1/ For convenience, the "Ministry of Health" is referred to throughout.

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civil works and goods were 82% and 26% higher than original estimates, respectively, while othercategories were lower (Table 8A).

15. Several factors affected project implementation at the outset. First, rivalry between the twohealth ministries complicated initial implementation and increased the resistance of the Ministry ofHealth to management improvements. Second, civil conflict in many parts of the Island in 1988-90disrupted public institutions, including medical facilities, some of which were closed for varyingperiods. Training of doctors and other medical staff was interrupted, which delayed staffing ofmedical facilities supported by the project. This difficulty was resolved by the time the project ended.

16. Third, the long-standing civil conflict in the northern and eastern regions of Sri Lankacontinued throughout the entire project period, making implementation of activities in these areasimpossible, although there was little direct effect on the project otherwise. However, in response tocivil and ethnic conflict, there was a major decentralization of governmental authority to the provincesin 1989, which included the health services, and further decentralization to the divisional level wasintroduced in 1993. As part of provincialization, a long overdue reorganization of primary healthcare was carried out. Project support for delivery of primary health care in three project areas wasadapted to the new system (paras. 24-25). However desirable in principle, the changes in what hadpreviously been a highly centralized system created confusion and uncertainty, and theiradministrative and financial implications are still being worked out. The provision of health servicesappears to have been maintained adequately, and several examples of encouraging local and provincialinitiatives can be cited.

17. The project's implementation experience reflected the priorities and strengths of theimplementing Ministry of Health. Those components and subcomponents concerned with servicedelivery--family planning, primary health care, malaria, gastro-intestinal infections--were by and largesuccessfully implemented. However, as noted above, with the major exception of the ManagementPlanning & Development Unit (para. 21), the Ministry of Health never implemented the managementaspects of the project. The following paragraphs summarize the implementation record of theindividual project components and subcomponents.

18. Health Manazement Improvement - Human Resource Development. The project called forthe creation of a human resources development (HRD) unit in the Ministry of Health throughreorientation of the existing unit under the Deputy Director General (Admin), to be redesignatedDDG (HRD), and the incorporation of all HRD functions carried out in the Ministry into the HRDunit. The reorientation did not take place, agreed incremental staff was not recruited, and the unitcontinued to do traditional establishment work. Of seven proposed studies, only two with a directbearing on establishment matters were carried out (Table 7).

19. The development of a computerized Human Resources Information system (HRIS) wasundertaken to improve personnel records, procedures, and management. With consultant assistance,considerable progress was made in designing the system, obtaining data from health facilities, andestablishing a database. However, at the end of the project the data base for the system had not beencompleted and provision of additional data required from central and provincial facilities wasuncertain. HRIS was as not functioning as a system and will not become sustainable unless input andupdating of records are linked to a larger human resources development effort and specifically to

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promotions and transfers. The post of Director (HRIS) was created only late in the project and byproject-end had not been filled.

20. Health Management Improvement - Financial & Budgetarv Control. The objective of thissubcomponent was to strengthen health management at central and peripheral levels by designing andimplementing financial management and budget control systems and streamlining operationalprocedures. The systems were to cover budgeting, resource allocation, financial and managementaccounting, and evaluation of financial performance as related to program outputs. Nothing was doneto implement these activities: agreed incremental staff was not appointed, no in-service training wasdone, and no consultant services tor the design of new systems were utilized. The mid-term reviewmission therefore recommended that the sub-component be canceled.

21. Health Management Improvement - Management and Planning. The project supported thecreation of a Management Development and Planning Unit (MDPU) in the Ministry of Health headedby a Deputy Director General Planning and staffed by four Directors for planning, managementtraining, organizational development and management information. Although all director posts wereinitially staffed, due to subsequent turnover at no time during the project were all of them filled. Theconcept of management development was new to the Ministry and was not understood by some ofthose staffing the MDPU, let alone the rest of the Ministry. Only about half of agreed supporting andadministrative positions were filled, and information systems development was not undertaken.Nevertheless, by project-end the MDPU was functioning. Available study tours and trainingprograms for staff were utilized. The MDPU carried out a number of planned activities, including in-service management training for DDHSs and other health staff (Table 6), needs assessment andcurriculum development for nursing officers, a ten-year Perspective Plan for Health, annualdevelopment plans for the Ministry, and other studies (Table 7). Given the well-known difficulties ofestablishing new institutional units as well as the staffing difficulties encountered, theaccomplishments of the MDPU were considerable. Measures to expand understanding of the role andfunction of the MDPU in the Ministry would have helped the Unit to become better established. Aconsultant report on the organization and functioning of the Unit was completed in 1994 but notutilized.

22. Health Management Improvement - Technical Assistance. The project supported a majorinternational technical assistance consultancy for management support covering financial andadministrative manuals, HRIS, a health planning data base, hospital management, health managementtraining, staffing and organization of the MDPU, and health manpower requirements; total cost wasUS$1.0 million. The consultancy tasks were linked to the management improvement components, sothat although most expected activities and products were completed (Appendix D.2), effectiveness wasuneven. In those cases where there was genuine interest on the part of MOH (e.g. hospitalmanagement, health management training), accomplishments were substantial. Where Ministrycommitment was lacking, however, utilization and follow up are uncertain or unlikely (e.g. HRIS,health manpower analysis). In the case of administrative manuals, it became clear that detailedknowledge of existing procedures was required and the task was turned over to national consultants.The limited impact of the technical assistance was a reflection of the lack of commitment on the partof MOH which constrained implementation of the management improvement component generally. Inretrospect, given the outlook of the Ministry and the project implementation difficulties which becameevident early in the project, IDA approval of an expensive, multi-task international technicalassistance contract seems questionable. A more carefully focused approach, taking account of MOH

capacities and utilizing national expertise wherever possible, would have been less costly and probablymore effective.

23. Health Management Improvement - Health Sector Policy Development. This sub-componentsupported a Health Strategy and Financing Study whose objectives were to: (i) compile acomprehensive data base on availability of health services, including utilization and costs, (ii) analyzethe causes of current problems of the health care system, including health care financing; and(iii) examine various policy options in terms of improving efficiency and equity of services. Thestudy was to be prepared by an expert consultant and completed by 1992, agreed recommendationswere to be implemented by the Ministry, and the findings were to provide the basis for further healthpolicy research. In fact, the study did not begin until 1992 and was completed in 1995, near the endof the project. Total cost was approximately $500,000. A workshop to review preliminary resultswas held in June 1994. Although a subsequent workshop planned to discuss the results andrecommendations of the final report never took place, study findings were utilized in the preparationof the health policy component of the follow-on project (para. 47). The study's recommendations aresummarized in Appendix D.3.

24. Health Management Improvement - Service Delivery. The goals of the service delivery sub-component of the management component were to strengthen the primary health care (PHC)infrastructure and to provide in-service training. The project supported a PHC model previouslyadopted by Government which called for a three-tiered structure of village health centers (GHCs),subdivisional health centers (SDHCs) and divisional health centers (DHCs). After the health serviceswere decentralized in 1989 and reorganized on a divisional basis under the newly created post ofDivisional Director of Health Services (DDHS), project support was adapted to the new system andinfrastructure was strengthened in a pilot division in each of three project districts. By the time of themid-term review, about 80% of planned works had been completed and all vehicles had beenprocured. Following the mid-term review, it was agreed that the project would further support thenew DDHS system through assistance for DDHS offices and quarters as well as mini-labs andemergency treatment units in peripheral hospitals in the project districts, and additional assistancealong these lines was included in the extension year. Once the provincial health services were fairlywell established, responsibility for implementing the service delivery aspects of the project,particularly civil works, was given to the provincial health departments, with the project coordinatormonitoring provincial activities through regular field visits and review meetings. This approachprovided good results.

25. Although delays in provision of equipment, furniture, electricity and water, and inappointment of sufficient numbers of staff, were experienced, the position by the end of the projectwas satisfactory. It was observed that virtually all GHCs, which combine living quarters and clinicspace, were occupied by the public health midwives (PHMs) for whom they were intended and thatlocal residence by PHMs significantly expanded the scope of their activities, especially householdvisits and provision of MCH services. Increases in early registration of pregnant women, post-natalvisits, use of modern contraceptive methods, and decreases in deliveries by untrained personnel wereall noted. However, the subdivisional centers appeared to be underutilized. In-service trainingprograms were carried out, including management training for DDHSs and team training of staffresponsible for preventive and curative services (Table 6), although in two of the three districts theteam training was done only in the final year of the project. The only part of the DDHS package thatwas not implemented was the development of information systems to support local-level planning.

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26. Logistics. The logistics component was intended to support improvements in two areas:drugs and supplies management, and vehicle and equipment maintenance and repair. Implementationof the component was unsatisfactory. The mid-term review recommended cancellation of thecomponent; however, Government took measures to ensure that the remaining civil works werecompleted (Table 6).

27. Civil works for the storage and accommodation of drugs were largely completed within twoyears of the start of the project, and vehicles were procured. However, completed buildings couldnot be made operational for periods ranging from six months to two years because of delays in theprocurement of equipment and supplies. While the additional storage space for drugs and suppliesundoubtedly eased previous storage problems, the drugs stores are reported to have been poorlydesigned and in need of modifications. Garages and service bays for repair of vehicles were alsoconstructed. The garages are now the responsibility of the provincial governments; two of them arefunctional, but the provincial councils must allocate resources for staff before the other seven becomeoperational. Since it appears to be difficult for the provincial governments to operate these facilities,the provincial health departments should consider leasing them to the private sector and obtainingneeded repair services on a contract basis.

28. The project contributed to the completion of a study of regional morbidity patterns to obtainbetter data on drug needs for primary health care, and lists of essential drugs were prepared andpublished. With this exception, however, the technical and management aspects of the componentwere almost entirely neglected. The underlying objective of the component was the development of aunified logistics system, and tO this end provision for technical assistance, staff, and equipment for acomputerized system was made. This assistance went virtually unutilized. Only a preliminaryinvestigation was undertaken, and planned technical assistance in specialized areas (equipmentmaintenance, pharmaceutical logistics and clinical pharmacology), as well as associated baselinestudies, were not carried out.

29. Family Planning. At the time of the mid-term review, the family planning component was theone component of the project that had made good progress. As planned, population strategy wasdeveloped in a series of workshops, and a Demographic & Health Survey comparable to an earliersurvey in 1987 was conducted (Appendix D. 1). Service delivery was strengthened through renovationof family planning clinics and improvement of sterilization facilities; in addition, traditional(ayurvedic) practitioners were trained. Information. Education and Communication (IEC) strategieswere developed as part of the population strategy workshops. Communication capacities werestrengthened through republication of existing effective family planning materials, development ofnew materials, and training of government and NGO staff in communication methods. Mass mediaefforts for family planning were also carried out. A program to train family planning volunteers inthe Mahaveli area was canceled when a survey indicated that family planning knowledge and practicein the area was satisfactory and replaced by programs to improve the family planning counselingskills of staff nurses and to train auxiliary health workers for two high-fertility districts. Funds weremade available to the Family Planning Association of Sri Lanka and the Sri Lanka Association forVoluntary Surgical Contraception for the training of health auxiliaries and nursing officers of basehospitals in family planning counseling. The effective implementation of the project-assisted packageof support for the family planning program, including infrastructure, training, and IEC, can beconsidered one of the factors responsible for the continued decline of fertility in Sri Lanka.

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30. Special Programs. Provision was made for special programs to address major causes ofmorbidity in three project districts. The programs were to be identified on the basis ofepidemiological analysis carried out in the first year of the project. However, this was not done, andmalaria, gastro-intestinal infections, and malnutrition were selected as the problems to be addressedon the basis of existing information.

31. The first special program developed was a pilot nutrition program incorporating on-sitesupplemental feeding for pregnant and lactating women and malnourished children ages 6-35 months.The program had difficulties from the outset. The area selected for the pilot lacked a medical officerand a public health nurse in post, and 6 or 11 public health midwife posts were vacant. A plannedbaseline survey was not carried out. Since the Family Health Bureau did not have an appropriateofficer, responsibility for the program was contracted to the Agrarian Research and Training Institute(ARTI). About 120 volunteers were trained and some 60 feeding centers were opened. However,the intended approach, a community-based program incorporating growth promotion, supplementaryfeeding and communication to effect behavioral change, was not fully understood or implemented.Local health staff were not involved in planning the program and relations between them and ARTIprogram staff were not good. A core technical group to support skills training, supervisory andmonitoring systems and beneficiary assessment never developed. The mid-term review missiontherefore recommended that the program be canceled.

32. Assistance for malaria control was used to support the introduction of the revised WHOmalaria control strategy adopted in 1993 to improve the technical capacity and effectiveness of theAnti-Malaria Campaign of the Health Ministry after resurgences of malaria in 1987 and again in1991. The revised strategy emphasized early diagnosis and prompt treatment, using mobile clinics inhigh-prevalence areas, and sustainable control measures including selective (rather than blanket)spraying for vector control, introduction of additional insecticides in order to prevent development ofresistance through rotation, and use of insecticide-impregnated bed nets. Support for the revisedstrategy was begun in two high-prevalence districts in 1993 and extended to two additional high-prevalence districts in 1994. Effective implementation resulted in substantial improvements in casedetection and treatment through mobile clinics, good acceptance and use of impregnated bed nets, anda major reduction in the amount of insecticide used for house spraying. The introduction of therevised strategy is credited with a significant role in recent declines in the prevalence of malaria.

33. On the basis of a study which indicated substantial lack of information and/or misinformationabout the causes and prevention of yastro-intestinal infections, a educational program was undertakenthat included public health inspectors, medical officers, school teachers and children, and foodhandlers (Table 6). IEC equipment was provided to health facilities. Survey evidence indicated thatthe program was able to improve knowledge and practice related to prevention of these diseases,although an epidemiological assessment was not possible because of lack of a baseline. However, theprogram seems to have been planned without any links to basic sanitation and water supply efforts,which probably limited its potential effectiveness.

Project Sustainability

34. In the context of the public health services in Sri Lanka, which have achieved impressiveresults and have been considered a priority by successive governments, project investments can bejudged as likely to be sustainable. One indication of government commitment is that incremental

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recurrent costs, with the exception of those for the special programs, were borne by Governmentthroughout the project. Of the special programs, only the malaria program involved modest post-project incremental costs, which will be further reduced by the end of the follow-on project, whenthey can be expected to be absorbed by the program. By the end of the project, the ManagementDevelopment and Planning Unit, the only major project investment in institutional development, wasfunctioning and appeared to be well on the way to institutionalization; its further development will besupported by the follow-on project. Implementation of the Human Resources Information System wasincomplete, but since it will also be supported by the follow-on project its ultimate sustainability willnot be tested for some time (para. 47).

35. The unanticipated provincialization of the health services, which among other consequencesgave the provincial governments responsibility for staffing and maintenance of most of the facilitiesconstructed with project assistance, has given rise to questions about the sustainability of thedecentralized health services generally. The provincial governments are known to operate underserious resource constraints, and in particular maintenance of small facilities in scattered areas islikely to be a problem. Nevertheless, since provincialization the health system has continued toprovide the good quality health services for which Sri Lanka is well known and, given the importanceof these services in the country, can be expected to continue to do so. The provincial governmentsare now responsible for staffing the vehicle repair and maintenance facilities that have beenconstructed with project support but have not yet done so in seven of nine cases. Since it appears tobe difficult for the provincial governments to operate these facilities, the provincial health departmentsneed to consider alternatives for obtaining vehicle repair services (para. 27).

IDA Performance

36. IDA played an active role in proiect development and preparation, including provision of aproject preparation facility which supported national consultancies and subsequent workshops fordevelopment of project components. What emerged was a complex and ambitious project, themanagement aspects of which went largely unimplemented. It is difficult to justify the complexproject recommended by the appraisal mission, which was technically strong but took inadequateaccount of the known risk of relying on the Ministry of Health to implement management reforms--lack of commitment to management reform is one of the project risks mentioned in the SAR. Inretrospect, IDA's conscientious effort to involve a broad group of stake holders in projectdevelopment did not suffice to guarantee effective ownership. In the event, it was the views of asmall group of key managers in the Ministry of Health whose views and priorities proved to becrucial. It would have been more realistic had the project design reduced the implementation risk bylimiting the number of reform activities rather than attempting to accomplish such a complex reformpackage in a single project.

37. IDA's failure to take adequate account of the views of the Ministry of Health was the majorcause of the unsuccessful effort to implement a pilot nutrition program. IDA carried out Nutritionsector work and made the development of a special nutrition program a priority early in the project.However, since the Ministry clearly did not welcome the effort and did not support it in the field, itssubsequent failure was predictable.

38. In some respects, IDA supervision of the project was effective. Particularly in the first halfof the project, supervision was technically strong, and three members of the project preparation team

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also participated in the mid-term review mission, thereby providing substantial continuity. The mid-term review mission utilized the recommendations of the review to reach agreement with Governmenton a revision of the project that identified what could realistically be accomplished in the remainder ofthe project, thus providing the basis for successful completion of the project.

39. However, early supervision of the project did not deal effectively with emerging difficulties;while management letters reflected IDA's concerns, no concrete steps were taken. When it becameapparent in the early stages that project management was unsatisfactory and that implementation ofmanagement reforms was unlikely, it would have been appropriate for IDA to have made a specialassessment of the situation and discussed the options, including restructuring of the project andcancellation of some or all of the project, with Government. In view of IDA's failure to addressimplementation issues in the first half of the project, the supervision record must be judged less thansatisfactory.

Borrower Performance

40. The Ministry of Finance and both of the then Health Ministries played major roles in projectdevelopment and preparation, and the standard of Borrower technical preparation was excellent.However, the priorities of the ministries involved proved to be quite different. The Ministry ofFinance supported the inclusion of major management reforms and a health policy study in theproject. After the project became effective, it became apparent that the Ministry of Health was notactually prepared to support implementation of management innovations and reforms and that therewas little interest, in some cases hostility, among senior managers in the Ministry. As a result, themanagement aspects of the project suffered from a lack of "ownership" on the part of the Ministryresponsible for their implementation.

41. In the first half of the project, serious project management and implementation difficultieswere experienced. At the beginning of the project, a full-time project coordinator was appointed anda project coordination office was set up. All senior managers in the Health Ministry and otherministries who were involved with project implementation were appointed members of a SteeringCommittee, which was chaired by the Secretary of Health and convened by the project coordinator.Since the Steering Committee was unable to devote detailed attention to project matters, the resultswere not satisfactory. Some senior managers had neither any commitment to the project nor anyunderstanding of its objectives and did not contribute to its progress. Relations between the projectcoordinator and many MOH officers were poor, so that the coordinator was unable to fill the gap.Additionally, there were major delays in procurement of equipment, furniture, supplies and utilities,resulting in corresponding delays in making facilities functional after completion of construction.

42. The Ministry of Health organized a thorough mid-term review of the project carried out by awell-qualified consultant team. The report of the review team was extremely critical of theperformance of the Ministry of Health; the Ministry and IDA jointly revised the project and theMinistry took steps to ensure improvements in project management, which became evident rapidly.Subsequent to the mid-term review, implementation of the revised project was excellent. TheMinistry made a systematic and very useful final review of the project after the credit closed(Appendix B). Thus, the project's implementation record was inconsistent, comprising both effectiveimplementation of service delivery components and almost total failure to implement most

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management reforms, while project management went from deficient in the first half to quitecompetent in the second half of the project.

43. Submission of disbursement applications was satisfactory. However, for the anticipatedfollow-on project, the project unit needs to upgrade its accounting and record-keeping procedures.Procurement activities suffered from lack of adequate understanding by project staff concerning IDAprocurement requirements and procedures. The Borrower was not in compliance with covenantsrelating to staffing until almost the end of the project period, but when the Credit closed only twocovenants relating to health financing and policy remained unmet, due to delayed completion of theHealth Strategy and Financing Study. These areas are expected to be covered in the follow-on project(para. 47).

Assessment of Outcome

44. This project is difficult to categorize as clearly "satisfactory" or "unsatisfactory" because itsresults were so mixed. Important aspects of project appraisal, implementation and supervision wereclearly unsatisfactory. The IDA appraisal mission did not take adequate account of known risks andrecommended an overly complex management-oriented project; subsequently, IDA did not take actionwhen the project quickly proved impossible to implement in its original form. For their part, theBorrower's policy and implementing ministries involved did not coordinate their approaches, with theresult that the implementing ministry did not take "ownership" of major aspects of the project.Additionally, project management in the first half of the project was deficient.

45. It should be noted that despite the many handicaps, the project accomplished significantservice delivery, institutional development, and research goals. However, given serious problems inall aspects of the project and failure to achieve many of the project's objectives, on balance theproject is rated "unsatisfactory.

Future Operation

46. An IDA mission in October 1995 discussed with Government project sustainability concernsand continuation of project-supported activities (Appendix A). Project-supported primary health careand family planning service delivery and IEC activities were implemented as part of ongoingprograms and will continue to be supported. Management training of DDHSs will be continued.Government gave assurances that needed modifications to the drug storage facilities supported by theproject would be made (para. 27). Government is aware of operational and maintenance issuesarising from provincialization of the health services; however, at the time of writing Government isconsidering additional decentralization measures and provision for support of operational andmaintenance responsibilities is not yet clear.

47. The proposed follow-on Health Services Project, which is expected to become effective in thesecond half of 1996, would continue support to the Anti-Malaria Campaign, the MDPU, and theHRIS and, drawing on the results of the Health Strategy and Financing Study, would begin to addressmajor health policy issues. The revised malaria strategy would be extended to additional high-prevalence districts, and the Anti-Malaria Campaign would undertake important surveillance andresearch activities as well. The MDPU would obtain support for two project objectives that were notachieved: access to health policy and financing expertise, and development of management

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information systems. The HRIS would obtain continued support for data collection and entry andwould have additional time in which to become institutionalized.

Key Lessons Learned

48. The following lessons concerning project design, management and implementation can bedrawn from the project.

a. In project development, failure by IDA to understand fully and take adequate accountof the priorities of the implementing Ministry led to lack of "ownership" of theproject on the part of that Ministry, which seriously compromised implementation(para. 36);

b. In project development, failure by IDA to ensure that senior managers understood andsupported project strategies for assistance to specific programs resulted in consequentfailure to utilize assistance for those programs (para. 36);

c. Project ownership and implementation difficulties were further exacerbated by thecomplexity of the project (para. 36);

d. Lack of effective project management in the early stages of the project was a keyfactor in implementation difficulties (para. 41);

e. Better familiarization of project staff with IDA procurement guidelines and procedureswould have helped to avoid delays in the procurement of equipment, furniture andsupplies (paras. 41; 43);

f. The frank mid-term assessment of project status carried out by the implementingministry played a key role in the mid-term revision of the project that led to greatlyimproved implementation in the latter part of the project (para. 42).

49. These points were carefully taken into account in the design and development of the follow-onHealth Services Project as well as orientation of project staff.

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Part II: Statistical Annexes

- 15 -

IMPLEMIENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT (CREDIT 1903-CE)

Table 1: Summary of Assessments

A. Achievement of obiectives Substantial Partial Nliot avolicable

Macro policies D D D

Sector policies D D DFinancial objectives D D DInstitutional development D D DPhysical objectives D D D

Poverty reduction D

Gender issues D D D

Other social objectives D D DEnvironmental objectives D D DPublic sector rnanagement D D D

Private sector development D D D

Other (specify) I a o n(Continued)

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Table 1: Summary of Assessments (continued)

B. Proiect sustainability Likelv Unlikely Uncertain(T/ (') (/)

HijzIyC. Bank performance satisfactory Satisfactory Deficient

Identification DI0Preparation assistance D DAppraisal D D

Supervision D 0 W

HiszhIvD. Borrower verformance satisfactorE Satisfactorv Deficient

() (* ()

Preparation D DImplementation D D

Covenant compliance D W D

Operation (if applicable) D D D

Hi2bJv Hi ghl vE. Assessment of outcome satisfactory Satisfactorv Unsatisfactorv unsatisfactorv

(T(/) (1 *)

O O. D

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IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Table 2: Related Bank Loans or Credits

Year ofLoan/Credit Title Purpose Approval Status

Poverty Alleviation Project To reorient and expand the 04/1991 Credit underexisting institutional capacity implementationto serve the poor, and to createadditional capacity; to developcredit and other services: toexpand productive wageemployment for the poor; todevelopment programs fornutritional interventions formalnourished children andpregnant mothers; to createpolicy research and programformulation capacity to takegreater account of issues ofpoverty and employment inoverall growth policies andpublic investment projects.

- 1i -

Table 3: Project Timetable

Step in project cycle Date planned Date actual/latestestimate

Identification August 1986 August 1986Preparation Feb. - March 1987 Feb. - March 1987Appraisal September 1987 September 1987Negotiations March 1988 March 1988Board Presentation May 5, 1988 May 31, 1988Signing July 8, 1988 July, 1988Effectiveness September 1988 April 4, 1989Midterm review January 1991 January 1993Project completion June 30, 1994 Sept. 30, 1995Credit closing Sept. 30, 1994 Sept. 30, 1995

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Table 4: Credit Disbursements: Cumulative Estimated and Actual(US$ millions)

FY89 FY90 FY91 FY92 FY93 FY94 FY95 FY96

Appraisal Estimate 2.00 7.10 11.90 14.40 16.30 17.30 17.50 -

Actual 0.20 0.83 1.00 2.23 5.66 7.56 10.56 11.49

Actual as % of Estimate 10% 12% 8% 15% 35% 44% 60% 66%

Date of final disburement 2/16/96

NB: US$4.7 million equivalent was canceled in August 1994.The Credit Closing Date was extended by one year, from September 30, 1994 to September30, 1995.

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Table 5: Key Indicators for Project Implementation

Expected Outcome Achievement

HEALTH MANAGEMENT IMPROVEMENTCOMPONENT

Rationalization of DDG (Admin.) unit in MCH Not accomplished

Rationalization of financial management and Not accomplishedbudget control in MOH

Creation of health planning and management Accomplished through establishment ofcapacity in MOH MDPU

Adoption of policies to improve efficiency and Not accomplishedequity of health system

Rationalization of health facilities and staffing Accomplished outside project throughprovincialization of health services

Expansion and improvement of PHC services in Accomplishedselected districts

Reduction of facility by-passing Not accomplished

LOGISTICS COMPONENT

Establishment of unified system for management Not accomplishedof drugs & supplies and vehicle & equipmentmaintenance

FAMILY PLANNING COMPONENT

Development and implementation of annual Accomplishedstrategies

Improvements in coverage and quality of service Accomplisheddelivery

Improvements in coverage and quality of IEC; Accomplishedinclusion of additional media; strengthening ofstaff interpersonal communication skills

Increase in contraceptive prevalence, especially Accomplisheduse of reversible contraceptive methods

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Table 6: Key Indicators for Project OperationA: Civil Works

Facilities Target Achievement

Service Delivery* DHCs 3 3

* SDHCs 8 8

* GHCs 105 105

* DDHS offices 20 20

. DDHS quarters 19 17

Logistics

. Construction of Divisional 9 9Drug Stores

. Renovation of Divisional Drug 9 9Stores

* Rehabilitation of Main Drug I IStore in Colombo

* Construction of new Drug 5 5Stores in Teaching Hospital

* Construction of Model 3 3Pharmacies with Facilities forRepackaging

* Construction of Garages and 9 9Service Bays

e Construction of Generator 9 '9Rooms

• Upgrading of ME Facilities 2 2

Family Planning

* Upgrading Clinics 250* 225

* Reduced from 750 in 1990.

DHC: Divisional Health CenterSDHC: Subdivisional Health CenterGHC: Gramodaya Health CenterDDHS: Divisional Director of Health ServicesETU: Emergency Treatment UnitME: Maintenance and Engineering Facilities

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B: In-Service Training

Project Component Trainees Number of YearProgram Content Courses

Management Development& Planning Unit

* Management Training Nursing Officers 4 1992-1993

* Management Training Public Health Nursing Sisters 3 1993

* Management Training Personnel of Dept. of Health 1 1992

* Management Training Division Director of Health Services 4 1993

* Training for Health Clerks 3 1992-1993Clerical Service

* Management Training DMOs and M.Os of PUs 2 1992-1993Program

* Health Administration Divisional Directors of Health Services 11 1993-1994and Management

* MSc in Medical Medical Officers 3 1994Administration

e Orientation Program Planning Div. New Recruits 1 1994

- Health Management Trainees in Health Management ITraining

- Medical Rewards Graduate Trainees MOH 1 1995Procedures

- Office Procedures Supervisory and Clerical Staff 1 1995

* Basic Computer MDPU Staff Officers 1 1995Techniques

Galle District

- Curricular Development Provincial Health Officers 2 1994Program

* Management Training PHC Staff Udugama 3 1994

Staff Mahamodera Hospital 14 1994

Clerical Staff Teaching Hospital 2 1994

Hospital Midwives 3 1994

Staff Teaching Hospital 17 1994

Matale District

* Team Training Field Staff 10 1994

* Management Training Nurses and Paramedical Staff 5 1994

Clerical Staff 1 1994

Minor Employees 14 1994

Drivers 2 1994

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Project Component Trainees Number of YearProgram Content Courses

Polonaruwa District* Management Training Nurses and Paramedical Staff 5 1995

Clerical Staff 2 1995

Minor Employees 16 1995* Management Training Field Staff 9 1995

* Interpersonal PHNs (2)* 1995Communication Training SPHMs (4)* 1995

PHIs (31)* 1995PHs (113)* 1995SDTs (8)* 1995Nursing Officers (Institute) (65)* 1995

Clerical Staff (B.H.) (127)* 1995

Para medical Staff (23)* 1995

Minor Staff (538)* 1995

Drivers (31)* 1995

Family Planning

* HEll Health Staff (Workshop) 3 1991-1993Training of Traditional Practitioners 15 1991-1995

27* Facility and Equipment Maintenance Workers 225 1991-1995

Maintenance* Inter Personal Inspectors 123 1991-1995

Communication* Clinic Counseling Staff Nurses (249)* 1991-1995

ProgramAuxiliary Health Workers 138 1991-1995

242Public Health Inspectors 2 1991-1994

Special Programs* Gastro Intestinal Diseases Food Handlers 115 1993-1994

School Programs 115

Training of FDI at Ministry Level I

Training Program for PHI 4

Training Program for MOH 3

Education Programs in Schools 120

* Nutrition Volunteers 4 1990-1991

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External Training Number of Participants

* Personnel Information Sustems; University of Sussex 3

* Curiculum Development for Nurses, University of Conneticut 2

* Management Methods in Health; Boston University 3

* Financial Management in Health; Boston University I

* Setting Tomorrow's Agenda; Seminar on Developing Issues in 2Public Health; Boston University

* Number of Trainees

DDHS: Divisional Director of Health ServicesDMO: District Medical OfficersFDI: Food InspectorsHEB: Health Education BureauITP: Inservice Training ProgramMO: Medical OfficerMOH: Medical Officer of HealthPD: Provincial DirectorPHI: Public Health InspectorPU: Peripheral Unit

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Table 7: Studies Included in the Project

The following studies were carried out with project support.

Human Resource Development

Title: Review of cadre levelsStatus: CompletedImpact: Action by DDG (Admin) pending

Title: Rationalization of recruitment proceduresStatus: CompletedImpact: Action by DDG (Admin) pending

Management Development & Planning Unit (MDPU)

Title: Health Strategy and Financing StudyStatus: Completed by consultant in 1995 after substantial delaysImpact: Delay in completion prevented action on recommendations during project;

recommendations provided basis for policy and financing component of follow-onproject; planned MOH workshop to disseminate and discuss recommendations not held

Title: Guidelines for preparation of capital investment plans to hospital servicesStatus: Completed as part of technical assistance consultancyImpact: Being utilized by Lady Ridgeway Hospital; utilization by other tertiary hospitals

expected

Title: Organization and Function of the MDPUStatus: Completed as part of technical assistance consultancyImpact: Action by DDG (Planning) pending

Service Delivery

Title: PHC Baseline Morbidity SurveysStatus: Carried out in three DDHS areas in 1993.Impact: Delay in implementation prevented use for assessment of project impact

Logistics

Title: Study of regional morbidity patternsStatus: Study carried out to provide basis for estimating PHC drug requirementsImpact: Provided input for revision of essential drug lists

Family Planning

Title: Family planning KAP study among settlers of the Mahaveli System G areaStatus: Carried out in 1990-91 by a private sector organizationImpact: Indicated that levels of family planning knowledge and practice were high enough so

- 26 -

that special assistance to the area was not needed.

Title: Demographic and Health SurveyStatus: Carried out in 1993 by the Dept. of the CensusImpact: Comparisons with comparable data from previous surveys enabled assessment of

changes in key demographic and health indicators

Title: Study of pricing structure of contraceptive and family planning servicesStatus: Carried out in 1992 by a private sector organizationImpact: Results taken under advisement by MOH

Special Programs

Title: KAP study concerning major causes of morbidity (malaria, gastro-intestinal infections,malnutrition) in three project districts

Status: Carried out in 1990 by Health Education BureauImpact: Provided inputs to design of special programs to address these concerns

Title: KAP study concerning gastro-intestinal infectionsStatus: Carried out in 1995 by Health Education BureauImpact: Indicated KAP improvements in this area

- 27 -

Table 8A: Project Costs

Project Costs by Expenditure Category(Rs million)

Category Appraisal Estimate ActualCivil Works 166.51 291.3Vehicles, Furniture, Equipment and Supplies 80.71 163.0Studies and Surveys; Training; Fellowships and 123.3 127.7

Workshops; Consultant ServicesFamily Planning Grants to NGOs; Special I 106.8. 12.5

Service Delivery ProgramsIEC Material Production and Dissemination 57.0Incremental Operation Cost 96.6 6.2Project Management* 3.0 4.0Project Preparation Facility 7.8Total 641.7, 604.7

Project Costs by Component(Rs million)

Component Appraisal estimate ActualManagement _

Management Improvement 87.6 96.4Service Delivery 94.4 209.2

Logistics 146.2 1 232.1Family Planning 128.7 52.9Special Programs 33.0 10.2Project Management* 3.0 4.0Physical Contingencies 49.30Price Contingencies 99.4Total 641.7 604.7

* Comprises Rs 1.45 million for equipment etc. and Rs 2.55 million for salaries and otheroperating expenditures.Note: In local currency terms, actual project expenditures were 94% of appraisal estimates. US$equivalent for actual costs are not available.

Table SB: Project Financing

Appraisal Estimate ActualLocal Costs (Rs million) 469.51 206.5Foreign Costs (US$ million) 5.7 3.5

From IDA Credit (Rs million) 525.01 555.1From GOSL Funds (Rs million) 116.7 49.6Total 1 641.7j 604.7

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IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Table 10: Status of Leal Covemsants

Origiinal RevisedCovenant Fulfill Fulfill

Text Reference Class(es) Status Date Date Description of Covenant Comments

Schedule 4. para La 5 CD Borrower to appoint health deputy directors general (DDGs) anddirectors with qualifications and experience satisfactory to tDA.

Schedule 4. para 2.a 5 C Borrower to appoint and maintain project coordinator withqualifications and experience satisfactory to IDA.

Scliedule 4, p.ra 2 h 5 C Borrower to amaintai Project Steering Committee uinder TORs andwith membership satisfactory to IDA.

Schedule 4. para 3.a 13 CD 08.31/92 12/31/94 Borrower to complete and furnish IDA with health strategy and Final report submitted early 1995.finiancing study carried out under TORs and by persona whosequalifications andaxperienice, ase satisfactory to IDA.

Schedule 4. para 3.b 2 NC 12/31/92 Borrower to implement mutually satisfactory health financing To be taken up by follow-on project.mesures.

Schedule 4. para 4 10 CD 08131/89 Borrower to provide TORs satisfactory to IDA for special service Programs for malaria and diarrhoeal diseasesdelivery programs, control implemented: malnutrition program

carxelled.

Schedule 4, paras 5. 6 5 NC Borrower to provide IDA with work plans for health policy research To be taken up by follow-on project.and iraining for nest calendar year.

Schedule 4. para 7 9 C 03/31195 03131/96 Borrower to complete mid-term and final project reviews under Mid-term review completed January 1993.TORs and by persons satisfactory to IDA; discuss with IDA: carry Final review completed January 1996.out mutually satisfactory action plan. Fulfillment 03/31/91:03/31/92.

Schedule 4. para 8 0 C Borrower to provide family planning grants to NGOs underI I I I I ~~~~~~~~~~arrangemrents satisfactory to IDA.

Status: C - Comphed withCD - Compliance afier DelayNC - Not Complied withSOON - Compliance Expected in Reasonably Short TimeCP - Complied with PartiallyNYD - Not Yet Due

Covenant Class

I. Accounts/audit2 Financial performancegenerate revenue from beneficiaries3. Flow and utiiiiation of Project funds4 Counterpart funding5. Management aspects of the Project or of its executing agency6. Environmental covenants7. Involuntary resetlement8. Indigenous people9 Monitoring. review and reporting10. Implemextation11 Sectoral or cross-secioral budgetary or other resource allocation12. Sectoral or cross-sectoral regulatory/institutional action13 Other

- 29 -

Table 12: Bank Resources: Staff Inputs

Number of Staff Weeks

Stage of Project Cycle Iota FY 81-84 FY 85F8 FY 87FY 88 FY 89 FY 90FY 91 FY 92FY 93 FY 94F:Y 95FY 96

Through appraisal 125.9 17.5 4.1 45.6 44.0 14.7

Appraisal to Board 39.4 39.4

Board to Effectiveness 3.6 3.6

Supervision 102.7 6.0 8.6 12.8 21.3 26.9 20.2 6.3 0.6

Completion 2.0 2.0

TOTALS 273.6 17.5 4.1 45.6 44.0 57.7 6.0 8.6 12.8 21.3 26.9 20.2 6.3 2.6

- 30 -

Table 13: Bank Resources: Missions

Performance RatingMonth/Yea Number of Days Specialized Staff Skills Implementation Development Types of

Persons in Field Represented Status Objectives ProblemsTHROUGH APPRAISAL AND EFFECTIVENESSSept. 87 6 21 Ar, FP, HF, NuFeb 88 1 6 Nu

SUPERVISIONMay 89 2 10 Nu.Mg 3 3 M,TJune 89 1 5 Nu 3 3 M, TAugnst 89 2 4 Nu, Mg 3 3 M, TJanuary 90 2 Nu,Mg 2 2February 90 1 ' Mg MJune 90 2 12 Nu,HF 2 2 MJune 91 3 1() Nu. Mg 2 2 MJanuary 92 5 12 Nu, PH, Mg. 3 3 M,June92 4 Nu, Ar, Mg, PH 2 2 MJanuary 93 5 16 Po, PH, Nu, HE, Mg 3 3 MAugust 93 3 10 Mg, Nu, 2 2January 94 4 16 PH. Po, Mg, 2 2Sept94 4 11 Po, PH, Mg, HE S S

Perfomance rating1: problem-free or minor problems2: moderate problems3: major problemsUS: unsatisfactoryS: satisfactory

Specialized staff skillsAr: architectDm: demogropherHF: health finance specialistIEC: information, education and communication specialistMg: management specialistNu: nutrition specialistPH: public health specialistSA: system analystTr: training specialist

Types of problemsF: financialM managementT: technical

The World Bank 1818 H Street, N.W. (202) 477-1234INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D.C. 20433 Cable Address: INTBAFRADINTERNATIONAL DEVELOPMENT ASSOCIATION U.S.A Cable Address: INDEVAS

- 31 - Appendix A

Page 1 of 2

April 17, 1996

Dr. Dudley DissenayakeSecretaryMinistry of Health, Highways and Social ServicesColombo, Sri Lanka

Dear Dr. Dissenayake:

SRI LANKA: Health & Family Planning Project (Cr 1903-CE)

We are now in the process of preparing our post-project assessment of the IDA-assistedHealth & Family Planning Project that closed last September. In reviewing the project, I amparticularly impressed with the ability of your Ministry, following a critical mid-term review, toimprove project management and implement the second half of the project in an excellentfashion.

I would also like to congratulate your Ministry for the very thorough and usefulcompletion reports on the project. On the basis of your reviews and discussions that were held atthe time of the last World Bank mission, I mention below a number of matters to ensure that theachievements of the project will be sustained now that the project has ended.

First, the review indicates that some facilities constructed early in the project alreadyrequire maintenance, and requirements will of course increase substantially over the comingyears. While we realize that the provincial governments now have the responsibility formaintenance of local health facilities, it is important that your Ministry take the lead in drawingthe attention of the provincial governments to maintenance needs and urging them to makeadequate provision; otherwise, the substantial project investment in support of primary healthcare will be endangered.

Second, I understand that seven of the nine garages constructed for vehicle repairs are notfunctioning because of lack of staff. Again, we realize that employment of staff for them hasbecome a provincial responsibility. However, the urgent attention of the provincial HealthMinisters and Health Secretaries needs to be drawn to this matter, so that the facilities do notcontinue to stand idle and unproductive.

Third, the review of the project's Logistics component notes a number of defects in thedesign of the drug stores constructed with project support which prevent them from functioningadequately. Difficulties involving loading platforms, ventilation, electrical systems, fencing, andsecurity are mentioned. Since these facilities remain the responsibility of your Ministry, we hopethat you will resolve these problems as soon as possible so that the facilities can be made fullyfunctional.

ITT 440098 RCA 248423 WUI 64145

- 32 - Appendix APage 2 of 2

Fourth, I am surprised to learn that a planned workshop to present and discuss therecommendations of the Health Strategy and Financing Study was not held. Given the valuabledata collected and analyzed by the study as well as the study's important recommendations in theareas of health policy and planning, I would urge you to reschedule the workshop in order tofacilitate dissemination of the study and promote discussion of the recommendations among thestaff of your own ministry, other departments of Government, and other organizations andindividuals concerned with health services and policy.

Finally, we believe that it is important for Sri Lanka's health system that the HumanResources Information System (HRIS) and the Management Development and Planning Unit(MDPU) developed with project assistance continue to function, and we are pleased to note thatboth will receive additional support from the proposed Health Services Project. The failure to fillthe position of a director for HRIS that was established before the project ended was adisappointment, and we would certainly be glad to learn that an appointment has now been made.Based on experience elsewhere, we also believe that HRIS will not be able to function asintended unless keeping HRIS data current is linked to promotions and transfers of health staff.Since other aspects of human resources management in your Ministry continue to presentproblems, the recommendation of the most recent World Bank mission that HRIS be transferredto MDPU should be given careful consideration.

I am encouraged to learn that the post of Director Management Information has beenfilled, so that for the first time since the beginning of the project in 1989 all four MDPUdirectors are now in place. The establishment of MDPU and its ability to carry out importantmanagement training and planning functions are among the project's most importantaccomplishments. With additional support from the proposed Health Services Project, it shouldbe possible to strengthen and expand the ability of the MDPU to provide health policydevelopment, planning and management support to your Ministry. We support therecommendation of the review that a program should be undertaken to explain the role andfunctions of MDPU to the other units and staff of your Ministry.

May I again offer my congratulations on the successful completion of the Health &Family Planning project.

With best regards,

Sincerely yours,

Barbara HerzChief

Population & Human Resources DivisionSouth Asia Country Department I

cc: Dr. R.C. RajapakseWorld Bank Project CoordinatorMinistry of Health

- 33 -

Apxpendix BPage 1 of 4

IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Borrower's Summary and Evaluation

A. Summary

1. A majority of the activities under the Family Planning Component had been completed atthe time of the Mid-Term Review carried out in January 1993.

2. Most of the IEC activities including mass media program have been conducted asscheduled.

3. Training of auxiliary health workers to work in the areas with high level of fertility andtraining of staff nurses in Family Planning counselling were carried out to help improve interpersonnel communication. Assessment of the impact of these inputs are not possible even thoughthere is a possibility that these inputs may have made a contribution to decrease in fertility and animprovement in knowledge and practices related to contraception as shown in the Demographic andHealth Survey.

4. At the Mid-Term Review there was a satisfactory level of completion of Civil Worksand much progress have been made since then in the provision of Furniture, Equipment and Staff.

5. In the case of In-Service Management Training of the field staff, though the trainingcommenced in the Galle District in early 1994, training in the other two districts were completed onlyin 1995. Thus it is not possible to make in assessment of the inputs of these activities. There weresome indication of improve use of MCH services in the periphery.

6. Improvement in Project Management were seen following the Mid-Term Review withacceleration in the implementation of Project activities through improved liaison with provincialauthorities and regular monitoring. Financial progress seen over the duration of the Project are inkeeping with these observations.

7. The Human Resources Division of the Ministry of Health, though expected to functionas a focal point for staff development works more as an establishment unit. The DDG (HRD) and theDirectors under him were totally unaware of their duties as enunciated in the Project. The personnelwork is distributed between the DDG (Administration) and DDG (Examination and Investigation).Lack of continuity of staff positions has not contributed to the Planning of the Unit. The presentDDG is the fourth person to occupy this position during the duration of the Project.

8. The studies that have been completed by the Human Resources Development Unit areareas that would directly contribute to a better handling of the establishment work.

- 34 -Apnendix BPage 2 of 4

9. There is acceptance by the Ministry regarding the need for an automated HumanResource Information System since this would offer a better frame work for manpower planning anddecision making. Though work on collecting information started late, progress has been steadythough data collection is slow in the Line Ministry institution compared to the provinces.

10. The Boston University consultancy would have made a greater contribution towards animprovement of the services provided by the Ministry of Health if the Ministry was ready to acceptthe guidance and training provided by the consultants. The Management Development and PlanningUnit is now institutionalized and is providing the service expected of it. However, due to lack ofstaff and commitment by the Ministry the work done by Mr. Peter Ship has not been utilized andthere does not appear to be any plans to continue his work.

11. The HRIS component too should have made a greater contribution had the Ministryrealized its importance and appointed staff to help the Director (HRIS).

12. Special Programs: These consisted of Malaria Control Program in the districts ofMatale, Polonnaruwa, Anuradhapura and Kurunegala, an integrated Nutrition Project and control ofGastro Intestinal Disease in the Matale and Polonnaruwa districts.

13. The Nutrition Project was wound up in 1993 as it failed in its objective to institute asuccessful model of a nutrition intervention package for replication in other areas.

14. Malaria transmission has declined in the last two years which could be attributed due tothe new strategies for malaria control. Mobile clinics, heightened surveillance activities and newspraying strategies, all supported by World Bank funds has helped in reducing the incidence of thedisease.

15. Intensified food hygiene education were carried out in all three areas and KAP study hasindicated an improvement in the awareness of the mode of the spread of the disease.

16. The Civil Works concerned with the storage of drugs and vehicle maintenance hadalmost been completed within two years of the start of the Project. The completed buildings howeverwere not operational for quite some time due to delays in the procurement and supply of equipmentdue to bureaucratic red tape. the equipment however has now been provided. The divisional drugstores, poor in design, have however eased the problems of storage space for drugs in the periphery.

17. The unified logistics system classified as a key note exercise did not go beyond thepreliminary investigation by a consultant.

18. Of the 162 positions identified to help improve the functioning of the drug stores and toman the garages and service bays, only 15 have been filled due to the fact that such appointmentswere the prerogative of the provincial councils and the construction work was done by the LineMinistry. This has resulted in the failure of the transport maintenance and repair facilities asenvisaged in the Project.

- 35 -Appendix BPage 3 of 4

19. The drug and supplies management of the Project has not received any significantcontribution as far as the Project aim of improving this aspects of the logistics services. Recruitmentof the divisional pharmacists and their training could have helped.

20. On the matter of the financial performance the records is poor as apart from capitalwork and purchase of vehicles and equipment financial provisions for improving the managementsystem were not utilized.

B. Evaluation by the Director General Health Services

21. The above project was successfully completed in September 1995 and I wish to thank theWorld Bank for supporting certain areas in the health sector that needed urgent and sustained support.

22. 1 am particularly impressed with the support given to the Service Delivery Component inthe health districts of Galle, Matale and Polonnaruwa. The provision of staff quarters and offices forDDHS and the construction of the Gramodaya Health Centers in the rural areas together with theprovision of transport to the Divisional Directors have helped reduce morbidity and generallyimproved Primary Health Care in the three districts.

23. The logistics component which included drug and supplies management, vehicle andequipment maintenance and repair has not produced the desired improvement in these fields. Theconstruction of divisional and hospital drug stores has helped in the distribution of drugs but, thevehicle maintenance has not had the desired effect due to the poor citing of the buildings and the nonappointment of required staff. Unfortunately, this is a consequence of decentralization in that thebuildings were constructed and equipped by the Central Ministry and Provincial councils wereexpected to provide staff.

24. I am happy to note the Family Health Component has been very successfully completedand Demographic and Health Survey carried out by the Department of Census and Statistics hasshown an improvement in the knowledge and practices related to contraception and marked decreasein fertility. The auxiliary health workers who were trained and appointed to some of the backwardareas in Puttalam and Kandy have helped the government health workers in their day-to-day duties.

25. The Mass Media activities carried out by the Health Education Bureau were completedas scheduled and KAP studies would have to be done to assess the impact.

26. The Human Resources Management and Human Resources Development have, I amafraid, not achieved its objective due to reasons beyond the control of the present Ministry. Stafftrained under this component have been transferred thus the Ministry not getting the benefits of thetraining. The Human Resources Information System is a useful tool in the management process but ithas to be strengthened for maximum benefits.

27. The Management Development and Planning Unit is now institutionalized and I ampositive will play a very important pivotal position in the health sector of this country. However, theBoston University consultancy would have made a greater contribution if the Ministry was ready with

- 36 -

Appendix BPage 4 of 4

the necessary infra-structure and manpower to accept the guidance and training provided by theconsultants.

28. The Malaria Control Program has certainly benefited by the support given by the WorldBank loan as shown by the drop in Malaria transmission in the last two years.

29. I am sure that had there been better Project Management from the beginning of theProject and the provision of adequate manpower the benefits could have been more. However, 86%expenditure is an indication of the efforts put in by the health staff of this country to achieve thedesired targets this, in spite of the disturbances and conflicts that the country had to undergo duringthe early years of the project.

Appendix C

Co-Financier's Evaluation

[There were no co-financiers.]

- 37 -

Appendix D-1

IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Fertility and Family Planning: 1987, 1993

1982-87 1988-93

Total Fertility Rate 2.82 2.26

1987 1993

Current Contraceptive Prevalence

Pill 4.1 5.5

IUD 2.1 3.0

Injection 2.7 4.6

Condom 1.9 3.3

Female Sterilization 24.9 23.5

Male Sterilization 4.9 3.7

Norplant 0.1

Total, Modern Methods 40.6 43.7

Safe Period 14.9 15.2

Withdrawal 3.4 5.0

Abstinence 2.8 2.2

Total, Traditional Methods 21.1 22.4

TOTAL 61.7 66.1

Source: Demographic and Health Survey Sri Lanka 1993. Department of Census and Statistics.

- 38 -

Appendix D-2Page I of 3

IMPLEMENTATION COMPLETION REPORT

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT(Credit 1903-CE)

Summary of Technical Assistance Consultancy for Management

The consultancv was carried out by the Boston University Center for International Health.The specific tasks carried out and the results as assessed by the Consultant are summarized below.

Task 1 Preparation of Implementation Plan

Status: Completed.

Task 2 Preparation of Finance and Administration Manuals

Status: This task was linked to the decentralization of powers to the Divisional Directors ofHealth Services in 1993. After an initial workshop and partial drafting of the finance manual, theMinistry decided to retain the responsibility for the work and the Consultant undertook no furtheractivities. (Further work on these manuals was undertaken by national consultants and by theMinistry itself. At the request of the Project Coordinator, an assessment of the Ministrv's drugdistribution system was undertaken by the Consultant and a report fumished in late 1992. Nofurther work in this area was undertaken by the Consultant.

Comments: Given the sensitive nature of such manuals and the fact that compiling themrequires close familiarity with existing procedures, the decision to have the manuals written byexperienced national consultants made sense. It is unclear why this task was included in theconsultancy in the first place.

Task 3 Human Resources Information System (HRIS)

Status: Design and specifications for HRIS were completed and a national consultant hiredto develop the software and provide staff for data entry. The data base program became operationalin 1993. At the end of the project, the data base contained only about 10,000 files, represented anestimated 40% of staff to be included. The files for some institutions which cooperated inestablishing the data base were completed; for others there was insufficient support to obtaincomplete data, particularly for minor staff. HRIS implementation was not begun in three provincesand was variable in the six provinces where it was introduced. Update procedures were notroutinely implemented. Permanent positions for the HRIS unit had been sanctioned but not filled.

Comments: Implementation of HRIS did not have a high priority with the Ministry, asindicated by delays in staff appointments and an unwillingness to require the managers of centralinstitutions to complete the submission of data or notify the HRIS unit of personnel actions as they

- 39 -

Appendix D-2Page 2 of 3

occur. As a result HRIS did not become an integral part of Ministry operations. The potentialvalue of HRIS for management and manpower planning purposes will not be realized until HRIScoverage is complete and current. Current HRIS status needs to be linked to transfers andpromotions to accomplish this.

Task 4 Health Planning Data Base

Status: Reports recommending priorities for the compilation a of health planning data base,a source for each data item, and a recommended approach to incremental development of a healthplanning data system were provided. A study tour of health planning data systems in Indonesia,Malaysia and Singapore for MOH staff was conducted.

Comments: In the absence of a Director Management Information in the MDPU, work onthe design of a health planning information svstem was halted in 1994. An essential requirement forfurther development is integration of the activities of the Medical Statistics unit and those of otherhealth information systems.

Task 5 Techniques of Analysis for Hospital Planning

Status: Workshop on hospital planning techniques conducted; step-down cost allocationmodel (Lotus-based) for use with costing effort at Lady Ridgeway Hospital programmed;population-based bed need analysis for Lady Ridgeway Hospital, which showed a smaller bedrequirement than assumed, completed; "Guidelines and Workbook for Preparing Capital InvestmentPlans to Expand/Extend Hospital Services" written and produced. However, it is not clear whetherthe Planning Workbook has been disseminated.

Comments: The Ministry needs to do a better job of anticipating the total operating costand affordability of its proposed capital budget. The procedures specified in the PlanningWorkbook will lead to more credible cost estimates for individuals proposals. The Ministry shouldaggregate the implications of these proposals, along with ministry-wide initiatives, and compare thetotal to the amount of funds which are likely to be available from the budget for health services.

Task 6 Support for Health Management Training

Status: Integrated teaching case of DDHS training course prepared; health economics,personnel supervision and leadership, hospital management and integrated case study taught in initialDDHS courses by consultant; DDHS budgeting model (Lotus-based) for use in training courseprogrammed; resources available for health management education and needs for managementtraining assessed; report including recommendations for initial supervisory training, certificate-levelcourse in health management, and Masters degree in Health Management completed and submitted;input including draft course outlines and textbooks to curriculum of M.Sc. in health administrationprovided; M.Sc. classes in financial management and seminar in health economics for MOH stafftaught by consultant. Drug supply course for M.Sc. was not taught due to schedule conflicts.

Comments: The M.Sc. in Health Administration is a first step in upgrading managementskills in the health sector. However, the M.Sc. can reach only a fraction of those with management

- 40 -

Appendix D-2Page 3 of 3

responsibilities in the Health Sector. Basic management training is required for all staff who deploysignificant resources or personnel and have budget responsibilities. We therefore recommend thatthe Ministry give consideration to a certificate-level course in Health management, which wouldinclude some of the materials in the M.Sc. Such a course could be offered to a wider range ofMOH staff when they first acquire management responsibility. Staff would remain in post whilereceiving this training.

Task 7 Study on Organization and Staffing of the Management Development Planning Unit

Status: Report and associated draft job descriptions for recommended positions submitted.

Comments: It seems unlikely that this report will be utilized to any significant extent.

Tasks 819 Development of a Model to Estimate Health Manpower Requirements

Status: Workload Indicators of Staffing Need (WISN) model (Lotus-based) designed andtumed over to MOH for use; one MDPU staff member trained in use of software; process forcreation of workload indicators by various professional groups completed and compared to existingstaffing; WISN calculations for most non-hospital cadres completed and compared to existing stafftactivity data collected, WISN calculations carried out, and comparisons to existing staffing made fora set of provincial, base and district hospitals. However, WISN calculations not completed forspecialty services in teaching hospitals because sufficient data was not submitted. Some WISNcalculations for hospitals in the selected districts were not completed because hospitals did notreturn full data requested.

Comments: The Ministry does not appear to assign any particular priority to this approachto manpower planning. It appears unlikely that the software will be utilized by the Ministry.

- 41 --

Appendix D-3

Recommendations of the Health Strategy and Financing Study

I. Helping People to Avoid Inappropriate Self Care

II. Improving Quality and Efficiency

I. Move outpatient services of major public hospitals to separate facilities.

2. Address by-passing of lower level facilities by improving quality of care.

3. If improving quality of care does llot solve by-passing problem, reform thereferral system by (a) instituting differential fees; and/or (b) requiringreferral for admission to higlher level facilities.

4. Determine more effective uses for types of facilities known to beineffective.

5. Address inefficiencies in the drug sector.

III. Providing Additional Resources

6. Institute user fees for all age groups older than one year.

7. Reserve IO percent of beds in all hospitals as pay beds.

8. Support development of cooperatively owned and operated healthfacilities.

IV. Building a Research Capacity

9. Build capacity for health systems research.

NB: The study does not recommenid public sector support for health insurance on thegrounds that i'ull risk coverage for all citizens is already provided. Other insurance wouldbe provided appropriately by private insurance companies.

NM:\SRI\PCR-A3.DOCFP.dr 4\8\96

IBRD 28020

80 81 82

SRI LANKA

-offa HEALTH AND FAMILY PLANNING PROJECT

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MAY I Q96

IMAGI MNG

Report No: 15763Type: ICR