Document of The World Bank. IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA UNI and UNI) CREDITS IN THE AMOUNTS OF

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA UNI and UNI) ON CREDITS IN THE AMOUNTS OF SDR MILLION (US$127.0 MILLION EQUIVALENT) AND SDR 57.3 MILLION (US$90.0 MILLION EQUIVALENT) Human Development Sector Health, Nutrition and Population (AFTHW) Country Department 1 AFCW2) Africa Region TO THE FEDERAL REPUBLIC OF NIGERIA FOR A HEALTH SYSTEMS DEVELOPMENT PROJECT - II December 7, 2012 Report No: ICR477

2 CURRENCY EQUIVALENTS (Exchange Rate Effective 11/22/12) Currency Unit = Naira (N) N 1 = US$ US $1.00 = N 157 ABBREVIATIONS AND ACRONYMS AF Additional Financing AfDB African Development Bank AM Aide memoire APL Adaptable Program Lending BCC Behavioral Change Communication CAP Change Agent Program CAS Country Assistance Strategy CHEW Community Health Worker CPPR Country Portfolio Performance Review CPS Country Partnership Strategy DCA Development Credit Agreement DFID UK Department for International Development DHPR Director of Health Planning and Research DM Decision Meeting DOTS Directly Observed Treatment Strategy D(PH) Director, Public Health D(PHC) Director, Primary Health Care DRF Drug Revolving Fund EA Environmental Assessment EMP Environmental Management Plan ELSS Emergency Life Saving Skills EOC Emergency Obstetric Care ESMF Environmental and Social Management Framework EU European Union FCT Federal Capital Territory FGN Federal Government of Nigeria FM Financial Management FMoF Federal Ministry of Finance FMoH Federal Ministry of Health FMR Financial Monitoring Report GFATM Global Fund for AIDS, Tuberculosis and Malaria GIS Geographic Information System GNP Gross National Product HDCC Health Data Consultative Committee HHRD Health Human Resources Development HGC Hospital Governing Council HMH Honorable Minister of Health HMIS Health Management Information System HR Human Resource HSDP II Health Systems Development Project HSF Health Systems Fund HSR Health Sector Reform HSRP Health Sector Reform Program HTI Health Training Institute ICR Implementation Completion and Results Report IDA International Development Association IEC Information, Education & Communication IEG Independent Evaluation Group IMCI Integrated Management of Childhood Illness ISR Implementation Status Report ITNs Insecticide Treated Nets KPI Key Performance Indicators LGA Local Government Area LSS Life Saving Skills M&E Monitoring & Evaluation MCH Maternal and Child Health MDGs Millennium Development Goals MMR Maternal Mortality Rate MOU Memorandum of Understanding MTPA Medium-Term Plan of Action MTR Mid-term Review NCD Non Communicable Disease NCH National Council on Health NCNM Nigerian Council of Nurses and Midwives NDHS Nigeria Demographic and Health Survey NEEDS National Economic Empowerment Development Strategy NGOs Non-Governmental Organization NHA National Health Accounts NHIS National Health Insurance Scheme NHMIS National Health Management Information System NICS National Immunization Cluster Survey NPHCDA National Primary Health Care Development Agency NRHS National Reproductive Health Survey NSHDP National Strategic Health Development Plan OPC Outpatient consultation PAD Project Appraisal Document

3 PCN Project Concept Note PDO Project Development Objective PHC Primary Health Care PIM Project Implementation Manual PIP Project Implementation Plan PPF Project Preparation Facility PPP Public Private Partnership POA Plan of Action PRSP Poverty Reduction Strategy Paper QAG Quality Assurance Group QALP Quality Assessment of Loan Portfolio QER Quality Enhancement Review RH Reproductive Health SCA Subsidiary Credit Agreement SDR Special Drawing Rights SEEDS State Economic Empowerment Development Strategy SHC Secondary Health Care SIL Specific Investment Loan TB Tuberculosis TT Task Team TTL Task Team Leader U-5MR Under-5 Mortality Rate UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children Fund USAID United States Agency for International Development US$ US Dollar WHO World Health Organization Vice President : Makhtar Diop Country Director : Marie-Françoise Marie-Nelly Sector Manager : Trina Haque Project Team Leader : F. Ayodeji Akala ICR Team Leader : F. Ayodeji Akala

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5 Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph FEDERAL REPUBLIC OF NIGERIA HEALTH SYSTEM DEVELOPMENT - II Table of Contents 1. Project Context, Development Objectives and Design 2 2. Key Factors Affecting Implementation and Outcomes 6 3. Assessment of Outcomes Assessment of Risk to Development Outcome Assessment of Bank and Borrower Performance Lessons Learned Comments on Issues Raised by Borrower/Implementing Agencies/Partners 29 Annex 1: Project Costs and Financing 31 Annex 2 : Descriptive Summary of Project Outputs 32 Annex 3: Economic and Financial Analysis 38 Annex 4: Bank Lending and Implementation Support/Supervision Processes 40 Annex 5: Federal Government Comments on ICRR 42 Annex 6: Comments on ICRR from some participating States 45 Annex 7: Summary of Borrower's ICR and/or Comments on Draft ICR 50 Annex 8: Co-financing Partners and Other Partners/Stakeholders : AfDB Project Completion Report 53 Annex 9: List of Supporting Documents 56 Annex 10: Overview of Financial Support for the Health Sector in Nigeria 59 MAP: 61

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7 A. Basic Information Country: Nigeria Project Name: Project ID: P L/C/TF Number(s): IDA ICR Date: 12/11/2012 ICR Type: Core ICR Lending Instrument: SIL Borrower: NIGERIA Original Total Commitment: Revised Amount: XDR M Environmental Category: C Implementing Agencies: The Federal Minsitry of Health Cofinanciers and Other External Partners: Africa Development Bank B. Key Dates Second Health Systems Development XDR M Disbursed Amount: XDR M Process Date Process Original Date Revised / Actual Date(s) Concept Review: 05/23/2000 Effectiveness: 05/23/2003 Appraisal: 01/22/2002 Restructuring(s): 09/29/ /20/2009 Approval: 06/06/2002 Mid-term Review: 12/01/ /14/2005 Closing: 07/01/ /30/2012 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Moderately Unsatisfactory High Moderately Unsatisfactory Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Unsatisfactory Government: Moderately Unsatisfactory Quality of Supervision: Moderately Implementing Moderately Unsatisfactory Agency/Agencies: Unsatisfactory Overall Bank Performance: Moderately Unsatisfactory Overall Borrower Performance: Moderately Unsatisfactory i

8 C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project Yes at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: Yes Moderately Unsatisfactory Quality at Entry (QEA): Quality of Supervision (QSA): None None Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health Sub-national government administration Theme Code (as % of total Bank financing) Child health Health system performance Other communicable diseases Participation and civic engagement Population and reproductive health E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Callisto E. Madavo Country Director: Marie Francoise Marie-Nelly Mark D. Tomlinson Sector Manager: Trina S. Haque Arvil Van Adams Project Team Leader: Francisca Ayodeji Akala Francois Decaillet ICR Team Leader: ICR Primary Author: Francisca Ayodeji Akala Peter D. Bachrach F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The overriding goal of this project is to assist the Nigerian Health authorities in their efforts to redress the serious deterioration in the delivery of basic health care services following decades of neglect and to build institutional capacities, paving the way for a more sustained development of the health care system. More specifically, the project would: (i) strengthen capacities for system management at the state level and encourage ii

9 an environment of broad based consultation; (ii) support improvements in the delivery of primary health care services with a particular focus on maternal and child health and reproductive health services; and (iii) assist the Federal Government to strengthen its policy formulation and further develop a system to monitor the health sector performance. (In Annex 1 of the PAD, the first sentence expresses the program goals while the second expresses the PDO. Schedule 2 of the DCA ignores the program goals and only includes the PDO. This ICR has opted for the DCA version). Revised Project Development Objectives (as approved by original approving authority) The objectives of the Project are to assist the Borrower in: (i) strengthening the capacities for management of the health system at the State level; (ii) improving the delivery of primary and secondary health care services with a particular focus on maternal and child health and reproductive health services in participating States; and (iii) strengthening, at the Federal level, policy formulation and delivery of secondary health care services with a particular focus on maternal and child health and reproductive health services, and further developing a system to monitor the performance of the health sector (amended DCA of September 22, 2005). (a) PDO Indicator(s) Indicator Indicator 1 : Value quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years (Original Credit): No. of states with approved 3-year rolling and annual work plans 36 States and FCT Not determined Not determined (2010) Source: Govt. KPI Report page 12 Date achieved 09/15/ /15/ /30/2010 Achieved. The KPI Report noted that after adoption of the 5-year National Comments Strategic Health Development Plan (NSHDP) in 2009, all 36 states and the (incl. % Federal Capital Territory (FCT) also approved their 5-year plans between 2009 achievement) and Indicator 2 : (Original Credit): % of states having developed state health accounts Value quantitative or Qualitative) Not determined Not determined 20 states (2011) Source: Govt. KPI Report Date achieved 09/15/ /15/ /30/2011 Comments Partially Achieved. The KPI Report noted that the State Health Accounts (SHA) (incl. % were developed but do not conform to internationally accepted SHA standards. achievement) Indicator 3 : (Original Credit): No. of states with certified/audited financial statements Value quantitative or Qualitative) Not determined Not determined 36 States and FCT (2010) Source: Govt. KPI Report iii

10 Date achieved 09/15/ /15/ /30/2010 Comments (incl. % achievement) Achieved. Although only 23 states confirmed the publication of their annual certified/audited accounts, as noted in the KPI Report, state legislatures cannot legally appropriate funds unless audited accounts are published yearly. Indicator 4 : (Additional Financing): % of states routinely linking State health plans with annual budgets Value quantitative or Qualitative) 0% 0% 100% Not determined Date achieved 09/15/ /15/ /08/ /30/2011 Comments (incl. % Not measured. Data not available to track this indicator. achievement) Indicator 5 : Component 2: Indicators 5a&b - (Original Credit): Attendance of patients at renovated PHC facilities (disaggregated between out-patients and in-patients) Value quantitative or Qualitative) Outpatients: 139,186 Inpatients: 14,840 Not determined Outpatients: 815,351 Inpatients: 136,027 Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Achieved. Outpatients: Based on 35 reporting states, this generally consistently Comments increased annually with a high of 1.1 million in (incl. % Inpatients: Based on 29 reporting states, in-patient attendance varied annually but achievement) generally increased. (Original Credit & Additional Financing): Increased % of children <1 year and Indicator 6 : < 2 years fully immunized Value quantitative or Qualitative) <1 year: 48,101 <2 years: Not determined Source: KPI Report data for 2004 <1 year: 13 % < 5 years: Not determined Source: NICS 2003 Not determined Not determined < 1 year: 80% < 5 years: 80% <1 year: 184,581 <2 years: Not determined Source: KPI Report data for 2004 <1 year: 53 % < 5 years: Not determined Source: NICS 2010 Date achieved 09/08/ /15/ /08/ /30/2011 Partially Achieved: The KPI Report used DPT3 as a proxy; in addition, the KPI Comments Report counted only the total number of children immunized in renovated (incl. % facilities. Based on 24 reporting states, number increased through 2009 before achievement) declining in 2010 & Indicator 7 : (Original Credit): Increased % of births attended by skilled health personnel iv

11 Value quantitative or Qualitative) (doctor, nurse, midwife) 35% Source: NDHS 2003 Not determined 39% Source: NDHS 2008 Date achieved 09/15/ /15/ /30/2011 Partially Achieved. The 2 DHS show virtually no change. However, from 33 Comments states, the KPI Report notes the numbers in project supported facilities, increased (incl. % annually from 217,543 in 2004 to 1.2million in 2010 before declining to 730,515 achievement) in Indicator 8 : (Additional Financing): % of pregnant women attending ante-natal clinics 20% 50% Value quantitative or Not determined Source: AF PP (Schedule Source: AF PP Qualitative) A) (Schedule A) Date achieved 09/08/ /08/ /30/2011 Partially Achieved. AF Paper established the baseline at 20% & target at 50% Comments without a source. The 2 DHS ( % and %) show no change. The (incl. % KPI report shows the number increased annually in project facilities (34,782 in achievement) 2004 to 227,746 in 2011). Indicator 9 : (Original credit): Increased TB detection rate 26.0% 28.9% Value quantitative or Not determined Source: KPI Report data Source: KPI Report Qualitative) for 2004 data for 2009 Date achieved 09/15/ /15/ /15/2009 National TB Program data indicate case detection rate rose from 26.0% (2004) to Comments 30.5% (2008) then declined to 28.9% (2009). Calculation of the rate has been (incl. % discontinued by WHO in # of positive cases increased by 300% from achievement) 2004 to Indicator 10 : Component 3: (Original Credit): Improved situation in the five areas of reform: Value quantitative or Qualitative) Not determined Not determined 8 policy/strategy documents Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments (incl. % achievement) Achieved. The 8 policy/strategy documents addressed each of the 5 areas of reform: packages of services, institutional reform, public-private partnership, health financing, & human resources. (b) Intermediate Outcome Indicator(s) Indicator Indicator 1 : Baseline Value Original Target Values (from approval documents) (Original Credit): 80% of activities carried out Formally Revised Target Values Actual Value Achieved at Completion or Target Years v

12 66% 67% Value 80% (quantitative Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /01/ /30/2011 Comments Partially achieved. Based on 34 reporting states, the proportion of planned (incl. % activities carried out varied from a low of 63% (2008) to a high of 77% (2009). achievement) (Original Credit): Increased number of Memorandums of Understanding (MOU) Indicator 2 : signed between the states and LGAs Value (quantitative or Qualitative) 51% Source: KPI Report data for 2004 Not determined 308 LGAs signed MOUs Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Achieved. Based on 23 reporting states, the number of signed MOU increased by Comments about 30 per year (except for 2008) from 51 to 308. It should be noted that (incl. % MOUs were required by the project only for LGAs where implementation achievement) activities took place. Indicator 3 : (Original Credit): Increased % of practicing midwives trained in life-saving skills. Value 8% 9% (quantitative Not determined Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments (incl. % achievement) Not Achieved. Based on 32 reporting states, an annual average of 8% of midwives were trained in Life Saving Skills (LSS), with the highest proportion in 2006 (13%) and the lowest in 2010 (4%). Indicator 4 : (Original Credit): Increased % of health staff at Primary Health Care (PHC) facilities trained in IMCI Value 2% 5% (quantitative Not determined Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Not Achieved. Based on 25 reporting states, an annual average of 5% of PHC Comments facility staff were trained in Integrated Management of Childhood Illness (incl. % (IMCI), with the highest proportion in 2007 (9%) and the lowest in 2006 and achievement) 2010 (4%). Indicator 5 : (Original Credit): Increased % of health staff (PHC & SHC) trained in DOTS for TB Value (quantitative or Qualitative) 188 Source: KPI Report data for 2004 Not determined 2,020 Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 vi

13 Comments (incl. % achievement) Indicator 6 : Value (quantitative or Qualitative) Partially Achieved. The number staff trained increased consistently over the duration of the project, particularly in Since the proportion of health staff trained was not calculated, the target is considered only partially achieved. (Original Credit): Increased % of States & LGAs having implemented the minimum HMIS package 61% 92% Source: KPI Report data for 2004 Not determined Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments (incl. % achievement) Achieved. Although no target was established, the proportion of LGAs implementing the minimum Health Management Information System (HMIS) package has increased to 92% (based on 28 reporting states). Indicator 7 : (Additional Financing): % of states producing satisfactory annual HMIS report 14% Value (quantitative or Qualitative) 0 Source: KPI Report data for % 100% Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/ /30/2011 Comments Not Achieved. The number of States producing satisfactory annual HMIS (incl. % Reports has not exceeded 9 (in 2010) and averaged 5 between 2005 and achievement) (Original Credit): Increased % of States having at least 3 communication node Indicator 8 : sites fully equipped and functional. Value (quantitative or Qualitative) 16% (5 of 32 reporting states) 63% (20 of 32 reporting states) Not determined Source: KPI Report data for 2004 Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments Achieved. Based on 32 reporting states, the number of internet connectivity sites (incl. % (used as a proxy for the original indicator) increased rapidly, from 16% (2004) to achievement) 69% (2009) before declining to 63% (2010 and 2011). Indicator 9 : Value (quantitative or Qualitative) (Original Credit): Number of studies carried out and completed 200 studies carried 22 studies carried out out Not determined Source: KPI Report data Source: KPI Report for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Achieved. The number of studies carried out varied considerably from 5 in 2007 Comments to 100 in National Council on Health memoranda indicatates an average (incl. % of state studies were conducted annually though not all financed by the achievement) project. (Original Credit): No. of nursing schools with adequate equipment and basic Indicator 10 : pedagogic materials vii

14 Value (quantitative or Qualitative) 25 Source: KPI Report data for 2004 Not determined 68 Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments (incl. % achievement) Partially achieved. Based on 30 reporting states, the number of adequately equipped nursing schools increased from 25 to 68. No target was determined and the increase is significant. (Additional Financing): % of Schools of Nursing and Midwifery accredited by the Nursing and Midwifery Council Indicator 11 : (Additional Financing): % of Schools of Health Technology with accredited courses of study Value (quantitative or Qualitative) N/M: 83% (64/77) HT: 83% (99/119) Source: KPI Report data for 2008 N/M: 100% HT: 100% N/M: 100% HT: 100% N/M: 64% (49/77) HT: 95% (113/119) Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/ /30/2011 Comments (incl. % achievement) Partially Achieved. The Additional Financing Paper formulated the target poorly and did not properly identify the source of baseline or target information for the Schools of Health Technology. (Additional Financing): Increased % of health staff at PHC facilities trained in Indicator 12 : IMCI in ELSS, LSS and IMCI at benefiting Schools of Health Technology, Nursing and Midwifery (disaggregated by Nurses and Midwives) Value (quantitative or Qualitative) 20% Source: AF Project Paper not determined 80% Source: AF Project Paper ELSS: 1351 LSS: 6,837 IMCI: 9,940 Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/ /30/2011 Comments (incl. % achievement) Achieved. Although the proportion of health staff trained was not calculated, the absolute numbers of staff trained would suggest that the overall proportion increased. Component 2: (Original Credit): % of LGAs in participating states with functioning cold chains. Indicator 13 : (Additional financing): % of LGAs in participating states with functioning cold chains Value 60% 100% 95.8% (quantitative not determined Source: AF Source: KPI Report or Qualitative) Source: AF Project Paper Project Paper data for 2011 Date achieved 09/30/ /15/ /30/ /30/2011 Comments (incl. % Achieved. Original Credit data not available. Based on the 27 states reporting in the KPI Report, 89.3% (not 60% as noted without a source in the AF Project viii

15 achievement) Paper) of the participating LGAs had functioning cold chains in 2004 & increased to 95.8% in Indicator 14 : (Original Credit): % of primary health facilities offering essential obstetric care. 46% Value (quantitative Not determined Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Partially Achieved. Although no target was set, an average of 43% project PHCs Comments (in 23 reporting states) offered this service (including drugs), with the highest (incl. % proportion in 2006 (51%) and the lowest in 2009 and 2010 (38% and 39% achievement) respectively). (Original Credit): % of health facilities offering access to essential laboratory Indicator 15 : exams. 9.5% Value (quantitative or Qualitative) Source: KPI Report data for 2004 not determined 43% 16.4% Source: KPI Report data for 2011 Date achieved 09/15/ /15/ /30/2011 Partially Achieved. Using a proxy indicator (number of project PHC facilities Comments providing malaria diagnostic examination) & based on 19 states reports, (incl. % proportion offering this examination reached 28-30% from before achievement) declining to 16% in Indicator 16 : (Original Credit): No. of TB patients under DOTS 22,635 44,160 Value (quantitative not determined Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments Achieved. Based on the 27 states reporting on the number of TB patients under (incl. % DOTS, the number increased steadily to almost 50,000 in 2009 before achievement) subsequently declining. The KPI Report assessed the quality of this data as poor. Components 3: (Original Credit): Completion/Acceptance of policies for health Indicator 17 : services delivery Value 3 policies 47 policies (quantitative Not determined Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Achieved. The KPI Report notes that 47 policy documents were adapted from the Comments FMOH and 8 policies were published by 11 reporting states at the end of the (incl. % project. As expected, different states may be adapting the same policy document achievement) e.g. HRH policy. (Original Credit): NHMIS capacity and minimum package provided at federal Indicator 18 : level Value Not determined not determined Not determined ix

16 (quantitative or Qualitative) Date achieved 09/15/ /15/ /30/2011 Comments (incl. % Not measured. achievement) Indicator 19 : (Original Credit): Health sector performance assessments undertaken 0 Value (quantitative Not determined Source: KPI Report data Source: KPI Report or Qualitative) for 2004 data for 2011 Date achieved 09/15/ /15/ /30/2011 Comments Partially Achieved. At the state level, no assessments were carried out until 2011 (incl. % when 11 states conducted their assessment with support from the project. achievement) G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP 11 Actual Disbursements (USD millions) 1 12/30/2002 Satisfactory Satisfactory /10/2003 Unsatisfactory Unsatisfactory /11/2003 Unsatisfactory Unsatisfactory /23/2004 Unsatisfactory Satisfactory /10/2004 Unsatisfactory Satisfactory /18/2005 Satisfactory Satisfactory /22/2005 Moderately Satisfactory Moderately Satisfactory /13/2006 Moderately Satisfactory Moderately Satisfactory /30/2006 Moderately Satisfactory Moderately Satisfactory /24/2007 Moderately Satisfactory Moderately Satisfactory /11/2007 Satisfactory Satisfactory /28/2008 Satisfactory Satisfactory /28/2008 Satisfactory Satisfactory /31/2008 Satisfactory Satisfactory /24/2009 Satisfactory Satisfactory /30/2009 Satisfactory Satisfactory /21/2009 Satisfactory Satisfactory /29/2010 Moderately Satisfactory Satisfactory /27/2011 Moderately Satisfactory Moderately Satisfactory /14/ /26/2012 Moderately Unsatisfactory Moderately Unsatisfactory Moderately Satisfactory Moderately Satisfactory x

17 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in USD millions 09/29/2005 Y S S /20/2009 N S S Reason for Restructuring & Key Changes Made Expand project s geographical and technical scope; eliminate counterpart financing, and reallocate resources Financing gap resulting from increasing LGA interest; need for additional resources to achieve the PDO If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Unsatisfactory Against Formally Revised PDO/Targets Moderately Satisfactory Overall (weighted) rating Moderately Unsatisfactory I. Disbursement Profile xi

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19 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. By the late nineties, Nigeria had suffered through decades of political and financial mismanagement, which had so negatively affected the social sectors that it ranked among the thirteen poorest countries in the world in terms of the UNDP Human Development Index. Official estimates indicated that the proportion of households living below the poverty line had risen steeply nationwide from 27% (1980) to close to 66% (1996). With a GNP per capita estimated at $300 (1998), the average Nigerian was living on less than one dollar per day. 2. Health situation and Government response. During the decades of military rule preceding the project, health outcomes had generally stagnated or deteriorated. The Project Appraisal Document (PAD) noted that: (i) maternal mortality rates were significantly higher and rates of decline in infant mortality were much slower than in other countries of similar income levels; (ii) total fertility and annual population growth rates had declined between 1982 and 1997 (from 6.9 to 5.3 and from 3.2 to 2.6 respectively) but attributed the decline to later childbearing rather than to improved access to family planning services; (iii) large inequalities existed in the coverage of basic services and in health and nutrition outcomes for the poor and non-poor with only 9% of the poorest women having access to a nurse or midwife at delivery and only 14% of children from the poorest families fully immunized (compared with 58% of children from the richest families); and (iv) a disproportionate burden of communicable diseases fell on the poor. 3. In addition, the PAD estimated that Nigeria spent less than $5.0 per capita of public resources on health care, considerably less than countries at similar socio-economic levels. Moreover, inefficiencies in public expenditures (e.g., constitutionally-mandated fiscal transfers from federal to state and local authorities, personnel costs often crowding out other essential inputs as well) as well as the division of responsibility for health between the three levels of government which, in the Nigerian context, means that the federal level has little leverage over the states and the states have little leverage over local governments have all contributed to persistently poor health outcomes. The perceived decline in the quality of government health services (deteriorated infrastructure and equipment, lack of drugs, low health staff morale, etc.) had contributed to a dramatic reduction in the utilization of health services. In contrast, private sector services had increased, with private expenditures estimated to represent over 70% of total health expenditures in Nigeria and household out of pocket expenditures accounting for most of these expenditures. 4. Finally, the PAD argued that Nigeria s three tiered health system (with service delivery responsibilities shared among federal, state, and local authorities) suffers from insufficient definition of roles and responsibilities, varying capacity to manage resources and responsibilities, significant costs 1, and issues of ownership and accountability. 5. With the return of civil administration in 1999, the Government initiated a broad-based consultative process to confirm its commitment to improving health care. The result was a Medium-Term Plan of Action ( ) to address: (i) primary, secondary, and tertiary care; (ii) sexual and reproductive health (including HIV/AIDS); (iii) disease control; (iv) drug production and management; and (v) sector organization and management (including development coordination). The PAD noted that: (i) the objectives of the Medium- Term Plan were generally reasonable but would probably require a ten-year time horizon; (ii) several key issues affecting health service delivery were beyond the scope of the sector (e.g., public sector management, fiscal decentralization, and civil service reform); and (iii) Bank support could only begin to address the medium-term agenda while laying the groundwork for further support. 6. Country Assistance Strategy and Rationale for Bank Involvement. Consistent with the Bank's Country Assistance Strategy (CAS) dated May 18, 2000 (Report No ) and the draft CAS of March 23, 2000, the project focused on: (i) strengthening social services to support poverty reduction and community 1 Management of health services at the different levels of government account for 26% of total health expenditure in Nigeria, more than 6 times the total of all donor contributions. 2

20 development by strengthening the technical content and reliability of health services to meet the needs of the poor and increasing the availability of services in poor communities; (ii) improving governance, efficiency and productivity in the public sector by strengthening budget management, procurement, information systems, and system management and promoting local autonomy and community involvement; and (iii) providing modest support for private sector development by contracting private sector providers to improve supplies and technical content of services and refining the project based on studies of the private sector. 7. The project was expected to contribute to the overarching goal of poverty reduction through higher productivity levels and improvements in health status. More specifically, it emphasized assistance to: (i) the states in rebuilding a minimum capacity for delivering public services especially for the poor; and (ii) the federal and state authorities in establishing the conditions for improved governance in the management of public funds in the health sector through the development of expenditure programs, mechanisms of accountability, and performance standards. 8. Bank involvement was justified by its ability to leverage: (i) its knowledge and experience from other countries in the implementation of similar operations promoting new ways of doing business in the health sector (e.g., programmatic support, public/private partnerships and health financing option.); (ii) its technical advantage of working in close collaboration with other networks (e.g., public sector management and fiscal decentralization); and (iii) its financial contribution which would be important both in relative terms and in conjunction with other development partners, such as the African Development Bank (AfDB) to maximize the support provided to participating states. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 9. With the overall objectives of assisting the Nigerian authorities to: (i) redress the deterioration in the delivery of basic health care services; (ii) build institutional capacities; and (iii) initiate sustained development of the health care system, the project had as Project Development Objectives to: (i) strengthen capacities for system management at the state level and encourage an environment of broad based consultation; (ii) support improvements in the delivery of primary health care services with a particular focus on maternal and child health and reproductive health services; and (iii) assist the Federal Government to strengthen its policy formulation and further develop a system to monitor the health sector performance. 10. The original key indicators 2, as defined in Annex 1 of the PAD, were linked as follows with the Project Development Objectives (PDOs): Component 1: Strengthen capacities for system management at the state level Number of states with approved 3-year rolling and annual work plans Proportion of states having developed state health accounts Number of states with certified/audited financial statements Component 2: Improve the delivery of primary health care services Increased utilization of primary health care facilities Increased proportion of children under one year and under two years fully immunized Increased proportion of births attended by skilled health personnel (doctor, nurse, midwife) Component 3: Assist the Federal Government in implementing its health sector reform agenda Improved situation in the five areas of reform: provision of the basic package of services; legal and institutional framework; role of the private sector; financial and fiscal management; and human resources 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 11. Beginning in March 2005, officials from the Federal Ministries of Finance (FMOF) and Health 2 Only two of the indicators (availability and quality of services and births attended by skilled staff) were routinely tracked by Government and the Bank until 2008 when the Additional Financing was approved. 3

21 (FMOH) and the states began discussions with the Bank to review the following issues under the project with a view to restructure: (i) governance and capacity-building; (ii) program priorities; (iii) project financing (counterpart requirements, budget categories and allocations); and (iv) monitoring and evaluation arrangements. 3 Changes in the DCA were officially requested in May and approved in September. The project s objectives were modified as follows: to assist the Borrower in: (i) strengthening the capacities for management of the health system at the State level; (ii) improving the delivery of primary and secondary health care services with a particular focus on maternal and child health and reproductive health services in participating States; and (iii) strengthening, at the Federal level, policy formulation and delivery of secondary health care services with a particular focus on maternal and child health and reproductive health services, and further developing a system to monitor the performance of the health sector. 12. In 2009, under the Additional Financing (AF), project activities were modified to finance: (i) improvements in the Schools of Health Technology, Nursing, and Midwifery in 36 States; (ii) development of primary health care services at community level (refurbishment, equipment, training, drugs and other medical supplies, immunization, etc.).; and (iii) strengthened M&E systems at Federal and State levels. 13. The PDOs remained unchanged, but the key performance indicators were modified/added to: (i) incorporate the lessons of the previous five years of implementation; (ii) better describe the intended results of the project; and (iii) strengthen the results focus of the monitoring and evaluation system. The additional KPI are indicated below by component 45 : Component 1: Strengthen capacities for system management at the state level Percentage of states routinely linking State health plans with annual budgets Component 2: Improve the delivery of primary health care services Percentage increase in total out-patient visits in health facilities constructed/rehabilitated/fully furnished) under AF Percentage of pregnant women attending antenatal clinics Immunization rate (for both under-1 year and under-5 years) 1.4 Main Beneficiaries and Benefits 14. Beneficiaries. The project was intended to benefit primarily poor Nigerians, who are the main users of public health services. The national focus was expected to have a potentially important impact in terms of reaching a large number of beneficiaries, particularly in terms of the availability and quality of basic health services for targeted children and women. In addition to beneficiary populations, other expected beneficiaries included: (i) the public health sector in general, which would benefit from activities aimed at strengthening the health sector reform agenda and preparing the groundwork for more sustained development; (ii) State and LGA health authorities, which would benefit from technical and managerial capacity building interventions; and (iii) non-public and community entities, which would be expected to play enhanced roles. 15. Benefits. Health benefits for the poor and especially for women and children comprised increased access and improved quality of health care services 6 and, in the longer term, reduced mortality and morbidity. Benefits for the health sector in general were expected to include: (i) improved management of sector resources (information, planning, and coordination), particularly through plans and budget allocations agreed on by State Governors and Health Commissioners; (ii) improved governance (ownership, decision- 3 These issues are addressed in more detail under Section 2.2 (Project Implementation). 4 The ISRs, commencing with Sequence 18, suggest that the Additional Financing Paper created new components but the Paper does not explicitly say this. See Section 1.6 below. 5 From 2008 the 3 of the new indicators were tracked by the Government and the Bank along with the 2 from the original credit already being tracked. The fourth new indicator on immunization was already one of the original credit indicators being tracked. 6 A qualitative social assessment during project preparation found that, while lack of physical access to services reduced utilization in some areas, the poor quality of health services was the principal reason that people were not using these facilities. 4

22 making, and accountability), through implementation of subsidiary agreements defining the roles and responsibilities of all parties in the implementation of the project; and (iii) improved performance (as measured by improved processes, better outcomes, and increased credibility). 1.5 Original Components 16. Component 1: Strengthen Capacity for System Management (All States, $53.78 million). All interested States would be eligible to participate in this component up to a total amount of $1.5 million per state. Sub-components areas comprised activities to support: (i) managerial processes and skills (e.g., improved budget management processes, state health accounts, and use of performance reviews); (ii) technical skill development; (iii) the Health Management Information System (HMIS); (iv) access to information and communication technology; and (v) research and studies. 17. Component 2: Strengthen the Delivery of Priority Health Services (Qualifying States, $63.70 million). Selected States would be eligible, in addition to the amounts in Component 1, an average amount of $3.5 million per state to support their programs, based on their perceived priority goals and objectives, as reflected in their Project Implementation Plans and approved annually after discussion with the Bank. 7 Emphasis would be placed on improving the delivery of primary health care services and particularly: (i) IMCI and strengthening immunization services; (ii) safe motherhood interventions, including the Mother- Baby Package, strengthening of state nursing schools, and improved emergency obstetric care in selected secondary care facilities; and (iii) communicable disease control, especially tuberculosis control. Though each state would have its own priorities and needs, selected activities would be expected to: (i) result in measurable improvements, particularly for the poor; and (ii) be perceived by the population as useful for meeting their needs. 18. The project would provide for: (i) rehabilitation and equipment of selected facilities, based on an inventory and plan; (ii) improved access to water; and (iii) logistical capabilities (i.e. vehicles). The project would provide funds to enable newly rehabilitated facilities to operate satisfactorily over a given period of time, while mechanisms are put in place for ensuring sustainability. 19. Component 3: Strengthen Capacity for key public health systems, functions and processes for Federal Ministry of Health ($7.92 million). The project would provide assistance to the Federal Ministry of Health to build capacity within the framework of the Government's Medium-Term Plan. Specifically, assistance would: (a) strengthen capacity in the areas of health sector reform, systems development, and good governance; (b) strengthen the health management information system, including both hardware and software and capacity to assess the health sector performance; (c) support essential national health research with a focus on health care financing; and (d) ensure project coordination, monitoring, and evaluation. 1.6 Revised Components 20. The AF Project Paper proposed allocating the additional resources for: (i) rehabilitating the Schools of Health Technology and Schools of Nursing and Midwifery ($16.53 million); (ii) supporting health services ($54.06 million); and (iii) strengthening monitoring and evaluation systems and processes at National and State levels ($9.41 million). Although it is not entirely clear from the Project Paper, the additional resources seem to have been integrated into the original components Other significant changes 21. In addition to the project restructuring in 2005 and the additional financing in 2009, a number of other important changes were approved during the original credit, including: (i) modification of procurement 7 It was agreed that for this component, the Bank would finance a maximum of 35% on civil works, 45% on goods and equipment, with the remainder for technical assistance and training. 8 The Project Paper states that project was not changed though components were grouped into 3 subsets to allow for easier implementation, but then presents the monitoring framework in terms of two components. The ISRs treat the changes in the Project Paper as new components. 5

23 procedures, prior review thresholds (April 2005, July 2006); (ii) revision of the disbursement categories, reallocation of the project proceeds, and changes in the subsidiary credit agreements with the states (September 2006); and (iii) extension of the closing date from July 1, 2007 to July 1, 2008 (March 2007) and subsequently to May 31, Finally, a reallocation of the remaining amounts of the credit was approved in February Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 22. Project preparation was influenced by the Bank s efforts to define an appropriate approach for assisting the country during the re-engagement process. On the one hand, the Interim Poverty Strategy recognized the Bank s role as one of helping the Nigerians to build their capacity to manage their own resources effectively, utilizing government services, the private sector, and local communities. On the other hand, the Bank s project preparation team had clear ideas about the scope and objectives of a potential health sector project. 23. While recognizing the need for continued dialogue on health sector reform, the preparation team s more immediate concern in December 1999 was to fast-track the presentation of the project to meet: (i) the short-term immediate need of continuing funding for those States which had benefited from the recently closed Health Systems Fund; and (ii) the longer-term need of addressing the dilapidated state of health services infrastructure which had been ignored over the previous decades of military rule. In the end, the project was appraised in February 2002, approved by the Board in June 2002, and became effective in May Over the preparation period the Bank negotiated the technical content, administrative arrangements, and potential political ramifications of the project design with Government to address immediate needs. There were clearly political economy issues that had to be dealt with by the Bank in re-engaging the Country that also manifested in the project preparation and design. 24. Project preparation. In December 1999, in parallel with the preparation of the ICR for the Health Systems Fund (HSF), the 16 participating States carried out Phase II Studies to lay the foundation for the second phase. These 16 states were joined by nearly all of the other 20 States (except Kano State) interested in participating in the second phase. Two project preparation workshops were conducted (with Bank assistance) in January and February 2000, and States prepared project papers, which (along with the proposal of the Federal Ministry of Health) were then consolidated into a proposal for consideration by the Bank. 25. A Project Concept Note (PCN) was subsequently prepared and reviewed in May Four key issues were discussed: (i) the size of the project, and particularly how FMoH had reduced the combined State and Federal proposals (estimated at more than US$1 billion) to US$275 million (of which the Bank was expected to finance US$240 million); (ii) the scope of the project, and more specifically, the phasing in of the States; (iii) the role of the Federal Ministry in coordinating the States in a context where the States were not interested in having FMoH assume such a responsibility; and (iv) the appropriate arrangements for monitoring and supervising the project, given the spread of funds and activities over 37 different implementing agencies (36 State Ministries of Health and one Federal Ministry of Health) and the impossibility of covering the country with traditional Bank-style supervision missions. 26. A pre-appraisal mission, comprising donor agencies active in the health sector in Nigeria for consultative discussions on the Medium-Term Plan of Action and Health Sector Reform, was originally announced for June 2000 but was subsequently postponed until September. 10 In addition to addressing the PCN review meeting issues, the mission informed the Government of the need for a Sector Policy Letter, 9 The original and revised closing dates mentioned in the AF memorandum of February 12, 2008 are different from those indicated in the DCA and the ISRs. 10 The Federal Ministries of Finance and Health believed that the State Project Implementation Plans were sufficiently advanced and that the Bank should shelve the pre-appraisal mission in favor of an immediate appraisal mission, but the Bank insisted on a pre-appraisal mission. 6

24 recommended a number of key policy measures, and requested specific timeframes for the implementation of these measures, considered as pre-requisites for a successful health systems project. The State Project Implementation Plans (PIP) were reviewed and revisions requested by end January for appraisal in February Correspondence after the pre-appraisal mission highlighted issues of the evolving project, including: (i) the degree of readiness of the project; (ii) the allocations to and ceilings for the amounts to individual states; and (iii) and the role of FMoH in coordinating the States. 27. The February 2001 preparation mission noted the improvements in the State PIPs and concluded that there was no need for further revisions of the State plans, but the Government had issues with: (i) the extent of planning (and preparation) missions with consequent delays in approving the project, which had been expected to be effective in June/July 2000; and (ii) the reduction in the amount of the credit from a twophased US$240 million project to a single US$120 million project 12 and in the number of States to participate in the project. The delays in project approval were due to the challenge of the Bank reaching agreement with the Government in terms of the scope of the project and what could realistically be achieved especially given the post military context and the related political economy of the Bank re-engaging with the Government at the time. 28. The Decision Meeting (DM) was organized in May 2001, with the Bank confirming its decisions to: (i) proceed with a project of US$125 million (but prepared to follow up with an additional IDA credit); (ii) limit the number of States to the 25 which were considered ready in terms of procurement and financial management; and (iii) demonstrate project support for the health reform process without overpromising on the implementation of reforms. The DM also addressed specific issues related to the flow of funds and monitoring and evaluation. Appraisal and negotiation of the credit were planned for June 2001 but deferred by FMoH pending clarifications on the issues raised in February; when the Country Director confirmed no changes in the Bank's position on these matters, preparation virtually ceased until another pre-appraisal mission was organized in January This mission resulted in the final organization of the project components, and the appraisal mission followed immediately thereafter in February Negotiations were conducted in April 2002, the project was approved by the Board on June 6, 2002, and the DCA was signed on February 25, AfDB s Board approved their portion of the project in September Soundness of the background analysis. In view of the expectations of the new civilian leadership, the project preparation team argued in the PCD memo that detailed economic and sector work (ESW) prior to sector assistance was idealistic. At the PCD review meeting it was agreed that: (i) even if additional ESW was required, it would be incorporated into the project itself; and (ii) an effective mechanism for dialogue and coordination would be established between the Government and the other sectoral development partners. 31. In addition, the PCD memo argued that this follow-on project would benefit sufficiently from the lessons learned from the previous Health Systems Fund project 14 as well as from other countries 15. HSDP II 11 The Bank requested extensive changes including: (i) additional information on health facilities and human resources; (ii) more participation in the planning and implementation; (iii) clearer indication of how the plans fit into the Statespecific strategic plans; (iv) specific proposals for including the private sector and the communities; (v) discussion of the long-term sustainability of the project benefits; and (vi) baseline data and targets on appropriate performance indicators. The Bank concluded that the need for a paradigm shift from a facility-centered planning to an intervention-centered planning and for shifting the focus from structures to services is the single most important point emerging from the mission s review of the PIPs. 12 In its response, the Bank reiterated its March 2001 position that subsequent assistance would be through a separate IDA credit, not a single credit bifurcated in two tranches, and would be based on the implementation performance of this first credit. 13 It should be noted that the challenges experienced during the appraisal phase are not uncommon in federal systems of government like Nigeria. 14 Curiously, the PAD does not cite the Imo State Health Project, though that ICR contains a number of interesting conclusions and pertinent lessons; see Section 6 of this ICR which discusses the lessons learned. 7