Document of The World Bank FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT FEDERAL REPUBLIC OF NIGERIA

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Human Development 3 Africa Region Document of The World Bank FOR OFFICIAL USE ONLY IMPLEMENTATION COMPLETION REPORT FEDERAL REPUBLIC OF NIGERIA IMO HEALTH AND POPULATION PROJECT (Ln UNI) December 22, 1997 Report No This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

2 CURRENCY EQUIVALENTS (October 31, 1997) Currency Unit = Naira US$1 = N81.90 WEIGHTS AND MEASURES Metric System FISCAL YEAR OF BORROWER January - December ABBREVIATIONS AND ACRONYMS ASEDS DRF EDP EDS FMOF FMOH FP/MCH HMB IEC ISEDS LGA MBHP NGO PCU PHC SMOH TBA VHW WHO Abia State Essential Drugs Programme Drug Revolving Fund Essential Drugs Programme Essential Drugs Services Federal Ministry of Finance Federal Ministry of Health Family Planning/Maternal and Child Health Health Management Board Information, Education, and Communication Imo State Essential Drugs Programme Local Government Authorities Minimum Basic Health Care Package Non-Governmental Organization Project Coordinating Unit Primary Health Care State Ministry of Health Traditional Birth Attendants Village Health Workers World Health Organization Vice President: Country Director: Sector Manager: Task Team Leader: Jean-Louis Sarbib (AFR) Yaw Ansu (AFC12) Helena Ribe (AFTH3) Shiyan Chao (AFTH3)

3 IMPLEMENTATION COMPLETION REPORT NIGERIA IMO HEALTH AND POPULATION PROJECT [Ln UNI] TABLE OF CONTENTS FOR OFFICIAL USE ONLY PREFACE EVALUATION SUMMARY... i PART I: PROJECT IMPLEMENTATION ASSESSMENT I. INTRODUCTION... 1 A. Macroeconomic Setting... 1 B. Bank's Role in the Sector... 2 II. PROJECT OBJECTIVES... 2 A. Project Objectives and Components... 2 B. Loan Covenants and Special Agreements... 3 C. Evaluation of Project Objectives... 3 III. IMPLEMENTATION EXPERIENCE AND RESULTS...4 A. Assessment of Project's Success and Sustainability... 4 B. Summary of Costs and Financing Arrangements... 6 C. Implementation Schedule... 6 D. Analysis of Key Factors Affecting Major Objectives... 6 E. Assessment of the Borrower's and the Bank's Performance... 8 F. Assessment of Project's Outcome... 8 IV. SUMMARY OF FINDINGS, FUTURE OPERATIONS AND KEY LESSONS LEARNED... 9 A. Important Findings of Project Implementation Experience... 9 B. Future Operations and Sustainability... 9 C. Lessons for Future Projects in the Sector PART II: STATISTICAL ANNEXES APPENDIXES: A. Missions' Aide-memoires B. Borrower's Contribution to the ICR This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

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5 IMPLEMENTATION COMPLETION REPORT FEDERAL REPIJBLIC OF NIGERIA IMO HEALTH AND POPULATION PROJECT [Ln UNI] PREFACE This is the Implementation Completion Report (ICR) for the Imo Health and Population Project in Nigeria, for which Loan 3034-UNI in the amount of US$ 27.6 million was signed on May 2, 1989 and made effective on December 15, The loan was closed on June 30, 1997 after two extensions from the original closing date of June 30, As of December 18, 1997 there was a balance of US$3.5 million. A small number of outstanding payments and special commitments totalling about US$5,000 require correction or finalization. Final disbursement is expected in January, 1998, at which time the undisbursed balance will be canceled. The ICR was prepared by Hong Chen with Shiyan Chao and David Peters, assisted by Ross Pfile (AFTH3), and reviewed by Irene Xenakis (AFTH3), Hazel Denton (SECBO) Helena Ribe (Technical Manager for AFTH3), Jerome Chevallier (Acting Country Director for Nigeria), and the Nigeria Country Team. Both Imo and Abia States, as well as the Federal Ministry of Health provided their own reports which were summarized and appear as appendixes to the ICR. Preparation of this ICR was begun during the Bank's supervision mission in June It is based on mission's discussions with the project staff and on materials in the project file. The Borrower helped to prepare the ICR by contributing its Implementation Completion Report and the views reflected in the mission's aide-memoire, and commenting on the draft ICR.

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7 IMPLEMENTATION COMPLETION REPORT FEDERAL REPUBLIC OF NIGERIA IMO HEALTH AND POPULATION PROJECT [LN UNI] EVALUATION SUMMARY 1. Introduction. The Imo Health and Population Project (IHPP) was the Bank's second project in the health, nutrition, and population (HNP) sector in Nigeria, and came at a time when the Bank's portfolio in Nigeria was expanding rapidly. Agreements for a loan of US$ 27.6 million for IHPP were signed on May 2, 1989, and became effective on December 15, The IHPP was similar to a previous US$ 34 million Sokoto Health Project (Ln UNI), which became effective in Both of these projects were designed to assist the State Government in improving health, nutrition, and family planning services, and in improving the Federal Ministry of Health's (FMOH) ability to help State and local health programs prepare new projects. 2. The Bank approved three other HNP projects in Nigeria after the IHPP. The National Essential Drugs Project (Ln UNI, effective 1991, closed 1997) supported the establishment of Essential Drugs Programs (EDPs) in seven States and the FMOH. The National Population Project (Cr UNI, effective 1992) provided funds for population activities mainly at the national level, but this project experienced significant implementation difficulties, and steps are being taken to cancel the loan. On the other hand, the Health System Fund Project (Ln UNI, effective 1992), which provides support to sixteen State Ministries of Health to improve service delivery, is achieving good results on the ground. 3. Project Objectives and Components. The Project was comprised of Part A, covering Imo State, and Part B, covering FMOH activities. The original objectives for Part A of the project were to assist the Government in improving the health and nutritional status of the people of Imo State through: (a) (b) strengthening State and local government institutional and financial capacity to plan, implement, monitor, and evaluate policies and programs for health, nutrition, and family planning; and improving the quality, effectiveness, and utilization of State and local services for health and family planning. 4. Each of these objectives involved a broad variety of activities. In 1993, when Imo State bifurcated into Imo and Abia States, Part A of the project carried over to both States in its entirety. 5. The objective for Part B of the project was to strengthen the capacity of FMOH to: (a) support State and local governments (LGAs) in developing strategies and plans of action to implement national health and population policies; and

8 (b) prepare health and population projects for internal and external financing by providing technical assistance and funding for project preparation. 6. Because of very slow implementation over the first five years of the project (only 17% of the loan was disbursed by March 1994) and a recognition that the project was too ambitious, a mid-term review (MTR) was conducted in June 1994 in order to simplify and restructure the project. The number of activities included in Part A of the project was reduced, and the project focused on delivering a Minimum Basic Health Care Package (MBHP) in each State through: (a) training and retraining primary health care personnel; (b) procuring and distributing essential drugs; and (c) upgrading health facilities. Part B of the project then concentrated on providing technical assistance to the two States to carry out project activities. 7. Loan Covenants and Special Agreements. Several Loan covenants and agreements were included to help the project achieve its objectives. Imo State established a Project Coordination Unit (PCU) and reorganized the State Ministry of Health's (SMOH) Public Health Division. The State was also expected to establish a State Population Council and Population Program, prepare an overall standardized public health staffing plan, and annually review with the Bank the financial plan for the health sector. Neither the staffing nor the financial plans were implemented. This failure was partly due to a new national health policy that made Local Government Areas (LGAs) rather than States responsible for staffing and financing primary health care facilities. 8. Evaluation of Project Objectives. Although the project aimed to address HNP development issues in Imo State, the original objectives were too broad. Most of the detailed implementation objectives were input based and too ambitious. During the MTR, a number of activities, where there was little or no implementation, were dropped, such as establishing the population program. The revised objectives remained somewhat ambitious, but they were more manageable and helped focus activities for the remainder of the project. IMPLEMENTATION EXPERIENCE AND RESULTS 9. Assessment of Project's Success and Sustainability. Although the project was able to meet the broad objective of providing support for Government efforts in Imo State, the project met few of the specific objectives of the project prior to the MTR. By the time of the MTR, the project had achieved limited success in improving the quality of services by initiating the renovation of 97 PHC clinics and 36 LGA drug stores, and initiating the EDP, but little else among the Part A components. The successes in Part B were even more limited. The project had provided minimal technical assistance to States through training in essential drugs programs, and through fellowships. 10. More substantial successes were achieved after the project was restructured at the MTR. The MBHP was introduced in targeted LGAs in both States: three LGAs in Imo State (these later became five LGAs) and nine in Abia State (Abia later expanded the MBHP to all 17 of its LGAs). The MBHP enabled the health providers and clients agree on a "floor" ii

9 package of services that each facility should provide. This was aided by bringing together community representatives and health care providers to assess local health problems and plan strategies. The planned training to support the MBHP was also accomplished. The project conducted intensive training of 838 Village Health Workers (VHW) and Traditional Birth Attendants (TBA) to ensure the provision of health services at the community level. The essential drugs programs were established in both States. Drug Revolving Funds (DRF) were set up at the State level and in health facilities. The DRFs in both States were able to sustain their capital stocks, though the sales of drugs were small, particularly in Abia State. Upgrading of health facilities was also completed. 119 PHC facilities were renovated and constructed under the project, and all 36 LGAs had pharmacy stores built or repaired. Medical equipment and drugs were supplied to some LGA facilities. In Imo State, the Public Health Laboratory was also built and equipped. 11. The sustainability of the project is uncertain. The basic infrastructure built under the project, such as the constructed and equipped health centers, pharmaceutical stores and the public health laboratory will continue to be used to provide health care services. The essential drugs programs will continue to provide drugs, and are operating with little decapitalization of drug stocks, and indicator of financial sustainability. The trained health workers should be able to provide a better quality of services and be able to supervise better. However, due to the late introduction of the MBHP, its long-term effects on service delivery and on people's health is not yet known. Although Imo and Abia States are planning to carry on with the MBHP activities, the sustainability of the project depends on continued financial and political support from the State and local governments, as well as support from local communities. This support has proved unreliable during the project period. Under the current institutional arrangements, the State's supervisory role in primary health care is very weak, because LGAs are financially independent from the State. The success of these primary health care activities will also depend very much on how active and how far each LGA fulfills its responsibilities. 12. Summary of Costs and Financing Arrangements. The total project cost of the project was estimated at appraisal to be US$ million with the Government contributing US$ 9.22 million. Cancellations prior to closure of the Loan amounted to US$ million. Total disbursements of the Loan by December 18, 1997 were US$ million, leaving an undisbursed Loan balance of US$ 3.50 million. At the time of the writing of the ICR, a few outstanding payments valued about US$5,000 are being corrected. The undisbursed balance of the Loan will be canceled in January, 1998, when the final payments will have been made. Government contributed US$ 2.07 million to the project. 13. Implementation Schedule. Identification to Negotiations took only nine months, but two years passed between Negotiations and Project Effectiveness. Implementation was also very slow during the first five years of the project life. The mid-term review was held in June, The closing date was extended twice for a total of two years. 14. Analysis of Key Factors Affecting Major Objectives. A number of constraints hindered the project from achieving its major objectives. The new national health policy iii

10 changed the roles for the federal, State, and local governments, weakened the State role in primary health care, whereas the project design did not adequately adapt to this and the federal government demanded that the project continue to address primary health care largely through the State structures. The project design was rigid in other ways, limiting LGA involvement when they were not able to pay the matching grants, and preventing local training until counterpart funds were released (this was amended after the MTR). Other factors under government control included: (a) the unavailability of counterpart funds for key project activities during much of the first five years prevented key State project activities from occurring, and remained a constraint for the FMOH; (b) constant turnover of government political leaders -- Health Commissioners changed almost annually, and they either misdirected counterpart funds and blocked project implementation, or ensured that particular project activities were completed; (c) the bifurcation of Imo State into Imo and Abia States, which distracted administrative efforts of the State Government at a critical point in project implementation. Weak project and financial management, particularly in Imo State also hampered implementation. Relevant factors generally not specifically under government control included: (a) poor communications and transportation infrastructure, which seriously hampered project implementation, particularly procurement activities, despite the appointment of a procurement agent; and (b) the significant currency devaluation and inflation, which made procurement and essential drugs program management difficult. 15. Assessment of the Borrower's and Bank's Performance. The Borrower's performance, which was not satisfactory during the first five years of project life, improved during the last two years. The federal and State governments did not use counterpart funds as required to undertake key project activities, which seriously disrupted project implementation. In the first five years, project management in Imo State did not improve despite training, and there was an apparent lack of commitment in the PCU and the Ministry to undertake the project activities. Nonetheless, after the MTR, the PCUs in both States were able to carry out the majority of their revised planned work programs. Imo State started to improve financial management and reorganize its financial unit towards the end of the project. However, the performance of the FMOH remained weak throughout the project. The overall performance of the Bank was not satisfactory. The project as designed was difficult to implement and did not sufficiently address the difficult and uncertain country conditions. The Bank did not change the project design in response to the change in policy. Frequent turnover of Bank staff did not ensure consistent supervision and implementation. When supervision visits occurred, they resulted in improved implementation, particularly in the later years. The Bank team's efforts to downsize and refocus the project at the MTR were critical in enabling the project to achieve some successes. The project would have benefited from fundamental restructuring shortly after the policy change. 16. Assessment of Project's Outcome. Few of the original objectives of the project were met prior to the MTR. Although much of the post-mtr objectives were achieved, on balance, the project did not achieve its overall objectives. Of the original objectives under Part A, little was done to improve State health management capacity, establish a population program, disease surveillance system, or conduct IEC activities. The PCU distracted the SMOH, rather than help to build its capacity. After the MTR, the project developed and iv

11 began implementation of an appropriate MBHP. The training provided to the health care workers enhanced their understanding of PHC services at the community level. The project constructed/renovated health facilities which improved the physical access of the facilities. The Part B objectives were clearly not achieved. The project was ineffective in building up FMOH's capacity to help States and LGAs develop health strategies. Support to States virtually collapsed during this time, and it is only more recently that the FMOH, supported by the Health System Fund Project, is restarting its support to State health planning. The sustainability of the project is uncertain, and its outcome is rated unsatisfactory. SUMMARY OF FINDINGS AND KEY LESSONS LEARNED 17. Key lessons learned from the project experience are summarized below. (a) (b) (c) (d) (e) (f) Project design should be more adaptable to major changes in health policy, and to respond to rapidly changing political environments. Between project appraisal and loan effectiveness, the Government published the National Health Policy, which had major implications for the project which should have been addressed earlier. A project that largely takes a supply approach needs strong capacity to administer and utilize inputs, or other policy objectives and activities will be difficult to achieve. Given the unstable environment and limited implementation capacity in Nigeria, project design should be focused on supporting relatively few activities until implementation capacity is demonstrated. Fewer inputs should be provided for a smaller range of activities, and more effort placed on the management of these inputs toward achieving more specific results. When Project Coordinating Units are established separately from the main Ministry, ownership by the Ministry can suffer. Technical staffs of the State Ministries of Health and Local Governments need to be part of the project implementation if their support is needed during implementation. In Nigeria, a more active role of States in supervision of PHC is needed. Community involvement in formulating policies and strategies for PHC development is important if they are to be accepted and implemented. Restructuring of the project was beneficial. The MTR should be done early in the project. The project design should be more adaptable to major changes in health policy, and to respond to the political environment. The appointment of a procurement agent does not necessarily solve all procurement problems or speed up implementation. The communication between the agent and the project staff needs to be very constructive to accomplish the complicated task of procurement. v

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13 IMPLEMENTATION COMPLETION REPORT FEDERAL REPUBLIC OF NIGERIA IMO HEALTH AND POPULATION PROJECT [Ln UNI] PART I: PROJECT IMPLEMENTATION ASSESSMENT 1. INTRODUCTION A. MACROECONOMIC SETTING 1.1 Nigeria has about 110 million people, by far the most populous country in sub- Saharan Africa; about one in every five people in the Region is a Nigerian. The country is poor despite its large and enterprising population and its considerable natural resources, including oil. The 1996 per capita income of $240 is below the level at the time of independence 37 years ago, and is only a fifth of what it was in the early 1980s. About 34 percent of the population falls below the poverty line. Basic social indicators now place Nigeria among the 20 poorest countries worldwide. Political instability and economic mismanagement explain a large part of the poor economic performance. 1.2 The project period (1990 to 1997) witnessed numerous policy and political changes in Nigeria that influenced the implementation. Nigeria's increasing fiscal indiscipline and progressive shift away from the structural adjustment policies adopted in 1986 culminated in the return to a regime of heavy controls in the foreign exchange and credit markets by The resulting rapidly worsening economic conditions (inflation peaked at 77% in 1994) led to a re-assessment of the policy direction. In January 1995, the government introduced a policy of "guided deregulation" and began to re-establish control over fiscal and monetary policy, evidenced by a remarkable stability of the market exchange rate to date and rapid disinflation. In 1996 Government continued the process of gradual liberalization, resulting in a small economic rebound of 3.1 percent growth. *1.3 The absence of a credible restructuring of federal expenditure priorities and of programs necessary to produce a structural fiscal balance leaves unresolved the sustainability of the macro-stabilization program initiated in Government still fails to move towards privatization. Budgetary transparency and accountability is limited (some 40 percent of federal expenditures occur off-budget). Budgetary allocation priorities were unchanged in 1996 and 1997 and continued to support wasteful expenditures. There is no demonstrated commitment to poverty alleviation or to rectifying a substantial deterioration in the quality of essential social and infrastructure services. Neither macro-economic, social, nor political stability is assured over the medium term. 1

14 B. BANK'S ROLE IN THE SECTOR 1.4 This loan financed the Bank's second project in the HNP sector in Nigeria. It was a State-level project, with a Federal component (Part B) to strengthen FMOH's capacity to assist State and local health programs and to prepare new HNP projects. At project preparation, the Bank's sectoral dialogue with the Government emphasized two critical needs: i) to undertake a strong population program, and ii) to address key health financing issues. With the support from the Bank, FMOH developed a new national population policy, and along with several States commissioned health financing studies. 1.5 Prior to this project, the Bank financed the Sokoto Health Project (Ln UNI) for US$ 34.0 million which became effective in January Three other projects were approved subsequently by the Bank in the health, nutrition, and population (HNP) sector. The National Population Project (Cr UNI, effective 1992) provides funds for population activities, initially through activities at the federal level, but implementation has been poor, and steps are being taken to cancel hte loan. The National Essential Drugs Project (Ln UNI, effective 1991, closed 1997) was used to establish Essential Drugs Programs (EDPs) in seven States and the FMOH, creating a system for the long term supply of safe, affordable and effective drugs. The Health System Fund Project (Ln UNI, effective 1992) provides support to 16 States to build up the institutional capacity and infrastructure of State health services, and to finance core State programs. 2. PROJECT OBJECTIVES A. PROJECT OBJECTIVES AND COMPONENTS 2.1 The project was divided into two parts: Part A for State activities; and Part B for Federal activities. The original objective for Part A was to assist the Government in its effort to improve the health and nutritional status of the people of Imo State through: (a) (b) strengthening the State and local government's institutional and financial capacity to plan, implement, monitor and evaluate their policies and programs for health, nutrition and family planning; and improving the quality, effectiveness and use of State and local services for health and family planning. Support for institutional development involved funding for equipment, materials, training, studies, and operating costs to plan and monitor HNP activities, and to establish a population program. 2.2 Support for improving the quality of HNP services included funds for equipping, training, and operating costs for family planning; renovating, constructing, and equipping primary health care (PHC) clinics; improving drug supply and distribution through establishment of essential drugs programs; establishing a disease surveillance and diagnostic service; supporting information, education, and communication (IEC) activities. In 1993, 2

15 Imo State was bifurcated into Imo and Abia States, and Part A of the project was carried over with the same components to both States. 2.3 The objective for Part B of the project was to strengthen the capacity of FMOH to: (a) support States and local government authorities (LGAs) in developing strategies and plans of action in order to implement the national health and population policies; and (b) prepare health and population projects for internal and external financing by providing technical assistance and funds for project preparation. 2.4 Because of very slow implementation (only 17% of the loan had been disbursed by March, 1994), a mid-term review (MTR) was held in June 1994 to simplify and restructure the project. Part A of the project was re-focused on the delivery of a Minimum Basic Health Care Package (MBHP) in each State by: (a) training and retraining primary health care personnel; (b) procuring and distributing essential drugs; and (c) upgrading health facilities. Part B of the project was changed to concentrate on providing technical assistance to the two States in order to carry out the project activities. B. LOAN COVENANTS AND SPECIAL AGREEMENTS 2.5 Several Loan covenants and agreements were included to help the project achieve its objectives. Imo State established a Project Coordination Unit (PCU) and reorganized the State Ministry of Health's (SMOH) Public Health Division. The State was also expected to establish a State Population Council and Population Program, prepare an overall staffing plan for public health facilities in accordance with a standard staffing pattern, and annually review with the Bank the financial plan for the health sector. None of the latter agreements were implemented, partly because under a new national health policy, Local Government Areas (LGAs) became responsible for staffing and financing primary health care facilities. C. EVALUATION OF PROJECT OBJECTIVES 2.6 Though the project intended to address issues relevant to the development of HNP in Imo State, the original project objectives were overly broad. The majority of the more detailed project implementation objectives were input based, and the activities outlined were too ambitious. During the MTR, the project was restructured by reducing the number of activities, where little progress had been made, including the population program. The new objectives remained somewhat ambitious, but were more manageable, and helped focus activities for the remainder of the project. 3

16 3. IMPLEMENTATION EXPERIENCE AND RESULTS A. ASSESSMENT OF PROJECT'S SUCCESS AND SUSTAINABILITY 3.1 The project only partially met a few of the original objectives of the project prior to the MTR. By 1994, the project had achieved limited success in improving the quality of services by initiating the renovation of 97 PHC clinics and 36 LGA drug stores, and initiating the EDP, but little else among the Part A components. The successes in Part B were even more limited. The project had provided minimal technical assistance to States through training in essential drugs prograrns, and through fellowships. Only 17% of the Loan was disbursed by March The Mid-term Review was conducted in June 1994, which was a critical point for the implementation of the project. The MTR simplified and restructured the project objectives and components in order for the project to concentrate on the activities that were essential to the main objectives and were achievable in the remaining life of the project. The project adopted a new approach to strengthen primary health care -- the development of the Minimum Basic Health Care Package (MBHP) for PHC facilities in the LGAs. The primary objective of this approach is to involve local communities in defining and implementing a package of primary health care services that meets the minimum requirement of the community. The project focused on the delivery of MBHP through: (a) training primary health care personnel; (b) procuring and distributing essential drugs; and (c) upgrading health facilities. Theproject was extended for eighteen months to try out this approach. In the end, the project was able to substantially achieve most of these revised objectives. 3.3 The MBHP was introduced in targeted LGAs in both States: three LGAs in Imo State (these later became five LGAs) and nine in Abia State (Abia later expanded the MBHP to all 17 of its LGAs). Both States conducted detailed assessment of the health facilities by collecting data on the prevalent diseases, services provided, personnel, material and equipment, drug situation, patient flow, and training provided. The MBHP enabled the health providers and clients agree on a "floor" package of services that each facility should provide. This was aided by bringing together community representatives and health care providers to assess local health problems and plan strategies. 3.4 The planned training to support the MBHP was accomplished. The project developed a training manual for each LGA based on the curriculum provided by the FMOH and integrated field visits into the training programs. Various training was conducted for trainers at LGA level. The trainers would train health workers in village health facilities. Due to the fact that LGAs were facing budget constraints, the project was not able to carry out as much training as required. States are preparing to use the staff from these model LGAs and continue to train other communities. Staff from the State Ministries of Health and PCUs in the two States also benefited from overseas training (Imo State-13 staff; Abia State-10 staff). The project conducted intensive training of the 838 Village Health Workers (VHW) and Traditional Birth Attendants (TBA) to ensure the provision of health services at the community level and also equipped them with simple tool kits. The State projects also 4

17 provided various local training to different cadres (doctors, pharmacists, nurses, accountants, policy makers, etc.) at the State level. The total of 1,240 health staff in Imo State and 749 in Abia State received training. The overall impact of the training provided is mixed, however. A significant number of staff left the sector or did not use the trained skills. 3.5 The essential drugs program was established in both States. The project succeeded in adopting the National Drug Formulary, developing an essential drugs list, introducing the use of generic drugs. The Imo State Essential Drugs Program was able to procure drugs through International Competitive Bidding. Drug Revolving Funds (DRF) were set up at both State and health facility levels. The DRFs at the State levels were able to sustain their capital stocks, though the sales of drugs were small, particularly in Abia State. The Abia State Essential Drugs Program (ASEDS) started late and only received the majority of ICB procured drugs in the last year of the project. Nevertheless, ASEDS develop its essential drug list and conducted a market survey on drug pricing. The project constructed pharmaceutical stores for each LGA and provided vehicles for drug distribution. 3.6 The planned upgrading of health facilities was completed. 119 PHC facilities were renovated and constructed and 36 LGA pharmacy stores were built under the project. The PCU buildings and the Central Pharmaceutical Stores were also constructed. Medical equipment and supplies were procured. Some are yet to be distributed to the facilities because lack of security or non-payment of matching grants by the LGAs. In Imo State, the Public Health Laboratory was also built and equipped. 3.7 The achievement of the Federal Component (Part B) was very limited. Before the MTR the major activities in Part B were overseas training. Some funds were provided to assist the development of new projects: The Population Project and Health System Fund Project. Due to the low impact from overseas training, (many trained staffs left their original jobs after the training), the MTR ceased foreign fellowships for the Federal component. Part B focused on provision of technical assistance to the States for preparation of health projects. Tlhis subcomponent was not implemented. 3.8 The sustainability of the project is uncertain. The basic infrastructure built under the project, such as the constructed and equipped health centers, pharmaceutical stores and the public health laboratory will continue to be used to provide health care services. The essential drugs programs will continue to provide drugs, and are operating with little decapitalization of drug stocks indicating some financial sustainability. The trained health workers should be able to provide a better quality of services and be able to supervise better. However, due to the late introduction of the MBHP, its long term effects on service delivery and on people's health are not yet known. Although Imo and Abia States are planning to carry on with the MBHP activities, the sustainability of the project depends on continued financial and political support from the State and local governments, as well as support from local communities. This support has proved unreliable during the project period. The performance of the project was highly dependent on the key managers' commitment and capability, which was unstable in Nigeria situation. Under the current institutional arrangements, the State's supervisory role in primary health care is weak, because LGAs are 5

18 financially independent from the State. The success of these primary health care activities will also depend very much on how active and how far each LGA fulfills its responsibilities. B. SUMMARY OF COSTS AND FINANCING ARRANGEMENTS 3.9 The total project cost was estimated at appraisal to be US$ million with the Government contributing US$ 9.22 million. Cancellations prior to project closing amounted to US$ million. Total disbursements of the Loan by December 18, 1997 were US$ million, with an undisbursed balance of US$ 3.50 million. There are a number of outstanding payments totalling about US$5,000 that will need to be made by January, 1998, at which time the undisbursed balance will be canceled. Government contributed US$ 2.07 million to the project. C. IMPLEMENTATION SCHEDULE 3.10 The loan was signed May 2, 1989, and became effective December 15, Implementation was very slow during the first five years of the project life. At the mid-term review in June 1994, it was agreed that the project scope be reduced. Project implementation improved significantly in both States and prospects for future progress in achieving development objectives seem likely. The original closing date was June 30, 1995, and was first extended to December 31, The project received another 6 month extension to complete delivery of the goods which were procured through ICB. D. ANALYSIS OF KEY FACTORS AFFECTING MAJOR OBJECTIVES 3.11 There were several factors that affected the project in achieving its major objectives. Key factors that were under the control of the government include: (a) (b) (c) The bifurcation of Imo State into Imo and Abia States in June It caused institutional changes and slowed down implementation. The change in the roles and responsibilities of the federal, State and local governments made the project design obsolete. The LGAs became financially and managerially autonomous from the States. The role of the State governments on primary health care was weakened, making it very difficult for the States to plan, supervise, and monitor PHC activities. The lack of support from the government hampered project implementation at the beginning of the project. According to the original design of the project, local training was to be funded by counterpart funds; however, there was no counterpart fund provided from the federal and State governments for these purposes, and local training was not carried out. The problem of insufficient funds was later solved by deducting at source for State funds, and the Bank revising the Loan Agreement to provide resources for training. However, the 6

19 federal Government never fulfilled its obligations on counterpart fund for this project. It has only contributed less than 3% of its expected counterpart funds to Abia State project, and 1.3% of its expected counterpart funds to Imo State project. The LGAs and communities also found it difficult to pay the required 10% matching grant for the civil works, equipment, and supplies that were to be handed over to them. (d) Constant turnover of State government (about once every year), LGA government, and project staff greatly affected project performance The factors that affected implementation and were subject to implementing agency control were as follows: (a) (b) (c) Poor ability to manage procurement within the PCU. At the mid-term review, it was recommended that a procurement agent would be used. However, the ICB procurement carried out by the procurement agent was also less than satisfactory. There were major delays on the part of the States, and the procurement agent was not able to provide the needed assistance to them. Twenty four percent of Imo State's goods and twenty seven percent of Abia State's goods procured by the procurement agent were not delivered. Weak financial management in Imo State. There were serious mismanagement of the Special Account and record keeping was not up to standards. The Bank tried to assist the State in improving its management by recommending them hire financial consultants. It was only towards the very end of the project that the State started take actions and reorganized its financial unit. Lack of involvement of Ministry of Health officials, or conflict between the Ministry and the PCU impeded implementation There were other factors which affected the project achieve its objectives. The significant currency devaluation and inflation, particularly between , made normal procurement difficult. The huge price variations of civil works complicated the normal execution of construction contracts. There were civil disturbances and strikes during the project period. The poor communications and transportation infrastructure in the country seriously affected project activities. Serious fuel shortages made project supervision and implementation very difficult. E. ASSESSMENT OF THE BORROWER'S AND THE BANK'S PERFORMANCE 3.14 The performance of the Borrower should be evaluated in two stages: (a) project start to mid-term review, (b) mid-term review to project completion. Project implementation was not satisfactory during the first part of project life. The federal and State governments did not release counterpart funds, which seriously disrupted project implementation, particularly 7

20 training activities and civil works. Little effort was put into establishing a population program. Project management in Imo State was not focused, suggesting a lack of commitment by the PCU and the State, particularly in comparison with Abia State, where performance was much better. Financial management performance was weak, especially in Imo State. After the mid-term review reduced the project scope, project implementation improved, most notably in Abia State. The PCUs in both States were able to carry out the majority of their revised planned work program. Towards the very end of the project, Imo State started take actions to improve its financial management and reorganized its financial unit The Bank's overall performance was deficient. The Bank appropriately identified primary health care as a critical area for support in the sector. However, the project design was far too complex, given circumstances. There was a lack of appreciation for the weak capacity and future constraints for the project. Between appraisal and effectiveness, a new national health policy removed State responsibility for most primary health care activities included in the project, yet the project design remained unchanged. The much needed midterm review was carried out with to much delay. The project scope was reduced then and implementation improved. The supervision visits conducted by the Bank proved to be beneficial to the project. States benefited a great deal from regular Bank visits and project implementation improved towards the end of the project. However, the project suffered from frequent change in task managers. F. ASSESSMENT OF PROJECT'S OUTCOME 3.16 Few of the original objectives of the project were met prior to the MTR. Although many of the post-mtr objectives were achieved, on balance, the project did not achieve its overall objectives. Of the original objectives under Part A, little was done to improve State health management capacity, establish a population program, and a disease surveillance system. The PCU became an implementation agency rather than assisting the SMOH to carry out the project activities. The successes in improving service quality were limited to beginning the renovation of health facilities and starting the essential drugs programs. The original Part B objectives were clearly not achieved. The project was ineffective in building capacity in the FMOH to help States and LGAs develop health strategies. Support to States virtually collapsed during this time, and it is only recently that the FMOH, assisted by the Health System Fund Project, is providing help to State health planning. The second Part B objective was also not met, as the FMOH did not make any significanrt contribution to the preparation of subsequent HNP projects. The project was, however, mostly satisfactory in meeting the revised objectives of the MTR. The project developed and began implementation of the MBHPs. The training provided to the health care workers enhanced their understanding of PHC services at the community level. The project constructed or renovated health facilities, which improved the physical access of the facilities. However, the project was not effective in strengthening the institutional capacity at the State and LGA levels. The sustainability of the project is uncertain and its outcome unsatisfactory. 8

21 4. SUMMARY OF FINDINGS, FUTURE OPERATIONS AND KEY LESSONS LEARNED A. IMPORTANT FINDINGS OF PROJECT IMPLEMENTATION EXPERIENCE 4.1 The performance of the Imo and Abia sub projects varied significantly. The project management in Imo State was weak for almost entire project period. Project managers and the Commissioners for Health in Imo State we constantly changed. The Imo project did not have a strong leadership until the end of the project, when the project was finally assigned a dynamic manager and was able to carry out more activities in a short period of the time. On the other hand, the Abia sub project started later but was able to accomplished much more than the Imo sub project. One of the reasons for the achievement was that the Abia sub project had a stronger managementeam and was supported by their Commissioner for Health. When the Bank Quality Assurance Group visited the Abia Project, they specifically commended the Abia project's achievement and recommended that the project should be extended. The commitment and capability of the project managers proved to be essential in achieving project results. The political support from the State government was also very critical to the success of the sub project. 4.2 The project was designed based on a supply approach. The project emphasized the delivery of inputs, though this required a level of administrative capacity which was lacking. With little attention during project preparation to the assessment of the institutional capacity in the project preparation, the project ended up with too many components and inputs to implement effectively, particularly in a high risk environment. Enormous efforts and resources from the Borrower and the Bank were spent on handling procurement and disbursement problems, leaving little energy left for other aspects of sector development. B. FUTURE OPERATIONS AND SUSTAINABILITY 4.3 Provision of primary health care in Nigeria is deteriorating. Strengthening the primary health care is much needed. The project improved some basic structures for the provision of primary health care in two States. The State governments expressed their commitmento the project and were willing to provide continued support (including financial resources) to the project, particularly for training activities. The States and the federal government prepared operational plans outlining their strategies to carry on the work initiated by the project. Committees have been established in each LGA to monitor and supervise the PHCs and carry out any future work. Imo State is planning to promote health services delivery from LGA to community level and extend the MBHP to the LGAs not covered by the project. Abia State will continue to mobilize communities in health care, and promote the MBHP in the health facilities. Both States are going to implement the Drug Revolving Fund in all LGAs. The federal government will provide support for the introduction of Minimum Health Care Packages in all LGAs in the two States. However, the sustainability of the project depends on policy and financial support from the Federal and State governments. The LGAs will have to play an active role in improving the services and maintaining the 9

22 infrastructures. Their resources are severely constrained, however, and they rely heavily on transfers from the federal Government. 4.4 There are no plans for lending to Nigeria. Bank support to the health sector continues through the ongoing Health System Fund Project. Some promising results are being achieved in several Sates concerned with this project. Lessons for Project Design C. LESSONS FOR FUTURE PROJECTS IN THE SECTOR 4.5 The project design should be more adaptable to major changes in health policy, and to respond to rapidly changing political environments. Between project appraisal and loan effectiveness, the Government published the National Health Policy, which had major implications for the project which should have been addressed. 4.6 Identifying indicators at the project outset is critical for project monitoring and evaluation. Only at a later stage performance indictors were added later and proved useful in monitoring the progress. For a project that lasts more than 5 years, particularly in a frequently changing political, social, and economic enviromnent, it is fundamental to review and re-plan the activities; good monitoring indicators are useful in this process. 4.7 The PCUs were designed to oversee project implementation carried out by various implementation agencies. In reality, the PCUs became implementation agencies and took over some responsibilities from the SMOH. A large-sized PCU in Imo State consumed substantial amount of project counterpart funds in the beginning of the project, without showing real progress in project implementation. The existence of the PCU actually undermined capacity building in the SMOH and weakened its ownership of the project. 4.8 Given the unstable environment and limited implementation capacity in Nigeria, project design should be simple and focused on supporting relatively few activities until implementation capacity is demonstrated. Understanding institutional capacity is critical to the project design. In particular, a project that is designed to primarily provide inputs needs to better ensure that administration of these inputs can be handled smoothly, or the majority of efforts by the Borrower and the Bank are spent on procurement and disbursement matters. If the capacity is weak, fewer inputs should be provided for a smaller range of activities, and more effort placed on the management of these inputs toward achieving more specific results. Realistically the institutional capacity can not be simply built through short-term training. Project Implementation 4.9 The MTR provided an opportunity to revisit the project design and evaluate implementation results against the project objectives. The MTR restructured the project and simplified the project components and activities. It proved to be highly beneficial. It should have been much done earlier. 10

23 4.10 Community involvement in formulating policies and strategies for PHC development is important if they are to be accepted and successfully implemented The appointment of a procurement agent does not necessarily solve all procurement problems or speed up implementation. Weak capacity in handling procurement hampered the whole project implementation. At the MTR, using a procurement agent to handle the procurementhrough ICB was recommended as a solution. The experience with a procurement agent in this project was not positive. Numerous mistakes and delays were made by both procurement agent and the project. There were communication difficulties among the procurement agent, the two State offices, the commercial banks, and the suppliers. On the other hand, the use of a procurement agent allowed the project managemento shift some of its attention from procurement to the development of MBHP. 11

24 PART II: STATISTICAL TABLES Table 1: Table 2: Table 3: Table 4: Table 5: Table 6A: Table 6B: Table 7: Table 8: Table 9: Summary of Assessments Related Bank Loans/Credits Project Timetable Loan Disbursements: Cumulative Estimated and Actual Studies Included in the Project Project Costs Project Financing Status of Legal Covenants Bank Resources: Staff Inputs Bank Resources: Missions

25 Table 1: Summary of Assessments A. Achievement of Objectives Substantial Partial Negligble Not applicabl Macro Policies El Ef Sector Policies 5 E5 El Financial Institutional Physical Poverty Gender Objectives E o o Development = r E] Objectives 5 5 Reduction E E El Issues i z l ri Other Social Objectives :i 5 Enviromnental Objectives El E El Public Sector Management E 0 E E Private Sector Development E E E 0 Other (specify) E E E 0 B. Project Sustainability Likely Unlikely Uncertain Highly C. Bank Performance Satisfactory Satisfactory Deficient Identification n E l Preparation Assistance E El Appraisal E El 0 Supervision [ El D. Borrower Performance Satisfactory Satisfactory Deficient Preparation E El Implementation E 0 Covenant compliance E E 0 E. Assessment of Outcome Satisfactory Satisfactory Unsatisfactory 13

26 Table 2: Related Bank Loans/Credits Loan/Credit Purpose Year of approval Status Preceding operations Ln Sokoto Health 1986 Closed Ln Urban Infrastructure 1988 Ln Highway Sector 1988 Ln Lagos Water 1988 Ongoing Following operations Cr Lagos Drainage & San 1993 Ongoing Cr State Roads II 1993 Ongoing Cr Development Communication 1993 Ongoing Cr Economic Management 1993 Ongoing Cr State Roads 1993 Ongoing Cr State Water I 1992 Ongoing Cr Environmental Manage 1992 Ongoing Cr Agricultural Research 1992 Ongoing Ln FADAMA 1992 Ongoing Cr Agriculture Tech Ongoing Cr Population 1991 Ongoing Cr Primary Education 1991 Ongoing Ln Water Rehabilitation 1991 Ongoing Ln Health Fund 1991 Ongoing Ln National Seed 1990 Ln Oyo State Urban 1990 Ongoing Cr Federal Univ. Development 1990 Closed Ln National Essential Drugs 1989 Closed 14

27 Table 3: Project Timetable Date actual/ Steps in Project Cycle Date Planned latest estimate Identification (Executive Project Summary) 3/20/87 Preparation 7/87 Appraisal 5/87 Negotiations 12/14-18/87 Board presentation 3/30/89 Signing 5/2/89 Effectiveness 7/31/89 12/15/89 Project completion 12/31/93 6/30/97 J Credit closing 6/30/95 6/30/97 Table 4: Loan Disbursements: Cumulative Estimated and Actual (US$ millions) FY90 FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98 Appraisal estimate Actual Actual as % of 24% 14% 11% 14% 19% 22% 24% 37% 45% estimate Date of final January, 1998 disbursement' I As of December 21, 1997, a small number of outstanding payments and special commitments totalling require correction or finalization. This should be done by January, 1998, and the residual balance of the Loan canceled. 15

28 Table 5: Studies Included in Project Purpose as defined at Year Study appraisal/redefined Status Impact of study - ~IMOl 1992 Training needs Assessment for Skill and Health service Completed Requisite training needs and types were health staff State/LGA/facility improvement. identified for each category of health level health workers. staff, three training committees set up leading to training planning meetings and action plan Distribution system for To design the distribution system for Completed Effective contraceptive distribution contraceptives in the public contraceptives in Nigeria - Part of system nation wide for easy accessibility Health sector of Nigeria. National population activity program. of contraceptives down to the grass os roots Comparison of cost of To ensure price competitiveness, Completed To ensure Project drugs are not communtiy used drugs at affordability of drugs to the people overpriced and prices are competitive to Government facility and especially at the grass roots level avoid expiration of drugs private retail shops (informal (uniform pricing) study) Market study for price To provide requisite data to develop Not elasticity and user fees. drug charges guidelines to determine Implemented appropriate fees to be charged at government facility Assessment of functional To detect problems in DRF Completed Improved DRF operations and skill at status of DRF at sustainability and records, systems facility level. LGA/facilities level (field visit and on the spot correction of problem - informal study) areas affecting sustainability of DRF.

29 Purpose as defined at Year Study appraisal/redefined Status Impact of study ABIA Development of minimum (1) To obtain inventory of health Completed Easy identification of number of PHCs Health service package in Abia facilities in the state. in each LGA and their individual needs State for effective and more efficient guide to (2) To develop minimum health ICB procurement of Hospital service package for each level of equipment. PHC. (3) To know what is available and obtainable facility by facility. (4) To know additional input needed to get the facilities to be able to deliver the MHSP. (5) To determine cost of the input. (6) To determine the time needed to get the input in place. (7) To obtain manpower/training need of each facility

30 Purpose as defined at Year Study appraisal/redefined Status Impact of study ABIA (continued) Minimum package service (1) To determine an individula Completed The project used it as a checklist for the delivery: Facility by facility plan for each health fcility in the distribution of equipment to the various inventory in the PHCs. LGAs indicating the tasks, materials, PHCs. equipment and personnel requirements of the facilities. (2) To serve as a guide ot the distribution of resources i.e. Hospital equipment to these facilities to actualize the utilization of the minimum Health service package. 00 FEDERAL 1989 Baseline Demographic social, To obtain baseline information on Completed Obtained imortant background statistical health survey of demographic characteristics, information on disease pattern types of Ohaozara and Onicha LGAs economic and social information, treatment sought, knowledge and use of for pilot project. health practices, use of private vs. ORT and EPI coverage of extensive use Public Health facilities. of TBAs. The nurses, midwives training programs of rht epilot program included key issues identified in the survey Inventory on PHC facilities as To determine the trend in patient Completed The information was shared with the part of the baseline survey in utilization of health facilities and nurses, midwives, during the training Ohaozara and Onicha LGAs. operation cost for three consecutive programs for the pilot project. years. The data complemented the report of the baseline survey.

31 Purpose as defined at Year Study appraisal/redefined Status Impact of study FEDERAL (continued) Study of drug market To provide baseline data and assist in Study was developing the level of drug charges not and phasing their implementation. undertaken Study of Price elasticity of To determine appropriate fee Study was user fees schedule and the phasing not implementation for both Government undertaken hospitals and PHC facilities. %O~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

32 Table 6A: Project Costs Item Appraisal estimate (US$M) Actual/latest estimate (US$) 1. Civil Works - Part A I-A. Abia Civil Works 2.15 I-B. Imo Civil Works Consultant Services Fellows A. Abia Consultants, Training B. Imo Consultants, Training Vehicles, Equipment Part A A. Abia Vehicles, Equipment B. Imo Vehicles, Equipment Drugs & Supplies Part A A. Abia Drugs & Supplies B. Imo Drugs & Supplies Preparing Future Projects Refund PPF 128-UNI Recurrent Costs Total Base Costs Contingencies Physical 3.16 Price 3.06 TOTAL Source: Project Files, Borrower's Completion Reports, and Bank Staff estimates. Table 6B: Project Financing Appraisal estimate (US$M) Actual/latest estimate (US$M) Source IBRD Federal Government State & Local Governments Local Autonomous Communities Total Source: Project Files, Borrower's Completion Reports, and Bank Staff estimates. 20

33 Table 7: Status of Legal Covenants STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS CREDIT/LOAN CD = Compliance AGREEMENT after Delay CP = Comp. with Partially NC = Not in Compliance. NYD = Not yet due 3.01 (a) Imo Sate shall with respect to Part A of the Project maintain or C None cause to be maintained a separate records and accounts adequate to reflect in accordance with sound accounting practices, its operations and financial conditions. 3.01(b) Imo State shall b (i) i) have the accounts and records referred to in paragraph 9a) of C None this Section for each fiscal year audited, in accordance with appropriate auditing principles consistently applied, by independent auditors acceptable to the Bank; (ii) ii) furnish to the Bank as soon as available, but in any case not later than six months after the end of each year: (A) certified CD None copies of its financial statements for such year as so audited, and (B) the report of such audit by said auditors of such scope and in such detail as the Bank shall have reasonably requested; (iii) iii) furnish to the Bank such other information concerning said C None records, accounts and financial statements as well as the audit thereof, as the Bank shall from time to time reasonably request. = _=_=_=

34 STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS CREDIT/LOAN CD = Compliance AGREEMENT after Delay CP = Cornp. with Partially NC = Not in Compliance. NYD = Not yet. d u e c (c) for all expenditures with respect to which withdrawals form C None the Loan Account were made for part A of the Project on the basis of statements of expenditure, Imo State shall: (i) i) maintain or cause to be maintained, in accordance with C None paragraph a) of this Section, records and accounts reflecting such expenditures; (ii) ii) retain until at least one year after the Bank has received the C None audit report for the fiscal year in which the last withdrawal form the Loan Account was made, all records (contracts, orders, invoices, bills, receipts and other documents) evidencing such expenditures; (iii) (iv) iii) enable the Bank's representatives to examine such records; C None and iv) ensure that such records and accounts are included in the C None annual audit referred to in paragraph (b) of this Section and that the report of such audit contains a separate opinion by said auditors as to whether the statements of expenditure submitted during such fiscal year, together with the procedures and internal controls, can be relied upon to support the related withdrawals.

35 STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS CREDIT/LOAN CD = Compliance AGREEMENT after Delay CP = Comp. with Partially NC = Not in Compliance. NYD = Not yet due Schedule 2.A Imo State shall reorganize SMOH's Public Health Division in C None a manner satisfactory to the Bank Schedule 2.B Imo State shall review with the Bank by June 30 each year NC LGAs now are responsible for State's financial Plan for the health sector primary health care. the funds are directly channeled from the Federal to the LGAs. the state does not have enough financial information for N.) primary health care activities w Schedule 2.E (i) Council to be established under part A (4)(A) of the Project C None Schedule 2.E (ii) Imo shall prepare and furnish to the Bank a state population CP None program satisfactory to the Bank Loan 3.01 (c) (i) Borrower shall under specific sub-head estimate in the budget C None provide amounts sufficient to cover the Borrower's counterpart contribution to the costs of the Project. Loan 3.01 (c) (iii) Borrower shall open and maintain a project account (the C None FMHSS Project Account) to be used exclusively to meet expenditures for Part B of the project and thereafter promptly pay each quarter of the year into Imo State Project Account, the borrower's counterpart contribution to the costs for that quarter of Part A and into FMHSS Project Account, Part B of the Project.

36 STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS CREDIT/LOAN CD = Compliance AGREEMENT after Delay CP = Comp. with Partially NC = Not in Compliance. _NYD = Not yetjue Loan 4.01 (a) (a) For all expenditures with respect to which withdrawals C None form the Loan Account were made on the basis of statements of expenditures, the Federal Government shall: (i) (i) maintain or cause to be maintained in accordance with CP A financial specialist has been sound accounting practices; hired to assist IMO in cleaning up its accounts. -PI r (ii) (ii) ensure that all records (contracts, orders, invoices, bills, C None receipts and other documents) evidencing such expenditures are retained until at least one year after the Bank has received the audit report for the fiscal year in which the last withdrawal from the Loan Account was made; and (iii) 4.01(b) (i) (iii) enable the Bank's representatives to examine such records. C None (b) The Federal Government shall: C None (i) have the records and accounts referred to in paragraph (a) CD None (i) of this Section and those for the Special Accounts for each fiscal year audited, in accordance with appropriate auditing principles consistently applied, by independent auditors acceptabie to the Bank;

37 STATUS SELECTION NO. OF COVENANT C = In Comp. COMMENTS CREDIT/LOAN CD = Compliance AGREEMENT after Delay CP = Comp. with Partially NC = Not in Compliance. I NYD = Not yet due l (ii) (ii) furnish to the Bank as soon as available, but in any case not CD None later than six months after the end of each such year the report of such audit by said auditors, of such scope and in such detail as the Bank shall have reasonably requested, whether the statements of expenditure, together with the procedures, can be relied upon to support the related withdrawals; U' (iv) (iv) furnish to the Bank such other infornation concerning said C None records and accounts and the audit thereof as the Bank shall from time to time reasonably request.

38 Table 8: Bank Resources: Staff Inputs Stage of Project Cycle Actual Staff Weeks US$ ('000) Preparation to appraisal Appraisal Negotiation through Board approval Supervision* Completion* TOTAL *Planned information is only available for FY96, FY97, and FY98, and comparison with actual is not meaningful. 26

39 Table 9: Bank Resources: Missions Performance ~R ating Stage of Month/ Number Days Specialized Implementation project cycle year of in staff skills Status persons Field represented Through appraisal 7/ / Appraisal through 9/87 2/ Board 6/ / / /89 1 SPE Board through 5/ effectiveness 6/90 5 SPS,Ph, HP, SPE, 2 PHS 4/91 5 A, SPE, AOO, PRS, PHS 3 Supervision 3/92 4 SU,AOO, A, Ph 3 6/93 2 HP 3 11/93 6 A, HP, PRS, PO 3 3/94 3 HE, PO, DC 2 6/94 5 DC,HE, HP,AOO, PRS 12/94 2 PO, HE S 4/95 4 PO, PRS, HE, Hpl S 3/96 4 PRS, E, HE, Hpl S 6/96 3 HE, PRA, E S 6/97 2 HE, PRA U Com pletion _ A=Architect AOO=Asst. Operations Officer DC=Division Chief E=Engineer HE=Health Economist HP-Health & Population Specialist HPI=Health Planner Ph=Pharmacist PHS=Public Health Specialist PO=Project Officer PRA=Procurement Analyst PRS=Procurement Specialist SPE=Sr. Project Economist SPS=Sr. Population Specialist SU=Surveyor 27

40

41 AIDE MEMiOIRE NIGERIA: IMO HEALTH AND POPULATION PROJECT (LN.3034-UNI) World Bank Completion Mission June 22-27, 1997 Introduction. 1. A World Bank completion mission to the Imo Health and Population project was undertaken from June 22-27, 1997 by Ms. Hong Chen (Procurement Analyst) and Ms. Anne Okigbo (Operations Officer). Mrs. 0. Omosaiye from the Federal Ministry of Health participated in the mission. The main objectives of the mission were to assess the overall achievements and shortcomings of the project through a review of the current status, impact, problems encountered, sustainability/next steps and lessons learnt of each component of the project. 2. The mission wishes to thank the Military Administrator of Imo State Colonel. T.K. Zubairu for his support. Recognition is also due to the Project Coordinator and her staff for the timely completion of the Project Completion Report and to colleagues in the project coordinating unit for the many useful reference materials provided. Project Overview. 3. The primary objective of the project was to improve access to basic health care services to all communities in Imo State through the provision of (a) renovation and construction of primarv health care centers and pharrnaceutical stores; (b) training of health care providers of all cadres; (c) provision of safe and affordable drugs and (d) to strengthen the state ministry of health institutional capacity to plan and implementheir policies for health, nutrition and family planning. PROJECT ACTIVITIES: Civil Works. 4. The mission was informed that all 63 primary health care centers planned for renovations/constructions have been completed and are distributed in all the 21 local governnents. (LGAs). Similarly, construction of pharmaceutical stores in each LGA have been completed. The mission visited the public health laboratory which is 85% completed and is expected to be finished before June 30, 1997.

42 S. Impact: The newly constructed maternity wards, staff quarters. hospital beds and cots and trained personnel provided not onlv improved access to health care services but also improved the quality of service delivery. Site visits were conducted to 5 completed primary health care centers. The mission was pleased to note that in one of the newly constructed 12 maternity facilities, all the beds were occupied. With the provision of staff quarters. nurses/midwives now live on the premises of the health centers. This has had the effect of (a) an increase in the number of live-in health care providers and (b) increase in the number of patients encouraging utilization of these facilities. 6. Problems: Due to the slow take off of the project. undue emphasis was placed on the civil works componento the detriment of service care delivery. This was corrected in 1995 with the introduction of the Minimum Basic Health package. A major problem has been that of matching grants expected to be paid by the communities. At the time of project design, the exchange rate was N4.35 to the US$1. Due to the fluctuation of the exchange rate, the communities have to pay more in Naira than originally calculated, and the communities are finding it difficult to pay the revised amount. As a consequence, it has delayed the hand over of the pharmaceutical stores by the project. Another problem has been the minimal involvement of communities at the beginning of the civil works. The mission was informed that communities would have liked to have been consulted on the location of the health centers, involved in the bidding processes etc. 7. Sustainability: Each LGA is responsible for the maintenance of their respective primary health care centers and pharmaceutical stores. Committees have been establishes in each LGA to monitor and supervise the PHCs and carry out any essential repair work. A vote has been made out for this purpose. Meetings are to be held regularly and minutes taken. Each committee has a set of written instructions on their roles and responsibilities. The test of the success of these committees would be how active and how far each takes up it's responsibilities. 8. Lessons Learnt: (a) the need to involve communities from the beginning which will create a sense of ownership; (b) the need to re-examine the requirements of community matching grants in cash; (c) the importance of building into the project design, a component/mechanism for maintenance and (d) the importance of good planning for civil works taking into account seasonality. For instance, despite contract awards, it was not possible in some cases to mobilize contractors due to the fact that the rainy season had just commenced. This delayed work considerably. 9. Next Steps: (a) The project unit in conjunction with the local governments will request that professional engineers are seconded to the works units in the LGA to further strengthen the unit. (b) The Petroleum Trust Fund (PTF) is planning on constructing one health center in each LGA. The project 2

43 unit is working with them to direct them to place these in areas that do not have any PHCs. Training. 10. A total of 13 staff from the State Ministry of Health and PCU have benefited from overseas training while 1,240 health care providers of different cadres have benefited from various local training. 11. Impact: The mission was informed that the overall training has been very beneficial as the knowledge and skills learnt have been put to practical use. The state adopted the training of trainers approach. which provided benefits to more health workers at local levels. Technical skills acquired enabled the PHC Coordinators develop strategies for PHC implementation. 12. Problems Encountered - The selection of individuals for training courses overseas was not always based on need. As such people who should have benefited from this component did not receive adequate training. A second difficulty was the lack of information about courses i.e. what was being offered and the location. Post course reports which were to be sent to the Bank were not submitted. Initially, there was no category in the Loan Agreement allocated for local training. It had originally been expected that this training would be paid for with local counterpart funds. The delays in receiving counterpart from the state and federal governments delayed this activity considerable. This was rectified at the MTR in Sustainability/Next Steps. As the training of public health laboratorians was not undertaken during the project life, the PCU will contact other agencies to solicit fund for this training. The consultants, ASPHALT will also be contacted to inquire how they can be of assistance. Similarly, local training for junior cadre of staff for the PHL will be sought locally with the assistance of the Federal Ministry of Health. Local training will be continued using state funds. Funding for foreign fellowships will similarly be sought from other donor agencies and NGOs. Imo State Essential Drugs (ISEDS). 14. ISEDS is a semi-autonomous unit under the project established to procure, distribute and set prices for essential drugs in the state. 15. Institutional Sustainability: After the project closes June 30, 1997, ISEDS will continue to operate as a semi-autonomous agency under the SMOH and will continue to procure and distribute drugs for Imo State. As such they will report to the Commissioner for Health in the state. ISEDS already has an independent budgetary allocation from which it receives funds directly from the state government. 3

44 16. To further ensure its institutional sustainability. ISEDS will request the state govenirnento establish it as a parastatal. The mission was informed that ISEDS already has Executive Council approval for its establishment as a separate entity and thus all that would be required would be to obtain same approval for an edict creating the agency as a parastatal. 17. In terms of staffing, ISEDS requires an additional pharmnacist. The mission was informed that there is a shortage of pharmacists in the public sector and therefore suggested that a pharmacy technician if available be given on the job training. 18. Drug Revolving Fund: ISEDS will continue to provide drugs for the 27 LGAs in the state on a cash and carry basis. They will also sell to community hospitals, NGOs, private practitioners through the Nigerian Medical Association, the Health Management Board of the state, the police and tertiary institutions. 19. Problems Encountered: The project faced constraint such as the inadequate amount of liquidity of the LGA DRFs and frequent change of executives who are signatories to the account at the LGA level. In order to isolate drug service delivery from executive responsibility and to ensure the sanctity of LGA funds and constant access to the account, it has been agreed that no elected officer will be signatory to the account. The signatories are to be any of the following two persons: head of the health department, treasurer of the local govemnment or head of personnel. 20. Also, - Six of the newly created LGAs do not have the seed capital for a DRF although all the operators have been trained. Agreement was reached with these LGA chairmen that votes for health would be released to ensure the start off of the DRFs. - None of the pharnaceutical stores have been handed over to the communitiesllgas because some have not paid up their matching grants in full and others have not collected the keys. The mission stressed the urgency of handing these stores over as drugs are shortly expected and would need to be safely stored. - The mission learnt that some of the LGAs have lost a considerable amount of money which had been placed in now distressed banks. - Finally, there has been a large influx of PTF drugs into the LGAs which were found to be inappropriate to the state. These have been retumed to the PTF. 21. Lessons Learnt. The use of ICB as a procurement method assures cost effective, safe and affordable drugs when procuring in bulk. However, because of 4

45 the length of time it takes from advertisement to shipment. there should be a better planning of a mix of procurement methods. The use of ICB has offered exposure to the international drug market which has proved to be useful knowledge. 22. Next Steps: (a) Request the state government to pass edict establishing ISEDS as a parastatal: (b) Request the SMOH to second a pharmacist or alternatively, train a pharmacy technician: and. (c) To enable ISEDS continue to procure through ICB. they will need to change Naira into international currency for payments. ISEDS will seek the advice of the Federal Ministrv of Finance in support of this endeavor. Mfinimum Basic Health Package. 23. A Minimum Basic Health Care Package was introduced and developed in 3 LGAs. These were modified to suit the requirements of each LGA. The introduction of the package was combined with intensive training of the village health workers and traditional birth attendants to ensure understanding of the package. Kits for these cadres of health worklers were provided and tits use was demonstrate during the training. It is intended that this package will be introduced in all the LGAs in the state. Sustainability of Project Activities - Thze Project Coordinating Unit. 24. The project coordinating unit's status as a World Bank assisted project unit will cease June 30, Proposals will be made to government to maintain the project unit as a secretariat. Terms of Reference have been drawn up for the proposed secretariat as well as its workplans- As the formulators of the Basic Minimum Health Package, the secretariat will work with the SMOH and LGAs to implementhe package in all LGAs. They intend to continue to monitor the implementation PHC activities, conduct local training, perform community mobilization activities, ensure the distribution of medical equipment and supplies as well as sourcing for external funding for PHC activities for the state from other donors and liaison with the private sector interested in health issues. 25. Funding for the secretariat is expected to come from the state government and will be sought from the PTF, FMOH, FMOF and National Planning Commission with whom this has already been discussed. To generate revenue, the secretariat will contract out its services in areas of specialization. Immediate Next Steps: 26. (a) PHL: The PCU will work with the SMOH and immnediately identify the staff to be seconded to the laboratory. They will also identify those that require local training and source the appropriate courses for them. They will also identify the higher level cadre of staff for overseas training. The technical committee working on the establishment of the PHL had recommended that the 5

46 PHL be established as a parastatal. The PCU is to work with the committee towards the final status of the PHL. The PCU will contact the consultants ASPHALT to inquire if there are any alternative sources of funding available to complete the consultancy on the installation of equipment as well as studies proposed. 27. (b) Distribution of medical equipment: The equipment meant for the PHCs have yet to be distributed. It was agreed that this would commence immediately. The PCU is to ensure the timely distribution of these equipment. 28. (c) LGA Stores: The completed pharmaceutical stores is yet to be handed over to the LGAs. This is to be done immediately and the PCU will ensure the handing over. DISCUSSIONS WITH THE MILITARY ADMINISTRATOR AND AGREEMENTS REACHED. 29. (a) Distribution of equipment. The mission stressed the urgency of distributing the equipment purchased for the PHCs before June 30th. This equipment was apparently not distributed due to the ongoing investigation into the theft of some of the equipment. The Military Administrator assured the mission that this would be done immediately. 30. (b) Handing over of the LGA pharmaceutical stores to the respective LGAs. Similarly, LGA pharm stores have not been handed over to the LGAs because some of the LGAs have been unable to pay up their matching grants. The mission again stressed the importance of having a functional store to house the drugs expected to arrive shortly. The mission requested the state governmento hand these stores over to the LGAs. On the issue of matching grants, the mission explained that when the project was designed, the matching grants of 10% at the exchange rate in 1988 was far below what it is today. The mission suggested that the matching grant contribution be reduced and allowance made for the LGAs to pay installments or devise other means for LGAs to pay in kind. The Militarv Administrator assured the mission that the process of handing over the stores would also begin immediately. 31. (c) Counterpart Contribution. The state government's counterpart contribution which is deducted at source monthly terminated December 1996 when the project was due to close. However, the project was extended for an additional 6 months but the counterpart was not renewed. The Military Administrator said he would ensure that the money owed to the project from December 1996 to June 1997 was paid. 32. d) ISEDS. The mission informed the Military Administrator that ISEDS will be seeking the status of a parastal for institutional stability. It already has an 6

47 Executive Council Memo establishing it as an autonomous body and receives a direct budgetary allocation from the government. 33. e) PCU Secretariat. The mission informed the Military Administrator that he would shortly be receiving a detailed memo from the PCU proposing the retention of the PCU as an entity to continue the work not completed by the project. Terns of Reference and work programme will be attached. The Military Administrator was informed of the importance of the project to sustain the efforts already achieved by under the project and would look favorably at the proposal. 7

48 AIDE AfEMOIRE NIGERIA: ABIA HEALTH AND POPULATION PROJECT (LN.3034-UNI) Introduction. World Bank Completion Mission June 22-27, A World Bank completion mission to the Imo Health and Population project was undertaken from June 22-27, 1997 by Ms. Hong Chen (Procurement Analyst) and Ms. Anne Okigbo (Operations Officer). Mrs. 0. Omosaiye from the Federal Ministry of Health participated in the mission. The main objectives of the mission were to assess the overall achievements and shortcomings of the project through a review of the current status, impact, problems encountered, sustainability/next steps and lessons learnt of each component of the project. 2. The mission wishes to thank the Military Administrator of Abia State Colonel. M.O. Fasanya and all staff of the project coordinating unit for their support. Project Overview. 3. The primary objective of the project was to provide access to basic health care services to all communities in Abia State through the provision of (a) renovation and construction of primary health care centers and pharmaceutical stores; (b) training of health care providers of all cadres; (c) provision of safe and affordable drugs and (d) to strengthen the state ministry of health institutional capacity to plan and implementheir policies for health, nutrition and farnily planning. PROJECT ACTIVITIES: Cvil Works. 4. The mission was informed that all civil works have been completed. A total of 56 primary health care centers planned for renovations/constructions have been completed and are distributed in all the 17 local governments. Similarly, 14 pharmaceutical stores in each of the old LGAs have been built. The PCU building, the central pharmaceutical store, and inflammable drug store have been finished and are now in use. S. Impact: The main project inputs under this component - newly constructed matemity wards, staff quarters, hospital beds and cots, and trained personnel provided not only improved access to health care services but also improved the

49 quality of service delivery. With the provision of staff quarters, nurses/midwives now live on the premises of the health centers. This has had the effect of: (a) an increase in the number of live-in health care providers, and (b) an increase in the number of patients encouraging utilization of these facilities. 6. Problems: It was found that undue emphasis was placed on the civil works componento the detriment of service care delivery. This was corrected in 1995 with the introduction of the Minimum Basic Health Care package. A major problem has been that some of the health centers are not fenced. The mission urged the state to fund the fencing of these facilities and improve its security, because lack of security was given as the reason that these facilities have not been handed over to the communities. Inflation led to delays in completing renovations as contractors were seeking variations. This was dealt with in 1995 by a World Bank mission. Contractors and project staff complained of long payment delays using the direct payment method. The mission explained that these delays were often not from the Bank's side but had frequently been found to be the result of delays in informing suppliers banks by the Central Bank. Another problem has been the minimal involvement of communities at the beginning of the civil works. The mission was informed that communities would have liked to have been consulted on the location of the health centers, involved in the bidding processes etc. 7. Sustainabilit/Next Steps: The Military Administration is interested in sustaining the programme. As such, counterpart will continue to be paid till December The mission was informed that there is interest to fence the already constructed facilities pending the availability of funds. The project unit would also like to construct LGA pharmaceutical stores in the 4 newly created LGAs. Communities are to be mobilized to maintain the facilities through the establishment of community committees. 8. Lessons Learnt: (a) the NCB procurement method for civil works resulted in good prices; (b) there is need to involve communities from the beginning which would create a sense of ownership. Training. 9. A total of 11 staff from the State Ministry of Health and PCU have benefited from overseas training while local training was provided for various cadres of health care providers. 10. Impact: The mission was informed that the overall impact has been very beneficial as the knowledge and skills learnt have been put to practical use. The local training created awareness and health care providers who benefited from the initial training have subsequently been used as resource persons for other training. 2

50 11. Problems Encountered - The selection of individuals for training courses overseas was not always based on need. As such people who should have benefited from this component did not receive adequate training. A second difficulty was the lack of information about courses i.e. what was being offered and the location. The local in house computer training proved not very useful as there were no computers to practice on afterwards. Abia State Essential Drugs (ASEDS). 12. Institutional Sustainability: ASEDS is currently under the project and the Director reports to the Project Coordinator. After the project closes June 30, 1997, the mission was informed that there were no plans to make separate arrangements for ASEDS. The mission reminded the PCU staff that ASEDS was designed to be a semi-autonomous body that would out live the project and as such, the state would have to decide what the status of ASEDS would be and informn the Bank. Agreement was not reached on whether ASEDS should be established as a parastatal or a division in the SMOH. 13. Drug Revolving Fund: A DRF has been established in all LGAs who are expected to buy from ASEDS on a cash and carry basis. These have not been tested yet as drugs are just arriving. 14. Problems Encountered. The mission was informed that the LGA pharmaceutical stores have not been handed over to the LGAs because they do not want the LGA to use these to store the PTF drugs. The mission reiterated that these stores are meant for drug storage from any source and belong to the LGAs once completed. The mission urged that these stores be handed over immediately. As the project has not received any drugs, the HMB currently buys it's drugs from the private sector. 15. Lessons Learnt. The use of ICB as a procurement method assures cost effective, safe and affordable drugs when procuring in bulk. The use of ICB has offered exposure to the international drug market which has proved to be useful knowledge. However, because of the length of time it takes from advertisement to shipment, there should be a better planning in the mix of procurement methods. Minimum Basic Health Package. 16. A minimum basic health care package was developed and introduced in all 17 LGAs instead of 9 LGAs as original planned. The packages were modified to suit the requirements of each LGA. The introduction of the package was combined with intensive training of the village health workers and traditional birth attendants to ensure better use of the package. 17. Problems Encountered: There has been irregular supervision from the SMOH due to transport difficulties. There is an inadequate level of manpower for 3

51 the health facilities. Currently, there is an embargo on the emplovment of higher level cadre of staff. The mission was also informed that there is a high attrition rate as some of the women trained at the lower level quit their jobs after getting married. 18. Next Steps: 1). The handing over of all facilities and pharmnaceutical stores. 2). Meetings with the LG/PHC Coordinators to assess the PHC system development. 3). Develop a plan to organize more training for the PHC coordinators to implementhe various minimum basic health packages. 4). The establishment of a disease surveillance and notification system. Sustainability of Project Activities -The Project Coordinating Unit. 19. The project coordinating unit's status as a World Bank assisted project unit will cease June 30, Proposals will be made to government to maintain the project unit as a secretariat for an extra 2 years. The mission was informed that the secretariat would liaise with the SMOH to ensure the smooth running of the facilities constructed as well as liaise with the local communities to ensure the maintenance of the facilities. Funding will be sought primarily from the state govermnent and it is expected that the Project Coordinator will report directly to the Military Administrator. 20. Immediate Next Steps: 1). The PCU will immediately hand over the health facilities and LGA pharmaceutical stores to their respective communities. Equipment and vehicles purchased will also be immediately distributed. 2). The Project Completion Report should be sent to the Bank before June 30, DISCUSSIONS WITH THE MILITARY ADMINISTRATOR AND AGREEMENTS REACHED. 21. The Military Administrator in Abia State commended the efforts undertaken by the project so far and requested the Bank for an additional 12 month extension. The Bank informed the Military Administrator that this could not be given due to various reasons. 22. (a) ASEDS. The mission requested the Military Administrator to look into the sustainability of ASEDS by ensuring its creation as an autonomous entity. 23. (b) Distribution of vehicles/equipment. The mission strongly urged that the vehicles and equipment meant for the LGAs are distributed before June 30th. The mission was assured that these would be done before the closing date. 24. (c) Handing over of PHCs and LGA pharmaceutical stores. The mission requested the Military Administrator that the PHCs as well as the LGA stores were meant to be built for the communities and therefore they should be handed over to the them immediately to enable the communities have access to basic 4

52 health care which is the primary objective of the project. The Military Administrator informed the mission that this would be done. 25. (d) Matching grants. The mission brought up the issue of matching grants to be paid by LGAs and communities. The mission explained that when the project was designed, the matching grants of 10% using the exchange rate in 1988 was far below what it is today. The mission suggested that the matching grant contribution be reduced and allowance made for the LGAs to pay installments or devise other means for the local communities to pay in kind. The Military Administrator assured the mission that he would follow up with this issue. 26. (e) Fencing. Some of the health facilities are not fenced and to ensure the safety of the staff and equipment, the mission strongly urged the state governnent to provide the necessary funds for the construction of fencing for those facilities that require this. 5

53 IMPLEMENTATION COMPLETION REPORT FEDERAL REPUBLIC OF NIGERIA IMO HEALTH AND POPULATION PROJECT SUMMARY OF GOVERNMENT'S REPORTS* As a result of the sharp decline in oil revenue in Nigeria in the 1980s, the Government was forced to cut back or abandon many of the Health programs which were started during the oil boom of the 1970s. The project under review was identified through a Structural Adjustment Program. Its aim was to improve health care delivery by emphasizing efficiency in the health sector, cutting off unnecessary expansion of health services, and mobilizing additional resources through cost recovery. The proposed project was to serve as a part of a coordinated package of financing and technical assistance to the Nigerian population and health sectors. The overall objective of the project was to assist the Government in improving the health and nutritional status of the population and to provide them with voluntary family planning services. Specific objectives included: (i) to assist in the State and Local Government institutional development and the financial capacity to plan, implement, monitor and evaluate health policies and programs; (ii) to assist the Govermment in the improvement of the quality and effectiveness of community-based primary health care activities; and (iii) to assist the FMOH's programs which support the state and LGA in the development of strategies and plans of action to implement the national health and population policies, and to prepare health, population and nutrition projects for internal and external financing. In summarizing the completion of the Imo Health Project, the Government reports (Federal, Abia, and Imo) give positive reviews of the overall implementation of the project, and rated the project as "satisfactory". All parties are confident of the sustainability of the progress attained, and report that the project has aided in reaching the national goal of good health for all by the year Quantitative progress reports on reaching project objectives range from 54.4% in Imo State to 75% in Abia Sate. However, all reports note the short timeframe of the project as one hurdle to full project implementation. The reports differ on their view of the complexity of the project, with two citing its complexities, and the other (Abia) stating that the project objectives "were neither complex, nor risky". Other common difficulties included: * Bureaucratic delays within the country which were often linked to changes in Government and/or policies leading to "undue delays in obtaining approvals for the implementation of articulated programs in the project". * Lack of anticipated funding at the local and Federal levels--local funding was, until very recently, non-existent in some states and the Federal Government contributed less than 3% of its expected counterpart funds. Some of this shortage may be linked to drastic changes in the foreign exchange rates; at project onset the rate was 4 Naira to the Dollar, at project completion it was 80 Naira to the Dollar. * Procurement delays due, in part, to a lack of understanding of procurement guidelines of the World Bank, and, in part to the appointment, at the insistence of the Bank, of a crown agent as the sole procurement agency for both states. In evaluating the World Bank's performance, a mixed message can be drawn from the reports. On one hand, the Federal report states that the Bank officials were "impressed with what they saw" and * Full reports are available in the Africa infornation Services Center.