|1. Project Data:
ICR Review Date Posted:
|Kh-health Sector Support Project
Project Costs(US $M)
|C3728, CH015, CH016
Loan/Credit (US $M)
|Health, Nutrition and Population
Cofinancing (US $M)
|UK: Department for International Development (DFID)
Board Approval Date
|Health (80%), Non-compulsory health finance (10%), Sub-national government administration (5%), Central government administration (5%)|
|Tuberculosis (23% - P)
Nutrition and food security (22% - P)
Health system performance (22% - P)
Child health (22% - P)
Rural services and infrastructure (11% - S)|
||ICR Review Coordinator:
||Judyth L. Twigg
|2. Project Objectives and Components:|
According to the Project Appraisal Document (PAD, p. 3) the development objectives were:
"to contribute to the improvement of the health status of the population by: (a) increasing the accessibility and the quality of health services; and (b) assisting the Kingdom of Cambodia to implement its Health Sector Strategic Plan and strengthen the sector's capacity to manage resources efficiently."
According to the Development Credit Agreement (schedule 2, p. 16) the objectives of the project were:
"to assist the Kingdom of Cambodia to improve the health status of its population, particularly the poor and rural population, through: (i) improvement in the accessibility, quality and affordability of health services in selected Provinces, and (ii) support for the implementation of its Health Sector Strategic Plan and strengthening of its capacity to carry out the health sector reform and to manage the health sector resources efficiently."
The objective of the DCA is used for this review as it points to the health outcomes of the poor and rural population.
b. Were the project objectives/key associated outcome targets revised during implementation?
Component 1: Improved Delivery of Health Services (appraisal, US$ 14.41 million; actual, US$ 15.70 million)
Component 1 was to focus on access, quality and affordability by financing the development of primary health care facilities, referral hospitals (at district and provincial levels), equipment, and maintenance. It was also to support training to improve service quality, the establishment of a Quality Improvement/Standards Unit in the Ministry of Health (MOH), and quality assurance activities in three districts in the Kampong Thom province. Other planned activities were performance-based contracting for district health services, activities to increase user participation in decision-making, health equity funds to pay for services provided to the poor, and improvement of drug quality and availability.
Component 2: Improved Programs Addressing Public Health Priorities (appraisal, US$ 10.21 million; actual, US$ 12.05 million)
Component 2 was to focus on infectious disease control (i.e. malaria, tuberculosis, dengue and sexually transmitted infections/HIV/AIDS, and nutrition). For malaria, support was to include the provision of insecticide treated bed-nets, training for better case management, improved surveillance, and information, education and communication activities. TB control activities were to include integration of activities at the Health Center (HC) and district hospital levels, increasing case detection and reducing default rates, improving laboratory capacity, and strengthening information, education and communication activities. For dengue control, the activities were to include strengthening early diagnosis, appropriate treatment, and vector control. For STI/HIV/AIDS, the project was to support procurement of drugs and 100% condom use among high risk groups. For nutrition, financing was to include training, information campaigns, and community outreach to support an essential package of preventive and curative services, such as exclusive breast-feeding up to 6 months, timely and adequate complementary feeding from 6 to 24 months, appropriate care of sick and malnourished children, micro-nutrient supplementation for women and children, and increased availability of iodized salt.
Component 3: Strengthened Institutional Capacity (appraisal, US$ 4.05 million; actual, US$ 6.54 million)
Component 3 was to provide support to key functions at central, provincial and district levels. This was to include oversight of policy, improving the legislative and regulatory framework, better sector planning and program coordination (specifically improving Ministry of Health analytical capacity for health financing, planning capacity at provincial and district levels, and coordination and monitoring of plan implementation). The component planned to improve sectoral management, including human resource planning and management, improvement of skills and performance, strengthening financial management systems and capacity, and recruitment of procurement consultants. The component sought to improve monitoring and evaluation (M&E) capacity, including surveillance of health service delivery outside the public sector, and the use of data to inform health sector governance and planning.
d. Comments on Project Cost, Financing, Borrower Contribution, and Dates
Actual total project costs were 7.7% higher than anticipated. The ICR does not provide information on reasons for the increased project cost.
The Cambodia Health Sector Support Program (HSSP) was designed and financed by the International Development Association (IDA), the Royal Government of Cambodia (RGC), the Asian Development Bank (ADB), and the UK Department for International Development (DfID). After inception they were joined by the United Nations Population Fund (UNFPA). Whereas DfID channelled funds through the World Bank Trust Fund, UNFPA and ADB funding was managed in parallel. Though UNFPA and the ADB had their own reporting systems, they joined common management arrangements under HSSP, which was seen as the first step towards a sector-wide approach (SWAp) (ICR, p.1).
The project was financed through an IDA credit of US$ 18.99 million, an IDA Grant for Poorest Country of US$ 8.96 million, an IDA Grant for HIV/AIDS of US$ 2.24 million, and a DFID Trust Fund grant of US$ 1.32 million (ICR, p. 25).
Against a planned US$ 3.00 million, the borrower contributed US$ 2.23 million. The Borrower's contribution was lower than anticipated because the World Bank agreed to increase the percentage of Bank financing for (i) works under categories A of the project from 90% to 100%; and (ii) consulting services under parts A and C of the project from 95% to 100%. In addition, a Health Equity Fund (HEF) was added with 50% counterpart financing, but the reduction in counterpart financing for other components offset this increase.
The project closed 4 years and 6 months later than initially planned. The original closing date of 12/31/2007 was extended to 12/31/2008 due to start-up delays and low disbursements. Two further extensions to 12/31/2010 and 21/31/2011 were granted to enabled the project to complete construction activities that had been subject to delays (ICR, p. 3).
|3. Relevance of Objectives & Design:|
a. Relevance of Objectives:
High. The development objectives were highly relevant to country conditions, Government policy, and the Bank's strategy at the time of appraisal, and they remained relevant at closure.
At the time of appraisal service utilization was inequitable, and access and affordability of services for the poor were seen as critical. Many health indicators were below the average of Southeast Asian Countries, with particular concern for communicable and infectious disease, malnutrition, and maternal and child mortality (PAD, p.9).
The Bank's most recent Country Partnership Strategy (2005 - 2008) contained a focus on equity in access to services and improving quality and efficiency of services to the poor (CPS, p. 35). The current Government Health Sector Strategic Plan (2008 -2015) renders the overarching objective of improving the health status of the population as very relevant, as addressing population health problems is termed a strategic priority. Similarly, improvements in accessibility, quality and affordability are framed as priorities (HSSP, p. 2). Capacity strengthening and managing resources efficiently are also mentioned.
b. Relevance of Design:
Substantial. The Project Appraisal Document's results chain is plausible. The development of health care facilities and support to infectious disease control programs credibly feed into the objective of improved health status of the population. Similarly, a focus on primary health care facilities feeds into the objective of improved access to health services (especially for the poor), and the support of health equity funds is likely to contribute to the affordability of health services to the poor. The establishment of a Quality Improvement/Standards Unit within the Ministry of Health (MoH) and quality assurance activities in selected districts are likely to have quality improvement implications. Finally, improved capacity to carry out health sector reform and manage the health sector efficiently are conceivably achieved through a component that focuses on improved monitoring and evaluation (M&E) capacity and better sector planning and program coordination.
The results framework captures well how inputs are intended to translate into outputs and outcomes, though it would have benefitted from more detail in measuring accessibility, quality, and improved capacity to carry out health sector reform and manage health sector resources efficiently.
|4. Achievement of Objectives (Efficacy) :|
The Project Development Objective (PDO) is broken down here into 5 parts: (1) to improve the health status of the population, particularly the poor and rural population; (2) to improve the accessibility of health services in selected provinces; (3) to improve the quality of health services in selected provinces; (4) to improve affordability of health services in selected provinces; and (5) to strengthen the capacity to carry out health sector reform and manage the health sector resources efficiently.
Some data in the ICR's cover datasheet and the discussion of key/core performance indicators in the main ICR text are conflicting, in which case the datasheet was given precedence.
Objective (1): To improve the health status of the population, particularly the poor and rural population:
Additional evidence presented by the region renders this objective Substantial.
The pulmonary TB smear (+) case detection rate increased from 57% in 2002 to 66% in 2011, missing the target of 70%.
The pulmonary TB smear (+) cure rate decreased from 93% in 2003 to 91% in 2011, meeting the target of >85%.
The percentage of children under 1 year of age fully immunized was not measured. Their immunization for measles increased from 39% in 2000 to 73.6% in 2010, surpassing the target of 70.0%.
The percentage of pregnant women receiving at least two antenatal care consultations increased from 29% in 2002 to 72% in 2010, nearly achieving the target of 75%.
The share of rural women receiving antenatal care increased from 25% in 2000 to 79% in 2010. No target was set.
The percentage of deliveries attended by trained staff increased from 20% in 2002 to 69.6% in 2010, nearly meeting the target of 70%.
The share of rural women delivering in health facilities increased from 11% in 2000 to 60% in 2010. No target was set.
The percentage of married women aged 15-49 years using modern contraceptives in public health services increased from 17% in 2002 to 35% in 2010, falling short of the target of 44%.
The HIV sero-prevalence rate among women attending antenatal care dropped from 1.9% in 2002 to 0.4% in 2010. No target was set.
The malaria case fatality rate of severe cases treated in public facilities per 100 patients decreased from 10.85% in 2002 to 0.22% in 2011. A target of 0.25% was set for 2010.
The incidence of malaria per 1000 inhabitants in high risk areas was reduced from 8.6 in 2002 to 3.34 in 2010, meeting the target of 3.58 in 2010.
The national average maternal mortality ratio measured in terms of live births increased from 437/100,000 in 2000 to 472/100,000 in 2005 and subsequently decreased substantially to 206/100,000 in 2010, exceeding the target of 243/100,000 live births.
The national average fertility rate decreased from 4.0 in 2000 to 3.4 in 2005 to 3.0 in 2010, exceeding the target of 3.5 in 2010. No disaggregated information is provided for the rate of the rural poor targeted under this project.
The national share of stunting among children under 5 years of age decreased from 45% in 2000 to 39.9% in 2010, missing the target of 22%. Rural stunting decreased by 8 percentage points from 51% in 2000 to 43% in 2010. No target was set.
The national share of wasting among children under 5 years of age decreased from 15% in 2000 to 10.9% in 2010, missing the target of 9%. Rural wasting among children under 5 years of age decreased by 8 percentage points from 16% in 2000 to 8% in 2010. No target was set.
The national percentage of children under 5 years of age who were underweight decreased from 45% in 2000 to 28.3% in 2010, meeting the target of 29%. The share of rural children under the age of 5 who were underweight was reduced by 9 percentage points from 41% in 2000 to 32% in 2010. No target was set.
The national mortality rate of children under 5 years of age decreased from 124/1,000 in 2000 to 54/1,000 in 2010, exceeding the target of 85/1,000. Child mortality in rural areas decreased from 18.1/1000 live births in 2000 to 4.9 live births in 2010. No target was set.
The national infant mortality rate per 1000 live births was reduced from 95 in 2000 to 45 in 2010, exceeding the target of 60. The infant mortality rate per 1000 live births in rural areas was reduced by 44% from 96 in 2000 to 54 in 2010. No target was set.
Child mortality in the poorest quintile declined from 127 per 1000 in 2005 to 90 per 1000 births in 2010, compared to a decline from 43 to 30 per 1000 among the richest quintile. This is an approximate 30% reduction in both groups.
Objective (2): To improve the accessibility of health services in selected provinces: Substantial
The number of health centers offering Minimum Package of Activities (MPA) services was 294 in 2003, and a target of 470 was set for 2006. In 2010, 469 out of 1010 offered the MPA.
In 2011, 56 referral hospitals offered the Complementary Package of Activities (CPA), against a target of 46 in 2006.
The per capita consultation rate in public facilities of new cases increased from 0.38 in 2002 to 0.63 in 2010. The target set for 2006 was 0.5.
Average distance for the poorest quintile to travel to a health center is reported to have fallen by 36% between 2004 and 2007 (Cambodia Social and Economic Survey 2004, 2007). The ICR does not provide further detail on this trend.
Objective (3): To improve the quality of health services in selected provinces: Modest
A Quality Assurance Office was established and is still functioning in the Ministry of Health (MOH), and various quality assessment tools were developed and implemented.
No consistent methodology was adopted to measure client satisfaction. In 2005, the percentage of patients satisfied with services received in public health facilities was 95% for the poorest and 89% for the better off. Satisfaction at public facilities was rated 8.4/10 in 2010 (ICR p. 41).
A study on the lessons of Health Equity Funds (HEFs) in Cambodia (WHO bulletin 2009) finds that HEF patients did not face stigma, were rarely charged unofficial fees, and helped improve overall quality of care. It is argued that these Funds address quality of care issues by providing additional facility revenues and establishing formal contractual arrangements. HSSP in total supported 13 HEFs.
The ICR provides no data comparable across time on patient satisfaction, or other evidence on quality of health services.
Objective (4): To improve affordability of health services in selected provinces: Substantial
The number of fully and partially exempted households for which costs have been paid by equity funds increased from 18,591 in 2003 to 227,457 in 2008. No target was set.
The percentage of people in the poorest quintile paying catastrophic out-of-pocket expenditures for health care was reduced from 3.6% in 2004 to 2.3% in 2009. No target was set.
An independent evaluation of the Health Sector Support Project (HSSP) commissioned by the MOH undertook a household survey and beneficiary assessment on Health Equity Funds (HEF), which concluded that HEFs reduce out-of-pocket and catastrophic spending by the poor on health (ICR, p.12). The ICR provides no information regarding the size of the impact or performance in comparison to control groups.
Objective (5): To strengthen the capacity to carry out health sector reform and manage health sector resources efficiently: Modest
The percent of Provincial Health Departments (PHD) producing annual health plans remained at 100% from 2004 to 2008, reaching its target of 100%.
The percent of Operational Districts (OD) producing annual health plans remained at 100% from 2004 to 2008, reaching its target of 100%.
The MoH recurrent budget (salary excluded) as a proportion of the total government recurrent budget increased from 9.5% in 2003 to 11.2% in 2008, missing the target of 11.9%.
The project team later provided further information: with project funding, the MOH introduced a rolling mid-term planning process and redefined the planning roles of the central, provincial, and district levels. The project supported the progressive decentralization of the planning process. Further, the project contributed to the organization of annual sector reviews, which brought together stakeholders to review sectoral achievements and discuss the comprehensive rolling plan.
Although there were activities implemented in this area, little information is provided in the ICR or in the additional information provided by the project team on improvements in the actual capacity to carry out health sector reform and manage health sector resources efficiently.
The PAD (p. 67) provided an economic analysis of the project including an estimated internal rate of return of 17% and a net present value of US$ 45 million. This return was seen as not robust in the face of moderate project risks without the added benefits from the priority programs.
No follow-up analysis was provided by the ICR.
Public sector reform and project investments were largely delayed, including the rebidding of civil works contracts that necessitated a further two-year extension. The rebidding process, however, resulted in 30% lower contract prices.
The ICR provides no further detail on implementation at least cost or other value-for-money analysis.
Overall efficiency is rated as modest.
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