|1. Project Data:
ICR Review Date Posted:
|Health And Nutrition Support Project
Project Costs(US $M)
Loan/Credit (US $M)
|Health, Nutrition and Population
Cofinancing (US $M)
Board Approval Date
|Health (63%), Central government administration (25%), Non-compulsory health finance (10%), Sub-national government administration (2%)|
|Nutrition and food security (29% - P)
Health system performance (29% - P)
Population and reproductive health (14% - S)
Other communicable diseases (14% - S)
Child health (14% - S)|
||ICR Review Coordinator:
|Judith Hahn Gaubatz
||Judyth L. Twigg
|2. Project Objectives and Components:|
a. Objectives:According to the Project Appraisal Document (PAD, page 10), the overall objective of the project was:
- to strengthen the health system and its capacity to improve the health and nutrition status of the population, notably of women, children and the poor, as it will support the implementation of the Government Program for the health and nutrition sectors during the period 2006-2008.
The PAD (page 10) also articulated the specific objectives as follows:
- to improve access to basic health services in underserved areas;
- to improve the equitable allocation of resources to underserved areas;
- to strengthen health sector management to raise efficiency; and
- to enhance and expand community-based communications for improved nutrition.
The Financing Agreement (page 5) includes the same articulation of the overall objective, but not the specific objectives. Therefore, as the PAD statement of objectives (both overall and specific) provides more clarity on the intended outcomes for assessment, it is used as the basis for this review.
b. Were the project objectives/key associated outcome targets revised during implementation?
c. Components:Note: Components 1-4 were to be implemented by the Ministry of Health and Social Affairs (MOHSA). Component 5 was to be implemented by the State Secretariat for the Promotion of Women (SECF).
1: Develop human resources and improve their geographical distribution (Appraisal: US$2.0 million; Actual: US$0.46 million): This component aimed to strengthen sector capacity to manage human resources, including through improved intersectoral coordination. Activities included: capacity-building activities for the Directorate of Human Resources, support for a human resources management system, establishment of a network system for information sharing, piloting of an accountability system for health care providers, coordination with training institutes, revision of curriculum and training programs, and integrated supervision (central, regional, and decentralized levels) of human resources.
2: Ensure adequate sector financing and equitable allocation of resources for the poor and for underserved geographical areas (Appraisal: US$1.5 million; Actual: US$0.28 million): This component aimed to improve existing processes and methods for financing, and to strengthen measures to ensure financial accessibility and utilization of services by the poorest and most vulnerable. Activities included: technical assistance for annual expenditure reviews and national health accounts, subsidization of essential health services for the poor, and support for establishing alternative financing systems at the community level.
3. Improve health sector management to raise efficiency (Appraisal: US$1.0 million; Actual: US$1.68 million). This component aimed to support the sector-wide approach, and to develop management capacity of health sector staff. Activities included: support for establishment of clear objectives, roles and relationships among the partners; support for improved coordination and execution of planning, budgeting, procurement, and financial management; and development of monitoring and evaluation modalities.
4. Improve the accessibility to quality and affordable health services in underserved areas (Appraisal: US$3.5 million; Actual: US$4.01 million). This component aimed to improve access to and quality of basic health services, and to raise demand for services. Activities included: construction of health posts in areas of low accessibility, support to the community approach for reaching low-access populations, improvement of the availability of drugs, and awareness-raising emphasizing prevention and behavioral change. These activities would focus on the reduction of child mortality (through the Integrated Management of Childhood Illnesses approach), the reduction of maternal mortality (through the improvement of emergency obstetrical and neonatal care), and the reduction in incidence of schistosomiasis.
5. Enhance and expand community-based communications for improved nutrition (Appraisal: US$2.0 million; Actual: US$2.73 million). This component aimed to improve access to basic essential health and nutrition services (i.e. micronutrient supplementation, de-worming, and distribution of bed-nets) and strengthen the capacity of SECF to plan, monitor and evaluate nutrition programs. Activities included implementation of community-based nutrition communication strategies, implementation of salt iodization activities, and training of community agents.
d. Comments on Project Cost, Financing, Borrower Contribution, and DatesProject cost:
- The actual project cost was US$11.2 million, according to the project team. Disbursements for Components 1 and 2 were lower than planned, primarily due to capacity constraints. The project team noted that there were challenges in coordination among the Directorates, which affected project implementation.
- The actual loan amount was US$10.8 million.
- The project was part of a sector-wide approach program (SWAp), although it focused on specific aspects of the national program rather than pooling funds with other donors. The ICR does not provide specific details on other donor funding, although it reports (page 35) that the share of IDA funding in the sector (total spending of government and donors) was 17%, compared to all other donors' share of 9% (no specific year provided).
- Counterpart funding of US$0.84 million was provided with no major issues reported.
- The closing date was extended from December 31, 2009 to June 30, 2011. Due to the August 2008 coup, Bank operations in the country were suspended for a period of one year. When operations were resumed in September 2009, only three months remained in the original project period. Thus, the Bank and Government agreed to extend the closing date to enable completion of activities.
|3. Relevance of Objectives & Design:|
a. Relevance of Objectives:Substantial. The objectives were fully consistent with the health and nutrition needs of the population, particularly for women, children and the poor, as reflected by a child mortality rate of 116 per 1,000 live births; infant mortality rate of 74 per 1,000 live births; maternal mortality rate of 747 per 100,000 live births; and chronic malnutrition affecting nearly one-third of children.) The objectives also appear relevant to the Government's priorities per the National Health and Social Action Policy (2005-2015) and the National Nutrition Development Policy (2005-2010), both of which had a strong poverty focus and aimed to accelerate outcomes in health and nutrition, although policies specifically related to the project are not clear. The objectives are also consistent with the Bank's Country Assistance Strategy (FY08-11), current at project closure, which emphasizes continued focus on improving access to health and nutrition services, while increasing focus on financial sustainability issues. Lastly, the objectives were highly relevant to the Bank's corporate priorities of achieving the Millennium Development Goals.
b. Relevance of Design:Substantial. The project design was built upon ongoing partnerships and the existing sector-wide approach (SWAp), while focusing on specific areas of responsibility for the Bank. These included public expenditure analysis, capacity-building, as well as nutrition policy. The project activities appropriately addressed supply (i.e. construction of health centers) and demand (i.e. community outreach, affordability) issues, as well as measures to increase sector management capacity. A significant proportion of project funds were to go towards treating diseases common among the poorest population groups (including schistosomiasis). While these activities were likely to achieve the intended intermediate outcomes (i.e. increased access to services, reduced inequities, improved efficiency) and contribute to overall outcomes (i.e. improved health and nutrition outcomes), the planned time frame of the project (three years) was likely too short.
|4. Achievement of Objectives (Efficacy) :|
Note: For the first three objectives below, the activities were part of a SWAp. The ICR does not provide specific details on other donors' activities (or financing amounts), although, as noted previously, it reports (page 35) that the share of IDA funding in the sector (total spending of government and donors) was 17%, compared to all other donors' share of 9% (no specific year provided).
To improve access to basic health in underserved areas.
Modest, due to mixed evidence of outcomes. Note: The health facilities financed by this component were selected based on low accessibility.
- Construction and equipping (medical equipment, maintenance tools, solar power) of 13 health posts and 1 health center.
- Conducting of three mass de-worming campaigns for the treatment of schistosomiasis, including development of awareness communication and provision of mebendazole drugs.
- Training abroad for 4 chief doctors of health centers, and training locally for 170 health personnel (on issues such as management of diarrhea, neonatal care ).
- Provision of 8 ambulances to health posts.
- Provision of 40 motorcycles to the head nurses of health posts.
(For all figures below, the baseline year was 2006 and the final year was 2011).
- The rate of mass treatment for schistosomiasis reached 100% in all four regions, from a baseline of 0%.. This represented the treatment of 209,340 children in primary schools, 28,610 children in Koranic schools, and 16,000 at-risk adults. Although data on prevalence would have been a more robust indicator of improvements in health, it is likely that the high rate of treatment would lead to decreased prevalence rates.
- The percentage of pre-natal centers offering subsidized services for pregnant women increased in all four regions, with targets fully or nearly achieved in three of the four regions. (Hodh El Chargui: 44% to 59% (target: 60%); Hodh El Gharbi: 48% to 57% (target: 66%); Assaba: 63% to 88% (target: 69%); Guidimaka: 73% to 77% (target: 79%).
- Evidence of improved coverage of pregnant women receiving two doses of a malaria prophylaxis (sulfadoxine-pyrimethamine - SP) is inadequate, due to unclear baseline figures. The ICR (page iii) reports baseline coverage of 0%, therefore indicating improvements in all seven regions. However, the PAD (page 38) reports baseline figures as follows: Hodh El Chargui: 51%; Hodh El Gharbi: 81%; Assaba: 50%; Traza: 61.5%; Guidimaka: 76%; Brakna: 86%; Tagant: 51%. End-project levels of coverage were as follows: Hodh El Chargui: 45% (target: 58%); Hodh El Gharbi: 32% (target: 88%); Assaba: 52% (target: 57%); Traza: 54% (target: 66%); Guidimaka: 50% (target: 83%); Brakna: 55% (target: 90%); Tagant: 29% (target: 57%).
To improve the equitable allocation of resources to underserved areas.
Negligible, due to lack of evidence on resource allocation outcomes.
- Training of staff in monitoring public spending on health, implementation and monitoring of national health accounts, financing of community health care, and management of community development programs. In addition, 53% of health committee members were trained on the cost recovery system, achieving the target of 50%.
- Completion of annual expenditure reviews of the health sector and national health accounts.
- Establishment of 20 health mutuelles (risk-sharing financing mechanisms at the community level), surpassing the target of 15.
- Implementation of awareness campaigns for communities to renew health committee members on the basis of newly established criteria.
- Health sector capacity in resource allocation was likely improved as a result of the outputs; however, the extent to which the improved capacity led to more equitable allocation of resources is unclear.
To strengthen health sector management to raise efficiency.
Modest, due to lack of information on efficiency outcomes.
- Development of the National Health Development Plan, including mobilization of partners.
- Conducting of annual reviews of the health sector to monitor results, and planning workshops to develop action plans.
- Signing of a Memorandum of Understanding among donors (for improved coordination) and creation of a Partner Group for the Development of Health, Social Action and Nutrition sectors.
- Development of tools for integrated supervision (i.e. with Human Resources Department, DSSB) of the health sector.
- Collection of health information for the years 2008, 2009, and 2010.
- Training of staff on human resource management and use of the national health information system.
- Updating of all health personnel files, in order to further develop human resources and improve geographical distribution.
- Conducting a study to assess premiums and the introduction of performance bonuses.
- Updating of human resource development strategic plan.
- Holding 9 coordination meetings with regional health departments and other Ministries (i.e. Public Service, Finance, Education).
- Health sector capacity in management was likely improved as a result of the outputs; however, the extent to which the improved capacity led to increased efficiency is unclear.
To enhance and expand community-based communications for improved nutrition.
Substantial, due to evidence of improved nutrition practices. Note: Activities under this component were not part of the SWAp, and therefore outcomes are attributable to the Bank's specific support.
- Development of communication strategy for behavior change in nutrition.
- Establishment of the National Council for the Development of Nutrition, chaired by the Prime Minister.
- Establishment of 36 community nutrition centers in four regions. These centers provided services such as micronutrient supplementation, monthly growth monitoring of children, and cooking demonstrations.
- Provision of micronutrients (iron folate and Vitamin A supplements) and drugs (mebendazole) to support national programs.
- Testing of salt iodization and conducting of awareness campaigns on the consumption of iodized salt.
- Training of staff on community nutrition, awareness raising, and community mobilization.
(For figures below, the baseline year was 2006 and the final year was 2011, unless otherwise noted).
- The percentage of women who practice exclusive breast feeding for the first six months after birth increased in project regions, although falling short of targets in all but one region. (Nouakchott: 15.2% to 40.2% (target: 44.1%); Nouadhibou: 21.9% to 46.9% (target: 25.8%); Gorgol: 17.6% to 42.6% (target: 42.7%); Assaba: 20.3% to 45.3% (target: 79.5%); Hodh El Garbi: 32.9% to 57.9% (target: 80%)).
- Coverage of Vitamin A supplementation for children under five years old increased from 43.15% to 103.42%, surpassing the target of 78%.
- The consumption of iodized salt in project regions increased from 28.3% in 2008 to 49.9% in 2010. No target was provided, and the source of the data is not clear.
To strengthen the health system and its capacity to improve the health and nutrition status of the population, notably of women, children and the poor.
Modest, based on the modest or negligible achievement of two out of the four specific objectives above, and limited information on other outcomes relevant to the overall objective.
Modest. The ICR does not provide sufficient evidence on the efficient use of project resources i.e. that the project was implemented at least cost or that the interventions as implemented were cost-effective. According to the ICR, there was a suspension of activities for one year during the project period, implementation and procurement delays due to capacity constraints in MOHSA, and delayed attempts by the Bank to restructure the project.
A project-specific economic and financial analysis was not conducted for the PAD, for reasons which included the following (PAD, page 23): i) the overarching goal of the project was to assist the Government to achieve the MDGs by means of "well proven cost effective strategies"; and ii) a public expenditure review had been recently conducted and "provided relevant information on and analysis of the sector policy from an economic perspective."
a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return at appraisal and the re-estimated value at evaluation:
* Refers to percent of total project cost for which ERR/FRR was calculated