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Implementation Completion Report (ICR) Review - Integrated Health Services Development

1. Project Data:   
ICR Review Date Posted:
Project Name:
Integrated Health Services Development
Project Costs(US $M)
 52.0  26.65
Cote d'Ivoire
Loan/Credit (US $M)
 40.0  24.23
Sector, Major Sect.:
Central government administration, Compulsory health finance, Health,
Law and justice and public administration; Law and justice and public administration; Health and other social services
Cofinancing (US $M)
 11.8  2.43
L/C Number:
Board Approval (FY)
Partners involved
Closing Date
09/30/2000 12/31/2004
Evaluator: Panel Reviewer: Group Manager: Group:  
Judith Hahn Gaubatz
Ridley Nelson Alain A. Barbu OEDSG

2. Project Objectives and Components:

a. Objectives
(1) To develop the health system in the Borrower’s territory by the introduction of reforms and the promotion of access and utilization of care in health districts, especially in the areas of reproductive health, family planning, sexually transmitted diseases and HIV/AIDS; (2) To create and make operational a framework to improve the performance of health district management teams; (3) To improve the performance of the health system by introducing the PMA (minimum package of health services) program, especially including reproductive health, family planning services, and services required to combat AIDS, sexually transmitted infections, and tuberculosis, and to address any need created as a result of the conflict; (4) To improve management and financing of the health sector; and (5) To execute and publish a General Census of the Population and Housing and analyze the results.

b. Components (or Key Conditions in the case of Adjustment Loans):
(1) The minimum package of services (PMA) and strengthening of departmental directorates (US$8.1m at appraisal, US$5.37m actual); (2) Reproductive health, family planning, and control of priority diseases including HIV/AIDS, STIs and tuberculosis (US$10.72m at appraisal, US$5.97m actual); (3) Health sector planning and financing (US$4.04m at appraisal, US$1.19m actual); (4) Population and housing census (US$5.42m at appraisal, US$5.79m actual); and (5) Project coordination (US$3.35m at appraisal, US$5.66m actual).

c. Comments on Project Cost, Financing, Borrower Contribution, and Dates
The project objectives were formally revised twice, in November 1998 and July 2000, with the intention of making the project less ambitious and more consistent with the country’s needs and limited capacities. Following the July 2000 restructuring, the estimated project cost was revised from $52.0m to $32.43m. The final project cost was $26.65m, 82.2% of the revised estimate. The revised credit was for $29.9m; the final credit disbursement was $24.23m, 81.0%. The revised estimated counterpart contribution was $2.57m; the final counterpart contribution was $2.43m, 94.6%. Approximately $400,000 in counterpart funds were misspent, but were yet to be repaid. The government was toppled by a military coup in December 1999. The project took 8 years to complete, although little was achieved for the first three years and the last two years of the project period due to suspension of lending to the country. Disbursements to Cote d’Ivoire were suspended for a total of 24 months (cumulatively, not consecutively) during the project period due to civil unrest and arrears. The project closing date was extended three times: from Sept. 2000 to Dec. 2004.

3. Relevance of Objectives & Design:

The broad objectives to develop the health system by introducing reforms, increase access, especially to PMA and RH/STI services, and improve management were highly relevant given the poor performance of the health sector. They were also consistent with the country’s National Health Development Plan. The project aimed to improve the health sector through interventions in service delivery and in management.

However, the objectives on creating an operational framework to assist district health teams and executing a population and housing census were less relevant as objectives;while they represented activities important for achieving the broader objectives, they would have been more appropriately articulated accordingly - as activities, not objectives.

In addition, the project design did not adequately build in measures in response to the risks that had been correctly identified during project preparation, namely weak capacity and limited commitment to a primary health care approach.

4. Achievement of Objectives (Efficacy) :

Overall, a number of important activities were initiated but only partially implemented. Thus, their contributions to achieving outcomes were limited as many did not reach the fully operational stage.

The achievement of the objective of introducing reforms and increasing access to and utilization of health services is rated negligible. A background study and draft legislation were prepared to improve the national reproductive health program, as well as a study on reforming the medical/paramedical studies curricula. 90 family planning centers, 3 regional health centers and 5 health clinics were established (i.e. constructed and equipped), though not yet made operational. 61 NGO subprojects were approved for financing (CFA750.5m total granted), including a number supporting PLWHA associations and post-conflict assistance; however, there was no information provided on the impact of these subprojects.

The achievement of the objective of creating a framework to improve the performance of district health teams is rated modest. Decentralized procedures and accounts for district health teams were established, though not yet operational. A specialized unit (UTAD) was established and provided technical support to district health teams in preparing health plans.

The achievement of the objective of improving the performance of the health system by introducing the PMA program is rated modest.District health plans which featured delivery of the PMA were prepared in all four pilot districts; however, they were not yet implemented therefore a systematic roll-out of the PMA program was not achieved. However, other elements in support of the program were financed: training tools for PMA service delivery were developed and RH/FP services (part of the PMA) were added to 95 out of the targeted 106 facilities. The percent of women aged 15-45 years old using modern contraceptive methods increased from 4% to 11%.

The achievement of the objective of improving management and financing of the health sector is rated negligible. Again, the project financed a number of activities intended to support this objective; however, the impact of these activities on achieving the objective is not clear. Training tools on the use of pharmaceuticals and the management information system (MIS) were developed, and a feasibility study on health insurance, as well as a public expenditure review for the health sector were completed. Policies and procedures to facilitate partnerships with NGOs and local communities were adopted.

The achievement of the objective of executing a general population and housing census is rated high. A population and housing census of the general population was executed, with the results published on the internet.

5. Efficiency:

Given the limited outputs and achievements of this project compared to the above-80% disbursement rate, the efficiency of the project is negligible.
6. M&E Design, Implementation, & Utilization:

An M&E system for the project and the national health plan was never established. There was only a limited number of outcome/impact indicators defined and collected in a satisfactory way. The output indicators were similarly inadequately defined. There was no baseline data provided for either outcome or output indicators.
7. Other (Safeguards, Fiduciary, Unintended Impacts--Positive & Negative):


8. Ratings:
OED Review
Reason for Disagreement/Comments
Institutional Dev.: 
Bank Perf.: 
UnsatisfactoryUnsatisfactoryThe ICR title page assigns a “Satisfactory” rating while the report text assigns an “Unsatisfactory” rating.
Borrower Perf.: 
Quality of ICR: 

- When insufficient information is provided by the Bank for OED to arrive at a clear rating, OED will downgrade the relevant ratings as warranted beginning July 1, 2006.
- ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness.

9. Lessons:

The Bank should examine more carefully the “source” of political and institutional commitment. This project depended on a change in “culture” – away from a highly medicalized model of health care and towards a primary public health care model – that did not materialize. Because there had been a foreign advisor championing and handling the national health program, the extent of ownership and commitment by the country itself was incorrectly understood.

Past portfolio performance in the country should inform project design; in particular, the average disbursement time should be considered when setting the number of years for project implementation.
Realistic time periods should be considered in setting project extensions. This project included activities that required longer implementation timeframes (i.e. construction) than the extensions allowed.

10. Assessment Recommended?  No


11. Comments on Quality of ICR:

While the ICR is overall satisfactory and provides specific, useful lessons, it does not adequately report on changes in the monitoring indicators in the SAR, which were still highly relevant despite the revised objectives. OED notes that due to the deteriorating political/security situation in Cote d’Ivoire, the ICR team was not able to visit the country to aid in preparation of the report.

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