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Implementation Completion Report (ICR) Review - Maternal Health & Child Development

1. Project Data:   
ES Date Posted:
Project Name:
Maternal Health & Child Development
Project Costs(US $M)
 31.22  24.07
Loan/Credit (US $M)
 21.8  20.7
Sector, Major Sect.:
Central government administration, Pre-primary education, Health,
Law and justice and public administration; Education; Health and other social services
Cofinancing (US $M)
 0  0
L/C Number:
L4086; L4087      
Board Approval (FY)
Partners involved
Closing Date
06/30/2003 06/30/2004
Prepared by: Reviewed by: Group Manager: Group:  
Howard Nial White
Denise A. Vaillancourt Alain A. Barbu OEDSG

2. Project Objectives and Components:

a. Objectives

The main objective of the Maternal Health and Child Development Project was to improve the health status of the underserved Paraguayan population, particularly women and children.

To achieve this objective the Project was to

(a) increase the coverage, quality and efficiency of basic maternal and child health services in six underserved departments in Northeastern Paraguay;

(b) increase the population’s knowledge about adequate health practices;

(c) pilot-test a strategy to enhance early child development in Asuncion; and

(d) strengthen management capability of the Ministry of Public Health and Social Welfare (Ministerio de Salud Pública y Bienestar Social, MSPBS) in support of an eventual decentralization of public health services in Project areas.

Hence, for the specific objectives (a), (b) and (d) the Project areas were the country’s six most underserved departments in Northeastern Paraguay.

b. Components

Original components

Component A: Maternal and Child Health Care (US$20.1 million, 74.3 percent, excluding contingencies)

This component aimed to improve the health conditions of poor women and children in six of the poorest, predominantly rural, departments in the Northeast of Paraguay through the following subcomponents:

A.1 Rehabilitation and Maintenance of Infrastructure and Equipment SubProjects (US$11.2 million). This subcomponent aimed to strengthen the delivery of maternal and child health care services in six targeted departments by improving existing infrastructure and ensuring the availability of needed equipment and adequate maintenance in regional hospitals and health centers.

A.2 Pharmaceuticals and Supplies (US$6.64 million). This subcomponent was to finance procurement and distribution of pharmaceuticals, medical supplies and pharmaceutical staff training for basic maternal and child health services in eligible health facilities.

A.3 Information, Education and Communication (US$1.19 million). This subcomponent aimed to promote preventive health care in the communities served by the project through a program of information, education and communication (IEC).

A.4 Training (US$1.05 million). This subcomponent aimed to support the design and implementation of an in-service training program for paramedical and medical personnel.

Component B: Early Childhood Development (ECD) Pilot (US$2.12 million, 7.8 percent excluding contingencies).

This pilot was to test a strategy to improve health and psychosocial development of 2-5 year old children
in poor areas of Asunción by establishing early childhood development centers (CEBINFAs) and
strengthening the Social Welfare Directorate’s (Dirección General de Bienestar Social, DGBS) capacity
to supervise ECD services and give technical assistance to communities interested in providing these
services on their own.

Component C: Support for Decentralization. (US$1.20 million, 4.4 percent excluding contingencies).

This component aimed to improve the management capacity of the MSPBS, in preparation for the eventual decentralization of public social services, including health. The management capacity of health sector staff was to be strengthened at the regional and central levels through: (a) staff training; (b) establishment of management information systems; (c) pilot activities to increase Project sustainability; and (d) financing recurrent costs to supervise maternal and child health services in the Project areas.

Component D: Project Administration, Monitoring and Evaluation. (US$3.17 million,11.7 percent excluding contingencies)

The Project was to be administered by a Project Coordination Unit (PCU), reporting directly to the MSPBS Minister and the General Directorate of Projects with International Cooperation (OPCI). The PCU was to be assisted by
Regional Coordination Offices (RCOs) established in each region. All Project resources were to be
managed centrally by the PCU, and funds were to be allocated annually to the regions based on Annual
Implementation Plans (Plan Operativo Annual), except for small civil works, goods and service contracts
which were to be procured by the RCOs.

Revised components

The project was restructured in 2000 as a result of which component B was discontinued and the scope of the remaining three components reduced. The project objectives remained unchanged.

c. Comments on Project Cost, Financing and Dates

The project got off to a very slow start: only six percent of total project costs had been disbursed after five years of operation. The project was then restructured. Discontinuation of component B (ECD), having spent only US$0.16 million of the budgeted US$2.12 million is one source of the overall shortfall in actual compared to planned total expenditure. However, the main reason for the lower overall expenditure was that no funds were required for contigency expenditures on account of the devaluation of the Guarani (put another way, the actual total expenditure on the four components was less than the actual planned total, so there was no need to call on the contingency) , although US$4.17 million had been set aside for this purpose. An undisbursed balance of US$0.35 million was cancelled. As these figures show, the savings from reduced in project costs resulted largely in lower contributions by government rather than lower utilization of the loan.

There was a one year extension to allow completion of disbursements.

3. Achievement of Relevant Objectives:

Overall: Unsatsifactory

Coverage rates in project areas improved, but well short of target of 100 percent, and impact indicators stagnant or worsening.

Increase the coverage, quality and efficiency of basic maternal and child health services in six underserved departments in Northeastern Paraguay: Partially achieved

In period 2001-2003 institutional deliveries increased from 72.9 to 75.7 percent in project areas (compared to 85.5 to 87.5 in country as whole).

Data show improvements in quality and efficiency in most areas, but not possible to identify a "project effect".

Increase the population’s knowledge about adequate health practices: Achieved

IEC activities were carried out in three of the six project departments, and each of these saw substantial increases in target knowledge (prenatal care, immunization and blood donations) from 2002-2004.

Pilot-test a strategy to enhance early child development in Asuncion: Not achieved

Community-based model was not working, and the approach was of limited relevance given data showing need for focus on infants, especially the peri-natal period.

Strengthen management capability of MSPBS in support of an eventual decentralization of public health services in project areas: Not achieved

Fiscal decentralization was resisted by administration, and lack of counterpart funds limited training.

4. Significant Outcomes/Impacts:

  • Improved service coverage in project areas (e.g. construction 4 new regional/district hospitals and rehabilitation of 5 others; rehabiliation 15 health centers and 22 health posts)
  • Some improvements in service quality and efficiency - an "efficiency index" based on staff ability and availability, physical plant, equipment, supplies and drugs rose from 39.4 in 2001 to 47.0 in 2004 (e.g. training of 1,400 health professionals to improve coordination with midwives)
  • Improved health knowledge in selected project areas

5. Significant Shortcomings (include non-compliance with safeguard features):

The project suffered from shortcomings in both design and implementation.

Design issues:
  • Over complex project design, including the ECD component (of questionable relevance) in a different geographical area to other components.
  • Weak M&E system, with over-ambitious set of indicators, but no attention to poor quality of data.
  • Over-ambitious coverage targets for project area.
  • Complex institutional arrangements

  • Lack of counterpart funding
  • Weak project management prior to restructuring
  • Planned baseline survey not carried out

6. Ratings:ICROED ReviewReason for Disagreement/Comments
Institutional Dev.:
Bank Performance:
Borrower Perf.:
Quality of ICR:

7. Lessons of Broad Applicablity:

Baseline data and a realistic set of monitoring and evaluation indicators (and targets) need to
be defined at appraisal. As the experience with the Project shows, leaving such definition to actual
Project implementation is highly risky. The planned baseline survey was not carried out, making not only
the evaluation of the Project very difficult but also depriving Project management in the Government and
the Bank of an important tool which could indicate that corrective action would need to be taken. Further,
the specified target that a basic package of relevant health services would be delivered to the entire poor
population in the Project areas was, in hindsight, a too ambitious target. Realistic target setting for
investment Project (especially in sectors like health where many factors – many of which beyond health
service delivery per se – influence outcomes,) is pivotal. Finally, the selection of indicators should be
limited to a small number of relevant and collectable list.

Project ownership across different levels of the institution is key to ensure continuity of project implementation and adequate level of implementation. The objectives and strategies of a social development project succeed only in so far as they are fully supported. To achieve this, concerted efforts to engage key members of the Government, the executing agency and the targeted communities as actors in the project need to be made from the earliest stages of project preparation.

Training and retraining strategies need to be part of a staff development system that considers not only the skill needs by level, but also the adequate methodologies to transmit said skills
to different types and levels of personnel, including on-the-job-training. Such training needs to be
followed-up by close supervision as part of a “mentoring/apprenticeship” approach. In terms of procedures,
it is also important that there is continuous technical support and training to the members of the PCU from
the Bank team, particularly in less developed countries. In Paraguay, the new PCU team (since 2000) did
not participate in Bank training and this made their work much more difficult. Yet, the frequent and
well-staffed supervision missions carried out during the second phase of project implementation helped the
new team revise the Project and improve implementation significantly.

Implementation arrangement need to be carefully tailored to institutional capacity of the client country and closely monitored during project implementation. The importance of this rather basic lesson cannot be overstressed, as witnessed when analyzing the Paraguay project at hand which was adversely affected by too broad and ambitious a design, coupled with an institutional set-up that made the functional integration of the project (and its administration unit) in the line structure of the Ministry difficult. Further, in settings where administrative and implementation capacity is weak, project activities centered around action-driven implementation of service delivery and their subsequent scaling-up can be more effective than plans of fundamental institutional change. It is also important to constantly monitor the institutional arrangement in such environments during project implementation and to adopt modifications, if necessary.

8. Audit Recommended?  No


9. Comments on Quality of ICR:

The ICR gives a thorough and candid account of the project and its shortcomings.

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