Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank Report No: ICR0000317 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-40520 MULT-56510) ON A CREDIT IN THE AMOUNT OF SDR196.1 MILLION (USD 300.0 MILLION EQUIVALENT) & GRANT IN THE AMOUNT OF USD 387.98 MILLION TO THE PEOPLE S REPUBLIC OF BANGLADESH FOR A HEALTH, NUTRITION AND POPULATION SECTOR PROGRAM Human Development Sector Bangladesh Country Management Unit South Asia Region June 27, 2012
CURRENCY EQUIVALENTS (Exchange Rate Effective) December 31, 2011 Currency Unit =Bangladesh Taka (Tk) Taka 84 = USD1 USD 0.0167 = Taka 1 FISCAL YEAR (July 1 June 30) ABBREVIATIONS AND ACRONYMS AIDS ANC APIR APR BDHS BMMS CES CIDA CPR DCA DFID DGFP DGHS DP DSF EC EKN ESD FM FMAU FMR FY GDP GOB HEU HIV HNP HNPSP HPSP HSDP HR HCWM IDA IMED IO IRR ISR JICA Acquired Immune Deficiency Syndrome Antenatal Care Annual Program Implementation Report Annual Program Review Bangladesh Demographic and Health Survey Bangladesh Maternal Mortality Survey Coverage Evaluation Survey Canadian International Development Agency Contraceptive Prevalence Rate Development Credit Agreement Department for International Development (United Kingdom) Directorate General of Family Planning Directorate General of Health Services Development Partner Demand-side Financing European Commission Embassy of the Kingdom of the Netherlands Essential Services Delivery Financial Management Financial Management and Audit Unit Financial Monitoring Reports Fiscal Year Gross Domestic Product Government of Bangladesh Health Economics Unit Human Immuno-deficiency Virus Health, Nutrition and Population Health, Nutrition and Population Sector Program Health and Population Sector Program Health Sector Development Program Human Resources Health Care Waste Management International Development Association Implementation, Monitoring & Evaluation Division, Ministry of Planning Intermediate Outcome Internal Rate of Return Implementation Status and Results Report Japan International Cooperation Agency
KfW LD LLP M&E MDG MDTF MIS MMR MOF MOHFW MOLGRDC MSA MTR NCD NGO NNP NPV NTP OP PAD PBF PDO PER PFM PIP PMA PSO RFW RVP SBA Sida SIP SWAp TA TB THE TTL UNFPA UESD WHO Kreditanstalt für Wiederaufbau (Germany) Line Director Local Level Planning Monitoring and Evaluation Millennium Development Goal Multi-Donor Trust Fund Management Information System Maternal Mortality Ratio Ministry of Finance Ministry of Health and Family Welfare Ministry of Local Government, Rural Development and Cooperatives Management Support Agency Mid Term Review Non-Communicable Diseases Non-Government Organization National Nutrition Program Net Present Value National Tuberculosis Program Operational Plan Project Appraisal Document Performance Based Financing Project Development Objective Public Expenditure Review Public Financial Management Program Implementation Plan Performance Monitoring Agency Program Support Office Results Framework Regional Vice President Skilled Birth Attendant Swedish International Development Cooperation Agency Strategic Investment Plan Sector-wide Approach Technical Assistance Tuberculosis Total Health Expenditure Task Team Leader United Nations Population Fund Utilization of Essential Service Delivery World Health Organization Vice President: Isabel M. Guerrero Country Director: Ellen A. Goldstein Sector Manager: Julie McLaughlin Project Team Leader: Bushra B. Alam ICR Team Leader: Bushra B. Alam ICR Primary Author: Finn Schleimann
BANGLADESH HEALTH NUTRITION AND POPULATION SECTOR PROGRAM CONTENTS 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 1. Project Context, Development Objectives and Design... 1 2. Key Factors Affecting Implementation and Outcomes... 6 3. Assessment of Outcomes... 15 4. Assessment of Risk to Development Outcome... 20 5. Assessment of Bank and Borrower Performance... 20 6. Lessons Learned... 23 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners... 24 Annex 1. Project Costs and Financing... 26 Annex 2. Outputs by Components... 27 Annex 3. Economic and Financial Analysis... 30 Annex 4. Bank Lending and Implementation Support/Supervision Processes... 37 Annex 5. Beneficiary Survey Results... 39 Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR... 40 Annex 7. Comments of Co-financiers and Other Partners/Stakeholders... 49 Annex 8. List of Supporting Documents... 52 Annex 9. Results Framework of HNPSP... 54
A. Basic Information Country: Bangladesh Project Name: Bangladesh - Health Nutrition and Population Sector Program Project ID: P074841 L/C/TF Number(s): IDA-40520,TF-56510 ICR Date: 06/26/2012 ICR Type: Core ICR Lending Instrument: SIM Original Total Commitment: Revised Amount: Environmental Category: B USD 300.00M (IDA Credit); USD 450.00M (MDTF) USD 300.00M (IDA Credit) USD 387.90M (MDTF) Implementing Agencies: Ministry of Health and Family Welfare Cofinanciers and Other External Partners: Canadian International Development Agency (CIDA) Embassy of the Kingdom of the Netherlands (EKN) European Commission (EC) Kreditanstalt für Wiederaufbau (KFW) Germany Swedish International Development Agency (Sida) UK Department for International Development (DFID) United Nations Population Fund (UNFPA) B. Key Dates Borrower: Disbursed Amount: Process Date Process Original Date GOVERNMENT OF BANGLADESH USD 293.40 M (IDA Credit) USD 387.80M (MDTF) Revised / Actual Date(s) Concept Review: 02/11/2004 Effectiveness: 06/14/2005 Appraisal: 11/17/2004 Restructuring(s): 10/22/2009 07/30/2010 03/02/2011 Approval: 04/28/2005 Mid-term Review: 04/01/2008 02/15/2008 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Closing: 12/31/2010 12/31/2011 Satisfactory Moderate Satisfactory Satisfactory
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation Performance Potential Problem Project Yes at any time (Yes/No): Problem Project at any time (Yes/No): Yes Indicators DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Sector Code (as % of total Bank financing) QAG Assessments (if any) Rating Quality at Entry (QEA): Moderately Satisfactory Quality of Supervision (QSA): Original Moderately Satisfactory Actual Central government administration 36 36 General education sector 4 4 General public administration sector 9 9 Health 40 40 Other social services 11 11 Theme Code (as % of total Bank financing) Child health 13 13 Health system performance 24 24 Nutrition and food security 25 25 Other communicable diseases 13 13 Population and reproductive health 25 25 E. Bank Staff Positions At ICR At Approval Vice President: Isabel M. Guerrero Praful C. Patel Country Director: Ellen A. Goldstein Christine I. Wallich Sector Manager: Julie McLaughlin Anabela Abreu Project Team Leader: Bushra Binte Alam Cornelis P. Kostermans ICR Team Leader: ICR Primary Author: Bushra Binte Alam Finn Schleimann
F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document [PAD]) The project assisted the Government of Bangladesh (GOB) in the implementation of its Strategic Investment Plan (SIP), 2003-2010, for the Health, Nutrition & Population Support Program (HNPSP) with support from a large group of Development Partners (DPs) through a Sector-wide Approach (SWAp). The main purpose of the SIP was to increase the availability and utilization of user-centered, effective, efficient, equitable, affordable and accessible quality services be it the Essential Services Package, improved hospital services, nutritional services or other selected services. To achieve these objectives, the program focused on three major reform areas: (i) Strengthening Public Health Sector Management and Stewardship Capacity, through development of pro-poor targeting measures as well as strengthening sector-wide governance mechanisms; (ii) Health Sector Diversification, through the development of new delivery channels for publicly and non-publicly financed services; and (iii) Stimulating Demand for essential services by poor households through health advocacy and demand-side financing options. Revised Project Development Objectives (PDO) The PDO as described in the PAD was not changed. During the Mid-Term Review (MTR), the Results Framework (RFW) was changed and the change was approved as part of a Regional Vice President level restructuring in October 2009. (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 Proportion of total Ministry of Health and Family Welfare (MOHFW) expenditure allocated to the 25% poorest districts (increasing to 40%) dropped during MTR. Revised to: percentage of MOHFW expenditures at the upazila level and below (on 07-Oct-2009) 1 25% (original indicator ) ; 50% revised 45% (for the revised 40 % on 07-Oct- 47% indicator) 2009 Date achieved 06/30/2005 06/30/2010 06/30/2011 06/30/2011 Comments 40% achieved; source: Public Expenditure Review 2008/09 (published in July (incl. % 2011). achievement) Utilization rate of Essential Services Delivery (ESD) of the two lowest income quintiles increased divided into two parts (a and b) during MTR. Indicator 2 : Revised to (on 07-Oct-2009): Utilization rate of ESD of the two lowest income quintiles: (a) Delivery attended by skilled personnel 2 1 Not the original PAD indicator, as it was changed at restructuring. 2 Modified from the original PAD indicator.
Value quantitative or Qualitative) 55% (as per PAD); baseline revised to 4.10% (for the revised indicator) during MTR 65% 10% set on 07-11.8% Oct-2009 Date achieved 12/01/2004 06/30/2010 06/30/2011 06/30/2011 Comments 131% achieved; source: Utilization of Essential Service Delivery Survey (UESD) (incl. % 2010. achievement) Indicator 3 : Utilization rate of ESD of the two lowest income quintiles: (b) Antenatal coverage (by medically trained provider) 3 55% (as per PAD); Value 40% revised baseline revised to 32.5% quantitative or 65% on 07-Oct- (for the revised indicator) Qualitative) 2009 during MTR 40.3% Date achieved 12/01/2004 06/30/2010 06/30/2011 06/30/2011 Comments (incl. % 104% achieved; source: UESD 2010. achievement) 26.5% (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Actual Value Formally Values (from Achieved at Revised approval Completion or Target Values documents) Target Years Indicator 1 : Proportion of births attended by skilled personnel (from 12% to 40 % by 2010) Value (quantitative 25% (as per PAD); baseline revised to 15.5% 40% 28% revised on 07-Octor Qualitative) during MTR 2009 4 Date achieved 06/30/2004 06/30/2010 06/30/2011 11/30/2011 Comments (incl. % achievement) 88% achieved; source: Bangladesh Maternal Mortality Survey (BMMS) 2010 Preliminary Report. Indicator 2 : Tuberculosis (TB) case detection rate (from 41% to 70% by 2010) Value (quantitative 41% (as per PAD); baseline revised to 46% 70% 72% revised on 07-Oct- 74% or Qualitative) during MTR 2009 Date achieved 06/30/2003 06/30/2010 06/30/2011 06/30/2011 Comments (incl. % achievement) Indicator 3 : 108% achieved; source: National TB Program (NTP) 2010 (as reported in Directorate General of Health Services [DGHS] Health Bulletin 2011). % of children 1-5 receiving Vitamin A supplements during the last 6 months Revised (on 07-Oct-2009) to: % of children age 9-59 months receiving vitamin A supplements during the last 6 months 5 3 Modified from the original PAD indicator. 4 Reduced from PAD (was 40%), but baseline also lower than what was assumed in PAD (originally 25%).
Value (quantitative or Qualitative) 81.80% 90% 90% 92% Date achieved 06/30/2004 06/30/2010 06/30/2011 06/30/2011 Comments (incl. % 124% achieved; source: Coverage Evaluation Survey (CES) 2011. achievement) Indicator 4 : Non-communicable disease (NCD) strategy developed and implemented as per details in results framework Value (quantitative or Qualitative) Strategy not yet developed. Strategy implemented Strategy developed; Strategy developed NCD risk and updated; NCD behavior risk behavior survey survey, NCD conducted; NCD piloting, and piloting and Injury Injury piloting piloting activities are activities are incorporated in the incorporated NCD Operational into the Plan operational plan (OP) Date achieved 12/01/2004 06/30/2010 06/30/2011 06/30/2011 Comments (incl. % Fully achieved; source: Annual Program Implementation Report (APIR) 2010. achievement) Indicator 5 : Proportion of contracts awarded within initial bid validity period (95% from 2006 onwards) Value (quantitative or Qualitative) N.A. 95% or more 90% or more 6 80% Date achieved 06/10/2005 06/30/2010 06/30/2011 06/30/2011 Comments (incl. % 89% achieved; source: APIR 2010. achievement) Demand-side financing (DSF) pilots on schedule as per details in results framework Indicator 6 : Revised to: % of women targeted by voucher scheme who deliver by skilled birth attendants (at facility or at home) 7 Piloted by 2006, Value N.A. (as per PAD); 60% revised evaluated in (quantitative 7% (for the revised on 07-Oct- 2007 and scaled up or Qualitative) indicator) 2009 in 2008 64% Date achieved 06/01/2005 06/30/2010 06/30/2011 06/30/2011 5 Slightly modified from the original PAD indicator 6 Changed from 95% to 90% at MTR 7 Modified from original PAD indicator
Comments (incl. % achievement) 108% achieved; source: Economic Evaluation of DSF Program for Maternal Health in Bangladesh 2010 Indicator 7 : % of districts with disease surveillance reports 8 N/A (as this Value indicator was (quantitative 52% 95% added during MTR or Qualitative) (on 07-Oct-2009) 95% Date achieved 12/01/2004 06/30/2011 06/30/2011 Comments (incl. % 100% achieved; source: APIR 2010. achievement) Indicator 8 : % of children (under 1 year) fully immunized 9 n/a (as this Value indicator was (quantitative 68.4% 85% added during MTR or Qualitative) (on 07-Oct-2009) 80% Date achieved 12/01/2004 06/30/2011 06/30/2011 Comments (incl. % 70% achieved; source: CES 2011. achievement) Indicator 9 : TB cure rate 10 n/a (as this Value indicator was (quantitative 85% 85% added during MTR or Qualitative) (on 07-Oct-2009) 92% Date achieved 12/01/2004 06/30/2011 06/30/2011 Comments (incl. % 108% achieved; source: NTP 2010 (as reported in DGHS Health Bulletin 2011). achievement) G. Ratings of Project Performance in ISRs No. Date ISR Actual Disbursements DO IP Archived (USD millions) 1 06/16/2005 Satisfactory (S) Satisfactory 0.00 2 12/15/2005 Moderately Satisfactory (MS) Moderately Satisfactory 0.00 3 05/10/2006 Moderately Satisfactory Moderately Satisfactory 43.07 4 10/27/2006 Moderately Satisfactory Moderately Satisfactory 54.57 5 04/25/2007 Moderately Satisfactory Moderately Satisfactory 131.05 6 05/25/2007 Moderately Moderately 131.05 8 Added to the original PAD indicators 9 Added to the original PAD indicators 10 Added to the original PAD indicators
Unsatisfactory Unsatisfactory 7 11/20/2007 Moderately Moderately Unsatisfactory Unsatisfactory 124.71 8 01/19/2008 Moderately Moderately Unsatisfactory Unsatisfactory 124.71 9 05/13/2008 Moderately Satisfactory Moderately Satisfactory 124.71 10 12/05/2008 Moderately Satisfactory Moderately Satisfactory 124.71 11 06/16/2009 Moderately Satisfactory Moderately Satisfactory 144.59 12 11/18/2009 Moderately Satisfactory Moderately Satisfactory 226.05 13 06/22/2010 Moderately Satisfactory Moderately Satisfactory 235.95 14 01/15/2011 Satisfactory Satisfactory 287.66 15 04/02/2011 Satisfactory Satisfactory 287.78 16 11/30/2011 Satisfactory Moderately Satisfactory 293.59 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in USD millions 10/22/2009 MS MS 171.95 07/30/2010 MS MS 235.98 03/02/2011 S S 287.66 Reason for Restructuring & Key Changes Made This was an RVP level restructuring to: (i) modify two PDO indicators and to refine the intermediate outcome indicators to improve relevance and accuracy in measurement; (ii) reduce the resource envelope for program parts/activities that have not been implemented and/or are progressing slowly, and to reallocate funds to pro-poor activities; and (iii) extend the Closing Date of the program by 1 year to December 2011. Approved by the World Bank s Country Director to document a change in the amount of the grant to: 1) include agreed additional contributions from CIDA and KfW; and 2) reduce DfID s original commitment of co-financing. Approved by the World Bank s Country Director. Restructuring to show (i) a reallocation of available funds between the disbursement categories, and (ii) increasing the amount of the grant from USD 335 million to USD 387.9 million.
I. Disbursement Profile $700,000,000 $600,000,000 $500,000,000 $400,000,000 $300,000,000 $200,000,000 $100,000,000 $0 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 Original amount Revised amount Cumulative expenditure
1. Project Context, Development Objectives and Design 1.1 Context at Appraisal In spite of being regularly affected by natural disasters and being one of the poorest and most densely populated countries in the world, Bangladesh sustained high rates of economic growth with considerable improvements in social indicators over the two decades preceding this project. As such, the country was well on the way to achieving many of the Health Nutrition and Population (HNP) related Millennium Development Goals (MDGs). Notwithstanding the achievements gained in the past years, Bangladesh faced an unfinished agenda of systemic problems, originally identified in the Health and Population Sector Strategy of 1997. In 1998, the strategy was translated into a five-year program, the Health and Population Sector Program (HPSP), which had marked a shift from multiple individual project approach to a single health Sector Wide Approach (SWAp). While key health outcomes had improved under HPSP, albeit at a faltering rate, the GOB s agenda of systemic reform could not be completed. At the appraisal of HNPSP, key issues faced by the sector included: Health Inequalities. Despite improvements in health indicators, the gap in health conditions between the rich and the poor remained high. There remained wide inequity, with children in the poorest households being more than twice as likely to be moderately malnourished, and four times as likely to be severely malnourished as children from the richest households. There was a pressing need to better address the health rights of poor people by targeting consumption subsidies and restructuring allocation mechanisms based on population and poverty indices. The Dynamics of Public and Non Public Health Service Provision. In Bangladesh, total annual per capita spending on health averaged US$12, of which only US$ 4 came from the public sector and the bulk (65%) 11 was funded from household out-ofpocket sources. Up to a third of the public budget on health was provided by DPs during 1998-2003. Almost half of the households used the non-public sector for treatment compared to only 10% who used the public sector. The remaining used traditional sources of care. Quality Health Care. Most services were provided by the non-public sector, more specifically by local unregistered, traditional practitioners, largely in a poorly regulated environment. Developing feasible and acceptable strategies for regulating and enforcing regulation of quality and volume was critical for health services and pharmaceuticals. 11 Bangladesh National Health Accounts, 1999-2001. Health Economics Unit, MOHFW, 2003 1
The sector was plagued by serious governance issues such as staff absenteeism, pilferage, extracting illegal payments from patients, and so forth. The Changing Epidemiology. In addition to the increasing incidence of injuries, accidents (drowning were the leading cause of mortality for the 1-5 year olds) and a growing risk of spread of Human Immuno-deficiency Virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS), Hepatitis B and C, amongst non-communicable diseases (NCD), cancer and cardio-vascular diseases were the leading causes of morbidity and mortality. The HNP needs of Marginalized Groups: Gender, disability, age, type of disease and cultural differences were the basis for discrimination, access and utilization of HNP services in Bangladesh. Poor women and children, especially those from tribal populations were being poorly served by the existing system, as were people with disabilities, the elderly, adolescents and HIV/AIDS patients. Maintaining the status quo was not the solution for Bangladesh, and the Government stated its intention to reform the HNP system through its Strategic Investment Plan (SIP), and proposed to significantly increase the level of spending on HNP. This intention confirmed GOB s commitment to pro-poor health service provision and to address the need to reappraise the essential core functions of the public sector. Under the SIP, new areas of focus were proposed which included a comprehensive approach to nutrition programming, introduction of demand side financing pilots, enhanced stewardship role of the government, developing incentives for health workers, and performance-based financing mechanisms. The SIP also laid out four broad policy directions that would have an impact on reducing health inequalities: (a) shifting resource allocations to poorer districts (or districts with poor health outcomes; (b) targeting and demand side subsidies to explore alternative ways of reaching to the poor; (c) diversification of service provision to improve the quality and coverage of HNP services through public-private partnerships; and (d) intersectoral collaboration to create linkages between the Ministry of Health and Family Welfare (MOHFW) and other ministries and programs which would have direct impact on the health status of the poor. The Health, Nutrition and Population Sector Program (HNPSP) was designed to address the above mentioned challenges and built upon the lessons learnt from the first health sector SWAp (HPSP). Under the new HNPSP (2005-2011), seven DPs (DfID, CIDA, EU, Sida, KfW, The Netherlands and UNFPA) contributed financing jointly with the International Development Association (IDA), and participated in joint implementation support activities, keeping in line with the signed Partnership Arrangement. The DPs setup a multi-donor trust fund (MDTF) with the Bank to support the Government s SWAp which was disbursed as co-financing with the Bank project. The total cost of HNPSP was US$4.3 billion (the Program ), of which US$3.1 billion was GOB funding and US$1.2 billion in DP funding. Of the DP funding, US$687.98 million was pooled funds (the Project which comprised of the MDTF of US$387.98 million and IDA credit of US$300 million) and the remaining US$512 million was parallel funding. During the 2
implementation of the program, the Bank administered the MDTF on behalf of the pooling partners and ensured fiduciary oversight of the funds spent. The MDTF included two portions one executed by GOB, the other by the Bank for supervision of MDTF and undertaking analytical and advisory activities. Overview of the sectors financing, budgeting and monitoring Partner Measured by Proportion Budget financing channel MOHFW - US$160.40 other million MOHFW Pooled Fund MOHFW - HNPSP IDA MDTF Non-pool partners MIS, Survey and administrative records Broad RFW & MIS, Survey and administrative records Project RFW (12), Survey and administrative records Broad RFW (30), Survey and administrative records Misc. project monitoring US$2,945.82 million US$300.00 million US$387.98 million US$512.00 million Total US$ 4306.20 million Revenue & Development Revenue & Development Development Miscellaneous project accounts Budget mechanism Through specific parallel projects 38 OPs Miscellaneous project budgets 1.2 Original Project Development Objectives (PDO) and Key Indicators The project was intended to assist the GOB in the implementation of its Strategic Investment Plan (SIP) 2003-2010, for the HNPSP in cooperation with a large group of DPs through a SWAp mechanism. The PDO of the project, as stated in the Project Appraisal Document (PAD) and in the Implementation Status and Results Reports (ISRs), was to Increase the availability and utilization of user centered, effective, efficient, equitable, affordable and accessible quality HNP services. The project was monitored using this PDO and was measured by the indicators outlined in the PAD and later revised during project restructuring in 2009. (See the ICR datasheet for details). It should be noted that the objective of the project, as stated in the Development Credit Agreement (DCA), differed from the description of the PDO in the PAD. The DCA 3
states that The objective of the Project, which is an integral part of the HNPSP is, inter alia to: (i) reduce infant, under-five child and maternal mortality and the proportion of malnourished children; (ii) eliminate the gender disparity in child malnutrition and mortality; (iii) ensure increased access to reproductive health services; (iv) lower total fertility with a view towards achieving replacement level by 2010; (v) reduce the burden of tuberculosis (TB), HIV/AIDS, malaria and other priority diseases; (vi) initiate a system to control newer health threats and protect health risks by improving emergency services; and (vii) improve the prevention and control of NCDs. These goals are consistent with the overall objectives of the HNPSP, as presented in the PAD, and were monitored by the overall HNPSP indicators, as presented in Annex 9 of this ICR. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification During the restructuring of the project in 2009 at the Regional Vice President level, one PDO indicator (Proportion of total MOHFW expenditure allocated to the 25% poorest districts) was replaced by Proportion of MOHFW expenditure at the Upazila level and below. This change better reflected MOHFW s regular monitoring and was a more realistic way of measuring the pro-poor resource allocation. Another PDO indicator (Utilization rate of Essential Service Delivery [ESD] of the two lowest income quintiles) was modified to better reflect improvements in two specific essential health services related to maternal health (i.e. skilled assistance during delivery and antenatal care (ANC) by medically trained provider), as follows: Utilization rate of ESD of the two lowest income quintiles: (a) Delivery attended by skilled personnel, and (b) ANC coverage by medically trained provider. In addition, during restructuring, two intermediate outcome (IO) indicators were deleted and three IO indicators were added to ensure better monitoring and better alignment with the project components and to better measure the PDO. Likewise, during restructuring, the GOB s Results Framework was also changed to reduce the number of indicators from the original 62 to 30 indicators. See Section below on Monitoring and Evaluation (M&E) for a detailed outline of these changes. 1.4 Main Beneficiaries The entire population of Bangladesh was to benefit from this project, with a special focus on the vulnerable population groups, e.g. the poor, women, children and the elderly. 1.5 Original Components The project had three components, which were closely interlinked. While the first component focused on objectives for service delivery in the classical primary health care domain and achieving the HNP MDG, the second was to develop policies and strategies to the changing disease burden due to urbanization and aging of the population. The third component was to address major policy reforms and strategies in order to achieve better equity and efficiency in the HNP sector. Disaggregated component costs were not specified. Component 1: Accelerating achievement of HNP-related MDG and Poverty Reduction Strategy Paper (PRSP) goals. The component was intended to support the delivery of a 4
package of essential services. The ESD would focus on (a) reduction of maternal mortality; (b) reduction of neonatal mortality; (c) reduction in childhood morbidity and mortality; (d) improvement in the nutritional status particularly of adolescent girls, pregnant and lactating women and children; (e) reducing fertility to replacement level; and (f) reducing the burden of TB and malaria and preventing and controlling HIV/AIDS. Component 2: Meeting emerging HNP sector challenges. This component was intended to support the development of policies and strategies for emerging challenges, with a focus on: (a) reduction of injuries and implementing improvements in emergency services; (b) prevention and control of major NCDs; (c) urban health service development; and (d) improvement of the HNP response to disasters. Component 3: Advancing HNP sector modernization. This component was intended to address the following health, nutrition and population (HNP) reforms: Public health sector management and stewardship capacity: Improving sector management would focus on improving institutional and personal skills for (i) better planning and monitoring; (ii) improved budget management through a medium term budgetary framework (MTBF) process; (iii) reform management; (iv) improved aid management; (v) development of proper contract documents and management of contracts with private and non-government organization (NGO) providers; (vi) information management; and (vii) development of alternative financing mechanisms. Major targets were established and agreed upon in order to implement a step-wise delegation of responsibility to promote decentralization and local level planning (LLP). Health sector diversification: In order to diversify service provision, MOHFW would build capabilities to become active service purchasers in partnership with NGOs and private providers. The pattern of service provision would be adjusted over time by the increasing use of contracts and commissions for NGOs to provide primary and secondary care in areas where they had a comparative advantage, and for private providers to offer secondary and tertiary services for poor people where they could do so cost-effectively and at high quality. Stimulating demand for HNP services: This was to be achieved through: (i) improving the sector s image and greater attention to effective communication, education and information strategies for key health problems; and (ii) expansion of demand-side financing. MOHFW initiated a pilot with technical support provided from the World Health Organization (WHO), of a voucher scheme to enable poor pregnant women to purchase maternal health services initially in 21 Upazilas and which was further expanded to 53 Upazilas during the life of HNPSP. Further piloting of other demand-side financing schemes, such as health insurance, were planned with the aim of scaling up following independent evaluation. 1.6 Revised Components N/A 5
1.7 Other significant changes The HNPSP was restructured three times, as follows: October 2009 (Regional Vice President Level): One PDO indicator was revised to improve measurement, implying a less specific but more realistic way of measuring pro-poor resource allocation, and in line with regular MOHFW monitoring. Another PDO indicator was made more specific for improved measurement. Also, the intermediate results indicator (for Component 2) indicating an increase from 5% to 10% in share of govt. expenditure allocated to MOHFW was removed as it was outside the authority of MOHFW. Lastly, other IO indicators were modified to enable better measurement of the PDO (see Section 1.3). Reduction of the resource envelope for those program activities that were lagging in implementation under component 3 of the Project, mainly under the aim of diversification 12 because of lack of progress by GOB to contract out services despite the presence of a large non-government and private entities in the health sector. The Closing Date was extended by one year to 2011 to ensure the full utilization of remaining resources. Overall, the restructuring was timely and contributed to the success of the program. 2010 (Country Director Level): To accommodate changes in the grant amounts from donors (DfID, KfW and CIDA). 2011 (Country Director Level): To accommodate an increase in grant amount and reallocation of funds between categories. Supplementing the restructuring there was an agreement at the Annual Program Review (APR) 2009, that funding would be reallocated towards pro-poor activities (e.g. essential drugs). 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Project preparation: The preparation of the HNPSP was informed by a thorough background analysis and building on GOB s HNP Strategic Investment Plan (SIP, 2003-2010) and was linked to the Poverty Reduction Strategy Paper (PRSP), with PDO and component objectives very relevant to the priorities of the country. The preparation 12 In the PAD, diversification is described as increasing use of contracts and commissions for NGOs to provide primary and secondary care in areas where they had a comparative advantage, and for private providers to offer secondary and tertiary services for poor people where they could do so cost-effectively and at high quality 6
specifically incorporated lessons learned from the previous support, the Health & Population Sector Program (HPSP) such as (a) clearly identifying the role of DPs and the Government with the GOB leading the program; (b) aligning technical assistance (TA) with policy documents; (c) carefully considering the political economy of reform; and (d) having demand-side strategies complement supply-side interventions. The preparation involved all major stakeholders, including the 16 members of the DP Consortium, civil society organizations (CSOs) and Bangladesh Medical Association (BMA). The risk assessment correctly identified most of the major risks, although the risk of commitment for the proposed sectoral reforms may have been rated too low. The problem of low GOB financing of the health sector was identified in the PAD, and the HNPSP, therefore, included a target of doubling MOHFW s share of the GOB budget (from 5 to 10%). This was a very ambitious target and the identified risk of GOB financing does not meet required spending level was, therefore, appropriately classified as Substantial. Project design: The choice of the lending instrument, the Sector Investment and Maintenance Loan (SIM), and the choice of the Sector-wide Approach (SWAp) was very appropriate given the nature, size and scope of the support envisioned and requested by GOB. A number of factors influenced the SWAp design that was developed, and the decisions as to how Bank and trust fund (pooled) financing would be disbursed, i.e. on a specific set of activities rather than supporting a time slice of the MOHFW program 13. Also, expanding the scope of the project to cover all of MOHFW budget items was not considered feasible as it would have significantly increased the burden for the Bank in terms of providing fiduciary oversight given the capacity constraints of MOHFW. HNPSP, therefore, was a hybrid between a project and a sector-wide program 14. While this approach was justified by the specific circumstances prevailing at the time of appraisal, the choice of a broader SWAp (i.e. financing a time slice of the MOHFW program rather than financing a specific set of activities) may have been a more ideal foundation for more far-reaching sector dialogue, both with respect to sector reforms, ongoing resource allocations and priorities within the sector. 2.2 Implementation General. HNPSP implementation really gathered momentum after the Mid-Term Review (MTR) in early-2008, following rather slow progress in the first two years. This was reflected in the downgrading of project ratings to Moderately Unsatisfactory in the ISR in mid-2007 after it became clear that there were real impediments to implementation which needed to be resolved. The delay in project start-up was due to unresolved audit observations from the previous program (HPSP). Also, the slow 13 The project did not finance all the activities as identified in the PIP for a specific time period, e.g. the project did not pay for staff salaries of MOHFW. 14 As stated in a paper co-authored by the TTL responsible for the PAD (Kostermans & Geli, undated) 7
implementation progress was due to the fact that sector programs such as HNPSP rely on adequate government leadership, which was not sufficiently strong (according to 2006 and 2007 APRs, and the Implementation, Monitoring & Evaluation Division [IMED] Evaluation), particularly during the first two years. Further, a critical TA body e.g. the Program Support Office (PSO) which was supposed to serve as the Program Implementation Unit, was not in place until the MTR in 2008. Indeed, in 2007, some DPs were contemplating whether to continue financing of the program which prompted the GOB and the DPs to jointly agree on six critical actions to be prioritized by the Ministry. This created new momentum, including increased government leadership, facilitated by the active engagement of the World Bank Country Office and British High Commission. Subsequently, implementation picked up momentum and four out of the six actions were achieved within a period of six months. Limited progress was achieved in the other two of the six action areas (putting Management Support Agency [MSA] in place and setting up a procurement tracking system in the Directorate General of Family Planning [DGFP]) as noted by the half-year stock take in November 2007. The program was restructured following the MTR (although formally recorded only in 2009) and by early-2008, the project rating was upgraded to Moderately Satisfactory in the ISR and then to Satisfactory in 2011. The Quality Assurance Review (QAG) in 2008 also rated the project as Moderately Satisfactory. At the end of project implementation in June 2011 (while the project formally closed in December 2011), most of the key targets were achieved as described in Section 3 and in the ICR Datasheet. The GOB and DPs put in a concerted effort to achieve the program targets despite the challenge of the program s size and scope. The program was guided by a series of high quality independent Annual Program Reviews. The APR had two parts assessment by an independent team which submitted a full APR report, and then based on the report, the GOB and DPs jointly agreed on Action Plans which were recorded in the Aide Memoire. Not all the recommendations provided by the independent team were implementable due to various constraints in the government systems and, therefore, were not included in the Action Plan. This APR mechanism functioned well. The IMED Evaluation 15 notes that the APRs became the main source of dynamism in performance evaluation and establishing the future course of action for the year. The following were some of the key issues which affected implementation either in a positive or negative way as well as some elements of the program which require a brief description to set project implementation within a broader context. While many of the issues described below were indeed major challenges, the overall implementation of the program turned out to be much more successful than indicated by the sum of these challenges. This is important to note, particularly given the large size of the program and the inherent and historically difficult environment of working in Bangladesh. 15 Implementation Monitoring & Evaluation Division (IMED), Ministry of Planning: End-Line Evaluation of Health, Nutrition and Population Sector Program (HNPSP), Final Report Sep 2011. 8
Political context. Bangladesh witnessed frequent (2006, 2008 and 2009) changes of government during the implementation period, leading to changes in national priorities as well as transfer of staff in key positions. One of the major effects of these changes was that the diversification process (i.e. outsourcing NGOs and private providers, as described in section 1.5) could not be implemented as originally planned. Consequently, when the program was restructured, the overall budget was reduced by the unspent funds in this area. Another example of this was that the original commitment to the PSO, MSA and Performance Monitoring Agency (PMA) was no longer there (discussed in details in the section on other institutional issues ). Furthermore, the frequent shift of Line Directors (LDs) (often only in position for less than a year), responsible for the operational plans 16 (OP), also emerged as a factor causing systemic inefficiencies. The attempt in the latter half of HNPSP to keep LDs for the major OPs in place for 2-3 years was only partly successful, as many LDs either retired or got promoted. Decentralization. Although a decentralization policy was approved in 2009, the health system in Bangladesh remained very centralized. It is widely agreed (PAD, MTR, APRs) that in order to improve service delivery at the primary level, delegation of authority over planning and budget at the upazila level had to be increased. Consequently, in terms of improving service delivery, the lack of progress on decentralization was problematic. In order to circumvent the slow progress of overall decentralization reform and to move towards functional integration of health and family welfare, an Upazila Health System (UHS) was suggested by the APR 2009, and also endorsed in the 2009 Aide Memoire to be piloted and subsequently implemented in the follow-on sector program. Budgeting & planning. The division of the health sector in a health and a family planning directorate, a division that extends from the center to the lowest institutional level of the service delivery system, (except the Community Clinics), impeded integrated budgeting and planning of health services at all levels. At the central level, integrated budgeting and planning was impeded because the development and revenue budgets were planned in different units, resulting in an absence of synchronization between the revenue and development budgets of MOHFW (IMED Evaluation). In addition, the structure of the two budgets was different: the revenue budget was allocated to facilities/institutions, while the development budget was allocated to programs. This problem was and remains pervasive in the GOB system and is not specific to the MoHFW. The Program Implementation Plan (PIP) of HNPSP identified a large number of OPs (38) for implementation of the program. The difficulties of integration between the silo-like OPs were identified as an important problem (MTR 2008), and IMED 2012 documented the inefficiencies that this led to, one example being constructed facilities not utilized to full capacity due to lack of coordination between the procurement of equipments and allocation of manpower. 16 Operational plan is defined as the primary implementation structure of the MOHFW s Health SWAp. There were 38 OPs distributed across the Directorate General of Health Services, Directorate General of Family Planning and the MOHFW and other agencies. Each OP reflected a priority area of the MOHFW s Health SWAp and was led by a Line Director with a functional administrative structure including staff, budget and infrastructure. 9
New institutions & TA (PSO, MSA & PMA): As part of the HNPSP, some new institutions were planned: the PSO and the MSA were created in 2007 and 2008 respectively. However, their effectiveness could be challenged, as there was a huge disconnect between these agencies and the Ministry whom they were supposed to support (as noted in the 2009 APR). The PMA was never established, but its function was integrated into the existing structures by hiring consultants. At the program design stage, there was ownership of these new structures at the top level management of MOHFW. With the change of government, the level of ownership also changed, exemplified by MOHFW not fulfilling the legal covenant of PSO/MSA for several years. Instead of showing flexibility, DPs insisted on having PSO/MSA/PMA despite the MOHFW s reluctance. MOHFW took so long (nearly two years) to evaluate the bidders proposals for PSO/MSA that good quality firms withdrew their proposal, and/or shortlisted firms were no longer in a position to field the staff indicated in their proposals. These delays also meant that firms that were awarded the contracts for PSO/MSA could not send experts as originally proposed and, therefore, the quality of the TA suffered and the TA institutions could not deliver as per expectations. This led the GOB to discontinue the contracts for PSO and MSA in 2010. NGO contracting. The diversification, particularly in terms of contracting of NGOs, did not progress as originally planned. This was mainly due to the shift in GOB s political preference as the new Government did not want to contract out essential public health service delivery, like nutrition, to the private sector. NGOs were contracted out for nutrition, TB and HIV services as a part of the diversification agenda. However, lack of capacity and planning at the implementer s level were two other issues that impeded the greater involvement of the non-government sector in the service delivery. For example, the National Nutrition Program (NNP) under HNPSP was plagued by regular interruptions in service delivery due to the government s delays in contracting the NGOs as service providers. Furthermore, the performance of some NGOs was questionable as documented in periodic performance reviews of NNP. Goods and Civil Works. The HNPSP financed capital investments, i.e. equipment and civil works, as well as procurement of goods such as essential drugs and vaccines, funding areas of major importance to the delivery of quality services. Capital investments and procurement of commodities ended up constituting 71% of the pooled funding expenditures (out of which 3% for civil works). These were major contributions to improving service delivery. Performance Based Financing (PBF). Twenty five percent of pooled funding was allocated for PBF based on fulfillment of agreed upon specific indicators. The indicators were agreed on with the government every year and the funds were provided when the indicator target were achieved. This modality was initially not very successful in terms of achieving the targets set, and in the first years the amount set aside for PBF was not disbursed. One reason could have been that the incentives provided by the PBF may not have been adequate, as the funds received for achieving the PBF target were not directly allocated to the level which was responsible for achieving the target. Nevertheless, due to the reallocation of the budget (in 2009), the GOB did not eventually lose any funding as a 10
consequence of noncompliance with the targets for obtaining the PBF associated funding. The MTR gave a quite harsh assessment of PBF, calling it an example of old fashioned conditionality, and inconsistent with Paris Declaration principles. While there is a certain truth to this, particularly as the first tranche was associated with establishing the PSO and MSA, there are also clear benefits in enhancing the focus on results by financial incentives. During the last two years, the PBF targets were met and the mechanism was well understood and it turned out to be useful as it enabled the MOHFW to use funds on priority activities, thereby serving as a valuable source of flexible funding. Eventually, the PBF did deliver results, and important lessons were learned regarding this new modality in development assistance. HNPSP Coordination. The HNP Coordination Committee and HNP Forum led by MOHFW, including DPs, assessed project progress and discussed implementation and policy issues. The DPs were organized in a HNP Consortium with a Chair, who spoke on behalf of the DPs as much as possible. MOHFW held Coordination Meetings (Secretary and the Director Generals of DGHS and DGFP) reviewing mainly the OPs, in principle monthly, but in practice less frequently. Monitoring was highly centralized leaving little discretion to lower level management (e.g. Divisional and Upazila). In addition Task Groups were established - following the recommendation of the first APR - to assist MOHFW in monitoring implementation progress of priority areas. The regularity and effectiveness of meetings varied; but it seems this modality was functional. The IMED Evaluation of HNPSP concluded that neither of the fora 17 engaged in systematic policy review because there was little demand/need for policy discussions from either the Ministry or the DPs. It should be noted that broader policy dialogue may not have been part of their terms of reference. Overall, the coordination provided good guidance on a number of implementation issues, but less so on higher level policy issues. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization Design. The HNPSP was monitored using two sets of indicators one for the full sector program with 62 indicators (PAD Annex 3A, p.34-39), which was revised during the MTR to a list of 30 indicators; and the other for the pooled fund, which was drawn from the broader Results Framework and included 10 key project indicators. This subset of indicators (PAD Annex 3A, p.33) was revised during the MTR and was used for reporting in the Bank s ISR. The Development Credit Agreement (DCA) PDO was referred to in Annex 4 of the PAD with a different set of 8 indicators (6 of which are of impact level indicators). Most but not all of the DCA PDO indicators were also part of the broader sector Results Framework (RF). An update of the status of indicators in the broader RF, including a number of those listed in Annex 4 of the PAD, is provided in the ICR Annex 9. 17 i.e. HNP Coordination Committee and HNP Forum 11